The Journal of Maternal-Fetal and Neonatal Medicine, 2012; 25(10): 21302134

2012 Informa UK, Ltd.

ISSN 1476-7058 print/ISSN 1476-4954 online
DOI: 10.3109/14767058.2012.666590

Assessing burnout among neonatologists

Carlo V. Bellieni1, Pierluigi Righetti2, Rosanna Ciampa2, Francesca Iacoponi3, Caterina Coviello1 &
Giuseppe Buonocore1
1Department of Pediatrics, Obstetrics and Reproduction Medicine, University of Siena, Sienna, Italy, 2Department of

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Developmental Psychology and Socialization, University of Padua, Padua, Italy, and 3Department of Biomedical Sciences,
University of Siena, Sienna, Italy
Objectives: To measure burnout in a cohort of neonatologists
and to explore its association with several psychological and
biographic factors. Materials and methods: A total of 110 neonatologists filled in a personal questionnaire composed of four
parts: (a) biographic data, (b) personal beliefs, (c) attitudes
toward clinical decisions and (d) a validated tool (the Link
Burnout Questionnaire [LBQ]) to assess their burnout. The LBQ
categorizes burnout into four subscales: psycho-physical exhaustion, relationship deterioration, sense of professional failure
and disillusion. Scores of each subscale range from 6 (minimum)
to 36 (maximum). Burnout values were matched with the data
of the personal questionnaire. Results: Most neonatologists
(60%65%) were in the at risk range for burnout. High burnout
was experienced by 30% of the neonatologists. Having no children is associated with low rates of burnout; work experience of
less than 5 years, believing that living with a physical disability
is unworthy and having recurrent death ideation are associated with high rates of burnout. The attitude to resuscitating a
24-week baby is inversely correlated with the disillusion rate.
Conclusion: In our cohort, burnout exceeds the alarm threshold
in one-third of cases. Some of the risk factors we examined were
correlated with burnout and should be considered in future
prevention programs.
Keywords: Burnout, disillusion, stress, neonatology

Introduction
Burnout as a syndrome is present in many individuals under
constant pressure [1]. It is particularly frequent among physicians,
overloaded between the demands of caring for sick patients and the
constraints of fewer organizational resources [2]. The symptoms
and signs of burnout include emotional exhaustion, cynicism,
perceived clinical ineffectiveness and a sense of depersonalization
in relationships with coworkers, patients or both [3]. Burnout has
been associated with impaired job performance and poor health,
including headaches, sleep disturbances, irritability, marital difficulties, fatigue, hypertension, anxiety, depression and myocardial
infarction. It can also contribute to alcoholism and drug addiction
[46]. Maslach and Leither [1] defined burnout as the index of the
dislocation between what people are doing versus what they are
expected to do, or an erosion of the soul [7]. Burnout spreads
gradually and continuously over time, sending people into a
downward spiral from which it is hard to recover [1,3].

The scarce studies on the causes of burnout are limited to the

influence of age or job [810], while burnout is not only due
to external stressors but also to biographic and psychological
features. In this study, we specifically analyzed these areas. We
investigated the causes and consequences of burnout in a cohort
of neonatologists working in delivery room.
This is the first study to measure the level of burnout in a large
cohort of neonatologists, to investigate whether some cultural
features can be correlated with burnout and to assess whether
burnout can influence clinical behaviors.

Materials and methods

The study was approved by the ethical board of Siena University
Hospital. A questionnaire was submitted to a cohort of doctors
frequently working in delivery room in Tuscany (Italy) hospitals.
We decided to enroll at least 100 participants. Since Tuscany
neonatologists were not enough to achieve this number, we also
included in our analysis the neonatologists of the five greatest
hospitals of another Italian region (Veneto) were two of us (RC
and PR) work. Of the five hospitals selected, only one hospital
declined to participate in this study.
The questionnaire
All participants were requested by e-mail to participate into the
survey, specifying that their participation was anonymous and
that they could anyway refuse. The 42-item questionnaire was
composed of four parts: (a) biographic data: age, sex, number of
children and so on; (b) personal beliefs: attitude toward handicap
or death and so on; (c) clinical decisions and (d) burnout. Burnout
was measured through the Link Burnout Questionnaire (LBQ), a
validated four-scale and 24-item questionnaire [11].
Burnout assessment
The LBQ has an elevated goodness-of-fit (root mean square
error of approximation < 0.08) and a statistically significant
correlation between the sub-scales of questionnaire (Cronbach
index < 0.68 for the inter-item consistency and testretest reliability was >0.74 using Cronbach ). The coherence between
LBQ and Maslach Burnout Inventory (MBI) was verified by
the Pearson correlation coefficient that was significant for all
the performed correlations. The results demonstrated a good
consistency, reliability and validity of LBQ. It is composed
of four subscales: psycho-physical exhaustion (PPExhaus),

Correspondence: Carlo V. Bellieni, Neonatal Intensive Care Unit, University Hospital of Siena, Viale M. Bracci 53100, Siena, Italy. Tel: 0039 0577 586550.
Fax: 0039 0577 586182. E-mail: cvbellieni@gmail.com

2130

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relationship deterioration (RelDeter), sense of professional

failure (ProfFail) and disillusion (Disill). The scores of each
subscale could be transformed into StaNine scores (range 19),
divided into low (12), critical (36) and high (79) according
with the MBI [12], a well-known burnout scale, from which
LBQ derives. The critical score is a risk range where the
first symptoms of burnout appear, but there is not yet a clear
burnout syndrome.
Data collection
A website was created where participants could fill-in the questionnaire. Every participant was given a password that allowed
each of them to enter only once the site. Data were collected
without any possibility to trace the author of the single questionnaire. Where it was impossible to contact them via e-mail,
or where explicitly requested, participants were allowed to
anonymously fill in a paper version of the questionnaire and
insert it into a closed box. At the end of the data collection,
the anonymous paper questionnaires were removed from the
Table I. The questionnaire, with answers in percent values.
Questionnaire
Biographic data
Sex
Age, years
Have you got children?
Have you any disabled relative or friend?
Years of service
Personal beliefs
Do you think it would be worth living
with a physical disability?
Do you think it would be worth living
with a mental disability?
Do you think it would be worth living
having lost communication ability?
Do you think it would be worth living
having lost working ability?
Do you have recurrent death ideation?
Does death provoke in you an unbearable
feeling?
Are you:
Religion:
Is religion important in your life?
Clinics
A 23-week baby is born and you are
called in the delivery room. Would you
begin intensive care?
A 24-week baby is born and you are
called in the delivery room. Would you
begin intensive care?
Burnout
Low (StaNine score 12)
Psycho-physical
exhaustion (%)
Relationship
deterioration (%)
Professional failure
(%)
Disillusion (%)

20.2

box and the data were transcribed in the database, with those
submitted electronically.
Data analysis
A statistical analysis of the data was performed using SPSS version
17 software (SPSS Inc., Chicago, IL). The data are expressed as
mean and standard deviation (SD) or as absolute frequency and
percentage (%). The influence of personal beliefs and biographic
data on burnout was examined through linear regression
reporting coefficients (B) . The possible influences of burnout
on resuscitation decisions were examined through chi-square test
or Fishers exact test. A p value of <0.05 (two-tailed) is considered
statistically significant.

Results
A total of 130 neonatologists were contacted, but only 110 (84.6%)
neonatologists filled in the questionnaire. The responses to the
questionnaire are shown in Table I.

Male (40%)
3550 (78.2%)
Y (67%)
Y (57.4%)
<5 (30%)
Y (89%)

Female (60%)
>50 (21.8%)
N (33%)
N (42.6%)
515 (33.6%)
N (11%)

Y (43.6%)

N (56.4%)

Y (54.5%)

N (45.5%)

Y (96.4%)

N (3.6%)

Y (35.5%)
Y (12.8%)

N (64.5%)
N (87.2%)

Agnostic (15.5%)
None (28.2%)
Y (62%)
Exceptionally (17.3%)

Atheist (12.7%)
Catholic (70.9%)
N (38%)
Seldom (29.1%)

Believer (71.8%)
Protestant Muslim

Exceptionally (0.9%)

Seldom (14.7%)

Always (84.4%)

Critical (StaNine
score 36)
67
67

>15 (36.4%)

Jewish

Other (0.9%)

Always
(50%)

High (StaNine
score 79)
12.8
33

25.7

66.1

8.3

25.5

63.6

10.9

Table II. Associations between biographic data, personal beliefs and the four burnout subscales. All other items, which do not appear in this table, had no
statistical association with any outcome.
Associated with high burnout (subscale)
Associated with low burnout (subscale)
Biographic data
Work experience <5 years (PPExhaus, ProfFail and RelDeter)
Having no offspring (RelDeter)
Personal beliefs
Believing that living with a physical disability is unworthy (RelDeter)
Having recurrent death ideation (PPExhaus, RelDeter and ProfFail)

2012 Informa UK, Ltd.

2132 C. V. Bellieni etal.

a 24-week baby rather than a 23-week baby was present with a
higher rate in favor of 24-week baby (p<0.001).
23-week baby resuscitation is positively influenced by working
in a third-level hospital (p=0.001), considering religion as important in life (p=0.028).
24-week baby resuscitation is positively influenced by working
in a third-level hospital (p=0.001) and negatively by high Disill
scores (p = 0.041) and by considering life unworthy if working
capacity is lost (p=0.012).

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Discussion
Figure 1.Percent values of low, critical and high burnout in the four
subscales. PE indicates psycho-physical exhaustion; RD, relationship
deterioration; PF, sense of professional failure and D, disillusion.

Burnout level
Mean scores of each burnout subscale (with SDs in brackets)
are 16.6 (5.7), 15.3 (4.8), 12.8 (4.5) and 12.6 (6.7) for PPExhaus,
RelDeter, ProfFail and Disill, respectively. When we transformed
data into StaNine, mean scores were 5.90 (1.4), 4.33 (1.8), 3.91
(1.7) and 4.04 (2.0) for PPExhaus, RelDeter, ProfFail and Disill,
respectively. Figure 1 shows each one of the four burnout
subgroups, according with the StaNine division in three levels
(low risk, critical and high risk).
When we compared our data with those of a previous group
of general medicine doctors [11], we saw that in our group mean
scores for PPExhaus, ProfFail and Disill are statistically lower,
while RelDeter scores are higher.
Influence of biographic data and personal beliefs on burnout
Biographic data
Hospital level, gender and age does not influence burnout.
Having had close relationship with disabled people does not
influence burnout. Having no children is associated with low
RelDeter (B = 0.750; p = 0.025), while work experience less
than 5 years is associated with high PPExhaus (B = 0.623;
p = 0.030), ProfFail (B = 0.624; p = 0.02) and RelDeter
(B=0.477; p=0.022).

Burnout is diffuse and alarming in the population of neonatologists we studied. It exceeds the low burnout range, most neonatologists being in the critical level for all four burnout categories
(Figure 1). In particular, no neonatologist is in the low range
of the RelDeter subscale, disclosing that social life is seriously
compromised among the members of our cohort that has significantly higher RelDeter values than general doctors [11]. Table II
recapitulates the association between biographic data, personal
beliefs and burnout.
Some considerations should be done, considering point-bypoint the main personal features we analyzed.
Working in a third-level hospital
These participants can actively take care of small prematures
because they work in highly technological hospital, and this
explains the different attitude toward the 23 week we found
between doctors working in third-level versus second-level
hospitals.
Shorter work experience (<5 years)
It is positively associated with burnout, maybe because a relative inexperience can provoke anxiety and stress significantly.
Disillusion does not appear among the risks that these scarcely
experienced doctors undergo, maybe because disillusion has not
yet had the time to appear.
Considering religion as an important factor in ones own life
This feature had already been associated with lower stress [13],
and this can be explained with a better disposition of religious
people to cope with and accept suffering.

Personal beliefs
Believing that living without the possibility of communicating, or
without working capability, or with mental disability is unworthy
has no influence on burnout. Having an unbearable death ideation
or believing that religion has a base role in own life also has no
influence on burnout.
Believing that living with a physical disability is unworthy is
associated with high RelDeter (B = 1.472; p = 0.004). Having
recurrent death ideation is associated with high PPExhaus
(B=1.018; p=0.016), RelDeter (B=0.782; p=0.019) and ProfFail
(B=0.830; p=0.029). Being atheist or agnostic is associated to
higher ProfFail (B = 0.792; p = 0.012) and Disill (B = 0.785;
p=0.033) with respect to believers.

Three psychological features associated with burnout

(a) Death ideation: It can influence burnout, though more studies
are needed to assess whether this is a cause or a consequence
of burnout. (b) Believing that life with a disability is unworthy:
Doctors who have this attitude may consider useless their efforts
to healing disabled babies, with a consequent sense of a waste
of energies and frustration. (c) Having no offspring: This factor
seems to prevent burnout. Having own children can induce
anxiety when facing other babies suffering and a consequent
sense of impotence.
The influence of burnout on medical decisions appears limited:
only disillusion, among burnout subscales, significantly influences resuscitation and only in the case of 24-week babies, but
not of 23-week babies.

Influence of burnout, biographic data and personal beliefs on

ethical decisions
Participants ethical decision on 23-week and 24-week resuscitation was the following and was influenced by burnout as follows: a
significant difference in number of doctors who would resuscitate

Burnout is a medical emergency among doctors. In 2001,

Richard Smith asked Why are doctors so unhappy? and
concluded that The most obvious cause of doctors unhappiness
is that they feel overworked and undersupported [14]. This indicates an impelling necessity to operate among doctors to prevent

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Burnout and neonatology2133

stress and discomfort. Strategies [15,16] exist in this sense. For
instance, it is important to permit temporary withdrawal from
direct patient care [17] especially from end-of-life settings [18],
encouraging hobbies [19] or sabbaticals [20], improving staff
meetings [17,18] or anticipatory socialization programs, which is
a way of preventing reality shock. The philosophy underlying
anticipatory socialization programs holds that reality shock
should be experienced before the individual begins his or her
first full-time job and that it should be experienced in a context
that permits and encourages the development of constructive
strategies for coping with the unexpected reality [21]. Burnout
influences not only doctors own lives but also their capability of
care and empathy, their attention and ability to overcome stress
in difficult situations. Thus, the prevention of doctors burnout
should be considered one of the patients main rights because a
stressed doctor can hardly be a good doctor [2225].
It is possible to introduce some improvements in everyday
hospital life, to prevent burnout.
A first strategy is to contrast the chronic understaffing, a
serious problem in todays organizations and corporations, by
trying to nurturing communication within the staff [26,27]. Team
building is a process that aims at developing teamwork and cooperation within a work unit, when the scarcity of human resources
imposes higher workloads. In order to form an effective team,
the members must respect each other and be motivated to use
their strength for the purpose of moving closer to their common
objective or goal. Each and every member of a team has a very
important role to play and this awareness can contrast burnout.
Another step to avoid burnout is overcoming the inadequacy
of resources. The general inadequacy of resources to maintain
the quality of service expected by the care provider and by the
care recipient, may be a cause of burnout in care providers. In
addition, the paucity of resources may require the care provider
to negotiate for the limited resources, establishing a competitive
atmosphere and the demise of the collegial relationships essential
to buffer the effect of work stress [28,29].
A third strategy to avoid burnout is to avoid repeating and
continuously facing the same situations: monotony is a cause of
stress [30], but it is much more ominous if the repetitive scene is
made of sorrow and painful situations. Thus, the clinical mansions
of each doctor should be periodically changed when possible,
or changed when a careful monitoring shows that the doctor is
undergoing stress and shows the first signs of burnout.
Stress proceeds not only from job but also from personal
psychological features [3133]: [a] critical element contributing to the stress that many conscientious doctors experience
is internal [34]. Thus, the psychological factors we showed to
be correlated with burnout have to be carefully considered in a
program of burnout prevention. The medical population should
be checked up for burnout risk factors and to receive an adequate
counseling [21].
A limitation of this study is that it disclosed a co-presence,
but not necessarily a causality of some features and burnout. We
cannot definitively consider these features as risk factors without
further and wider analysis. These data are nevertheless an important step toward a more thorough analysis and prevention of
burnout.

Conclusion
In conclusion, it is important to objectively measure burnout:
it is a syndrome whose first symptoms should be precociously
individuated. It is important to have a reliable measurement tool.
2012 Informa UK, Ltd.

Some risk factors are preventable, and a serious prevention might

improve doctors lives and consequently their performance.
Declaration of Interest: The authors report no conflicts of
interest.

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