Coping with Stress and Types of Burnout: Explanatory

Power of Different Coping Strategies

Jesus Montero-Marin1,2,6*, Javier Prado-Abril3, Marcelo Marcos Piva Demarzo4, Santiago Gascon5,6,
Javier Garcı́a-Campayo2,3,6
1 Faculty of Health Sciences and Sports, University of Zaragoza, Huesca, Spain, 2 Department of Psychiatry, University of Zaragoza, Zaragoza, Spain, 3 Psychiatry Service,
Miguel Servet University Hospital, Zaragoza, Spain, 4 Department of Preventive Medicine, Universidade Federal de São Paulo (UNIFESP), São Paulo, Brasil, 5 Department of
Psychology, University of Zaragoza, Teruel, Spain, 6 REDIAPP ‘‘Red de Investigación en Actividades Preventivas y Promoción de la Salud’’ (Research Network on
Preventative Activities and Health Promotion), Zaragoza, Spain

Abstract
Background: Burnout occurs when professionals use ineffective coping strategies to try to protect themselves from work-
related stress. The dimensions of ‘overload’, ‘lack of development’ and ‘neglect’, belonging to the ‘frenetic’, ‘under-
challenged’ and ‘worn-out’ subtypes, respectively, comprise a brief typological definition of burnout. The aim of the present
study was to estimate the explanatory power of the different coping strategies on the development of burnout subtypes.

Methods: This was a cross-sectional survey with a random sample of university employees, stratified by occupation
(n = 429). Multivariate linear regression models were constructed between the ‘Burnout Clinical Subtypes Questionnaire’,
with its three dimensions –overload, lack of development and neglect– as dependent variables, and the ‘Coping Orientation
for Problem Experiences’, with its fifteen dimensions, as independent variables. Adjusted multiple determination coefficients
and beta coefficients were calculated to evaluate and compare the explanatory capacity of the different coping strategies.

Results: The ‘Coping Orientation for Problem Experiences’ subscales together explained 15% of the ‘overload’ (p,0.001),
9% of the ‘lack of development’ (p,0.001), and 21% of the ‘neglect’ (p,0.001). ‘Overload’ was mainly explained by ‘venting
of emotions’ (Beta = 0.34; p,0.001); ‘lack of development’ by ‘cognitive avoidance’ (Beta = 0.21; p,0.001); and ‘neglect’ by
‘behavioural disengagement’ (Beta = 0.40; p,0.001). Other interesting associations were observed.

Conclusions: These findings further our understanding of the way in which the effectiveness of interventions for burnout
may be improved, by influencing new treatments and preventive programmes using features of the strategies for handling
stress in the workplace.

Citation: Montero-Marin J, Prado-Abril J, Piva Demarzo MM, Gascon S, Garcı́a-Campayo J (2014) Coping with Stress and Types of Burnout: Explanatory Power of
Different Coping Strategies. PLoS ONE 9(2): e89090. doi:10.1371/journal.pone.0089090
Editor: Gozde Ozakinci, University of St Andrews, United Kingdom
Received August 1, 2013; Accepted January 20, 2014; Published February 13, 2014
Copyright: ß 2014 Montero-Marin et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits
unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
Funding: This study was possible as a result of the support received from the Research Network on Preventative Activities and Health Promotion (RD06/0018/
0017) and the Health Sciences Institute of Aragon (IACS). MMPD is grateful to the CNPq - Brazilian National Council for Research and Technology Development -
for a postdoctoral fellowship (Science without Borders Program). The funders had no role in study design, data collection and analysis, decision to publish, or
preparation of the manuscript.
Competing Interests: The authors have declared that no competing interests exist.
* E-mail: jmontero@unizar.es

Introduction endured. Its presence has been associated with a worsened self-
perception of health and a large amount of somatic comorbidity
Policies and interventions to promote mental health should be [5]. Burnout has traditionally been described as a relatively
designed to effectively involve the work environment and process uniform entity in all individuals, with more or less consistent
as a key arena for action [1]. The majority of people in developed aetiology and symptoms [6]. According to the classical definition,
and developing countries now live in cities and are formally or this syndrome includes the dimensions of exhaustion, cynicism and
informally linked to workplaces where most of their productive professional inefficacy [7,8]. ‘Exhaustion’ is the feeling of not being
lives are spent [2]. Studies have shown the importance of work able to offer any more of oneself at an emotional level; ‘cynicism’
stressors both in the generation and prevention of mental disorders represents a distant attitude towards work, those served by it, and
[3], but there is still a lack of policies and interventions that colleagues; and ‘inefficacy’ is the feeling of not performing tasks
effectively improve workers’ mental health and prevent disorders. adequately or being incompetent at work. These dimensions are
Interestingly, even among mental health workers, work-related strongly associated with each other, providing a unitary although
mental disorders are highly prevalent [4]. Thus, work environ- three-dimensional definition of burnout [9].
ments and processes are key elements in public health. Nevertheless, different burnout types have been proposed,
Burnout syndrome is an important work-related disorder of according to the degree of dedication at work [10]. The ‘frenetic’
psychosocial origin, caused when stressful working conditions are burnout type works increasingly harder, to the point of exhaustion,

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 Coping with Stress and Types of Burnout

in search of success, and presents involvement, ambition and programmes for the syndrome that might potentially be more
overload. The ‘under-challenged’ type has to cope with monot- effective [26]. In this context, the aim of this work was to estimate
onous and unstimulating conditions that fail to provide satisfaction the explanatory power of the different styles of coping with stress
and feels indifference, boredom and lack of personal development. on the development of different burnout subtypes, evaluating the
The ‘worn-out’ type gives up when faced with stress or the absence contribution of specific coping strategies. In general terms, the
of gratification and shows lack of control, lack of acknowledgement hypotheses were established according to the degree of dedication
and neglect [11,12]. The dimensions of overload, lack of at work shown by the different burnout subtypes. The frenetic
development and neglect, belonging to the frenetic, under- burnout subtype is a highly dedicated profile, which means that
challenged and worn-out subtypes, respectively, comprise a the related overload could be associated with active coping
definition of burnout that comes close to the standard perspective strategies, such as those included in problem-focused coping. The
[9,13]. ‘Overload’ refers to individuals’ feeling of risking health under-challenged burnout subtype is a profile characterised by an
and personal life in the pursuit of good results and is significantly intermediate dedication to work, meaning that the related lack of
associated with exhaustion; ‘lack of development’ refers to the development could be associated with avoidance coping strategies.
absence of personal growth experiences for individuals together The worn-out burnout subtype is a profile characterised by a low
with their desire to take on other jobs where they can better level of dedication, meaning that the associated neglect could be
develop their skills and is markedly associated with cynicism; due to a behavioural impairment related to the use of disengage-
‘neglect’ refers to individuals’ disregard as a response to any ment strategies. In essence, this grading of the levels of dedication
difficulty and is strongly associated with inefficacy [13,14]. While could be pointing to different stages in the longitudinal develop-
approaching the standard definition, the dimensions referred to in ment of the syndrome. Different coping strategies for stress could
the typological model show little relation to each other, which be contributing to each of these [10,12].
allows a differential characterisation of the syndrome to be made
by means of clinical profiles [13]. Methods
In general, ‘burnout’ is a subject’s response to chronic work-
related stress and is an attempt to adapt to or protect oneself from Study design
it [15]. Stress has been defined as the result of a relationship with We used a cross-sectional survey design. Participants gave
the environment that the person appraises as significant for his or informed consent and then completed an online self-assessment
her well-being, and in which demands tax or exceed available survey.
coping resources. Coping is defined as cognitive and behavioural
efforts to manage specific internal and/or external demands that Participants
are appraised as taxing or exceeding the person’s resources The study population consisted of all employees of the
[10,16]. A person will be psychologically vulnerable to a particular University of Zaragoza, Spain, who were working in January
situation if he or she does not possess sufficient coping resources to 2008 (N = 5,493), comprising a multi-occupational group that
handle it adequately and places considerable importance on the
included jobs of differing nature and complexity. These workers
threat implicit in the consequences of this inadequate handling.
form a population that is at risk of developing burnout, as they
There are different general trends in coping with stress, such as
consist of professionals working face-to-face with other people
cognitive or behavioural coping, cognitive or behavioural avoid-
[15]. The required sample size was calculated to be able to make
ance, emotion-focused coping or substance use [17–19]. From this
estimates with a 95% confidence level, with a 3.5% margin of
perspective, burnout may be observed as a progressively developed
error, and assuming an 18% prevalence of burnout [30]; thus, the
condition resulting from the use of the ineffective coping strategies
sample size needed was 427 participants. Given that the response
with which professionals try to protect themselves from work-
rate for previous web-mail surveys had been approximately 27%
related stress situations [20].
[31,32], 1,600 people were selected from an alphabetical list of the
There is an accumulation of evidence linking coping styles with
entire workforce by means of random stratified sampling with
stress and burnout. At first, coping style was studied as a relatively
proportional allocation depending on occupation (58% teaching
stable characteristic of the person, regardless of the nature of the
and research staff –‘TRS’, 33% administration and service
task or situation, showing that certain inflexible coping styles could
personnel –‘ASP’, and 9% grant holders –‘GRH’. GRH refers
be associated with higher levels of stress [21,22]. Subsequently, the
to ‘undergraduate’ or ‘postgraduate’ students, employed by the
emphasis was placed on the relationship between the coping style
and the situation [16]. Early research seemed to support the idea university to reinforce different types of services, and to ‘pre-
that problem-focused coping was a better strategy than emotion- doctoral’ or ‘post-doctoral’ students, both postgraduates, specifi-
focused coping for stress management. However, it was later found cally employed to perform research project-related tasks. Sample
that there were sub-factors that did not allow the application of size calculation and random sampling were performed using
such a general conclusion [23]. Problem-focused coping is not an Epidat 3.1 software.
appropriate strategy to address stress if the situation is uncontrol-
lable or chronic [24], as it could lead, in this case, to a progressive Procedure and ethics statement
process of behavioural disengagement [25]. Emotional coping has In April 2008, an e-mail was sent to the selected individuals
been noted to be detrimental if it involves distancing, avoidance or explaining the aims of the research, to whom it was directed, the
denial regarding the situation but is an effective strategy if it voluntary nature of participation, the potential benefits and risks,
involves a positive reappraisal [26,27]. In the long term, the key and data confidentiality. This message contained a link to the
factor for developing the burnout syndrome seems to be the degree online questionnaire and access passwords for participants to
of passivity that the subject acquires [19,28,29]. complete the questionnaire, after providing informed consent.
So far, possible relationships between burnout types and coping Participants had to mark the acceptance of the conditions imposed
strategies have not been explored. A better knowledge of the by the consent form in order to activate the access passwords.
coping strategies associated with each burnout profile could Upon completion of the survey, all participants received an
promote the development of specific treatments and preventive anonymous report with an explanation of their results, as

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 Coping with Stress and Types of Burnout

gratitude. The project was approved by the Clinical Research The explanatory power of the coping strategies in relation to the
Ethics Committee of Aragon, Spain. burnout types was assessed by constructing multiple linear
regression models. For this purpose, the BCSQ-12 subscales
Measurements overload, lack of development and neglect were considered
Sociodemographic and occupational characteri- dependent variables, while the dimensions of the COPE were
stics. Participants were first asked a set of questions dealing considered independent variables, so that three models were
with sociodemographic and occupational characteristics, including constructed. The possible influence of the sociodemographic
the following: age, sex, relationship status (‘yes’ or ‘no’ to being in variables were controlled, and they were included in each model.
a stable relationship), level of education (‘secondary or lower’, The predictive capacity of the models was examined by the
‘university degree’, ‘doctorate’), occupation type (‘TRS’, ‘ASP’, significance of the F value associated with the regression by means
‘GRH’ – and within this group ‘undergraduate’, ‘post-graduate’, of analysis of variance. Multiple correlation coefficients (Ry.123)
‘pre-doctoral’ and ‘post-doctoral’), years of service (‘,4’, ‘4–16’, were calculated to quantify the degree of association between each
‘.16’ – according to the sociodemographic characterisation of the dependent variable and the independent variables taken as a set.
burnout profiles [11,33]), contract duration (‘permanent’ vs Multiple determination coefficients (R2y.123) and adjusted multiple
‘temporary’), contract type (‘full-time’ vs ‘part-time’), whether determination coefficients (adj-R2y.123), were also calculated to
they had taken sick leave in the previous year (‘yes’ vs ‘no’), and evaluate the explanatory capacity of the coping strategies [35,36].
the number of sick leave days taken. The ‘raw’ relationship of each independent variable with each
Burnout subtypes. Participants were asked to complete the dependent variable was calculated by applying Pearson’s r
‘Burnout Clinical Subtypes Questionnaire’ (BCSQ-12) in its correlation coefficient. The individual contribution of the inde-
Spanish language version [13]. This questionnaire consists of 12 pendent variables in each multivariate model was estimated by
items, evenly distributed into 3 dimensions (comprising 4 items in means of the calculation of the standardised slope coefficients
each). The ‘frenetic’ subtype is represented by the ‘overload’ (Beta). Partial correlation coefficients (Ry3.12) were calculated,
dimension (e.g., ‘‘I overlook my own needs to fulfil work indicating the correlation between two variables when the effect of
demands’’); the ‘under-challenged’ subtype by the ‘lack of the other variables included in the equation was removed. Semi-
development’ dimension (e.g., ‘‘My work doesn’t offer me partial correlation coefficients (Ry(3.12)) were also calculated, the
opportunities to develop my abilities’’); and the ‘worn-out’ subtype square of which showed the increase in the coefficient of
by the ‘neglect’ dimension (e.g., ‘‘When things at work don’t turn determination after including a specific variable in a model,
out as well as they should, I stop trying’’). Participants had to partialising the influence of the other included variables. The
indicate the degree to which they agreed with each of the Wald test was used to evaluate the statistical significance of the
statements presented according to a Likert-type scale with 7 contribution of each variable to each model. Tolerance (T) values
response options, scored from 1 (‘totally disagree’) to 7 (‘totally were calculated to rule out possible collinearity problems. The
Kolmogorov-Smirnov (KS) test was used to determine whether the
agree’). Each of the dimensions received a score, which is
conditional distribution of the residuals met the assumption of
presented as a sum of its constituent items divided by the number
normality. Finally, it was confirmed that the Durbin-Watson
of items (scaled score). The factorial validity of the BCSQ-12
values (DW) approached a value <2.00 to rule out autocorrelation
presents consistent results in the study population, with a$0.80
problems in the errors [35,36].
reliability for each of the constituent dimensions and good power
All of the tests were bilateral and were performed with a
for explaining the burnout standard measures [9,13].
significance level of a,0.05. Data analysis was conducted with the
Coping strategies. Participants were then asked to complete
SPSS-15 statistical software package.
the Spanish version of the ‘Coping Orientation for Problem
Experiences’ (COPE) [17,18]. This instrument, widely used for the
evaluation of stress-coping strategies, incorporates 60 items Results
distributed into 15 scales that show the behaviour implemented In order to adhere to standards for data availability, all
in the coping process to address stress. In the Spanish version, materials used to produce the results in this paper will be made
these scales are ‘social support’, ‘religion’, ‘humour’, ‘substance available upon request. This includes [37]: 1.- The list of
use’, ‘planning’, ‘behavioural disengagement’, ‘venting of emo- documents and data files that are needed in order for replication
tions’, ‘acceptance’, ‘denial’, ‘restraint’, ‘focus on solving situa- to be possible, 2.- A detailed list of what will be provided by the
tions’, ‘personal growth’, ‘positive reinterpretation’, ‘distracting authors, and 3.- What steps, and in what sequence, the interested
activities’ and ‘cognitive avoidance’. Participants had to indicate researchers need to take in order for this data to be made
the degree to which they agreed with each of the items according available. In addition, the authors will post these materials on the
to a Likert-type scale with four response options, scored from 1 (‘I group’s website [38].
don’t usually do this at all’) to 4 (‘I usually do this a lot’). The score
from each dimension was presented as a sum of its constituent Sample characteristics
items divided by the number of items (scaled score). The A total of 429 respondents were included in the study,
instrument presents adequate psychometric properties in the representing a response rate (RR) of 26.8%. The RRs by
original and adapted versions; it shows good levels of internal occupation were distributed as follows: 21.6% ‘TRS’, 31.1%
consistency and test-retest reliability; and it has been specifically ‘ASP’, 43.1% ‘GRH’ (x2 = 37.44; df = 2; p,0.001). The mean age
used in other studies with employees of Spanish universities of participants was 40.10 years (SD = 9.98), with 43.9% males.
[17,18,34]. The majority (78.4%) were in a stable relationship and 13.6% had
achieved secondary or lower schooling; 50.2% had university
Data analysis degrees and 36.2% held doctorates. In terms of job position,
A descriptive analysis of participants’ sociodemographic and 46.9% were ‘TRS’; 38.5% were ‘ASP’; and 14.6% were ‘GRH’
occupational characteristics was made using means and percent- (11.3% ‘undergraduate’, 6.4% ‘postgraduate’, 74.2% ‘pre-doctor-
ages according to the nature of the variables. al’ and 8.1% ‘post-doctoral’). In terms of length of employment,

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 Coping with Stress and Types of Burnout

25.5% had been working at the university for ‘less than 4 years’, Discussion
with 41.1% working ‘between 4 and 16 years’ and 33.4% for
‘more than 16 years’. In total, 58.7% were permanent employees This is the first study that has evaluated the explanatory power
and the majority (88.3%) worked full time. During the previous of different coping strategies in relation to the brief typological
year, 29.8% of the participants had taken sick leave. The mean definition of burnout syndrome [13]. Other works have indicated
sick leave days for those who had taken them was 24.88 days the relevance of coping on burnout syndrome as classically defined
(SD = 66.22). [39], but not on the subtypes. Multiple regression analysis showed
that the dimensions of the BCSQ-12 were significantly explained
Descriptives and raw correlations by the coping strategies. Overall, the starting hypotheses were
confirmed: overload was explained by the focus on the solving of
The BCSQ-12 subscales showed the following descriptive
situations, although it was also explained by religion and mainly by
results: ‘overload’ Mean = 3.41 (SD = 1.53), ‘lack of development’
venting of emotions; lack of development was explained mainly by
Mean = 3.14 (SD = 1.68) and ‘neglect’ Mean = 2.20 (SD = 1.06).
cognitive avoidance, although it was also explained by venting of
Table 1 shows the descriptives of the COPE subscales. Table 1
emotions and behavioural disengagement; and neglect was only
also presents the r values for the raw correlation between the
explained by behavioural disengagement, which is consistent with
subscales. As can be observed, all of the BCSQ-12 dimensions
the general proposals of a previous study [33]. Other interesting
showed significant associations with some of the coping strategies.
associations were observed that might be consistent with the idea
that the development of the syndrome would correspond with the
Regression models burnout types as stages [10,12]. These findings may be relevant to
As observed in Tables 2, 3 and 4, the explanatory power of all improve the effectiveness of current interventions on burnout, by
models was reasonable. The most explained burnout dimension influencing preventive programmes adjusted by the specific
was ‘neglect’ (21%), whilst the least explained burnout dimension features of the strategies for handling stress in the workplace [40].
was ‘lack of development’ (9%), with ‘overload’ in the middle The study participants were middle-aged European adults,
(15%). The fit of the multivariate linear regression models, which mostly women, in a stable relationship and with high levels of
was evaluated using the variance analysis, was good in all cases education, mostly working as TRS. Most had worked at the
(p,0.001), with adequate standard error values. DW values were university for between four and sixteen years; more than half were
all appropriate, ruling out self-correlation problems in the errors. permanent employees and most of them worked full-time.
Residual distribution was normal in all cases, making it possible to Approximately one third of the participants had taken sick leave
accept the basic assumptions needed to go ahead with the in the previous year, with a mean of almost four weeks. With
regression. The T values of variables were high, meaning that they regard to the scores obtained for the different scales utilized, the
were models without redundant variables for information purpos- BCSQ-12 dimension with the lowest mean score was neglect,
es. As can be observed, the standard errors from slopes were low perhaps because of the social desirability effect, given the
(,0.25). The main coping strategy that contributed to explaining importance that western countries give to accomplishment at
‘overload’ was ‘venting of emotions’ (Beta = 0.34; p,0.001). work [12]. Substance use was the COPE dimension with lowest
‘Cognitive avoidance’ was the main coping strategy explaining
mean score, meaning that it was the coping strategy least reported
‘lack of development’ (Beta = 0.21; p,0.001). ‘Neglect’ was mainly
by the participants. Likewise, this result should be viewed with
explained by ‘behavioural disengagement’ (Beta = 0.40; p,0.001).
caution due to the well-known social desirability effect related to
Not all intercepts were significant. self-reporting of substance use or misuse [41].

Table 1. Descriptives and raw correlations for the BCSQ-12 and COPE subscales.

Coping strategies Mean SD Overload Lack of development Neglect

Social support 2.50 0.68 0.12* 20.08 20.08

Religion 1.37 0.69 0.12* 0.08 0.01
Humour 2.07 0.76 0.02 ,0.01 20.04
Substance use 1.12 0.40 0.13** 0.08 0.11**
Planning 2.67 0.60 0.14** 20.13** 20.22***
Behavioural disengagement 1.52 0.64 20.02 0.23*** 0.45***
Venting of emotions 2.28 0.66 0.34*** 0.15** 0.18***
Acceptance 2.51 0.64 20.02 20.06 20.02
Denial 1.60 0.41 0.12* 0.15** 0.11*
Restraint 2.35 0.50 0.08 0.03 0.10*
Focus on solving situations 2.37 0.61 0.24*** 20.07 20.09
Personal growth 2.98 0.72 0.04 20.06 20.18***
Positive reinterpretation 2.61 0.61 0.11* 20.05 20.11*
Distracting activities 2.23 0.50 0.10* 0.03 0.02
Cognitive avoidance 1.65 0.54 0.08 0.29*** 0.27***

*** p,0.001; ** p,0.01; * p,0.05 (bilateral).

doi:10.1371/journal.pone.0089090.t001

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 Coping with Stress and Types of Burnout

Table 2. Regression coefficients for the COPE with regard to the ‘Overload’ dimension of the BCSQ-12.

Coping strategies Ry.123 R2y.123 adj-R2y.123 F (df1/df2) pa Se DW pb

0.44 0.19 0.15 5.24 (18/404) ,0.001 1.41 1.92 0.767

Ry3.12 Ry(3.12) T B (95% CI) Se Beta pc

Intercept 0.17 (21.34–1.67) 0.76 0.828

Social support 20.09 20.08 0.63 20.24 (20.49–0.02) 0.13 20.10 0.068
Religion 0.10 0.09 0.89 0.22 (0.01–0.43) 0.11 0.10 0.040*
Humour 0.04 0.03 0.76 0.07 (20.13–0.28) 0.10 0.04 0.487
Substance use 0.05 0.05 0.81 0.19 (20.18–0.57) 0.19 0.05 0.316
Planning 0.03 0.02 0.46 0.09 (20.25–0.42) 0.17 0.03 0.605
Behavioural disengagement 20.02 20.02 0.60 20.05 (20.32–0.22) 0.14 20.02 0.728
Venting of emotions 0.30 0.29 0.72 0.78 (0.54–1.02) 0.12 0.34 ,0.001*
Acceptance 20.04 20.04 0.68 20.12 (20.37–0.14) 0.13 20.05 0.377
Denial 0.04 0.04 0.61 0.17 (20.25–0.59) 0.21 0.05 0.421
Restraint 0.01 0.01 0.61 0.04 (20.30–0.38) 0.17 0.01 0.827
Focus on solving situations 0.11 0.10 0.55 0.33 (0.04–0.63) 0.15 0.13 0.029*
Personal growth 0.01 0.01 0.51 0.04 (20.22–0.30) 0.13 0.02 0.780
Positive reinterpretation 0.05 0.05 0.52 0.17 (20.14–0.48) 0.16 0.07 0.290
Distracting activities 20.01 20.01 0.62 20.04 (20.38–0.31) 0.18 20.01 0.826
Cognitive avoidance 20.02 20.02 0.68 20.07 (20.37–0.24) 0.15 20.02 0.664

Ry.123 = multiple correlation coefficient. R2y.123 = coefficient of multiple determination. adj-R2y.123 = adjusted coefficient of multiple determination. pa = p value for
variance analysis associated with the regression. Se = standard error. DW = Dubin-Watson value. pb = p value for K-S test for normality contrast on residuals.
Ry3.12 = partial correlation coefficient. Ry(3.12) = semi-partial correlation coefficient. T = tolerance value. B = regression slope. CI = confidence interval. Beta = standardised
slope. pc = p value of Wald test result. * = significant value (p,0.05).
doi:10.1371/journal.pone.0089090.t002

Table 3. Regression coefficients for the COPE with regard to the ‘Lack of development’ dimension of the BCSQ-12.

Coping strategies Ry.123 R2y.123 adj-R2y.123 F (df1/df2) pa Se DW pb

0.36 0.13 0.09 3.36 (18/404) ,0.001 1.60 2.04 0.060

Ry3.12 Ry(3.12) T B (95% CI) Se Beta pc

Intercept 2.09 (0.38–3.79) 0.87 0.016

Social support 20.09 20.08 0.63 20.25 (20.54–0.04) 0.15 20.10 0.086
Religion 0.07 0.07 0.89 0.18 (20.06–0.41) 0.12 0.07 0.140
Humour 0.02 0.01 0.76 0.04 (20.20–0.27) 0.12 0.02 0.763
Substance use 20.04 20.04 0.81 20.18 (20.60–0.25) 0.22 20.04 0.415
Planning 20.04 20.04 0.46 20.17 (20.55–0.21) 0.19 20.06 0.387
Behavioural disengagement 0.10 0.10 0.60 0.32 (0.01–0.63) 0.16 0.12 0.041*
Venting of emotions 0.11 0.10 0.72 0.30 (0.03–0.57) 0.14 0.12 0.032*
Acceptance 20.09 20.08 0.68 20.26 (20.55–0.04) 0.15 20.10 0.085
Denial 0.03 0.03 0.61 0.16 (20.31–0.63) 0.24 0.04 0.501
Restraint 20.02 20.02 0.61 20.08 (20.47–0.31) 0.20 20.02 0.695
Focus on solving situations 0.03 0.02 0.55 0.09 (20.25–0.43) 0.17 0.03 0.606
Personal growth 0.05 0.05 0.51 0.15 (20.15–0.44) 0.15 0.06 0.328
Positive reinterpretation 0.05 0.04 0.52 0.16 (20.19–0.51) 0.18 0.06 0.363
Distracting activities 20.04 20.04 0.62 20.16 (20.55–0.23) 0.20 20.05 0.427
Cognitive avoidance 0.19 0.18 0.68 0.66 (0.32–1.00) 0.18 0.21 ,0.001*

Ry.123 = multiple correlation coefficient. R2y.123 = coefficient of multiple determination. adj-R2y.123 = adjusted coefficient of multiple determination. pa = p value for
variance analysis associated with the regression. Se = standard error. DW = Dubin-Watson value. pb = p value for K-S test for normality contrast on residuals.
Ry3.12 = partial correlation coefficient. Ry(3.12) = semi-partial correlation coefficient. T = tolerance value. B = regression slope. CI = confidence interval. Beta = standardised
slope. pc = p value of Wald test result. * = significant value (p,0.05).
doi:10.1371/journal.pone.0089090.t003

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 Coping with Stress and Types of Burnout

Table 4. Regression coefficients for the COPE with regard to the ‘Neglect’ dimension of the BCSQ-12.

Coping strategies Ry.123 R2y.123 adj-R2y.123 F (df1/df2) pa Se DW pb

0.50 0.25 0.21 7.31 (18/404) ,0.001 0.93 2.00 0.110

Ry3.12 Ry(3.12) T B (95% CI) Se Beta pc

Intercept 1.34 (0.35–2.34) 0.51 0.008

Social support 20.04 20.04 0.63 20.07 (20.24–0.10) 0.09 20.05 0.395
Religion ,20.01 ,20.01 0.89 ,20.01 (20.14–0.14) 0.07 20.00 0.964
Humour 20.02 20.02 0.76 20.03 (20.17–0.10) 0.07 20.02 0.635
Substance use 20.01 20.01 0.81 20.01 (20.26–0.24) 0.13 20.01 0.921
Planning 20.10 20.08 0.46 20.22 (20.44–0.01) 0.11 20.12 0.057
Behavioural disengagement 0.33 0.31 0.60 0.65 (0.47–0.83) 0.09 0.40 ,0.001*
Venting of emotions 0.09 0.08 0.72 0.15 (20.01–0.31) 0.08 0.10 0.060
Acceptance 20.09 20.07 0.68 20.15 (20.32–0.02) 0.09 20.09 0.087
Denial 20.08 20.07 0.61 20.21 (20.49–0.06) 0.14 20.08 0.128
Restraint 0.09 0.07 0.61 0.20 (20.03–0.42) 0.12 0.10 0.086
Focus on solving situations 0.08 0.07 0.55 0.16 (20.04–0.36) 0.10 0.09 0.117
Personal growth 20.07 20.06 0.51 20.12 (20.29–0.06) 0.09 20.08 0.184
Positive reinterpretation 0.08 0.07 0.52 0.18 (20.03–0.38) 0.10 0.10 0.094
Distracting activities 0.02 0.02 0.62 0.05 (20.18–0.28) 0.12 0.02 0.691
Cognitive avoidance 0.08 0.07 0.68 0.17 (20.03–0.37) 0.10 0.09 0.094

Ry.123 = multiple correlation coefficient.R2y.123 = coefficient adj-R2y.123 = adjusted

of multiple determination. a
coefficient of multiple determination. p = p value for
b
variance analysis associated with the regression. Se = standard error. DW = Dubin-Watson value. p = p value for K-S test for normality contrast on residuals.
Ry3.12 = partial correlation coefficient. Ry(3.12) = semi-partial correlation coefficient. T = tolerance value. B = regression slope. CI = confidence interval. Beta = standardised
slope. pc = p value of Wald test result. * = significant value (p,0.05).
doi:10.1371/journal.pone.0089090.t004

The raw correlations showed that denial presented low but the stronger one. This result seems to support the burnout
significant associations with all of the BCSQ-12 dimensions, so it typology as a classification of the syndrome according to the
may be present as a characteristic common to each burnout type. commitment at work, as underlies this theoretical proposal [10].
This commonality could be explained by the viewpoint of social Lastly, positive reinterpretation was directly and significantly
exchange [5,42,43]: feelings of discontentment are present in all related to overload, and inversely and significantly related to
the profiles owing to the discrepancy between the personal neglect. These relationships could indicate an important difference
contributions and the gratification obtained in return [6,44]. We between the profiles with regard to their particularities and their
were therefore able to associate the denial characteristic of the contrast in engagement [26,27].
general lack of acceptance observed throughout the burnout types. We observed that overload was mainly explained by venting of
Acceptance is a modern construct in medicine and psychology that emotions as a coping strategy. In general, the use of palliative
is related to psychological flexibility and resilience [45–49]. Thus, strategies with a focus on emotions is related to physical discomfort
denial could be driving workers to a dysfunctional manner of [28]. An emotion-oriented coping style can predict emotional
coping with their daily stressors in the workplace. Venting of exhaustion and depression, and may contribute to the develop-
emotions also presented significant bivariate relationships with all ment and maintenance of psychological problems [26]. In fact,
of the subscales belonging to the different burnout subtypes. This reductions in the use of emotion-focused coping may decrease
coping strategy could be a general feature of burnout, although the levels of exhaustion [27]. On the other hand, as previously stated,
specific content presented in the complaints could be different overload was also explained by the focus on solving situations. This
depending on the type of burnout experiences, as has recently strategy could be responsible for maintaining high levels of efficacy
been reported [50]. Consequently, the frenetic subtype would in this subtype of burnout [6,10–12,52]. Actually, problem-focused
complain about the organizational hierarchy, which imposes limits coping behaviours have been associated with high demands and
to his or her high ambition; the underchallenged subtype would high levels of self-efficacy [53]. Nevertheless, the fact that venting
express distress about the routine nature of his or her obligations, of emotions gains greater relevance than focusing on solving
which would hinder personal development; and the worn-out situations when explaining overload alerts us to the psychological
subtype would be annoyed by the monitoring systems, owing to his distress that this burnout profile suffers. Finally, overload was also
or her negligent behaviour. The perception of continuous explained by religion. This relationship can be understood if we
complaints by colleagues could increase the emotional exhaustion consider effort and resignation at work to be fundamental western
experienced and contribute to the development of negative values. This aspect is reflected in the positive relationships between
attitudes, creating a type of ‘contagion’ mechanism for spreading religious coping and anxiety symptoms [54], and in the tendency
the syndrome to other colleagues in the workplace [15,51]. to rely on religious beliefs and practices in times of illness to relieve
Planning was significantly associated with all the BCSQ-12 stress, retain a sense of control and maintain hope, meaning and
dimensions, positively in the case of overload and negatively for purpose [55]. In summary, the overloaded frenetic subtype
the lack of development and neglect, the latter association being appears to be the most work-involved profile, given its coping

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 Coping with Stress and Types of Burnout

pattern based on solving situations. The use of this strategy in an achievement [56]. Therefore, this burnout type would benefit
inflexible way, as a result of high ambition, could lead to from developing presence at work through mindfulness or values-
exhaustion, especially if the subject blames others for his or her based therapies, both of which are included in ACT and have
dysphoric feelings, using venting of emotions at the same time proven successful in the treatment of burnout [68,69]. Moreover,
[56]. This burnout type would need to improve emotional this burnout type could also benefit from the use of positive
regulation to contribute to the reduction of the psychopathological reappraisal coping [70], which is absent in this profile.
symptoms of burnout [26]. This strategy would not suffice, The main limitation of this study is the fact that its cross-
however, if it were not accompanied by increasing psychological sectional design did not allow us to draw strict conclusions about
flexibility, something that has been shown to be relevant to the the aetiology of burnout subtypes. Furthermore, the fact that the
treatment of burnout [56,57], and which is underpinned by study population consisted of employees of a single university, who
therapies such as the Acceptance and Commitment Therapy were ultimately self-selected, and the difference found in the
(ACT) [58]. response rates by type of occupation, reduced the possibilities for
In general terms, the neglect dimension of the worn-out type of generalising our results. We also observed that grant holders were
burnout is found in the opposite situation because it carries lack of more participative than others and were therefore over-represent-
dedication. In fact, neglect was only significantly explained by ed, which can be explained by their reduced tendency to show
behavioural disengagement, the inverse strategy of problem- neglect [13]. In general, as we did not have sociodemographic data
focused behavioural coping; thus, it was associated with a passive from the total reference population, it was not possible to contrast
coping tendency, which has been positively associated with high to what extent the obtained sample was representative of it. In
levels of job stress [59]. This type of coping is also positively related addition, the fact that measurements of stress in the workplace
to all classical burnout symptoms and is negatively linked to self- were not taken partly hindered the interpretation of our results.
efficacy and job satisfaction [19,29]. The use of the disengagement The study also has many strengths: it was carried out with a
coping strategy has been said to mediate the relationships between
random, broad and multi-occupational sample of employees in at-
job stress and burnout [25], and it may be the main variable
risk occupations with face-to-face personal contacts [15]. Addi-
responsible for inefficacy [9,12]. In other words, the neglected
tionally, the fit of the regression models was adequate. The
worn-out subtype is immersed in abandonment at work, using
distribution of residuals was normal, and no autocorrelation or
behavioural disengagement as a coping strategy. The use of this
collinearity problems were detected, so the basic assumptions for
strategy may result from inconsequential histories of contingencies
the type of data analysis utilised were accepted. Finally, data
regarding awards and control [33] and could drive one to low
quality was controlled by eliminating possible errors in the
performance levels through inefficacy perception [60], which may
questionnaire transcription process through the use of purpose-
cause difficulties in alleviating stress [61]. In general, this burnout
type seems to first require behavioural activation, perhaps by designed software.
giving priority to commitment aspects from ACT or other types of
cognitive and behavioural therapies to reduce stress and burnout Conclusions
symptoms [62], but also by eliminating negative burnout-related Our findings support the hypothesis that different coping styles
cognitions that would serve to perpetuate the syndrome [63,64]. are associated with the diverse burnout subtypes. Overload was
Lack of development from the under-challenged type of explained mainly by venting of emotions, although it was also
burnout was significantly explained by both venting of emotions
explained by a focus on solving situations and religion; lack of
and behavioural disengagement, which are also present in
development was explained mainly by cognitive avoidance, but it
overload and neglect, respectively. Thus, lack of development
was also explained by venting of emotions and behavioural
seems to be in a middle position between the extremes, as it shares
disengagement; neglect was explained only by behavioural
characteristics with the other two profiles. However, it was mainly
disengagement. In general, a progressive decrease in levels of
explained by cognitive avoidance as a coping strategy, which has
engagement is understood to be the response adopted by workers
also been related to physical discomfort [28], so this profile of
experiencing burnout in order to cope with stress and frustration
burnout would have particular features along those lines as well. In
general, escapist coping strategies such as avoidance, even if used [9]. This aspect seems to be an important factor in explaining the
only occasionally, may be strong predictors of burnout in its differences between the subtypes from a longitudinal perspective
classical definition [65], and may increase the use of substance [6,10–12], and could be the keystone for developing new
abuse as a coping strategy [29]. The presence of avoidance in treatment interventions adjusted to the coping strategies of each
general [66], and experiential avoidance in particular [67], has particular case. Cognitive and behavioural therapies, such as
specifically been related to depersonalisation, the corresponding ACT, may be useful for all burnout types, emphasising the
cynicism dimension in the human services professions. This last different modules according to the degree of dedication at work.
one is high and directly associated with lack of development, which However, this therapeutic model is hypothetical and its effective-
is likely due to a relative distancing from obligations [9,12]. ness must be evaluated.
Avoidance is also related to the absence of acceptance [45–49],
reinforcing a dysfunctional coping profile. Consequently, the Author Contributions
development-lacking under-challenged subtype takes a step toward Conceived and designed the experiments: JMM JGC. Performed the
indifference, owing to its use of cognitive avoidance as a main experiments: JMM. Analyzed the data: JMM. Contributed reagents/
coping strategy. The utilization of this strategy could raise levels of materials/analysis tools: JMM SG. Wrote the paper: JMM JPA MMPD.
boredom and cynicism, increasing detachment from tasks as a Interpreted the results, drafted the manuscript and read and approved the
result of distorted basic assumptions regarding success and final version: JMM JPA MMPD SG JGC.

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 Coping with Stress and Types of Burnout

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