Burn-out Syndrome and Behavior in Conflict Situations among Nurses and Doctors

Due to its influence on behavior, the burn-out syndrome among nurses and doctors is an actual problem of modern management of medical employees. This study was conducted among 189 nurses and doctors and its aim was to examine the influence of burn-out syndrome on their behavior in conflict situations. The levels of burn-out syndrome and the most common type of behavior in conflict situations in nurses and doctors were studied. The types of behavior in conflict situations could be “competing”, “collaborating”, “compromising”, “avoiding” and “accommodating”, which were measured with the Bulgarian version of The Thomas-Kilmann Conflict Mode Instrument (TKI). Establishing the level of burn-out among nurses and doctors is necessary for purposeful therapeutic work aimed at developing work-related stress tolerance and for better control of behavior in conflict situations. The presented results show a higher “reduced personal accomplishment” for doctors compared to nurses.


Introduction
The professions of a doctors and nurses are one of the most noble, humane and necessary professions in the world, but at the same time one of the most difficult, because in the hands of a doctors and nurses are people's lives. The problem of burnout syndrome among doctors and nurses is relevant to the current stage of psychology development. The popularity of research on this issue is rapidly increasing due to the fact that a significant number of highly qualified doctors have low stress tolerance and are subjected to burnout syndrome. According to Silkina, Sanshokova and Sergeyeva (2014) the implementation of measures aimed at developing emotional and psychological stress tolerance, both during medical training and in the course of further work, it will prevent the formation of a "burnout syndrome" common among doctors. Similarly, professional burnout affects the work and life of nurses (Ivanova, 2017).
The theoretical interest in the topic of burn-out syndrome is due to its practical value. Since the burn-out syndrome occurs in people in the context of their work and has negative consequences for them, all organizations working for psychological well-being are interested in the factors and their consequences. Despite the many research on the topic, interest in it does not diminish. In fact, burn-out is a metaphor. Schalufeli and Enzmann (1998: 1) assert that burnout "describes a state of exhaustion similar to the smothering of a fire or the extinguishing of a candle". For the first time the term of staff burn-out was used by the American Psychiatrist H. Frundenberger (1974), in order to describe the psychological and physical state. He revealed frustrations in work, emotional and mental exhaustion, which were defined as defeat, exhaustion, wear and tear, occurring in a person due to excessive demands on their own resources and strength.
Classical manifestations of burnout, as defined by Maslach and Jackson (1996), usually include the following components in the structure: The burnout syndrome is an inability of effectively functions in own professional work, which is the result of prolonged and severe stress (Nenova et al., 2005). In exercising a profession that involves a stressful environment (such as that of nurses and doctors) there is mobilization of internal resources that can have serious consequences. According to a study conducted by Selye (1936) on the onset and development of stress, in the event that a person has been subjected to stress factors for 3 years, stress becomes chronic.
The factors of the working environment that most often affect on the appearance and development of the burnout syndrome can be summarized as follows: overload, unclear roles and role-conflict, lack of control over work, poor communication and lack of positive feedback, stressful interpersonal responsibilities, bureaucracy of the system (Nenova et al., 2005). This specific psychic reaction called "burnout" is a result of the transformation of motivation in the system "human-to-human" of jobs related to health, education, fight against crime, etc. The professional duties in these working groups require intensive interpersonal communication, cooperation as well as permanent exchange of information (Stamenkova, 2005). At the same time conflict is a natural process in work organizations and in other areas of everyday life.
Based on the individual character of the personality, where there is a significant discrepancy between the expectations and desires of the people, conflict is a natural part of the relationship with others (Riggio, 2015). Thus, in the words of Stankov (2006: 142), "the person is the factor that creates the conflict situation because a conflict outside society and separated from interpersonal relations does not exist".
In itself, the conflict situation is expressed in a sharp escalation of the tensions that have arisen in a given community as a result of opposing the interests of the members involved in the particular interaction. The conflict situation as an objective incompatibility is precisely the reason for confronting the goals, the ideas, the needs of the participants and the impossibility of realizing it on an individual plan (Dessev, 2006).
Or, as the authors Dontsov and Polosova (1980: 121) summarize, conflicting behavior is a system of "emotionally colored actions", impeding the achievement of goals by opposing side.
Above all, the situation as a process of action predetermines a certain form of activity. On the basis of this view, the situation has a completely objective character but is broken through the individual's consciousness, transformed into a subjective one. Thus the situation acquires a complex of objective and subjective elements that affect the person for a certain period of time and in response to all this a certain form of behavior.
At the base of each conflict situation is the tension that originates at the beginning can escalate to a very high degree. On the other hand, the tense personality can also have a positive effect, where it leads to increased self-control, the person mobilizes his internal potential to overcome unpleasant life situations, expand experience, and strengthen the will. In this way, Mysliffchenko admits that these critical moments are important for building individuality in the consciousness and the moral persistence of the individual (Mysliffchenko, 1977).
Kenneth Thomas and Ralph Kilmann elaborate a tool which measure person's behavior in a conflict situation where the interests between are not incompatible. It is in such a situation that a person's behavior can take two dimensions: assertiveness, the degree in which person seeks to satisfy its own interests and co-operativeness, the extent in which it tries primarily to satisfy the interests of other people (Kilmann & Thomas, 1977) Thus, according to the Thomas-Kilmann Conflict Mode Instrument (TKI), there are two dimensions of human behavior, which unlock five models as a response in a conflicting situation (Thomas, 1992): • Competing -characterized with confidence and non-cooperation. This is a powerfuloriented model that uses all appropriate ways to reach its own personal position; • Adaptation -distinguished by insecurity and cooperation. It relates to the fact that the person ignores himself satisfy, then care about interests of others. Sometime it is like element of sacrifice in the name of foreign well-being; • Avoidance -instability and non-cooperation. With this model, the person does not pursue either its own interests or of the others one. In this way, it distanced itself from the conflict situation. Avoidance can be expressed as diplomatically avoiding the problem, postponing it to a more appropriate moment, or simply withdrawing from the threatening conflict situation; • Collaboration -in the same time is sustainability and co-operative. It is about trying to engage in teamwork with others to find solutions, which is acceptable to everyone's interests. It also includes attempts to find a creative solution to interpersonal problems; • Compromise -moderation in sustainability and cooperation. The main purpose of this method is to find solution that will satisfy everyone in conflict situation. In some cases, the compromise may mean splitting the differences between two positions, exchanging interests, or looking for a quick solution.

Aim
The main aim of this study is to follow actual level of burnout syndrome and most common type of behavior in conflict situations among nurses and doctors in Bulgarian hospital.

Hypothesis
Our main suggestion is that there are differences in level of burnout syndrome among nurses and doctors with different main type of behavior in conflict situations: (1) We suppose that there will be statistical significant differences in "reduced personal accomplishment" between males and females.
(2) We assume that nurses will have higher emotional exhaustion than doctors, also doctors will have higher dehumanization than nurses.

Methodology
This research was conducted in a Republic of Bulgaria, in Blagoevgrad town, through period from September to October 2018. To determine the professional burnout syndrome, was used the most popular tool MBI (Maslach burnout inventory) in its Bulgarian version. The questionnaire includes three scales: "Emotional exhaustion" (EI); "Dehumanization" (DH); "Reduced personal accomplishment" (RA) (Tsenova, 1992). The types of behavior in conflict situations could be "competing" "collaborating", "compromising", "avoiding" and "accommodating" which were measured with the Bulgarian version of the Thomas-Kilmann Conflict Mode Instrument (TKI) (in Ivanov, 1999). There are examined 189 medical employees (doctors and nurses) from Multiprofile Hospital for Active Treatment in Blagoevgrad, between 24 and 65 years (M=43.82; SD=12.54). For statistical analysis SPSS 16 was used.

Results of research
In this study we hold on Maslach's suggestion to use the scales of MBI one by one, then to evaluate common ball (Maslach & Jackson, 1996). According to our main aim to follow actual level of burnout syndrome and most common type of behavior in conflict situations among nurses and doctors in Bulgarian hospital, we find out that 51.9% of the participants in our research have high level of "emotional exhaustion". Similar results are also found on the "dehumanization" scale, where 53.4 % of surveyed persons show high values. In terms of "reduced personal accomplishment" there are 44.4% of participants with high level results ( Table 2). As a conclusion of these results, it can be argued that half of medical workers who participated in the study had a high level of burnout syndrome. The second part of our main aim is to find out the most common type of behavior in conflict situations among nurses and doctors in Bulgarian hospital. It was found that most of the participants in this research react with "competing" in conflict situation (37.6%) and with "compromising" (33.9%). That means that competing and compromising are the most common type of behavior in conflict situations among medical workers, who participated in current research. In terms of the profession -51.6 % from doctors react with competing in conflict situations. For nurses the most common behavior in conflict situations is compromising -32.7 % from nurses (Table 3). For proving the hypothesis different statistical analysis was used. For first suggestion that there are statistical significant differences in "reduced personal accomplishment" between males and females independent Samples T-test was used. The procedure finds significant differences in scale "reduces personal accomplishment" between males and females: T(189)=1.976; p=0.5 with M(males)=37.07; SD(males)=6.37 and M(females)=34.17; SD(females)=8.32. The observed means show higher levels of "reduced personal accomplishment" for the males in compare with females and the results are statistical significant (p=0,5), so the first hypothesis is approved.
Independent Samples T-test for other MBI scales was used. Significant differences in "emotional exhaustion" between males and females was found: T (189)  Our second hypothesis is that nurses will have higher emotional exhaustion than doctors, also doctors will have higher dehumanization than nurses. For proving the first part of the hypothesis T-test was used. Following the used statistical procedure were found significant differences in "emotional exhaustion" between doctors and nurses: T(189) =4.483; p=0.00 with M(doctors)=37.64; SD(doctors)=12.16 and M(nurses)=29.72; SD(nurses)=12.11. In other words these results display that doctors have higher emotional exhaustion than nurses. Despite significant results, the first part of our second hypothesis is not approved. About finding differences in dehumanization among nurses and doctors again T-test was used: T(189)=1.245; p=0.215 with M(doctors)=15.37; SD(doctors)=9.63 and M(nurses)=13.66; SD(nurses)=9.23. The observed means display higher dehumanization in doctors than in nurses, but the results are not statistically significant, so the second part of the second hypothesis is not approved.
The differences in "reduced personal accomplishment" among doctors and nurses were also checked. The T-test found statistical significant differences between the groups: T(189)=7.722; p=0.00 with M(doctors)=39.80; SD(doctors)=5.62 and M(nurses)=32.25; SD(nurses)=7.58. The presented results show a higher "reduced personal accomplishment" for doctors compared to nurses.
Our main suggestion is that there are differences in level of burnout syndrome among nurses and doctors with different main type of behavior in conflict situations. For this hypothesis nonparametric test of Kruskal-Wallis was used. The results show higher emotional exhaustion, dehumanization and reduced personal accomplishment in participants with competing as a behavior in conflict situations in compare to participants with other main type of behavior in conflict situations. So our main hypothesis is approved.

Discussion
According to all three components of burnout syndrome: emotional exhaustion depersonalization and reduced personal accomplishment and the obtained mean values it can be said that the doctors are with higher burnout syndrome in compare with the nurses. It was found that 51.9% of the medical workers have high level of "emotional exhaustion". Similar results are also found about the "dehumanization", where 53.4 % of them show high values. In terms of "reduced personal accomplishment" there are 44.4% of participants with high level results. Competing and compromising are the most common type of behavior in conflict situations among medical workers. Doctors react with competing in conflict situations and for nurses the most common behavior in conflict situations is compromising. It was found that there are differences in level of burnout syndrome among nurses and doctors with different main type of behavior in conflict situations. The established results relate only for those who participated in this study.