INTRODUCTION:

Nursing is a stressful profession that deals with human aspects of health and illness and can ultimately lead to job dissatisfaction and burnout. Burnout is a mental condition defined as the body’s response to the failure of the coping strategies that individuals typically utilize to manage stress at work (Bureau of Labor Statistics, 2012)

Burnout is described as feelings of emotional exhaustion, depersonalization and reduced personal accomplishment. It is well-known that burnout is a major problem for many professions. Nurses are considered to be particularly susceptible to this.

Measuring burnout among nurses is important because their well-being has implications for stability in the healthcare workforce and for the quality of care provided.

Before1990:

In Marxist feminism, the sexual division of labor is constructed by capital, which always finds the cheapest source of labor to maximize profit. Braverman (1974) took off from this Marxist perspectives theorized on the need of capitalism to maximize labor leading to monotony and marginalization in the industrial organization. This can explain the phenomenon of burnout experienced by the women nurses in this study. Brown Miller in 1976 pointed out that in the economic sphere, patriarchy manifests in forms of gender segregation and gendered division of labor.

The term "burnout" originated in the 1940s as a word to describe the point at which a jet or rocket engine stops operating (Felton JS, 1998). The word was first applied to humans in the 1970s by the psychiatrist Herbert Freudenberger, who used the term to describe the status of overworked volunteers in free mental health clinics in 1998 and he defined burnout as the "progressive loss of idealism, energy, and purpose experienced by people in the helping professions as a result of the condition of their work" (Edelwich J, 1980)

Cherniss in 1980 conducted interviews with public human services professionals and found that mistrust, organizational conflict, rigid role structure, isolating work practices, and entrenched patterns of uncommunicative social interaction are a source of burnout among workers. Other identified sources of burnout include employment insecurity and casualties of the work-force, issues with management and the system and difficulties with the nature of work.

Sandra Brown in 1986 performed a study to examine the relationship between use of coping strategies and burnout among 150 randomly selected staff nurses from four hospitals, two significant canonical variate sets differentiated nurses on the dimension of burnout Nurses who experienced increased levels of burnout used the coping strategies of escape/avoidance, self-controlling and confronting (P<0.001). Nurses who experience decreased levels of burnout used the coping strategies of planful problem solving, positive reappraisal, seeking social support, and self controlling (P<0.003). The positive relationship between planful problem solving and reduced burnout levels supports the theoretical framework of Lazarus .This framework asserts that during the appraisal process, persons evaluate the harmfulness of an event and their own coping resources.

Jan Hare and Clara C. Pratt in 1988 performed a study and this study examined interpersonal, intrapersonal and situational factors expected to contribute to the six dimensions of burnout among nursing staff who worked in acute care and long-term care health facilities. Findings revealed that work relationships and tension-releasing and instrumental problem-focused coping were the most powerful predictors of burnout. Based upon this, it was concluded that nursing burnout is both an organizational and a personal problem. Recommendations for practice are presented

Dr. Margaret Topf in 1989 conducted a study on Personality hardiness, occupational stress, and burnouts were investigated in 100 critical care nurses. Hardiness was predictive of occupational stress and burnout. Hierarchical multiple regressions revealed that one of the three dimensions of hardiness, commitment to work, was the only variable to account for significant amounts of variance across the measures of burnout. The study did not provide support for the stress buffering effect of hardiness. The findings are discussed in terms of other research on burnout in critical care nurses and recent issues on the conceptualization of hardiness.

Alison E. Hipwell and Patrick A. Tyler in 1989 was designed a study to examine the hypothesis that occupational stress in nurses is a function of how they perceive their work environment. ‘Work overload’ and the ‘death and dying’ of patients were identified as the major sources of stress for all the nurses. In general, although there was little difference between the specialized and non-specialized groups of nurses in the degree of stress experienced, the work environments were found to be dissimilar. The reported level of dissatisfaction with their work environment combined with certain demographic characteristics was found significantly to predict the degree of stress experienced. These findings have implications for the organization of the ward and for the skills taught to nurses by which stress may be managed or alleviated.

1990-2000:

Dr. Sharon, E. Robinson and Sari L. Roth in 1991 worked on nurse’s burnout. This study was an examination of the combined ability of perceived work environment, demographic, and work-related variables to predict burnout among nurses at a large metropolitan hospital. The three dimensions of burnout measured were emotional exhaustion, depersonalization, and personal accomplishment. High work pressure and low work involvement and supervisor support predicted emotional exhaustion. Task orientation, work pressure, work involvement, and age predicted both depersonalization and personal accomplishment. Burnout among nurses on each of the three work shifts also was examined. Results are discussed from the perspective of how to decrease or to prevent burnout among nurses.

Glass, David C and Mc Knight in 1993 assessed depression, burnout, and perceived job control (PJC) in 162 nurses. Depression accounted for over 19% of the variance associated with emotional exhaustion, an index of burnout, and PJC accounted for another 6%. Factor analysis of the scales used to measure depression and burnout documented their discriminant validity. Perceptions of uncontrollability were significantly related to higher levels of depression and burnout.. Structural equations modeling suggested that perceived uncontrollability is associated with burnout, which, in turn, is related to depressive affect. Against a criterion of actual job control, non-burned-out overestimated their control, whereas burned-out approached complete agreement with criterion. Despite evidence for a "depressive realism effect," greater perceptual accuracy was not attributable to depression among the more burned-out nurses.

Van Servellen G, Leake B. in 1993 were examined burn-out among nurses working on acquired immunodeficiency syndrome (AIDS) special care units (SCUs), oncology SCUs, medical intensive care units (ICUs) and general medical units to measure the extent to which delivery method (SCU, ICU, and general unit), patient diagnosis, or other key personal and work-related characteristics were associated with the level of distress in these nurses. There was one exception: medical ICU nurses scored significantly lower on the Personal Accomplishment and for the Emotional Exhaustion and Personal Accomplishment indicated that greater job influence had a significant protective effect on emotional exhaustion and enhanced personal accomplishment. As expected, job tension was a key predictor of exhaustion and being white was associated with greater feelings of accomplishment. Working in a medical ICU continued to show a negative impact on accomplishment when race and other important covariates were controlled and working on an AIDS SCU was predictive of exhaustion in a multivariate context (P < .05).

Wright, Theresa and Blache, Catherine in 1993 performed a study to determine whether hardiness is a predictor of burnout and whether it can buffer the effect of stress on burnout. Results indicated that hardiness and burnout had a significant inverse relationship (r=0.66). Stress and the stress-hardiness interaction term accounted for 29% of the variance in burnout scores. This study found hardiness to be a predictor of burnout and a buffer in the stress-burnout relationship. Furthermore, the relationship between hardiness and stress was found to be stronger than that between stress and burnout. Further study is needed to verify that hardiness is a stress mediator in nursing and to determine how to best promote hardiness in nurses.

W. B. Schaufeli and B. Janczur in 1994 presented a cross-national study on burnout among 200 Polish and 183 Dutch female nurses. The reliability and the factorial validity of the Maslach Burnout Inventory (MBI) are satisfactory in both countries. However, evidence for the content validity of the MBI is likewise equivocal in both samples. Polish nurses are significantly more burned out than their Dutch colleagues, even after controlling for differences in work situations in both countries. Subjective work stressors (i.e., uncertainty and a perceived imbalance between investments and outcomes in relationships with patients) contribute most strongly to bum out in Polish as well as in Dutch nurses. Personality characteristics and aspects of the work situation play a less prominent role. Although the work situation of Polish and Dutch nurses differs considerably, psychological variables-notably, experienced job stress-are likewise crucial in understanding burnout among nurses of both countries.

Mark C. Eastburg in 1994 conducted a study and This study sought to find evidence for: (a) a relationship between increased levels of work-related social support and decreased burnout, (b) a relationship between personality traits and burnout, and (c) a significant interaction of social support and extraversion in relation to burnout. A strong negative correlation between work-related social support and burnout was found. Also, nurses whose supervisors received positive-feedback training showed significant reductions in emotional exhaustion, compared to those whose supervisors did not receive this training. Some dimensions of personality explained a significant amount of burnout. The study also provided further evidence of the interactive effect of social support and extraversion in relation to an emotional distress variable. That is, extraverted nurses required more work-related peer support than did introverts to avoid emotional exhaustion.

Beth Hartman Ellis and Katherine I. Miller in 1994 determined the impact of specific types of supportive communication on burnout, organizational commitment, and retention for practicing nurses. Hypotheses regarding the influence of informational, emotional, and instrumental social support were tested with survey data gathered from a large group of employed nurses. Results indicate targeted effects of instrumental and informational support, but broader effects for emotional support in organizational outcomes. Although significant relations were found for supportive communication and personal control, results indicate that other rationales explaining the link between social support and burnout may be warranted.

Irena Iskera-golec andSimon Folkard in 1996 conducted a study in whichthe aim of the study was to compare measures of health, sleep, psychological and social well-being, job satisfaction and burnout of ICU nurses on 12- and 8-h shifts. The groups of subjects were matched for age, length of shift work experience, marital status and number of hours worked. The 12-h shift nurses, when compared to their 8-h shift colleagues, experienced more chronic fatigue, cognitive anxiety, sleep disturbance and emotional exhaustion. Job satisfaction seems to be independent of the shift duration. The nurses on 12-h shifts reported less social and domestic disruption than those on 8-h shifts. The 12-h shift nurses showed worse indices of health, well-being and burnout than the 8-h shift nurses. It is suggested that this may be associated with their longer daily exposure to the stress of work. The increased number of rest days of 12-h shift nurses seems to be insufficient to dissipate the adverse health and well-being effects that built up over their longer shifts.

D. C. Glass and J. D. McKnight in 1996 reviewed a subset of the literature concerned with burnout, depressive symptomatology, and perceptions of job control. It appears that the first two constructs share appreciable variance but are not isomorphic. Research also indicates that the development of burnout has a modest association with perceptions of job uncontrollability (i.e., perceived lack of autonomy and little decisional latitude). A conceptual model proposing that perceived uncontrollability induces depression indirectly by operating through differences in the magnitude of burnout received only equivocal support in longitudinal studies. Prospective designs were proposed as a high priority for future burnout research.

J. J. Hillhouse and Christine M. Adler in 1997 did a comprehensive and reliable assessment of work stress, burnout, affective, and physical symptomatology. As previous attempts to categorize nursing stress and burnout by ward type have yielded inconsistent results, an alternative method for grouping nursing stress effects was sought. These nurses were separated into two equal groups using random sampling procedures. Cluster analysis of this data revealed groupings which were based on nursing stressors (particularly workload and conflict with physicians), social support, and patient loads. Results suggest that the effects of stress have more to do with the characteristics of the work environment and overall workload than with the degree of specialization on the unit. Results also suggest that intraprofessional conflict (i.e. with other nurses) is less psychologically damaging than is interprofessional conflict (i.e. conflict with physicians).

P. S. Simoni and J.J. Paterson in 1997 were studied relationships among hardiness, coping approach, and burnout in a sample of 440 nurses. Within each of the coping approaches used, subjects with greater hardiness reported less stress in the form of burnout than did those with less hardiness. Subjects using direct-active coping (changing the stressor, confronting the stressor, finding positive aspects in the situation) had the lowest burnout scores, and those using direct-inactive coping (ignoring the stressor, avoiding the stressor, leaving the stressor) had the highest score and chi-square analysis identified independence between hardiness and coping approach. Analysis of variance identified no interaction between hardiness and coping behavior categories for burnout; however, the lowest burnout scores were encountered among nurses with greater hardiness who used direct-active coping behaviors. These findings suggest that both hardiness and direct-active coping approaches can be used independently or in concert to reduce burnout. Rationale is provided for preparing practitioners to engage in problem-solving approaches, assertive interaction, and active and direct methods of conflict resolution.

E. Demerouti andA. Bakker in 2000 Conducted a study among 109 German nurses, tested a theoretically derived model of burnout and overall life satisfaction. The model discriminates between two conceptually different categories of working conditions, namely job demands and job resources. It was hypothesized that: (1) job demands, such as demanding contacts with patients and time pressure, are most predictive of exhaustion; (2) job resources, such as (poor) rewards and (lack of) participation in decision making, are most predictive of disengagement from work; and (3) job demands and job resources have an indirect impact on nurses’ life satisfaction, through the experience of burnout (i.e., exhaustion and disengagement). A model including each of these relationships was tested simultaneously with structural equations modelling. Results confirm the strong effects of job demands and job resources on exhaustion and disengagement respectively, and the mediating role of burnout between the working conditions and life satisfaction..

Penson et al in 2000 elaborated that Organizational role stressors are major contributors to burnout and thus hospital administrators should be able to address key issues in organizational role stressors such as inter-role distance which covers work home conflict e.g. work in hospital interfering with the demands at home.

2001-2012:

Demir and Ulusoy et.al. 2003 and Sherman, 2004 found that A number of personal factors have also been associated with burnout. These include perfectionism, over-involvement with patients, self-esteem, sense of mastery and purpose in life, low education level, low work experience, low status, economic hardships, difficulty in childcare and doing house chores, and personal and family health problems

Brooker and Nicol in 2003 emphasize the fact that burnout often occurs as a result of factors outside the individual’s control and burnout has contributed to many nurses leaving, not only intensive care environments, but also the profession of nursing. Burnout is not only seen as costly for the organization, but for the patient as well, because a nurse who feels ineffective, frustrated and stressed is unlikely to deliver quality care.

Geyer 2004 argues that this absence of ‘caring for the career’, in addition to being a major factor for the low morale evidenced in nursing, is one of the biggest contributing factors to compassionate fatigue and burnout among nurses.

Geyer 2004 identified the predominant international trend, in respect of the alleviation of excessive workloads; avoiding compassionate fatigue and preventing burnout, as the implementation of legislation advocating minimum adequate staffing ratios per unit. Most international ratios stipulate that a ratio of one registered nurse to four patients is required for a general ward and one nurse–to-patient ratio in intensive care units, in addition to other categories of nurses, for example staff nurses and nursing auxiliaries.

Lambert and Lambert in 2004 studied on the factors of burnout and examined the relationships among various workplace stressors, ways of coping, demographic characteristics, physical and mental health among Japanese hospital nurses. They found that workload and number of people living in the household were the best predictors of physical health. Meanwhile the best predictors of mental health were likelihood to leave the job, lack of support in the work place and escape-avoidance mechanism.

Taylor and Barling, 2004 described that Burnout can also be caused by poor interpersonal factors such as problems with doctors, aggressive and criminal consumers, undervaluing consumers and nurses, physical and emotional constraints of the workplace, nurse-nurse relationships, and horizontal violence.

Ozgencil et al. in 2004 found that burnout was associated with increased prevalence of depression among ICU nurses. Also, series of hierarchical regression analyses in a study provided significant evidence for the crossover of burnout (exhaustion and cynicism) and work engagement (vigor and dedication) among partners ( Bakker, Demerouti and Schaufeli, 2005) showing that burnout is related to workload, degree of involvement with patients, lack of social support and role conflict (Coyle, et.al., 2005).

Lewis and King in 2005 states that burnout contributes significantly to staff turnover and that burnout may be attributed to a combination of factors inherent in the work situation, such as staff shortages, lack of time and excessive workloads. Additional factors that contribute towards burnout are identified as relating to organizational relationships – relationships that reveal a paucity of social support from management.

Lewis and King, 2005 further argues that if management structures are to be proactive in preventing burnout among personnel, they need to recognize that nursing personnel require not only satisfaction regarding their working needs, but also quality living in their workplace environment. This is supported by Callagnan (2003) stating that job satisfaction is related to the freedom to make decisions and of having ‘job control’ in terms of being able to exercise professional latitude King, (2005).

According to Ozyurt A, Hayran. O and Sur in 2006 burnout has been the subject of various investigations aiming to elucidate and disentangle the complex relationships and interactions that moderate and influence it. Burnout has been found to be associated with decreased job performance and low career satisfaction and has a special significance in health care, where staff experience psychological, emotional and physical stress.

Walvoord, 2006, pointed out that it is important to identify predictors of burnout, recognize who is suffering, and eventually apply methods to prevent burnout and stress in the workplace. She further explained that, known factors contributing to burnout development are staff shortages, compassion fatigue, work environment, and job satisfaction, while gender, age, lower academic status, qualifications, training, and number of years in the field are indicators of who is suffering. These factors can be categorized as either personal factors or organizational factors, which can be targeted in coming up with programs to reduce burnout. Other researchers have looked into the work-related aspects of burnout.

Embriaco and Nathalie et.al. in 2007 reported that Based on most recent studies, severe burnout syndrome (as measured using the Maslach Burnout Inventory) is present in about 50% of critical care physicians and in one third of critical care nurses. Strikingly, determinants of burnout syndrome are different in the two groups of caregivers. Namely, intensivists who have severe burnout syndrome are those with a high number of working hours (number of night shifts and time from last vacation) but determinants of severe burnout syndrome in ICU-nurses are related to ICU organization and end-of-life-related characteristics. ICU conflicts, however, were independent predictors of severe burnout syndrome in both groups.

Jinky Leilanie Lu in 2008 conducted a study aims to look into the possible interaction between situational factors, role stressors, hazard exposure on burnout among nurses in various hospital departments. The study showed that there is a significant correlation existing between burnout and self efficacy, hazard exposure and organizational role stress along with age and illness. In addition, organizational role stress and age have been found to be independent and most significant predictors of burnout.

P. Toullic and L. Papazian et.al. in 2007 reported that Of the 2,392 respondents (82% female), 80% were nurses, 15% nursing assistants, and 5% head nurses. Severe BOS-related symptoms were identified in 33% respondents. By multivariate analysis, four domains were associated with severe BOS: (1) personal characteristics, such as age (2) organizational factors, such as ability to choose days off or participation in an ICU research group ((3) quality of working relations (1–10 scale), such as conflicts with patients, relationship with head nurse or physicians and (4) end-of-life related factors, such as caring for a dying patient and number of decisions to forego life-sustaining treatments.

Siying Wu and Wei Zhu et.al. in 2007 prepared a report of a study of occupational burnout among nurses in China in which Scores for burnout of surgical and medical nurses were statistically significantly higher than those of other nurses (P < 0·05). Lower educational status was associated with lower professional efficacy, and younger nurses reported higher levels of burnout. The most significant predictors of emotional exhaustion were role overload, responsibility, role insufficiency and self-care (P < 0·05). The most significant predictors of cynicism were role insufficiency, role boundary, responsibility and self-care (P < 0·05). The most significant predictors of professional efficacy were role insufficiency, social support and rational/cognitive coping (P < 0·05).

Gurses, A.P and Carayon in 2007 worked on Performance Obstacles of Intensive Care Nurses and mentioned that Nurses from 17 intensive care units (ICUs) of seven hospitals in Wisconsin participated in the study. The most frequently experienced performance obstacles included noisy work environment (46%), distractions from families (42%), hectic (40%) and crowded work environments (37%), delay in getting medications from pharmacy (36%), spending considerable amount of time teaching families (34%), equipment not being available-someone else using it (32%), patient rooms not well-stocked (32%), insufficient workspace for completing paperwork (26%), seeking for supplies (24%) or patients' charts (23%), receiving many phone calls from families (23%), delay in seeing new medical orders (21%), and misplaced equipment (20%).

Melanie Verdon, and Paolo Merlani, in 2008 did a study on burnout of Surgical I.C.U team and reported that Ninety-seven of 107 questionnaires (91%) were returned. Of the members of ICU nursing team, 28% showed a high level of burnout. They reported a number of concerns, and that they felt discomfort and suffering. There was a discrepancy between the factors felt to be important by them and those statistically related to the burnout. Among the reported concerns, only the lack of patients' co-operation, the organization of the service and the rapid patient turnover were independently associated with a high level of burnout. As many as 49% of the nursing team felt stressed

CONCLUSION:

Recent studies reported high levels of severe burnout syndrome in healthcare workers and identified potential targets for preventive strategies such as ICU working groups, communication strategies during end-of-life care and prevention and management of conflicts.

It is important to reduce occupational stress in nurses and to strengthen their coping resources to prevent burnout. This could be achieved with job redesign, modification of shift work systems, and by offering occupational health education.

REFERENCES:

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Received on 22.03.2013 Modified on 15.04.2013

Asian J. Nur. Edu. and Research 3(2): April.-June 2013; Page 101-106