The Association of Psychosocial Risk Factors with the Burnout Syndrome in Dentists in Guadalajara , Jalisco Mexico

The purpose of this study was to determine the association of psychosocial risk factors with the burnout syndrome in 144 dentists. Semi structured interviews were made and the Maslach Burnout Inventory and the Psychosocial Risk Factors Questionnaire were implemented. The results determined a direct relation between the Commuting to Work dimension of psychosocial risk factors and the MBI Burnout Syndrome (rp = 0.23; rp = 0.21 y rp = −0.23; p < 0.05). The data classified 10% of the participants at a severe level of low Personal Realization in combination with Social Situations and Commuting of the psychosocial risk factors. They also reported Emotional Exhaustion of the burnout syndrome. Conclusion: The percentage of dentists with a high burnout level was similar to that reported in other studies and showed a significant relationship with Commute Situations as a psychosocial risk factor.


Introduction
These days evaluating the burnout syndrome on professionals providing health services is key to timely diagnosis y intervention in the work context.Its tridimensional acceptance (emotional exhaustion, depersonalization and cynicism) have produced two theoretical schools of thought: those who consider it a condition due to the consequences of chronic work stress (Grau, Flichtentrei, Suñer, Prats, & Braga, 2009), or as an initial process due to stressful work conditions and the lack of institutional support, triggering non-adaptive responses by the worker (Castro, 2013;Gil-Monte, 2005;Martinez-Perez, 2010).
Conceiving the burnout syndrome as a process demands an analysis of the interaction between personal aspects (emotional, cognitive and attitudinal) and the worker's psychological resources or specific material (Abdulghafour, Bo-Hamra, Kamel, & El-Shazly, 2011;Diaz-Bambula, Lopez-Sanchez, & Varela-Arevalo, 2012;Tejada & Gomez, 2012).Different investigations consider the burnout syndrome basically as exhaustion in the face of stress conditions brought on by work activities that triggers a series of negative health consequences (Ríos, Reyes, López, Morillo, & Bullón, 2010;Moreno-Jimenez, Garrosa, & Rodriguez, 2009) such as alienation and depersonalization (the second dimension in the concept of this syndrome), a response that depends on the particular activity performed by the professional (Moreno, Galvez, Garrosa, & Mingote, 2006).Furthermore, the balance between work demands, expectations and achieving goals at work will also determine the satisfaction of achievement (the third dimension).It should be underscored that in the manifestation process of the burnout process, it is important to know the presence of previous and non-work conditions that, when combined with the traits of the organization, create the worker's particular responses.
Different studies have shown the importance of timely diagnosis of the burnout syndrome in health professionals whose primary activity is to provide assistance or health services to others, mainly because it may hinder interpersonal relations at work and create conflicts resulting in the appearance of physical symptoms as well as negative attitudes towards those whom they are attending (Lee et al., 2011;Ochomogo & Barrera, 2011;Leon-Rubio, Leon-Perez, & Cantero, 2011;Millan & D'Aubeterre, 2012;Robles & Casares, 2010).
Some researchers have studied personal psychosocial variables that are considered protective from burnout such as engagement, motivation, work satisfaction and self-efficacy (Zhang & Feng, 2011) while others mention negative consequences such as emotional discomfort, absenteeism, depression and anxiety (Rios, Reyes, Lopez, Morillo, & Bullon, 2010;Leon-Rubio, Cantero, & Leon-Perez, 2011), or organizational variables such as an activity overload, negative perception of the organizational environment, job ambiguity, job seniority and decision-making autonomy among others (Patlán, 2012;Castañeda & Garcia, 2013;Gopalan, Culbertson, & Leiva, 2013).Nevertheless, few reports link social non-work variables to the burnout syndrome, such as life satisfaction, economic autonomy, negative changes to vital events, etc.
The dentistry profession is particularly recognized as highly stressful due to its treatment of users reacting with fear or anguishing over treatment, and exposure to occupational risks such as noise, temperature, specific postures, the chemical substances they handle and work overload in some cases among others (Ibañez, Bicenty, Thomas, & Martinez, 2011;Pozos-Radillo, Preciado, Plascencia, Acosta, & Aguilera, 2015;Saliba-Garbin, Reis dos Santos, Fagundes-Freire, & Gonzalvez, 2011).And if you link it to commuting conditions, especially in urban areas with scarce public transportation designs, roads not apt for automobiles or limited parking spaces, they can be associated with the burnout of these professionals.
Therefore the objective of this study was to determine the association between the perception of personal social risk factors and commuting to work with the dimensions of the burnout syndrome in dentists working in the downtown area of Guadalajara, Jalisco, Mexico.

Participants
An analytical cross sectional study was made of 144 dentists working in the downtown area of Guadalajara, Mexico during the period of 2013-2014.It should be mentioned that the conditions were peculiar at the time of the evaluation due to parking, mobility and living limitations plus infrastructure works being executed to remodel the design of a XVII century city to meet the demands of what it has turned into, third place in the country's economy; said works are supposed to be finished by in 2017.Sixty-two percent of the participants (89) were women and 38% (55) men.Seventy-one percent (102) said they were married or in a commitment with someone.
All the surveyed parties held a Degree in Dentistry with an average of 16 (SD = 10.4) years of professional seniority.Two dentists (2%) said they worked three days a week for 10 to 12 continuous hours at their office; 49% (70) said they worked 5 days a week for 8 to 12 hours and another 49% (70) worked six days a week for 8 to 10 hours.Two participants who worked at the own office also mentioned having another full-time employment as teachers, working for 50 hours spread out over six days a week.

Maslach Burnout Inventory (MBI)
The inventory adapted by Seisdedos (1997) was used to evaluate three dimensions: emotional exhaustion (EE), depersonalization (DP) and low self-realization at work (SR).It comprises 22 questions, with response options in scale from 0 to 6 points.A high Cronbach reliability is reported for EE 0.90, DP 0.79 and SR 0.71 with a factorial validity (0.58; 0.36; and −0.15 respectively) and convergence with different variables.
Psychosocial Risk Factor Questionnaire in Workers (PRFQW) This questionnaire, expressly designed for this investigation, was used to evaluate three dimensions: a) social or commuting aspects, b) personal aspects and c) way conditions (home-work-home) that workers refer to as stressful.It includes 27 questions with dichotomous response options (Yes-No).Each dimension consists of nine items where an affirmative answer has a value of one and a negative answer zero; thus the sum score of items per dimension weighs the number of events mentioned as stressful in each dimension.Preliminary studies showed sensitivity above 0.47 and specificity above 0.85.The reliability for the commuting dimension was Cronbach 0.50 alpha for the social dimension and 0.22 alpha for the personal dimension (Appendix).

Procedure
Dental offices were located in the downtown area of the city of Guadalajara.We proceeded to survey the dentists who were working on the day of the visit, beginning in the first quadrant until the outskirts of four square kilometers.Participation was voluntary with a semi structured interview lasting approximately 45 minutes covering social, academic and work data.The activity was performed between September 2013 and February 2014.
The variables measured on a nominal scale were analyzed with percentage distributions while variables on a numeric scale with measurements of central tendency, arithmetic mean variance and standard deviation.The relationship between the psychosocial risk factors and the burnout syndrome was calculated with Pearson r with a significant value of p ≤ 0.05.Data were analyzed with IBM-SPSS software (version 19, USA) under the university's license.
The protocol of this study was registered under number C1-11308 by the Evaluation and Ethics Committees of the University of Guadalajara.The investigation was carried out with the voluntary informed consent of the participants.The work was compliant with the General Regulations of the General Health Act for the area of Health Research in Mexico (RLGS, 1986) and compliant with the Declaration of Helsinki (2013).

Results and Findings
Of the 144 dentists evaluated with MBI, 34 (24%) of the participants showed a high level of emotional exhaustion, described a sensation of "having no more to give of themselves", of feeling worn out when expressing their emotions.High levels of the depersonalization dimension or the indifferent treatment of users were recorded in 39 (27%) of the participants.Lastly, low self-realization was recorded in 69% (99) of the dentists with a low level of feeling low professional competency and success in treating their patients (Table 1).
The perception of stressful social situations was recorded in 83% (120) of the surveyed dentists who said they had no time to talk to their neighbors or were unable to organize leisure or fun activities with their family.In the personal aspect dimension, 95% (137) were recorded in risk situations due to lack of planning their immediate future and perceiving disorder at home.The commuting dimension (home-work-home) recorded 86% (124) at risk because of their concern of arriving late to work due to slow transportation and because they often break traffic laws (Table 2).The data were analyzed with Pearson r statistics and it was determined that the commuting dimension (home-work-home) was associated with the MBI dimensions.Furthermore, the personal aspect dimension has a significant inverse relationship with the MBI Depersonalization dimension (Table 3).
Table 4 shows the distribution of participants according to the combination of risk levels in the dimensions of the Occupational Psychosocial Risk Factor Questionnaire.We should underscore that 10% ( 14) of the participants reported being at risk due to commuting conditions in combination with low self-realization while 12% (17) mentioned it is due to the situations they face in their social setting.

Discussion
A significant statistical relationship was determined in this study between psychosocial risk factors due to commuting situations perceived as stressful and the emotional exhaustion dimension of the burnout syndrome.Difficult traffic experiences, the lack of parking spaces for the vehicles driven by the surveyed professionals as well as contamination in the city are likely important aspects in their manifestation of exhaustion.One can see that a worker may arrive at his or her workplace with a prior load of emotional reactions that exacerbate working conditions that are also a source of stress.
This suggests that in the context of this investigation, psychosocial factors external to work activities experienced as stressors have a close relationship with emotional exhaustion at work and the manifestations of burnout syndrome-related symptomology.This is consistent with the models created by researchers including Önder & Basim (2008), Sanin & Salanova (2014), Gopalan, Culbertson, & Leiva (2013), Leon-Rubio, Leon-Perez, & Cantero (2013) among others.
The psychosocial factor of commuting (home-work-home) perceived as a stressor in this study showed high scores in the participants although no significant relationship was maintained with the Depersonalization and the Self-Realization dimensions of the burnout syndrome.This factor is considered to be a potentially dangerous condition in our country for worker protection and is legally classified (Mexico's Federal Labor Law).We should highlight that there are few studies associating commuting conditions with the burnout syndrome.For example, Marinaccio et al. (2013) mentions that commute time (lasting more than an hour) and the work shift seem to be associated with greater levels of risk for stress.But it is incompatible with the results offered by Nivens & Nordstrom (2012) who studied the effects of driving a vehicle to work.Those data say there is no significant relationship with stress and the burnout syndrome.Nonetheless and not unlike other studies, it is suggested in the context of this study that psychosocial factors external to work activities experienced as stressors  may exacerbate the relationship with emotional exhaustion at work and with the symptomology associated with the burnout syndrome (Montero-Marin, Araya, Olivan, Skapinakis, Martinez, & Garcia, 2012).
It is important to consider the three-dimensional structure of the burnout syndrome as a process in keeping with the phases proposed by theoreticians, in which the fundamental indicator is in the high scores of the emotional exhaustion dimension.The results of this study were similar to those reported by Visoso et al. (2012) in his study of dentistry teachers at a Mexican university, and they are congruent with the average data reported in other samplings in this country (Juarez-Garcia, Idrovo, Camacho-Avila, & Placencia-Reyes, 2014).
They are also similar to the percentages of high burnout levels in dentists at different institutions in other regions, as reported by Robles & Casares (2010) who analyzed the relationship with health problems (without specifying which).The variables of hiring, fixed shift and more than 10 years seniority (work conditions) are related to the burnout syndrome as reported in a study by Castañeda & Garcia (2013) with dentists providing social care and treating the university community.Nevertheless, the average parameters reported are below the normal cutoff point although the percentage (52%) that it specifies as risky for the syndrome is higher than what is reported here.
Nevertheless, the levels of burnout syndrome reported here are higher those of other Latin American populations (Millan & D'Auberterre, 2012;Ochomogo & Barrera, 2011).Possibly the percentages of professionals affected by the burnout syndrome vary from other studies due to the fact that the information-gathering method is reported in very diverse ways (Schaufeli & Taris, 2005).Nonetheless, this study tried to limit possible biases in administering the questionnaires by observing the procedures indicated in the manuals and obtaining information during semi structured interviews face to face with the participants, which the authors consider a strength in the consistency of the analyzed data.
Like all observational and cross sectional studies, this one has several limitations given that the information was gathered with self-report questionnaires (where the answer is evaluated by the respondent).Besides, the stress coping pattern and other socioeconomic or demographic factors that may interact with the burnout syndrome response were not assessed.Future research should include objective measures from the viewpoint of those who make up the social networks at work (colleagues and superiors) as well as studies including an analysis of clinical histories and workplace and environmental conditions that may play a role in the presence of burnout symptomology.

Conclusion
A statistically significant relationship was determined between psychosocial risk factors due to commuting to work perceived as a stressor and the emotional exhaustion dimension of the burnout syndrome.Between 4% and 10% of dentists showed to be at risk due to social and personal aspects and commuting in combination with a high level of emotional exhaustion, depersonalization and low achievement realization.The study contributes by showing the interaction of non-work psychosocial factors (commuting) with the burnout syndrome dimensions, thereby contributing to the theoretical concept of the syndrome process.

Table 1 .
Level of stress burnout syndrome on dentists working in the downtown area ofGuadalajara, Mexico (2013-2014).

Table 2 .
Psychosocial factors perceived as a source of stress on dentists working in the downtown area ofGuadalajara,  Mexico (2013-2014).

Table 3 .
Correlation between psychosocial factors and stress burnout syndrome on dentists working in the downtown area ofGuadalajara, Mexico (2013-2014).

Table 4 .
Classification by risk level and factors psychosocial on dentists working in the downtown area ofGuadalajara,  Mexico (2013-2014).