BURNOUT AND ITS ASSOCIATED FACTORS AMONG NURSES IN A ...

International Journal of Public Health and Clinical Sciences e-ISSN : 2289-7577. Vol. 5:No. 6

November/December 2018

Siti Hajar R., Huda BZ

https://doi.org/10.32827/ijphcs.5.6.215

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Open Access: e-Journal

BURNOUT AND ITS ASSOCIATED FACTORS AMONG

NURSES IN A TERTIARY HOSPITAL, MALAYSIA

Siti Hajar R.1, *Huda BZ.2

1MPH Candidate, Department of Community Health, Faculty of Medicine, Universiti Putra

Malaysia, Serdang, Selangor, Malaysia.

2Department of Community Health, Faculty of Medicine, Universiti Putra Malaysia, Serdang,

Selangor, Malaysia.

*Corresponding author: Dr Huda binti Zainuddin, Department of Community Health, Faculty

of Medicine and Health Sciences, Universiti Putra Malaysia. [email protected]


ABSTRACT

Background: Burnout is a condition consists of physical, mental and emotional exhaustion

that is due to long term exposure to challenging work situations. Burnout is a significant

problem in the nursing profession and can cause serious impact on the health of the staff,

patient care and the healthcare service. More information regarding burnout and its associated

factors among nurses in Malaysia is needed to prevent the syndrome and to determine the

appropriate intervention strategies. The study aimed to determine the proportion of burnout

among nurses in Hospital Serdang and its associated factors.

Materials and Methods: A cross sectional study was done among 509 nurses through simple

random sampling using validated self-administered questionnaires that consists of Perceived

Stress Scale (PSS-10) and Copenhagen Burnout Inventory (CBI).

Result: Proportion of nurses with burnout were 24%, whereby 61.9% had personal burnout,

30.8% work related burnout and 11.2% patient related burnout. Burnout had a significant

association with working experience (p= 0.0039), working area (p= 0.047), work related

stress (p=0.001), work schedule (p=0.003) and job satisfaction (p=0.001).

Conclusion: Occupational related characteristic such as working experience, working area,

work related stress, work schedule and job satisfaction were associated with burnout. It is

recommended that the hospital management conduct a prevention program through

modification of burnout associated factors and organise a stress reduction program in order to

address this situation. Cohort study should be conducted in future study to include more

hospital and to explore more on personal factors that may affects burnout among nurses.

Keywords: Nurse, burnout, work related stress


mailto:[email protected]






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1.0 Introduction

Burnout syndrome is a significant problem in the modern working environment. It has been

discovered globally that the prevalence of burnout has increased markedly and affecting 19%

to 30% of employees in the general working environment (Finney, Stergiopoulos, Hensel,

Bonato & Dewa, 2013). Maslach and Jackson (1981) described burnout as a response to

prolong exposure to work-related stress, and it comprises three components, such as

emotional exhaustion, depersonalisation (cynicism) and reduced professional efficacy (low

personal accomplishment). Meanwhile, Ribeiro et al. (2014) identified burnout as physical,

physiological and psychological stress response of an individual to prolonged exposure to

intense interpersonal, emotional and work related pressure.

Burnout is also known to affect individuals in a variety of profession, particularly professions

that require intense interaction with other people such as police officers, social workers,

teachers and nurses (Basinska, Wiciak, Dåderman, 2014; McFadden, Campbell & Taylor,

2015; Abenavoli, Jennings, Greenberg, Harris & Katz, 2013). Several studies reported that

healthcare professions are among the most at risk to burnout (Losa Iglesias, Vallejo &

Fuentes, 2010; Spence Laschinger, Leiter, Day & Gilin, 2009). A study conducted among

healthcare worker in Southwest Ethiopia, showed highest prevalence of burnout was among

nurses (82.8%) and the lowest prevalence was observed among laboratory technicians (2.8%)

(Biksegn, Kenfe, Matiwos & Eshetu, 2016). Another study conducted in Taiwan revealed that

among medical personnel, nurses has the highest work related burnout. The prevalence of

work related burnout among the medical personnel were 66% among nurses, 61.8% physician

assistants, 38.6 % physicians, 36.1% administrative staff and lastly, 31.9% medical technician

(Chou, Li & Hu, 2014).

Trbojevic-Stankovic et al. (2015) claimed that nurses are more susceptible to burnout than

other healthcare workers due to their close interpersonal relationship with patients. According

to William and Smith (2013), nurses are consistently reported to experience higher level of

stress compared to other profession. Nurses are exposed to emotional nature of patient

demand, inter-professional and interpersonal conflict, and prolong working hours. Therefore,

they are susceptible to psychological stress and mental health problem which makes them

vulnerable to burnout (Watanabe et al., 2015, Raftopoulos et al, 2012).

Burnout can cause several impacts to the nurses, patient and the organisation. A study

conducted by Suñer-Soler et al. (2014), revealed that burnout was significantly associated

with perception of having made mistake (OR = 1.05, CI 95% 1.04-1.07), personal

deterioration (OR= 1.07, CI 95%: 10.7-1.08) and family deterioration (OR =1.06, CI 95%:

1.05-1.07). Burnout also affects the healthcare organisation whereby burnout causes the

nurses to have the intention to leave the profession (OR=1.07, CI 95%:1.07-1.08) and

frequent absenteeism (OR= 1.03, CI 95%: 1.02-1.04) (Suñer-Soler et al., 2014).






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2.0 Materials and Methods

2.1 Study location and population

This study was conducted in Hospital Serdang, a government hospital located at Sepang

district in Selangor state, Malaysia. Hospital Serdang (HS) is a tertiary government hospital

and also a teaching hospital for Universiti Putra Malaysia (UPM) medical student. This

hospital consists of 694 beds with 20 clinical department and providing services such as

inpatient, outpatient and daycare.

The study population were registered nurses (head nurse, staff nurse, community nurse) who

work in HS.

2.2 Questionnaires

Malay language version of Perceived Stress Scale (PSS) -10 questionnaire was used to assess

the perception of stress in a person’s life by measuring the thoughts and feeling in the past

month. It also measures unexpected and uncontrollable life situation that happened to an

individual. The questionnaire consist of 10 items which uses the 5 point Likert scale (0 =

never, 1 = almost never, 2 = sometimes, 3= fairly often, and 4= very often). The total of the

10 items represent the total of perceived stress score with the score more than 17 representing

the higher level of perceived stress (Cohen, 1988).

Burnout among nurses were assessed using the Malay language version of the Copenhagen

Burnout Inventory (CBI-M). The CBI-M consists of 19 items and 3 subsections which

includes personal burnout (6 items), work related burnout (7 items) and client related burnout

(6 items) (Cronbach’s alpha = 0.83 to 0.87 for three factors) (Andrew Chin et al., 2017). This

questionnaire uses 5 point Likert Scale, and scale score were calculated by taking the mean of

the items in the scale. In this study, burnout was defined as a total mean score of 50 or above

(Biksegn et al., 2016).

Pretesting was conducted among 57 Universiti Putra Malaysia nurses working in HS. The

Cronbach’s alpha value for the perceived stress and burnout were good (0.83 and 0.92

respectively).

2.3 Data Collection

The self-administered questionnaires were distributed to the eligible respondents that were

selected by simple random sampling. Each components of the questionnaire were explained to

the respondents by the researcher. Respondents were allowed to answer the questionnaire

within 5 working days. If the nurses were absent during the distribution of the questionnaire,

explanation and written instructions were given to the sister in charge of the ward for them to

explain to the absent respondents. Reminders were given for those who are unable to submit

the questionnaires on the collection day and another 5 days were given to submit it.






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2.4 Data Analysis

Data collected in this study were analysed using SPSS Version 23. The data regarding

sociodemographic characteristics (gender, ethnicity and marital status) and occupational

related characteristics (nurse’s grade, working area, work schedule and job satisfaction) were

analysed descriptively in frequencies and percentages; then analysed for measures of central

tendency and dispersion (median and interquartile range). Meanwhile, age, working

experience and work related stress were not normally distributed. The total score of the 19

items of Copenhagen Burnout Inventory subscale were calculated and total mean score was

obtained. The total mean score were classified into ‘no burnout’ (mean score <50) and

‘burnout’ (mean score ≥ 50). This was based on the classification used by Biksegn et al

(2016). Meanwhile, in Perceived Stress Scale, 10 items were summed to obtain the total score

of Perceived Stress Scale. The association between the independent variables and burnout

were done using chi square test whereby p value was set as 0.05.

2.5 Ethics

Informed written consent were obtained from those who agreed to participate in this study.

Ethical approval was obtained from the Ethic Committee for Research Involving Human

Subjects Universiti Putra Malaysia (Jawatankuasa Etika Universiti untuk Penyelidikan

Melibatkan Manusia, JKEUPM) and Medical Research and Ethics Committee (MREC),

Ministry of Health Malaysia. This study also had obtained permission from HS director.

3.0 Result

A total of 565 questionnaires were distributed to the eligible respondents. The completed

questionnaires received were 509, making the response rate for the study was 90.1%.

3.1 Sociodemographic and Occupational Related Characteristics of Respondents

3.1.1 Sociodemographic Characteristics of Respondents

Table 1. Sociodemographic characteristics of respondents (N=509)

Median (IQR) Min, Max Frequency (n) Percentage (%)

Age 31 (8) 23, 57 - -

Gender

Male 25 4.9

Female 484 95.1

Ethnicity

Malay 461 90.6

Chinese 6 1.2

Indian 20 3.9

Others 22 4.3

Marital Status

Unmarried 128 25.1






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Married 381 74.9

Numbers of children

No children 181 35.6

1 – 3 children 269 52.8

> 3 children 59 11.6

Table 1 shows the sociodemographic characteristics of respondents. There were a total of 509

respondents with age ranged from 23 to 57 years old and the median of age was 31 (IQR=

8.0). Majority of the respondents were female (95.1 %), Malay (90.6%) and married (74.9%).

Out of 509, about 52.8% have 1 to 3 children, 35.6% have no children and 11.6 % have

children more than 3.

3.1.2 Occupational Related Characteristics of Respondents

Table 2. Occupational related characteristics of respondents (N=509)

Median

(IQR)

Min, Max Frequency

(n)

Percentage

(%)

Working Experience (years) 6 (9) 1, 30 - -

Grade

U 19 70 13.8

U 29 374 73.5

U 32 65 12.8

Working Area (Department)

Medical 146 28.7

Cardiology 80 15.7

Surgical 96 18.9

Cardiothoracic 47 9.2

O&G 64 12.6

ED 24 4.7

Anaesthesiology 52 10.2

Work related stress score 19 (6) 4, 32 - -

Work Schedule

Office hour 65 12.8

Shift Hour 444 87.2

Job Satisfaction

Low 28 5.5

Moderate 312 61.3

High 169 33.2

Table 2 shows the occupational related characteristics of respondents. The working

experience ranged from 1 to 30 years and the median was 6 (IQR=9). The respondents were

from different grades of which 73.5% were U 29, 13.7% were U 19 and 12.8% were U 32.

Among the 509 respondents, 28.7 % were working in Medical department, 18.9% in Surgical

department, 15.7% in Cardiology department, 12.6% in O&G department, 10.2% in

Anaesthesiology department, 9.2% in Cardiothoracic department, and 4.7% in Emergency

department. Majority of the respondents were working in shift hour (87.2%) followed by

office hour (12.8%). Meanwhile, work related stress score among the respondents ranged

from 4 to 32 with a median of 19 (IQR=6). With regard to job satisfaction, 61.3% of






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respondents had moderate job satisfaction, 33.2% high job satisfaction and 5.5% low job

satisfaction.

3.2 Burnout and Its Dimensions among Respondents

Table 7. Burnout and its dimension among respondents (N=509)

Frequency (n) Percentage (%)

Overall burnout 122 24.0

Burnout dimensions

Personal burnout 315 61.9

Work related burnout 157 30.8

Patient related burnout 57 11.2

Table 7 shows the proportion of burnout and its dimensions among 509 respondents. About

24 % (122) of nurses in HS were experiencing burnout. Among the burnout dimensions,

personal burnout was the highest (61.9%), followed by work related burnout (30.8%), and

patient related burnout (11.2%).

3.3 Association between Burnout and Sociodemographic Characteristics among Nurses.

Table 3. Association between burnout and sociodemographic characteristics (N= 509)

Variables Overall Burnout Test Statistics

No

N (%)

Yes

N (%) 2 df p-value

Age (Years old)

21-30 186 (74.1) 65 (25.9) 1.01 1 0.315

≥31 201 (77.9) 57 (22.1)

Gender

Male 21 (84.0) 4 (16.0) 0.916 1 0.339

Female 366 (75.6) 118 (24.4)

Ethnicity

Malay 351 (76.1) 110 (23.9) 0.031 1 0.860

Non-Malay 36 (75.0) 12 (25.0)

Marital Status

Unmarried 97 (75.8) 31 (24.2) 0.006 1 0.939

Married 290 (76.1) 91 (23.9)

Numbers of

Children

0 137 (75.7) 44 (24.3) 0.018 2 0.991

1-3 205 (76.2) 64 (23.8)

>3 45 (76.3) 14 (23.7)

Table 3 shows the association between burnout and sociodemographic characteristics of the

nurses. There was no significant difference between nurses age group 21 -30 years old and 31

years and above (2 =1.01, df = 1, p= 0.315). Female nurses have higher burnout level

(24.4%) as compared to male nurses (16.0%). Gender was not significantly associated with

burnout (2 =0.916, df= 1, p= 0.339). With regard to ethnicity, non-Malay shows higher

burnout level (25%) but it was not statistically significant different from non-Malay (2 =






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0.031, df= 1, p= 0.860). This study also revealed that marital status and number of children

were not associated with burnout (2 =0.006, df= 1, p= 0.939, 2 =0.018, df= 1, p= 0.991).

3.4 Association between Burnout and Occupational Related Characteristics among

Nurses.

Table 4. Association between Burnout and Occupational Related Characteristics (N= 509)

Variables Overall Burnout Test Statistics

No

N (%)

Yes

N (%) 2 df p-value

Working Experience

(Years)

< 10 249 (73.2) 91 (26.8) 4.393 1 0.039

10 ≥ 138 (81.7) 31 (18.3)

Nurses Grade

U 19 55 (78.6) 15 (21.4) 2.611 2 0.271

U 29 278 (74.3) 96 (25.7)

U 32 54 (83.1) 11 (16.9)

Working Area

(Department)

Non Surgical 239 (79.1) 63 (20.9) 3.935 1 0.047

Surgical 148 (71.5) 59 (28.5)

Work related Stress

Low 162 (95.3) 8 (4.7) 51.972 1 0.001

High 225 (66.4) 114 (33.6)

Working Schedule

Office hour 59 (90.8) 6 (9.2) 8.881 1 0.003

Shift hour 328 (73.9) 116 (26.1)

Job Satisfaction

Low 12 (42.9) 16 (57.1) 40.483 2 0.001

Moderate 222 (71.2) 90 (28.8)

High 153 (90.5) 16 (9.5)

Table 4 demonstrates that nurses working experiences had significant association with

burnout (2 = 4.393, df = 1, p= 0.039) whereby nurses with working experience less than 10

years were experiencing higher burnout level (26.8%) as compared to those who works more

than 10 years (18.3%). Meanwhile, nurses grade show no significant relationship with

burnout (2 = 2.611, df = 1, p= 0.271).

In this study, the results shows that working area has a significant association with burnout (2

= 3.935, df = 1, p= 0.047), where 28.5% of nurses working in the surgical department were

experiencing burnout. Apart from that, nurses with high work related stress (33.6%) were

experiencing more burnout than those with low work related stress (4.7%) and the difference

was significant (2 = 51.972, df = 1, p= 0.001). Meanwhile, work schedule seems to have a

significant relationship with burnout (2 = 8.881, df = 1, p= 0.003). Nurses working in shift

hours (26.1%) were experienced burnout as compared to nurses working during office hour

(9.2%). Lastly, job satisfaction shows a significant association with burnout (2 = 40.483, df






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= 1, p= 0.001). Nurses with low job satisfaction showed highest burnout level (57.1%),

followed by moderate job satisfaction (28.8%) and high job satisfaction (9.5%).

4.0 Discussion

The results revealed that almost one-fourth of the nurses experienced burnout. This study also

found that majority of nurses were suffering personal burnout, while about 42% of them had

work-related and patient-related burnout. The results were relatively higher compared to a

previous study carried out by KJ, Bhat Pookala and Chandra Das (2014), whereby they

reported that the proportion of dimensions were 27.2% for personal burnout, 14.7% work

related burnout and 9.4% patient related burnout. The possible reason for the differences in

work related burnout could be due to the difference in patient workload in the health facilities.

The higher proportion of work-related and patient-related stress in this study should be a

warning sign for workplace intervention.

On the other hand, this study revealed that the proportion of overall burnout and work related

burnout was slightly lower than that of Jordan, Fenwick, Slavin, Sidebotham and Gamble

(2013). They reported that 30% of nurses experienced general burnout and 57% experienced

work related burnout. This discrepancy is likely due to the difference in the setting and the

working areas involved in the study. The study by Jordan et al, had smaller sample size (110

samples) and data was collected among midwives working in one maternity unit. By contrast,

this study was conducted in a tertiary hospital and involved the various departments in the

hospital.

Personal burnout refers to a degree of physical and psychological exhaustion experienced by

an individual in home environment that includes ongoing health problem of loved ones,

financial problem or relationship problem (Chin et al., 2016). This study revealed that 61.9%

of nurses were experiencing personal burnout whereby similar finding was obtained from a

study conducted in Australia which show that 57% of nurses experiencing personal burnout

(Jordan et al., 2013). In this current study, it was found that personal burnout was

significantly associated with work schedule, work related stress and job satisfaction with

higher prevalence of personal burnout among nurses working in shift hour, high work related

stress and low job satisfaction. The possible reason is that nurses working in shift hour causes

an impairment to sleep quality and disturbance to the personal life. Prolong exposure to this

situation may leads to work related stress, low job satisfaction and finally burnout among the

nurses.

In this study, it was found that burnout have no significant association with sociodemographic

characteristics. However, this study revealed that working experienced was significantly

associated with burnout, whereby nurses with working experience less than 10 years were

experiencing higher burnout level. This finding is consistent with studies conducted by Jordan

et al. (2013) which shows that high prevalence burnout were found among nurses with less

working experiences. Similarly, a study by Ang et al. (2016), revealed that lesser working

experience was associated with burnout. It was assumed that nurses with longer working

experience have better coping capacity to manage stressful event especially at the workplace

(Hoseini, Sharifzadeh & Khazaie, 2011).






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In this study, the majority of the nurses had relatively shorter working experience whereby

they were still in the stage of adapting with work scope and they had less capability in

managing stressful events. Similar explanations were given by Qu and Wang (2015), that

nurses at this stage were concentrating more on finding solution for problem in the nursing

field. Unfortunately, their management skills has not fully matured yet. The researcher also

stated that, nurses in their study were at the period whereby they were first time parent and

they were still trying to adjust with social role as parent (Qu & Wang, 2015).

With regards to working area, this study shows that there was a statistically significant

association between working area and burnout whereby nurses working in surgical based area

showed higher prevalence of burnout. This study has similar finding with studies conducted in

Jordan and Japan which shows that working area were significantly associated with burnout

(Mudallal & Othman, 2017; Ohue et al., 2011). However, some studies pointed out that

higher burnout level were found in nurses working in Psychiatry (Giorgi et al., 2017),

intensive care units (Mudallal & Othman, 2017) and oncology department (Ksiazek,

Stefaniak, Stadnyk, Ksiazek (2011). The inconsistency between the results could be explained

in terms of differences in the working area. This study was conducted among all working

areas whereas, other studies conducted at specific locations such as intensive care, oncology

department and psychiatry area.

The study found that there was significant association between work schedule with burnout

among nurses in HS in which nurses working in shift hour were experiencing higher level of

burnout. This finding concurs with studies conducted in central Italian hospital (Giorgi et al.,

2017) and tertiary hospital in Singapore (Ang et al., 2016) which showed significant

association between work shift and burnout. In this study, working in shift was associated

with higher job stress among the nurses. Prolonged exposure and unmanaged stress may result

in burnout among the nurses.

In this study, it was found that work related stress is significantly associated with burnout.

This finding is similar to a study done by Myhren, Ekeberg & Stokland (2013) and Wang et

al. (2013) which revealed that work related stress was significantly associated with burnout.

Work related stress is considered as an individual’s reaction to threatening work environment.

In this study, high workload, inadequate equipment, shortage of staff, and work shift among

nurses were contributor to work related stress.

With regards to job satisfaction, this study concluded that the level of job satisfaction was

significantly associated with burnout, whereby lower job satisfaction showed higher

prevalence of burnout. A study by Myhren et al., (2013) showed similar result, job

satisfaction were significantly associated with higher burnout. In this study, some of the

nurses experienced low job satisfaction due to inadequate equipment in the workplace and

frequent non-functioning of equipment. Inadequate resources and lack of technical support

will cause a delay in the management of the patient, increases the workload of nurses and thus

lead to burnout (Klopper, Coetzee, Pretorius & Bester, 2012).






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5.0 Conclusion and recommendation

More than one fourth of the nurses in the tertiary hospital were experiencing burnout whereby

almost half of them were having burnout due to work-related and work context factors. It is

recommended that the hospital management plan and organise stress prevention and

management programme for the high risk group. The intervention should be strategized at the

modification and handling of the work-related factors. A cohort study involving more

hospitals should be conducted in future to determine the causal effect and to explore further

on personal factors that may lead to burnout among nurses.

Acknowledgement

This study is part of requirement of Master Public Health Prograame at Department of

Community Health, Faculty of Medicine and Health Sciences, Universiti Putra Malaysia. The

study was approved by the National Medical Research Registry (NMRR) of Ministry of

Health, Malaysia (KKM.NIHSEC.P18-647 (5)). The authors also would like to thank the

hospital director and the nurses of the Hospital Serdang for their cooperation during data

collection, and also the Director General of Health Malaysia for the permission to publish this

manuscript (KKM.NIHSEC. 800-4/4/1 Jld 62(31)).

Declaration

Authors declare that the above manuscript has not been published or submitted to other

journal and this study did not receive any funding.

Conflict of Interest

This study has no conflict of interest.

Authors contribution

Author 1: Siti Hajar Binti Rosli (data collection, data analysis, paper writing)

Author 2: Dr Huda Binti Zainuddin (research concept, study design, review of manuscript)






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