Prevalence of exhaustion symptoms and associations with school level, length of work experience and gender: a nationwide cross-sectional study of Swedish principals

In contrast to research on teachers occupational stress, health and wellbeing (e.g., [1‐6]), the health consequences of occupational stress on school principals has received less research attention. The need for new insights in this understudied area of concern have been acknowledged [7‐9]. Indeed, as leaders, principals occupy a key position and have extensive responsibilities and accountability in several areas such as the work environment, pedagogical development, staffing and budgets, etc. [10, 11]. So, as part of the educational system, the actions of principals may contribute to public health via their influences on teachers, children and youth.

To function in their work role, principals, just as any employee, need proper organisational preconditions, motivation, and good health [12, 13]. It is therefore conspicuous that studies from, for example, Australia [8, 14‐18], Belgium [19], Canada [9], Israel [20, 21], Ireland [7], Malaysia [22], United Kingdom [23] and the United States of America [24, 25] collectively indicate that principals have a stressful work situation that put them at risk for work overload, chronic stress and, eventually, conditions such as burnout [26], exhaustion disorder (ED) [27] or other forms of poor health (e.g., cardiovascular disease) [14, 28]. In addition, overstressed principals may contribute to secondary effects by discontinuing their job or negatively influencing the health and wellbeing of staff and students via sub-optimal leadership (e.g., hasty decision-making, lack of strategic planning, limited access to support, etc.). For example, teachers who report experiencing poor leadership tend to report higher burnout scores [2]. And stress and strain have been reported to bi-directionally transmit between principals and teachers [20].

Nevertheless, Swedish research is lacking, and since many international studies have been made prior to the 2010s, their relevance for understanding contemporary principals’ mental health status is declining. Yet, the workload of principals remains a concern in many countries. And, in 2018, questions on principals’ stress were introduced in the Teaching and Learning International Survey (TALIS) [29]. However, these questions only concern perceived sources of stress and do not gauge the mental health status of principals. Yet, according to TALIS, Swedish principals perceived that bearing too much administrative work, having extra duties due to absent school staff, and accommodating students with special needs to be the three most prevalent sources of stress [30].

The importance of monitoring a broad range of psychosocial hazards at work (e.g., violence, harassment, work-life balance, and work-related stress) has been recognized [31]. And the potential consequences of poorly managed psychosocial hazards such as poor mental health and psychiatric disorders attributed to stressful work conditions is not only a concern for principals. It is also a lasting public health concern in many countries [32‐36]. And in response to this concern, the Swedish National Board of Health and Welfare (NBHW) adopted the diagnosis of exhaustion disorder (ED) in 2005 [27, 37]. Incorporated within the diagnostic entity F43 “Reactions to severe stress and adjustments disorders” and ICD-10 code F43.8 “Other reactions to severe stress” [37], ED was designated F43.8A. In contrast to burnout, which focuses on various psychological manifestations of exhaustion (e.g., exhaustion, cynicism and decreased professional efficacy) [26], ED emphasises the physiological aspects that are associated with the excessive and often paralyzing feelings of tiredness, which is a core symptom in both burnout and ED [38, 39]. In contrast to the ED diagnosis, the burnout diagnosis (Z73.0) carries a lower weight in that it is placed in the ICD-10 category “Problems related to life management difficulty” [37]. Observably, this lower diagnostic weight appears to be retained in the forthcoming ICD-11 [40]. However, in ICD-11, the conceptualisation of burnout (QD85) has been improved and clarified. And it is now explained that burnout is a result from chronic workplace stress and a phenomena that is constrained to the occupational context and distinct from adjustment disorder (6B43) [40].

The ED diagnosis was introduced to facilitate the clinical management of people who had sought help for a work-related symptomatology characterised by psychological and physiological complaints relating to excessive tiredness without co-occurring signs of psychiatric morbidity or other conditions (e.g., depression, diabetes, general anxiety, heart disease, substance abuse, thyroid disease, etc.). Presumably, ED is the result of insufficient rest and recovery from very frequent, or excessively long-lasting, stress responses [27, 41‐43]. From this perspective, it should be noted that about 70% of the principals in Sweden are women [44]. And it is known that men and women who perform similar work display similar physiological stress responses [45] and tend to develop similar types of health issues [46]. Accordingly, male and female principals who perform similar work should develop similar health problems. However, on average, women are also known to report more numerous, intense, and frequent bodily symptoms than men [47], and to be more long-term sick-listed than men. This includes sick-listing for psychiatric diagnoses (e.g., depression, anxiety and/or ED), which, since 2014, have been the most common cause of sick-listing in Sweden [48, 49].

Because there are no physiological changes that indisputably define ED, diagnosis and treatment efforts are dependent on analysing contextual circumstances and subjective symptoms. So, to facilitate the detection, monitoring and treatment of ED, the Self-reported Exhaustion Disorder Questionnaire [50] and the Karolinska Exhaustion Disorder Scale (KEDS) [51] were developed. In addition, the Lund University Checklist for Incipient Exhaustion (LUCIE) [52, 53] was developed to assess the earliest signs of exhaustion. Despite conceptual differences, instruments designed to assess symptoms of burnout and ED are known to be positively correlated and thus share common ground [54].

The prevalence rates for the four incremental LUCIE-steps of exhaustion signs (from no exhaustion to possible exhaustion disorder) were: Step 1-GG = 48.8% (n = 1083; 95% CI = 46.7 to 50.9%); Step 2-YG = 25.6% (n = 569; 95% CI = 23.9 to 27.5%); Step 3-RG = 15.4% (n = 341; 95% CI = 13.9 to 16.9%); and Step 4-RR = 10.2% (n = 226; 95% CI = 9.0 to 11.5%). Compared to male principals, female principals had higher prevalence rates of exhaustion in Step 4-RR and lower prevalence rates in Step 1-GG. There was no difference between men or women with regard to the intermediate steps Step 2-YG and Step 3-RG (Table 3).

In total, 29.0% (n = 644; 95% CI = 27.2 to 30.9%) of the principals met the exhaustion criteria in KEDS. More female principals reported signs of exhaustion than their male colleagues (Table 3). The mean KEDS sum score in the total study sample was 14.4 (SD = 8.4; 95% CI = 14.0 to 14.8). For principals who met the exhaustion criteria in KEDS, the mean KEDS sum score was 24.9 (SD = 5.3; 95% CI = 24.5 to 25.3), whereas principals without an exhaustion warning had a mean KEDS sum score of 10.2 (SD = 4.9; 95% CI = 9.9 to 10.4).

The present study aimed to gauge the occurrence of early and manifest signs of exhaustion among Swedish principals. The results showed that 29% of the principals met the exhaustion criteria in KEDS (i.e., a score ≥ 19), whereas 25% had stress (Step 3-RG =15%) or exhaustion (Step 4-RR = 10%) warnings in LUCIE. These prevalence rates are noticeably higher than the prevalence rates observed in a Swedish study sample drawn from a highly educated part of the general population. In this population sample, the occurrence of exhaustion was 5% in LUCIE and 13% in KEDS [53, 54]. The prevalence rates of stress and exhaustion warnings in LUCIE are also higher when compared with data from another Swedish study comprising 863 leaders and employees in a politically governed regional organisation [61]. In this organisation sample, the occurrence of stress and exhaustion warnings in LUCIE were 8 and 5.5%, respectively [61]. In addition, the prevalence rates of signs of exhaustion in LUCIE were also higher among the principals when compared with a Swedish occupational sample consisting of 3658 occupational therapists (94% females) [62]. In this sample of occupational therapists, the occurrence of stress and exhaustion warnings in LUCIE were 11 and 7%, respectively.

Furthermore, a comparison between the group of principals who met the exhaustion criteria in KEDS (i.e., a score ≥ 19) and 698 care-seeking patients with diverse occupational backgrounds [57] also reveal that the principals expressed a noticeable level of exhaustion complaints. While the principals had a lower mean KEDS sum score than the care-seeking patients who received “stress-related diagnoses (i.e., F43)”, they scored almost on par with the care-seeking patients who received “psychiatric diagnoses other than stress (i.e., F [except F43] + Z56)” and clearly higher than care-seeking patients who received “somatic diagnoses (other codes than F-codes and Z56)” [57]. Moreover, when comparing the principals who met the exhaustion criteria in KEDS and a group of 390 Swedish patients undergoing a 24-week multimodal treatment for their diagnosed and pronounced manifestations of stress-related exhaustion [63], the principals scored substantially lower on KEDS than the patient group did immediately before their treatment. However, compared with the patients post assessment and follow-up scores 12 month later, the principals who met the exhaustion criteria in KEDS scored at a similar level as the patient group on both occasions at which the patients’ average scores remained above the level for exhaustion indication in KEDS [63].

Altogether, the results suggest that a large group of principals have reduced mental health. This observation aligns with the few previous studies that have contained validated and specific scales for mental health [8, 20, 23]. Comparison across studies should, however, be made with caution due to differences in study sample compositions, the instruments used, the year data was collected, and variations across countries that are contingent on variations in the educational system. In addition, due to the differences in questionnaire design, layout, scoring procedures and the period the questions refer to; caution should be exercised when comparing LUCIE and KEDS scores. For example, the 28-item LUCIE covers the spectra from the earliest signs of exhaustion to heavy signs possibly indicative of ED by asking for the occurrence and severity of various symptoms in six domains the last 4 weeks [53]. In contrast, the 9-item KEDS focus on assessing symptoms of exhaustion disorder and comprises nine domains during the last 2 weeks [51]. And in a previous study, we observed a low agreement between LUCIE and KEDS classifications of exhaustion [53]. On the other hand, LUCIE and KEDS scores are positively correlated to each other and to the Shirom-Melamed Burnout Questionnaire [64], which suggest that these instruments share common ground [53, 54].

Nevertheless, female principals reported more signs of exhaustion than their male colleagues in both LUCIE (11% vs. 6%, respectively) and KEDS (31% vs. 24%, respectively). This aligns with the fact that women compared with men tend to report more intense, numerous and frequent bodily symptoms [47], and have higher prevalence rates of symptoms of depression and depression diagnoses, in which exhaustion is a core symptom [65]. Observably, many explanations have been proposed as contributing factors. Examples are biological differences, variations in symptom appraisal and symptom perception, socialisation and social roles, abuse and trauma, and gender bias in research etc. [47, 66]. Nonetheless, that female principals report more exhaustion symptoms than male principals align with previous studies in which gender differences in both LUCIE [52] and KEDS [53] have been reported. However, gender differences have not always consistently been observed in LUCIE [53] or KEDS [57]. It is unclear why female principals in the present study report more exhaustion symptoms than their male colleagues. In light of the background questions, a differential exposure to non-work related stress, a lack of access to social support in the private life, or lifestyle differences (i.e., frequency of alcohol intoxication, smoking, and leisure-time physical activity) appear as unlikely explanations for this gender difference. Indeed, female and male principals reported similar levels of exposure to non-work-related stress. And while female principals reported cohabiting to a slightly lesser extent, they did report a greater access to social support in their private life. While female principals reported being less physically active during their leisure time than male principals, they reported similar levels of smoking and being intoxicated by alcohol more seldomly than their male counterparts. The significance of any gender difference in lifestyle behaviours is, however, obscured by the fact that the principals’ lifestyle habits in general suggest that they are ostensibly as healthy as, or healthier, than the general population in Sweden [67]. For example, that only 5% of the principals reported being daily or occasional smokers, and that 12% reported having sedentary leisure time, are more favourable than the national estimates of 14% (2018) and 16% (2015) for the population in the ages 45 to 64, respectively [67]. That fewer principals smoke than in the general population agrees with their relatively high socioeconomic status [68] and with a previous observation in an Australian study [14].

Interestingly, no differences were found in relation to school level. This contrast with previous observations from United Kingdom in a male-dominated study sample [23]. In this large-scale study, the level of mental ill health (as assessed by the Crown Crisp Experiential Index) was inversely related to school level. Accordingly, the highest level of mental ill health was found in primary schools followed by secondary schools and further/higher education institutions [23]. More recent studies have either kept school level constant [7] or have not included school level as a factor in the statistical analyses [8]. However, for the reasons previously outlined above, comparison across studies should be made with caution.

Although a chi-square test initially indicated an association between KEDS and length of work experience as a principal, post-hoc testing failed to confirm any difference. Nevertheless, a gender-stratified analysis indicated that male principals with 3 to 5 years of work experience had higher prevalence rates of exhaustion signs in KEDS when compared with their male colleagues with 5 to 10 years of work experience, or with more than 10 years of work experience. However, given that length of work experience as a principal was correlated with the participants’ chronological age, it is plausible that “third-variable” factors confound the analysis. For example, in an Australian study, it was observed that older principals reported lower levels of stress and burnout than younger principals, whereas work experience did little to protect against the reporting of adverse psychosocial factors [8]. Anyhow, the absence of clear associations with school level and length of work experience may indicate that these two higher-order constructs either have a low explanatory power for principals’ mental health or that they are just too crude as analytical units.

Close to one third of the principals met the KEDS exhaustion criteria, and on LUCIE every fourth principal showed severe stress signs or possible exhaustion disorder. And a larger proportion of women than men met the exhaustion criteria in KEDS and reported possible exhaustion disorder in LUCIE. Thus, a large group of Swedish principals working in pre-schools, compulsory schools, upper secondary schools or adult education displayed a symptomatology of signs of exhaustion that, if sustained, might lead to poor health. The scope and seriousness of complaints suggest that education authorities, or other relevant stakeholders, ought to take some form of preventive actions. However, effective combinations of individual, group, organisational and/or societal preventive activities remain to be identified and tested.