Job burnout in psychiatric and medical nurses in Isfahan, Islamic Republic of Iran

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A.R. Yousefy¹ and Gh.R. Ghassemi²

ABSTRACT By means of the Maslach Burnout Inventory, we examined job burnout among randomly selected nurses working on psychiatric (55 nurses) and medical units (51 nurses) at 2 university hospitals in Isfahan during 2003. Psychiatric nurses experienced a greater degree of emotional exhaustion than the medical nurses (P < 0.05). Significant positive correlation was noted between age, years of experience and frequency of on-calls and emotional exhaustion for the psychiatric nurses. Frequency of on-calls was also significantly associated with a sense of non-accomplishment. Longer duration of service was accompanied by higher degree of emotional depersonalization for the medical nurses.

L’épuisement professionnel chez les infirmières psychiatriques et médicales à Ispahan (République islamique d’Iran)

RÉSUMÉ Au moyen de l’inventaire d’épuisement professionnel de Maslach, nous avons examiné l’épuisement professionnel chez des infirmières choisies au hasard dans les services psychiatriques (55  infirmières) et les services médicaux (51 infirmières) de deux hôpitaux universitaires à Ispahan en 2003. Les infirmières psychiatriques connaissaient un degré plus important d’épuisement psychologique que les infirmières médicales (p < 0,05). Une corrélation positive significative a été constatée entre l’âge, les années d’expérience, la fréquence des astreintes et l’épuisement émotionnel des infirmières psychiatriques. La fréquence des astreintes était également associée de manière significative à un sentiment de non-accomplissement. Une plus longue durée du service s’accompagnait d’un degré plus élevé de dépersonnalisation pour les infirmières médicales.

¹Medical Education Research Centre, Isfahan University of Medical Sciences, Isfahan, Islamic Republic of Iran.
²Department of Psychiatry, School of Medicine, Isfahan University of Medical Sciences, Isfahan, Islamic Republic of Iran (Correspondence to Gh.R. Ghassemi: This email address is being protected from spambots. You need JavaScript enabled to view it.).
Received: 29/04/03; accepted: 26/01/05
EMHJ, 2006, 12(5): 662-669

Introduction

As a prototype of stress, job burnout is being increasingly recognized as one of the most serious occupational health hazards, resulting in job dissatisfaction, lowered productivity, absenteeism, high turnover, and a state of disequilibrium [1]. Work-related factors such as work pressure without support, ever-changing expectations, new job requirements, role conflict, and role ambiguity comprise some of the stressors which can cause job burnout syndrome [2]. Personality traits such as idealism and a need for self-affirmation and work orientation can increase the risk of job burnout [3]. Maslach views job burnout as a response to chronic interpersonal and emotional stressors on the job, resulting in negative feelings such as incompetence, lack of achievement and productivity at work [4]. Emotional exhaustion ranging from mild boredom to severe depression, depersonalization and treating people in an unfeeling way and poor sense of personal accomplishment are viewed as the key elements of job burnout [5]. As a result of burnout people develop negative self-concept and become detached, apathetic, angry or hostile in their work place [5]. Job burnout has cumulative effects on mental health, quality of life, family life and last but not least on productivity [5].

Burnout is a major problem in the helping professions such as nursing, medicine, social work, law enforcement and education [6]. Nursing staff face working places with blood and urine, disturbed sleeping pattern, frequent emergency situations, inappropriate expectations from patients and their relatives, insufficient nursing staff and lack of authority in decision-making, all of which can cause job burnout for nurses [7–9]. Bearing in mind the nature of the nursing profession, attempts have been made over the past 2 decades to investigate the magnitude and implications of job burnout among nurses working in various departments [8–19]. Some of the factors that have been reported to be associated with job burnout are: individual characteristics, threats to job control, hardness of training, workload, interpersonal relationships with colleagues, knowledge of nursing, bureaucratic-political constraints, level of education, night shifts, being hospital-based, working on medical and surgical wards and negative work–home interference. Stress management had a pivotal role in controlling job-induced stress and burnout [20].

Attempts have also been made to study the phenomenon of burnout among nurses working in mental health fields, yielding interesting findings. In studying 296 nurses working with medical units, critical units, operation rooms, and psychiatric units in different hospitals, Cronin-Stubbs and Rooks observed significant differences in the frequency and intensity of occupational stress and burnout among the subjects [21]. Critical and medical nurses in this study encountered occupational stressors more frequently and intensely than psychiatric and operation room nurses. Stress in psychiatric nurses is further attributed to administrative and organizational factors. Fagin and co-workers (1996) attributed burnout among psychiatric nurses to staff shortages, health service changes, poor morale and not being notified of changes before they occurred [22]. As regards sex, female nurses were characterized by fewer symptoms of burnout, relatively high emotional intelligence profiles, and lower social skills than male nurses [23].

Most of these studies were conducted in Europe and the United States and have focused primarily on nurses in general. There is a dearth of literature about working conditions and job burnout among psychiatric nurses in the Iranian context. With special reference to psychiatric nurses, most studies suggest that they deal with atypical patients and receive less recognition by the administrative authorities and community in general [23]. It is argued that psychiatric nurses face unique job challenges compared to their counterparts who work in non-psychiatric wards. Given the lack of information, the present study was an attempt to gauge and compare burnout experience between hospital nurses working in psychiatric and non-psychiatric units in Isfahan, Islamic Republic of Iran.

Methods

This study was based on a sample drawn from the nursing staff working with 2 major university hospitals in Isfahan during May–December 2003 (Khorshid Medical Centre and Al Zahra Medical Centre). The former is a general hospital with a psychiatric ward and the latter is a postgraduate hospital with critical care unit and intensive care unit where the medical nurses were working.

Adopting a random sampling method, nurses working in psychiatric and general wards with more than 1 year of work experience were approached. While assuring them about the confidentiality, their participation in the study was made voluntary. Thus, 55 nurses working in psychiatric units and 51 nurses working in general wards were recruited and completed the questionnaire satisfactorily. The participants were matched for age, sex, education, marital status and years of experience. Data were collected by means of the Maslach Burnout Inventory (MBI) which was originally designed by Maslach and Jackson in 1981 [24]. Personal data (such as age, years of experience, education) were collected in a separate interview with close- and open-ended questions.

The MBI, which is originally in English, was translated into Farsi by a group of 5 professors from nursing and medicine fields. In order to test language validity, the Farsi version obtained was translated back to English by another group of 5 professors. Then the Farsi version was reviewed and revised. The final Farsi version was pilot tested on a sample group of nursing lecturers. It was concluded that the Farsi version obtained was highly valid for use. There were 22 items for which the minimum score was 0 and the maximum possible score was 96. A score of at least 48 was considered a case of burnout. Higher score indicated higher chances of burnout. The nurses completed questionnaire by themselves and anonymously.

The MBI has 3 sub-scales: Emotional Exhaustion (EE), Depersonalization (DP), and Personal Accomplishment (PA). EE consists of 9 items measuring the perception of being used up, frustrated, tired or stressed. DP consists of 5 items which pertain to perceptions of treating others impersonally, becoming callous and/or hardened emotionally. PA consists of 8 items which measure perceptions of having an influence on others, working well with others and dealing well with patients and their problems. High EE and DP, and low PA are considered to indicate burnout [25]. Each item consisted of a 5-point rating scale (0 = never; 1 = a few times a year; 2 = a few times a month; 3 = a few times a week; 4 = every day).

Attempts have been made to establish a relationship between certain ascribed and achieved characteristics of an individual in an organization and job burnout. To this end we attempted to establish the correlation between certain work and the demographic characteristics of the participants with the parameters of burnout.

Cronbach alpha reliabilities for the 3 sub-scales ranged from 0.72 to 0.89 and test–retest reliabilities ranged from 0.61 to 0.82. Data were analysed using SPSS, version 10 and the Student t-test, Pearson correlation coefficient (r) and analysis of variance were computed.

Results

The sample comprised 55 psychiatric nurses as the study group and 51 medical nurses as the control group. The mean age (standard deviation) for the study group was 35 (4.6) years and 33.2 (4.5) years for the whole group. The nurses were typically female, unmarried and graduates in nursing. The majority of the nurses working with psychiatric and general units were graduates; a small percentage of them were not graduates, but they had had long working experience (about 12 years) in their field. The average number of years of work experience for the psychiatric nurses was 12.8 (3.9) years and for controls it was 10.7 (4.6) years. Demographic characteristics of the participants are given in Table 1.

As per the operational definition, EE, DP, PA constituted the 3 aspects of job burnout. Analysis of the data showed that nurses working in psychiatric units experienced a higher degree of EE [21.07 (SD 8.87)] as compared to those who worked in other units [16.64 (SD 7.54)], indicating the feelings of being used up, frustrated, tired or stressed (P < 0.05). In terms of DP, the mean score for non-psychiatric nurses was higher [4.96 (SD 5.5)] than that of psychiatric nurses [4.38 (SD 5.1)] but this was not statistically significant. The mean score for PA was higher among psychiatric nurses [15.87 (SD 11.63)] compared to non-psychiatric nurses [13.82 (SD 9.83)] indicating that psychiatric nurses felt that they had less influence over their patients and units, or could not work well or the way they wanted to be with their patients. However, this difference was not statistically significant (Table 2).

Table 3 shows the correlation between job burnout and the demographic characteristics of the nurses. For psychiatric nurses, there was significant positive correlation between age (r = 0.3), years of work experience (r = 0.3), and frequency of on-calls (r = 0.6) with degree of EE and PA. In the case of non-psychiatric nurses, there was a negative correlation between their years of work experience and emotional exhaustion (r = –0.5).

Discussion

It is reported that at the global level nurses face several challenges and are ranked 27th among 130 professionals requesting psychological counselling [8]. This study was an endeavour to assess the magnitude and extent of job burnout among hospital nurses working in psychiatric and non-psychiatric units in Isfahan. There is ample evidence to show the implications and cumulative effects of job burnout on mental health, quality of life, family life and work life. Job burnout can typically manifest itself in the form of boredom, severe depression, negative self-concept, sense of detachment, apathy, anger and hostility in the affected individual’s work place [26]. Job burnout is a response to chronic interpersonal and emotional stressors on the job, resulting in negative feelings such as incompetence, lack of achievement and productivity at work [4].

The results of this study reveal high levels of job burnout in 2 dimensions of the job burnout syndrome among our sample of nurses, EE and PA. Also, significant differences were observed in the EE dimension of burnout syndrome between nurses working in psychiatric and non-psychiatric units. EE experienced by nurses is generally attributed to the nature of their job in terms of patient’s behaviour as well as the interaction of the superiors with the nurses. This observation may be attributed to the overall environment which prevails in psychiatric wards.

Our study showed a positive correlation between age and years of experience with EE. It is possible this observation is related to the very fact that with age one’s tolerance for demanding situations and stressful work environment decreases. In the beginning of their career, nurses may be more motivated but in due time their eagerness to continue as an ordinary nurse may decline, as they do not see coherence between their needs and the stresses which they experience. Comparison of male and female nurses working in psychiatric units showed that male nurses experienced a higher degree of EE. This difference, though statistically not significant, may be attributed to nurse’s expectations from their job and their adjustment in their work place. Krausz and associates hold the view that male nurses have poorer coping ability as compared to their female counterparts [27]. It has been reported that work-setting satisfaction is the most significant predictor of EE, of DP, of job pressure, of job satisfaction, and of PA [28].

In terms of health service delivery, job burnout in health professionals and especially in nurses has a direct impact on the health care system. These include poor quality of health care delivery and loss of people’s lives and material resources. To this end, several measures have been proposed to prevent the harmful consequences of this phenomenon. Jansen and co-workers believe that instead of changing the work content we can decrease the feelings of burnout by paying attention to supervisory support, peer relationships and individual training programmes [29]. Health authorities are particularly advised to undertake a systematic and continuous assessment of the nursing staff work performance. Results of Jansen and co-workers’ study once again confirm that stress is a problem for ward-based mental health nurses. These observations have 2 main implications: first, we need models of the stress process that are empirically based and which help us identify the moderating variables that can reduce the impact of stressors on nurses. Secondly, we need to use their knowledge to deliver stress management interventions for staff. Employee stress can have profound effects on an organization, such as increases in worker’s compensation claims and cost of production.

Both health and legal experts assert that the time to deal with workplace stress is before it manifests itself in the costly worker compensation claims. Knowing the negative consequences of job burnout, it is imperative to combat stress in the work place. Health managers are expected to determine if their employees are experiencing harmful stress in the work place before it is too late. They should provide a conductive environment for the employees to talk freely and confidently about their problems and by, introducing wellness programmes, involve them in appropriate physical activities to vent out their anger and hostility. Hospitals are strongly advised to conduct regular training courses for the nursing staff in order to manage the art of stress management and develop healthy coping strategies to neutralize the negative impacts of workload. Prior organizational commitment, self-efficacy, and healthy coping skills have a key role in predicting high risk nurses for job burnout [1,30]. Some suggest involvement of psychiatric liaison service as a possible method to provide support to the nurses [31]. Adequate supervisory and organizational support, peer relationships and individual training courses are able to improve the quality of patient care and diminish the chances of post-traumatic stress disorder, job dissatisfaction and burnout [15,18,32].

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