Professional stress

A study to compare work stress and burnout in two similar professional
groups – podiatrists and dentists.  By P
Mandy and A Mandy


The aim of this study was to compare work stress and burnout in two similar professional
groups. Burnout was measured in a group of podiatrists (chiropodists) using the
Maslach Burnout Inventory (MBI) and Work Stress Inventory, and the results were
compared to those published by Croucher et al (1998), who investigated an
equivalent group of dentists.

Podiatrists had significantly higher scores on the MBI scale (p<0.0001).
Qualitative analysis of the Work Stress Inventory identified as key issues the
themes of isolation, lack of public understanding of the podiatrist’s scope of
practice, and lack of career structure within the NHS. The similarities and
differences of professional practice were considered, and it was suggested that
low status contributed to the aetiology of burnout and work stress in

Work Stress Inventory

This validated questionnaire (Powell 1992) consisted of 56 items describing
various types of work stress. Respondents identified the amount of stress each
item caused them on a six-part Likert scale, which ranged from 0 (no stress) to
5 (much stress). Scoring the Work Stress Inventory results in seven work stress
factors: quality/quantity; role issues; responsibility/authority; social
relationships; job satisfaction; organisational issues; and domestic effects.
In addition there was an open-ended question about any sources of job stress
not covered by the questionnaire.

Maslach Burnout Inventory

This is a validated questionnaire consisting of 22 statements about
work-related feelings, which measures the degree of burnout in three
sub-scales: emotional exhaustion (EE), depersonalisation (DP) and personal
accomplishment (PA).

The emotional exhaustion sub-scale assesses feelings of being emotionally
overextended and exhausted by work; depersonalisation measures the degree of
loss of feelings towards patients; and personal accomplishment measures
feelings of competence and success.

Each statement is measured on a scale of 0-6, in which 0 = never, 1 = a few
times a year, 2 = once a month, 3 = a few times a month, 4 = once a week, 5 = a
few times a week, and 6 = every day. The score for each sub-scale may be
compared to published normative values, or, using a "cut-off"
criterion, classified into high, moderate or low categories. Burnout is
pictured as a continuous variable, ranging from low to high.

High scores on the EE and DP sub-scales and low scores on the PA sub-scales
mean respondents are exhibiting burnout (table 2), but the use of MBI for
diagnosis is not recommended.

Statistical analyses

The MBI scores were found to be normally distributed, and therefore
parametric tests were used. The Work Stress Inventory gave rise to ordinal data
requiring non-parametric analyses.

Where the data was normally distributed, Pearson’s correlation coefficients
were calculated; where data were not found to be normally distributed,
Spearman’s rank coefficients were calculated.


Five hundred questionnaires were distributed: 320 were completed, and 17
were either spoilt or returned where respondents had moved without a forwarding
address. Eleven questionnaires were returned by people who had left the
profession and were therefore of no use. Finally, 291 usable questionnaires
were analysed. The proportion of usable questionnaires was therefore 58 per

A power analysis (Bolton 1990) was performed to determine whether the sample
size was enough to compare the means of two groups and measure significant
differences (comparing the calculated mean from the sample with published
normative data: Maslach & Jackson 1986). The power calculation for a
two-tailed hypothesis with a 5 per cent alpha value and a 99 per cent beta
value indicated that the sample size necessary to determine that a five-unit
change would be 74 subjects per group. It is normally acceptable to use an 80
per cent power to decide the sample size, so being able to use a 99 per cent
power confirms the sample’s appropriateness.

Table 1 indicates the mean scores for each sub-scale of the MBI for
podiatrists and dentists and MBI published normative data (Maslach &
Jackson 1986). Data are compared using students’ two-sample t-test.

Podiatrists demonstrated significantly higher scores on each of the
sub-scales than those produced by the dentists (p

Table 2 indicates the cut-off criterion for each sub-scale on the Maslach
Inventory, and indicates the scoring.

Work Stress Inventory results

Spearman rank correlation analyses were performed between the work stress
inventory scores, which were ordinal data, and MBI scores. Correlation scores
indicated a weak association with the work stress factors, none of which was
found to be significant.

Work Stress Inventory qualitative comments

Seventy-nine respondents provided comments about their work stress. These
were analysed by theme, and six areas of importance were identified.

Too much work

Themes included too much administration, waiting lists, record keeping, time
pressures, seeing extra patients, no cover for illness, and meeting targets.


Themes included lack of teamwork, lack of colleagues and feelings of

Patients’ lack of understanding

Themes included patients’ lack of understanding of the scope of the work
done by podiatrists.

Lack of career structure

Respondents reported a lack of promotion prospects and poor career prospects
in the NHS. The insecurity of temporary contractual work was also noted.

Psychosocial problems

Respondents commented about dealing with patients’ emotional problems,
cultural and ethnicity problems, bullying and aggression at work.

Legal issues

Respondents reported concerns about patient complaints and legal issues.


On first consideration, the professions of podiatry and dentistry seem to
have little or nothing in common, other than they can both be classified as
healthcare professions. However, the two share a long and ancient history.
There is evidence that foot and dental care was undertaken in Egyptian, Grecian
and Roman civilisations. Probably of more relevance is the work of the barber
surgeons and itinerant market traders in the 17th and 18th centuries, in which
corn-cutting and tooth-drawing were undertaken by the same individuals (Hillam

Although from about 1850 the combined practice of foot and oral care became
less common, it is only in the past 100 years that the two practices have
become completely independent (Seelig 1953).

The management of chronic repeatable lesions means the pattern of patient
care is very similar, with patients attending for regular clinical appointments
which could be considered out-patient in nature. The one major difference is
that although the public regularly visit the dentist for preventative oral
monitoring, no such provision is made for podiatry patients. Given the pattern
of patient care, it is not surprising that the working environment is almost
identical, with a chair for the patient, operators’ chairs, illumination and
clinical or surgical instruments. The differences found in this study must
therefore have another cause.

Podiatrists’ scores for each sub-scale in the MBI are significantly higher
than those recorded for dentists by Osborne & Croucher (1994), even though
the samples, in terms of providing community-based care, were similar. However,
when considering the distribution of scores, it is interesting to note that
those for podiatry do not follow the suggested pattern, which suggests burnout.
In scoring the Maslach inventory, a high score for emotional exhaustion and
depersonalisation and a low score for personal accomplishment indicate burnout.
This suggests podiatrists still have a sense of achievement when dealing with
their patients. However, this is not the case for dentists, who have lower
levels of personal accomplishment.

A further explanation of this finding is suggested when it is compared with
the work stress inventory results, which demonstrated only weak correlations
between the seven factors and the three burnout sub-scales, none of which was
statistically significant. However, the qualitative comments gave some valuable
information which might help explain the exceptionally high scores detected by
the MBI.

The Work Stress Inventory results highlight themes that are common to the
dental profession, including isolation, problems with patient/therapist
interaction and lack of career direction. Although it was noted earlier that
the surgical environment was similar for both professions, a clear distinction
is the number of podiatrists employed in a practice.

In the NHS, podiatry clinics are usually designed for one or two people, and
there may be a foot care assistant. However, several dentists usually practise
together, and there will be a dental nurse or assistant who works with the
dentists. In podiatry, the foot care assistants usually work independently and
have their own caseloads, and in private practice podiatrists are often sole
practitioners. The study by Croucher et al (1998) clearly identifies that the
greater the number of dentists working in a practice, the smaller the emotional
exhaustion and depersonalisation scores. This notable difference might well
explain the comments about isolation, lack of teamwork and lack of colleagues.
This would also help to explain the feelings of overwork expressed by the
podiatry sample.

One stressor that was not common in dentistry is "identification of
patients’ lack of understanding of scope of practice". This was clearly
identified by the podiatrists as a cause for concern and was specifically
identified as an additional stressor in the questionnaire. It may be that
patients’ lack of understanding of the profession undermines the podiatrists’
feelings of professional standing, increasing their feelings of
disillusionment. The issue of professional status is complex, and has been
investigated by many disciplines.

However, for the purposes of this paper, the adoption of the Government’s
standard classification of occupations (1990) is enough to highlight the
differences. Dentists are specified as group 1, "professional", and
podiatrists are in group 2, "intermediate". There is also evidence
that the status of podiatry is much lower in the eyes of the public than those
of other healthcare professions (Mandy 2000). This may partly explain the
significantly higher levels of burnout found among podiatrists compared to

Although the podiatry sample aimed to investigate people who had been
qualified for only three years, this would include mature practitioners as well
as younger ones. Podiatry often attracts people in later years who want a
change of vocation and re-train. This was not allowed for in the survey.

In conclusion, this study has added some interesting results to the
literature investigating burnout and work stress. The key finding is that
professional status might have some effect on burnout and work stress, and
might explain the differences between two very similar but also clearly
different professions. This has also initiated some studies into podiatry, an
under-researched profession from a psychosocial perspective.


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