The vulnerability to burn out in healthcare personnel according to the Stoyanov-Cloninger model: evidence from a pilot study

Main Article Content

Ralitsa D. Raycheva
Radost S. Asenova
Dimitar N. Kazakov
Simeon Y. Yordanov
Tanya Tarnovska
Drozdstoy Stoyanov Stoyanov


Background: The vulnerability to burn out is determined by the specific interaction of the two domains – personality disposition and complementary anomalies in the psychological climate of the work place. Our basic hypotheses include inferences in 3 different, but strongly associated dimensions: specific personality traits as measured by the Temperament and Character Inventory (TCI-R) will reveal profiles of vulnerability vs. resilience to burn out; dimensions of the psychological climate will elicit the relevant precipitating factors determining burn out and dimensions where significant relations between personality structure, psychological climate and burn out are anticipated.Aim: To design a complex person-centered model (battery of assessment tools) for early detection of burn out in populations of healthcare employees at risk and to determine the profile of the individual vulnerability to burn out both in terms of personality and psychological climate.Methods: Based on a literature research, 5 healthcare personnel risk groups were identified as being highly affected by burn out syndrome: (i) general practitioners; (ii) palliative care physicians and nurses; (iii) psychiatrists; (iv) oncologists & (v) emergency and intensive care personnel. The battery was tested on 73 randomly selected healthcare professionals from the above-mentioned groups.The following methods were employed in our cross-sectional study in order to construct the assessment battery: Personality Profile Inventory: TCI-R – 240 items; Inductive Measurement of Psychological Climate - 40 items Psychological Climate Inventory (courtesy of Koys and DeCotiis); Measurements of burn out as control condition – 22 items Maslach Burn Out Inventory.Results: Temperamental traits (harm avoidance and persistence) and Character dimensions (self-directedness and cooperativeness) have been largely correlated with burn out performance, mostly represented by emotional exhaustion, de-personalization and reduced personal accomplishment and result from psychological climate impact, mediated by 8 basic criteria: independence, unity, confidence, pressure, support, recognition, honesty and innovation.Conclusion: We have identified so far two groups of vulnerability (proneness) and protective (resilience) factors in relevance with the emergence of burn out syndrome in healthcare personnel. The vulnerability is defined with the following constellations: (i) high levels of harm avoidance in combination with pressure leads to high emotional exhaustion; (ii) high persistence in combination with low autonomy leads to low personal accomplishment and high emotional exhaustion. The resilience is outlined with the following constellations: (i) high persistence with high autonomy determines high personal accomplishment and low emotional exhaustion; (ii) self-directedness is an independent indicator of resilience: (iii) high personal accomplishment and low emotional exhaustion (i.e. protects from burn out regardless of the psychological climate at workplace) & (iv) cooperativeness in combination with high cohesion determines a low level of de-personalization. Also, cohesion and fairness from the Psychological Climate Inventory define resilience to burn out as independent indicators.

Article Details

Health Profession Issues
Author Biography

Drozdstoy Stoyanov Stoyanov

Drozdstoj (Drossi) Stoyanov was born on July, 20th 1980 in Sofia, Bulgaria in the family of outstanding psychiatrists. He graduated from the high school at the age of 15 (1996), and received his MD from the Medical University of Sofia at the age of 21 (2002). Prof. Stoyanov developed and defended a PhD thesis in the field of neurology and psychiatry in 2005, certified in December 2007 by the Government Specialty Board with the rank of Psychiatrist and was elected associate professor of medical psychology in 2008. He is co-founder of the Balkan Association of History and Philosophy of Medicine (2005) as well as the Balkan Academy for Philosophy, Psychiatry and Psychology (2007) and designed the peer-reviewed project for the establishment of the first University Centre in Philosophy and Mental Health (UCPMH) in South-Eastern and Central Europe. The Centre organized two consequent international symposia in the field in 2008 and 2009. Prof. Stoyanov was invited at the discretion of the Chair into the Philosophy Special Interest Group of the Royal College of Psychiatrists in 2007 and was awarded Postgraduate Certificate in Philosophy of Mental Health from the University of Central Lancashire, United Kingdom in October 2010. In 2009 the Center for Philosophy of Science, University of Pittsburgh, USA elected Prof. Stoyanov for Visiting Fellow.Prof. Stoyanov hold the position of Vice Dean for International Affairs of the Faculty of Public Health, University of Medicine, Plovdiv from 2009 to 2011. Since 2011 he has been appointed assoc. professor in the Faculty of Medicine, Department of Psychiatry and Medical Psychology and Special Advisor Strategic Parnerships to the Vice Rector. Besides he still acts as Deputy Director and Scientific Secretary of the Expert Board of UCPMH and  works as practicing psychiatrist in the ‘St. Ivan Rilski’ State Psychiatric Hospital.He published and/or edited about 110 papers, three monographs and a textbook of psychology and received a number of awards for his research such as Hippocratic Medal from the International Hippocratic Foundation for his contributions in philosophy of medicine. Drossi’s latest publications are on the convergent trans-disciplinary validity of the methods and categories in psychology and psychiatry.Since 2007 Prof. Stoyanov acts as a member of the Editorial board, secretary coordinator (2009) and most recently as Deputy Editor-in-chief (2010) of the International Annual for History and Philosophy of Medicine. Besides he has been Chair of Conceptual group in the Global Network for Diagnosis and Classification launched by the World Psychiatric Association (2008) as well as member of the teaching committee of the European Association for Communication in Healthcare (2010).  Selected publications list:Stoyanov,D. (1999) About Schweitzer, In: Young medics about Albert Schweitzer, Albert Schweitzer World Academy of Medicine, Ed. K. Imjelinsky, WarsawStoyanov, D. S. et Al (2006), Comorbidity Monograph 4, Perspectives across Europe, European Collaborating Centers for Addiction Studies, Eds A.Baldacchino, J.Corkery, LondonStojanov, D.S.(2007), Validation theory - from basic neuroscience to pharmaco-psychology, SA Journal of Psychiatry, Vol.13, 3, 2007:116Stoyanov, D. St (2009)., Review - Psychiatry as Cognitive Neuroscience: Philosophical Perspectives, Metapsychology, Volume 13, Issue 47Stoyanov, D.St.(2009),The Cross-Validation in the Dialogue of Mental and Neuroscience, Dial Phil. Ment. Neuro. Sci,  2(1): 24-28Stoyanov, DS, PK Machamer and KF Schaffner (2010), In quest for scientific status of psychiatry: towards bridging the explanatory gap, In: Traditions and Innovations in Psychiatry, World Psychiatric Association, St. Petersburg: 44-45Stoyanov, D and KWM Fulford (2010), Values based medical practice: challenges before the system of education and healthcare in Bulgaria, In: Public Health and Health Care in Greece and Bulgaria: the challenge of cross-border collaboration, Papazissis Publishers, Athens: 327-334Stoyanov D (2010), Why a logical-pragmatic perspective on validity in mental health is not sufficient: introduction of the principle of convergent trans-disciplinary cross-validity, Dial Phil. Ment. Neuro. Sci, 3(1): 25-26


Stoyanov, D.S. & Cloninger, C.R. (2011). Relation of People Centered Public Health to Person Centered Health Care Management. International Journal of Person Centered Medicine 2 (1) 90-95.

Maslach, C., Jackson, S.C. & Leiter, M.P. (1996). Maslach Burnout Inventory. Palo Alto, California: Consulting Psychologists Press.

Maslach, C., Schaufeli, W.B. & Leiter, M.P. (2001). Job burnout. Annual Review of Psychology 52, 397-422.

Kumar, S., Bhagat, R.N., Lau, T. & Ng, B. (2006). Psychiatrists in New Zealand: are they burning out, satisfied at work and, in any case, who cares? Australasian Psychiatry 14, 20-23.

Beckstead, J. (2002). Confirmatory factor analysis of the Maslach Burnout Inventory among Florida nurses. International Journal of Nursing Studies 39, 785-792.

Koys, D.J. & DeCotiis, T.A. (2001). Inductive measures of psychological climate. Human Relations 44, 265-285.

Cloninger, C.R., Przybeck, T., Svrakic, D.M. & Wetzel, R. (1994). The Temperament and Character Inventory: A Guide to its Development and Use. Center for Psychobiology of Personality, Washington University, St Louis, MO.

Cloninger, C.R. (2004). Feeling Good. The Science of Well-Being. New York, NY: Oxford University Press.

Svrakic, D.M., Whitehead, C., Przybeck, T.R. & Cloninger, C.R. (1999). Differential diagnosis of personality disorders by the seven-factor model of temperament and character. Archives of General Psychiatry 50, 991–999.

Paisley, K. & Powell, G.M. (2007). Staff burn-out prevention and stress management. Child and Adolescent Psychiatric Clinics of North America 16 (4) 829–841.

Stoyanov, D.S. & Cloninger, C.R. (2011). Relation of People-Centered Public Health to Person-Centered Health care Management: a case study. Presented at the Fourth Geneva Conference on Person-Centered Medicine. Geneva, May 2011.

Kumar, S. (2007) Burnout in psychiatrists. World Psychiatry 6, 186-189.

Pejuskovic, B., Lecic-Tosevski, D., Priebe, S. & Toskovic O. (2011). Burn-out syndrome among physicians – the role of personality dimensions and coping strategies. Psychiatria Danubina 23, (4) 389-395.

Lecic-Tosevski, D., Pejovic-Milovancevic, M., Pejuskovic, B., Deusic-Popovic, S., Hoftvedt, B.O. & Tanovic-Mikulec, E. (2006). Burnout syndrome of general practitioners in postwar period. Epidemiologia e Psichiatria Sociale 4, 307-310.

Embracio, N., Papazian, L., Kenetish-Barnes, N., Pochard, F. & Azoulay, E. (2007). Burnout syndrome among critical care healthcare workers. Current Opinion in Critical Care 13, 482-488.

Sharma, A., Sharp, D.M., Walker, L.G. & Monson, J.R. (2008). Stress and burnout in colorectal and vascular surgical consultants working in the UK National Health Service. Psychooncology 17, 570-576.

Katschnig, H. (2010). Are psychiatrists an endangered species? Observations on internal and external challenges to the profession. World Psychiatry 9, 21-28.

Bruce, S.M., Conaglen, H.M. & Conaglen, J.V. (2005). Burnout in physicians: a case for peer-support. Internal Medicine Journal 35, 272-278.

Kushnir, T. & Cohen, A.H. (2006). Job structure and burnout among primary care pediatricians. Work 27, 67-74.

Lesić, A.R., Stefanović, N.P., Perunicic, I., Milenković, P., Tosevski, D.L. & Bumbasirević, M.Z. (2009). Burnout in Belgrade orthopedic surgeons and general practitioners, a preliminary report. Acta Chirurgia Iugoslavia 56, 53-59.

Arigoni, F., Bovier, P.A. & Sappino, A.P. (2010). Trend of burnout among Swiss doctors. Swiss Medical Weekly 140, 13070.

Pejuskovic, B. & Lecic-Tosevski, D. (2011). Burnout in psychiatrists, general practitioners and surgeons. World Psychiatry 10, 78.

Hyman, S.A., Michaels, D.R., Berry, J.M., Schildcrout, J.S., Mercaldo, N.D. & Weinger, M.B. (2011). Risk of burnout in perioperative clinicians: a survey study and literature review. Anesthesiology 114 (1) 194-204.

Cloninger, C.R., Svrakic, D.M. & Przybeck, T.R. (1993). A psychobiological model of temperament and character. Archives of General Psychiatry 50, 975-990.

Takeuchi, M., Miyaoka, H., Tomoda, A., Suzuki, M., Lu, X. & Kitamura, T. (2011). Validity and reliability of the Japanese version of the Temperament and Character Inventory: a study of university and college students. Comprehensive Psychiatry 52 (1) 109-117.

Cloninger, C.R., Przybeck, T.R. & Svrakic, D.M. (1991). The Tridimensional Personality Questionnaire: U.S. normative data. Psychological Reports 69 (3) 1047-1057.

Gundersen, L. (2001). Physician burnout. Annals of Internal Medicine 4, 145-148.

Mitra, S., Sinha, P.K., Gombar, K.K. & Basu, D. (2003). Comparison of temperament and character profiles of anesthesiologists and surgeons: a preliminary study. Indian Journal of Medical Sciences 6, 431-436.

Piedmont, R.L. (1993). A Longitudinal Analysis of Burnout in the Health Care Setting: The Role of Personal Dispositions. Journal of Personality Assessment 61 (3) 457-473.

Spickard, A., Gabbe, S.G. & Christensen, J.F. (2002). Mid-Career Burnout in Generalist and Specialist Physicians. Journal of the American Medical Association 288 (12) 1447-1450.

Buhler, K.E. & Land, T. (2003). Burnout and personality in intensive care: An empirical study. Hospital Topics: Research and Perspectives on Health Care 8, 5-12.

Eastburg, M.C., Williamson, M., Gorsuch, R. & Ridley, C. (1994). Social Support, Personality, and Burnout in Nurses. Journal of Applied Social Psychology 24 (14) 1233–1250.

Gustafsson, G., Persson, B., Eriksson, S., Norberg, A. & Strandberg, G. (2009). Personality traits among burnt out and non-burnt out health-care personnel at the same workplaces: a pilot study. International Journal of Mental Health Nursing 18, 336-348.

Deckard, G., Meterko, M. & Field, D. (1994). Physician Burnout: An Examination of Personal, Professional, and Organizational Relationships. Medical Care 32 (7) 745-754.

Glasberg, A.L., Eriksson, S. & Norberg, A. (2007). Burnout and „stress of conscience“ among healthcare personnel. Journal of Advanced Nursing 13, 392-403.

Keinan, G. & Melamed, S. (1987). Personality characteristics and proneness to burnout: A study among internists. Stress Medicine 3 (4) 307–315.

Narumoto, J., Nakamura, K., Kitabayashi, Y., Shibata, K., Nakamae, T. & Fukui, K. (2008). Relationships among burnout, coping style and personality: Study of Japanese professional caregivers for elderly. Psychiatry and Clinical Neurosciences 62, 174-176.

Gárriz, M. & Gutiérrez, F. (2009). Personality disorder screenings: a meta-analysis. Actas espanolas de psiquiatria 37 (3) 148-152.

Goekoop, J.G., DeWinter, R.F.P. & Goekoop, R. (2011). An Increase of the Character Function of Self-Directedness Is Centrally Involved in Symptom Reduction during Remission from Major Depression. Depression Research and Treatment In press.

Juradoa, D., Gurpequi, M., Moreno, O., Fernández, M.C., Luna, J.D. & Gálvez, R. (2005). Association of personality and work conditions with depressive symptoms. European Psychiatry 20 (3) 213–222.

Naito, M., Kijima, N. & Kitamura, T. (2000). Temperament and Character Inventory (TCI) as Predictors of Depression among Japanese College Students. Journal of Clinical Psychology 56 (12) 1579–1585.

Bakker, A.B., Van Der Zee, K.I., Lewig, K.A. & Dollard, M.F. (2006). The relationship between the Big Five personality factors and burnout: a study among volunteer counselors. Journal of Social Psychology 146, 31–50.

Gandoy-Cregoa, M., Clementeb, M., Mayán-Santosa, J.M. & Espinosab, P. (2009). Personal determinants of burnout in nursing staff at geriatric centers. Archives of Gerontology and Geriatrics 48 (2) 246–249.

Barrick, M.R. & Mount, M.K. (1991). The Big Five personality dimensions and job performance: a meta-analysis. Personnel Psychology 44, 1–26.

Hurtz, G.M. & Donovan, J.J. (2000). Personality and job performance: the Big Five revisited. Journal of Applied Psychology 85, 869–879.

Krasner, M.S., Epstein, R.M., Beckman, H., Suchman, A.L., Chapman, B., Mooney, C.J. & Quill, T.E. (2009). Association of an Educational Program in Mindful Communication With Burnout, Empathy, and Attitudes Among Primary Care Physicians. Journal of the American Medical Association 302 (12) 1284-1293.

Kim, H.J., Shin, K.H. & Swanger, N. (2009). Burnout and engagement: A comparative analysis using the Big Five personality dimensions. International Journal of Hospitality Management 28, 96–104.

Oginska-Bulik, N. (2006). Occupational stress and its consequences in healthcare professionals: the role of type D personality. International Journal of Occupational and Environmental Health 10, 113-122.

Alemany, M.A., Berini, A.L. & Gay, E.C. (2008). The burnout syndrome and associated personality disturbances. The study in three graduate programs in Dentistry at the University of Barcelona. Medicina Oral Patologia Oral Cirugia y Bucal 13, 444-450.

Schimpf, T. (2009). Personality traits and burnout in clinical psychologists. Dissertation 2009; 112 p accessed 07.06.2012

Patteroson, M.G., West, M.A., Shackleton, V.J., Dawson, J.F., Lanthorm, R., Maitlis, S., Robinson, D.L. & Wallace, A.M. (2005). Validating the organizational climate: Links to managerial practices, productivity and innovation. Journal of Organizational Behavior 26 (4) 379-408.

Martin, A.J., Jones, E.S. & Callanc, V.J. (2005). The role of psychological climate in facilitating employee adjustment during organizational change. European Journal of Work and Organizational Psychology 14 (3) 263-289.

Coomber, B. & Barriball, K.L. (2007). Impact of job satisfaction components on intent to leave and turnover for hospital-based nurses: a review of the research literature. International Journal of Nursing Studies 44 (2) 297-314.

Carr, J.Z., Schmidt, A.M., Ford, J.K. & DeShon, R.P. (2003). Climate perceptions matter: A meta-analytic path analysis relating molar climate, cognitive and affective states, and individual level work outcomes. Journal of Applied Psychology 88 (4) 605-619.

Crabbe, J.M., Bowley, D.M., Boffard, K.D., Alexander, D.A. & Klein, S. (2004). Are health professionals getting caught in the crossfire? The personal implications of caring for trauma victims. Emergency Medicine Journal 21 (5) 568–572.

Chiriboga, D.A. & Bailey, J. (1986). Stress and burnout among critical care and medical surgical nurses: a comparative study. Critical Care Quarterly 9 (3) 84–92.

García-Izquierdo, M. & Ríos-Rísquez, M.I. (2012). The relationship between psychosocial job stress and burnout in emergency department: An exploratory study. Nursing Outlook. Article in press. Accessed 11.06.2012.

Byrne, Z.S., Jason, S., Kenneth, T. & Hochwarter, W. (2005). The interactive effects of conscientiousness, work effort, and psychological climate on job performance. Journal of Vocational Behavior 66 (2) 326–338.

Cooper, C.L. & Baglioni, A.J. (1988). A structural model approach toward the development of a theory of the link between stress and mental health. British Journal of Medical Psychology 61, 87–102.

Giliberta, D. & Dalozb, L. (2008). Disorders associated with burnout and causal attributions of stress among health care professionals in psychiatry. European Review of Applied Psychology 58 (4) 263–274.

Iacovides, A., Fountoulakis, K.N., Kaprinis, S. & Kaprinis, G. (2003). The relationship between job stress, burnout and clinical depression. Journal of Affective Disorders 75 (3) 209–221.

Plana, A.B., Fabregat, A.A. & Gassió, J.B. (2003). Burnout syndrome and coping strategies: a structural relations model, Psychology in Spain 7 (1) 46-55