*Article* **New Burnout Evaluation Model Based on the Brief Burnout Questionnaire: Psychometric Properties for Nursing**

**María del Carmen Pérez-Fuentes 1,\* , María del Mar Molero Jurado 1, África Martos Martínez <sup>1</sup> and José Jesús Gázquez Linares 1,2**


Received: 19 November 2018; Accepted: 30 November 2018; Published: 2 December 2018

**Abstract:** Health care personnel are considered one of the worker sectors most exposed to heavier workloads and work stress. One of the consequences associated with the exposure to chronic stress is the development of burnout syndrome. Given that evaluating this syndrome requires addressing the context in which they are to be used, the purpose of this work was to analyze the psychometric properties and structure of the Burnout Brief Questionnaire (CBB), and to propose a more suitable version for its application to health professionals, and more specifically nurses. The final study sample was made up of 1236 working nursing professionals. An exploratory factorial analysis was carried out and a new model was proposed through a confirmatory factorial analysis. Thus, validation of the CBB questionnaire for nursing health care personnel showed an adequate discrimination of the items and a high internal consistency of the scale. With respect to the factorial analysis, four factors were extracted from the revised model. Specifically, these new factors, called job dissatisfaction, social climate, personal impact, and motivational abandonment, showed an adequate index of adjustment. Thus, the Brief Burnout Questionnaire Revised for nursing staff has favorable psychometric properties, and this model can be applied to all health care professionals.

**Keywords:** burnout; psychometric properties; nursing

## **1. Introduction**

The number of health care workers in Spain increases year after year, as the number of official association members testifies, in fields such as medicine, which in 2015 increased by 1.9%. The number of nurses rose by 3.4% [1] to nearly 300,000 registered nurses according to the latest data from the National Statistics Institute [2]. Furthermore, the role of nursing personnel is more and more important, and the emotional skills and stressful work climate of nurses must be taken into account, but not only for them, as there are now studies analyzing these factors even in students of physiotherapy, for example [3]. Therefore, nurses are gradually facing situations and settings with more pressure and heavier workloads [4], which produce scenarios filled with strain and job stress [5].

According to the Encyclopedia of Mental Health, burnout syndrome is a type of response to chronic emotional and interpersonal stress factors at work, which is recognized as a serious occupational hazard [6]. The presence of stressors at work maintained over long periods of time can cause burnout in workers, especially those who maintain a constant direct care relationship with service users, as is the case of health care personnel [7], although this syndrome may also be discussed in other areas [8–10].

The presence of burnout syndrome in workers leads to physical, occupational, and psychological consequences, in particular, cardiovascular problems, pain, depressive symptoms, sleep problems, alcohol abuse, absenteeism, and job dissatisfaction [11]. Its appearance has also been associated with a multitude of individual and psychosocial variables [12,13].

One of the behaviors associated with this syndrome is demotivation [5,14]. Specifically, the deterioration of professional motivation, which affects almost half of nursing personnel [15], is a process derived from the perception of absence of reward and culminates in the individual's depersonalization [16]. Motivation, which refers to choices of ends and means, depends in large part on an individual's beliefs and values at the time a situation is evaluated. Motivation generates feelings that lead to action on the job, while demotivation creates limits and promotes expressions of displeasure and distress [17]. According to a study by Achour et al. [18], lack of recognition and motivation are two challenges that health care personnel must face as heavier workloads are assigned and measurements of performance become stricter. This directly affects their performance and job satisfaction [19]. So nursing professionals with the most intrinsic motivation (that is, motivated by their own enjoyment of performing the task for humanitarian reasons) and extrinsic motivation (associated with economic characteristics and scheduling flexibility) show higher levels of job satisfaction and less burnout [20].

Job satisfaction specifically refers to the enjoyment individuals find in their job [21]. Lack of satisfaction in health care jobs has been associated with the presence of burnout in workers, and also with the intention of quitting the profession and diminishing quality of the care given [22,23]. According to Farnaz et al. [24], job satisfaction in nursing is associated mainly with environmental factors, in detriment to sociodemographic and individual factors, so improving satisfaction in job positions involves enriching the characteristics of the organizations nurses work in.

The workplaces with the highest quality, with regard to both setting and structure, are associated with greater well-being and lower levels of burnout among health care personnel [25,26]. Therefore, it is of vital importance that healthy work environments, where the psychological health of nursing staff is given attention, be promoted [27]. In turn, study of the prevention, treatment, and measurement of severe widespread problems in this population, such as burnout syndrome, must continue to progress [28].

The most widely used instrument for the evaluation of burnout is the Maslach Burnout Inventory (MBI) [29]. This instrument was designed for evaluating professionals, such as nurses, who perform their job while interacting with users of their service [30], and has been extensively described and validated internationally [31]. Its manual describes burnout as occurring at high levels of emotional exhaustion and depersonalization, in combination with low scores in personal accomplishment. However, other studies [32] make use of alternative proposals to determine the presence of burnout, such as the definition by Poncet et al. [33], who estimated that this syndrome is present among professionals with a cumulative score over –9 on the MBI.

Although there are studies confirming the Maslach Burnout Inventory questionnaire's three dimensions [34–36], other studies have found factor structures based on two [37,38] and five dimensions [39,40]. Densten [39], after confirmatory analysis of the instrument, found that the structure based on five scales was more strongly supported than the model of three, or even four. Thus, while the depersonalization factor was maintained in this new division of factors, emotional exhaustion was divided into "somatic strain" and "psychological strain," while personal accomplishment was broken down into "self-accomplishment" and "working with others."

Another alternative instrument to the MBI for evaluating burnout is the Brief Burnout Questionnaire (CBB) [41]. The CBB comprises 21 items that evaluate not only the syndrome itself, but also its antecedents and consequences. That is, it understands burnout as a process [42]. The instrument was validated in teaching professionals, showing adequate convergent validity with the MBI on the total burnout scale (but not, however, on all the syndrome factors), so the authors recommended it for evaluating some elements present in the burnout process (specifically antecedents, burnout, and consequences), but not for direct evaluation of its specific components. Few studies have used this questionnaire [43–45], as shown in the review by Ahola et al. [46], who indicated that they were unaware of the existence of the questionnaire's validation. It has also been adapted for use with housewives [47], in which a three-factor structure similar to the one found in the original questionnaire was found. However, this instrument has received some criticism. For example, in the validation done in a sample of teachers in Aragon Province, Spain [48], no significant differences were found on some of the scales between men and women, which might be due to the inappropriateness of the items in showing the behavior associated on each scale. The results have also shown low reliability, and it was concluded that its use has generated little validity, mainly because of its factor division [49].

According to Domínguez-Lara [50], the multifactor internal structure of burnout evaluation instruments must be analyzed considering the context where they are going to be used, since even though the construct may have a good theoretical basis, the configuration of its structure may vary when used in real environments. Therefore, the purpose of this study is to show that the CBB is a valid model for different cultures and societies, as this scale has awakened great interest in recent years. In addition to analyzing its psychometric properties and structure, this study proposes the best version or model for its application to health care professionals, and nurses in particular.
