An- Najah National University Faculty of Graduate Studies Burnout amongst Governmental Mental Health Professionals in West Bank, Palestine By Niveen Maher Abul-Hawa Supervisor Dr. Mohammad Marie This Thesis is Submitted in Partial Fulfillment of the Requirements for The Degree of Master in Public Health, Faculty of Graduate Studies, An-Najah National University, Nablus-Palestine. 1029 ii Burnout amongst Governmental Mental Health Professionals in West Bank, Palestine By Niveen Maher Abul-Hawa This Thesis was Defended Successfully on 7/2/2019 and approved by: Defense Committee Members Signatures 1. Dr. Mohammad Marie / Supervisor …...………... 2. Dr. Suheir Al-Sabbah / External Examiner …..………… 3. Dr. Adnan Sarhan / Internal Examiner …………….. iii Dedication For all those who are persistent to making a difference in people‟s lives despite their Burnouts; those who chose to light the way instead of extinguishing while no one have recognized. For my parents, Maher & Hanan Abul-Hawa, sisters and friends who supported me constantly. Their infinite, unconditional love and encouragement will forever be cherished. iv Acknowledgement This study aims to assess Burnout amongst mental health professionals who work in the governmental mental health institutions and workplaces in the West Bank. It is implemented by Niveen Maher Abul-Hawa; MPH graduate at An-Najah National University- Nablus and supervised by Dr. Mohammad Marie; Assistant Professor in the Faculty of Medicine and Health sciences at An-Najah National University- Nablus. The preparation of this study would not have been possible without the collaboration of the Palestinian Ministry of Health, Faculty of Graduate Studies at An-Najah National University – Nablus, all the governmental mental health workplaces in the middle region (Ramallah & Jericho), north region (Nablus, Tubas, Jenin, Salfit, Qalqelia, Tulkarm),south region (Bethlehem & Hebron), in addition to all participants. Special thanks to Dr. Mohammad Marie for his guidance, assistance, and wisdom. Of course not to mention my parents: Hanan and Maher Abul- Hawa, whom their full support was the main reason for this success. I wish also to thank Mr. Marwan Zuhd; the statistician who helped in the analysis of data, for his advices and suggestions. v اإلقرار الرسالة التي تحمل العنوان: أنا الموقع أدناه مقدم Burnout amongst Governmental Mental Health Professionals in West Bank, Palestine أقر بأن ما اشتممت عميو ىذه الرسالة إنما ىي نتاج جيدي الخاص، باستثناء ما تمت اإلشارة إليو يل أية درجة أو لقب عممي أو بحثي حيثما ورد، وأن ىذه الرسالة ككل، أو أي جزء منيا لم يقدم لن لدى أية مؤسسة تعميمية أو بحثية أخرى . Declaration The work provided in this thesis, unless otherwise referenced, is the researcher's own work, and has not been submitted elsewhere for any other degree or qualification. Student's name: اسم الطالب: Signature: التوقيع : Date: التاريخ: vi List of Content No Content Pages Dedication Iii Acknowledgment Iv Declaration V List of Tables Viii List of Appendices Ix List of Abbreviations X Study Terms Xi Abstract Xiii Chapter One: Introduction 1 1.1 Background 1 1.2 Significance of the Study 3 1.3 Problem Statement 4 1.4 The Aim of the Study 4 1.5 Research Questions 4 1.6 Operational Definitions 5 Chapter Two: Literature Review 7 2.1 Burnout Definition 8 2.2 Burnout Brief History 8 2.3 International, Arabic, and Palestine Studies that Exclusively Utilized MBI-HSS 10 2.4 Risk factors and Prevalence of Burnout 11 2.5 Burnout Consequences, Preventions, and Interventions 20 Chapter Three: Methodology 24 3.1 Study Design 24 3.2 Study Setting 25 3.3 Target Population 26 3.4 Sample Size & Technique 26 3.5 Questionnaire 27 3.6 Validity & Reliability 29 3.7 Data Collection 30 3.8 Data Analysis 31 3.9 Ethical Consideration 31 3.10 Limitation of the Study 32 Chapter Four: Results 33 4.1 Introduction 33 4.2 Levels of Burnout amongst Mental Health Professionals 34 4.2.1 Levels of Burnout amongst Mental Health Professionals due to EE Items 35 vii 4.2.2 Levels of Burnout amongst Mental Health Professionals due to DP Items 36 4.2.3 Levels of Burnout amongst Mental Health Professionals due to PA Items 37 4.3 Differences of MBI due to Socio-demographic Variables 38 4.3.1 Differences of MBI-EE due to Socio-demographic Variables 38 4.3.2 Differences of MBI-DP due to Socio-demographic Variables 40 4.3.3 Differences of MBI-PA due to Socio-demographic Variables 42 Chapter Five: Discussion 45 5.1 Prevalence of Burnout 45 5.1.1 Emotional Exhaustion (EE) 46 5.1.2 Depersonalization (DP) 46 5.1.3 Personal Accomplishment (PA) 46 5.2 Significant differences between socio-Demographic factors and Burnout 47 5.3 Conclusion 49 5.4 Strengths of the Study 50 5.5 Difficulties of the Study 50 5.6 Recommendations 51 5.7 Implication of the Study 52 References 54 Appendices 65 ب انًهخض viii List of Tables No Subject Pages Table (2-1) International, Arabic, and Palestine Studies that Exclusively Utilized MBI-HSS 10 Table (3-1) Distribution of the Mental Health Professionals‟ Socio-Demographic Data 26 Table (3-2) Reliability (Cronbach‟s Alpha) of MBI Subscales 30 Table (4-9) Levels of Burnout amongst Mental Health Professionals based on MBI-HSS Subscales: Emotional Exhaustion (EE), Depersonalization (DP), Personal Accomplishment (PA) 34 Table (4-10) The means and Standard Deviations of Emotional Exhaustion (EE) by Items 35 Table (4-11) The Means and Standard Deviation of Depersonalization (DP) by Items 36 Table (4-12) The Means and Standard Deviations of Personal Accomplishment (PA) by Items 37 Table (4-13) Differences of MBI-EE Scores due to Socio- demographic Variables (results from One-way ANOVA) 38 Table (4-14) Differences of MBI- EE Scores due to Gender Variable (results from independent t-test) 40 Table (4-15) Differences of MBI- DP Scores due to Socio- demographic Variables (results from One-way ANOVA) 40 Table (4-16) Differences of MBI- DP Scores due to Gender Variable (results from independent t-test) 41 Table (4-17) Differences of MBI-PA Scores due to Socio- demographic Variables (results from One-way ANOVA) 42 Table (4-18) Differences of MBI-PA Scores due to Gender Variable (results from independent t-test) 43 ix List of Appendices No Subject Pages Appendix (1) Literature Reviews on Risk Factors and Prevalence of Burnout 66 Appendix (2) Arabic Participant Information Sheet 69 Appendix (3) (A) Arabic Consent Form 72 (B) Arabic Socio-Demographic Sheet 74 (C) Arabic Maslach Burnout Inventory-Human Services Survey (MBI-HSS) 75 Appendix (4) (A) English Consent Form 78 (B) English Socio-Demographic Sheet 80 (C) English Maslach Burnout Inventory-Human Services Survey (MBI-HSS) 81 Appendix (5) Scoring and Interpretation Key of MBI- HSS 83 Appendix (6) An-Najah National University - Institutional Review Board (IRB) Ethical Approval 84 Appendix (7) An-Najah National University – Graduate Studies Approval 85 Appendix (8) Palestinian Ministry of Health‟s Letter of Approval 86 x List of Abbreviations SD Standard Deviation PMoH Palestinian Ministry of Health MBI-HSS Maslach Burnout Inventory – Human Services Survey EE Emotional Exhaustion DP Depersonalization PA Personal accomplishment WHO-AIMS World Health Organization – Assessment Instrument For Mental Health Systems WHO World Health Organization xi Study Terms Mental Health Professionals = Mental Health Workers: The Mental health professionals or workers are the people who offer mental health care services for improving the mental health and quality of life of the clients. Such as: psychiatrists (medical doctors in the mental health field that can prescribe medications), psychologists (practitioners who provide cognitive and behavioral therapy), psychiatrist nurses (who are monitoring treatment and implementation, and assisting patients), social Workers (assist clients who suffer from certain social conditions), and occupational therapists (assist with developmental conditions, such as Autism, or can help children struggling with medical conditions) (“Mental Health Foundation of New Zealand”, n.d.). Burnout = Job Burnout, occupational Burnout, and work-related Burnout: Burnout is "A psychological syndrome of exhaustion, cynicism, and inefficacy, which is experienced in response to chronic job stressors”. In essence, they described Cynicism as “a negative, callous, or excessively detached response to various aspects of the job”, Exhaustion: “Feelings of being overextended and depleted of one‟s emotional and physical resources”, and inefficacy: “Feelings of incompetence and lack of achievement in work” (Maslach & Leiter, 2000, P.368). xii Maslach Burnout Inventory-Human Services Survey (MBI-HSS): The most widely used tool for measuring Burnout. It is adapted for professionals in the caring professions, including nurses, physicians, mental health workers, and therapists, The Burnout is measured throughout three subscales; emotional exhaustion, depersonalization, and personal accomplishment emerged (Maslach & Leiter, 2016). MBI three dimensions = MBI three subscales: Emotional Exhaustion: measures feelings of being emotionally overextended, and the lack of energy to use or offer, where depersonalization measures sets of unpleasant feelings toward clients, such as insensitive behaviors or not being empathetic and cynical, and personal accomplishment measures feelings of incompetence and negative evaluation of one‟s work, where they feel ineffective (Schaufeli, Leiter & Maslach, 2009). xiii Burnout amongst Governmental Mental Health Professionals in West Bank, Palestine By Niveen Maher Abul-Hawa Supervisor Dr. Mohammad Marie Abstract Burnout in general is a gradual process of feeling the loss of motivation and energy to deal with daily issues that occurs over an extended period of time, where it might effects on the mental, social, or physical well-being, and reduces the productivity. Purpose: This study aims to assess the level of Burnout amongst mental health Professionals in the West Bank governmental mental health workplaces, to investigate Burnout presence and the significant differences between the Burnout level on the three dimensions of emotional exhaustion (EE), depersonalization (DP), and personal accomplishment (PA) with the socio- demographic factors. Methods: This cross – sectional study is utilizing a socio-demographic sheet and (MBI-HSS) to investigate the presence and level of Burnout, in addition to the significant difference between the independent variables (socio-demographic factors) and dependent variables (the level of Burnout on EE, DP, & PA) amongst a convenient sample of 149 mental health workers that include: Psychologists, Psychiatrists, Social Workers, Psychiatric nurses, or occupational therapists who are working in the governmental mental health workplaces in the West Bank, in the middle region (Ramallah, Jericho), south region (Bethlehem, Hebron),and north xiv region (Tubas, Qalqilia, Tulkarm, Jenin, Salfit, and Nablus) . The 138 valid questionnaires were analyzed using SPSS version 20. One way ANOVA test is used to analyze groups which contain more than two socio- demographic variables such as age, marital status, workplace location, educational level, years of experience, and specialty, while an independent t- test is used to analyze socio-demographic groups which contain two variables such as gender, and monthly income. Results: Moderate level of Burnout on EE and DP, while nearly moderate on PA. Professionals have reported the mostly high level on (EE) (37%), low level on (PA) (47%), and low level on (DP) (51%). Tests showed significant differences on the three subscales due to marital status, specialization, gender, and age. Conclusion: The lack of resources along with the high demand impulse Burnout in the WB mental health workplaces. This study recommends future research to investigate the reasons behind the Burnout prevalence amongst the mental health professionals who work in the governmental mental health workplaces in the West Bank. Keywords: Burnout, Mental health professionals/workers/providers, West Bank/Palestine, Socio-demographic factors, Risk factors 1 Chapter One Introduction This chapter will discuss the background, significance of the study, problem statement, the aim of the study and research questions, in addition to the operational definitions. 1.1 Background Burnout can be defined as feelings of exhaustion, cynical attitude toward the job and the people involved, and reduced sense of personal accomplishment or work efficacy. In a radical meaning, Burnout takes away a persons‟ spirit (Maslach et al., 2001). The prevalence of Burnout in Jewish and Arab Israelis, as well as many other populations is significant. After the research of Burnout had burgeoned, it became clear that Burnout occurred cross culturally and is prevalent across a variety of occupations and thus Maslach and her colleagues had developed a general MBI to include teachers, managers, and clerical workers in the mid-1990s (Stalker & Harvey, 2002). In addition to the emergence of Burnout amongst different occupations, it had been assessed in different countries as well. After the initial emergence of Burnout in the Unites States of America in the 1970s,the concept was introduced in Western Europe, particularly the United Kingdom, Holland, Belgium, Germany, and Scandinavia and Finland. Despite the different value systems, Burnout was prevalent in Israel amongst the Jewish and Arab Israeli populations, and in the rest of Western and Eastern Europe, 2 Asia, the Middle East, Latin America, Australia, New Zeeland, Africa, China, and to the Indian Subcontinent (Pines, 2000b). The incidence of Burnout and its recognition has increased substantially over the last few years, according to the WHO report, in a 5-year prospective intervention study by Borritz and colleagues (2006), where they comprised 2,391 employees from different organizations in the human service sector. They found that health care workers had high levels on work- and client-related burnout, where supervisors and office assistants had low levels on both scales. Also, a review study by Lloyd, King, and Chenoweth in (2002) found that social workers may experience higher levels of Burnout than comparable occupational (WHO, 2010). Assumingly, these studies, in addition to the studies mentioned in the literature review, indicates the relevance of Burnout in all occupations and locations, where this issue is not taken seriously as should be. In essence, Burnout amongst mental health workers is an essential matter to be investigated, especially nowadays where Burnout is considered as a global phenomenon which prevents health care professionals from delivering the necessary quality of care (Laschinger & Montgomery, 2014). Accordingly, this study is conducted to reveal the presence of Burnout amongst mental health professionals who work in the governmental mental health workplaces in the West Bank. 3 1.2 Significance of the Study In the West Bank, mental health is not taken seriously by the society. In most cases, people do not seek help at an early stage but wait until they are chronically sick, or their condition has severely deteriorated. This adds to the burden on the mental health workers, especially as the governmental mental health workplaces suffer from a shortage of mental health workers in relation to the huge number of cases (Vanheule, Lievrouw & Verhaeghe, 2003). The phenomenon of Burnout has been studied by researchers in many different countries and different populations from different occupations as mentioned previously, as well as in the West Bank, but nationally, studies were mostly directed to health care areas other than mental health, and no studies were conducted to assess Burnout amongst mental health workers in the governmental mental health workplaces as noticed by the researcher. Accordingly, the fact that mental health facilities work to improve the cognitive, behavioral and mental health of individuals; it should be ensured that the psychological conditions amongst mental health workers would be acknowledged and taken seriously. Unfortunately, this is not the case in the West Bank and in spite of the importance of the mental health workers‟ psychological health and its sensitivity, researchers have not done it justice, to investigate Burnout amongst mental health professionals in the governmental mental health workplaces in the West Bank, Palestine. Thus, this study is the first in the West Bank to be conducted regarding this issue. 4 1.3 Problem Statement Assessing Burnout amongst governmental mental health professionals in the West Bank is very important to address, because it adversely affects not only the target population but also extends to the clients. 1.4 The aim of the Study The aim of this study is to assess the level of Burnout amongst mental health professionals in the West Bank governmental mental health workplaces.  The specific objectives of this study are: 1- To investigate the presence of Burnout amongst the mental health professionals in the West Bank governmental mental health workplaces. 2- To assess the level of Burnout amongst the mental health workers in the West Bank governmental mental health workplaces on the three subscales: emotional exhaustion, depersonalization, and personal accomplishment. 3- To investigate the significant differences of socio-demographic factors in Burnout on the three subscales: emotional exhaustion, depersonalization, and personal accomplishment, including: age, gender, workplace location, educational level, monthly income, specialty, and years of experience. 1.5 Research Questions 1- Is Burnout present amongst mental health professionals in the West Bank governmental mental health workplaces? 5 2- What is the level of Burnout amongst the mental health professionals in the West Bank governmental mental health workplaces due to the three MBI subscales items? 3- Are there any significant differences between Burnout on the three MBI subscales and the given socio-demographic factors? 1.6 Operational Definitions and Theoretical Framework Operational Definitions  Palestinian Ministry of Health (PMoH) The Palestinian Ministry of Health is the Palestinian State independent institution that works with other relevant parties to develop the health policies and legislations, structures, strategic planning, projects and regulations to continuously improve the performance of the health sector to maintain the constant provision of comprehensive and good health services in all public and private health sectors.  West Bank Governmental Community Mental Health Workplaces According to the World Health Organization- Assessment Instrument for Mental Health Systems (WHO-AIMS) report on Mental Health System in West Bank and Gaza, 2016: The Palestinian governmental agency; The Ministry of Health is taking responsibility to provide mental health services to the Palestinian people primarily and secondarily, therefore, community mental health and healing centers/clinics are secured and distributed within all regions; middle region (Jericho & Ramallah), south region (Bethlehem 6 & Hebron), north region (Nablus, Tulkarm, Tubas, Qalqilia, Salfit, Jenin). One psychiatric hospital located in Bethlehem and 10 primary out-patients governmental community centers/clinics distributed amongst the 10 districts.  Mental Health Workers in the West Bank Governmental Mental Health Workplaces Professionals who offer mental health services to improve the mental health of the Palestinian people, as psychiatrists, psychologists, social workers, psychiatric nurses, and occupational therapists are estimated to be 241 according to the WHO-AIMS report in 2016, taking into consideration the probability of there being more or less than this figure. Summary: This chapter has discussed the background which illustrated the work-related Burnout effects on variety of populations, specifically on mental health workers, and clarified the importance of Burnout nationally and globally. 7 Chapter Two Literature Review The literature review chapter will give more details about Burnout. The history and various definitions, measurement tools, and models inclusively to the health care professions will be demonstrated. Additionally to the International, Arabic, and Palestine studies that exclusively utilized MBI- HSS, the risk factors of Burnout, prevalence amongst mental health professionals worldwide and nationally, and the consequences, preventions, and interventions. Search Strategy A detailed search strategy was developed and revised appropriately for the following electronic databases: PubMed, Google Scholar, and Research Gate for the time period 1978 – 2018, using English, and Arabic languages. The terms used while searching were Burnout, mental health professionals/ workers/ or providers, West Bank/ Palestine, socio-demographic factors, and risk factors .The keywords are stated in the abstract. The researcher had reviewed journals, academic studies and articles, in addition to relevant academic books (e.g. The Maslach Burnout Inventory manual), organizational publications (e.g. WHO-AIMS), and grey literature such as unpublished studies (e.g. Naerat, 2016). Two summary tables illustrate the 15 literatures reviewed regarding risk factors and prevalence of Burnout as shown in Appendix 1, and the 21 international, Arabic, and Palestinian studies that exclusively utilized MBI-HSS are included. 8 2.1 Definition of Burnout Definitions of Burnout varied between researchers, and had not been unified because of their substandard agreement on how Burnout develops and whether it is an event or a process, and what stage should be considered a development of Burnout (Burisch, 2002). Kyriacou defined Burnout as a behavioral indicator of a long term and constant psychological stress resulting gradual exhaustion and depletion of job satisfaction and enthusiasm to achieve goals, and as a sequel, individuals become more stressed and concerned about being appreciated in accordance to their provision (Kyriacou, 2001).Whereas, Maslach and her colleagues defined Burnout as a “syndrome of emotional exhaustion, depersonalization, and reduced sense of personal accomplishment that can occur among individuals who work with people in some capacity” (Jackson, Leiter, & Maslach, 1996, p.4). 2.2 Burnout Brief History This section gives a brief recognition on how the term Burnout was coined and introduced to researchers, and how related research had progressed Before the early 1970s, the term „Burnout‟ was used as an expression referred to the destructive effects of the chronic abuse of drugs at that period of time. In the early seventies the term caught the attention of Herbert Freudenberger; an American practicing and consulting psychologist, in a clinic in New York for drugs addiction recovery, and 9 initiated the use of this term describing the gradual emotional exhaustion, the lack of motivation and the poor commitment through observing the volunteers in the clinic, and as a person who had faced similar symptoms, he was dedicated to spread the knowledge and awareness of the existence of Burnout, but he was more interested in preventing the emergence of Burnout rather than investigating the foundation. Concurrently, in California, a social psychology researcher; Christina Maslach, and her colleagues fell upon the term „Burnout‟ while interviewing human services workers in the University of California, and they were interested in understanding the coping mechanisms for their emotional exhaustion, negative perceptions of themselves and their clients, and their work proficiency while obligated to maintain the quality of services provided in a high demanding job. Afterwards, Maslach and her colleagues developed a self-reporting questionnaire thorough a process of interviews, observation, and psychometric development, to assess Burnout amongst the caring professions which includes human services, health care, education, psychotherapy, and any other client-centered professions which known as MBI; Maslach Burnout Inventory. In the middle 1990s till 2000s, the MBI was developed, evaluated and used in different countries, and Burnout research had been nourished by the practical, empirical, and academic streams, even though the streams had not interacted, thousands of related studies were published. The notable, global and significant phenomenon of Burnout had arisen in the twentieth century because of the bureaucratic system, poverty, and cultural revolution. (Neckel, Schaffner, & Wagner, 2017) 10 However, many researchers amongst the world where interested in studying this phenomenon of Burnout and conducted different studies. 2.3 International, Arabic, and Palestine Studies that Exclusively Utilized MBI-HSS (Table 2-1) Table (2-1) illustrates the international, Arabic, and studies which had been conducted in Palestine that Exclusively Utilized MBI-HSS. INTERNATIONAL ARABIC COUNTRIES PALESTINE H ea lt h C a re P ro fe ss io n s Cagan & Gunay, 2015.The Job Satisfaction and Burnout Levels of Primary Care Health Workers in the Province of Malatya in Turkey. (Turkey) Al-Imam & Al-Sobayel, 2014. The Prevalence and Severity of Burnout among Physiotherapist in an Arabian Setting and Influence of Organizational Factors: An Observational Study. (Saudi Arabia) Naerat, 2016. Burnout and Psychological Distress among Primary Health Care Nurses in North West Bank. (West Bank) Shafaghat, Zarch & Kavosi, 2016. Studying the Status of Job Burnout and its relationship with Demographic Characteristics of Nurses in Shiraz Nemazee Hospital. (Iran) Sabbah et al., 2012. Burnout among Lebanese Nurses: Psychometric Properties of the Maslach Burnout Inventory- Human Services Survey (MBI- HSS). (Lebanon) Abushaikha & Hazboun, 2008. Job Satisfaction and Burnout among Palestinian Nurses. West Bank. (West Bank) Muhammad & Nawaz, 2014. Socio-demographic and Occupational Aspects in Relation with Physicians‟ Burnout and Career Satisfaction in Pakistan. (Pakistan) Khashaba et al., 2014. Work Related Psychosocial Hazards among Emergency Medical Responders (EMRS) in Mansoura City. (Egypt) Canadas et al., 2018. Gender, Marital Status, andChildren as Risk Factors of Burnout in Nurses: A Meta-Analytic Study. (Gernada, Spain) Linzer et al., 2001. Predicting and Preventing Physician Burnout: Results from the United Stated and Netherlands. (United States and Netherlands) 11 Chou, Li, & Hu, 2014. Job Stress and Burnout in Hospital Employees: Comparisons of Different Medical Professions in a Regional Hospital in Taiwan. (Taiwan) M en ta l H ea lt h P ro fe ss io n s Ean, 2017. Study on the Job Satisfaction and Burnout among Medical Social Workers in Government Hospitals in Malasyia. (Malasyia) Musa, 2009. Mental Health Problems and Job Satisfaction amongst Social Workers in the United Arab Emirates, Abu Dhabi.(Abu-Dhabi) Abu Akar, 2013.Burnout among Mental Health Workers in Gaza Strip. (Gaza) Bakker,A., Demerouti,E., & Schaufeli, W.(2005). The crossover of burnout and work engagement among working couples (U.S.A) Hamaideh, 2011. Burnout, Social Support, and Job Satisfaction among Jordanian Mental Health Nurses. (Jordan) Alhajjar et al., 2012. Burnout and Self-esteem among Social Workers in Gaza,Palestine. (Gaza) Deckel & Peled. (2008). Staff Burnout in Israeli Battered Women‟s Shelter. (Israel) Jaharmi & Thomas., 2013. The Relationship between Burnout and Job Satisfaction among Mental Health Workers in the Psychiatric Hospital Bahrain. (Bahrain) Abdallah, 2009. Prevalence and Predictors of Burnout among Palestinian Social Workers. (West Bank) Al-Dubai, S.A, Rampal, K.G. (2010).Prevalence and associated factors of Burnout among dates in Yemen. 2.4 Risk factors and Prevalence of Burnout This section exposes national and international research regarding Burnout prevalence, and its association with socio-demographic factors amongst health care and mental health populations. It nourishes our present study and offers it guidance to be compared with other national and international studies. According to the reviewed literature, Burnout development amongst mental health professionals or any other health care professionals are likely to be associated to several risk factors; it could be socio-demographic, cultural, or work life. The socio-demographic factors, such as: age, gender, marital status, monthly income, years of experience, or specialty. 12 In this study, investigating the relationship between the socio–demographic factors and Burnout is one of the objectives. Therefore, several studies will be demonstrated on this regard. The cultural factors are surely associated with Burnout. As reported by the study “Predicting and Preventing Physician Burnout: Results from the United Stated and the Netherlands”, to compare the physicians in the Netherlands with the physicians in the United States, they found that older physicians in the United States reported an increased sense of control in their work field compared with the younger physicians. Meanwhile, they haven‟t found significant differences between physicians in the Netherlands (Linzer et al., 2001). Christina Maslach, the creator of the MBI, agrees with several of models including the JD-R model. Accordingly, she combined the areas of factors of work life that contribute to Burnout development. In order to assess what in the work environment contributes in developing Burnout, Maslach had categorized six factors as follows, (1) lack of control, such as, opportunity to solve problems, make choices and decisions about your work. (2) Insufficient reward; financial or social rewards are important for recognition. (3) Lack of community; social support and healthy relationships with colleagues, coworkers, managers and clients play a big role in the psychological wellness. (4) Absence of fairness; equity and equality in rules, justice, and respect to everyone. (5) Conflict in values; whether the values of the professionals and organization are intersecting or parallel. (6) Work overload; excessive demands, or the amount of work to 13 be accomplished in a given time, usually the stress resulting from workload extends to personal and social life, causing physical and intellectual burden (Leiter & Maslach, 2000). In Spain, a study was published in 2018, to investigate the relationship between Burnout syndrome and socio-demographic factors amongst nurses, by assessing the impact of gender and marital status on the three subscales of Burnout, (emotional exhaustion, depersonalization, and personal accomplishment). They have taken 78 studies to analyze using meta- analysis, 57 studies were enrolled to investigate the gender correlation with Burnout, and 32 for marital status. They found a significant relation between depersonalization and gender (r = 0.078), and marital status (r = 0.047).Also, they have found that Single, or divorced men were related to highest levels of Burnout amongst nurses and had higher tendency to present negative attitudes towards clients and coworkers at the workplace (Canadas-De la Fuente et al., 2018). Another study that included 942 participants in Slovenia was conducted to assess demographic variables and working conditions in relation with Burnout amongst individuals with different profiles using the MBI. The outcomes were classed into four categories: low burnout, high burnout, high emotional exhaustion, and low personal accomplishment. Individuals in different categories had differed significantly in terms of age. The younger respondents; under 30 years of age, had experienced low personal accomplishment and high emotional exhaustion, while the respondents who 14 are over 49 years had experienced low Burnout (Boštjančič, Kocjan, & Stare, 2015). In Pakistan, a study was established in 2014 to determine the job Burnout prevalence amongst physicians along with the three dimensions, and to identify the socio-demographic factors and their relation to three dimensions of job Burnout, using a convenient sample of 640 physicians working in one of the largest public teaching hospitals in the second largest city in Pakistan, Lahore, where 331 questionnaires were valid for analysis. The results showed very high levels of emotional exhaustion amongst the physicians who are suffering from moderate job burnout. Socio- demographic factors had shown high influence on job Burnout development, where the participants who are less than 24 years old scored high emotional exhaustion, and there was no significant differences detected between genders, marital status, number of children and residential status in relation with EE, DP, and PA (Muhammad & Nawaz, 2014). Another study was conducted in 2013 to investigate the “relationship between Job Burnout and Gender-Based Socio-Demographic Characteristics”, selecting a random sample of 89 workers from various industries in Lahore, after 11 questionnaires were eliminated because of incomplete data, and found significant differences between males and females regarding marital status, where married men had higher scores of Burnout than married women. Also, Females had high scores on EE subscale, while men had high scores on PA. Burnout amongst women was related to educational level where the higher the educational level the 15 higher Burnout scores, and work experience where less experience is related to higher Burnout scores, while amongst men Burnout was related to age, where (24–35 years) groups recorded high level of Burnout, because of being shocked of reality or early career Burnout (Nabi Khan, 2013). In accordance, Çapri mentioned in his study that several researches which aimed to study the relation between Burnout and gender had reported higher levels of Burnout amongst females than men (Çapri, 2013). On the other hand, there are several studies also that had found higher levels of Burnout amongst men than women (Hammer & Zimmerman, 2010), and also there are several studies which found no differences between males and females (Benbow & Jolley, 2002) In 2014, a study was composed in California to examine the correlations of Burnout amongst human service workers in a non-urban setting, where a convenient sample of 288 participants was selected. Results had found that workers experienced moderate to high levels of job Burnout which were significantly correlated with age, gender, education, and experience (Thomas, Kohli, & Choi, 2014). A study was made in Finland in 2008, had mentioned that several studies reported that with age, Burnout levels tend to decrease, on the other hand, another studies had the opposite finding. This study selected two representative samples of 9,922 employees that are in three age groups: young group (18–34), middle age (35–49), and aging (50–64) by gender to explore the relationship between Burnout levels and age by gender. The outcome was that Burnout scored the highest amongst young women in their early working years while in aging women, the 16 Burnout levels was highest amongst the older women. On the other hand, there was an association amongst men in the middle age only. Whereas, the educational levels, specialty, and marital status did not have any relation (Ahola et al., 2008). In Iran, in 2016, a study was conducted to evaluate the levels of Burnout amongst nurses in Shiraz Nemazee Hospital and to investigate the relation between Burnout and the age, gender, marital status, job experience, education level factors. The results found significant differences between depersonalization with age and marital status, where age groups 41- 50 and singles scored the highest. But there was no significant differences in between gender, education level and work experience (Shafaghat & Kavosi, 2016). Lots of studies were conducted to investigate Burnout and its relation with the socio-demographic factors, in different countries and amongst variety of populations. Obviously, results findings differ depending on the culture, geographical area, work environment, and economic situation, etc. Thus this deviation somehow explains the variety of models and tools to investigating Burnout by researchers. There is an identical study had been conducted in the Islamic University-Gaza to investigate the prevalence of job Burnout in seven mental health centers located in Gaza amongst 118 mental health professionals, including: psychiatrists, psychiatric nurses, psychologists, and social workers, using MBI-HSS, and socio-demographic variables. They found that 54.9 % of participants are suffering from Burnout, significantly due to the educational levels, but they have not 17 found any relation with gender, age, location, marital status, income, experience, or specialization (Abu Akar, 2013). Although, not finding a relation between Burnout and specialization may be true, one study had found that 89% of psychiatrists had experienced or susceptible to developing severe Burnout. Likewise, on the regard of specialty, a study that aims to investigate the prevalence of Burnout in Australian occupational therapists was conducted. Results had found that occupational therapists who work in the mental health field are scoring higher Burnout levels, especially on the personal accomplishment subscale, than the occupational therapists working in other areas of health care. This finding had been justified by reviewing the literature of some studies where researchers had stated that the susceptibility of developing Burnout amongst occupational therapists that are in the mental health field has to do with the nature of their jobs. On this regard, a cross-sectional survey was conducted in Italy by La salvia and colleagues (2009), which aimed to explore the relation between job-related characteristics and organizational factors in developing Burnout amongst mental health staff, selecting 2000 mental health professionals, including: psychiatrists, psychologists, psychiatric nurses, occupational therapists, and social workers. The results found one in five mental health professionals had developed Burnout; psychiatrists and social workers suffered from severe emotional exhaustion (50.0% and 37.6%), and also recorded the highest levels of severe depersonalization (23.0% and 21.0%), where social workers had been the least to report scores on the personal accomplishment subscale, 18 respectively, High emotional exhaustion scores were found amongst workers who had been working in the mental health field more than one year, and recorded higher levels of depersonalization in favor of men, where the professionals who had been in the field for more than six years recorded significant high threat of developing Burnout (Lasalvia et al., 2009). Carrying to the Middle East, in Jordan a descriptive study aimed to measure Burnout levels amongst mental health nurses, in other words (psychiatric nurses) and to investigate the correlations. 181 psychiatric nurses from all mental health workplaces in Jordan were selected to complete the questionnaires. Results had shown high levels of EE and moderate levels of DP and PA (Hamadieh, 2011). Where, in the UAE a study was established by Dr. Saif Musa (2009) to investigate the prevalence of Burnout and secondary traumatic stress and its association with job satisfaction in Dubai and Alian Cities. A random sample of 180 social workers working in schools, centers, hospitals, and charity organizations had completed the given questionnaires, and analysis reported no significant differences in Burnout due to age , but a relationship existed due to workplace location (Musa, 2009). For more information about Burnout prevalence in the Arab countries, a systematic review study was conducted by Elbarazi, Loney, Yousef, & Elias (2017) to estimate the Burnout prevalence amongst health care professionals and to explore the related individual and work-related factors, selecting English and Arabic studies on this regard from 1980 to 19 2014 that used MBI. The studies varied from Bahrain, Egypt, Jordan, Lebanon, Palestine, Saudi Arabia and Yemen, Palestine and other Arab countries. Results reported high EE, high DP and low PA, where Burnout levels were associated with demographic factors, such as: gender, nationality, working years, working hours, and shift patterns. This study had considered three studies conducted in Palestine, one in Gaza and two in the West Bank, where social workers, occupational therapists, and mental health workers were included. The analysis showed that social workers in Gaza had scored higher levels of Burnout compared to the West Bank (high EE 56.2 vs. 20.0%, high DP 67.0 vs. 46.7%, low PA 85.8 vs. 53.3%; respectively) .Thus, this finding had been justified by the distinction of policy, society, culture, and working and living circumstances. Critically, this study mentions that there is an absence of research which aims to investigate Burnout in health care professions, mental health field in particular in Palestine territories (Elbarazi et al., 2017) Despite the undeniable significance of Burnout amongst mental health professionals according to the evident literature, surprisingly, the British psychological Society reported a study‟s finding which notified that mental health professionals do not recognize their own Burnout until they suffer the emotional and physical symptoms and thus their work had been already affected, even though this is the case, ironically, they tend to ignore the symptoms and do not seek help. This study had been conducted by Ledingham, Standen, & Skinner, to addresses mental health professionals recognition to their own Burnout. They selected 55 mental health 20 professionals, including: (psychologists, psychiatrists, psychiatric nurses, social workers, occupational therapists) to complete a qualitative questionnaire expressing their attitudes, perceptions and believes about Burnout and how it might affect their work life, in addition to 12 mental health professionals who were interviewed thoroughly. It is critical to mention that most participants were women aged over 40. (60 %) aged over 40, and (33 %) were over 50 (British Psychological Society, 2015). 2.5 Burnout Consequences, Preventions, and Interventions This section will illustrate the Burnout consequences, preventions, and intervention as clarified in previous studies. Consequences The literature of this study concludes the Burnout consequences amongst mental health professionals, where it is clear that when a person struggles emotional exhaustion, lacking the sense of self-worth, drained of energy, feeling negatively toward the self and the others, diminishing the sense of personal accomplishment, suffering from physical fatigue, and cannot bare the little routines such as washing up, dealing with clients and authorities, and job demands, frequently and constantly. Thus, these struggles would definitely lead to negative attitudes or turnover on authorities (Chemiss, 1980), reduced sense of commitment and belonging to the organization and to the humane mission, moreover the morality of the professionals might be effected where professionals tend to have long term sick leaves, nonetheless they do not provide the care properly, because they are barely 21 helping themselves to pass through another day. These consequences extend to job performance, services provided, and to the clients, family members, and friends. Not only would it affect the work life but also the lifestyle, and attitudes toward the others, and the quality of life in general. In severe cases it might lead to depression or suicide (Burke, Greenglass, & Konarski, 1995). There is a study that had been published by Morse and colleagues in 2012 to study Burnout consequences, prevention programs and interventions, where they analyzed eight studies from European countries which most included psychiatrists and psychiatric nurses, and two studies in the United States. Results had found (62.5%) of programs implemented in these studies succeeded to decrease Burnout development significantly amongst the mental health professionals, where trainings, supervision sessions, and workshops were involved (Morse et al., 2012). Prevention and Intervention This study demonstrated the necessity of interventions to be applied for prevention and recovery through individual programs and organizational strategies. Halbesleben & Buckley, (2004) mentioned that even though several studies found effective results from the interventions applied on individuals, some other studies did not agree with the individual-based interventions but more encouraged change in organizational environment and culture, such as workshops and trainings arrangements directed to the supervisors and 22 heads of departments to improve their leadership skills, and to be aware of workers development tools. The organization should also intend to work on the six work life areas explained by Maslach, so that professionals should be given more control, and rewarded sufficiently, where the workplace should arrange events to increase the social support between workers, balance between demands and resources, and build a workplace that is based on equity, justice, and respect, so that colleagues would share same values. With this intention, it is recommended to use both individual programs along with organizational strategies. ( Halbesleben & Buckley, 2004) In fact, a study targeted the governmental hospitals to study the Burnout and job satisfaction amongst medical social workers in Malaysia, selecting 143 participants who were distributed between 58 governmental hospitals to complete Human Service Job Satisfaction Questionnaire (HSJSQ).The results reported that the work life , and organizational culture were significantly associated with Burnout (Ean, 2017). Generally speaking, Burnout is a severe problem that effects negatively on professionals or workers in the health care professions, where they feel hopeless, irritable, impatient, and may include physical illness, poor relationships with clients, family members and coworkers, and may lose attention and memory, and in severe cases might lead to depressions and suicide as mentioned above. 23 The professional or work-related Burnout is not just about working for long hours, but a conflict between values, expectations, and resources, which often can be avoided. By addressing Burnout, and implementing interventions or prevention strategies the professionals‟ personal wellness and thus the quality of service provided would enhance and as a result the recipients will be satisfied. Summary: Clearly, from the review of Burnout literature, there is a research gap in the West Bank. For interpretation, the problem of Burnout development amongst mental health professionals as a whole working in the West Bank governmental workplaces had not been addressed so far. Additionally, due to literature we have recognized the prevalence of Burnout and its association to socio-demographic factors. 24 Chapter Three Methodology The Methodology section will demonstrate the study design, study setting, target population, sample size and technique, in addition to the questionnaire, including the used instrument for this study and its validity and reliability, besides the data collection, data analysis, ethical consideration, and difficulties of the study. 3.1 Study Design A quantitative cross-sectional study design was conducted. This research purpose was to assess the level of Burnout amongst mental health professionals working in the West Bank governmental mental health workplaces and the questions were “What is the level of Burnout amongst the target population?”, and “Are there any Significant differences between Burnout and socio-demographic factors?”, therefore the quantitative design; which is numerical based, is the regularly used method for assessment and descriptive studies, and it is usually used to determine the relationship between an independent variable (e.g. socio-demographic variables) and another dependent variable (e.g. Burnout subscales) to establish the associations, on the other hand it is not a time consuming method. 25 3.2 Study Setting This study was conducted amongst a convenient sample of mental health professionals who were working in the governmental mental health workplaces in all the West Bank districts which including: the middle region (Ramallah and Jericho), south region (Bethlehem and Heabron), and north region (Tubas, Nablus, Jenin, Qalqelia, salfeet, and Tulkarem), where East Jerusalem was excluded from this study due to practical difficulties. According to the World Health Organization- Assessment Instrument for Mental Health Systems (WHO-AIMS) report on Mental Health System in West Bank and Gaza, 2016: The Palestinian governmental agency; The Ministry of Health is taking responsibility to provide mental health services to the Palestinian people primarily and secondarily, therefore, community mental health and healing centers/clinics are secured and distributed within the West Bank regions. One psychiatric hospital located in Bethlehem and 10 primary out-patients governmental community centers/clinics distributed amongst the three regions. Professionals who offer mental health services to improve the mental health of the Palestinian people, as psychiatrists, psychologists, social workers, psychiatric nurses, and occupational therapists are estimated to be 241 according to the WHO- AIMS report in 2016, taking into consideration the probability of having more or less than this number . 26 3.3 Target Population The Mental health professionals including: psychiatrists, psychologists, social workers, occupational therapists and psychiatric nurses, were estimated to be 241 mental health professionals who work in the governmental mental health workplaces in the West Bank/Palestine. 3.4 Sample Size and technique: Table (3-1).Distribution of the Mental Health Professionals’ Socio- Demographic Data Socio-Demographic Data Frequency (%) Age (years) 20-30 years 17 12 31-40 years 59 43 41-50 years 44 32 More than 50 years 18 13 Gender Male 66 48 Female 72 52 Marital Status Single 16 12 Married 117 84 Divorced / Widowed 5 4 Monthly Income 3000 NIS and Less 14 10 More than 3000 NIS| 124 90 Location Middle Region 11 8 South Region 99 72 North Region 28 20 Educational Level Diploma 36 26 B.A 61 44 M.A 34 25 PH.D 7 5 Years of Experience Less than 5 years 11 8 Between 5-10 years 43 31 Between 11-15 years 34 25 More than 15 years 50 36 27 Professionals’ Specialty Psychiatrists 17 12 Psychologists 20 15 Social workers 22 16 Psychiatric nurses 71 51 Occupational therapists 8 6 The convenient sample of 241 mental health professionals from both genders of psychiatrists, psychologists, psychiatric nurses, social workers, and occupational therapists who are working in the governmental mental health workplaces in the three regions of the West Bank including: the middle region (Ramallah and Jericho), south region (Bethlehem and Hebron), and north region (Tubas, Nablus, Jenin, Qalqelia, salfeet, and Tulkarem), in both clinics and psychiatric hospital were taken into consideration as our population. For the record, 138 questionnaires were valid for analysis. The table (3-1) shows the distribution of the mental health professionals‟ socio-demographic data. 3.5 Questionnaire A structured questionnaire was consisted of two sections. The first section contained socio-demographic factors, which were about 8 questions including: age, gender, marital status, location of workplace, educational level, years of experience, monthly income, and specialty, in order to investigate the significant differences between the socio- demographic variable and Burnout sub-scales. 28 The second section included a Burnout measurement instrument; (MBI- HSS) Maslach Burnout Inventory – Human Services Survey. A self- reporting questionnaire, that was reliable and was validated. This tool was used globally on research investigating Burnout, consisting of 22 items answered on a 7-point Likert scale, covering three areas: emotional exhaustion, depersonalization, and personal accomplishment. However, according to Shaufeli & Taris (2005), the MBI-HSS was considered as the „gold standard‟ to measure Burnout, this tool is the most validated and most used worldwide. Instrument of the study MBI-HSS is composed of 22 questions regarding the three dimensions: nine questions to evaluate emotional exhaustion (1-2-3-6-8-13-14-16-20). Five questions to evaluate depersonalization (5-10-11-15-22) and eight to evaluate personal accomplishment (4-7-9-12-17-18-19-21). Participants would have to rate the statements on a 7-point scale ranging from 0=never to 6=every day, in more detail 0 (never), 1 (a few times per year), 2 (once a month), 3 (a few times per month), 4 (once a week), 5 (a few times per week) and 6 (every day). According to Scoring and Interpretation Key – MBI-HSS, the results of the summation of each dimension represented the score of each. For emotional exhaustion subscale, if the score was between (0-16) then the level was considered low, and if the results were between (17-26), the level was considered as moderate and high if (27 or over). For depersonalization 29 subscale, the level was considered low when the results were between (0- 6), moderate (7-12), and high if results were between (13 or over). Whereas, personal accomplishment (the reduced sense of personal accomplishment) was considered low if the results were between (0 -31), moderate (32-38), and high (39 or over), see appendix (5). A participant was considered to have a high level of Burnout when getting high scores on emotional exhaustion and depersonalization, and low scores on personal accomplishment (Qiao & Schaufeli, 2011). 3.6 Validity and Reliability The MBI was the most frequently used instrument worldwide to assess Burnout, it was valid, accepted, and reliable. It was translated into many languages and validated. The English version was as shown in appendix (4) section (C). Furthermore, the Arabic version of the Maslach Burnout Inventory as shown in appendix (3) section (C). It was validated and widely used among studies in Arabic language, some of these studies were conducted in Algeria by Nuaimeh (2013), Saudi Arabia by Al-arayda (2016), Jordan by Al-Dumur (2008) and Palestine, the West Bank in particular by Naerat (2016), and Odeh (1998). Gaza by Shalah (2015), and Abu Akar (2013). Several studies were carried out by Iwanicki & Schwab (1981) and Gold (1984) to assess internal reliability of the three subscales, which reported that the Cronbach alpha ratings of 0.90 for emotional exhaustion, 0.76 Depersonalization, and 0.76 for Personal accomplishment that were 30 reported by Schwab. In addition to Gold‟s (1984) Cronbach‟s alpha coefficient yielded .90 for Emotional Exhaustion, .74 for Depersonalization, and .72 for Personal Accomplishment. Table 3-2 Reliability (Cronbach’s Alpha) of the MBI subscales Measure No of items Cronbach‟s α MBI subscales Emotional exhaustion (EE) 9 0.91 Depersonalization (DP) 5 0.88 Personal Accomplishment (PA) 8 0.85 All MBI subscales 22 0.85 In this study, a Cronbach‟s Alpha for MBI subscales (table 3-2) were: emotional exhaustion (0.91), depersonalization (0.88), and personal accomplishment (0.85), and for all MBI subscales (22 items) questionnaire (0.85), as shown in table (3-2). 3.7 Data Collection The data collection process took place in the mental health centers in the middle region (Ramallah, and Jericho), north region (Nablus, Jenin, Tubas, Salfit, Tulkarm, Qalqelia), and south region (Hebron, and Bethlehem), in addition to the psychiatric hospital located in Bethlehem. The questionnaires were delivered to the officials by hand. Whereas, the researcher had explained to the participants briefly about the purpose of this study, and the completing process of the questionnaires, and reassured their confidentiality reservation, and confirmed their right for not answering the questions they don‟t want to answer, and their capability to withdraw from the study without any consequences. 31 The questionnaires were collected at the same day of visit to each workplace, expect the psychiatric hospital in Bethlehem due to the nature of work in hospitals, mental health professionals work on day or night shifts, therefore, the questionnaires were collected after 10 days of the distribution. The whole data collection process took time from the first of October 2018, till the 31 of October 2018. Bearing in mind the questionnaire was timesaving. 3.8 Data Analysis All collected data were analyzed using Statistical Package for the Social Sciences (SPSS) version 20, which was used to analyze survey data and to get the results of all research questions. One way- ANOVA test was used to measure the differences in MBI-HSS subscales due to socio-demographic variables which contain more than two variables (age, marital status, workplace location, educational level, years of experience, and specialty), and independent t-test for socio-demographic variables that contained two variables (gender and monthly income). P -value ≤ 0.05, p-value = 0.001, and p-value = 0.004 were considered to be statistically significant in all cases. 3.9 Ethical consideration The research was conducted after the Graduate Studies Council (appendix 7) and IRB approval (appendix 6), in addition to the approval of the Ministry of Health that was acquired and attained (appendix 8). 32 Afterwards the questionnaires (appendix 3, sections B & C) and participant information sheet (appendix 2) were distributed amongst the study participants after receiving their absolute consent, and the purpose of the study was adequately explained. Confidentiality of participants was reserved and the data were collected for the study use only in accordance to the principles of research ethics. Moreover, each participant had the right to withdraw freely from the study without any consequences. The study was conducted after participants consent (appendix 3 section A) 3.10 Limitation of the Study The main limitation in this study is the partially filled or incomplete questionnaires. Also some participants have filled the questionnaires chaotically or have withdrawn in the last minutes. As a result, 149 questionnaires have been reduced to 138 valid questionnaires for analysis. Summary: A quantitative cross-sectional study was conducted, utilizing the MBI-HSS tool to measure Burnout, selecting a random representative sample of 149 mental health professionals who are working in the West Bank governmental mental health, counting 138 valid questionnaires for analysis. 33 Chapter four Results This section will analyze the level of Burnout due to EE, DP, & PA, and the significant difference on MBI-EE, MBI-DP, and MBI-PA due to socio- demographic factors. 4.1 Introduction The results and findings of the 138 analyzed questionnaires will be presented statistically in order to answer the following thesis questions: “Is Burnout present amongst mental health professionals in the West Bank governmental mental health workplaces?”, “What is the level of Burnout amongst the mental health professionals in the West Bank governmental mental health workplaces due to the three MBI subscales items?”, and “Are there any significant differences between Burnout on the three MBI subscales and the given socio-demographic factors?”. Through finding means, standard deviations, and p-value. 34 4.2 Level of Burnout amongst Mental Health Professionals Table (4-1). Levels of Burnout amongst Mental Health Professionals based on MBI-HSS Subscales: Emotional Exhaustion (EE), Depersonalization (DP), Personal Accomplishment (PA). Subscale Overall Mean (SD) Burnout Low Moderate High No (%) No (%) No (%) Emotional Exhaustion (EE) 23.09 (13.5) 45 (33) 42 (30) 51 (37) Depersonalization (DP) 8.09 (7.93) 70 (51) 26 (19) 42 (30) Personal Accomplishment (PA) 31.11 (10.63) 65 (47) 32 (23) 41 (30) *SD = Standard Deviation * High Burnout: EE score ≥27, DP ≥13, PA (0-13) *Moderate Burnout: EE score (17-26), DP (7-12), PA (32-38) *Low Burnout: EE score (0-16), DP (0-6), PA ≥39 *PA: Low score indicates high Burnout, and high score indicates low Burnout on the PA “Is Burnout present amongst mental health professionals in the West Bank governmental mental health workplaces?” It is clear from table (4-1), that out of the 138 mental health professionals who completed the MBI-HSS, on the EE scale, 45 (33%) of the respondents scored low, 42 (30%) scored on moderate, and 51 respondents (37%) scored high on the emotional exhaustion subscale. Whereas, on the DP subscale, 70 (51%) respondents scored low, 26 (19%) scored moderate, and 42 (30%) of the respondents scored high on the depersonalization subscale. Meanwhile, on the PA subscale, 65(47%) respondents scored low, 32 (23%) respondents scored moderate, and 41 (30%) professionals scored high. 35 The mental health professionals have reported the mostly high levels of Emotional Exhaustion subscale (EE) (37%), low levels of Personal Accomplishment (PA) (47%), and low levels of depersonalization (DP) (51%). Also, the table shows the overall mean of EE, DP, & PA. The scores are moderate Burnout on EE score (17-26), & DP (7-12), while nearly moderate on PA (32-38). Scores that indicate negative condition in any two of the three subscales, indicates the presence and occurrence of Burnout (Cogan & Gunay, 2015; Holmes et al., 2014). Therefore, Burnout is present amongst mental health professionals in the West Bank governmental mental health workplaces. 4.2.1 Level of Burnout amongst Mental Health Professionals due to EE Items Table (4-2). The means and Standard Deviations of Emotional Exhaustion (EE) by Items Item Mean SD Rank I feel emotionally drained from work. 2.62 1.93 4 I feel used up at the end of the workday. 3.30 1.91 1 I feel fatigued when I get up in the morning and have to face another day on the job 2.70 2.02 3 Working with patients is a strain. 3.01 1.92 2 I feel burned out from work. 2.57 2.03 6 I feel frustrated by job. 1.94 1.92 8 I feel I'm working too hard on my job. 2.59 2.00 5 Working with people puts too much stress. 2.51 1.84 7 I feel like I‟m at the end of my rope 1.84 2.10 9 Emotional Exhaustion (EE) 23.09 13.5 36 “What is the level of Burnout amongst the mental health professionals in the West Bank governmental mental health workplaces due to the three MBI subscales items?” In order to answer this question, the researcher has found the mean and the standard deviation for each item on the emotional exhaustion subscale. Table (4-2) shows, the greatest symptom of the emotional exhaustion appears to be “I feel used up at the end of the workday” (mean = 3.30), followed by “Working with patients is a strain” (mean = 3.01), the item “I feel fatigued when I get up in the morning and have to face another day on the job" comes after with (mean=2.70). The least symptom of emotional exhaustion is “I feel like I‟m at the end of my rope” (mean = 1.84). The mean score of emotional exhaustion (EE) equals (23.09), which is between (17- 26). The level of EE dimension is considered to be moderate. 4.2.2 Level of Burnout amongst Mental Health Professionals due to DP Items Table (4-3) .The Means and Standard Deviation of Depersonalization (DP) by Items Item Mean SD Rank I treat patients as impersonal „objects‟. 1.32 1.82 5 I‟ve become more callous toward people. 1.68 2.01 3 I worry that this job is hardening emotionally. 1.80 2.05 1 I don‟t really care what happens to patients. 1.57 1.93 4 I feel patients blame me for their problems. 1.72 1.90 2 Depersonalization (DP) 8.09 7.93 37 Table (4-3) shows, the greatest symptom of depersonalization appears to be “I worry that this job is hardening emotionally.” (Mean = 1.80), followed by “I feel patients blame me for their problems.” (Mean = 1.72), the item “I‟ve become more callous toward people" comes after with (mean=1.68). The least symptom of depersonalization is “I treat patients as impersonal „objects‟. (Mean = 1.32). The mean score of depersonalization (DP) equals (8.09) which is between (7- 12). The level of DP dimension is considered to be moderate. 4.2.3 Level of Burnout amongst Mental Health Professionals due to PA Items Table (4-4). The Means and Standard Deviations of Personal Accomplishment (PA) by Items Item Mean SD Rank I can easily understand patients‟ feelings. 3.55 1.99 8 I deal effectively with the patients‟ problems. 3.90 1.90 3 I feel I'm positively influencing other people's lives through my work. 4.18 1.86 1 I feel very energetic. 3.80 1.91 7 I can easily create a relaxed atmosphere. 3.86 1.82 5 I feel exhilarated after working with patients. 4.08 1.88 2 I have accomplished many worthwhile things in my job. 3.87 1.85 4 I deal with emotional problems calmly. 3.86 1.92 6 Personal Accomplishment (PA) 31.11 10.63 Table (4-4) shows, the greatest symptom of personal accomplishment appears to be “I feel I'm positively influencing other people's lives through my work” (mean = 4.18), followed by “I feel exhilarated after working 38 with patients” (mean = 4.08), the item “I deal effectively with the patients‟ problems" comes after with (mean=3.90). The least symptom of personal accomplishment is “I can easily understand patients‟ feelings”. (Mean = 3.55). The mean score of personal accomplishment (PA) equals (31.11), which is between (32- 38). The level of PA dimension is considered to be nearly moderate. 4.3 Differences of MBI due to Demographic Variables In order to answer the question “Are there any significant differences between Burnout on the three MBI subscales and the given socio- demographic factors?” The researcher considers every dimension with the demographic variables, where differences are judged to be statistically significant when p-value ≤ 0.05, p- value = 0.001, and p- value = 0.004 4.3.1 Differences of MBI- EE due to the Demographic Variables Table (4-5) Differences of MBI-EE Scores due to Socio-demographic Variables (results from One-way ANOVA) Variable Mean SD F value P value Age 20-30 years 23.29 14.16 0.40 0.75 31-40 years 22.86 13.22 41-50 years 24.43 14.56 > 50 years 20.33 11.20 Marital status Single 17.38 13.49 3.12 0.05 Married 24.26 13.29 39 Divorced or widow 14.00 11.00 Workplace Location Middle Region 22.82 11.67 0.92 0.40 South Region 23.97 12.98 North Region 20.07 15.64 Educational Level Diploma 23.83 11.36 0.98 0.40 Bachelor 21.77 13.25 Master 23.09 14.91 Ph.D. 30.71 17.71 Years of Experience Less than 5 years 20.91 15.12 0.33 0.81 5-10 years 24.09 14.33 11-15 years 21.68 13.64 More than 15 years 23.66 12.44 Specialization Psychiatrist 29.88 14.99 3.68 0.004 Psychologist 16.90 11.88 Social worker 16.32 13.04 Psychiatric nurse 25.56 12.73 Occupational therapist 20.71 9.84 The differences of Burnout regarding Emotional Exhaustion (EE) due to age, marital status, workplace location, educational level, years of experience, and specialization, were examined by One-Way ANOVA test. The One-Way ANOVA test results displayed in table (4-5) showed no significant difference in MBI-EE level between the age groups (P-value = 0.75), educational levels (P-value = .760), years of experience (P-value = 0.81), or workplace locations (F=0.92, P-value = 0.40). However, there was a significant difference in MBI-EE means between marital status groups (F=3.12, P-value = 0.05) due to the married with (mean = 24.26), and professionals‟ specialization (F=3.61, P-value = 0.004), to the psychiatrists with (mean =29.88). 40 Table (4-6) Differences of MBI- EE Scores due to Gender and Monthly income Variable (results from independent t-test) Variable Mean SD t- value P value Gender Male 26.50 14.34 2.93 0.004 Female 19.96 11.85 Monthly income 3000 Nis and less 21.71 15.36 -0.40 0.69 More than 3000 Nis 23.24 13.28 The differences of Burnout regarding Emotional Exhaustion (EE) due to gender and monthly income are examined by Independent-t test. The Independent-t test results displayed in table (4-6), it showed there is a significant difference in MBI-EE level between males and females professionals with (P-value = 0.004), male workers got higher mean score than females, while there is no significant differences in monthly income(P=0.69). 4.3.2 Differences of MBI- DP due to the Demographic Variables Table (4-7) Differences of MBI- DP Scores due to Socio-demographic Variables (results from One-way ANOVA) Variable Mean SD F value P value Age 20-30 years 10.94 8.17 1.37 0.26 31-40 years 7.83 8.36 41-50 years 8.36 8.17 >50 years 5.61 4.69 Marital status Single 4.75 6.95 2.44 0.09 Married 8.72 8.03 Divorced or widow 4.20 5.22 Workplace Middle Region 6.36 6.92 0.30 0.74 41 Location South Region 8.32 8.02 North Region 7.96 8.17 Educational level Diploma 9.81 7.13 0.93 0.43 Bachelor 7.30 7.96 Master 7.41 9.00 Ph.D. 9.57 5.77 Years of experience Less than 5 years 8.64 8.36 0.16 0.92 5-10 years 8.60 8.17 11-15 years 7.41 8.09 More than 15 years 8.00 7.74 specialization Psychiatrist 7.53 6.29 5.02 0.00 Psychologist 4.65 6.60 Social worker 4.32 7.74 Psychiatric nurse 10.97 7.93 Occupational therapist 3.00 4.69 Table (4-7) shows no significant difference in MBI-DP level between the age groups (P-value = 0.26), marital status (P-value = .09), educational levels (P-value = .43), years of experience (P-value = 0.92), or workplace location (p-value = 0.74). However, there is a significant difference in MBI-DP means due to Specialization (F=5.02, P-value = 0.00), the highest among professionals who are psychiatric nurses with mean (10.97). Table (4-8) Differences of MBI- DP Scores due to Gender and Monthly income Variable (results from independent t-test) Variable Mean SD t- value P value Gender Male 10.42 8.52 3.43 0.001 Female 5.96 6.73 Monthly Income 3000 Nis and less 7.21 7.28 -0.44 0.66 More than 3000 Nis 8.19 8.03 42 Table (4-8) shows significant differences in MBI-DP level between males and females professionals with (P-value = 0.001), male workers got higher mean score than females, while no significant differences are found due to monthly income (p-value = 0.66) 4.3.3 Differences of MBI- Personal Accomplishment (PA) due to the Demographic Variables Table (4-9) Differences of MBI-PA Scores due to Socio-demographic Variables (results from One-way ANOVA) Variable Mean SD F value P value Age 20-30 years 25.47 10.88 2.80 0.04 31-40 years 30.46 11.46 41-50 years 32.66 9.76 >50 years 34.78 7.53 Marital status Single 33.44 8.76 0.45 0.64 Married 30.85 10.61 Divorced or widow 29.80 16.98 Workplace Location Middle Region 35.91 6.47 1.92 0.15 South Region 30.10 11.02 North Region 32.79 10.04 Educational level Diploma 29.81 9.02 0.31 0.82 Bachelor 31.77 10.32 Master 31.56 12.65 Ph.D. 29.86 11.92 Years of experience Less than 5 years 31.45 9.45 1.12 0.34 5-10 years 29.47 10.34 11-15 years 30.00 13.33 More than 15 years 33.20 8.86 specialization Psychiatrist 33.06 10.07 3.30 Psychologist 33.85 10.66 43 Social worker 35.68 12.35 0.01 Psychiatric nurse 27.80 9.72 Occupational therapist 36.71 5.22 Table (4-9) above shows no significant difference between marital status (P-value = .64), workplace location (P-value = 0.15), educational levels (P- value = .82), years of experience (P=0.34). However, there is a significant difference in MBI-PA means between specialization groups (F=3.30, P- value = 0.01) due to occupational therapists with mean (36.71), and age groups (F=2.80, P-value = 0.04) due to professionals who are more than 50 years old with mean (34.78). Table (4-10) Differences of MBI-PA Scores due to Gender and Monthly income Variable (results from independent t-test) Variable Mean SD t- value P value Gender Male 30.52 10.32 0.39 0.53 Female 31.65 10.95 Monthly Income 3000 NIS and less 31.14 10.52 0.01 0.99 More than 3000 NIS 31.10 10.68 Table (4-10) shows no significant difference in MBI-PA level between males and females workers with (P-value = 0.53) or monthly income (p-value = 0.99). Summary: The mental health professionals who work in the west Bank governmental mental health workplaces were found to suffer a moderate level of Burnout on Emotional exhaustion, and depersonalization, while nearly moderate on the personal accomplishment subscale. Whereas, the 44 mental health professionals have reported the mostly high levels on (EE) (37%), low levels on (PA) (47%), and low levels on (DP) (51%). Significant differences between independent variables (socio- demographic), and dependent variables (Burnout level on EE, DP, and PA) were found due to gender, age, specialization, and marital status. 45 Chapter Five Discussion This chapter will discuss the major findings of the present study comparably to the literature related to Burnout. The found significant differences between socio-demographic variables and Burnout level will be interpreted, and justified according to the researcher. Additionally, the conclusion, strengths and limitations, recommendations, and the implication of the study will be settled. 5.1 Prevalence of Burnout This study have found that Burnout is present in a moderate level on (EE) with an overall mean of (23.09), & (DP) with the mean (8.09).While nearly moderate on the (PA) with mean (31.11).Most of the population have reported high level on (EE) (37%), low level on (PA) (47%), and (DP) (51%). Burnout had been often reported in moderate and high levels amongst mental health professionals (Maslach & Leiter, 2008). However, according to the literature, the prevalence of Burnout in Arab countries are comparable to the non-Arabic speaking countries such as United States of America, Canada, Britain, France, etc. Some Burnout studies results were congruent and some other studies exceeded the levels (Elbarazi et al., 2017). Correspondingly, our present study finding is suitable. In this section, we will compare this study with similar and incompatible findings with other national and international studies for each subscale. 46 5.1.1- Emotional Exhaustion subscale Most of the studies, have found high level reports of emotional exhaustion by the mental health professionals. Congruently with a study established in Pakistan, by Muhammad & Nawaz (2014), where the results shows very high scores on emotional exhaustion amongst the subjects who are suffering from moderate job Burnout, and similarly to Adenkan et al. (2008),and Ashtari et al. (2009). 5.1.2 Depersonalization Similar to Selmanovic et al. (2011), most of the population has scored low on (DP), unlike La salvia et al. (2009); their population reports highly on depersonalization amongst the mental health staff in Italy. 5.1.3 Personal accomplishment Our study reports that (47 %) of mental health professionals score highly on the low score of personal accomplishment, which means most of the participants suffer from reduced sense of personal accomplishment, Likewise Alhajjar et al. (2013), where social workers in Gaza score similarly, in addition to Abu Akar, (2013), in which most of the mental health professionals in Gaza suffered from reduced sense of personal accomplishment. The results of Hamadieh (2011) reports are incompatible with the present study, where most of psychiatric nurses have high scores on the moderate personal accomplishment subscale in Jordan. In addition to Sturgess & Poulsen (2013) study, in which occupational therapists in the 47 mental health field have significantly more Burnout on the reduced sense of personal accomplishment. 5.2 Significant differences between socio-Demographic factors and Burnout The significant differences between socio- demographic variables and Burnout level are found in this study on the three subscales due to marital status in favor to the married (MBI-EE), specialization in favor to psychiatrists (MBI-EE), psychiatric nurses (MBI-DP), and occupational therapists (MBI-PA), gender in favor to men (MBI-EE) (MBI-DP), and age groups in favor to the mental health professionals who are more than 50 years old (MBI-PA). Canadas-De la Fuente et al. (2018), had found a significant relation between depersonalization and marital status (r = 0.047). Also, they have found that Single, or divorced men were related to highest levels of Burnout and had higher tendency to present negative attitudes towards clients and coworkers at the workplace. This study is against the present study findings. The justification might be that married people have great responsibilities toward their children, families, and work. Also, burden can be greater in favor to the financial support, especially in Palestine, as alleged by the researcher. This finding has been justified by the literature review according to the researcher by explaining the challenges psychiatrists and psychiatrist nurses have to confront every day, where they providing care to recipients 48 who might behave violently, along with high job demands, restricted regulations, and dealing with family members of clients, as a result they will be emotionally exhausted and cynical. Likewise, an Australian study by Thomas, Kohli, and Choi in (2014) had found that occupational therapists who work in the mental health field are scoring higher Burnout levels, especially on the personal accomplishment subscale, than the occupational therapists working in other areas of health care. We assume that researchers have stated that the susceptibility of developing Burnout amongst occupational therapists working in the mental health field has to do with the nature of their jobs, where they are dependent on authority, and not considered as team players. Regarding the gender, Brake, Bloemendal, & Hoogstraten, (2003) findings are compatible to our study, but unlike Benbow & Jolley (2002), and Hastings & Bham (2003),where they had not found any differences between males and females. According to the researcher , these results might be justified by the natural capability of women in multi-tasking, while men operate better when duties are one at a time, also Palestinian women are supported socially by their families in particular. Boštjančič, Kocjan, & Stare (2015) in Slovenia, have found that individuals in different categories has differed significantly in terms of age. The younger respondents; under 30 years of age, had experienced low personal accomplishment and high emotional exhaustion, while the respondents who are over 49 years had experienced low Burnout. Another study in Lahore, Pakistan to investigate the “relationship between Job Burnout and Gender- 49 Based Socio-Demographic Characteristics”, found that Burnout was related to age, where (24–35 years) groups recorded high level of Burnout, because of being shocked of reality or early career Burnout (Nabi Khan, 2013). On the other hand, other studies have the opposite findings, where results are relatively similar to our study. One study in Pakistan has found Burnout level is the highest amongst the older participants (Ahola et al., 2008). Ending at a study in Iran has been conducted to evaluate the levels of Burnout amongst nurses in Shiraz Nemazee Hospital. The results found significant differences between depersonalization with age, where age groups 41- 50 scored the highest (Shafaghat & Kavosi, 2016). Assumingly, older mental health professionals score highly in the reduced sense of personal accomplishment might not be having more capacity to adapt or cope with work-related stress, or even with the work environment changes and challenges, like new job system, or new technologies, which as a result causes a loss of sense in their achievement in the profession. 5.3 Conclusion The reviewed literature compatibly with the present study, confirm that Burnout prevalence varies undeniably in the Worldwide. The lack of resources along with high demands factor is assumed for Burnout presence in the West Bank amongst the mental health professionals working in the governmental mental health workplaces. The WHO-AIMS report in 2016 had confirmed that the shortage of resources in the West Bank, whether they are financial resources or human resources 50 are effecting severely on the development of the mental health area, not to mention the scarcity of mental health professionals comparatively with the number of the West Bank population (2.3 million). Not to mention, the shortage in facilities where only one psychiatric hospital is established in the West Bank which is located in Bethlehem (WHO-AIMS, 2016). Furthermore, it has been reported by Dr. Samah Jaber; chair of the Mental Health Unit at the Palestinian Ministry of Health, and her colleagues that there are only 20 psychiatrists in the West Bank, in which most of them work in the private sector, and the mental health field is definitely struggling from health care personnel shortage. Moreover, the mental health problems are usually managed by general practitioners, who are not able to receive consultation for severe and complicated cases, in addition to the lack of clinical exposure in the training programs (Jaber et al., 2013). 5.4 Strengths of the Study This study is the first to be conducted to investigate Burnout amongst the mental health professionals in the governmental community mental health workers in the West Bank. The MBI-HSS instrument “is currently considered as the „gold standard‟ to measure Burnout, this tool is the most validated and most used worldwide” (Schaufeli & Taris, 2005, P.256). 5.5 Difficulties of the Study The process of the questionnaire distribution amongst the districts of the West Bank was not flexible as anticipated. The distance between the location of the administration buildings and the community mental health 51 centers in some districts was one of the main endured difficulties. Taking into consideration, the consent form that was sent by the Palestinian Ministry of Health to the primary health care centers was obligated to be received directly by the researcher from the administration building to be delivered to the authorized members in the primary health care centers. For this fact, the mobility by public transportation was time, energy and money consuming. Additionally, some mental health professionals did not accept to participate in the study, and some questionnaires were filled out carelessly. 5.6 Recommendations  Improving the organizational culture, by embracing transparency, recognizing and rewarding valuable contributions, cultivating strong relationship between coworkers and officials, and giving regular feedback.  Creating events, training programs, and workshops to talk about Burnout as the main matter, so mental health workers can talk, share, and express their experiences openly without feeling unprofessional, and to develop effective communication skills and establishing a good relationship with the mental health workers, so they can seek help without restrictions or fear of rejection, and providing supervisors for the mental health workers.  Assessing Burnout amongst mental health professionals every few months, by creating survey software using the MBI-HSS tool to investigate 52 its prevalence and Engaging occupational therapists in team work, so a team atmosphere can be promoted.  Expanding the studies to explore causes of the Burnout, and using longitudinal designs to confirm the risk factors.  It is necessary for the governmental institutions or organizations to adapt with the changes that are happening in the world, and not to restrict old management strategies on new generations who are filled with complete different perspectives.  Clarifying duties and job description, and career development plan and providing sufficient job resources and decreasing heavy demands when necessary. 5.7 Implication of the Study This study has enriched the research of the West Bank. It highlighted the matter of Burnout presence amongst the mental health professionals who are working in the governmental mental health workplaces and investigated the association between Burnout and socio-demographic factors, in the time when research is absent. The target of this study is to spot a light on Burnout amongst the mental health professionals for further seeking of attention, intervention and prevention from the officials for a better provided quality of mental health care services and better quality of life. Furthermore, the literature has mentioned strategies to prevent and treat this issue, and noted some recommendations which are likely to be effective for 53 the mental health workplaces in the West Bank, Palestine. 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