Introduction

Burnout is a psychosomatic syndrome with three dimensions: emotional exhaustion, feelings of depersonalization, and reduced personal accomplishment [1]. With improvements in the social security system and reform of the medical system in China, the accompanying increasing cost of medical treatment, excessive workload, excessive prescribing behavior, tense doctor-patient relationships, burnout syndrome is common in medical workers [2–4]. A recent national survey of the fourth national health services indicated that job satisfaction influences medical workers' burnout and intention to leave their organization [5, 6]. The recent surge in medical disputes, such as violent riots, attacks, and protests in hospitals, have greatly increased the psychological burden for medical workers [4]. Tasks related to scientific research also add to the pressure on medical workers. If these pressures cannot be relieved, emotional exhaustion would result in burnout.

Work-family conflict is a phenomenon first proposed by Greenhaus et al. (1985). They reported that changes in the work environment (promotion and further education) would occupy more family time, while marriage and births of children could influence work efficiency [7]. Frone and Michael et al. found that good family support reduces individuals' negative experiences at work [8], and other studies confirm that the work-family relationship is associated with burnout syndrome [9–11].

Lazarus and Folkman proposed the transaction model of stress, and indicated that perceived social support is based on an individual's assessment of the support available in a given situation, including availability of support and satisfaction with support [10]. Cohen and Wills report that having a source of support available in a stressful situation can significantly decrease its harmful impact [12]. By seeking social support, individuals can find sympathy or help from others and obtain effective coping strategies; conversely, individuals would experience burnout syndrome if they do not get social support [13].

Job satisfaction is an important variable for predicting burnout syndrome [14–16] that affects burnout syndrome through organizational commitment [17–20]. Moreover, intrinsic and extrinsic job satisfaction significantly influences burnout in clinical physicians and nurses through social support, work environment, and work hours [21, 22]. Thus, job satisfaction is a meaningful factor in occupational burnout syndrome. Previous studies in various countries have investigated the correlation of job satisfaction with burnout among corporate employees and nurses [23–28], but few have reported on these correlations in Chinese physicians and public health workers [6].

The concept of burnout was first proposed by Freudenburger in the 1970s, and is widely discussed in clinical psychology [29]. Burnout means the wearing out of an individual due to excessive demands on his or her resources. According to Schaufeli’s theory, burnout may cause exhaustion, result in indifference toward work, and decrease job satisfaction and professional efficacy [30]. The correlation between burnout and job satisfaction has been examined in many previous studies [24, 31, 32]. Some have reported that lack of social support at work significantly contributes to occupational burnout [33, 34]. Although many studies have investigated the relationship among job satisfaction, social support, and occupational burnout, none has evaluated the interrelationship of occupational burnout, work-family conflict, social support, and job satisfaction among physicians, nurses, and public health workers. Therefore, we carried out a cross-sectional study to estimate the role of work-family conflict, self-reported social support, and job satisfaction in burnout syndrome among medical workers in southwest China.

Materials and methods

Results

A total of 1382 medical workers were enrolled in the sample group. Of these, 807 were clinical physicians, 404 were nurses, and 171 were public health workers. The socio-demographic characteristics of investigated subjects are shown in Table 1. Of the 1382 medical workers, 59.6% were female, 71.2% were above 30 years of age, 74.7% had attained a bachelor degree or above, 40.0% had fewer than 10 service years, and 77.0% had no administrative duties.

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Table 1. Socio-demographic characteristics of investigated subjects.

https://doi.org/10.1371/journal.pone.0171679.t001

The mean scores for emotional exhaustion, job dedication, and job engagement were 14.778±7.857, 14.249±8.148, and 10.513±6.697, respectively (Table 2). The level of work-family conflict was high, with mean scores for conflicts of time, behavior, and pressure of 11.339±3.194, 10.133±3.131, and 10.873±3.354, respectively. The mean score of self-reported social support was 9.574±2.329. Levels of job satisfaction were relatively high, with mean scores for satisfaction with the job itself, work environment, job rewards, organizational management, and medical practice environment of 8.878±2.264, 8.659±1.992, 7.215±2.545, 4.773±1.208, and 3.578±1.370, respectively.

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Table 2. Mean values of burnout syndrome, work family conflict, social support at work and job satisfaction of the investigated subjects.

https://doi.org/10.1371/journal.pone.0171679.t002

The correlation of burnout syndrome with job satisfaction, work-family conflict, and self-reported social support was evaluated by Pearson correlation analysis (Table 3). Burnout syndrome was positively related to three dimensions of work-family conflict (P<0.001), but negatively correlated with five dimensions of job satisfaction (all P values<0.001). Burnout syndrome was negatively associated with self-reported social support (P<0.001).

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Table 3. Pearson correlation analysis of the relationship of work-family conflict, social support at work, and job satisfaction with burnout syndrome.

https://doi.org/10.1371/journal.pone.0171679.t003

The influence of demographic factors, work-family conflict, self-reported social support, and job satisfaction on burnout syndrome was analyzed by a four-stage general linear model (Table 4). In the general linear regression models, work-family conflict, self-reported social support, and job satisfaction were considered as principal predictors.

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Table 4. General linear model analysis with burnout syndrome dimensions as a dependent variable.

https://doi.org/10.1371/journal.pone.0171679.t004

In Model 1, our analysis indicated that demographic factors contributed a 5.4% criterion variance in burnout syndrome (F = 4.720, P<0.001, R² = 0.054). In Model 2, we added a work-family conflict dimension into the analysis based on Model 1, and observed that it accounted for a 2.6% variance in burnout syndrome (F = 5.93, P<0.001, R² = 0.080). In Model 3, we added self-reported social support to Model 2, and found that it explained 5.7% of the variance in burnout syndrome (F = 9.532, P<0.001, R² = 0.137). In Model 4, job satisfaction dimensions were brought into the analysis based on Model 3, and accounted for 17.8% of the variance in burnout syndrome (F = 21.608, P<0.001, R² = 0.315).

In Model 4, female gender emerged as a predictor of burnout syndrome compared to male [b = -2.937, 95% CI = (-5.294, -0.580), F = 5.977, P = 0.015]; a lower technical title was related to higher level of burnout syndrome [b = 10.727 for no title, 95% CI = (5.026, 16.429), P<0.001; b = 11.282 for medical assistant, 95% CI = (60184, 16.381), P<0.001; b = 8.228 for resident physician, 95% CI = (4.131, 12.326), P<0.001; b = 5.687 for attending physician, 95% CI = (1.925, 9.450), P = 0.003; F = 5.024, P = 0.001; reference group: above associate chief physician]; and lack of administrative duties was associated with higher level of burnout syndrome [b = 2.618, 95% CI = (0.074, 5.162), F = 4.076, P = 0.044] relative to workers with administrative duties. Conflict of time between work and family was correlated with burnout syndrome [b = -0.067, 95% CI = (-0.118, -0.017), F = 6.818, P = 0.009]. Self-reported social support [b = -0.130, 95% CI = (-0.187, -0.073), F = 19.931, P<0.001], job-itself satisfaction [b = -0.331, 95% CI = (-0.392, -0.271), F = 117.237, P<0.001], job rewards satisfaction [b = -0.058, 95% CI = (-0.113, -0.004), F = 4.391, P = 0.036] and organizational management satisfaction [b = -0.076, 95% CI = (-0.124, -0.028), F = 9.550, P = 0.002] were negatively associated with level of burnout syndrome.

Discussion

This study investigated the relationship of social-demographic factors, work-family conflict, self-reported social support, and job satisfaction with burnout syndrome among medical workers in southwestern China. We observed that female gender, having a lower technical title and lacking administrative duties were positive predictors for burnout syndrome. Moreover, we found that job satisfaction greatly influenced the level of burnout syndrome, and that work-family conflict and self-reported social support had smaller effects.

In our general linear model analysis, we observed that 2.6% of the variance in burnout syndrome was explained by work-family conflict, principally conflicts of time. A recent meta-analysis of 20 published studies indicated that nursing professionals are vulnerable to depression when they experience conflicts between family and work [37], and depression may promote burnout syndrome. Shanafelt et al. performed a large sample study of 24,922 American surgeons, and reported that work-family conflict was independently associated with burnout [9]. Only 36% of participating surgeons felt that they had enough time for their personal and family life [9]. Martini performed a study in 307 medical workers, and reported that strong work-family conflicts significantly contributed to burnout syndrome [11]. Our findings are in line with such previous results. Time spent taking care of children and housework can impact energy devoted to work [8, 11], while family support helps equip individuals with more energy, confidence, and enthusiasm for their work.

Self-reported social support explained 5.7% of the variance in burnout syndrome in our study. Social support could bring more confidence, satisfaction, and enthusiasm in work, and high social support equates to great social status [10]. Rzeszukek M et al. indicate that the level of burnout symptoms is related to perceived social support [38]. Richa et al. performed a study in French workers, and reported that lack of social support from supervisors, colleagues, and the social community at work, along with work-family conflict, significantly increased burnout [39]. These studies indicate that strong social support at work could reduce burnout syndrome, which supports the findings of our study.

We found that job satisfaction accounted for 17.8% of the variance of burnout syndrome, making it a great influence on the level of burnout syndrome compared with other factors. Satisfaction with the job itself, job rewards, and organizational management each had significant negative associations with burnout. High satisfaction with job rewards corresponds with high income, which would promote individuals' enthusiasm for work and reduce their negative feelings about it [39]. Organizational management includes system construction and leadership behavior; satisfaction with organizational management indicates high-quality leadership and support from supervisors. Zhang et al. reported that satisfaction with the job itself, job rewards, and organizational management were negatively correlated with emotional exhaustion, which directly affects burnout syndrome [6]. However, satisfaction with the work environment and environment for medical practice did not influence burnout [6]. These results are in line with our findings.

Females had a higher level of burnout syndrome in our general linear model analysis than males. Similarly, one study of 5558 neurologists reported that females had lower levels of job satisfaction than males [23]. In general, females are not only responsible for paid work, but also spend more time on housework and caring for children than do males. In addition, a recent study indicates that female physicians more often work in part-time jobs than males, and leading positions are mostly held by male physicians [40]. Therefore, female physicians are more vulnerable to high levels of emotional exhaustion and depression compared to males [40]. These factors may result in burnout syndrome at work. Female medical workers should be given more care and support in their work.

We observed that the medical workers with lower-level technical titles had more burnout syndrome than those with higher-level titles. A recent study similarly indicated that different technical titles were associated with different levels of burnout syndrome [41]. Medical workers with lower technical titles tend to have lower income, higher pressure to attain promotions, fewer social resources, and more energy devoted to coping with problems in work, which may influence their job satisfaction and result in burnout syndrome. Conway et al. indicated that lower technical titles were correlated with relatively high turnover, whereas those with higher technical titles stayed in jobs for longer [42]. Spending longer in a position corresponds with good work experiences and more resources and support from supervisors, which may reduce burnout syndrome. Similarly, those with administrative duties have more opportunities for promotions and greater social resources, and thus have less risk of suffering from burnout syndrome.

In models 1 and 2 of our general linear model analysis, gender and technical title were not associated with burnout syndrome; rather, these two factors became significant in the combined analysis with self-reported social support and job satisfaction in Model 3. Therefore, the relationships between burnout syndrome and gender and technical title may be influenced by self-reported social support and job satisfaction.

Three strengthens of this study should be mentioned. First, a self-administered questionnaire was used, and subjects were unaware of the research hypothesis. Therefore, information bias could be avoided. Second, Sichuan Province has a population of about 80 million, accounting for 41.67% of the population of southwest China, and is home to 55.18% of southwest China’s medical workers [43]. Thus, our sample is likely representative of southwest China. Third, our study was the first to investigate the association of work-family conflict, self-reported social support, and job satisfaction with burnout syndrome in medical workers of southwest China.

Two limitations should be considered. First, the questionnaire used is not an international questionnaire, but was developed to fit conditions in China. However, the questionnaire has shown good reliability and validity [36]. Second, this was a cross-sectional study, meaning it had low power to detect causal effects. Therefore, perspective studies are needed to confirm our findings.

Conclusions

In conclusion, the present study suggests that work-family conflict and self-reported social support slightly affect the level of burnout syndrome, while job satisfaction greatly influences burnout among medical workers of southwest China. Moreover, females and those with lower technical titles and without administrative duties are more vulnerable to burnout syndrome than their counterparts. Our study provides evidence that should be considered by health management institutions as they establish policies to prevent burnout syndrome in medical workers of southwest China.

Supporting information

Acknowledgments

We gratefully acknowledge the help of all medical workers who participated into our investigation, and all the investigators who help us to collect the questionnaires. We also thank the help of Shawna Williams for editing this manuscript.