Impact of Occupational Stress and Burnout

International journal of Innovative Research in Management ISSN 2319 6912
(January 2014, issue volume 1)
Impact of Occupational Stress and Burnout on Employee Job

Performance: A Study of Nurses in Rural Clinics of Bushbuckridge in
Mpumalanga Province
Mr. Madala Gilbert Khosa*, MrIshmael Tiriyo, Ms. Guillermina Ritacco1 and
Prof. Adolf Lowies1
1
Management College of Southern Africa (MANCOSA)
*MBA dissertation student
Corresponding Author:
Ms. Guillermina Ritacco
Research HOD - MANCOSA
ABSTRACT
This study was conducted to assess the impact of stress and burnout on performance of
registered nurses in the primary healthcare facilities of Bushbuckridge sub-district, in
Mpumalanga province. A survey of the literature on nurses reveals that although a great deal
of research has been carried out relating to occupational stress and burnout , little has been
written about the impact of stress and burnout on performance of nurses in rural setting in
South Africa. In carrying out the study, a random sample technique was used to select 50
registered nurses from 38 primary healthcare facilities. A quantitative, explorative,
descriptive and correlational research design was employed in this study to gather
information about the impact of occupational stress and burnout on performance of registered
nurses. After gathering relevant data, a descriptive and correlation analysis was conducted to
determine the relationship between stress and performance, as well as burnout and
performance. The findings of the study revealed that job stress and burnout do not impact
registered nurses job performance.
KEYWORDS: Stress, Burnout, Performance, Health Sector, Rural Clinics, Nurses
1. Introduction
The nursing profession has been depicted as one of the most stressful occupations across the
globe, and this makes nurses exceptionally susceptible to burnout. The negative impact of
occupational stress and burnout on organizational performance is undisputable. Research
studies have revealed that high level of stress and associated burnout among nurses leads to
decreased performance (Menze, 2006:55, Bhaga, 2010:52 and Hamaguchi et al., 2009: 643).
The South African health system consists of public and private health sectors. Pillay (2009:
2) noted that approximately82% of the South African population depends on the public
healthcare services, and accounts to 40 % of the total health expenditure. The private sector
which accounts for 60% of the total expenditure provides services for the 18% of the
population,who are privately insured. Therefore, the public healthcare sector is overused and
yet underfunded. Not surprisingly, there are daily reports of poor patient care, lack of
resources such as medications and other resources, and patients being turned away because
there are no healthcare workers and other services at the facility.
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Occupational stress and burnout are but one of the factors that bedevil the healthcare sector in
South Africa, particularly the public sector. Nurses occupational stress and burnout
commonly result in myriad health-related problems that have direct negative organizational
consequences such as absenteeism, performance deficits, increase staff turnover and so forth
(Bhaga, 2010: 52, Campbell, Lawrence, Spiehler and Williams, 2009:4). Regardless of the
approach to occupational stress, what remains obvious is that management should develop
comprehensive stress management programmes for nurses as a priority to prevent stress and
burnout, and by extension, prevent poor performance. The researchstudy aimed to identify
the relationship between occupational stress and burnout, and job performance of nurses in
rural clinics of Bushbuckridge sub-district, in Mpumalanga Province, South Africa.
1.1 Research Problem

Until now, few research studies have been conducted on the impact of stress on the
performance of nurses in rural clinics of South Africa. Occupational stress in nursing has
been studied extensively, however most of these studies were conducted in urban hospitals or
developed countries (Makie, 2006, Menze, 2006, Kane 2009, Lu, 2008 and Patrick and
Lavery, 2007). The healthcare system in South Africa is nurse-driven; nurses outnumber
doctors 5 to 1. As a result majority of the population receive their formal health care from
nurses rather than doctors. South Africa has adopted a primary health care approach, and the
clinics form the point of entry to access healthcare services in this country.
South Africa has the highest number of people living with HIV/AIDS in the world (Research
Brief, 2008: 6). The country has changed its legislative policies thereby allowing nurses to
assume a greater role in the management of patients with HIV/AID including diagnosis and
management of these patients. All the clinics in the Bushbuckridge sub-district are currently
rolling-outantiretroviral treatment (ART)and most of them started initiating this treatment in
early 2010. The majority of the nurses in these facilities complain about how stressful it is
working in rural clinics.
1.2 Aim and objectives

The purpose of the study is to investigate the relationship between job stress and burnout on
the performance of nurses in rural clinics.
The research objectives were:

To investigate the prevalence of workplace stress and burnout amongst nurses in rural public
clinics.
To investigate how workplace stress and burnout of nurses has impacted on their
performance.
To investigate factors that cause workplace stress and burnout amongst nurses.
To investigate effective and efficient ways of managing workplace stress and burnout of
nurses.
2. Literature review
The South African health system consists of the public and private sector. The public health
sector further consists of 3 levels: level one consisting of primary health care (PHC) clinics
and district hospitals, level two comprises of regional hospitals and level three comprises of
academic hospitals (Ngwenya, 2009:31). Registered nurses (RNs) are found throughout the 3
levels and form the largest group of the health care system in this country. However, PHC
facilities are mainly managed by RNs alone. RNs in the primary health care facilities play a
significant role in the South African healthcare system, as they are the first point of contact
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for patients in the health care system. What happens at this level has serious impact on the
health care services and the cost thereof in South Africa.
2.1 Occupational stress

Occupational stress results from the interaction of the employee and the conditions at work.
Stress is recognized world-wide as responsible for many challenges to employees mental and
physical health, and impaired organizational performance (Park, 2007:5).
There are many definitions of stress and occupational stress in the literature, even experts do
not agree on the definition of stress. Occupational stress as defined by Albrecht, Carr, Kelly
and Keaton (2011:32) is a perceived difference between the professional demands and a
persons ability to carryout those demands. Meanwhile, Gardner and Cummings (1998) as
cited by Bowen, Ferris, Hall, Hochwarter, Perrewe and Treadway (2006:219) argue that
occupational stress occurs whenever job-related stimuli cause a job holders experienced
activation level to deviatesubstantially from ones characteristic level of activation. That is,
when an employees resources have reached disequilibrium, the employee will experience an
elevated level of strain.Therefore, occupational stress may occur under certain conditions and
not others, and be experienced by some individuals and not others.
However, Chan, Huang and Tsai (2009:443) defined occupational stress as harmful physical
andemotional responses incurred in the work environment. Many authors (Albrecht et al.,
2011:32, Agolla and Ongori, 2008:125, Haarr, Kwak and Morash, 2006:541) dispute this and
state that occupational stress is not necessarily always harmful. Stress helps employees to
stay focused, energetic and alert at work. In other words, if the level of stress is acceptable,
the employees performance will be enhanced. Workplace stress becomes unhealthy if it is
not manageable, and will therefore result in negative consequences like poor productivity,
poor physical and mental health, and so forth. As a result a stress-free workplace is virtually
impossible to achieve. Organizations should therefore focus on keeping their employees
healthier and productive by putting in place programmes that will help deal with stress at
workplace, rather than focusing on complete reduction of stress.
Albrecht et al. (2011: 33) further identified two main types of stress, the first one is acute
stress which results from unexpected stressors and is short-lived, and the second is chronic
stress which results from unresolved issues or conditions, and manifests as a state of ongoing
physiological agitation. Albrecht et al (2011:33) further argue that chronic stress deserves
serious attention because if it is left unresolved it can have disastrous consequences like
absenteeism, increased turnover rates, low productivity and poor organizational performance.
This in turn will cost the organizations or companies as they would not be able to perform
competitively against their rivals, and it will also result in loss of profit.
2.2 Causes of Occupational Stress

Empirical studies (Agolla and Ongori, 2008, Hannan, Hussain, Mahmood, and Muhammad,
2010, Mojoyinola, 2008, and Clements, Milliken and Tillman, 2007, and Chang, Eatough,
Djurdjevic and Rosen, 2010:3) have identified the following as the general causes of
occupational stress to a wide spectrum of employees:
Work Overload;
Time Pressure;
Role Ambiguity;
Long Work Hours;
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Inadequate Staffing Levels;

Shift Work;
Exposure to Infectious Hazardous Substances;
Lack of Supervision;
Inadequate Training;
Inappropriate Working Conditions;
Poor relations with colleagues; and
Lack of Social Support at Work.
Working long hours might be beneficial in the short term but long term consequences are
evident. Several studies (Burke and McAteer, 2007: 244) found working long hours to be
associated with stress, burnout and adverse health outcomes particularly cardiovascular
disease. Working long hours was also found to be associated three-fold risk of coronary heart
disease, four-fold risk of diabetes, increased injury rate, reduced job performance and
increased mortality.
Many research studies have identified the following factors as some of the most common
causes of occupational stress in the nursing profession (NIOSH, 2008:1, Agolla and Ongori,
2008: 124, Bhaga, 2010: 39 and Gibbens (2007:55) :
Work overload;
Time pressure;
Lack of social support at work;
Needle stick injuries;
Exposure to infectious disease;
Role ambiguity and conflicts;
Career development issues;
Exposure to work-related violence or threats;
Understaffing;
Shift work; and
Dealing with difficult or seriously ill patients.
2.3 Burnout
Burnout affects all occupations but is said to be more prevalent in service professions like
didactic and healthcare services (Ashtari, Farrhady and Khodae, 2009:71, Pines and Ronen,
2008:678). Employees from the service profession are particularly prone to burnout due to
the nature of the interpersonal and organizational factors. However, nurses are above-average
risk group when it comes to occupational stress (Rothmann and van der Colff, 2009:1 and Lu,
2008: 63).
Burnout in the nursing profession arises from the stressors that are brought about by caring
for ill people. Hasselhorn, van Dam and van Der Heijden (2009:616) state that nurses tend to
leave the profession at a much greater rate compared to other profession because of burnout,
and this result in shortage of nurses. Furthermore, this shortage of nurses is associated with
poor standards of patient care and further increase in pressures on the nurses left on the job.
According to Aiken et al. (2002) as cited by Hasselhorn et al. (2009:617) the high turnover of
nurses was associated with high workloads, burnout and jobdissatisfaction. Therefore, greater
understanding of burnout in the nursing profession is very important if standards of patient
care are to improve.
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Burnout is commonly conceptualized as a tripartite syndrome consisting of the following:

emotional exhaustion, depersonalization, and reduced personal accomplishment(Jennings,
2008: 1, and Patrick and Lavery, 2007: 43). Ashill, Carruthers, Rod, and Thirkell (2009:339)
define burnout as a syndrome comprised of two components: emotional exhaustion and
depersonalization. Burnout is also defined as a psychologicalsyndrome, in response to
chronic job interpersonal stress (Ashtari et al., 2009:71). Thus burnout may represent the
chronic prolonged stress, which develops much later than job stress. Bakker, Dollard,
Schaufeli, Taris and Schreurs (2007:769), simply defines burnout as a syndrome of
exhaustion (that is, energy depletion), cynicism (that is, callous attitudes towards work and
others) and reduced professional efficacy. Malkia and Vuorensyrja (2010:385) define
exhaustion as a deep psychological and physical fatigue often caused by anxiety and or
depression. In addition, reduced professional inefficacy occurs along with exhaustion and
come about as a result of failure to provide fair, appropriate input at work and in turn this
leads to notions of lack of occupational accomplishments. On the other hand, the combination
of this 2 syndrome tends to make the burnout individual to become angry and irritable, and
ultimately cynical.
A considerable number of studies confirm that burnout is one of the consequences of

occupational stress (Ashtari et al., 2009:71, Ashill et al., 2009:340, Barnett and McCormick,
2010: 280). However, few authors cited in literature believe that there is no link between
occupational stress and burnout (Pines, 1993 as cited by Barnett and McCormick, 2010: 280).
Barnett and McCormick (2010:280) further conclude that intense stress does not necessarily
cause burnout, but it can. According to Ashill et al. (2009:338) burnout is a form of
psychological strain resulting from persistentwork stress. While chronic occupational stress
may cause burnout, not everyone who has stress will have burnout. Burnout usually occurs in
those individuals who are highly motivated, in other words you cannot burnout unless you
were on fire (Bernett and McCormick, 2010: 280). These authors further cite other authors
who argued that the response to occupational stressors and the potential for burnout to
develop largely depend on the individuals response to the environment. As a result not
everyone who has similar chronic or intense stress will have burnout.
South African healthcare workers suffer from extremely high levels of occupational stress
(Pillay, 2009: 52 and Murphy and von Holdt, 2008:3). Consequently, burnout amongst South
African nurses will be expected to be high as well, when taking into consideration that the
level burnout in nursing profession has been found to be high in many studies conducted
globally (Rothmann and van der Colff, 2009:1).
2.4 Causes of Burnout

Burnout in nursing has been studied extensively and nurses were found to be suffering from
high level of burnout as compared to the general population (Alexander, 2009:11). Alexander
(2009) further states that burnout emanate from the work environment, however not every
employee exposed to the same working conditions will experience burnout. Furthermore,
there are many risk factors that are positively associated with burnout and they are divided
into three groups namely: work environment, demographic variables and personality traits.
Alexander (2009: 18) cited one pool and a study conducted in the United States of America
which demonstrated that high level of burnout was associated with about 50% of nurses
considering leaving their jobs. Thus, high turnover of nurses in health care settings is closely
associated with burnout, and the high turnover in turn directly results in shortages. The nurses
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that remain will become dissatisfied with the working environment because of shortage. Job
dissatisfaction will in turn lead to burnout, and more nurses will leave. Alexander (2009)
further cited another survey which was also conducted in USA, and this survey found that
about 45% of nurses left the profession because of stress and burnout. As illustrated in
figure2.4, the ongoing shortage of nurses is directly related to the high turnover of nurses
which in turn results from burnout. Burnout and shortage continue to worsen and escalates to
job dissatisfaction which in turn leads to burnout, high turnover and more shortages which
further leads to more job dissatisfaction.
Figure 2.4: Nursing Shortage/Burnout Cycle
Source : Alexander (2009: 18)
In light of this, its quite clear that if left unattended the consequences will cost health care
organizations significantly and will result in deterioration of patient care provided. The
factors that may potentially lead to burnout as mentioned above are grouped into three
categories: work environment, demographic variables and personality traits.
2.5 Occupational Stress and Job Performance

Organizations and governments as well depend on the performance of their employees to
meet their intended goals. Job performance is defined by Chang et al. (2010:4) as behaviours
engaged in by employees at work that are in keeping with the organizational goals. Poor
performance by employees will significantly have detrimental effects to organizations,
resulting in poor productivity and even causing organizations to go bankrupt. Organizations
with stressful working conditions productivity were found to be negatively affected and that
there was a negative impact on service delivery (Bhaga, 2010: 51). South African nurses as
stated above were found to have extremely high level of stress; consequently their
productivity is expected to be low.
Mathis and Jackson (2000) as cited by Menze (2006:61) define productivity as a measure of
the quality and quantity done considering the cost of the resources it took to do the work. The
author further stated that the performance of an employee depends on three factors namely:
ability to do the work, level of effort and support given to the employee. These three factors
relate to each other in the following way: performance (P) is derived from the result of ability
(A) multiply by effort (E) multiply by support (S) that is: P= A x E x S. If any of the three
factors is reduced or diminished, performance will be negatively affected. Occupational stress
has tremendous effect on organizations effectiveness and affects productivity in many fronts:
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High rate of Absenteeism

High staff Turnover
Increasing unsafe Working Practices and Accidents rates
Increasing complaints from Patients and Patients Family members
Staff Recruitment
Increasing Liability to Legal claims
Organizations Image
Menze (2006:55) concluded that occupational stress may be responsible for many of the
organizational outcomes such as decline in performance, job dissatisfaction, lack of
motivation and commitment, as well as an increase in absenteeism and turnover. However,
stress is not always deleterious, some employees excel in their performance when under little
stress and thus they are more productivity under these conditions (Desseler, 2000 as cited by
Menze, 2006:56). Thus, the consequences of occupational stress in healthcare settings will
lead to more devastating consequences and might result in loss of lives of patients and/ or
healthcare workers.
2.6 Burnout and Job Performance

The available research suggests stress and burnout leads to poor performance
(Campbell,Lawrence, Spiehler and Williams, 2009: 4, and Bousinakis and Halkos,
2009:416). Empirical studies (Campbell et al., 2009:4and Kehoe, Montgomery,
Panagopoulou, and Valkanos, 2010:109) indicate that healthcare workers that are burnt out
may be unable to deliver safe and high-quality service to their patients. Studies indicate that
nurses at the hospitals where there are many medical errors have higher level of stress and
burnout than those in hospitals with lesser medical errors (Hamaguchi et al., 2008:643).
All available studies conclude that burnout in healthcare sector leads to suboptimal patient
care, however they are inconclusive with regard to which of the three dimensions of burnout
is associated with suboptimal patient care. Sharom, Nirel and Vinokur (2006) as cited by
Campbell et al. (2009:4) found that emotional exhaustion was associated with suboptimal
patient care, whereas Keijsers , Schaufeli, LeBlanc, Zwerts and Miranda (1995) also cited by
Campbell et al. (2009:4) found that all three dimensions of burnout were associated with
suboptimal patient care. Other studies cited by Campbell et al. (2009:8) identified
depersonalization as a negative predictor of quality of patient care. The link between job
performance and burnout is based on the premise that burnt out nurses may not be able to
engage with their patients, and thus providing suboptimal care.
Burnout as mentioned above come about as results of stressors at work, however, the
consequences of burnout can extend to the personal lives of nurses resulting in addictive
behaviours such as substance abuse (Alexander, 2009:16). Burnout and occupational stress
lead directly to many health issues like headaches, backache, stomach ache, heart attacks, job
dissatisfaction, anxiety, depression and so forth (Flaschner, Gill and Shachar, 2006:470).
These health problems will obviously have an adverse effect on employees performance
which will ultimately detract from the quality of care. Simply put, poor performance of RNs
means inadequate healthcare which will in turn result in exorbitant costs of the whole health
system as a result will affect patients care and safety as well.
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Given the central role that the RNs play in the healthcare system, the adverse effects of
burnout on this group of workers have the potential to undermine the healthcare delivery in
South Africa. The consequences of burnout on RNs in rural settings will be more devastating
as their roles are mainly linked to patient care. Poor job performance will be the ultimate
result of burnout in professional nurses. Burnout leads to absenteeism and poor productivity
and both in turn will result in high workload for the remaining nurses and this will further
worsen the quality of care.
3. Methodology
3.1 Method of Data collection
Questionnaires were used to collect data. Questionnaires are inexpensive, and can be
delivered in person, by email or mail. The disadvantages of using questionnaires include low
response rate and response bias, difficult to interpret subjects responses, and difficult to
check if the subject understood the questions (Bless et al. (2006:137).
The first part of the questionnaire attempted to delineate demographic profiles of the
registered nurses, namely age, gender, years of experiences as a registered nurse and marital
status. The questions on demographic profiles were included because literature indicates that
gender, age, marital status and years of experiences are some of the factors that were found to
be closely linked to stress and burnout in nurses.
Section A of the questionnaire related to factors causing occupational stress among registered
nurses in primary health care facilities, and a modified version of the Nurse Stress Scale
(NSS) was used. The NSS was designed to measure the frequency and factors causing stress
among nurses in different hospital units (Makie, 2006:52). The NSS has 34 statements that
describe the factors that were identified as causes of occupational stress in the nursing
profession. Only 22 statements of the NSS were used in this study. All questions that were
asked required a Lickert Scale response ranging from 0 never to 3 very frequently.
Section B: This section used the Maslach Burnout Inventory-Health Services Scale (MBI-
HSS) which consists of 22 items looking at work related burnout. The Maslach Burnout
Inventory was first developed by Christina Maslach in 1986. Only 16 items of the MBI-HSS
were used in the current study.MBI-HSS is the only measure that addresses all three core
components of burnout in the healthcare profession, namely depersonalization, emotional
exhaustion and reduced personal accomplishment. MBI-HSS items are written in the form of
statements about feelings related to work activities of healthcare professionals. These
statements are rated according to the seven point Lickert scale ranging from 0 (never) to 6
(everyday).
3.2 Sample size and sampling technique

The target population in this study consisted of registered nurses from the 38 clinics in the
Bushbuckridge Sub-district.There are 231 professional or registered nurses in the PHC clinics
of the Bushbuckridge Sub-district, in Mpumalanga province. A non-probability sampling
technique was adopted due to access restraints to nurses, as the Bushbuckridge sub-district
comprised a large geographic catchment area. A totalof 100 questionnaires were distributed
to nursing and management staff; 50 to nursing staff (consisting of the Nursing Stress Scale
and Maslach Burnout Inventory)and another fifty questionnaires to management staff
(consisting of the Nursing Performance scale).
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3.3 Variables measured

The variables measured include as independent variables:
Burnout: as measured by the Maslach Burnout Inventory
Stress: as measured by the Nursing Stress Scale
And as dependent variable:

Job performance: as measured by the Nursing Performance Scale
3.4 Method of data analysis

The questionnaires were checked for missing data and for correct completion. Descriptive
statistics namely, the mean, frequency, standard deviation were used to describe and
summarize the data on stress, burnout and job performance, collected from the respondents.
Analytic statistics, included the independent t-tests, ANOVA and Pearsons correlations.
4. Results and discussion

4.1The sample
The sample consisted of 50 nurses of which 84% were female and 16% male. In terms of age,
82% of the respondents were between the ages of 36 years and 50 years, 10% were over 50
years of age, 4% were between the ages of 26 and 35 and 4% between the ages of 18 and 25
years.
Sixty four percent of respondents were married, 30% were single, 4% separated and 2%
widowed. Forty four percent of the respondents have between 10 and 20 years in the nursing
field, 22% have between 5 and 10 years. On the other hand, only 26% indicated they have
more than 20 years experience and only 2% have below 1 year experience in the nursing
career or professional.
4.2 Occupational Stress

In terms of occupational stress, the dataset (Table 4.2) shows that generally the sample of
nurses experience medium to high levels of persistent stress. The areas of stress most
frequently experienced include death of patients (A2), the development of relationships with
patients (A3), difficulties in work relationships (A16), unpredictable staffing schedules(A17),
clerical/ non-nursing duties (A18), lack of emotional support for nurses(A19), lack of
sufficient time to complete tasks (20) and having to work through breaks (A21).
Table 4.2 Nursing Stress Scale results

Nursing Stress Scale Percentage
Never Occasionally Frequently Very
frequently
A1 Do you feel Helpless when a 2 14 42 42
Patients Health fails to improve?
A2 Are you Disturbed / Affected by the 6 16 10 68
Death of a Patient?
A3 Are you Disturbed / Affected by the 0 18 6 76
Death of a Patient whom you
Developed a close Relationship?
A4 Have you occasionally watched a 2 22 44 32
Patient suffer?
A5 Are you in Conflict with the Clinical 14 40 36 10
9
Mentor (Doctor/Nurse)?
A6 Are you afraid of making a mistake 6 44 24 26
when treating a Patient?
A7 Have you ever had a disagreement 10 44 32 14
concerning the treatment of a
patient?
A8 Do you feel inadequately prepared 8 44 38 10
to help with Emotional needs of a
Patient's Family?
A9 Are you feeling prepared to deal 14 32 32 22
with emotional needs of a patient?
A10 Do you occasionally deal with 2 32 18 48
Abusive Patients?
A11 There is no opportunity to share 10 42 30 18
Experiences and Feelings with other
Personnel in the Clinic?
A12 There is no opportunity at the Clinic 16 40 22 22
to express my feelings towards
Patients?
A13 Are there Conflicts between you and 16 16 28 40
the Operational Manager /
Supervisor?
A14 Are you occasionally criticized by 24 16 20 40
the Operational Manager?
A15 Do you have difficulties in working 68 16 10 6
with nurses of the Opposite Sex?
A16 Do you have difficulties working 6 14 60 20
with a particular nurse?
A17 There is unpredictable Staffing and 10 14 24 52
Scheduling?
A18 There are too many Non-nursing 6 2 30 62
Tasks required supporting the daily
duties of nurses at the clinic such as
Clerical duties?
A19 There is not enough time to provide 6 4 30 60
Emotional support to patients?
A20 There is not enough time to 2 12 28 58
complete all my nursing duties?
A21 Do you occasionally work through 10 8 16 66
breaks?
A22 Are you certain regarding the 14 22 32 32
Operations and Functioning of
specialized Equipment?
Of the stressors examined and excluding working with nurses of the opposite sex, the
frequency of the stressors experienced is medium to high. This suggests that not only are
nurses under stress, the stressors are persistent.
4.3 Burnout
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The Maslch burnout inventory as shown in Table 4.3a is made up of three subscales:
emotional exhaustion, depersonalization and personal accomplishment. Table 4.3 shows the
frequency distribution in percentages per item for the sample. The results indicate that in
terms of feeling emotionally drained, 26% feel emotionally drained every day, 22% one a
week, 18% once a month, 16% a few times per month, 8% once a year, 4% a few times a year
and 6% never. As can be seen, the distribution per item varies, with items 2, 3, 7, and 15
ranking highly for his sample. On the other hand, items 4, 5, 8, 10 ad 12 are ranked lower
indicate lower levels of burnout in terms of those items.
Table 4.3aMaslach Burnout Inventory item frequencies

Maslach Burnout Percentage
Inventory
Nev A few Onc A few Once Once Everyd
er times e a times per a ay
a year year per month week
month
1 Do you feel 6 4 8 16 18 22 26
Emotionally Drained
from your work?
2 Do you feel fatigued 8 8 4 10 18 16 36
when you get up in
the morning to face
another day at work?
5 Do you find working 30 10 14 20 2 8 16
with people a strain?
1 Do you feel 12 6 4 16 36 18 8
1 Frustrated by your
Job?
1 Does working with 22 6 14 26 8 10 14
Emotional exhaustion
3 people directly put

too much Stress on
you?
1 Do you occasionally 14 0 2 12 8 20 44
5 feel as if you are at
the end of your rope
(stuck in a situation)?
3 Do Patients 14 12 8 12 10 10 34
Compliment your
Service Delivery?
4 Were you ever told 36 20 12 12 6 4 10
by Patients they are
happy with the way
you treat them?
Depersonalization
8 Have you become 28 2 4 10 26 14 16

more callous
(Unsympathetic or
Heartless) towards
other people since
you took up this Job?
11
9 Are you worried that 14 8 2 8 34 12 22

the Profession has
hardened your
Emotions?
1 Do you Care what 44 16 12 16 4 6 2
2 happens to your
Patients?
6 Do you efficiently 14 10 10 18 6 14 28
and Effectively deal
with your patients'
problems?
7 Do you feel you 20 2 6 10 10 22 30
positively influence
other people's life
through your work?
1 Do you feel Energetic 30 30 12 8 6 4 10
Personal accomplishment
0 in your Job?
1 Do you feel 10 18 14 18 4 10 26
4 exhilarated (refreshed
or stimulated) after
working closely with
Patients?
1 Do you deal with 2 0 38 32 20 4 4
6 work related
problems calmly?
Table 4.1.3b shows the calculated item averages as well as the sample subscale averages and
the inventory standardized averages. As can be seem, the sample has scored higher on two of
the subscales and lower on the other as compared to the population on which the measure was
standardized. According to Maslach, Leiter, and Schaufeli (2009), higher scores indicate
higher levels of emotional exhaustion, and depersonalization and personal accomplishment.
What the results show is that for this sample, there exist high levels of emotional exhaustion,
high levels of depersonalization and low levels of personal accomplishment.
Table 4.3b calculated item averages for the Maslach Burnout Inventory
Maslach Burnout Sample Subscale Standardized population
Item Average
Inventory average average
1 4.06
2 4.14
5 2.42 3.62
Emotional exhaustion 2.3
11 3.96
13 2.78
15 4.36
3 3.58
4 1.84
2.724
Depersonalization 8 3.1 1.7
9 3.64
12 1.46
12
6 3.46
7 3.74
Personal 2.852
10 1.82 4.3
accomplishment
14 3.22
16 2.02
4.4 Performance Rating

In terms of the performance ratings (Table 4.4) of nurses by their managers, 78% of
managers felt that the nurses performance was satisfactory. Twenty percent of the nurses
were ranked as good performers with only 2% of nurses ranked as unsatisfactory performers.
Despite the fact that the nurses in this study are overly stressed and burnt out as described
above, they still perform well.
Table 4.4: Overall Performance Rating by managers
Cumulative
Frequency Percent Valid Percent Percent
Valid Unsatisfactory 1 2.0 2.0 2.0
Performance
Satisfactory Performance 39 78.0 78.0 80.0
Good Performance 10 20.0 20.0 100.0
Total 50 100.0 100.0
Figure 4.4:
Frequency Bar
Chart of
Overall
Performance
Rating by Manager
4.5 Stress, Burnout and Performance

As reflected in the items above, although as reported by nurses they exhibit high levels
ofstress and burnout, the link between stress and burnout and performance as has been shown
in other studies is not reflected in this sample.
13
Tables 4.5 and 4.6, the Kruskal Wallis tests between burnout, stress and performance show
no significant relationship between the variables (p >0.05). These results are unexpected and
are in opposition to what most studies have found (Awan et al., 2012:26). This means that for
this sample of nurses, stress and burnout has little to no effect on nurses performance.
Although as can be seen in table 4.1.6 test items 27, 27, 32 and 43 show an association
between stress and burnout, overall, the burnout indicator does not show this association.
Table 4.5 Performance and stress

Q2 Q3 Q5 Q6 Q8 Q10 Q11 Q12 Q13 Q16 Q17 Q18 Q21 Q22
Chi- .841 .778 .541 .364 .954 .284 2.044 .025 .251 .869 1.376 .843 2.026 2.011
Square
Df 2 2 2 2 2 2 2 2 2 2 2 2 2 2
Asymp. .657 .678 .763 .834 .621 .868 .360 .987 .882 .648 .502 .656 .363 .366
Sig.
Exact Sig. .748 .203 .650 .671 .391 .904 .307 .673 .626 .402 .281 .763 .204 .146
Point .008 .003 .010 .011 .011 .004 .006 .013 .006 .002 .001 .003 .015 .003
Probability
a. Kruskal Wallis Test
b. Grouping Variable: Performance
Table 4.6 Performance rating and Burnout

Q23 Q25 Q26 Q27 Q28 Q30 Q32 Q33 Q34 Q35
Chi- 2.916 .047 5.298 3.806 1.970 3.332 3.577 2.548 3.065 1.953
Square
Df 2 2 2 2 2 2 2 2 2 2
Asymp. .233 .977 .071 .149 .373 .189 .167 .280 .216 .377
Sig.
Exact Sig. .067 .840 .016 .039 .140 .055 .018 .099 .033 .318
Point .000 .000 .000 .000 .000 .001 .000 .002 .000 .000
Probability
a. Kruskal Wallis Test
b. Grouping Variable: Performance
5. Conclusions and recommendations

The aim of the research was to investigate the relationship between job stress and burnout on
the performance of nurses in rural clinics. The objectives of the study were to investigate the
prevalence of workplace stress and burnout amongst nurses in rural public clinics, to establish
how workplace stress and burnout of nurses has impacted on their performance and to
investigate factors that cause workplace stress and burnout amongst nurses.
The research showed that there is a negative relationship between job stress and burnout on
the performance of nurses in rural clinics of Bushbuckridge. Supporting the literature, the
results showed that nurses in BBR Sub-district are highly stressed, with the main causes of
stress been work overload, time pressure, and lack of social support, understaffing, role
ambiguity, as well as dealing with severely ill or dying patients. The findings also showed
that RNs in this subdistrict experience a high level of burnout, in keeping with the view in the
14
literature that high level of stress in the caring profession will ultimately lead to burnout. The
majority of the respondents were rated as average performers, and only 20% as good
performers. Therefore, there is negative relationship between job stress and job performance,
as well as between burnout and job performance.
5.1 Recommendations
In view of the research aims, the following recommendations are thereby proposed, whilst the
research findings serve as the basis for the recommendations to be made. The
recommendations are as follows:
A stress free environment is impossible to achieve, but that does not mean that
managers should tolerate it. The cost of stress to organizations is too much to ignore.
Managers should carefully and regularly monitor the level of stress among their
employees. The managers should be able to identify factors that causes distress and
implement policies that will reduce and manage both stress and burnout.
The managers in the sub-district can implement the following strategies to manage
and prevent burnout and stress:
Appropriate workload
Addressing the causes of work overload might be a more appropriate strategy and will
prevent recurring stress and burnout that largely arise from work overload. Even
though the solution to work overload is addressing understaffing, employing more
RNs to cover all facilities might not be possible because of the dire shortage of nurses
in the country. However, managers should always ensure that new nurses that are
employed should be distributed equitably to cover all facilities in the sub-district. In
cases where there are no RNs available to fill the posts, additional enrolled and
auxiliary nurses can be employed and utilized efficiently as per their scope.
Employing clerical staff such as data capturers and front desk staff will go a long way
in reducing non-nursing tasks that RNs are currently performing. The managers
should also ensure that appropriate workload is assigned to each employee; this
strategy has been proven to reduce and prevent stress and burnout.
Improve Communication and Relationships amongst employees
Bad communication has been cited in the literature and this study as one of the major
causes of stress (Albrecht et al., 2011:36). Bad communication if not managed
appropriately will result in conflicts in the workplace. This study has revealed that
RNs cited conflict with their managers and clinical mentors as one of the major causes
of stress. Managers should ensure that role and performance expectations are clarified
earlier on to avoid conflicts in the future. Employees should receive feedback after
their performance evaluation. Managers should also create an atmosphere that allows
effective two-way communication. Improve communication amongst the staff in a
clinic can go a long way in ensuring that stress is prevented or minimized. Managers
should ensure that all new staff members are inducted, and that appropriate time is
allocated to induction and training.
Good relationships amongst the staff in the clinic may also reduce the level of stress
and burnout. The study has revealed that conflicts are cited as been stressful by nurses
and that they have no opportunity to share their experiences with other colleagues in
the facility. Correct stress management should start from good interpersonal
relationships Managers should promote constructive resolution of conflicts and avoid
bias towards those that they have close relationships with. Regular staff meeting in the
clinics will enable the employees to know and understand one another and thereby
lessening conflicts amongst each other. This in turn will result in lower level of stress
and burnout. Talking to each other (peer support) helps to deal with stress. Peer
15
support will only be possible if nurses are able to share their experiences with each
other.
Counseling
The sub-district should ensure that all RNs have access to psychological counseling
and therapy at least once a year. For those that are stressed and burnt out this services
should be made available as soon as possible, in order to prevent negative
consequences of chronic stress. Policies that reduce stress and burnout should be
implemented in the facilities.
Staff Development
Staff development and continuing education should be made available to all staff.
Employees should be encouraged to attend workshops to enhance their skills and
learn new things. Skills development as discussed in the literature has been shown to
reduce the level of stress and burnout.
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20

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International journal of Innovative Research in Management ISSN 2319 6912

(January 2014, issue volume 1)

Impact of Occupational Stress and Burnout on Employee Job

KEYWORDS: Stress, Burnout, Performance, Health Sector, Rural Clinics, Nurses

1.1 Research Problem

1.2 Aim and objectives

The research objectives were:

2.1 Occupational stress

2.2 Causes of Occupational Stress

Inadequate Staffing Levels;

Burnout is commonly conceptualized as a tripartite syndrome consisting of the following:

A considerable number of studies confirm that burnout is one of the consequences of

2.4 Causes of Burnout

Figure 2.4: Nursing Shortage/Burnout Cycle

Source : Alexander (2009: 18)

2.5 Occupational Stress and Job Performance

High rate of Absenteeism

2.6 Burnout and Job Performance

3.2 Sample size and sampling technique

3.3 Variables measured

And as dependent variable:

3.4 Method of data analysis

4. Results and discussion

4.2 Occupational Stress

Table 4.2 Nursing Stress Scale results

Table 4.3aMaslach Burnout Inventory item frequencies

3 people directly put

8 Have you become 28 2 4 10 26 14 16

9 Are you worried that 14 8 2 8 34 12 22

4.4 Performance Rating

Table 4.4: Overall Performance Rating by managers

4.5 Stress, Burnout and Performance

Table 4.5 Performance and stress

Table 4.6 Performance rating and Burnout

5. Conclusions and recommendations

Alexander, L. L. (2009). Burnout: Impact on Nursing. CME Resource. Available from:

Available from: www.emeraldinsight.com/0268-3946.htm.[Accessed on the 4 th of May

Bousinakis, D. and Halkos, G. (2010).The effect of stress and satisfaction on productivity.

Campbell, T. (1996).Technology, Multimedia and Qualitative Research in Education.Journal

Chan, C., Huang, W. and Tsai, F. (2009).Occupational Stress and Burnout of

Kehoe, I., Montgomery, A., Panagopoulou, E. and Valkanos, E. (2011).Connecting

and Management, 25 (1), 108-123. Available from:www.ncbi.nlm.nih.gov/pubmed/21542465

Malkia, M. and Vuorensyrja, M. (2010).Nonlinearity of the effects of police stressors on

Maslach, C., Leiter, M. P., &Schaufeli, W. B. (2009).Measuring burnout.In C. L. Cooper &

NIOSH (2008).Exposure to Stress.Occupational Hazards in Hospitals. Publication no. 2008-

Patrick, K, and Lavery, J, F. (2007).Burnout in Nursing.Australian Journal of Advanced

Pillay, R. (2009).Retention strategies for professional nurses in South Africa.Leadership in

Pines, A.M. and Ronen, S. (2008).Gender differences in engineers burnout.Equal

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