Burnout Syndrome and Engagement in Health Care Workers: An Approach from the GenderPerspective*
Síndrome de burnout y engagement en trabajadores de la salud: un abordaje desde la perspectiva de género
Síndrome de Burnout e engajamento em profissionais de saúde: uma abordagem na perspectiva de gênero
Burnout Syndrome and Engagement in Health Care Workers: An Approach from the GenderPerspective*
Revista Gerencia y Políticas de Salud, vol. 22, 2023
Pontificia Universidad Javeriana
Eliana Quiroz-González a firstname.lastname@example.org
Universidad Católica de Pereira, Colombia
Julia Castaño-González email@example.com
Universidad Católica de Pereira, Colombia
Gina Marcela Arias-Rodríguez firstname.lastname@example.org
Universidad Católica de Pereira, Colombia
Received: 24 october 2022
Accepted: 11 january 2023
Published: 15 october 2023
Resumen: el burnout y el engagement tienen un impacto en la salud de los trabajadores. El objetivo del presente estudio fue analizar la influencia del género en el síndrome de burnout y el engagement entre trabajadores de la salud colombianos. El estudio consistió en un diseño no experimental, transversal, con un alcance explicativo. Participaron 972 profesionales de la salud (Mujeres = 78,3% y Hombres = 21,7%) con una edad media de 34 años. Utilizamos un cuestionario ad hoc, la Utrecht Work Engagement Scale (UWES-9) y el Maslach Burnout Inventory-Human Services Survey (MBI-HSS). El análisis de los datos se realizó en SPSS v.22 y AMOS v.25. Se encontraron diferencias significativas en despersonalización, con mayor afectación en los hombres (Z = -2,44, p = 0,015). No se encontraron diferencias con respecto a otras dimensiones del burnout y engagement en función del género. El modelo de ecuaciones estructurales señaló que el género no influye en el burnout ni en el engagement, pero indica que el burnoutejerce una influencia negativa sobre el engagement. Se utilizó un diseño transversal y autoregistros. Se sugieren estudios experimentales y longitudinales, así como la integración de variables contextuales que pueden alterar los fenómenos estudiados. Los resultados del estudio pueden apoyar a los líderes de recursos humanos en los procesos de toma de decisiones y promoción la salud mental en el trabajo, generando intervenciones desde una perspectiva de género.
Palabras clave:síndrome de burnout, género, salud mental, equilibrio trabajo-vida.
Abstract: Burnout and engagement have an impact on workers' health. The aim of the present study was to analyze the influence of gender on burnout syndrome and engagement among Colombian health workers. The study consisted of a non-experimental design, cross-sectional with an explanatory scope. It comprised 972 healthcare professionals (Women = 78.3% and Men = 21.7%) with an average age of 34 years. We used one ad hoc questionnaire, the Utrecht Work Engagement Scale (UWES-9) and the Maslach Burnout Inventory-Human Services Survey (MBI-HSS). The analysis of the data was performed in SPSS v.22 and AMOS v.25. Significant differences were found regarding depersonalization, with greater affectation in men (Z = -2.44, p = 0.015). No differences were found regarding other burnout and engagement dimensions as an outcome of gender. Using a structural equation model, we found that gender did not affect burnout or engagement, but that burnout negatively influenced engagement. The study used a cross-sectional design. This suggests experimental and longitudinal studies and the integration of contextual variables that can alter the studied phenomena. The study's results can support human resource leaders in decision-making processes and mental health promotion in workplaces, generating interventions from a gender perspective.
Keywords: burnout syndrome, gender, mental health, work-life balance.
Resumo: Burnout e engajamento impactam na saúde dos trabalhadores. O objetivo do presente estudo foi analisar a influência do gênero na síndrome de burnout e no engajamento entre trabalhadores de saúde colombianos. O estudo consistiu em um desenho não experimental, transversal, com escopo explicativo. Foi composto por 972 profissionais de saúde (Mulheres = 78,3% e Homens = 21,7%) com idade média de 34 anos. Usamos um questionário ad hoc, a Utrecht Work Engagement Scale (UWES-9) e o the Maslach Burnout Inventory-Human Services Survey (MBI-HSS). A análise dos dados foi realizada no SPSS v.22 e AMOS v.25. Diferenças significativas foram encontradas em relação à despersonalização, com maior afetação nos homens (Z = -2,44, p = 0,015). Não foram encontradas diferenças em relação a outras dimensões de burnout e engajamento em função do gênero. Usando um modelo de equação estrutural, descobrimos que o gênero não afetou o burnout ou o engajamento, mas que o burnout influenciou negativamente o engajamento. O estudo utilizou um desenho transversal. Isso sugere estudos experimentais e longitudinais e a integração de variáveis contextuais que podem alterar os fenômenos estudados. Os resultados do estudo podem apoiar os líderes de recursos humanos nos processos de tomada de decisão e promoção da saúde mental nos locais de trabalho, gerando intervenções na perspectiva de gênero.
Palavras-chave: síndrome de burnout, gênero, saúde mental, equilíbrio trabalho-vida.
In social and organizational research, gender represents an individual fundamental dimension (1). Although the study of gender in working environments has generated multiple controversies (2), it is essential to crucial to consider the gender gap when analyzing work phenomena. Taking this dimension as a central focus in our analyses, rather than treating it as a secondary issue, it urges us to overcome "gender blindness" (3) and enable us to conduct meaningful diagnoses and interventions in workplaces by addressing gender-related differences (4).
Gender is one of the main risk factors that lead to burnout syndrome (5). While there are arguments favoring exhaustion as a particularly female experience, the available evidence is heterogeneous (6). This heterogeneity in empirical data urges us to focus even more on working environments from a gender perspective.
Today, burnout is acknowledged to be experienced by men and women in different ways. Gender differences found in burnout research outcomes must be carefully considered since it can be assumed that women become more fatigued than men. Such an interpretation could lead to particular effects when selecting and promoting workers, causing employment discrimination and the invisibility of this phenomenon to men (2). In this sense, it is proposed to assume the gender category as an analytical category that allows explaining and interpreting the phenomena differently for women and men. It is worth noting that women may be at greater risk of experiencing burnout. However, it is important to acknowledge that this phenomenon also occurs in men, albeit to a lesser extent.
Previous studies have reported significant differences in burnout dimensions according to gender (4). Similarly, some recent studies pointed out differences in engagement associated to gender (7–9). Nevertheless, empirical data regarding the influence of gender on burnout and engagement have been mixed. Moreover, despite the growing literature on this subject, there is still a lack of clarity regarding the role that gender plays in burnout and engagement, particularly among healthcare workers in Latin American. Thus, considering this study is centered on Latin American healthcare workers, mainly on female nurses, we adopted care theory as an analysis perspective (10).
It should be noted that in Latin American investigations, descriptions around gender have been presented as a secondary matter to the subject of burnout and engagement. Nevertheless, given the relevance of these phenomena concerning the various organizational consequences, it is necessary to continue their study addressing gender as the primary variable of the analysis and not as an issue comparable to the remaining sociodemographic dimensions. Consequently, we aimed to 1) Analyze the influence of gender on burnout syndrome and engagement; and 2) Describe the relationship between burnout and engagement among Colombian healthcare workers.
Burnout Syndrome and Engagement
Burnout syndrome is an occupational disease with an increasing prevalence (11), which occurs as a response to work overload (12). It occurs when workers consume their emotional resources in the labor scene to such an extent that they cannot contribute anymore. This syndrome has three dimensions: Emotional Exhaustion; Depersonalization; and Reduced personal accomplishment. Consequently, burnout workers are tired, assume cynical attitudes, and perceive themselves as ineffective (13). More specifically, burnout has been described as a consequence of a crisis in professional self-efficacy (14).
This syndrome represents a worldwide concern, generally among healthcare professionals (15) whose high prevalence has been documented (16), and particularly among nursing personnel who are predominantly women. Upon analyzing burnout among healthcare professionals in a country like Colombia, it becames imperative to approach this labor phenomenon from a gender perspective. In Colombia, burnout has been documented among healthcare professionals (17).
Engaged workers present high levels of energy and mental resistance. They have a high work involvement, feel inspired by their job, and have high concentration levels in their work tasks. Furthermore, engaged workers face work challenges with a positive attitude and are less likely to abandon the organization or company (19). From the outset, engagement has been associated with physical and psychological well-being (20). Due to the positive effects of engagement on people, work teams, and organizations, engagement research has risen in prominence over the last few years (21).
Job Demands–resources Theory explains both burnout syndrome and engagement. Job demands refer to physical, psychological, organizational, or social aspects that require a worker's continuous effort. Job resources absorb or reduce these requirements and their physical and psychological costs. The dynamic interaction between job demands and job resources can trigger a deterioration in health (e.g., burnout syndrome) or a motivational process (e.g., engagement) (22).
Considerations from a Gender Perspective
Gender as an analytical category (23) encourages us to think about the differences experienced by women and men in diverse states, such as burnout syndrome and engagement. From the beginning of the 20th century, labor studies have incorporated a gender perspective and focused on the relationship between work and women, total workload, double presence, and work–life balance (3). Nowadays, an exciting horizon is opening up to study certain psychological phenomena in workplaces, particularly in health institutions. Accordingly, the Theory of Care (proposed by Carol Gilligan, 1982) has been laid out as a perspective of analysis (24). This theory indicates the need to analyze gender differences in working life, and considers - in terms of gender - that work experiences are different; even more so if one takes into consideration that the status, recognition, prestige and sociocultural value assigned to professions is also different (25).
The Theory of Care provides a perspective for analyzing the issue of care duties’ distribution. Traditionally, these duties have been assigned to women in daily lives, when they are engaged in childcare and household responsibilities. Moreover, in more recent, this trend has extended to encompass public and professional life. This phenomenon has led to the fact that mainly women practice healthcare professions.
The theory includes three care dimensions: affective, cognitive, and practical (10). Those dimensions are essential to analyze the experience of emotional exhaustion, depersonalization, and reduced personal accomplishment. From a gender perspective, this proposal invites us to examine the relationship among female carers, the feminization of particular professions, and the distinctive role that gender plays in those experiences.
This issue has been explored, but relevant information remains insufficient (26). Studies tend to consider sex and gender variables, treating the, as interchangeable. In gender studies, it is common to assume that both variables (sex and gender) are socio-cultural constructs and not mere biological differences (27). This fact paves the way to understanding the perspective of gender as a symbolic construction established over the biological data of sexual differentiation (28). This differentiation affects the individual, familiar, labor, and social dimensions. To be precise, gender is taken as a broader category of analysis that is not reduced to a mere sexual differentiation but instead deepens the discussion on the social order based on sexual differences. Therefore, when observed in a particular socio-cultural context, experiences will be markedly different for men and women (22).
Women and men discern and experience factors that cause stress at the workplace differently due to gender particularities. For example, it has been found that perceiving inequity and imbalance between a high effort and a low reward at work generates burnout in women but not in men (29).
As was mentioned above, research results in this area are not conclusive. According to one study, burnout was found in higher prevalence in women than in men that work in healthcare services (30). However, other studies found that men experience a higher prevalence of the syndrome (31). Moreover, other results show that women obtain higher emotional exhaustion scores, but men tend to obtain higher depersonalization scores (6).
Concerning engagement, some researchers consider that engagement is dependent on gender (32). Even though there were no statistically significant differences among primary health workers, greater engagement has been identified in men (33). Some other studies showed differences in engagement dimensions related to gender (8).
This study used a non-experimental design with an explanatory scope (34). It comprised 972 workers belonging to nine Colombian healthcare institutions. The sampling was purposive, including women (n = 761) and men (n = 211). As a criterion for inclusion, the participants should have had more than six months of working experience in the institution and carry out clinical assistance labor.
We used a sociodemographic questionnaire that inquired about gender and other variables. Our study used the Maslach Burnout Inventory-Human Services Survey (MBI-HSS) in its Spanish version (35). This instrument comprises 22 items divided into three dimensions: nine items related to emotional exhaustion, five for depersonalization, and eight for reduced personal accomplishment. It has a Likert seven-point response format: from 0 (never) to 6 (every day).
To evaluate engagement, we used the Spanish version of the Utrecht Work Engagement Scale (UWES-9) (36). The scale consists of nine items and uses a Likert seven-point response format: from "never"  to "always" . With three items, the scale looks into each of the three dimensions of engagement.
The collected data was transferred to Microsoft Excel and exported to version 22 of SPSS software. The data analysis comprised six phases. In the first phase, normality and homoscedasticity were verified using Kolmogorov–Smirnov and Levene tests. The hypothesis test was conducted using the Mann–Whitney U test nonparametric technique.
The number of observable variables (items) was reduced in the second phase through Exploratory Factor Analysis (EFA). In this phase, we implemented the Kaiser–Meyer–Olkin (KMO) test, Bartlett's test of sphericity, the Promax rotation procedure, and the maximum-likelihood extraction method (37).
In the third phase, to determine the number of both latent variables and observable variables included in the structural equation modeling methodology. Confirmatory Factor Analysis (CFA) was used in AMOS software (version 25).
In the fourth phase, we carried out convergent and discriminant validity analyses of the final measurement model and composite reliability. In the fifth phase, the factorial invariance of the obtained measurement model for the gender variable was analyzed. For the factorial analysis, the assumptions of the metric and configured invariances were determined.
Lastly, a factorial invariance analysis was carried out for the gender variable. Additionally, we designed a path diagram of the final structural model with the corresponding fit model: Chi-squared Test over the Degrees of Freedom (CMIN/DF), the Comparative Fit Index (CFI), the Standardized Root Mean Square Residual (SRMR), the Root Mean Square Error of Approximation (RMSEA), and the p-value of Close Fit (PCLOSE).
Exploratory Factor Analysis
We estimated an EFA with the total population (N = 972), which indicated satisfactory results in the Kaiser–Meyer–Olkin test (KMO = 0.88) and Bartlett's test of sphericity (644.56; gl. = 117, p < 0.000), which guaranteed the EFA suitability. The factor extraction method used for the EFA was the analysis of maximum likelihood and Promax rotation procedure with Kaiser standardization. Subsequently, the model does not include the items that indicated factor loadings of < 0.30 (38). Under this parameter, some items were eliminated1. Given the preceding, this EFA hypothesizes a factorial structure composed of three latent variables: the first one is made up only of the engagement factor, and the other two are associated with burnout syndrome.
Confirmatory Factor Analysis
The CFA assumed the measures of adequacy conducted in the EFA. According to the factor matrix analysis, the CFA was estimated through the covariance matrix and by establishing the empirical rule of factorial loadings ≥ 0.50. The items that did not meet this statistical criterion were reviewed by researchers, who theoretically discussed the decision to remove them from the analysis (39).
For engagement, the variable one corresponding to vigor was eliminated due to its load of < 0.50. So, the six remaining variables (2 and 5 = vigor; 3, 4, and 7 = dedication; 6 = absorption) define the engagement latent variable. Concerning burnout, the CFA indicated to eliminate two variables (1 and 6 = emotional exhaustion), variable seven and nine of personal accomplishment, and item five in depersonalization. In consequence, burnout variable confirmed two latent variables: burnout I (2, 3, 8, and 14 = emotional exhaustion) and burnout II (10 and 11 = depersonalization; 16 = motional exhaustion). For the analysis, burnout I will be equivalent to emotional exhaustion, and burnout II will be equal to depersonalization; this depersonalization is connected to direct work with other people.
This study invoked the considerations of Law 1090 of 2006 (40), Resolution 8430 of 1993 (41) and the Helsinki Declaration (42). The ethical committees of the participating institutions approved the research, as did the ethics committee of the Universidad Católica de Pereira. The investigation used informed consent forms, guaranteeing data confidentiality and acknowledging the participation's voluntary nature.
The participants' average age was 34 years. The McDonald's omega reliability coefficient was ω = 0.85 for the MBI-HSS and ω = 0.92 for the UWES.
At a descriptive level, the data analysis showed differences in depersonalization. At the same time, at a probabilistic level, significant differences associated with gender were observed (Z = -2.44, p = 0.015), with a more significant effect on men. The results did not exhibit differences regarding the emotional exhaustion and the personal accomplishment dimensions (see table 1).
Table 1 presents the gender-related disparities pertaining to the dimensions of engagement. According to the engagement variables, the bivariate analysis did not report significant differences among women and men (vigor: Z = -1.37, p = 0.172; dedication: Z = -1.30, p = 0.194; absorption: Z = -1.67, p = 0.095).
Reliability Indicators and Validity of the Model
The scales' reliability was revised through the coefficient omega. The three latent variables demonstrated adequate internal consistency in the model. Moreover, the average variance extracted indicated a fair value for engagement. Hence, the condition of convergent validity was accepted (see Table 2).
Lastly, the discriminant validity reported significant negative correlations between the two latent variables (burnout and engagement). A positive correlation between burnout's two dimensions was also found, even though it is an expected relationship due to the construct's nature.
Likewise, The square root of the average variance extracted the average variance extracted that obtained its square root (values that appear in bold type) exceeded the correlation coefficients, indicating the fulfillment of discriminant validity.
The Goodness of Fit Indicators of the Model
The fit model proposed with the group gender variable based on the relationships with engagement, emotional exhaustion (burnout I), and depersonalization (burnout II) were met with acceptable parameters (CMIN/DF = 2.727, CFI = 0.952, SRMR = 0.051, RMSEA = 0.042, and PClose = 0.992).
The latter measurement model supported configuration and metric invariances to determine gender influence. The estimators were found to be significant for men and women (p < 0.05). In other words, burnout adversely affected engagement. With the result of the z-score, it was concluded that there was no gender influence.
The structural equation model's results showed that gender did not influence burnout syndrome nor engagement. However, consistent with the univariate analysis showed differences in the depersonalization dimension, especially affecting men (43). This point could be associated with the fact that men tend to be very competitive in work scenarios (29). They perceive their working environment in a more threatening way (44). From the socio-cultural dimension, we could affirm that aspects such as rationality and emotional distancing are involved in men's learning process, facilitating such behavior.
In this study, women scored higher on emotional exhaustion, although this result was not statistically significant. A previous study showed elevated scores on emotional exhaustion in female social workers in the public health system. (45). According to a previous meta-analysis, women had a higher emotional exhaustion score (2). The culturally shared idea that family care is women's responsibility could explain that result (46). In terms of socio-cultural learning, the values adopted by women are associated with bonding and caring for others. This association does not imply that these responsibilities are inherently assigned to women, butrather rather reflects the gender and sexual distribution of work within Wetern cultures (23).
Exhaustion in women should also be analyzed from the perspective of labor market changes. In Latin America, towards the middle of the 20th century, women entered the labor market and started having greater economic participation (47). Consequently, the double working day demands that women also take the responsibilities historically relegated to them in domestic labor and child care, which make them invest more time, effort, and energy.
In this sense, women perform care tasks that bring them into conflicts in their personal and working life. For instance, they are forced to relinquish working hours or to work shifts to deal with domestic labor (48). In part, this fact explains the gender pay gap that benefits men, and it also explains why men keep taking up higher supervision and responsibility positions. Ultimately, the interaction between work and family has a higher cost for women. Various studies demonstrated a more significant physical and mental deterioration in women trying to find an equilibrium between both environments (49).
Women's participation in the labor field is growing, while men's domestic tasks are not proportional. Women have been accomplishing leading roles, but they continue performing the same tasks at home. A balance between domestic and labor responsibilities is necessary since the imbalance in this relationship affects women. Thus, gender equality in domestic duties and child care is a way of achieving welfare for both women and men (49).
Moreover, the feminization of household tasks generates a question regarding organizations' ideal workers, since often the ideal worker is one who always has time available for work, and thus should be exempt from family duties (46). This issue implies considering the particular workers' demands so as to create work alternatives that balance work and family life.
In this study, men's personal accomplishments obtained a slightly higher score. A similar result was obtained for a group of neurologists in Brazil (50). However, contrary to the findings related to Brazilian doctors, in which women's scores in personal accomplishment was significantly higher (43).
Concerning engagement, we did not find average differences related to gender dimensions. However, the results were very close. Men obtained higher scores both in vigor and absorption, while women obtained higher scores in dedication. Previous studies also showed no significant differences in the engagement dimension linked to gender (51,52). However, in an Argentinian community dedicated to food commercialization, differences were reported. For example, men obtained higher scores in the three dimensions (8). We can conclude that it is easier for men to engage than women. Hence, women have fewer opportunities for experiencing engagement (53).
A negative relationship was found between burnout and engagement, fulfilling the second objective of this study. This discovery is coherent with previous results (54, 55). Other reports showed that exhaustion and cynicism are negatively related to engagement (56). In this sense, it has been proposed that the "heart of the burnout" is exhaustion and depersonalization or cynicism (57). Hence there would be a negative correlation between these dimensions and engagement.
Therefore, while burnout workers are exhausted and perceive their work in a threatening way, the engaged ones probably enjoy the task and perceive their work as challenging. Nevertheless, even though these phenomena are conceptually opposed, the evidence shows that the presence of one does not guarantee the absence of the other. Indeed, both states may be present simultaneously in one worker. For instance, dedication and absorption could be developed in parallel with exhaustion (19).
All of these factors complicate the understanding of both phenomena and establish fundamental challenges for an intervention, which must have a perspective centered on the person's welfare and not only aim to reduce discomfort. While this study indicates that burnout affects the experience of engagement, it is essential to study the protective factors that buffer the occurrence or effects of burnout (58). In this sense, one way to prevent burnout is to promote engagement (59).
Preventing burnout in healthcare workers becomes a priority task, because once they are burned out, engaging them in motivational processes becomes complex and costly. This issue should be addressed in workplaces urgently. Today’s institutions acknowledge that to be competitive in a changing market, they need proactive workers with excellent performance (60). Job satisfaction, mental health, welfare (61), and engagement are required phenomena. Especially after facing the COVID-19 pandemic, which left important effects on workers (62) and pointed to the central place of health systems (63), which is the role of those who care for others, i.e., health professionals.
To achieve more engaged workers, it is suggested for organizations to consider the gender perspective. This perspective will allow organizations to obtain information about workers' affectations and create concrete policies that promote job satisfaction. In the same way, organizations will participate in contemporary debates about multilateral organizations' requirements. For instance, the International Labor Organization adopted the Sustainable Development Goals (SDGs), particularly SDG 5 concerning gender equality and women empowerment (64).
The univariate analysis showed differences in the depersonalization dimension. On the one hand, women had greater emotional exhaustion than men, but paradoxically, they possessed higher dedication scores. On the other hand, men had higher depersonalization scores, personal accomplishment, vigor, and absorption.
The structural equation model indicated that gender did not influence burnout nor engagement experiences. However, it suggested that burnout affects engagement negatively. This indicates that the bunout negatively affects the engagement regardless of gender.
From a practical perspective, these findings will serve as a guide for human resource leaders in designing interventions. These actions should be especially aimed at preventing depersonalization in male workers.
In this way, the construction of policies and interventions to prevent burnout and promote engagement facilitates a more favorable environment to deconstruct gender stereotypes, languages, and sexist practices that disdain women's and men's roles.
Limitations and future research
One of the main limitations of this research consisted in using self-reporting and not having homogenous samples between men and women. A broader sample of women was obtained because the participating health institutions had greater female participation than men. On the other hand, in this research we explicitly studied health professionals, so the findings cannot be generalized to other professions or occupations.
One of the principal future challenges consists in using specialized theories such as the Theory of Care and intersectionality theory to investigate in more detail professional experiences.
It is necessary to analyze all burnout syndrome dimensions and engagement phenomena to generate contributions to this incipient debate. In that sense, analyzing burnout syndrome and engagement from a gender perspective is relevant for such a debate. Future research would obtain additional in-depth qualitative data concerning all dimensions of men's and women's experiences. For instance, viewpoints such as: "I feel strong and vigorous," or "when I am working, I forget everything else around me," would be worth investigating from a qualitative gender perspective (including semi-structured interviews, in-depth interviews, and focal groups). This proposal makes sense if we recognize the association between "vigor" or "force" and masculine cultural values. Concerning women, the maternity experience and the work–family tension could impact their responses concerning whether they can or cannot forget other life dimensions that are separate from the labor field.
Similarly, this research exposes the methodological challenges involved in investigating workplace phenomena because the gender and intersectional perspectives include overlapping dimensions such as gender, social and profession status, and race/ethnicity, which are especially relevant in the Latin American context.
Finally, governmental actions are necessary—primarily actions related to rest periods, licenses, flexible timetables for men and women, and organizational policies that promote workers' mental health. These policies should focus on well-being promotion. Generally, organizational policies have been centered on risk, stress, and burnout prevention, leaving aside the promotion of positive attitudes. It is necessary to design intervention models for Latin American. Experimental designs can verify the utility of these models in reducing burnout syndrome and the promotion of engagement.
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Tipología de artículo: de investigación
Items eight and nine corresponding to engagement were excluded. Likewise, for burnout syndrome, items number 4, 7, 9, 10, 11, 12, 13, 15, 17, 18, 19, 20, 21 and 22 were removed too.
a Autor de correspondencia. Correo electrónico: email@example.com