The relationship between job burnout and quality of work life in pre-hospital emergency staff: Descriptive-correlation study

Background and aims: Pre-hospital emergency staff are often faced with highly stressful situations, leading most often to occupational burnout. One of the crucial factors affecting job burnout is the quality of work life. Therefore, this study investigated the relationship between job burnout and quality of work life (QWL) among pre-hospital emergency staff in Chaharmahal and Bakhtiari province in 2021. Methods: The descriptive-correlation study was conducted on 295 pre-hospital emergency staff in Chaharmahal and Bakhtiari provinces in 2021. The instruments used in this study to collect data were Richard Walton’s Quality of Work Life Questionnaire and Maslach’s Burnout Inventory. The data were analyzed with SPSS-16 statistical software using descriptive and inferential statistics. Results: There was a significant inverse relationship between work-life quality and job burnout among pre-hospital emergency staff ( P < 0.001, r = -0.553). The study’s findings showed that the average score of the QWL and job burnout among study participants was 64.73 ± 11.58 and 81.53 ± 10.35, respectively. Conclusion: Identifying the dimensions of job burnout and the quality of work-life among pre-hospital emergency staff can provide vital information to policymakers in the health field, especially pre-hospital emergencies. Thus, decision-makers and administrators with effective management can develop appropriate policies to reduce job burnout, improve the QWL, increase job productivity, and ultimately satisfy the demands of patients.


Introduction
Pre-hospital emergency staff is present as first responders in emergencies.They face highly stressful and challenging situations, which lead to psychological stress for the emergency staff (1).It takes time to think about all aspects of the patient quickly, which can lead to a series of stressful reactions (2,3).
Studies show that long-term stress in the work environment can lead to resignation, frequent absences, reduction of correct and timely decisions, depression, fatigue, and finally, the occurrence of burnout syndrome (4,5).Freudenberger initially coined the burnout term in 1974 (6).Job burnout is a psychological syndrome among healthcare personnel, especially nurses and prehospital emergency staff, and is a response to chronic job stress (7).Factors affecting the job burnout of prehospital emergency staff are environmental conditions, environmental noise, many patients on the scene, death of patients on the scene and security risks, high workload, low salaries and benefits, and lack of equipment (2,8,9).Pre-hospital care providers are expected to perform their duties in unpredictable conditions regardless of the situation or organization in which they work (10).Prehospital emergency staff may be exposed to risks such as infectious organisms, emotional stress, fatigue, physical violence, and traffic accidents, which affect job burnout (11).
Job burnout leads to mental-physical injuries in prehospital emergency staff.If job burnout is not recognized and a solution to reduce or prevent it is not designed, it can lead to the loss of an individual's efficiency and a decrease in physical and mental health (12).
Since pre-hospital care providers are the first people who appear on the scene and manage patients and injured people, it is vital to evaluate the state of job burnout in these people (11).The findings of Shareinia and colleagues' study showed that the level of burnout among pre-hospital care providers was moderate in terms of emotional exhaustion and depersonalization and high in terms of personal sufficiency (13).Conversely, the findings of Abbaspour et al reported that about 40% of pre-hospital emergency medical services (EMS) workers had high levels of mental stress (14).The study of França and De Martino (15) and Sabbaghi et al reported highlevel burnout among pre-hospital emergency staff (16).
On the other hand, the optimal use of human resources in any organization depends on positive actions that will provide complete or relative satisfaction to employees; otherwise, the organization's performance may decrease.Thus, the happiness or dissatisfaction with one's career is called the quality of work life (QWL).(17).The QWL is an organizational culture or a management strategy in which employees feel ownership, responsibility, and self-esteem; moreover, the effectiveness and efficiency of the organization increase by raising the status and dignity and providing the possibility for the promotion of employees (18).Studies have shown that employees with a high QWL have higher job satisfaction and performance and are less inclined to quit or change the workplace.Moreover, designing programs to improve the QWL has reduced absenteeism and increased the positive attitude of employees (19,20).In connection with the pre-hospital emergency staff, the pressure resulting from emergency work tensions is one of the most critical issues affecting a person's physical and mental performance, ultimately affecting their quality of life and work (11).Factors such as the lack of time in providing relief services, the acute condition of the patient or the injured person, and escaping from labels such as incompetence in the lifesaving of patients speed up decision-making in stressful situations, causing a significant effect on reducing the quality of life among pre-hospital emergency staff (21).
Myhren and colleagues' study on nurses (22) in a university hospital in Oslo, Norway, showed a significant negative correlation between job satisfaction and occupational burnout among nursing staff in two subscales: emotional exhaustion and depersonalization.However, no significant correlation was found between job satisfaction and occupational burnout among nursing staff under the personal accomplishment component.Moreover, the study of Negahdari et al showed a significant inverse relationship between work-life quality and occupational stress of pre-hospital emergency staff in Shiraz (23).Therefore, considering the fundamental differences between the natures of services provided in hospitals and pre-hospital emergency centers, the results of the studies conducted on nurses cannot be generalized to pre-hospital emergency staff.Therefore, this study attempted to investigate the relationship between job burnout and QWL among pre-hospital emergency staff in 2021.

Materials and Methods
A descriptive-correlation type of study design was used in this study.A total of 295 nurses working in the emergency medical centers of Chaharmahal and Bakhtiari province, affiliated to Shahrekord University of Medical Sciences, and met the inclusion criteria were included in the study.It is important to stress that the survey was based on a census selection.The inclusion criteria were as follows: having a desire to participate in the study, having at least six months of work experience, having at least a diploma, and working in emergency medical centers under the titles within the technician category (an assistant, junior, mid, and senior technician).The data collection tools were a demographic characteristics questionnaire, a quality of work-life questionnaire, and a job burnout questionnaire.The demographic questionnaire included age, education, work experience in the EMS 115, marital status, employment status, second job, number of monthly shifts, and base type.Richard E Walton proposed eight major conceptual categories of QWL, including 35 questions and eight components, namely: fair and adequate compensation, safety and health in working conditions, opportunity for use and capacity development, career opportunities and security, social integration at work, constitutionalism in the organization of work, work and total living space, and social relevance of life at work (24).The questionnaire items were rated on a five-point Likert scale; the minimum and maximum possible scores were 35 and 175, respectively.In this questionnaire, total scores of 35-80, 81-130, and 131-175 indicated people experiencing poverty, medium, and good quality of work-life, respectively (25).The validity of the questionnaire designed in the studies conducted on nurses in Iran was confirmed using content and face validity (25,26).In the current study, Khaghanizadeh et al confirmed the reliability of the questionnaire by determining the internal consistency with Cronbach's alpha of 0.95 (26).
Maslach designed the Maslach burnout questionnaire.The 22-item self-report Maslach Burnout Inventory (MBI) on a six-point Likert scale was used to measure burnout, which consisted of emotional exhaustion, depersonalization, and personal accomplishment.The minimum possible score was 22, and the maximum was 132; higher scores indicate more problems (27).The validity of the questionnaire designed in the studies conducted on healthcare providers was confirmed using content and face validity (28).In the current study, the reliability of the questionnaire was measured by Maslach and Jackson using internal consistency with Cronbach's alpha of 0.95 (29).
After receiving a letter of introduction from the Ethics Committee of Alborz University of Medical Sciences and Health Services and presenting it to the Vice-Chancellor for Research & Technology of Shahrekord University of Medical Sciences, he obtained permission to enter the research environment (Emergency Bases/centers 115).Before completing the questionnaires, the researcher provided participants with information regarding the study.The participants who met the inclusion criteria received written informed consent.The data collected based on a census selection were analyzed with SPSS-16 statistical software using descriptive and inferential statistics (Pearson's correlation coefficient, simple linear regression at 95% confidence interval).

Results
The results showed that the mean and standard deviation of the pre-hospital emergency staff participating in the study without and with work experience were 34.16 ± 7.75 and 12.7 ± 3.84, respectively.The vast majority of nurses were married (78.9%), had Bachelor's degree or higher (67%), were formally employed (45.9%), had a second job (80%), worked in an urban base (46.7%), and worked as an emergency technician (69.6%) (Table 1).The mean and standard deviation of work-life quality and job burnout were 64.11 ± 73.58 (out of a total score of 175) and 81.10 ± 53.35 (out of a total of 132), respectively.The findings of this study showed that the QWL has a significant inverse relationship with job burnout (r = 0.62, P < 0.001) (Table 2).The results of the linear regression analysis showed that quality of work-life accounts for 38% of changes in job burnout (P < 0.001) (Table 3).

Discussion
The present study's findings showed that the QWL among emergency medical technicians was poor.In line with this study, Negahdari et al found that the QWL among the pre-hospital emergency staff of urban and road emergency bases is at an average level (23).In this regard, the results of a study conducted by Faraji et al on nurses serving in a teaching hospital showed poor quality of life (30).Moreover, Fleet and colleagues' study on nurses and physicians working in rural Emergency Departments (ED) in Québec indicated poor QWL (31).Similarly, in a descriptive study, Suleiman et al reported a moderate level QWL among nursing staff (32).Although the number of studies conducted to investigate the job burnout level among emergency medical workers is minimal, and most studies have been conducted in hospital settings, the results showed that emergency workers are exposed to various stressors in their working conditions.Their stress can hurt the body, mind, individual performance, and productivity and ultimately affect the quality of their working life.In this study, the most important reasons for the low quality of life among emergency medical technicians were low pay, lack of promotion opportunities, high stress, poor communication, low job security, and low motivation for work.The vast majority of emergency medical technicians are forced to work more hours or two or more shifts because of providing financial relief to their families or the lack of experienced technicians, which can affect their mental health and ultimately reduce the quality of their lives.The study showed that emergency medical technicians experienced higher levels of job burnout.
Similarly, research by Eslami Aliabadi et al on prehospital emergency technicians in South Khorasan found that their average burnout score was higher than that of job burnout (33).Crowe et al. (2018), in a descriptive and analytical study on 10 540 paramedics professionals staff, found that the study participants had high levels of burnout (34).In a study conducted by Shahsavani et al on pre-hospital emergency staff, a quarter of the pre-hospital emergency staff had a high level of burnout, and more than half of pre-hospital emergency technicians had a moderate job burnout level (35).In another study conducted by Cicchitti et al on pre-hospital emergency staff in Italy, the Similarly, Ayşegül and Erkan reported a statistically significant inverse relationship between the QWL and job burnout among healthcare workers in Turkey (38).The increase in the QWL among nurses leads to the improvement of the nurse's attitudes and emotional commitment and, as a result, the reduction of their intention to leave work.Therefore, effective strategies for improving the QWL can be used among emergency medical workers to reduce job burnout.

Implications and limitations
Awareness of the levels of job burnout and work-life quality of these individuals can provide vital information for policymakers in the field of health, especially in pre-hospital emergencies, so that with appropriate policymaking and management, they can reduce job burnout and improve their work-life quality, and as a result, reduce turnover and staff turnover and increase job productivity, ultimately leading to patient satisfaction.One of the most significant limitations of the research is the high workload of nurses and the need for more time to complete the questionnaire, leading to the lack of accuracy in completing the questionnaire.In addition, psychological conditions, the level of motivation, accuracy, and inclination to answer the questions may affect the results.Moreover, in this study, the data was collected using a questionnaire, while if interviews and qualitative data collection methods were also used, much more precise results would be obtained.

Conclusion
This study aimed to determine the relationship between job burnout and QWL among pre-hospital emergency staff.Generally, there is a statistically significant inverse relationship between the caring environment for elderly people and lost care.Therefore, to reduce the lost care in hospitals, a fundamental approach is required to change the characteristics of the care environment, including providing sufficient human resources, establishing onthe-job training programs, and providing adequate and suitable equipment and facilities for the personnel, especially nurses, providing healthcare services.The main goal of emergency medical technicians is to provide care to critically ill patients and help them recover.Therefore, emergency medical technicians can play an important role in counseling, skill-training, and managing stressful situations by participating in counseling courses.Improve the quality of working life, reduce job burnout, and increase the patient's satisfaction with the care services they receive.

Table 2 .
The relationship between the quality of work-life and job burnout among study participants

Table 3 .
Predicting job burnout based on the quality of work-life among study participants

Table 1 .
Frequency distribution of demographic variables of study participants