Burnout Syndrome Among Filipino Nurses.

A Q Methodology
Maria Carolina Bondoc1,2,3, Rizza Jane Abanto1,2,3, Anne Clarisse Dela cruz1,2,3, Graciela Joyce
Guinto1,2,3, May Ann Manaois1,2,3, Catrina Mogar1,2,3, Lu Ed Sanchez1,2,3, Chelsea Ella Kari
Yuzon1,2,3, Sharon B. Cajayon, RN, MAN1,2,3,4 and Melody Gatdula, RN, MAN1,2,3,4

1
College of Nursing
3
Our Lady of Fatima University
Cabanatuan Campus

4
Research Adviser

December 2020
 Endorsement

This thesis entitled: “Burnout Syndrome Among Filipino Nurses. A Q Methodology” prepared by
Maria Carolina D. Bondoc et al. of BSN4Y1-1, in partial fulfillment of the requirements for the
degree Bachelor of Science in Nursing has been examined and now recommended for Oral
Examination.

This is to certify that Maria Carolina D. Bondoc et al. are ready for the Oral Examination.

Francis Vasquez III, RN, MAN

Adviser

This is to certify that the thesis: “Burnout Syndrome Among Filipino Nurses. A Q Methodology”
prepared and submitted by Maria Carolina D. Bondoc et al. of BSN4Y1-1, is recommended for
Oral Examination.

Sharon B. Cajayon, RN, MAN

Chair

Gerardo A. Nicholas, RN, RM, MAN, RPT, MAED Christoper R. Aranda

Member Member

Maria Luisa T. Uayan, DHSc, MSN

Dean, College of Nursing
 Certificate of Originality

We hereby declare that this thesis is our own work and that, to the best of our knowledge and belief,
it contains no material previously published or written by another person nor material to which to
a substantial extent has been accepted for award of any other degree or diploma of a university or
other institute of higher learning, except where due acknowledgement is made in the text.

We also declare that the intellectual content of this thesis is the product of our work, even though
we may have received assistance from others on style, presentation, and language expression.

Maria Carolina D. Bondoc

Principal Investigator

Members:
Rizza Jane Abanto
Anne Clarisse Dela Cruz
Graciela Joyce Guinto
May Ann Manaois
Catrina Mogar
Lu Ed Sanchez
Chelsea Ella Kari Yuzon

Francis Vasquez III, RN, MAN

Adviser

Date
 Table of Contents

Endorsement i
Certificate of Originality ii
Table of Contents iii
List of Tables v
List of Figures vi
List of Appendices vii
Abstract 1
1.0 Introduction 2
2.0 Review of Related literature 3
2.1 Theoretical Knowledge 3
2.2 Literature Review 4
2.2.1 Burnout Syndrome 4
2.2.2 Types of Burnout 5
2.2.3 Roles of Nurses in the Community 5
2.2.4 Filipino Nurses 6
2.2.5 Nurses’ Coping Strategies 7
2.2.6 Q Methodology 8
2.2.7 PQM Software 8
2.3 Research Questions 8
3.0 Methods 8
3.1 Research Design 8
3.2 Research Locale 9
3.3 Population and Sampling 9
3.4 Research Ethics 9
3.5 Research Instruments 10
3.6 Data Collection 11
3.7 Data Analysis 12
1.0 Introduction

Burnout syndrome exists as one of the major problems in the healthcare industry with most
reports showing increased rate over the years. This phenomenon has been identified as frequent
among nurses and physicians whose core functions in the organization requires high demands of
interaction with people. According to Maslach (2001), Burnout syndrome is a prolonged response
to chronic stressors on the job and is characterized by physical, mental and emotional restlessness
affecting the nurse's interpersonal interaction efficiency. This illness leads to emotional instability
and professional inefficacy among nurses and poses a challenge in the delivery of quality care to
patients (Biksegn et al., 2016: Cañadas-De la Fuente et al., 2015). Obradovic, Obradovic, and Skoro
(2013), for their part, identified nurses as highly susceptible to burnout syndrome due to the nature
of their work and their working environment.

The prevalence of burnout syndrome among nurses has recently caught considerable
attention in research studies due to the complex and impact to the professional practice. Nurse
burnout and job dissatisfaction have also received increasing attention due to the widespread
shortage of nurses, which is expected to rise further in the next 10 years (WHO, 2006). Notably,
research in this area is gradually expanding across many counties with emphases on burnout
measurement and evaluation and developing an early intervention that will improve the working
environment of healthcare professionals.

Although research on burnout syndrome received adequate interest, limited studies are
present in certain geographical locations specifically in developing nations such as the Philippines.
It has been an unrelenting argument that the nurses in the Philippines experience extreme cases of
stress due to the lingering issues of excessive workload, inadequate compensation, and
understaffing situations that may lead to health-related consequences and compromised quality of
patient care.

This present work centers on exploring the existence and prevalence of Burnout Syndrome
among Filipino nurses and to evaluate other risk factors that led to the identified prevalence of the
condition among these nursing professionals via Q methodology. Additionally, the study will
delve into the nurses’ feelings, how it affects the quality of their lives, and help identify various
coping strategies they can use to prevent burnout syndrome. This research hopes to expand the
already existing theories on the causes and coping strategies of burnout syndrome. It will likewise
provide an avenue for hospital organizations in the Philippines to develop a structural program that
will give empowerment to nurses and strengthen the organization, improve the working
environment, and maintain the quality of patient care despite the very unpredictable demands of
the profession. The study will also serve as a rich point of reference for researchers who may want
to conduct related studies on burnout syndrome among nurses in other nations in the near future.

2.0 Review of Related Literature

2.1 Theoretical Framework

This study is anchored on the theory of Kanter and Neuman respectively.

On one hand, Kanter’s theory of structural empowerment has six conditions required for
empowerment to take place and this includes an “opportunity for advancement”, “access to
information”, “access to support”, “access to resources”, “formal power”, and “informal power”.
Formal and informal power are two systemic sources of power that should exist in organizations.
Kantor’s theory has proven to have a measurable impact on both employee empowerment and job
satisfaction as well as organizational morale and success, especially in healthcare settings (Wagner
et al., 2010). Furthermore, Kanter suggests that with the proper support tools and information,
people’s skill base will improve and make informed decisions and overall accomplish more,
thereby benefiting the organization as a whole (Fox, 1998). This theory reveals the importance of
structural empowerment that will greatly improve the organizational structure of the healthcare
industry, thus decreasing the development of burnout syndrome among these healthcare
professionals.

On the other hand, Betty Neuman’s system model views a client as an open system that
responds to different stressors in the environment. The client system consists of a basic or core
structure that is protected by lines of defenses, however, when stressors break into the system, the
lines of resistance are activated resulting to instability and damage to the line of mechanism which
can affect the individual’s physical, psychological and emotional aspects. To maintain the stability
and flexibility of a nurse, Neuman provides three levels of prevention which are the primary
prevention, secondary prevention, and tertiary prevention. Primary prevention focuses on keeping
stressors and the stress response from a harmful effect on the body. It includes health promotion
and maintaining wellness. Secondary prevention focuses on preventing damage to the central core
by strengthening the internal lines of resistance and removing the stressor. And tertiary prevention
occurs after the client has been treated through secondary prevention. In Neuman’s system model,
by an effective coping mechanism, stressors can be prevented in invading our system; thereby,
maintains or restores the stability of our health, mind, and emotions.

2.2 Literature Review

2.2.1 Burnout Syndrome

The term burnout was first used by Herbert Freudenberg, a healthcare provider to describe
his physical and emotional as well as his co-workers’ experience. It was defined as a state of
physical, physiological, and psychological exhaustion or reaction that results from long-term
exposure to work-related stress.

According to Maslach and Jackson, burnout is a response to chronic work-related stress

comprising three dimensions: emotional exhaustion, depersonalization, and personal
accomplishments. Other studies report high prevalence rates of emotional exhaustion and
depersonalization accompanied by low levels of personal accomplishments among the nursing
profession (Al-turki 2010). Research studies explain that burnout does not occur in short term, but
gradually escalates and can create long-term problems, such as a feeling of hopelessness, distress,
and failure to comply to work requirements, which have an impact in all aspects of human life.
Several risk factors have been identified. Burnout syndrome prevention is as significant as the
factors contributing to it and as it appears, more so are the clinical interventions being applied, as
Guillermo A. author of Risk Factors and Prevalence of Burnout Syndrome in the Nursing
Profession. The study addresses two types of relevant variables: personal variables and
organizational variables. According to Shimizutani et al, (2008), an industrial stressor such as work
not commensurate to employee's load capacity can lead to burnout of different levels, depending
on the factors with regards to the personality and character of the employee. There is a study that
says the relationship status of the healthcare team strongly affects burnout status. Asrat B. et al.
2013 said that having a pleasant relationship with their bosses reduce the risk of having burnout up
to 61%.

2.2.2 Types of Burnout

 According to the study of Montero-Marin et al (2014), different burnout types have been
proposed according to the degree of dedication at work. These subtypes, respectively, encompass
the meaning of burnout syndrome near the accepted views of the public.

2.2.2.1 Frenetic Type

First is the ‘Frenetic’ type, who does work in an increasing manner to the point
of complete exhaustion.

2.2.2.2 Under-challenged Type

The ‘under-challenged’ type deals with the unstimulating work environment

that decreases the satisfaction of an individual that gives way to the absence of personal
growth.

2.2.2.3 The worn-out type

The ‘worn-out’ type is the state of being consumed or drained to the point of
giving up in times of stress.

2.2.3 Role of Nurses in the community

Nurses play a significant role in the social community. They are equipped with knowledge,
skills, and attitudes that influence the positive outcomes of health-related needs. With the
continuous advancement and reforms in the healthcare system all over the world, the Nursing
profession has a critical role in contributing to these changes and demands to meet safe, accessible,
and quality patient-centered care. It is in no doubt that harnessing the required changes to deliver a
renewed focus on nursing practice will not be easy. Individually, it requires an examination of one's
own knowledge, skills, and attitudes and whether that places you as ready to contribute or resist the
coming change (Salmond and Echevarria, 2017). Several nursing roles in the New Healthcare
Arena have been identified.
 The care system must be shifted from focusing on illness to prioritizing wellness and
prevention. Illness to wellness and prevention is the set priority and the dynamics between wellness
and health education programs, and programs to address environmental triggers of preventable
disease conditions, as well as care problems that are delivered by providers. Furthermore, in
achieving the goal towards better quality, better service, and lower costs per unit of service, Care
Continuum serves as a key player. The Continuum of care concept was proposed in 1894 and was
conceptualized as a patient-centered system that guides and follows individuals over time
(potentially from birth to end of life) using a diversified health programs, to wit, all levels from
social to mental health services vastly covering all levels and intensity of care (Evashwick, 1984).
Another study dealt with the understanding of data in order to better understand the care that nurses
deliver. It is important to consider the information on the population from which the individual is
drawn. An approach called Practice-based population health (Cusack, Knudson, Kronstadt, Singer
& Brown, 2010) states that information from a population, mainly group of patients within a care
setting or practice-based are extracted to enhance the quality of care and clinical outcomes of such
group.

2.2.4 Filipino Nurses

The Philippines is one of the leading producers of professional nurses across the globe. As
one of the largest distributors of human export in different countries in exchange for remittances,
the Philippines supports the Filipino nurses under the government policy to be part of the health
workforce mobility of economically well-off countries around the globe such as Australia who is
likely to employ nurses of other nations because of their aging population and maldistribution of
nurses. The research study of K Marcus, S Short, and B Nardi assessed Filipino-qualified nurses
who secured registered nursing status in Australia on their sector of employment, their level of
labor, market integration, their level of theoretical knowledge, clinical, and cross-cultural
communication skills. The result heeded a conclusion that Filipino nurses were considered good
on their clinical skills but lack knowledge about nursing theories.

The concerns discussed were migration, communication skills, theoretical knowledge,

nursing skills, and the Australian lifestyle. Filipino nurses who migrated in Australia had varying
methods in coming to work for the country. It was discovered that Filipino nurses were either
migrating as students, spouses or arriving from other temporary countries like the US before
deciding to stay in Australia.

A study in Australia, reveals that Filipino nurses who migrated and received training had a
good set of skills in the clinical field and were described as hard-workers and caring towards patient
but was short in theoretical knowledge.

One of the main issues that challenged most Filipino nurses upon their arrival was
understanding varying accents and identifying slang words that were thought to make an impact at
work; however, patient safety was not compromised.

The literature substantiates that Filipino nurses are well-educated which enables them to
be globally competent. The Senior managers interviewed for this study said that Filipino nurses
had adequate clinical and medication skills but lacked the depth of knowledge in theory.

2.2.5 Nurses’ Coping Strategies

In general, ‘burnout’ is a subject’s response to chronic work-related stress and is an attempt

to adapt to or to protect oneself from it by Montero-Marin et al (2014). Stress is defined as the state
of mental tension caused by problems in life or even at work while coping is a way of managing
both internal and external stressors in life. There is evidence gathered that is relatively significant
in the relationship between coping strategies with stress and burnout. During the early studies,
problem-focused coping was given emphasis in managing stress rather than emotional coping. So
far, the relationship between burnout types and coping strategies is yet to be explored. A better
understanding of the coping styles for each burnout types could further develop for the specific
treatments and preventive management of the syndrome that might possibly be more efficient.

2.2.6 Q Methodology

Q methodology is a systematic study of the participants’ viewpoints. It investigates the

perspective or opinion of the participants about a certain topic, phenomenon or interest into a
normal distribution (- to +) grid. Results are interpreted using a factor analysis, then through factor
analysis, people are clustered together who share similar ways of thinking. The variables are
individuals, not traits, thus, it is considered a by- person factor analysis rather than by- trait factor
analysis.

In conducting a Q- methodological study the researcher must start with a concourse. The
concourse is a population of opinion statements on the phenomenon of interest derived from day to
day and ordinary conversation that offers a vehicle to gain insights into human behavior. The
researchers gather information through an opinion statement from an ordinary conversation that
will become variables in the questionnaire.

2.2.8 PQM Software

PQM software is a statistical program used to compute the relationships among Q sorts that
are gathered and collected, which then factor – analyzed using the Centroid or PCA method. Then,
after computing/ selecting the factors that are relevant and highlighting the entries that define the
factors, the analysis will produce a variety of tables on factor loadings, statement factor scores, and
discriminating statements for each of the factors.

2.3 Research Questions

2.3.1 To determine if burnout syndrome exists and prevalent among Filipino nurses.

2.3.2 To identify the contributing factors that led to the prevalence of job burnout.

3.0 Research Methodology

3.1 Research Design

This study utilized Q methodology which is a combination of qualitative and quantitative

approaches that allows the researchers to investigate a complex problem from perspectives of
participants who represents the different stance of the given phenomenon. The combination of the
strengths of both qualitative and quantitative research of Q methodology establishes a simultaneous
study of objective and subjective issues to determine an individual’s perceptions and forecast the
likelihood of participation (Cross, 2005). This method was deemed fit since the aim of the study
is to capture the idea of subjectivity that will enable participants to uncover viewpoints,
perspectives, opinions, and feelings on the contributing factors of burnout.

3.2 Research Locale

The research team collected data at a government tertiary hospital in Metro Manila,
Philippines. The diversified demographics and the number of nurses employed sufficed the criteria
needed for the completion of the data gathering.

3.3 Population and Sampling

Purposive sampling technique was applied in this study. This is an approach where
researchers used good judgment to set criteria in selecting subjects that will validate the purpose of
the study.

The researchers selected 100 participants who have met the following criteria: (1) Filipino;
(2) Male or Female; (3) 23 years of age and older (4) a registered nurse; (5) 2 years or more of
work experience and; (6) currently working as a professional nurse in a government tertiary hospital
situated in Metro Manila. Participants who did not meet the set criteria were excluded from the
study.

3.4 Research Ethics

Ethical approval was obtained from the Institutional Ethics Review Committee (IERC) of
Our Lady of Fatima University (2018-IERC1-20204). The participants of the study were all
provided with informed consents containing full disclosure of the study. The researchers foremost
concern is to communicate ethical considerations in accordance with the Nuremberg code and
guarantees that all (1) participants shall be free from harm and free from exploitation (2) principles
of justice is employed, give right to fair treatment, right to privacy, respect anonymity and
confidentiality, and respect for human dignity. (3) participants must be aware that participation in
the research study is voluntary and withdrawal from it at any time shall be accepted without
questions or penalty. Participants were also given reassurance of confidentiality and anonymity and
that participation in the study will not in any way compromise their employment in the agency.
Data collected are stored electronically to a password-protected computer and is only
accessible to the researchers. Results will only be utilized for the purpose established in this study.

3.5 Research Instruments

3.5.1 Maslach Burnout Inventory (MBI)-Human Services Survey

The MBI-Human Services Survey form is the new version of the Maslach Burnout
Inventory originally created by Christina Maslach and Susan E. Jackson in the 1970’s. This was
specifically designed to measure burnout among professionals wherein the core function within the
organization requires direct and close interaction with the recipients of services. The survey form
contains 22 items divided and scored into three subscales: emotional exhaustion, depersonalization,
and reduced personal accomplishment. The written statements for each of the subscale reflects on
the personal attitudes and feelings and is answered in terms of frequency on a 7-point scale ranging
from 0, “never” to 6 “everyday”.

Many debates and discussions among scholars have emerged to test the validity and
reliability of the MBI instrument in different versions and languages; however, inarguably unveiled
substantial evidence that strongly and consistently yielded significant key outcomes in measuring
burnout.

3.5.2 Q methodology

An excellent instrument to measure attitudinal fluctuations has been identified as the Q

Methodology (Cook, Scioli, & Brown, 1975). It is the systematic and vital quantitative measure of
subjectivity (McKeown & Thomas, 1988). This was pedigreed mainly for psychology research and
continues to have been effective in measuring respondents' subjective viewpoints, attitudes, and
perceptions (Brown 1993).
 This research method is designed to utilize Q-cards in collecting data with information
derived from related studies on burnout syndrome among nurses. Participants were provided with
16 cards with its corresponding card number and a Q-sort grid to guide participants in writing the
card number ranging from -3 to +3. Q methodology constitutes five steps as summarized in Figure
1.

Step 1 30 statements were extracted from a reconnaissance of

Concourse of Statements related literature.
Step 2 Statements were reviewed for similarity and redundancy
Selection of the Q-set by the nursing research facilitator and experts from RDIC
and 16 statements were selected.
Step 3 Participants who were identified burnout based on MBI-
Selection of the P-set HSS results were selected as the P-set.
Step 4 Participants sorted their arrangements on a 16-cell grid.
Q-sort and interview After completion of the Q-sort, semi-structured
interviews were conducted.
Step 5 PQM software was utilized to analyze the Q-sort and find
Q-factor analysis patterns of similarities between participants
Figure 1. Five step approach to Q-methodology

3.6 Data Collection

The following procedures were employed to enable the gathering of pertinent information
needed to serve the purpose of the study.

3.6.1 Permission to conduct the study

The principal and assistant investigator proceeded to the office of the Chief Nurse and
Training officer and submitted the requirements to conduct the study. After obtaining the approval
letter, the chief nurse endorsed the researchers to the head nurses of each department where data
gathering commenced simultaneously.
 Each participant was provided with a participant information sheet containing full
disclosure of the study and was also given an opportunity to ask questions. The research team
ensured that all criteria were met. The researchers also conveyed all pertinent information
including the possibility of proceeding to the next step of data collection which is the Q-sort.

After receiving the signed informed consent, Maslach Burnout Inventory for Human
Services Survey (MBI-HSS) form containing 22 items was given to each of the participants to
answer. A code was assigned and written on the form to enable identification of the participant
who will proceed to Q-sort.
The researchers collected the responses and concurrently scored the three subscales:
emotional exhaustion, depersonalization and personal accomplishment using the MBI-HSS Scoring
and Interpretation Key.