Relationships Between the Level of Social Competence and Work-Related Behaviors in a Group of Physicians, Nurses, and Paramedics

The functioning of people in the work environment, as well as their satisfaction with professional achievements are highly determined by their social competence, attitudes towards work, strategies adopted to cope with problems, and an emotional stance on the professional roles ^{1, 2, 3}.

One indicator of competence is the effectiveness of people’s functioning in real professional and social situations, which means efficiency in achieving goals, the ability to build interpersonal bonds, a lack of excessive psychological and psychophysiological costs associated with work and social relations, and agreement between behavior and job requirements as well as social standards ^{4, 5, 6}. A high social competence of physicians and nurses seems to be a factor that protects them against burnout syndrome. It is negatively correlated with burnout in the dimensions of emotional exhaustion, emotional detachment, and dehumanization, and positively correlated with a sense of a personal accomplishment ^{3, 7, 8}. Other authors imply that aspects which should be taken into account when diagnosing burnout syndrome include the interaction between employees and their work environment, their attitudes to job requirements, and their experiences with various situations at work ^{9, 10}. Discrepancies between job-related situational restraints and one’s communicative and interpersonal skills in social situations, as well as assertive competence in intimate and social exposure situations, explain the essence of the burnout problem ^{1, 9, 10}. Other authors maintain that job burnout positively correlates with the levels of emotional and social intelligence ^{11, 12, 13}.

Originally burnout syndrome was described as a loss of motivation and physical power to work, perceived as workers’ withdrawal syndrome, resulting from overloading with tasks posed by social and physical work environment ¹⁴, and as a consequence of exposure to prolonged work-related stress ¹⁵. This syndrome is mainly observed in jobs which involve contact with other people, the necessity of making quick and responsible decisions, and personal involvement. This problem affects especially representatives of emotionally demanding professions, such as physicians, nurses, and paramedics ^{16, 17, 18}.

Characterized by high dynamism, burnout syndrome is regarded as a challenge for public health due to its increasing incidence and negative ― both personal and institutional ― consequences for the healthcare system ¹⁷. Researchers agree that burnout does not give symptoms immediately, but develops gradually in response to long-term exposure to stress ^{19, 20}. Negative work consequences have direct effects on employees’ health, and an indirect impact on the quality of healthcare, as well as legal and economic issues ^{3, 18, 21, 22, 23, 24}. In individual cases, burnout syndrome is manifested by psychosomatic (weakness, sleeplessness) and emotional (anger and depression) problems, as well as hostility, aggression, apathy, the lack of confidence in other workers, and isolation ¹⁸. Burnout syndrome can also be perceived as a risk factor for heart diseases, pain, and spinal diseases ¹³.

In the International Classification of Diseases (ICD-10), burnout syndrome is coded as ICD-10 Z73.0. Unlike other diseases counted among occupational disorders, it does not entail dysfunction of a specific organ or system. It is rather a psychosocial state, which should be distinguished from physical fatigue and depression ¹⁶.

The aim of this study was to analyze relationships between the job-related behavior types and the levels of social competence presented by physicians, nurses, and paramedics employed in various healthcare centers in Poland, with regard to sociodemographic factors. The following hypotheses were formulated:

There are differences in the severity of burnout syndrome between physicians, nurses, and paramedics, depending on age, sex, education, years in the profession, and years in the previous job.

Medical workers with high social competence show a low level of burnout syndrome.

There is a relationship between the social competence of medical workers and the types of job-related behaviors, suggesting burnout syndrome.

The study was conducted in Poland in 2015–2016 with the consent of the Bioethical Commission of the Pomeranian Medical University in Szczecin, Poland (KB-0012/92/12/2014).

Purposive random sampling was used to select study participants. Those invited to the study were physicians and nurses from internal diseases, surgical, and pediatric wards, and other healthcare institutions in Szczecin, paramedics providing emergency service in Szczecin, and primary care physicians from Szczecin and Wrocław. All people employed in selected healthcare centers had equal chances to take part in the study.

Our research on social competence, as well as behaviors and experiences associated with work, involved 432 medical workers from two medical centers (Szczecin and Wrocław), composed of 144 (33.49%) physicians, 160 (37.73%) nurses, and 122 (28.77%) paramedics. 185 (42.82%) respondents had master’s degree education. The average age of the medical workers was 33.6 ± 11.7 years and the median was 28 years (range: 21–66 years). Detailed sociodemographic data are presented in Table 1, together with the activity in scientific societies and organizations, as well as the participation in education of students and healthcare workers. 112 (25.92%) participants were engaged in scientific work; the majority of these were physicians (40.43%, 38). 115 (26.62%) respondents, including 47 (47.9%) physicians and 40 (34.8%) nurses, indicated that they were involved in the education of students and workers.

Three research instruments were employed in the study, namely the Social Competence Questionnaire (SCQ) ²⁵, a standardized questionnaire, the Work-related Behavior and Experience Patterns – AVEM ^{1, 9, 10}, and a self-developed questionnaire for sociodemographic data.

The level of social competence was measured using the SCQ developed by Anna Matczak (2012) ²⁵. This is a self-report instrument consisting of 90 items, including 60 diagnostic items (concerning social competence) and 30 nondiagnostic items (concerning other abilities). The total score for the diagnostic items is a general indicator of social competence. Surveyed individuals assess their effectiveness in performing tasks (How well would you manage if …?) using a four-point scale: definitely well, quite well, rather poorly, definitely badly. The sum of the scores for the diagnostic items is the total score. The diagnostic items have been developed on the basis of the classification of difficult social situations proposed by Argyle. Four types of situations were distinguished:

1) intimate situations (I), which refer to close interpersonal contact; 2) social exposure situations (SE), which refer to competence, which determines the effectiveness of behaviors in the situations of social exposure; 3) formal situations, which require accommodating oneself to strictly defined rules or regulations; and 4) situations demanding assertiveness (A), which are associated with competence that determines the effectiveness of behaviors in situations that require assertiveness ²⁶. Based on the results of factor analysis, three out of the four social scales were included in the final version of the questionnaire:

The (I) scale, which refers to competence determining the effectiveness of behaviors in situations of close interpersonal contact with patients, listening to patients, showing understanding and empathy for their fears, and tolerance for their impatience and dissatisfaction with therapeutic effects. This scale contains 15 items; the minimum score is 15 points, and the maximum is 60 points. The (SE) scale, which refers to being an object of attention and potential appraisal from many people; it includes 18 items and has a minimum score of 18 points and a maximum of 72 points. The (A) scale, which refers to attaining one’s own goals and satisfying needs through persuasion, and the ability to influence other and resist the influence of others; it includes 17 items, and has a minimum score of 17 points and a maximum score of 68 points. The point scores were converted into sten scores: 1–3 sten was considered a low score, 4–7 sten was considered an average score, and 8–10 was considered a high score ²⁵.

The AVEM questionnaire measures people’s individual resources in the context of dealing with job requirements, types of behavior, a risk of developing mental health problems, possible threats, and trends in the field of psychological interventions ^{1, 10}.

The AVEM questionnaire consists of 66 statements divided into 11 scales (each including 6 statements) and rated on a five-point Likert scale (from fully agree to fully disagree). The questionnaire scales measure three dimensions of work-related behavior and experiences that determine one’s effectiveness at work ^{1, 9, 10}:

1. Commitment to work expressed in terms of perceived significance of work, career ambition, tendency to exert, striving for perfection, emotional distancing. A positive behavior type in relation to job requirements is manifested by high perceived significance of work, as well as conscious regulation of energy expenditures. These factors determine one’s ability to maintain detachment from difficult situations at work.

2. Resistance to stress are regarded in terms of one’s tendency to resign in the case of failure, active coping with problems, as well as balance and emotional stability. The arrangement of these features reflects different levels of work satisfaction, individual stress-coping strategies, and general attitudes towards life.

3. Emotional or subjective well-being is described in terms of work satisfaction, life satisfaction, and perceived social support. This is a specific psychological factor that protects workers’ mental health, and determines individual ways of dealing with job requirements.

The scores for 11 scales can be calculated using a spreadsheet. Raw results are converted into standard results by means of tables with normalized data. The spreadsheet shows centile scores, and those obtained through converting them into stanine scores. Based on the interplay of these 11 scales, four types of behavior and experiences can be derived by means of cluster analysis ^{10, 17}:

Type G – “healthy-ambitious”

Type S – “unambitious”

Risk Type A – “excessively ambitious”

Type B – “burnout”

The respondents’ responses for the AVEM questionnaire were organized and entered to the UPS computer system (license no. PRV/010612/EDU), which is an integral part of the questionnaire and serves for computing data. Responses to specific questions were introduced according to the key, and the respondents were assigned to one of four types of behavior.

The type of distribution was determined for all variables. The Shapiro–Wilk test was employed to verify the normality of these distributions. Arithmetic means, standard deviations, medians, and ranges of variability (extremes) were calculated for the measurable (quantitative) variables, while frequencies (percentages) were determined for qualitative variables. Logistic regression was used to determine the influence of explanatory variables on the odds ratio (OR) of having higher social competence with a 95% confidence interval. The level of significance for all tests was set at p ≤ 0.05. Statistical analysis was performed using SPSS v. 18 software.

The majority of the healthcare workers (62.7%, 271) had average general social competence (4–7 sten), and 15.3% (66) had low competence (1–3 sten). High levels of general social competence and A, I, and SE competence were observed in every sixth medical worker ― Table 2. Analysis of the levels of general competence and competence in the I , A, and SE scales demonstrated significant differences between physicians, nurses, and paramedics. Competence in intimate situations (I) ― which involve listening to patients confiding their personal problems ― statistically significantly differs nurses (6.84 ± 2.67) from physicians (5.62 ± 2.37) and paramedics (5.81 ± 2.19) ― F = 11.09, p < 0.0001. Competence in situations demanding assertiveness (A) ― meaning exerting influence on and resisting influence of other people ― differentiates nurses from physicians, and physicians from paramedics (F = 11.09, p < 0.0001). Competence in social exposure situations (SE) ― which refers to being an object of attention and potential appraisal ― differs paramedics from nurses (F = 2.87, p = 0.06). Symptoms of burnout syndrome (Type B) were observed in 25% (106), symptoms of excessive ambition (Risk Type A) in 24.1% (102), and healthy behaviors (Type G) in 31.8% (135) of the respondents (Chi2 = 27.95, p < 0.0001). Types of behavior predominating among paramedics were Type G (healthy-ambitious) and Type S (unambitious). Physicians presented mainly Type B (burnout), and nurses ― Type B (burnout) and Type G (healthy-ambitious) ― Table 3.

Type G was mostly found in paramedics (over 40%). What is striking is a relatively small proportion of Type S (unambitious) behaviors, i.e. those that do not pose a threat to mental health. What differs Type S from other types is a distinct tendency to detach oneself from problems associated with work, accompanied by low tendency to resign in the case of failure. An essential characteristic of workers who present this type of behavior is a relatively high level of internal balance and emotional stability, satisfaction with life, high perceived social support, and relative satisfaction with life beyond work. This type was observed in 22% of paramedics, every fifth nurse (21.3%), and only every seventh physician (14%) - Table 3.

Types of behavior and experiences observed in the studied professional groups depended on age, years in the profession, and years in the previous job – Table 4. Other contributors were: female sex in a group of paramedics (Chi2 = 13.44, p = 0.004), third-level education in a group of nurses (Chi2 = 15.60, p = 0.02), work in a hospital in a group of paramedics (p = 0.02), and membership of scientific societies and social organizations (Chi2 = 7.33, p = 0.05). Women are less likely to (15.2%) present Type S behavior than men (OR = 0.85, 95% CI 0.71-1.01), p = 0.07.

The functioning of healthcare workers in a therapeutic team is determined by many factors, of which social and professional competence, stress-coping styles, and attitudes towards work all play especially important parts ^{27, 28, 29}.

This study involved a group of physicians, nurses, and paramedics, i.e. medical workers who experience psychological strain at work. The fact that not all medical workers exposed to the same organizational and psychological influences develop burnout syndrome, leads to the conclusion that different factors can contribute to burnout syndrome in a different way, depending on specific individuals and professional groups. One of these factors is social competence of medical workers. This thesis is supported by the results reported by other authors ^{6, 7}, and our own findings, demonstrating the presence of burnout syndrome (Type B) in one-fourth of medical workers (more physicians and nurses than paramedics). A risk of this type of behavior and experiences is higher among individuals showing low competence in intimate situations (I) that are associated with listening to patients and making decisions. Equally unfavorable behavior and experiences are those recognized as Risk Type A, suggesting that a person is too involved in the job and strives for professional perfection. This group incorporated less than one-fourth of all respondents, including every third physician and every fifth nurse. Physicians and nurses belong to a group which needs immediate and effective preventive interventions to protect their mental health ⁹.

Burnout syndrome affects increasingly younger people, with fewer years worked. Even more worrying is the fact that physicians with job burnout are younger than nurses both in terms of age and years of service. These results correspond with the level of social competence. In the study group, more than three-fourths of medical workers had either a medium or a low competence level, and only one-fifth had a high competence level. Pereira-Lima and Loureiro (2015) investigated 400 medical residents in Brazil to learn how social competence was related to burnout syndrome and mental health problems. They found that a high social competence level was statistically significantly related to the absence of job burnout, measured by the Burnout Syndrome Inventory (BSI), and the lack of anxiety and depression symptoms. And analogically, lower competence levels were more often accompanied by burnout, anxiety and depression ³.

In their large-scale study, performed using the AVEM questionnaire, Voltmer, E., et al. (2010) compared work-related behaviors and experiences of German physicians (n = 344) and nurses (n = 389) at different stages of their professional career. They revealed that 22% of physicians of different specialties presented Risk Type A. The nurses had a lower proportion of healthy behaviors (Type G) (11.6%) compared with physicians (16.7%), and at the same time the highest proportion of behaviors associated with burnout syndrome (32.8% vs. 27.3% of physicians). Differences in mental health dimensions were mainly observed in the context of work commitment and resilience to stress ³⁰.

Different results were obtained in our study. Nurses presenting Type G (healthy-ambitious) behaviors were more numerous (28.1%) than physicians (23.9%), but less numerous than paramedics (45.9%). These behaviors are characterized by high career ambition combined with moderate perceived significance of work and moderate tendency to exert, low tendency to resignation, active coping with problems, as well as balance and emotional stability. Type G individuals show positive emotions, such as a high satisfaction with life, perceived social support, and a feeling of professional success. Risk Type A (excessively ambitious) was observed in 24.1% of the respondents, including less than one-third of physicians, one-fifth of nurses, and slightly fewer paramedics (18%). Considering the course and causes of the burning-out process, as well as its health (emotional), social, and economic consequences, such an interplay of behavior types (A and B) should be regarded as an alarming phenomenon. Medical workers who present behaviors typical of Risk Type A (excessively ambitious) and Type B (burnout) urgently need psychological support.

Aouli, B., and Haj-Bakri, B., (2006) found that out of 100 internists analyzed by the AVEM questionnaire, as many as 44% were burnt out, 28% were at a risk of burnout syndrome, and only 6% exhibited Type G (healthy-ambitious) behavior. According to these authors, Type G employees had most probably worked out a protective barrier against burnout syndrome. This barrier is a high social competence level that enables adaptation to difficult working conditions ³¹. On the other hand, the study of 63 primary care physicians, conducted by Sapilak, B., et al (2006), revealed that 29% (18) of them developed a full-blown burnout syndrome according to Christina Maschlash’s criteria, and that burnout syndrome positively correlated with the number of workplaces ¹⁶.

Type S (unambitious), involving reduced work commitment ― which in a longer perspective can lead to dissatisfaction with oneself and the feeling of being unsuccessful at work ― was observed in more than one-fifth of paramedics (22.1%, 27) and nurses (21.3%, 34), and only 14.1% (20) of physicians. This type of work-related behavior is very desirable in jobs involving a substantial psychological burden, such as rescue jobs. Traits characteristic of Type S help workers act and make decisions with due caution, and reduce their own exertions ¹⁰.

Our analysis shows that age, female sex, years in the profession, and years in the previous job increase the incidence of job burnout among nurses. Taking into account the mean age of the nurses in the study and all nurses in Poland (49 years in 2016), we can say that this group of medical workers is at the highest risk of burnout syndrome (especially nurses employed in primary care centers, as well as palliative and long-term care) ^{32, 33}. Maslach, C., et al. (2001) noticed that burnout syndrome affects more women than men. If depersonalization is stronger in men, then emotional exhaustion and the feeling of poor personal achievements are more common among female healthcare workers ³⁴.

Our study demonstrated that years worked in one place substantially contributed to nurses’ burnout, which means that the longer nurses worked in the same place, the more often they presented Type B (burnout) behavior (p = 0.02). A similar relationship was reported by Ross J, et al., (2009), who confirmed that many years’ service in one place causes a feeling of being overloaded, and is one of risk factors for burnout syndrome ³⁵. It was also established that burnout syndrome is related to the level of education ― Type G (healthy-ambitious) is significantly more common among individuals with third-level education. Third-level education favors emotional distancing from problems at work, and the functioning according to Type S (unambitious). Ceslovitz, S., B., (1989) conducted a study on job burnout and stress-coping strategies among American nurses. They found that nurses with burnout syndrome significantly more often used escape, avoidance, and emotion-control strategies (p < 0.001). Their counterparts showing no burnout symptoms were more likely to actively cope with problems and search for social support (p =0.003) ³⁶.

Burnout syndrome (Type B) occurs in physicians, nurses and paramedics regardless of their place of work, it is related to low level of social competence, particularly in intimate situations. Selected variables differentiate the occurrence of types of professional burnout between groups of professionals.

Our findings show clearly that the problem of job burnout in the studied professional groups is important and requires holistic therapeutic and preventive solutions. It is important that a diagnosis of work-related behavior types and social competence measurement should be supplemented with analysis of external learning and working conditions.

Prevention of burnout syndrome should start as early as during the process of educating future medical workers, through improving their social competence. It can be achieved by using appropriate methods, such as training of assertiveness, interpersonal skills, communication methods, and coping with stress in social exposure situations.

Ours is one of relatively few studies searching for the connection between burnout syndrome and social competence of physicians, nurses, and paramedics. Competence, which visibly protects medical workers against job burnout (diagnosed on the basis of work-related behaviors and experiences), involves assertive competence, competence in intimate situations, and competence in social exposure situations.

Several practical implications can be derived from the results presented in this study. It seems that the most important conclusion is that social competence of physicians, nurses, and paramedics can act as a buffer against negative consequences of gainful employment, often involving negative emotions. This observation gains special importance in the context of the possibility of training social competence at work ³⁷, as it contributes to the prevention of burnout syndrome.

In future study projects dealing with the relationship between competences of medical professionals with the risk of burnout syndrome and socio-demographic variables, the use of analysis methods developed by Fei Hao et al, 2015, Shuai LI, 2016 and Kar et al, 2016, ought to be considered. Correspondence analysis of a number of variables will help determine which of these variables have the strongest influence on the level of social competence ^{38, 39, 40}.

Limitations. The sample size of 432 health workers may not have been adequate to power the study to allow for generalization of the findings to a national level. Another limitation is the fact that the data were gathered via self-reports. However, the study was prospective, which diminishes the risk for problems related to common method bias.

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