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Burnout among Nurses in Intensive Care Units, Internal Medicine Wards and Emergency Departments in Greek Hospitals
E. Adali 1 , Priami M 2
1. RN PhD, Clinical Professor, Nursing Depart., T.E.I of Athens, Greece 2. Assistant Professor, Nursing Depart., University of Athens, Greece
ABSTRACT: This study compared the levels of burnout syndrome among nurses in different nursing specialties and the environmental factors that contribute to the development of burnout. A sample of 233 nurses in five hospitals was selected. Study results indicated that nurses of emergency departments showed significantly higher levels of emotional exhaustion in comparison to nurses working in intensive care and internal medicine units. For the intensive care nurses, significant predictors included peer cohesion, control, involvement, and task orientation, while, for the internal medicine nurses, significant predictors were involvement, workload, physical comfort, task orientation and autonomy. Finally, for the nurses of emergency departments, significant predictors included involvement, workload, innovation, supervisor support, age and task orientation. In conclusion environmental factors seem to have an impact to the development of nurses’ burnout. KEY WORDS: Burnout, Nurses, Hospital, Work Environment.
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the coworkers. Finally.6.12. nalization and accomplishments. Among the reasons contributing to the development of burnout are the following: 1) the time that nurses spend for the patients’ care. 4) work load16 . 3) the contact with patients having increased emotional demands15. burnout is a syndrome emotional a low which characterized by exhaustion.9. the control he exerts over the events Page 2 of 19 . Burnout develops as a response to the chronic emotional strain. and the person who receives that help1. his values.11. the nursing burnout results in poor patient care. burnout has been closely related to both the absenteeism of nurses from work7 and abandoning nursing8. Additionally. which is the result of dealing with other people and especially with people who cope with serious problems. his motivations for having chosen a humanistic profession20 . Very important for the development of burnout are also the personality characteristics of the individual.3. his self-esteem. primarily people who are somehow dealing with other people in their work. It directly affects the worker and it presents with various symptoms. mainly because of the nature and the emotional demands of their profession2.13 2) the contact with patients having a poor prognosis14. which results from the social interaction between the person who provides help. his Burnout is a serious problem. the family and the social ccording to Maslach.ICUs and Nursing Web Journal ISSUE 11th (July – September 2002) ISSN 1108-7366 All rights reserved INTRODUCTION A is related to the deterioration of relationships between the nurse and the patients. both somatic and psychological2. depersolevel of personal affects environment4. 5) ambiguity and role conflict6 . Thus.5. It expectations from himself and the others21 . burnout could be considered as a type of professional stress. 7) lack of job satisfaction18 and 8) fear of death19. his ability to express his feelings.3.10. 6) lack of support on the part of the supervisor and Nurses are particularly susceptible to the development of burnout. colleagues17.
internal medicine wards. They argued that the causes of stress were the noise levels. The results showed that nurses who were not working in ICUs reported higher levels of burnout than those working in ICUs. Moreover. and to the work overload25. Even though the tension of occupational stress was much greater for workers in ICUs. differences in the degree of burnout experienced by nurses working in different fields. it did not consist a forecasting factor for work burnout. pediatric. gynecological and surgery wards) confirm the significance of the interpersonal environment23. it was found that there was no difference between the three dimensions of the syndrome among nursing Page 3 of 19 . Cronin-Stubbs & Rook23 studied stress and work In a research on 354 members of nursing personnel. Kelly & Cross27 used comparative groups in order to examine job related stress and work burnout. the physical environment and generally the work environment. This may be attributed to the conflicts among staff. In their research they compared nurses The comparisons among different hospital units (operation theatres. personnel working in ICUs and those working in other departments26. There are working in ICUs with nurses of other specialties who were working in two urban hospitals.ICUs and Nursing Web Journal ISSUE 11th (July – September 2002) ISSN 1108-7366 All rights reserved and the others. It is said. surgery and psychiatric departments) in three hospitals. All these factors influence the way of handling an emotional strain1 .24. Moreover. and his personal style. burnout in working environment among the members of the exhaustion and depersonalization in comparison to nurses of Intensive Care Units (ICUs) and other specialties. the nursing personnel who were working in emergency departments experienced significantly higher levels of emotional burnout among 296 nurses of four different nursing specialties (ICUs. to the decreased expertise of the workers. that some people are more stress resistant. and thus less vulnerable to the development of burnout22.
or Universities. Internal Medicine Wards. They were all graduates of either Technological Educational Institutions. Chiriboga and Baily28 concluded in their study that working in Intensive Care Units or in any other field of nursing practice the nurse doesn’t seem to be affected by the degree of the experienced burnout.ICUs and Nursing Web Journal ISSUE 11th (July – September 2002) ISSN 1108-7366 All rights reserved nursing personnel of the four different OBJECTIVES The purposes of the study were: 1) the investigation of the degree of burnout specialties was not statistically significant. we recorded the views of nursing personnel working in 5 Emergency Departments. METHODS Sample The sample of the study consisted of 223 nurses working in five Public Hospitals in the area of Athens. and Intensive Care Units and 2) the identification of job related factors that contribute to the development of burnout. nurses who are less involved in decision making consider their work as less challenging and they express a higher degree of burnout. even though work overload during the recent decades is particularly increased because of the deficiency of nursing personnel. were chosen according to the following criteria: 1. in Emergency Departments. experienced by nurses working in Public Hospitals in the area of Athens. The nurses. 2. It is possible that some other environmental characteristics are more important for the development of burnout. work burnout syndrome of nursing personnel has not been far-reached by Intensive Care Units. For example. the particular socio-demographic features. who participated in the study. researchers. They had experience in clinical nursing of at least one Page 4 of 19 . and particularly. and the job related risks. 20 Internal Medicine Wards and 7 In Greece. such as the degree of participation in the work. In particular.
the task orientation. The 42. which was developed by Maslach and Jackson29. Tools For the collection of data the following tools were used: 1. The Work Environment Scale developed by Moos and Insel30 . in order to assess the comprehensibility of the questions. which consists of 90 questions of right-false type. Pilot study A pilot study was conducted.2%). 31. support. and finally the physical comfort. 2. The time needed to complete the questionnaires was Page 5 of 19 . the clarity. the depersonalization and the low personal accomplishments. 3. The results of nurses (10. They orally accepted to participate in the present study.7% of the total sample) working in different clinical fields other than those of the main study. 3. A general information questionnaire. the supervisor's estimated about 30 to 40 minutes.ICUs and Nursing Web Journal ISSUE 11th (July – September 2002) ISSN 1108-7366 All rights reserved year. the autonomy. the managerial control.33.9% in Emergency These questionnaires were translated in Greek first by the investigators translator and then. It consists of 22 questions and records 3 dimensions of burnout: the emotional recorded the demographic and professional features of the sample of the study it formulated by the investigators according to similar questionnaires found in Greek and international literature26. The Maslach Burnout Inventory.5% of our sample are working in Internal Medicine Wards (n=99). the innovation. 32: A total of 414 questionnaires was distributed and the response rate was 223 (56. an an independent made inverse Departments (n=51). the work pressure. This scale assesses the worker’s involvement. the 35.6% in Intensive Care Units (n=83) and the 21. translation. the coworker’s cohesion. addressed to 25 exhaustion. No modifications were required.
The assessment of the factors that are associated with high scores of emotional exhaustion and depersonalization will provide the evidences as to which factor contributes to the development of burnout. In order to define the best variables that The questionnaires were completed by the nurses. number of children. In the selection procedure participated only the variables found to have a statistically significant correlation with burnout in the partial correlation analysis (i. The selection of the variables was done by the backward elimination procedure in the level of significance p=0.e. environment subscales) was evaluated by using the Spearman’s correlation coefficient. work experience and the work High scores of burnout reflect high scores of emotional exhaustion and depersonalization and low scores of personal accomplishments. the correlation of each variable with burnout). The nurses were not able to complete the questionnaires on the same day because of work pressure. the method of Multiple Linear Regression was used. No further modifications were needed. questionnaires were anonymous. Statistical analysis The possible association of burnout with the different independent variables (age. The same procedure was followed for the main study as well. and they were returned to the investigator after seven days. Approval to conduct the pilot study was obtained from the Boards of Directors and the Nursing service Multiple linear regression analysis Administration of each Hospital. Page 6 of 19 .05.ICUs and Nursing Web Journal ISSUE 11th (July – September 2002) ISSN 1108-7366 All rights reserved the pilot study were considered to be positive because they revealed the adequacy of our tools. The contribute in a statistically significant degree to the interpretation of the presence of burnout. assisting by the guidelines written on the first page of each questionnaire. The agreement to complete the questionnaire was considered as consent to the participation in the study.
41 6.8% of the nurses possed a nursing specialization title. had 6% of the nurses and 23. Institutions. Masters degree or Ph.72 2.45 1.4% of the nurses in our sample had a work experience of 6-10 years. and 21.020 NS NS NS 0.5% of the nurses dedicate less than 25% of their time and 22. Table 1.D. 21. The 63. in the total sample and in the different Wards of the Hospital.40 0.73 1. Most nurses were married with 1-2 children and they had a work experience of up to 10 years.026) In particular. nurses who work in Page 7 of 19 .025 correlation between Burnout Characteristics Table 2 presents the burnout experienced by nurses. 26. 24% were holding warding position and 12. Concerning the work experience.6% of the total were simple clinical nurses. There was found a burnout and of the study Ward of the Hospital (p=0.91 2.3%).9% of the nurses spend 50% of their time.15 1.17 SD 6.7% had Some of the features of our sample are presented on Table 1. When concerning the time that nursing personnel spends during its working hours caring for the patients. whereas the majority of nurses (38.34 statistically significant P-value 0.7%) were graduates of Technological Educational a work experience of 1-5 years. The educational level of nurses had a University degree (5.1% were head nurses. Sample description Variables Age Number of children Work experience Time in present position Time for direct care M 34.80 7. 44.7%). with mean age 34 years.2% 1610 years.ICUs and Nursing Web Journal ISSUE 11th (July – September 2002) ISSN 1108-7366 All rights reserved RESULTS The majority of nurses were female (91.
43 6-48 50 35.66±8.14±10.34 2-51 82 97 51 21.86 0-28 80 7.99 0-48 226 7.01±11.ICUs and Nursing Web Journal ISSUE 11th (July – September 2002) ISSN 1108-7366 All rights reserved Emergency Departments report a higher degree of burnout compared to nurses working in ICUs.47 0-48 79 34.05±9.53±11.09 0.59 26.78 24.55 14-48 97 3533±3.01 0-21 96 7.60±11. Burnout in Intensive Care Units (ICU).44 Page 8 of 19 . Table 2. and in Emergency Departments (ED) Variables Total ICU IMW ED p-Value Emotional Exhaustion Ν X±SD Min-Max Depersonalization Ν X±SD Min-Max Personal Accomplishment Ν X±SD Min-Max 226 35.85±5.49±6.99 0-24 50 9.12±530 0-28 230 24. Internal Medicine Wards (IMW).49±5.026 0.29 2-51 5-48 5-46 0.74±10.
529 0.005).146 0.005 0.ICUs and Nursing Web Journal ISSUE 11th (July – September 2002) ISSN 1108-7366 All rights reserved Intensive care units (ICUs) The predictors of burnout for nurses working in ICUs were the following: For the emotional exhaustion: low co-worker control (p=0.015).938 -1. task orientation (0.032). Environmental predictors of burnout in Intensive Care Units (Ν=83) Subscales Emotional Exhaustion Predictor Coworker cohesion Managerial control Involvement Managerial control Age Personal Accomplishment Task orientation Managerial control 1.015 Page 9 of 19 .749 St.001 0.488 0.093 -0.001 0.363 0.01) and managerial control cohesion (p=0. For personal accomplishments: age (p=0.035). For the depersonalization: low worker involvement (p=0. (Table 3) Table 3.709 1.000) and inadequate managerial (p=0. Error 0.001) and inadequate managerial control (p=0.035 Depersonalization 0.535 0.032 Slope -1.613 -1.561 0333 0350 p-value 0.000 0.165 0.
the work overload (p=0.000 0.000) is predictor for the increased depersonalization whereas the autonomy is predictor for personal accomplishments (Table 4).042 1.521 2.237 -1. Error 0. The poor task orientation (p=0.047) are associated with high levels of emotional exhaustion. Table 4.ICUs and Nursing Web Journal ISSUE 11th (July – September 2002) ISSN 1108-7366 All rights reserved Internal Medicine Wards The low degree of involvement (p=0.000 Emotional Exhaustion Work pressure Physical comfort Depersonalization Personal Accomplishment Task Orientation Time for direct care Autonomy Page 10 of 19 .000 0.014 0.605 0. The above mentioned factors are predictors for the emotional exhaustion. Environmental predictors of burnout in Internal Medicine Wards (N=99) Subscales Predictor Involvement Slope -1.834 St.014).047 0.616 0344 0.583 0.442 -1.455 3.001 0.408 p-value 0.773 0.000) and the poor physical comfort (p=0.
711 1. Error p-value Emotional Exhaustion Involvement Work pressure Innovation -2.539 0.036 0. (Table 5) Table 5.185 0.036).006 0. Environmental predictors of burnout in Emergency Departments (Ν=51) Subscales Predictor Slope St.006) and the lack of innovation (p=0.ICUs and Nursing Web Journal ISSUE 11th (July – September 2002) ISSN 1108-7366 All rights reserved Emergency Departments The low level of involvement (p=0.807 0.010 Depersonalization Personal Accomplishment Supervisor Support Age Task orientation 0.653 0.262 0.010) are the predictors of emotional exhaustion.000 Page 11 of 19 .188 3.000) influence the personal accomplishments. while the age (p=0. the work overload (p=0.003).723 0.006 0.159 0. The supervisor support influences the depersonalization (p=0.006) and the task orientation (p=0.911 0335 0.606 -2.003 0.
A possible explanation of this particular finding seems to be that the work is not the single source of satisfaction for nurses. The degree of depersonalization was also higher in Emergency Even though the 64% of the sample were simple nurses. These data are in accordance with international data 34. while they spend most of their time (33% Departments but not in a statistically significant degree compared with Intensive Care Units and Internal Medicine Wards.26 approximately) patients46 . with mean age below 40 years and an average experience in nursing of less than 15 years. compared with American levels36 and Greek data37. This finding comes in agreement with a research concerning the distribution of time of the nursing personnel. In their research they found that nurses spend about 22% of their time for direct nursing care. given that the 60% of nurses in our sample were married. These estimations are in accordance with the estimations of Candley26 . the working conditions in hospitals don’t really favour the long-term stay of nurses in their work35 .ICUs and Nursing Web Journal ISSUE 11th (July – September 2002) ISSN 1108-7366 All rights reserved DISCUSSION The majority of nurses of the sample were female. In particular. or change of work area. nurses reports range of normal to high levels of personal accomplishments.) and nursing assistants are commissioned to direct care. In any case. compared with nurses working in Intensive Care Units and Internal Medicine Wards. Page 12 of 19 . This is an indication that nurses prefer to consume their time with other occupational duties (managerial. education etc. for indirect care of their The total degree of the reported burnout in the sample of our study is thought to be moderate. emergency departments reported a statistically higher degree of burnout. nurses working in and suggest that nurses tend to withdraw early from the clinical sector possibly because of early retirement. they spend the least time (less than 25%) of their working hours for direct care.45. Probably.
and thus the nurse has a stronger control over the significantly related with the working period of the nursing personnel in ICUs. both for nurses spent working for a specific department. the nursing duties in ICU seem to permit greater freedom to nurses for the Page 13 of 19 research who argue that the longest period of time a nurse has . Additionally. This finding contradicts Robinson’s et al 38 environment compared to the open Wards. The average period of time that the nursing personnel (of this study’s sample) stayed in ICU was working in ICUs and emergencies. Emotional exhaustion was found to be is a closed Unit without visitors. approximately 7 years. the less emotional exhaustion he experiences. are still occupied with nursing duties and feel satisfied for it. in order to prevent emotional exhaustion. There is no such finding when looking at previous and recent bibliography. They also favour the application of new approaches. dedicated a significant part of their working hours for direct nursing care. This is a significant result for the present study because it indicates that nurses who have a close The comparison of working conditions among different Units suggests that the ICUs offer a more pleasant natural environment. according to which the environment in ICUs is more depressive. feelings. This finding seems to contradict a general perception that exists among nurses. A probable explanation for this is that older nurses are those who manage to control occupational tension successfully. Nursing personnel feels that ICUs are high demanding departments and really stressful23 . and had increased significantly their personal accomplishment certain periods of time and afterwards they must be removed to different nursing units. This finding indicates that nurses of ICUs should stay in ICUs for Nursing personnel of Internal Medicine Wards. This finding can be attributed to the fact that the ICU occupational relationship with their patients receive personal accomplishment feelings from it.ICUs and Nursing Web Journal ISSUE 11th (July – September 2002) ISSN 1108-7366 All rights reserved Age was found to be significantly related with personal accomplishment.
The work pressure is statistically higher in Emergency Departments in comparison to the other wards. when the nurse feels that his/ her work won’t be The Emergency Departments are usually very busy and they are dealing with lots of people. The predictors of emotional exhaustion are the following: 1) the self-actualization of the supervised nurses.39 depersonalization. The advantages of the positive social interaction within the work environment are closely related to the decrease Page 14 of 19 .is closely related to the feeling of personal accomplishments. and the integration of their task.e. he/she develops a more impersonal relation with the patient. low degree of involvement. 2) the increased work pressure and 3) the absence of change along with the limited application of new approaches. who claim that good relationships between the nurse and the supervisor are inversely related to the degree of degree of cohesion and the inadequate managerial control. the efficiency. the task orientation – i. the emphasis given by the nurses to the right scheduling. Intensive Care Units (ICU) In ICUs. Additionally. criticized by the supervisor. It is probable. the present study showed that support from the supervisor is a predictor (related to) for depersonalization. Finally. the supervisor’s preparation may be inappropriate for their work and thus they become overprotective and limiting freedom and Some of the problems faced by the nurse in the everyday practice are the time pressure. the critical condition of the patients and the conflicts between the nurse and the patient. the predictors for the development of emotional exhaustion are the low co-worker In contrast to the findings of Leiter and Maslach25.ICUs and Nursing Web Journal ISSUE 11th (July – September 2002) ISSN 1108-7366 All rights reserved application of more sophisticated ideas in comparison with Internal Medicine Wards and Emergency Departments.
On the other hand. the which results from the strong managerial control and the lack of innovations40.The Internal Medicine Wards of the Hospitals where we conducted our study are Page 15 of 19 .ICUs and Nursing Web Journal ISSUE 11th (July – September 2002) ISSN 1108-7366 All rights reserved of burnout38. whereas the strong managerial control along with good relationships among staff can protect nurses against the additional demands created by the patients41 . findings agree with the findings of other investigators26. our the Nursing Administration work pressure and the physical comfort. nurses who are focused on their duties (task orientation) and they are under intensive control from the Administration. In particular. trigger the emotional withdrawal and contribute to the development of high degrees of burnout 28. Additionally the regular supervision has a supportive role for nurses42. Generally. The low degree of involvement of nurses in their job and the inefficient control on behalf of the supervisor. when recognizes the important contribution to nurses in decision making for issues concerning the care of the patient 40.28 Our findings concerning the control are in accordance with the findings of Constable and Russel 41 . such as the description and the task obligations b) the poor communication within the hospital and c) the worker’s low degree of involvement in decision making. the predictors for emotional exhaustion were the involvement. Internal Medicine Wards In Internal Medicine Wards. have a stronger feeling of personal accomplishments. in spite of the fact the sample of their study consisted exclusively of nurses working in Military Hospitals. the managerial control is inefficient. 42. The reasons for poor co-worker cohesion are mainly focused on a) the ill-defined responsibilities. The management of job related stress requires a high level of coworker cohesion18 . The continuous work overload along with the limited involvement of nurses. the nurses tend to develop burnout more frequently. 41. when the work pressure is heavy and the nurse’s physical comfort is inadequate while considered to be successful in the hospitals. who have great familiarity with special rules. As it concerns the parameter of involvement. are closely associated with the development of impersonal behaviour.40.
accomplishments. The freedom in the care of patients reinforces the feeling of satisfaction and personal accomplishment. Some investigators suggest that staff autonomy is a substantial parameter.44 The thorough investigation of the international literature reveals the existence Page 16 of 19 . and were not evaluated in the present study. the employees tend to feel more integrated and they believe that they have accomplished their tasks successfully. in a more representative sample and in a wider geographical area. especially when it refers to complex duties. suggest further investigation of the problem. 43 who support that nurses working in ICU enjoy a higher degree of autonomy. and the places where nurses can rest during their shift are almost non-existent. the freedom and independence are is of high within the workplace. In other words. the personality features of the worker) that are associated with burnout. 40. the work environment is anything but comfortable and pleasant for the worker. This finding however doesn’t agree with the findings of other investigators. The limitations of our study are mainly due to relatively low number of participants and The autonomy of nurses in Internal Medicine Wards is a predictor for personal to the limited geographical distribution of the sample. These results however. of many other stressors (such as the jobrelated stress. Thus.ICUs and Nursing Web Journal ISSUE 11th (July – September 2002) ISSN 1108-7366 All rights reserved usually dealing with many patients.
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Brokalaki H. GR-163 44 Ilioupolis. 10: 131-136. and Lanara V. A. Scand J Caring Science 1996. Lemonidou C. Allocation ofnursing time. Greece Email: gioeva@otenet. 12 Egeos street. Mantas J.gr Page 19 of 19 . Adali. Corresponding author: E. Plati C.ICUs and Nursing Web Journal ISSUE 11th (July – September 2002) ISSN 1108-7366 All rights reserved 46.
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