Burnout Syndrome : population-based study on public servants

OBJECTIVE: To identify predictors of Burnout syndrome among workers in the public sector. METHODS: Cross-sectional study with a representative sample consisting of 879 municipal civil servants in a city of the metropolitan region of Porto Alegre, Southern Brazil. In order to measure the demographic variables and related characteristics of work we used a questionnaire developed for this purpose. The perception of the work environment was measured by the Work Atmosphere Scale. The Maslach Burnout Inventory was used to assess burnout syndrome. Three multiple stepwise linear regression tests were performed, in which each dimension of the syndrome was considered outcome while the other variables were estimated as predictors, adjusted for gender and age. RESULTS: The variables related to perceptions of work environment were the ones which most contributed to the occurrence of burnout. Perceiving work as stressful and the presence of people who negatively affect the work environment contributed to the explanatory model of the three dimensions. There were nine variables which comprised a predictive model which explained 43% of Emotional Exhaustion. The variable ‘perceives how stressful the job appeared to be' had the highest explanatory power. In Despersonalization, eight variables comprised 25% of the model and, once again, ‘perceives how stressful the job appeared to be' was the variable with the highest explanatory power. ‘Low Professional Fulfi llment' revealed a set of variables with an explanatory power of 20%; a working environment considered to be good showed a higher weighting, showing it to be inversely associated. CONCLUSIONS: Public servants' perceptions of their work environment play an important role as a predictor of burnout. Viewing work as stressful and the presence of people who negatively affect the environment proved to be the elements of greatest importance. DESCRIPTORS: Burnout, Professional, epidemiology. Public Administration. Job Satisfaction. Working Conditions. Occupational Health. Original Articles Burnout Syndrome in workers in the public sector Palazzo LS et al The importance of personnel management in the public sector is increasing as these institutions are faced with demands to improve the quality of the services provided within the context of scarce resources. Brazilian public organisations suffer from a lack of suitable management tools, centralised decision making with little opportunity for local administration, paternalism and signifi cant political infl uence on personnel management.18 These factors, allied with precarious working conditions, may place civil servants at risk of burnout syndrome. Burnout syndrome is a psychosocial phenomenon, which arises as a response to chronic, interpersonal stressors, present at work. It has three dimensions: emotional exhaustion – lack of energy, enthusiasm and a feeling of depleted mental resources; depersonalization – the worker treats clients, colleagues and the organisation itself in an impersonal way, distancing themselves; and low professional fulfi lment – the worker tends to evaluate themselves negatively, feeling unhappy and dissatisfi ed with their professional development.11,13 Pioneering studies on the topic appeared in the 1970s and were based on the experiences of workers whose tasks entailed caring for people and meeting their needs, such workers in the teaching and health sector. These studies concentrated on the provider-recipient dyad. However, research was also carried out within organisations with hierarchies, functions, roles, resources and interpersonal relationships (colleagues, bosses, the public), and the context in which the activity was carried out should be taken into account.11 Burnout syndrome is the result of chronic stress, typical of day-to-day work, mainly when under excessive pressure and confl ict with low levels of emotional reward and recognition.11 One of the main factors in its occurrence is a lack of community spirit in the organisation, i.e. lack of quality interpersonal interactions, constant conflict, lack of support, cliques and difficulties working as a team.13 Burnout rates may differ according to individual variables,16 work context,11 the way work is organised17 and the country.24 burnout syndrome is associated with feeling exhausted, insomnia, migraines, chronic fatigue, muscular tension,11 cardiovascular problems,22 depression, anxiety and increased tranquiliser and anti-depressant use.1 It is also strongly associated with workers feeling undervalued, absenteeism, high staff turnover,15,17 negative organisational results and low levels of commitment at work.20 Even though burnout syndrome is recognised as a signifi cant problem in the health of the workforce, there INTRODUCTION a Study carried out by the Public Health Post Graduation Program of the Universidade Luterana do Brasil, from 2005 to 2008. are few populational studies on civil servants. Varhama & Bjorkqvist23 found 29% of individuals were burnt out and 50% had witnessed examples of burnout in colleagues in a Finnish municipality. In Brazil, lack of knowledge on the part of health professionals increases the diffi culty of identifying the problem.5 With the aim of contributing to increasing knowledge of this problem and providing a basis for preventative measures, this study aims to identify predictive factors of burnout syndrome in civil servants.

The importance of personnel management in the public sector is increasing as these institutions are faced with demands to improve the quality of the services provided within the context of scarce resources.Brazilian public organisations suffer from a lack of suitable management tools, centralised decision making with little opportunity for local administration, paternalism and signifi cant political infl uence on personnel management. 18These factors, allied with precarious working conditions, may place civil servants at risk of burnout syndrome.
Burnout syndrome is a psychosocial phenomenon, which arises as a response to chronic, interpersonal stressors, present at work.It has three dimensions: emotional exhaustion -lack of energy, enthusiasm and a feeling of depleted mental resources; depersonalization -the worker treats clients, colleagues and the organisation itself in an impersonal way, distancing themselves; and low professional fulfi lment -the worker tends to evaluate themselves negatively, feeling unhappy and dissatisfi ed with their professional development. 11,13oneering studies on the topic appeared in the 1970s and were based on the experiences of workers whose tasks entailed caring for people and meeting their needs, such workers in the teaching and health sector.These studies concentrated on the provider-recipient dyad.However, research was also carried out within organisations with hierarchies, functions, roles, resources and interpersonal relationships (colleagues, bosses, the public), and the context in which the activity was carried out should be taken into account. 11rnout syndrome is the result of chronic stress, typical of day-to-day work, mainly when under excessive pressure and confl ict with low levels of emotional reward and recognition. 11One of the main factors in its occurrence is a lack of community spirit in the organisation, i.e. lack of quality interpersonal interactions, constant conflict, lack of support, cliques and difficulties working as a team. 13rnout rates may differ according to individual variables, 16 work context, 11 the way work is organised 17 and the country. 24burnout syndrome is associated with feeling exhausted, insomnia, migraines, chronic fatigue, muscular tension, 11 cardiovascular problems, 22 depression, anxiety and increased tranquiliser and anti-depressant use. 1 It is also strongly associated with workers feeling undervalued, absenteeism, high staff turnover, 15,17 negative organisational results and low levels of commitment at work. 20en though burnout syndrome is recognised as a signifi cant problem in the health of the workforce, there are few populational studies on civil servants.Varhama & Bjorkqvist 23 found 29% of individuals were burnt out and 50% had witnessed examples of burnout in colleagues in a Finnish municipality.In Brazil, lack of knowledge on the part of health professionals increases the diffi culty of identifying the problem. 5th the aim of contributing to increasing knowledge of this problem and providing a basis for preventative measures, this study aims to identify predictive factors of burnout syndrome in civil servants.

METHODS
The data analysed are part of a wider investigation entitled "Mobbing, gender and culture".a A crosssectional study was used, with a representative sample of 879 municipal civil servants from a medium sized city in Porto Alegre area between 2006 and 2007.The target population was made up of 4,304 civil servants, working in the municipality in January 2005.In order to calculate the sample size we used parameters of 50% estimated prevalence, error 3 and 95% confi dence level, making 833 subjects.We added 10% to this to make up for potential losses, making a total of 925 participants.The subjects were selected via their civil servant registration numbers, which were drawn from the Excel® programme from information provided by the Municipal Administration Secretary.
In order to collect the data, we used a self-reporting tool made up of four sections: 1) demographic variables: sex, age (in years) and marital status (with or without a partner); 2) work characteristics: length of time working in the institution (years); position in the organisational hierarchy (worker; supervisor; coordinator; director); hours worked weekly; own office or sharing with colleagues; dealing with the public (yes, no); supervisor, coordinator or boss present in the workplace (yes, no); interpersonal confl icts (yes, no) and physical risk (no, low, high); 3) perception of work: perceiving the work to be stressful, rating the atmosphere at work as good; feeling valued; rudeness; rating the work environment as democratic (participative); unfriendly colleagues; colleagues requiring you to do tasks that are not your responsibility; presence of individuals who negatively affect the working environment; cliques in the workplace; gossip; colleagues complaining for no reason; chances to infl uence decision making; working with uncooperative individuals and 4) Maslach Burnout Inventory (MBI).
The section on perception of the workplace was drawn up based on the Work Atmosphere Scale of 13 questions to be responded to on a Likert type scale, varying from 0 to 4 (0 = never, 1 = rarely, 2 = sometimes, 3 = often and 4 = very often).This scale was translated into Portuguese and adapted for this study and had moderate internal consistency ( = 0.67).
The MBI, translated and adapted for use in multifunctional samples, 4 was used to evaluate burnout syndrome.It is made up of 22 items referring to the three dimensions of burnout: emotional exhaustion ( = 0.90), depersonalization ( = 0.66) and low professional fulfi lment ( = 0.78).A system using 1 to 5 points was used (1 = never; 2 = rarely 3 = sometimes; 4 = often and 5 = always).
We conducted a pilot study with 49 subjects in order to analyse the suitability of the questionnaire and the logistic of data collection.Each civil servant chosen by draw to take part was located and invited.The data were collected by a team of post-graduate and graduate students in the area of health from the Universidade Luterana do Brasil.They had been trained in order to ensure standardised procedures of data collection.Training took place over four weeks, with the help of an instruction manual.The team met weekly during the data collection period to hand in and check the completed questionnaires and to discuss any diffi culties.
The data was inputted into the database and analysed using the SPSS, version 17.0 statistical package.
Stepwise multiple linear regression analysis was carried out for each outcome, controlled for sex and age.The other variables were considered predictors.We used the variables of age and length of time working at the institution in continuous multivariate analysis.P < 0.05 was considered to be statistically signifi cant.
This study was approved, after obtaining the consent of the Municipal Secretariat of Administration, by the Ethical Committee of the Universidade Luterana do Brasil (protocol nº 2005-056H).Participants signed consent forms.In order to guarantee the anonymity of the participants, the completed questionnaires were sealed in an envelope and deposited in an urn by the participant themselves.

RESULTS
The participants were predominantly female (69.2%), in the 40 to 49 age group (41.6%) and lived with a partner (64.0%).They had mainly been working in the institution for between one and 11 years (37.4%); the majority reported that they were civil servants (87.5%), worked a 40hr week (52.3%),shared an offi ce with colleagues (94.2%), dealt with the public (89.3%), had a supervisor, coordinator or boss located at their place of work (82.4%) and perceived low physical risk in their activities (48.4%) (Table 1).
As regards the points given to the dimensions, emotional exhaustion had the highest mean (M) (M: 2.23; SD: 0.91), followed by low professional There was a model composed of nine predictor variables in emotional exhaustion, which explained 43.0% of its occurrence: perceiving work as stressful was the variable with the greatest explanatory power.Being female, rudeness and individuals who negatively affected the working environment all participated directly in the model.Age, rating the atmosphere at work as good, democratic environment, sharing an offi ce with colleagues and the chance to infl uence decision making were inversely associated with emotional exhaustion.In other words, when the age was lower, the atmosphere perceived to be worse, having their own offi ce and the lower the chance of participating in decision making were, the greater the rate for this dimension (Table 2).
Eight factors explained 25% of the depersonalization model; perceiving the work as stressful was the variable with the greatest explanatory power.This variable and the presence of gossip, rudeness, interpersonal confl ict and individuals who negatively affect the atmosphere at work contribute directly to the occurrence of this dimension.Age, dealing with the public and perceiving the atmosphere to be democratic were inversely associated, i.e. the younger the workers were, the less contact they had with the public and the lower the perception of the workplace as democratic, the higher the rate for this dimension.
Low professional fulfi lment had a set of variables with an explanatory power of 20%.A good atmosphere and the chance of infl uencing decision making were the variables with the most weight.These variables, and sex, dealing with the public and perceiving the atmosphere to be democratic were inversely associated, i.e. rating the atmosphere as good, the chance of infl uencing decision making, being male, having contact with the public and perceiving the atmosphere to be democratic diminished the incidence of reduced personal accomplishment.On the other hand, the presence of individuals who negatively affect the atmosphere at work, and perceiving the job to be stressful favoured the manifestation of low professional fulfi lment.

DISCUSSION
The workers' perception of their work is fundamental in the appearance of burnout syndrome, mainly, as shown in this study and corroborated by other authors, 7,9,16 when the activity is viewed as stressful or involves individuals who have a negative effect on the atmosphere.This may be because Burnout syndrome is a result of the quality of the relationship between the subject and the atmosphere of their workplace, 11 which can be understood as the way they interact with others, the management style and the values of the institution. 11,18Political interference from outside, discontinuity in management and in projects and the privileges that surround institutionalised norms predominate in many public institutions, which generates pressure and stress. 18The greater the incongruence between the workers' values, expectations and objectives and their work, the greater the likelihood of burnout. 13e characteristics of the workplace context possess an importance which permeates the profession and the characteristics of the position. 13This is in accordance with the results, as variables related to the characteristics of the task do not feature as predictors, with the exception of dealing with the public and the presence of infl ict, both of which are to do with interpersonal relationships.The relationship between the individuals who make up the organisation is one of the most important factors in the occurrence of burnout syndrome, not just in relation to the clientele dealt with, but also, primarily, in relation to the quality of interactions with colleagues 13,21 and superiors. 6This study's fi ndings indicate that working with the public is related to lower scores for the syndrome.
Marital status is not part of the explicative model for the syndrome; sex is relevant in different ways to emotional exhaustion and low professional fulfi lment and age was not part of the explicative model for low professional fulfi lment in the sample we analysed.This suggests that the characteristics of the workplace atmosphere are those most strongly associated with burnout syndrome, rather than socio-demographic variables. 11,19r emotional exhaustion, feeling worn out increases along with the perception of the job being stressful, with rudeness and the presence of individuals who negatively affect the working environment and having an offi ce to themselves.However, it decreases when the atmosphere is rated as good and when the civil servant feels they can participate in the institution's decision making, which corroborates what other studies have reported. 6,10rking in an offi ce alone may indicate a lack of social support, a situation often associated with burnout. 11,13f the inability to cope with stress is persists, this can develop into the syndrome. 8Sharing diffi culties with co-workers and supervisors helps the professional and is an important protective factor. 6,10The possibility of infl uencing decision making strengthens the feeling of being valued and improves engagement and involvement at work. 14,10personalization is the dimension which best refl ects the prevailing interpersonal context in the workplace.It represents a fundamental element of burnout syndrome, as it is characterised by the worker's negativity, indifference or distance towards both colleagues and aspects of the job itself. 12In this study, the rates of depersonalization increased as the civil servant viewed the job as stressful, with the presence of gossip, rudeness, interpersonal confl icts and individuals who negatively affected the atmosphere of the workplace.When the worker viewed that atmosphere as democratic and participative, the levels for this dimension decreased. 3,23,24characteristic of the public sector in Brazil is that it is made up of two groups of civil servants: permanent (career) and non-permanent (who get in through political means).This can create protectionism, diffi culty in defi ning positions and roles and poor interaction between colleagues.According to Maslach, 12 there is a strong link between the emotional exhaustion and depersonalization dimensions, as dysfunctional interpersonal relationships are generated by high levels of tension and diffi culties young civil servants have in coping, as shown by this study.For the author, a certain amount of psychological distance may be viewed as a good individual response to stressful situations.However, if used to excess, this may have negative repercussions on the worker's interaction with colleagues and clients, contributing to the civil servant no longer being suitably involved with their work.
Low professional fulfi lment is the dimension which shows negative self-evaluation on the part of the worker, with feelings of incompetence and that the job is not fulfi lling. 11This dimension appears more complex and, in some environments, appears as a consequence of the other two, or in parallel with them. 12The more positive the perception of the workplace atmosphere and the more opportunities there are to participate in decision making, the greater the sensation of fulfi lment and the lower the rates of low professional fulfi lment.The opposite occurs when the civil servant perceives their job to be stressful, works with individuals who negatively affect the atmosphere and is unable to take part in institutional decision making.
Civil servants are more vulnerable to politically motivated interference, sometimes far from the objectives of the institution.This makes it more diffi cult for the civil servant to manage the resources necessary for carrying out their work, in a context in which responsibility exceeds authority and autonomy. 18These are situations which act as stress factors, enabling the appearance of feelings of incompetence, especially in those individuals who feel responsible for producing results, but for whom the structure of the workplace itself does not provide them with the resources necessary to achieve them. 11The result may be the emergence of tensions arising from dissatisfaction and frustration with personal and professional projects, placing the civil servants at risk of burnout syndrome. 12e levels of low professional fulfi lment found in this study were lower among those who dealt with the public.It is possible that some workers, in order to cope with the negative feelings, prioritise their clients, developing relationships which help them overcome defi ciencies within the workplace and the dysfunctional relationships with colleagues and superiors.Being male appeared in the predictive model related to low professional fulfi lment.Men may feel more affected by frustrations at work which women, for cultural reasons related to need for status, do not feel.
The fact that data collection took place within the institution itself was a limitation of the study.Even with the emphasis on anonymity and procedures in place to ensure it, it is possible that some of the participants gave more positive responses as they worried about suffering reprisals were their identity to be revealed or even that they gave more negative responses to attract the attention of those responsible.
Finally, there is a situation unique to transversal study, those who were not at work, usually as they were on sick leave, did not participate, leading to "healthy worker effect". 14This may mean that the contribution of each variable to the model was underestimated.The results obtained corroborate data from other studies and reinforce the idea that identifying predictors is fundamental to achieving organisational change, aimed at improving both the workers' health and the quality of service they provide to society.
Brazilian literature on burnout syndrome in public servants is incipient, which makes comparing national studies diffi cult.Carlotto & Câmara 5 stated the need to broaden national research on the topic, as it is a fi eld which has been little explored and has important social repercussions.
In many public institutions, bureaucracy, politically motivated interference, centralised decision making, paternalism, the disruption of long-term projects with confl icts of objectives and sometimes unprofessional management are prevalent. 18This organisational atmosphere may place any civil servants at risk of developing health problems, such as burnout syndrome.According to Maslach 12 , interventions focussing on the individual are not effective, it is necessary to put in place preventative strategies which act directly on the organisation and the workplace atmosphere.

INTRODUCTIONa
Study carried out by the Public Health Post Graduation Program of the Universidade Luterana do Brasil, from 2005 to 2008.

Table 1 .
Demographic and work characteristics for municipal civil servants.Rio Grande do Sul, Southern Brazil, 2006 to 2007 (n = 879).

Table 2 .
Multiple linear regression for the three dimensions of Burnout syndrome, work variables and workplace atmosphere factors for civil servants, controlled by sex and age.Rio Grande do Sul, Southern Brazil, 2006 to 2007.