Attachment Style as a Predictor of Burnout and Work Engagement Among Health Professional Caregivers
Department of Psychology, Bar-ilan univerisy, Israel
Received Date: 13/11/2020; Published Date: 24/11/2020
*Corresponding author: Meni Koslowsky, Department of Psychology, Bar-Ilan Univerisy, Israel
Cite this article: Odelia Ben Haroush and Meni Koslowsky*, Attachment Style as a Predictor of Burnout and Work Engagement Among Health Professional Caregivers. Op Acc J Bio Sci & Res 5(1)-2020
1.1. Background: Burnout is a very common phenomenon among health professional caregivers. Individuals suffering from the syndrome put patients at risk besides manifesting various types of health problems. There are many studies dealing with burnout factors as a result of working conditions and organizational culture. Also, personality traits are known to be risk factors for high levels of burnout. More information about personality risk factors for burnout is needed to limit its occurrence and to determine which is the most appropriate clinical and organizational intervention when the condition appears. Unlike burnout, work engagement is a positive, fulfilling, work-related state that creates its own positive feedback mechanism, in terms of appreciation, recognition, and success. Higher work engagement is associated with increased quality of treatment to patients.
1.2. Objectives: The objective of this study is to explore anxious attachment style as a possible personality predictor of those who are likely to burnout and show high work engagement among health professional caregivers. In addition, the effect of mindfulness as a moderator of the relationship will be examined.
1.3. Methods: The investigators here examined a sample of Israeli nurses (N=61), nearly all of whom were full-time employees. Four instruments were used: MBI- Maslach Burnout Inventory (1996), The UWES Questionnaire- Utrecht Work Engagement Scale (2003), SRMA- Self-Report Measures of Adult Attachment (1998) and Mindfulness- FFMQ questionnaire- The Five Facet Mindfulness Questionnaire (2006).
1.4. Results: Burnout, and not engagement, was found to be significantly associated with anxious attachment style. Although mindfulness as a whole was not found to moderate the relationship, it did show a significant effect on the anxious attachment style-burnout at two levels of the moderator.
1.5. Discussion: According to the present findings, it would seem that management must understand that burnout formation is a complex process that appears to depend on personal factors, and likely, organizational characteristics that need to be determined in future research .
Keywords: Attachment theory; work engagement; burnout; mindfulness.
The comment that both burnout and work engagement are associated with one’s level of functioning at work [1,2] is particularly crucial for professions whose core tasks have an important impact on others (i.e. the recipients of services). One such professional group is physicians, whose ability to meet key tasks (i.e. the delivery of adequate care) affects the morbidity and mortality of their patients. Burnout, which mainly affects professionals who work directly with the beneficiaries of their services , is nowadays one of the most studied subjects in health and occupational psychology due to the findings that have indicated an association with severe economic and social consequences . The healthcare sector represents an interesting arena for the study of workers’ engagement and its organizational antecedents, as hospitals are paradigmatic examples of high-contact services in which the patient-medical interaction is at the heart of the delivery process. Because of the span and intensity of patients’ encounter with nurses and physicians, it is likely that workers’ engagement not only positively affects performance measures, such as productivity or profitability, but also patients’ perceived quality and satisfaction . Specific personality characteristics have been shown to play a crucial role in the way employees express their energy and efficacy when performing their jobs [6,7]. Researchers are becoming increasingly interested in how early experiences within the family are relevant to an individual’s behavior at work later in life. A such, research on attachment styles in organizational contexts is growing, especially regarding occupational burnout. Pines  observed that the anxious and the avoidant attachment styles have a positive relationship with burnout . This result was confirmed by studies conducted among security guards  and working adults in Israel , suggesting that attachment style is an antecedent of burnout and, possibly, also of several related outcomes [11,12]. As such, the present study tests a personality measure as a predictor of burnout and engagement and includes a moderator that may help explain when the relationship is stronger.
Burnout. The term ‘burnout’ was first introduced by Freudenberger in 1974 to describe the conditions in which a person experiences physical and mental exhaustion caused by occupational stress . Later, Maslach and Jackson  defined burnout as a three-dimensional syndrome that consisted of depersonalization, emotional exhaustion, and low personal accomplishment [14,15]. Burnout is especially common in jobs that are directly related to people, especially in the case of healthcare professionals who provide patient care services and face more challenges including communication with patients and their relatives as well as interaction with colleagues in teams .
Assessment of burnout prevalence in a number of public sector jobs using the MBI has indicated the burnout rate varies from 13%-17%, whereas the corresponding rate in healthcare-related occupations, especially in the nursing profession, is 30%-50% [16,17] Therefore, nurses are more likely to develop burnout in comparison with those in other occupations due to their workload, work shift duration, imbalance between work and personal life, and patients’ complaints and requests .
The consequences of burnout are not limited to the personal well-being of healthcare workers. Nurse burnout has been associated with higher rates of both patient mortality  and dissemination of hospital-transmitted infections . High rates of physician burnout also correlate with lower patient satisfaction ratings . As it often leads to turnover, burnout has significant financial implications for health care organizations. The cost of turnover among RNs in the States is estimated at 1.2 to 1.3 times their salary (estimated total costs of $82,000–$88,000 per RN in 2007 . Costs to replace a physician depends on specialty, location, and length of vacancy, with estimates running from hundreds of thousands to more than $1 million .
Yet, not all individuals who experience the same working conditions develop the syndrome, which suggests the importance of individual/personality factors. Determining which characteristics are most associated with the phenomenon can help in better predicting those who are likely to be the highest risk for developing burnout.
One of the more widely used measures for predicting individuals’ work behaviors  is one’s personality that often helps explain how one processes and responds to various situational cues and environmental features in the workplace [24,25]. The personality characteristics of each individual play a relevant role in the way they work and the vitality and efficacy with which they perform their job . They are also related to the perception of work events as stressful, such that individuals prone to anxiety are more vulnerable to job stress . Studies suggest that personality factors are related to the frequency of occurrence of burnout syndrome in health professionals . Previous studies have focused on the relationship between personality and burnout by using Five Factor Theory or the so-called ‘‘Big Five’’. This model has been one of the most widely used trait measurement theories and suggests five basic factors. This theory found that Individuals with high neuroticism levels are more prone to feeling angry, anxious, depressed or stressed , are less able to control their emotions when faced with negative or stressful situations , and exhibit immature defense mechanisms that increase their exhaustion .
As such, this theory may act as a theoretical lens for providing insight into how individual differences may explain burnout and work-related performance .
One of the positive constructs that has received high consideration by academics and managers alike is work engagement . Unlike burnout, work engagement is defined as a positive, fulfilling, work-related state of mind characterized by vigor, dedication, and absorption. Vigor is characterized by high levels of energy and mental resilience while working, the willingness to invest effort in one’s work, and persistence even in the face of difficulties. Dedication is characterized by a sense of significance, enthusiasm, inspiration, pride, and challenge. Absorption is characterized by being fully concentrated and deeply engrossed in one’s work, whereby time passes quickly, and one has difficulties with detaching oneself from work . "When workers have high energy and self-efficacy, that helps them to exercise influence over events that affect their lives. For example, because of their positive attitude and activity level, engaged employees create their own positive feedback, in terms of appreciation, recognition, and success. Further, work engagement enhances revenues , safety outcomes , customer satisfaction , and creativity . Many interviewees indicated that their enthusiasm and energy e.g. in sports, creative hobbies, and volunteer work". Work engagement has been linked to performance among healthcare professionals . Such employees who are engaged are also less likely to commit medical errors . Healthcare professionals are well-known for high levels of work engagement, that is, their absorption in their work and dedication to patient care .
Relationship between Burnout and Work Engagement
The two concepts have been discussed quite extensively in the literature [39,40]. Yet, the exact relationship between burnout and work engagement has generated debates among researchers. Initially, work engagement was posited as the opposite of burnout [41,42] and that both concepts can be assessed using the same questionnaire. In response to this perspective, other researchers showed that burnout and work engagement may have different correlation patterns with variables measuring various job characteristics . Work engagement has incremental effects over burnout in longitudinal studies . In addition, investigators report that burnout and work engagement have different associations with certain personality variables such as neuroticism or extraversion . Based on these various findings, researchers have generally assumed that burnout and work engagement are constructs that describe connected, yet distinct forms of well-being .
According to certain theories of personality, childhood experiences are crucial in developing different types of affective bonds and proximity-seeking scenarios [47,48]. These attachment styles seem to affect functioning in adulthood, e.g., in romantic relationships or at work [49,50]. For example, an avoidant attachment style is related to higher turnover intentions and lower levels of organizational commitment [51,52]. Thus, attachment theory may be viewed as a relational framework for understanding interpersonal relationships and behaviors at work. Specifically, attachment theory focuses on the individual differences that may impact work behavior and attitudes . Therefore, this theory may act as a theoretical lens for providing insight into how individual differences may be associated with burnout and work engagement. As the research has shown various patterns of relationships between burnout and work engagement, it is important to understand what predictors overlap and which ones are unique to each phenomenon .
In recent years, there has been a growing interest in understanding how employees’ attachment style predicts workplace behaviors, such as individual emotional regulation, turnover intention, and organizational citizenship behavior . When attachment security is threatened, Bowlby  believed that the child responds in a predictable sequence. Typically protest and anger are the first responses, followed by some form of clinging and seeking, which then gives way to depression and despair. Finally, if the attachment figure does not respond, detachment and separation occur. Within this global, predictable sequence of behaviors, people respond to, or prepare for, stress differently. Different style categories have been suggested:
1. The secure style is defined by confidence in the availability of attachment figures in times of stress and comfort with closeness.
2. The avoidant style is characterized by insecurity in others’ intentions and preference for emotional distance.
3. The anxious-ambivalent style is characterized by insecurity concerning others’ responses combined with desire for intimacy and high fear of rejection. .
Following these ideas, Hazan & Shaver  examined working models of attachment in adults, using the tripartite classification of infant attachment styles . The secure style, they discovered, is defined by confidence in the availability of attachment figures in times of stress and comfort with closeness. The avoidant style is characterized by insecurity in others’ intentions and preference for emotional distance. The anxious-ambivalent style is characterized by insecurity concerning others’ responses combined with desire for intimacy and high fear of rejection.
Burnout and Attachment Style
The results obtained in this study suggest that aqueous and ethanol stem bark extracts of D. guineense stem bark are rich sources (reservoirs) of important vitamins.
As Such, we Hypothesize
H1: a. Anxious attachment style is positively correlated with burnout
Work engagement and attachment style:
A person with a secure attachment style typically is expected to exhibit a healthy pattern of behavior, manifested in the ability to work well alone or with others by forming supportive, reciprocal relationships. Individuals with high levels of secure attachment have been found to seek and use social support at work [60, 61]. The link between the secure attachment style and health and well-being has received substantial empirical support [62,63]. Specifically, the secure style has been associated with less distress and fewer adverse psychological and physical symptoms [49,61].
As opposed to the secure style description above, insecurely attached individuals, including both anxious and avoidant attachment styles, view relationships differently and engage in different self-regulation strategies. Anxious individuals try to achieve security by minimizing their distance from others. At work, anxious individuals may appear clingy because of their desire to seek out and use more support than necessary. Acting on this desire may drive others away. They may drain their support systems by failing to reciprocate and provide support to others. In studies of military personnel in officer training and basic training groups, candidates with anxious attachment styles were less likely to graduate successfully from training programs [60,61]. Those high in anxiety have been shown to have higher levels of distress, negative affect, and physical and psychological symptoms [49,61]. Therefore, evidence links attachment styles with interpersonal processes and with important work-related outcomes. One internal state that may be affected by attachment style is work engagement.
As Such, we Hypothesize
H2: a. Anxious attachment style is negatively correlated with work engagement
Mindfulness as a Moderator
Several perspectives of mindfulness have been offered (Figure 1). Particularly relevant here is the notion that mindfulness involves a process of openly attending, with awareness, to one's present experiences. This contrasts with much of our daily life experience where we often find ourselves unintentionally letting our minds wander , running on automatic pilot , or suppressing unwanted experiences .
Figure 1: Anxious attachment style is negatively correlated with work engagement
Yet, two features appear in most definitions of mindfulness. First, as mentioned above, mindfulness grounds one’s attention and awareness to the present experience. This can manifest itself in many forms, including awareness of body sensations, emotional reactions, mental images, mental talk, and perceptions (e.g., sounds). Researchers have described this monitoring aspect of mindfulness as “watchfulness” or a “lucid awareness of each experience that presents itself” [67,68]. Moreover, many contemporary formulations of mindfulness posit that one actively adopts an attitude of openness or acceptance toward one's experience. This open and accepting attitude consists of attending to experience with a curious, detached, and nonreactive orientation. Importantly, this attitude of acceptance toward experience is not one of passive resignation to one's current circumstances but rather one of “inviting in” experiences, even if they are difficult.
Mindfulness may be a potential coping strategy that moderates the negative effects of appraised stress. Research on mindfulness interventions on a nursing staff has revealed that mindfulness was associated with lower levels of reported stress [69,70], improved coping with stress and diminished burnout [71-73], decreased EE and anxiety , and increased life satisfaction . It would seem that mindful individuals have greater abilities to handle stressors, which argues for a moderating role in the stress-adverse mental health outcomes association [76,77]. When employees maintain active observation and attention to their work environment, they are likely to manifest a high degree of vigilance and sensitivity to internal experiences and external situations.
As Such, the Following Hypotheses are Suggested
H3: a. Mindfulness moderates the relationship between attachment style and burnout such that for high mindfulness, the attachment style-burnout link is weaker.
b. Mindfulness moderates the relationship between attachment style and work engagement such that for high mindfulness, the attachment style-burnout link is weaker.
Participants- Data were collect from 61 nurses who worked in hospitals, health maintenance organizations (HMO), and senior citizen facilities.
Instruments- Each nurse will complete 4 questionnaires that measure: Work engagement, Burnout, Attachment style and Mindfulness.
Work engagement by UWES Questionnaire- Utrecht Work Engagement Scale (2003). The questionnaire includes 17 items at 3 categories: vigor, dedication, and absorption. The correlation between each category and the attachment style was examined. Participants used a 7-pointfre-quency scale (ranging from 0-never to 6 always) to indicate the extent to which they experienced each item (e.g., "my job inspired me".). Cronbach alpha values range from mid-.80’s to low .90’s . Cronbach alpha here was .84
Burnout by Maslach Burnout Inventory-General Scale (MBI-GS) Participants used a 7-point frequency scale (ranging from “0”-never to” 6” daily) to indicate the extent to which they experienced each item (e.g., "I feel emotionally drained from my work.”) . Cronbach’s alpha here was .81.
a. Attachment style- by SRMA- Self-Report Measures of Adult Attachment (1998). The questionnaire includes 36 items (ranging from 1- disagree to 6- very agree). Half of the items are for anxious attachment style and half of the items are for avoidant attachment style. In one study that specifically focused on anxious attachment style, the Cronbach alphas were .94 . The alpha coefficient here was .86.
a. Mindfulness- FFMQ questionnaire- The test consists of 39 items (ranging from 1-never to 5- always) the scores provide an estimate of where we stand in terms of mindfulness and self-awareness. Support for the validity of the FFMQ has included demonstrating associations between the measure and amount of meditation experience, with facets of the FFMQ shown to mediate the link between meditation experience and psychological wellbeing . The alpha coefficient here was .80
b. Demographic questionnaire: This questionnaire contains demographic questions such as age, sex, Marital Status, number of children, years of seniority as a nurse, management experience and a percentage of office.
The study sample included 61 nurses from several hospitals, health maintenance organizations (HMO), and senior citizen facilities. (Table 1) presents the means, standard deviations, and intercorrelations among the study variables. All Cronbach alpha coefficients were above .80, a very satisfying result. In examining the specific hypotheses, the findings showed that hypotheses 1 was confirmed. The correlation between anxious attachment style and burnout was significant (.37, p < .01) As for hypothesis 2, anxious attachment style was not found to be significantly correlated with work engagement. As such, hypothesis 2 was not confirmed.
Table 1: Means, standard deviations, and intercorrelations among study variables.
The third hypothesis was examined using the SPSS Process procedure  for testing mindfulness as a moderator. In all cases, independent variable and 2 dependent variables, no significant moderation was observed. Interestingly, in case, the interaction term, anxious X mindfulness, the R squared increase just barely missed from being significant (F = 3.93, P < .052). An examination of the moderator at three levels of moderator (1 SD below the mean, at the mean, and 1 SD above the mean), showed that the moderator was significant twice. The correlation between anxious attachment style and burnout was stronger for those subjects at the mean of mindfulness (effect = .24, t = 2.87, p < .01, LLCI = .0726 ULCI =..4086) and for those one standard deviation above the mean (effect = .41, t = 3.55, p < .01, LLCI = .1767, ULCI =.6346). As such, partial moderation was obtained.
This study analyzed the relationship between certain personality factors among health professional caregivers: Anxious attachment style with burnout and work engagement. We also examined whether high levels of mindfulness moderate the relationship between these attachment styles and burnout and work engagement.
Burnout was found to be positively correlated with anxious attachment style. The results here with a sample of nurses are consistent with the findings from studies using samples from other populations [49,82]. Individuals who developed anxious attachment style due to specific circumstances during their childhood burn out more often and more strongly occurs. In contrast, in the current study these personality factors did not show a correlation with work engagement, so the hypothesis was not confirmed. Mindfulness was shown to serve as a partial moderator.
This study has some limitations
The first limitation is "self-report"- The findings of this study were based exclusively on self-report data, generally considered susceptible to common method bias effects. However, employees remain in the best position to know their own (dis)comfort with interpersonal relations. Since we focused on employees’ perceptions and personal preferences, self-reports were the relevant measurement method. The second limitation is the fact that data were collected at one point in time. The results of our study, therefore, do not demonstrate casual effects which are usually shown via experimentation or longitudinal design. The third limitation of this study is its generalizability, due to the highly delimited nature of the subject sample in a single country setting. The inferences drawn from such a sample in Israel may not be fully generalizable to employees from other countries with different national culture.
Further research is suggested to explore the effectiveness of intervention when performed among employees with an anxious attachment style. For example, Maslyn et al.  examined psychological attachment styles (secure, anxious, and avoidant) as antecedents to LMX (Leader-Member Exchange theory) quality both directly and through their impact on employees’ efforts to build high quality LMX relationships. The findings indicated that secure and anxious attachment styles were associated with LMX only by exerting an effort program specifically aimed at relationship development with the manager .
In addition, it is important to check whether the relationship between attachment style with the outcome measures used here are stable and generalizable. In other words, will repeating the study with other health professionals yield similar results. As such, a longitudinal study that includes personality and situational characteristics (psychosocial environment, work schedule, feelings of control or empowerment) provide a better understanding of when the personality-outcome measures are stronger.
The most important implication from these findings is that there is no ‘‘one size fits all’’ solution to enhance work engagement or burnout. Therefore, according to this study and others, management must understand that burnout formation is a complex process that appears to depend on both organizational and personal factors. Thus, it is of great importance to conduct future research in this area to learn how to best adapt each employee to his/her work environment while taking into consideration each one’s personality characteristics.
Conflicts of Interest
The authors have no conflicts of interest to declare.
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