Relationship of Glass Ceiling and Mental Health with Burnout in Women Working in Khansar and Golpayegan Health Care Networks in 2018

ORIGINAL ARTICLE Background: Burnout affects people's occupational performance and reduces their efficiency. The present study was conducted to investigate the relationship of glass ceiling and mental health with burnout among women working in Khansar and Golpayegan health care networks. Methods: The study population of this analyticalcorrelational study consisted of women working in Khansar and Golpayegan health care networks in 2018. In order to collect data, 159 women were selected from these health care networks using convenience random sampling. Data collection instruments were General Health Questionnaire, Glass Ceiling Inventory and Burnout Questionnaire. After collecting the questionnaires and drawing raw data, analysis of the data was performed using descriptive statistics (mean and standard deviation) and inferential statistics (Pearson's correlation coefficient and multiple regression analysis). Results: Glass ceiling perception was correlated with emotional exhaustion 0.49 and personal accomplishment -38.8, and mental health with emotional exhaustion 0.54 and personal accomplishment -0.50 among women employed in Khansar and Golpayegan health care networks (P-value < 0.001). Predictor variables (glass ceiling perception and mental health) could significantly predict emotional exhaustion and personal accomplishment. The model's coefficient of explanation also showed predictor variables (glass ceiling perception and mental health) could explain 46.2% and 26% of the variation in emotional exhaustion and personal accomplishment in these women. Conclusion: Given the significant role of glass ceiling perception and mental health in predicting emotional exhaustion and personal accomplishment of employed women, it is suggested that the causative agents of the glass ceiling and damaging ones to mental health in employed women be taken into account to prevent burnout among them.


Introduction
Working is essential for the continuation of life and the survival of community sustainability. The living costs of every individual are provided by work and the degree of self-sufficiency of each country depends on the level and type of performance of its working population. Skilled, interested and trained human resources in advanced industrial societies have had an undeniable impact on their development. It is necessary for a person to have a job that is compatible with his/her natural characteristics and the needs of the community, so that maximum efficiency of individuals can be used. 1 One of the main pillars of each organization is its human resources and without paying attention to the dimensions, motivations, and desires of individuals in the organization, it is definitely difficult for the organization to achieve its goals. In this regard, successful organizations are able to pay adequate attention to the degree of irritability and the role of the various factors in motivating individuals, and recognizing the different dimensions and angles of employee behavior and discovering his/her potential in the organization, so that they can guide him/her toward general purposes of the organization. 2 Burnout is one of the main occupational issues that are commonly seen as a response to job and organizational pressures among human services staff. Burnout is a decrease in individual's adaptability to stressors and is a syndrome consisting of physical and emotional fatigue that leads to a negative self-concept, negative attitude toward the job, and a lack of communication with clients when performing duties. 3,4 Burnout syndrome is an important problem in modern working environments and its prevalence has increased significantly over the past decade. 5 Burnout is an emotional fatigue syndrome, depersonalization and a decrease in personal success that can be found among people delivering some kind of the public services. 6 Emotional exhaustion refers to a condition in which the mental resources of the staff are reduced to a degree that they are no longer able to deliver the services they are expected to deliver. 7 Fatigue represents the most significant component of stress in burnout. In addition, depersonalization has been defined as an ineffective coping mechanism due to occupational stress, which makes the staff become insensitive, cold, and negative in their dealings with others. The definitions of the depersonalization have been labeled with the word pessimism. The last dimension, in a positive way, has been characterized with sense of personal success, which is a feeling of depression expressed by employees, so that they no longer manage to achieve their goals and lose their confidence in their ability to perform their duties at the workplace. Burnout also has a negative impact on the quality of life of employees with intercommunication involvements and aggression. Feelings associated with burnout include disappointment, weakness, inability to achieve work goals, and decreased involvement in work. 10 Several psychological, environmental, social and occupational factors can affect the incidence rate of burnout in people, especially women. One of the variables that seem to lead to burnout in female employees is glass ceiling. Women's failure to achieve high levels of management is referred to as the glass ceiling. Glass ceiling is just the barriers facing women in reaching the top level of the organization. 11 Accordingly, Sharif (2015) found in his research that women considered the maledominant atmosphere in organizations and the lack of acceptance of female managers by men as barriers to their promotion. 12 In examining the causes of this issue, the glass ceiling and the factors affecting its development are the first subject to be addressed. Accordingly, the absence of women in executive management positions is not due to lack of managerial skills but due to cultural factors or organizational culture dominating highly patriarchal organizations. 13 Another psychological component that can affect the phenomenon of burnout is the level of mental health. 14 The topic of health in general, and mental health in particular, is one of the challenging issues and is affected by normality and abnormality that in turn is influenced by and gain meaning from social perspective, statistical and personal distress as well as the view of social disability or dysfunction. 15 Adler defines competence in the development of social relations, Levinson in responsibility for others, and the reconciliation of the individual with his/her income and the recognition of the temporal and spatial situations, and Ginsburg in mastery, skill and communication in the three important areas of life, namely, love, work and recreation, and Rank mental health as life without fear and sin. 16 In terms of positive and holistic psychology, mental health includes the individual's ability to enjoy life, create balance between life activities and make attempt to achieve mental healing. 17 Given the adverse role of burnout in occupational and communication productivity of individuals and the need to identify the related psychological and occupational components to plan for the application of appropriate therapeutic and educational methods, as well as lack of research on the relationship of glass ceiling and mental health with burnout among women working in Khansar and Golpayegan health care networks, this study was conducted to determine the relationship between these variables. Therefore, the main question of the present research is whether there is a significant relationship of the glass ceiling and mental health with burnout among women working in Khansar and Golpayegan health care networks.

Methods
This analytical-correlational research was conducted to investigate the relationship of glass ceiling perception and mental health with burnout among women working in Khansar and Golpayegan health care networks. The study population consisted of women working in Khansar and Golpayegan healthcare networks in 2018. The samples of the study were 159 women working in Khansar and Golpayegan health care networks. Sample size was determined according to the Morgan and Krejcie Table ( 1970). The sampling method was convenience random sampling. The inclusion criteria included female gender, working in Khansar and Golpayegan health care networks, willingness to participate in the study and lack of suffering from acute psychological and physical illnesses. Exclusion criteria included the lack of the questionnaire, giving unclear response(s) to the questionnaire's items, withdrawal from the study, and the incidence of an environmental or physical problem for the participant.

General Health Questionnaire
This questionnaire, developed by Goldberg and Hiller, is used to detect mental disorders in various centers and environments. The items that examine the mental status of a person in the last month address certain symptoms such as abnormal thoughts and feelings and aspects of visible behavior. Therefore, the items emphasize the current situation and time. 18 This 28-item questionnaire includes four subscales, with seven items addressing each subscale. The subscales are physical symptoms (items 1 -7), anxiety symptoms and sleep disorders (items 8 -14), social function (items 15 -21), and depression symptoms (items 22 -28). To sum the items' scores, they are divided into 0, 1, 2, and 3. The minimum and maximum possible scores are 28 and 84, respectively. The lower the score on the questionnaire, the better the mental health. 19 Bakhshi Sourshojani (2008) reported the content validity of this questionnaire for Iranians desirable. 20 He also estimated the reliability of the subscales of this questionnaire at 0.69 -0.91.

Glass Ceiling Questionnaire
The Glass Ceiling Questionnaire was developed by Smith in 2012. This 38-item questionnaire consists of four subscales including denial (items 1-10), acceptance (items 11 -20), resignation (items 21 -31), and resilience (items 32-38). Items on two subscales denial and resilience are graded in reverse order. In this questionnaire, a 5-point Likert scale (scored 1 -5) is used for scoring items. The lowest attainable score of the questionnaire is 38 and the highest attainable score 190. Accordingly, the questionnaire's cut-off score is 144. This questionnaire had previously been translated from Persian into English in the study of Tabebordbar, Kamani, and Manouchehri by two translators. The original text and Persian duplicate of the questionnaire were reviewed by two management experts that had translation competencies. After conducting the necessary corrections, the Persian duplicate was given to two management professors to investigate its content and face validity. The face and content validity of the questionnaire was confirmed by the professors. The reliability of this questionnaire was estimated by the cited researchers at 0.70-0.83. 22 Smith reported the Cronbach's alpha coefficient for resignation, denial, acceptance, and resilience at 0.71, 0.81, 0.72, and 0.70, respectively. 23

The Maslach and Jackson Burnout Inventory
The Maslach and Jackson Burnout Inventory have 25 items and measures four factors. The first nine items are related to emotional exhaustion, the following eight items to personal accomplishment, the subsequent five items to depersonalization, and the last three items to involvement. This questionnaire measures all four subscales of burnout. For scoring each subscale, each item is given two scores (frequency and severity). If the respondents ticks Never, he/she will be given score zero in both frequency and severity. Otherwise, if he/she ticks the choices on frequency and severity, he/she will be given the score 1-6 on frequency (from a few times per year to every day) and score 1-7 on severity (from very low to very high) depending on the selected choice. When scores on each item are determined, then the scores of the subscales can be calculated by summing the scores of their respective items. The scores of the four subscales cannot be summed, because in some subscales, high scores represent low levels of burnout (such as emotional exhaustion) and in some subscales (such as personal accomplishment), low scores represent high levels of burnout. 23 Using Cronbach's alpha coefficient, Maslach and Jackson calculated the internal consistency of the inventory for the frequency at 0.83 and for the severity at 0.84. Besides, the reliability coefficient of the questionnaire was 0.82 for the frequency and 0.53 for the severity. Based on the internal consistency reports, a strong correlation (r = 0.79) was obtained between the responses given in testretest. In a preliminary study carried out by Badri Gargari (1995), the psychometric characteristics below were obtained: emotional exhaustion 0.78; personal accomplishment 0.79; depersonalization 82.2; and involvement 81.8.
Reliability of fatigue scales Emotional, personal accomplishment, depersonalization and involvement in this study were 0.79, 0.77, 0.81 and 0.80 respectively using Cronbach's alpha coefficient, respectively. Analysis of the raw data drawn in this study was done by SPSS 23 using descriptive and inferential statistics, Pearson's correlation coefficient and multiple regression analysis. First, by means of Pearson's correlation coefficient, the relationship of the glass ceiling and mental health with burnout was investigated, and then by using multiple regression, the contribution of each of these predictor variables to predicting
Ninety participants 62.5% had less than 10 years of work experience, 39 (27.1%) a work experience of 10 -20 years, and 15 (10.4%) a work experience of 20 years or more.
The total score on burnout cannot be obtained by summing up the scores on its subscales. It should also be noted that according to the General Health Questionnaire's scoring, higher scores represent lower mental health and vice versa. The results of the Kolmogorov-Smirnov test showed that the data fulfilled normal distribution presumption (P-value < 0.05). Homogeneity of variance was also estimated by Levene's test. Our results indicated that the statistical test was not significant; indicating that homogeneity of variances was observed (P-value < According to Pearson's correlation coefficients, it is clear that there is a significant correlation between the glass ceiling perception and emotional exhaustion 0.49 and personal accomplishment -0.88 in our participants. Besides, mental health was significantly correlated with emotional exhaustion 0.54 and personal accomplishment -0.51 in our participants. It should be noted that according to the General Health Questionnaire's scoring, higher scores represent lower levels of mental health. Accordingly, mental health had an inverse correlation with emotional exhaustion and a positive correlation with personal accomplishment. After ensuring correlation between the components, the regression tables are analyzed to determine the contribution of each of the predictor variables (glass ceiling perception and mental health) to predicting variables (emotional exhaustion, personal accomplishment, depersonalization and involvement) significantly in women working in Khansar and Golpayegan health care networks.
Based on the results of the above table, the F values in regression model for emotional exhaustion and personal accomplishment are significant.
However, the F values in regression model for depersonalization and involvement were not significantly different.
Therefore, predictor variables (glass ceiling perception and mental health) could significantly predict criterion variables (emotional exhaustion and personal accomplishment) in our participants. The model's coefficient of explanation also showed that predictor variables (glass ceiling perception and mental health) could explain 46.26% and 26% of the variation in the emotional exhaustion and the personal accomplishment in our participants. The regression coefficients of the emotional exhaustion and personal accomplishment scores in women working in Khansar and Golpayegan health care networks were examined based on predictor variables (glass ceiling perception and mental health). It should be noted that regression coefficients of depersonalization and involvement scores were not investigated due to insignificant results obtained from analysis of variance in these variables. First, it should be noted that the study of the collinearity of predictor variables by the tolerance index in the emotional exhaustion variable indicated that 0.86 variance in glass perception was not explained by mental health and 84% of the variance in mental health was not explained by glass ceiling perception, which indicates a low correlation between predictor variables, which provides the basis for using regression analysis for the emotional exhaustion variable. The study of the collinearity of predictor variables by the tolerance index in the personal accomplishment variable indicated that 0.77 variance in glass ceiling perception was not explained by mental health and 81% of the variance in mental health was not explained by glass ceiling perception, which indicates a low correlation between predictor variables, which provides the basis for using regression analysis for the personal accomplishment variable.
The results of the above table show that in the emotional exhaustion, regression coefficients of glass ceiling perception and mental health are significant. Thus, a 1-point increase in glass ceiling perception, if mental health remains fixed, would lead to an average increase of 0.42 standard deviation in emotional exhaustion. Besides, a 1-point increase in mental health, if glass ceiling perception remains fixed, would lead to an average increase of 0.45 standard deviation in emotional exhaustion. In the personal accomplishment variable, the coefficients of regression for glass ceiling perception and mental health were significant. Thus, a 1-point increase in glass ceiling perception, if glass ceiling perception remains fixed, would lead to an average decrease of 0.30 standard deviation in personal accomplishment. In addition, a 1-point increase in mental health, if the glass ceiling perception component remains fixed, would lead to an average decrease of 0.45 standard deviation in personal accomplishment. Regarding the standard beta coefficients, the mental health is considered a stronger predictor for emotional exhaustion and personal accomplishment than the glass ceiling perception.
In the implementation of this research, as in any other research, there were some limitations. For example, this research was conducted only on the women working in Khansar and Golpayegan health care networks. Precautions should be taken to generalize results to other groups and cities. In addition, the present study suffered from a methodological limitation, as the causal inference from our study's findings is limited due to its correlational design. Finally, the lacks of cooperation of officials in some of the centers, as well as the unwillingness of some women working in these centers, were among the other limitations of the study.  Table 3. Summary of analysis of variance of regression model of scores on emotional exhaustion, personal accomplishment, depersonalization and involvement in women working in Khansar and Golpayegan health care networks based on predictor variables (glass ceiling perception and mental health)

Discussion
The purpose of this study was to investigate the relationship of glass ceiling and mental health with burnout in women working in Khansar and Golpayegan health care networks. The results of the data analysis showed that glass ceiling perception and mental health were significantly correlated with emotional exhaustion and personal accomplishment in women working in Khansar and Golpayegan health care networks. In addition, the results showed that glass ceiling perception and mental health could predict emotional exhaustion and personal accomplishment. In addition, the model's explanation coefficient also showed that the glass ceiling perception and mental health could explain 46.2% and 26% of the variation in emotional exhaustion and personal accomplishment, respectively, in our participants.
Regarding the correlation of glass ceiling perception with emotional exhaustion and personal accomplishment in women, the results of this study are consistent with the study of Glass and Cook. 25 They reported that women perceived the glass ceiling as one of their main occupational barriers, and also believed that the leaders of the organizations were involved in the emergence of this process, and therefore they lost their job enthusiasm and their performance was influenced.
In agreement with the current study, the study of Titrek et al. (2014) showed women were highly interested in developing their own personal skills to become leaders in society, and they increasingly believed that they could be leaders in the community. 26 Nevertheless, women in Turkey still believe that there are particular obstacles facing them towards becoming a manager (leader), which reduces their job performance. In addition, in a study that reported consistent results 22 with the present study, a significant relationship was observed between the belief in women's glass ceilings and its subscales, i.e., resilience, resignation, acceptance and denial, and the mental success in employed women. The study of Ataf et al. (2017) showed that the four main categories of barriers to women's access to management positions, from the perspective of women, were personal barriers, organizational barriers, social barriers and political barriers, of which organizational barriers (glass ceiling) was the most important factor and had an adverse impact on the psychological status of employed women. 27 To explain this finding, it should be argued that, according to Akpinar Sposito (2013), women consider male-dominated atmosphere of organizations and the lack of accepting female managers by men to be obstacles to their promotion. 28 In examining the causes of this issue, the glass ceiling and the factors effective on its development needs to be addressed first. The most important factor for gender inequalities in organizations and the main obstacle to women's career advancement is the existence of a glass ceiling. 29 The invisible barriers and glass ceiling, as referred by the researchers, are in fact all false beliefs and perceptions regarding women in society; and these gender stereotypes act unconsciously in society and the organization, and prevent the progress of women in different areas. This process makes women more emotionally exhausted due to their emotional characteristics compared to men's, and therefore their personal performance in the workplace is influenced. Regarding the significant correlation of mental health with emotional exhaustion and personal accomplishment in employed women, our results are in agreement with the findings of Motalebi and Kiani (2017), as they found that mental health was associated with burnout among teachers. 30 In addition, Marvian Hosseini and Lariye Dashte Bayaz (2015) studied the role of burnout in the relationship between stress and job performance in staff. The results of that study showed that there was a significant relationship stress and burnout between burnout and job performance, and stress and job performance. 31 In explaining the significant relationship between anxiety symptoms and emotional exhaustion, it should be argued that anxiety is a diffuse, unpleasant and vague feeling of fear and apprehension with unknown origin, including uncertainty, helplessness, and physiological excitation. Anxiety includes negative emotion and a feeling of concern about the danger that is likely to occur. 32 An anxious person has a constant feeling of concern arousal, and excitability. This process causes him/her to constantly experience psychological, emotional, and physiological tiredness. Accordingly, employed women with anxiety symptoms develop emotional exhaustion.
In addition, the results of this hypothesis indicate the relationship of depression with emotional exhaustion and personal accomplishment. In explaining this finding, it should be argued that depressive disorder is also one of the most common psychological problems in adults and employees. 33 Depressive disorder is defined as a psychological problem in which a person constantly experiences deep and persistent discomfort and reduced interest in all activities. 34 Depressive disorder affects normal personal and family performance adversely. Depression symptoms create negative emotions. Previous studies have also shown that people with symptoms of depression suffer from numbness in social, occupational, sexual, emotional and psychological areas. This process makes employed women with depression symptoms avoid the work environment or become inactive in the workplace, and experience decline in job performance and emotional exhaustion.
Accordingly, it is suggested that this research be replicated across other cities and other groups because of the generalizability of the results, so that the effect of cultural differences can be identified. It is also suggested that in future research, experimental research methods be conducted using appropriate psychological therapeutic methods, to avoid methodological limitations of causal inference.

Conclusion
In a general conclusion, it should be argued that due to the significant role of the components of glass ceiling perception and mental health in predicting emotional exhaustion and the personal accomplishment of employed women, the causative agents of the glass ceiling and damaging ones to mental health of employed women should be taken into account to prevent burnout.

Conflicts of Interest
In this study, was not reported any potential conflicts of interest with the authors.