Canadian Journal of Administrative Sciences Revue canadienne des sciences de ladministration 26: 722 (2009) Published online in Wiley

Interscience (www.interscience.wiley.com). DOI: 10.1002/CJAS.91

Workplace Risks and Stressors as Predictors of Burnout: The Moderating Impact of Job Control and Team Efcacy
Arla L. Day*
Saint Marys University

Aaron Sibley
Dalhousie University

Natasha Scott
Saint Marys University

John M. Tallon Stacy Ackroyd-Stolarz

Dalhousie University Abstract Air medical healthcare (AMH) professionals care for critically-ill individuals while conveying them to healthcare centres from distant, and frequently dangerous, locations. AMH professionals experience additional health and safety issues beyond the typical stressors faced by other healthcare professionals. Therefore, we integrated the safety and psychosocial health literatures to examine the relationship between workplace stressors (risk perception, worries, and patient-care barriers) and two components of burnout (emotional exhaustion; depersonalization), and the moderating impact of job control and team efcacy for 106 Canadian AMH professionals. Worries over medical hassles and barriers to patient care uniquely predicted emotional exhaustion. Lack of perceived control over ones job was related to exhaustion and depersonalization after controlling for stressors. Job control and team efcacy buffered some of the stressor-burnout relationships. Copyright 2009 ASAC. Published by John Wiley & Sons, Ltd. JEL Classication: J28 Keywords: job stressors, safety incidents, job control, team efcacy, burnout
Preparation of this manuscript was supported by research grants from the Foundation for Air Medical Research *Please address correspondence to: Dr. Arla L. Day, Department of Psychology, Saint Marys University, Halifax, NS, B3H 3C3, Canada. Email: Arla.Day@smu.ca.

Rsum Les professionnels de la sant qui travaillent dans les avions (AMH) soccupent des personnes gravement malades tout en les transportant des coins loigns et le plus souvent dangereux vers des centres de soins. Cest pourquoi les professionnels ont des problmes de sant et de scurit particuliers qui viennent sajouter aux lments stressants < <classiques>> auxquels les autres professionnels de la sant sont confronts. Dans la prsente tude, nous nous basons sur les publications relatives la scurit et la sant psychosociale pour examiner les relations entre les facteurs stressants dans le milieu de travail (perception du risque, inquitudes, obstacles aux soins des malades) et deux composantes de la fatigue professionnelle (la fatigue motionnelle et la dpersonnalisation) auprs de 106 AMH canadiens. Nous nous penchons aussi sur limpact modrateur du contrle du travail et de lefcacit collective. Les rsultats indiquent (1) que les inquitudes lies aux complications mdicales et aux obstacles aux soins des malades prdisent exceptionnellement lpuisement motionnel; (2) quune fois les facteurs stressants pris en compte, le manque de contrle peru relie lpuisement et la dpersonnalisation; (3) que le contrle du travail et lefcacit collective exercent un effet tampon sur la relation facteur stressant-puisement professionnel. Copyright 2009 ASAC. Published by John Wiley & Sons, Ltd. Mots-cls : facteurs de stress au travail, incidents de scurit, contrle du travail, efcacit collective, puisement professionnel

Copyright 2009 ASAC. Published by John Wiley & Sons, Ltd.

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There has been a substantial increase in occupational health and safety (OHS) research in recent years (e.g., Cadieux, Roy, & Desmarais, 2006; Salminen, Kivimaki, Elovainio, & Vahtera, 2003), and there is a growing body of evidence documenting burnouts deleterious effects on quality of care and physical health. Much of this research has focused on healthcare workers, and has identied the various predictors of employee health and strain (e.g., Aasa, Brulin, Angquiest, & Barnekow-Bergkvist, 2005). Emergency medical responders, such as air medical healthcare (AMH) professionals, face many of the same safety issues and safety incidents (e.g., needlestick injuries Peate, 2001) and psychosocial stressors (e.g., concerns about patient care) that are found in most healthcare settings (Aasa et al.), but these emergency healthcare providers have all but been ignored in research. AMH professionals are comprised of individuals from various healthcare professions (e.g., physicians, nurses, paramedics) who are responsible for transporting and caring for critically ill patients from distant locations to healthcare centres. Because of the nature of their jobs, AMH professionals face a number of additional psychological and physical stressors. For example, they must contend with constant loud noise, vibration, and altitude changes (Hickman & Mehrer, 2001), and they frequently work in isolated and dangerous locations. Therefore, we address the paucity of research involving these AMH professionals and identify the unique stressors they may experience by surveying AMH professionals across Canada. We have integrated the safety and psychosocial health literatures in order to: examine various antecedents of burnout (in terms of safety incidents, worries, and barriers to patient care); assess the extent to which organizational (i.e., job control) and workgroup (i.e., team efcacy) factors are related to lower levels of burnout; and examine the extent to which job control and team efcacy buffer the negative impact of these work stressors on burnout.

(i.e., depersonalization or cynicism, Maslach et al., 2001). Although this phenomenon may be used as a protective coping mechanism by healthcare workers, it may manifest as a depletion of emotional resources. Conversely, the third component of burnout (i.e., personal accomplishment) is a positive quality that includes feelings of productivity, competence, and achievement (Maslach et al., 1996). Some researchers have argued that personal accomplishment may be relegated to the status of a . . . coping strategy (Cox et al., p. 190) and that only using the rst two components may be more appropriate when studying healthcare workers (Kalliath, ODriscoll, Gillespie, & Bluedorn, 2000). Therefore, we have focused only on the components of exhaustion and depersonalization. The negative impact of burnout has been well documented (Halbesleben & Buckley, 2004; Maslach et al., 2001). Burnout (emotional exhaustion in particular) has been associated with low levels of physical energy, fatigue, personal distress, insomnia (Lindblom, Linton, Fedeli, & Bryngelsson, 2006), and increased risk of cardiovascular disease (Melamed, Shirom, Toker, Berliner, & Shapira, 2006). Burnout has traditionally been viewed as a consequence of human service work due to the unbalanced relationship between the caregiver and the recipient (Schaufeli, Maslach, & Marck, 1993). As a result, burnout has been studied extensively in many healthcare occupations (Shanafelt, Bradley, Wipf, & Back, 2002) with the exception of the AMH profession. Moreover, because burnout has typically been studied solely in the context of psychosocial health, it is important to examine burnout in terms of both safety related antecedents and psychosocial sources, as well as its mitigating factors for AMH professionals. Sources of Burnout Maslach et al. (2001) concluded that burnout is a prolonged response to chronic job stress (p. 405), and it is viewed as a reaction to the work environment in terms of depletion of energy and coping resources (Shirom, 2003). The conservation of resource (COR) theory is a theory of resource utilization (Hobfall & Freedy, 1993)1 and may be useful when assessing burnout. According to the COR model, individuals strive to obtain and maintain what they value (i.e., resources). Stress and burnout can occur when individuals lose their resources and are unable to restore them (Hobfall & Freedy) or when employees perceive threats to their resources due to work-related demands, such as a loss of work-related resources or from insufcient returns on investment in resources (Halbesleben & Buckley, 2004).

Burnout Burnout is a work-specic syndrome consisting of the components of emotional exhaustion, depersonalization, and personal accomplishment (Maslach, Jackson, & Leiter, 1996; Maslach, Schaufeli, & Leiter, 2001). Emotional exhaustion is the most commonly measured and reported of the three components (Cox, Tissarand, & Taris, 2005) and is characterized by a depletion of emotional, physical, and interpersonal resources causing the individual to feel fatigued (Leiter, 2005, p. 132). This exhaustion leads employees to emotionally and cognitively distance themselves from work and become cynical

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Moreover, COR theory postulates that burnout occurs not only when there is an actual loss in resources, but even if employees only perceive threats to their resources (Halbesleben & Buckley, 2004). Therefore, employees perceptions of the work environment may be important to our understanding of burnout. These perceptions may manifest themselves in terms of worrying about work conditions. For healthcare professionals, many work-related demands can be perceived as threats to resources because they create barriers to providing quality patient care (Sochalski, 2001). AMH professionals may face additional barriers to patient care due to their unique work environment (e.g., ying to remote locations). Thus, we assessed the burnout components of exhaustion and depersonalization by incorporating psychosocial health and safety research. Specically, we examined the experiences of AMH professionals regarding their stressors and demands, in terms of safety incidents, worry over work hassles and hazards, and barriers to patient care. Safety incidents. There are common factors that link safety incidents and poor employee health outcomes, such as stress and burnout. For example, Briner, Amati, and Lardner (2003) used human factors and stress models in the offshore oil and gas industry to argue that 70% of the common work-related stressors are also potential causes of safety incidents. That is, many of the same factors associated with a workplace incident are also related to stress and burnout. Moreover, safety incidents tend to be associated with increased burnout. Nurses who reported a higher number of needlestick injuries also experienced greater levels of emotional exhaustion (Clarke, Sloane, & Aiken, 2002). Similarly, ambulance personnel who experienced physical strain on the job also experienced higher levels of emotional exhaustion (van der Ploeg & Kleber, 2003). However, the relationship between burnout and exposure to safety incidents that are common to the AMH profession (e.g., being hit by debris from the helicopter rotor wing) has yet to be examined. In addition to actually being involved in a work-related incident, both the perception of risk of exposure to various work hassles and hazards, and the worry associated with these events may also contribute to burnout. Worry about work hazards and job hassles. Exposure to stressors can increase burnout and strain. For example, higher exposure to acute stressors (e.g., going to the scene of a severe accident) can negatively affect emergency personnels health (van der Ploeg & Kleber, 2003). Similarly, nurses who face higher job risks (e.g., exposure to infected patients or materials, poor air quality) may experience more emotional exhaustion (Leiter, 2005).

In addition to actual exposure, perceived risk of exposure also may increase burnout. According to risk perception theory, perceptions of risk are made up of a cognitive component (e.g., perception of the probability of being injured) and an affective component (i.e., an emotional reaction to the risk that is manifested as worry, Rundmo, 2000). Worry is a long-term feeling that may vary in intensity, depending on how much one thinks about the risk (Rundmo, 2002). Perceived risk is associated with job stress (Rundmo, 1995) and physical strain symptoms (e.g., Ulleberg & Rundmo, 1997). Similarly, a high degree of worry is associated with increased health complaints (e.g., headaches, Aasa et al., 2005). Both cognitive and affective risk perception have been examined in the context of acute job hazards (acute or catastrophic high-impact hazards, which tend to be perceived as being beyond ones control) and more prevalent, chronic job hassles (i.e., more common, daily hassles that tend to be less severe and perceived as being more within ones control, Baugher & Roberts, 1999). Baugher and Roberts assessed the extent to which petrochemical plant employees worried about two types of hazards: risk of re/explosions (i.e., acute events) and exposure to chemicals (i.e., a chronic hazard for this occupation, which is somewhat under employees control). They found that despite the infrequency of acute events (i.e., re/explosions) and despite a substantially low degree of perceived risk of these events, petrochemical workers still had a high degree of worry about them. Accordingly, we could expect AMH professionals to experience increased worry about acute hazard exposure, despite the low occurrence of acute work hazards (e.g., a helicopter crash). Baugher and Roberts (1999) also found that worrying about typical workplace conditions (e.g., handling hazardous chemicals for petrochemical workers) was relatively high. Similarly, the literature on chronic stressors and job hassles suggests that typical or daily stressors have a signicant impact on many health outcomes, such as burnout (Day, Therrien, & Carroll, 2005), and may even impact health outcomes to a greater extent than do acute job stressors (Day & Livingstone, 2001). AMH and other emergency medical professionals regularly encounter chronic medical-related hassles or obstacles. For example, obstacles (such as receiving incomplete patient information) are associated with increased levels of burnout and fatigue among ambulance personnel (van der Ploeg & Kleber, 2003). Therefore, it is important to examine worries regarding both acute hazards and more common hassles for AMH professionals. The emphasis on worrying about the event, rather than the experience of the event itself, is important because some of the risks faced by AMH professionals

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have the potential to be severe or even fatal (e.g., crashes) but with a low incidence of occurrence. Similarly, they may be acute incidents, such that they occur in a nite time period. Thus, compared to the actual incidence of these events, affective risk perception (worry) of these incidents is a more accurate measure of the long-term psychosocial health of AMH professionals. Based on the literature on affective risk perceptions, hazards, and hassles, it is feasible that worrying about hassles and acute events (e.g., hazards, disasters) may be associated with increased burnout. These affective reactions to other aspects of the profession of healthcare, such as patient care, may also be important in understanding burnout. Barriers to patient care. The unique working conditions of AMH professionals often create challenges in providing care to patients in terms of physical environment (e.g., AMH professionals work in cramped quarters in extreme temperatures) and aspects of the job (e.g., lack of prior contact with the patient). In most cases, the transport involves a critically ill patient, with time being an important factor in their patients outcome. Frequently, AMH professional do not have time to be fully briefed on the patients condition, or the patients condition may not be known if the transport is occurring from a scene of an accident. These types of barriers to care may increase levels of burnout for AMH professionals. Although barriers have not been examined specically as an antecedent of burnout, emotional exhaustion is correlated with lower quality of patient care (Shirom, Nirel, & Vinokur, 2006). Burnout is also associated with more patient adverse events (i.e., falls, nosocomial infections, medication errors, and patient complaints, Laschinger & Leiter, 2006). However, little research has examined whether barriers to patient care are associated with burnout. Barriers to care restrict caregivers access to resources, which would increase strain according to the COR model. Similarly, according to the risk perception literature, barriers that have the potential to compromise patient care may be perceived by AMH professionals as risks to patient safety, which have the potential to increase levels of burnout for AMH professionals. Therefore, the combined effects of (a) safety incidents, (b) worries about ones work environment and job hassles, and (c) experiencing barriers to patient care may create burnout for AMH professionals because these stressors may deplete personal energy and coping resources. We have focused on these three aspects because they are relevant to AMH professionals, they integrate the safety and psychosocial health research on risk perceptions, hazards, hassles, and stressors, and they represent classic examples of potential demands, risks, and stressors that may be relevant to other healthcare professionals and emergency response personnel. Based

on past research ndings, it was expected that both the individual and joint effects of these factors would be associated with increased burnout. That is,
Hypothesis 1: Burnout symptoms in AMH professionals are positively associated with: safety incidents (H1a); worries about medical hassles and catastrophes (i.e., affective risk perception; H1b); and potential barriers to patient care (H1c).

Although many AMH professionals experience these safety incidents, worries, and barriers, the negative personal outcomes, such as depleted energy and burnout, are not inevitable. That is, AMH professionals who feel that they have adequate resources to cope with these workrelated stressors may experience more positive psychosocial outcomes (Lazarus & Folkman, 1984). Two factors that are likely pertinent to AMH professionals in helping them alleviate negative outcomes are job control and condence in the competence of ones team (i.e., team efcacy). Job Control Providing employees more control over aspects of their jobs, such as increasing decision-making capabilities and work autonomy, may allow employees to exert more inuence over the stress-provoking areas of their work life (Dwyer & Ganster, 1991). According to the job demand-control model, the interaction of high job demands and low decision latitude (job control) are characteristic of high strain jobs (Karasek & Theorell, 1990). Job control is associated with many organizational and individual outcomes (for reviews, see Spector, 1986; de Lange, Taris, Kompier, Houtman, & Bongers, 2003). For example, control over ones work environment is associated with lower burnout in nurses (Aiken, Clarke, Sloane, Sochalski, & Silber, 2002) and physicians (Keeton, Fenner, Johnson, & Hayward, 2007). In addition to these direct benets of reducing strain, job control may moderate the relationship between stressors and employee outcomes (e.g., blood pressure, Fox, Dwyer, & Ganster, 1993). However, despite research examining the direct effects of job control on burnout, few studies have examined the moderating impact of job control on burnout and the results of these few studies have been mixed (e.g., Kittel & Leynen, 2003; Pomaki & Mayes, 2002). Job control may have an even greater role in high risk industries, such as air medical transport, where workplace hazards are prevalent. Increasing job control in these industries is important because it creates a greater sense of inuence over ones environment (Leiter, 2005) and may allow employees to reduce uncertainty and

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work-related hazards and risks. Employees who have high job control believe they are less vulnerable to workplace hazards and risk (Leiter & Robichaud, 1997). Therefore, job control should be associated with decreased burnout, and it may also buffer the negative effects of safety incidents and concerns on burnout. That is:
Hypothesis 2a: Job control is associated with lower burnout, even after controlling for the effects of work stressors. Hypothesis 2b: Job control moderates the relationship between work stressors and burnout, such that high levels of control buffer the negative impact of the stressors on the degree of burnout experienced.

More specically, AMH professionals with a high degree of job control are likely to have low levels of burnout regardless of the amount of stressors they experience. However, stressors and burnout are likely to be signicantly and positively related when job control is low. That is, stressors likely associate positively with burnout only when the AMH professionals have a low degree of perceived job control. The prevalence of work-related worry and safety incidents in healthcare professions has received a lot of attention (e.g., Yassi, Gilbert, & Cvitkovich, 2005), and there have been calls for improving the health and safety of healthcare professionals. In addition to organizational variables (i.e., job control), group-level variables, such as being surrounded by competent colleagues, may be a resource that increases self- and team-efcacy and reduces burnout. Team Efcacy Air medical transport depends on a small group of professionals working together in a very small, cramped space. Because of the large amount of interdependence required from the whole crew, it is important that AMH professionals perceive other crew members as competent. Few studies, however, have directly examined the relationship between perception of condence in ones team and individual-level well-being. Condence in ones team is a function of an individuals team efcacy beliefs (Gully, Incalcaterra, Joshi, & Beaubien, 2002; Lee, Tinsley, & Bobko, 2002). Team efcacy builds on the self efcacy literature and refers to the belief that the team has the ability to successfully perform the job tasks (Lindsley, Brass, & Thomas, 1995). Although most research has focused on self efcacy, team efcacy is gaining more attention, especially in the context of teambased work. In fact, team- and self-efcacy may have a reciprocal relationship, especially in highly interdepen-

dent situations, such as air medical transports (Lindsley et al.). Research has suggested that perceived competence of ones colleagues and team members may be associated with individual and group performance. Teamwork collective efcacy was related to individual teamwork behaviour and to team performance of business students (Tasa, Taggar, & Seijts, 2007). Collective efcacy was related to team adaptive performance of undergraduates learning a ight-simulation task (Chen, Thomas, & Wallace, 2005). Research has also suggested, although to a lesser extent, that perceived competence of ones team members may be associated with decreased burnout. Zeller and colleagues (1999) found that collective efcacy beliefs were negatively related to burnout in nurses. In addition to the direct effects of efcacy on individual outcomes, efcacy may moderate the relationship between stressors and individual outcomes (Bandura, 1997; Grau, Salanova, & Peir, 2001). Jex and Bliese (1999) found that collective efcacy moderated the relationship between some work stressors and outcomes in one of two ways: high collective efcacy was associated with higher satisfaction, regardless of the level of the work overload, whereas respondents with low collective efcacy had lower satisfaction especially when experiencing high overload. Conversely, collective efcacy was positively related to higher commitment, regardless of the level of the task signicance, with the relationship being stronger at high levels of efcacy. In related research on self-efcacy, individual professional selfefcacy buffered the relationship between level of job routine and the cynicism component of burnout, between role conict and cynicism, and between role conict and organizational commitment (Grau et al.); high efcacy was associated with lower cynicism regardless of the level of role conict. In both of these studies, however, self- and collective-efcacy only moderated some of the relationships. Thus, efcacys ability to moderate relationships between stressors and strains may be contingent on the specic stressors and outcomes (Jex & Bliese). Therefore, we have integrated these streams of research by examining the direct and moderating effects of team efcacy. We have extended research that has focused on self-efcacy by examining the direct relationship of team efcacy with burnout, as well as its moderating impact on the relationship between specic safety and psychosocial stressors relevant to AMH professionals and burnout.
Hypothesis 3a: Team efcacy is negatively associated with burnout, even after controlling for the effects of the work stressors.

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Hypothesis 3b: Team efcacy moderates the relationship between work stressors and burnout, such that high levels of efcacy buffer the negative impact of work stressors on the degree of burnout experienced.

That is, AMH professionals reporting high levels of team efcacy will report low levels of burnout regardless of the amount of stressors they experience. However, stressors and burnout will relate positively when perceived team efcacy is low. Method Scale Development Because of the unique nature of AMH professionals and because job-specic measures of chronic stressors can be the strongest predictor of psychological strain (Beehr, Jex, Stacy, & Murray, 2000), we tailored the survey to AMH professionals. Accordingly, we conducted focus groups with Subject Matter Experts (SMEs; i.e., a Medical Director for a provincial AMH program; a medical student who had some ight experience, and 11 ground paramedics who had similar duties, education levels, and work practices as AMH professionals). All SMEs, with the exception of two ground paramedics, were male. Initially, a small group of these SMEs identied the work-related factors that affected AMH professionals, as well as the specic behaviours that represented these factors. Using this information and the safety and stress literatures, we created our initial pool of items. Based on standard psychometric principles, we reviewed these items and revised them to ensure that they were comprehensive, at an appropriate reading level, clear, free of bias and errors, unambiguous, and relevant to the domain of interest (Crocker & Algina, 1986). We created ve scales to assess: (a) the frequency to which AMH professionals experienced specic incidents and injuries (i.e., safety incidents); (b) the degree to which AMH professionals worried about medical-related factors (i.e., medical hassles); (c) the degree to which AMH professionals worried about acute incidents/hazards (i.e., catastrophes); (d) the degree to which AMH professionals felt that specic work barriers compromised patient care (i.e., barriers to patient care); and (e) AMH professionals perceived condence in the competence of their team (i.e., team efcacy). We prepared test specications for these scales, incorporated a 5-point Likert-type response format, and created a draft of the entire survey. We conducted further focus groups with the same group of 11 ground paramedics. They reviewed the nal

versions of the items, scales, and overall survey, and provided feedback on the feasibility of the scales (e.g., to ensure the items were relevant). They made minor revisions to the wording of some of the items and instructions and agreed that all of the issues had been adequately covered and that the items were clear and unambiguous. Respondents Surveys were distributed to all AMH professionals in Canada (N = approximately 261) through the internal mailing system of each AMH program by the air medical directors (AMDs). The AMDs also sent out reminder letters two weeks and ve months after the initial surveys were distributed. AMDs received a small honorarium for facilitating the survey distribution process. To ensure condentiality and anonymity, completed surveys were returned directly to the principal researchers in a sealed, prepaid, self-addressed envelope provided with the survey. Responses were gathered from 106 AMH professionals across Canada (response rate = 40.6%). Participants ages ranged from 24 to 61 (M = 37.5 years, SD = 7). The respondents were predominantly male (62.3%). Forty nine respondents were paramedics, 31 were nurses, 17 were physicians, 5 were respiratory therapists, 6 were nurse/paramedics, and 3 were other. They had been employed in the air medical transport industry for an average of 6.4 years (SD = 6) and worked in this position for an average of 25 hours a week (SD = 14.4). These characteristics matched the population of AMH professionals in Canada. Measures Participants provided background information (i.e., age, gender, profession, hours worked per week, years employed in their present job) and they completed the following scales.2 Safety incidents. A 6-item3 scale was developed to assess to the extent to which AMH professionals experienced safety incidents at work. Using a ve-point Likerttype scale (1 = never to 5 = constantly, nearly every trip), respondents indicated how often they had been exposed to various conditions and incidents at work over the past year (e.g., being hit by debris thrown by rotor; exposure to toxic fumes). The internal reliability for this scale was a = .78, with all corrected item-total correlations over r = .42. Work-related worries. Two scales were developed to assess worries about job hazards: (a) worries about

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typical, chronic medical hassles (over which AMH professionals have some control; i.e., medical-based hassles); and (b) worries about catastrophic hazards (over which the AMH professionals would have little control; e.g., a helicopter crash). A 4-item Worries about Medical Hassles scale measured the extent to which AMH professionals worried about medical-related factors (e.g., caring for the sickest of patients ; transferring a patient with unknown communicable diseases). Respondents used a 5-point Likert-type scale (1 = not at all to 5 = a great deal) to indicate the extent to which these medical issues created worry or anxiety for them. The internal reliability for this scale was good (a = .81), with all corrected item-total correlations above r = .54. An 8item Worries about Catastrophic Events assessed the degree to which AMH professionals worried about major incidents occurring on the job (e.g., crashing in the water/drowning; having an onboard re). Respondents used 5-point Likert-type scale (1 = never to 5 = always) to indicate the extent that they worried about these events. The internal reliability for this scale was a = .88, with all corrected item-total correlations above r = .49. Barriers to patient care. An 8-item scale was developed to measure the extent to which AMH professionals believed that specic work issues/barriers compromised patient care (e.g., ergonomic design of the cabin; extreme temperatures in helicopter). A 5-point Likerttype scale (1 = not at all to 5 = a great deal) and its internal reliability was a = .82, with all individual items total correlations above r = .40. Team efcacy. AMH professionals completed a 5item scale measuring their perceived condence in their own competence and their teams competence. These items focused on professional efcacy (Grau et al., 2001) and were based on previous work on individual and collective self efcacy (e.g., Bandura, 1997; Tasa et al., 2007). Moreover, because of the high risk environment in which AMH professionals work, the scale focused on competence in handling emergency situations. Respondents rated each item (e.g., I have received the proper training to deal with all in-ight emergencies; My crew has the necessary skills to handle any crisis that may arise) on a 5-point Likert-type scale (1 = strongly disagree to 5 = strongly agree). The internal reliability for this scale was good (a = .82), with all corrected itemtotal correlations above r = .56. Job control. A reduced, 10-item version of the 22item Job Control Scale (Dwyer & Ganster, 1991) was used to measure job control. Respondents were asked to indicate the degree of control they have over various aspects of their job (such as control over the quality of their work and the amount of resources they receive)

using a 5-point Likert-type scale (1 = very little to 5 = very much). The internal reliability for this scale was good (a = .79), with all individual item-total correlations above r = .28. Burnout. Two of the three subscales of the Maslach Burnout Inventory (Maslach et al., 1996) were used to measure burnout: the 9-item Emotional Exhaustion subscale (feeling drained of emotion and fatigued) and the 5-item Depersonalization subscale (feeling detached from ones emotions and other people). The items in the MBI were reworded, such that the word client was changed to patient. AMH professionals responded using a 7-point Likert-type scale (0 = never to 6 = every day). The internal reliability for emotional exhaustion was good (a = .91), with all corrected item-total correlations above r = .55. The internal reliability for Depersonalization was adequate (a = .61), with all corrected item-total correlations above r = .17. In order to gather further information on the factor structure of the ve scales that were developed for this survey and to ensure that the items from these scales demonstrated discriminant validity from each other, we conducted a Principal Components Analysis (PCA; using an oblique rotation) of all of these items. PCA was selected over common factor analysis because the goal of PCA is to extract maximum variance from a data set with a few orthogonal factors (Tabachnick & Fidell, 2007, p.663). That is, PCA is used to reduce a large number of items down to a smaller number of components. Because our aim was to ensure that our theoretical model was justied by using the fewest number of scales to adequately represent all of the items, PCA was the appropriate analysis. The scree plot clearly indicated the presence of ve components. The 31 items from all ve scales loaded highly on their respective component. Three of the 31 items also had moderate loadings on a second component (<.45), but all of them loaded more highly on their hypothesized component. The correlations among these ve components were low (rs ranged from r = .26 to r = .18). These results provide evidence that the scales were reliable, that the items measured distinct constructs, and that common method variance was not a substantial issue.

Results Means, standard deviations, scale reliabilities, and correlations among the study variables are presented in Table 1. Both emotional exhaustion and depersonalization were signicantly correlated with work medical hassles,

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Table 1 Means, Standard Deviations, and Correlations among the Study Variables (N = 106)
M SD 1 2 3 4 5 6 7 8 9 10 11 12 13

WORKPLACE RISKS, STRESSORS, AND BURNOUT

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1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. .04 .65c .46c .04 .10 .05 .02 .08 .07 .15 .05 .11 .43c .49c .27b .19 .26b .29b .07 .25a .14 .69c .01 .13 .04 .02 .14 .02 .13 .32b .39c .05 .02 .07 .27b .10 .25a .30b (.78) .30b .23b .29b .32b .00 .29b .17 (.85) .36c .41c .36c .23a .42c .27b (.88) .38c .31b .44c .34c .26b

Age Gender # of work hours Nursesd Paramedicsd Safety incidents Medical hassles Catastrophes Barriers to patient care Job control Team efcacy Emotional exhaustion Depersonalization

37.5 24.98 2.12 2.61 1.91 2.43 3.81 3.97 1.14 0.64

7.01 14.44 0.70 0.93 0.59 0.65 0.52 0.60 0.98 0.63

.12 .08 .15 .11 .18 .16 .09 .01 .08 .05 .02 .27b

(.82) .48c .33b .53c .31b

(.79) .42c .51c .45c

(.82) .33b .27b

(.91) .49c

(.61)

Note: Reliabilities are on the diagonal in parentheses. p < .05; b p < .01; c p < .001, two-tailed. The sample size for the correlations involving gender = 103 because 3 individuals did not indicate their gender. d Two dummy variables were calculated, such that Nurses were coded 1, and paramedics and physicians were coded as 2. For Paramedics, paramedics were coded as 1, and nurses and physicians were coded as 2; Physicians became the referent group.

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catastrophe hazards, and barriers to patient care, respectively. Exhaustion, but not depersonalization, was related to safety incidents. Both of the moderators (job control and team efcacy) were signicantly and positively related to burnout.

Moderated Regressions Moderated regression analyses were conducted to examine the effects of the individual stressors in predicting burnout (i.e., Hypothesis 1a, b, c), the incremental variance in burnout explained by job control and team efcacy (i.e., Hypotheses 2a & 3a), and the moderating effects of job control and team efcacy (i.e., Hypotheses 2b & 3b). We used the procedures for moderated regression analysis recommended by Aiken and West (1991). Prior to analysis, all of the variables were standardized and interaction terms were created between the predictors (i.e., safety incidents, medical hassles, catastrophes, and barriers) and the moderators (i.e., job control and team efcacy). For each of the four analyses, the four predictor variables were entered in the rst step, the moderator was entered in the second step, and the interaction terms were entered in the third step. We plotted all signicant interactions at high and low values of the predictor and moderator (i.e., 1 SD above and below the mean, Aiken & West) and assessed their slope.

To ensure that our results were not impacted by various work factors, we conducted another set of analyses in which we rst controlled for age, gender, number of work hours, and job type. Because of the multiple job types, we created a dummy variable for nurses (nurses = 1, physicians and paramedics = 0) and for paramedics (paramedics = 1, physicians and nurses = 0). Results were very similar for the two sets of analyses in terms of percent of variance accounted for by the study variables, and their respective betas, such that we argue the effect size was not changed. Thus, we report the analyses without the control variables and note any substantive differences throughout the results section to ensure an accurate representation of the results. Regardless of the moderator used, the rst step of the regressions was identical for each outcome. That is, the safety incidents, hassles, catastrophes, and barriers accounted for 35% of the variance in emotional exhaustion when they were entered on the rst step (R2 = .35, F = 13.32, p < .001), with medical hassles (b = .19, p < .05) and barriers to care (b = .38, p < .001) uniquely predicting exhaustion (see Tables 2 and 3). The safety incidents, hassles, catastrophes, and barriers accounted for 14% of the variance in depersonalization when they were entered on the rst step (F = 4.04, p < .01; see Tables 2 and 3); however, none of these stressors uniquely predicted depersonalization. These results provide partial support for Hypothesis 1b and 1c.; Hypothesis 1a was not supported.

Table 2 Moderating Effect of job Control on the Relationship between Safety Incidents, Hazards, and Patient Care Barriers and Burnout
Step Emotional exhaustion b 1. Predictors Safety incidents Medical hassles Catastrophic worries Barriers to patient care 2. Moderator Job control 3. Interactions Safety incidents X job control Medical hassles X job control Catastrophic worries X job control Barriers to Patient care X job control Total R2 Note: a p < .05; b p < .01; c p < .001; N = 105. R 2 .35c .10 .19a .11 .38c .05b .27b .09b .06 .22a .14 .17a .49c .06 .18 .01 .16 .27c .36c .04 .05 .13 .13 .20 .09c b BURNOUT Depersonalization R2 .14b

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Table 3 Moderating Effect of Team Efcacy on the Relationship between Safety Incidents, Hazards, and Patient Care Barriers and Burnout
Step Emotional exhaustion b 1. Predictors Safety incidents Medical hassles Catastrophic worries Barriers to patient care 2. Moderator Team efcacy 3. Interactions Safety incidents X team efcacy Medical hassles X team efcacy Catastrophic worries X team efcacy Barriers to patient care X team efcacy Total R2 Note: a p < .05; b p < .01; c p < .001; N = 105. R2 .35c .10 .19a .11 .38c .02 .14 .07a .04 .03 .04 .27b .44c .12 .13 .08 .20 .21c .16 .05 .05 .13 .13 .20 .02 b BURNOUT Depersonalization R2 .14b

Job Control. Job control accounted for an additional 5% of the variance in exhaustion when entered in the second step (R2 = .05, F = 8.44, p < .01), supporting Hypothesis 2a. The interactions between stressors and job control accounted for an additional 9% of variance in exhaustion (F = 4.04, p < .01). Two of the interaction terms were signicant: job control by medical hassles (b = .22, p < .05) and job control by barriers to care (b = .17, p < .05),4 providing partial support for Hypothesis 2b. Job control buffered the relationship between medical hassles and exhaustion and between barriers to patient care and exhaustion. More specically, there was no relationship between hassles and exhaustion at high levels of job control (t = .01, ns), such that levels of emotional exhaustion were low at high levels of job control, regardless of the level of hassles. However, there was a signicant, positive relationship between hassles and exhaustion at low levels of job control (t = 4.57, p < .001; see Figure 1). Similarly, there was no relationship between patient care barriers and exhaustion at high levels of job control (t = 1.22, ns), such that levels of emotional exhaustion were low at high levels of job control, regardless of the level of barriers perceived to patient care (see Figure 2). Again, there was a signicant, positive relationship between barriers and exhaustion when job control was low (t = 4.80, p < .001).

Figure 1. The moderating effect of job control on the relationship between worries about medical hassles and emotional exhaustion
1.8 1.6 1.4 Emotional Exhaustion 1.2 1 0.8 0.6 0.4 0.2 0 Medical Hassles Low Job Control High Job Control

When predicting depersonalization, job control accounted for an additional 9% of the variance when entered in the second step (F = 11.93, p < .001),5 supporting Hypothesis 2a. In the third step, the interactions between predictors and job control accounted for an

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Figure 2. The moderating effect of job control on the relationship between barriers to patient care and emotional exhaustion
1.8 1.6 1.4 Emotional Exhaustion

Figure 3. The moderating effect of perceived team efcacy on the relationship between barriers to patient care and emotional exhaustion
2 1.8 1.6 Emotional Exhaustion 1.4 1.2 1 0.8 0.6 0.4 0.2 0 Low Team Efficacy High Team Efficacy

1.2 1 0.8 0.6 0.4 0.2 0 Barriers to Patient Care Low Job Control High Job Control

Barriers to Patient Care

additional 4% of the variance in depersonalization (F = 1.34, ns); none of the four interaction terms were signicant, thus failing to support Hypothesis 2b. Team Efcacy. When predicting emotional exhaustion, team efcacy only accounted for 2% of the variance in step 2 (F = 2.33, ns),6 failing to support Hypothesis 3a. The interaction terms accounted for an additional 7% of the variance (F = 3.11, p < .05), and one of the interactions was signicant (team efcacy by barriers to patient care; b = .27, p < .01),7 providing partial support for Hypothesis 3b. As shown in Figure 3, perceived team efcacy buffered the negative effects of barriers to patient care on emotional exhaustion. That is, there was no relationship between patient care barriers and exhaustion at high levels of team efcacy, such that levels of emotional exhaustion were low at high levels of team efcacy, regardless of the level of barriers perceived to patient care (t = 1.10, ns). However, there was a signicant, positive relationship between exhaustion and barriers when team efcacy was low (t = 6.61, p < .001). When depersonalization was the outcome, team efcacy only accounted for an additional 2% in the second step (F = 2.34, ns), failing to support Hypothesis 3a. In the third step, the interactions between predictors and team efcacy accounted for an additional 5% of the variance in depersonalization (F = 1.36, ns), and none of the four interaction terms were signicant, thus failing to support Hypothesis 3b.8

Discussion Summary Despite the large amount of research conducted on employee burnout in healthcare settings, AMH professionals have been ignored. Given their unique working environment, it is important to understand the factors that affect their wellbeing. Moreover, integrating the safety and psychosocial health literatures helps us better understand the experiences not only of AMH professionals, but of all workers, especially those in high risk industries. Therefore, the primary goals of this study were to: (a) investigate the extent to which work stressors (i.e., safety incidents, risk perceptions/worries about medical hassles and catastrophes, and barriers to patient care) were associated with burnout of Canadian AMH professionals; and (b) examine the extent to which job control and team efcacy were directly related to decreased burnout, and the extent to which they buffered the negative impact of the work stressors on burnout. Stressors and burnout. As expected, with the exception of the relationship between safety incidents and depersonalization, exhaustion and depersonalization had signicant zero-order correlations with all of the stressors, indicating that safety incidents, worries about medical hassles and catastrophes, and barriers to patient care are all specic health risks for AMH professionals. When

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examined jointly, these stressors accounted for signicant variance in depersonalization and exhaustion; however, none of the stressors uniquely predicted depersonalization, and only medical hassles and barriers to care uniquely predicted exhaustion. These results support past research that has shown a relationship between emotional exhaustion and physical injuries and risks (e.g., Clarke et al., 2002; Leiter, 2005). Moreover, our ndings extend past research by showing specic relationships with both safety incidents and worries about medical hassles and catastrophes. Our research also supports and extends past research demonstrating a link between work-related worries and health complaints (Aasa et al., 2005; Neale, 1991). Finally, we have extended past studies on burnout and patient care (e.g., Laschinger & Leiter, 2006; Shirom, Nirel, & Vinokur, 2006) by demonstrating that worrying about barriers to patient care is associated with increased exhaustion and depersonalization. Collectively, our ndings reinforce the notion that these factors can have substantial relationships with burnout. Job control. Consistent with past research (e.g., Aiken et al., 2002), job control related negatively to both components of burnout, even after controlling for work stressors. Job control did not moderate any of the relationships between the stressors and depersonalization. However, it alleviated some of the safety and health risks by moderating two of the relationships between the stressors and emotional exhaustion. That is, the relationship between medical hassles and exhaustion was nonsignicant at high levels of job control, such that AMH professionals with high job control had low emotional exhaustion, regardless of the level of medical hassles. Conversely, medical hassles were signicantly related to exhaustion at low levels of job control, such that AMH professionals had the highest levels of exhaustion when they had low job control and were worried about medical hassles. Job control also buffered the negative effects of barriers to patient care on emotional exhaustion. There was no relationship between barriers and exhaustion at high levels of job control (i.e., AMH professionals with high job control had low emotional exhaustion, regardless of the degree to which they worried about barriers to patient care), but there was a signicant relationship between barriers and exhaustion at low levels of job control (i.e., AMH professionals had the highest levels of exhaustion when they had low job control and believed that work factors compromised patient care). These results provide further evidence of the importance of job control in mitigating the negative impact of stressors on individual outcomes. Team efcacy. When examining the zero-order correlations, AMH professionals who had greater condence

in their teams skills and training experienced lower exhaustion and depersonalization. However, after controlling for the impact of the stressors, team efcacy did not account for any incremental variance in either of the burnout components. The addition of the interaction terms accounted for a signicant increase in the variance accounted for in emotional exhaustion. More specically, team efcacy buffered the negative impact of barriers to quality patient care on emotional exhaustion. That is, there was no signicant relationship between barriers to patient care and exhaustion at high levels of team efcacy: AMH professionals who had high condence in the ability of their team experienced low emotional exhaustion, regardless of the degree they worried about patient care barriers. Conversely, there was a signicant relationship between barriers to patient care and exhaustion at low levels of team efcacy, such that AMH professionals who had a low degree of condence in the ability of their team and worried about patient care barriers experienced higher emotional exhaustion. Contributions to Scholarship These results support and extend past research in several important ways. We examined the understudied, but integral, profession of AMH professionals. Findings from our study may generalize to other emergency response occupations. We integrated the literatures on safety and psychosocial health. Despite Briner et al.s (2003) suggestion that safety incidents and health outcomes may have similar causes, few studies have combined these areas to examine both psychosocial health and safety incidents, especially in relationship to burnout. We have extended the job control research by providing evidence that job control may buffer the relationship between medical hassles and patient care barriers with emotional exhaustion. Moreover, we have provided some theoretical and empirical support for examining worries in the context of a source of burnout. Our work on team efcacy builds on the work of Grau et al. (2001) on professional efcacy to include a focus on team efcacy (including perceptions of self and other team members), and to examine the direct relationship of team efcacy with burnout. We also have extended the work on team and collective efcacy (e.g., Chen et al., 2005; Tasa et al., 2007) by using a nonstudent sample, and examining the relationship of team efcacy with individual health outcomes. We also extended past work on the moderating effects of efcacy (see Grau et al.; Jex & Bliese, 1999) by examining this construct in the context of its ability to buffer the negative effects of specic safety and psychosocial stressors (which were relevant to AMH professionals) on burnout.

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Applied Implications There are several implications of our research not only for the AMH profession, but also for all emergency healthcare response occupations and the healthcare industry in general. Our study provides another impetus for organizations to reduce the frequency of safety incidents. That is, reducing incidents is not only important for the inherent improvement to employee safety, but it may also be important as a means to improve employee psychosocial health by minimizing emotional exhaustion. The positive impact of job control is promising and has practical implications for organizations and their employees. For example, many of the stressful aspects of the work environment of AMH professionals are not easily changed. However, providing these individuals with more control over various aspects of their jobs (e.g., scheduling of work, unit policies, and procedures) may help reduce burnout and buffer the negative impact of stressors on burnout. Although the results pertaining to condence in team efcacy were less conclusive, it is possible that increasing condence in ones own abilities as well as in the ability of ones team may be an effective way for organizations to reduce employees levels of burnout. Interventions, such as crew resource management training, may be benecial to increasing team efcacy because it emphasizes teamwork, communication, and individual skill development. As noted below, any intervention should not be undertaken prior to further research because causality can not be inferred in any of the above relationships.

Limitations and Future Research Directions There are several limitations that should be considered in the present study. The sample consisted of AMH professionals within Canada and the overall sample size was fairly small (106 participants). We wanted to focus on this population due to its unique characteristics. Given that there were only 261 AMH professionals in Canada at the time of the study, the sample constituted a large proportion of individuals employed in the air medical transport occupation. However, because of the specialized nature of this occupation, the results may be somewhat limited in their generalizability. These issues should be examined with a larger, international sample of individuals within this occupation, as well as in related healthcare occupations. Similar to many studies on burnout, we used a cross sectional design to test the relationships among the study

variables. This design limits our ability to infer causality in any of the reported relationships. Although we have not made any causal statements about the direction of ndings, the wording of the theories may suggest that certain variables (e.g., safety incidents) precede burnout. Although this suggestion may be correct, it also is plausible that burnout impacts perceptions of the work context, resulting in increased frequency of experienced safety incidents and increased risk perceptions. Alternatively, these safety incidents, risk perceptions, and burnout may have reciprocal or cyclical relationships, which spiral into greater negative individual outcomes over time. In creating our survey, we tried to emphasize the timing of the stressors to precede the personal outcomes. That is, we asked individuals to think about rates of occurrence over the past year when responding to safety incidents and worries, whereas we primed individuals to think about how they felt in the last few weeks when responding to psychosocial issues (including burnout). In order to clarify the directionality of these relationships, future research should incorporate a longitudinal design. Although it wasnt part of our initial hypotheses, we included two dummy coded variables (for job type) in our correlation matrix to be used as control variables in our moderated regression analyses. These variables were related to some of the stressors and outcomes, but did not have a substantive impact on the other results. Future research should examine whether there are mean differences in these stressors, moderating variables, and psychosocial outcomes across occupations, and also whether there are different patterns of relationships for these groups. Common method variance (CMV) is a widespread concern in much survey research, although its impact may be overstated (Spector, 2006). The presence of nonsignicant correlations in the correlation matrix somewhat mitigates our concern that all of the results are a function of CMV (Lindell & Whitney, 2001). Moreover, the use of hierarchical and moderated regressions helps to reduce concerns that CMV was a signicant problem (Evans, 1985). That is, if the signicant relationships could only be explained by CMV, then it would be impossible to account for any incremental variance in subsequent steps. Because many of our steps explained additional variance in emotional exhaustion and depersonalization, the concern regarding CMV is reduced to some extent. However, future research should move beyond self report to examine alternative methods and measures of assessing the study variables. Future research should extend our research to other issues pertaining to burnout and stress in emergency medical professions. For example, past research has

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found that social support is an important factor in reducing burnout (Maslach et al., 2001). The working environment of AMH professionals requires them to work in small teams, with little direct contact from management. This lack of contact may lead to feelings of isolation and a lack of support. Therefore, the impact of co-worker, supervisor, and organizational support on the physical and psychosocial health of emergency medical professionals should be studied. Finally, future research on health outcomes should include not only the absence of negative psychological and physical health factors as indicators of employee well-being, but also the presence of positive psychological and physical outcomes (Kelloway & Day, 2005). Conclusion Employees in healthcare occupations may experience high degrees of burnout as a result of their job. These levels of burnout may be exacerbated in emergency response occupations that involve dangerous work environments, such as air medical transport. We found that, in general, the risk of safety incidents, as well as worries about medical issues and extreme catastrophes and barriers to patient care were associated with increased burnout for AMH professionals. However, this burnout was somewhat alleviated through increased job control and increased team efcacy. Notes
1 Thanks to an anonymous reviewer for suggesting the inclusion of this rationale. 2 Other items and scales, which are not reported here, were included in the survey. 3 Although the scale was originally a 7-item scale, one item had a low frequency and variability, and was subsequently discarded. 4 This interaction was only marginally signicant when the control variables were included (which may be due to a loss of degrees of freedom and a smaller sample size). However, the magnitude was only slightly reduced (b = .15, p = .10). 5 This step became nonsignicant when the control variables were included (R2 = .02, F = 2.64, p = .11). 6 This step became signicant when the control variables were included (R2 = .03, F = 4.11, p < .05). 7 This step and interaction was only marginally signicant when the control variables were included. However, the magnitude was only slightly reduced (b = .21, p = .06). 8 When predicting depersonalization, one interaction (competence by barriers to patient care) became signicant when the control variables were included (b = .24, p = .05).

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