Raul Anderson Domingues Alves da Silva1; Ana Karine Macedo Teixeira1; Myrna Maria Arcanjo Frota1; Jacques Antonio Cavalcante Maciel1; Mariana Ramalho de Farias2
BACKGROUND: The particular characteristics of oral health care might influence job satisfaction and occurrence of burnout among providers, with consequent impact on their quality of life and the quality of care delivery. In the present study, we analyzed job satisfaction among oral healthcare providers affiliated with the public health service in Sobral, Ceará, Brazil, work-related factors and prevalence of burnout.
METHODS: Cross-sectional study performed in 2017 with 95 oral healthcare providers allocated to primary and secondary care facilities. We administered a sociodemographic questionnaire, the Occupational Stress Indicator scale and theMaslach Burnout Inventory-Human Services Survey. The data were analyzed by means of the χ2 test; the significance level was set to p<0.05.
RESULTS: Job dissatisfaction was associated with precarious working conditions and lack of professional recognition; satisfaction was associated with interpersonal relationships. The overall prevalence of burnout was low (1.05%), however, on subscale analysis 37.9% of the participants exhibited low personal accomplishment and 22.1% high emotional exhaustion.
CONCLUSION: The results for job dissatisfaction and burnout subscales point to the need for more thorough investigation of the working conditions of oral healthcare providers.
Keywords: job satisfaction; burnout, professional; occupational health; dentistry; dental staff.
INTRODUÇÃO: O trabalho em saúde bucal possui características específicas que podem influenciar os níveis de satisfação do profissional e o desenvolvimento da síndrome de Burnout, interferindo na qualidade de vida desses profissionais e nos serviços prestados por eles. O presente trabalho buscou analisar os níveis de satisfação dos profissionais de saúde bucal da rede pública de Sobral, Ceará, os fatores inerentes à ocupação e estimar a prevalência da síndrome de Burnout entre eles.
MÉTODOS: O estudo transversal foi realizado em 2017 com 95 profissionais inseridos nos níveis primário e secundário de atenção por meio dos questionários: Occupational Stress Indicator, Maslach Burnout Inventory-Human Services Survey e um sociodemográfico. Os dados foram analisados pelo teste do χ2 com o nível de significância p<0,05.
RESULTADOS: Os resultados mostraram que os aspectos de insatisfação se relacionaram às condições precárias de trabalho e à baixa valorização profissional, enquanto o nível de satisfação estava associado ao relacionamento interpessoal. A prevalência geral da síndrome foi baixa (1,05%), entretanto na análise das subescalas observou-se que 37,9% apresentaram baixa realização pessoal e 22,1% demonstraram alta exaustão emocional.
CONCLUSÃO: A insatisfação laboral e os níveis das subescalas de Burnout evidenciaram a necessidade de uma investigação mais aprofundada das condições de trabalho desses profissionais.
Palavras-chave: satisfação no trabalho; esgotamento profissional; saúde do trabalhador; odontologia; recursos humanos em odontologia.
As a process of production, work has a central place in the life of people. It behaves as a stimulus for recognition, personal accomplishment, quality of life and interaction and material exchange with nature. Yet workers may develop or not resistance to physical and mental pressures at work, which might result in occupational diseases1.
Healthcare workers are particularly susceptible to occupational hazards which derive from interpersonal relationships inherent to their job2. Job satisfaction, defined as a pleasant emotional state in self-assessment of work3, has direct relationship with the quality of care delivery, since the latter is associated with well-being at work and other related factors, such as engagement and organizational commitment2,4.
A large part of the scholars who study job satisfaction have resource to Herzberg's two-factor theory, according to which two sets of variation factors might influence job satisfaction. Intrinsic motivators are job-related aspects, such as recognition, tasks and responsibilities. In turn, hygiene/extrinsic factors depend on conditions external to workers, as e.g. safety, working conditions and salary. Intrinsic motivators might afford satisfaction, while lack of hygiene/extrinsic factors might result in dissatisfaction4,5.
The work process in oral health care is characterized by particular aspects likely to influence job satisfaction. According to several studies conducted with dentists5,6, some among such aspects are productivity, stress level, salary, resource shortage, working hours, and perceived staff quality. Oral healthcare providers, dentists in particular, are exposed to occupational stress and are at high risk of burnout, which factors are strongly associated with job satisfaction5.
Burnout was first described in 1974 by Freudenberger as the result of exhaustion, disappointment and loss of interest in work, being more common among workers whose job involves service delivery, and consequently direct contact with other people2. This notion was revised by Maslach and Jackson, who defined burnout as a multifactorial syndrome, having emotional distress as initial symptom and characterized by physical and mental exhaustion, which makes workers lose their energy and will to work1,2,5.
Burnout has three components: emotional exhaustion (EE), characterized as emotional tension leading to a feeling of exhaustion; depersonalization (DP), i.e. a negative, often indifferent or cynic attitude toward clients; and low personal accomplishment (PA), which interferes with the interpersonal skills required in professional practice. While also physical exhaustion might be a sign of burnout, emotional exhaustion is considered to be the core aspect of this condition6,7.
Health problems related to stress and burnout among oral healthcare providers have been reported for more than 50 years, as well as high levels of job dissatisfaction and moderate prevalence of burnout in several parts of the world6-8. The prevalence of burnout among oral healthcare providers in Brazil has been scarcely analyzed, and there are also few studies on burnout and job satisfaction among oral health technicians and secondary care providers in public facilities, which makes this type of studies relevant.
Accurate knowledge about job satisfaction and prevalence of burnout among oral healthcare providers is necessary to improve their level of job satisfaction, and consequently the quality of care delivery. Therefore, the aim of the present study was to analyze job satisfaction and prevalence of burnout among oral healthcare providers affiliated with the public health system in Sobral, Ceará, Brazil.
The present was a cross-sectional, exploratory and quantitative study. Participants were all Family Health Strategy dentists (D, n=42) and oral health technicians and assistants (T/A, n=46), as well as all dentists (n=36) and T/A (n=24) in the secondary care network in Sobral. Dentists enrolled in the Family Health Multiprofessional Residency program and employees on maternity leave or vacation at the time of data collection were excluded.
Data collection was performed in May and June 2017. For participants in primary care facilities, data collection took place during monthly permanent education meetings at Viscount Sabóia Family Health Training School and Health Basic Units. For the participants enrolled in secondary care, data collection was performed at Sergio Arouca Municipal Oral Health Specialties Center and Dean Ícaro de Souza Moreira Oral Health Specialties Center.
Eligible subjects were invited to participate in the study and informed as to its aims. We administered a questionnaire to collect sociodemographic data and two scales to measure job satisfaction and burnout, to wit, Occupational Stress Indicator (OSI)3 and Maslach Burnout Inventory-Human Services Survey (MBI-HSS)9.
OSI enables measuring job satisfaction through investigation of 22 psychosocial aspects of work represented by 22 items. Questions are responded on a Likert scale, with the scores ranging from 1 to 6. The total score is categorized as: job dissatisfaction (22-80), intermediate (81-100) and satisfaction (101-132). In the present study, we calculated absolute and relative frequencies according to professional category and level of care, and also for the overall sample. In the calculation of the level of satisfaction corresponding to each analyzed psychosocial aspect of work, we categorized the responses as follows: score 1 or 2 (dissatisfaction), 3 or 4 (intermediate) and 5 or 6 (satisfaction), which were also analyzed according to professional category and level of care.
MBS-HSS comprises 22 items distributed across three subscales which represent the components of burnout, i.e. EE, DP and PA. Items are responded on a Likert scale, with the score ranging from 1 to 6. The global score is obtained by adding the scores on the individual items and is categorized as follows: EE-≥27 high, 17-26 moderate, and ≤16, low ; DP ≥13 high l, 7-12 moderate, and ≤6 low; and PA (reverse score) 0-31 high, 32-38 moderate, and ≥39 low. Burnout was defined as abnormal scores on all three subscales, i.e. high EE and DP and low PA.
The demographic and psychometric information was entered in an electronic database and tabulated according to absolute and relative frequencies. Data analysis was performed with software Statistical Package for the Social Sciences (SPSS® version 22.0, IBM, U.S.A). Association between OSI variables (job satisfaction) and burnout was investigated by means of the χ2 test with 95% confidence interval. The significance level was set to p<0.05.
The authors declare they have no conflict of interest and complied with all ethical requirements for research involving human beings. All the participants signed an informed consent form. The study was approved by the research ethics committee of Universidade Federal do Ceará, ruling no. 2,506,284.
The return rate for the 148 recruited subjects was 64.2%, therefore, the final sample comprised 95 participants, 52.6% allocated to primary care (n=50; D, n=33; T/A, n=17) and 47.4% secondary care (n=45; D, n=29; T/A, n=16) facilities. The sample included participants from both sexes, with higher prevalence of females (80%) and dentists (65.3%). Most participants were attending or had completed graduate education (85.4%). The largest proportion of participants had worked 6 to 10 years in the profession (38.7%) and 1 to 5 years in public healthcare facilities (43.1%), worked 40 hours/week (83.1%) and did not have management or supervision tasks (97.8%) (Table 1).
The highest levels of job satisfaction corresponded to the following aspects: interpersonal relationships at work (83%), work content (77%), communication and information flow between employer and employees (61%) and motivation (52%). The aspects associated with the lowest levels of satisfaction were: salary as a function of professional experience and degree of responsibility (15%), opportunities to fulfill aspirations and ambitions (22%), change and innovation implementation style (25%) and degree of job security (27%).
We found statistically significant difference in job satisfaction on comparison according to professional category (p<0.001). About 34% of the dentists reported to be dissatisfied with their job versus 6% of T/A. Job satisfaction did not differ according to level of care (primary vs. secondary, p<0.246) (Table 2).
On analysis of job satisfaction relative to each psychosocial aspect of work included in OSI, we found statistically significant difference between the two groups of participants relative to: change (p<0.001), salary (p<0.002), aspirations (p<0.004), supervision (p<0.005), growth (p<0.006), communication (p<0.009), decision making (p<0.018) and image (p<0.036). However, analysis of absolute and relative values indicated high levels of dissatisfaction relative to variable salary (p<0.002) and high levels of satisfaction with communication (p<0.009) in both groups. In regard to the items associated with intermediate level of satisfaction, change stood out among the dentists (p<0.001) and growth among T/A (p<0.006) (Table 3). On comparison according to level of care, we found significant difference only for item image (p<0.006) which promoted moderate satisfaction among the dentists and a high level of satisfaction among T/A (Table 4).
The prevalence of burnout was low for the overall sample (1.05%), with a single case in the group of T/A. The frequency of scores indicative of burnout on each subscale was: low PA 37.9%, high EE 22.1% and high DP 9.5%. About 53.6% of the participants exhibited abnormal scores on at least one subscale and 6.3% on 2 subscales. On comparative analysis, we found significant difference only in subscale EE between D and T/A (p<0.010) and in subscale PA between participants allocated to primary and secondary care facilities (p<0.042) (Table 5).
The difference in levels of job satisfaction found between the two analyzed occupational groups (D and T/A) is related to the specific personal characteristics of each individual. Measuring job satisfaction and its impact on the lives of workers is a complex process, since several factors may behave as both determinants and consequences. Job satisfaction is associated with personal values, and depends on individual differences resulting from innate factors in interaction with the individual lived experience10.
Analysis of job satisfaction in relation to aspects of the work process allowed detecting the participants' degree of satisfaction relative to factors: decision making, communication, supervision, changes, growth, aspirations and salary. T/A reported higher levels of satisfaction in regard to all these factors compared to the dentists. Accurate understanding of these aspects is even more relevant as a function of the difference of the influence of exhaustion on occupational factors between D and A/T7.
Implementation of changes and innovations, participation in decision making, communication, flow of information in the workplace and how supervision effectively occurs were some of the main factors which caused dissatisfaction. The reason might be related to the process of implementation of actions in healthcare services, i.e. usually vertically and without the participation of workers in decision making. Lack of support, organization and communication between managers and workers might contribute to the occurrence of administrative problems, and subject workers to situations characterized by abuse of power11.
T/A reported to be more satisfied in regard to their expectations to fulfill their goals compared to the dentists. This finding is due to the positive image the former have of their job, which the precarious conditions notwithstanding, is not seen as a cause of disease, but as a means to provide care to others and thus contribute to the development of altruism. To this group, the relevance of their social role therefore counterbalances their precarious working conditions11.
Also salary was mentioned as one of the main causes of job dissatisfaction6,12, with higher prevalence than that reported in a study performed in Piracicaba, São Paulo, Brazil, of 54%13. Salary dissatisfaction appears as a critical issue in the literature1, which evidences a close relationship between salary and job satisfaction. Job satisfaction occurs when salary and benefits are good10. However, healthcare workers are still discontented with their salary, and describe their job has bringing poor financial return11.
Working conditions characterized by repetitive and specialized tasks and work overload are mentioned as a cause of distress among dentists1. In addition, professionals in public institutions might develop mental exhaustion as a function of the high volume of patients and the need to have a second job14, resulting in loss of labor rights and lack of leisure time when they have to spend their free time in a second job or in additional training to keep themselves in the labor market11.
The low level of satisfaction with career growth possibilities reported by T/A corroborates the results of a study performed in Bahia, Brazil, according to which oral health assistants in public institutions were dissatisfied with the labor guarantees and career opportunities. In addition, the fact that a large part of the municipal oral healthcare providers did not have a formal employment relationship or career plan made this the main cause of job insecurity15.
Despite their poor working conditions and countless reported problems, some participants described some positive aspects of their job11, with direct correlation between job satisfaction and positive interpersonal relationships4. Also care delivery and motivation resulting from professional recognition and free flow of information and communication influence job satisfaction11. Our results corroborate these observations, and evidence the relevance of reinforcing these aspects to improve the satisfaction, and consequently also the quality of life of this population of workers.
An interesting finding concerns the relationship between job satisfaction and identification with the organization's external image or achievements. The fact that secondary care providers were more satisfied with their own image might be accounted for by the high level of specialization required by their job. When care is provided as a technical activity involving high technology and a considerable level of specialization, it becomes substantially meaningful to the professionals, with consequent impact on job satisfaction1. As a result, professional skills are increasingly valued, with consequent increase of job satisfaction and of the feeling of being better prepared for the job.
The prevalence of burnout for the overall sample was 1.05%, therefore much lower than the global average (10% to 21% among dentists)16 and that reported in studies performed in Brazil (Ceará, 32%8; São Paulo, 17%17 and 48%2) and other countries (United Kingdom, 8%18; Northern Ireland, 16%6; Netherlands 11% to 16%9). We were able to locate one single study with a similar low prevalence (2.5%), performed in the Netherlands19, in which also the PA component was the most affected (30.8%).
In several similar studies, participants reported poorer PA (Hong Kong, 39.0%20; South Korea, 31.5%21; United Kingdom, 31.9%18). These findings suggest that just as in the present study, job satisfaction was also low among those samples of dentists. Therefore, the low prevalence of burnout notwithstanding, one should take the nature and potentialities of job dissatisfaction, as well as its influence on the occurrence of burnout into consideration. On these grounds, our findings are consistent with the results of other studies which evidenced negative correlation between burnout and job satisfaction, and described several causes of stress among dentists, including the work environment22, time pressure and financial concerns20. The subscale scores obtained in the present study point to a considerable propension to burnout among the analyzed population, even though in small degree. In addition, early signs of emotional exhaustion and feelings of low personal accomplishment should be considered as an initial warning in regard to the risk of burnout23.
Although EE was the least affected component of burnout, Maslach observes it is the most frequently reported symptom, and is likely to cause burnout when preventive measures are not implemented24. A study performed in Finland found that EE might transmit between members of the dental staff (D and T) when interpersonal relationships are positive and frequent, but only when the partner who is higher in the hierarchy (D) exhibits a high level of EE7. This finding stresses the relevance of separate subscale analysis to identify causal factors and their influence on job satisfaction, and consequently also the implementation of efficacious measures.
In regard to sociodemographic factors, one study performed with dentists in Yemen25 found that the degree of dissatisfaction with psychosocial aspects of work had direct correlation with age under 30 (71.4%) and less than 5 years of professional experience (73.1%). In regard to the frequency of burnout as a function of sex, there are discrepancies in the literature, with reports of higher prevalence among men2,6,26 or women8,27, as also in the present study. In any case, it is believed that the burnout components might vary according to sex8.
One further explanation for the low frequency of burnout we found is related to the number of participants with adequate professional qualifications. Professionals who attended graduate studies might acquire more accurate knowledge, better techniques and communication skills, and thus are better equipped to deal with patients, which might contribute to reduce the effects of burnout20. Contrariwise, lack of career perspectives among the less qualified dentists might play a crucial role in the development of burnout28. One study performed in India found that PA was significantly higher among the dentists with better qualifications23.
Significant association between the scores on all three burnout subscales was found for a small proportion of the sample (1.05%). Association between two components was found for 6.3% of the participants, while 54.6% exhibited abnormal scores on one subscale at least. As per Te Brake et al.'s29 categorization criteria, 69.9% of the participants can be considered as at high risk for burnout, and thus with "considerable reason for concern." Therefore, even when the risk of burnout manifests as abnormal scores on one or two subscales only, it should receive the due attention through preventive measures to reduce negative impacts on the affected workers29.
Despite their relevance, burnout, its diagnosis, treatment and consequences for the lives of oral healthcare providers are still scarcely investigated. Exhaustion resulting from occupational stress might cause several mental disorders, including difficulties in relationships, attention and to cope with tension, sleep disorders, lack of relax and energy2, and anxiety attacks, which frequency might be three times higher compared to other healthcare workers30. Also physical disorders are possible, such as weight gain or loss, immune system weakness, potentiation of digestive and cardiovascular problems, headache, arthritis, hormonal dysfunction, and musculoskeletal and nervous fatigue25,30.
Substantial suicide rates among dentists16,30, neglect of measures against the main causes of stress24 and job exhaustion16 among this professional group are liable to increase the risk of job dissatisfaction, and thus contribute to the occurrence of burnout. This type of findings evidence the relevance of the quality of life and occupational health of workers in the public sector to minimize the effects of burnout2.
Among the main limitations of the present study, its cross-sectional design does not allow for direct identification of causal factors of job satisfaction or burnout. Nevertheless, information on job satisfaction and the prevalence of burnout, with the corresponding association with sociodemographic factors, affords a better understanding of these conditions, and facilitate more thorough studies with more complex designs. Another limitation derives from the rate of participation: in some cases data collection was performed in the workplace, and some eligible subjects adduced they were not available. Other subjects, mainly T/A, refused participation for fear that reporting discontentment could lead to retaliation from the management. A third group manifested lack of interest to participate in the study.
An additional reason for the low prevalence of burnout we found might be the way we approached it in analysis, to eventually become a confounding factor. However, the subscale scores indicate a considerable propension to this syndrome among the participants. Even when they exhibit several aspects in common, the relationship between job satisfaction and burnout still has to be better explained.
The source to understand someone else's distress are their narratives, which authenticity might be marred by distortions originated in personal interests and defensive strategies1 resulting in bias, and in some cases also in masking burnout, which might have reflected on the results of the present study. However, both veiled forms of distress and defensive strategies are relevant for reflected on the results of the present study. However, both veiled forms of distress and defensive strategies are relevant for the purposes of the present study, and are a source of learning and reflection for future studies on this subject.
The results of the present study indicate dissatisfaction with several job-related aspects among oral healthcare providers, particularly those associated with poor working conditions and professional recognition (salary, opportunities to fulfill ambitions and aspirations, security and organizational structure). Yet, the participants manifested high levels of satisfaction in regard to other aspects, namely, those related to interpersonal relationships (personal contacts, work content, communication and flow of information, image and motivation). More thorough reflection on the working conditions of oral healthcare providers is needed to improve the approach to causative factors and reduce their levels of job dissatisfaction through organizational and individual preventive strategies to thus minimize the effects of burnout on this population of workers, and consequently improve the quality of care delivery.
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8 de Dezembro de 2018.
Aceito em 13 de Julho de 2019.
Fonte de financiamento: nenhuma