The overall purpose of this thesis is to investigate whether there is an association between “stress of conscience” — that is, stress related to a troubled conscience — and burnout, and to obtain an enhanced understanding of factors related to stress of conscience and burnout in healthcare. Of the four “studies” included, one uses qualitative research methods and the others use quantitative research methods. The data are based on cross-sectional questionnaire studies (I, II, and IV) and open-ended interviews (III). We could find no existing suitable instrument for measuring troubled conscience in healthcare, and so we constructed and tested the “Stress of Conscience Questionnaire” (SCQ) (I), a nine-item instrument for assessing stressful situations and the degree to which they trouble the conscience. We included 164 participants in the pilot studies, an additional 444 in the main analysis, and 55 in the test-retest verification. Participants had various occupational backgrounds and were recruited from different parts of Sweden. Our findings suggest that the SCQ is a valid and reliable measurement for use in various healthcare contexts. Cronbach’s α for the overall scale was 0.83, ensuring internal consistency. Explorative factor analysis identified and labelled two factors: “internal demands” and “external demands and restrictions”. To investigate factors related to stress of conscience and burnout (II, IV) we used a sample of 423 healthcare personnel from various specialities and with various occupations, from a district in northern Sweden. Multiple regression analysis showed that the factors related to stress of conscience (II) were: perceiving that conscience warns us against hurting others while at the same time not being able to follow one’s conscience at work, and having to deaden one’s conscience in order to keep working in healthcare; and also moral sensitivity items belonging to the factor “sense of moral burden”. In addition, deficient social support from superiors, low levels of resilience, and working in internal medicine wards were all associated with stress of conscience. The model explained 40% of the total variance. Interviews were conducted with 30 healthcare managers, to illuminate their explanatory models of the sources contributing to burnout in healthcare settings (III). The data were analysed using qualitative content analysis. The findings indicate that continuous reorganisation and downsizing of health care has reduced resources, while at the same time demands and responsibilities have increased. These problems are compounded by high ideals and expectations, making staff question their own abilities and worth. All in all this throws healthcare employees into a spiralling sense of inadequacy and an emerging sense of pessimism and powerlessness. Multiple regression analysis showed that having to deaden one’s conscience, stress of conscience from lacking the time to provide the necessary care, the work being so demanding that it influences one’s home life, not being able to live up to others’ expectations, low social support from co-workers, and low levels of resilience were all related to emotional exhaustion. Other factors that had an impact were being female, being a physician or being other healthcare professional and working in geriatric care or a primary healthcare centre. The full model explained 59% of the variance. Factors contributing to depersonalisation were: having to deaden one’s conscience, stress of conscience from not being able to live up to others’ expectations and from having to lower one’s aspirations to provide good care, deficient social support from co-workers, and being a physician; however, the percentage of variation explained was smaller (30%) (IV). The findings indicate that burnout is related to being unable to live up to one’s moral convictions; thus, it is a consequence of healthcare employees’ feeling that they are not acting on their values and for the wellbeing of the patients.

Background. Police work is a stressful occupation with frequent exposure to traumatic events and psychological strain from work might increase the risk of burnout. This thesis focuses on patrolling police officers (PPO), who work most of their time in the community and have daily contact with the public. Since police work traditionally is a male coded occupation we assume that there are differences between women and men in burnout as well as experiences from psychosocial work environment. Aim. The overall aim of this thesis is to explore burnout, psychosocial and physical work environment, coping strategies, and stress of conscience when taking gender into consideration among patrolling police officers. Methods. This thesis employs both qualitative and quantitative methods. In Paper I a qualitative approach with narrative interviews was used where male PPO described experiences of traumatic situations when caring for victims of traffic accidents. A convenience sample of nine male PPO from a mid-sized police authority was recruited. Interviews were analyzed using qualitative content analysis. Papers II, III, and IV were based on a cross-sectional survey from a randomly selected sample stratified for gender from all 21 local police authorities in Sweden. In the final sample, 1554 PPOs were invited (778 women, 776 men), response rate was 55% (n=856) in total, 56% for women (n=437) and 53% for men (n=419). The survey included a self-administered questionnaire based on instruments measuring burnout, stress of conscience, psychosocial and physical work environment, and coping. Results. Findings from Paper I were presented in three themes; “being secure with the support system,” “being confident about prior successful actions,” and “being burdened with uncertainty.” Results from Paper II showed high levels of emotional exhaustion (EE), 30% for female PPOs and 26% for male PPOs. High levels of depersonalization (DP) were reported for 52 % of female PPO, corresponding proportions for male were 60%. Multiple logistic regression showed that stress of conscience (SCQ-A), high demand, and organizational climate increased the risk of EE for female PPO. For male PPO stress of conscience (SCQ-A), low control and high demand increased the risk of EE. Independent of gender, stress of conscience (SCQ-A) increased the risk of DP. Psychometric properties of the WOCQ were investigated with exploratory factor analysis and confirmatory factor analysis, a six-factor solution was confirmed. DIF analysis was detected for a third of the items in relation to gender. In Paper IV a block wise hierarchical multiple regression analysis was performed investigating the predictive impact of psychological demand, decision latitude, social support, coping strategies, and stress of conscience on EE as well as DP. Findings revealed that, regardless of gender, risk of EE and DP increased with a troubled conscience amongst the PPO. Conclusion. “Being burdened with uncertainty” in this male-dominated context indicate that the PPO did not feel confident talking about traumatic situations, which might influence their coping strategies when arriving to a similar situation. This finding can be related to Paper II and IV showing that stress of conscience increased the risk of both EE and DP. The associations between troubled conscience and the risk of experiencing both emotional exhaustion and depersonalization indicate that stress of conscience should be considered when studying the influence of the psychosocial work environment on burnout. Results from this study show that the psychosocial work environment is not satisfying and needs improvement for patrolling police officers in Sweden. Further studies including both qualitative and quantitative (longitudinal) methods should be used to improve knowledge in this area to increase conditions for preventive and rehabilitative actions.