CURRENT ISSUES
Nurse Satisfaction and Burnout in Shanghai Neurology Wards Hui Jiang1, *, PhD, RN, Chen Li2, *, PhD, Yan Gu1, BSN, RN & Haiyan Lu1, BSN, RN 1 Nursing Department, Shanghai East Hospital, Tongji University School of Medicine, Shanghai, China 2 College of Humanities and Social Science, Shanghai University, Shanghai, China
Keywords
Abstract
Burnout; China; Maslach Burnout Inventory; nurses; neurology ward; questionnaire survey; satisfaction. Correspondence Hui Jiang, Deputy Nursing Director of Shanghai East Hospital, Tongji University School of Medicine, No. 150, Jimo Road, Pudong New Area, Shanghai 200120, China. E-mail:[email protected] *These authors contributed equally to this work. Accepted May 31, 2014. doi: 10.1002/rnj.174
Purpose: To explore satisfaction and burnout of nurses working in neurology wards in Shanghai, China. Design: A descriptive cross-sectional questionnaire survey. Methods: Three hundred and eighty-seven nurses from 23 neurology wards in 21 tertiary general hospitals were recruited using cluster sampling. The valid response rate was 94.83%. Findings: Nurse satisfaction with the salary/wages, the job and the nurse staffing level were 21.79%, 37.33%, and 40.87%. A high nurse burnout rate was found as: emotional exhaustion (EE) ≥ 27 (89.92%); depersonalization (DP) ≥ 10 (92.64%); and reduced personal accomplishment (PA)≤ 33 (79.29%). Conclusions: Most nurses in the neurology wards were dissatisfied and had high levels of burnout. Experienced, intermediate and senior nurses were at the highest risk for job turnover. Clinical Relevance: Nurse administrators should take effective measures to increase nurse satisfaction and decrease burnout to retain experienced nurses and keep the stability of nursing workforce.
Introduction Nursing is a profession that requires a person to have ability, compassion, and dedication to patient caregiving, which must be provided 24 hours per day (Marjorie & Alice, 2010). The work performance of nurses undoubtedly influences outcomes for both patients and hospitals (Clark, 2009). However, in the current medical system, as patient acuity and complexity increase, the nursing staff must assume a heavy burden of duties to meet the requirements for high-quality nursing care and to address the nursing shortage and the high turnover rate. Nursing shortage is expected to become even more critical in the future, as the total demand for nurses outpaces the number of nurses entering the workforce in many countries (Peltier, Pointer, & Schibrowsky, 2006). There are several reports that nurse satisfaction and burnout are closely related to nurse retention (Aiken, Clarke, Sloane, Sochalski, & Silber, 2002; Xie, Wang, & Chen, 2010). As job
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dissatisfaction and burnout increase, the likelihood of nurses leaving their employment setting increases, which will exacerbate the current shortage of nurses and result in poor patient outcomes (Hassmiller & Cozine, 2006). Therefore, nurse satisfaction and burnout status are critical issues that should become the major concerns for nurse administrators (McGlynn, Griffin, Donahue, & Fitzpatrick, 2012). Background Nurses are on the front line of hospital services in the healthcare sector. A hectic, fast-paced work environment, irregular work schedules, and specific work environments make nurses vulnerable to dissatisfaction and burnout (Xie et al., 2010). Nurse satisfaction reflects a positive affective orientation toward work and the organization, whereas nurse dissatisfaction reflects a negative affective orientation (Taunton et al., 2004). Satisfied employees © 2014 Association of Rehabilitation Nurses Rehabilitation Nursing 2016, 41, 120–127
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tend to be more productive, creative, and committed to their employer. Thus, nurse satisfaction is the most frequently cited factor in nurse turnover (Moumtzoglou, 2010). Nurse burnout has been used to describe the syndrome of exhaustion. According to Maslach, Schaufeli, and Leiter (2001), burnout is defined as continuous work pressure that is ineffectively handled and is comprised of the following three dimensions: emotional exhaustion (EE); depersonalization (DP); and reduced personal accomplishment (PA). The EE component represents the basic individual stress dimension of burnout. It also refers to feelings of being overextended and depleted of one’s emotional and physical resources. The DP component represents the interpersonal context dimension, which refers to a negative, callous, or excessively detached response to various aspects of the job. The PA component represents the self-evaluation dimension, which refers to feelings of incompetence and a lack of achievement and productivity at work. Burnout was associated with higher scores on the EE and DP subscales and a lower PA score (Beckstead, 2002). A high burnout score on the Maslach Burnout Inventory (MBI) is associated with a subjective lack of well-being and/or feelings of an inability to perform the job well (Ringrose, Houterman, Koops, & Oei, 2009), and leads to lower productivity and effectiveness (Leiter & Maslach, 2009). It is highly probable that nurse dissatisfaction and burnout, unless handled appropriately, will worsen the nursing shortage and reduce healthcare standards internationally (Lei, Hee, & Dong, 2010). The normative values of burnout published for nurses and physicians in the USA are 22.19, 7.12, and 36.53 for the EE, DP, and PA subscales, respectively (Maslach, Jackson, & Leiter, 1996). A study conducted in Hong Kong revealed that nurses in Hong Kong experience very high levels of burnout. With respect to EE and DP, the Hong Kong mean scores were 28.12 and 13.81, respectively. No significant difference existed between the mean PA scores of the Hong Kong nurses (mean = 38.80) and the U.S. sample (mean = 36.53; Taormina & Law, 2000). A comprehensive survey study conducted in the United States, Canada, England, Scotland, and Germany (Aiken et al., 2001) revealed that nurse dissatisfaction and burnout have become commonplace in developed countries and pose a threat to the healthcare system. Studies involving general nurses in China have found that the average burnout score for EE was 38.1, compared with 30.3 in Europe (You et al., 2013). Studies conducted in Shanghai showed that nurses had a high level of EE and DP, but a low level of PA at a tertiary © 2014 Association of Rehabilitation Nurses Rehabilitation Nursing 2016, 41, 120–127
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general hospital (Xie et al., 2010). Studies on nurse satisfaction and burnout have mainly focused on nurses working in general wards (Lu, Ruan, Xing, & Hu, 2013; Xie et al., 2010; You et al., 2013), the ICU (Li, Ruan, & Jiang, 2013), or the emergency department (Wu, Sun, & Wang, 2011). Nurse satisfaction and burnout in the neurology ward have not been studied. Therefore, there is a need for nurse administrators to understand the level of satisfaction and burnout in specific units to identify interventions that could maintain the size and professional longevity of the nurse workforce. Study Design Aims The purpose of this study was to evaluate nurse satisfaction and burnout from nurses working in neurology wards in Shanghai, China, and to determine measures to increase nurse satisfaction and decrease nurse burnout. These measures will ultimately be beneficial for alleviating the current nursing shortage and strengthening the quality of nursing care. Methods This study used a descriptive cross-sectional design with a structured questionnaire survey to investigate nurse satisfaction and burnout. Cluster sampling was used to recruit registered nurses from the neurology wards of all the tertiary general hospitals in Shanghai, which is a large city in China with approximately 23 million people that is faced with the challenges of an overcrowded population and a nursing shortage. A descriptive and comparative design was used for the data analysis. Setting and Participants All of the nurses working in the neurology departments in tertiary general hospitals in Shanghai were invited to participate. Altogether, nurses working in 23 neurology wards at all 21 tertiary general hospitals were recruited as participants. The inclusion criteria were as follows: (1) volunteering for the study and having no mental or psychological disorders; and (2) possessing a Practicing Nurse Certificate and working continuously in the Department of Neurology for ≥6 months. The exclusion criteria were as follows: head nurses; sick leave; maternity leave; absent due to vacation, or on continuing education leave.
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Study Instruments A self-reported questionnaire was used in this study. The survey questionnaire was developed by the research team based on a literature review and the purpose of the study. The questionnaire consisted of three parts: the demographics of the nursing staff, nurse satisfaction, and nurse burnout based on the MBI. All questions were written in simple Chinese. The demographic section included the name of the hospital, gender, age, marital status, education, years of work experience, and academic level. Nurse satisfaction was measured by three single questions with five response categories. The three questions were as follows: (1) Are you satisfied with your job? (2) Are you satisfied with your salary/wages? and (3) Are you satisfied with the current nurse staffing level in your ward? The respondents used a 5-point Likert-type response format, ranging from strongly dissatisfied to strongly satisfied (scored from 1 to 5) based on their feelings of satisfaction with each item. Twenty nurses from the neurology ward were recruited for the pilot study and the Cronbach’s alpha for this part (three items) was 0.82. The third section was the Chinese version of the MBI and included 22 items (EE, nine items; DP, five items; and PA, eight items) on a 7-point Likert scale (0, never; 1, a few times per year or less; 2, once per month or less; 3, a few times per month; 4, once per week; 5, a few times per week; and 6, every day). Nurses chose the proper response based on their own feelings of the frequency of burnout. Cronbach’s alpha for the 22 items was 0.84. Cronbach’s alpha for EE, DP, and PA was 0.85, 0.78, and 0.82, respectively, which showed good internal consistency for the questionnaire (Lu et al., 2013). The level of burnout experienced was categorized as follows: for EE, ≥27 was high; for DP, ≥10 was high; and for PA, ≤33 was low (Maslach et al., 1996).
Data Collection The data were collected from September to November 2013. Permission was obtained from the nursing director of each hospital before the study commenced. Two investigators were trained by the researchers to give instructions to the participants and facilitate the distribution and collection of the questionnaires. The training included information on the research goals, sampling methods, and correct delivery and return process for the questionnaires. Nurses who met the eligibility criteria in the units were invited to participate in the study. An
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information sheet, which summarized the study’s purpose and methodology, was disseminated to the participants. The nurses were asked to complete the survey without consulting other staff. The completed surveys were placed in self-sealing envelopes by the participants, then placed into a sealed box on the unit. These strategies were designed to protect the privacy of the nurses and to increase the response rate. Subsequently, the nurse manager returned the sealed questionnaires to the investigator, who returned all sealed questionnaires to the principal researcher. All nurses on the selected wards were recruited. Ethical Considerations Institutional Review Board approval was obtained before the study. Informed consent was obtained from each hospital and each sampled nurse. To ensure rights and privacy, all participants were informed that the data emerging from the study would be kept confidential, that anonymity was assured, and that they could withdraw from the study without prejudice. Statistical analysis Statistical analyses were performed using SPSS (version 17.0 for Windows; SPSS, Inc., Chicago, IL, USA). Descriptive statistics were used to analyze the demographic characteristics of the participants and the nurse scores of satisfaction and burnout. Frequencies were described using means and standard deviations (SD), and comparisons between different groups were analyzed using single-factor analysis of variance (ANOVA). Twotailed tests of mean differences were used throughout, and the 0.05 level was used as the criterion for determining statistical significance. Results General Characteristics of the Participants Of the 410 available nurses, 387 agreed to participate and return the questionnaire, with 367 providing complete information on the questionnaire. The valid response rate of the survey was 94.83%. All 367 nurses who were surveyed were females, with an average age of 28.39 5.83 years and an average number of years working of 7.63 6.52 years. Their marital and obstetric statuses were as follows: 158 nurses (43.05%) were © 2014 Association of Rehabilitation Nurses Rehabilitation Nursing 2016, 41, 120–127
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unmarried; 70 nurses (19.07%) were married, but without children; and 139 nurses (37.87%) were married with children. The years of working in nursing were: ≤4 years, 165 nurses (44.96%); 5–9 years, 102 nurses (27.79%); and ≥10 years, 100 nurses (27.25%). The highest level of education achieved by the majority of the participants was an associate degree (237 [64.58%]), followed by a baccalaureate degree (92 [25.07%]) or a diploma (38 [10.35%]). The majority of nurses were at professional levels 1 and 2 (319 [86.92%]) followed by level 3 or above nurses (48 [13.08%]). Description of Nurse Satisfaction and Burnout Table 1 shows the means, range of score, standard deviations, satisfaction rates, and burnout rates for the variables used in the study. The mean nurse satisfaction scores were 3.23 (SD, 0.87), 3.31 (SD, 0.81), and 2.82 (SD, 0.91) for job, the nurse staffing level, and the salary/ wages, respectively. Satisfaction rate refers to the nurses who scored 5 (strongly satisfied) or 4 (satisfied). Table 1 shows that satisfaction with the salary/wages was the lowest (21.79%), followed by satisfaction with the job (37.33%) and the nurse staffing level (40.87%). The ranges of the burnout score were from 0–54 for EE; 0–30 for DP and 0–48 for PA. The mean nurse burnout scores were EE, 36.35 (SD, 8.64); DP, 17.59 (SD, 5.62); PA 28.56 (SD, 7.28). A high nurse burnout rate was calculated, as follows: EE ≥ 27 (89.92%); DP ≥ 10 (92.64%); and PA ≤ 33 (79.29%). Comparative Analysis Among Different Groups The nurses were classified into three groups according to their years of work experience, the highest nursing educa-
tion level, and professional level. As shown in Table 2, among the three satisfaction items, there were no significant differences in two satisfaction items (the nurse staffing level and the salary/wages) in the different work experience, educational, and professional level groups. In addition, there were no significant differences in satisfaction with the job among the different educational levels. There were significant differences in job satisfaction among nurses with different levels of work experience and at different professional levels (p < 0.01). Least significant difference (LSD) analysis of the two groups indicated that nurses with more work experience and at higher professional levels have lower satisfaction with jobs. As shown in Table 3, there were no significant differences in the DP and PA scores among the three different groups. There were no significant differences in the EE subscale scores among nurses with different educational levels; however, there were significant differences in the burnout EE scores among the nurses with different levels of work experience and at different professional levels (p < 0.05). Discussion In the current medical system, the nursing model has changed from disease- to patient-oriented, and requires nurses to provide holistic biopsychosocial–spiritual highquality nursing care to meet patients’ expectations and demands (Nathenson, 2012; Lei et al., 2010). Nurse satisfaction and burnout have been identified as key factors to retain qualified nurses and secure the nursing care quality (Lu, While & Barriball, 2007). In China, since the introduction of China’s open-door policy in the 1980s, big changes have occurred in nursing to meet the increasing healthcare demands for the massive population. Hospitals
Table 1 Description of Nurse Satisfaction and Burnout Mean Nurse satisfaction Satisfaction with job Satisfaction with nurse staffing Satisfaction with salary/wages MBI nurse burnout Emotional exhaustion Depersonalization Lack of personal accomplishment
Range of Score
SD
Satisfaction Rate, n (%)
3.23 3.31 2.82
1–5 1–5 1–5
0.870 0.805 0.907
137 (37.33%) 150 (40.87%) 80 (21.79%)
36.35 17.59 28.56
0–54 0–30 0–48
8.64 5.62 7.28
– – –
Burnout Rate, n (%) – – – 330 (89.92%) 340 (92.64%) 291 (79.29%)
Note: The satisfaction rate is the rate of the combination of the survey answers “strongly satisfied” and “satisfied.” The burnout rate is the rate of a high burnout score.
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Table 2 Comparative Analysis of Nurse Satisfaction Among Different Nurse Groups F-value p-value
Satisfaction With Staffing Level (Mean SD)
F-value p-value
165 102 100
3.30 0.77 3.40 0.85 2.97 0.98
7.325 0.001
3.30 0.81 3.47 0.73 3.20 0.85
3.006 0.051
2.81 0.90 2.94 0.86 2.71 0.95
1.690 0.186
38 237 92
3.36 0.76 3.13 0.91 3.25 0.78
1.420 0.247
3.42 0.73 3.27 0.83 3.39 0.70
1.031 0.358
2.89 0.919 2.78 0.880 2.89 0.973
0.497 0.685
158 161 48 367
3.33 3.12 2.74 3.23
n Work experience 4 years or below 5–9 years ≥10 years Educational background Diploma Associate degree Baccalaureate degree or above Professional level Level 1 Level 2 Level 3 and above Total
Satisfaction With Salary/Wages (Mean SD)
Satisfaction With Job (Mean SD)
0.78 0.84 1.23 0.87
6.374 0.000
3.32 3.30 3.30 3.31
0.78 0.76 1.20 0.81
2.82 0.863 2.79 0.909 2.90 1.055 2.82 0.91
0.013 0.987
F-value p-value
0.284 0.753
Note: LSD analysis of two groups: 4 years or below* ≥10 years, p < 0.01; 5–9 years*10 years, p < 0.01; level 1*level 3 and above, p < 0.01; level 2*level 3 and above, p < 0.01. Table 3 Comparative Analysis of Nurse Burnout Among Different Nurse Groups
Work experience 4 years or below 5–9 years ≥10 years Educational background Diploma Associate degree Baccalaureate degree or above Professional level Level 1 Level 2 Level 3 and above Total
n
Burnout EE (Mean SD)
F-value p-value
Burnout DP (Mean SD)
F-value p-value
Burnout PA (Mean SD)
F-value p-value
165 102 100
35.62 8.69 35.44 9.25 38.30 7.68
3.921 0.021
17.77 5.72 17.18 6.17 17.69 4.92
0.372 0.690
28.39 7.32 28.41 8.01 28.94 6.51
0.214 0.808
38 237 92
36.75 11.56 36.98 7.56 35.64 8.85
0.600 0.615
16.19 6.92 18.12 5.10 17.59 5.84
1.432 0.233
27.06 9.03 28.90 6.37 28.74 8.05
1.189 0.314
158 161 48 367
35.08 37.42 38.40 36.35
9.32 8.12 6.49 8.64
4.230 0.015
17.54 17.50 19.33 17.59
5.96 5.42 4.76 5.62
1.892 0.152
28.07 28.64 30.21 28.56
7.78 7.08 6.16 7.28
1.446 0.237
Note: LSD analysis of two groups: 4 years or below* ≥10 years, p < 0.05; 5–9 years * ≥10 years, p < 0.05; level 1*level 2, p < 0.05; level 1 *level 3 and above, p < 0.01.
in China are classified into three grades, based on the facility, equipment, and staffing. The higher the grade, the more sophisticated the facility. Tertiary hospitals are usually located in large cities and referred to as general hospitals (Xie et al., 2010). Currently, there are five levels of nursing education (diploma program, associate program, baccalaureate degree, master’s degree, and PhD degree; Liu et al., 2011) and five levels of professional academic titles for nurses stratified as junior (levels 1 and
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2), intermediate (level 3), and advanced (levels 4 and 5), in accordance with their educational background, ability in nursing service, and experience in nursing practice (Hui, Wenqin, & Yan, 2013; Yun, Shen, & Jiang, 2010). Although in China the baccalaureate degree level of education began in 1983, the master’s degree level of education in 1994, and the PhD degree level of education in 2004, the nursing workforce with high educational background still account for a small percentage of the nursing © 2014 Association of Rehabilitation Nurses Rehabilitation Nursing 2016, 41, 120–127
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workforce and these nurses are mainly in the fields of teaching, management, and research. The majority of the front line clinical nurses are still educated at the associate degree level (Wang et al., 2013; Yun et al., 2010). The benchmarks of levels 4 and 5 set high and strict criteria which resulted in a limited number of nurses achieving career advancement. The nurse staffing model in China uses the 1:0.4 bed-to-nurse ratio or the 1:8 nurse-topatient ratio for general inpatient units to allocate the nursing staff in comparison with the 1:5 mandatory nurse-to-patient ratio in California (USA) and the 5:20 staffing model in Victoria, Australia; (Chapman, Spetz, & Seago, 2009; Gerdtz & Nelson, 2007). Although nurses are the vital front line staff, their salary/wages remain the lowest among the medical work group (physicians and technicians). The heavy workload, inadequate nurse staffing, low salary/wages, physician-dominated work environment, and regular night shift made nursing unpopular career in China, except for the easy employment opportunities. Employment turn over for nurses is quite easy, especially experienced senior nurses (Lei et al., 2010). Clinical front line nurses were mainly at a young age and junior level (Wang et al., 2013). Our study findings also clearly demonstrate that the current nursing workforce in the inpatient neurology wards in Shanghai, China, is mainly composed of young, junior, and associate degree nurses and mainly junior level 1 or 2. The nurses in the neurology wards were dissatisfied with the salary/wages, the job, and the nurse staffing, and the majority of the nurses expressed excessive burnout rates and burnout scores. Based on the statistical analysis in our study, experienced level 3 nurses were less satisfied with their job and expressed more burnout in their work than did the younger junior nurses; a possible reason for this observation may be that this group of nurses account for a small proportion of nurses in the ward, however they possess rich experiences in handling challenging situations, and very often these nurses are needed to supervise the junior nurses. The experienced intermediate and senior nurses also have more responsibility for patient safety and quality of nursing care, in addition to their usual work assignments and rotate shifts with the junior nurses. There is major concern that the number of experienced nurses with professional titles may gradually decrease as a result of the heavy responsibilities they shoulder which is contributing to their burnout and dissatisfaction with their job. The erosion of experienced nurses will lead to insufficient professional capability and limits the development of nurses, which then will impact © 2014 Association of Rehabilitation Nurses Rehabilitation Nursing 2016, 41, 120–127
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the quality of the nursing service. Therefore, the development of relevant solutions to ensure nurse satisfaction and reduce nursing burnout could play a crucial role in fostering nurse retention and secure the stability of the nursing workforce. To meet the challenges of nurse turnover, efforts to retain senior registered nurses are needed to ensure that a sufficient number of experienced registered nurses are available to mentor younger nurses in the future. Nurse administrators need to examine factors, such as income level, staffing level, and work environment, to improve the nurse staffing level, change the status of work overload, design an effective, rational salary structure and payment model, and create career development programs for nurses that can increase nurse satisfaction and decrease nurse burnout. These measures will play a vital role to increase nurse satisfaction and alleviate nurses’ burnout to help nurse retention and improve the quality of nursing service. Clinical Relevance The nursing workforce in neurology wards is closely related to the patient rehabilitation process. The inpatient neurology wards admit patients with a diagnosis of acute cerebral infarction, acute cerebral hemorrhage, or transient ischemic attack (TIA); other than the symptoms of the disease, most of these patients have additional symptoms and needs, such as high blood pressure, consciousness disorders, self-care deficiencies, movement deficiencies, Ryle’s feeding tubes, urinary catheters, and most require rehabilitation care in addition to the treatment programs. With the instruction and help from professional, experienced nurses, patients can gain the maximum level of wellness and achieve their optimal level of functioning. The nurse satisfaction and burnout results in this study indicated that nurses are not satisfied with the pay, the job, or the nurse staffing level, and that most nurses have high burnout, while working in a neurology ward. Thus, improving nurse satisfaction and decreasing nurse burnout will be very important to keep the stability of the nursing workforce, secure the quality and promote patient recovery. Conclusion Nurse satisfaction and burnout are important issues in nursing. This study highlights the need for careful evaluation of the situation of Chinese nurses, with an eye for the retention of skilled senior nurses. Nurse staffing in
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Key Practice Points Nurse satisfaction and burnout are the main indicators for nurse retention, but the issue on specific neurology wards has not been studied. This research revealed that nurses working in neurology wards are not satisfied with the pay, the job, and nurse staffing, and most of the nurses had high burnout. More alarming is the findings that experienced, qualified senior nurses in neurology wards are less satisfied and have more burnout in their jobs, which may lead to a higher tendency for turnover. The stability of nursing workforce in neurology wards plays a key role in patient rehabilitation. Therefore, nurse administrators need to pay close attention to the stability and quality of the nursing workforce.
China is inadequate. The mix of nurses, regardless of educational background, work experience, and academic level, is not sufficient to meet present and future challenges to nursing. Nurses are not satisfied with their job, nurse staffing, or payment. In this study, the majority of nurses in neurology wards met the criteria for high burnout. Clearly, this is an alarming result that must be taken seriously. More concerning is the high burnout rates for the experienced nurses and the impact of losing such wealth and resource. Finding ways to increase nurse satisfaction and decrease nurse burnout is in the best interest of healthcare system. Nursing administrators should pay more attention to the status of nurse satisfaction and burnout, initiate proposals for programs to alleviate the stress of hospital work, and help nurses to be more engaged with their jobs by providing more opportunities for training and education for nurses, increasing the nurse staffing level, enhancing nursing autonomy, and empowering intermediate and senior nurses to reduce nurse turnover. The greater the scope and variety of a nurse’s coping strategies, the better the chance of improving nurse satisfaction, and reducing nurse burnout. Therefore, nurses’ work engagement, nursing care quality, and the rehabilitation process will be improved. Limitations There were some limitations to this study. The study was conducted on the neurology wards of tertiary general hospitals in the highly developed and densely populated city of Shanghai. It may not be possible to generalize the
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results to other wards, other hospitals, nor other locations in China. A significantly larger sample size will be needed to better understand the nurse satisfaction and burnout status in China. Acknowledgments The authors are grateful to all of the participating nurses for their involvement, to the research nurses for data collection, and to the directors of the nursing departments for their cooperation. The authors thank the Department of Health in Pudong for the funding support for this project. The views expressed in this article are those of the authors. Conflict of Interest: The authors declare there were no conflicts of interest with respect to this publication. Author Contributions: Hui Jiang was responsible for all aspects of the research study, including conceptualization of the design, data collection, analysis, drafting, and revision of manuscript. Chen Li assisted with the design of the research and drafting of the manuscript revisions. Yan Gu participated in the numerous revisions of the manuscript. Haiyan Lu assisted with interpretation and formatting the presentation of the results. Funding: This project was funded by Scientific Development Research Funds founded by Pudong New Area Health Bureau, Grant-in-Aid No. PW2012A-3. References Aiken, L.H., Clarke, S.P., Sloane, D.M., Sochalski, J.A., Busse, R., Clarke, H. et al. (2001). Nurses’ reports on hospital care in five countries. Health Affairs (Millwood), 20(3), 43–53. Aiken, L.H., Clarke, S.P., Sloane, D.M., Sochalski, J., & Silber, J.H. (2002). Hospital nurse staffing and patient mortality, nurse burnout, and job dissatisfaction. JAMA. Journal of the American Medical Association, 288(16), 1987–1993. Beckstead, J.W. (2002). Confirmatory factor analysis of the Maslach Burnout inventory among Florida nurses. International Journal of Nursing Studies, 39, 785–792. Chapman, S.A., Spetz, J., & Seago, J.A. (2009). How have mandated nurse staffing ratios affected hospitals? Perspectives from California hospital leaders. Journal of Healthcare Management, 54(5), 321–335. Clark, P.R. (2009). Teamwork, building healthier workplaces and providing safer patient care. Critical Care Nursing Quarterly, 32(3), 221–231. © 2014 Association of Rehabilitation Nurses Rehabilitation Nursing 2016, 41, 120–127
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with the professional practice model. Journal of Nursing Management, 20, 260–265. Moumtzoglou, A. (2010). The Greek nurses’ job satisfaction scale:development and psychometric assessment. Journal of Nursing Measurement, 18(1), 60–69. Nathenson, P. (2012). Application of holistic nursing in the rehabilitation setting. Rehabilitation Nursing, 27(3), 114–118. Peltier, J.W., Pointer, L., & Schibrowsky, J.A. (2006). Internal marketing and the antecedents of nurse satisfaction and loyalty. Health Marketing Quarterly, 23(4), 75–108. Ringrose, R., Houterman, S., Koops, W., & Oei, G. (2009). Burnout in medical residents: a questionnaire and interview study. Psychology, Health and Medicine, 14(4), 476–486. Taormina, R.J., & Law, C.M. (2000). Approaches to preventing burnout: the effects of personal stress management and organizational socialization. Journal of Nursing Management, 8, 89–99. Taunton, R.L., Bott, M.J., Koehn, M.L., Miller, P., Rindner, E., Pace, K. et al. (2004). The NDNQI-adapted index of work Satisfaction. Journal of Nursing Management, 12(2), 101–122. Wang, Y., Wei, S., Li, Y., Deng, S., Luo, Q., & Li, Y. (2013). Challenges and a response strategy for the development of nursing in China: a descriptive and quantitative analysis. Journal of Evidence-Based Medicine, 6, 21–33. Wu, H., Sun, W., & Wang, L. (2012). Factors associated with occupational stress among Chinese female emergency nurses. Emergency Medical Journal, 29(7), 554–558. doi:10. 1136/emj.2010.094391. Xie, Z., Wang, A., & Chen, B. (2010). Nurse burnout and its association with occupational stress in a cross-sectional study in Shanghai. Journal of Advanced Nursing, 67(7), 1537–1546. You, M., Aiken, L.H., Sloane, D.M., Liu, K., He, G., Hu, Y. et al. (2013). Hospital nursing, care quality and patient satisfaction: cross-sectional surveys of nurses and patients in hospitals in China and Europe. International Journal of Nursing Studies, 50, 154–161. Yun, H., Shen, J., & Jiang, A. (2010). Nursing shortage in China: state, causes, and strategy. Nursing Outlook, 58, 122–128.
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Nurse Satisfaction and Burnout in Shanghai Neurology Wards Hui Jiang1, *, PhD, RN, Chen Li2, *, PhD, Yan Gu1, BSN, RN & Haiyan Lu1, BSN, RN 1 Nursing Department, Shanghai East Hospital, Tongji University School of Medicine, Shanghai, China 2 College of Humanities and Social Science, Shanghai University, Shanghai, China
Keywords
Abstract
Burnout; China; Maslach Burnout Inventory; nurses; neurology ward; questionnaire survey; satisfaction. Correspondence Hui Jiang, Deputy Nursing Director of Shanghai East Hospital, Tongji University School of Medicine, No. 150, Jimo Road, Pudong New Area, Shanghai 200120, China. E-mail:[email protected] *These authors contributed equally to this work. Accepted May 31, 2014. doi: 10.1002/rnj.174
Purpose: To explore satisfaction and burnout of nurses working in neurology wards in Shanghai, China. Design: A descriptive cross-sectional questionnaire survey. Methods: Three hundred and eighty-seven nurses from 23 neurology wards in 21 tertiary general hospitals were recruited using cluster sampling. The valid response rate was 94.83%. Findings: Nurse satisfaction with the salary/wages, the job and the nurse staffing level were 21.79%, 37.33%, and 40.87%. A high nurse burnout rate was found as: emotional exhaustion (EE) ≥ 27 (89.92%); depersonalization (DP) ≥ 10 (92.64%); and reduced personal accomplishment (PA)≤ 33 (79.29%). Conclusions: Most nurses in the neurology wards were dissatisfied and had high levels of burnout. Experienced, intermediate and senior nurses were at the highest risk for job turnover. Clinical Relevance: Nurse administrators should take effective measures to increase nurse satisfaction and decrease burnout to retain experienced nurses and keep the stability of nursing workforce.
Introduction Nursing is a profession that requires a person to have ability, compassion, and dedication to patient caregiving, which must be provided 24 hours per day (Marjorie & Alice, 2010). The work performance of nurses undoubtedly influences outcomes for both patients and hospitals (Clark, 2009). However, in the current medical system, as patient acuity and complexity increase, the nursing staff must assume a heavy burden of duties to meet the requirements for high-quality nursing care and to address the nursing shortage and the high turnover rate. Nursing shortage is expected to become even more critical in the future, as the total demand for nurses outpaces the number of nurses entering the workforce in many countries (Peltier, Pointer, & Schibrowsky, 2006). There are several reports that nurse satisfaction and burnout are closely related to nurse retention (Aiken, Clarke, Sloane, Sochalski, & Silber, 2002; Xie, Wang, & Chen, 2010). As job
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dissatisfaction and burnout increase, the likelihood of nurses leaving their employment setting increases, which will exacerbate the current shortage of nurses and result in poor patient outcomes (Hassmiller & Cozine, 2006). Therefore, nurse satisfaction and burnout status are critical issues that should become the major concerns for nurse administrators (McGlynn, Griffin, Donahue, & Fitzpatrick, 2012). Background Nurses are on the front line of hospital services in the healthcare sector. A hectic, fast-paced work environment, irregular work schedules, and specific work environments make nurses vulnerable to dissatisfaction and burnout (Xie et al., 2010). Nurse satisfaction reflects a positive affective orientation toward work and the organization, whereas nurse dissatisfaction reflects a negative affective orientation (Taunton et al., 2004). Satisfied employees © 2014 Association of Rehabilitation Nurses Rehabilitation Nursing 2016, 41, 120–127
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tend to be more productive, creative, and committed to their employer. Thus, nurse satisfaction is the most frequently cited factor in nurse turnover (Moumtzoglou, 2010). Nurse burnout has been used to describe the syndrome of exhaustion. According to Maslach, Schaufeli, and Leiter (2001), burnout is defined as continuous work pressure that is ineffectively handled and is comprised of the following three dimensions: emotional exhaustion (EE); depersonalization (DP); and reduced personal accomplishment (PA). The EE component represents the basic individual stress dimension of burnout. It also refers to feelings of being overextended and depleted of one’s emotional and physical resources. The DP component represents the interpersonal context dimension, which refers to a negative, callous, or excessively detached response to various aspects of the job. The PA component represents the self-evaluation dimension, which refers to feelings of incompetence and a lack of achievement and productivity at work. Burnout was associated with higher scores on the EE and DP subscales and a lower PA score (Beckstead, 2002). A high burnout score on the Maslach Burnout Inventory (MBI) is associated with a subjective lack of well-being and/or feelings of an inability to perform the job well (Ringrose, Houterman, Koops, & Oei, 2009), and leads to lower productivity and effectiveness (Leiter & Maslach, 2009). It is highly probable that nurse dissatisfaction and burnout, unless handled appropriately, will worsen the nursing shortage and reduce healthcare standards internationally (Lei, Hee, & Dong, 2010). The normative values of burnout published for nurses and physicians in the USA are 22.19, 7.12, and 36.53 for the EE, DP, and PA subscales, respectively (Maslach, Jackson, & Leiter, 1996). A study conducted in Hong Kong revealed that nurses in Hong Kong experience very high levels of burnout. With respect to EE and DP, the Hong Kong mean scores were 28.12 and 13.81, respectively. No significant difference existed between the mean PA scores of the Hong Kong nurses (mean = 38.80) and the U.S. sample (mean = 36.53; Taormina & Law, 2000). A comprehensive survey study conducted in the United States, Canada, England, Scotland, and Germany (Aiken et al., 2001) revealed that nurse dissatisfaction and burnout have become commonplace in developed countries and pose a threat to the healthcare system. Studies involving general nurses in China have found that the average burnout score for EE was 38.1, compared with 30.3 in Europe (You et al., 2013). Studies conducted in Shanghai showed that nurses had a high level of EE and DP, but a low level of PA at a tertiary © 2014 Association of Rehabilitation Nurses Rehabilitation Nursing 2016, 41, 120–127
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general hospital (Xie et al., 2010). Studies on nurse satisfaction and burnout have mainly focused on nurses working in general wards (Lu, Ruan, Xing, & Hu, 2013; Xie et al., 2010; You et al., 2013), the ICU (Li, Ruan, & Jiang, 2013), or the emergency department (Wu, Sun, & Wang, 2011). Nurse satisfaction and burnout in the neurology ward have not been studied. Therefore, there is a need for nurse administrators to understand the level of satisfaction and burnout in specific units to identify interventions that could maintain the size and professional longevity of the nurse workforce. Study Design Aims The purpose of this study was to evaluate nurse satisfaction and burnout from nurses working in neurology wards in Shanghai, China, and to determine measures to increase nurse satisfaction and decrease nurse burnout. These measures will ultimately be beneficial for alleviating the current nursing shortage and strengthening the quality of nursing care. Methods This study used a descriptive cross-sectional design with a structured questionnaire survey to investigate nurse satisfaction and burnout. Cluster sampling was used to recruit registered nurses from the neurology wards of all the tertiary general hospitals in Shanghai, which is a large city in China with approximately 23 million people that is faced with the challenges of an overcrowded population and a nursing shortage. A descriptive and comparative design was used for the data analysis. Setting and Participants All of the nurses working in the neurology departments in tertiary general hospitals in Shanghai were invited to participate. Altogether, nurses working in 23 neurology wards at all 21 tertiary general hospitals were recruited as participants. The inclusion criteria were as follows: (1) volunteering for the study and having no mental or psychological disorders; and (2) possessing a Practicing Nurse Certificate and working continuously in the Department of Neurology for ≥6 months. The exclusion criteria were as follows: head nurses; sick leave; maternity leave; absent due to vacation, or on continuing education leave.
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Study Instruments A self-reported questionnaire was used in this study. The survey questionnaire was developed by the research team based on a literature review and the purpose of the study. The questionnaire consisted of three parts: the demographics of the nursing staff, nurse satisfaction, and nurse burnout based on the MBI. All questions were written in simple Chinese. The demographic section included the name of the hospital, gender, age, marital status, education, years of work experience, and academic level. Nurse satisfaction was measured by three single questions with five response categories. The three questions were as follows: (1) Are you satisfied with your job? (2) Are you satisfied with your salary/wages? and (3) Are you satisfied with the current nurse staffing level in your ward? The respondents used a 5-point Likert-type response format, ranging from strongly dissatisfied to strongly satisfied (scored from 1 to 5) based on their feelings of satisfaction with each item. Twenty nurses from the neurology ward were recruited for the pilot study and the Cronbach’s alpha for this part (three items) was 0.82. The third section was the Chinese version of the MBI and included 22 items (EE, nine items; DP, five items; and PA, eight items) on a 7-point Likert scale (0, never; 1, a few times per year or less; 2, once per month or less; 3, a few times per month; 4, once per week; 5, a few times per week; and 6, every day). Nurses chose the proper response based on their own feelings of the frequency of burnout. Cronbach’s alpha for the 22 items was 0.84. Cronbach’s alpha for EE, DP, and PA was 0.85, 0.78, and 0.82, respectively, which showed good internal consistency for the questionnaire (Lu et al., 2013). The level of burnout experienced was categorized as follows: for EE, ≥27 was high; for DP, ≥10 was high; and for PA, ≤33 was low (Maslach et al., 1996).
Data Collection The data were collected from September to November 2013. Permission was obtained from the nursing director of each hospital before the study commenced. Two investigators were trained by the researchers to give instructions to the participants and facilitate the distribution and collection of the questionnaires. The training included information on the research goals, sampling methods, and correct delivery and return process for the questionnaires. Nurses who met the eligibility criteria in the units were invited to participate in the study. An
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information sheet, which summarized the study’s purpose and methodology, was disseminated to the participants. The nurses were asked to complete the survey without consulting other staff. The completed surveys were placed in self-sealing envelopes by the participants, then placed into a sealed box on the unit. These strategies were designed to protect the privacy of the nurses and to increase the response rate. Subsequently, the nurse manager returned the sealed questionnaires to the investigator, who returned all sealed questionnaires to the principal researcher. All nurses on the selected wards were recruited. Ethical Considerations Institutional Review Board approval was obtained before the study. Informed consent was obtained from each hospital and each sampled nurse. To ensure rights and privacy, all participants were informed that the data emerging from the study would be kept confidential, that anonymity was assured, and that they could withdraw from the study without prejudice. Statistical analysis Statistical analyses were performed using SPSS (version 17.0 for Windows; SPSS, Inc., Chicago, IL, USA). Descriptive statistics were used to analyze the demographic characteristics of the participants and the nurse scores of satisfaction and burnout. Frequencies were described using means and standard deviations (SD), and comparisons between different groups were analyzed using single-factor analysis of variance (ANOVA). Twotailed tests of mean differences were used throughout, and the 0.05 level was used as the criterion for determining statistical significance. Results General Characteristics of the Participants Of the 410 available nurses, 387 agreed to participate and return the questionnaire, with 367 providing complete information on the questionnaire. The valid response rate of the survey was 94.83%. All 367 nurses who were surveyed were females, with an average age of 28.39 5.83 years and an average number of years working of 7.63 6.52 years. Their marital and obstetric statuses were as follows: 158 nurses (43.05%) were © 2014 Association of Rehabilitation Nurses Rehabilitation Nursing 2016, 41, 120–127
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unmarried; 70 nurses (19.07%) were married, but without children; and 139 nurses (37.87%) were married with children. The years of working in nursing were: ≤4 years, 165 nurses (44.96%); 5–9 years, 102 nurses (27.79%); and ≥10 years, 100 nurses (27.25%). The highest level of education achieved by the majority of the participants was an associate degree (237 [64.58%]), followed by a baccalaureate degree (92 [25.07%]) or a diploma (38 [10.35%]). The majority of nurses were at professional levels 1 and 2 (319 [86.92%]) followed by level 3 or above nurses (48 [13.08%]). Description of Nurse Satisfaction and Burnout Table 1 shows the means, range of score, standard deviations, satisfaction rates, and burnout rates for the variables used in the study. The mean nurse satisfaction scores were 3.23 (SD, 0.87), 3.31 (SD, 0.81), and 2.82 (SD, 0.91) for job, the nurse staffing level, and the salary/ wages, respectively. Satisfaction rate refers to the nurses who scored 5 (strongly satisfied) or 4 (satisfied). Table 1 shows that satisfaction with the salary/wages was the lowest (21.79%), followed by satisfaction with the job (37.33%) and the nurse staffing level (40.87%). The ranges of the burnout score were from 0–54 for EE; 0–30 for DP and 0–48 for PA. The mean nurse burnout scores were EE, 36.35 (SD, 8.64); DP, 17.59 (SD, 5.62); PA 28.56 (SD, 7.28). A high nurse burnout rate was calculated, as follows: EE ≥ 27 (89.92%); DP ≥ 10 (92.64%); and PA ≤ 33 (79.29%). Comparative Analysis Among Different Groups The nurses were classified into three groups according to their years of work experience, the highest nursing educa-
tion level, and professional level. As shown in Table 2, among the three satisfaction items, there were no significant differences in two satisfaction items (the nurse staffing level and the salary/wages) in the different work experience, educational, and professional level groups. In addition, there were no significant differences in satisfaction with the job among the different educational levels. There were significant differences in job satisfaction among nurses with different levels of work experience and at different professional levels (p < 0.01). Least significant difference (LSD) analysis of the two groups indicated that nurses with more work experience and at higher professional levels have lower satisfaction with jobs. As shown in Table 3, there were no significant differences in the DP and PA scores among the three different groups. There were no significant differences in the EE subscale scores among nurses with different educational levels; however, there were significant differences in the burnout EE scores among the nurses with different levels of work experience and at different professional levels (p < 0.05). Discussion In the current medical system, the nursing model has changed from disease- to patient-oriented, and requires nurses to provide holistic biopsychosocial–spiritual highquality nursing care to meet patients’ expectations and demands (Nathenson, 2012; Lei et al., 2010). Nurse satisfaction and burnout have been identified as key factors to retain qualified nurses and secure the nursing care quality (Lu, While & Barriball, 2007). In China, since the introduction of China’s open-door policy in the 1980s, big changes have occurred in nursing to meet the increasing healthcare demands for the massive population. Hospitals
Table 1 Description of Nurse Satisfaction and Burnout Mean Nurse satisfaction Satisfaction with job Satisfaction with nurse staffing Satisfaction with salary/wages MBI nurse burnout Emotional exhaustion Depersonalization Lack of personal accomplishment
Range of Score
SD
Satisfaction Rate, n (%)
3.23 3.31 2.82
1–5 1–5 1–5
0.870 0.805 0.907
137 (37.33%) 150 (40.87%) 80 (21.79%)
36.35 17.59 28.56
0–54 0–30 0–48
8.64 5.62 7.28
– – –
Burnout Rate, n (%) – – – 330 (89.92%) 340 (92.64%) 291 (79.29%)
Note: The satisfaction rate is the rate of the combination of the survey answers “strongly satisfied” and “satisfied.” The burnout rate is the rate of a high burnout score.
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Table 2 Comparative Analysis of Nurse Satisfaction Among Different Nurse Groups F-value p-value
Satisfaction With Staffing Level (Mean SD)
F-value p-value
165 102 100
3.30 0.77 3.40 0.85 2.97 0.98
7.325 0.001
3.30 0.81 3.47 0.73 3.20 0.85
3.006 0.051
2.81 0.90 2.94 0.86 2.71 0.95
1.690 0.186
38 237 92
3.36 0.76 3.13 0.91 3.25 0.78
1.420 0.247
3.42 0.73 3.27 0.83 3.39 0.70
1.031 0.358
2.89 0.919 2.78 0.880 2.89 0.973
0.497 0.685
158 161 48 367
3.33 3.12 2.74 3.23
n Work experience 4 years or below 5–9 years ≥10 years Educational background Diploma Associate degree Baccalaureate degree or above Professional level Level 1 Level 2 Level 3 and above Total
Satisfaction With Salary/Wages (Mean SD)
Satisfaction With Job (Mean SD)
0.78 0.84 1.23 0.87
6.374 0.000
3.32 3.30 3.30 3.31
0.78 0.76 1.20 0.81
2.82 0.863 2.79 0.909 2.90 1.055 2.82 0.91
0.013 0.987
F-value p-value
0.284 0.753
Note: LSD analysis of two groups: 4 years or below* ≥10 years, p < 0.01; 5–9 years*10 years, p < 0.01; level 1*level 3 and above, p < 0.01; level 2*level 3 and above, p < 0.01. Table 3 Comparative Analysis of Nurse Burnout Among Different Nurse Groups
Work experience 4 years or below 5–9 years ≥10 years Educational background Diploma Associate degree Baccalaureate degree or above Professional level Level 1 Level 2 Level 3 and above Total
n
Burnout EE (Mean SD)
F-value p-value
Burnout DP (Mean SD)
F-value p-value
Burnout PA (Mean SD)
F-value p-value
165 102 100
35.62 8.69 35.44 9.25 38.30 7.68
3.921 0.021
17.77 5.72 17.18 6.17 17.69 4.92
0.372 0.690
28.39 7.32 28.41 8.01 28.94 6.51
0.214 0.808
38 237 92
36.75 11.56 36.98 7.56 35.64 8.85
0.600 0.615
16.19 6.92 18.12 5.10 17.59 5.84
1.432 0.233
27.06 9.03 28.90 6.37 28.74 8.05
1.189 0.314
158 161 48 367
35.08 37.42 38.40 36.35
9.32 8.12 6.49 8.64
4.230 0.015
17.54 17.50 19.33 17.59
5.96 5.42 4.76 5.62
1.892 0.152
28.07 28.64 30.21 28.56
7.78 7.08 6.16 7.28
1.446 0.237
Note: LSD analysis of two groups: 4 years or below* ≥10 years, p < 0.05; 5–9 years * ≥10 years, p < 0.05; level 1*level 2, p < 0.05; level 1 *level 3 and above, p < 0.01.
in China are classified into three grades, based on the facility, equipment, and staffing. The higher the grade, the more sophisticated the facility. Tertiary hospitals are usually located in large cities and referred to as general hospitals (Xie et al., 2010). Currently, there are five levels of nursing education (diploma program, associate program, baccalaureate degree, master’s degree, and PhD degree; Liu et al., 2011) and five levels of professional academic titles for nurses stratified as junior (levels 1 and
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2), intermediate (level 3), and advanced (levels 4 and 5), in accordance with their educational background, ability in nursing service, and experience in nursing practice (Hui, Wenqin, & Yan, 2013; Yun, Shen, & Jiang, 2010). Although in China the baccalaureate degree level of education began in 1983, the master’s degree level of education in 1994, and the PhD degree level of education in 2004, the nursing workforce with high educational background still account for a small percentage of the nursing © 2014 Association of Rehabilitation Nurses Rehabilitation Nursing 2016, 41, 120–127
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workforce and these nurses are mainly in the fields of teaching, management, and research. The majority of the front line clinical nurses are still educated at the associate degree level (Wang et al., 2013; Yun et al., 2010). The benchmarks of levels 4 and 5 set high and strict criteria which resulted in a limited number of nurses achieving career advancement. The nurse staffing model in China uses the 1:0.4 bed-to-nurse ratio or the 1:8 nurse-topatient ratio for general inpatient units to allocate the nursing staff in comparison with the 1:5 mandatory nurse-to-patient ratio in California (USA) and the 5:20 staffing model in Victoria, Australia; (Chapman, Spetz, & Seago, 2009; Gerdtz & Nelson, 2007). Although nurses are the vital front line staff, their salary/wages remain the lowest among the medical work group (physicians and technicians). The heavy workload, inadequate nurse staffing, low salary/wages, physician-dominated work environment, and regular night shift made nursing unpopular career in China, except for the easy employment opportunities. Employment turn over for nurses is quite easy, especially experienced senior nurses (Lei et al., 2010). Clinical front line nurses were mainly at a young age and junior level (Wang et al., 2013). Our study findings also clearly demonstrate that the current nursing workforce in the inpatient neurology wards in Shanghai, China, is mainly composed of young, junior, and associate degree nurses and mainly junior level 1 or 2. The nurses in the neurology wards were dissatisfied with the salary/wages, the job, and the nurse staffing, and the majority of the nurses expressed excessive burnout rates and burnout scores. Based on the statistical analysis in our study, experienced level 3 nurses were less satisfied with their job and expressed more burnout in their work than did the younger junior nurses; a possible reason for this observation may be that this group of nurses account for a small proportion of nurses in the ward, however they possess rich experiences in handling challenging situations, and very often these nurses are needed to supervise the junior nurses. The experienced intermediate and senior nurses also have more responsibility for patient safety and quality of nursing care, in addition to their usual work assignments and rotate shifts with the junior nurses. There is major concern that the number of experienced nurses with professional titles may gradually decrease as a result of the heavy responsibilities they shoulder which is contributing to their burnout and dissatisfaction with their job. The erosion of experienced nurses will lead to insufficient professional capability and limits the development of nurses, which then will impact © 2014 Association of Rehabilitation Nurses Rehabilitation Nursing 2016, 41, 120–127
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the quality of the nursing service. Therefore, the development of relevant solutions to ensure nurse satisfaction and reduce nursing burnout could play a crucial role in fostering nurse retention and secure the stability of the nursing workforce. To meet the challenges of nurse turnover, efforts to retain senior registered nurses are needed to ensure that a sufficient number of experienced registered nurses are available to mentor younger nurses in the future. Nurse administrators need to examine factors, such as income level, staffing level, and work environment, to improve the nurse staffing level, change the status of work overload, design an effective, rational salary structure and payment model, and create career development programs for nurses that can increase nurse satisfaction and decrease nurse burnout. These measures will play a vital role to increase nurse satisfaction and alleviate nurses’ burnout to help nurse retention and improve the quality of nursing service. Clinical Relevance The nursing workforce in neurology wards is closely related to the patient rehabilitation process. The inpatient neurology wards admit patients with a diagnosis of acute cerebral infarction, acute cerebral hemorrhage, or transient ischemic attack (TIA); other than the symptoms of the disease, most of these patients have additional symptoms and needs, such as high blood pressure, consciousness disorders, self-care deficiencies, movement deficiencies, Ryle’s feeding tubes, urinary catheters, and most require rehabilitation care in addition to the treatment programs. With the instruction and help from professional, experienced nurses, patients can gain the maximum level of wellness and achieve their optimal level of functioning. The nurse satisfaction and burnout results in this study indicated that nurses are not satisfied with the pay, the job, or the nurse staffing level, and that most nurses have high burnout, while working in a neurology ward. Thus, improving nurse satisfaction and decreasing nurse burnout will be very important to keep the stability of the nursing workforce, secure the quality and promote patient recovery. Conclusion Nurse satisfaction and burnout are important issues in nursing. This study highlights the need for careful evaluation of the situation of Chinese nurses, with an eye for the retention of skilled senior nurses. Nurse staffing in
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Key Practice Points Nurse satisfaction and burnout are the main indicators for nurse retention, but the issue on specific neurology wards has not been studied. This research revealed that nurses working in neurology wards are not satisfied with the pay, the job, and nurse staffing, and most of the nurses had high burnout. More alarming is the findings that experienced, qualified senior nurses in neurology wards are less satisfied and have more burnout in their jobs, which may lead to a higher tendency for turnover. The stability of nursing workforce in neurology wards plays a key role in patient rehabilitation. Therefore, nurse administrators need to pay close attention to the stability and quality of the nursing workforce.
China is inadequate. The mix of nurses, regardless of educational background, work experience, and academic level, is not sufficient to meet present and future challenges to nursing. Nurses are not satisfied with their job, nurse staffing, or payment. In this study, the majority of nurses in neurology wards met the criteria for high burnout. Clearly, this is an alarming result that must be taken seriously. More concerning is the high burnout rates for the experienced nurses and the impact of losing such wealth and resource. Finding ways to increase nurse satisfaction and decrease nurse burnout is in the best interest of healthcare system. Nursing administrators should pay more attention to the status of nurse satisfaction and burnout, initiate proposals for programs to alleviate the stress of hospital work, and help nurses to be more engaged with their jobs by providing more opportunities for training and education for nurses, increasing the nurse staffing level, enhancing nursing autonomy, and empowering intermediate and senior nurses to reduce nurse turnover. The greater the scope and variety of a nurse’s coping strategies, the better the chance of improving nurse satisfaction, and reducing nurse burnout. Therefore, nurses’ work engagement, nursing care quality, and the rehabilitation process will be improved. Limitations There were some limitations to this study. The study was conducted on the neurology wards of tertiary general hospitals in the highly developed and densely populated city of Shanghai. It may not be possible to generalize the
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results to other wards, other hospitals, nor other locations in China. A significantly larger sample size will be needed to better understand the nurse satisfaction and burnout status in China. Acknowledgments The authors are grateful to all of the participating nurses for their involvement, to the research nurses for data collection, and to the directors of the nursing departments for their cooperation. The authors thank the Department of Health in Pudong for the funding support for this project. The views expressed in this article are those of the authors. Conflict of Interest: The authors declare there were no conflicts of interest with respect to this publication. Author Contributions: Hui Jiang was responsible for all aspects of the research study, including conceptualization of the design, data collection, analysis, drafting, and revision of manuscript. Chen Li assisted with the design of the research and drafting of the manuscript revisions. Yan Gu participated in the numerous revisions of the manuscript. Haiyan Lu assisted with interpretation and formatting the presentation of the results. Funding: This project was funded by Scientific Development Research Funds founded by Pudong New Area Health Bureau, Grant-in-Aid No. PW2012A-3. References Aiken, L.H., Clarke, S.P., Sloane, D.M., Sochalski, J.A., Busse, R., Clarke, H. et al. (2001). Nurses’ reports on hospital care in five countries. Health Affairs (Millwood), 20(3), 43–53. Aiken, L.H., Clarke, S.P., Sloane, D.M., Sochalski, J., & Silber, J.H. (2002). Hospital nurse staffing and patient mortality, nurse burnout, and job dissatisfaction. JAMA. Journal of the American Medical Association, 288(16), 1987–1993. Beckstead, J.W. (2002). Confirmatory factor analysis of the Maslach Burnout inventory among Florida nurses. International Journal of Nursing Studies, 39, 785–792. Chapman, S.A., Spetz, J., & Seago, J.A. (2009). How have mandated nurse staffing ratios affected hospitals? Perspectives from California hospital leaders. Journal of Healthcare Management, 54(5), 321–335. Clark, P.R. (2009). Teamwork, building healthier workplaces and providing safer patient care. Critical Care Nursing Quarterly, 32(3), 221–231. © 2014 Association of Rehabilitation Nurses Rehabilitation Nursing 2016, 41, 120–127
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