International Journal of Nursing Practice 2008; 14: 19–25
RESEARCH PAPER
The role of burnout among Hungarian nurses Ilona Palfi RN MSc Senior Lecturer, Institute of Nursing and Patient Care, Faculty of Health Sciences, University of Pecs, H-7621 Pecs, Vorosmarty u. 4. Hungary
Katalin Nemeth RN MNS Assistant Lecturer, Institute of Nursing and Patient Care, Faculty of Health Sciences, University of Pecs, H-7621 Pecs, Vorosmarty u. 4. Hungary
Zsuzsanna Kerekes MSc Assistant Lecturer, Institute of Behavioural Sciences, Faculty of Medicine, University of Pecs, H-7621 Pecs, Szigeti u. 12. Hungary
Janos Kallai MSc PhD Professor, Institute of Behavioural Sciences, Faculty of Medicine, University of Pecs, H-7621 Pecs, Szigeti u. 12. Hungary
Jozsef Betlehem RN MNS MEdu PhD Principal Lecturer, Institute of Nursing and Patient Care, Faculty of Health Sciences, University of Pecs, H-7621 Pecs, Vorosmarty u. 4. Hungary
Accepted for publication July 2007 Palfi I, Nemeth K, Kerekes Z, Kallai J, Betlehem J. International Journal of Nursing Practice 2008; 14: 19–25 The role of burnout among Hungarian nurses This study was aimed to explore the occurrence of burnout among nurses in health and social institutions in Baranya County of Hungary, to reveal the connections between burnout and sociodemographic factors, and to learn its extent in different types of care. The survey was a one-off, representative sample with 805 questionnaires processed. The questionnaire was an internationally used and accepted standard paper designed for assessing burnout syndrome. The sample was given by nurses working in health and social care institutions in 2001. Intensive care nurses have the highest scores for burnout, followed by nurses in long-term care. Active ward nurses show the lowest scores for burnout. Burnout is twice as high among intensive care nurses (10.7%) than among long-term care nurses (3.6%), and the least is among active ward nurses (0.6%). Leaving one’s job is closely connected with burnout (66%). Prevention could save health-care workers from burnout and leaving the job independently from nurses’ sociodemographic factors. Key words: burnout, Hungarian nurses, psychosocial factors, stress.
Correspondence: Jozsef Betlehem, Institute of Nursing and Patient Care, Faculty of Health Sciences, University of Pecs, H-7621 Pecs, Vorosmarty u. 4, Hungary. Email:
[email protected]
ethical criteria.1,2 The quality of care mainly depends on the technical background, but its psychosocial circumstances––the attitude and behaviour of the healthcare staff taking care of patients directly or indirectly–– could strengthen or weaken the effects of the technical background. Such changes multiply the probability of conflict situations, causing additional stress.3 Caring for people can be stressful and arduous work.4 Too much stress might cause physical or mental illness and impair judgement, making it impossible for nurses to
doi:10.1111/j.1440-172X.2007.00662.x
© 2008 The Authors Journal compilation © 2008 Blackwell Publishing Asia Pty Ltd
INTRODUCTION Changes in health care Changes in health care seem to be an everyday occurrence. New systems of medical and nursing care also involve new professional, economic, psychological and
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overcome the stressors.5 Some of the stressors are work overload, lack of control at work, non-supporting staff, limited promotion, unclear roles, the suffering and death of patients, shift work, routine and underpaid work.6–8 The reactions to work-related stressors depend on the personality, how ‘steady’ the person is, his/her health at the time, previous experiences of stress and the means of coping strategies available. The perceived work stress and personality failures play an important role in the formation of burnout. The burnout syndrome means hopelessness and indifference.9–11 All these characteristics are found in organizations such as health-care institutions, as they involve the personalities of the employees and their interpersonal communication at every level of their work, and which might therefore become sources of stress.12,13 These factors can be divided into two groups: Originating from the character of the work Originating from the personality traits of individuals The character of a given area of work could involve various stress-induced conditions.14 Jobs are connected to role expectations that must be fulfilled. Thus, the working conditions, the information flow (or lack of it at certain levels) and the effectiveness (or otherwise) of management could all be important sources of stress. Several characteristic features of the individual could also be sources of stress. Some people become easily frustrated, indicating that their distress level is high. Others lack positive thinking, making a good working atmosphere difficult and damaging the efficacy of teamwork.15,16 Stress seems to be a central phenomenon at both the community and individual levels examined by Piko.17–19
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Definition and categorization of the burnout syndrome in the study Burnout and work deformation are psychosocial terms and therefore different from clinical diseases such as depression. With these terms, psychosociology focuses on the mutual relationships between an individual and his/ her environment. The affected person as the active member of society is the cause of the dangerous situation, and therefore seen as a subject of danger. It is then very difficult to confess to this in a profession or society whose norms are achievement and self-sacrifice. Burnout collides with the triad of the millennium: faster, further and higher. Complaints endanger the physical and psychological well-being, as well as social relationships.20 © 2008 The Authors Journal compilation © 2008 Blackwell Publishing Asia Pty Ltd
The phenomenon of burnout among health-care workers Burnout is a fuzzy term, involving workplace stress as well as satisfaction. Trying to differentiate between symptoms causes problems as well, because burnout results in similar symptoms of depression or anxiety. The conditions of burnout can be elucidated from the circumstances in which they appear. Motivation, satisfaction and stress can be part of any job or relationship, but burnout appears only in supporting relationships. Education and marriage belong to these relationships as well. The main factors of these relationships are establishing, maintaining and keeping the connection at a certain ‘heat’ level. If ‘heat’ is significantly reduced, burnout appears.21
Mutual relationship between burnout and family Some examples from the everyday life of nurses and their families are:22 Night and weekend work shifts might lead to a narrowing and losing of social relationships or to the isolation of the individual. The demand for constant professional empathy needs so much energy that nurses have little of it left for private life. Nurses always strive to maintain hope in people who suffer or who are in crises. Nurses can identify with their patients in that they share the patients’ depressing problems, therefore the nurses’ own lives might become a shadow world. In order to do work and maintain hope, nurses need to have their own source of energy. They expect their families to support them in maintaining their working ability. Nurses often take home not only their unfinished work, but daily workloads as well. After a hard day, nurses cannot give maximum support to their family. On the contrary, they need support from the family. The dynamics of sale and purchase becomes unbalanced. Thus, spouses cannot receive active attention or children a mother, who is meant to be a supporter for them. In the present climate of health-care reform, there is a need for empirical data on the relationship between nurses’ psychosocial work environment and their health. Because health is a complex concept, we have chosen the frequency of some common, psychosomatic symptoms as a health indicator that reflects the physical bodily
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Burnout syndrome among Hungarian nurses
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Figure 1. The model of factors affecting the burnout syndrome (Source: Palfi29).
complaints resulting from somatization of psychosocial processes.18,23–25 Psychosomatic health complaints, such as fatigue, palpitations, sleeping problems or tension headache, are quite common in the general population as well as among nurses.16,26,27 Fatigue, muscular tension and headache are particularly common among women.23,24 Studies have revealed that the frequency of these symptoms is associated with the self-perception of health, quality of life and personal life satisfaction. In Hungary, this might have an impact on leaving the job first to abroad (Western countries) and then to other sectors, like trade.28 The main goals of this study were to reveal the frequency of occurrence of the burnout syndrome, to define the social and demographic factors that influence the formation of the syndrome, and to map the physical and psychological load on nurses in different health-care institutions. The model of the factors affecting the development of burnout syndrome is shown in Figure 1.29 We hypothesized that the social and demographic factors (age, sex, education, scope of work, time spent in health care, second job, job leaving) influence the formation of burnout among nurses, and certain institutional factors (type of care, types of hospital units, salary) play a role in the formation of burnout.
METHODS Participants The participants of the cross-sectional survey were nurses chosen randomly from the health and social care institutions in Baranya County, Hungary. The participants in this
survey were nurses working in intensive care, long-term care and active wards of the University Clinics and in Social Care Institutes. Of the 1050 self-completed questionnaires sent out to nurses, 920 were returned and 805 analysed, giving a response rate of 76.6%. Ninety-four per cent (756 persons) of the responding nurses were female and 6% (49 persons) were male. The average age was 34 years (range 18–61 years). The age distribution was as follows: 46% (366 persons) < 31 years, 38% (309 persons) 31–45 years and 16% (130 persons) > 45 years. The mean of years spent in health care is 13.13 years (min: 6 months, max: 42 years). Educational qualifications were: unskilled nurses (18%), highly qualified nurses (82%) and nurses with degrees (6%).
Measurement tools The measurement tool for collecting information is a self-completed, closed ending, anonymous questionnaire containing various items on sociodemographic data, psychosomatic symptoms and psychosocial work environment. The questionnaire consisted of three parts: Sociodemographic factors The Burnout Questionnaire (BOQ; adapted from Freudenberger and Richelson in 1980,30 enabling us to examine the stages of burnout in the sample population) The Individual Burnout Symptomatic Questionnaire (BOS; used/developed by Appelbaum in 1980;1 this related to physical and psychological symptoms of burnout)
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© 2008 The Authors Journal compilation © 2008 Blackwell Publishing Asia Pty Ltd
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The measures of the variables were subjective (i.e. they were the perceptions of the participants). It could be argued, however, that the perceptions of the participants are important in stress research, as strain might be largely an individual’s reaction to his/her subjective environment. Regardless of an employee’s opinion, it cannot be said that he/she experiences stress unless the respondent evaluates a job as stressful.31 As a method of evaluating the psychometric properties of the instrument, test–retest reliability was assessed over a 1-month period with a subsample (n = 30) of participants who completed the questionnaire once, and then again 2 weeks later. The analysis of the reliability of the single items was based on cross-tabulations of answers given in the original and the second data collections. The weights given to the observed and expected frequencies were used to calculate Cohen’s (1968) kappa (k). The kappas for the single items were found to be in the range of 64–78%, which must be regarded as good.32
The examined variables Burnout was measured using the BOQ30 which has been widely used in Hungarian studies. This is a 15-item measure containing five-point Likert-type scales, where 1 indicated no symptoms and 5 the most symptoms. More burnout is indicated by higher scores on emotional exhaustion and depersonalization, and by lower scores on personal accomplishment. Overall, internal consistency was measured by using Cronbach’s alpha with reliability coefficients of 0.87 with the present sample. The physical and psychological symptomatology of burnout was measured by 30 items with the BOS.1 All items contained a five-point Likert-type scale, with 1 indicating no symptoms and 5 meaning very serious physical and psychological symptoms. Also the internal consistency was counted by Cronbach’s alpha coefficient which was 0.92.
nomic (as controlling) variables, while in model 2 measures of psychosocial work environment were added. The main goal of this hierarchical approach was to examine the relative role of psychosocial work environment with regard to nurses’ psychosomatic health, controlling for sociodemographic and socioeconomic differences.
RESULTS The measurement tool was aimed to elucidate the behaviour patterns of the individual suffering from burnout in real-life situations. Grades of burnout intensity in the studied population are detailed in Table 1. The total scores of the questionnaire were compared with the age, post and work relationships of the participants. The sociodemographic data were compared with one another as well. Using the comparison, the total scores were not correlated with age, post or work relationships. The results from the sociodemographic factors could not support the first hypothesis (Tables 2,3). On the other hand, having a second job and the thought of leaving the job have an effect on burnout. More than 90% of the participants said that they had a second job, owing to their low income. They have to work on their free days, or they have to do a second shift elsewhere (cleaning, in commerce or as saleswomen). We Table 1 Grades of burnout intensity in the population studied Grade
N = 805
%
Feels very good Things needed to pay attention to Being in danger Being in the state of burnout Needs cure
237 244 273 44 7
29.4 30.3 33.9 5.5 0.9
Statistical analysis The spss for MS Windows Release 10.0 program (SPSS Inc., Chicago, IL, USA) was used in the calculations and the minimum significance level was set to 5%. Significant differences between the subsamples were determined by the chi-squared test. Linear regression models were applied to examine the relative effects of sociodemographics, socioeconomic variables and measures of work environment on psychosomatic symptomatology. The baseline model included sociodemographic and socioeco© 2008 The Authors Journal compilation © 2008 Blackwell Publishing Asia Pty Ltd
Table 2 Correlation of Burnout Questionnaire scores and personal data Burnout Questionnaire
Correlation
Significance
Age Position Work experiences in years
0.048 -0.026 0.032
0.172 0.470 0.370
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Table 3 Regressive coefficient of personal data and Burnout Questionnaire Independent variable
Coefficient
Constant Position Satisfaction with wages Marital status Type of care Number of children Taking part in higher education Age Any second jobs Work experiences in years Sex Thinking of leaving health care Qualification
Unstandard coefficient b
Standard coefficient b
Significance
26.778 -1.001 1.815 -0.092 -1.321 0.144 1.388 0.104 -1.928 -0.015 1.940 0.219 0.011
0.000 -0.046 0.043 -0.029 -0.104 0.046 0.041 0.095 -0.084 -0.014 0.041 0.072 0.005
0.000 0.229 0.221 0.544 0.004** 0.194 0.253 0.109 0.020* 0.814 0.246 0.041* 0.918
* < 0.05, ** < 0.01.
assessed the significance of job leaving separately from the significance of attendance records and second job. This fact shows that leaving one’s job is closely connected with burnout. Sixty-six per cent of the persons questioned said that they would consider leaving their job, while only 34% had not considered it. According to the burnout scale distribution, the surveyed population was divided into groups of different health-care units. The distribution of the numeric data follows the normal distribution in each of the three areas. The percentile data of each burnout stage show that nurses who need to cure the burnout syndrome in intensive care units account for 1.3% (5 persons), but 9.4% (35 persons) are in the state of burnout, while 2.9% (2 persons) in long-term care units, with the rate being even lower at 0.6% (1 person) in active wards (Table 4).
CONCLUSION The primary objective of the study was to define those personal and environmental factors that seem to be responsible for the development of affective exhaustion, reduction of personal achievement or the formation of burnout. Comparing the three types of questions in the questionnaire, we can see that each of them can be well used as a source of external validity.
The total scores of the tests correlated well with each other. When comparing the total scores and the personal and workplace features of the questionnaire, we came to the conclusion that the sociodemographic data are not significant for the formation of burnout. The results depend on workplace conditions, or the attendance records of the institute or unit. It means that personal data were not important risk factors. Burnout is twice as high among nurses working in intensive care units (10.7%) compared with nurses working in long-term care units (3.6%), and the least is in nurses working in active wards (0.6%). It is probable that nurses working in intensive care units cannot solve situations day-by-day and to escape these needs a lot of energy or causes anxiety. Low salaries could be considered as a main problem in health care; this fact forces nurses to undertake a second job. Tired nurses cannot fulfil the expectations; therefore, they are frustrated and often make mistakes. Nurses might waste their qualification if they leave their job, or those nurses who persist in their posts pay a high psychological price. Employers lose devoted people and get poor performance from their employees. Last but not least, patients do not receive quality nursing. © 2008 The Authors Journal compilation © 2008 Blackwell Publishing Asia Pty Ltd
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Table 4 Grades of burnout intensity in different departments Grade of burnout intensity
Workers at intensive care unit N
Feels very good Things needed to pay attention to Being in danger Being in the state of burnout Needs care Total
%
Workers at active department N
%
Workers at chronic department N
%
114 113
30.5 30.2
28 55
18.1 35.5
95 76
34.4 27.5
107 35
28.6 9.4
71 1
45.8 0.6
95 8
34.4 2.9
5 374
1.3 100.0
0 155
0 100.0
2 276
0.7 100.0
RECOMMENDATIONS TO PREVENT BURNOUT SYNDROME
• Better work schedules • Sharing responsibility in work teams • Real objectives for effectiveness and feedback • Better working conditions and autonomy • Mutual support from family and workplace • Professional development and promotion for nurses • Time for rest and recreation • Relaxation techniques, regular fitness exercises • Definitions of work objectives and economic use of
time. Failure might lead to dissatisfaction Ability to say ‘no’ in certain cases Separation of private and working life Reduced work responsibility, overload, ambiguous situations, conflicts Case discussions, Bálint groups, regular supervision and attendance at supervision These examples illustrate that unclear and intertwined situations could mean heavy loads demanded from people. They are aware of these facts, especially when change is not possible for them. Such events lead to crises. We can prevent burnout if we pay attention to the people who pursue nursing as a profession. Today they nurse our loved ones, but tomorrow they will be the patients.
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