RESEARCH ARTICLE

Burnout, Coping and Job Satisfaction in Service Staff

Treating Opioid Addicts—from Athens to Zurich
Reissner Volker1, Baune Bernhard2, Kokkevi Anna3, Schifano Fabrizio4, Room Robin5,
Palm Jessica6, Stohler Rudolf7, DiFuria Lucia8, Rehm Jürgon9, Hölscher Franz10,
Schwarzer Christine11 & Scherbaum Norbert10*
1
Addiction Research Group at the Department of Psychiatry and Psychotherapy, Department of Child and Adolescent Psychiatry and
Psychotherapy, Rhine State Hospital, University of Duisburg-Essen, Germany
2
Department of Psychiatry, School of Medicine James Cook University, Townsville, Australia
3
Department of Psychiatry, University Mental Health Research Institute (UMHRI), Athens, Greece
4
School of Pharmacy, University of Hertfordshire, United Kingdom
5
Centre for Social Research on Alcohol and Drugs. Stockholm University, Stockholm, Sweden; School of Population Health, University
of Melbourne; and AER Centre for Alcohol Policy Research, Turning Point Alcohol & Drug Centre, Fitzroy, Victoria, Australia
6
Centre for Social Research on Alcohol and Drugs, Stockholm University, Stockholm. Sweden
7
Department of Psychiatry, University of Zurich (PUK), Zurich, Switzerland
8
Servizio Salute, Assessorato Salute Regione Marche, Ancona, Italy
9
ISGF Addiction and Health Research Institute, Zürich, Switzerland
10
Addiction Research Group at the Department of Psychiatry and Psychotherapy, Rhine State Hospital, University of Duisburg-Essen,
Germany
11
Heinrich Heine-University Duesseldorf, Department of Education and Counselling, Duesseldorf, Germany

Summary
The Treatment-systems Research on European Addiction Treatment study (TREAT-project) is a longitudinal mul-
ticenter study on predominantly opioid-dependent patients and their health-care system in six European cities. As
part of the examination of the drug services, this study evaluates level of burnout, coping strategies, perceived self-
efficacy and job satisfaction among health-care workers treating opioid addicts. Employees were recruited from
organizations in Athens, London, Padua, Stockholm, Zurich and Essen. The Maslach burnout inventory, Brief
COPE, general self-efficacy questionnaire and a job satisfaction scale were filled in by about 383 drug service
workers. One-third of the staff suffer from severe burnout. London and Stockholm colleagues are significantly more
burdened than Zurich personnel where job satisfaction is highest. No cross-national differences could be detected
concerning coping styles or level of perceived self-efficacy. Burnout is positively correlated to passive coping strate-
gies and negatively linked to self-efficacy and job satisfaction. Males experience more depersonalization. Organiza-
tional features such as the entry-threshold level of the institution or out- vs. inpatient setting are relevant for coping
strategies and job satisfaction. These and other findings are discussed in relation to preliminary data from the
TREAT-project on characteristics of opioid addicted patients and other specific features of the drug treatment
system. Copyright © 2009 John Wiley & Sons, Ltd.

Keywords
burnout; coping; drug addiction, european drug service worker; TREAT

*Correspondence
Norbert Scherbaum, Klinik fuer abhängiges Verhalten und Suchtmedizin, Rheinische Kliniken Essen, Universität Duisburg-Essen.
Virchowstr. 174, 45147 Essen.
Email: norbert.scherbaum@uni-due.de

Published online in 16 September 2009 Wiley InterScience (www.interscience.wiley.com) DOI: 10.1002/smi.1276

Stress and Health 26: 149–159 (2010) © 2009 John Wiley & Sons, Ltd. 149
Burnout, Coping and Job Satisfaction
Introduction
Burnout is an important problem for service workers
as teachers, therapists or medical staff, caused by
occupational distress (e.g. Wu, Zhu, Li, Wang, &
Wang, 2008). Maslach, Jackson, and Leiter (1996)
define three main symptoms of burnout: (1) emotional
exhaustion; (2) depersonalization (e.g. detached,
impersonal responses toward the service recipient); and
(3) reduced personal accomplishment (lack of compe-
tence and achievement). Burnout is generally associ-
ated with higher rates of illness, increased use of alcohol
and drugs, lower career satisfaction, high staff turnover
but also reduced quality of service, resulting in poor
patient outcome (e.g. Moore & Cooper, 1996; Brennan
& Gareis, 1999).
Investigations on burnout were conducted in many
different sectors of human services. In contrast, studies
on drug service workers specifically treating severely
affected opioid-dependent patients are scarce and
cross-cultural studies even more so. Research designs
focussing on burnout in services similar to drug ser-
vices targeted staff from medical, or less often, from
general psychiatric settings. Studies conducted in these
sectors report burnout-prevalences between 20 and 48
per cent depending on profession and medical special-
ity (Kluger, Townend, & Laidlaw, 2003; Fagin, Brown,
& Bartlett, 1995)
Reasons for burnout in medical settings for example
are high caseloads or pressure to avoid mistakes and
difficult interpersonal relationships with patients. In
the drug services, health-care professionals deal with
additional problems because of the nature of the
patients’ opioid dependence: The course of opioid
addiction is associated with medical and psychiatric
comorbidity (HIV-infection, hepatitis, mood and per-
sonality disorders) as well as accumulated social prob-
lems such as broken families, dissocial behaviour and a
high mortality (e.g. Wall et al., 2000; Sorensen, Jepsen,
Hastrup, & Juep, 2005).
Amongst other factors, coping strategies mediate
burnout. They comprise of stabilizing cognitive and
behavioural efforts to maintain psychosocial adapta-
tion in times of stress. Coping styles can be divided into
active coping (active approach to the stressor) and
passive coping [e.g. denial, withdrawal (Lazarus &
Folkman, 1984)]. A flexible, adapted choice of both
strategies often leads to better adaptation (e.g. Shen,
2009). Studies in nurses show that passive coping is a
150
R. Volker et al.
predictor of negative mental health outcomes and emo-
tional exhaustion (Tyler & Cushaway, 1992; Greenglass
& Burke, 2002). Passive coping is associated with stress
by contact to patients and job dissatisfaction (Tyson,
Pongruengphant, & Aggarwal, 2002) as well as poor
work adjustment in clinical psychologists (Kuyken,
Peters, Power, & Lavender, 2003).
General self-efficacy (GSE) is the belief in one’s com-
petence to deal with challenging new tasks and to cope
with adversity in a broad range of stressful situations
(Bandura, 1997). In staff from medical settings negative
correlations emerged between GSE and burnout
(Greenglass & Burke, 2002; Golub et al., 2008). O’Brien
and Page (1994) showed that self-efficacy is positively
correlated with job-satisfaction in nurses from medical
and surgical settings.
Job satisfaction can be defined as the reactions, feel-
ings and emotions developed by members of an orga-
nization regarding their occupation (Best & Thurston,
2006; Spector, 1997). In nurses occupational stress and
phenomena like absenteeism, employee turnover are
associated with low job satisfaction (Coomber &
Barriball, 2007).
To the best of our knowledge, this is the first inves-
tigation to date which focuses on European drug service
workers’ burnout, coping strategies and job satis-
faction. We are not aware of any studies that have
simultaneously assessed these variables in health-care
professionals treating primarily opioid-dependent
patients. Additionally, the study provides insight into
how members of staff cope with burnout, and which
individual work-related and regional factor predict
burnout. This cross-national study provides the unique
opportunity to compare data from six different Euro-
pean locations. Thus, it may bring empirical evidence
about cultural factors influencing the well-being of
drug service staff from different treatment systems,
stimulate ideas for preventing job burnout and improv-
ing job satisfaction and working life.
Research hypotheses are the following:
1. Burnout-levels amongst European drug service
workers will be high and differences in burnout and
job satisfaction across Europe are to be expected.
2. Drug service workers, in general, will prefer active
coping; those severely burnt-out will prefer passive
coping styles.
3. Different individual and organizational variables
are related to burnout, job satisfaction, coping
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R. Volker et al.
strategies or self-efficacy and may be risk factors
for emotional exhaustion.
Materials and methods
Procedure
This investigation is part of the Treatment-systems
Research on European Addiction Treatment study
(TREAT), which aims at a comparative cross-sectional
and longitudinal description of the health-care system
for drug addicts and the system’s patients in six large
European cities: Athens, London, Padua, Stockholm,
Zurich and Essen.
Drug treatment systems differ across Europe. The
categorization by Klingemann and Hunt (1998), focus-
ing on sociological and health care aspects, guided us
in the selection of participating countries. The authors
distinguish between:
• systems entirely or mostly based on the paradigm of
drug prohibition and the abstinence paradigm (e.g.
Sweden, Finland);
• experimental systems (e.g. England, Netherlands,
Switzerland);
• systems mostly determined by cost-efficient pragma-
tism (e.g. Germany, Austria); and
• systems where the tradition of treating alcohol
dependents largely shaped the drug-treatment
system (e.g. Italy, Greece, France, Spain).
In a second step, information on therapeutic institu-
tions in the participating regions was collected by inter-
viewing several key informants in each site with a
standardized questionnaire. This procedure provided
data on number and types of drug treatment units in
the respective sites. Workplaces in the area’s drug ser-
vices were classified into different categories which
represent variables in the analysis of burnout, job sat-
isfaction and coping strategies: primary treatment
approach, threshold for admission and setting. The
primary treatment approach of the institution was
defined in terms of the basic treatment concept such as
medical (e.g. medication) vs. psychotherapeutic vs.
socio-educational vs. other therapy. Another feature of
institutions caring for drug addicts is the threshold for
admission. Admission to a high threshold facility is
only permitted if certain conditions are fulfilled by
patients (e.g. detoxification as precondition for an
admission to long-term treatment). Finally, institutions
Stress and Health 26: 149–159 (2010) © 2009 John Wiley & Sons, Ltd.
Burnout, Coping and Job Satisfaction
can be divided into outpatient settings, such as out-
reach work or walk-in clinics, and inpatient settings,
including short-term hospital stays or long-term resi-
dential treatment.
Due to the large number of facilities in London, only
the south-western boroughs of the city were chosen. In
Stockholm, a representative selection of institutions
was made using a weighted procedure reflecting the
different types of treatment programmes and propor-
tions of patients treated. In all other regions, drug
service personnel from all institutions were asked to
participate. The following inclusion and exclusion cri-
teria were defined for the drug service workers partici-
pating in the study:
Inclusion criteria:
Health-care workers employed in treatment
units delivering counselling or therapy for pre-
dominantly opioid addicts.
Exclusion criteria:
1. Health care workers employed in institutions
dealing solely with financial or legal problems of
the patients.
2. General practitioners were excluded from the
study as opioid-dependent patients usually are
only a small minority of their patients.
The subjects were asked to fill out the following
questionnaires: Maslach burnout inventory [MBI,
(Maslach et al., 1996)], Brief COPE (Carver, 1997), GSE
(Schwarzer, 1993) and a job satisfaction scale. All ques-
tionnaires are well-established research scales and were
available in most languages. If not, they were adopted
according to the translation-back-translation protocol
of the World Health Organization (Room, Janca,
Bennett, Schmidt, & Sartorius, 1996). In order to
protect the employees’ identity, they were asked to
assign themselves a code. Through this procedure, ano-
nymity was assured and subjects got a computerized
feedback on their personal results.
To avoid a ‘Blue Monday’—bias questionnaires were
distributed on a randomized day. For organizational
reasons, the GSE scale was applied in four (Athens,
Essen, Stockholm, Zurich), and Brief COPE in three
regions only (Essen, Stockholm, Zurich). Table I shows
the number of staff (from 28 in Padua to 147 in Athens)
as well as the return rate, which ranges between 32 per
cent and 68 per cent (43 per cent overall).
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Burnout, Coping and Job Satisfaction R. Volker et al.

Table I. Questionnaire distribution, return rates and sample size

City Questionnaires Number of staff/distributed Questionnaires Return rate

used questionnaires completed (per cent)

Athens MBI/JS/GSE 368 147 46.8

Essen MBI/JS/GSE/Brief COPE 99 67 67.7
London MBI/JS 149 57 38.3
Padua MBI/JS 80 28 35.0
Stockholm MBI/JS/GSE/Brief COPE 111 35 31.5
Zürich MBI/JS/GSE/Brief COPE 108 49 45.4
Total — 902 383 42.5

MBI: Maslach burnout inventory; JS: job satisfaction; GSE: generalized self-efficacy scale.

Table II. Sociodemographic and job related characteristics of drug service workers

Athens Essen London Padua Stockholm Zurich Total

N 147 67 57 28 35 49 383
Age (years)
Mean 33.51 35.49 39.81 38.69 49.65 41.68 37.82
SD 6.64 7.63 11.13 7.97 8.08 7.67 9.38
Gender (per cent)
Female 67.3 58.2 54.4 53.6 65 53.1 60.5
Male 32.0 41.8 43.9 42.9 30 44.9 37.4
Job experience (years)
Mean 1.92 2.22 2.71 3.14 3.58 2.71 2.45
SD 0.89 1.02 1.26 1.27 1.51 1.31 1.25
Profession (per cent)
Nursing staff 23.8 19.4 36.8 28.6 55 12.2 26.9
Social work 21.1 55.2 22.8 35.7 5 20.4 26.4
Therapeutic staff 42.9 19.4 28.1 21.4 17.5 57.1 34.1
Others 12.2 6.0 12.3 14.3 22.5 10.2 12.1

SD: standard deviation.

Sample characteristics
The majority of respondents were female (60 per cent).
There is no significant site-effect on gender distribution
(χ2 = 5.92, df = 5, p = 0.314), but there is on age
(F = 30.28, df = 5.378, p < 0.001) and job experience
(F = 17.59, df = 5.374, p < 0.001). The oldest drug
service sample with the longest experience was found
in Stockholm (see Table II). On average, Swedish
employees were aged 50, in contrast to their colleagues
from Athens who were aged 34 years. The experience
in the treatment of opioid addicted patients ranged
from a top average of 3.5 years (Stockholm) down to
1.9 years (Athens). Different health-care systems rely on
different professions in the treatment of patients. In
Stockholm, the majority of drug service workers are
trained nurses. Therapeutic staff such as psychiatrists,
psychologists and other therapists dominates the Athens
and Zurich teams. The patient from Essen most often
faces a social worker.
Measures
MBI
Burnout was assessed using the MBI, a 22-item,
internationally acknowledged scale by Maslach et al.
(1996). It covers the three main domains of burnout:
emotional exhaustion, depersonalization and reduced
personal accomplishment. Constructs are measured on
a seven-point Likert scale from 0 (never) to 6 (every
day). Subscale scores can be classified into ‘high’,
‘average’ and ‘low’ severity categories (e.g. high emo-
tional exhaustion: ≥21 points; average: 14–20 points;
low: ≤13 points). Note that for the personal accom-
plishment scale, a low number indicates burnout.

152 Stress and Health 26: 149–159 (2010) © 2009 John Wiley & Sons, Ltd.
R. Volker et al.
The Brief COPE (Carver, 1997)
The brief COPE is a 28-item questionnaire which
enquires about 14 theoretically and factor–analytically
derived coping styles, classified into active versus
passive coping. It can be adapted to any situation such
as occupational stress, and predicts clinically relevant
outcome across many populations (Meyer, 2000).
GSE 10-item-questionnaire
The version used here was developed by Schwarzer
(1993). A typical item is ‘I can handle whatever comes
my way’. The response format is a four-point scale.
High scores signal an optimistic belief in self-efficacy.
Job satisfaction
was measured on the basis of a job satisfaction analy-
sis every 30 minutes of one working day. Subjects were
asked to rate their satisfaction with their specific occu-
pation on a five-point Likert scale from 1 (very satis-
fied) to 5 (not satisfied at all): the higher the average
mean-score for the working day, the lower the job
satisfaction.
Across all regional samples alpha coefficients of the
burnout, coping, self-efficacy and job satisfaction vari-
ables varied from 0.67 (active coping, Essen) to 0.96
(job satisfaction, Padova) with one exception (0.50
passive coping, Essen). These reliabilities were judged
to be sufficient for survey research.
Figure 1 Percentage of drug service providers with severe burnout
Stress and Health 26: 149–159 (2010) © 2009 John Wiley & Sons, Ltd.
Burnout, Coping and Job Satisfaction
Statistical analysis
Group comparisons were carried out by analysis of
variance for continuously distributed variables with
corrected degrees of freedom if necessary (post-hoc:
Tamhane), t-tests for dependent and independent
samples, and by χ2-test for dichotomous variables. A
logistic regression was conducted and odds ratios (OR)
and 95 per cent confidence intervals (CI) were calcu-
lated to determine predictors of burnout. All analyses
were performed using SPSS v10.0.
Results
Burnout across European drug
service workers
In our sample, 29 per cent of drug service workers are
suffering from severe symptoms of emotional exhaus-
tion and depersonalization according to the definition
by Maslach et al. (1996). The feeling of not being good
enough at job, to a severe degree, is experienced by 14.5
per cent (high emotional exhaustion; see Figure 1).
Regarding emotional exhaustion—which is commonly
defined as the main criterion of burnout—in London
and Stockholm, 44 per cent of personnel are categorized
as being highly burnt out; while in Padua, Athens and
Essen, the range is between 30 and 24 per cent. In Zurich
there are only 8 per cent severely affected staff. The
highest percentage of subjects distancing themselves
from their emotional ties to the patients is found in
153
Burnout, Coping and Job Satisfaction R. Volker et al.

Essen (42 per cent; category high depersonalization), in
contrast to Padua, with the lowest rate (22 per cent).
The rates for the category low personal accomplishment
range down from 26 per cent in Stockholm and Padua
to 4.1 per cent for Zurich.
Differences in burnout and job
satisfaction across European drug
service workers
Table III presents regional differences for the mean-
scores of the three aspects of burnout. Health-care
workers from London (p < 0.01), Stockholm (p < 0.01)
and Athens (p = 0.011) were more severely disturbed
by emotional exhaustion than their colleagues from
Zurich. Team members from Essen find themselves
more depersonalized than staff from Padua, Stockholm
and Zurich (p = 0.022). Differences concerning the
mean scores for personal accomplishment were not
significant.
The average job satisfaction was reported to be ‘satis-
factory’. But there were differences between the regions
(F = 2.67, df = 5; 364, p = 0.022); it was significantly
better in Zurich or Athens than in Essen.
Coping with occupational stress and burnout
In general, active strategies to cope with occupa-
tional stress were preferred to passive ones (t = 25.764,
df = 154, p < 0.01). No differences were detected
between the sites on active or passive coping. The same
is true for perceived self-efficacy (see Table IV). Staff
classified as highly emotionally exhausted according to
the definition of Maslach et al. (1996), use passive
coping strategies more often than those with average or
low scores (t = 5.148, df = 150, p < 0.01).
Individual and organizational factors
associated with burnout
Correlations between the four main variables are
presented in Table V. Emotional exhaustion and dep-
ersonalization are associated with the dominance of
passive coping styles, low self-efficacy and less job sat-
isfaction. Feelings of personal accomplishment corre-
late with efforts to actively solve occupational problems,
high self-efficacy and positive views on the job. Drug
service workers scoring high on the active coping scale
also experience a stronger self-efficacy. They perceive
themselves more effective in solving problems. Passive

Table III. Mean scores for burnout and job satisfaction

Athens Essen London Padova Stockholm Zurich Total

Burnout
N 147 67 57 28 35 49 383
Emotional exhaustion
Mean** 16.64 15.06 19.07 15.89 18.79 11.59 16.25
SD 8.69 8.36 10.56 9.15 11.58 5.30 9.18
Alpha reliability 0.86 0.87 0.87 0.86 0.93 0.73 0.85
Depersonalization
Mean* 5.63 7.04 5.14 4.41 4.28 4.82 5.48
SD 4.51 4.67 5.28 4.39 4.94 3.61 4.64
Alpha reliability 0.67 0.71 0.85 0.67 0.78 0.67 0.71
Personal accomplishment
Mean 37.05 35.18 35.47 33.78 34.00 37.86 36.05
SD 5.84 6.50 6.21 8.37 8.89 6.20 6.70
Alpha reliability 0.79 0.74 0.68 0.69 0.85 0.71 0.74
Job satisfaction
N 144 61 53 26 37 49 370
Mean* 2.04 2.23 2.07 2.32 2.05 2.03 2.09
SD 0.46 0.46 0.59 0.76 0.52 0.40 0.51
Alpha reliability 0.84 0.81 0.90 0.96 0.88 0.78 0.87

One-way analysis of variance: * p < 0.05; ** p < 0.001.

Burnout severity degree (Maslach et al., 1996)
Emotional exhaustion: high: ≥21; medium: 14–20; low: ≤13.
Depersonalization: high: ≥4; medium: 5–7; low: ≤4.
Personal accomplishment: high: ≤28; medium: 33–29; low: ≥34.
SD: standard deviation.

154 Stress and Health 26: 149–159 (2010) © 2009 John Wiley & Sons, Ltd.
R. Volker et al. Burnout, Coping and Job Satisfaction

Table IV. Mean scores for active/passive coping strategies and self-efficacy

Athens Essen London Padua Stockholm Zurich Total

Active coping
N — 67 — — 39 49 155
Mean — 2.51 — — 2.68 2.60 2.58
SD — 0.31 — — 0.64 0.34 0.43
Alpha reliability — 0.67 — — 0.89 0.66 0.78
Passive coping
Mean — 1.65 — — 1.77 1.64 1.68
SD — 0.24 — — 0.40 0.29 0.30
Alpha reliability — 0.50 — — 0.73 0.68 0.62
Self-efficacy
N 147 67 — — 39 49 302
Mean 30.60 29.5 — — 29.5 29.3 30.0
SD 3.98 3.29 — — 4.73 4.26 4.01
Alpha reliability 0.85 0.76 — — 0.82 0.85 0.82

One-way analysis of variance.

SD: standard deviation.

Table V. Correlations between burnout, coping, self-efficacy nurses, social workers) did not differ concerning any of
and job satisfaction the four study variables. Another factor that might be
related to burnout is experience on the job. In this study
Active Passive Self- Job
Coping Coping efficacy satisfaction subjects working for more than 2 years with drug
addicted patients did not distinguish themselves from
Emotional exhaustion 0.12 0.47** −0.26** 0.24**
Depersonalization −0.08 0.29** −0.21** 0.24**
those with less addiction work experience in terms of
Personal 0.23** −0.13 0.37** −0.26** burnout, coping strategies or job satisfaction. Hierarchi-
accomplishment cal position or primary treatment approach of the
Active coping — 0.32** 0.30** −0.16 organization (medical vs. psychotherapeutic vs. socio-
Passive coping — — −0.31 −0.25**
educational vs. other) did not have any effect either.
Self-efficacy — — — −0.27**

* p < 0.05; ** p < 0.001.

strategies to ward off negative emotions went along
with low job satisfaction, which in turn is associated
with lower self-efficacy.
Considering the whole sample of European drug
service workers together, other job-related or organiza-
tional characteristics were investigated which might be
associated with the main variables. Males are more prone
to depersonalization (T = −2.63, df = 277.54, p = 0.009).
Gender differences were not demonstrated for coping
strategies, self-efficacy or job satisfaction. Staff from
inpatient settings show more active coping behaviour
than staff from outpatient services (T = −2.445, df = 148,
p = 0.016). No such difference could be found for passive
strategies. Members of high-threshold services distin-
guish themselves in their superior job satisfaction (T =
2.611; df = 348,088; p = 0.009). In the combined sample,
the different professions (e.g. doctors, psychotherapists,
Risk factors for emotional exhaustion
Finally, the relationship between the above mentioned
variables and the major burnout factor emotional
exhaustion was examined by a logistic regression
model. The stepwise, backwards regression (Wald)
controlled for sociodemographic/job-related variables
(age, gender, profession, experience on the job, posi-
tion, work satisfaction), coping strategies (active/
passive coping, self-efficacy) and organizational fea-
tures such as the entry-threshold level of the institution,
out- vs. inpatient setting or recruitment site. The result-
ing odds ratios were interpreted as the relative risk of
suffering from high emotional exhaustion. The analysis
included 142 persons from Essen, Stockholm and
Zurich who had filled in the complete set of question-
naires. For job-related variables general job satisfaction
emerged as significant predictor. Staff with low satisfac-
tion at the work place show a 13.2 fold risk of being
burned out (95 per cent CI = 1.5–9.3). Drug service

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Burnout, Coping and Job Satisfaction
Table VI. Logistic regression model of ‘high emotional exhaustion’ status
Variable B SE B Wald
Male 0.69 0.506 1.86
Passive Coping 1.32 0.464 8.13
Job satisfaction 2.58 0.675 14.62
Stockholm 1.73 0.610 8.03
* p < 0.05; ** p < 0.001; N = 142 from Essen, Stockholm, Zurich.
Nagelkerke R2 = 0.411.
B = regression coefficient, SEB = standard error of B.
personnel from Stockholm are associated with a higher
burnout rate (OR = 5.6, 95 per cent CI = 1.7–18.6). The
frequent use of passive coping strategies was also a pre-
dictor of high emotional exhaustion (OR = 3.8, 95 per
cent CI = 1.5–9.3). (see Table VI ).
Discussion
About one-third of European drug service workers are
affected by a severe, clinically relevant burnout syn-
drome. As comparable data from other studies of health
workers caring mainly for opioid-addicts are not avail-
able, studies on adjoining occupational fields should be
considered. With emotional exhaustion being regarded
as the main symptom, drug workers’ burnout is posi-
tioned in mid-range as compared to other health-care
service workers (Butterworth, Carson, Jeacock, White,
& Clements, 1999; Iacovides, Fountoulakis, Moysidou,
& Ierodiakonou, 1999; Grassi & Magnani, 2000). Fagin
et al. (1995) report that 45 to 48 per cent of an English
sample of psychiatric nurses were highly emotionally
exhausted. In contrast to those working in the medical
field, investigations on community mental health staff
from Austria (Swoboda et al., 2005) or Germany
(Messenzehl et al., 2007) both measured a rate of 19
per cent being emotionally drained. This is, to our
knowledge, the first study to simultaneously assess
burnout, coping styles and job satisfaction on a sample
solely consisting of drug service workers for opioid-
dependent patients.
In addition, it is unique in providing data from a
cross-cultural design including data on the patients
under treatment. For the Zurich drug service workers,
the prevalence of burnout is significantly lower than in
Stockholm or London. As in this study, other organiza-
tion-related factors were not directly linked to burnout;
patients’ characteristics may be the cause for this
finding. Data provided by the TREAT study show that
156
R. Volker et al.
Significance Odds ratio 95% Confidence interval
0.173 1.99 0.74–5.38
0.004* 3.76 1.51–9.33
<0.001** 13.20 3.52–49.55
0.005* 5.64 1.71–18.64
Zurich patients utilize drug services more often than
their European counterparts and receive the highest
social support from drug workers and non-
professionals. On the other hand, opioid addicts from
Stockholm receive low informal and formal social
support accompanied by one of the lowest rates of
health-care system utilization. Given the finding that
close contact with the severely affected patients is
considered as the main reason to develop burnout, drug
workers in Zurich may deal with a more stable popula-
tion which in turn is a protective factor. A similar effect
from caring for ‘healthier’ populations could explain
why staff from high-threshold facilities are more
content with their jobs. For instance, a patient taken
into long-term rehabilitative therapy has to be abstinent
from illegal drugs and alcohol and thus undergo detoxi-
fication treatment first. He learns to comply with rules
and standards of different therapeutic institutions and
already has experience with therapeutic inpatient set-
tings and should have gained some insight into his dis-
order. He is more motivated and has a higher chance to
achieve abstinence, which in turn may motivate his
therapists.
In the literature, there is some dispute over gender
bias regarding burnout. Several studies on medical
personnel did not discriminate between the sexes
(Naisberg-Fennig, Fennig, Keinan, & Elizur, 1991;
Kirkcaldy & Martin, 2000). Grassi and Magnani (2000)
discuss a higher burnout-risk for male general practi-
tioners. In this study high depersonalization rates are
found especially among males.
Depersonalization, as the act of distancing oneself
from the patient, may be interpreted as a passive coping
style, which is positively associated with burnout states.
Highly burnt out drug service workers appraise their
situation as uncontrollable, and thus, try to evade their
negative emotions. Similar coping patterns were found
by Deary, Agiuos, and Sadler (1996) in stressed psychia-
Stress and Health 26: 149–159 (2010) © 2009 John Wiley & Sons, Ltd.
R. Volker et al.
trists and other medical specialities. As a consequence,
perceived self-efficacy is reduced (Schwarzer, Boehmer,
Luszczynska, Mohamed, & Knoll, 2005).
Like other medical staff experiencing less or no
burnout (Tattersall, Bennett, & Stirling, 1999; Tyson
& Pongruengphant, 1996; Tyson, Pongruengphant, &
Aggarwal, 2002), drug service workers in general prefer
active coping. This is especially true for subjects from
inpatient settings, possibly as the situation on a ward
seems to be more controllable than, for example, in a
street-work setting. For the whole sample, the frequent
use of passive coping strategies indicates a high risk for
burnout. No significant cross-European differences
were found concerning coping mechanisms or self-
efficacy. Obviously, organizational variables exert a
higher influence than general cultural differences,
which are marginal between western countries but sig-
nificant in comparison with eastern cultures (Chun,
Moos, & Cronkite, 2006).
As is to be expected, job satisfaction is negatively
correlated to burnout, passive coping styles are posi-
tively linked to self-efficacy. It also is a significant pre-
dictor of high emotional exhaustion. Job satisfaction is
relatively low in Essen, where high depersonalization
rates prevail, and highest in Zurich. Despite above-
average rates of emotional exhaustion, drug service
workers in Stockholm and London seem relatively high
in their contentment on the job. According to the
model presented by Porter and Lawler (1968) there are
several other variables that were not ascertained in this
study which influence employee satisfaction (e.g. mon-
etary or non-monetary rewards, career perspectives,
role-conflicts). They may help to account for the differ-
ences between the six European sites.
Methodical problems to be considered are the ques-
tionnaire return-rate and—given a medium to low
return rate—selection bias. In the literature on burnout,
reported response rates for medical services are between
39 per cent and 80 per cent (e.g. Stordeur, D´hoore, &
Vandenberghe, 2001; Siguero, Perez, Gonzalez, &
Cermeno, 2003). Therefore, the response rate in this
study (average 43 per cent) is acceptable, especially con-
sidering the length of the questionnaire and possible
fears of respondents that their personal results might
leak through to their employers or superiors. A more
specific reason for selection bias is burnout itself.
Severely burnt-out drug workers may have refused par-
ticipation more often. This has to be taken into account
in interpreting the results. Another methodical problem
Stress and Health 26: 149–159 (2010) © 2009 John Wiley & Sons, Ltd.
Burnout, Coping and Job Satisfaction
is the cross-cultural applicability of those question-
naires which had to be translated into foreign languages
(especially Brief COPE and job satisfaction analysis).
Because of financial reasons, an international standard-
ization study could not be undertaken. Nevertheless,
it may be assumed that the close translation of the
source questionnaire according to translation-back-
translation-protocol will result in an adequate target
language questionnaire. In addition, the four main
concepts of this study should be meaningful to the
study of participants sharing a western-Europe cultural
background.
The data presented here show a considerable extent
of burnout and identified direct and indirect risk-
factors on an individual and structural level. For the
first time, international differences were verified in
drug service workers for burnout and job satisfaction,
but not for such influencing variables as coping styles
or perceived self-efficacy. This calls for follow-up work
such as a differentiated examination of each site to
devise specific interventions on an individual or orga-
nizational level. For instance, what are the organiza-
tional reasons (e.g. work-processes, staffing etc.) for
high depersonalization rates in Essen’s drug services? In
general, our data suggest a focus on improving coping
skills. Especially male drug service workers in low-
threshold or outpatient settings should be targeted. To
prevent human costs for employees and patients, as
well as for health-care system providers (Felton, 1998),
stress audits, counselling to gain a stable work–life
balance and other quality management measures
should be established to reduce burnout.
Acknowledgments
This project has been funded by the European Com-
mission (QLRT 199900873). Thanks are also due to all
researchers in the cooperating European centres. We
are also indebted to all drug service workers who took
part in this study.
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