Risk factors and prevalence of burnout syndrome in the nursing ...

International Journal of Nursing Studies 52 (2015) 240–249

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Risk factors and prevalence of burnout syndrome in the nursing profession ˜ adas-De la Fuente a, Cristina Vargas a, Concepcioń San Luis b, Guillermo A. Can ˜ adas a, Emilia I. De la Fuente a,* Inmaculada Garcıá a, Gustavo R. Can a b

University of Granada, Spain Universidad Nacional de Educacioń a Distancia, Spain

A R T I C L E I N F O

A B S T R A C T

Article history: Received 28 November 2013 Received in revised form 30 June 2014

Background: The burnout syndrome is beginning to be regarded as an occupational illness of high prevalence among nursing in Spain. Individuals suffering from the syndrome manifest important health problems. More information about prevalence and risk factors for burnout is needed to prevent the syndrome and to determine the most appropriate clinical interventions when the disorder appears. Objectives: Burnout levels were evaluated in a group of nurses. The objectives of this study were to estimate the prevalence of burnout, to identify the variables related to burnout and to propose a risk profile for this syndrome among the nursing personnel. Setting: The study was carried out in public health centers in Andalusia (Spain). Methods: The sample consisted of 676 nursing professionals from public health centers. Dependent variables were the three Burnout dimensions: emotional exhaustion, depersonalization and personal accomplishment. Independent variables were sociodemographic, organizational, personality-related variables. Results: The nurses manifested average to high burnout levels. There were statistically significant differences in burnout levels associated with the following variables: age, gender, marital status, having children, level of healthcare, type of work shift, healthcare service areas and conducting administrative tasks. Burnout was also associated with personality-related variables. Conclusions: The prevalence of burnout among nursing professionals is high. Gender, age, marital status, level of healthcare, work shift and healthcare service areas predicted at least one of the dimensions of the syndrome. Neuroticism, agreeability, extraversion and conscientiousness are personality traits that predict at least two of the dimensions of burnout syndrome in nurses. Therefore, personality factors should be considered in any theory of risk profiles for developing burnout syndrome in the nursing profession. ß 2014 Elsevier Ltd. All rights reserved.

Accepted 2 July 2014 Keywords: Burnout professional Cross-sectional studies Nursing Prevalence Risk factors

* Corresponding author at: Departamento de Metodologıá de las Ciencias del Comportamiento, Facultad de Psicologıá, Universidad de Granada, Campus Universitario de Cartuja s.n., 18071 Granada, Spain. Tel.: +34 958243744; fax: +34 958243443. ˜ adas-De la Fuente), [email protected] (C. Vargas), [email protected] (C. San Luis), [email protected] (I. Garcıá), E-mail addresses: [email protected] (G.A. Can ˜ adas), [email protected] (E.I. De la Fuente). [email protected] (G.R. Can http://dx.doi.org/10.1016/j.ijnurstu.2014.07.001 0020-7489/ß 2014 Elsevier Ltd. All rights reserved.

G.A. Canãdas-De la Fuente et al. / International Journal of Nursing Studies 52 (2015) 240–249

What is already known about the topic? Excessive levels of continual stress can result in burnout. Nurses suffering from burnout usually manifest psychosomatic, emotional, attitude and behavioral problems. What this paper adds A high percentage of nurses from the Andalusian Health Service presented medium-high levels of burnout. Burnout is largely explained by individual personality traits and the healthcare field where the nurses work. Explanatory models associated with each of the Burnout dimensions included other socio-demographic and organizational variables. An initial risk profile for burnout syndrome in this group of professionals is established. 1. Introduction The burnout syndrome is a significant problem in modern working environments and its prevalence has increased substantially over the past decade. The most accepted definition of burnout is that proposed by Maslach and Jackson (1981), who described it as a response to chronic work-related stress comprising three components or dimensions: emotional exhaustion, depersonalization, and personal accomplishment. Emotional exhaustion refers to the physical and emotional overloads that result from interactions with co-workers and healthcare users. Depersonalization is the development of cynical attitudes and responses toward fellow workers and the beneficiaries of the services that one provides. Reduced personal accomplishment refers to the tendency of nurses to adopt a negative self-concept as a consequence of unrewarding situations. From a long-term perspective, overwork and high stress levels can cause workers to suffer burnout (Tucker et al., 2012). However, in return, both personal resources and job resources can lead to engagement, positive outcomes, greater efficiency, and commitment to work, all of which are directly opposed to burnout (Garrosa et al., 2011; Schaufeli and Bakker, 2004). Individuals suffering from burnout usually manifest psychosomatic problems (weakness and insomnia), emotional problems (anxiety and depression), attitude problems (hostility, apathy and distrust) and behavioral problems (aggressiveness, irritability and isolation), among other problems (Adriaenssens et al., 2012; Jansson-Frojmark and Lindblom, 2011; Leape et al., 2012). Moreover, burnout affects nurses’ workplaces, both public and private (more sick leave, diminished work effectiveness, more absenteeism, etc.). The users of healthcare services are also affected as the quality of healthcare deteriorates (Brinkert, 2010; Clausen et al., 2012; Schmidt and Diestel, 2012). Because of the nature of their job, nurses are at risk of developing burnout syndrome (Lorenz et al., 2010). Recent studies relate high levels of emotional exhaustion to an increase in morbidity associated with related psychiatric disorders (Renzi et al., 2012). Other studies report high prevalence rates of emotional exhaustion and

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depersonalization accompanied by low levels of personal accomplishment among nursing personnel (Al-Turki, 2010). All of these research studies found that the work environment and the nurses’ personal and social situation have an impact on the advent and potentially on the development of the disorder (Albaladejo et al., 2004). As Vargas et al. (2014) and Pereda-Torales et al. (2009) argue, any evidence of the protective and risk factors for burnout are of great interest to the scientific community. More information about these factors is needed to prevent burnout syndrome and to determine the most appropriate clinical interventions when the disorder appears. Thus, research in the field addresses two types of relevant variables: personal variables (socio-demographic and personality-related variables) and organizational variables (those pertaining to the occupational environment of the participating nurses) (Aydemir and Icelli, 2013). Personal variables have traditionally been regarded as less relevant than organizational variables. Nevertheless, an organizational stressor, such as a work overload, can lead to different levels of burnout, depending on the personality factors of the employee (Shimizutani et al., 2008). In other words, some people are more susceptible to burnout than others. It is thus crucial to take individual differences into account in order to better understand why some people are at greater risk of burnout than others (Maslach et al., 2001; Pick and Leiter, 1991). Socio-demographic variables have been studied extensively though the results obtained have been contradictory. With regard to age, some studies conclude that burnout decreases with age (Alacacioglu et al., 2009; Kanai-Pak et al., 2008), whereas others report the opposite (Losa Iglesias et al., 2010) or even question the association between age and the syndrome (Gosseries et al., 2012). The high levels of burnout in younger workers could be due to the fact that this group has less professional experience and thus have not had sufficient time to formulate effective strategies for dealing with occupational stress (Bilge, 2006). When Alarcon et al. (2009) performed a metaanalysis of the relation between gender and burnout, they found that there are important gender-specific differences in burnout levels. More specifically, women seem to experience more emotional exhaustion whereas men are more prone to depersonalization. A possible reason for is that unlike men, women tend to respond more emotionally to stressful work situations (Schaufeli and Enzmann, 1998). With regard to marital status, various studies conclude that married individuals are more likely to suffer from emotional exhaustion, though the results of other studies contradict this finding (Al-Turki, 2010; Lin et al., 2009; Moreira et al., 2009). On the other hand, married people have higher levels of personal fulfillment than single people (Maslach, 2003), which could be due to the support that they receive from their partners. There are also conflicting results about having children. The prevailing view is that nurses with children have higher levels of emotional exhaustion (Moreira et al., 2009), although nurses with children also report higher personal accomplishment (Ayala and Carnero, 2013). Nurses with children are generally older, more stable, and more emotionally mature (Maslach, 2003), which contributes to a feeling of

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greater personal fulfillment. Nonetheless, their higher level of emotional exhaustion could stem from the responsibility of having children and the problem of reconciling work and family life. Over the last decade, several studies underline the significance of psychological variables and have found that certain personality traits could be conducive to the advent of the syndrome or, on the contrary, may protect against the development of the disorder (Fornes-Vives et al., 2012; Hudek-Knezevic´ et al., 2011; Narumoto et al., 2008). All previous studies have focused on the relationship between personality and burnout by using Five Factor Theory or the so-called ‘‘big five’’. This model has been one of the most widely used trait measurement theories, and describes personality in terms of five basic factors. The ‘‘big five’’ personality factors are neuroticism (level of emotional instability), agreeableness (level of interpersonal tendencies to approach or reject others), conscientiousness (level of self-control and self-determination), extraversion (level of energy and sociability), and openness to experience (level of intellectual curiosity and esthetic sensibility) (e.g., Costa and McCrae, 1992; McCrae and Costa, 1999). In this sense, Alarcon et al. (2009) found that emotional exhaustion and depersonalization have a negative relationship with emotional stability, agreeableness, conscientiousness, and extraversion. On the other hand, personal accomplishment is positively related to emotional stability, agreeableness, conscientiousness, extraversion, and openness to experience. Neuroticism (the opposite of emotional stability) is characterized by a tendency to negatively interpret events (Watson and Clark, 1984) and show negative emotions such as anxiety, depression, and frustration (Costa and McCrae, 1992). For this reason, people with higher levels of neuroticism tend to use coping strategies based on avoidance and distraction (Bakker et al., 2006). In all likelihood, this type of behavior could lead to higher levels of emotional exhaustion and depersonalization along with a lower sense of personal accomplishment. Agreeability is associated with individuals who are more cooperative, flexible, and trusting (Costa and McCrae, 1992). In stressful situations, such people seem to use coping strategies that focus directly on the problem. The use of effective coping strategies is also characteristic of responsible people who are able to organize and plan their work and time (Costa and McCrae, 1992). Similarly, extroverts, who by nature are more sociable, enthusiastic, and self-confident (Costa and McCrae, 1992), are more likely to be optimistic and are thus able to positively reevaluate problems (Bakker et al., 2006). Finally, openness to experience is typical of independent people who are tolerant of ambiguity and who are capable of embracing new experiences and ideas (Costa and McCrae, 1992). People with a more open mind often use humor as a strategy to cope with stressful situations (McCrae and Costa, 1986). The use of the most effective coping strategies, which is characteristic of people with the positive personality factors of emotional stability, agreeableness, conscientiousness, extraversion, and openness to experience, can led to lower levels of emotional exhaustion and depersonalization as well as a higher level of personal accomplishment.

Certain occupational variables, such as the type of shift (De la Fuente et al., 2013; Stimpfel et al., 2012), seniority (Cabrera Gutie´rrez et al., 2005), or work-related emotional demands (Bartram et al., 2012), have been related to burnout. Emotional exhaustion levels are lower among those who have worked at the same job or in the same type of healthcare service for more time and among those who work in service areas that are considered less stressful. The contrary result occurs, for example, among those who work in the intensive care unit (Ayala and Carnero, 2013). Excessively short breaks between work shifts contributes to greater emotional exhaustion (Drach-Zahavy and Marzuq, 2013), and insufficient time for completing tasks generates higher levels of emotional exhaustion and depersonalization (Naruse et al., 2012); these stressful job conditions can result in reduced personal accomplishment (Garrosa et al., 2010). This may be due to the fact that these professionals lack sufficient resources to be able to successfully adapt to highly demanding work contexts that can vary considerably from day to day. These findings indicate that the panorama of research on the burnout syndrome has varied considerably over the last 40 years. Initially, burnout research was composed of exploratory empirical studies whose objective was to quantify burnout levels in professionals and identify some of the covariables related to the development of the syndrome. Although there are currently different approaches to elaborating a model of burnout risk, most authors seem to agree on the existence of a structured set of personal and occupational risk factors associated with burnout dimensions (Aydemir and Icelli, 2013). In this type of model, work environment variables are generally regarded as those most closely related to this syndrome (Maslach et al., 2001). Nevertheless, there remains a certain controversy regarding the relevance of socio-demographic variables, above all as variables that modulate other burnout variables. Finally, recent research highlights the need to consider personality factors and incorporate them into the profile of professionals most at risk of developing the syndrome. For this reason, the research described in this paper examined whether personality factors are relevant to a burnout risk profile for nursing professionals. This study had the following objectives: (1) to estimate the prevalence of burnout syndrome; (2) to study the association between burnout levels and variables traditionally considered risk factors for the syndrome; and (3) to define the burnout syndrome risk profile in a sample of nurses. 2. Methods 2.1. Participants A total of 676 nursing professionals from the Andalusian Health Service (Spain) comprised the study sample. The average age of the participants was 44.58 (SD = 8.18), and the percentage of women was 66%. All participants had bachelor’s degrees and provided partial or total direct care as professional nurses. The overall response rate was


81.6%. Nine participants were excluded from the study because of missing data. 2.2. Instruments A set of questionnaires was administered to obtain socio-demographic and occupational information. The following variables were assessed: age, gender, marital status (married, separated or divorced, unmarried, and widowed), number of children (no children, one child, two children, and three or more children), the level of healthcare (primary vs. hospital healthcare), healthcare service areas (surgical healthcare, medical attention healthcare, maternal and infant healthcare, emergency and critical healthcare, and community healthcare), job shift (rotating, morning shift, afternoon shift, and night shift), on-call requirement (yes vs. no), administrative tasks in their occupational area (yes vs. no), seniority in the current job and seniority in the profession. Burnout syndrome was measured using the Maslach Burnout Inventory (MBI; Maslach and Jackson, 1981) adapted for the Spanish population (Seisdedos, 1997). It comprises 22 items with a seven-point Likert response scale from zero (‘‘Never’’) to six (‘‘Every day’’). The MBI has three dimensions: emotional exhaustion (EE; nine items), depersonalization (D; five items) and personal accomplishment (PA; eight items). Individuals with a high level of burnout were defined based on the Spanish cut-off scores. For emotional exhaustion, the cut-off point for a high level was >24; for depersonalization, it was >9; and for personal accomplishment, it was