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Burnout, psychosomatic symptoms and job satisfaction

among Dutch nurse anaesthetists: a survey

V. MEEUSEN1, K. VAN DAM2, C. BROWN-MAHONEY3, A. VAN ZUNDERT1 and H. KNAPE41Department of Anaesthesiology, Catharina Hospital, Brabant Medical School, Eindhoven, The Netherlands, 2Department of Work andOrganizational Psychology, Tilburg University, Tilburg, The Netherlands, 3Petris Center on Health Markets and Consumer Welfare, Berkeley,CA and 4Department of Anaesthesiology, Division of Perioperative and Emergency Care, University Medical Center Utrecht, Utrecht, TheNetherlands

Background: To meet the increasing demand for healthcareproviders, it is crucial to recruit and retain more nurse anaes-thetists (NAs). The majority of NAs in the Netherlands are 445years old, and retaining them in their jobs is very important.

This study investigates the relationships among burnout, phy-sical health and job satisfaction among Dutch NAs.Methods: Two thousand NAs working in Dutch hospitalswere invited to participate in this online questionnaire. Wetested the relationships among burnout, psychosomaticsymptoms, sickness absence, perceived general healthand job satisfaction.Results: Nine hundred and twenty-three questionnaireswere completed and analysed (46% response rate). Burn-out and psychosomatic symptoms were negatively asso-ciated with job satisfaction, and predicted 27% of job

satisfaction. Perceived general health was positively andsickness absence was negatively related to job satisfaction.Older NAs had a higher incidence of burnout than theiryounger counterparts.

Conclusions: The results confirmed the importance of ahealthy psychosocial work environment for promoting jobsatisfaction. To prevent burnout, further research is neces-sary to determine the factors causing stress. These findingsmay also apply to anaesthesiologists who share many tasksand work in close cooperation with NAs.

Accepted for publication 29 December 2009

r 2010 The AuthorsJournal compilation r 2010 The Acta Anaesthesiologica Scandinavica Foundation

AN increasing shortage of anaesthesia profes-sionals is expected in Europe in the nextdecade. This is due to a high retirement rate andto increasing demands from an ageing population.It is therefore important to focus on job satisfactionin anaesthesia to be able to retain experiencedanaesthesia personnel.

The role of the nurse anaesthetist (NA) can bestressful because they are repeatedly confrontedwith changing patient needs, medical problemsand suffering while dealing with demands from

surgeons, supervising anaesthesiologists and theirhierarchical supervisors.1,2

Burnout often occurs among younger (ageo30years) and less experienced employees, possibly dueto reality shock or early career burnout, caused bya lack of job experience or by facing the harshrealities.3 Burnout is a work-related psychologicalsyndrome in response to chronic job stress, charac-terized by feelings of emptiness, fatigue, exhaustion,physical symptoms and an increased incidence of

sickness absence.47 Long-standing stress at workcan adversely affect physical and mental health, andis associated with, e.g., muscular strains and inju-ries,8 cardiovascular diseases811 and drug or alco-hol abuse culminating in suicide.12,13 Althoughcausality is not yet found, higher mortality rates14

and suicidality or suicide rates among anaesthesiol-ogists12,13,15 were reported in several studies,whereas others found equal mortality rates.1618

In this study, we examined stress-related symp-toms and job satisfaction in NAs working in Dutch

hospitals. We hypothesized that burnout and psy-chosomatic symptoms are positively related to eachother but negatively related to job satisfaction.Second, we hypothesized that sickness absencewas negatively related to job satisfaction, whileperceived general health was positively related tojob satisfaction. The third hypothesis in this studywas that younger or recently qualified NAs hadhigher levels of burnout compared with their olderand more experienced colleagues.

616

Acta Anaesthesiol Scand 2010; 54: 616621Printed in Singapore. All rights reserved

r 2010 The Authors

Journal compilationr 2010 The Acta Anaesthesiologica Scandinavica Foundation

ACTA ANAESTHESIOLOGICA SCANDINAVICA

doi: 10.1111/j.1399-6576.2010.02213.x


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Methods

After Medical Ethical Committee approval (Cath-arina Hospital, Eindhoven, the Netherlands), thestudy was launched in January 2007, at the annualNational Congress of Dutch Nurse AnaesthetistsSociety [Nederlandse Vereniging van Anesthesie-medewerkers (NVAM)]. All congress participants

received an invitation to complete the online ques-tionnaire anonymously. During that same week,NVAM members received an invitation to partici-pate in the study. Written information was also sentto the head nurses of all Dutch hospitals usingNAs, asking them to encourage participation in thestudy.

InstrumentsIn the questionnaire, we acquired information

about the following: job satisfaction, psychoso-matic symptoms, burnout, sickness absence andperceived general health. We recorded demo-graphic information such as age, gender, numbersof years practising anaesthesia since certification,percentage of employment (full-part-time) andwhether they are working in academic hospital(type of hospital) and with anaesthesia residents.

Burnout was measured using the Dutch versionof the Maslach Burnout Inventory, developed in1986,19 which is judged to be a very reliabletool.4,5,20 The questionnaire consisted of 16 items,

with three subscales measuring the dimensionsemotional exhaustion (feelings of being overex-tended and depleted), depersonalization (indiffer-ent attitude toward ones service or care) andprofessional accomplishment.4,5 Items were work-related, and rated on a seven-point Likert scaleranging from never (1) to always (7). The burn-out dimension accomplishment was measured ona positive scale and was reversed for statisticalanalyses. Global burnout resulted in the enumera-tion of the three subscales.20

Psychosomatic symptoms were measured with

the Permanent Onderzoek LeefSituatie [perma-nent study of living conditions (POLS)] question-naire, developed in 1997 and used by the Dutchgovernment for longitudinal studies. Participantswere asked about seven symptoms: gloom, anxiety,headache, fatigue, sleeplessness, back pain andjoint/muscle pain (yes5 1 and no5 0). They werealso asked about their incidence of sickness ab-sence during the previous year and to rate theirperceived general health on a five-point scale:

(15very bad through 55very good). Self-ratedhealth has also been used in other studies.1,21

In this study, we measure the overall attitudetowards job satisfaction, which can be described asa global feeling about the job.22Job satisfaction wasmeasured in three ways satisfaction with the job,the organization and the departments atmosphere

on a four-point scale (15

totally disagree, 25

dis-agree, 35 agree and 45 totally agree). Previousstudies support the usefulness of global measure-ments in single-shot surveys.1,23

Statistical analysisThe reliability of the measurement model was ana-lysed using factor analysis (SPSS 16.0 system, SPSSInc., Chicago, IL). Principal Axis factoring withoblimin rotation (eigenvalues 41) resulted in thefollowing six factors: exhaustion (a50.86), accom-

plishment (a5

0.77), depersonalization (a5

0.67);physical symptoms (a50.60), mental symptoms(a50.63) and satisfaction factor (a50.72), in combi-nation explaining 43.4% of the variance of the model.The variable global burnout had an a score of 0.86.We performed a hierarchical multiple regressionanalysis to determine the predictive value of globalburnout and psychosomatic symptoms for job satis-faction. Results with a significance level 0.05 weredeemed significant.

Results

Demographic informationOut of 2000 Dutch NAs working in the Nether-lands, 923 filled out the questionnaire (46% re-sponse rate). Forty-one failed to complete itentirely and were excluded from further study.Analysis was performed on the 882 completedresponses (male : female5 451 : 431). The character-istics of the participants are shown in Table 1. Threeitems percentage of employment, whetherthey worked in an academic hospital and the

presence of anaesthesia residents were not re-lated to burnout, psychosomatic symptoms or jobsatisfaction.

Hypothesis one was confirmed: global burnout(r5 0.50, Po0.01), physical (r5 0.11, Po0.01)and mental health (r5 0.28, Po0.01) symptomswere negatively associated with job satisfaction.Global burnout and physical and mental healthsymptoms associated positively with each other(Table 2).

Health and job satisfaction among nurse anaesthetists

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The presumed negative relationship (hypothesistwo) between sickness absence and job satisfaction(r5 0.21, Po0.01), and the positive relationshipbetween perceived general health and job satisfac-tion (r5 0.17, Po0.01), could be confirmed (Table

2). This study showed two or more psychosomaticsymptoms in 450% of the NAs (Table 1). The totalnumber of psychosomatic symptoms was higheramong females, who had a significantly higherincidence of headache (38.1% vs. 22.6%, Po0.001),fatigue (55.2% vs. 44.1%, Po0.01), backache (43.2%vs. 28.4%, Po0.001) and muscular pain (39.9% vs.30.6%, Po0.05).

Confirmation of hypothesis three, that the inci-dence of burnout was higher among younger orrecently qualified NAs, could not be found. A signi-ficantly positive relationship was demonstrated

between age and burnout (r5

0.07, Po0.05), whichwas due to depersonalization (r5 0.16, Po0.01)and exhaustion (r5 0.10, Po0.01). Physical andmental health symptoms were not age related.

In the hierarchical regression analysis, predictivevalues of global burnout, physical and mentalsymptoms for job satisfaction with sequential ad-justment for potential confounders and mediatorswere analysed (Table 3). The type of hospital, andthe presence of anaesthesia residents in the hospi-tal, predicted 2% of the variance in job satisfaction(respectively, b5 0.10 and 0.15) in model 1. The

number of years since certification or the status ofbeing a student did not show any predictive valuefor job satisfaction. In model 2, 7% of the variancewas predicted by sickness absence and perceivedgeneral health. Finally, in model 3, 27% of thevariance in job satisfaction was predicted by globalburnout. Mental and physical symptoms played norole in predicting job satisfaction. In model 3,sickness absence lost its significance almost com-pletely and perceived general health totally.

Discussion

The main findings of the study were that (a)burnout and psychosomatic symptoms were nega-tively associated with job satisfaction; (b) burnout

predicted 27% of job satisfaction among DutchNAs; (c) perceived general health was positivelyand sickness absence was negatively related to jobsatisfaction; and (d) older NAs had a higher in-cidence of burnout than their younger counter-parts.

The relationship in our study, between globalburnout and psychosomatic symptoms, and theirnegative association with job satisfaction, corre-sponded to the results among other healthcareproviders,1,21,24 although some authors could notconfirm this.25,26 The negative association between

burnout and job satisfaction in our study (b5

0.47)clearly matched with previously published studies,ranging from b5 0.40 to 0.52.3,24,26 We alsofound a very strong association between globalburnout and the burnout dimension exhaustion,which is considered the essence of burnout.1,47

This study mainly shows short-term sicknessabsence, which is considered as a type of copingbehaviour used in situations where a longer recov-ery period is needed as, e.g., in cases of stress.9,2729

Because of these higher levels of stress, NAs maybe less effective at work and consequently experi-

ence decreased job satisfaction.3

Several studiescontend that the level of job satisfaction is a pre-dictor for long-term sickness absence.30,31

We found two or more psychosomatic symptomsin 450% of the NAs, which is substantially higherthan among employees in the general public(810%). This corresponds to the results of Mer-etoja,32 who found severe side-effects (e.g., cardio-vascular diseases, metabolic disorders) amonganaesthesiologists when working night shifts. The

Table 1

Characteristics of the participants, n5882.

Age, years (%) Certification years (%) Sickness absence, days/months (%) Psychosomatic symptoms, n (%)

o20 (0.5) o1 (12.4) None (53.4) 0 (27.4)2024 (4.1) 15 (18.9) 16 days (34.7) 1 (18.7)2529 (13.5) 610 (12.5) 714 days (5.9) 2 (19.8)3034 (12.1) 1115 (15.5) 1528 days (3.2) 3 (13.7)3539 (13.7) 1620 (14.1) 12 months (0.9) 4 (11.7)

4044 (15.0) 420 (26.6) 27 months (1.2) 45 (7.7)4549 (21.2) o7 months (0.7)5054 (13.7)5559 (5.4)460 (0.8)

V. Meeusen et al.

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higher incidence of psychosomatic symptoms infemales in our study conforms to data fromothers,27,33 and can be explained by the combina-tion of outside employment and family responsi-bilities among females,21,33 and their highersensitivity to internal, physical sensations.33

The relationship between age and stress levels

varies widely, from no relationship33,34

to higherstress levels in young physicians and nurses.25,3537

We could not find signs of a reality shock. Thismay be due to the low number of student partici-pants (8.8%), although the number of recentlycertified NAs was sufficient to draw conclusions(certification o5 years5 31.3%; o1 year5 13.8%).In our study, age related significantly to exhaustionand depersonalization. It is possible that olderemployees experience insufficient recovery time,inducing emotional exhaustion.6,7 The finding thatthis exhaustion did not correlate to the percentage

of employment or sickness absence is interesting.This could mean that only the duration of theworking day is important. We did not evaluatethis relationship. The relation between age anddepersonalization can possibly be explained bythe limited career options for Dutch NAs. Afterspending many years as NAs, employees may feelthat the job lacks variety and opportunitiesfor personal growth.31,38 Although Dutch NAsalways work under (indirect) the supervision ofTa

ble2

Mutualassociationsofthedifferentvariablesamong882participants.

M

SD

1

2

3

4

5

6

7

8

9

1

0

11

12

1.

Agez

5.7

1

1.9

8

1.0

0

2.

Gender

0.4

9

0.5

0

0.2

8w

1.0

0

3.

Certificationz

3.8

0

1.7

8

0.8

0w

0.2

2w

1.0

0

4.

Sicknessabsencek

1.7

0

1.0

4

0.0

5

0.0

2

0.0

2

1.0

0

5.

Perceivedgeneralhealth

4.1

1

0.6

8

0.0

8*

0.0

2

0.0

6

0.2

6w

1.0

0

6.

Exhaustion

2.2

1

0.8

1

0.1

0w

0.0

1

0.1

0w

0.2

9w

0.3

7w

1.00

7.

Depersonalization

2.6

9

0.9

5

0.1

6w

0.0

8*

0.2

1w

0.1

9w

0.1

9w

0.59

w

1.0

0

8.

Accomplishment

3.3

6

0.8

5

0.0

6

0.1

2w

0.0

6

0.1

7w

0.2

8w

0.40

w

0.3

4w

1.0

0

9.

Globalburnout

2.7

6

0.6

8

0.0

7*

0.0

3

0.0

9w

0.2

7w

0.3

6w

0.84

w

0.7

7w

0.7

6w

1.0

0

10.

Physicalsymptoms

0.3

7

0.4

2

0.0

3

0.1

5w

0.0

5

0.1

0w

0.1

9w

0.27

w

0.1

2w

0.1

1w

0.2

1w

1.0

0

11.

Mentalsymptoms

0.2

4

0.2

1

0.0

4

0.1

0w

0.0

2

0.2

4w

0.3

4w

0.54

w

0.2

9w

0.3

2w

0.4

9w

0.3

3w

1.0

0

12.

Jobsatisfaction

2.7

9

0.5

5

0.0

1

0.0

1

0.0

1

0.2

1w

0.1

7w

0.38

w

0.4

3w

0.3

9w

0.5

0w

0.1

1w

0.2

8w

1.0

0

Mean,standarddeviationsand

correlationcoefficients(bivariate,

two-tailed).

Significantcorrelationatlevel.

*Po0.0

5.

wPo0.0

1,n5

882.

zAge(years):o20(1),2024(

2),2529(3),3034(4),3539(5),4044(6),4549(7),5054(8),5559(9

),460(10).

Gender:male(0),female(1).

zCertification:numberofyears

practisinganaesthesiasincecertificatio

n:o1(1),15(2),610(3),1115(4)

,1620(5),420(6).

k

Sicknessabsenceduringthep

reviousyear:0days(0),16days(1),

714days(2),1528days(3),12mo

nths(4),27months(5),and47mon

ths(6).

Table3

Hierarchical multiple regression analysis to determine the pre-dictive value of global burnout and psychosomatic symptoms for

job satisfaction.

Variable Model 1 b Model 2 b Model 3 b

Academic hospital 0.10w 0.11w 0.09wAnaesthesiaresidents

0.15z 0.14z 0.12z

Sickness absence 0.17z 0.07*Perceived generalhealth

0.13z 0.03

Physicalsymptoms

0.01

Mental symptoms 0.04Global burnout 0.47zAdjusted R2 0.02 0.07 0.27F (df/df) 9.25 (2/879) 17.83 (4/877) 47.10 (7/874)

Each model includes the variables from the preceding model sothat the final model, model 3, includes all the variables listed inthis table. Model 1 predicted 2% of the variance in job satisfac-tion in model 1. Model 2 predicted 7% of the variance, andfinally, in model 3, 27% of the variance in job satisfaction waspredicted by global burnout (n5882).Values in the tables are standardized beta values (b).*Po0.05.wPo0.01.zPo0.001.


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an anaesthesiologist, the supplemental presence ofand cooperation with anaesthesia residents waspositively associated with job satisfaction, as itlikely increases the opportunities for postgraduatetraining and professionally discussion.

Although causality may be different (e.g., deci-sion latitude, hierarchical and social relations,

roles),

39

the associations found in this study corre-late to the findings among anaesthesiolo-gists.12,21,24,25,34,35,4042 Among anaesthesiologists,high stress levels were related to low social sup-port, on-call-related stress (sleep deprivation andphysical fatigue)12,15,32,34,35 and the lack of auton-omy (work pace and participation).24 Lindforset al.21 found job control as a mean factor forjob satisfaction, although for women, mental healthand for men organizational justice were also corre-lated to job satisfaction.

This study had several limitations. First, because

it had a cross-sectional self-report design, wecannot draw conclusions about the causality andlevels of burnout and physical and mental healthproblems. Self-reports are subject to bias: transientmood states and personality traits can interferewith outcome measures,43,44 because they interactwith ones perceptions. Employees who suffer fromstrain or burnout are likely to have higher rates ofjob turnover.3,6 This self-selection process allowscomparatively healthy employees to remain in jobs.The response rate of this study (46%) was lowcompared with a clinical trial, and one can debate

whether the perceptions reported in this studyreflect those of the total population. However,this response rate is comparable to the 3853%response rates found in other anonymous multisitesurveys of hospital-based nursing personnel;45 weattempted to discover the possible reasons for thelow response rate by asking the supervisors ofanaesthesia departments, and the following rea-sons were given: no computer available, not inter-ested, questions were too personal and no time.

In conclusion, the association between job satis-faction and burnout and psychosocial symptoms

among Dutch NAs has been identified in thisstudy. Burnout even predicted job satisfaction by27%. Our results confirm the importance of ahealthy psychosocial work environment for pro-moting higher levels of job satisfaction. A highdegree of job satisfaction is an important drive forNAs to participate in the healthcare job market,which is very important against the background ofexisting and increasing shortage of personnel. Thesefindings may also apply to anaesthesiologists who

share many tasks and work in close cooperationwith NA. Further research is essential to determinethe specific interaction between sickness absence,perceived general health and job satisfaction thatmight shed light on the causes of burnout, and howthey relate to job satisfaction among NAs.

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Address:Vera MeeusenDepartment of AnaesthesiologyCatharina Hospital Brabant Medical SchoolEindhovenMichelangelolaan 2

5623 EJ EindhovenThe Netherlandse-mail: [email protected]


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