A Systematic Review of Organisational Causes of Nursing Burnout

A literature review of organisational causes of nursing burnout, effects and recommendations for practice
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Acknowledgments
The first acknowledgment is to God Almighty who has inspired me and given me the ability and desire to carry out this study. This project would not have been possible without the support, guidance and patience of special people to whom I owe my gratitude. I would like to acknowledge and thank my principal supervisor, Associate Professor, and my second supervisor,
Associate Professor. I would also like to thank the faculty and staff of the Discipline of Nursing and Midwifery of Nursing for their unwavering encouragement and emotional support. Further, I wish to acknowledge and thank the University and the Ministry of Higher Education, Australia, for supporting me in this endeavor. I would also like to thank the administrators and nurses from the hospitals in Australia who kindly gave their time towards the data collection. I gratefully acknowledge the funding given by the University which made my study possible. The foreign-trained nurses who live and work in Saudi Arabia and who participated in the study; you were courageous. Thank you to the hospital owners, directors, nursing directors, and quality managers for your openness to engage in the unmapped territory. To my friend and colleague Dr Kamal Hijjazi, thank you for guiding me through the quantitative process as the expert statistician. A special acknowledgement to my friends and colleagues who contributed their time, expert knowledge, and encouragement during this process.
Table of Contents
TOC \o "1-3" \h \z \u Acknowledgments PAGEREF _Toc414895929 \h 2
Table of Contents PAGEREF _Toc414895930 \h 3
Introduction…………………………………………………………………………………… ……… PAGEREF _Toc414895931 \h 4
1.1background to project4
1.2context of the study5
1.3Rationale7 HYPERLINK \l "_Toc414895933"
1.4 the research problem7
2.0 Aims/objectives of the project.8
2.1The research questions8
3.0 Method 9
4.0 Literature Review10
4.1 Organisational Causes ………...……………………………………………………………...14
4.1.1 Working Environment PAGEREF _Toc414895941 \h 14
4.1.2Area of Clinical Practice PAGEREF _Toc414895942 \h 15
4.1.3 Lack of adequate job resources PAGEREF _Toc414895943 \h 16
4.1.4 Organizational Leadership……………………………………………….…………...18
4.1.5Job Demands………………………………………………………………………….. PAGEREF _Toc414895942 \h 19
4.2 Effects of Burnout20
4.2.1 Effects on well-being of the nurses20
4.2.2 Effects on quality healthcare provision21
4.2.3 Effects on Patient safety and patient health outcome PAGEREF _Toc414895947 \h 22
4.3 Recommendations25
4.3.1 Intristic Motivation and Empowerment……………………………………………… PAGEREF _Toc414895949 \h 28
4.3.2 Prevention Measures31
6.0 Discussion32
7.0 Recommendation for Action…………………………………………………………………38
1. Introduction
1.1. Background to Project
Nursing is one of the most stressful professions among all human occupations. At the core of nursing profession is the concept of compassion and involvement that goes beyond the giving of physical care. This is the essence behind the stressful nature of the profession. According to Sabbah & colleagues (2012), nursing deals with health and illness aspects of human condition that can be stressful and likely to lead to burnout and job dissatisfaction
(Sabbah et al. 2012).
Burnout got a standardized definition by Maslach (1982), prior to which the term was defined in different ways by different individuals (as cited by Maslach, 2005). According to Maslach, burnout is a state of emotional exhaustion, depersonalization and a low sense of personal accomplishment mostly prevalent among individuals exposed to stressful environment as a result of human interaction in the work (Maslach, 2005). In relation to this literature review, nursing can therefore be termed as a human services profession that involves high exposure to conditions that cause burnout.
Over the past three decades interest in burnout among nurses has dramatically increased as its significant negative impacts on patients were revealed (Nayeri & Faghihzadeh, 2009; Akkus, & Aksu, 2010). The phenomenon of burnout is especially of interest to the nursing profession because of the working environment nurses are exposed to. Nurses work under narrow time pressures, exposure to advancing technologies, interacting with multiple people and in conditions with risky personal health safety (Akkus, Karacan, Goker & Aksu, 2010). Burnout among nurses has thus been studied in numerous countries for many years using the Maslach Burnout Inventory (MBI) (Beckstead, 2002). In recent years the focus has tended to shift towards increasing attention to the well-being of health care professionals including nurses rather than patient safety alone (Jordan & Gamble, 2013).
In 1996 Maslach reported that nurses who interact with other staff and patients in such circumstances experience more emotional draining and chronic stress that can lead to burnout
(as cited in Gillespie & Melby, 2003). Ersoy-Kart (2009) also indicated that being exposed to psychosocial risk factors such as heavy workloads or patients who are violent, abusive or seriously ill in the emergency and critical care units may alter the psychological and physical well-being of the health care professional involved which may eventually lead to burnout when the problem is not alleviated (Ersoy-Kart, 2009). Certain job environment characteristics such as the stress, interpersonal conflicts, exposure to death and dying and noise pollution have been found to have empirical correlation with burnout among nurses (Beckstead, 2002).
Despite the numerous studies conducted regarding burnout in the US, Europe, Australia, and parts of Asia, more research on this issue of interest is needed particularly in Saudi Arabia. This literature review aims to add on more research on the limited research available by assessing levels of burnout and associated factors among nurses working in Saudi Arabia (Garrick, 2012).
1.2. Context of the study
The concept of burnout was first described in 1974 by Freudenberger, an American phycho-analyst as the reaction to interpersonal stressors on the job (Freudenberger, 1974). Maslach, Jackson (1976), then described the scientific concept, importance of early diagnosis and interference (Maslach, 2001). However, it is important to note that no universally accepted definition for the term exits. Many scientific researchers and scholars believe that the concept of burnout has a complex indicator of primarily exhaustion symptoms as a response to prolonged interpersonal and emotional exposure to stressful working environment that leads to depersonalization. In a general term burnout can be defined as the disenchantment and flattening of the fizz of life (Maslach, 2001). It is important to recognize burnout symptoms and the sources of stress so as to be able to incorporate self-rescue techniques and preventive strategies.
Burnout has negative effect that impact on nurse compassion thereby affecting the outcomes of quality nursing care and patient outcomes (Burton, 2008). Deficiency of compassion in nursing profession leads to poor quality nursing care, negative patient outcomes and a disdain for humanity (Almalki, 2012). Nurses are trained to place the needs of their clients before themselves. They expend each operational day undergoing emotional pressure of inpatient or outpatient some of who are in critical conditions. Their work involves emotional strain, together with other stress factors inherent in the nursing work environment. This results in nurse professionals being vulnerable to stress and burnout (Buchan, 2002). This literature review seeks to establish how burnout can be effectually minimized among nurses working in Saudi Arabia so as to create an environment best for quality nursing care delivery.
1.3Rationale
This literature review seeks to understand why burnout exists among nurses working in Saudi Arabia. Its findings are significant venture towards psychological health promotion among nursing staff and thereby facilitating in the provision of better and more efficient health care services. This would be achieved by minimizing fatal medication and therapeutic errors, staff turnover, absenteeism and inter-personal conflict (Almalki, 2012). Minimizing these effects would contribute to productivity and the effectiveness of heath care provision to the societal needs (Neal-Boylan, et al. 2013).
By evaluating the situation, the report aims at providing recommendations which are helpful in changing the situation so as to improve the quality of nursing healthcare as defined by World Health Organization (WHO), hospitals, and insurance providers (Hunt, 2009).
1.4 Problem Statement
Apart from the physical demands of the nursing profession, nurses are engaged in dealing with human health issues (Sabbah et al. 2012). The profession also necessitates the use of mental energy thereby causing mental exhaustion especially in an environment that exposes one to stressful situations and events. Exposure to the stressful situations and events leads to emotional exhaustion which defines the concept of burnout in part as addressed by the MBI Surveys (Sabbah et al. 2012).
Burnout has negative consequences for nurses. Researchers have identified that burnout have various consequences on those whom suffer from the condition. It causes physical illness, emotional stress, a sense of reduced effectiveness and dysfunctional attitudes and behaviour among nurses (Scarnera, et al. 2009). In the working environment burnout may also lead to decreased motivation, high rates of absenteeism, increased job turnover rates, occupational injuries and increased interpersonal conflicts in the workplace. It has also been associated with insomnia and increased substance abuse (Naude & Rothmann, 2004). The burnout condition can compromise the social interaction capacity in the work place as well as in the community thereby impacting the social status of a nurse negatively.
The impact of the situation of burnout among nurses may also impact negatively on patient care provision by causing increased medication errors and reduced attention to the patients (Naude & Rothmann, 2004). Naude & Rothmann (2004), notes that the negative effects of burnout extend beyond the personal consequences by resulting into work-related problems such as nursing turnover, poor quality of care, increased absenteeism, lowered productivity and interpersonal problems (Naude & Rothmann, 2004). This means that, burnout may affect the reputation of the health care facilities in terms of the quality of health care being provide and the trust the community places on the professionals of that health care facility.
Nurses working in several specialty settings such as mental health, intensive care, pediatrics, and oncology departments have particularly been found to be more vulnerable to more stressors of burnout. In emergency and critical care units issues of life are particularly mentally and emotionally draining for nurses. Nursing staff working in such high psychological demanding areas are often faced with continuous heavy demands of sympathy, pity and compassion.
Cases of burnout among nurses in Saudi Arabia have been on the increase over the past couple of years (Gillespie & Melby, 2003). The quality of nursing care has become increasingly compromised by nurse burnout (Scarnera, et al. 2009). Therefore there is increased need to exploring the underlying organisational causes of nursing burnout, the effects of burnout and to provide recommendations for practice that would improve the situation. This literature review examines those issues with an aim of providing recommendations that can be helpful in reducing the problem of nursing burnout.
2.0Aims/objectives of the project.
This literature review investigates burnout among hospital nurses in Saudi Arabia. The project explores the prevalence and nature of burnout in the nursing population in that country. The literature review then provides recommendations that can be used to develop a strategy for reducing burnout. From this purpose several research objectives were set and a number of research questions established from those objectives.
* To examine the literature to identify Saudi Arabia’s organisational causes of nursing burnout.
* To explore the effects of burnout among hospital nurses in Saudi Arabia.
* To provide recommendations and solutions that will lead to reduction in the levels of burnout among nurses working in Saudi Arabia (Burton, 2008).
2.1The research questions
* What are the causes of burnout among hospital nurses in Saudi Arabia?
* Are there any relationships between burnout and organizational pertinent variables such as hospital type, salary, night shifts and over-time work?
What programmes are needed and what processes should be followed in order to reduce burnout among hospital nurses in Saudi Arabia? Plowright (2007).
3.0Method
A literature search has been performed by retrieving full text articles using bibliographic databases. A specific search strategy was used where articles written in English, articles involving nurses and those that explicitly focus on the relationship between nurses and burnout were searched. Articles searched were those published from 2005 onwards and articles published in peer-reviewed journals (Jezuit, 2012).
The specific search strategy was applied to search literature in database search engine. In order to review the literature on burnout among nurses in Saudi Arabia, the following keywords were entered; burnout, nurses, Saudi Arabia, emotional exhaustion, depersonalization, personal achievement, Maslach burnout inventory, work related stress, job satisfaction, age, years of experience, Intensive Care Unit, nurse work environment, area of clinical practice, job resources, organizational leadership, job demands, quality healthcare, patient safety, intrinsic motivation and empowerment were searched. The search terms were entered into the following database search engines: CINAHL (Cumulative Index to Nursing and Allied Health Literature) in Medline and Pubmed- Cochrane Library -Embase, Medline (Medical Literature Analysis and Retrieval System Online) and Pubmed, Cochrane Library, PsycINFO (Psychological Information Database). STATRef medical and nursing eBooks and Ovid nursing and medical collection (Jezuit, 2012). Using the above search engines, literature was collected for review.
4. Literature Review
This review of literature section analyses the available literature on nursing burnout including, definition, the historical background, signs and symptoms, causes and complications of burnout (Karlsson, Skargren, & Kristenson, 2010). The section also highlights how burnout relates to stress, emotional exhaustion, Depersonalization, coping strategies, social support and burnout measures in Saudi Arabia (Karlsson, Skargren, & Kristenson, 2010). The specific organisational causes of burnout and the effects of burnout are also discussed. Finally, recommendations has been made to reduce burnout among nurses In Saudi Arabia.
Cases of burnout among nurses in Saudi Arabia have been on the increase over the past couple of years (Gillespie & Melby, 2003). The quality of nursing care has become increasingly compromised by nurse burnout (Scarnera, et al. 2009). Extensive research has sought to establish the relationship between nurse burnout and patient satisfaction (Ersoy-Kart, 2009). Such research has provided evidence showing burnout as a key issue that needs to be addressed in regard to healthcare personnel (Hsu, et al. 2010). Most of these studies have been able to clearly show the effects of nurse’s burnouts on patient outcomes. Patient satisfaction is a key component of nursing practice and quality of health care in general. The problems of nurse burnout not only affect the nurse but it also brings adverse effect on patient outcomes (Almalki, 2012). Therefore there is an increased need to improve the responsiveness on burnout for the sake of patient safety as well as the nurse’s well-being (Hsu, et al. 2010).
Based on present empirical evidence burnout among nurses is closely connected to job satisfaction (Gillespie & Melby, 2003). A close association exists between burnout among the nurses and outcomes of job satisfaction which leads to increased nurse turnover, increased nursing absenteeism and poor quality nursing care as well as a higher dependence and over reflection of financial burdens to healthcare organizations (Almalki, 2012).
4.1 Organizational Causes
Nursing is a profession that deals with aspects of human health and illness. The profession is thus full of stressful events and situations that can ultimately lead to job dissatisfaction and burnout (Sabbah & Droubi, 2012). Much research has indicated that nurses face many stressors in the course of their career including organizational reorganization and downsizing, heavy workload, lack of social recognition, inadequate pay, inadequate preparation needed in meeting needs of patients, and exposure to situations that involve death or dying (McVicar, 2003). All these stressors contribute to the increased rate of nursing burnout.
4.1.1 Working Environment
Researchers have identified factors in the working environment which have been associated with stress, burnout and poorer health for nurses (Nayeri, et al. 2009). The working environment factors identified by researchers include a lack of control over one’s work, high working hours, lack of support in the working interactions, to deal with death and dying and extreme workload (Gombor, 2009).
According to a study published in Saudi Medical Journal, many nurses confirmed that current workloads were involving and caused burnout (Al-Turki, 2010). The authors in that journal has described burnout using a number of symptoms including constant headaches, irritability, chronic fatigue, insomnia, back pain, weight gain, high blood pressure and depression (Al-Turki, 2010). The study showed that 49% of nurses working in Saudi Arabia who are aged below 30 and 40% of aged over 30 experienced high levels of burnout (Al-Turki, 2010).
(Almalki, et al. 2012) reported that the environment in which nurses’ work contributes to burnout and other outcomes such as medical errors (Almalki, et al. 2012). Until substantial reforms are made, these factors are likely to continue being a threat to nurses thereby being a threat to patient safety. The IOM pointed to numerous studies that demonstrate the fact that many health problems such as increased bleeding, infections, cardiac and respiratory failure among nurses is associated with inadequate numbers of nurses as well as poor working environment for nurses (IOM, 2014).
A study that involved a survey of 250 nurses was conducted in King Fahd University Hospital in 2013 (Al-Turki, et al. 2011). The survey was conducted with an aim of establishing the major causes of burnout among nurses in Saudi Arabia. Two hundred self-administered questionnaires were used to collect information from the respondents. The data collected was amazed using Statistical Package for the Social Sciences (SPSS), version 14.0. A p -value of <0.05 was considered to be significant statistically (Watson et al. 2008).
198 nurses representing /77.2%/ of the total sample completed the questionnaire. Average age was 34.64 ± 5.37 years. 45% percent (89 nurses) showed high emotional exhaustion (EE) and 57 (28.9%) had moderate frequency of EE.
According to this study, nurses working shifts of ten hours or longer were up to two and a half times more likely to experience burnout than those who worked for lesser shifts
(Neal-Boylan, & Sigma Theta Tau International, 2013). The results of the study showed that nurses working less hours on average showed lower incidence of EE (P ≤ 0.001). 83 nurses (42%) had high frequency of depersonalization (DP) and 61 (30.8%) had moderate frequency of DP (Al-Turki, et al. 2011). 71.5% had moderate to low personal accomplishment (PA). Non-Saudi nurses were considerably more prone to EE (28.3 ± 13.1 versus 22.6 ± 3.9) than Saudi nurses (P = 0.004; 94% CI: <9.74) (Arikan et al. 2007). The study recommended that the working conditions be improved so as to develop strategies to cope and alleviate stressful situations among the nurses (Watson et al. 2008).
Another article by Juraschek (2012) indicate several reasons why nurses suffer burnout. The main cause presented in the article is low staffing levels. The primary issue associated with low staffing is that nurses are overworked. Overworked nurses feel unable to manage their workload.
4.1.2 Area of Clinical Practice
A survey was done by Al-Turki HA, Sadat-Ali M, Al-Elq AH, Al-Mulhim FA, Al-Ali AK in 2010. The study sought to find the causes of burnout among Saudi Arabian Nurses. The research involved a survey of 60 female nurses from King Fahd University Hospital which is a tertiary care hospital in the eastern province with 510 nurses. A Maslach burnout Inventory (MBI) questionnaire with demographic factors such as age, marital status, and number of years worked were used to gather information (Maslach. 2005).
The MBI factors that were used in the analysis of burnout syndrome (BS) were emotional exhaustion, personal accomplishment and depersonalization (More, Vito, & Walsh, 2012). From the 60 questionnaires distributed to nurses, 37 nurses (62.1%) were filled and returned
(Al-Turki, et al. 2011). Average age for the nurses who successfully completed the survey was 28 years while the average work duration in the nursing profession was 27.365 months (Al-Turki, et al. 2011). The findings of the survey was that 17 nurses which represents 45.9 % of the total percentage showed high frequency of Emotional Exhaustion while 13 nurses (35.2 %) showed moderate rate of EE. High depersonalization was recorded among 18 nurses (48.9%) while moderate signs were found in 15 (40.5%) (Al-Turki, et al. 2011). However, it should be noted that this study by Al-Turki and his colleagues had a small sample size. A larger sample would yield results that would have a higher level of generalisability.
Based on area of practice, Emotional Exhaustion was higher among the nurses who worked in critical care areas such as the operating room, oncology, emergency room and intensive care units in comparison to the nurses working in less critical areas such as those taking care of patients in wards and in the outpatient clinics (Al-Turki, et al. 2011). The authors stated that critical care nurses are more vulnerable to burnout because of the complex nature of patients’ health problems in those areas and because they tend to go through higher frequencies of life-and-death issues (Al-Turki, et al. 2011).
The conclusion is that majority of the nursing staff working in more critical and demanding units had high frequency of EE and DP and were in a state of burnout (Al-Turki, et al. 2011). This means that the area of practice is an important predictor in the development of burnout among nurses. Nurses working in intensive care units (ICUs) are specially characterized by a high level of work-related stress, a risk factor that results in burnout syndrome (Duvall, 2010). A study report by Embriaco, Papazian, Kentish- Barnes, Pochard, & Azoulay, (2007) showed that severe burnout syndrome is associated with decreased well-being of the nursing staff affected by the condition. It also leads to reduced quality care, increased costs associated to absenteeism and high nursing turnover. All of these effects have devastating consequences in the performance of ICU (Embriaco, et al. 2007).
4.1.3 Lack of adequate job resources
Lack of adequate job resources has been studied by researchers. The job resources that has been extensively studied is social support where a strong and consistent evidence base has been established that a lack of social support is related to burnout (Al-Turki, et al. 2011). Job resources also involve information and control (IOM, 2014). Research for organizational and management environment in which work occurs has highlighted the importance of the values implicit in organizational structures and processes (More, Vito, & Walsh, 2012).
These values are instrumental in shaping the cognitive and emotional relationship that people develop with their work (Böhmert et al. 2011). The organizational context in ...