Burnout among advanced life support paramedics in Johannesburg, South Africa
- Correspondence to Christopher Stein, Department of Emergency Medical Care, Faculty of Health Sciences, University of Johannesburg, Doornfontein, Johannesburg 2028, South Africa;
Contributors WS conceived the study, collected and analysed data and approved the final manuscript. BVN analysed data and approved the final manuscript. CS analysed data, drafted and approved the final manuscript.
- Accepted 9 March 2012
- Published Online First 13 April 2012
Objectives To establish the prevalence of burnout among advanced life support (ALS) paramedics in Johannesburg, South Africa and assess the relationship between burnout and a number of demographic characteristics of the sampled ALS paramedics.
Design Cross-sectional internet-based survey.
Method Survey invitations were sent via email to 98 registered ALS paramedics in the Johannesburg area. The survey questionnaire was created by combining the Copenhagen Burnout Inventory (CBI) with numerous distractor questions. Burnout was defined as a CBI score >50. Descriptive analysis was performed and results subjected to Chi-square testing in order to establish dependencies between burnout scores and demographic factors.
Results A 46% (n=45) response rate was obtained. Forty responses were eligible for analysis. 30% of these respondents had total burnout according to their CBI score, while 63% exhibited some degree of burnout in one of the CBI subcategories. The results of the subcategory analyses showed that 23% of respondents experienced burnout in the patient care-related category, 38% experienced burnout in the work-related category and 53% experienced burnout in the personal burnout category. There were no statistical differences in the burnout scores according to gender (p=0.292), position held (p=0.193), employment sector (p=0.414), years of experience (p=0.228) or qualification (p=0.846). Distractor questions showed that paramedics feel overworked, undervalued, poorly remunerated and unsupported by their superiors.
Conclusion This sample of Johannesburg-based paramedics had a greater prevalence of burnout compared with their international counterparts. Further research is needed to identify the true extent of this problem.
- Emergency medical services
- emergency ambulance systems
- prehospital care
- clinical management
Perlman and Hartman in 1982 coined one of the current accepted definitions for burnout, namely “a negative response to continued emotional stress that is characterised by emotional and/or physical exhaustion, lowered productivity and depersonalisation.”1 Emergency care is well known as a stressful clinical environment to work in. This is even more so in the prehospital environment, characterised by difficult and inhospitable work conditions, potentially dangerous and uncontrolled environments, and a limited clinical armamentarium.
Only a few studies have been conducted internationally on the prevalence of burnout among paramedics. These have generally demonstrated a high prevalence of burnout, with work environment factors contributing more significantly to burnout than patient care-related factors.2–5
This study aimed to determine the prevalence of burnout among ALS paramedics in Johannesburg and to assess the relationship between burnout and five demographic and job-related characteristics: (1) gender, (2) employment position, (3) qualification, (4) employment sector and (5) years of experience.
In South Africa, one of the three educational pathways can be followed to become an ALS paramedic. The first is to complete a 1200 h certification course as a Critical Care Assistant (CCA) after being certified as a Basic Life Support paramedic (160 h of training) and Intermediate Life Support paramedic (470 h of training) and gaining experience in these respective ranks. The second method is to complete a 3-year full-time National Diploma in Emergency Medical Care (NDip) and the final method is to complete a 4-year full-time professional degree in Emergency Medical Care (BDegree). This study included ALS paramedics holding all of the above qualifications.
A cross-sectional, internet-based survey was used. This survey contained an exact replica of the Copenhagen Burnout Inventory (CBI) which was administered along with 13 distractor questions. The resultant survey questionnaire was called the Stressor Assessment Questionnaire in order to intentionally not use the term ‘burnout’. The distractor questions were based on factors identified in an extensive literature review to be contributory to the development of burnout. The CBI consists of 19 questions divided into three burnout categories namely personal (a state of prolonged physical and psychological exhaustion), work-related (a state of prolonged physical and psychological exhaustion, which is perceived as related to the person's work) and patient-related (a state of prolonged physical and psychological exhaustion, which is perceived as related to the person's work with patients).6
Responses were represented in a Likert-type format and, depending on the option a respondent selected for each question, a numerical value between 0 and 100 was assigned. After all the questions had been answered, an average burnout score was calculated for each section in accordance with the CBI scoring system. A total burnout score was calculated from all three sections, based upon which a score >50 denotes total burnout as recommended by the authors of the CBI.6 The validity, reliability and internal consistency of the CBI has been previously demonstrated.6 ,7
Ninety-eight ALS paramedics in Johannesburg were identified from the Health Professions Council of South Africa paramedic register and invited via email to take part in the online survey. The invitation contained a link and password to access the survey. Before access was granted, the respondent was required to consent by ticking a check box on the opening page of the survey and respondents could withdraw at any time before final upload of responses to the survey database. Identifying data were not recorded as part of the survey result set.
Only ALS paramedics who were sent the invitation link were allowed access to the survey and after each respondent completed the survey, the survey website blocked any further attempts at completion. The first survey invitation was sent on 7 June 2010. Two reminders were sent on 21 June 2010 and 5 July 2010. The survey was closed on 12 July 2010.
Data were analysed descriptively. χ2 tests were used to assess the dependence between burnout as a binary ‘yes/no’ variable based on the CBI threshold score of 50, and participant's gender, employment position, qualification, employment sector and years of experience. SPSS (V.15.0, SPSS Science) was used for data analysis and p<0.05 was considered significant.
Ethical approval for this study was granted by the Faculty of Health Sciences Academic Ethics Committee at the University of Johannesburg.
Forty-five surveys were returned yielding a response rate of 46%, although only forty of these (41%) were complete and eligible for analysis. Thirty per cent of all respondents (12) had a total CBI score of ≥50, while 63% (25) scored ≥50 in one or more of the three burnout categories. Table 1 shows descriptive data for scores from each of the CBI burnout categories, and the total CBI burnout score.
Frequency analysis of burnout categories showed that 23% (9) of respondents experienced burnout in the patient care-related category, 38% (15) experienced burnout in the work-related category and 53% (21) experienced burnout in the personal burnout category.
Table 2 shows descriptive data and the distribution of mean CBI scores over chosen demographic factors. p values are for χ2 tests assessing dependence between a binary burnout variable (‘yes/no’, depending on CBI score) and the relevant row factor.
Analysis of the 13-distractor questions included in the questionnaire indicated that 25% of all the respondents felt that their role in patient treatment is undervalued and that they do not receive credit for their expertise. Furthermore, 84% felt that their salaries were inadequate and 35% felt that they were treated badly by emergency centre staff. More than 50% of the respondents felt overworked and 55% indicated that they did not receive adequate support from their superiors.
The 30% prevalence of total burnout among Johannesburg-based ALS paramedics in this study is greater than that identified in other studies (16%).2–5 This is slightly higher than burnout prevalence reported among South African police officers, where burnout was reported to be high in 22% of respondents in the emotional exhaustion category of the Maslach Burnout Inventory.8 By contrast, the current study showed a lower prevalence of burnout than that identified in a survey of personnel working in a hospital trauma unit in Johannesburg, where between 50% and 61% experienced high degrees of burnout in the three categories of the Maslach Burnout Inventory.9 Burnout in other non-emergency healthcare fields tends to be much lower, for example, among occupational therapists (11%), occupational physicians (10%), general medical practitioners (8%) and nurses (8%).10
The highest mean burnout scores were found in the personal burnout category, defined by the CBI as a state of prolonged physical and psychological exhaustion. Similarly, of all ALS paramedics with CBI scores >50 (burnout as per CBI definition), the largest proportion were in the personal burnout category. In keeping with other studies on burnout among paramedics, the current study identified the patient care-related burnout category as having the lowest mean burnout score of the three categories.2–5
That burnout related to patient care in the prehospital emergency care environment is not the greatest overall contributor to burnout seems counter-intuitive. However, several authors have suggested that this may be because individuals with personality types who would naturally choose this field of work are inherently drawn to these stressors, and therefore are able to develop coping strategies specific to them early on in their careers. The role of patient care in adding to their burnout scores may therefore prove to be of little or no significance.2 ,3 ,5
Reasons for the relatively higher work-related burnout scores may be related to responses given to the distractor questions administered along with the CBI. Some respondents felt that their work was undervalued, while many indicated that they were comparatively poorly remunerated for the long hours they worked and did not enjoy much support in the work environment from their superiors. All of these factors have been found to contribute to the development of burnout.1–5 ,10
Although the above discussion may shed some light on the results of this study by drawing upon international literature on burnout, it does not explain why the prevalence of burnout is higher in this sample of South African paramedics, compared with that identified among paramedics in other countries. Characteristics of the typical case load seen by South African paramedics and of the nature of Emergency Medical Services (EMS) in South Africa may explain this observation.
South Africa has a high prevalence of injury, particularly injury due to inter-personal violence. The country's overall violent death rate is close to five times the worldwide average and injury overall is the second leading cause of death.11 This, coupled with a large burden of infectious disease12 including a high percentage of young adults with HIV, means that EMS throughout the country tend to be under-resourced for the large populations and high call volumes serviced, especially in densely populated urban areas such as Johannesburg.13
Prolonged exposure to the environment described above may be a source of heightened emotional stress among paramedics, a situation which might aggravate the already stressful environment of prehospital emergency care. This could be expected to influence the patient-care related dimension of burnout, and the personal and work-related components.
The literature has identified female paramedics,4 and those with higher levels of education14 as being more prone to burnout. Although trends towards higher burnout scores in these groupings were observed in the current study (table 2), no significant relationship was found between the prevalence of burnout and these or any other demographic factors studied.
In a more general sense, Schaufeli has suggested some possible reasons as to why paramedics might be more prone to burnout than others in the ‘caring professions’. First, he cites a study suggesting that working within the community, and not in a hospital or office, might lead to greater levels of burnout. Added to this is the observation that in order to prevent burnout, a reciprocal relationship needs to be cultivated between the healthcare worker and the patient—the worker needs to see the patient improve and experience the patient's gratitude. Considering that paramedics are involved in very short-term acute care and then transfer care of the patient to emergency department staff, the weakness of this link becomes obvious. When added to the work-related factors described above, it is perhaps not surprising that paramedics might display such high levels of burnout.10
Although this study was limited by a relatively small sample, it suggests that ALS paramedics may indeed be predisposed to burnout and highlights the need for further research in this area. Only an awareness of the true extent of this problem will allow for appropriate corrective and supportive measures to be taken to try and prevent it. This may be done through campaigns emphasising early awareness of burnout and its symptoms. These should be initiated in South African EMS, and the provision of easy access to counselling and support services for burnout intervention programmes. Of particular importance is the need for both person- and organisation-directed intervention for best possible effect, and refresher courses for longest-term benefit.15
If left unchecked, burnout among ALS paramedics may have serious implications for the quality of emergency care delivered by them, and for their retention in the prehospital environment.
Competing interests None.
Ethics approval The ethics approval was provided by University of Johannesburg, Faculty of Health Sciences Academic Ethics Committee.
Provenance and peer review Not commissioned; externally peer reviewed.