Burnout among nursing staff in accident and ... - Wiley Online Library

Journal of Clinical Nursing 2003; 12: 842–851

Burnout among nursing staff in accident and emergency and acute medicine: a comparative study MARK GILLESPIE MSc, RN Lecturer in Emergency Nursing, University of Ulster, Londonderry, UK

VIDAR MELBY B S c , M P h i l , R N T Senior Lecturer in Emergency Nursing, University of Ulster, Londonderry, UK Accepted for publication 30 April 2003

Summary • This study was designed to identify the prevalence of burnout among nurses working in Accident and Emergency (A & E) and acute medicine, to establish factors that contribute to stress and burnout, to determine the experiences of nurses affected by it and highlight its effects on patient care and to determine if stress and burnout have any effects on individuals outside the clinical setting. • A triangulated research design was used incorporating quantitative and qualitative methods. • Maslach Burnout Inventory was used. • Nurses working in acute medicine experienced higher levels of emotional exhaustion than their A & E counterparts. The overall level of depersonalization was low. High levels of personal accomplishment were experienced less by junior members of staff. • Stress and burnout have far reaching effects both for nurses in their clinical practice and personal lives. If nurses continue to work in their current environment without issues being tackled, then burnout will result. The science of nursing does not have to be painful, but by recognition of the existence of stress and burnout we can take the first steps towards their prevention. Keywords: accident and emergency, burnout, emergency care, nursing, stress.

Introduction Nursing staff working in demanding areas such as Accident and Emergency (A & E) or acute medicine are likely to spend considerable time during their working day

Correspondence to: Mark Gillespie, Lecturer in Emergency Nursing, University of Ulster, Magee Campus, Londonderry, BT48 7JL, Northern Ireland. (tel.: +44 (0) 2871 375005, e-mail: m.gillespie@ ulster.ac.uk).

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in intense interactions with people. The nature of the A & E department is often physically demanding and nurses are also continually faced with heavy demands for pity, sympathy and compassion (Malach-Pines, 2000). The service in which nurses now work has a cost-conscious ethos, in which practitioners have found difficulty meeting expectations. Maslach et al. (1996) indicated that persons who continually work with people under such circumstances find that the chronic stress can be emotionally draining and can lead to burnout. 2003 Blackwell Publishing Ltd

Professional issues in clinical nursing Research to date appears to focus upon investigating the prevalence of burnout among medical staff in the UK, and little appears to be written with reference to nursing personnel. Farrington (1999) reported that one of the main reasons why nurses leave the National Health Service (NHS), is to prevent increasing levels of stress and burnout. Whilst much has been written about burnout in nursing staff, hard evidence of its extent is lacking (Walsh, 1998). This study examined various aspects of burnout amongst nurses in an A & E department and in an acute medical ward in one NHS Trust.

Review of the literature The term ‘burnout’ is used in the nursing literature synonymously with stress. The literature would suggest that the term ‘stress’ is used in everyday language, loosely, to refer to the process of coping with the daily rigours life can present. Thompson (1994) suggested that stress is a demand made upon our physical or mental energy, often excessively, resulting in stress related physiological problems. This definition implies that stress is harmful when pressures are excessive. Stress is often seen as the first stage of a chronic process and, unless specific interventions are implemented, the individual might experience burnout. Freuberger (1994) first coined the term ‘burnout’ after observing fatigue and frustrations caused by excessive demands upon resources among staff working in the US. Duquette et al. (1997) suggested that the manifestations of burnout are related to work stress sustained over time and reported that individuals exhibit psychological, psychophysiological and behavioural symptoms. Burnout can be described as a haemorrhaging of oneself and depletion of energy in which personal resources seem to be at an end, leaving individuals helpless and negative (Farrington, 1999). Burnout has been shown to manifest itself more frequently in professionals who are involved in aspects of caring (Severinnson & Kamaker, 1999). Hannigan et al. (2000) argued that many nurses now view burnout as an occupational hazard. Benner & Wrubel (1984) indicated that those who experienced burnout find nursing an endless series of demands and they become alienated from their clinical colleagues. Providing nursing care has now become a series of technical tasks, often called caring, but care is not described in an active sense. Client contact is often the core of people work (Bakker et al., 1996), where clients bring problems to caregivers. These problems generate tensions when the caregiver cannot resolve the problems due to insufficient training, a shortage of personnel or lack of support from colleagues or the establishment. Vincent & 2003 Blackwell Publishing Ltd, Journal of Clinical Nursing, 12, 842–851

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Billings (1988) demonstrated that burnout was related to poor management and Boyle (1991) showed that good networks among staff helped to reduce burnout. McGrath et al. (1985) argued that nurses often experienced burnout when there was a reduced sense of personal accomplishment and a sense of failure when meaning cannot be found through work. Hudak & Gallo (1994) wrote that, as a result of burnout, critical care nurses either leave, or if they remain, function ineffectively. It has been suggested that women experience burnout more often than their male counterparts because they become more emotionally involved (Almberg et al., 1997). Pitman & Warelow (2000), however, argued that men who choose a career in nursing appeared to have deeper levels of caring and commitment than female counterparts, and suggested females could switch off more easily after they had finished their working day. Those who enter nursing often do so with a need to replicate significant experiences from their own childhood, and optimize dreams and expectations passed on by family members (Almberg et al., 1997). These individuals often enter the profession with high expectations that are difficult to meet. Freuberger (1994) argued that many of those who enter caring professions have a personality type that may leave them more open to the effects of stress and burnout (Table 1). Koivula & Paunonen (2000) supported this notion and suggested that burnout can originate from nursing work itself, as well as from characteristics of the worker and the environment. Burnout has been well documented across nursing and other disciplines where its detrimental effects have been demonstrated. Examples of its effects are absence from work, being moved easily to tears and outbursts of anger. When individuals who have entered the profession with high expectations face hurdles in the provision of quality nursing care, conflict can arise, symptoms may manifest themselves and individuals become unable to cope. Nurse education is now university-based and students are encouraged to become knowledgeable, practical, proactive, questioning doers who Table 1 Personality types that may leave individuals susceptible to the effects of burnout 1. Dedicated personality

Type of individual who is committed to their work but tends to get overinvolved and takes too much on 2. Over committed Persons who tend to have an personality unsatisfactory life outside of work and then use their work as a haven 3. Authoritarian The type of individual who so needs to be in personality control that no one else can do the job as well as he/she can

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strive to implement current evidence. Such practitioners can greatly enhance the quality of patient care. Due to the demands of the clinical setting and staff shortages, implementation of such care may then prove difficult. Students in this climate will remain unable to practice in the fashion in which they were encouraged, resulting in patients not being able to gain from the skills that these individuals worked so hard to obtain. Loss of control has been highlighted as being closely linked to burnout (Schmitz et al., 2000). When individuals cannot resolve inherent difficulties in their daily work there may be a loss of control. Dolan (1998) found lack of control to be a central component in those who have experienced burnout. Schmitz et al. (2000) found that nurses who believe they have little or no control over events in their lives may be more vulnerable to stress and burnout compared with nurses who are believed to be in personal control. More emphasis on social skills training may be required, as this has been shown to increase problem solving and practical skills (Spence, 1994), along with an increase in autonomy in the clinical area, which may enable individuals to exert more control. Individuals working in areas where verbal and physical aggression is prevalent are more likely to experience the effects of burnout (Coffey, 1999). Walsh (1998) suggested A & E was an area, which fitted all the requirements in relation to the prevalence of verbal and physical aggression. Individuals working in such areas can lose their ability to empathize, a personal quality crucial in therapeutic relationships. Nursing is traditionally a female dominated profession and Howard (1999) suggested that it has all the inherent pitfalls of female organizations, one such pitfall being violence. Whitehorn (1997), who carried out research in A & E, argued that violence is one of the most insidious and pervasive environmental stressors and ranks only second to police in the risk for actual violence against their person. A further American study by Whitehorn (1997) found that 63% of nurses polled had experienced verbal abuse within a year, 35% had experienced attempts at physical harm and 21% had been victims of physical attacks. Effects of burnout can range from a degree of dysfunction to exhaustion (Tavares, 1994). Nurses may experience varying symptoms of burnout, such as reduced self-esteem, lack of confidence, poor job satisfaction, inability to relax and enjoy life, inability to keep things in perspective and form balanced judgements. Burnout has been described as a disease of over commitment (Cherniss, 1980), where there is a constant desire to achieve only the best. In behavioural terms, Maslach (1982) described the resulting nursing care as lacking in concern, detached,

impersonal and, even, dehumanizing. Tavares (1994) has shown that carers are seldom just innocent victims of negative factors beyond their control; they are also secret contributors because of their own egocentric attitudes. Melchoir et al. (1996) indicated that a lack of support was central to nurses experiencing burnout and led to increased absenteeism and reduction in productivity. Lack of support and backup were found by Dolan (1998) to be significant contributing factors to burnout and highlighted staffing problems as an area of concern. Edwards et al. (2000) suggested that burnout has social and interpersonal implications in that symptoms are contagious and can affect colleagues. Relationships may suffer, as individuals become more irritable and short-tempered. Table 2 lists coping strategies to combat burnout that have been highlighted by Millar & Burnard (1994). It has been argued that nursing as a profession has regarded stresses leading to burnout as a personal responsibility of nurses, with less attention being paid to adjusting the working environment. In addition, limited attention has been paid to stress management in the workplace. Koivula & Paunonen (2000) suggested that managers often underestimate the risks involved and require knowledge development of these phenomena in order to gain insight into burnout and its lasting effects. It has been suggested that a return to hospital style matrons, who are more often aware of local issues and concerns of their nursing colleagues (Stordeur et al., 2001), may be appropriate. Traditionally, in the NHS, new innovation was implemented in a top down approach. This approach can increase the prevalence of burnout among nurses by managers who continue to exert control (Stordeur et al., 2001). Ciancio (2000) suggested that nurses would feel anger towards managers but fear retaliation, causing them to redirect anger towards peers. Some authors have argued that those in managerial positions fail to recognize the suffering of employees and have difficulty in admitting error, even when faced with the fact that new plans clearly are not working (Schmitz et al., 2000). Green (1996) maintained that there is denial of the problem, resulting in managers further detaching themselves from their workforce. Table 2 Coping strategies aimed at reducing burnout • • • • • • •

Smoking Crying Increased alcohol intake Snacking Denial and withdrawal Physical exercise Meditation and yoga

2003 Blackwell Publishing Ltd, Journal of Clinical Nursing, 12, 842–851

Professional issues in clinical nursing Walsh (1998) suggested that, due to the limited amount of evidence available with reference to the prevalence and effects of burnout among A & E nurses, research findings would provide greater insight into this area of nursing. The aim of this study was to investigate the prevalence of this phenomenon among a sample of nurses working in an A & E department and an acute medical ward, looking closely at contributing factors and determining its effects on individuals outside the clinical setting. From the reviewed literature it is evident that a limited amount of up-to-date empirical information was available. Information, that is available, focused largely on the prevalence of stress and burnout in the workplace, but little was available on the effects on life outside the clinical setting. The need for qualitative research to complement existing data is thus evident.

Methods DESIGN

A triangulated research design, incorporating both quantitative and qualitative methods, was used in this study to yield the most complete picture of nurses’ experiences. Polit & Hungler (1993) suggested that the use of multiple methods in data collection and interpretation about phenomena help in reaching an accurate representation of reality. Focus group interviews were the chosen qualitative method as individuals may be more comfortable in voicing opinions in the company of colleagues rather than the researcher alone. Parahoo (1998) suggested that, by using focus group interviews, data can be quickly obtained and they allow the opportunity to reflect on and react to opinions of others providing valuable insights for the researcher. Qualitative data were analysed using content analysis. Polit & Hungler (1993) indicated that the data analysis can be potentially challenging, as there are systematic rules for analysing and presenting the data gathered. The process of analysing the qualitative information gathered was aided by a staged process, suggested by Miles and Hubermans (1994), in order to identify emerging themes. Non-parametric tests were performed in order to investigate the strength of relationships present in the data. SAMPLE

The target population for this study was A & E nurses and those working in acute medicine in an NHS Trust. Twenty-eight questionnaires were distributed to each setting. The clinical grades of those sampled ranged from 2003 Blackwell Publishing Ltd, Journal of Clinical Nursing, 12, 842–851

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D to H. Ages ranged from 23 to 56 years and only one respondent was male. Those with less than 1 year experience were excluded from the study in order to ensure individuals had received sufficient exposure to the day-to-day demands of the clinical setting. Three nurses were randomly selected to take part in each of the focus group interviews, after gaining consent from each of the clinical settings and were assured that they could withdraw at any time. Ethical approval was sought and granted by the Trust’s committee. Information gathered was tape-recorded and transcribed verbatim. Such interviews provided the author the opportunity to gain valuable insight into how stress and burnout can affect life outside the clinical setting. This is an area untouched by the Maslach Burnout Inventory and the current literature. DEMOGRAPHIC DATA

Prior to completing questionnaires, individuals were asked to identify how long they had worked in their respective departments, their age, gender and years of experience. This information, as well as clinical grade and area of work, were deemed crucial for comparison of clinical settings. INSTRUMENT

The Maslach Burnout Inventory (Maslach et al., 1996) focuses on work and requires individuals to respond to each statement on the 22-point questionnaire by making one of the following responses: • Never • Few times a year • Once a month • Few times a month • Once a week • Few times a week • Everyday. This tool has been extensively piloted and tested for reliability and validity. Internal consistency has been widely tested using Cronbach’s coefficient alpha. It is widely viewed as the tool of choice for measuring such a phenomenon (Hannigan et al., 2000). The tool is designed to assess three aspects of the burnout syndrome: emotional exhaustion, depersonalization and personal accomplishment. Each statement on the 22-point questionnaire pertains to one of the three subscales mentioned. Individuals who experienced high sores in emotional exhaustion and depersonalization are more at risk of burnout than those with low scores in each of the subscales.

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Personal experiences are under-represented at present in the available literature, therefore an open-ended question was added to permit respondents to identify areas of their work that they deemed stressful.

Results A total of 30 questionnaires was returned from the 56 distributed, a response rate of 60%. The response rate from nurses from acute medicine was 57% (n ¼ 16) and 71% from A & E nurses (n ¼ 20). Ages of respondents ranged from 23 to 56 years and only one of the respondents was male. Respondents were asked to indicate how long they had worked in their respective clinical settings (Table 3), and to identify three things that they perceived to be stressful in their daily work and suggest solutions. Content analysis revealed broad themes, namely staffing, patient issues, work pressures, management issues and medical staff. Figure 1 Emotional exhaustion in relation to clinical area.

Emotional exhaustion This subscale assesses feelings of being emotionally overextended and exhausted by one’s work. The results demonstrated that there is an increased prevalence of nurses working in acute medicine who experience higher levels of exhaustion than their counterparts in A & E. This equates to 56% of those working in acute medicine compared with 20% of those working in A & E (Fig. 1). Statistical analysis using Mann–Whitney Test revealed that nurses working in acute medicine experienced more fatigue when getting up in the morning to face another day (P ¼ 0.039), when compared with those nurses from A & E (Table 4). Those working in A & E experienced more medium levels of emotional exhaustion. Those holding positions grades D or E were more likely to experience high levels of exhaustion than their senior counterparts (Fig. 2).

Table 3 Years of staff experience Number of years in department Staff grade

1–5

5–10

>11

Grade Grade Grade Grade Grade

11 2 1

4 6 1

3 3 2 2

18 11 4 2 1

10

36

Total

D E F G H

1 14

12

Total

Table 4 Statistical analysis relating to emotional exhaustion Area of work

n

Mean rank

P-value

3. I feel fatigued when I get up in the morning

A&E Acute med.

20 16

15.27 22.53

0.039

17. I can easily create a relaxed atmosphere with my recipients

A&E Acute med.

20 16

21.88 14.28

0.030

Question no.

Few nurses reported high levels of exhaustion who had between 1 and 5 years or 11 or more years of experience. Fifty-eight per cent of those who had between 6 and 10 years experience demonstrated high levels compared with 29% in those with between 1 and 5 years and 20% of those with 11 or more years (Fig. 3). From observation of emotional exhaustion subscales there would, in Figs 2 and 3, appear to be a correlation between years of experience and clinical grade in relation to levels of emotional exhaustion. No significance (P ¼ 0.526) was however found after univariate analysis of variance. Individual items pertaining to this subscale yielding responses occurring at least once per week were ‘I feel used up at the end of the day’ and ‘I feel frustrated by my job’. 2003 Blackwell Publishing Ltd, Journal of Clinical Nursing, 12, 842–851

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Figure 4 Levels of depersonalization in relation to area of work.

Figure 2 Emotional exhaustion in relation to staff grade.

Hayter (1999) found similar results in his work with nurses who worked with HIV patients. An individual item that yielded responses a few times per week, was ‘I have become more callous since taking up this job’. All these respondents worked in A & E.

Personal accomplishment

Figure 3 Levels of emotional exhaustion in relation to years in department.

This subscale assesses feelings of competence and successful achievement in one’s work. Analysis highlighted that 63% of those sampled demonstrated high levels of personal accomplishment while 27% demonstrated medium levels (Fig. 5). No apparent difference was found between the clinical settings. High levels of personal accomplishment were experienced less by those more junior members of staff, or grades D or E (Fig. 6). Statistical analysis using Kruskal–Wallis test revealed a difference in relation to years of experience (P ¼ 0.031) (Table 5). Nurses with between 6 and 10 years of experience were less likely to create a relaxed atmosphere whereas those with 11 or more years were less likely to achieve worthwhile things in their job.

Depersonalization This subscale measures lack of feeling and impersonal response towards recipients of one’s care. Analysis highlighted that 86% of respondent’s experienced low levels and 14% medium levels of depersonalization. No statistical significance was found between clinical areas. Five individuals experienced medium levels who were either grades D or E (Fig. 4). Duration of clinical experience did not appear to have any effect on the level of depersonalization experienced. 2003 Blackwell Publishing Ltd, Journal of Clinical Nursing, 12, 842–851

Focus group interviews The purpose of these interviews was to probe and establish if stress and burnout had any effect on individuals’ lives outside the clinical area. Additional information was provided which overlapped with issues already dealt with and this aids contextualizing individuals’ experiences. Key themes that emerged after content analysis are identified in Table 6. The characteristics common to those involved in the focus group interviews were that

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M. Gillespie and V. Melby Table 5 Statistical analysis relating to personal accomplishment

Question

Experience (years)

n

Mean rank

17. I can easily create a relaxed atmosphere with my recipients

1–5 6–10 11+

14 12 10

22.39 12.58 20.15

0.031

19. I have accomplished many worthwhile things in this job

1–5 6–10 11+

14 12 10

24.39 18.13 10.70

0.005

P-value

Table 6 Effects of burnout

Figure 5 Levels of personal accomplishment in relation to area of work.

• • • • • •

Exhaustion Insomnia Increased alcohol/tobacco consumption Irritability/inability to relax Little time for reflection/teambuilding Relationship with partners and siblings

Discussion The total response rate of 60% comprised 71% from the A & E department and 57% from an acute medical ward. These results should be borne in mind when interpreting the findings. Whilst this study involved modest sample sizes and cannot be generalized to all nurses working in such areas, it may be an important indicator in highlighting issues for further study.

Emotional exhaustion

Figure 6 Levels of personal accomplishment in relation to staff grade.

they were all females, at either grades D or E. None of the individuals had more than 11 years of experience. The themes identified may have, if sustained over time implications for the health of the individual and may place significant stress on relationships with partners and siblings.

It appeared from the result that nurses working in acute medicine experience higher levels of emotional exhaustion than their counterparts in A & E. This may explain the lower response rate from nurses in that area, as nurses are already experiencing a demanding working environment and have no time during the working day to complete questionnaires. Many reasons were put forward by the nurses that could help to explain the high levels of emotional exhaustion. Staff shortages figured prominently and a number of areas were cited, including the use of bank/ agency staff. These individuals had no experience of the layout of the clinical area and staff felt they spent valuable time showing individuals where to locate resources or how to use equipment. Bank staff appear to be increasingly used to fill gaps in the roster. Skill mix at weekends, during holidays and on night shift were identified as major issues in that junior nurses were left to fulfil very senior roles on wards. This would tend to support the authors 2003 Blackwell Publishing Ltd, Journal of Clinical Nursing, 12, 842–851

Professional issues in clinical nursing findings that high levels of emotional exhaustion are more prevalent between grades D and E staff. The notion that stress and burnout was more prevalent among grades D and E was contradicted by Chapman (1997), who speculated that those who carry moderately heavy administrative and teaching roles, as well as clinically active, are most susceptible (i.e. Sisters/Charge Nurses). Cost-effectiveness remains a major issue in today’s NHS and with a reduction in staff nurses of 9% from the year 1990 (D.H.S.S.P.S., 2002) and an increase in patient numbers, staff are more susceptible to stress and burnout. Coupled with an increase in workload, staff perceived patients and relatives to have an increasing expectation of what the service could provide. Aggression, both physical and verbal, was found to be more prevalent when A & E waiting times increased or there were bed shortages in the ward setting. One staff nurse commented: …. Due to an increase in workload, going without meal breaks is now recognized as a way of keeping up with the demands of the clinical setting. There was a perceived lack of support from those in managerial positions and communication was deemed to be poor. Vincent & Billings (1988) support this view and demonstrated that increasing levels of stress can be traced back to poor leadership and management styles. The literature indicates that managers often deny there is a problem and detach themselves further from the problem (Green, 1996). A further cause of emotional exhaustion highlighted by staff was lack of time for group reflection. Taylor (2000) deemed this essential for revising existing practice and realizing the potential for improvements and change. Little time for team building exercises was also highlighted as a factor contributing to stress. Wright (2000) argued that by providing team building and developing a shared meaning in the workplace individuals appear to have few sick days. Content analysis identified that nurses had difficulties with junior medical staff, who were deemed to be heavily dependent on nurses for support and direction. Heyworth (1993) highlighted that medical Senior House Officers were unaware of their professional boundaries and what exactly was expected from them. Length of shifts was reported as a problem, which may contribute to emotional exhaustion and was perceived by staff to be physically and mentally draining. Shift patterns, including rotation to night duty, were deemed to be areas causing concern in that individuals felt too fatigued to concentrate. Statistical analysis supports this notion, as nurses working in acute medicine felt fatigued when they got up in the morning and had to face another day. 2003 Blackwell Publishing Ltd, Journal of Clinical Nursing, 12, 842–851

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Nurses in acute medicine perceived the A & E department to be a source of stress by continually ringing to determine bed availability, or presenting to the ward without prior notice leading to patients having to wait on trolleys. Nurses felt this to be dehumanizing and embarrassing for the individual concerned and this, in turn, caused further stress on the nurse. Clinical grading demonstrated a trend, also, whereby levels of emotional exhaustion dipped among those with between 5 and 10 years. Is it possible this might contribute to individuals’ leaving the field of nursing? Goldberg et al. (1996) argued that those who became disillusioned within a work force either left or stayed and continued to function ineffectively. There was ‘a feeling of being used up at the end of each day’ and ‘a feeling of job frustration’ among respondents. Kilfedder et al. (2001) support this view and suggested that nurses who are continually exposed to unremitting stress will demonstrate negativity towards their job. Walsh (1998), however, argued that experience did not have an effect on the level of emotional exhaustion experienced. The subscale that the researcher had least causes for concern with was depersonalization, as 86% of those sampled experienced low levels. This leads the author to contend that, although there are extreme pressures in today’s modern NHS, nurses remain committed to the provision of individualized nursing care for patients and relatives. If, however, nurses continue to work under such pressures and demands, this may change in the future. Hudak & Gallo (1994) consider that constant denial of the self leads to individuals becoming devalued, depersonalized and unrecognized. Bailey (1985) argued that if individuals continue to care too much for others at the expense of themselves, then burnout would be the end result. Nursing staff identified that the Trust could further enhance their levels of accomplishment by the provision of funding for specialist courses in order to advance clinical skills and implement an improved career pathway. Facilities for families were deemed to be poor, and time was limited for spending in patient/family interactions. Admission to a hospital is a crisis for the patient and family members; failure to recognize this and respond appropriately is to fail in holistic care in its purest sense (Viney, 1996). Appropriate interactions with the patient and their families leads to a decrease in anxiety, increased reassurance, better co-operation, improved rapport and mutual understanding (Quinn, 1996). Nurses have recognized this as an area of concern, but feel that a lack of resources hinders them in their role. One nurse commented that:

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…. It’s now health care assistants that provide nursing care as we are caught up completing meaningless paperwork, which is duplicated many times over. Statistical analysis highlighted that nurses working in A & E were more likely to create a relaxed atmosphere than nurses in acute medicine. This could be related to the higher prevalence of emotional exhaustion among nurses working in acute medicine. Further analysis revealed that nurses in their first 5 years of clinical practice are more likely to be able to create a relaxed atmosphere, those with 11 or more years of experience were less likely to accomplish worthwhile things. This serves to support the researcher’s findings that, as years of experience increase, personal accomplishment decreases. This may help to support the view that individuals either leave the service or remain, but function less effectively. Previous studies have not identified years of experience as contributing to the level of accomplishment experienced among clinical staff (Hayter, 1999).

Interview interpretation This study highlighted that stress from the clinical area can carry over into individuals’ personal lives. Coping mechanisms, such as smoking and alcohol consumption, helped nurses to unwind after a busy shift. Ceslowitz (1989) suggested that the use of palliative coping mechanisms leaves fundamental problems untouched. Heyworth (1993) argued that greater support networks, interpersonal relationships and teamwork are more healthy methods of raising morale and lowering stress. Personal relationship problems were highlighted that was attributed to long working hours and changes to shifts at short notice. Long working hours were also deemed anti social and did not lend themselves well to family life. One nurse commented that: … Herself and her partner were like passing ships in the night. Staff increasingly felt they were becoming more irritable and had difficulty in relaxing, often directing outbursts towards loved ones. Further research is, therefore, needed as this is an area, which has received little attention in current research.

Limitations of the study The sample was small in numbers and findings cannot therefore be generalized beyond this sample of participants. Twenty individuals failed to return completed

consent forms after reminder letters were sent out. Parahoo (1998) pointed out that respondent’s time is often precious with little time and enthusiasm for questionnaires on top of other paperwork. The possibility of type I errors should also be considered when multiple comparisons were made. This study was however exploratory in nature and has suggested areas for further study using a larger sample. The sample size was small and the distribution assumptions for parametric testing were not met, therefore non-parametric statistical procedures were used. Findings reported do, however, indicate trends that have implications for nursing. Methods triangulation placed further confidence in the findings of this study and enhanced validity and reliability. Emerging themes were discussed with a fellow researcher and clinical colleagues to minimize the likelihood of bias. Investigator triangulation enhances reliability and validity further. From the literature review there was a strong focus on gender and levels of burnout. This study, however, had only one male participant, which is an area which should be focused upon in further work on this subject. Hayter (1999) in earlier work, however, did not establish any link among similar sample sizes.

Conclusions Stress and burnout appears to have far reaching effects for nurse in their clinical practice and in life outside the clinical area. Nurses working in acute medicine were deemed to be more exhausted than their counterparts in A & E. Individuals suggested that this was often due to circumstances beyond their control, such as resource issues. The results have demonstrated that, despite the rigours of their daily work, nurses feel they remain able to implement holistic individualized nursing care. Caution should be noted as the literature contends that if nurses continue to care at the expense of themselves than burnout will be the end result. The perception of the care given from a patient’s perspective should be an area considered for future research in this area. Urgent attention and support is now required in order to tackle the identified issues. If we are to care for the carers then this should be a consideration in planning for future research. Stress and burnout appears to be an occupational hazard that can result in permanent damage. The science of nursing does not have to be painful, but by recognition of the existence of stress and burnout we can take the first steps towards prevention.


Professional issues in clinical nursing

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