Burnout: interpreting the perception of Iranian primary rural health care providers from working and organizational conditions.

OBJECTIVES: Health care providers in the rural centers offer the primary health services in the form of proficiencies and professions to the most required target population in the health system. These services are provided in certain condition and population with a verity of limitations. This study aimed to describe and interpret the experiences of the employees from their own working condition in the rural health centers.
METHODS: The present study conducted in a qualitative research approach and content analysis method through individual and group interviews with 26 employed primary health care providers (including 7 family physicians, 7 midwives, and 12 health workers) in the rural health centers in Isfahan in 2009. Sampling was done using purposive sampling method. The data were analyzed using qualitative content analysis as constant comparative basis.
RESULTS: During the content analysis process, six themes were obtained; "instability and frequent changes", "involved in laws and regulations", "pressure and stress due to unbalanced workload and manpower", "helplessness in performing the tasks and duties", "sense of identity threat and low self-concept", and "deprivation of professional development". The mentioned themes indicate a main and more important theme called "burnout".
CONCLUSIONS: Health services providers in the rural health centers are working in stressful and challenging work conditions and are suffered from deprivation of something for which are responsible to the community.

INTRODUCTION

Primary health care (PHC) in the Islamic Republic of Iran has experienced three 12-year periods: The first twelve years, i.e. 1972 through 1983, gaining experiences and period and development of the program, the second 12-year period, i.e. 1984 through1995, quantitative and qualitative development of the health care network, and during the third one (1996-2008), the country has witnessed efforts for effecting fundamental reforms in the health care networks which despite its gradual speed, is so important.[1]

Generally, the importance of human resources management (HRM) to the success or failure of health system performance has, until recently, been generally overlooked. In recent years, it has been increasingly recognized that getting HR policy and management “right” has to be at the core of any sustainable solution to health system performance.[2]

Today, there is a growing interest in the psychosocial work environment of health care staff since they are at high risk for burnout, role conflict and job dissatisfaction.[3] From many accounts healthcare professionals are at increased risk for professional burnout. Professional burnout is generally described as prolonged stress that impairs one's ability to perform his or her job in demanding situations;[45] because they are exposed to psychological, emotional, and also physical stress.[36]

The previous studies generally have been reviewed the job stressors,[78] psychological-behavioral responses to the job stress,[9] organizational support and practices, physical and psychological responses to work, patient relationships and other job content, and other external factors in the nurses.[10]

A few studies have been done about factors associated with the burnout[11] and burnout dimensions[12] in the physicians and health workers. Very limited studies in the world and Iran also have been done about job satisfaction, job stress, and affecting factors on the burnout and its consequences in the primary health staff.[31314]

According to the recent studies, there are too many limitations and high pressures which indicated the high risk of job stress for the employees in the position of the community health care. Furthermore, the frequency, intensity and the effect of job stress in the occurrence of various dimensions of job stress and depression have been studied and reviewed largely on the nurses and in a relatively lower rate on the physicians and health workers. The present study aimed to describe and interpret the experiences of the employees, such as family physician, midwives, and health workers, from their own working condition in the rural health centers three decades after their vast and valuable activities using qualitative approach.

METHODS

The present study conducted in a qualitative research approach and content analysis method through individual and group interviews[1516] with 26 employed primary health care providers (including 7 family physicians, 7 midwives and 12 health workers) in the rural health centers in Isfahan from October 2008 through September 2010. Sampling was done using purposive sampling method and continued until the data saturation.

The inclusion criteria were having at least one year experience and providing full-time services in the health houses and health centers.

In order to collect the data, the participants were invited to form the focus group meeting after obtaining permission from the Deputy Vice Chancellor Research and cooperation with Health Deputy of Isfahan University of Medical Sciences and providing introduction letter to Provincial Health Center. Explanation and justification about the aims of study was clearly stated and written consent form was received from the participants.

The in-depth and semi-structured interviews -suitable for the qualitative studies- conducted in individual and group interviews using open ended questions.[17]

Analyzing the data was done using content analysis method.[18] Then, in order for inductive analysis, organizing data was done using open coding process, creating subcategories and categories and abstraction.[19]

In this study, each one of the interviews formed the study analysis unit. The interviews divided into semantic units and then the semantic units were compressed and summarized. The summarized semantic units had been more abstracted and were converted to the codes. At the time of compressing and coding the semantic units, the text and general background of the interviews were considered. Temporary categories were discussed and revised by the researchers. At the end, the basic and infrastructure meaning i.e. the hidden content in the categories were regulated in the form of six themes and these themes ultimately were put into the overall and central theme of the “burnout” which indicated the main theme and substantial data.

Trustworthiness of the data was analyzed through revising by the participants and reviewing by the non-participants. Diversity in sampling helped in transferability of the data. Credibility of the findings and data quality coverage was evaluated by the categories through showing quotations method from the written text and also searching the coincidence and agreement between other researchers, experts, and the participants.[20]

Verifiability and auditing the data was done through description of full details of analysis process and obtaining the results so that the readers could have a clear understanding of done analysis method, its strengths, and limitations. Conformability or authentication had been strengthened by offering rich and strong results along with appropriate quotations and peer review debriefing by some of the professors and other people who were experienced in qualitative researches.[20]

RESULTS

The participants’ profile is given in Table 1.

Table 1

Participants’ profile based on profession, age, sex, work experience and marital status

In the first step of the content analysis from analysis of the data obtained from individual interviews and focus group, 991 codes, 55 subcategory, and 21 categories were obtained.

In the second step, six themes were obtained from these categories [Figure 1]. The mentioned themes indicated a main and more important theme called burnout, which are as the following:

Figure 1

Six central themes associated with the burnout

1. Instability and frequent changes

Frequent (and often unexpected) changes in type of the services and instability in definition of the target population and recipients of the services following the new programs and instructions which every day are sent from the higher centers and authorities with no clear purpose, cause instability, turbulence, and tiredness in the health care providers: “In my opinion, changes should be purposeful. It means, in every system, we naturally need changes because the system needs improvement. Our processes should be improved too, but these changes are not purposeful”[D2 – c28]; “The number of offices have increased dramatically with too many changes which are not really helpful for people and health. It will just make the staff tired” [D4 – c38].

Some of them expressed dissatisfaction from lack of awareness from their future obligations and tasks, being unimportant in the system and not being the consultant party to determine the type of the reforms and its procedure as an executor and also a beneficiary person: “That means some unnecessary tasks. We really have no idea about what we are supposed to do tomorrow”[D2 – c314];“ They never ask about our opinions in any tasks” [B11 – c227].

The physicians expressed their dissatisfaction from the coverage population instability and their increase; the midwives from the frequency of the covered villages and providing services to other villages with unfamiliar people; and mid-wives and health workers dissatisfied from providing service to the high risk Afghan population.

2. Involved in laws and regulations

The care providers complained about multiple, inappropriate, hindrance and non-beneficial regulations, and had an unpleasant feeling and experience toward them: “They waste our useful time and this is the same for doctors and midwives too. We suggested several times, a doctor and a midwife should be incharge and assistants can have a time–out, but no one paid attention and the system didn’t accept” [D6 – C57].

They also complained about rigid and inflexible regulations and laws, hindrance instructions and inconsistent laws to the community conditions: “In the present situation, the physicians are evaluated based on the statistics and the recorded issues due to the little flexibility of the system .” [D1 – C83].

One of the most important factors for their dissatisfaction was increasing their working hours regardless of the actual needs of the people, because all those hours were in the afternoon which was non-beneficial and boring:“Our work time is too long. We are too exhausted to get home at 5:00” [B4 – C24].

3. Pressure and stress due to unbalanced workload and manpower

Unbalanced workload and manpower caused stress and pressure on the care providers due to high population coverage and lack of sufficient manpower: “There is too much work and it is too diverse too” [B4 – C266]; “Every year and even everyday, they increase the responsibilities of the health workers” [B3 – C28].

All of them complained about high number of the clients and providing service to the high population in a limited time: “I think each of us should visit at least about 50 or 60 patients, but I think it is not practically possible” [D7 – C2].

All of them, particularly the health workers, expressed dissatisfaction from paperwork and spending so much time to register the services. They believed so much registration of the cases was one of the time consuming and useless factors in addition to reduction of the care time, failure in the services quality, waiting of the customers and making frequent mistakes: “These days our job is just a kind of bureaucracy” [B8 – C107].

Some of them were dissatisfied from repeated and parallel services in the form of new services: “Another problem is that we have a series of parallel tasks. I say that I had already filled out the health case of this woman why should I do that in a form of professional health care again” [D2 – C312].

Job stress and the current psychological pressures in the work were experienced by all of them and highly affected them: “We need our psychological health too. We are always stressed-out” [D5 – C111].

4. Helplessness and frustration in performing the tasks and duties

Sense of frustration in the duties and unfinished services was one of the most common issues of the provided services, so that all of them expressed dissatisfaction and severe pressure from lack of enough time due to plurality and diversity of the tasks: “How much energy does a health worker have?” [B9 – C189]; “There are a lot of expectations from family doctors”[D7 – C24]. “We don’t have enough time to do all the tasks” [D7 – C33].

Furthermore, interference of the heterogeneous tasks and also conflict between roles and tasks had caused disorder and confusion in implementing the tasks and also created many problems for them which consequently caused severe work pressure and dissatisfaction in them: “Because of too much work and different tasks that needs to be done and because of too many patients that we have, we have no time to educate people as we should do” [D6 – C5].

5. Deprivation of professional development

The participants expressed this feeling due to impossibility of the scientific promotion, lack of suitable conditions to update scientific information, lack of opportunity for acquiring new skills, and lack of opportunity for independent decision-making: “According to the project of family doctor, there would be no opportunities for doctors’ scientific improvement” [D2 – C333].

The health workers were worried about lack of the opportunity to promote scientific level and acquiring scientific capabilities and physicians discomfort from lack of enough time to study and access to update scientific resources and references: “During the recent years, I really had no time to study at nights, therefore, I had to use my previous knowledge” [D2 – C337]; “It's true that one person is doing too many tasks, but maybe he didn’t realize some of them completely” [B1 – C90]; “Most of the time in visiting a patient, I should be really careful to diagnose the sickness” [D1 – C21].

6. Sense of identity threat and low self-understanding

The majority of the care providers expressed dissatisfaction from information resources, improper evaluation methods, underestimation and quantitative attitude in the system, number of the monitoring and observers, unfair judgment of the observers, and ultimately improper evaluation of the feedback. This event, in many of them was manifested as “low self-feeling, defenseless, and depressed” which were appeared as negative worthlessness feeling, insignificance, and unimportance: “The health workers are under too much pressure”[B9-C174]; “In my opinion, in this system, doctors have no good social level”[D5 – C31];“ In some cases, they really scorned us”[B11 – C206].

The defenseless feeling had been created due to negative experience of the authorities hearken and lack of right to protest: “Whenever we complain, they say you shouldn’t have chosen this major” [B6 – C212].

They were also dissatisfied from focusing on the written evaluation and reports without regard to the quality of the provided work: “They They would never accept our performance, even if we had already done that, unless we record our work.”[D7 – C30].

The central theme: Burnout

The second analysis and comparison of the mentioned six themes indicated that those themes showed a more inner and more abstract feeling in the participants’ toward the working condition which was the very burnout. So that the themes of instability, pressure, threat, frustration, deprivation and worthlessness along with emotional exhaustion and depersonalization in all the care providers, and individual failure of the health workers, lack of motivation in the work and extreme fatigue all indicated the inner feeling and event, general and more important called burnout: “We are really frustrated with no motivation in our job” [B8 – C103]. “We really get tired” [B8-C97].

Depersonalization dimension was evident in all the service providers: “Sometimes I wish there were no visitors when I get to work” [B2 – C284]. The feeling of individual failure was evident in the health workers and they had experienced all the dimensions of the burnout: “There is no internal –satisfaction either” [B11 – C71].

DISCUSSION

The results of this study indicated that understanding and feeling of the health care providers in the primary rural health centers were as the following: Feeling instability and frequent changes with no purpose in the organization; involved in laws and regulations; pressure and stress due to unbalanced workload and manpower; frustrated in performing the tasks; deprivation of the professional development; and sense of identity threat and low self-understanding, which these themes can represent the indices of a theme i.e. burnout. Reliable sources consider burnout as a syndrome which includes exhausted, fatigue, and overworking which appear as negative attitude and feeling toward people whom work with, toward their own professional roles, and also emotional exhaustion. It also is a syndrome which includes emotional exhaustion, such as fatigue and severe emotional pressure, depersonalization, such as lack of kindness and tenderness toward others, and reduction of the adequacy feeling and personal success e.g. negative assessment from his/her potential abilities for success in the work. This syndrome may be seen more among the professions which directly deal with people than other jobs.[132122]

The significant note in the study results were job stress and pressure due to frequent changes which was resulted from undesirable nature of the changes structure and not involving the care providers in decision-making about its quality and quantity had caused increase in workload, inconsistencies, and contradictions in the roles and ambiguity and amaze for the care providers and eventually predisposing the incidence of different dimensions of burnout in them.

Although changing is considered necessary because of the importance of dynamic health care delivery system, however, frequent changes in the services causes instability, turbulence, and turmoil in the services and leads to pressure, dissatisfaction, and finally incompetent and burnout in the care providers.

In the present study, the care providers described the frequent changes and instability in the system as a useless and purposeless case. In their opinion, the changes had not sequence and order and could not correct the previous weaknesses. They did not consider the changes motion as monotonous and believed it was fast at the beginning and then gradually slow and boring and they also believed that this was the reason of previous left unfinished services and also imposing repetitive and parallel services to the system in the form of new services, besides they expressed dissatisfaction from lack of participation in decision making about the changes.

Glasberg et al also mentioned that one of the major sources of burnout was the frequent changes due to budget reduction and instability in the work.[23]

All the care providers were dissatisfied from notification of the rules and inflexible and inconsistent instructions with the community condition. They also complained about their useless presence in the afternoon hours and anachronistic increase of working hours. In addition, they expressed dissatisfaction from being unauthorized to plan and regulate inappropriate services to the community under its circumstances and consequently neglect the health of some of the target population groups such as men.

According to the study findings of Glasberg et al, one of the factors associated with emotional exhaustion in the service providers was lack of enough time for providing the required care and inability to meet the needs of others, besides, one of the factors associated with depersonalization was reduction of the desire to provide optimal services and inadequate support of the partners in addition to the above mentioned cases.[23]

According to the majority of the care providers, due to lack of balance and coordination between workload and human power and also the increase of expectation of the system from them, high workload, and increasing the frequency and variety of tasks, the services left unfinished and were not given with an optimal quality with itself caused the disability in conducting the tasks and pressure and stress in them. Furthermore, increase the documentations and paperwork caused reduction of the care time, reduction in the services quality and making frequent mistakes and severe anxiety in them.

The study of Ahmadinia et al indicated that high workload, lack of environmental hygiene observation and commuting problem in the women health workers, insufficient salary and benefits, insufficient life facilities, housing problem and lack of vehicle in the men health workers were the affecting factors on job dissatisfaction. Moreover, the health workers were unhap-py from the reaction of the observers and highranking officials.[24] Furthermore, in the study of Arab, rural population size and coverage satellite villages and provide basic facilities mentioned as the affecting factors on job dissatisfaction of the health workers.[14]

The study of Weymouth in Australia on the employed nurses in the remote distances showed that low information, high stress, inadequate resources, and unrealistic expectations of society and managers led to high workload and the feeling of lack of being understood and support by the managers.[25]

The study of Grunfeld et al in Canada also indicated that increasing the workload had been the main source of job stress in nurses and had caused concern in them due to negative effects resulted from high workload and reduction of the services quality and loss their spirit.[26]

The study of Gotz in Germany showed that general practitioners were dissatisfied from the incoming level, working hours, and mental conditions of the work.[27]

In addition to the above mentioned cases, high workload along with the social and demographic factors as well as smoking had been found the affecting factors on physical and mental health of the physicians and nurses.[21]

Multiplicity of the tasks and difference in their nature caused interference in the tasks and sometimes even conflict in playing the roles and confusion in the service providers caused many problems for them.

Lu et al in their study showed the organizational factors, factors related to job and patient care, ambiguity and conflict in the role, job stress and organizational commitment as related factors to job satisfaction and also willingness to keep the job.[8]

The care providers were dissatisfied from the current evaluation process and recognized resource information of the evaluators and their assessment method as an inappropriate method and believed underestimation and quantitative attitude in the system have been ruled out and judgments were unfair about the quality of their services.

Lack of professional development opportunities means lack of scientific promotion and lack of updating the information and the care providers complained about lack of opportunity to acquire skills and lack of enough opportunity for independent decision making. While, in the study of Buciuniene on reforming in the health care system in Lithuania showed that physicians had the most satisfaction from their independence level and relation with the partners and also they had quality of management. However, despite physicians’ satisfaction from job independency, they were dissatisfied from social status and high workload.[28]

The study of Kushnir et al showed that continuing medical education had negative correlation with job stress and positive correlation with job satisfaction among the family physicians and the family physicians that had necessary opportunity and possibility for keeping the professional information updated had lower stress and burnout.[29]

The present study indicated that after emotional exhaustion with high intensity and after depersonalization with relatively more limited extent were observed in all the care providers, such as family physicians, midwives and health workers, but the important thing is that after individual failure and inability in performing the tasks with high intensity was observed only in the health workers and in addition to the inner sense in the health workers, its outer understanding was done by the physicians and mid-wives and proved this issue.

Severinsson in his study on burnout in the Australian nurses showed that the process of high demand from the nurses caused reduction in control level of the affairs and weakness and inability feeling and led to inability to perform the tasks and job stress and physical problems, such as blood pressure, in them. The feeling of disability in the nurses was revealed in depression, frustrated, and loneliness. Suspension between suffering and desire related to the nurses’ experience was one of the events that led to emotional and mental problems in the nurses.[30]

CONCLUSION

Analyzing and discussing the above mentioned findings from the perception of the care providers from their working condition indicated that burnout was their main and central theme from understanding and experience of their working conditions. Health service providers in the health centers who are the messengers and life and health guards of the people, due to stressful and challenging working condition, are being suffered from deprivation of something for which they are responsible for the society, therefore, it is worthy that in order for full effectiveness, the policy makers and managers consider the organizational factors affecting on performance method of the staff.[31] The managers should look for the early symptoms and signs of the burnout in order for development the willingness of the employees to keep working and increase their spirit[4] and also consider the improvement of their health and working condition which is like a container for the gift of the health. The services providers need emotional support, besides they also have the right to be principally monitored regularly and their services carefully be controlled and guided and a fair judgment should be done about their services. They should be helped so that they can realize their own capabilities and some effective measures should be done in order to eliminate the defects and solve their working problems. It should be tried to minimize the environmental stressful conditions and regulate the system's expectations with their capabilities so that stress and pressure of the work, inability, weakness, and depression be minimized in them and subsequently the job satisfaction be increased and thus, the quality of services and health of the coverage community be improved.