Assessing the utility of the Oldenburg Burnout Inventory for staff working in a Psychiatric Intensive Care Unit. A Pilot Study

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1 About the Authors Assessing the utility of the Oldenburg Burnout Inventory for staff working in a Psychiatric Intensive Care Unit. A Pilot Study Authors: Dr Ahmed Saeed Yahya, Dr Margaret Phillips, Dr Meena Naguib & Dr Jude Chukwuma Dr Ahmed Saeed Yahya is a Psychiatry year three Core Trainee at Barnet, Enfield and Haringey Mental Health NHS Trust. Dr Margaret Phillips is a Speciality Doctor at Barnet, Enfield and Haringey Mental Health NHS Trust. Dr Meena Naguib and Dr Jude Chukwuma are both Consultant General Adult Psychiatrists working in Barnet, Enfield and Haringey Mental Health NHS Trust. Introduction Working in a Psychiatric intensive unit is stressful for staff. There are higher than average levels of violence and disturbed behaviour. Alongside managing violence and aggression, staff must deal with frequent verbal abuse, and also supporting patients through the recovery process. This places huge demands on staff leading to increased levels of staff burnout and subsequent increase in sickness rates. Reports of staff sickness within the PICU setting are quite high. Records have revealed that in the year 2011, within a six month period, there were 247 reports of staff sickness in a NHS Psychiatric intensive Care unit. Totman et al have reported the lack of peer support and also leadership from the clinical team may contribute to reduced levels of morale within the staff force (Totman et al 2011). Prolonged periods of stress can lead to health consequences such as burnout. Burnout can be defined as an affective reaction to on-going stress whose core content is the gradual depletion over time of individual s intrinsic energetic resources (Demerouti et al 2002). The two core components of the burnout syndrome are exhaustion and disengagement. These are the two key elements of Oldenburg Burnout Inventory s two factor structure. Exhaustion is defined as a consequence to intensive physical, affective and cognitive strain that is a long term consequence of exposure to job demands. Disengagement is defined as distancing of an individual from their work (Demerouti et al 2010). The most commonly used Burnout Scale in studies is the Maslach Burnout inventory. It is based on a three factor model of burnout and includes scales to measure emotional exhaustion, depersonalisation and personal accomplishment (Dahlin et al 2007). Several studies have highlighted the invariance structure of the Maslach Burnout inventory across various occupational groups and across nations. All items within each subscale of the Maslach Burnout inventory are all framed in the same direction. All exhaustion and cynicism items are phrased negatively whereas all professional efficacy items are phrased in a positive manner. If this is analysed from a psychometric perspective then this one sided scale is inferior to scales which include both positively and

2 negatively worded items. This is because they can lead to artificial factor solutions in which positively and negatively worded items are likely to cluster. The factorial validity of the Oldenburg Burnout inventory has been confirmed in studies conducted across different nations (Halbesleben et al 2005). In this report we summarise the findings of a pilot evaluation of the Oldenburg Burnout Inventory (OLBI) in a cohort of staff working in a London based male Psychiatric Intensive care unit. Methods A literature search was undertaken to identify the use of the OLBI in measuring staff burnout in the psychiatric setting. Our search did not yield any articles which discussed the use of this inventory in the psychiatric intensive care setting. The OLBI was administered on a single occasion to twenty five staff members from our Psychiatric intensive care unit on the week beginning Monday 10 th July The questionnaire was completed anonymously by staff. We printed many paper copies and left them in the central ward station whereby staff were encouraged to complete the form and leave them in a separate folder which we also provided. Staff were advised not to provide any personal details so that they could not be identified. The OLBI assessed the two core features of burnout which are exhaustion and disengagement from work. The OLBI covered the affective, cognitive and physical aspects of exhaustion. The inventory used was identical to the scale discussed in the Demerouti, Mostert and Bakker journal article (Demerouti et al 2010).. The individuals who completed the OLBI scale were from various health care disciplines. These included nursing, occupational therapy and clerical staff who worked on the unit. The inventory in the OLBI contains items which are worded positively and negatively. This is so that both ends of the continuum are measured. An example of this is that exhaustion and vigour are both opposite ends of one dimension. Questions about these items were both framed in the inventory. The OLBI was based on a Likert type scale. It had a series of sixteen statements which the respondent may agree or disagree with. The scale was used to allow the individual to express how much they agreed or disagreed with a particular statement. The four responses for each statement included; strongly agree which scored one point, agree which scored 2 points, disagree which scored the individual three points and strongly disagree which scored the maximum four points. Statements 1, 3, 6, 7, 9, 11, 13 and 15 from the OLBI tested disengagement. Statements 2, 4, 5, 8, 10, 12, 14, 16 were measuring exhaustion. For particular statements the scoring was reversed with higher scores indicating greater burnout. This scoring applied for statements 2, 3, 4, 6, 8 9, 11 and 12. Bar Charts highlighting the modal and median responses per statement

3 MODAL RESPONSES PER STATEMENT Mode response

4 MEDIAN RESPONSES PER STATEMENT Median response

5 Results The response rate in this pilot study was high and all participants completed the OLBI in its entirety. The scale only took a few minutes for each participant to complete and the interpretation of the scoring process took little time. Statements which measured disengagement included statements 1, 3 (R), 6 (R), 7, 9 (R) 11 (R) 13 and 15. (R) Indicates a reversed item whereby higher scores indicate more burnout. Respondents scored highly with a mode of 2 (Agree) on the statement 11 Sometimes I feel sickened by my work tasks. On all the other disengagement items the modal scores indicated that members of staff were not showing signs of burnout in these items. Statements which measured exhaustion were items 2(R), 4(R), 5, 8 (R), 10, 12(R), 14 and 16. (R) again indicated a reversed item whereby higher scores indicted greater burnout. The modal responses for statement 2: There are days when I feel tired before I arrive at work was 2 (Agree) which meant that most respondents who completed the OLBI felt tired before they arrived at work. Respondents scored highly with a mode of 2 (agree) on statement 8: During my work I feel emotionally drained. This was what we expected from staff working on a PICU Psychiatric ward whereby staff manage patients who are very challenging with fluctuating mental states. The modal score was 4 (strongly disagree) for the statement: After working I have enough energy for my leisure items. Also the modal score was 2 (agree) for the statement: After my work I usually feel worn out and weary. Most staff on the ward would work long days whereby their shift would begin at 7:30 hours in the morning and finishing at 20:00 hours in the evening leaving them understandably little time and energy to partake in their leisure activities. Discussion In this study we aimed to evaluate the use of the OLBI in establishing the signs of burnout in staff working in a North London based Psychiatric Intensive care unit. The most frequent symptoms were tired before work, lack of energy for leisure activities, feeling emotionally drained and feeling weary/worn out after a shift. Harrison and Westwood 2009 note that one of the predictors amongst burnout in therapists is emotional over involvement (Rzeszutek et al 2014). Lent and Schwartz (2012) have noted that many therapists aim to provide care for their clients at the expense of their own well being which can result in them having a lack of energy for work (Rzeszutek et al 2014). The findings from this study have demonstrated that there are signs of emerging burnout in the staff working on our ward. There were signs of exhaustion and disengagement. There appeared more evidence of exhaustion amongst the staff with them scoring more highly on the statements that specifically measured this. The findings support the notion that working in a Psychiatric intensive care unit involve a number of challenges in particular managing the workload and the high levels of disturbed behaviour on the unit. A compensatory strategy may involve a redefinition of task requirements and an even spread of these across the workforce. Another consideration in reducing exhaustion could be introducing a change in the pattern of the length of shifts. These could be shortened and changed from the current long day format to a shorter form. A consideration from the medical team has been to introduce a

6 weekly hourly group session whereby all the staff on the ward could meet and use the group as an open space to discuss problems encountered over the week and get feedback and support from peers. We conclude from the study that the OLBI is a satisfactory tool for measuring burnout for staff who work in Psychiatric intensive care units. Administering this tool to our staff have made us as the medical team consider making changes to our service so we can reduce the fatigue within our staff population. Limitations There may have been some form of response bias when completing the inventory as staff may have felt pressured to give answers they felt were acceptable. We tried to minimise this by alleviating the pressure to complete the questionnaire. We also asked that the questionnaire was completed anonymously with no staff identifiable information provided. This was a small sample (25 participants). No definite conclusions can be drawn without further replication by highly powered studies. Recommendations We have discussed about introducing a weekly group therapy session for staff which will be led by the ward Consultant Psychiatrist Dr Meena Naguib. This session would be used as an open space whereby staff can speak freely about difficulties encountered during the previous week. From this difficulties in the working environment can be identified and there can be some discussion about changing our present service to benefit staff. We also advise that the OLBI is a screening measure that can be conducted six monthly in our unit to measure signs of exhaustion and disengagement for our workforce. Key Points The Utility of Oldenburg Burnout Inventory in Psychiatric settings Reports of greater levels of staff sickness in Psychiatric Intensive Care settings. Findings from study show emerging signs of burnout in staff population on our unit. Introduction of weekly group therapy for staff to counteract burnout.

7 Acknowledgement(s) We thank the Barnet, Enfield and Haringey Trust library for their support with Literature searching. We would also like to thank Iona Crawford ( Associate Mental Health Worker) who provided us support with the data analysis. We are also grateful for the administrative support received from the Audit and Medical Records departments at Barnet, Enfield and Haringey NHS Trust. Financial Support Statement There has been no financial support for this work. References Dahlin M, Joneborg N, Runeson B (2007). Performance- based self esteem and burnout in a cross-sectional study of medical students. Medical Teacher 29, Demerouti E, Mostert K, Bakker A (2010). Burnout and Work Engagement: A Thorough Investigation of the Independency of Both Constructs. Journal of Occupational Health Psychology 15, Demerouti E, Bakker A, Nachreiner F, Ebbinghaus M (2002). From mental strain to burnout. European Journal of Work and Organizational Psychology 11, Halbesleben J, Demerouti E (2005). The construct validity of an alternative measure of burnout: Investigating the English translation of the Oldenburg Burnout Inventory. Work and Stress 19, Rzeszutek M, Schier K (2014). Temperament Traits, Social Support, and Burnout Symptoms in a Sample of Therapists. Psychotherapy 51, Totman J, Hundt G, Wearn E, Paul M, Johnson S (2011). Factors affecting staff morale on inpatient mental health wards in England: a qualitative investigation. BMC Psychiatry 11, 1-10.