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Meskari M, Akbarfahimi M, Kamali M. The Relationship Between Rehabilitation Therapists’ Attitudes Towards Individuals With Disabilities and Job Burnout: An Empirical Investigation. Func Disabil J 2023; 6 (1) : 196.2
URL: http://fdj.iums.ac.ir/article-1-234-en.html
1- Department of Management, School of Rehabilitation Sciences, Iran University of Medical Sciences, Tehran, Iran.
2- Department of Occupational Therapy, Neuroscience Research Center, School of Rehabilitation Sciences, Iran University of Medical Sciences, Tehran, Iran. , akbarfahimi.m@iums.ac.ir
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Introduction
The term “burnout syndrome”, coined in 1974, characterizes a psychological state stemming from prolonged workplace stress [1]. Job burnout, which is common in caregiving roles, encompasses emotional exhaustion, depersonalization, and reduced personal accomplishment [2]. Emotional exhaustion indicates fatigue and diminished motivation, while depersonalization reflects a negative outlook. Reduced personal accomplishment relates to a negative self-evaluation [3].
Burnout widely affects individuals, society, and organizations in professions, particularly healthcare [4]. At an individual level, it leads to fatigue, discomfort, and cognitive-emotional distress, with broader consequences, such as disrupted relationships and reduced service quality [5]. Healthcare professionals, including rehabilitation therapists, face heightened vulnerability, with estimates indicating prevalence among nurses (10%-70%) and doctors (30%-50%) in the United States [6].
Investigating the relationship between work-related quality of life and job satisfaction among Iranian occupational therapists offers critical insights into burnout dynamics [7]. Consequences extend to caregivers, patients, and institutions, impacting safety and well-being [1, 8]. Occupations in the service and caregiving sectors, which entail extensive interaction with individuals grappling with psychological, social, or physical challenges, are particularly susceptible to occupational stress and burnout [9]. This phenomenon is most pronounced in professions requiring sustained engagement with individuals, as evident in nurses, who are at heightened risk due to their prolonged interactions with patients [10]. Burnout is multifaceted and rooted in individual attributes, demands of healthcare occupations, and organizational factors [11].
According to the World Health Organization’s (WHO) international classification of functioning, disability, and health, disability significantly affects major life activities, emphasizing the need for rehabilitation services [12]. A complex concept, disability globally impacts 15.6% of adults aged 18 years and older [13].
In healthcare, particularly rehabilitation, professionals grapple with individuals’ challenges, emphasizing the pivotal role of attitudes in the rehabilitation process [14]. Attitudes, whether positive or negative, serve as predictive factors of behavior [15]. Personality traits, linked to burnout, include extroversion, agreeableness, conscientiousness, and openness associated with lower burnout levels, while neuroticism is linked to higher levels in specific professions [16]. Individual factors, such as age, gender, and emotional intelligence influence job burnout [1, 3]. Given rehabilitation therapists’ extensive interactions, they face an elevated risk. Identifying factors influencing job burnout and developing interventions can mitigate human and financial costs [17].
Amid extensive research in organizational psychology, organizational behavior, and human resources, and recognizing burnout’s established links with employee behavior, investigating its prevalence among rehabilitation therapists and related factors becomes crucial. This study was conducted to examine the relationship between attitudes toward individuals with disabilities and job burnout, enriching theoretical knowledge. Insights from this research can guide stakeholders, including the Ministry of Health and relevant institutions, in evidence-based interventions to alleviate job burnout among rehabilitation therapists.

Materials and Methods
Study design

The present study adopted a correlational research design, specifically categorized as a subset of descriptive-analytical research. Its primary objective was to explore the relationship between variables associated with job burnout and attitudes toward individuals with disabilities. Within the realm of correlational research, this study falls under the category of bivariate correlation, which aims to examine the interrelationships between two specific variables.

Participants
The study included 261 individuals from various fields of rehabilitation, including occupational therapy, physiotherapy, speech therapy, audiology, orthotist, and prosthetist. The inclusion criteria included active employment in governmental or non-governmental rehabilitation clinics in Tehran Province, Iran, possession of a medical system card within a rehabilitation field, engagement in a minimum of 25 work hours per week, and an accumulation of at least one year of professional experience in their respective roles. Participation in the study was contingent upon meeting these criteria and providing informed consent.

Sampling method
The research employed a quota sampling approach to select the participants. This method involved sampling therapists from a list based on their diverse fields of study. The number of individuals selected from each category was proportional to the number of members on the respective list. This method was conducted to ensure representation across various subgroups of rehabilitation therapists.

Sample size
The sample size for this study was determined at a 95% confidence level with a test power of 80%, as a result, the required sample size was 261 individuals. This calculation, necessitated by the absence of prior studies on the relationship between the variables of interest, was guided by expert estimates of a correlation coefficient of approximately 0.20. The power test, set at 0.80, minimizes the probability of committing a type II error, ensuring the robustness of the statistical analysis.

Procedure
Recruitment process

Participants were recruited through a combination of in-person visits to rehabilitation clinics and online communication. The research team initiated face-to-face discussions with therapists or provided comprehensive written explanations online. This initial engagement aimed to ensure a clear understanding of the research project’s objectives and the full scope of their prospective involvement.

Enrollment of interested participants
Therapists who expressed a genuine interest in participating in the study were formally registered as research participants. Their informed consent was documented during the registration process.

Replacement of departing participants
In instances where a participant chose to discontinue their involvement in the study, a random selection method was employed to fill the vacant position and maintain the sample’s integrity.

Data collection tools
Demographic information questionnaire

This questionnaire collected crucial demographic data from the participants. Information gathered included age, gender, education, marital status, profession, work experience, type of rehabilitation center (public or private), and the weekly level of service provision activity.

Attitude towards people with disabilities questionnaire (form A)
 Form A of the attitude towards people with disabilities questionnaire, developed by Yuker et al. in 1970, was used. This questionnaire assesses individuals’ attitudes towards people with disabilities and consists of 30 items. It is divided into two sections, one covering personal characteristics and the other containing attitude-related questions. Respondents use a Likert scale to express their agreement, ranging from “completely agree” to “completely disagree”. This allows the categorization of responses into six distinct levels with corresponding scores from +1 to +6. The cumulative scores range from 30 to 180, with higher scores indicating more positive and supportive attitudes toward people with disabilities [18]. Aran et al. validated this tool in Persian, reporting an internal correlation coefficient of 0.75 and a Cronbach’s α of 0.85. Typically, it takes around 15 minutes to complete [19].

Maslach job burnout questionnaire
The Maslach burnout inventory, developed by Maslach and Jackson in 1981, assesses burnout levels with three subscales, emotional exhaustion, depersonalization, and personal accomplishment. Respondents rate 22 items on a Likert scale. The questionnaire uses two response types, frequency (0 to 6) and intensity (0 to 6) instructions [4].
The scoring process categorizes questions into emotional exhaustion (9 items), depersonalization (5 items), and personal accomplishment (8 items). Interpretation of scores involves identifying “high”, “moderate”, or “low” burnout levels on each subscale.
Cronbach’s α coefficients confirm questionnaire reliability, 0.92 for emotional exhaustion, 0.79 for depersonalization, and 0.71 for personal accomplishment [20].
The questionnaire has been validated in Persian, and its use in research is well-established [21].

Statistical analysis
Data analysis encompassed both descriptive and inferential statistical methods. At the descriptive level, measures, such as frequency, percentage, Mean±SD were utilized to provide a comprehensive overview of the data.
For the inferential phase, the normality of data distribution was assessed using the Kolmogorov-Smirnov test. To examine the hypotheses, statistical techniques, including correlation coefficients, linear regression, and analysis of variance (ANOVA) were employed.
Data were analyzed using the SPSS statistical software, version 26, with a significance level of 0.05.

Results
The study participants’ demographic characteristics, as summarized in Table 1, encompassed various factors, such as age, work history, weekly working hours, field of study, educational qualifications, workplace type, gender, and marital status.


The average age of the participants was 26.77 years, with a standard deviation of 3.87. In terms of work history, the participants had an average of 4.42 years of experience, with a standard deviation of 3.38. The average weekly working hours were approximately 34.73 hours, with a standard deviation of 15.4.
Regarding the field of study, most participants were in the field of physiotherapy (37.9%), followed by occupational therapy (18.4%), and speech therapy (13.0%). In terms of educational qualifications, 59.0% of participants held a bachelor’s degree, 32.6% had a master’s degree, and 8.4% had a PhD degree.
In the context of workplace centers, 83.9% of participants worked in private centers, while 16.1% worked in government centers. The gender distribution showed that 62.5% of participants were women, and 37.5% were men. Concerning marital status, most participants (75.9%) were single, while 24.1% were married (Table 1).

Data distribution 
To assess the normality of the dataset, the Kolmogorov-Smirnov test was conducted with a significance level of 0.05. As depicted in Table 2, the results indicated that the Kolmogorov-Smirnov test was not significant (P>0.05) for any of the research variables, signifying that all variables followed a normal distribution.


Consequently, parametric analyses were appropriate for the dataset.
Table 3 presents the Pearson correlation coefficient results for the study variables.


It reveals the correlation values (r) and corresponding significance values for each variable, including attitude, which predicts job burnout, emotional exhaustion, depersonalization, and personal accomplishment. Additionally, the Table shows correlations between age (y), work experience (y), and working hours per week (h) with the relevant variables. A statistically significant negative correlation is observed between job burnout and attitude, and between age and job burnout, as well as a statistically significant positive correlation between working hours per week and job burnout.
Table 4 presents the results of regression analysis, showcasing the predictive relationship between attitude and the study variables.


The attitude is the independent variable, and dependent variables are job burnout, emotional exhaustion, depersonalization, and personal accomplishment. These results highlight that attitude significantly predicts job burnout, emotional exhaustion, depersonalization, and personal accomplishment, with adjusted R2 ranging from 0.32 to 0.53, indicating the proportion of variance in these variables explained by attitude.
The results in Table 5 indicate that at the significance level of P<0.05, the null hypothesis was rejected for both attitude and job burnout scores.


This implies that a significant difference existed among the attitudes of rehabilitation therapists toward individuals with disabilities. Subsequently, Tukey’s post hoc test was conducted to further explore where these differences lay.
Tukey’s post hoc test results revealed that the significant difference was primarily between the occupational therapy group and the other rehabilitation groups. In simpler terms, it suggests that occupational therapists exhibited a more positive attitude towards individuals with disabilities compared to their counterparts in other rehabilitation fields.
The results presented in Table 6 show that, similarly to the attitude scores, the null hypothesis was rejected with a significance level of P<0.05 regarding job burnout scores.


This signifies a substantial difference in the job burnout experienced by rehabilitation therapists working with people with disabilities. The subsequent Tukey’s post hoc test aimed to pinpoint the specific groups contributing to this discrepancy.
The analysis demonstrates that physiotherapists exhibited the highest job burnout among all rehabilitation therapists, setting them apart from their peers in other rehabilitation fields.

Discussion
The results of this study showed a significant and inverse correlation between job burnout and its constituent dimensions, including emotional exhaustion, depersonalization, reduced personal accomplishment, and the attitudes held by rehabilitation therapists towards individuals with disabilities. In essence, as the levels of job burnout escalate, a tendency for rehabilitation therapists to harbor increasingly negative attitudes towards individuals with disabilities becomes apparent. Job burnout encompasses a multifaceted state marked by physical, emotional, and cognitive fatigue, precipitated by protracted exposure to demanding work conditions, coupled with interprofessional conflicts and a waning commitment to both the work and its recipients [22]. Within the confines of this syndrome, individuals grapple with reduced vigor, diminished competence, and a growing reluctance to engage in work-related tasks. Inevitably, this condition can foment negative behaviors and attitudes, including mood swings and professional discontent. For professionals continually dedicated to aiding others, such as rehabilitation therapists, the burden often proves twofold, a factor that contributes to heightened job burnout. Such individuals are beset by elevated stress, a dwindling inclination for work, and consequent job dissatisfaction. Concomitantly, the compounding of negative feelings and a propensity to shift blame to others occurs. Therefore, as job burnout intensifies, the likelihood of a negative attitude emerging is significantly elevated.
Moreover, emotional exhaustion associated with job burnout entails the depletion of emotional reserves within an individual, ultimately leading to a loss of motivation and rendering work a burdensome endeavor. Simultaneously, a reduced perceived level of competency and the inability to effectively perform tasks, along with unfavorable self-assessments concerning work-related performance, can significantly heighten the sense of exhaustion among therapists [23]. Depersonalization, a facet of job burnout, denotes a pessimistic outlook towards service recipients or work in its entirety. It effectively describes a state of emotional detachment from those in need of direct care or attention, thereby fostering an emotionally distant and impassive approach toward others [2]. This aspect poses a pronounced risk within people-oriented vocations, such as rehabilitation therapy, where direct interaction with individuals with disabilities is a foundational tenet of the profession. The attitudes held by rehabilitation therapists towards individuals with disabilities bear considerable weight in the context of the rehabilitation process [14]. The emergence of symptoms associated with job burnout, such as diminished motivation, declined enthusiasm, despondency, and apathy, invariably paves the way for the development of a negative attitude. Thus, the amplification of burnout levels and its constituent dimensions significantly heightens the likelihood of a negative attitude taking root.
Additionally, this study discerned a noteworthy relationship between job burnout and select demographic variables. It identified a negative correlation between age and work experience while establishing a positive relationship with the number of working hours per week. These results are largely consistent with previous research, as reflected in the work of Escudero-Escudero et al. [5], Ahmadi et al. [24], and Bruschini et al. [25]. Bruschini et al. reported a heightened vulnerability to burnout among young physiotherapists with limited professional experience, in stark contrast to their older, more seasoned counterparts [25]. Consistent with the present results, the research outcomes of Escudero-Escudero et al. [5] and Ahmadi et al. [24 ] confirm a positive correlation between job burnout and youthful age, coupled with limited experience [5, 24]. The underlying rationale for these trends lies in the greater susceptibility of younger rehabilitation therapists, characterized by their inexperience and consequent inability to effectively navigate the challenges and stressors inherent in the workplace. These individuals are profoundly affected by workplace issues, primarily due to their lack of experience. Attaining more extensive experience is essential to successfully confront and surmount the impediments and challenges that lie before them. Furthermore, the significant and positive correlation between the number of working hours per week and job burnout is consistent with the results of Ahmadi et al. [24], Rezaee et al. [26], and Scott et al. [27]. Extended working hours expose rehabilitation therapists to augmented stress levels and heightened workplace pressure, thus significantly contributing to the development of burnout.
The study also showed that attitudes are positively linked with age and work experience while bearing a negative correlation with the number of working hours per week. The significance of healthcare professionals’ attitudes, including rehabilitation therapists, cannot be understated within the realm of disability rehabilitation. These attitudes hold the power to shape the response of individuals with disabilities to treatment and their acceptance of rehabilitation progress, and they can further predict the behavior of service recipients [28]. Age and work experience cultivate psychological resilience in rehabilitation therapists, enabling them to confront the inherent challenges of working with individuals with disabilities. Accumulated experiences equip these professionals with a more positive attitude towards individuals with disabilities [29]. In stark contrast, extended working hours lead to heightened fatigue, work-related stress, and eventual burnout, thereby fostering the development of a negative attitude.
In addition, a comprehensive analysis of rehabilitation therapists’ attitudes towards individuals with disabilities highlighted a statistically significant difference, primarily discerned between occupational therapists and other rehabilitation groups. Occupational therapists exhibited a more favorable attitude towards individuals with disabilities compared to their peers. This proclivity towards a more positive attitude is the product of direct engagement with individuals with disabilities, affording occupational therapists a deeper understanding of the unique challenges and requirements of this demographic. Furthermore, these professionals develop a realistic perspective on individuals with disabilities, thereby reinforcing their positive attitude. The education method can be effective on burnout, therefore, further research is recommended.
Conversely, concerning an examination of burnout scores among rehabilitation therapists working with individuals with disabilities, the results unequivocally revealed that physiotherapists registered the highest levels of burnout. This result is consistent with the research conducted by Bruschini et al., who highlighted a pronounced prevalence of burnout in the physical therapy domain [25]. Correspondingly, it is consistent with the observations made by Bruschini et al., who found no significant divergence in job burnout across diverse categories of healthcare professionals, encompassing physiotherapists, speech therapists, and occupational therapists. The discrepancy can be ascribed to the specific challenges posed by physiotherapy as a rehabilitation discipline. The nature of physiotherapy, which involves unceasing patient interaction, recurrent physical activities, and strenuous postures during work, heightens the risk of work-related issues. Consequently, physiotherapists are exposed to a greater propensity for physical injuries, including those impacting the back, wrists, and neck. These injuries are typically instigated by activities, such as patient lifting and transfer, assisting in falls, handling heavy objects, and executing manual techniques such as mobilization and soft tissue work [30]. Consequently, higher levels of burnout among physiotherapists are unsurprising.

Conclusion
The study provided valuable insights into the complex dynamics of burnout and attitudes among rehabilitation therapists, revealing significant correlations between job burnout and negative attitudes towards individuals with disabilities. Physiotherapists, in particular, exhibited the highest levels of burnout, potentially attributed to the demanding nature of their work.
These results underscored the importance of targeted interventions to address burnout and improve attitudes in the rehabilitation therapy profession. Strategies focusing on enhancing workplace conditions, providing mental resilience training, and fostering self-awareness aligned with the overarching goal of elevating therapist well-being and, consequently, the quality of patient care.

Limitations
It is crucial to acknowledge the limitations of the study. The participant sample, predominantly consisting of individuals with relatively low work experience, may limit the generalizability of the results. Additionally, the diverse methods employed for data collection introduced potential biases, affecting the broader applicability of the results.

Recommendations for future research
Building on these results, future research endeavors can explore the intricate relationship between personality factors (resilience, emotional regulation, religious beliefs) and burnout among rehabilitation therapists. Investigating structural factors in the work environment and their impact on job burnout can provide nuanced insights. Given the increasing demand for physiotherapy, understanding the unique factors contributing to burnout among physiotherapists is crucial for developing targeted interventions.
These research suggestions aim to contribute to a nuanced understanding of burnout and attitudes among rehabilitation therapists, offering evidence-based strategies to enhance healthcare delivery and therapist well-being.

Ethical Considerations
Compliance with ethical guidelines

This study was approved by the Ethics Committee of Iran University of Medical Sciences (Code: IR.IUMS.REC.1401.781). 

Funding
The research received funding from the Research Vice President of Iran University of Medical Sciences (Grant No.: 24143).

Authors' contributions
Conceptualization, Supervision: Malahat Akbarfahimi; Methodology: Mohammad Kamali; Investigation: Mehdi Meskari; Writing-review & editing: All authors. 

Conflict of interest
The authors declared no conflict of interest.


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Type of Study: Research | Subject: Professional education and practice
Received: 2023/11/15 | Accepted: 2024/01/15 | Published: 2023/02/26

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