Nigerian Journal of Clinical Practice

ORIGINAL ARTICLE
Year
: 2019  |  Volume : 22  |  Issue : 2  |  Page : 167--173

The impact of family physicians' thoughts on self-efficacy of family physician's core competencies on burnout syndrome in İzmir: A nested case–control study


O Aygun1, V Mevsim2,  
1 Göre Family Medicine Center, Nevsehir, Turkey
2 Department of Family Medicine, Dokuz Eylül University, İzmir, Turkey

Correspondence Address:
Dr. O Aygun
Göre Family Medicine Center, Nevsehir
Turkey

Abstract

Background: Burnout is a psychosocial syndrome, involving feelings of emotional exhaustion, depersonalization, and diminished personal accomplishment at work. Its occurrence is high in healthcare personnel. Job satisfaction is achieved through the feeling of being professionally competent and is an important condition that prevents burnout syndrome. Aim: This study aimed to determine the impact of family physicians' thoughts on self-efficacy of family physician's core competencies on burnout syndrome in İzmir. Subjects and Methods: The study was a nested case–control study and was carried out within the İzmir province from 2013 to 2014. The subject population included 2185 family physicians working in the family medicine centers in the metropolitan districts of İzmir. A total of 395 family physicians who were employed at family medicine centers agreed to participate in the study. After the assessment according to the Maslach Burnout Inventory, 185 physicians had burnout, whereas 210 physicians did not have burnout. Physicians who had burnout were considered as 50% prevalence in the control group; the sampling size was calculated as at least 138 individuals for unpaired cases and control groups, with 0.05 error margin and 80% power. Results: While burnout syndrome was detected in 80.0% of physicians who thought that they were incompetent, it was detected in 30.1% of physicians who believed that they were sufficiently competent in terms of core competencies. Conclusion: Insufficient belief in core competencies by family physicians increases the occurrence of burnout syndrome in these individuals.



How to cite this article:
Aygun O, Mevsim V. The impact of family physicians' thoughts on self-efficacy of family physician's core competencies on burnout syndrome in İzmir: A nested case–control study.Niger J Clin Pract 2019;22:167-173


How to cite this URL:
Aygun O, Mevsim V. The impact of family physicians' thoughts on self-efficacy of family physician's core competencies on burnout syndrome in İzmir: A nested case–control study. Niger J Clin Pract [serial online] 2019 [cited 2019 Apr 21 ];22:167-173
Available from: http://www.njcponline.com/text.asp?2019/22/2/167/251799


Full Text



 Introduction



The term “burnout syndrome” was first introduced by Freudenberger in 1974 to describe exhaustion, frustration, and walkouts seen among volunteer health workers.[1] It was later described by Maslach and Jackson (1981) as the individuals' (in line of their job) depersonalization (DP) against the people they meet, feeling of exhaustion, and reduction in individual success and competency.[1],[2],[3],[4]

Burnout syndrome is now known to be a major health problem, especially among healthcare professionals. It is reported that in the healthcare sector, the prevalence of burnout syndrome at work varies between 25% and 60%.[5],[6]

Education is an important factor to prevent burnout syndrome. A majority of the studies have shown that the incidence of burnout syndrome decreases as the education level increases.[7],[8],[9],[10] Because education increases vocational competence, which in turn increases one's self-efficacy, the occurrence of burnout syndrome decreases. It is a job satisfaction that people think they are competent at the job they do. Job satisfaction is one of the most important conditions that prevent burnout.[11]

The healthcare system was restructured in Turkey in 2007. In this healthcare transformation program, the “family medicine system” was started to be applied in health services in primary healthcare. In the family medicine centers, medical doctors with bachelor's degrees and specialist family physicians who have completed family medicine specialty training after they have graduated from medical faculty were employed.[12]

The World Organization of National Colleges, Academies and Academic Associations of General Practitioners/Family Physicians (WONCA) has defined the core competencies that a family physician for each country should have, independent of the different health systems across countries.[10]

The 11 central characteristics define the discipline related to 11 abilities that every family doctor should master. They can be clustered into six core competencies which are primary care management, person-centered care, specific problem-solving skills, comprehensive approach, community orientation, and holistic modeling.[10]

It is a job satisfaction that people think they are competent at the job they do. Job satisfaction is one of the most important conditions that prevent burnout. The aim of this study was to determine the impact of family physicians' belief of self-efficacy regarding core competencies on burnout syndrome in İzmir.

 Subjects and Methods



The ethical approval of this study, which was performed as a specialist thesis study, was obtained from the Noninvasive Researches Ethics Committee of the Faculty of Medicine of Dokuz Eylül University on November 15, 2012 (protocol number 717-GOA; decision number 15.11.2012/37-13).

This study was a nested case–control study. It was carried out within the province of İzmir from 2013 to 2014. The target population of the study consisted of 2185 family physicians who were employed in family healthcare centers in the metropolitan districts of İzmir. A cluster sampling method was used to select the sample, and the districts in İzmir were determined as clusters. Starting from the family healthcare center numbered 1 in the first selected district in the sampling, data collection was started by administering a questionnaire to the consenting physicians.

The sample size was calculated for unmatched case–control study in OpenEpi, Version 3.[13] Control-to-case ratio was determined to be 1:1. Physicians who had burnout were considered as 50% prevalence in the control group; the sampling size was calculated to be 138 individuals for unpaired cases and control groups, with 0.05 error margins and 80% power. A total of 395 family physicians or family specialist physicians who were employed at family medicine centers and agreed to participate in the study were reached. Next, 395 questionnaires were included in the database. After assessment according to the Maslach Burnout Inventory (MBI),[1] 185 physicians were determined to have burnout, whereas the remaining 210 physicians were found not to have burnout. Subjects with a high burnout syndrome score were included in the study group, whereas those with a low burnout score were included in the control group. Then, case and control groups were matched according to sex and age groups and were grouped into two, each consisting of 113 physicians.

In the study, the data were collected by the researchers using survey forms developed in accordance with the literature and Maslack Burnout Inventory developed by Maslack C in 1981.[1] Questionnaires were filled by researchers and pollsters using face-to-face interviews with physicians.

The survey form included questions on the demographic data, personal characteristics, life activities, working conditions, and thoughts about self-efficacy on core competencies of physicians. The MBI was applied for detecting burnout.

In the questionnaire form, the questions were prepared according to the literature to obtain opinions about the working environment. These questions were arranged in a 5-point Likert scale with regard to the specificity of in-team roles, status of in-team relations, number of staff, and adequacy of technical equipment, with scores from 1 to 5 indicating “agree” to “completely disagree.” The working environment evaluation score was calculated using the sum of these four question scores (min = 5, max = 20). It was considered that subjects achieving scores of ≥16 rated the working environment as good, whereas those who achieved a score of [10] were formed in the form of a 5-point Likert scale. Physicians were asked to evaluate thoughts on self-efficacy of their own core competencies as 1 = very insufficient and 5 = very sufficient at the Likert scale. Physicians were asked about 11 abilities relevant to under six core competencies. If the score of the scale was 26 points and above, it was considered sufficient, whereas scores below 26 points were considered to be insufficient.

The MBI was used to determine the burnout status of physicians. It was developed by Maslach,[1] and the Turkish validity reliability study conducted by Ergin et al. is a scale consisting of 22 items.[14] In the evaluation of the scale, it was concluded that the extent of burnout was proportional to higher scores in emotional exhaustion (EE) and DP dimensions, which are two of the three dimensions of burnout, and lower scores in the feeling of diminished personal achievement (PA).[15],[16]

As a result of scoring according to MBI, which includes three subdimensions, namely, EE, DP, and PA, the subdimensional scores were obtained. EE and DP scores were calculated as 1 = never, 2 = rarely, 3 = sometimes, 4 = very often, and 5 = always are obtained by evaluating the 5-point Likert-type scale. PA was assessed in the opposite manner, that is, 1 indicated “always” and 5 indicated “never.”[14]

It has been reported in the literature that by evaluating highest scores that can be received from the subdimensions and by proportioning to the possible highest scores, new levels can be determined for the subdimensions.[15],[16] In Aydın et al.'s study, it was stated that burnout can be divided into three groups of low, medium, and high by considering the maximum score that can be obtained from the scale, and cut-off points can be determined by subtracting the minimum from the maximum score of the subdimensions and dividing the result by three. The cut-off points and groupings in this study were used as suggested by Aydın et al.[17] According to the EE scores they suggested in their studies, they grouped the scores of 30 and above as high, 19–29 medium, and 8–18 low. According to the DP scores, they grouped the scores as 23 and above as high, 15–22 as medium, and 6–14 low. According to PA scores, they grouped the scores of 30 and above as high, 19–29 medium, and 8–18 low.[17] As a total score of scale, they grouped the scores of 81 and above as high, 51–80 medium, and 22–50 low. Considering group scores, participants who had medium and high scores were included in the case group, whereas the ones with low scores were included in the control group.

In the evaluation of thoughts on self-efficacy of family medicine core competencies, the scores of seven questions were used. In the scoring, the minimum points were subtracted from the maximum points that can be taken from the seven questions, and this point is divided into two and the cut-point is determined.[17]

Physicians who scored ≤25 were considered as thinking insufficient on core competencies, and those who scored ≥26 were considered as thinking sufficient on core competencies. The scale used for evaluating core competency is of the 5-point Likert-type and consists of seven items. In this study, the validity reliability study of this index is not intended; it only examines its internal consistency. Cronbach's alpha (α) internal consistency coefficient of the scale was found to be 0.815 (P < 0.001).[18]

The variables affecting the burnout were evaluated in the logistic regression model according to burnout subdimensions. Models were designed by variables such as age, specialty, economic status, attendance at congresses, healthy sleep, number of consultation per day, and self-efficacy thoughts on core competencies.

The variables in the study were evaluated using Statistical Package for Social Sciences (SPSS) for Windows, version 15.0. In the statistical analysis of the data, descriptive analyses (mean, standard deviation, and percentage), Student's t-test, Chi-square analysis, correlation analysis, and logistic regression analysis were used. P < 0.05 was considered significant.

 Results



The data of 226 family physicians were evaluated in the study. The mean score of MBI of family physicians was determined as 59.4 ± 14.9. According to MBI subdimensions, the mean scores of EE, DP, and PA were, respectively 23.6 ± 9.5, 16.9 ± 5.4, and 18.8 ± 5.1. The results of the mean scores of some characteristics are shown in [Table 1].{Table 1}

The case and control groups were matched in terms of age and sex. [Table 2] shows some characteristics of the case and control groups [Table 2].{Table 2}

The proportion of those who thought sufficient on family medicine core competencies was higher in the control group than in the case group, whereas the ratio of those who thought insufficient was higher in the case group than in the control group (P = 0.001) [Table 3].{Table 3}

Some risk factors that affected causing burnout, it was found that 28.3% of subjects in the case group and 15% in the control group did not participate in training in continuous medical education. The proportion of those who did not attend congresses in the case group was found to be 65% and that in the control group was found to be 54.9%.

According to EE subscale score, EE decreased with age, total duration of the profession, and participation levels in training activities; the points of positive effects of the working environment increased, and the relationship between these was significant (P < 0.05) [Table 4].{Table 4}

EE also decreased when the subjects believed that they were sufficient in terms of family medicine core competencies, and this relationship was found to be moderate and significant (r = −0.377, P = 0.001) [Table 4].

According to DP, it decreased when the served population increased and when the physicians felt more confident in terms of family medicine core competencies. The relationship between both the parameters and DP was found to be weak and significant (r = 0.181, P = 0.004; r = −0.318, P = 0.00, respectively) [Table 4]. As DP increases, EE also increases, and the relationship between the two was significant but weak (r = −0.13, P = 0) [Table 4].

Regarding PA, as the participation in the congresses increases, PA also increases, and this increase is found to be weak and significant (r = 0.214, P = 0.001). As the participation in training activities increases, PA also increases, and this relationship was very weak and significant (r = 0.174, P = 0.004). As the score of feeling confident in terms of family medicine core competencies increases, PA increases, and this increase is found to be moderate and significant (r = 0.517, P = 0.001) [Table 4].

The causes of burnout syndrome formation were analyzed in the logistic regression model. Assessment was made with the logistic model created according to Burnout Syndrome subscales. The analysis results are shown in [Table 5].{Table 5}

EE is 2.64 times more common in those who think that they are sufficient in family medicine core competencies compared with the ones who think that they are not in the model created for EE evaluation [Table 5]. DP is 2.60 times more common in those who think that they are sufficient in family medicine core competencies compared with the ones who think that they are not in the model created for EE evaluation [Table 5]. PA is 8.78 times more common in those who think that they are not sufficient in family medicine core competencies compared with the ones who think that they are in the model created for EE evaluation [Table 2].

 Discussion



To the best of our knowledge, there are no studies on the subject that we examined in the literature; however, there are studies analyzing the relationship between competence perception and burnout among educators. Similar to the results we obtained in our study, another study conducted among music teachers in 2016 revealed that one of the reasons of professional satisfaction and burnout experienced by music teachers is the low perception of professional competence.[17],[19] According to this study, music teachers who felt incompetent, especially in the professional sense, were experiencing more burnout, whereas those with higher perception of competence were experiencing both occupational satisfaction and less occupational burnout in schools.[17],[19] Kushnir et al. showed that finding opportunities to update professional knowledge was negatively associated with burnout and positively associated with occupational satisfaction.[20] Participation in follow-up medical activities and international congresses after graduation in the case group was lesser than that in the control group (P < 0.005). Similarly, in a study conducted among urology specialists, it was determined that DP scores of the ones who received postgraduate training were lower than those who did not receive such training, and these differences were statistically significant.[20],[21]

In our study, we determined that EE was high among family medicine specialists; however, their PA was also high. In a study entitled “A research on burnout syndrome in anesthesiologists in the Eastern Mediterranean region,” the average scores of EE, DP, and PA of the research assistant physicians were higher than those of the specialist physicians.[20],[21] Similarly, in a study entitled “Factors affecting depression frequency and affecting factors in practitioners and specialist doctors in Mersin Province,” DP scores were high and PA scores were low among general practitioners compared with specialist physicians, and no difference was found in EE scores.[22],[23] There is a need to conduct a study with a greater number of specialists to determine why specialty training as a qualified training leads to DP while increasing PA.

Our study had certain limitations. The proportion of specialists in the case group including burnout physicians was significantly less; we believe that the correlation between specialty and burnout syndrome should be reinvestigated with a larger number of specialists. Furthermore, because the study was carried out in İzmir province, we think that the positive impact (high income, high education level, sunny weather, chaotic absence of city life, Mediterranean climate, and lifestyle) contributed by the city might display the burnout to be lower than the normal level. The lack of any measurement instrument related to family medicine core competencies questioned in our study was evaluated as a limiting factor.

 Conclusion



We observed that strong vocational training, knowledge, and skills are protective factors for burnout syndrome. Therefore, participation and encouragement of the physicians in in-house trainings, congresses, and professional skill courses to improve their professional knowledge are imperative.

We propose that measures should be implemented to enable physicians to be professionally confident for reducing burnout and increasing professional efficiency, along with conducting activities and participating in follow-up trainings after graduation.

Financial support and sponsorship

İzmir Dokuz Eylül University Rectorate Scientific Research Projects.

Conflicts of interest

There are no conflicts of interest.

References

1Freudenberger HJ. Staff burnout. J Soc Issue 1974;30:159-65.
2Freudenberger HJ. The staff burn-out syndrome in alternative institutions. Psychother Theory Res Pract 1975;12:73.
3Italia S, Favara Scacco C, Di Cataldo A, Russo G. Evaluation and art therapy treatment of the burnout syndrome in oncology units. Psychooncology 2008;17:676-80.
4Seta CE, Paulus PB, Baron RA. Effective Human Relations: A Guide to People at Work. Boston, MA: Allyn and Bacon; 2000.
5Maslach C, Goldberg J. Prevention of burnout: New perspectives. Appl Prevent Psychol 1998;7:63-74.
6Yao DC, Wright SM. National survey of internal medicine residency program directors regarding problem residents. JAMA 2000;284:1099-104.
7Shanafelt TD, Bradley KA, Wipf JE, Back AL. Burnout and self-reported patient care in an internal medicine residency program. Ann Int Med 2002;136:358-67.
8Collier R. Healthier doctors, healthier patients. CMAJ 2012;184:E895-6.
9Basım H, Sesen H. Effect of some demographic variables of professional burnout: A study in the public sector. Available from: http://eabegeedutr/pdf/6_2/c6-s2-m3pdf. [Last Updated on 2018 Aug 16; Last cited on 2017 Jul 21].
10Allan J. The European Definition of General Practice/Family Medicine. Barcelona: WONCA Europe; 2002.
11Gorgulu O, Akilli A. The determination of the levels of burnout syndrome, organizational commitment, and job satisfaction of the health workers. Available from: http://www.njcponline.com/temp/NigerJClinPract 20148-1018714_024947.pdf. [Last cited on 2017 May 09].
12Soysal A, Kiraç R, Ali A. The satisfaction measures Diyarbakir of family medicine public system and family medicine in Turkey. Dicle University Journal of Faculty of Economics and Administrative Sciences. 2016;6:76-89.
13Kelsey JL, Whittemore AS, Evans AS, Thompson WD. Methods in Observational Epidemiology. 2nd ed. [Table 12], [Table 13], [Table 14], [Table 15]. New York, NY: Oxford University Press; 1999.
14Ergin C, editor. Adapting burnout and Maslach burnout scale in doctors and nurses. VII Scientific Studies of National Psychology Congress; 1992.
15Çokluk Ö. Estimation of burnout in the teachers and teachers who work in the mental and hearing impaired school. Unpublished master's thesis, Ankara University Institute of Social Sciences, Ankara;1999.
16Arslan G, Aslan G. Measurement of special education teachers' burnout levels (Tokat Example). J Edu Sci Res 2014;4:49-66.
17Oǧuzberk M, Aydın A. Burnout in mental health professionals. J Clin Psychiatry 2008;11:167-79.
18Taber KS. The use of Cronbach's alpha when developing and reporting research instruments in science education. Research in Science Education. Available from: https://doi.org/10.1007/s11165-016-9602-2. [Last cited on 2018 Sep 26].
19Talşık E. The investigation of relation between perceived professional proficiency, professional satisfaction and burnout levels of ın-service music teachers. J Fac Edu 2016;1:1-14.
20Kushnir T, Cohen AH, Kitai E. Continuing medical education and primary physicians' job stress, burnout and dissatisfaction. Med Educ 2000;34:430-6.
21Maslach C, Jackson SE. The measurement of experienced burnout. J Organ Behav 1981;2:99-113.
22Rama-Maceiras P, Jokinen J, Kranke P. Stress and burnout in anaesthesia: A real world problem? Curr Opin Anesthesiol 2015;28:151-8.
23DemirA, Ulusoy M, Ulusoy M. Investigation of factors influencing burnout levels in the professional and private lives of nurses. Int J Nurs Stud 2003;40:807-27.