Introduction
The constant increase of pressure in the workplace and divergence between the job requirements and efficiency demanded from each subject have resulted in the manifestation of new psychosocial risks that include burnout syndrome. The prevalence of this syndrome is increasing in health professionals, establishing itself as a relevant element with evident repercussions for both society and public health, thus causing a huge cost in social and economic spheres.1
Burnout syndrome is known as an inappropriate response to the chronic stress developed in the workplace, its appearance principally observed among professionals whose jobs involve other people’s care. This situation is due to the establishment of deep and important interpersonal relationships between the patient and the professional in which human, personal, and emotional implications are instituted.2–4
Veterinarians, due to the nature of their job, are exposed daily to special working conditions that give them an elevated risk of suffering from burnout syndrome. Exposure to daily stressors leads to the appearance of negative consequences in both their social and working life. Moreover, the enormous emotional and affective bond established directly with their patients (the animals to which they show devotion) is another relevant factor leading to this psychological problem.5
Compassion fatigue is like burnout, and both processes may intermingle often due to the special characteristics of the veterinary profession. Compassion fatigue is a type of burnout that appears because of the direct relation and bond established between professionals and their patients. On the other hand, burnout comes from the stress of the interaction with the work environment.6
The huge number of stressors in the workplace of veterinarians implies a high probability of suffering from stress, depression, compassion fatigue, emotional fatigue, and, in more advanced stages, burnout syndrome. Indeed, veterinary work is perceived as stressful by 80% of UK veterinarians.7,8 We can point to many different stressors in the veterinarian’s workplace, including the excess of work and long working hours, demanding clients and the appearance of economic conflicts with them, transmission of bad news, ethical and moral stress, negative balance between their social and working life, and continuous exposure to euthanasia.9 To this long list, some indirect stressors can be added, such as dealing with animal abuse; the necessity to maintain their business; high competitiveness in the search for new clients, products, or services that will allow a relevant degree of differentiation to be reached in comparison with others; the daily necessity to recycle and catch up with the newest acknowledgments; interpersonal conflicts in the workplace; the fear of committing mistakes with the diagnosis or treatment of their patients’ diseases; and the relatively low salaries.9 Other important causes are the lack of definition of the working role and, in general terms, the scarce social recognition that exists toward the veterinary profession.7,10
It must also be stated that the veterinary practice is forced to occupy a difficult and complex moral position because it serves both human and animal interests, 2 elements that may not always be free from conflict. In the thin line that demarcates both interests, ethical conflicts are common.7 This is mainly because veterinarians are always seeking a balance between their obligations to ensure their patients’ welfare and, at the same time, meet the expectations of the patients’ owners, which can depend on specific issues such as economic conditions or other veterinarians’ opinions.7,10
In the same way, veterinarians suffer daily exposure to their patient’s death, frequently due to the practice of euthanasia. It must be outlined that in our current world, animals, especially domestic animals, are part of the family and become inseparable partners for their owners with whom they establish emotional bonds that can be even more important than those established with other human beings. This fact justifies the mourning that many owners experience over the death of their pets.9–12 Thus, on many occasions veterinarians must communicate with and comfort heartbroken owners, a duty that requires huge emotional involvement.9
Regarding studies assessing the burnout prevalence among veterinary professionals, several have been conducted to date, although much fewer in comparison with other health-care professions such as nursing. Besides, a great amount of studies measure the prevalence of this syndrome among veterinary students. However, all these studies indicate that veterinarians have a higher rate of suicide connected with an abnormally high level of mental distress, compassion fatigue, and burnout.7,13–16
Regarding Spanish veterinarians, a recent survey with a sample of veterinary professionals (n = 380) across the globe placed them among the most dissatisfied in Europe and 19% claimed to feel “completely” burnt out. These results placed Spain in the second position internationally only after Argentina (31%) and sharing this position with the US (19%).17
This situation may be explained by the poorer social and economic recognition that veterinarians suffer in Spain in comparison with neighboring countries such as France and Germany, where veterinarians belong to the upper social class. In fact, the average salary earned by veterinary professionals in Spain in 2019 was under 28,000 euros, whereas in Europe the average was 39,803 euros.18 In this line, we must also remember that low income has been identified as a source of stress among veterinarians and there is a gender salary gap of 9.4% among veterinarians in Spain.13,19,20
With all these considerations, the aim of this research was to assess the potential level of burnout syndrome among Spanish clinical veterinarians and analyze its prevalence in the veterinary collective to demonstrate its current presence and tackle it in a coherent way.
Materials and Methods
This was a cross-sectional observational study using an anonymous survey conducted between January and April 2020. The survey was delivered using Google Forms, and the link to the survey, its purpose, and the dates the survey was available were distributed via email by Professional Associations of Veterinary Medicine in Spain among their collegiate members.
Participants
The target population for this study was Spanish veterinarians. All veterinarians registered in Spain were asked to participate voluntarily in the study. The inclusion criteria for the study were having a degree in veterinary medicine and actively working in clinical practice with small or large animals in Spain.
Ethics
Research involving human beings must comply with the ethical principles of respect for human dignity, confidentiality, nondiscrimination, and proportionality between the risks and expected benefits and, if applicable, must have the consent of the people involved or their legal representatives through a written report. To this end, we requested authorization and approval from the Clinical Research Ethics Committees of the University of Extremadura in Spain. However, in Spain, if certain research projects are going to be carrying out opinion surveys on various topics or questions, professional situations, or degrees of satisfaction involving work done with adults and does not imply the inclusion of clinical data from the participant, authorization from the Bioethics and Biosafety Committee is not required.
With all these considerations, ethical approval was not required at the time the study was conducted. Moreover, the study was conducted in full compliance with the ethical considerations of the Declaration of Helsinki.21 All study data were treated, and the confidentiality and anonymity of the participants were preserved in accordance with the Spanish Organic Law on Personal Data Protection and Guarantee of Digital Rights.22
Nonetheless, in the submitted email, it was explicitly stated that full anonymity and confidentiality were guaranteed and only the researchers had access to the unprocessed data. Also, a preamble was included in the survey that indicated it was part of a research project, explaining what it consisted of and what was intended to be obtained.
Instrument
The questionnaire comprised 30 questions and was divided into 2 parts (Supplementary Appendix S1). The first part contained 8 questions relating to sociodemographic information on gender, age, years in practice, working situation, type of practice (small or large animals), satisfaction toward the profession, whether there was an ethical dilemma over the convenience of euthanasia, and, if yes, why.
The second part of the questionnaire was the Maslach Burnout Inventory Human Services Survey (MBI-HSS, adapted to a Spanish-speaking population), which is a validated instrument for assessing the frequency and intensity of burnout syndrome.23 It consists of 22 items, rated on a 7-point Likert scale (0 = never to 6 = every day), divided into 3 MBI dimensions formed by the sum of different items: emotional exhaustion (EE; 9 items: 1, 2, 3, 6, 8, 13, 14, 16, and 20, with a maximum score of 54 points), depersonalization (DP; 5 items: 5, 10, 11, 15, and 22, with a maximum score of 30 points), and personal accomplishment (PA; 8 items: 4, 7, 9, 12, 17, 18, 19, and 21, with a maximum score of 48 points). The reference values for determining burnout syndrome were > 26 points for EE, > 9 points for DP, and < 33 points for PA.24,25 Before being sent, the usability and functionality of all the questionnaires were tested.
Participants were able to respond to the survey by entering the personal email and a password provided by the authors to each Professional Associations of Veterinary Medicine member in Spain. In this type of closed survey the participant had to register, which helped prevent duplicate entries from the same participant. All participants had the possibility to modify their answers by using the back button. After 3 months, the survey was closed to any participants and completed questionnaires were collected.
Data analysis
All analyses were performed using commercial statistical software (SPSS version 25.0; IBM Corp). The Cronbach α was determined for each subscale and individual item to evaluate the reliability of the MBI-HSS in the group of veterinary professionals. Reliability scores ≥ 0.5 were considered acceptable.26
The MBI-HSS scores were calculated as means ± SD (SD). MBI-HSS mean scores for DP, EE, and PA were confirmed to be normally distributed by use of the Shapiro-Wilk test. Afterwards, to check whether there were differences between the scores for DP, EE, and PA for gender and type of practice, we used a t test for independent groups.
Results
With regard to the response rate, the questionnaire was answered by 282 Spanish veterinarians from the total of 3,970 (response rate = 7.1%), distributed as 162 women and 120 men (57.4% and 42.6%, respectively; Table 1). The majority of participants (31.6%) were 31 to 40 years old, 154 (54.6%) individuals had been working for > 10 years, 157 (55.7%) were working with small animals, and 125 (44.3%) were working with large animals.
Sociodemographic variables of gender, age, and field of work.
| Variable | Frequency | % | Valid % | Accumulated % |
|---|---|---|---|---|
| Gender | ||||
| Male | 120 | 42.6% | 42.6% | 42.6% |
| Female | 162 | 57.4% | 57.4% | 100.0% |
| Total | 282 | 100.0% | 100.0% | |
| Age (y) | ||||
| 23–30 | 74 | 26.2% | 26.2% | 26.2% |
| 31–40 | 89 | 31.6% | 31.6% | 57.8% |
| 41–50 | 71 | 25.2% | 25.2% | 83.0% |
| > 51 | 48 | 17.0% | 17.0% | 100.0% |
| Total | 282 | 100.0% | 100.0% | |
| Field of work | ||||
| Large animals | 125 | 44.3% | 44.3% | 44.3% |
| Small animals | 157 | 55.7% | 55.7% | 100.0% |
| Total | 282 | 100.0% | 100.0% | |
Test reliability coefficients (Cronbach α) were 0.72 for PA, 0.89 for EE, and 0.55 for DP. Minimum acceptable value for reliability coefficient is 0.5; consequently, the coefficients indicated acceptable reliability.
The MBI-HSS scores for the participants and the comparison of the mean burnout scores between gender and field of work are summarized (Tables 2 and 3). Regarding gender, results showed statistical differences (P < .05) in EE and DP. There was no statistical difference (P > .05) in PA. In the same line, statistical differences (P < .05) in EA and DP were found when type of practice was compared. There was no statistical difference (P > .05) in PA regarding type of practice.
Scores on the Maslach Burnout Inventory (MBI) subscales and classification of burnout level.
| MBI subscale | Mean ± SD | Low | Medium | High |
|---|---|---|---|---|
| EE (9 items, 0–54) | 28.95 ± 11.62 | n = 56 (20%) | n = 62 (22%) | n = 164 (58%) |
| DP (5 items, 0–30) | 13.77 ± 5.25 | n = 5 (2%) | n = 66 (23%) | n = 211 (75%) |
| PA (8 items, 0–48) | 35.38 ± 6.59 | n = 105 (37%) | n = 99 (35%) | n = 78 (28%) |
| Level | Low | Medium | High | |
|---|---|---|---|---|
| EE (0–54) | 0–18 | 19–26 | 27–54 | |
| DP (0–30) | 0–5 | 6–9 | 10–30 | |
| PA (0–48) | 39–48 | 32–38 | 0–31 |
DP = Depersonalization. EE = Emotional exhaustion. PA = Personal accomplishment.
Comparison of the mean burnout scores between gender and field of work.
| Variable | EE | DP | PA |
|---|---|---|---|
| Gender | |||
| Male | 24.42 | 12.95 | 36.08 |
| Female | 32.31 | 14.38 | 34.83 |
| P value | .000 | .024 | .113 |
| Field of work | |||
| Large animals | 25.45 | 12.78 | 12.95 |
| Small animals | 31.74 | 14.56 | 14.38 |
| P value | .000 | .04 | .024 |
See Table 2 for the key.
Scores for EA were higher in women (32.31 ± 10.66) compared to men (24.42 ± 11.34) and in veterinarians working with small animals (31.74 ± 11.85) compared to those working with large animals (25.45 ± 10.33); results show the existence of statistical differences (P < .05). Scores for PA were not different between gender (P = .076) and type of practice (P = .113). Scores for DP were higher in women (14.38 ± 5.06) compared to men (12.95 ± 5.04) and in veterinarians working with small animals (14.56 ± 5.06) compared to those working with large animals (12.78 ± 5.33). The results were statistically different (P < .05).
According to Maslach, while higher mean scores for EE and DP scale corresponded to higher degrees of burnout, lower PA scores correlated to higher degrees of burnout.27 Besides, burnout level was classified into 3 groups: low, moderate, and high. The cutoff points for this classification are presented (Table 2). Low degree of burnout was indicated by low scores on EE (0 to 18) and DP (0 to 5) and high scores on PA (0 to 31), high degree of burnout was indicated by high scores on EE (27 to 54) and DP (10 to 30) and low scores on PA (39 to 48), and moderate degree of burnout was indicated by moderate scores on EE (19 to 26), DP (6 to 9), and PA (32 to 38).25,26,28 According to the classification, 23.04% (n = 65) of the considered population suffered from high burnout syndrome (high EE and DP, along with low PA). In general, the average scores were 29 points for EE, 14 points for DP, and 35 points for PA (Table 2).
As previously indicated, differences were found in the prevalence of burnout depending on gender and type of practice. A higher prevalence of burnout was associated with small animal veterinarians (75.38%; n = 49) in comparison with veterinarians who develop their professional practices with large animals (24.62%; 16). Regarding gender, women showed a higher prevalence of burnout (66.15%; n = 34) compared to men (33.85%; 22).
When analyzing some of the 22 items of the MBI-HSS, regarding Item 1, 72 (25.5%) participants claimed to feel emotionally exhausted by their job a few times per month, 54 (19.1%) felt that way a few times per week, and only 10 (3.5%) denied ever feeling emotionally exhausted by their jobs. For Item 8, 62 (22%) participants claimed to feel burned out a few times per month, 52 (18.4%) a few times per week, and 32 (11.3%) every day. On the other hand, 21 (7.4%) participants claimed that they never felt burned out.
Item 13 addressed job frustration. Among the participants, 56 (19.9%) claimed to feel frustrated a few times per year and 36 (12.8%) denied ever feeling frustrated. On the contrary, 48 (17.0%) participants claimed to feel frustrated a few times per week and 23 (8.2%) every day. Item 14 of the MBI-HSS (Figure 1) asked the participants if they thought they were working too much and the vast majority believed they were: 90 (31.91%) veterinarians felt that way every day, 58 (20.6%) felt that way a few times per week, and only 10 (3.5%) claimed that they never felt that way. Finally, regarding Item 16, 54 (19.1%) participants confirmed that they felt stressed every day, 44 (15.6%) felt stressed a few times per year, and 17 (6%) never felt stressed.
Maslach Burnout Inventory (MBI) variables: Item 14, “I think I am working too much.”
Citation: Journal of the American Veterinary Medical Association 261, 5; 10.2460/javma.22.09.0407
Using data obtained directly from both parts of the questionnaire, analysis of the relationship between the sociodemographic and MBI variables was carried out. First, Item 8 was associated with gender (Figure 2). As observed, women felt more burned out due to their job compared to men. Of the 162 women respondents, 38 (23.5%) claimed to feel burned out a few times per month and 22 (13.6%) every day. Of the 120 male respondents, 25 (20.8%) claimed to feel burned out a few times per year, 24 (20%) claimed to feel that way a few times per month, and 10 (8.3%) claimed to feel burned out every day.
Relation between gender and Item 8 from the MBI: “I feel burned out.”
Citation: Journal of the American Veterinary Medical Association 261, 5; 10.2460/javma.22.09.0407
Field of work was also associated with Item 8, observing that veterinarians working with small animals felt more burned out than those working with large animals (Figure 3). Of the 157 veterinarians working with small animals, 34 (21.7%) claimed to feel burned out a few times per month, 29 (18.5%) a few times per week, and 28 (17.8%) every day. On the other hand, of the 125 professionals working with large animals, 28 (22.4%) claimed to feel burned out by their job a few times per month, 23 (18.4%) a few times per week, and only 4 (3.2%) every day.
Relation between field of work and Item 8 from the MBI: “I feel burned out.”
Citation: Journal of the American Veterinary Medical Association 261, 5; 10.2460/javma.22.09.0407
Discussion
Nowadays, there are not enough data with sufficient precision to establish a prevalence of burnout among any group of professionals compared to the prevalence of this syndrome among the general population. So far, the area in which most of the studies were carried out have focused on professions that develop their work maintaining direct contact with people such as health professionals, educators, security forces, social workers, and prison officials.
According to published studies of health professionals, the most notably affected are nurses, doctors, dentists, and psychologists.29 Of these, special emphasis is placed on the nursing professional sector, with multiple publications revealing the existence of prevalences from 30.5% to 39% and the female gender being most affected.27,30
Regarding the veterinary profession, our results revealed that a remarkable number of veterinarians confirmed feeling emotionally exhausted, burned out, frustrated, or stressed by their job. Indeed, according to the FVE study18 conducted in 2018, 26% of European veterinarians from a sample of 14,559 had stopped working for more than 2 weeks due to burnout, depression, or compassion fatigue. From the total Spanish sample of 2,641 veterinarians, 32% were affected by this situation, placing Spain in the fifth position in relation to the other 30 countries represented in the study. This same study18 revealed that among the Spanish sample, 5% claimed to never feel useful, 28% sometimes, 47% frequently, and 19% every day.
When the sociodemographic and MBI variables were analyzed, our results showed that, in general terms, women and small animal veterinarians feel more burned out due to their job than others. In the field of gender, our results corroborated the findings of other studies among American veterinarians showing that both women and men suffer moderate levels of stress.31–33 Also, a recent study34 carried out with a sample of 1,403 Canadian veterinarians showed that women had higher average levels of stress, emotional exhaustion, and depression and less resilience than men. Along the same lines, other studies have found differences connected to gender, mental disorders, and states of anxiety being more common in women.25,28,35
In this line, some authors have tried to explain the poorer mental health of female veterinarians. Bartram and Baldwin7 pointed out that this situation may be because of poorer integration within a profession that has traditionally been predominantly masculine. Along the same lines, some authors suggest that female veterinarians show higher levels of empathy with animals, show higher concern for their welfare and animal rights, and attach more importance to the human-animal bond.36–38 A study38 focusing specifically on the mental health of female veterinarians revealed that women with 2 or more children had lower levels of anxiety and depression compared to subjects who had no direct offspring. On the other hand, a recent study39 showed that women from their sample reported being primarily responsible for household chores such as meal preparation and parenting responsibilities. This workload from household chores together with that existing in the work area may explain the increase in levels of anxiety and depression in women. Given the apparently poorer mental health among women in the veterinary profession and its current feminization, some authors point out that there is a high risk of magnification of mental issues in the veterinary sector.34
Regarding the field of work, there are few studies that compare the prevalence of burnout syndrome according to the type of veterinary practice. One study40 revealed that clinical veterinarians working with small and large animals show higher levels of depression and anxiety in comparison to nonclinical professionals. Our findings were consistent with another study,16 which remarked that large animal clinical veterinarians show better mental well-being than both clinical and nonclinical veterinary professionals.
In the field of veterinary medicine, studies using the MBI as a measure of the prevalence of burnout have mostly been carried out in university students. One of these studies was recently conducted among 496 veterinary students at the University of Belgrade.41 The results showed a 43.3% prevalence of burnout syndrome among the students, with high levels of EE and DP (in 45% and 79.9% of the sample, respectively) and a low level of PA (in 50.5% of the sample). The same study41 highlighted that the higher EE scores belonged to students in the third year of their degree, when the clinic subjects begin their respective clinical practices in which they have to cope with animals and their owners. Along the same lines, another study42 with a sample of 193 veterinarian students from 6 different universities in Australia showed that 30% of participants were at higher risk of suffering from burnout syndrome.
Our study also revealed that, considerably, 23.04% (n = 65) of the sample suffered from high burnout syndrome. In this line, the results from another recent study34 conducted in Canada with a sample of 1,403 veterinarians revealed that 493 (35%) participants were suffering from burnout syndrome, with average scores of 26, 8.8, and 36.6 points for EE, DP, and PA, respectively. Our results were also in no contrast with those obtained from a study43 conducted in the Veterinary Faculty of Utrecht with a sample of 727 veterinarians that established a 14% prevalence of burnout syndrome and estimated a 15% risk of suffering burnout in the future. Finally, in the same lines, a study44 with a sample of 785 Finnish veterinarians estimated that 40% of the sample showed moderate clinical signs of burnout syndrome and 1.7% showed serious clinical signs.
Concerning euthanasia, most of our participants claimed to have carried out convenience euthanasia and the majority affirmed that the decision was due to the owner’s economic situation. This kind of situation provokes stress and moral dilemmas in professionals due to the impossibility of following their own ethical principles.45,46 According to the results of a study47 conducted in 2015, moral stress is the main cause of compassion fatigue among veterinarians. The main source of stress in these professionals is the practice of euthanasia either when the professional does not consider it medically justifiable or it is clearly indicated but the owner refuses.25,26,47
The practice of euthanasia contributes in a decisive way to the prevalence of suicide risk and psychological stress among veterinarians.48 During university education, veterinarians acquire a vision of euthanasia as an acceptable way to relieve animals from their suffering and this vision may affect how they value human life, including a reduction in fear toward death.35,48
Due to the nature of the veterinary profession, there are many other stressors that can lead to the development of burnout among these professionals. Some studies have cited the following as main stressors among veterinary professionals: long working hours, excessive workload, keeping up their knowledge and technical skills, client expectations and relationship, salary, uncomfortable working positions, gender salary gap, and recovery of amounts of money not paid by clients.15,49,50
In the same line, other studies emphasize age as a factor closely linked to the level of work stress suffered by veterinary professionals, more markedly affecting young professionals under 35 years of age. In addition, 1 study14 states that veterinarians experience higher levels of burnout in the first 5 years after graduation.
Variables that may have a direct relation to the development of burnout syndrome in veterinarians and should be analyzed further in the future are age, gender, and field of work. According to the observed results, the prevalence of high burnout syndrome among the Spanish veterinarians of our sample was 23.04%, showing high average levels of EA and DP and medium levels of PA in comparison with the reference values given for these health-care professionals. Veterinarians working with small animals showed a higher prevalence of burnout syndrome than those working with large animals. Also, women showed higher levels of burnout syndrome in comparison to men.
Burnout syndrome implies a current risk for the health of veterinarians that can have direct consequences on the work environment, affecting the way these professionals perform their professional activity. In this sense, the main factor of protection against burnout syndrome lies in the use and conservation of adaptive coping strategies that can be classified into individual, professional, and organizational levels.
However, our study had some limitations. First, because it was a cross-sectional study, we could not establish causal relationships. Second, the low response rate could have introduced bias into the results. A possible explanation for this is the existence of self-selection bias due to the risk that only the people experiencing any of the characteristics addressed in the study completed our survey.
On the other hand, our study had some important strengths. In the first place, this study was one of the very few assessing burnout syndrome among Spanish veterinarians. In this line, our results provided some data to establish this syndrome as a relevant and actual concern in the field of veterinary medicine due to the huge repercussions for both society and public health. However, being aware of all limitations, further studies are needed to confirm these findings.
Supplementary Materials
Supplementary materials are posted online at the journal website: avmajournals.avma.org
Acknowledgments
This work was cofinanced by the European Regional Development Fund and the Junta of Extremadura (GR 18080).
The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.
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