Relationship between Hardiness and Risk of Burnout in a Sample of 92 Nurses Working in

Oncology and AIDS Wards

Author(s): A. Costantini, L. Solano, R. Di Napoli and A. Bosco
Source: Psychotherapy and Psychosomatics, Vol. 66, No. 2 (March-April 1997), pp. 78-82
Published by: S. Karger AG
Stable URL: https://www.jstor.org/stable/45116061
Accessed: 22-04-2020 16:26 UTC

JSTOR is a not-for-profit service that helps scholars, researchers, and students discover, use, and build upon a wide
range of content in a trusted digital archive. We use information technology and tools to increase productivity and
facilitate new forms of scholarship. For more information about JSTOR, please contact support@jstor.org.

Your use of the JSTOR archive indicates your acceptance of the Terms & Conditions of Use, available at
https://about.jstor.org/terms

S. Karger AG is collaborating with JSTOR to digitize, preserve and extend access to

Psychotherapy and Psychosomatics

This content downloaded from 82.76.227.99 on Wed, 22 Apr 2020 16:26:55 UTC
All use subject to https://about.jstor.org/terms
 Regular Article

Psychotherapy
Psychother Psychosom 1997;66:78-82
and Psychosomatics

A. Costantini a
L. Solanob Relationship between Hardiness
R Di Napoli a
A. Boscob
and Risk of Burnout in a Sample of
a Dipartimento di Salute Mentale, 92 Nurses Working in Oncology and
Ospedale Forlanini, e
b Dipartimento di Psicologia,
AIDS Wards
Università di Roma 'La Sapienza',
Roma, Italia

KeyWords Abstract
Hardiness Background: The present study tested the hypothesis that particular person-
Coping ality dispositions act as resistance resources in the encounter with stressful life
Stress events. Methods: The sample consisted of 100 student nurses working in crit-
Burnout ical areas (oncology and AIDS). At the beginning of the 2nd year course sub-
Nursing jects were administered the Kobasa Hardiness Scale and at the end of the year
the Maslach Burnout Inventory. Results: Higher hardiness levels at the begin-
ning of the course were associated with lower emotional exhaustion and higher
personal achievement scores at the end. As predicted, findings show hardiness
scores to be predictive of the risk of burnout. Conclusions: A screening of
personality traits could be useful in preventing the risk of burnout in nurses
working in critical areas.

Introduction Among personality factors capable of buffering the

negative impact of stressful events, one of the most inter-
The effect of stressful life events in the pathogenesisesting
of paradigms is hardiness. This construct was intro-
somatic and psychiatric pathology is widely documented duced by Kobasa [7] and utilized in a series of studies
in the literature [1-3]. [8-10]. In a longitudinal investigation on 670 executives,
When confronted with stressful life events, however, subjects with high levels of occupational stress showed a
not all subjects show the same reaction. This was already significantly lower number, and lower severity, of physi-
recognized by Selye [4]. cal and mental symptoms and disease episodes, in the
Antonovsky [5] introduced the term 'resistancepresence re- of high levels of hardiness. This dimension is
sources', by which he designated factors capable of 'buff-supposed to influence coping processes (cognitive ap-
ering' the effects of stressful events. praisal and related actions): it is formed by a constellation
Research has been recently investigating possible path-of personality features, commitment, control, and chal-
ways relating stressful events, emotional states and onsetlenge.
and course of diseases; involvement of the psychoneu- 'The commitment disposition is expressed as a tenden-
roimmunological axis is certainly demonstrated [for cy toainvolve oneself in (rather than experience alienation
review see 6]. from) whatever one is doing or encounters ... committed

KARGER © 1997 S. Karger AG, Basel

0033-3 1 90/97/0662-0078$ 1 2.00/0
Dr.ssa Anna Costantini
Viale di Villa Massimo 24
E-Mail karger@karger.ch 1-00161 Rome (Italy)
Fax + 41 61 306 12 34
http:// www. karger, eh

This content downloaded from 82.76.227.99 on Wed, 22 Apr 2020 16:26:55 UTC
All use subject to https://about.jstor.org/terms
persons' relationships to themselves and to the environ-
ment involve activeness and approach rather than passiv-
ity and avoidance' [8] (e.g. Item 1: 'I often wake up eager
to take up my life where it left off the day before'; item 23:
'I really look forward to my work').
'The control disposition is expressed as a tendency to
feel and act as if one is influential (rather than helpless) in
the face of the varied contingencies of life ... Control
enhances stress resistance by increasing the likelihood
that events will be experienced as a natural outgrowth of
one's actions and, therefore, not as foreign, unexpected,
and overwhelming experiences' [8] (e.g. item 5: 'I usually
feel that I can change what might happen tomorrow, by
what I can do today'; item 25: 'When I am at work I know
when I need to ask for help').
'The challenge disposition is expressed as the belief
that change, rather than stability, is normal in life, and
that changes are interesting incentives to growth rather
than threats to security' [8] (e.g. item 2: 'I like a lot of
variety in my work'; item 24: 'It doesn't bother me to step
aside for a while from something I'm involved in, if I'm
asked to do something else').
In synthesis, these three dimensions allow a cognitive
appraisal through which events appear meaningful, less
overwhelming and undesirable; they allow coping actions
capable of transforming events, making them less stress-
ful, rather than avoiding them. Subjects high on these
dimensions should therefore be capable of avoiding bio-
logical states leading to disease or immune depression.
Kobasa [8] developed a questionnaire which makes it pos-
sible to obtain separate scores on the three dimensions
and a general hardiness score.
One form of occupational stress-related pathology, par-
ticularly investigated in the helping professions, is the
burnout syndrome. This entails both physical and psychic
symptoms, thus configurating an actual disease syndrome
[11,12].
Burnout is cumulative and progressive. In an initial
stage, the most common symptoms are physical and emo-
tional exhaustion. Common complaints are headache,
fatigue, sleep disorders. If the situation persists, symp-
toms of burnout become behavioral or social. A general
sense of meaninglessness, apathy, cynicism and detach-
ment from work and patients become apparent. In the
final phase proper depression may be present: subjects in
burnout may feel they are personal failures. Burnout has
been measured through self-administered questionnaires,
among which one of the most common is the Maslach
Burnout Inventory [13].
Hardiness and Burnout Psychother Psychosom 1997;66:78-82 79
This content downloaded from 82.76.227.99 on Wed, 22 Apr 2020 16:26:55 UTC
All use subject to https://about.jstor.org/terms
No occupation is without stress. A moderate degree of
tension may be propulsive and challenge the staff to oper-
ate at optimal levels. Excessive stress, however, may cause
deterioration in the relationship with patients, in the qual-
ity of professional performance, and is responsible for 30-
40% of absence from work in the British National Health
Service [14, 15]. In an empirical survey in Great Britain,
50% of junior and senior doctors and health service man-
agers showed high emotional distress levels, and more
than 25% were significantly depressed, scoring >8 on the
D scale of the Hospital anxiety and depression scale [16].
In a study on 3,500 Swedish nurses, 40% responded that,
despite a high degree of job satisfaction, they felt too tired
after work to socialize with the family, and 45% had seri-
ously considered quitting their job [17], Another study on
the same population showed a high correlation between
job satisfaction and absenteeism [18].
Some areas of medicine, such as oncology and AIDS
care, expose members of staff to higher work-related
stress. The need to deal with dying and death, the feeling
of helplessness linked with the limits of medicine in these
pathologies, the length of disease, the need to maintain an
empathie reaction with patients suffering or dying, the
risk that empathy might lead to identification, are poten-
tially stressful situations for caregivers [19, 20]. A survey
on 598 oncologists [21] found in 56% of cases a self-report
of burnout in professional life.
As a further specification, younger subjects appear
more affected [22]. In agreement with previous observa-
tions, Watson [23] found a correlation between higher lev-
els of stress and younger age in a sample of 393 physi-
cians. Younger subjects appeared more sensitive to the
problem of death and showed more difficulty in dealing
with cancer patients.
In line with the literature on resistance resources
reported above, different personality traits should make
the individual more or less susceptible to the risk of burn-
out in these areas. The hypothesis of our work is that a
hardy personality could represent a protection factor
against burnout.
Purpose of the Study
The aim of the study is to evaluate the relationship
between hardiness scores and the possibility of burnout in
a sample of student nurses working in oncology and AIDS
wards.
 Materials and Methods
Subjects
All student nurses attending the 2nd year of the Nursing School of
the S. Camillo and Forlanini Hospitals, Roma, amounting to 100
subjects, 52 females and 48 males, mean age 24.4, were included. The
course, which lasted from September to July, included 638 h of theo-
retical tuition and 1 , 1 60 h of practice (under supervision) in so-called
critical areas (oncology and AIDS). In the 1st school year only obser-
vation (in other areas) was scheduled. This was, therefore, the first
working clinical experience for the students.
Of the initial participants only 92 (48 females and 44 males) com-
pleted the course.
drome: emotional exhaustion (EE), depersona
of) personal achievement (PA). It was utilized
tion [24].
Statistical Analysis
Multivariate analysis of variance (ANOVA) was performed, us-
ing as dependent variables the three burnout symptom scores, and as
independent variable the hardiness dimension, categorized as high/
low (above/below the median). For the analysis, burnout scores were
transformed into standard scores, so that the mean of each distribu-
tion is = 0 and standard deviation is = 1 . Separate ANOVAs were
then performed for the three symptom scales.

Method
At the beginning of the year of practice subjects were adminis- Results
tered the Kobasa Hardiness Scale and at the end of the year the Mas-
lach Burnout Inventory. Administration took place in the usual Descriptive statistics of both scales employed are
school setting and was performed by a trained psychologist.
shown on table 1. Mean hardiness was 66.80 (SD 8.3),
Measures while the median was 66.40. Of the 92 students examined,
The Hardiness Scale [8] is composed of 50 items, each on40 (43%) showed low burnout scores, 37 (40%) medium,
a 4-
point scale. It was utilized in a recent Italian translation15(17%)
(see high.
Acknowledgements). MANOVA proved significant at p < 0.002, Rao's r =
The Maslach Burnout Inventory [13] is composed of 22 items,
5.30. Results of separate ANOVAs for the three burnout
each on a 7-point scale, assessing three symptoms of the burnout syn-
variables are reported in table 2. Significant differences in
relationship to hardiness levels were obtained for EE,
which appeared lower (mean = 13.78 ± SD 9.79) in sub-
Table 1. Descriptive statistics of hardi-
ness and burnout scores
jects with high hardiness than in subjects with low hardi-
ness (mean = 19.67 ± SD 8.13), and for PA, which
Hardiness Mean 66.84 appeared higher (mean = 42.00 ± SD 5.71 vs. 38.50 ±
SD 8.35 SD 5.65) in subjects with high hardiness. Differences in
Minimum 42.03
DP, though showing the expected trend, did not reach sta-
Maximum 80.23
Median 66.40
tistical significance. For the sake of comparison, means
and standard deviations from an Italian population of
Burnout Low 40 (43%)
748 health care operators [24] are also reported in ta-
Medium 37 (40%)
ble 2.
High 15(17%)
Figure 1 gives a graphic illustration of results.

Table 2. Means and standard deviations of raw scores and of standardized scores of the three bumout subscales in
high and low hardiness groups: ANOVA

High hardiness Low hardiness F(l,90) plevel Gen. population

EE 1 3.78 ± 9.79 19.67±8.13 20.18± 11.29

Mean standard score -0.31 0.31 9.86 0.002

DP 4.42 ±4.82 5.83±5.36 7.03±5.90

Mean standard score -0.14 0.14 1.72 NS

PA 42.00±5.71 38.50±5.65 32.52±8.66

Mean standard score 0.29 -0.29 8.42 0.004

Means and standard deviations in the Italian gener

80 Psychother Psychosom 1997;66:78-82 Costantini/Solano/Di Napoli/Bosco

This content downloaded from 82.76.227.99 on Wed, 22 Apr 2020 16:26:55 UTC
All use subject to https://about.jstor.org/terms
 stressful life events into one's own existential project (th
challenge dimension) and to endow them with sense and
purpose (the commitment dimension), may allow him/
her to consider work in the oncology/ AIDS ward as
stimulating experience allowing personal growth and a
possibility of viewing life from a different perspective.
Cognitive and behavioral flexibility, motivation to carry
out plans successfully, endurance under stress, which ar
all features of a hardy personality, could favor the process
of adaptation which is inevitable for anyone beginning t
work in oncology [20] and prevent the burnout syn
drome.
The design of the study could be further improved by
measuring burnout also before the beginning of clinica
practice. In this case, the dependent variable investigated
could be the difference in burnout scores before and after
practice. Further longitudinal studies are also needed to
investigate whether these findings may be extended to
other health care professionals, such as residents in onco
logy, senior oncologists, social workers, radiotherapists
Fig. 1 . Maslach Burnout Inventory profiles at the end of a 1-year etc.
practice in oncology and AIDS wards. Subjects with high hardiness
Our preliminary findings, suggesting the importance of
scores at the beginning of practice (□) show lower burnout scores
hardiness as one possible mediator between stressfu
(lower EE, p = 0.002; higher PA, p = 0.004) than subjects with low
hardiness at the beginning of practice (■). working environments and burnout, may be relevant t
the problem of staff selection and training. If our result
are confirmed, the instrument employed in our investiga
tion could be at least tentatively employed in the selectio
Discussion of staff to be assigned to 'high tension' wards as oncolog
or AIDS with positive consequences on the quality of
Causes of work stress are multiple: institutional,care, per-
periods of absence from work, risk of definite drop
out with
sonal and professional. In this investigation we focused onwaste of economic resources deployed in train
ing. Similarly,
personality aspects as risk, or alternatively, protection fac- our findings are in support of a trainin
tors in respect to the possibility of burnout. Results
effort
of our
in the development in staff members of the psycho-
logical
study suggest how certain subjects 'resist' better attitudes subsumed under the heading of hardi-
in a pro-
fession needing strong psychic commitment, ness. in which
they are confronted daily with difficult and little defined
existential problems of human beings (disease, death, suf-
fering). This confirms observations by KobasaAcknowledgements
on the
function of hardiness as a resistance resource in buffering
We thank Dr. Susan Levenstein and her group, Divisione
effects of working stressful events.
troenterologia, Ospedale Nuovo Regina Margherita, for supply
The next step is: in what ways may hardiness have of a recent version of the Kobasa Hardiness Scale.
Italian translation
influenced the process of adaptation to life inWeoncology
also thank Dr. Levenstein for kindly revising the manuscript.
and AIDS wards in these young nurses and therefore pro-
tected them from burnout?
An internal locus of control (the control dimension)
allows the hardy nurse working with cancer patients to
believe that, although he/she may not have chosen to work
in an oncology or AIDS ward, the ways in which he/she
lives the situation will depend on how he/she will be capa-
ble to handle the experience. The tendency to integrate

Hardiness and Burnout Psychother Psychosom 1997;66:78-82 81

This content downloaded from 82.76.227.99 on Wed, 22 Apr 2020 16:26:55 UTC
All use subject to https://about.jstor.org/terms
 References

1 Brown GW, Harris T (eds): Life Events and Ill- 10 Kobasa SC, Puccetti M: Personality and social 18 Petterson IL, Arnetz BB, Arnetz GE: Predic-
ness. London, Guilford Press, 1989. resources in stress resistance. J Pers Soc Psy- tors of job satisfaction and job influence -
2 Tennant C: Life-event stress and psychiatric ill- chol 1983;45:839-851. results from a national sample of Swedish
ness. Curr Opin Psychiatry 1994;7:207-212. 1 1 Freudenberger HJ: Staff burn-out. J Soc Issues nurses. Psychother Psychosom 1995;64:9-19.
3 Solano L, Coda R: Relazioni, Emozioni, Salute. 1974;30:159-165. 19 McElroy AM: Burnout. A review of the litera-
Padova, Piccin, 1994. 12 Freudenberger H J: Burnout. Doubleday, An- ture with application to cancer nursing. Cancer
4 Selye H: The Stress of Life. New York, chor, 1980. Nurs 1982;5:211-217.
McGraw-Hill, 1956. 13 Maslach C, Jackson SE: Maslach Burnout In- 20 Lederberg M: Psychological problems of staff
5 Antonovsky A: Health, Stress and Coping. ventory Manual. Palo Alto, Consulting Psy- and their management; in Holland JC, Row-
Washington, Jossey-Bass, 1979. chologist Press, 1981. land JC (eds): Handbook of Psychooncology.
6 Biondi M, Kotsalidis G: Psychoneuroimmu- 14 Coe A: High anxiety. Nurs Times 1992;88:26- New York, Oxford University Press, 1989.
nology today: Current concepts and relevance 30. 2 1 Whippen DA, Canellos GP: Burnout syndrome
to human disease; in Lewis CE, O'Sullivan C, 15 Rees D, Cooper C: Occupational Stress in in the practice of oncology: Results of a random
Barraclough J (eds): The Psychoimmunology of Health Service Employees. London, HMSO, survey of 1000 oncologists. J Clin Oncol 1991;
Cancer. Mind and Body in the Fight of Surviv- 1990, pp 163-172. 9:1916-1920.
al. London, Oxford University Press, 1994, pp 16 Caplan RP: Stress, anxiety and depression in 22 Ulrich A, Fitzgerald P: Stress experienced by
3-54. hospital consultants, general practitioners and physicians and nurses in the cancer ward. Soc
7 Kobasa SC: Stressful life events, personality senior health service managers. BMJ 1 994; 309: Sei Med 1990;31:1013-1022.
and health: An inquiry into hardiness. J Pers 1261-1263. 23 Watson M, Parr M, Ellis N: Aspetti stressanti
Soc Psychol 1979;37:1-11. 17 Petterson IL, Arnetz BB, Arnetz GE, Horte dell'attività clinica in oncologia; in Grassi L
8 Kobasa SC, Maddi RS, Kahn S: Hardiness and LG: Work environment, skills utilization and(ed): Il Disagio Psichico in Oncologia. Ferrara,
health: A prospective study. J Pers Soc Psychol health of Swedish nurses - results from a na- Spazio, 1993.
1982;42:168-177. tional questionnaire study. Psychother Psycho-24 Maslach C, Jackson SE: Maslach Burnout In-
9 Kobasa SC, Maddi RS, Puccetti M: Personality som 1995;64:20-31. ventory Manuale; Italian adaptation by Sirigat-
and exercise as buffers in the stress-illness rela- ti S, Stefanile C. Firenze, Organizzazioni Spe-
tion. J Behav Med 1982;5:4-15. ciali, 1993.

82 Psychother Psychosom 1997;66:78-82 Costantini/Solano/Di Napoli/Bosco

This content downloaded from 82.76.227.99 on Wed, 22 Apr 2020 16:26:55 UTC
All use subject to https://about.jstor.org/terms