Job Burnout Process and its Implications in HRM Practices : A Case Study of Trainee Doctors in Public Health Organization

This study explores process of job burnout based on a case study conducted on trainee doctors in Lady Willington Hospital, Lahore. The study builds arguments from Job Demand-Resource (JD-R) model and explains the process in light of Conservation of Resource (COR) theory. Qualitative research methodology has been adopted in which data is collected through three focus group discussions and twenty-one semi-structured in-depth interviews. The procession development of job burnout syndrome is explored and presented in a model in which emotional exhaustion is found to be the first stage of burnout leading to depersonalized approach of doctors towards patients and colleagues which generate feelings of diminished self accomplishments. Theoretical and practical implications of findings are discussed.


INTRODUCTION
Job Burnout is conceptualized as unique type of strain pattern, comprised of emotional exhaustion, depersonalization and reduced self-accomplishments (Maslach and Jackson, 1981).It has significant implications for individuals as well as the organizations.In context of individual perspective, burnout is related to issues like decreased self-esteem, depression, fatigue, anxiety and deterioration of physical health (Toker and Biron, 2012;Singh and Suar, 2010;Kahill, 1988;Burke and Deszca, 1986;Jackson and Maslach, 1982).In the context of organizational perspective, burnout is linked with job related tension and decreased level of job commitment (Jackson et al., 1986;Firth and Britton, 1989).In light of both these perspectives, implementing effective individual and managerial strategies, to control this issue, are critical for organizations.Therefore, management needs to have clear and precise understanding of job burnout process and development of its various stages.
Although a host of literature has been produced on this phenomenon, however the concept has been derived empirically and majority of the studies have targeted causal models of job burnout.So far, little attention is paid on theoretical explanation of process and no consensus is developed on underlying mechanism of interrelationship among its various components (Hills et al., 2004;Toppinen-Tanner et al., 2002).Moreover, the few studies targeting explanation of burnout theory (Hobfoll, 1998(Hobfoll, , 2001;;Bakker et al., 2004) are done in western culture.Whereas, it is increasingly being realized that cultural differences across different societies are important to understand variations in burnout phenomenon (Haque and Aslam, 2011).Therefore, cultural variations raise important question of generalizability and suitability of theories across different cultures which have received little attention (Jamal, 2005;Rothmann, 2003).Although several researchers in Pakistan have conducted studies on job burnout in various occupations (Jamal, 2008;Haque and Aslam, 2011;Jalees and Zeeshan, 2008), however most of these studies have aimed at driving causal relationships using models developed in western countries and little attention is paid towards the theory behind development of burnout process capturing possible cultural effects.
Considering the aforementioned gaps in the earlier studies, this study has been conducted in a public health institute to explore the job burnout process and the underlying relationship of its components.The group of post graduate trainee doctors has been selected for data gathering as these are the individuals who have relatively more set of constraints associated with their job and role as compared to their seniors as well as peers working in private organizations.The study expects that theses constraints can increase their exposure to job burnout.
As burnout is a response to prolonged stressors, the understanding of the factors that contribute to burnout is very important.Therefore the study is also aimed at identifying initiators of job burnout.Furthermore, the outcomes of this phenomenon are delineated.Following are the objectives of present study: • To explore the process of job burnout among trainee doctors in Pakistan • To theoretically explain the process of job burnout among trainee doctors in Pakistan • To explore factors that initiate burnout among trainee doctors in the context of public hospitals in Pakistan • To identify the outcomes of job burnout among trainee doctors The exploration of the process of job burnout and identifications of the factors involved in this issue require in-depth knowledge of the phenomenon.Henceforth, a qualitative research is conducted incorporating a case study design.Three focus group discussions and twenty-one in-depth interviews are conducted with post graduate trainee doctors taking Lady Wallington Hospital, Lahore as case of study.

CONCEPTUAL AND THEORETICAL FRAMEWORK
The concept of job burnout was originated with the research in caregivers and human services professionals who experienced emotional depletion and loss of energy due to their unique relations with their clients who depend on them for the solutions to their pain and sufferings (Lee and Akhtar, 2007).The initial investigations into this phenomenon are found in the articles of Freudenberger (1974Freudenberger ( , 1977a, b) , b) who also coined the term 'burnout' and described it as loss of idealism and passion for work.Since then a host of literature has been produced to conceptualize and investigate the phenomenon.But, So far, no consensus is developed on a single definition of job burnout.The most popular and widely used definition of burnout is provided by Maslach and colleagues who have conceptualized it as umbrella term comprised of three components: emotional exhaustion, depersonalization and reduced self accomplishment (Maslach and Jackson, 1981;Maslack, 1982;Maslach and Leiter, 2001).These three dimensions are conceptually distinct but empirically interrelated concepts (Toppinen-Tanner et al., 2002).Emotional exhaustion refers to the emotional state of the person characterized by depleted resources and lack of energy (Maslach, 1982).Another dimension is depersonalization which is also referred as dehumanization or cynicism.It is characterized by negative, cynical or excessively detached response to coworkers, clients and the organization.Visible symptoms include showing less interest in the issues of clients, avoiding conversations with colleagues at workplace, too much use of jargons and use of disparaging or abstract language (Maslach and Pines, 1977).Third dimension of burnout is reduced self accomplishment which is "characterized by a tendency to evaluate oneself negatively" (Cordes and Dougherty, 1993: 623).People feel dissatisfaction with their work related progress and experience less sense of accomplishments in their lives.
Shirom and colleagues conceptualized job burnout somewhat differently as a multidimensional construct mainly comprised of emotional exhaustion, physical fatigue and cognitive weariness (Shirom, 2003;Shirom and Melamed, 2006;Melamed et al., 2006).The three components are closely interrelated (Toker and Biron, 2012).Although Shirom-Melamed conceptualization is also popularized in burnout literature, but Maslach and colleagues' dimensions are more widely used in empirical research.Moreover, these dimensions capture emotional, mental as well as interpersonal aspects of job burnout syndrome.Therefore, Maslach and colleagues' conceptualization of burnout is utilized in this study.
Although it is widely accepted that burnout components are closely linked with each other (Toppinen-Tanner et al., 2002;Toker and Biron, 2012) but less consensus is developed regarding the procession development of the three components of burnout.Particularly, whether the components of burnout are developed simultaneously or one component gives way to another.According to a process model developed by Golembiewski and colleagues depersonalization develops first as a coping measure to handle stressful conditions, followed by diminished personal accomplishment and eventually ends up with emotional exhaustion (Golembiewski et al., 1996).Leiter and Maslach (1988) suggest another process of burnout in which due to taxing stressful conditions person becomes emotionally drained and exhausted which leads to depersonalization as a coping mean which in turn weakens sense of accomplishment.Empirical evidence of Leiter and Maslach model is found in cross-sectional and longitudinal studies (Bakker et al., 2000;Toppinen-Tanner et al., 2002) Another model is developed by Leiter (1993) in which exhaustion gives way to cynicism whereas reduced self efficacy is developed separately It is empirically supported by Cordes et al. (1997).Van Dierendonck et al. (2001) come up with another sequence in which reduced self accomplishment leads to cynicism which in turn creates emotional exhaustion.
Theoretically, job burnout is a unique effective response to the prolonged and chronic interpersonal stressors which depletes person's energetic and coping resources.In this regard, Hobfoll's Conservation of Resources (COR) theory offers important theoretical insight for the explanation of burnout phenomenon (Hobfoll, 1998;2001).COR theory considers burnout as the state resulting from long term process of resource loss which gradually develops while depleting individual's intrinsic energetic resources (Hobfoll and Freedy, 1993).The basic principle of COR theory is that people struggle to obtain, retain, foster and protect their resources.Hence, most important human motivation is preservation and accumulation of resources.The resources are not only the key to survival and well-being but also are important to maintain and achieve valued resources or to protect against resource loss.People experience stress when the resources are either threatened with loss, are actually lost or are not gained even after significant resource investment.Burnout occurs as a result of slow bleed out of resources without counterbalancing resource gain.The value of the resources, which a person needs to conserve, is defined in the context of the social environment and culture of the society (Hobfoll, 2001).If resource valuation is culturally defined, then burnout process has important linkage with the social and cultural environment.Moreover, organizational context is also significantly important to understand this process.It is being highlighted that burnout is not neutral, rather is a product of a broader cultural and institutional characteristics (Hobfoll, 2001;Meyerson, 1994).Accepting the perspective of COR theory, Bakker and Demerouti (2006) have presented Job Demand-Resources model (JD-R) to understand the dual process of interaction between job demands and job resources in creating job stress and job motivation.JD-R model proposes that all work characteristics can be classifies either as job demands or job resources (Bakker et al., 2003).Job demands include those "physical, psychological, social and organizational aspects of the job that require sustained physical and/or psychological efforts" (Bakker and Demerouti, 2006: 312).Job resources refer to those "physical, psychological, social and organizational aspects of the job" that help in achieving work goals, reducing job demands and stimulating personal growth.Job burnout occurs when individual is faced with more strain created by job demands and less motivation in work place due to less job resources available (Broeck et al., 2008).Taking insight from JD-R model, the study builds its basic argument that individual feels strain when job demands are more whereas job resources are less.The discrepancy between job demand and resources posit possible threat of resource loss.In the light of COR theory, the study further argues that continuous cycles of resource loss can expose a person to burnout.
With these arguments, it is expected that doctors may expose to job burnout because they are continuously faced with high job demands.The job of the doctors can be demanding due to number of reasons: work stressors, role conflict, role ambiguity, extra workload, long and hectic duty hours, acute conditions of patients and emergencies etc.It is therefore argued that doctors may be exposed to various factors that may create stress and emotional exhaustion leading to burnout.To deal with these job demands they may experience loss or threat of loss of their personal energetic and coping resources and even the threat of not gaining resources even after investment of valuable resources which may expose them to job burnout.The loss or threat of resource loss is further enhanced among Post Graduate Trainee (PGTs) doctors because they are faced with more resource constraints (for example contract based temporary hiring and no incentives in addition to pay/stipend) as compared to the doctors who have completed their specialization training and are settled either in government or private health organizations.In addition to constraint of personal resources, the constraint of organizational and job resources is also important, particularly in the context of developing country like Pakistan where public hospitals are faced with lack of resources while number of patients for getting services is quite high.The selected case for study, Lady Willington Hospital, is a general public hospital where number of patients is usually very high.It is very close to the peripheries and majority of the patients coming to the hospital are not highly educated; hence the chances of severity of cases is also quite high.It is therefore argued that the trainee doctors have to face more critical cases which can arouse stress.

METHODOLOGY
For the purpose of doing in-depth analysis of the issue, case study design is used in which post graduate trainee doctors of Lady Wallington Hospital are taken as subject of case analysis.Qualitative research is conducted because the study aimed at exploring the process and underlying organization-specific factors behind this phenomenon.Qualitative research can potentially generate knowledge about unexpected job demands and resources pertinent to the selected case which may overlook if standardized questionnaire is used.Data is collected through focus group discussions and in-depth interviews.The purpose of conducting focus group discussion is to develop a broad understanding of the issue and to capture wide variety of the antecedents and consequences whereas in-depth interview is a very useful method to understand the process of burnout in detail.These two techniques are useful when study requires both breadth and depth (Hesse-Biber and Leavy, 2006).Three focus group discussions and twenty-one semi-structured in-depth interviews are conducted.Respondents are selected through non probability sampling method incorporating convenient sampling technique due to cost and time constraints..The average age of respondent's lies between 24-37 years and all are serving in the hospital for more than 2 years.

Burnout initiators:
The focus group discussions and in-depth interviews with doctors revealed various factors that create job strain exposing doctors to job burnout syndrome.Various factors identified by the respondents are analyzed by classifying them into two broad categories.The first category consists of job demands which include different physical, psychological, social and organizational aspects of doctor's job that demand physical, cognitive or emotional efforts from doctors.The second category consists of all different resources available to doctors that can help in meeting job demands and are important for achieving work goals and individual's expectations.
Among job demands, frequent and emotionally demanding interaction with patients is reported as an important stress creating factor.Doctors have to deal with people for the solution of their health problems.The patients rely on doctors for relieve of their suffering which demands that doctors should provide their patients emotional, intellectual and physical support.Doctors feel emotionally drained when their own resources (i.e., time, energy) are exhausted to provide such support.Another job demand is excessively heavy workload.A common theme emerged from the data is that doctors are faced with large number of patients and their schedule is very hectic.It is reported that the timings are not flexible and schedules include both day and night duties.Due to long and disturbing duty hours, doctors seem to face difficulties in managing their work and family life conveniently.Their family members also feel disturb due to the long, inflexible duty schedule.'My wife remains unhappy with my long and disturbing duty hours…she always feels that I have no time for her', reported a respondent.It indicates that doctors are faced with role conflict.In addition their role conflict, they have also reported role ambiguity.Their responsibilities are not properly spelled out to them.'How can I rate my performance when I don't know what my senior registrar exactly expects from me', said a respondent in the interview when he was asked to rate her performance.It appears that either job responsibilities are not clearly designed or not conveyed to the doctors properly.This role ambiguity creates stress.'I am responsible for each and every activity related to patients when I am on duty…so much so that several times I have myself arranged the blood to save lives of the patients…ultimately, all responsibility is put on me whenever there is a mishap', reported a doctor.Taken as a whole, doctors have reported that their job contains excessive demands which require considerable physical, cognitive and emotional efforts.
On the other hand several resource constraints are revealed during discussions with trainee doctors.Most importantly respondents have reported unfavorable and inconvenient physical environment of the hospital.Trainee doctors are not provided with enough resources to complete their tasks efficiently.The facilities available in the hospital are far less than the number of patients to deal with.'Usually the number of patients is so high that we have four to five patients on single bed', said a respondent.Another reported, 'instruments, operation tables, blood availability, laboratory facility, medicines…all are far less than the number of patients.'Moreover the administrative staff, nurses and other helping workers are also inefficient and irresponsible who bring stress for the doctors.Another very commonly projected theme is the low pay and incentives.Trainee doctors have the perception that their work is far more than what they are getting.Furthermore, the pay package, which is fixed stipend, is not enough to meet their expenses.As far as nature of their task is concerned, doctors consider it as significant.The profession of doctor is perceived as noble profession in the society.Several respondents reported that they receive appreciation and gratitude from patients for extending valuable services to them.While other reported that the feedback in form of appreciation or gratitude from either the patients or organization sources is non-existent.The performance evaluation is not clearly communicated.Moreover, pay is fixed and has no link with the performance.Hence, hard work and exceptional performance receives no reward.Another important factor is lack of social support in work environment.The relations with the supervisor and senior doctors appear to be unpleasant.A common theme emerged from the data is that the supervisor and seniors do not understand the problems of post graduate trainees and are un-cooperative and blaming in critical situations.Although some doctors said that they discuss their work related and personal problems with other colleagues but presence of professional jealousy among colleagues is also highlighted by some respondents.Taken as a whole, data has revealed that doctors are faced with several resource constraints as compared to multiple demands of their profession.

Process of job burnout:
It appears from the data that the process of job burnout begins to a greater extent as a result of excessive job demands whereas resources are not available to efficiently meet these demands.The discrepancies between demands and resources make the job of trainee doctors stressful exposing them to emotional exhaustion.
As revealed from the data, the trainee doctors experience high level of provocation from extensive and emotionally demanding interactions with the patients which makes them emotionally exhausted.High work load (long duty hours, large number of patients) is also reported extensively that exposes the doctors to physical exhaustion in addition to emotional strain.In addition to work place demands, doctors are also faced with multiple demands from their family and relatives.Culturally, people having family terms with doctors, expect a lot from them.Respondents reported that it's a common perception in the society that doctor can offer solution to any health related problem they are faced with.It is also expected by their families that after completing their MBBS they should earn handsome pay package and support their families whereas during post graduate training program doctors earn fixed stipend which is not enough even to meet personal expenses.It appears that different roles place manifold and conflicting demands on doctors which create stress leading to exhaustion.Efforts to resolve conflicting demands can create frustration and emotional strain (Fisher and Gitelson, 1983).On the other hand, the available resources to meet these demands are not sufficient such as time and money constraints, lack of physical facilities in hospital, out dated machinery and inefficient supporting staff which leads to excessive expenditure of physical and emotional energy of doctors which enhances the feelings of being emotionally drained.Being physically and emotionally exhausted, doctors feel loss of energy in handling tasks.'I feel a sense of being physically run up due to this workload', said one of the respondents.Literature also supports linkage of excessive high workload with emotional exhaustion (Friesen and Sarros, 1989;Maslach and Pines, 1977;Pines and Maslach, 1978).Theses excessive demands as compared to limited resources make them physically and emotionally exhausted with the feelings of over consumption of their valuable personal resources (time, energy etc.).Doctors experience either resource loss or threat of valuable resource loss.Doctors reported that they are faced with these resource consumption situations over a long time period which makes them vulnerable to resource loss.'it is more than 4 years after completion of MBBS that I am doing hard still I am not settled enough to meet my responsibilities…I am fed up from this struggle', said one of the respondents.
The repeated cycles of over resource consumption create emotional exhaustion.In this stage, doctors feel lack of energy and fitness towards job, Depersonalization is developed as a coping strategy to deal with physical and emotional exhaustion and to avoid possible resource losses specially when other coping resources are not available in workplace in form of supervisor's or colleagues' support.It is revealed from data that trainee doctors perceive lack of social support from colleagues in their work place.Support from supervisor and senior doctors is also missing in critical situations.Feelings of lack of support enhances depersonalization in which doctor develops cynical attitude towards patients, work and colleagues perhaps as a coping response to avoid further resource consumption.
This cynical attitude towards patients and colleagues results in lack of interest in patients and job.Also due to distance from colleagues and work there is less appreciation at workplace which leads to low selfrating.Lack of positive feedback from supervisor is also very important here.Trainee doctors have reported that their mistakes are highlighted repeatedly whereas hard work is never appreciated by the supervisor.It is also revealed that feedback, in form of objective performance rating, is missing here.It creates feelings of lower sense of self-rating.Moreover, trainee doctors are also not provided with specific targets to be achieved, rather they are expected to be responsible for everything to treat patients.This work ambiguity also appears to effect self-rating and feelings of personal accomplishment.A respondent pointed out it as 'How can I rate my performance when I am not aware of what exactly my senior registrar expects for me'.
The role of personal expectations for achievements is very important here.Maslach (1982) suggest that that those who begin to burn out tend to be overachievers who have high expectations.From the data it appears that doctors have high expectations from their job in terms of rewards, acknowledgment, high pay and career advancement.Not only doctors, but also their family members and overall people in society have high expectations from doctor's in-terms of their high career achievements and economic stability.Unmet expectations enhance feelings of reduced selfaccomplishment.In the interviews the doctors seem to have feel frustration due to unmet expectations as expressed by a respondent, 'I feel that I am achieving less than I should.'The unmet expectations create feelings in trainee doctors that their significant resources are consumed as compared to their achievements and they are not gaining valuable resources even after significant resource investment.Feelings of diminished self accomplishment further develops cynical attitude towards their work and patients.Specially, when they feel that they are not good at work.They develop detach attitude towards patients becoming depersonalized.

Consequences of job burnout:
From the interviews and FGD conducted, it appears that job burnout is linked with several behavioral, attitudinal and interpersonal consequences.Moreover the doctors have also reported deterioration of physical and psychological health.
The physical consequences include fatigue, insomnia, severe headaches and gastrointestinal disturbances.Deterioration of mental health in form of depression and anxiety is also revealed.Some interpersonal consequences are also projected.The job related activities of the doctors seem to have deleterious effects on their personal life.Due to depersonalization component of burnout, doctors tend to withdraw from their friends and reduce socializing.They have also reported impatience, irritation and moodiness while dealing with other people.
The behavioral consequences entail organizational outcomes and consumption behaviors.The organizational outcomes include turnover, lack of commitment and more absenteeism.Consumption behavior like smoking has also been mentioned by a doctor.Findings of the study are summarized in Table 1.

THEORETICAL DISCUSSION
The study attempted to explore the process of job burnout among trainee doctors in terms of development and relationship of various components of job burnout.It is revealed that doctors are faced with various resource constraints in terms of lack of time, lack of physical facilities in hospital, outdated machinery and equipments, inefficient supporting staff.On the other hand, they are faced with excessive demands such emotionally demanding interactions with patients, high work load, dependency of patients on doctors for relief of their suffering and conflicting demands of family and job.The discrepancy between demands and resources creates significant strain in their job.Repeatedly dealing with multiple demands in face of resource constraint makes doctors emotionally exhausted in the first stage.Hence, the starting point of job burnout process is emotional exhaustion.As a defensive strategy to deal with exhaustion, they develop a cynical attitude towards patients perhaps to avoid the situation.Lack of social support from colleagues and supervisors further enhances such feelings resulting in their depersonalization from patients, colleagues and seniors.Depersonalized attitude results lack of positive feedback (such as appreciation and recognition from colleagues) in workplace which creates lower sense of Fig. 1: Process of job burnout self accomplishment especially when they have high expectations from their professional life.Lack of selfaccomplishments further enhances depersonalized attitude when individual feels that he/she is not good at work.Likewise, depersonalization not only leads to lack of self-accomplishment but also further enhances emotional exhaustion.
This process of job burnout among doctors is presented in a model in Fig. 1 Consumptions of Resources (COR) theory (Hobfoll, 2001) provides important explanation of the process of job burnout identified in this study.The multiple and conflicting demands require significant resource consumption.Faced with various resource constraints, doctors experience threat of valuable resource loss, actual resources loss or feeling of not gaining resources even after significant resource investment.The repeated cycles of resource loss makes they emotionally exhausted exposing them to the first stage of job burnout.Hobfoll and Freedy (1993) put it as burnout is a long term process of resource loss that gradually develops overtime.Depersonalization with patients can be a coping strategy to avoid further resource loss.Supportive work environment can play a very important

Emotional exhaustion
Lack of energy chronic fatigue and tiredness role in gaining resources.Social support can increase a people's belief that they are able to cope with the situation by enhancing their perception that others will provide the necessary resources (Cohen and Wills, 1985).But the trainee doctors, in the present study, lack support from colleagues and seniors which makes it more difficult to gain and conserve valuable resources.

Reduced self accomplishment
According to COR theory, continued cycles of resource loss lead to negative emotions and can damage psychological well-being of individual (Hobfoll, 2001).Also, when people are faced with significant resource losses, they concentrate more on their weaknesses then on strength.Hence, faced with continuous and significant resource losses, doctors develop diminished sense of self-accomplishments especially when doctors feel that they are not gaining valuable resources even after significant resource investment.
The value of the resources, which a person needs to conserve, is defined in the context of the social environment and culture of the society (Hobfoll, 2001).If resource valuation is culturally defined, then burnout process has important linkage with the social and cultural environment.Moreover, organizational context is also significantly important to understand this process.Being a case study, the present research explored the process of burnout and contributing organizational factors to this issue in the context of public hospitals while capturing Pakistani culture.For example, it is found that, in general, people in Pakistani society have high expectations from doctors regarding economic stability, career success and high life standard.The profession of doctor is considered as high-status and prestigious.Therefore, doctors need necessary resources to come up to the expectations of the society.Faced with considerable resource constraints they experience threat of not coming up to the expectations of the society.
Although a host of literature is produced on job burnout phenomenon, still theoretical explanation of the process of job burnout has received less attention which the present study has attempted.The study also explored several burnout initiators pertinent to the context of public hospitals in Pakistan (low pay, high work load, low doctor to patients ratio, lack of facilities etc.) which can provide important implications for managerial and HR policies.The sequential process of job burnout explored by the present study is important because it can guide for the intervention strategies to tackle with the situation before it becomes verse.

IMPLICATIONS FOR MANAGEMENT AND HR POLICIES
The study has found several organizational factors that contribute in initiating and enhancing the feelings of job burnout among doctors in public hospitals which provide important implications for human resource management practices.With the changes in the HR practices, numerous efforts that can be made to overcome the burnout situations before the arousal.In order to proactively overcome the burnout situation, some recommendations for HR management practices are given here to deal with the factors that were most frequently reported in the interviews and FGD as responsible for burnout: • Stress Management Training (SMT) Programs can also be arranged for the doctors to enhance their stress management skills to enable them work in stressful situations and manage their stress levels, which can lead to higher instances of burnout.• Supervisory support can be an effective coping resource is handling stressful situations at work and to deal with conflicting family-job demands.
Training of supervisors and management is required so that they are more receptive and attentive to employee's problems related to conflicting demands from family and work.This support is crucial to sort out solutions to role conflicts.
• During the study, the lack of facilities provided within the hospitals was identified as catalyst to the burnout process.These facilities majorly include beds, operation tables, instruments, medicines, blood availability and laboratory which are far less than actually required.The hospital management should take appropriate measures to indentify the need of these facilities within the hospital according to the turnover of the patients.Once the need assessment is performed, the provision of these facilities should be arranged.

LIMITATIONS AND CONCLUSION
In this study data is collected through focus group discussion and in-depth interviews.One of the limitations of focus group discussion is that individual responses are not independent of one another as during discussion the participants often agree with responses from fellow members.However, this problem is tackled through in-depth interviews so that respondents may feel free to present their views in detail.However, biasness due to the subjective views of the doctors and the researcher can be a possible threat to objectivity.Being a case study the generalizability of the findings may also be limited.However, in order to capture contextual factors case study is a suitable design.Generalizability of findings can be enhanced by using multiple case studies in future studies.
Despite these limitations, the study has provided a significant contribution by exploring the process of job burnout within the cultural and organizational context.For this purpose, qualitative research methodology is incorporated to capture richer descriptions and unexplored areas of the phenomenon.Theoretically, burnout phenomenon has its important linkage with the intrinsic desire of individual to conserve resources.Thus the findings support COR theory (Hobfoll, 2001) concluding that doctors experience threat to conservation of resources which expose them to job burnout when such threats are prolonged over a long time period.Emotional exhaustion is found to be the initial stage of job burnout leading to depersonalized approach of doctors towards patients and colleagues which generates the feelings of diminished self accomplishments.
The sequential process identified is valuable to identify the critical stage of the problem and proactively use intervention strategies before the problem arise up to the negative consequences of burnout.The study has also provided several suggestions for human resource management practices which can be used as intervention strategies to proactively cope with the phenomenon.

Table 1 :
(Hobfoll, 2001)ons and major findings Research questionsMajor findings What are the factors that initiate burnout among doctors in the context of public hospitals in Pakistan?Conservation of Resource (COR) theory(Hobfoll, 2001)best explains the phenomenon.Due to resource constraints doctors are faced with resource loss, threat of resource loss, or threat of not gaining resources even after investment of valuable resources.Multiple and prolonged cycles of resource loss exposes doctors to job burnout What are the outcomes of job burnout among doctors?
Physical: Fatigue, insomnia, severe headaches and gastrointestinal disturbances, anxiety Behavioral: Smoking, lack of commitment and more absenteeism, turnover Interpersonal: Reduced socializing in society

•
Work overload has been one of the most significant factors of causing stress.Doctors have identified that number of patients is too high as compare to on duty doctors.It implies the need for doing hiring need analysis.The average turnover of the patients per doctor should be worked out to identify hiring needs and accordingly, number of doctors should be managed.•Compensation policies also need revision.Trainee doctors are taking stipend with no other benefit.
(KPIs)based on job descriptions.Supervisors should be provided training to rate the performance and provide objective feedback to doctors and other staff based on predefined KPIs.