ICUs and Nursing Web Journal ISSUE 11th (July September 2002) ISSN 1108-7366 All rights reserved

Burnout among Nurses in Intensive Care Units, Internal Medicine Wards and Emergency Departments in Greek Hospitals

E. Adali 1 , Priami M 2

1. RN PhD, Clinical Professor, Nursing Depart., T.E.I of Athens, Greece 2. Assistant Professor, Nursing Depart., University of Athens, Greece

ABSTRACT: This study compared the levels of burnout syndrome among nurses in different nursing specialties and the environmental factors that contribute to the development of burnout. A sample of 233 nurses in five hospitals was selected. Study results indicated that nurses of emergency departments showed significantly higher levels of emotional exhaustion in comparison to nurses working in intensive care and internal medicine units. For the intensive care nurses, significant predictors included peer cohesion, control, involvement, and task orientation, while, for the internal medicine nurses, significant predictors were involvement, workload, physical comfort, task orientation and autonomy. Finally, for the nurses of emergency departments, significant predictors included involvement, workload, innovation, supervisor support, age and task orientation. In conclusion environmental factors seem to have an impact to the development of nurses burnout. KEY WORDS: Burnout, Nurses, Hospital, Work Environment.

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INTRODUCTION

is related to the deterioration of relationships between the nurse and the patients, the coworkers, the family and the social

ccording to Maslach, burnout is a syndrome emotional a low which characterized by

exhaustion, depersolevel of personal affects

environment4,5,6. Additionally, burnout has been closely related to both the absenteeism of nurses from work7 and abandoning nursing8. Finally, the nursing burnout results in poor patient care,9,10,11,12.

nalization and accomplishments,

primarily

people who are somehow dealing with other people in their work. Burnout develops as a response to the chronic emotional strain, which is the result of dealing with other people and especially with people who cope with serious problems. Thus, burnout could be considered as a type of professional stress, which results from the social interaction between the person who provides help, and the person who receives that help1.

Among

the

reasons

contributing

to

the

development of burnout are the following: 1) the time that nurses spend for the patients care,13 2) the contact with patients having a poor prognosis14, 3) the contact with patients having increased emotional demands15, 4) work load16 , 5) ambiguity and role conflict6 , 6) lack of support on the part of the supervisor and

Nurses are particularly susceptible to the development of burnout, mainly because of the nature and the emotional demands of their profession2,3.

colleagues17, 7) lack of job satisfaction18 and 8) fear of death19. Very important for the

development of burnout are also the personality characteristics of the individual, his motivations for having chosen a humanistic profession20 , his

Burnout is a serious problem. It directly affects the worker and it presents with various symptoms, both somatic and psychological2,3. It

expectations from himself and the others21 , his values, his self-esteem, his ability to express his feelings, the control he exerts over the events

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ICUs and Nursing Web Journal ISSUE 11th (July September 2002) ISSN 1108-7366 All rights reserved

and the others, and his personal style. All these factors influence the way of handling an emotional strain1 . It is said, that some people are more stress resistant, and thus less vulnerable to the development of burnout22.

personnel working in ICUs and those working in other departments26.

Kelly & Cross27 used comparative groups in order to examine job related stress and work burnout. In their research they compared nurses

The comparisons among different hospital units (operation theatres, pediatric, gynecological and surgery wards) confirm the significance of the interpersonal environment23,24. There are

working in ICUs with nurses of other specialties who were working in two urban hospitals. They argued that the causes of stress were the noise levels, the physical environment and generally the work environment. The results showed that nurses who were not working in ICUs reported higher levels of burnout than those working in ICUs.

differences in the degree of burnout experienced by nurses working in different fields. This may be attributed to the conflicts among staff, to the decreased expertise of the workers, and to the work overload25.

Cronin-Stubbs & Rook23 studied stress and work In a research on 354 members of nursing personnel, the nursing personnel who were working in emergency departments experienced significantly higher levels of emotional burnout among 296 nurses of four different nursing specialties (ICUs, internal medicine wards, surgery and psychiatric departments) in three hospitals. Even though the tension of occupational stress was much greater for workers in ICUs, it did not consist a forecasting factor for work burnout. Moreover, burnout in working environment among the members of the

exhaustion and depersonalization in comparison to nurses of Intensive Care Units (ICUs) and other specialties. Moreover, it was found that there was no difference between the three dimensions of the syndrome among nursing

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ICUs and Nursing Web Journal ISSUE 11th (July September 2002) ISSN 1108-7366 All rights reserved

nursing

personnel

of

the

four

different

OBJECTIVES The purposes of the study were: 1) the investigation of the degree of burnout

specialties was not statistically significant.

Chiriboga and Baily28 concluded in their study that working in Intensive Care Units or in any other field of nursing practice the nurse doesnt seem to be affected by the degree of the experienced burnout. It is possible that some other environmental characteristics are more important for the development of burnout, such as the degree of participation in the work, the particular socio-demographic features, and the job related risks. For example, nurses who are less involved in decision making consider their work as less challenging and they express a higher degree of burnout.

experienced by nurses working in Public Hospitals in the area of Athens, and particularly, in Emergency Departments, Internal Medicine Wards, and Intensive Care Units and 2) the identification of job related factors that

contribute to the development of burnout. METHODS Sample The sample of the study consisted of 223 nurses working in five Public Hospitals in the area of Athens. In particular, we recorded the views of nursing personnel working in 5 Emergency Departments, 20 Internal Medicine Wards and 7

In Greece, work burnout syndrome of nursing personnel has not been far-reached by

Intensive Care Units.

researchers, even though work overload during the recent decades is particularly increased because of the deficiency of nursing personnel.

The nurses, who participated in the study, were chosen according to the following criteria: 1. They were all graduates of either Technological Educational Institutions, or Universities. 2. They had experience in clinical nursing of at least one

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year. 3. They orally accepted to participate in the present study.

support, the autonomy, the task orientation, the work pressure, the clarity, the

managerial control, the innovation, and finally the physical comfort. 31, 32: A total of 414 questionnaires was distributed and the response rate was 223 (56.2%). The 42.5% of our sample are working in Internal Medicine Wards (n=99), the 35.6% in Intensive Care Units (n=83) and the 21.9% in Emergency These questionnaires were translated in Greek first by the investigators translator and then, an an

independent

made

inverse

Departments (n=51).

translation. No modifications were required. 3. A general information questionnaire,

Tools For the collection of data the following tools were used: 1. The Maslach Burnout Inventory, which was developed by Maslach and Jackson29. It consists of 22 questions and records 3 dimensions of burnout: the emotional

recorded the demographic and professional features of the sample of the study it formulated by the investigators according to similar questionnaires found in Greek and international literature26,33.

Pilot study A pilot study was conducted, addressed to 25

exhaustion, the depersonalization and the low personal accomplishments. 2. The Work Environment Scale developed by Moos and Insel30 , which consists of 90 questions of right-false type. This scale assesses the workers involvement, the coworkers cohesion, the supervisor's estimated about 30 to 40 minutes. The results of nurses (10,7% of the total sample) working in different clinical fields other than those of the main study, in order to assess the

comprehensibility of the questions. The time needed to complete the questionnaires was

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the pilot study were considered to be positive because they revealed the adequacy of our tools. No further modifications were needed.

environment subscales) was evaluated by using the Spearmans correlation coefficient.

In order to define the best variables that The questionnaires were completed by the nurses, assisting by the guidelines written on the first page of each questionnaire. The contribute in a statistically significant degree to the interpretation of the presence of burnout, the method of Multiple Linear Regression was used. The selection of the variables was done by the backward elimination procedure in the level of significance p=0.05. In the selection procedure participated only the variables found to have a statistically significant correlation with burnout in the partial correlation analysis (i.e. the correlation of each variable with burnout).

questionnaires were anonymous, and they were returned to the investigator after seven days. The nurses were not able to complete the

questionnaires on the same day because of work pressure. The agreement to complete the questionnaire was considered as consent to the participation in the study. Approval to conduct the pilot study was obtained from the Boards of Directors and the Nursing service

Multiple linear regression analysis Administration of each Hospital. The same procedure was followed for the main study as well. Statistical analysis The possible association of burnout with the different independent variables (age, number of children, work experience and the work High scores of burnout reflect high scores of emotional exhaustion and depersonalization and low scores of personal accomplishments. The assessment of the factors that are associated with high scores of emotional exhaustion and depersonalization will provide the evidences as to which factor contributes to the development of burnout.
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RESULTS The majority of nurses were female (91,3%), with mean age 34 years. Most nurses were married with 1-2 children and they had a work experience of up to 10 years. The educational level of nurses had a University degree (5,7%), whereas the majority of nurses (38,7%) were graduates of Technological Educational

a work experience of 1-5 years, and 21.2% 1610 years.

When

concerning the

time

that

nursing

personnel spends during its working hours caring for the patients, 44,5% of the nurses dedicate less than 25% of their time and 22,9% of the nurses spend 50% of their time. The 63,6% of the total were simple clinical nurses, 24% were holding warding position and 12,1% were head nurses.

Institutions. Masters degree or Ph.D. had 6% of the nurses and 23,8% of the nurses possed a nursing specialization title. Concerning the work experience, 26.4% of the nurses in our sample had a work experience of 6-10 years, 21.7% had

Some of the features of our sample are presented on Table 1.

Table 1. Sample description

Variables Age Number of children Work experience Time in present position Time for direct care M 34,45 1,72 2,80 7,91 2,17 SD 6,40 0,73 1,41 6,15 1,34 statistically significant P-value 0,020 NS NS NS 0,025 correlation between

Burnout Characteristics
Table 2 presents the burnout experienced by nurses, in the total sample and in the different Wards of the Hospital. There was found a

burnout and of the study Ward of the Hospital (p=0.026) In particular, nurses who work in

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Emergency Departments report a higher degree of burnout compared to nurses working in ICUs.

Table 2. Burnout in Intensive Care Units (ICU), Internal Medicine Wards (IMW), and in Emergency Departments (ED)
Variables Total ICU IMW ED p-Value

Emotional Exhaustion XSD Min-Max Depersonalization XSD Min-Max Personal Accomplishment XSD Min-Max 226 35,059,47 0-48 79 34,668,55 14-48 97 35333,43 6-48 50 35,1410,99 0-48 226 7,855,86 0-28 80 7,496,01 0-21 96 7,495,99 0-24 50 9,12530 0-28 230 24,0111,34 2-51 82 97 51 21,7410,78 24,6011,59 26,5311,29 2-51 5-48 5-46

0,026

0,09

0,44

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ICUs and Nursing Web Journal ISSUE 11th (July September 2002) ISSN 1108-7366 All rights reserved

Intensive care units (ICUs) The predictors of burnout for nurses working in ICUs were the following: For the emotional exhaustion: low co-worker

control (p=0.005). For the depersonalization: low worker involvement (p=0.001) and

inadequate managerial control (p=0.035). For personal accomplishments: age (p=0.015), task orientation (0.01) and managerial control

cohesion (p=0.000) and inadequate managerial (p=0.032). (Table 3)

Table 3. Environmental predictors of burnout in Intensive Care Units (=83)

Subscales Emotional Exhaustion Predictor Coworker cohesion Managerial control Involvement Managerial control Age Personal Accomplishment Task orientation Managerial control 1,709 1,165 0,529 0,535 0,001 0,032 Slope -1,938 -1,613 -1,093 -0,749 St. Error 0,488 0,561 0333 0350 p-value 0,000 0,005 0,001 0,035

Depersonalization

0,363

0,146

0,015

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Internal Medicine Wards The low degree of involvement (p=0.014), the work overload (p=0.000) and the poor physical comfort (p=0,047) are associated with high levels of emotional exhaustion. The above

mentioned factors

are

predictors

for

the

emotional exhaustion. The poor task orientation (p=0.000) is predictor for the increased

depersonalization whereas the autonomy is predictor for personal accomplishments (Table 4).

Table 4. Environmental predictors of burnout in Internal Medicine Wards (N=99)

Subscales

Predictor Involvement

Slope -1,455 3,442 -1,237 -1,521 2,042 1,834

St. Error 0,583 0,773 0,616 0344 0,605 0,408

p-value 0,014 0,000 0,047 0,000 0,001 0,000

Emotional Exhaustion

Work pressure Physical comfort

Depersonalization Personal Accomplishment

Task Orientation Time for direct care Autonomy

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Emergency Departments The low level of involvement (p=0.003), the work overload (p=0.006) and the lack of innovation (p=0.010) are the predictors of

emotional exhaustion. The supervisor support influences the depersonalization (p=0.036),

while the age (p=0.006) and the task orientation (p=0.000) influence the personal

accomplishments. (Table 5)

Table 5. Environmental predictors of burnout in Emergency Departments (=51)

Subscales

Predictor

Slope

St. Error

p-value

Emotional Exhaustion

Involvement Work pressure Innovation

-2,188 3,606 -2,159

0,711 1,262 0,807

0,003 0,006 0,010

Depersonalization Personal Accomplishment

Supervisor Support Age Task orientation

0,723 0,539 0,911

0335 0,185 0,653

0,036 0,006 0,000

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DISCUSSION
The majority of nurses of the sample were female, with mean age below 40 years and an average experience in nursing of less than 15 years. These data are in accordance with international data
34,45,26

approximately) patients46 .

for indirect

care of their

The total degree of the reported burnout in the sample of our study is thought to be moderate, compared with American levels36 and Greek data37. In particular, nurses working in

and suggest that nurses

tend to withdraw early from the clinical sector possibly because of early retirement, or change of work area. Probably, the working conditions in hospitals dont really favour the long-term stay of nurses in their work35 .

emergency departments reported a statistically higher degree of burnout, compared with nurses working in Intensive Care Units and Internal Medicine Wards. The degree of

depersonalization was also higher in Emergency Even though the 64% of the sample were simple nurses, they spend the least time (less than 25%) of their working hours for direct care. This is an indication that nurses prefer to consume their time with other occupational duties (managerial, education etc.) and nursing assistants are commissioned to direct care. This finding comes in agreement with a research concerning the distribution of time of the nursing personnel. In their research they found that nurses spend about 22% of their time for direct nursing care, while they spend most of their time (33% Departments but not in a statistically significant degree compared with Intensive Care Units and Internal Medicine Wards. These estimations are in accordance with the estimations of Candley26 . In any case, nurses reports range of normal to high levels of personal accomplishments. A possible explanation of this particular finding seems to be that the work is not the single source of satisfaction for nurses, given that the 60% of nurses in our sample were married.

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Age was found to be significantly related with personal accomplishment, both for nurses

spent working for a specific department, the less emotional exhaustion he experiences. Nursing personnel feels that ICUs are high demanding departments and really stressful23 . The average period of time that the nursing personnel (of this studys sample) stayed in ICU was

working in ICUs and emergencies. A probable explanation for this is that older nurses are those who manage to control occupational tension successfully, are still occupied with nursing duties and feel satisfied for it.

approximately 7 years. This finding indicates that nurses of ICUs should stay in ICUs for

Nursing personnel of Internal Medicine Wards, dedicated a significant part of their working hours for direct nursing care, and had increased significantly their personal accomplishment

certain periods of time and afterwards they must be removed to different nursing units, in order to prevent emotional exhaustion.

feelings. There is no such finding when looking at previous and recent bibliography. This is a significant result for the present study because it indicates that nurses who have a close

The comparison of working conditions among different Units suggests that the ICUs offer a more pleasant natural environment. They also favour the application of new approaches. This finding seems to contradict a general perception that exists among nurses, according to which the environment in ICUs is more depressive. This finding can be attributed to the fact that the ICU

occupational relationship with their patients receive personal accomplishment feelings from it.

Emotional

exhaustion

was

found

to

be

is a closed Unit without visitors, and thus the nurse has a stronger control over the

significantly related with the working period of the nursing personnel in ICUs. This finding contradicts Robinsons et al
38

environment compared to the open Wards. Additionally, the nursing duties in ICU seem to permit greater freedom to nurses for the
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research who

argue that the longest period of time a nurse has

ICUs and Nursing Web Journal ISSUE 11th (July September 2002) ISSN 1108-7366 All rights reserved

application of more sophisticated ideas in comparison with Internal Medicine Wards and Emergency Departments.39

depersonalization, the present study showed that support from the supervisor is a predictor (related to) for depersonalization. It is probable, when the nurse feels that his/ her work wont be

The Emergency Departments are usually very busy and they are dealing with lots of people. The work pressure is statistically higher in Emergency Departments in comparison to the other wards.

criticized by the supervisor, he/she develops a more impersonal relation with the patient.

Additionally, the supervisors preparation may be inappropriate for their work and thus they become overprotective and limiting freedom and

Some of the problems faced by the nurse in the everyday practice are the time pressure, the critical condition of the patients and the conflicts between the nurse and the patient. The predictors of emotional exhaustion are the following: 1) the

self-actualization of the supervised nurses. Finally, the task orientation i.e. the emphasis given by the nurses to the right scheduling, the efficiency, and the integration of their task- is closely related to the feeling of personal accomplishments.

low degree of involvement, 2) the increased work pressure and 3) the absence of change along with the limited application of new approaches. Intensive Care Units (ICU) In ICUs, the predictors for the development of emotional exhaustion are the low co-worker In contrast to the findings of Leiter and Maslach25, who claim that good relationships between the nurse and the supervisor are inversely related to the degree of degree of cohesion and the inadequate

managerial control.

The advantages of the

positive social interaction within the work environment are closely related to the decrease
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of burnout38,40. The reasons for poor co-worker cohesion are mainly focused on a) the ill-defined responsibilities, such as the description and the task obligations b) the poor communication within the hospital and c) the workers low degree of involvement in decision making,

findings agree with the findings of other investigators26,28 Our findings concerning the control are in accordance with the findings of Constable and Russel
41

, in spite of the fact the

sample of their study consisted exclusively of nurses working in Military Hospitals, who have great familiarity with special rules. Internal Medicine Wards In Internal Medicine Wards, the predictors for emotional exhaustion were the involvement, the

which results from the strong managerial control and the lack of innovations40. The management of job related stress requires a high level of coworker cohesion18 , whereas the strong

managerial control along with good relationships among staff can protect nurses against the additional demands created by the patients41 . Additionally the regular supervision has a supportive role for nurses42. the managerial control is inefficient, the nurses tend to develop burnout more frequently. Generally, The low degree of involvement of nurses in their job and the inefficient control on behalf of the supervisor, are closely associated with the development of impersonal behaviour. On the other hand, nurses who are focused on their duties (task orientation) and they are under intensive control from the Administration, have a stronger feeling of personal accomplishments. As it concerns the parameter of involvement, our the Nursing Administration work pressure and the physical comfort. In particular, when the work pressure is heavy and the nurses physical comfort is inadequate while

considered to be successful in the hospitals, when recognizes the important contribution to nurses in decision making for issues concerning the care of the patient 40, 42. The continuous work overload along with the limited involvement of nurses, trigger the emotional withdrawal and contribute to the development of high degrees of burnout 28, 41.The Internal Medicine Wards of the Hospitals where we conducted our study are
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usually dealing with many patients, and the places where nurses can rest during their shift are almost non-existent. In other words, the work environment is anything but comfortable and pleasant for the worker.

of many other stressors (such as the jobrelated stress, the personality features of the worker) that are associated with burnout, and were not evaluated in the present study. The limitations of our study are mainly due to relatively low number of participants and

The autonomy of nurses in Internal Medicine Wards is a predictor for personal

to the limited geographical distribution of the sample. These results however, suggest further investigation of the problem, in a more representative sample and in a wider geographical area.

accomplishments. The freedom in the care of patients reinforces the feeling of satisfaction and personal accomplishment. This finding however doesnt agree with the findings of other investigators, 43 who support that nurses working in ICU enjoy a higher degree of autonomy. Some investigators suggest that staff autonomy is a substantial parameter, especially when it refers to complex duties. Thus, the freedom and independence are is of high within the

workplace, the employees tend to feel more integrated and they believe that they have accomplished their tasks successfully. 40,44

The

thorough

investigation

of

the

international literature reveals the existence

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24.

Leiter

M.P.

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46. Lemonidou C, Plati C, Brokalaki H, Mantas J. and Lanara V. Allocation ofnursing time. Scand J Caring Science 1996, 10: 131-136.

Corresponding author: E. A. Adali, 12 Egeos street, GR-163 44 Ilioupolis, Greece Email: gioeva@otenet.gr

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