Community Ment Health J DOI 10.1007/s10597-014-9818-4
BRIEF COMMUNICATION
Predictors of Burnout Among Nurses in Taiwan Huan-Fang Lee • Miaofen Yen • Susan Fetzer Tsair Wei Chien
•
Received: 10 January 2014 / Accepted: 10 December 2014 Ó Springer Science+Business Media New York 2014
Abstract Nurse burnout is a crucial issue for health care professionals and impacts nurse turnover and nursing shortages. Individual and situational factors are related to nurse burnout with predictors of burnout differing among cultures and health care systems. The predictors of nurse burnout in Asia, particularly Taiwan, are unknown. The purpose of this study was to investigate the predictors of burnout among a national sample of nurses in Taiwan. A secondary data analysis of a nationwide database investigated the predictors of burnout among 1,846 nurses in Taiwan. Hierarchical regression analysis determined the H.-F. Lee Department of Nursing, Institute of Allied Health Sciences, National Cheng Kung University, Tainan City, Taiwan H.-F. Lee Nursing Department, Chi-Mei Medical Center, Tainan City, Taiwan M. Yen (&) Department of Nursing, National Cheng Kung University, Tainan City, Taiwan e-mail: [email protected] M. Yen Institute of Allied Health Sciences, National Cheng Kung University, Tainan City, Taiwan S. Fetzer Department of Nursing, University of New Hampshire, Durham, NC, USA T. W. Chien Business Management Department, Chi Mei Medical Center, Tainan City, Taiwan T. W. Chien Chia Nan University of Pharmacy and Science, Tainan City, Taiwan
relationship between predictors and burnout. Predictors of Taiwanese nurse burnout were age, physical/psychological symptoms, job satisfaction, work engagement, and work environment. The most significant predictors were physical/psychological symptoms and work engagement. The variables explained 35, 39, and 18 % of the emotional exhaustion, personal accomplishment, and depersonalization variance for 54 % of the total variance of burnout. Individual characteristics and nurse self-awareness, especially work, engagement can impact Taiwanese nurses’ burnout. Nurse burnout predictors provide administrators with information to develop strategies including education programs and support services to reduce nurse burnout. Keywords
Burnout Nurse Predictors
Introduction Burnout is far more common among healthcare workers than among other professional groups (Iglesias et al. 2010; Spence Laschinger et al. 2009). Nurse burnout leads to predicted turnovers that result in manpower shortages and crucial staffing issues. In Taiwan, with nearly 40 % of the nation’s nurses not practicing, 89 % of hospitals surveyed reported that it was difficult to recruit nurses (Lu 2013). Jourdain and Chenevert (2010) have noted that burnout within the nursing profession is an especially important factor when there is a shortage of nurses. Nurse burnout has been investigated since the 1970s in Western countries. However, only two studies have investigated nurse burnout in Taiwan. Hsieh et al. (2004) explored the relationships between characteristics, coping strategies, and burnout among 147 psychiatric nurses. However, both studies of Taiwanese nurses used limited
123
Community Ment Health J
samples and failed to identify predictors of burnout. Researchers have suggested that larger sample sizes, expanding the data collection area, and exploring different working environments are needed to investigate burnout differences across health care systems and countries (Lin et al. 2009; Maslach et al. 2001). Burnout is defined as experiencing a state of emotional exhaustion similar to the extinguishing of a candle. According to Maslach (1982), consisting of three dimensions: emotional exhaustion, depersonalization, and a reduced sense of personal accomplishment. Emotional exhaustion occurs when individuals overextend themselves and feel emotionally overwhelmed. Depersonalization refers to treating the patient as an object with an attitude of indifference. A reduced sense of personal accomplishment occurs when individuals think of themselves negatively, consider themselves failures, and believe themselves to be inadequate in work-related situations. According to Maslach et al. (2001), individual factors, including age, marital status, and length of employment, in addition to situational factors including hospital type and work unit, can affect nurse burnout. Nurse self-awareness has also been found to be related to burnout, including physical/psychological symptoms, work environment, job satisfaction, and work engagement (Gonza´lez-Roma´ et al. 2006; Hanrahan et al. 2010; Kanai-Pak et al. 2008; Schaufeli and Bakker 2004; Weng et al. 2011). Age is the most consistent demographic variable related to burnout; however, reports have been inconsistent (Iglesias et al. 2010; Maslach et al. 2001; Poncet et al. 2007; Wang et al. 2010). Whitmer et al. (2009) indicated that problemsolving capacity and self-reliance are different between individuals born from 1965 to 1980 (generation X) and those born from 1981 to 2000 (generation Y). Generation X individuals who have stronger problem-solving capacities are more self-reliant. They work hard at their jobs and strive for work accomplishments. However, challenging workloads with family care responsibilities place them in stressful situations. Generation Y individuals have been cared for by overprotective parents. They expect immediacy and value speed more than accuracy. Researchers have reported that generation Y nurses experience burnout more frequently than do older nurses (Lin et al. 2009; Maslach et al. 2001; Meeusen et al. 2010; Poncet et al. 2007). Maslach et al. (2001) noted that work experience was confounded with age when evaluating burnout. The work experience of younger nurses is usually less than the experience of older staff. The relationship between burnout and age among Taiwanese nurses is unknown. Most studies have reported that critical care nurses experience higher levels of burnout (Cho et al. 2009; Poncet et al. 2007; Taylor and Barling 2004). However, the greatest percentages of nurses in hospitals practice in
123
general medical-surgical units. Aiken et al. (2002) found that nurses who work in general units have a high level of burnout because of higher patient-to-nurse ratios, failureto-rescue rates, and patient mortality. Nurses’ self-awareness of physical and psychological symptoms, work environment, job satisfaction, and work engagement has also been shown to be related to nurse burnout (Gonza´lez-Roma´ et al. 2006; Hanrahan et al. 2010; Korkeila et al. 2003; Weng et al. 2011). Physical and psychological symptoms, such as being tense and easily irritated, having difficulty sleeping, and experiencing feelings of helplessness and depression are similar to the characteristics of burnout (Hsu et al. 2010; Klersy et al. 2007; Poncet et al. 2007; Spence Laschinger and Leiter 2006). Korkeila et al. (2003) indicated that depression is associated with a high level of emotional exhaustion, with a reported odds ratio of 6.9. In summary, individual and situational factors can result in burnout and negative nurse self-awareness. Although research related to nurse burnout has been conducted in Western countries, a lack of understanding remains regarding burnout among nurses in Asia. The influence of these predictors among nurses in Taiwan is unknown. The aim of this study was to investigate the predictors of burnout among nurses across Taiwan.
Methods A secondary data analysis was conducted to investigate the predictors of burnout among nurses in Taiwan. The data were obtained from the NURSE-Outcomes study, a nationwide survey of nurse workload and patient outcomes in Taiwan conducted from 2008 to 2010. Description of the NURSE-Outcomes Database The NURSE-Outcomes study collected data using a proportional stratified random sample of the 483 hospitals in Taiwan. Thirty-five hospitals participated, including four medical centers, nine regional hospitals, and 22 district hospitals accredited by the Taiwan Joint Commission. The hospitals were stratified by geographic location as north or south. Of the 1,896 nurses invited to provide data, 1,846 completed questionnaires. Measurements Data from five instruments completed during the NURSEOutcomes were obtained. The Maslach Burnout Inventory– Human Service Survey (MBI–HSS)—Chinese version is a 20-item scale measuring burnout and was tested by Lee et al. (2013) on Taiwanese nurses. The 7-point Likert scale rates
Community Ment Health J
how often the subject experiences burnout, from never = 0 to every day = 6. Three subscales were used to measure emotional exhaustion (eight items), poor sense of personal accomplishment (eight items), and depersonalization (four items). In the Lee et al. (2013) study, the Cronbach’s a values were 0.85, 0.91, 0.86, and 0.65 for the total scale, emotional exhaustion, reduced personal accomplishment, and depersonalization, respectively, and the validity scores included a goodness of fit index (GFI) of 0.92, adjusted goodness of fit index (AGFI) of 0.90 and root mean square error of approximation (RMSEA) of 0.05. The Brief Symptom Rating Scale (BSRS-5)—Chinese version developed by Lee et al. (2003) uses five items to screen physical/psychological symptoms on a 5-point scale, ranging from 1 = never to 5 = very serious, with higher scores indicating poorer physical and psychological health status. The Cronbach’s a values reported by Lee et al. (2003) ranged from 0.77 to 0.90. The Mueller/McCloskey Satisfaction Scale (MMSS) measures nurses’ job satisfaction on a 5-point scale over eight domains: satisfaction with extrinsic rewards, scheduling, family/work balance, coworkers, interaction, professional opportunities, praise/recognition, and control/ responsibility (Mueller and McCloskey 1990). The Chinese version uses a scale from 1 = never satisfied to 5 = very satisfied, with a reported Cronbach’s a of 0.89 (Li et al. 2002). The Utrecht Work Engagement Scale (UWES-9) measures the work-related state of fulfillment and consists of nine items used to assess work engagement (Schaufeli et al. 2006). The 7-point scale ranges from 1 = never to 7 = very serious, with a higher score reflecting greater engagement. The original Cronbach’s a was 0.92 (Schaufeli et al. 2006), and the value in the current study was 0.91. The Nursing Work Index-Revised (NWI-R) (Aiken and Patrician 2000) measures the practice environment on four dimensions. A 4-point Likert scale is used to measure selfawareness of work environment, from 1 = never agree to 4 = agree totally, with higher scores indicating positive self-awareness. The original Cronbach’s a was from 0.84 to 0.97 (Aiken and Patrician 2000). For the current study, only 15 items from three dimensions, autonomy, control over practice, and doctor-nurse relationships, were analyzed with Cronbach’s a from 0.80 to 0.87.
variables and burnout, a two-step hierarchical regression analysis was performed. In step 1, the demographic variables were entered; the nurse self-awareness variable was entered in step 2. The ‘tolerance’ value was used to check the collinarity problem. The value of tolerance in the current study was closed to one, indicating there was no collinarity problem (Wu 2009). The data were analyzed using the Statistical Package for the Social Sciences (Version 17) (SPSS/IBM Inc., Chicago, IL, USA).
Results 98 % (n = 1,814) of the 1,846 nurses were female, and 74 % (n = 1,372) were unmarried. The mean subject age was 29 years (SD 5.26). There was nearly equal representation from northern and southern Taiwan. Half of the subjects (n = 938, 50.8 %) practiced in medical units. Nurses who worked in regional or district hospitals (p \ 0.001) and in northern Taiwan (p = 0.002) reported lower levels of personal accomplishment. There were no significant differences in the burnout subscales with respect to the area of practice or gender. The nurses who were not married had higher scores on the three burnout subscales, indicating they experienced higher levels of burnout. Except for age and NWI-R score, there were significant correlations among all variables (p \ 0.001). Physical/ psychological symptoms were the highest correlate of emotional exhaustion (r = 0.48); work engagement was the highest correlate of personal accomplishment and depersonalization (r = -0.615, r = -0.326, respectively). Work engagement was the variable most strongly correlated with the total burnout score among variables related to nurse self-awareness (r = -0.633). The significant categorical and continuous variables were included in the linear regression model to predict total burnout and the subscales of emotional exhaustion, personal accomplishment, and depersonalization. The explained variances were 54, 35, 39, and 18 %, respectively. Work engagement explained the greatest variance in the total burnout score; personal accomplishment, depersonalization, and physical/psychological symptoms explained the most variance in emotional exhaustion.
Statistical Analyses
Discussion
Descriptive statistics were used to describe subject characteristics. Differences were examined using t tests or analysis of variance (ANOVA). Pearson correlations were used to examine the association among continuous data. To investigate the relationship between all significant
Among the Taiwanese nurses in this study, geographical location, hospital type, marital status, and age were significantly related to burnout. Age was negatively related to burnout, with younger nurses reporting greater burnout than older nurses. These findings are similar to those of
123
Community Ment Health J
previous studies (Maslach et al. 2001; Meeusen et al. 2010; Poncet et al. 2007). The mean age of nurses in the current study represented generation Y individuals. The differences between unmarried and married nurses’ burnout subscale scores were significant; however, the mean scores differed only slightly (range 1–2.9 points). Therefore, it was expected that marital status would not be significant in step 2 of the hierarchical regression. The significant mean difference in scores may have been due to the large sample size. Physical/psychological symptoms were the strongest predictor of emotional exhaustion in this nationwide sample. The findings were similar to those of Van der Doef et al. (2012), who noted that East African nurses who reported having more somatic complaints also reported more emotional exhaustion. Therefore, chronic environmental stressors in the workplace may contribute to physical/psychological symptoms such as anxiety, insomnia, and depression, and these symptoms contribute to emotional exhaustion. A strong positive correlation was identified between work engagement and a sense of personal accomplishment. Work engagement has been considered the opposite of burnout and a protective factor against burnout (Prins et al. 2010; Schaufeli et al. 2002). The current study supports the findings of other studies (Demerouti et al. 2010; Prins et al. 2010) that noted that individuals with more engagement had higher personal accomplishment. When work engagement is low, there is little opportunity for personal or professional accomplishment. Therefore, the lack of accomplishment leads to less desire for work engagement. Work engagement explained the most variance in burnout, personal accomplishment, and depersonalization among nurses in Taiwan. These findings are consistent with those of previous studies of European and South African nurses, who also had higher burnout scores with less work engagement (Demerouti et al. 2010; Prins et al. 2010).
Conclusions Personal characteristics can be used to predict nurse burnout among Taiwanese nurses. Younger nurses with compromised physical/psychological symptoms are at risk of emotional exhaustion. Work engagement is a strong predictor of a sense of personal accomplishment. Strategies are needed to improve physical/psychological symptoms and work engagement among nurses in Taiwan to avoid burnout. Acknowledgments This study was funded by the Department of Health, Executive Yuan, R. O. C. (TAIWAN) (DOH099-TD-M-11397025).
123
Ethical Standard This study was received ethical approval from National Cheng Kung University Hospital review board (No. 96E6245).
References Aiken, L. H., & Patrician, P. A. (2000). Measuring organizational traits of hospitals: The revised nursing work index. Nursing Research, 49(3), 146–153. doi:10.1097/00006199-20000500000006. 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. Journal of the American Medical Association, 288(16), 1987–1993. doi:10.1001/jama. 288.16.1987. Cho, S. H., June, K. J., Kim, Y. M., Cho, Y. A., Yoo, C. S., Yun, S. C., & Sung, Y. H. (2009). Nurse staffing, quality of nursing care and nurse job outcomes in intensive care units. Journal of Clinical Nursing, 18(12), 1729–1737. doi:10.1111/j.1365-2702. 2008.02721.x. Demerouti, E., Mostert, K., & Bakker, A. B. (2010). Burnout & work engagement: A thorough investigation of the independence of both constructs. Journal of Occupational Health Psychology, 15(3), 209–222. doi:10.1037/a0019408. Gonza´lez-Roma´, V., Schaufeli, W. B., Bakker, A. B., & Loret, S. (2006). Burnout & work engagement: Independent factors or opposite poles? Journal of Vocational Behavior, 68(1), 165–174. doi:10.1016/j.jvb.2005.01.003. Hanrahan, N. P., Aiken, L. H., McClaine, L., & Hanlon, A. L. (2010). Relationship between psychiatric nurse work environments & nurse burnout in acute care general hospitals. Issues in Mental Health Nursing, 31(3), 198–207. doi:10.3109/0161284090 3200068. Hsieh, C. J., Hsieh, H. Y., Chen, P. H., Hsiao, Y. L., & Lee, S. (2004). The relationship between hardiness, coping strategies & burnout in psychiatric nurses. The Journal of Nursing, 51(3), 24–33. Hsu, H. Y., Chen, S. H., Yu, H. Y., & Lou, J. H. (2010). Job stress, achievement motivation & occupational burnout among male nurses. Journal of Advanced Nursing, 66(7), 1592–1601. doi:10. 1111/j.1365-2648.2010.05323.x. Iglesias, M. E. L., Vallejo, R. B., & Fuentes, P. S. (2010). The relationship between experiential avoidance & burnout syndrome in critical care nurses: A cross-sectional questionnaire survey. International Journal of Nursing Studies, 47(1), 30–37. doi:10.1016/j.ijnurstu.2009.06.014. Jourdain, G., & Chenevert, D. (2010). Job demands-resources, burnout and intention to leave the nursing profession: A questionnaire survey. International Journal of Nursing Studies, 47(6), 709–722. doi:10.1016/j.ijnurstu.2009.11.007. Kanai-Pak, M., Aiken, L. H., Sloane, D. M., & Poghosyan, L. (2008). Poor work environments & nurse inexperience are associated with burnout, job dissatisfaction & quality deficits in Japanese hospitals. Journal of Clinical Nursing, 17(24), 3324–3329. doi:10.1111/j.1365-2702.2008.02639.x. Klersy, C., Callegari, A., Martinelli, V., Vizzardi, V., Navino, C., Malberti, F., Tarchini, R., Montagna, G., Guastoni, C., Bellazzi, R., Rampino, T., David, S., Barbieri, C., Dal Canton, A., Politi, P. Working Group on Burnout, & Dialysis. (2007). Burnout in health care providers of dialysis service in Northern Italy—A multicentre study. Nephrology Dialysis Transplantation, 22, 2283–2290. doi:10.1093/ndt/gfm111. Korkeila, J. A., To¨yry, S., Kumpulainen, K., Toivola, J., Ra¨sa¨nen, K., & Kalimo, R. (2003). Burnout & self-perceived health among Finnish psychiatrists & child psychiatrists: A national survey.
Community Ment Health J Scandinavian Journal of Public Health, 31(2), 85–91. doi:10. 1080/14034940210133880. Lee, M. B., Liao, S. C., Lee, Y. J., Wu, C. H., Tseng, M. C., Gau, S. F., & Rau, C. L. (2003). Development & verification of validity & reliability of a short screening instrument to identify psychiatric morbidity. Journal of the Formosan Medical Association, 102(10), 687–694. Lee, H. F., Chien, T. W., & Yen, M. (2013). Examining factor structure of Maslach burnout inventory among nurses in Taiwan. Journal of Nursing Management, 21(4), 648–656. doi:10.1111/j. 1365-2834.2012.01427.x. Li, C. C., Tsay, S. L., Yip, P. K., & Su, H. F. (2002). Outcome of the clinical pathway for ischemic stroke patients. Formosan journal medicine, 6(5), 672–681. Lin, F., St John, W., & McVeigh, C. (2009). Burnout among hospital nurses in China. Journal of Nursing Management, 17(3), 294–301. doi:10.1111/j.1365-2834.2008.00914.x. Lu, M. S. (2013). The challenge & strategies of nursing managers in 21 country. The Fifth Membership Conference of TANP in Nongovernment HSOs. Taiwan, Taipei. Maslach, C. (1982). The cost of caring. Englewood Cliffs, NJ: Prentice-Hall Inc. Maslach, C., Schaufeli, W. B., & Leiter, M. (2001). Job burnout. Annual Review of Psychology, 52(1), 397–422. doi:10.1146/ annurev.psych.52.1.397. Meeusen, V., Van Dam, K., Brown-Mahoney, C., Van Zundert, A., & Knape, H. (2010). Burnout, psychosomatic symptoms & job satisfaction among Dutch nurse anaesthetists: A survey. The Acta Anaesthesiological Scandinavica Foundation, 54, 616–621. doi:10.1111/j.1399-6576.2010.02213.x. Mueller, C. W., & McCloskey, J. C. (1990). Nurses’ job satisfaction: A proposed measure. Nursing Research, 39(2), 113–117. Poncet, M. C., Toullic, P., Papazian, L., Kentish-Barnes, N., Timsit, J. F., Pochard, F., et al. (2007). Burnout syndrome in critical care nursing staff. American Journal of Respiratory and Critical Care Medicine, 175(7), 698–704. doi:10.1164/rccm.200606-806OC. Prins, J. T., Hoekstra-Weebers, J., Gazendam-Donofrio, S. M., Dillingh, G. S., Bakker, A. B., Huisman, M., et al. (2010). Burnout & engagement among resident doctors in the Netherlands: A national study. Medical Education, 44(3), 236–247. doi:10.1111/j.1365-2923.2009.03590.x. Schaufeli, W. B., & Bakker, A. B. (2004). Job demands, job resources & their relationship with burnout & engagement: A multi-sample
study. Journal of Organizational Behavior, 25(3), 293–315. doi:10.1002/job.248. Schaufeli, W. B., Salanova, M., Gonzalez-Roma, V., Bakker, A. B., & Alez-rom, V. G. (2002). The measurement of engagement & burnout: A two-sample confirmatory factor analytic approach. Journal of Happiness Studies, 3(1), 71–92. doi:10.1023/A: 1015630930326. Schaufeli, W. B., Bakker, A. B., & Salanova, M. (2006). The measurement of work engagement with a short questionnaire: A cross-national study. Educational and Psychological Measurement, 66(4), 701–716. doi:10.1177/0013164405282471. Spence Laschinger, H. K., & Leiter, M. P. (2006). The impact of nursing work environments on patient safety outcomes: The mediating role of burnout engagement. Journal of Nursing Administration, 36(5), 259–267. Spence Laschinger, H. K., Leiter, M., Day, A., & Gilin, D. (2009). Workplace empowerment, incivility, & burnout: Impact on staff nurse recruitment & retention outcomes. Journal of Nursing Management, 17(3), 302–311. doi:10.1111/j.1365-2834.2009. 00999.x. Taylor, B., & Barling, J. (2004). Identifying sources & effects of carer fatigue & burnout for mental health nurses: A qualitative approach. International Journal of Mental Health Nursing, 13(2), 117–125. doi:10.1111/j.1445-8330.2004.imntaylorb.doc.x. Van der Doef, M., Mbazzi, F. B., & Verhoeven, C. (2012). Job conditions, job satisfaction, somatic complaints & burnout among East African nurses. Journal of Clinical Nursing, 21, 1763–1775. doi:10.1111/j.1365-2702.2011.03995.x. Wang, L., Kang, Y. H., & Wu, D. (2010). A review of research & strategies for burnout among Chinese nurses. British Journal of Nursing, 19(13), 844–850. Weng, H. C., Hung, C. M., Liu, Y. T., Cheng, Y. J., Yen, C. Y., Chang, C. C., & Huang, C. K. (2011). Associations between emotional intelligence & doctor burnout, job satisfaction & patient satisfaction. Medical Education, 45, 835–842. doi:10. 1111/j.1365-2923.2011.03985.x. Whitmer, M., Hurst, S., & Prins, M. (2009). Intergenerational views of hardiness in critical care nurses. Dimensions of Critical Care Nursing, 28(5), 214–220. doi:10.1097/DCC.0b013e3181ac4b82. Wu, M. L. (2009). SPSS & the application and analysis of statistics. Taipei: Wu-Nan Book Inc.
123
BRIEF COMMUNICATION
Predictors of Burnout Among Nurses in Taiwan Huan-Fang Lee • Miaofen Yen • Susan Fetzer Tsair Wei Chien
•
Received: 10 January 2014 / Accepted: 10 December 2014 Ó Springer Science+Business Media New York 2014
Abstract Nurse burnout is a crucial issue for health care professionals and impacts nurse turnover and nursing shortages. Individual and situational factors are related to nurse burnout with predictors of burnout differing among cultures and health care systems. The predictors of nurse burnout in Asia, particularly Taiwan, are unknown. The purpose of this study was to investigate the predictors of burnout among a national sample of nurses in Taiwan. A secondary data analysis of a nationwide database investigated the predictors of burnout among 1,846 nurses in Taiwan. Hierarchical regression analysis determined the H.-F. Lee Department of Nursing, Institute of Allied Health Sciences, National Cheng Kung University, Tainan City, Taiwan H.-F. Lee Nursing Department, Chi-Mei Medical Center, Tainan City, Taiwan M. Yen (&) Department of Nursing, National Cheng Kung University, Tainan City, Taiwan e-mail: [email protected] M. Yen Institute of Allied Health Sciences, National Cheng Kung University, Tainan City, Taiwan S. Fetzer Department of Nursing, University of New Hampshire, Durham, NC, USA T. W. Chien Business Management Department, Chi Mei Medical Center, Tainan City, Taiwan T. W. Chien Chia Nan University of Pharmacy and Science, Tainan City, Taiwan
relationship between predictors and burnout. Predictors of Taiwanese nurse burnout were age, physical/psychological symptoms, job satisfaction, work engagement, and work environment. The most significant predictors were physical/psychological symptoms and work engagement. The variables explained 35, 39, and 18 % of the emotional exhaustion, personal accomplishment, and depersonalization variance for 54 % of the total variance of burnout. Individual characteristics and nurse self-awareness, especially work, engagement can impact Taiwanese nurses’ burnout. Nurse burnout predictors provide administrators with information to develop strategies including education programs and support services to reduce nurse burnout. Keywords
Burnout Nurse Predictors
Introduction Burnout is far more common among healthcare workers than among other professional groups (Iglesias et al. 2010; Spence Laschinger et al. 2009). Nurse burnout leads to predicted turnovers that result in manpower shortages and crucial staffing issues. In Taiwan, with nearly 40 % of the nation’s nurses not practicing, 89 % of hospitals surveyed reported that it was difficult to recruit nurses (Lu 2013). Jourdain and Chenevert (2010) have noted that burnout within the nursing profession is an especially important factor when there is a shortage of nurses. Nurse burnout has been investigated since the 1970s in Western countries. However, only two studies have investigated nurse burnout in Taiwan. Hsieh et al. (2004) explored the relationships between characteristics, coping strategies, and burnout among 147 psychiatric nurses. However, both studies of Taiwanese nurses used limited
123
Community Ment Health J
samples and failed to identify predictors of burnout. Researchers have suggested that larger sample sizes, expanding the data collection area, and exploring different working environments are needed to investigate burnout differences across health care systems and countries (Lin et al. 2009; Maslach et al. 2001). Burnout is defined as experiencing a state of emotional exhaustion similar to the extinguishing of a candle. According to Maslach (1982), consisting of three dimensions: emotional exhaustion, depersonalization, and a reduced sense of personal accomplishment. Emotional exhaustion occurs when individuals overextend themselves and feel emotionally overwhelmed. Depersonalization refers to treating the patient as an object with an attitude of indifference. A reduced sense of personal accomplishment occurs when individuals think of themselves negatively, consider themselves failures, and believe themselves to be inadequate in work-related situations. According to Maslach et al. (2001), individual factors, including age, marital status, and length of employment, in addition to situational factors including hospital type and work unit, can affect nurse burnout. Nurse self-awareness has also been found to be related to burnout, including physical/psychological symptoms, work environment, job satisfaction, and work engagement (Gonza´lez-Roma´ et al. 2006; Hanrahan et al. 2010; Kanai-Pak et al. 2008; Schaufeli and Bakker 2004; Weng et al. 2011). Age is the most consistent demographic variable related to burnout; however, reports have been inconsistent (Iglesias et al. 2010; Maslach et al. 2001; Poncet et al. 2007; Wang et al. 2010). Whitmer et al. (2009) indicated that problemsolving capacity and self-reliance are different between individuals born from 1965 to 1980 (generation X) and those born from 1981 to 2000 (generation Y). Generation X individuals who have stronger problem-solving capacities are more self-reliant. They work hard at their jobs and strive for work accomplishments. However, challenging workloads with family care responsibilities place them in stressful situations. Generation Y individuals have been cared for by overprotective parents. They expect immediacy and value speed more than accuracy. Researchers have reported that generation Y nurses experience burnout more frequently than do older nurses (Lin et al. 2009; Maslach et al. 2001; Meeusen et al. 2010; Poncet et al. 2007). Maslach et al. (2001) noted that work experience was confounded with age when evaluating burnout. The work experience of younger nurses is usually less than the experience of older staff. The relationship between burnout and age among Taiwanese nurses is unknown. Most studies have reported that critical care nurses experience higher levels of burnout (Cho et al. 2009; Poncet et al. 2007; Taylor and Barling 2004). However, the greatest percentages of nurses in hospitals practice in
123
general medical-surgical units. Aiken et al. (2002) found that nurses who work in general units have a high level of burnout because of higher patient-to-nurse ratios, failureto-rescue rates, and patient mortality. Nurses’ self-awareness of physical and psychological symptoms, work environment, job satisfaction, and work engagement has also been shown to be related to nurse burnout (Gonza´lez-Roma´ et al. 2006; Hanrahan et al. 2010; Korkeila et al. 2003; Weng et al. 2011). Physical and psychological symptoms, such as being tense and easily irritated, having difficulty sleeping, and experiencing feelings of helplessness and depression are similar to the characteristics of burnout (Hsu et al. 2010; Klersy et al. 2007; Poncet et al. 2007; Spence Laschinger and Leiter 2006). Korkeila et al. (2003) indicated that depression is associated with a high level of emotional exhaustion, with a reported odds ratio of 6.9. In summary, individual and situational factors can result in burnout and negative nurse self-awareness. Although research related to nurse burnout has been conducted in Western countries, a lack of understanding remains regarding burnout among nurses in Asia. The influence of these predictors among nurses in Taiwan is unknown. The aim of this study was to investigate the predictors of burnout among nurses across Taiwan.
Methods A secondary data analysis was conducted to investigate the predictors of burnout among nurses in Taiwan. The data were obtained from the NURSE-Outcomes study, a nationwide survey of nurse workload and patient outcomes in Taiwan conducted from 2008 to 2010. Description of the NURSE-Outcomes Database The NURSE-Outcomes study collected data using a proportional stratified random sample of the 483 hospitals in Taiwan. Thirty-five hospitals participated, including four medical centers, nine regional hospitals, and 22 district hospitals accredited by the Taiwan Joint Commission. The hospitals were stratified by geographic location as north or south. Of the 1,896 nurses invited to provide data, 1,846 completed questionnaires. Measurements Data from five instruments completed during the NURSEOutcomes were obtained. The Maslach Burnout Inventory– Human Service Survey (MBI–HSS)—Chinese version is a 20-item scale measuring burnout and was tested by Lee et al. (2013) on Taiwanese nurses. The 7-point Likert scale rates
Community Ment Health J
how often the subject experiences burnout, from never = 0 to every day = 6. Three subscales were used to measure emotional exhaustion (eight items), poor sense of personal accomplishment (eight items), and depersonalization (four items). In the Lee et al. (2013) study, the Cronbach’s a values were 0.85, 0.91, 0.86, and 0.65 for the total scale, emotional exhaustion, reduced personal accomplishment, and depersonalization, respectively, and the validity scores included a goodness of fit index (GFI) of 0.92, adjusted goodness of fit index (AGFI) of 0.90 and root mean square error of approximation (RMSEA) of 0.05. The Brief Symptom Rating Scale (BSRS-5)—Chinese version developed by Lee et al. (2003) uses five items to screen physical/psychological symptoms on a 5-point scale, ranging from 1 = never to 5 = very serious, with higher scores indicating poorer physical and psychological health status. The Cronbach’s a values reported by Lee et al. (2003) ranged from 0.77 to 0.90. The Mueller/McCloskey Satisfaction Scale (MMSS) measures nurses’ job satisfaction on a 5-point scale over eight domains: satisfaction with extrinsic rewards, scheduling, family/work balance, coworkers, interaction, professional opportunities, praise/recognition, and control/ responsibility (Mueller and McCloskey 1990). The Chinese version uses a scale from 1 = never satisfied to 5 = very satisfied, with a reported Cronbach’s a of 0.89 (Li et al. 2002). The Utrecht Work Engagement Scale (UWES-9) measures the work-related state of fulfillment and consists of nine items used to assess work engagement (Schaufeli et al. 2006). The 7-point scale ranges from 1 = never to 7 = very serious, with a higher score reflecting greater engagement. The original Cronbach’s a was 0.92 (Schaufeli et al. 2006), and the value in the current study was 0.91. The Nursing Work Index-Revised (NWI-R) (Aiken and Patrician 2000) measures the practice environment on four dimensions. A 4-point Likert scale is used to measure selfawareness of work environment, from 1 = never agree to 4 = agree totally, with higher scores indicating positive self-awareness. The original Cronbach’s a was from 0.84 to 0.97 (Aiken and Patrician 2000). For the current study, only 15 items from three dimensions, autonomy, control over practice, and doctor-nurse relationships, were analyzed with Cronbach’s a from 0.80 to 0.87.
variables and burnout, a two-step hierarchical regression analysis was performed. In step 1, the demographic variables were entered; the nurse self-awareness variable was entered in step 2. The ‘tolerance’ value was used to check the collinarity problem. The value of tolerance in the current study was closed to one, indicating there was no collinarity problem (Wu 2009). The data were analyzed using the Statistical Package for the Social Sciences (Version 17) (SPSS/IBM Inc., Chicago, IL, USA).
Results 98 % (n = 1,814) of the 1,846 nurses were female, and 74 % (n = 1,372) were unmarried. The mean subject age was 29 years (SD 5.26). There was nearly equal representation from northern and southern Taiwan. Half of the subjects (n = 938, 50.8 %) practiced in medical units. Nurses who worked in regional or district hospitals (p \ 0.001) and in northern Taiwan (p = 0.002) reported lower levels of personal accomplishment. There were no significant differences in the burnout subscales with respect to the area of practice or gender. The nurses who were not married had higher scores on the three burnout subscales, indicating they experienced higher levels of burnout. Except for age and NWI-R score, there were significant correlations among all variables (p \ 0.001). Physical/ psychological symptoms were the highest correlate of emotional exhaustion (r = 0.48); work engagement was the highest correlate of personal accomplishment and depersonalization (r = -0.615, r = -0.326, respectively). Work engagement was the variable most strongly correlated with the total burnout score among variables related to nurse self-awareness (r = -0.633). The significant categorical and continuous variables were included in the linear regression model to predict total burnout and the subscales of emotional exhaustion, personal accomplishment, and depersonalization. The explained variances were 54, 35, 39, and 18 %, respectively. Work engagement explained the greatest variance in the total burnout score; personal accomplishment, depersonalization, and physical/psychological symptoms explained the most variance in emotional exhaustion.
Statistical Analyses
Discussion
Descriptive statistics were used to describe subject characteristics. Differences were examined using t tests or analysis of variance (ANOVA). Pearson correlations were used to examine the association among continuous data. To investigate the relationship between all significant
Among the Taiwanese nurses in this study, geographical location, hospital type, marital status, and age were significantly related to burnout. Age was negatively related to burnout, with younger nurses reporting greater burnout than older nurses. These findings are similar to those of
123
Community Ment Health J
previous studies (Maslach et al. 2001; Meeusen et al. 2010; Poncet et al. 2007). The mean age of nurses in the current study represented generation Y individuals. The differences between unmarried and married nurses’ burnout subscale scores were significant; however, the mean scores differed only slightly (range 1–2.9 points). Therefore, it was expected that marital status would not be significant in step 2 of the hierarchical regression. The significant mean difference in scores may have been due to the large sample size. Physical/psychological symptoms were the strongest predictor of emotional exhaustion in this nationwide sample. The findings were similar to those of Van der Doef et al. (2012), who noted that East African nurses who reported having more somatic complaints also reported more emotional exhaustion. Therefore, chronic environmental stressors in the workplace may contribute to physical/psychological symptoms such as anxiety, insomnia, and depression, and these symptoms contribute to emotional exhaustion. A strong positive correlation was identified between work engagement and a sense of personal accomplishment. Work engagement has been considered the opposite of burnout and a protective factor against burnout (Prins et al. 2010; Schaufeli et al. 2002). The current study supports the findings of other studies (Demerouti et al. 2010; Prins et al. 2010) that noted that individuals with more engagement had higher personal accomplishment. When work engagement is low, there is little opportunity for personal or professional accomplishment. Therefore, the lack of accomplishment leads to less desire for work engagement. Work engagement explained the most variance in burnout, personal accomplishment, and depersonalization among nurses in Taiwan. These findings are consistent with those of previous studies of European and South African nurses, who also had higher burnout scores with less work engagement (Demerouti et al. 2010; Prins et al. 2010).
Conclusions Personal characteristics can be used to predict nurse burnout among Taiwanese nurses. Younger nurses with compromised physical/psychological symptoms are at risk of emotional exhaustion. Work engagement is a strong predictor of a sense of personal accomplishment. Strategies are needed to improve physical/psychological symptoms and work engagement among nurses in Taiwan to avoid burnout. Acknowledgments This study was funded by the Department of Health, Executive Yuan, R. O. C. (TAIWAN) (DOH099-TD-M-11397025).
123
Ethical Standard This study was received ethical approval from National Cheng Kung University Hospital review board (No. 96E6245).
References Aiken, L. H., & Patrician, P. A. (2000). Measuring organizational traits of hospitals: The revised nursing work index. Nursing Research, 49(3), 146–153. doi:10.1097/00006199-20000500000006. 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. Journal of the American Medical Association, 288(16), 1987–1993. doi:10.1001/jama. 288.16.1987. Cho, S. H., June, K. J., Kim, Y. M., Cho, Y. A., Yoo, C. S., Yun, S. C., & Sung, Y. H. (2009). Nurse staffing, quality of nursing care and nurse job outcomes in intensive care units. Journal of Clinical Nursing, 18(12), 1729–1737. doi:10.1111/j.1365-2702. 2008.02721.x. Demerouti, E., Mostert, K., & Bakker, A. B. (2010). Burnout & work engagement: A thorough investigation of the independence of both constructs. Journal of Occupational Health Psychology, 15(3), 209–222. doi:10.1037/a0019408. Gonza´lez-Roma´, V., Schaufeli, W. B., Bakker, A. B., & Loret, S. (2006). Burnout & work engagement: Independent factors or opposite poles? Journal of Vocational Behavior, 68(1), 165–174. doi:10.1016/j.jvb.2005.01.003. Hanrahan, N. P., Aiken, L. H., McClaine, L., & Hanlon, A. L. (2010). Relationship between psychiatric nurse work environments & nurse burnout in acute care general hospitals. Issues in Mental Health Nursing, 31(3), 198–207. doi:10.3109/0161284090 3200068. Hsieh, C. J., Hsieh, H. Y., Chen, P. H., Hsiao, Y. L., & Lee, S. (2004). The relationship between hardiness, coping strategies & burnout in psychiatric nurses. The Journal of Nursing, 51(3), 24–33. Hsu, H. Y., Chen, S. H., Yu, H. Y., & Lou, J. H. (2010). Job stress, achievement motivation & occupational burnout among male nurses. Journal of Advanced Nursing, 66(7), 1592–1601. doi:10. 1111/j.1365-2648.2010.05323.x. Iglesias, M. E. L., Vallejo, R. B., & Fuentes, P. S. (2010). The relationship between experiential avoidance & burnout syndrome in critical care nurses: A cross-sectional questionnaire survey. International Journal of Nursing Studies, 47(1), 30–37. doi:10.1016/j.ijnurstu.2009.06.014. Jourdain, G., & Chenevert, D. (2010). Job demands-resources, burnout and intention to leave the nursing profession: A questionnaire survey. International Journal of Nursing Studies, 47(6), 709–722. doi:10.1016/j.ijnurstu.2009.11.007. Kanai-Pak, M., Aiken, L. H., Sloane, D. M., & Poghosyan, L. (2008). Poor work environments & nurse inexperience are associated with burnout, job dissatisfaction & quality deficits in Japanese hospitals. Journal of Clinical Nursing, 17(24), 3324–3329. doi:10.1111/j.1365-2702.2008.02639.x. Klersy, C., Callegari, A., Martinelli, V., Vizzardi, V., Navino, C., Malberti, F., Tarchini, R., Montagna, G., Guastoni, C., Bellazzi, R., Rampino, T., David, S., Barbieri, C., Dal Canton, A., Politi, P. Working Group on Burnout, & Dialysis. (2007). Burnout in health care providers of dialysis service in Northern Italy—A multicentre study. Nephrology Dialysis Transplantation, 22, 2283–2290. doi:10.1093/ndt/gfm111. Korkeila, J. A., To¨yry, S., Kumpulainen, K., Toivola, J., Ra¨sa¨nen, K., & Kalimo, R. (2003). Burnout & self-perceived health among Finnish psychiatrists & child psychiatrists: A national survey.
Community Ment Health J Scandinavian Journal of Public Health, 31(2), 85–91. doi:10. 1080/14034940210133880. Lee, M. B., Liao, S. C., Lee, Y. J., Wu, C. H., Tseng, M. C., Gau, S. F., & Rau, C. L. (2003). Development & verification of validity & reliability of a short screening instrument to identify psychiatric morbidity. Journal of the Formosan Medical Association, 102(10), 687–694. Lee, H. F., Chien, T. W., & Yen, M. (2013). Examining factor structure of Maslach burnout inventory among nurses in Taiwan. Journal of Nursing Management, 21(4), 648–656. doi:10.1111/j. 1365-2834.2012.01427.x. Li, C. C., Tsay, S. L., Yip, P. K., & Su, H. F. (2002). Outcome of the clinical pathway for ischemic stroke patients. Formosan journal medicine, 6(5), 672–681. Lin, F., St John, W., & McVeigh, C. (2009). Burnout among hospital nurses in China. Journal of Nursing Management, 17(3), 294–301. doi:10.1111/j.1365-2834.2008.00914.x. Lu, M. S. (2013). The challenge & strategies of nursing managers in 21 country. The Fifth Membership Conference of TANP in Nongovernment HSOs. Taiwan, Taipei. Maslach, C. (1982). The cost of caring. Englewood Cliffs, NJ: Prentice-Hall Inc. Maslach, C., Schaufeli, W. B., & Leiter, M. (2001). Job burnout. Annual Review of Psychology, 52(1), 397–422. doi:10.1146/ annurev.psych.52.1.397. Meeusen, V., Van Dam, K., Brown-Mahoney, C., Van Zundert, A., & Knape, H. (2010). Burnout, psychosomatic symptoms & job satisfaction among Dutch nurse anaesthetists: A survey. The Acta Anaesthesiological Scandinavica Foundation, 54, 616–621. doi:10.1111/j.1399-6576.2010.02213.x. Mueller, C. W., & McCloskey, J. C. (1990). Nurses’ job satisfaction: A proposed measure. Nursing Research, 39(2), 113–117. Poncet, M. C., Toullic, P., Papazian, L., Kentish-Barnes, N., Timsit, J. F., Pochard, F., et al. (2007). Burnout syndrome in critical care nursing staff. American Journal of Respiratory and Critical Care Medicine, 175(7), 698–704. doi:10.1164/rccm.200606-806OC. Prins, J. T., Hoekstra-Weebers, J., Gazendam-Donofrio, S. M., Dillingh, G. S., Bakker, A. B., Huisman, M., et al. (2010). Burnout & engagement among resident doctors in the Netherlands: A national study. Medical Education, 44(3), 236–247. doi:10.1111/j.1365-2923.2009.03590.x. Schaufeli, W. B., & Bakker, A. B. (2004). Job demands, job resources & their relationship with burnout & engagement: A multi-sample
study. Journal of Organizational Behavior, 25(3), 293–315. doi:10.1002/job.248. Schaufeli, W. B., Salanova, M., Gonzalez-Roma, V., Bakker, A. B., & Alez-rom, V. G. (2002). The measurement of engagement & burnout: A two-sample confirmatory factor analytic approach. Journal of Happiness Studies, 3(1), 71–92. doi:10.1023/A: 1015630930326. Schaufeli, W. B., Bakker, A. B., & Salanova, M. (2006). The measurement of work engagement with a short questionnaire: A cross-national study. Educational and Psychological Measurement, 66(4), 701–716. doi:10.1177/0013164405282471. Spence Laschinger, H. K., & Leiter, M. P. (2006). The impact of nursing work environments on patient safety outcomes: The mediating role of burnout engagement. Journal of Nursing Administration, 36(5), 259–267. Spence Laschinger, H. K., Leiter, M., Day, A., & Gilin, D. (2009). Workplace empowerment, incivility, & burnout: Impact on staff nurse recruitment & retention outcomes. Journal of Nursing Management, 17(3), 302–311. doi:10.1111/j.1365-2834.2009. 00999.x. Taylor, B., & Barling, J. (2004). Identifying sources & effects of carer fatigue & burnout for mental health nurses: A qualitative approach. International Journal of Mental Health Nursing, 13(2), 117–125. doi:10.1111/j.1445-8330.2004.imntaylorb.doc.x. Van der Doef, M., Mbazzi, F. B., & Verhoeven, C. (2012). Job conditions, job satisfaction, somatic complaints & burnout among East African nurses. Journal of Clinical Nursing, 21, 1763–1775. doi:10.1111/j.1365-2702.2011.03995.x. Wang, L., Kang, Y. H., & Wu, D. (2010). A review of research & strategies for burnout among Chinese nurses. British Journal of Nursing, 19(13), 844–850. Weng, H. C., Hung, C. M., Liu, Y. T., Cheng, Y. J., Yen, C. Y., Chang, C. C., & Huang, C. K. (2011). Associations between emotional intelligence & doctor burnout, job satisfaction & patient satisfaction. Medical Education, 45, 835–842. doi:10. 1111/j.1365-2923.2011.03985.x. Whitmer, M., Hurst, S., & Prins, M. (2009). Intergenerational views of hardiness in critical care nurses. Dimensions of Critical Care Nursing, 28(5), 214–220. doi:10.1097/DCC.0b013e3181ac4b82. Wu, M. L. (2009). SPSS & the application and analysis of statistics. Taipei: Wu-Nan Book Inc.
123
