Measuring burnout syndrome requires reliable and standardized measures

Dear Editor in Chief,

We have appreciated the paper by Zakaria et al. showing a high prevalence of burnout syndrome (BOS) among emergency healthcare workers (HCWs) in Malaysia during COVID-19 pandemic. ¹ This finding is certainly in line with the literature as high levels of stress, fear, anxiety, depression, sleep disturbances, and post-traumatic stress disorders among emergency and frontline HCWs during the COVID-19 have resulted in high levels of BOS and turnover intention. ²

However, the instrument (i.e. the “Burnout Questionnaire Form”) used by Zakaria et al. for measuring BOS raises some concerns. First, the authors used a burnout measure with unknown validity and reliability. Second, Zakaria et al. referred to the 2019 World Health Organization (WHO’s) definition of burnout (i.e. BOS as an occupational syndrome characterized by exhaustion, cynicism related to one’s job, and reduced professional efficacy), which is consistent with that given by Maslach and Leiter, who described BOS as a combination of high exhaustion and depersonalization and low personal accomplishment. ³ Various tools to measure BOS have been developed over the years, based on different assumptions about what burnout is and based on different definitions of this syndrome. ³ However, the Maslach Burnout Inventory (MBI) is considered the “gold standard” for measuring job burnout, as it aligns with the WHO’s 2019 definition MBI and is the only burnout measure that can assess all three subdimensions of BOS. In the literature, an individual should be considered as clinically burned out when he or she has a “high” score on exhaustion in combination with a “high” score on either of the two remaining MBI dimensions. ³

Third, Zakaria et al. suggested a correlation between BOS and some job-related factors such as “demand coping with an angry public,” “job overload,” “lack of clear guidelines,” “rapid program changes,” and “pay too little.” However, they did not use validated instruments to study some relevant job-related risk factors. ¹ In the literature, the most cited job models for predicting BOS are the “Job Demand-Support” model, the “Effort-Reward Imbalance” model, the “Job Demand Resources” model, and the “Mediation” model. This latter focuses on six “Areas of Worklife” (AWS) and could be used in combination with the MBI for conducting among HCWs analyses of association between their burnout profile and job-related factors. Just to cite some examples, high workloads (high demands and low resources) usually predict high emotional exhaustion (“overextended” profile), while problems with fairness in the workplace, or social rewards and recognition correlate with high cynicism or low professional efficacy. ⁴

As there is an on-going debate on the relationship between BOS and depression, and depressive and burnout symptoms often co-occur and develop in tandem, it is important to accurately determine the incidence and the prevalence of burnout. Therefore, it is worthy using MBI or other reliable and widely used tools for measuring BOS in occupational contexts. The usage of standardized measuring instruments allows occupational stakeholders to conduct high-quality studies, which are needed for publishing high-quality systematic reviews and meta-analyses ⁵ and designing effective evidence-based strategies to protect mental health of emergency HCWs during and post-COVID-19 pandemic.