Burnout Syndrome in Reception Systems for Illegal Immigrants in the Mediterranean. A Quantitative and Qualitative Study of Italian Practitioners

: Illegal immigration throughout the Mediterranean Sea is an intense and epoch-making phenomenon. This quantitative and qualitative study, based on the framework of the JD-R Model of burnout, described and assessed the risk of burnout among practitioners working in the reception system for illegal immigrants. A sample of Italian practitioners completed the Link Burnout Questionnaire (N = 193) and a semistructured interview (N = 108). The analysis of the questionnaires was carried out via ANOVA and χ 2 test. The content of the interviews was examined using T-LAB. Quantitative results showed that the sample was generally at risk of burnout, and about a quarter were at severe risk. Qualitative results highlighted aspects of burnout that are speciﬁc to this working context: large workload, mental fatigue, and lack of social support; inability to understand the language and cultural di ﬀ erences of the immigrants; having to deal with organisational problems that come up repeatedly. This study o ﬀ ers coping strategies that can improve organisational health and performance of practitioners working in illegal immigration. Italy’s shape, geographical location, and geo-political role make it a case in point for the whole European continent regarding the sustainability of illegal immigration across the Mediterranean Sea.


Introduction
Illegal migration from North African and Middle Eastern countries into southern European countries is a complex, multifaceted phenomenon, vast in terms of numbers and, to some extent, epoch-making. Immigrant flows put a strain on the reception centres in the European countries involved. This phenomenon can cause practitioners working with illegal immigrants to suffer from stress, which may turn into psychological and social distress, or even verge on burnout. Within the framework of the psychology of sustainability [1], it is therefore important to monitor the risk of organisational distress among these workers, determine strategies to enhance their performance [2] and promote processes of social and economic development that can help to properly sustain the management of illegal immigration [3].

Illegal Immigration in the Mediterranean Sea
Illegal immigration is mainly due to the extreme physical and economic hardship that characterises the African continent and Middle Eastern countries in comparison to better-off European countries [4]. these activities are mainly law enforcement officers (Guardia di Finanza, who investigate financial and smuggling crimes; Coast Guard; Frontex, the European Boarder and Coast Guard), medical staff (doctors and nurses), psychologists working for volunteer-based national agencies (e.g., Civil Protection, Caritas, Red Cross), and humanitarian organisations (e.g., Save the Children, UNHCR). Some organisations working during this phase and at this level also operate as European hotspots in Lampedusa, Trapani, Pozzallo, and Taranto.
First-line Reception. All illegal immigrants who wish to apply for international protection are taken to Government First Reception Centres (CAS is the Italian acronym). Theoretically speaking, asylum applicants should stay in these centres no longer than 30 days, which is considered to be enough to certify their identity, prepare and submit their application for international protection, properly assess their health conditions, and determine any particularly vulnerable situations.
Second-line Reception. llegal immigrants are transferred to the Centres of the Protection System for Asylum Applicants and Refugees (SPRAR is the Italian acronym). These centres can accommodate: (a) immigrants who have already submitted their application to obtain refugee status and are waiting for a decision to be taken by the local authorities in charge of international protection; (b) immigrants who have already been granted refugee status but who cannot provide a living for themselves and their families. The staff working in these centres comprise qualified workers and a multidisciplinary team that works to meet the beneficiaries' needs. They offer assistance, information, and managing services; psychological support; and intercultural mediation. Coordinating and administrative staff members run the centres, while intercultural mediators, psychologists, general workers, professional educators, lawyers, and social workers can be clustered under the "(asylum) practitioners" category. All support and assistance services are carried out via an intertwined network that involves SPRARs, prefects, social services, healthcare services, local authorities, public security services, job centres, schools offering courses in Italian and educational integration, volunteer-based organisations, NGOs (Non Governative Organisations, e.g., social cooperatives), and all relevant regional commissions [13].
Between 2016 and 2017, Italy witnessed increasing influxes of sea arrivals. In response to this emergency, the Italian government issued a special decree [14] to create a number of Emergency Reception Centres (CAS), conceived to solve the accommodation problem that ensued after the arrival of many illegal immigrants. These centres can vary in terms of type and size, and may be private accommodations (apartments, hotels, unused buildings, etc.). From its creation onwards, the Italian reception system has proven to have some critical problems, including the insufficient number of SPRARs across the country. In January 2017 (the latest government data available), Italy had 6917 CASs scattered across the country, but only 552 active SPRARs [17]. The insufficient number of SPRARs (and consequently the problems connected with the whole reception system) has had a negative effect on CASs, which went from being temporary emergency centres to second-line reception centres, i.e., long-stay accommodation centres. CASs now accommodate illegal immigrants for periods ranging from six/eight months to one and a half or two years. Consequently, CASs have had to develop objectives and services that are typical of second-line reception centres.
The whole system is currently under reorganisation and new rules are being implemented in order to provide a better network of local services. CASs are being progressively closed and the managing system of SPRARs is being restructured, changing into the International System for the Protection of Adults and Unaccompanied Underage Foreigners (the Italian acronym is SIPROIMI), which to date includes 689 centres [18].

Psychological Distress and Burnout within Illegal Migration Contexts
The European countries mostly affected by illegal immigration from North African and Middle Eastern countries are trying to respond with regulations, facilities, and organisation models that aim to handle this phenomenon and make it sustainable in the long-term. They have been doing so amid a difficult situation within the EU, due to the many dynamic, cultural, social, economic, and political differences that characterise its member states. Over the last few years, many psychological studies have devoted attention to the investigation of distress and suffering among forced migrants in general (cf. for instance [19,20] on refugees and asylum seekers) and illegal migrants coming from the southern Mediterranean in particular [21][22][23][24][25][26]. However, little attention has been paid to the psychological effects this phenomenon has on the practitioners working with illegal migrants. Even less attention has been devoted to those working on the frontline to rescue, care, receive, and help migrants upon arrival and during the initial integration period.
Drennan and Joseph [27], Century and colleagues [28], and Guhan and colleagues [29] have carried out qualitative studies (based on semistructured interviews) on small samples of English health visitors and primary care counsellors who helped refugee mothers or asylum seekers. These studies have unveiled practitioners' difficulties in meeting the many (health, economic, relation, legal) needs of their clients, as well as the emotional strain (reaching burnout) they are subject to when handling their clients' requests. Furthermore, their disorientation has emerged, along with uncertainties due to their personal inexperience in dealing with their clients' multiple, complex problems, which have often led practitioners to develop feelings such as powerlessness and solitude.
Puvimanasinghe and colleagues [30] have investigated practitioners' empowerment and effectiveness via qualitative face-to-face interviews involving Australian doctors, psychologists, nurses, operators, and coordinators (N = 26). This study has demonstrated that experience, adequate training, empathy, and ability to identify with the refugees, coupled with good supervision and organisational support, can positively influence practitioners' commitment and satisfaction. All these factors can also help to boost work satisfaction and cultural flexibility, thus helping to develop vicarious resilience (VR) among practitioners. Vicarious resilience is extremely important as it can help fight vicarious trauma (VT), a type of discomfort practitioners are subject to when they work with deeply traumatised people such as forced migrants.
People working for NGOs are also affected because they often work on the frontline. Robinson [31] conducted a series of interviews with 30 Australian and English workers in different fields. The study revealed some factors that cause stress among NGO workers, including the conflict between their humanitarian objectives and those pursued by the countries migrants come from and arrive in, the quality of the practitioners' commitment, personal involvement and workload, migrants' extremely emotional cries for help, and life threatening risks.
Social organisations have been examined by Viola and colleagues [32]. They conducted a qualitative study based on semistructured interviews with 20 Italian practitioners, showing that these workers' difficulties in promoting social integration programmes for migrants are normally linked to many factors, e.g., the inability to communicate with migrants due to language barriers, differences and cultural stereotypes, lack of employment and economic hardship, as well as problems regarding the lack of local support and services.
As far as volunteers are concerned, Simsa and colleagues' [33] qualitative study was the result of interviews with 42 Austrian volunteers working for several associations that helped those refugees and asylum seekers who reached the country during the migration crisis that hit the Mediterranean Sea in 2015/2016. This study brought to the fore the risks run by those who are often called to fill the gap left by the lack of governmental organisations, consequently forcing volunteers to take action. The most common problems these operators experience include physical and emotional strain (resulting from their continuous contact with traumatised people, constant and prolonged voluntary commitment, and lack of adequate rest), burnout and post-traumatic symptoms caused by stress, inability to organise themselves, lack of guidelines, and their consequent need for adequate coordination.
As may be gathered, it seems clear that, within the context of forced and illegal migration, the many players involved in helping them are at constant risk of suffering from work-related types of stress, among which burnout is the most likely to appear.
Burnout is one of the most studied work-related syndromes in recent decades, particularly within the service sector and healthcare. Its preliminary definitions focus on relational and emotional aspects, especially within the so-called 'helping professions'. Maslach [34,35] described burnout as a syndrome that is characterised by emotional exhaustion, disengagement, and professional inefficacy. Burnout is seen as a response to the chronic emotional effort required when working with people in need. Maslach and Leiter [36,37] have suggested conceptualising burnout as a syndrome that particularly affects service providers. Over the last decade, burnout has been clearly framed within the Job Demands-Resources (JD-R) model of work-related stress [38][39][40]. According to this model, organisations are characterised by job demands and job resources (e.g., physical, psychological, social, and organisational). Generally speaking, burnout stems from excessive job-related demands that lead to exhaustion, while inadequate job resources lead to work disengagement. Overall, burnout is conceived as the opposite of work engagement [41][42][43].
Recently, some scholars have turned their attention to burnout as a work-related syndrome that affects the helping professions [44][45][46]. For instance, Santinello and colleagues [47] proposed adding 'disillusionment' to the abovementioned dimensions (i.e., exhaustion, disengagement, and lack of professional efficacy). Edelwich and colleagues and Pines et al. [48] had already included this dimension in their model because they claimed that professional expectations and motivation play a key role in developing burnout. According to these authors, expectations and motivations are essential to those vocationally devoted to helping others because these aspects define their role in society and give meaning to their lives.
Despite the fact that burnout is a syndrome that greatly affects those working to help illegal immigrants, studies devoted to its investigation are scant. Noteworthy examples are Apostolidou's [49], Graffin's [50], and Posselt and colleagues' [51] studies with small samples of (English and Australian) practitioners assisting refugees and asylum seekers. These studies demonstrated that all these respondents felt emotionally exhausted by their clients' suffering. Also, these practitioners were so taken in by their patients' traumas that they felt powerless (or ineffective) and started questioning their way of seeing "the world", themselves, and their work (disengagement). The respondents also developed burnout due to the legal and administrative difficulties they had to face in trying to obtain refugee status for their clients. Nevertheless, these authors remarked that practitioners felt that being able to help these types of patients fostered the development of their social engagement (efficacy) and made them feel that their work was socially important (satisfaction). Both these aspects appear to help workers to protect themselves from burnout. These studies also demonstrated that relying on the importance of their work and the support of their coordinators helps these workers to protect themselves from burnout.
Currently, the literature on the burnout of practitioners working with the illegal immigrants constantly arriving in many Mediterranean countries is, to the best of our knowledge, very scant. The studies that deal with this phenomenon are mainly based on small-scale qualitative samples. Besides, such works rarely take into account the complex organisation system handling immigration. Hence, it is important to further study the risk of burnout among these practitioners by also taking into account the reception system within which they work. It is also essential to know who they are so as to evaluate what factors foster or impair their well-being and performance at work.
Aims. The main objective of this quantitative and qualitative study was to describe and assess the risk of burnout among workers in the Italian reception system for illegal immigrants. In addition, it sought to report on these practitioners' reasons for their work-related wellbeing and distress, which in turn can help us come up with coping strategies that can improve their organisational health and performance.
Generally speaking, this study was based on the framework of Job Demand-Resources theory (JD-R) [38,40,52]. As explained earlier, this theoretical framework has been extensively and successfully used to assess burnout syndrome [41,42,44]. This approach demonstrates that burnout is currently one of the most important types of distress among workers within the service sector. It also defines a set of individual and work-related dimensions that can be positive (resources) and negative (demands). These dimensions interact in many ways, thus leading either to workers' wellbeing or to their distress. This research project and related questionnaire (as described in the "Material and Methods" section below) have been designed drawing on JD-R theory in general, and the JD-R model for burnout in particular. These approaches consider dichotomic and polarised dimensions, which are positive (resources) and negative (demands), as well as concurring variables and personal experiences.

Research Design
This project was based on a descriptive cross-sectional model used to collect qualitative and quantitative data. We opted for this approach because we were interested not only in evaluating the level and breadth of the risk of burnout among practitioners working in the reception of illegal immigrants in general (which can be detected via standardised questionnaires), but we also sought to describe these workers' everyday life, experiences, evaluation, and strategies to handle challenging situations while on the frontline. A total of 210 questionnaires were distributed (sent by e-mail or delivered by hand, as described below). The respondents were selected across Italy and according to their willingness to partake in this study. Before starting, we submitted a formal request to the institutions and organisations involved for approval. Those that accepted forwarded all the information about our research project to their members, who freely decided whether or not to take part in the survey. The survey tried to cover all levels of the Italian reception system for immigrants. The data were collected between September 2017 and November 2019.

Assessment Instruments
The assessment instrument was divided into three main parts. The first part was an information sheet containing instructions on how to complete the questionnaire, as well as information regarding the Italian law on data protection and privacy. The second part comprised a list of questions aimed at retrieving sociodemographic data such as gender, where respondents work (i.e., north, centre, south, or islands), type of activity, reception facility (rescue at disembarking, CAS, SPRAR), whether they work on a voluntary basis or if they are paid professionals, their professional qualification, and years of experience. The last part comprised a self-report questionnaire aimed at detecting burnout and a list of questions to be asked during a semistructured interview, as further explained below.
Psychophysical exhaustion: (-) e.g., "I'm physically exhausted by my job" (+) e.g., "When I work, I feel very energetic" Relational deterioration: (-) e.g., "I have the feeling that most of my clients don't follow my instructions" (+) e.g., "I'm satisfied with my relationship with my clients" Professional inefficacy: (-) e.g., "I feel my skills are inadequate to face unforeseen situations" (+) e.g., "I feel I can effectively organise the activities my professional role calls for" Disillusion: (-) e.g., "I think that if I could turn back time, I'd choose another job" (+) e.g., "I still feel motivated by my professional ideals" All the answers were based on a six-point Likert time scale (1 = never; 6 = every day). Semi-structured Interviews. In order to detect the practitioners' motivation and ideas regarding their experiences of burnout and/or working wellbeing, we created a semi-structured model to carry out individual interviews. As mentioned earlier, the data under analysis were collected in part via face-to-face interviews and in part through emails (since some organisations did not grant our interviewers permission to enter their facilities). Hence, semi-structured interviews proved to be a sufficiently flexible tool that could be completed by the interviewers or independently by interviewees, without impairing the aims of the study. This model comprised eight questions, two for each dimension seeking to investigate burnout via an LBQ questionnaire. Within each set of questions, one sought to explore the negative aspects and distress (-, similar to the job demands in the JD-R Model) as part of the respondents' job, while the other question tried to determine the positive aspects (+, similar to the job resources in the JD-R). The questions were: Psychophysical exhaustion: (-) "What makes you feel tired in your job?" (+) "What makes you feel energetic in your job?" Relational deterioration: (-) "What makes you feel involved in your relationship with the immigrants?" (+) "What make you feel detached in your relationship with the immigrants?" Professional inefficacy: (-) "What makes you feel capable of doing your job?" (+) "What makes you feel ineffective in your job?" Disillusion: (-) "What makes you feel successful in your job?" (+) "What makes you feel disappointed and disillusioned in your job?" All participants freely decided when answering these questions, depending on their willingness.

Participants
All the participants that took part in this survey worked in centres and facilities that are part of the Italian reception system. They were in direct contact with illegal immigrants.
The respondents reflected the Italian reception system. The sample was made up of 25.9% unpaid volunteers and 74.1% paid professionals. All the main professional figures normally working in the reception system were represented: 91 operators (47.2%, educators, social workers, people working in logistics, and daily routine staff), 34 psychologists (17.6%), 25 healthcare staff (13.0%, doctors, obstetricians, nurses), 17 administrative staff members (8.8%), 14 security staff members (7.3%), 11 cultural mediators (5.7%), and 1 lawyer (0.5%). In order to better define the data obtained about the participants' professional qualifications, and thus making such data consistent with our research objectives, we decided to categorise these professional figures into two broad clusters: High touch-including all those professionals who deal with immigrants' difficulties and suffering on a daily basis. This category included operators, administrative staff, cultural mediators, and security staff (133; 68.9%); Low touch-including all those professionals who sporadically deal with immigrants' difficulties and suffering. They arrange occasional meetings with the migrants. This category included healthcare staff (doctors and nurses), psychologists, and a lawyer (60; 31.1%).
Finally, as far as work experience is concerned, 50 participants (25.9%) had been working in the field for up to 2 years, 41 (21.2%) for 3-4 years, and 102 (52.8%) for 5 years or more.
In addition, 108 participants also agreed to complete a semistructured interview (redemption = 51.4%); 75 completed face-to-face interviews (which were transcribed verbatim and on average lasted 29 min, since the shortest lasted 12 min and the longest 54), while 33 answered via email. The reason for such a low redemption percentage for the semistructured interviews in comparison to the returned questionnaires was explained by some participants during personal or email interviews. Many feared being identified and thought they might have problems at work, especially because they highlighted many of the problems and negative aspects of the reception system. Some respondents claimed their fears were amplified by the low number of staff members in some facilities; others pointed out that the lack of staff was a concern for coordinators and managers too. Data collection in SPRARs proved to be particularly difficult due to the lack of staff-only a few staff members agreed to take part in the survey or the semistructured interviews. Therefore, it may not be surprising that those who agreed to be interviewed declared the level of reception they work in (rescue at disembarking, CAS, SPRAR) and where they work (north, centre, south, or islands), but withheld information regarding demographics. Table 1 plots the distribution of the 108 interviewees in terms of working area (reception system level) and geographical distribution.

Methodology and Data Analysis
LBQ Questionnaires Analysis. According to the scoring rules laid down for the LBQ questionnaire, the obtained scores were inverted for those items on each scale this procedure is required for. Subsequently, a mean value for all burnout dimensions was calculated for the whole sample. Therefore, it was possible to determine which participants could be said to be generally well (stanine ≤2 for all scales), which were clearly suffering from burnout (stanine ≥8 for all scales), and which were at risk of burnout [47].
Furthermore, we devised a linear model for each dependent variable that included demographic variables as possible predictors; these variables were also considered with all their two-way interactions. For each model, we selected a series of stepwise predictors based on the Akaike Information Criterion (AIC) [53]. Data analysis was carried out using the statistical environment R version 3.6.2 [54], and the step function available in the MASS package [55], as well as the ANOVA function implemented in the car package [56], which allows to use type II decomposition for the analysis of variance. In addition, the Duncan post hoc test was used to describe those predictors that were statistically significant within each dimension of burnout. Lastly, we used the χ 2 test to verify whether there were significant differences in the frequency distributions among practitioners who were particularly at risk of burnout (i.e., those with stanine scores of all 4 dimensions ≥5, as it is the midpoint on the scale) in relation to the main sociodemographic variables. IBM Statistical Software for the Social Sciences [57] was used for this purpose. Significance for all the analysis conducted during this study was set at α = 0.05.
Analysis of the Semi-structured Interviews. All interviews (be they face-to-face or via email) were transcribed verbatim. The content of each interview was examined using T-LAB 8.0, a software for text analysis. This software carries out a semiautomatic text analysis (computer-assisted qualitative data analysis software-CAQDAS) [58][59][60] that enables the conceptual mapping of the corpus, connecting portions of text based on specific research hypotheses regarding variables defined by the researchers.
According to this methodology, the single words are defined as "lexical units" (LUs); these words might be present in the text either in their original form or in their headword format, which is activated by the semiautomatic process of "lemmatisation" (for instance, reconducting the word taller to the adjective tall). The "context units" (CUs) identify the subsets in the corpus, whereby it is possible to subsume all the textual data (e.g., paragraphs or sentences). The CUs may be identified by the researchers using the variables under investigation (e.g., using the responses given to different questions). The textual unit imported into the software is divided into CUs. The software applies a semiautomatic lemmatisation procedure to each word it recognises. A customised version of this process can be used by researchers to revise automated lemmatisations, and/or in order to evaluate the words unlemmatised by the software in their context (e.g., at sentence level). Customising the vocabulary means verifying unclassified words (i.e., they are not included in the software dictionary), word homographs (with the same spelling, words that are spelled the same but potentially have more than one meaning), and words that require disambiguation. Subsequently, the lemmatised text is analysed, focusing on the occurrences (frequency of use) of words in the whole corpus, and then compared with the occurrences in different subsets of the corpus. This study included a comparative analysis, which was carried out via a "specificity analysis" procedure [61][62][63]. This procedure assessed the textual relationships between words across different sections of many interviews according to the significant variables identified for this study. In this type of analysis, the LUs typical of a corpus subset are highlighted by identifying a categorical variable (e.g., identifying responses given to a specific question). Underused and overused words in a specific portion of the text are analysed and compared with the occurrence of the same word in the whole corpus. The statistical assessment is based on the χ 2 test [64], which is applied within a 2 × 2 contingency table. The threshold value of χ 2 is preliminarily 3.84 for 1 degree of freedom and a significance of 0.05; when p = 0.01, the threshold value of χ 2 becomes 6.64. Once the value of χ 2 computed is greater than the threshold, it is possible to say that a word is significantly overused rather than underused in a subset of the corpus.
Regarding the textual analysis of the corpus, the responses were transcribed and organised as a whole data set, which was subsequently transformed into a .txt file (compatible with T-LAB).
Due to our obligation to comply with privacy regulations and the interviewees' reluctance to disclose personal data, we were unable to match the text of the interviews with the interviewee who uttered or wrote it.

Ethical Issues
This research project was authorised by the Ethics Committee of the University of Cagliari (approval number 009858 dated May, 22 2020), and was thus conducted in full compliance with the Ethical Principles of Psychologists and the Code of Conduct of the APA (American Psychological Association), integrated into the AIP's ("Associazione Italiana Psicologia") Code of Ethics. The project did not address any sensitive topics and was carried out by informed and consenting adults. Lastly, in accordance with Italian privacy law, the project guaranteed anonymity and privacy to all participants.

Quantitative Analysis
Sample Profile. According to the guidelines laid down in the LBQ instruction manual [47], on the whole, all respondents appeared to be at risk of burnout. Although at different levels, all their dimensions scored above stanine 2 and were below 8. Table 2 shows the mean values of the burnout dimensions in decreasing order. Gender did not seem to be a significant variable within the sample since both male and female participants scored equally in terms of mean values for all four burnout dimensions.
As far as the area the participants come from (north, centre, south, and islands), ANOVA detected significant differences for all four burnout dimensions (cf. Table 3). The psychophysical exhaustion dimension scores were lower in southern Italy and on the islands than in the northern and central areas of the country. Relational deterioration scores were significantly lower on the islands than in the north, south, and centre of Italy (with aggregated value). Professional inefficacy scores were significantly lower among participants in the south, centre, and on the islands (aggregated value) compared to participants in the north. Disillusionment tended to score lower in the south and the islands than in the north and centre of the country. On the whole, these findings show that the scores for all four dimensions increased when moving from the south and islands to the centre and north of Italy. Within the reception system (rescue at disembarking, CASs, SPRARs), mean values for psychophysical exhaustion, relational deterioration, and professional inefficacy were generally similar. In contrast, results showed that disillusionment (F (2) = 3.87; p = 0.022) scored lower during disembarking rescue activities (M = 4.15) than within CAS and SPRARs contexts (M = 4.95). Table 4 compares the values for the dimensions for (nonprofit) volunteers and (profit) paid practitioners.  Regarding professional inefficacy, paid practitioners and volunteers generally scored equally. In contrast, psychophysical exhaustion, relational deterioration, and disillusionment scored lower among volunteers than paid practitioners.
Professional inefficacy and disillusion were not significantly different in relation to years of experience (cf. Table 5). In contrast, psychophysical exhaustion and relational deterioration scored higher among practitioners with more experience.  Table 6 shows the burnout differences according to the respondents' professional qualifications. The values have been clustered under the high touch and low touch categories. As may be noted, high touch participants scored significantly higher mean values for all four dimensions.
No (second-level) interactional effects in relation to the sociodemographic variables under investigation were detected as far as burnout is concerned.
Profile of Participants at High Risk of Burnout. According to the guidelines laid down in the LBQ instruction manual [47], three participants displayed a general state of wellbeing (scoring stanine ≤2 for all four dimensions); none of the participants suffered from burnout (not scoring ≥ 8), yet almost all participants (N = 190) are at risk of burnout, although at different levels. In order to better learn about and describe the practitioners most at risk of burnout, we selected those at high risk of burnout, scoring stanine ≥ 5 (which is the intermediate score on the scale). According to this criterion [47], we identified 51 participants at high risk of burnout (26.8% of the sample at risk of burnout). We checked their profiles against the established sociodemographic variables. Table 7 shows their profiles.  Gender wise, no significant differences were detected, whereas geographical distribution appears to have more significant consequences. Participants working in the north of Italy seemed to be more at risk than those working respectively in the centre, south, or on the islands. Interestingly, the respondents working in CASs were three times more at risk than those working in disembarking rescue activities and 12 times more at risk than those working in SPRARs (an estimation carried out using the correction procedure proposed by Yates [65]). It should be noted that the number of paid asylum practitioners in the sample was four times higher than the volunteers. In terms of professional qualifications, the high touch practitioners were much more at risk of burnout than the low touch practitioners. Finally, participants with more years of experience were much more at risk of burnout than co-workers with fewer years of experience.

Qualitative Analysis
The corpus originally included N = 21,920 occurrences (tokens), with N = 3427 types (the questions used during the interviews were excluded from the corpus). Vocabulary customisation was conducted on N = 2292 lemmata; the hapax (words used only once in the corpus) was N = 1852. In order to identify the list of key words required by T-LAB to run the data analysis, a threshold of five occurrences was established, which led to the identification of n = 249 key words.
Overused and underused lemmata for each dimension of burnout [48] were analysed; as mentioned earlier, these dimensions have a positive and a negative pole (as also explained in the JD-R Model [41,42]).
For each modality, the occurrences of the words in each specific group were examined and then compared with the total occurrences of the same word in the whole corpus.
Subsequently, we used a qualitative approach to investigate these dimensions and concentrated on the interviewees' ideas regarding each dimension. To this end, we checked how single linguistic items were expressed within larger units. In other words, we attempted to extract complex meaningful units and determine specific themes according to an in-depth analysis of the corpus as a whole and by taking into account the dimensions of burnout. As a result, we detected paradigmatic sentences that were part of the interviewees' answers. Table 8 shows the overused and underused words referring to both poles of psychophysical exhaustion. Within the negative pole of psychophysical exhaustion, "tired" and "exhaustion" refer to fatigue and the excessive use of personal resources, which are typical of this phenomenon. Words such as "shift", "timetable", and "stress" refer to workload in quantitative terms, while "bureaucracy" and "psychological" refer to mental exhaustion. The pronoun "we" was significantly underused, thus suggesting that the participants' jobs are tiring due to a lack of social support. Other underused words were "manage" and "like", which recall participants' negative feelings regarding their failure. Some of the sentences that reflected practitioners' experience were: "I'm mentally exhausted, tired of working in this sector. I'm tired of dealing with difficult clients"; "I'm tired of my shifts, we're always working, because we have to be available all the time for anything"; "I'm tired of wasting precious working time solving problems that come up because of miscommunication"; "When I try to explain things that are important and fundamental to clients' life plan and nobody listens to me".
As to the positive pole, the most overused words were "energy", "pleasure", "motivate", and "passion", which can be directly linked to the feelings of those who are engaged in what they do. Words such as "nice/beautiful" and "see" can be linked to the fact that working hard helps reach a given objective and this, in turn, increases motivation. Furthermore, words like "choose", "study", and "path" are connected with the idea that participants see themselves as able to help migrants obtain "lucky" (here meaning "positive") results. Again, these words are likely to be uttered by people who feel engaged and able to find the right path to obtain a positive result (for themselves and their clients): "To see people succeed, to see young people find their way, here, in Italy"; "Honestly, we work for a good cause and we are inspired by values such as reception and respect"; "The satisfaction you get from establishing a very good relationship with the clients and not disappointing them". Table 9 plots the overused and underused lemmata for relational deterioration in both poles. Table 9. Over-and underused lemmata for relational deterioration 1 .

Relational Deterioration-Negative Pole (Disengagement))
Overused Within the negative pole of relational deterioration, "we" exemplifies the relational nature of this dimension. Words like "detached" and "detachment" suggest that the participants experience difficult relations with the immigrants, the former distance themselves from the latter. This attitude was expressed by words that are negatively loaded and express emotions ("becoming angry", "demand") that suggest frustration and the difficulty of mutual "understanding". Some answers by the practitioners also reflected this condition: "It's impossible to completely detach when you work in reception, but it's important to follow procedures, good practices, to solve some problems"; "Some of the young men have the wrong attitude; in order to get them to understand this and be coherent so they don't feel different from us, I treat them as I'd treat an Italian".
As regards the positive pole of relational deterioration (involvement), the fact the immigrants have a "story" to "tell" shows that narrating their experience can be a "powerful" and "empathetic" way to "involve" practitioners and establish a "relationship" ("relate") with them. Hearing the immigrants tell their stories and feel "touched" by them appeared to be a "powerful" means to get closer so that immigrants and practitioners feel as if they are a "family". Interestingly, "job" was more underused in the negative than in the positive pole of this dimension. This phenomenon may depend on the fact that, even if participants are aware that what they do is merely instrumental to the reception process, they still see their job in terms of creating a relationship and helping others. Some telling examples are: "The devastating past of some of the clients hosted in this facility"; "I like talking with them and I grow fond of them when they tell me their stories, but you also need to know how to approach them, you need to be patient and very charismatic"; "What makes me feel involved is that the migrants are in the same situation"; "They place all their trust in me, this is what collaborating means". Table 10 reports on the overused and underused lemmata for professional inefficacy in both poles. The negative pole of this dimension shows that the overused words referred mainly to professional inefficacy due to a "language barrier" (cf. "language", "speak", "difficulty", "English", "French"). However, such inefficacy was not only due to the fact that practitioners and immigrants speak a different language, but also because of "cultural" differences, different ways of "feeling" things (in different cultures), and the lack of mutual "awareness". No significantly underused words were detected. Here are some examples: "Language is a problem"; "Sometimes language barriers are the main limitation when speaking with the guests at the SPRAR, as they obviously need the constant help of the practitioners to make contact with the outside world and this causes some frustration".
One important element that the words connected to professional effectiveness seem to share relates to personal soft and life-long "skills" (cf. "manage", "patient", "solve", "ability"), along with the participants' "experience": "It's an ongoing learning process, you never stop. Naturally, slowly, when I keep experimenting, I become more confident and I feel that I have experience, but I also have a lot to learn"; "My experience as a community educator helps me, I manage to handle unforeseen circumstances and solve problems, which are often trivial but can become complex in contexts like this". Table 11 summarises the overused and underused words for disillusionment in both poles. Table 11. Over-and underused lemmata for disillusion 1 .

Disillusion-Negative Pole (Disillusion)
Overused The overused words in the negative pole of disillusionment referred to participants' commitment to the "management" of "reception", although they get "disappointed" because they have to "wait" and be subject to the slow pace of the reception procedures, which sometimes involve "redoing" the same job under the same conditions and seeing the same problems and situations "coming back" (meaning repeating themselves), even if the practitioners have already worked hard to try and face or solve such problems. The fact that these practitioners receive low "pay" added to their frustration: "Managing reception, too many things to deal with and too many bureaucratic problems"; "The way reception centres are managed and the lack of information"; "If I could go back, I wouldn't choose to work here because, despite all my hard work, my expectations have not been met at all, having good intentions is not enough to handle immigration projects like this".
The overused words for fulfilment were linked mainly to the clients. The "young person" (the vast majority of the clients in the centres are males and female young people, many of whom are underage or children) the participants managed to "help" ("being useful") "satisfy" (meaning meet) their needs, which made practitioners feel "satisfied", causing self-fulfilment, and building "team" work spirit among co-workers. This aspect prevailed over individual pronouns such as "I", which was indeed significantly underused in the corpus. Some paradigmatic answers provided by the respondents: "I feel satisfied when I can earn the trust of my client"; "I am satisfied with my work if I concentrate on the young people we work with"; "The fact that I feel I am able to organise activities properly, and the relationship I create with the clients"; "The goal of our work is to guarantee their integration in Italy, when we have managed to do this, it has been really satisfying"; "It's mainly the positive feedback from the clients that motivates me and makes me feel useful and satisfied".

Quantitative Findings
The sample under investigation has been shown to be generally at risk of burnout. Relational deterioration scored highest, thus confirming the complexity and intensity of the participants' relationship with their clients. Psychophysical exhaustion scored second highest and this may be related to the distress many practitioners experience. Disillusionment and professionally inefficacy scored lower than the other dimensions (i.e., they were both below stanine 5). This suggests that, despite relational problems and weariness, practitioners generally seem able to work effectively and their vocation and motivation are still driving forces for what they do.
By looking at the participants' profiles according to the sociodemographic variables (ANOVA), we could not detect any significant gender-based differences. These findings may need to be further investigated, yet they may be considered valid since all the practitioners at all reception levels carry out tasks that do not require gender-related skills.
All the participants working in southern Italy or on the islands scored lower than their northern and central counterparts in terms of burnout level. These findings are in contrast with what one might expect, since migration flows normally reach the southern coasts of Italy and its islands (especially Sicily), thus making it more likely to affect the facilities and practitioners in these areas. Consequently, practitioners in these areas would be expected to suffer from higher levels of burnout, but two explanations for these results can still be found. On the one hand, they may depend on the nature of burnout itself and its relation to stress and coping. The literature has extensively demonstrated that any strain deriving from a stressor can be adequately faced when it is still possible to successfully complete a task (cf. for instance [38,40,41]). Hence, the practitioners in the south of Italy and on its islands may score lower in terms of burnout because their response (coping) to a stressor (immigration) that is extremely challenging is nevertheless effective and positive on the whole. The other possible explanation may be cultural and connected with the attitude that has developed across the north and centre of Italy over the last decade. These parts of the country appear to be quite intolerant and at times openly hostile to illegal immigrants, resulting in many people voting for political parties that support such an attitude. Several public opinion surveys seeking to retrieve voting intentions have demonstrated that these political parties can count on the support of 35%-45% of the Italian electorate, which goes above 60% in the north of Italy [66][67][68][69]. These political parties promote social, local, and national policies aiming at fighting illegal immigration, e.g., attempts to progressively close down SPRARs, economic sanctions against NGOs working to rescue migrants, and closing ports of call to NGOs' boats and sometimes to the boats belonging to the Italian military forces because they have helped to rescue migrants. Since this anti-illegal immigration sentiment has been pervasively and systematically spreading throughout Italian public opinion, it may be argued that this negative perception about immigrants has also become part of practitioners' way of thinking and attitude. All in all, the analysis of the data under investigation in light of these two explanations (which are not mutually exclusive) seemed to reach a sort of paradox. The practitioners in the south and on the islands are less likely to develop burnout than their northern and central counterparts, even if the former are under greater stress from illegal immigration than the latter. Northern and central practitioners are under less stress from illegal immigration but are more at risk of burnout because they are less inclined to deal with it owing to their negative attitude towards this phenomenon. The northern and central practitioners' perception is imbued with negative feelings and the anti-immigration political attitude that has been spreading for a long time throughout the areas where they work.
As for the three reception levels (rescue at disembarking, CAS, SPRAR), burnout scored low in terms of disillusionment for participants working in disembarking rescue activities. These findings appear plausible if we bear in mind that these practitioners primarily aim to save lives, which is also a default objective at this level of reception.
As far as the distinction between volunteers (nonprofit) and paid practitioners is concerned, excluding professional efficacy, all the other three burnout dimensions returned lower scores for volunteers than for professionals. One possible explanation is that the former work on a volunteer-basis and this may protect them from burnout. Besides, since they are volunteers, they may (theoretically) choose if and when to devote their time to helping immigrants or decide to rest or do something else. In contrast, paid practitioners may not have chosen to work in this field. For instance, law enforcement officers, military forces, and healthcare practitioners may be forced to work in these contexts, whether they like it or not. This may add to their distress and burnout.
The findings regarding psychophysical exhaustion and relational deterioration among practitioners that have the highest number of years of experience are generally in line with existing findings in the literature, which links prolonged exposure to stressors to increasing levels of stress [34,36,37]. This fact is particularly true for the psychophysical exhaustion dimension, whereas the increasing levels of relational deterioration may be explained by the fact that many immigrants stay in reception centres for much longer than expected. As explained earlier, immigrants tend to stay longer because of their high numbers and the complexity and length of verification procedures and Italian bureaucracy. All these factors can create frustration, discomfort, and aggression among immigrants, thus having negative effects on their relations with the practitioners.
The high touch practitioners generally scored higher in all four dimensions than anyone else. Again, these results are perfectly in line with the basic dynamics of burnout [34,37], which is intrinsically linked to the continuous and prolonged exposure of practitioners to their clients' suffering.
As for quantifying the burnout syndrome, although none of the participants appeared to clearly suffer from burnout, only a very limited number of practitioners appeared to enjoy overall wellbeing (3), while a quarter of them (26.8%, 51 practitioners) were at severe risk of burnout (stanine ≥ 5). These findings confirm the importance of detecting burnout and its destructive potential. The profile of practitioners at severe risk of burnout does not differ substantially from the others: no gender-based differences could be detected and the number of participants in the north of Italy was higher than those in all the other areas under investigation. Interestingly though, the practitioners working in CASs are more at risk than those working at other levels (rescue at disembarking and SPRARs). There are more paid practitioners at severe risk of burnout than volunteers; practitioners who are in regular and systematic contact with their clients' difficulties (high touch) are more at risk than those with sporadic contact with them. Lastly, practitioners with more years of experience are more at risk than those who have been working in these contexts for shorter periods of time.

Qualitative findings
The semistructured interviews carried out for this study helped to extend the existing knowledge regarding burnout within the helping professions [34,36,44,45] to the investigation of burnout among asylum practitioners working with illegal immigrants. Most importantly, within the perspective of JD-R model of burnout, the results obtained have highlighted aspects of this syndrome that are specific to this working context and may at most be considered demands or resources [38,41,44,46].
According to our findings, the participants' psychophysical exhaustion is caused mainly by their workload and mental fatigue (cf. [31] for similar findings) and it becomes even worse due to the lack of social support (demands), which they can clearly perceive (cf. [30] for similar findings), as well as a sense of failure. As for engagement, the most recurrent theme was to ensure that the respondents' objectives are reached, especially if it means that such objectives are to benefit the immigrants in the long term (the satisfaction deriving from obtaining positive results can be seen as a resource that boosts commitment).
Detachment and distancing seem to be the main strategies practitioners use when their relationship with the immigrants (for various reasons) deteriorates due to their emotional involvement, the information they share and the requests that are put forward (demands). That said, practitioners do not feel their job is merely instrumental. The migrants' stories and narrations (filled with suffering, difficulties, humanity, and inhumanity) seem to be what really make practitioners stick with their clients. These stories create a sense of community and family. The possibility of sharing experiences and perceiving commitment as something that goes beyond mere duty can be seen as resources.
Not having a technically adequate mastering of the clients' language and their inability to understand cultural differences (consistent with the findings in Viola and colleagues [32]) seem to be the main sources of the participants' professional inefficacy (this can be considered a demand and, at the same time, a source of frustration for migrants). In contrast, the practitioners' professional effectiveness appears to be boosted by their existing and developing transversal (individual and relational) skills, which increase with experience (these can be considered resources, as also proven by Puvimanasinghe and colleagues [30]).
Disillusionment regarding the usefulness of the participants' job is mainly the result of organisational problems (as also demonstrated by Posselt et al. [51]; and Simsa and colleagues [33]), such as having to deal with the same problems that come up repeatedly. The situation is also complicated by the fact that both migrants and practitioners are frustrated by migrants' long stay in reception centres because of the high numbers of incoming clients and the complexity of Italian bureaucracy (these demands have also been detected by Posselt [51]). Participants' self-realisation is mainly boosted by the feeling of helping others (resources also found in Apostolidou [49]) and meeting the needs of (mostly young and very young) migrants, as well as having their contribution acknowledged, especially when they become a team, a working group that coordinates to reach its objectives (resources also suggested in Guhan [29] and Posselt and colleagues [51]).

Limitations and Future Research
This research study has several limitations. Firstly, the group of respondents was selected ad hoc, depending on their voluntary participation, but the fact that this research project had been approved beforehand by the organisations they work for might have influenced the way they answered both in the questionnaire and during the interviews. However, the sample is relatively large, covering all levels of the Italian reception system, many professional figures, roles, and the geographical area in which they are located. Furthermore, no statistically controlled procedures for case selection were applied during this study. Secondly, the data collected were essentially subjective (self-reporting questionnaires and semistructured interviews). Besides, as far as the semistructured interviews are concerned, the words used in the questions might have inevitably influenced the interviewees and their answers. Considering the vulnerable and critical context within which the data were collected, objective data could not be obtained (e.g., requests for sick leave, data on absences due to illness, or any other data regarding the personnel involved), which could offer important information regarding work-related stress or burnout. Thirdly, as mentioned above, it was impossible to match and cross check the data in the self-reporting questionnaires and those collected during the interviews. Future qualitative studies will hopefully help to overcome the present limitations. These studies will be based on an in-depth analysis of the interviews given to the respondents, distinguishing between the reception level and the geographical areas within which they work.

Contribution to Knowledge and Practical Implications
The results obtained in this study can help to establish possible action strategies to support practitioners while working with illegal immigrants to achieve and maintain their general wellbeing and work effectiveness. According to the JD-R model of burnout, in order to avoid psychophysical exhaustion, the quantity (shifts, timetables, tasks) and quality (complexity and mental activity) of the workload should be reduced, while also encouraging cohesion and social support from coordinators and among the practitioners themselves. In addition, practitioners should obtain more feedback regarding the outcome of the immigration programmes they work for, as well as have a more active role in planning, programming, and developing actions.
As for relational deterioration, the interviewees have underscored how hearing immigrants narrating, telling, and sharing their stories is a powerful tool that can help fight detachment. Likewise, the perception that their work is not merely instrumental, but rather vocational and humanitarian, also helps them. Relational involvement can be fostered by organising ad hoc, open, well-established activities, during which these stories can be told, shared, and discussed. Practitioners' motivation should also be monitored and assessed.
The feeling of inefficacy could be lessened by organising adequate language courses (as least for the most common languages), courses to encourage cultural awareness, and courses to develop and enhance soft and life-long skills, be they individual or relational. Also, activities that promote reflection, sharing, and supervision could be implemented, and the practitioners' existing experience could be shared to improve the overall situation within these contexts.
Disillusionment and feelings of helplessness are mainly due to the Italian reception system, specifically its inefficiency and problems. However, despite its problems, this system is extremely complex and involves many players, and it is based on principles and values such as the willingness to help and the power of humanity [70]. It would be important to help these practitioners to work more as a team and a system, for instance by creating team building activities and offering them the opportunity to take part in the overall organisation of these reception centres, thus increasing their motivation, satisfaction, sense of achievement, and occupational wellbeing.

Conclusions
Illegal immigration throughout the Mediterranean is an intense, epoch-making phenomenon. The many complex causes that have given rise to it are likely to cause it to continue for many decades to come. Therefore, it is very important to systematise a process that can make its handling sustainable at the national and European level. However, sustainability needs to address two major issues. On the one hand, there are migrants with their suffering, difficulties, needs, and hopes. On the other hand, there are reception centres and practitioners who work to assist migrants fleeing misery and prosecution and trying to help them during the social integration process. Hence, the results presented here have some implications, not only for the organisation of the reception system strictu sensu, but also in relation to the social and cultural policies of those European countries dealing with illegal immigration. Some of the problems and challenges pointed out by the practitioners (which lead to stress and discomfort for those working on the frontline) are linked to the lack of human, economic, and structural resources to handle illegal immigration, which is often compensated by voluntary work. Like all the Mediterranean European countries, Italy struggles to overcome the idea that this situation has to be managed in terms of an emergency that is temporary and needs to be overcome individually. Conversely, illegal immigration is increasingly becoming a structured phenomenon that has to be tackled in an organised and systematic manner at the European level. Moreover, it seems that over the last few years the territorial agencies that work in education, social integration, and acceptance of diversity (e.g., schools) have found themselves unequipped to build and foster integration, although this has happened unevenly across the country.
In conclusion, this research has hopefully helped to raise awareness about occupational health in Italian reception centres for illegal immigrants. Italy's shape, geographical location, and geo-political role make it a case in point for the whole European continent regarding the sustainability of the reception of illegal migration across the Mediterranean Sea.