To the best of our knowledge, this is the first study to demonstrate that the severity of psychological symptoms, measured by the BSRS-5, can be significantly associated with burnout among different sex and age, and that this effect persists after controlling for common potential confounders , including age, sex, smoking, alcohol consumption, exercise, and chronic diseases (HTN, DM, and hyperlipidemia). We also performed the stratified analysis to identify the association of high workload and poor health status ratings with burnout among middle-aged men and women.
The result showed that the prevalence of burnout among the entire sample population, men, and women was 8.2%, 11.8% and 7.8%, respectively (p= 0.04). Compared with other studies1,2,4,5, the possible reasons for the lower incidence of burnout found in this study included different departments including in this study, not only physicians and nurses. Second, the participants in this study were generally younger than those in other studies (median 38.4 years)19,20,21. Finally, 86.8% of the participants in this study possessed a higher level of education (higher than university) as compared to participants in other studies19,20,21. A previous study described a high risk of burnout mostly among women with low education levels22.
Burnout, SRH and psychologic symptoms are not consistent with age and gender in HCWs in different departments12,13,23,24. Previous study had clarified that age and sex are a potential modulator of health risks caused by psychosocial work conditions25. Surveys of physicians from different specialties found that burnout was self-reported had found that women were more likely to exhibit burnout symptoms than were men26,27,28. Age was an independent variable associated with burnout, with younger physicians at a higher risk of burnout than older physicians29. In previous studies mentioned that it was also worth noting that age may influence burnout more than gender did27.
Most of previous studies are based on different indicators to discuss age or sex stratification13,21,24,29. Few studies have combined psychological symptoms, health status ratings, age, and sex into groups to explore the correlation with burnout. This study shows that whether men and women are over 30 with a high BSRS-5 score or poor health status ratings is higher than that of people under 30 years old. This echoes with previous studies of individual indicators, these previous results show that poor SRH increases with age, and the level of burnout among employees aged 30–40 is higher than that of other age groups11,13.
In terms of sex, previous studies proposed that burnout symptoms vary according to the different life stages of working men and women28,30. Their research found that two groups including aged 20–35 years and aged 55 years and above were particularly susceptible to burnout, and that different psychosocial conditions needed to be considered. Therefore, in our study, we include different psychosocial factors (such as BSRS-5 and health status ratings) that caused different levels of burnout among men and women of different age groups.
Studies have mentioned that physical and mental diseases affect psychological symptoms and burnout15,31. We excluded participants with uncontrolled chronic diseases and mental and sleep disorders. However, we found that some under-treatment chronic diseases (HTN, DM, hyperlipidemia) did not cause burnout [HTN: 1.64 (0.88–3.07); DM: 1.37 (0.65–2.90), and hyperlipidemia: 0.86 (0.34–2.16)].
Recent research has stated that poor sleep quality is common, and associated with increased burnout, among clinicians delivering care to COVID-19 patients32. In this model, self-reported poor sleep quality was significantly associated with burnout (OR = 4.13, 95% CI 2.33–7.32, p< 0.05), whereas short sleep duration (< 6 h) was not (OR = 0.73, 95% CI 0.41–1.30, p= 0.28). Interestingly, we found that sleep quality was more strongly related to burnout than sleep duration, even during the non-pandemic period (longer sleep time). [OR = 1.11, 95% CI 0.97–1.28, p = 0.14] and poor self-assessed sleep quality [OR = 1.78, 95% CI 1.08–2.23, p = 0.004]).
As age increases, physical and mental health susceptibility increases. Stressful work conditions, such as long hours of work and heavy workload, may induce greater physiological responses in older workers13. Our study shows that middle-aged/elderly HCWs with longer working hours and night shifts exhibit greater physical and psychological reactions than younger staff, especially among women. Among the work characteristics, longer working hours (more than 46 h/week) for women and night shift jobs for both men and women aged 30 years or above were found to be the most common predictors of high burnout. These findings support the results of a previous study conducted in Taiwan and other countries13,33,34,35.
Pappas et al. found that nurses in Greece with poor SRH were significantly more likely to be female, between the ages of 30–39 years, have long working hours, and rotating shifts36. The impact of poor self-assessed sleep quality on men and women younger than 30 years was more significant than on those older than 30 years. The OR for men was higher than that for women (men, OR: < 30 years of age vs. ≥ 30 years of age = 4.20: 3.30; women, OR: < 30 years of age vs. ≥ 30 years of age = 2.20 :1.77; all, p< 0.05). Our research has the same findings for HCWs as the study by Pappas et al. The results of our research and previous studies on hospital workplaces37 are inconsistent with previous results in the general population37,38. This may be due to the influence of the work characteristics.
Although burnout, anxiety, and depression have many overlapping issues, Fischer et al. focused on 715 critical care clinicians in Brazil and, using appropriate statistical methods, they found that burnout was statistically distinct from anxiety and depression15th. These findings suggest that health professionals at high risk of stress need to be screened for both burnout and clinical psychological symptoms to provide timely and efficient treatment. Even the BSRS-5 is not a generic questionnaire and is not commonly used in burnout studies. The reasons why we chose it for the measurement tool first: it contains only five items and can be administered to subjects to complete independently and quickly. This questionnaire is already recommended to the general public to detect psychological symptoms and suicide prevention in Taiwan39,40,41. Second: good reliability of MBI-HSS and BSRS-5 was checked among all participants in our study (Table 1). This study provides additional evidence that may be suitable for the evaluation of psychological symptoms in HCWs with burnout syndrome.
The strengths of our study are as follows: first, we use simple BSRS-5 score and health status ratings problems to reveal the association and evaluate the burnout problem among HCWs. We also performed age and sex stratification to facilitate burnout prevention in high-risk HCWs of a particular age and sex. Second, we excluded participants with untreated chronic diseases and mental and sleep disorders to prevent any interference with the results for burnout.
Alternatively, this study had some limitations. First, nearly 90% of the participants were women (men = 296, 10.5%; women = 2517, 89.5%). Although the chi-square test showed significant differences between the proportions of men and women for the burnout categories and levels of the BSRS-5 scores, there were some restrictions in the case of men when stratifying analysis by age and sex because of the small sample size (men: < 30 years of age, n = 69; ≥ 30 years of age, n = 227). Due to the absence of measurement of social desirability, in the future, data should be collected from multiple hospitals and regions, and studies should include more male participants. Second, this study was cross-sectional, and it was insufficient to confirm the causes and effects of psychological symptoms and burnout. Third, this study did not discuss family-related factors, including the pressure and time spending of taking care of children, organizing housework, etc., which have made the gender-related differences between work and non-work stressors. Fourth, we evaluated health status ratings by asking two questions including two items (physical health condition and sleep quality) because of the limitation related to the total number of items in the questionnaire; we did not use the more common “Perceived Wellness Survey,” which comprises 36 items42. Finally, this study was a voluntary response sample, and there was a problem of self-selection bias.
The BSRS-5 score is associated with the scores of at least two domains of the Chinese version of MBI-HSS for HCWs, whereas mild physical illness (such as HTN, DM, and hyperlipidemia) may not influence the results in the case of some participants. Researchers and health practitioners should pay attention to the influence of age and sex when using the measures of the BSRS-5, health status ratings, and burnout as indicators to detect health risks associated with adverse psychosocial work conditions.