Revista Colombiana de Psicología

Universidad Nacional de Colombia

revpsico_fchbog@unal.edu.co
ISSN (Versión impresa): 0121-5469
COLOMBIA

2006
Bernardo Moreno Jiménez / Raquel Rodríguez Carvajal / Lilian Velasco Furlong / Eva
Garrosa Hernández / Ma. Eugenia Morante Benadero
BURNOUT PROCESS AND HIV/AIDS: MAIN IMPLICATIONS FOR HEALTH CARE
WORKERS
Revista Colombiana de Psicología, número 015
Universidad Nacional de Colombia
Bogotá, Colombia
pp. 67-80

Red de Revistas Científicas de América Latina y el Caribe, España y Portugal

Universidad Autónoma del Estado de México

http://redalyc.uaemex.mx
 EL PROCESO DE BURNOUT Y EL VIH/SIDA: PRINCIPALES
IMPLICACIONES EN LOS TRABAJADORES DE LA SALUD

Burnout process and hiv/aids: main implications for health care workers

Moreno-Jiménez, Bernardo1; Rodríguez-Carvajal, Raquel2;

Departamento de Psicología. Universidad Autónoma de Madrid.
Velasco Furlong, Lilian3
Facultad de Ciencias de la Salud. Universidad Rey Juan Carlos.
Garrosa Hernández, Eva4; Morante Benadero, Mª Eugenia5.
Departamento de Psicología. Universidad Autónoma de Madrid.

Abstract RESUMEN

Burnout has been identified as a significant problem in El síndrome de desgaste se ha identificado como un pro-
health care professions, particularly for those working in blema significativo en las profesiones asociadas con el cuida-
chronic care. Occupational burnout is conceptualised as a do de la salud; en particular, para quienes trabajan en cuidado
particular type of stress occurring principally in professional crónico. El desgaste por el trabajo está conceptualizado como
contexts where work overload demands, especially those of un tipo particular de estrés que ocurre primordiamente en
an interpersonal nature, lead to chronic emotional exhaus- contextos profesionales donde las demandas excesivas de
tion, depersonalization and reduced sense of personal ac- trabajo, en especial las de naturaleza interpersonal, producen
complishment explaining most of the physical and psycho- cansancio emocional crónico, despersonalización y reducen
logical problems at work. The issue of burnout in health care el sentido de logro personal explicando la mayoría de los
workers in the area of HIV disease has become increasingly problemas físicos y psicológicos en el trabajo. El tema de la
important in the past decade. However, there has been little quema en el trabajo en el área de las enfermedades asociadas
systematic research in this area. The present article is a selec- con el SIDA se ha hecho cada vez más importante en la pa-
ted review of the literature, through more than 200 articles sada década. Sin embargo, ha habido poca investigación sis-
on burnout in health care workers treating HIV/AIDS pa- temática en este campo. Este artículo es una revisión selecta
tients published since 1988. The main purpose is to provide de la literatura en más de 200 artículos sobre el síndrome en
a framework and a global paradigm of the burnout process trabajadores de la salud que tratan pacientes con VIH/SIDA
in different health workers looking after patients with AIDS. y que fueron publicados desde 1988. El propósito principal
Among the aspects evaluated are the process, stressors, bu- es proporcionar un marco teórico y un paradigma global del
ffers and consequences of burnout. The analysis shows the proceso de desgaste. Entre los procesos evaluados están los
presence of methodological inconsistencies that have hinde- procesos, estresares, amortiguadores y las consecuencias del
red the development of a coherent view in this specific field, desgaste. El análisis muestra la presencia de inconsistencias
and the establishment of effective prevention and interven- metodológicas que han dificultado el desarrollo coherente
tion programmes. en este campo específico y el establecimiento de programas
efectivos de intervención.
Keywords: revision, burnout, physicians, nurses, volun-
teers, HIV/AIDS. Palabras clave: estudio teórico, burnout, médicos, enfer-
meras, voluntarios, VIH/SIDA

Correo electrónico:
E- Mail: bernardo.moreno@uam.es
Dirección: Departamento de Psicología Biológica y de la Salud
Facultad de Psicología, Universidad Autónoma de Madrid
Ctra. Colmenar, km. 15, 28049 Madrid, Spain Artículo recibido: 28 de febrero de 2006
Teléfono: 00.34.91.397.5185 Fax: 00.34.91.397.5215. Artículo aceptado: 26 de abril de 2006

Revista Colombiana de Psicología

67
 One of the problems affecting HIV/AIDS care pro- is incurable. The work of HIV/AIDS caregivers with
fessionals is the Burnout Syndrome. Initially, burnout burnout is characterized by an excessive stressful job
was described by Freudenberger (1974) as the feelings implying a lack of privacy in the work environment,
experienced by professional workers when their emo- little autonomy or responsibility and an unclear job
tional resources were exhausted. Later, Maslach and description. Lastly, several organizational factors emer-
Jackson (1981, 1982, 1986) redefined the concept as a ge as stressors, such as financial problems, inadequate
particular kind of stress occurring primarily in occu- job training and education, lack of reference material
pations in which the environment is very demanding, and lack of medication and sanitary supplies.
especially the interpersonal jobs, where aspects such Levels of distress suffered by HIV/AIDS caregivers
as chronic emotional exhaustion, depersonalization are high, and while this epidemic grows, with the con-
and lack of personal accomplishment are found. This sequent overload for the Health Services, caregiving
led to an operationalization of the syndrome that faci- falls to relatives and communities. These groups, whi-
litated the construction of the evaluation instrument ch constitute a valuable resource, are scarcely recog-
most commonly used today: ‘The Maslach Burnout nized. The care quality they offer and their ability to
Inventory’, or MBI.(Maslach & Jackson, 1986) More provide it long-term depend on how their well-being
recently, Leiter (1991) suggested burnout as a social and mood are protected, so that it is essential to con-
phenomenon, which responds to occupational stres- tinue research in this area in order to identify support
sors. The most important and significant consequen- and prevention strategies. These are the reasons why
ces of the Burnout Syndrome are high staff rotation, studies on burnout and its impact on health profes-
dropout and low productivity, consequences that have sionals and volunteers are necessary. It is relevant and
repercussions at organizational level as well as for ser- urgent to establish the principal parameters for this
vices and individuals (Gueritault-Chalvin, Kalichman, process in HIV/AIDS caregivers.
Demi & Peterson, 2000). Since Burnout research has been incepted nearly 30
The triggering factors of burnout and stress expe- years ago, the construct has been a factor that affects the
rienced by health workers and volunteers working with effect of stress in health. Although nearly 8 000 articles
HIV/AIDS-infected people are related to a variety of about burnout can be found, there is little research on
topics: job interpersonal relations, caregiver-patient re- burnout in specifically HIV/AIDS caregivers. Taking
lationship, the nature of the disease involved, and task them as a whole will let us glimpse a framework and a
and organizational factors (Bellani et al., 1996; Bar- global paradigm of the burnout process in AIDS care-
bour, 1995; Lloyd, 1995; Lert & Marne, 1992; Gallop, givers. The research on the computer databases Psych-
Lancee, Taerk, Coates & Fanning, 1992; Delph, 1991; Info of the American Psychological Association and
Siminoff, Erlen & Lidz, 1990; Smyser, Bryce & Joseph, Medline using the keywords “burnout, HIV, AIDS,
1990; Blumenfield, Sith, Milazzo, Seropian & Worm- caregivers, physicians, nurses, volunteers” for articles
ser, 1987; Douglas, Kalman & Kalman, 1985) As far as published in academic journals, resulting in more than
interpersonal work relations are concerned, burnout 100 studies. After eliminating duplicates and studies
in HIV/AIDS caregivers emerges as related to a lack of that were not related to burnout and HIV caregivers
initiative or a leader figure for decision-making, lack of (e.g., those that were related to occupational stress), the
recognition in one’s work and lack of support and su- 43 remaining studies were reviewed for inclusion.
pervision. As regards the caregiver-patient relationship,
an excessive sense of duty about people suffering from Burnout Levels In Relation
AIDS and their families, personal identification with To Hiv/Aids Caregivers
the AIDS patients, fear of the patient’s death, and lack Most of the burnout syndrome studies in HIV/
of respect or sympathy between health care worker and AIDS caregivers have focused on nurses, physicians,
patient are common factors associated with burnout and volunteers.
in HIV/AIDS workers. As far as the actual nature of
the disease is concerned, burnout is related to aspects Nurses
such as the stigma associated with HIV and AIDS, se- The aspects related to burnout studied in nurses, as
crecy and fear in HIV/AIDS sufferers about revealing found in the theoretical review by Garret (1999) were
their condition, fear of infection and the fact that AIDS attitudes, ethical dilemmas related to death, symptoms

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68
management, new treatments and unpredictable reac- nett et al., 1994), mostly when they experience less
tions, as well as involvement, empathy and risk of HIV social support (Garside, 1993). Some possible reasons
infection. Garret mentioned that most of these studies for this lack of research are that physicians claim that
are merely descriptive and based on personal experien- emotions have no place in their role, and that talking
ces, clinical observations, anecdotal events and questio- about HIV/AIDS outside of work would only affect
nnaires. Miller (1995) compared 100 oncology nurses their emotions, possibly causing depression (Garside,
with 103 AIDS nurses and found high burnout and 1993). Deckhard, Meterko and Field (1994) suggested
stress levels in both samples, with no statistical differen- that the burnout process in doctors begins when they
ces. Plante and Burchard (1995) mentioned that nurses concentrate on their professional career, ignoring their
were more vulnerable than other health professionals emotional needs. This author used the MBI (Masla-
to suffer high levels of burnout, since they had a sense ch Burnout Inventory) in 342 physicians, and found
of duty and support vis-à-vis their patients, which cause a significant relationship between high burnout levels
high demands both at work and when not at work. Fau- and organizational factors.
ra, Roige and Serra (1995) found that hospital nurses
experienced higher levels of burnout than community Volunteers
nurses, mainly because of work overload. Bennett, Kela- As regards volunteers, their work with HIV patients
her and Ross (1994) studied the importance of social su- is considered as a risk factor. Guinan, McCallum, Pa-
pport as a burnout buffer, and found that social stigmas inter, Dykes and Gold (1991) found that one-fifth of
associated with HIV patient care correlated with high the sample had moderate or high scores in emotio-
burnout levels in 84 health care workers, including phy- nal exhaustion, depersonalization and lack of perso-
sicians and nurses. However, these workers only sought nal accomplishment. According to Nesbitt and Ross
social support when experiencing burnout. Similar data (1996) most caregivers: a) do not have adequate trai-
were found in the study by Catalan et al.(1996) while ning, b) have not planned to be a volunteer, c) have a
Peragallo, Ferrer and Guarda (1995) found that nurses close relationship with the AIDS patient, and d) have
who assimilated their spiritual-religious and psycholo- other jobs. All of these are risk factor variables. Oktay
gical problems into their professional activity developed (1992) mentioned that the main stressors in this sam-
stress and fear of infection and used exaggerated pre- ple are: excessive work hours and low salaries, poor
ventive measures. On the other hand, Visintini et al. career opportunities, ambiguity and role conflicts,
(1996) found that HIV/AIDS caregivers turned out not disputes with co-workers and supervisors, poor job
to be at risk for developing burnout syndrome, ratifying security and lack of autonomy, among others. Mi-
data found by Miller and Gillies (1996). Furthermore, ller (1993) assessed psychological vulnerability and
Parsons (1995) who had worked mainly in Australia and burnout in 103 health workers at seven hospitals.
Asia, found that nurses were the most effective health Volunteers reported that their job was more stressful
professionals for HIV/AIDS preventive education and than non-volunteers, who said it was stressful only
care, as well as palliative care. In fact, in these countries sometimes. Nevertheless, there were no differences
there had been an increase in educational programmes in burnout levels between them (Miller, 1993). Simi-
for nurses, helping to diminish negative thoughts and larly, Folkman, Chesney and Christopher-Richards
feelings about their patients’ future and their death. A (1994) found that burnout was higher in informal
situation faced by nurses that is highly likely to cau- caregivers than in professionals.
se burnout is the death of a child. Furthermore, nur- Despite the scarcity of studies on significant diffe-
ses’ scarce contact with the scientific literature affects rences in burnout prevalence in relation to HIV care-
their professional development, leading to inadequate givers, there is evidence of the involvement of diffe-
training for HIV/AIDS caregiving and facilitating the rent processes and variables, as will be discussed in the
spread of the disease (Parsons, 1995). following paragraphs. However, much more needs to
be learned about the burnout phenomenon for the-
Doctors se populations. For example, it is not known whether
Studies on burnout in AIDS doctors are scarce, AIDS health workers are just the same as other health
though some research suggests that physicians have workers in terms of their burnout experience, or whe-
higher burnout levels than other health workers (Ben- ther they are different. Nor is it entirely clear whether

Revista Colombiana de Psicología

69
the burnout concept provides a sufficient explanatory in depersonalization and heterosexual women scored
framework for the experience of AIDS health work, lower in burnout. It was also found that those with
particularly in the case of voluntary caregivers. higher educational levels and higher salaries had more
emotional exhaustion. These results suggested that the
Burnout Levels In Relation sociodemographic profile related to burnout in this
To Sociodemographic Variables sample was a young, homosexual, salaried man with
high educational level. Other authors have proposed
Although some studies have shown that sociode- age as the only variable related to burnout and leaving
mographic variables are not the most determinant in one’s job (Guinan et al., 1991, Maslanka, 1996; Ra-
the development of burnout, others suggest these va- phael, Kelly, Dunne & Greig, 1990; Williams, 1988).
riables as buffers, so that, age, gender, experience or Maslanka (1996) established age as a predictive varia-
paid/non-paid work can influence the burnout pro- ble of burnout in 256 volunteers. Differences in social
cess. Some studies reported that burnout correlates and work conditions in different professions and cul-
negatively with age, and positively with single status tures may explain this variety of results.
and childlessness, (Maslach & Jackson, 1981, 1986; Likewise, transcultural studies have demonstrated
Miller, 1992) while others suggested that there are no a diversity of results according to communities. Thus,
significant differences by marital status, years in care- in Uganda the caregiver role was generally assumed by
giving or years in AIDS units (Bellani et al., 1996; Mi- older and younger relatives (Seeley et al., 1993), while
ller, 1991). in the United Kingdom 87% of AIDS-infected indivi-
duals reported that their principal caregivers were close
Nurses friends and/or partner (McCann & Wadsworth, 1992).
As regards HIV nurses, recent data showed higher This research is still in its infancy, so that the num-
scores for burnout in women than in men (Hayter, ber of studies is small. Furthermore, the majority of it
1999) though in previous studies no relationship was has been carried out in urban contexts in industriali-
found between age, time spent with patients, gender zed countries. It remains unclear how differences in
and burnout. Gueritault-Chalvin et al. (2000) found culture, prevalence of AIDS, demographic patterns,
that younger nurses with an internal locus of control and health worker roles may affect the development of
and perceived job overload showed a higher risk of de- burnout across cultures and communities.
veloping burnout. Other studies showed that sociode-
mographic variables, such as being younger, single and Burnout Levels In Relation
a nurse, especially coupled with inexperience, could To Stressors
be predictors of burnout (Bellani et al., 1996; Oktay,
1992; Silverman, 1993; Gillespie & Numerof, 1991). Nurses and doctors
Ross and Seeger (1988) have suggested that there
Doctors are specific stressors related to burnout in HIV/AIDS
In samples of doctors working with HIV/AIDS pa- caregivers. These authors considered that these va-
tients, Lert, Chastang and Castano (2001) found no riables would be more situational –such as patient’s
relationship between sociodemographic variables and youth, patient’s emotional needs, impact of the neu-
organizational factors in emotional exhaustion. De- rological aspects of the illness and number of deceased
personalization appeared mostly in male physicians, patients – than personality-related.
though with lower levels than in their co-workers Klonoff and Ewers (1990) claimed that an im-
from other specialization areas. Finally, physicians portant stressor for nurses is inexperience with HIV/
with full-time jobs had the lowest levels of personal AIDS patients and the attitudes of their friends and
accomplishment. family toward their care. They therefore proposed the
provision of information about transmission of the ill-
Volunteers ness. Ross (1993) mentioned other stressors that could
Claxton, Catalán and Burgess (1998) suggested facilitate burnout: general job stressors (e.g., role am-
that young and homosexual volunteers tended to have biguity), lack of autonomy, emotionally demanding
higher burnout levels, while lesbians had lower scores work and tasks, social stigmas, homophobia and sexual

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70
discrimination, fear of contagion, affection and worry the greatest stressors in HIV/AIDS nurses. Similarly,
involved in taking care of seriously ill patients, and homophobia was found in the studies made by Ross
ethical and legal dilemmas. Lert et al. (2001) pointed and Seeger (1988) and Strathdee, Flannery and Gra-
out the following: work overload, time pressure (whi- ydon (1991) as a risk factor in developing high levels of
ch correlated with high emotional exhaustion levels), burnout. Masterson-Allen, Mor, Laliberte and Mon-
conflicting demands, complex job structure, role am- tiero (1985), working with young patients, found that
biguity and lack of resources. Even though general closeness to patients of the same age emerged as one of
burnout descriptions were initially conceptualised as the main stressors in HIV/AIDS nurses. Hayter (1999)
contextual stressors, later formulations have pointed proposed lack of clinical supervision, job overload and
to the importance of individual and contextual inte- traumatic experiences (terminal illness and death) as
ractions (Francis, 1989). For Lert et al. (2001) speci- the variables most related to stress in Canadian com-
fic care of HIV/AIDS patients did not lead to either munity nurses. However, the results showed that in
occupational stress or satisfaction, since individuals this sample (with 50% burnout prevalence), neither
with the highest stress level have a greater probability work overload nor direct time spent with patients was
of applying for another speciality. Thus, work overload significantly related to burnout levels. Miller (1995)
is considered one of the most determinant stressors found that their patients’ death had less emotional im-
in burnout (Gillispie & Numerof, 1991). Claxton et pact in AIDS nurses than oncology nurses.
al. (1998) showed that emotional exhaustion was po-
sitively related to seriously injured patients and hours Volunteers
spent with them weekly. Depersonalization was ne- Ross, Greenfield and Bennett (1999) suggested di-
gatively related to closeness to patients. Personal ac- fferences not only among stressors, but also between
complishment was positively related to closeness and the kind and significance of rewards, depending on
hours spent with them weekly. Thus, less contact with whether volunteers were religious or secular. Fur-
patients could decrease the importance of situational thermore, these informal caregivers do not have an
factors, but increase the relative importance of per- established work schedule or time limits, which resul-
sonal vulnerability to stressors. Bennett, Kelaher and ts in a more demanding task, and they often showed
Ross (1993) concluded that burnout was more related “survivor’s guilt” when they were exposed to HIV vi-
to intensity than to workload or direct contact with rus without being infected. Also, role conflict affected
patients, and Bellani et al. (1996) drew similar conclu- relationships with close friends or partners emerged
sions. Reilly (1994) suggested that nurses with more when the demands and responsibilities of care came
responsibilities could distinguish between different into conflict with expectations and previous relational
stressors and become more tolerant. Later, Slone and patterns (Folkman et al., 1994).
Stephany (1995) identified the importance of ethical Although many studies concentrate on the stressors
dilemmas (especially related to death) faced by nurses, involved in AIDS-related care, it has been noted that in
which included conflict between physicians and relati- the HIV/AIDS context there are also rewards that may
ves and management of pain and symptoms. This was balance burnout. These include the rewards of working
identified as an important reason why they experien- in a new and personally relevant field, the social recog-
ce feelings of frustration about the inability to satisfy nition, the gratitude of clients and patients, and a sense
patients, especially chronic ones. Brown et al. (2002) of achievement in making psychosocial (as opposed to
mentioned specific emotional stressors related to HIV/ physical) progress with clients and patients.
AIDS, such as fear of contagion, work and personal
life stigma, problems related to transmission, and loss Burnout Levels In Relation
of patients (Bolle, 1988; Gilman, 1991; Gordon, Ulri- To Buffers
ch, Feeley & Pollack, 1993). Van Servellen and Leake
(1994) found, using the MBI, high stress levels and Coping Styles
emotional exhaustion in 153 nurses, along with po- According to Martin (1990), coping styles related to
sitive correlations with age, work hours and fear of lack of commitment are associated with high burnout le-
contagion. Dunkel and Hatfield (1986) and Dreidger vels in HIV caregivers. Thus, nurses who used active co-
and Cox (1991) described fear of contagion as one of ping styles coped better with stress. Furthermore, when

Revista Colombiana de Psicología

71
they faced critical situations, they used stress management clinical supervision. This data is in contrast to that of
techniques. On the other hand, nurses who employed other studies, in which supervision was found to be
coping styles such as avoidance or escape showed high critical (Bolle, 1988; Randolph, Price & Collins, 1986;
stress levels. Depersonalization is often used as a coping Hare, Pratt & Andrews, 1988).
style where an individual does not feel emotional ties In physicians, volunteers and social workers, it
with others. Fatalistic attitudes, negative expectations and has been suggested that social support is an important
trust in faith, prayers and miracles, all of them external protective factor for stress (Brown, Stermock, Ford &
coping styles, predicted burnout, according to Bennett et Geary, 1999). Research showed that getting on well
al. (1993). In another study, Bennett et al. (1994) found with team-mates is associated with less risk of burnout
that high burnout levels were related to external coping (Tannenbaum & Butler, 1992). Co-worker support is
styles, while low levels of burnout were associated with essential in intervention programmes because it redu-
internal coping. Gueritault-Chalvin et al. (2000) in a path ces occupational stress levels. Regarding informal ca-
analysis study concluded that both internal (protective regivers, research has shown that the seeking of social
factor) and external coping styles could explain burnout support varies according to the environment and atti-
more than age and job overload. tudes of the community in which HIV/AIDS patients
are treated. Attitudes to homosexuals could be relevant
Locus of Control in situations in which HIV/AIDS is related to a gay/bi-
One of the critical aspects of human behaviour is sexual community lifestyle (Maslach & Ozer, 1995).
being able to control or, at least, predict consequen-
ces. Therefore, there is greater probability of suffering Over-Involvement
physical and psychological health damage when there Involvement and degree of implication with HIV/
is no opportunity for control, and where there are fe- AIDS patients generally imply a series of psychological
elings of being in an uncontrollable or unpredictable risks, such as an increase in fear of death and anxiety.
situation (Janis & Rodin, 1979). Research on locus of However, if identification levels are related to an increa-
control in HIV caregivers has shown an association se in job significance and commitment, such identifica-
with burnout – that is, internal-locus individuals have tion serves as a protective factor, aiding job satisfaction
less probability of experiencing high burnout levels. and intellectual stimulation (Ross & Seeger, 1988). In
Likewise, sense of control in professional health wor- that sense, Visintini et al. (1996) concluded that a ten-
kers was related to professional self-efficacy levels dency to over-involvement with patients was related
(Maslach & Ozer, 1995). positively to burnout, unlike empathy with controlled
attitudinal development was a protective factor in 410
Co-worker and Supervisor Support HIV/AIDS nurses. Another aspect of over-involvement
As regards social support research, Miller (1995) with patients is the impact of their death. Hayter (1999)
claimed that lack of co-worker support, as well as lack reported that over-involvement and death of patients
of resources and sources of support, could facilitate contributed notably to stress and burnout. Unlike
burnout syndrome in HIV caregivers. Some authors, other authors (Bennett et al., 1993; Masterson-Allen
such as Hayter (1999) reported a strong relationship et al., 1985; Perrault, Scherer & Adolph, 1996) Hayter
between burnout and lack of co-worker relationships found no association between degree of identification
in community HIV nurses. The informal support role with patients and levels of burnout in any of its dimen-
of family and friends is an important protective factor, sions. Nowadays, these data show over-involvement as
in addition to work support and supervision. These a risk factor in the burnout process, especially when it is
three elements are critical for avoiding burnout, since related to death of patients, and identification with job
in this profession the high level of isolation makes it sense and job significance as a protective factor.
difficult for professional relationships to develop. In
this line, Haviland et al. (1997) found that humour, Positive Buffers and Others
support sources and supervisor support appear to re- Bennett, Ross and Sunderland (1996) emphasized
duce stress in professional HIV nurses. Palsson, Ha- a series of rewards, which would act as positive bu-
llberg, Norburg and Bjorvell (1996) detected no sig- ffers in HIV physicians. These included intellectual
nificance differences in burnout related to access to stimulation, co-worker appreciation and the gratitude

Revista Colombiana de Psicología

72
of patients and relatives. Similarly, autonomy, intellec- agues, rather than any specific job task, is the most
tual stimulation, promotion opportunities and personal salient factor in enhancing employee retention. Ross
growth have appeared as buffers and protective factors and Seeger (1988) and Ross et al. (1999) found that the
against burnout (Silverman, 1993; Ross & Seeger, 1988; burnout process and dropout in HIV caregivers differs
Gilman, 1991;Brown et al., 1999;Bennett, 1991; Glass, between salaried workers and volunteers, who can lea-
McKnight & Valdimarsdottir, 1993). Other positive bu- ve the job without suffering any kind of financial di-
ffers specifically related to volunteer work are coping sadvantage. In volunteers, the rewards are not protec-
styles (Martin, 1990; Bennett & Kelaher, 1994), indivi- tive factors for burnout. According to these authors,
dual motivation (Calvert, Flynn, Fraser & Long, 1991), the best predictors of dropout are patient problems,
personality (Bellani et al., 1996; Keinan & Melamed, role ambiguity, emotional overload, organizational
1987), empathy with patient (Visintini et al., 1996) and, factors and intensity of depersonalization.
job reward perception (Bennett et al., 1996).
To summarize, while most studies on stress and Physical and Psychological Consequences
burnout in AIDS health care have focused on the ne- HIV/AIDS caregivers are increasingly confronted
gative and difficult aspects of this work, few have con- by this infection, and many of them experience phy-
sidered the caregiving variables that may buffer against sical, behavioural and cognitive/affective symptoms
stress. In this sense, coping skills and social support commonly associated with chronic stress. These
clearly buffer the development of burnout and inten- symptoms may be physical (physical exhaustion, hea-
tion to leave their job. daches and back pain, sleeplessness, gastro-intestinal
disturbances), behavioural (proneness to irritation,
Consequences In Burnout Process proneness to anger, increased alcohol and drug use,
marital and relationship problems, inflexibility in
Job Satisfaction problem-solving), and cognitive/affective (emotional
Job satisfaction emerged as negatively related to numbness, emotional hypersensitivity, over-identifi-
perceived stress levels and positively related to willing- cation with patients, grief and sadness, pessimism and
ness to remain in one’s job (Brown et al., 2002). Al- hopelessness, boredom, cynicism, indecision, and in-
though in a recent study it was found that MBI scores attention (Visintini et al., 1996; Miller, 1995). Some
predicted dissatisfaction and dropout in HIV/AIDS studies mention that in HIV-related samples of doc-
volunteers (Ross et al, 1999), caring for people with tors, suicide rates are two or three times higher than
HIV illness can provide substantial satisfaction related in general samples, both in earlier studies (Emerson &
to the caregiver’s sense of doing good, obtaining the Hughes, 1986) and more recent ones (Boxer, Burnett
patient’s appreciation, or seeing improvement in the & Swanson, 1995; Carpenter, Swerdlow & Fear, 1997;
patient’s condition (Nashman, Hoare & Heddeshei- Juel, Mosbech & Tøttruphansen, 1999).
mer, 1990). Horstman and McKusick (1986), in their While a great deal of the literature examines links
study on the psychosocial reaction of physicians wor- between workers and burnout to examine who may
king with AIDS, assessed several factors, including be prone to this problem and what style of functio-
career satisfaction. Over 40% of the sample said that ning may place a worker at risk of burnout, the work
contact with the AIDS epidemic had led to increased context and management style may also hold the key
intellectual stimulation and career satisfaction. to staff dissatisfaction, stress and burnout. Many heal-
th workers have not had sufficient preparation for the
Dropout and Job Retention emotional reality of their work and its subsequent im-
According to the four-year study carried out by pact on their personal functioning.
Brown et al. (2002) on the relationship between
burnout, occupational stress and job retention, the Methodological And Psychometric
best predictor for job retention in HIV caregivers is Inconsistencies
coworker-perceived stress levels, that is, the higher the
coworker-perceived stress level, the greater the pro- Generally, data on burnout levels, stress factors,
bability that the person will leave the job. In addition, the most efficient coping styles, personal commitment
they concluded that support from professional colle- and the relationships with sociodemographic variables

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73
Table 1: Methods

Authors N Sample Country Design Instruments

Miller and Gillies, MBI (1982)
161 Oncologists England Transversal
1996 GHQ (1988)
MBI (1981)
Nesbitt and Ross, HIV Volunteer Inventory (1991)
155 Volunteers US Transversal
1996 GHQ (1979)
TRIG (1987)
MBI (1981)
Bennett Ross and
174 Volunteers US Transversal HIV Volunteer Inventory (1991)
Sunderland, 1996
AIS (1991, 1994)
Visintini and Cam- MBI (1981)
410 Nurses Italy Transversal
panini, 1996 AIS (1991)
MBI (1986)
444 Longitudinal
Maslanka, 1996 Volunteers US HIV-related events (1988)
(589) (3 years)
PERI Scale (1978)
MBI (1981)
Bellani and Furlani, H e a l t h AIQ (1976)
194 Italy Transversal
1996 workers 16PF (1970)
ASQ and CDQ (1976)
MBI (1981)
Claxton Catalan and HAD (1983)
324 Volunteers England Transversal
Burgess, 1998 Calvert Motivational Checklist
(1991)
MBI (1984)
Hayter, 1999 30 Nurses England Transversal
AIS (1995)
MBI (1981)
Ross, Greenfield and 76 Longitudinal HIV Volunteer Inventory (1991)
Volunteers US
Bennett, 1999 (174) (2 years) GHQ (1979)
TRIG (1987)
MBI (1986)
Gueritault-Chalvin Ways of Coping (1984)
445 Nurses US Transversal
et al., 2000 Internal-External Locus of Control
(1966)
MBI (1986)
Lert, Chastang and
670 Physicians France Transversal GHQ (1972)
Castano, 2001
CMHQ (1996)
MBI (1986)
75 H e a l t h Longitudinal
Brown et al., 2002 US Perceived job stress and satisfaction
(213) workers (4 years)
(1992)

Note: The N column (subjects) shows in brackets the number of individuals who began the longitudinal study.

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74
Table 2: Analyses

Prevalence in
Authors Correlation ANOVA MANOVA Regression
burnout
Miller and Gillies, 1996 Yes - Yes Yes Yes
Nesbitt and Ross, 1996 - Yes - - Yes
Bennett, Ross and Sunderland, 1996 - Yes Yes - Yes
Visintini and Campanini, 1996 Yes - Yes - Yes
Bellani and Furlani, 1996 - Yes Yes - Yes
Claxton, Catalan and Burgess, 1998 - Yes Yes - Yes
Hayter, 1999 Yes Yes Yes - -
Ross, Greenfield and Bennett, 1999 - Yes - - Yes
Gueritault-Chalvin et al., 2000 - Yes - - Yes
Lert, Chastangand Castano, 2001 - - Yes Yes Yes
Brown et al ., 2002 Yes - Yes - Yes

Note: It is shown some of the analyses more used.

such as age, gender and professional experience, are tervention programmes, especially in volunteers, even
quite inconsistent. One explanation for this variance though there are intervention guidelines drawn up by
in the data would be the heterogeneity of the sample UNICEF, the WHO and the World Bank.
(nurses, physicians, and volunteers), organizational Bennett (1995) pointed out that AIDS-related care
group of reference, specialities considered, work status requires important work on communication with pa-
and gender. Another possible explanation is the diver- tients and relatives and the service provided to them,
sity of methodologies. Methodological variability for and she made various intervention programmes to
some relevant studies with a high citation index from help the development of adaptative coping styles in
the period 1996-2003 is shown in Table 1. health workers and consequently decreased burnout
Furthermore, the psychometric problems of the levels related to individual motivation. In professio-
MBI (Maslach & Jackson, 1981, 1986) (the main ques- nal health workers, emotional exhaustion feelings can
tionnaire used in all the reviewed studies) must be be associated with time pressure, lack of authority/au-
considered with respect to construct validity (Burke, tonomy, interaction problems with patients and con-
1989; Koeske & Koeske, 1989; Schaufeli & Van Die- frontation with death.
rendonck, 1995), boundary points used for defining Some issues for the prevention and treatment of
burnout levels (Schaufeli & Van Dierendonck, 1995), burnout are related to nurses’ opportunities to discuss
and the implications of the three dimensions for defi- their professional worries. Phone lines were even set
ning burnout (Golembiewski & Munzenrider, 1983; up in an attempt to decrease their anxiety. Alternative
Van Dierendonck, Schaufeli & Sixma, 1994). therapies have also been used, including meditation,
Another complementary problem is that the me- aromatherapy, acupuncture and massage techniques
thodological procedure used is not always the appro- (Van Dierendonck et al., 1994). Reilly (1994) poin-
priate one. In some cases, studies using transversal ted out that nurses must be trained to recognize and
methodology employ causal reasoning (Gueritault- cope with stress, and proposed that hospitals should
Chalvin et al., 2000; Nesbitt & Ross, 1996). The di- develop social support programmes, time-manage-
fficulties of comparing data increase when the analysis ment techniques for training nurses to manage their
processes are qualitatively different, even when con- time and organize their tasks, and stress-management
ceptual foci or hypotheses are similar. (see Table 2). technique programmes. As regards co-workers, it is
Some research on intervention programmes for proposed that several strategies should be used to de-
preventing burnout consequences has been develo- crease organizational stress, through staff team work,
ped (Eakin & Taylor, 1990; Ross, Alteimer & Russell, meetings and conferences, paving the way for emo-
1989), but there are currently hardly any scientific pu- tional expression, social support, humour, spirituality
blications that experimentally validate training and in- and organization (Lloyd, 1995).

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 Although there is little information on the impact causing stress on the main caregivers and external fa-
of intervention programmes on burnout, there are su- mily helpers.
ggestions that HIV/AIDS education programmes can As regards burnout consequences in professionals,
reduce health carers’ anxiety and stress, and that mu- they are more intensive in caregivers who are also in-
tual support groups can reduce staff turnover. fected, or in the same risk group. For example, in young
HIV physicians, suicide rates are two or three times
Conclusions higher than the same sociodemographic sample (Rose
& Rosow, 1973; Richings, Khara & McDowell, 1986).
In spite of the theoretical, conceptual and metho- Substance abuse is 30 times higher in physicians than
dological obstacles discussed in this review, it seems in a general sample (Rucinski & Cybulska, 1985), 1%
important to establish the demographic, situational even being drug-dependent, and alcohol consumption
and general burnout parameters in HIV/AIDS wor- is also higher (Murray, 1976). This data is so signifi-
kers. This may clarify which aspects are more general, cant that some authors consider these statistics to be
and therefore situationally stable, even though iden- the consequences not only of stress, but also of certain
tifying these differences may involve an exhaustive childhood problems and personality traits. It has also
analysis or meta-analysis of these parameters. In prin- been mentioned that physicians and nurses feel that
ciple, it would seem necessary to carry out intra-group they fulfil their obligations in treating HIV/AIDS pa-
analyses, since the heterogeneity in stressors and bu- tients, but have negative feelings because most health
ffers means that each burnout sample is influenced in systems do not use psychological approaches.
a different way. Intervention programmes are recommended for
As regards formal HIV caregivers, there are few helping staff to deal with difficult aspects of their
studies about significant differences in burnout pre- work. Such programmes should involve stress ma-
valence. It has been shown that HIV nurses are more nagement techniques, coping techniques, approaches
vulnerable to high levels of burnout, by comparison for dealing with death, staff support and professional
with other health workers (Plante & Bouchard, 1995; supervision.
Faura et al., 1995), but other studies suggest that HIV In research on the burnout process in professionals
physicians are the group with the highest burnout le- and volunteers working with HIV/AIDS it is impor-
vels (Bennett et al., 1994; Garside, 1993; Deckhard et tant to note that the number of studies and data obtai-
al., 1994). These inconsistencies could be explained by ned up to now are relatively scarce, and that most of
the different organizational conditions. the research has been carried out in urban areas and in
The differences and similarities between health industrialized countries. This leaves a knowledge gap
care workers and volunteers need to be clarified, and in relation to cultural differences, prevalence levels,
their significance considered. Some authors argue that demographic patterns in AIDS infection and the diffe-
burnout levels are higher in informal caregivers than rent HIV/AIDS caregiver roles that may be affecting
in professionals (Oktay, 1992; Miller, 1993; Folkman the incidence and development of burnout in different
et al., 1994). These data can be explained by the fact countries and communities. It should also be borne in
that volunteers may lack training and skills, as well as mind that a substantial proportion of those working
having to deal with role conflicts. Meanwhile, studies with HIV-infected patients are not health workers,
in relation to sociodemographic variables do not ap- but volunteers. Although this group have to face the
pear to be conclusive, though youth is considered as a same risks as the health workers, their work situation
risk factor in most of them, probably because of lack of is different in many aspects, which must all be taken
experience and unrealistic job expectations. into consideration (Maslach & Ozer, 1995). Finally, it
As it has been shown, most caregivers experience is important to have reliable and valid measures availa-
stress caused by the specific nature of the job, that is, ble for testing hypotheses on the relationship between
treating a chronic illness that especially affects young AIDS care and burnout.
people. Also, lack of communication between caregi- This review has attempted to consider the literatu-
vers and supervisors is a common cause of stress re- re on burnout, considering different types of care wor-
lated to job environment. AIDS can have important kers, and variables such as sample, sociodemographics,
effects on personal relationships and family dynamics, stressors, buffers and consequences. Future research

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76
in this area is necessary to obtain more conclusive data Brown, L.K., Schultz, J.R., Forsberg, A.D., King, G.,
from a more global paradigm of the burnout process, Kocik, S.M. & Butler, R.B. (2002). Predictors of
with a view to the development of prevention and in- retention among HIV/hemophilia health care pro-
tervention programmes for the different health wor- fessionals. General Hospital Psychiatry, 24, 48-54.
kers treating HIV/AIDS patients. Brown, L.K., Stermock, A.C., Ford, H.H. & Geary, M.
(1999). Emotional reactions of hemophilia health
References care providers. Haemophilia, 5, 127–31.
Burke, R.J. (1989). Toward a phase model of burnout.
Barbour, R.S. (1995). The implications of HIV/AIDS Some conceptual and methodological concerns.
for a range of workers in the Scottish context. Group of Organizational Study, 14, 23–32.
AIDS Care, 7, 521–35. Calvert, G.M., Flynn, R., Fraser, P. & Long, J. (1991).
Bellani, M.L., Furlani, F., Gnecchi, M., Pezzotta, P., Volunteers’ motivation and the Terrence Higgins Trust.
Trotti, E.M.& Bellotti, G.G. (1996). Burnout and Proceedings of the British Psychology Society
related factors among HIV/AIDS health care wor- Conference; London.
kers. AIDS Care, 8, 207–21. Carpenter, L.M., Swerdlow, A.J. & Fear, N.T. (1997).
Bennett, L., Kelaher, M. & Ross, M. (1994). Quality Mortality of doctors in different specialties: fin-
of life in health care professionals: Burnout and its dings from a cohort of 20,000 NHS hospital con-
associated factors in HIV/AIDS related care. Psy- sultants. Occupational and Environmental Medicine,
chology & Health, 18, 273-83. 54, 388–95.
Bennett, L., Kelaher, M. & Ross, M.W. (1993). Burnout Catalan, J., Burgess, A., Pergami, A., Hulme, N., Ga-
and coping. In: Van Dis, Van Dongen (Eds.), Burnout zzard, B. & Phillips, R. (1996). The psychological
in HIV/AIDS health care volunteers pp. 41-51. Ams- impact on staff of caring for people with serious
terdam: University of Amsterdam Press. diseases: The case of HIV infection and oncology.
Bennett, L. & Kelaher, M. (1994). Longitudinal pre- Journal of Psychosomatic Research, 40, 425–35.
dictors of burnout in HIV/AIDS health professio- Claxton, R.P., Catalán, J. & Burgess, A.P. (1998). Psy-
nals. Australian Journal of Public Health, 18, 334-6. chological distress and burnout among buddies:
Bennett, L., Ross, M.W. & Sunderland, R. (1996). The demographic, situational and motivational factors.
relationship between recognition, rewards and AIDS Care, 10, 175-90.
burnout in AIDS caring. AIDS Care, 8, 145-53. Deckhard, G., Meterko, M. & Field, D. (1994). Phy-
Bennett, L. (1991). The experience of nurses working sician burnout: An examination of personal, pro-
with hospitalized AIDS patients. Australian Journal fessional, and organizational relationships. Medical
of Social Issues, 27, 125–43. Care, 32, 745-54.
Bennett, L. (1995). The Sydney Study: Interventions to as- Delph, Y. (1991). El SIDA: La perspectiva del médico
sist responses of health care professionals in HIV/AIDS. (Aportes de la ética y el derecho al estudio del SIDA No.
In: Bennett, L., Miller, D. & Ross, M. (Eds.), Heal- 530). Washington, DC: Organización Panamerica-
th Workers and AIDS: Research, intervention and current na de la Salud.
issues in burnout and response. Chur, Switzerland: Douglas, J., Kalman, C.M. & Kalman, T.P. (1985). Ho-
Harwood Academic Publishers. mophobia among physicians and nurses: an empi-
Blumenfield, M., Sith, P.J., Milazzo, J., Seropian, S. & rical study. Hospital and Community Psychiatry, 36 ,
Wormser, G.P. (1987). Survey of attitudes of nur- 1309–11.
ses working with AIDS patients. General Hospital Dreidger, S.M. & Cox, D. (1991). Burnout in nurses
Psychiatry, 9, 58–63. who care for PWAs. AIDS Patient Care, 2, 197–
Bolle, J.L. (1988). Supporting the deliverers of care: 203.
strategies to prevent burnout. The Nursing Clinics of Dunkel, J. & Hatfield, S. (1986). Counter-transferen-
North America, 23, 843–50. ce issues in working with people with AIDS. Social
Boxer, P.A., Burnett, C. & Swanson, N. (1995). Sui- Work, 31, 114–7.
cide and occupation: a review of the literature. Jo- Eakin, J.M. & Taylor, K.M. (1990). The psychosocial
urnal of Occupational and Environmental Medicine, 37, impact of AIDS on health workers. AIDS, 4, 257-
442–52. 262.

Revista Colombiana de Psicología

77
Emerson, H. & Hughes, H. (1976). Death rates of Guinan, J.J., McCallum, L.W., Painter, L., Dykes, J. &
male white physicians in the United States. Ameri- Gold, J. (1991). Stressors and rewards of being an
can Journal of Public Health, 16, 1088–93. AIDS emotional support volunteer: a scale for use
Faura, T., Roige, M. & Serra, R. (1995). The preva- by care-givers for people with AIDS. AIDS Care, 3,
lence of the hospitalisation and primary care nur- 137-50.
sing staff burnout syndrome. Enfermería Clínica, 5, Hare, J., Pratt, C.C. & Andrews, D.A. (1988). Predic-
105–10. tors of burnout in professional and paraprofessio-
Folkman, S., Chesney, M.A. & Christopher-Richards, nal nurses in hospitals and nursing homes. Interna-
A. (1994). Stress and coping in caregiving partners tional Journal of Nursing Studies, 25, 105–15.
of men with AIDS. The Psychiatric Clinics of North Haviland, M.L., Healton, C.G., Weinberg, G.S., Mes-
America, 17, 35-53. seri, P.A., Aidala, A.A., Jetter, D., et al. (1997). De-
Francis, P.A. (1989). Moral beliefs of physicians, me- livering HIV/AIDS services: the professional care
dical students, clergy, and lay people concerning provider speaks out. American Journal of Preventive
AIDS. Journal of the National Medical Association, 87, Medicine, 13(6 Suppl), 12-8.
114–7. Hayter, M. (1999). Burnout and AIDS care-related
Freudenberger, J.H. (1974). Staff burnout. Journal of factors in HIV community Clinical Nurses Spe-
Social Issues, 30, 159–65. cialists in the North of England. Journal of Advanced
Gallop, R.M., Lancee, W.J., Taerk, G., Coates, R.A. & Nursing, 29, 984-93.
Fanning, M. (1992). Fear of contagion and AIDS: Horstman, W. & McKusick, L. (1986). The impact of
nurses’ perception of risk. AIDS Care, 4, 103. AIDS on the physician. In L. McKusick (Ed.), What
Garrett, C. (1999). Stress, coping , empathy, secondary trauma- to do about AIDS, (pp.63-74), Berkeley: University
tic stress and burnout in health care providers working with of California Press.
HIV infected individuals, Unpublished doctoral thesis. Janis, I.L.& Rodin, J.(1979). Attribution, control, and
Garside, B. (1993). Physicians mutual aid group: Res- decision making: Social Psychology and health care. In:
ponse to AIDS-related burnout. Health & Social Stone GC, Cohen F, Adler NE, (Eds.), Health Psy-
Work,18, 259-67. chology (pp. 487-521). San Francisco: Jossey-Bass.
Gillespie, D.F. & Numerof, R.E. (1991). Burnout Juel, K., Mosbech, J. & Tøttruphansen, E. (1992).
among health service providers. Administration and Mortality and causes of death among Danish me-
Policy in Mental Health, 18, 161–71. dical doctors, 1973–1992. Journal of Epidemiology, 28,
Gilman, R. (1991). From resistances to rewards: social 456–60.
workers’ experiences, and attitudes toward AIDS. Keinan, G. & Melamed, S. (1987). Personality charac-
Journal of Contemporary Human Services, 593–601. teristics and proneness to burnout: a study among
Glass, D.C., McKnight, J.D. & Valdimarsdottir, H.B. internists. Stress Medicine, 3, 307-15.
(1993). Depression, burnout, and perceptions of Klonoff, E.A. & Ewers, D. (1990). Care of AIDS pa-
control in hospital nurses. Journal of Consulting and tients as a source of stress to nursing staff. AIDS
Clinical Psychology, 61, 147–55. Education and Prevention, 2, 338-348.
Golembiewski, R.T. & Munzenrider, R. (1983). Tes- Koeske, G.F. & Koeske, R.D. (1989). Construct vali-
ting the phase models of burn-out: mappings on a dity of the Maslach burnout inventory: a critical
cluster of worksite descriptors. Journal of Health and review and reconceptualization. Journal of Applied
Human Resources Administration, 374–92. Behavioral Science, 25, 131-44.
Gordon, J.H., Ulrich, C., Feeley, M. & Pollack, S. Leiter, M. (1991). The dream denied: professional
(1993). Staff distress among haemophilia nurses. burnout and the constraints of human service or-
AIDS Care, 5, 371–9. ganizations. Canadian Psychiatry, 32, 547-55.
Gueritault-Chalvin, V., Kalichman, S.C., Demi, A. Lert, F., Chastang, J.F. & Castano, I. (2001). Psycholo-
& Peterson, J.L. (2000). Work-related stress and gical stress among hospital doctors caring for HIV
occupational burnout in AIDS caregivers: test of patients in the late nineties. AIDS Care, 13, 763-
a coping model with nurses providing AIDS care. 78.
AIDS Care, 12, 149-61.

Revista Colombiana de Psicología

78
Lert, F.& Marne, M.J. (1992). Hospital care for drug in HIV/AIDS health staff. In: Bennett L, Miller D,
users with AIDS or HIV infection in France. AIDS Ross M (Eds.), Health Workers and AIDS: Research,
Care, 4, 333–8. intervention and current issues in burnout and response.
Lloyd, G.A. (1995). Social works responses to HIV Disea- Chur, Switzerland: Harwood Academic Publishers.
se. In: Bennett L, Miller D, Ross M (Eds.), Health Miller, D. & Gillies, P. (1996). Is there life after work?
Workers and AIDS: Research, intervention and current Experiences of HIV and oncology health staff.
issues in burnout and response. Chur, Switzerland: AIDS Care, 8, 167–82.
Harwood Academic Publishers. Murray, R.M. (1976). Characteristics and prognosis of
Martin, D.A. (1990). Effects of ethical dilemmas on alcoholic doctors. British Medical Journal, 2, 1537-9.
stress felt by nurses providing care to AIDS pa- Nashman, H.W., Hoare, C.H. & Heddesheimer, J.C.
tients. Critical Care Nursing Quarterly , 12, 53-62. (1990). Stress and satisfaction among professionals
Maslach, C. & Jackson, S. (1981). The measurement who care for AIDS patients: an exploratory study.
of experienced burnout. Journal of Occupational Be- Hospitals Topics, 68, 22-28.
havior, 2, 99–113. Nesbitt, W.H. & Ross, M.W. (1996). Prediction of
Maslach, C. & Jackson, S.E. (1982). Burnout in health grief and HIV/AIDS-related burnout in volun-
professions: a social psychological analysis. In: Sanders teers. AIDS Care, 8, 137.
GS, Suls J (Eds.), Social Psychology of Illness (pp227– Oktay, J.S. (1992). Burnout in hospital social workers who
51) London: Lawrence Erlbaum. work with AIDS patients. Social Work, 37, 432–9.
Maslach, C. & Jackson, S.E. (1986). Maslach Burnout Palsson, M., Hallberg, I.R., Norburg, A. & Bjorvell,
Inventory Manual. 2nd ed. Palo Alto, CA: Consul- H. (1996). Burnout, empathy and sense of cohe-
ting Psychologists Press. rence among Swedish district nurses before and
Maslach, C. & Ozer, E. (1995). Theoretical issues rela- after clinical supervision. Scandinavian Journal of
ted to Burnout in AIDS health workers. In: Bennett L, Caring Science, 10, 19–26.
Miller D, Ross M (Eds.), Health Workers and AIDS: Parsons, C.D.F. (1995). HIV/AIDS nursing in south-east
Research, intervention and current issues in burnout and Asia and Australia. In: Bennett L, Miller D, Ross M
response. Chur, Switzerland: Harwood Academic (Eds.), Health Workers and AIDS: Research, interven-
Publishers. tion and current issues in burnout and response. Chur,
Maslanka, H. (1996). Burnout, social support and Switzerland: Harwood Academic Publishers.
AIDS volunteers. AIDS Care, 8, 195-206. Peragallo, N., Ferrer, X. & Guarda, L.B. (1995). The
Masterson-Allen, S., Mor, V., Laliberte, L. & Montie- impact of HIV/AIDS on health workers in South Ame-
ro, L. (1985). Staff burnout in a hospice setting. rica. In: Bennett L, Miller D, Ross M (Eds.), Health
Hospice Journal, 1, 1–15. Workers and AIDS: Research, intervention and current
McCann, K. & Wadsworth, E. (1992). The role of issues in burnout and response. Chur, Switzerland:
informal carers in supporting gay men who have Harwood Academic Publishers.
HIV related illness: What do they do and what are Perreault, R.M., Scherer, E. & Adolph, R. (1996).
their needs? AIDS Care, 4, 25-34. Challenges of grief and multiple loss: responding to com-
Miller, D. (1991). Occupational morbidity and bur- munity-based care providers for people with HIV/AIDS.
nout: lessons and warnings for HIV/AIDS carers. Proceedings of the International Conference on
International Review of Psychiatry, 3, 439-449. HIV/AIDS; July 8; Vancouver. Canada.
Miller, D. (1992). Staff stress in HIV health care wor- Plante, A. & Bouchard, L. (1995). Occupational stress,
kers. AIDS Care, 4, 429-432. burnout, and professional support in nurses wor-
Miller, D. (1993). HIV/AIDS health workers stress king with dying patients. Omega, 32, 93-109.
and stress prevention. AIDS Care, 5, 517-21. Randolph, G.L., Price, J.L. & Collins, J.R. (1986). The
Miller, D. (1995). Stress and burnout among health- effects of burnout prevention training on burnout
care staff working with people affected by HIV. Bri- symptoms in nurses. Journal of continuing education in
tish Journal of Guidance and Counselling, 23, 19-32. nursing , 17, 43–9.
Miller, D. (1995). The UK Multicentre Occupational Mor- Raphael, B., Kelly, B., Dunne, M. & Greig, R. (1990).
bidity Study (MOMS): Issues of Methodology, volunteer Psychological distress among volunteer AIDS coun-
bias and preliminary findings on preferences for staff support sellors. The Medical Journal of Australia, 152, 275.

Revista Colombiana de Psicología

79
Reilly, N.P. (1994). Exploring a paradox: Commitment and recommendations for the role of psychiatry.
as a moderator of the stressor-burnout relationship. American Journal of Psychiatry, 150, 705–12.
Journal of Applied Social Psychology, 24, 397-414. Siminoff, L.A., Erlen, J.A.& Lidz, C.W. (1990). Stig-
Richings, J.C., Khara, G.S. & McDowell, M. (1986). ma, AIDS, and quality of nursing care: state of the
Suicide in young doctors. British Journal of Psychia- science. Journal of Advanced Nursing, 16, 262–9.
try, 149, 475-8. Slone, M. & Stephany, T. (1995). Stressors of hospice
Rose, K.D. & Rosow, I. (1973). Physicians who kill home care nurses caring for AIDS patients: A pilot
themselves. Archives of General Psychiatry, 29, 800-5. study. American Journal of Hospice and Palliative Care ,
Ross, E. (1993). Preventing burnout among social 12, 32-6.
workers employed in the field of AIDS/HIV. Social Smyser, M.S., Bryce, J. & Joseph, J.G. (1990). AIDS
Work in Health Care, 18, 91-105. related knowledge, attitudes and precautionary be-
Ross, M.W. & Seeger, V. (1988). Determinants of repor- haviours among emergency medical professionals.
ted burnout in health professionals associated with Public Health Reports, 105, 496–504.
patients with AIDS. AIDS & Society, 2, 395-97. Strathdee, S., Flannery, J. & Graydon, D. (1991).
Ross, M.W., Greenfield, S.A. & Bennett, L. (1999). Stressors in the AIDS hospice environment. AIDS
Predictors of dropout, and burnout in AIDS volun- Patient Care, 8, 82–9.
teers: a longitudinal study. AIDS Care, 11, 723–31. Tannenbaum, J. & Butler, R.B. (1992). Reducing sta-
Ross, R.R., Alteimer, M. & Russell, D.W. (1989). Job ff stress: a multicenter hemophilia support group.
stress, social support and burnout among counse- AIDS Patient Care, 21–4.
ling centre staff. Journal of Counselling Psychology, 46, Van Dierendonck, D., Schaufeli, W.B. & Sixma, H.J.
464-70. (1994). Burnout among general practitioners: a
Rucinski, J. & Cybulska, E. (1985). Mentally ill doc- perspective from equity theory. Journal of Social and
tors. British Journal of Hospital Medicine, 33, 90-4. Clinical Psychology, 13, 86–100.
Schaufeli, W.B. & Van Dierendonck, D. (1995). A Van Servellen, G. & Leake, B. (1994). Burnout in
cautionary note about the cross national and clini- hospital nurses: a comparison of AIDS, oncology,
cal validity of cut-off points for the Maslach Bur- general medical and intensive-care unit nurse sam-
nout Inventory. Psychological Reports, 76, 1083–90. ples. Journal of Professional Nursing, 9, 169–77.
Seeley, J., Kajura, E., Bachengana, C., Okongo, M., Visintini, R., Campini, E., Fossati, A., Bagnato, M., No-
Wagner, U. & Mulder, D. (1993). The extended vella, L. & Caffei, C. (1996). Psychological stress in
family and support for people with AIDS in a rural nurses’ relationships with HIV-infected patients: the
population in west Uganda: A safety net with ho- risk of burnout syndrome. AIDS Care, 8, 183–94.
les? AIDS Care, 5, 117-22. Williams, M.J. (1988). Gay men as ‘buddies’ to persons
Silverman, D.C. (1993). Psychosocial impact of HIV- living with AIDS and ARC. Smith College Studies in
related caregiving on health providers: a review, Social Work, 59, 38-51.

Revista Colombiana de Psicología

80