Burnout in the nursing profession A literature review
The aim of this literature review is to identify the significant factors related to burnout in the nursing profession. Nurses are most susceptible and vulnerable to the development of burnout, mainly because of the nature and emotional demands of their job. Burnout in the nursing profession is a significant concern in nursing, because it has detrimental effects both on individuals and organisations. For the individual nurse, the neuroendocrine response yields physiologic reactions that may ultimately contribute to illness. In the health care organisation, work burnout may contribute to absenteeism and turnover, both of which detract from the quality of care. Burnout is reported to originate from work itself as well as from characteristics of the individual nurse. There are also buffers to mitigate the development of burnout.
Freudenberger (1974) first coined the term "burnout" to describe the build-up of feelings that professionals experience when their emotional resources are depleted (Janssen, Schaufeli & Houkes 1999). Maslach and Jackson (1981) further refined this term as a syndrome of emotional exhaustion, depersonalisation and reduced personal accomplishment. Their study is a piece of seminal work and their concept on burnout has been widely accepted since. Emotional exhaustion manifests in nurses as a general loss of feeling and concern, trust, interest, and spirit. It also involves feelings of fatigue, being used up, irritability, frustration and wearing out (Maslach et al 1981). Depersonalisation refers to showing a detachment of the nurse from the patient by actively ignoring the qualities that make them unique and engaging people (Maslach et al 1981). The third dimension of the burnout syndrome is the tendency of nurses in evaluating their work negatively. Nurses feel unhappy about themselves and dissatisfied with their accomplishments on the job (Maslach et al 1981).
Burnout is measured by the Maslach Burnout Inventory (Maslach et al 1981). The internal consistency of this tool has been widely tested using Cronbach's coefficient alpha (Maslach, Jackson & Leiter 1996) and hence could be considered to be a standard measure for burnout (Hannigan, Edwards, Burnard, Coyle & Fothergill 2000). This survey tool is a 22 item questionnaire consisting of the three subscales mentioned above of the burnout syndrome. The items are scored in a 7-point Likert scale ranging from 0 (never) to 6 (daily). A high degree of burnout is reflected in high scores on the emotional exhaustion (EE) and depersonalisation (DP) subscales and a low score on the personal accomplishment (PA) which is rated inversely. An average degree of burnout is reflected in average scores on the three subscales and a low degree of burnout is reflected in low scores on the EE and DP subscales and a high score on the PA subscales (Maslach et al 1981).
Burnout is often been reported as a causing factor for attrition of nurses from the nursing profession (Armstrong-Stassen, Al-Ma'aitah, Cameron & Horsburgh 1994). In addition burnout in nursing has been associated with poor patient satisfaction and poor patient outcome (Vahey, Aiken, Sloane, Clarke & Vargas 2004, Nayeri, Negarandeh, Vaismoradi, Ahmadi & Faghihzadeh 2009). These adverse outcomes of burnout could have significant indelible impact on the Singapore government's aim to establish Singapore as a reputable medical hub in the ASEAN region. Studies and statistics have shown that nurses in Singapore are at risk of developing burnout (Boey, Chan, Ko, Goh & Lim 1997, Lim & Yuen 1998, EnterpriseOne 2006), however, surprisingly, no research have been done in Singapore to assess the level of burnout and the related factors of burnout in their nurses. Therefore, this literature review is initiated to generate a comprehensive understanding of what is known about burnout in the nursing profession. This could have implications for understanding the overall well-being of the nurses in Singapore.
Aims and Objectives
Aim and objective: To identify the significant factors related to burnout in the nursing profession.
A literature search was conducted using the keywords 'nurses' and 'burnout' on CINAHL and MEDLINE. The search is supplemented with a manual search in journals published in Singapore for further information regarding related research conducted in the local context and a supplementary follow-up of other cited materials in Google Scholar, where appropriate.
Collating the evidence from the literature led to the identification of three main themes for the related factors of burnout for nurses. The themes are stress of the health care professionals, individual variables and leadership as the buffering factor.
The proposition that high stress clinical care settings as organisational stressors have been extensively examined. Therefore not surprisingly, studies on burnout done in medical, surgical and high dependency units were most prominent (Nayeri et al 2009, Adali & Pirami 2002). Gillespie and Melby (2003) purported that the reason is because the nursing staffs working at these demanding areas are likely to spend considerable time during their working day in intense interactions with people. While Maslach-Pines (2000) suggested that it is because the nature of the work of these departments is often described as physically demanding and nurses are also continually faced with heavy demands for pity, sympathy and compassion. However, while many studies demonstrate a strong correlation between high levels of stress in high stress work environments and increased incidence and degree of burnout among nurses (Schmitz, Neumann & Oppermann 2000), others produce evidence showing there is no correlation (Buunk, Ybema, Zee, Schaufeli & Gibbons 2001). In the study conducted by Buunk et al (2001), it is being demonstrated that nurses working in high stress, specialised environments are less burned out than their counterparts working in those perceived as low stress environments. However, it should be noted that the participants for their research are nurses who have at least 10 years of working experience. They would have been able to handle their stress more efficiently and would have been less prone to burnout. Therefore, it can be argued that this research lost its reliability because the sample represents a group of generally "healthy workers" (Demerouti, Geurts, Bakker & Euwema 2004:997). Moreover, the researchers also conducted a face-to-face interview with the participants. By the interview questions, the participants could infer that the researchers are interested to determine their stress related behaviour. Therefore, the sensitive nature of these questions would have inflicted a response bias as participants do not want to be stigmatised as not being able to cope (Maslach, Jackson & Leiter 1996).
In more recent years, among the organisational stressors, workload as a contributing factor to burnout is more commonly reported and associated with the emotional aspect of the burnout syndrome (Greenglass, Burke & Moore 2003, Lin, St John & McVeigh 2009). Taris, Le Blanc, Schaufeli and Schreurs (2005) suggested that a high score on this single aspect of the burnout syndrome will be sufficient enough to predict burnout. Authors proposed that the 21st century health care reform has further intensified nurses' workload. The work intensification studies in and around health care are providing convincing evidence on the extent to which efficiencies achieved by health care organisations are largely due to the increased workloads of nurses as a result of both staff reductions and increasing activity and patient complexity (Green 2004, Aiken, Clarke, Sloane & Sochalski 2001). It is argued that increased workload will lead to increased stress and in turn leads to higher chances of burnout (Maslach & Leiter 2008). Therefore, it can be speculated that there should be widespread concomitant increase in reported severity of burnout due to the increased pressure on nurses. Nonetheless, the question remains as to why in the same situational conditions, some nurses burn out, whereas others show no syndrome.
The most likely explanation is that causes of burnout are found in both the environment and the individual. Significant relationships between burnout and certain demographic characteristics have been reported but the results are still far from conclusive. The few socio-demographic variables most commonly being investigated are age, gender and marital status. In their study, Maslach, Schaufeli and Leiter (2001) reported that age has most consistently been related to burnout. Burnout has been observed more often among young workers than among those aged over 30 or 40 years and it seems to occur rather early in one's work career.
Schaufeli and Greenglass (2001) accounted that regarding gender differences in burnout, results are mixed and may reflect difference in roles or occupations. Maslach et al (2001) found that emotional exhaustion has usually been reported to be more common among women, whereas depersonalisation has been more common among men. Bakker, Demerouti and Schaufeli (2002) conducted a study in which a wide range of different occupations and organisations were recruited and answered through the internet, women reported higher levels of burnout than men did, particularly when they were relatively young or had relatively little work experience. However, the respondents were mostly men and rather young (Bakker et al 2002). Schaufeli and Enzmann (1998) with regard to marital status, those who are unmarried, especially men, appear to be more prone to burnout compared with those who are married. Singles seem to experience even higher burnout levels than those who are divorced.
Personality characteristics as the psychological aspects of individual variables were explored as an important variable in the burnout process in a number of investigations (Simoni & Paterson 1997, Allen & Mellor 2002, Bühler & Land 2003). However, the specific features of personality that affect the perception of burnout remain unclear. Garrosa, Moreno-Jiménez, Liang and González (2008) proposed a model of prediction of burnout in nursing and they reported that their findings give support that personality factors are significant predictors of the three aspects of burnout. But the authors were not clear on which personality characteristics were investigated. Allen et al (2002) and Zellars, Perrewé and Hochwarter (2000) reported that neuroticism is associated with the emotional exhaustion aspect of burnout and external locus of control also demonstrated positive relationship with burnout. However, Bühler et al (2003) and Toscano and Ponterdolph (1998) reported that findings are mixed for hardiness.
Interestingly, more recent studies indentified leadership as a factor related to burnout (Kanste, Kyngäs & Nikkilä 2007, Corrigan, Diwan, Campion & Rashid 2002). Leadership issues did not appear as a noteworthy factor related to burnout in earlier studies, even though it had been discussed some twenty years ago by Bass (1985). Nonetheless, leadership issues cannot be considered as new, but rather they appear to have increased in relative significance. Weber (2007) articulated that the increasing calls over the last decade for considering leadership as a related factor of burnout is particularly because of the chronic recruitment and retention issues confronting the nursing profession. There is also a rich source of comment on the impact of health care reform on nurses and nursing in the health care sector research literature (Aiken et al 2001). In a study conducted by Laschinger and Leiter (2006), their findings also support the key role of strong nursing leadership in creating conditions for work engagement and ultimately, safe, high-quality patient care. Demerouti, Bakker, Nachreiner and Schaufeli (2000), in their proposed model of burnout and life satisfaction amongst nurses, identified that an individual's engagement with their work will predict a degree of low burnout. However, Stordeur, D'hoore and Vandenberghe (2001) warned that if leaders are too tyrannical and control-oriented, their leadership could exacerbate the burnout process.
Among the different types of leadership, transformational leadership has been most commonly proposed and viewed as a buffer which moderates the impact of burnout (Stordeur et al 2001). Transformational leaders are visionary, balanced, self-aware and confident of breaking existing professional boundaries (Stordeur et al 2001). Nonetheless, findings from the study by Stordeur et al (2001) have to be viewed with cautious. This is because they only attempted to measure the relationship between leadership and the emotional aspects of the burnout syndrome. The other two dimensions, depersonalisation and lack of personal accomplishment were not measured. Further studies would have to be taken to establish implicit links between leadership and burnout. Ulrich, Buerhaus, Donelan, Norman & Dittus (2005) found that effective control over practice resulted in increased status, respect and recognition. Hochwälder (2008) further emphasised that through a chain reaction, transformational leadership style engenders group cohesion and empowerment in nurses and hence it has been found that transformational leadership is inversely correlated with burnout in nurses.
Past research on burnout in Singapore is generally anecdotal in nature (Tung 2000). Others attempt to investigate the nurses' stress level and their association with the psychological well-being and several work-related outcomes such as job satisfaction, organisational commitment, intention to quit and job-induced tension (Boey et al 1997, Lim et al 1998). In a study on stress among nurses in the emergency department in Singapore, Lateef, Ng and Anatharaman (2001) reported that the nurses who are older, have more working experiences and hold higher positional post had lower stress scores as compared to those who are younger, have less working experience and have lower positional post. However, the authors did not proffer insights to explain these observable facts. While such research gives indication that there is a high level of stress in the nurses in Singapore, it cannot be implied that there would be a high degree of burnout in these nurses. While it is clear that stress results in burnout among some individuals, also apparent, yet not explained by the empirical evidence is the fact that others faced with high levels of stress do not experience burnout. Therefore an implicit relationship of high level of stress and high degree of burnout cannot be deduced because there is evidence of high stress being associated with low burnout (Bunnk et al 2001). Therefore, studies on burnout have to be conducted to investigate the burnout phenomenon among the nurses in Singapore. For the time being, it could only be speculated that nurses in Singapore are at risk of developing burnout.
From the findings, it is shown that nursing burnout appears to be the result of not only contextual factors but also individual factors. Results from the studies on the socio-demographic variables and personality characteristics are weak and ambiguous. Only age has been identified as a relatively good correlate to burnout, with younger nurses being more susceptible. It would be reasonable to believe that younger nurses are more at risk to burnout because they have to move from a familiar educational environment into the workforce where there are high expectations of them to rapidly function as a competent nurse (Schaufeli et al 1998). As a result, they experience challenges transitioning from student to practicing professional nurse (Godinez, Schweiger, Gruver & Ryan 1999).
Transformational leadership could result in low burnout. It is important to note that low degree of burnout represents a positive psychological state and an effective state of well-being (de Rijk, Le Blanc, Schaufeli & de Jonge 1998). In the emerging literature, there is a shift from the traditional focus on weaknesses and malfunctioning toward understanding human strength and optimum functioning at work (Gustafsson & Strandberg 2009). Conceiving of low burnout as wellness makes a contribution to the literature because it focuses on the positive aspects of work. Positive research has the potential to improve the image of nursing and attract a new generation to the profession. It also have implications for identifying and modifying possible areas of frustration that would result in burnout and thus help relieve the high costs of turnover by improving nurse retention (Teng, Shyu & Chang 2007). The major contribution of such an approach is that it enhances the understanding of how the management of the health care organisational can affect nurses' well-being. This knowledge is essential for the future development and well-being of all nurses and the profession of nursing.
Current research focuses on examining the burnout phenomenon in acute settings and their findings have presented evidence that the level of burnout might not be influenced by different clinical settings. Therefore, future studies should move beyond the acute care settings to better understand the burnout phenomenon.
Except for one, all authors of the research used for this literature review utilised cross-sectional methodology, therefore, casual relationships cannot be made from their results. Their findings also cannot be generalised in another milieu. Longitudinal research is required in order to enhance the understanding of the burnout process. Maslach et al (1981) had pointed out that longitudinal research although presents a large challenge, it is of critical importance for the comprehension of burnout. Future longitudinal examinations should establish a profile of the nurses at the beginning of their employment then follow up over a longer period of time in correlation with burnout status and the related factors influencing the development of the burnout process (Ekstedt & Fagerberg 2005).
For all of the studies used for this literature review, the data are collected using self-reports from the participants. Many authors warned that self-reported data might be contaminated by common method variance, because both the independent and dependent variables are based upon one source of information which is the participants (Demerouti et al 2000). Therefore, future research should also utilised objective means for collecting the result findings.
The concept of burnout has sustained the interest of nurses and researchers for several decades. Despite the large amount of studies done in attempt to investigate and predict the related factors of burnout, no conclusive data could be drawn. This is because the health care system is in constant change. The factors that relate to burnout will present different relative significance with the changes. Notwithstanding this, the related factors to burnout could generally be classified as both organisational and personal related. Therefore, to base practice, burnout intervention programmes should be multidimensional consisting of work-related as well as personal directed approaches.
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