qualitative research on nursing burnout

• Open access
• Published: 05 June 2020

Burnout in nursing: a theoretical review

• Chiara Dall’Ora 1 ,
• Jane Ball 2 ,
• Maria Reinius 2 &
• Peter Griffiths 1 , 2  

Human Resources for Health volume  18 , Article number:  41 ( 2020 ) Cite this article

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Workforce studies often identify burnout as a nursing ‘outcome’. Yet, burnout itself—what constitutes it, what factors contribute to its development, and what the wider consequences are for individuals, organisations, or their patients—is rarely made explicit. We aimed to provide a comprehensive summary of research that examines theorised relationships between burnout and other variables, in order to determine what is known (and not known) about the causes and consequences of burnout in nursing, and how this relates to theories of burnout.

We searched MEDLINE, CINAHL, and PsycINFO. We included quantitative primary empirical studies (published in English) which examined associations between burnout and work-related factors in the nursing workforce.

Ninety-one papers were identified. The majority ( n = 87) were cross-sectional studies; 39 studies used all three subscales of the Maslach Burnout Inventory (MBI) Scale to measure burnout. As hypothesised by Maslach, we identified high workload, value incongruence, low control over the job, low decision latitude, poor social climate/social support, and low rewards as predictors of burnout. Maslach suggested that turnover, sickness absence, and general health were effects of burnout; however, we identified relationships only with general health and sickness absence. Other factors that were classified as predictors of burnout in the nursing literature were low/inadequate nurse staffing levels, ≥ 12-h shifts, low schedule flexibility, time pressure, high job and psychological demands, low task variety, role conflict, low autonomy, negative nurse-physician relationship, poor supervisor/leader support, poor leadership, negative team relationship, and job insecurity. Among the outcomes of burnout, we found reduced job performance, poor quality of care, poor patient safety, adverse events, patient negative experience, medication errors, infections, patient falls, and intention to leave.

Conclusions

The patterns identified by these studies consistently show that adverse job characteristics—high workload, low staffing levels, long shifts, and low control—are associated with burnout in nursing. The potential consequences for staff and patients are severe. The literature on burnout in nursing partly supports Maslach’s theory, but some areas are insufficiently tested, in particular, the association between burnout and turnover, and relationships were found for some MBI dimensions only.

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Introduction

The past decades have seen a growing research and policy interest around how work organisation characteristics impact upon different outcomes in nursing. Several studies and reviews have considered relationships between work organisation variables and outcomes such as quality of care, patient safety, sickness absence, turnover, and job dissatisfaction [ 1 , 2 , 3 , 4 ]. Burnout is often identified as a nursing ‘outcome’ in workforce studies that seek to understand the effect of context and ‘inputs’ on outcomes in health care environments. Yet, burnout itself—what constitutes it, what factors contribute to its development, and what the wider consequences are for individuals, organisations, or their patients—is not always elucidated in these studies.

The term burnout was introduced by Freudenberger in 1974 when he observed a loss of motivation and reduced commitment among volunteers at a mental health clinic [ 5 ]. It was Maslach who developed a scale, the Maslach Burnout Inventory (MBI), which internationally is the most widely used instrument to measure burnout [ 6 ]. According to Maslach’s conceptualisation, burnout is a response to excessive stress at work, which is characterised by feelings of being emotionally drained and lacking emotional resources—Emotional Exhaustion; by a negative and detached response to other people and loss of idealism—Depersonalisation; and by a decline in feelings of competence and performance at work—reduced Personal Accomplishment [ 7 ].

Maslach theorised that burnout is a state, which occurs as a result of a prolonged mismatch between a person and at least one of the following six dimensions of work [ 7 , 8 , 9 ]:

Workload: excessive workload and demands, so that recovery cannot be achieved.

Control: employees do not have sufficient control over the resources needed to complete or accomplish their job.

Reward: lack of adequate reward for the job done. Rewards can be financial, social, and intrinsic (i.e. the pride one may experience when doing a job).

Community: employees do not perceive a sense of positive connections with their colleagues and managers, leading to frustration and reducing the likelihood of social support.

Fairness: a person perceiving unfairness at the workplace, including inequity of workload and pay.

Values: employees feeling constrained by their job to act against their own values and their aspiration or when they experience conflicts between the organisation’s values.

Maslach theorised these six work characteristics as factors causing burnout and placed deterioration in employees’ health and job performance as outcomes arising from burnout [ 7 ].

Subsequent models of burnout differ from Maslach’s in one of two ways: they do not conceptualise burnout as an exclusively work-related syndrome; they view burnout as a process rather than a state [ 10 ].

The job resources-demands model [ 11 ] builds on the view of burnout as a work-based mismatch but differs from Maslach’s model in that it posits that burnout develops via two separate pathways: excessive job demands leading to exhaustion, and insufficient job resources leading to disengagement. Along with Maslach and Schaufeli, this model sees burnout as the negative pole of a continuum of employee’s well-being, with ‘work engagement’ as the positive pole [ 12 ].

Among those who regard burnout as a process, Cherniss used a longitudinal approach to investigate the development of burnout in early career human services workers. Burnout is presented as a process characterised by negative changes in attitudes and behaviours towards clients that occur over time, often associated with workers’ disillusionment about the ideals that had led them to the job [ 13 ]. Gustavsson and colleagues used this model in examining longitudinal data on early career nurses and found that exhaustion was a first phase in the burnout process, proceeding further only if nurses present dysfunctional coping (i.e. cynicism and disengagement) [ 14 ].

Shirom and colleagues suggested that burnout occurs when individuals exhaust their resources due to long-term exposures to emotionally demanding circumstances in both work and life settings, suggesting that burnout is not exclusively an occupational syndrome [ 15 , 16 ].

This review aims to identify research that has examined theorised relationships with burnout, in order to determine what is known (and not known) about the factors associated with burnout in nursing and to determine the extent to which studies have been underpinned by, and/or have supported or refuted, theories of burnout.

This was a theoretical review conducted according to the methodology outlined by Campbell et al. and Pare et al. [ 17 , 18 ]. Theoretical reviews draw on empirical studies to understand a concept from a theoretical perspective and highlight knowledge gaps. Theoretical reviews are systematic in terms of searching and inclusion/exclusion criteria and do not include a formal appraisal of quality. They have been previously used in nursing, but not focussing on burnout [ 19 ]. While no reporting guideline for theoretical reviews currently exists, the PRISMA-ScR was deemed to be suitable, with some modifications, to enhance the transparency of reporting for the purposes of this review. The checklist, which can be found as Additional file 2 , has been modified as follows:

Checklist title has been modified to indicate that the checklist has been adapted for theoretical reviews.

Introduction (item 3) has been modified to reflect that the review questions lend themselves to a theoretical review approach.

Selection of sources of evidence (item 9) has been modified to state the process for selecting sources of evidence in the theoretical review.

Limitations (item 20) has been amended to discuss the limitations of the theoretical review process.

Funding (item 22) has been amended to describe sources of funding and the role of funders in the theoretical review.

All changes from the original version have been highlighted.

Literature search

A systematic search of empirical studies examining burnout in nursing published in journal articles since 1975 was performed in May 2019, using MEDLINE, CINAHL, and PsycINFO. The main search terms were ‘burnout’ and ‘nursing’, using both free-search terms and indexed terms, synonyms, and abbreviations. The full search and the total number of papers identified are in Additional file 1 .

We included papers written in English that measured the association between burnout and work-related factors or outcomes in all types of nurses or nursing assistants working in a healthcare setting, including hospitals, care homes, primary care, the community, and ambulance services. Because there are different theories of burnout, we did not restrict the definition of burnout according to any specific theory. Burnout is a work-related phenomenon [ 8 ], so we excluded studies focussing exclusively on personal factors (e.g. gender, age). Our aim was to identify theorised relationships; therefore, we excluded studies which were only comparing the levels of burnout among different settings (e.g. in cancer services vs emergency departments). We excluded literature reviews, commentaries, and editorials.

Data extraction and quality appraisal

The following data were extracted from included studies: country, setting, sample size, staff group, measure of burnout, variables the relationship with burnout was tested against, and findings against the hypothesised relationships. One reviewer (MEB) extracted data from all the studies, with CDO and JEB extracting 10 studies each to check for agreement in data extraction. In line with the theoretical review methodology, we did not formally assess the quality of studies [ 19 ]. However, in Additional file 3 , we have summarised the key aspects of quality for each study, covering generalisability (e.g. a multisite study with more than 500 participants); risk of bias from common methods variance (e.g. burnout and correlates assessed with the same survey. This bias arises when there is a shared (common) variance because of the common method rather than a true (causal) association between variables); evidence of clustering (e.g. nurses nested in wards, wards nested in hospitals); and evidence of statistical adjustment (e.g. the association between burnout and correlates has been adjusted to control for potentially influencing variables). It should be noted that cells are shaded in green when the above-mentioned quality standards have been met, and in red when they have not. In the ‘Discussion’ section, we offer a reflection on the common limitations of research in the field and present a graphic summary of the ‘strength of evidence’ in Fig. 1 .

Graphical representation of strength of relationships with burnout

Data synthesis

Due to the breadth of the evidence, we summarised extracted data by identifying common categories through a coding frame. The starting point of the coding frame was the burnout multidimensional theory outlined by Maslach [ 7 ]. We then considered whether the studies’ variables fit into Maslach’s categorisation, and where they did not, we created new categories. We identified nine broad categories: (1) Areas of Worklife; (2) Workload and Staffing Levels; (3) Job Control, Reward, Values, Fairness, and Community; (4) Shift Work and Working Patterns; (5) Psychological Demands and Job Complexity; (6) Support Factors: Working Relationships and Leadership; (7) Work Environment and Hospital Characteristics; (8) Staff Outcomes and Job Performance; and (9) Patient Care and Outcomes. In the literature, categories 1–7 were treated as predictors of burnout and categories 8 and 9 as outcomes, with the exception of missed care and job satisfaction which were treated both as predictors and outcomes.

When the coding frame was finalised, CDO and MLR applied it to all studies. Where there was disagreement, a third reviewer (JEB) made the final decision.

The database search yielded 12 248 studies, of which 11 870 were rapidly excluded as either duplicates or titles and/or abstract not meeting the inclusion criteria. Of the 368 studies accessed in full text, 277 were excluded, and 91 studies were included in the review. Figure 2 presents a flow chart of the study selection.

Study selection flow chart

The 91 studies identified covered 28 countries; four studies included multiple countries, and in one, the country was not reported. Most were from North America ( n = 35), Europe ( n = 28), and Asia ( n = 18).

The majority had cross-sectional designs ( n = 87, 97%); of these, 84 were entirely survey-based. Three studies were longitudinal. Most studies were undertaken in hospitals ( n = 82). Eight studies surveyed nurses at a national level, regardless of their work setting.

Sample sizes ranged from hundreds of hospitals (max = 927) with hundreds of thousands of nurses (max = 326 750) [ 20 ] to small single-site studies with the smallest sample being 73 nurses [ 21 ] (see Additional file 3 ).

The relationships examined are summarised in Table 1 .

Measures of burnout

Most studies used the Maslach Burnout Inventory Scale ( n = 81), which comprises three subscales reflecting the theoretical model: Emotional Exhaustion, Depersonalisation, and reduced Personal Accomplishment. However, less than half (47%, n = 39) of the papers measured and reported results with all three subscales. Twenty-three papers used the Emotional Exhaustion subscale only, and 11 papers used the Emotional Exhaustion and Depersonalisation subscales. In nine studies, the three MBI subscales were summed up to provide a composite score of burnout, despite Maslach and colleagues advising against such an approach [ 22 ].

Five studies used the Copenhagen Burnout Inventory (CBI) [ 23 ]. This scale consists of three dimensions of burnout: personal, work-related, and client-related. Two studies used the Malach-Pines Scale [ 24 ], and one used the burnout subscale of the Professional Quality of Life Measure (ProQoL5) scale, which posits burnout as an element of compassion fatigue [ 25 ]. Two studies used idiosyncratic measures of burnout based on items from other instruments [ 20 , 26 ].

Factors examined in relation to burnout: an overview

The studies which tested the relationships between burnout and Maslach’s six areas of worklife—workload, control, reward, community, fairness, and values—typically supported Maslach’s theory that these areas are predictors of burnout. However, some evidence is based only on certain MBI dimensions. High scores on the Areas of Worklife Scale [ 27 ] (indicating a higher degree of congruence between the job and the respondent) were associated with less likelihood of burnout, either directly [ 28 , 29 ] or through high occupational coping self-efficacy [ 30 ] and presence of civility norms and co-worker incivility [ 31 ].

The majority of studies looking at job characteristics hypothesised by the Maslach model considered workload ( n = 31) and job control and reward ( n = 10). While only a few studies ( n = 9) explicitly examined the hypothesised relationships between burnout and community, fairness, or values, we identified 39 studies that covered ‘supportive factors’ including relationships with colleagues and leadership.

A large number of studies included factors that fall outside of the Maslach model. Six main areas were identified:

Working patterns and shifts working ( n = 15)

Features inherent in the job such as psychological demand and complexity ( n = 24)

Job support from working relationships and leadership ( n = 39)

Hospital or environmental characteristics ( n = 28)

Staff outcomes and job performance ( n = 33)

Patient outcomes ( n = 17)

Individual attributes (personal or professional) ( n = 16)

Workload and staffing levels

Workload and characteristics of jobs that contribute to workload, such as staffing levels, were the most frequently examined factor in relation to burnout. Thirty studies found an association between high workload and burnout.

Of these, 13 studies looked specifically at measures of workload as a predictor of burnout. Workload was associated with Emotional Exhaustion in five studies [ 32 , 33 , 34 , 35 , 36 ], with some studies also reporting a relationship with Depersonalisation, and others Cynicism. Janssen reported that ‘mental work overload’ predicted Emotional Exhaustion [ 37 ]. Three studies concluded that workload is associated with both Emotional Exhaustion and Depersonalisation [ 38 , 39 , 40 ]. Kitaoka-Higashiguchi tested a model of burnout and found that heavy workload predicted Emotional Exhaustion, which in turn predicted Cynicism [ 41 ]. This was also observed in a larger study by Greengrass et al. who found that high workload was associated with Emotional Exhaustion, which consequently predicted Cynicism [ 42 ]. One study reported no association between workload and burnout components [ 43 ], and one study found an association between manageable workload and a composite burnout score [ 44 ].

Further 15 studies looked specifically at nurse staffing levels, and most reported that when nurses were caring for a higher number of patients or were reporting staffing inadequacy, they were more likely to experience burnout. No studies found an association between better staffing levels and burnout.

While three studies did not find a significant association with staffing levels [ 32 , 45 , 46 ], three studies found that higher patient-to-nurse ratios were associated with Emotional Exhaustion [ 47 , 48 , 49 ], and in one study, higher patient-to-nurse-ratios were associated with Emotional Exhaustion, Depersonalisation, and Personal Accomplishment [ 50 ]. One study concluded that Emotional Exhaustion mediated the relationship between patient-to-nurse ratios and patient safety [ 51 ]. Akman and colleagues found that the lower the number of patients nurses were responsible for, the lower the burnout composite score [ 52 ]. Similar results were highlighted by Faller and colleagues [ 53 ]. Lower RN hours per patient day were associated with burnout in a study by Thompson [ 20 ].

When newly qualified RNs reported being short-staffed, they were more likely to report Emotional Exhaustion and Cynicism 1 year later [ 54 ]. In a further study, low staffing adequacy was associated with Emotional Exhaustion [ 55 ]. Similarly, Leineweber and colleagues found that poor staff adequacy was associated with Emotional Exhaustion, Depersonalisation, and Personal Accomplishment [ 56 ]. Leiter and Spence Laschinger explored the relationship between staffing adequacy and all MBI subscales and found that Emotional Exhaustion mediated the relationship between staffing adequacy and Depersonalisation [ 57 ]. Time pressure was investigated in three studies, which all concluded that reported time pressure was associated with Emotional Exhaustion [ 58 , 59 , 60 ].

In summary, there is evidence that high workload is associated with Emotional Exhaustion, nurse staffing levels are associated with burnout, and time pressure is associated with Emotional Exhaustion.

Job control, reward, values, fairness, and community

Having control over the job was examined in seven studies. Galletta et al. found that low job control was associated with all MBI subscales [ 40 ], as did Gandi et al. [ 61 ]. Leiter and Maslach found that control predicted fairness, reward, and community, and in turn, fairness predicted values, and values predicted all MBI subscales [ 35 ]. Low control predicted Emotional Exhaustion only for nurses working the day shift [ 62 ], and Emotional Exhaustion was significantly related to control over practice setting [ 63 ]; two studies reported no effect of job control on burnout [ 44 , 64 ].

Reward predicted Cynicism [ 35 ] and burnout on a composite score [ 44 ]. Shamian and colleagues found that a higher score in the effort and reward imbalance scale was associated with Emotional Exhaustion, and higher scores in the effort and reward imbalance scale were associated with burnout measured by the CBI [ 65 ].

Value congruence refers to a match between the requirements of the job and people’s personal principles [ 7 ]. Value conflicts were related with a composite score of burnout [ 44 ], and one study concluded that nurses with a high value congruence reported lower Emotional Exhaustion than those with a low value congruence, and nurses with a low value congruence experienced more severe Depersonalisation than nurses with a high value congruence [ 66 ]. Low value congruence was a predictor of all three MBI dimensions [ 35 ] and of burnout measured with the Malach-Pines Burnout Scale [ 67 ]. Two studies considered social capital, defined as a social structure that benefits its members including trust, reciprocity, and a set of shared values, and they both concluded that lower social capital in the hospital-predicted Emotional Exhaustion [ 33 , 36 ]. A single study showed fairness predicted values, which in turn predicted all MBI Scales [ 35 ]. Two studies looked at community, and one found that community predicts a composite score of burnout [ 44 ], while the other found no relationships [ 35 ].

While not directly expressed in the terms described by Maslach, other studies demonstrate associations with possible causal factors, many of which are reflected in Maslach’s theory.

In summary, there is evidence that control over the job is associated with reduced burnout, and value congruence is associated with reduced Emotional Exhaustion and Depersonalisation.

Working patterns and shift work

Shift work and working patterns variables were considered by 15 studies. Overall, there was mixed evidence on the relationship between night work, number of hours worked per week, and burnout, with more conclusive results regarding the association between long shifts and burnout, and the potential protective effect of schedule flexibility.

Working night shifts was associated with burnout (composite score) [ 68 ] and Emotional Exhaustion [ 62 ], but the relationship was not significant in two studies [ 69 , 70 ]. Working on permanent as opposed to rotating shift patterns did not impact burnout [ 71 ], but working irregular shifts did impact a composite burnout score [ 72 ]. When nurses reported working a higher number of shifts, they were more likely to report higher burnout composite scores [ 68 ], but results did not generalise in a further study [ 69 ]. One study found working that overtime was associated with composite MBI score [ 73 ]. On-call requirement was not significantly associated with any MBI dimensions [ 71 ].

The number of hours worked per week was not a significant predictor of burnout according to two studies [ 25 , 53 ], but having a higher number of weekly hours was associated with Emotional Exhaustion and Depersonalisation in one study [ 70 ]. Long shifts of 12 h or more were associated with all MBI subscales [ 74 ] and with Emotional Exhaustion [ 49 , 75 ]. A study using the ProQoL5 burnout scale found that shorter shifts were protective of burnout [ 25 ].

Having higher schedule flexibility was protective of Emotional Exhaustion [ 46 ], and so was the ability to schedule days off for a burnout composite score [ 76 ]. Having more than 8 days off per month was associated with lower burnout [ 69 ]. Stone et al. found that a positive scheduling climate was protective of Emotional Exhaustion only [ 77 ].

In summary, we found an association between ≥ 12-h shifts and Emotional Exhaustion and between schedule flexibility and reduced Emotional Exhaustion.

Psychological demands and job complexity

There is evidence from 24 studies that job demands and aspects intrinsic to the job, including role conflict, autonomy, and task variety, are associated with some burnout dimensions.

Eight studies considered psychological demands. The higher the psychological demands, the higher the likelihood of experiencing all burnout dimensions [ 72 ], and high psychological demands were associated with higher odds of Emotional Exhaustion [ 62 , 78 ]. Emotional demands, in terms of hindrances, had an effect on burnout [ 67 ]. One study reported that job demands, measured with the Effort-Reward Imbalance Questionnaire, were correlated with all burnout dimensions [ 79 ], and similarly, Garcia-Sierra et al. found that demands predict burnout, measured with a composite scale of Emotional Exhaustion and Cynicism [ 80 ]. According to one study, job demands were not associated with burnout [ 73 ], and Rouxel et al. concluded that the higher the job demands, the higher the impact on both Emotional Exhaustion and Depersonalisation [ 64 ].

Four studies looked at task nature and variety, quality of job content, in terms of skill variety, skill discretion, task identity, task significance, influenced Emotional Exhaustion through intrinsic work motivation [ 37 ]. Skill variety and task significance were related to Emotional Exhaustion; task significance was also related to Personal Accomplishment [ 60 ]. Having no administrative tasks in the job was associated with a reduced likelihood to experience Depersonalisation [ 71 ]. Higher task clarity was associated with reduced levels of Emotional Exhaustion and increased Personal Accomplishment [ 58 ].

Patient characteristics/requirements were investigated in four papers. When nurses were caring for suffering patients and patients who had multiple requirements, they were more likely to experience Emotional Exhaustion and Cynicism. Similarly, caring for a dying patient and having a high number of decisions to forego life-sustaining treatments were associated with a higher likelihood of burnout (measured with a composite score) [ 76 ]. Stress resulting from patient care was associated with a composite burnout score [ 73 ]. Patient violence also had an impact on burnout, measured with CBI [ 81 ], as did conflict with patients [ 76 ].

Role conflict is a situation in which contradictory, competing, or incompatible expectations are placed on an individual by two or more roles held at the same time. Role conflict predicted Emotional Exhaustion [ 41 ], and so it did in a study by Konstantinou et al., who found that role conflict was associated with Emotional Exhaustion and Depersonalisation [ 34 ]; Levert and colleagues reported that role conflict correlated with Emotional Exhaustion, Depersonalisation, and Personal Accomplishment. They also considered role ambiguity, which correlated with Emotional Exhaustion and Depersonalisation, but not Personal Accomplishment [ 39 ]. Andela et al. investigated the impact of emotional dissonance, defined as the mismatch between the emotions that are felt and the emotions required to be displayed by organisations. They reported that emotional dissonance is a mediator between job aspects (i.e. workload, patient characteristics, and team issues) and Emotional Exhaustion and Cynicism. Rouxel et al. found that perceived negative display rules were associated with Emotional Exhaustion [ 64 ].

Autonomy related to Emotional Exhaustion and Depersonalisation [ 60 ], and in another study, it only related to Depersonalisation [ 43 ]. Low autonomy impacted Emotional Exhaustion via organisational trust [ 82 ]. Autonomy correlated with burnout [ 67 ]. There was no effect of autonomy on burnout according to two studies [ 58 , 63 ]. Low decision-making at the ward level was associated with all MBI subscales [ 77 ]. Decision latitude impacted Personal Accomplishment only [ 36 ], and in one study, it was found to be related to Emotional Exhaustion [ 78 ]. High decision latitude was associated with Personal Accomplishment [ 41 ] and low Emotional Exhaustion [ 33 ].

Overall, high job and psychological demands were associated with Emotional Exhaustion, as was role conflict. Patient complexity was associated with burnout, while task variety, autonomy, and decision latitude were protective of burnout.

Working relationships and leadership

Overall, evidence from 39 studies supports that having positive support factors and working relationships in place, including positive relationships with physicians, support from the leader, positive leadership style, and teamwork, might play a protective role towards burnout.

The quality of the relationship with physicians was investigated by 12 studies. In two studies, having negative relationships with physicians was associated with all MBI dimensions [ 77 , 83 ]; quality of nurse-physician relationship was associated with Emotional Exhaustion and Depersonalisation, but not PA [ 50 ]. Two studies found an association with Emotional Exhaustion only [ 55 , 84 ], and one concluded that quality of relationship with physicians indirectly supported PA [ 36 ]. This was also found by Leiter and Laschinger, who found that positive nurse-physician collaborations predicted Personal Accomplishment [ 57 , 85 ]. When burnout was measured with composite scores of MBI and a not validated scale, two studies reported an association with nurse-physician relationship [ 20 , 76 ], and two studies found no associations [ 56 , 63 ].

Having support from the supervisor or leader was considered in 12 studies, which found relationships with different MBI dimensions. A relationship between low support from nurse managers and all MBI subscales was observed in one study [ 77 ], while two studies reported it is a protective factor from Emotional Exhaustion only [ 58 , 83 ], and one that it was also associated with Depersonalisation [ 86 ]. Kitaoka-Higashiguchi reported an association only with Cynicism [ 41 ], and Jansen et al. found it was only associated with Depersonalisation and Personal Accomplishment [ 60 ]. Van Bogaert and colleagues found that support from managers predicted low Emotional Exhaustion and high Personal Accomplishment [ 84 ], but in a later study, it only predicted high Personal Accomplishment [ 36 ]. Regarding the relationship with the manager, it had a direct effect on Depersonalisation, and it moderated the effect of time pressure on Emotional Exhaustion and Depersonalisation [ 59 ]; a protective effect of a quality relationship with the head nurse on a composite burnout score was also reported [ 76 ]. Two studies using different burnout scales found an association between manager support and reduced burnout [ 25 , 67 ]. Low trust in the leader showed a negative impact on burnout, measured with a composite score [ 87 ]. Two further studies focused on the perceived nurse manager’s ability: authors found that it was related to Emotional Exhaustion [ 46 ], and Emotional Exhaustion and Personal Accomplishment [ 50 ].

Fourteen studies looked at the leadership style and found that it affects burnout through different pathways and mechanisms. Boamah et al. found that authentic leadership—described as leaders who have high self-awareness, balanced processing, an internalised moral perspective, and transparency—predicted higher empowerment, which in turn predicted lower levels of Emotional Exhaustion and Cynicism a year later [ 54 ]. Authentic leadership had a negative direct effect on workplace bullying, which in turn had a direct positive effect on Emotional Exhaustion [ 88 ]. Effective leadership predicted staffing adequacy, which in turn predicted Emotional Exhaustion [ 57 , 85 ]. Authentic leadership predicted all areas of worklife, which in turn predicted all MBI dimensions of burnout [ 30 ], and a similar pathway was identified by Laschiner and Read, although authentic leadership impacted Emotional Exhaustion only and it was also through civility norms and co-worker incivility [ 31 ]. Emotional Exhaustion mediated the relationship between authentic leadership and intention to leave the job [ 89 ]. ‘Leader empowering behaviour’ had an indirect effect on Emotional Exhaustion through structural empowerment [ 29 ], and empowering leadership predicted trust in the leader, which in turn was associated with burnout composite score [ 87 ]. Active management-by-exception was beneficial for Depersonalisation and Personal Accomplishment, passive laissez-faire leadership negatively affected Emotional Exhaustion and Personal Accomplishment, and rewarding transformational leadership protected from Depersonalisation [ 90 ]. Contrary to this, Madathil et al. found that transformational leadership protected against Emotional Exhaustion, but not Depersonalisation, and promoted Personal Accomplishment [ 43 ]. Transformational leadership predicted positive work environments, which in turn predicted lower burnout (composite score) [ 44 ]. Positive leadership affected Emotional Exhaustion and Depersonalisation [ 56 ] and burnout measured with a non-validated scale [ 20 ].

Teamwork and social support were also explored. Co-worker cohesion was only related to Depersonalisation [ 58 ]; team collaboration problems predicted negative scores on all MBI subscales [ 38 ], and workplace support protected from Emotional Exhaustion [ 72 ]. Similarly, support received from peers had a protective effect on Emotional Exhaustion [ 60 ]. Collegial support was related to Emotional Exhaustion and Personal Accomplishment [ 39 ], and colleague support protected from burnout [ 67 ]. Interpersonal conflict affected Emotional Exhaustion through role conflict, but co-worker support had no effect on any burnout dimensions [ 41 ], and similarly, co-worker incivility predicted Emotional Exhaustion [ 31 ], and so did bullying [ 88 ]. Poor team communication was associated with all MBI dimensions [ 40 ], staff issues predicted burnout measured with a composite score [ 73 ], and so did verbal violence from colleagues [ 68 ]. One study found that seeking social support was not associated with any of the burnout dimensions, while another study found that low social support predicted Emotional Exhaustion [ 37 ], and social support was associated with lower Emotional Exhaustion and higher Personal Accomplishment [ 21 ]. Vidotti et al. found an association between low social support and all MBI dimensions [ 62 ].

Work environment and hospital characteristics

Eleven studies were considering the work environment measured with the PES-NWI scale [ 91 ], where higher scores indicate positive work environments. Five studies comprising diverse samples and settings concluded that the better rated the work environment, the lower the likelihood of experiencing Emotional Exhaustion [ 32 , 47 , 49 , 51 , 92 ], and four studies found the same relationship, but on both Emotional Exhaustion and Depersonalisation [ 50 , 66 , 93 , 94 ]; only one study concluded there is an association between work environment and all MBI dimensions [ 95 ]. Negative work environments affected burnout (measured with a composite score) via job dissatisfaction [ 96 ]. One study looked at organisational characteristics on a single scale and found that a higher rating of organisational characteristics predicted lower Emotional Exhaustion [ 82 ]. Environmental uncertainty was related to all MBI dimensions [ 86 ].

Structural empowerment was also considered in relation to burnout: high structural empowerment led to lower Emotional Exhaustion and Cynicism via staffing levels and worklife interference [ 54 ]; in a study using a similar methodology, structural empowerment affected Emotional Exhaustion via Areas of Worklife [ 29 ]. The relationship between Emotional Exhaustion and Cynicism was moderated by organisational empowerment [ 40 ], and organisational support had a protective effect on burnout [ 67 ]. Hospital management and organisational support had a direct effect on Emotional Exhaustion and Personal Accomplishment [ 84 ]. Trust in the organisation predicted lower levels of Emotional Exhaustion [ 82 ] and of burnout measured with a composite MBI score [ 87 ].

Three studies considered whether policy involvement had an effect on burnout. Two studies on the same sample found that having the opportunity to participate in policy decisions was associated with reduced burnout (all subscales) [ 57 , 85 ], and one study did not report results for the association [ 20 ]. Emotional Exhaustion mediated the relationship between nurses’ participation in hospital affairs and their intention to leave the job [ 97 ]; a further study did not found an association between participation in hospital affairs and Emotional Exhaustion, but only with Personal Accomplishment [ 50 ]. Lastly, one study investigated participation in research groups and concluded it was associated with reduced burnout measured with a composite score [ 76 ].

There was an association between opportunity for career advancement and all MBI dimensions [ 77 ]; however, another study found that having promotion opportunities was not related to burnout [ 79 ]. Moloney et al. found that professional development was not related to burnout [ 67 ]. Two studies considered pay. In one study, no effect was found on any MBI dimension [ 73 ], and a very small study ( n = 78 nurses) reported an effect of satisfaction with pay on Emotional Exhaustion and Depersonalisation [ 34 ]. Job insecurity predicted Depersonalisation and PA [ 79 ].

When the hospital adopted nursing models of care rather than medical models of care, nurses were more likely to report high levels of Personal Accomplishment [ 57 , 85 ]. However, another study found no significant relationship [ 20 ]. Regarding ward and hospital type, Aiken and Sloane found that RNs working in specialised AIDS units reported lower levels of Emotional Exhaustion [ 98 ]; however, ward type was not found to be significantly associated with burnout in a study on temporary nurses [ 53 ]. Working in different ward settings was not associated with burnout, but working in hospitals as opposed to in primary care was associated with lower Emotional Exhaustion [ 71 ]. Working in a small hospital was associated with a lower likelihood of Emotional Exhaustion, when compared to working in a community hospital [ 63 ]. Faller’s study also concluded that working in California was a significant predictor of reduced burnout.

When the hospitals’ investment in the quality of care was considered, one study found that having foundations for quality of care was associated with reduced Emotional Exhaustion only [ 50 ], but in another study, foundations for quality of care were associated with all MBI dimensions [ 83 ]. Working in a Magnet hospital was not associated with burnout [ 53 ].

In summary, having a positive work environment (generally work environments scoring higher on the PES-NWI scale) was associated with reduced Emotional Exhaustion, and so was higher structural empowerment. However, none of the organisational characteristics at the hospital level was consistently associated with burnout.

Staff outcomes and job performance

Nineteen studies considered the impact of burnout on intention to leave. Two studies found that Emotional Exhaustion and Cynicism had a direct effect on turnover intentions [ 28 , 99 ], and four studies reported that only Emotional Exhaustion affected intentions to leave the job [ 21 , 32 , 37 , 100 ], with one of these indicating that Emotional Exhaustion affected also intention to leave the organisation [ 32 ], but one study did not replicate such findings [ 101 ] and concluded that only Cynicism was associated with intention to leave the job and nursing. Similarly, one study found that Cynicism was directly related to intention to leave [ 35 ]. A further study found that Emotional Exhaustion affected turnover intentions via job satisfaction [ 88 ], and one article reported that Emotional Exhaustion mediated the effect of authentic leadership on intention to leave [ 89 ]. Emotional Exhaustion was a mediator between nurses’ involvement with decisions and intention to leave the organisation [ 97 ]. Burnout measured on a composite score was associated with a higher intention to leave [ 96 ]. Laeeque et al. reported that burnout, captured with CBI, related to intention to leave [ 81 ]; Estryn-Behar et al. used the same scale to measure burnout and found that high burnout was associated with higher intention to leave in all countries, except for Slovakia [ 102 ]. Burnout, measured with the Malach-Pines Scale, was associated with intention to quit, and stronger associations were found for nurses who had higher perceptions of organisational politics [ 103 ]. Burnout (Malach-Pines Scale) predicted both the intention to leave the job and nursing [ 67 ]. Three studies investigated the relationship between burnout and intention to leave; one of these aggregated all job outcomes in a single variable (i.e. job satisfaction, intention to leave the hospital, applied for another job, and intention to leave nursing) and reported that Depersonalisation and Personal Accomplishment predict job outcomes [ 84 ]; they replicated a similar approach and found the same associations [ 36 ]. They later found that all MBI dimensions were associated with leaving the nursing profession [ 104 ]. Only one study in a sample of 106 nurses from one hospital found an association between Depersonalisation and turnover within 2 years [ 105 ].

Two studies looked at the effect of burnout on job performance: one found a negative association between burnout (measured with CBI) and both task performance and contextual performance [ 106 ]. Only Emotional Exhaustion was associated with self-rated and supervisor-rated job performance of 73 RNs [ 21 ]. Missed care was investigated in three studies, and it was found to be both predictor of Emotional Exhaustion [ 32 ], an outcome of burnout [ 20 , 103 ].

Four studies considered sickness absence. When RNs had high levels of Emotional Exhaustion, they were more likely to experience short-term sickness absence (i.e. 1–10 days of absence), which was obtained from hospital administrative records. Similarly, Emotional Exhaustion was associated with seven or more days of absence in a longitudinal study [ 105 ]. Emotional Exhaustion was significantly associated with reported mental health absenteeism, but not reported physical health absenteeism, and sickness absence from administrative records [ 21 ]. One study did not find any meaningful relationships between burnout and absenteeism [ 107 ].

Emotional Exhaustion was a significant predictor of general health [ 73 ], and in a further study, both Emotional Exhaustion and Personal Accomplishment were associated with perceived health [ 70 ]. Final-year nursing students who experienced health issues were more likely to develop high burnout when entering the profession [ 26 ]. When quality of sleep was treated both as a predictor and outcome of burnout, relationships were found in both instances [ 106 ].

Focussing on mental health, one study found that burnout predicted mental health problems for newly qualified nurses [ 30 ], and Emotional Exhaustion and Cynicism predicted somatisation [ 42 ]. Depressive symptoms were predictive of Emotional Exhaustion and Depersonalisation, considering therefore depression as a predictor of burnout [ 108 ]. Rudman and Gustavsson also found that having depressive mood and depressive episodes were common features of newly qualified nurses who developed or got worse levels of burnout throughout their first years in the profession [ 26 ]. Tourigny et al. considered depression as a predictor and found it was significantly related to Emotional Exhaustion [ 107 ].

Eleven studies considered job satisfaction: of these, three treated job satisfaction as a predictor of burnout and concluded that higher levels of job satisfaction were associated with a lower level of composite burnout scores [ 52 , 96 ] and all MBI dimensions [ 94 ]. According to two studies, Emotional Exhaustion and Cynicism predicted job dissatisfaction [ 54 , 101 ], while four studies reported that Emotional Exhaustion only was associated with increased odds to report job dissatisfaction [ 73 , 82 , 88 , 100 ]; one study reported that Cynicism only was associated with job dissatisfaction [ 99 ]. Rouxel et al. did not find support in their hypothesised model that Emotional Exhaustion and Depersonalisation predicted job satisfaction [ 64 ].

In summary, considering 39 studies, there is conflicting evidence on the direction of the relationship between burnout and missed care, mental health, and job satisfaction. An association between burnout and intention to leave was found, although only one small study reported an association between burnout and turnover. A moderate relationship was found for the effect of burnout on sickness absence, job performance, and general health.

Patient care and outcomes

Among the patient outcomes of burnout, quality of care was investigated by eight studies. Two studies in diverse samples and settings reported that high Emotional Exhaustion, high Depersonalisation, and low Personal Accomplishment were associated with poor quality of care [ 109 , 110 ], but one study found that only Personal Accomplishment was related to better quality of care at the last shift [ 104 ]; Emotional Exhaustion and Cynicism predict low quality of care [ 54 ]; two articles reported that Emotional Exhaustion predicts poor nurse ratings of quality of care [ 82 , 84 ]. A high burnout composite score predicted poor nurse-assessed quality of care [ 96 ]. In one instance, no associations were found between any of the burnout dimensions and quality of care [ 36 ].

Five studies considered aspects of patient safety: burnout was correlated with negative patient safety climate [ 111 ]. Emotional Exhaustion and Depersonalisation were both associated with negative patient safety grades and safety perceptions [ 112 ], and burnout fully mediated the relationship between depression and individual-level safety perceptions and work area/unit level safety perceptions [ 108 ]. Emotional Exhaustion mediated the relationship between workload and patient safety [ 51 ], and a higher composite burnout score was associated with lower patient safety ratings [ 113 ].

Regarding adverse events, high DEP and low Personal Accomplishment predicted a higher rate of adverse events [ 85 ], but in another study, only Emotional Exhaustion predicted adverse events [ 51 ]. When nurses were experiencing high levels of Emotional Exhaustion, they were less likely to report near misses and adverse events, and when they were experiencing high levels of Depersonalisation, they were less likely to report near misses [ 112 ].

All three MBI dimensions predicted medication errors in one study [ 109 ], but Van Bogaert et al. found that only high levels of Depersonalisation were associated with medication errors [ 104 ]. High scores in Emotional Exhaustion and Depersonalisation predicted infections [ 109 ]. Cimiotti et al. found that Emotional Exhaustion was associated with catheter-associated urinary tract infections and surgical site infections [ 114 ], while in another study, Depersonalisation was associated with nosocomial infections [ 104 ]. Lastly, patient falls were also explored, and Depersonalisation and low Personal Accomplishment were significant predictors in one study [ 109 ], while in a further study, only Depersonalisation was associated with patient falls [ 104 ]. There was no association between burnout and hospital-acquired pressure ulcers [ 20 ].

Considering patient experience, Vahey et al. concluded that higher Emotional Exhaustion and low Personal Accomplishment levels were associated with patient dissatisfaction [ 93 ], and Van Bogaert et al. found that Emotional Exhaustion was related to patient and family verbal abuse, and Depersonalisation was related to both patient and family verbal abuse and patient and family complaints [ 104 ].

In summary, evidence deriving from 17 studies points to a negative effect of burnout on quality of care, patient safety, adverse events, error reporting, medication error, infections, patient falls, patient dissatisfaction, and family complaints, but not on pressure ulcers.

Individual characteristics

In total, 16 studies, which had examined work characteristics related to burnout, also considered the relationship between characteristics of the individual and burnout. Relationships were tested on demographic variables, including gender, age, and family status; on personality aspects; on work-life interference; and on professional attributes including length of experience and educational level. Because our focus on burnout is as a job-related phenomenon, we have not reported results of these studies into detail, but overall evidence on demographic and personality factors was inconclusive, and having family issues and high work-life interference was associated with different burnout dimensions. Being younger and not having a bachelor’s degree were found to be associated with a higher incidence of burnout.

This review aimed to identify research that had examined theorised relationships with burnout, in order to determine what is known (and not known) about the factors associated with burnout in nursing and to determine the extent to which studies have been underpinned by, and/or have supported or refuted, theories of burnout. We found that the associations hypothesised by Maslach’s theory between mismatches in areas of worklife and burnout were generally supported.

Research consistently found that adverse job characteristics—high workload, low staffing levels, long shifts, low control, low schedule flexibility, time pressure, high job and psychological demands, low task variety, role conflict, low autonomy, negative nurse-physician relationship, poor supervisor/leader support, poor leadership, negative team relationship, and job insecurity—were associated with burnout in nursing.

However few studies used all three MBI subscales in the way intended, and nine used different approaches to measuring burnout.

The field has been dominated by cross-sectional studies that seek to identify associations with one or two factors, rarely going beyond establishing correlation. Most studies were limited by their cross-sectional nature, the use of different or incorrectly applied burnout measures, the use of common methods (i.e. survey to capture both burnout and correlates), and omitted variables in the models. The 91 studies reviewed, while highlighting the importance of burnout as a feature affecting nurses and patient care, have generally lacked a theoretical approach, or identified mechanisms to test and develop a theory on the causes and consequences of burnout, but were limited in their testing of likely mechanisms due to cross-sectional and observational designs.

For example, 19 studies showed relationships between burnout and job satisfaction, missed care, and mental health. But while some studies treated these as predictors of burnout, others handled as outcomes of burnout. This highlights a further issue that characterises the burnout literature in nursing: the simultaneity bias, due to the cross-sectional nature of the evidence. The inability to establish a temporal link means limits the inference of causality [ 115 ]. Thus, a factor such as ‘missed care’ could lead to a growing sense of compromise and ‘crushed ideals’ in nurses [ 116 ], which causes burnout. Equally, it could be that job performance of nurses experiencing burnout is reduced, leading to increased levels of ‘missed care’. Both are plausible in relation to Maslach’s original theory of burnout, but research is insufficient to determine which is most likely, and thereby develop the theory.

To help address this, three areas of development within research are proposed. Future research adopting longitudinal designs that follow individuals over time would improve the potential to understand the direction of the relationships observed. Research using Maslach’s theory should use and report all three MBI dimensions; where only the Emotional Exhaustion subscale is used, this should be explicit and it should not be treated as being synonymous to burnout. Finally, to move our theoretical understanding of burnout forward, research needs to prioritise the use of empirical data on employee behaviours (such as absenteeism, turnover) rather than self-report intentions or predictions.

Addressing these gaps would provide better evidence of the nature of burnout in nursing, what causes it and its potential consequences, helping to develop evidence-based solutions and motivate work-place change. With better insight, health care organisations can set about reducing the negative consequences of having patient care provided by staff whose work has led them to become emotionally exhausted, detached, and less able to do the job, that is, burnout.

Limitations

Our theoretical review of the literature aimed to summarise information from a large quantity of studies; this meant that we had to report studies without describing their context in the text and also without providing estimates (i.e. ORs and 95% CIs). In appraising studies, we did not apply a formal quality appraisal instrument, although we noted key omissions of important details. However, the results of the review serve to illustrate the variety of factors that may influence/result from burnout and demonstrate where information is missing. We did not consider personality and other individual variables when extracting data from studies. However, Maslach and Leiter recently reiterated that although some connections have been made between burnout and personality characteristics, the evidence firmly points towards work characteristics as the primary drivers of burnout [ 8 ].

While we used a reproducible search strategy searching MEDLINE, CINAHL, and PsycINFO, it is possible that there are studies indexed elsewhere and we did not identify them, and we did not include grey literature. It seems unlikely that these exist in sufficient quantity to substantively change our conclusions.

Patterns identified across 91 studies consistently show that adverse job characteristics are associated with burnout in nursing. The potential consequences for staff and patients are severe. Maslach’s theory offers a plausible mechanism to explain the associations observed. However incomplete measurement of burnout and limited research on some relationships means that the causes and consequences of burnout cannot be reliably identified and distinguished, which makes it difficult to use the evidence to design interventions to reduce burnout.

Availability of data and materials

Not applicable

Abbreviations

• Maslach Burnout Inventory

Copenhagen Burnout Inventory

Professional Quality of Life Measure

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Dall’Ora, C., Ball, J., Reinius, M. et al. Burnout in nursing: a theoretical review. Hum Resour Health 18 , 41 (2020). https://doi.org/10.1186/s12960-020-00469-9

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Stress, Burnout, and Low Self-Efficacy of Nursing Professionals: A Qualitative Inquiry

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• 1 Woosong Language Institute, Woosong University, Daejeon 34514, Korea.
• PMID: 33114006
• PMCID: PMC7712145
• DOI: 10.3390/healthcare8040424

Nursing professionals face a high level of stress and burnout due to overloaded responsibilities, which may cause a low level of self-efficacy. From the perspective of nursing professionals, the research aims to understand what are the sources of stress and burnout which would reduce the self-efficacy and the unbalanced patient ratio and how would nursing professionals describe their experiences, sources of stress and burnout, and self-efficacy. Based on the snowball sampling strategy, 60 nursing professionals were invited for qualitative research data collection. Based on the lens of the self-efficacy approach, the results indicated that the environmental factors, including workplace bullying, family stress, misunderstanding of public members, and personal development and career enhancement took important roles in increasing their stress and burnout and in reducing their self-efficacy. The outcomes of this study discovered the social status and discrimination toward nursing professionals. Government leaders, policymakers, and researchers should take this research as an opportunity to reform their policy for human resource management and education for the respectfulness of medical and nursing professionals in the public health system.

Keywords: bullying; burnout; discrimination; registered nurse; self-efficacy; stress.

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The authors declare no conflict of interest.

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Peer-reviewed

Research Article

The relationship between workload and burnout among nurses: The buffering role of personal, social and organisational resources

Roles Conceptualization, Data curation, Formal analysis, Investigation, Methodology, Project administration, Resources, Software, Validation, Visualization, Writing – original draft, Writing – review & editing

Affiliation Institute of Occupational, Social and Environmental Medicine, University Medical Center of the Johannes Gutenberg University Mainz, Mainz, Germany

Roles Conceptualization, Data curation, Investigation, Methodology, Project administration, Resources, Software, Writing – review & editing

Roles Conceptualization, Funding acquisition, Investigation, Resources, Writing – review & editing

Roles Conceptualization, Investigation, Methodology, Project administration, Resources, Supervision, Writing – review & editing

Affiliation Institute for Health Services Research in Dermatology and Nursing (IVDP), University Medical Center Hamburg-Eppendorf, Hamburg, Germany

Roles Conceptualization, Investigation, Methodology, Resources, Supervision, Writing – review & editing

Affiliations Institute for Health Services Research in Dermatology and Nursing (IVDP), University Medical Center Hamburg-Eppendorf, Hamburg, Germany, Department for Occupational Medicine, Hazardous Substances and Health Science, Institution for Accident Insurance and Prevention in the Health and Welfare Services (BGW), Hamburg, Germany

Roles Conceptualization, Funding acquisition, Investigation, Methodology, Project administration, Resources, Supervision, Writing – review & editing

¶ ‡ These authors are joint senior authors on this work.

Affiliations Institute of Occupational, Social and Environmental Medicine, University Medical Center of the Johannes Gutenberg University Mainz, Mainz, Germany, Federal Institute for Occupational Safety and Health (BAuA), Berlin, Germany

Roles Supervision, Writing – review & editing

* E-mail: [email protected]

• Elisabeth Diehl, 
• Sandra Rieger, 
• Stephan Letzel, 
• Anja Schablon, 
• Albert Nienhaus, 
• Luis Carlos Escobar Pinzon, 
• Pavel Dietz

• Published: January 22, 2021
• https://doi.org/10.1371/journal.pone.0245798
• Peer Review
• Reader Comments

Workload in the nursing profession is high, which is associated with poor health. Thus, it is important to get a proper understanding of the working situation and to analyse factors which might be able to mitigate the negative effects of such a high workload. In Germany, many people with serious or life-threatening illnesses are treated in non-specialized palliative care settings such as nursing homes, hospitals and outpatient care. The purpose of the present study was to investigate the buffering role of resources on the relationship between workload and burnout among nurses. A nationwide cross-sectional survey was applied. The questionnaire included parts of the Copenhagen Psychosocial Questionnaire (COPSOQ) (scale ‘quantitative demands’ measuring workload, scale ‘burnout’, various scales to resources), the resilience questionnaire RS-13 and single self-developed questions. Bivariate and moderator analyses were performed. Palliative care aspects, such as the ‘extent of palliative care’, were incorporated to the analyses as covariates. 497 nurses participated. Nurses who reported ‘workplace commitment’, a ‘good working team’ and ‘recognition from supervisor’ conveyed a weaker association between ‘quantitative demands’ and ‘burnout’ than those who did not. On average, nurses spend 20% of their working time with palliative care. Spending more time than this was associated with ‘burnout’. The results of our study imply a buffering role of different resources on burnout. Additionally, the study reveals that the ‘extent of palliative care’ may have an impact on nurse burnout, and should be considered in future studies.

Citation: Diehl E, Rieger S, Letzel S, Schablon A, Nienhaus A, Escobar Pinzon LC, et al. (2021) The relationship between workload and burnout among nurses: The buffering role of personal, social and organisational resources. PLoS ONE 16(1): e0245798. https://doi.org/10.1371/journal.pone.0245798

Editor: Adrian Loerbroks, Universtiy of Düsseldorf, GERMANY

Received: July 30, 2020; Accepted: January 7, 2021; Published: January 22, 2021

Copyright: © 2021 Diehl et al. This is an open access article distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

Data Availability: According to the Ethics Committee of the Medical Association of Rhineland-Palatinate (Study ID: 837.326.16 (10645)), the Institute of Occupational, Social and Environmental Medicine of the University Medical Center of the University Mainz is specified as data holding organization. The institution is not allowed to share the data publically in order to guarantee anonymity to the institutions that participated in the survey because some institution-specific information could be linked to specific institutions. The data set of the present study is stored on the institution server at the University Medical Centre of the University of Mainz and can be requested for scientific purposes via the institution office. This ensures that data will be accessible even if the authors of the present paper change affiliation. Postal address: University Medical Center of the University of Mainz, Institute of Occupational, Social and Environmental Medicine, Obere Zahlbacher Str. 67, D-55131 Mainz. Email address: [email protected] .

Funding: The research was funded by the BGW - Berufsgenossenschaft für Gesundheitsdienst und Wohlfahrtspflege (Institution for Statutory Accident Insurance and Prevention in Health and Welfare Services). The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.

Competing interests: I have read the journal’s policy and the authors of this manuscript have the following competing interests: The project was funded by the BGW - Berufsgenossenschaft für Gesundheitsdienst und Wohlfahrtspflege (Institution for Statutory Accident Insurance and Prevention in Health and Welfare Services). The BGW is responsible for the health concerns of the target group investigated in the present study, namely nurses. Prof. Dr. A. Nienhaus is head of the Department for Occupational Medicine, Hazardous Substances and Health Science of the BGW and co-author of this publication. All other authors declare to have no potential conflict of interest. This does not alter our adherence to PLOS ONE policies on sharing data and materials.

Introduction

Our society has to face the challenge of a growing number of older people [ 1 ], combined with an expected shortage of skilled workers, especially in nursing care [ 2 ]. At the same time, cancer patients, patients with non-oncological diseases, multimorbid patients [ 3 ] and patients suffering from dementia [ 4 ] are to benefit from palliative care. In Germany, palliative care is divided into specialised and general palliative care ( Table 1 ). The German Society for Palliative Medicine (DGP) estimated that 90% of dying people are in need of palliative care, but only 10% of them are in need of specialised palliative care, because of more complex needs, such as complex pain management [ 5 ]. The framework of specialised palliative care encompasses specialist outpatient palliative care, inpatient hospices and palliative care units in hospitals. In Germany, most nurses in specialised palliative care have an additional qualification [ 6 ]. Further, nurses in specialist palliative care in Germany have fewer patients to care for than nurses in other fields which results in more time for the patients [ 7 ]. Most people are treated within general palliative care in non-specialized palliative care settings, which is provided by primary care suppliers with fundamental knowledge of palliative care. These are GPs, specialists (e.g. oncologists) and, above all, staff in nursing homes, hospitals and outpatient care [ 8 ]. Nurses in general palliative care have basic skills in palliative care from their education. However, there is no data available on the extent of palliative care they provide, or information on an additional qualification in palliative care. Palliative care experts from around the world consider the education and training of all staff in the fundamentals of palliative care to be essential [ 9 ] and a study conducted in Italy revealed that professional competency of palliative care nurses was positively associated with job satisfaction [ 10 ]. Thus, it is possible that the extent of palliative care or an additional qualification in palliative care may have implications on the working situation and health status of nurses. In Germany, there are different studies which concentrate on people dying in hospitals or nursing homes and the associated burden on the institution’s staff [ 11 , 12 ], but studies considering palliative care aspects concentrate on specialised palliative care settings [ 6 , 13 , 14 ]. Because the working conditions of nurses in specialised and general palliative care are somewhat different, as stated above, this paper focuses on nurses working in general palliative care, in other words, in non-specialized palliative care settings.

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https://doi.org/10.1371/journal.pone.0245798.t001

Burnout is a large problem in social professions, especially in health care worldwide [ 19 ] and is consistently associated with nurses intention to leave their profession [ 20 ]. Burnout is a state of emotional, physical, and mental exhaustion caused by a long-term mismatch of the demands associated with the job and the resources of the worker [ 21 ]. One of the causes for the alarming increase in nursing burnout is their workload [ 22 , 23 ]. Workload can be either qualitative (pertaining to the type of skills and/or effort needed in order to perform work tasks) or quantitative (the amount of work to be done and the speed at which it has to be performed) [ 24 ].

Studies analysing burnout in nursing have recognised different coping strategies, self-efficacy, emotional intelligence factors, social support [ 25 , 26 ], the meaning of work and role clarity [ 27 ] as protective factors. Studies conducted in the palliative care sector identified empathy [ 28 ], attitudes toward death, secure attachment styles, and meaning and purpose in life as protective factors [ 29 ]. Individual factors such as spirituality and hobbies [ 30 ], self-care [ 31 ], coping strategies for facing the death of a patient [ 32 ], physical activity [ 33 ] and social resources, like social support [ 33 , 34 ], the team [ 6 , 13 ] and time for patients [ 32 ] were identified, as effectively protecting against burnout. These studies used qualitative or descriptive methods or correlation analyses in order to investigate the relationship between variables. In contrast to this statistical approach, fewer studies examined the buffering/moderating role of resources on the relationship between workload and burnout in nursing. A moderator variable affects the direction and/or the strength of the relationship between two other variables [ 35 ]. A previous study has showed resilience as being a moderator for emotional exhaustion on health [ 36 ], and other studies revealed professional commitment or social support moderating job demands on emotional exhaustion [ 37 , 38 ]. Furthermore, work engagement and emotional intelligence was recognised as a moderator in the work demand and burnout relationship [ 39 , 40 ].

We have analysed the working situation of nurses using the Rudow Stress-Strain-Resources model [ 41 ]. According to this model, the same stressor can lead to different strains in different people depending on available resources. These resources can be either individual, social or organisational. Individual resources are those resources which are owned by an individual. This includes for example personal capacities such as positive thinking as well as personal qualifications. Social resources consist of the relationships an individual has, this includes for example relationships at work as well as in his private life. Organisational resources refer to the concrete design of the workplace and work organisation. For example, nurses reporting a good working team may experience workload as less threatening and disruptive because a good working team gives them a feeling of security, stability and belonging. According to Rudow, individual, social or organisational resources can buffer/moderate the negative effects of job demands (stressors) on, for example, burnout (strain).

Nurses’ health may have an effect on the quality of the services offered by the health care system [ 42 ], therefore, it is of great interest to do everything possible to preserve their health. This may be achieved by reducing the workload and by strengthening the available resources. However, to the best of our knowledge, we are not aware of any study which considers palliative care aspects within general palliative care in Germany. Therefore, the aim of the study was to investigate the buffering role of resources on the relationship between workload (‘quantitative demands’) and burnout among nurses. Palliative care aspects, such as information on the extent of palliative care were incorporated to the analyses as covariates.

Study design and participants

An exploratory cross-sectional study was conducted in 2017. In Germany, there is no national register for nurses. Data for this study were collected from a stratified 10% random sample of a database with outpatient facilities, hospitals and nursing homes in Germany from the Institution for Statutory Accident Insurance and Prevention in Health and Welfare Services in Germany. This institution is part of the German social security system. It is the statutory accident insurer for nonstate institutions in the health and welfare services in Germany and thus responsible for the health concerns of the target group investigated in the present study, namely nurses. Due to data protection rules, this institution was also responsible for the first contact with the health facilities. 126 of 3,278 (3.8%) health facilities agreed to participate in the survey. They informed the study team about how many nurses worked in their institution, and whether the nurses would prefer to answer a paper-and-pencil questionnaire (with a pre-franked envelope) or an online survey (with an access code ). 2,982 questionnaires/access codes were sent out to the participating health facilities (656 to outpatient care, 160 to hospitals and 2,166 to nursing homes), where they were distributed to the nurses ( S1 Table ). Participation was voluntary and anonymous. Informed consent was obtained written at the beginning of the questionnaire. Approval to perform the study was obtained by the ethics committee of the State Chamber of Medicine in Rhineland-Palatinate (Clearance number 837.326.16 (10645)).

Questionnaire

The questionnaire contained questions regarding i) nurse’s sociodemographic information and information on current profession as well as ii) palliative care aspects. Furthermore, iii) parts of the German version of the Copenhagen Psychosocial Questionnaire (COPSOQ), iv) a resilience questionnaire [RS-13] and v) single questions relating to resources were added.

i) Sociodemographic information and information on current profession.

The nurse’s sociodemographic information and information on current profession included the variables ‘age’, ‘gender’, ‘marital status’, ‘education’, ‘professional qualification’, ‘working area’, ‘professional experience’ and ‘extent of employment’.

ii) Palliative care aspects.

Palliative care aspects included self-developed questions on ‘additional qualification in palliative care’, the ‘number of patients’ deaths within the last month (that the nurses cared for personally)’ and the ‘extent of palliative care’. The latter was evaluated by asking: how much of your working time (as a percentage) do you spend with care of palliative patients? The first two items were already used in the pilot study. The pilot study consisted of a qualitative part, where interviews with experts in general and specialised palliative care were performed [ 43 ]. These interviews were used to develop a standardized questionnaire which was used for a cross-sectional pilot survey [ 6 , 44 ].

iii) Copenhagen Psychosocial Questionnaire (COPSOQ).

The questionnaire included parts of the German standard version of the Copenhagen Psychosocial Questionnaire (COPSOQ) [ 45 ]. The COPSOQ is a valid and reliable questionnaire for the assessment of psychosocial work environmental factors and health in the workplace [ 46 , 47 ]. The scales selected were ‘quantitative demands’ (four items, for example: “Do you have to work very fast?”) measuring workload, ‘burnout’ (six items, for example: “How often do you feel emotionally exhausted?”), ‘meaning of work’ (three items, for example: “Do you feel that the work you do is important?”) and ‘workplace commitment’ (four items, for example: “Do you enjoy telling others about your place of work?”).

iv) Resilience questionnaire RS-13.

The RS-13 questionnaire is the short German version of the RS-25 questionnaire developed by Wagnild & Young [ 48 ]. The questionnaire postulates a two-dimensional structure of resilience formed by the factors “personal competence” and “acceptance of self and life”. The RS-13 questionnaire measures resilience with 13 items on a 7-point scale (1 = I do not agree, 7 = I totally agree with different statements) and has been validated in representative samples [ 49 , 50 ]. The results of the questionnaire were grouped into persons with low, moderate or high resilience.

v) Questions on resources.

Single questions on personal, social and organizational resources assessed the nurses’ views of these resources in being helpful in dealing with the demands of their work. Further, single questions collected the agreement to different statements such as ‘Do you receive recognition for your work from the supervisor? ’ (see Table 4 ). These resources were frequently reported in the pilot study by nurses in specialised palliative care [ 6 ].

Data preparation and analysis

The data from the paper-and-pencil and online questionnaires were merged, and data cleaning was done (e.g. questionnaires without specification to nursing homes, hospitals or outpatient care were excluded). The scales selected from the COPSOQ were prepared according to the COPSOQ guidelines. In general, COPSOQ items have a 5-point Likert format, which are then transformed into a 0 to 100 scale. The scale score is calculated as the mean of the items for each scale, if at least half of the single items had valid answers. Nurses who answered less than half of the items in a scale were recorded as missing. If at least half of the items were answered, the scale value was calculated as the average of the items answered [ 46 ]. High values for the scales ‘quantitative demands‘ and ‘burnout‘ were considered negative, while high values for the scales ‘meaning of work’ and ‘workplace commitment’ were considered positive. The proportion of missing values for single scale items was between 0.5% and 2.7%. Cronbach’s Alpha was used to assess the internal consistency of the scales. A Cronbach’s Alpha > 0.7 was regarded as acceptable [ 35 ]. The score of the RS-13 questionnaire ranges from 13 to 91. The answers were grouped according to the specifications in groups with low resilience (score 13–66), moderate resilience (67–72) and high resilience (73–91) [ 49 ]. The categorical resource variables were dichotomised (example: not helpful/little helpful vs. quite helpful/very helpful).

The study was conceptualised as an exploratory study. Consequently, no prior hypotheses were formulated, so the p-values merely enable the recognition of any statistically noteworthy findings [ 51 ]. Descriptive statistics (absolute and relative frequency, M = mean, SD = standard deviation) were used to depict the data. Bivariate analyses (Pearson correlation, t-tests, analysis of variance) were performed to infer important variables for the regression-based moderation analysis. Variables which did not fulfil all the conditions for linear regression analysis were recoded as categorical variables [ 35 ]. The variable ‘extent of palliative care’ was categorised as ‘≤ 20 percent of working time’ vs. ‘> 20 percent of working time’ due to the median of the variable (median = 20).

The first step with regard to the moderation analysis was to determine the resource variables. Therefore all resource variables that reached a p-value < 0.05 in the bivariate analysis with the scale ‘burnout’ were further analysed (scale ‘meaning of work’, scale ‘workplace commitment’, variables presented in Table 4 ). The moderator analysis was conducted using the PROCESS program developed by Andrew F. Hayes. First, scales were mean-centred to reduce possible scaling problems and multicollinearity. Secondly, for all significant resource variables the following analysis were done: the ‘quantitative demand’, one resource (one per model) and the interaction term between the ‘quantitative demand’ and the resource, as well as the covariates ‘age’, ‘gender’, ‘working area’, ‘extent of employment’, the ‘extent of palliative care’ and the ‘number of patient deaths within the last month’ were added to the moderator analysis, in order to control for confounding influence. If the interaction term between the ‘quantitative demand’ and the resource accounted for significantly more variance than without interaction term (change in R 2 denoted as ΔR 2 , p < 0.05), a moderator effect of the resource was present. The interaction of the variables (± 1 SD the mean or variable manifestation such as yes and no) was plotted.

All the statistical calculations were performed using the Statistical Package for Social Science (SPSS, version 23.5) and the PROCESS macro for SPSS (version 3.5 by Hayes) for the moderator analysis.

Of the 2,982 questionnaires/access codes sent out, 497 were eligible for the analysis. The response rate was 16.7% (response rate of outpatient care 14.6%, response rate of hospitals 18.1% and response rate of nursing homes 16.0%). Since only n = 29 nurses from hospitals participated, these were excluded from data analysis. After data cleaning , the final number of participants was n = 437.

Descriptive results

The basic characteristics of the study population are presented in Table 2 . The average age of the nurses was 42.8 years, and 388 (89.6%) were female. In total, 316 nurses answered the question how much working time they spend caring for palliative patients. Sixteen (5.1%) nurses reported spending no time caring for palliative patients, 124 (39.2%) nurses reported between 1% to 10%, 61 (19.30%) nurses reported between 11% to 20% and 115 (36.4%) nurses reported spending more than 20% of their working time for caring for palliative patients. Approximately one-third (n = 121, 27.7%) of the nurses in this study did not answer this question. One hundred seventeen (29.5%) nurses reported 4 or more patient deaths, 218 (54.9%) reported 1 to 3 patient deaths and 62 (15.6%) reported 0 patient deaths within the last month.

https://doi.org/10.1371/journal.pone.0245798.t002

Table 3 presents the mean values and standard deviations of the scales ‘quantitative demands’, ‘burnout’, and the resource scales ‘meaning of work’ and ‘workplace commitment’. All scales achieved a satisfactory level of internal consistency.

https://doi.org/10.1371/journal.pone.0245798.t003

Bivariate analyses

There was a strong positive correlation between the ‘quantitative demands’ and ‘burnout’ scales (r = 0.498, p ≤ 0.01), and a small negative correlation between ‘burnout’ and ‘meaning of work’ (r = -0.222, p ≤ 0.01) and ‘workplace commitment’ (r = -0.240, p ≤ 0.01). Regarding the basic and job-related characteristics of the sample shown in Table 2 , ‘burnout’ was significantly related to ‘extent of palliative care’ (≤ 20% of working time: n = 199, M = 46.06, SD = 20.28; > 20% of working time: n = 115, M = 53.80, SD = 20.24, t(312) = -3.261, p = 0.001). Furthermore, there was a significant effect regarding the ‘number of patient deaths during the last month’ (F (2, 393) = 5.197, p = 0.006). The mean of the burnout score was lower for nurses reporting no patient deaths within the last month than for nurses reporting four or more deaths (n = 62, M = 42.47, SD = 21.66 versus n = 116, M = 52.71, SD = 20.03). There was no association between ‘quantitative demands’ and an ‘additional qualification in palliative care’ (no qualification: n = 328, M = 55.77, SD = 21.10; additional qualification: n = 103, M = 54.39, SD = 20.44, p = 0.559).

The association between ‘burnout’ and the evaluated (categorical) resource variables is presented in Table 4 . Nurses mostly had a lower value on the ‘burnout’ scale when reporting various resources. Only the resources ‘family’, ‘religiosity/spirituality’, ‘gratitude of patients’, ‘recognition through patients/relatives’ and an ‘additional qualification in palliative care’ were not associated with ‘burnout’.

https://doi.org/10.1371/journal.pone.0245798.t004

Moderator analyses

In total, 16 moderation analyses were conducted. Table 5 presents the results of the moderation analyses where a significant moderation was found. For ‘workplace commitment’, there was a positive and significant association between ‘quantitative demands’ and ‘burnout’ (b = 0.47, SE = 0.051, p < 0.001). An increase of one value on the scale ‘quantitative demands’ increased the scale ‘burnout’ by 0.47. ‘Workplace commitment’ was negatively related to ‘burnout’, meaning that a higher degree of ‘workplace commitment’ was related to a lower level of ‘burnout’ (b = -0.11, SE = 0.048, p = 0.030). A model with the interaction term of ‘quantitative demands’ and the resource ‘workplace commitment’ accounted for significantly more variance in ‘burnout’ than a model without interaction term (ΔR 2 = 0.021, p = 0.004). The impact of ‘quantitative demands’ on ‘burnout’ was dependent on ‘workplace commitment’ (b = -0.01, SE = 0.002 p = 0.004). The variables explained 31.9% of the variance in ‘burnout’.

https://doi.org/10.1371/journal.pone.0245798.t005

Regarding the ‘good working team’ resource, the variables ‘quantitative demands’ and ‘burnout’ were positively and significantly associated (b = 0.76, SE = 0.154, p < 0.001), and the variables ‘good working team’ and ‘burnout’ were not associated (b = -3.15, SE = 3.52, p = 0.372). A model with the interaction term of ‘quantitative demands’ and the ‘good working team’ resource accounted for significantly more variance in ‘burnout’ than a model without interaction term (ΔR 2 = 0.011, p = 0.040). The ‘good working team’ resource moderated the impact of ‘quantitative demands’ on ‘burnout’ (b = -0.34, SE = 0.165, p = 0.004). The variables explained 29.7% of the variance in ‘burnout’.

The associations between ‘quantitative demands’ and ‘burnout’ (b = 0.63, SE = 0.085, p < 0.001), between ‘recognition supervisor’ and ‘burnout’ (b = -7.29, SE = 2.27, p = 0.001), and the interaction term of ‘quantitative demands’ and the resource ‘recognition supervisor’ (b = -0.34, SE = 0.108, p = 0.002) were significant. Again, a model with the interaction term accounted for significantly more variance in ‘burnout’ than a model without interaction term (ΔR 2 = 0.024, p = 0.002). ‘Recognition from supervisor’ influenced the impact of ‘quantitative demands’ on burnout for -0.34 on the 0 to 100 scale. The variables explained 33.7% of the variance in ‘burnout’.

Figs 1 – 3 demonstrates simple slopes of the interaction effects of ‘workplace commitment’ predicting ‘burnout’ at high, average and low levels ( Fig 1 ) respectively with and without the resource ‘good working team’ ( Fig 2 ) and ‘recognition from supervisor’ ( Fig 3 ). Higher ‘quantitative demands’ were associated with higher levels of ‘burnout’. At low ‘quantitative demands’, the ‘burnout’ level was quite similar for all nurses. However, when ‘quantitative demands’ increased, nurses who confirmed that they had the resources stated a lower ‘burnout’ level than nurses who denied having them. This trend is repeated by the resources ‘workplace commitment’, ‘good working team’ and ‘recognition from supervisor’.

https://doi.org/10.1371/journal.pone.0245798.g001

https://doi.org/10.1371/journal.pone.0245798.g002

https://doi.org/10.1371/journal.pone.0245798.g003

The palliative care aspect ‘extent of palliative care’ showed that spending more than 20 percent of working time in care for palliative patients increased burnout significantly by a value of approximately 5 on a 0 to 100 scale ( Table 5 ).

The aim of the present study was to analyse the buffering role of resources on the relationship between workload and burnout among nurses. This was done for the first time by considering palliative care aspects, such as information on the extent of palliative care.

The study shows that higher quantitative demands were associated with higher levels of burnout, which is in line with other studies [ 37 , 39 ]. Furthermore, the results of this study indicate that working in a good team, recognition from supervisor and workplace commitment is a moderator within the workload—burnout relationship. Although the moderator analyses revealed low buffering effect values, social resources were identified once more as important resources. This is consistent with the results of a study conducted in the field of specialised palliative care in Germany, where a good working team and workplace commitment moderated the impact of quantitative demands on nurses burnout [ 52 ]. A recently published review also describes social support from co-workers and supervisors as a fundamental resource in preventing burnout in nurses [ 53 ]. Workplace commitment was not only reported as a moderator between workload and health in the nurse setting [ 37 ], but also as a moderator between work stress and burnout [ 54 ] and between work stress and other health related aspects outside the nurse setting [ 55 ]. In the present study, the effect of high workload on burnout was reduced with increasing workplace commitment. Nurses reporting a high work commitment may experience workload as less threatening and disruptive because workplace commitment gives them a feeling of belonging, security and stability. However, there are also some correlation studies which observed no direct relationship between workplace commitment and burnout for occupations in the health sector [ 56 ]. A study from Serbia assessed workplace commitment by nurses and medical technicians as a protective factor against patient-related burnout, but not against personal and work-related burnout [ 57 ]. Furthermore, a study conducted in Estonia reported no relationship between workplace commitment and burnout amongst nurses [ 58 ]. As there are indications that workplace commitment is correlated with patient safety [ 59 ], the development and improving of workplace commitment needs further scientific investigation.

This study observed slightly higher burnout rates among nurses who reported a ‘good working team’ for low workload. This fact is not decisive for the interpretation of the moderation effect of this resource because moderation is present. When workload increased, nurses who confirmed that they worked in a good working team stated a lower burnout level. However, the result of the current study showed that a good working team is particularly important when workload increases, in the most extreme cases team work in palliative care is necessary to save a person’s life. Because team work in today’s health care system is essential, health care organisations should foster team work in order to enhance their clinical outcomes [ 60 ], improve the quality of patient care as well as health [ 61 ] and satisfaction of nurses [ 62 ].

The bivariate analysis revealed that nurses who reported getting recognition from colleagues, through the social context, salary and gratitude from relatives of patients stated a lower value on the burnout scale. This is in accordance with the results of a qualitative study, which indicated that the feeling of recognition, and that one’s work is useful and worthwhile, is very important for nurses and a source of satisfaction [ 63 ]. Furthermore, self-care, self-reflection [ 64 ] and professional attitude/dissociation seem to play an important role in preventing burnout. The bivariate analysis also revealed a relationship between resilience and burnout. Nurses with high resilience reported lower values on the burnout scale, but a buffering role of resilience on burnout was not assessed. The present paper focuses solely on quantitative demands and burnout. In future studies, the different fields of nursing demands, like organisational or emotional demands, should be assessed in relation to burnout, job satisfaction and health.

Finally, we observed whether the consideration of palliative care aspects is associated with burnout. The bivariate analysis revealed a relationship between the extent of palliative care, number of patient deaths within the last month and burnout. Using regression analyses, only the extent of palliative care was associated with burnout. Since, to the best of our knowledge, the present study is the first study to consider palliative care aspects within general palliative care in Germany, these variables need further scientific investigation, not only within the demand—burnout relationship but also between the demand—health and the demand—job satisfaction relationship. Furthermore, palliative care experts from around the world considered the education and training of all members of staff in the fundamentals of palliative care to be essential [ 9 ]. One-fourth of the respondents in the present study had an additional qualification in palliative care, which was not obligatory. We assessed a relationship between quantitative demands and burnout but no relationship between an additional qualification and quantitative demands nor burnout. Nevertheless, we assessed a protective effect of the additional qualification within the pilot study in specialised palliative care, in relation both to organisational demands and demands regarding the care of relatives [ 6 ]. This suggests that the additional qualification is a resource, but one which depends on the field of demand. Further analyses would be required to review benefits achieved by additional qualifications in general palliative care.

The variable extent of palliative care is the one with the most missing values in the survey, thus future analyses should not only study larger samples but also reconsider the question on extent of palliative care.

Finally, it can be said that the main contribution of the present study is to make palliative care aspects in non-specialised palliative care settings a subject of discussion.

Limitations

The following potential limitations need to be stated: although a random sample was drawn, the sample is not representative for general palliative care in Germany due to a low participation rate of the health facilities, a low response rate of the nurses, the different responses of the health facilities and the exclusion of hospitals. One possible explanation for the low participation rate of the health facilities is the sampling procedure and data protection rules, which did not allowed the study team to contact the institutions in the sample. Due to the low participation rate, the results of the present study may be labelled as preliminary. Further, the data are based on a detailed and anonymous survey, and therefore the potential for selection bias has to be considered. It is possible that the institutions and nurses with the highest burden had no time for or interest in answering the questionnaire. It is also possible that the institutions which care for a high number of palliative patients may have taken particular interest in the survey. Additionally, some items of the questionnaire were self-developed and not validated but were considered valuable for our study as they answered certain questions that standardized questionnaires could not. The moderator analyses revealed low effect values and the variance explained by the interaction terms is rather low. However, moderator effects are difficult to detect, therefore, even those explaining as little as one percent of the total variance should be considered [ 65 ]. Consequently, the additional amount of variance explained by the interaction in the current study (2% for workplace commitment and recognition of supervisor and 1% for good working team) is not only statistically significant but also practically and theoretically relevant. When considering the results of the current study, it must be taken into account that the present paper focuses solely on quantitative demands and burnout. In future studies, the different fields of nursing demands have to be carried out on the role of resources. This not only pertains for burnout, but also for other outcomes such as job satisfaction and health. Finally, the cross-sectional design does not allow for casual inferences. Longitudinal and interventional studies are needed to support causality in the relationships examined.

Conclusions

The present study provides support to a buffering role of workplace commitment, good working teams and recognition from supervisors on the relationship between workload and burnout. Initiatives to develop or improve workplace commitment and strengthen collaboration with colleagues and supervisors should be implemented in order to reduce burnout levels. Furthermore, the results of the study provides first insights that palliative care aspects in general palliative care may have an impact on nurse burnout, and therefore they have gone unrecognised for too long in the scientific literature. They have to be considered in future studies, in order to improve the working conditions, health and satisfaction of nurses. As our study was exploratory, the results should be confirmed in future studies.

Supporting information

S1 table. number of questionnaires sent out to facilites and response rate..

https://doi.org/10.1371/journal.pone.0245798.s001

Acknowledgments

We thank the nurses and the health care institutions for taking part in the study. We thank D. Wendeler, O. Kleinmüller, E. Muth, R. Amma and C. Kohring who were helpful in the recruitment of the participants and data collection.

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A Qualitative Reexamination of the Key Features of Burnout

Tavella, Gabriela B(Psych) Hons; Parker, Gordon MD, PhD, DSc, FRANZCP

School of Psychiatry, University of New South Wales; and Black Dog Institute, Sydney, NSW, Australia.

Send reprint requests to Gordon Parker, MD, PhD, DSc, FRANZCP, School of Psychiatry Central, Level 1 AGSM Building, UNSW, Sydney, Australia, 2052. E-mail: [email protected] .

Burnout is generally defined as a triad of emotional exhaustion, lack of empathy, and reduced professional accomplishment constructs. We sought to determine in an exploratory, qualitative study whether these three constructs adequately represent burnout. Participants who self-identified as experiencing burnout completed a questionnaire that asked about their experiences of the condition. A qualitative thematic analysis was undertaken to determine the primary symptom constructs nominated by participants. The thematic analysis resulted in 12 symptom clusters or “themes” being identified as putative burnout features, with several of these themes overlapping with features identified in our independent quantitative analysis. Although we found emotional exhaustion, lack of empathy, and reduced professional accomplishment to be commonly nominated symptoms of burnout, the distinctive presence of several additional themes suggests that the burnout syndrome comprises a broader set of symptom constructs than those currently accepted as the defining features of the condition.

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Compassionate care: a qualitative exploration of nurses’ inner resources in the face of burnout.

1. Introduction

2. objectives, 2.1. main objective, 2.2. secondary objectives.

• Explore the inner resources determined by McGahie’s model [ 55 ], as well as other emerging themes [ 63 , 64 ], in order to develop an explanatory model of the influence of inner resources on compassionate care delivery [ 64 , 65 , 66 ];
• Examine perceptions of compassionate care at different stages of nursing careers (students nurses and nurses with experience);
• Establish if and how these social processes evolve over time, with exposure to stressful environments and experiences in the workplace [ 67 ];
• Frame compassion positively as a potential tool to protect professional satisfaction and consequently professional (compassionate) care delivery [ 22 , 68 ].

3.1. Study Design

3.2. time period, 3.3. participants.

• Nursing students registered at the Universitat de Illes Balears in their first through to fourth year of studies between 2022 and 2025;
• Qualified nurses with a minimum of one year’s experience up to thirty-five years;
• Willingness to participate in the study, give voluntary consent, agree for anonymised transcripts to be used for further analysis and potential publication.
• Other medical professionals that were not nurses;
• Unwillingness to comply with proceedings.

3.4. Sample

3.5. data collection.

• Welcome, purpose of study explained, opportunity to resolve doubts, and ice-breaker/establish participant characteristics;
• Work conditions and professional quality of life;
• Inner resources, where: cognitive capacity, spirituality and morality, affect and awareness of self and others will be explored, as well as other resources suggested by participants;
• Compassionate care and what it means to the participant, and an exploration of it as a positive tool in the work place;
• Proposals for future improvement of education/support/mental health;
• Closing remarks and space for questions and comments.

3.6. Data Analysis

4. trustworthiness, 4.1. rigour, 4.2. credibility, 4.3. social desirability bias, 4.4. auditability/repeatability, 4.5. fittingness, 4.6. reflexivity, 5. ethical considerations, 5.1. confidentiality, 5.2. autonomy, 5.3. fairness, 6. expected results, 6.1. potential limitations and benefits, 6.2. anticipated outcome, supplementary materials, author contributions, institutional review board statement, informed consent statement, data availability statement, public involvement statement, guidelines and standards statement, conflicts of interest.

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Flowers, S.-L.d.; Guillén-Solà, M.; Sansó, N.; Galiana, L. Compassionate Care: A Qualitative Exploration of Nurses’ Inner Resources in the Face of Burnout. Nurs. Rep. 2024 , 14 , 66-77. https://doi.org/10.3390/nursrep14010006

Flowers S-Ld, Guillén-Solà M, Sansó N, Galiana L. Compassionate Care: A Qualitative Exploration of Nurses’ Inner Resources in the Face of Burnout. Nursing Reports . 2024; 14(1):66-77. https://doi.org/10.3390/nursrep14010006

Flowers, Sarah-Louise d’Auvergne, Mireia Guillén-Solà, Noemí Sansó, and Laura Galiana. 2024. "Compassionate Care: A Qualitative Exploration of Nurses’ Inner Resources in the Face of Burnout" Nursing Reports 14, no. 1: 66-77. https://doi.org/10.3390/nursrep14010006

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• Research article
• Open access
• Published: 13 January 2021

An intervention to decrease burnout and increase retention of early career nurses: a mixed methods study of acceptability and feasibility

• Judy Brook   ORCID: orcid.org/0000-0002-8867-0150 1 ,
• Leanne M. Aitken 1 ,
• Julie-Ann MacLaren 1 &
• Debra Salmon 1  

BMC Nursing volume  20 , Article number:  19 ( 2021 ) Cite this article

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To understand the experiences of nursing students and academic staff of an intervention to decrease burnout and increase retention of early career nurses, in order to identify acceptability and feasibility in a single centre.

Internationally, retention of nurses is a persistent challenge but there is a dearth of knowledge about the perspectives of stakeholders regarding the acceptability and feasibility of interventions to resolve the issue. This study reports an intervention comprising of mindfulness, psychological skills training and cognitive realignment to prepare participants for early careers as nurses.

This is an explanatory sequential mixed methods study, conducted by a UK university and healthcare organisation. Participants were final year pre-registration nursing students ( n  = 74) and academics ( n  = 7) involved in the implementation of the intervention.

Pre and post measures of acceptability were taken using a questionnaire adapted from the Theoretical Framework of Acceptability. Wilcoxon Signed Ranks test was used to assess change in acceptability over time. Qualitative data from semi-structured interviews, focus groups and field notes were thematically analysed, adhering to COREQ guidelines. Data were collected February to December 2019.

One hundred and five questionnaires, 12 interviews with students and 2 focus groups engaging 7 academic staff were completed. The intervention was perceived as generally acceptable with significant positive increases in acceptability scores over time. Student nurses perceived the intervention equipped them with skills and experience that offered enduring personal benefit. Challenges related to the practice environment and academic assessment pressures. Reported benefits align with known protective factors against burnout and leaving the profession.

Planning is needed to embed the intervention into curricula and maximise relationships with placement partners. Evaluating acceptability and feasibility offers new knowledge about the value of the intervention for increasing retention and decreasing burnout for early career nurses. Wider implementation is both feasible and recommended by participants.

Peer Review reports

The retention of nurses in the international healthcare workforce is a persistent issue, with nurse vacancies increasing in many high and middle-income countries. Nurses are integral to strong and resilient health systems but current deficits between supply, demand, and population need threaten to impact on universal health coverage goals [ 1 ]. Consideration of strategies to mitigate the nursing workforce deficit has become central to health policy nationally and globally [ 1 , 2 ].

Increasing the number of student nurses as a pipeline to supply the workforce is a central approach to meeting need, and newly qualified nurses form the largest group entering the profession. However, these nurses are also particularly vulnerable [ 3 ], with 30–60% leaving their first place of employment within 1 year [ 4 , 5 , 6 ]. The transition from student to qualified nurse can be overwhelming, especially in a complex, fast-paced and pressured work environment [ 7 ]. This situation is compounded by rising nurse vacancies and has the potential to lead to burnout.

Burnout is a concept related to negative perception of the work environment, often linked with decisions to leave the nursing workforce [ 8 ]. It is characterised by depleted personal and/or social resources [ 9 ] and has significant consequences for healthcare organsiations, the individual and the patient population [ 8 ]. Known organisational and individual predictors of burnout allow interventions to be designed that will not only impact on burnout but also attrition from the profession.

This paper reports on the feasibility of implementation of an intervention to decrease burnout and increase retention of early career nurses. The perspectives of nursing students and university academic staff were sought in order to measure acceptability and identify barriers and facilitators to implementation and assess future scope for wider implementation.

Many examples of initiatives to support newly qualified nurses to stay in post and the profession have been reported. A large systematic review [ 10 ] identified key characteristics of interventions that were effective, with inconsistent or limited benefits frequently identified. The review exposed gaps related to three areas: evidence citing the explicit involvement of student or newly qualified nurses in the design of these interventions; the perspectives of the student or newly qualified nurses about the acceptability of the interventions; and the feasibility of the interventions from the perspectives of all stakeholders.

The expression ‘nurse retention’ is often used interchangeably with ‘turnover’ or ‘intention to leave’, and such confusion of terms perpetuates ambiguity and lack of understanding [ 11 ]. In this paper, the term ‘nurse retention’ describes a focus on decreasing attrition and minimising nurse turnover, to keep nurses in an organisation’s employment.

The concept of nurse retention consists of four attributes: motivation, intention, and individual decision; strategy and intervention; geographic context; and attachment to work [ 12 ]. To capture individual decision making, development of any interventions to support retention should incorporate the perspectives of those participating. Exploring acceptability supports understanding of the interactions, relationships and sociocultural contexts that influence perspectives of the intervention [ 13 ], and how this impacts feasibility and outcomes. It is likely to be interaction between characteristics of the individuals involved, the structure and workplace culture of the delivery environment, and characteristics of the intervention that act as facilitators or barriers to implementation [ 14 ]. Exploring these uncertainties in a feasibility study allows a larger study greater chance of success [ 15 ] and informs any required redesign [ 16 ].

The study aimed to understand the experiences of nursing students and academic staff who were involved in the implementation of an educational intervention, aimed at identifying and measuring acceptability, with a view to identifying barriers and facilitators to implementation and assessing future scope for the intervention.

This explanatory, sequential mixed methods research study combined insight from questionnaire data with participant accounts, providing a comprehensive evaluation of the feasibility and acceptability of the intervention. The sequence of processes is illustrated in Fig.  1 .

Diagram illustrating the mixed methods processes used in the study

This study was conducted as a partnership between a UK university and a large inner-city UK NHS healthcare organisation. The intervention was implemented at a university site familiar to the students. Intervention delivery and participant data collection occurred whilst the students were attending full-time clinical placements at the partnership NHS organisation sites, all situated within 10 miles of the University. The NHS organisation is located in a culturally and demographically diverse area, with the most unstable nursing workforce in England [ 17 ]. Relatively high cost of living, high population density, and proximity of many healthcare organisations in the city contribute to high turnover of nurses.

Sample selection

Student participants in the study consisted of adult or child nursing students who were in the final year of their pre-registration nursing programme and who had engaged with the intervention. Academic participants included any members of the academic workforce who had been involved in the implementation of the intervention, including facilitators and nursing programme directors. All participants were purposively selected and invited by email and face-to-face to engage with the study.

• Intervention

The intervention was co-designed by nursing students, early career nurses and researchers, drawing on evidence from the nursing literature, individual and collective experience. This innovative approach resulted in an intervention consisting of 3 or 4 days, called ‘Activity Days’, added to the nursing curriculum, in the final trimester of the pre-registration nursing programme between January and May 2019 for students working towards adult or children’s nursing qualifications. The content of the intervention is outlined in Fig.  2 . Acceptance and Commitment Therapy is an evidence-based cognitive behavioural skills programme that helps people relate differently to difficult thoughts and emotions so they can construct their life around what really matters to them [ 18 ]. Social capital refers to the professional relationships, shared sense of identity, understanding, values and reciprocity that students and early career nurses develop with their colleagues to enable them to thrive in the workplace and is likely to have an impact on retention [ 19 ]. Sessions related to time management, assertiveness, coping with stress and opportunities to discuss any current issues with placements were also incorporated.

Content of the Intervention Activity Days

Data collection

Quantitative questionnaire data on acceptability of the intervention and attendance data were collected, followed by qualitative data collection using semi-structured interviews, focus groups and reflective field notes. Data were collected between January and August 2019.

Attendance data

Student attendance at each of the intervention sessions was monitored and collated.

Questionnaire data

Questionnaires based on the seven constructs of the Theoretical Framework of Acceptability of Healthcare Interventions [ 13 ] were developed (Fig.  3 ) and used a likert-type scale to collect data with additional free-text options. Open questions were included as a strategy to identify further issues for inclusion in the interviews and focus groups and to complement responses to closed questions [ 20 ]. The questionnaire detail is provided in Table 1 .

Theoretical Framework of Acceptability of Healthcare Interventions, adapted from Sekhon et al., [ 13 ], and applied to the intervention

A pretest-posttest quasi-experimental design was used to explore changes in participant perceptions of acceptability; questionnaires were completed prospectively (prior to experiencing the intervention) and retrospectively (after experiencing the intervention) to explore changes in perception of acceptability over time. Question phrasing was changed for each data collection point to reflect the temporal nature of the process.

Semi-structured interviews with students

Students who volunteered were interviewed, either face-to-face or by telephone and audio recorded. Each participant was only interviewed once. The topic areas were derived from the questionnaire data and included what went well, what could be changed, challenges, perceptions of relevance and benefit, and future scope of the intervention. Interviews were conducted using a conversational style that involved questions and prompts where appropriate. Interviews lasted on average 40 min and only involved the interveiwer and interviewee.

Staff focus groups

Academic staff were invited to take part in a focus group to discuss their experience. Topic areas were determined by issues raised in the questionnaire data and included logistical challenges, relevance and appropriateness of the intervention content, ideas for improvement and future scope, and any unintended consequences of the intervention on curricula or clinical placements. Focus groups involved only the participants and the facilitator, lasted 1 h and were audio recorded.

Reflective field notes

Intervention facilitators were invited to provide reflective notes about their experience of the sessions, particularly how they felt as facilitators, what went well, what was challenging and how the process could have been improved. Four of the 6 facilitators provided field notes.

Ethical considerations

Ethical approval and permission to conduct the research was gained from the university and health service. Specific consideration was given to the voluntary nature of participation, including lack of coercion, the need for informed consent and respecting the anonymity of the participants. Participation was voluntary and informed consent was gained from all participants at the beginning of the study and repeated prior to participation in interviews or focus groups.

Data analysis

Questionnaire data were analysed initially by all members of the research team to inform the discussion points for the interviews and focus groups.

Quantitative data

Acceptability questionnaire descriptive statistics were reported as frequency of response choice for each question. Wilcoxon signed ranks were used to compare pre and post intervention paired mean ranks to assess difference over time. Attendance data were reported as frequency for each session and each student group.

Qualitative data

Thematic analysis of acceptability questionnaire free text comments, focus groups, interviews, and field notes followed Braun and Clarke’s [ 21 ] six phases. Data from staff and student participants were analysed separately. Data analysis was supported by use of Nvivo software V12.

Validity and reliability/rigour

The multi-component Theoretical Framework of Acceptability supports an acceptability issue to be identified at source and allows refinement of an intervention prior to wider implementation [ 13 ]. To enhance content and construct vaidity, the questionnaire was piloted with a small group of non-participants and reviewed by the framework author, after which small changes to wording were made to improve clarity. Questionnaires were self-administered in the presence of the intervention facilitators. Use of participant numbers mitigated social desirability bias by reassuring participants of the confidentiality of their answers.

Interview and focus group guides were formulated following analysis of questionnaire data and decisions about which aspects required further explanation. Interviews with students were conducted by two female researchers; a nurse with experience and training in qualitative research, and an experienced academic with a PhD in Psychology. The researchers facilitated the intervention but did not have any previous relationship or ongoing influence. Focus groups with academic staff were conducted by an experienced female academic post-doctorate researcher independent to the staff group, with no prior relationship, ongoing influence or previous nursing experience. The researchers introduced themselves and the study to the participants at the start of the focus groups and interviews. For the duration of the study the research team met regularly for reflexive discussions to explore their biases, assumptions and relationship to the research topic. All qualitative data were collected on University premises or by telephone. Data collection ceased once all volunteers had been interviewed, recurring themes were noted by the interviewers and data saturation was deemed to have been reached.

To preserve the anonymity of the participants, and mitigate bias, each participant was assigned a number and this was thereafter used to identify quotes from interviews or field notes.

Seventy-four students engaged with the intervention and 70 completed the acceptability questionnaire at one or more time points. The mean age of student participants who attended 1 or more intervention sessions and completed 1 or more acceptability questionnaires was 26 years (SD 6.54). Fifty (71%) were undertaking adult nursing programmes and 20 (29%) undertaking child nursing programmes, with 47 (67%) studying for a bachelor’s degree (BSc) and 23 (33%) studying for a post graduate diploma (PGdip). Twelve students were interviewed, and 7 academic staff attended one of two focus groups. Academic staff were either Lecturers or Senior Lecturers teaching on the nursing programmes. As participants were volunteers, reasons for non-participation in the interviews or focus groups are unknown.

Few students attended all of the intervention sessions, however, highest attendance (72–84%) was for the mixed group of adult and child nursing post graduate diploma students. As this was the second degree for these students, they were older, more experienced at studying and potentially more experienced at managing multiple priorities. Lowest attendance was for BSc undergraduate degree child nursing students (26–41%). These students were the youngest group, the first cohort to receive the intervention and were working full-time in their final placement, which was critical to complete their academic programme to qualify as nurses. Further detail is given in Table  2 .

Acceptability questionnaire results

One hundred and five questionnaires were completed (64 pre and 51 post). Students found the intervention generally acceptable and their perception of acceptability increased pre to post intervention (Table  3 ). For five of the seven acceptability constructs, a significant positive increase in perception occurred. Students enjoyed the intervention more over time, increasingly perceived that it was effective, felt the intervention fitted with their personal values, gained clarity and understanding about the intervention, and became more confident in their ability to take part. Conversely, responses to questions related to the extent to which taking part interfered with other priorities, indicated that over time the opportunity cost of participating became significantly greater. Perceived effort to participate, relating to the construct of burden, trended towards an increase over time but not significantly. For most items on the acceptability questionnaire there was no association between perceptions of acceptability prior to participation and frequency of attendance, although participants who attended 2–4 sessions (compared to 1 session) were more likely to agree that they were clear how participating would help them to cope better with the transition from student to qualified nurse (χ2 13.53, p  = 0.004) (Table 3 ).

Qualitative findings

Thematic analysis conducted on interview and focus group data, reflective field notes and free text comments from the acceptability questionnaires, identified three themes in both student and academic staff data: experience; identifying facilitators and overcoming barriers; and future scope. Six subthemes included: content and relevance; delivery and logistics; attendance, engagement and timing; role of the practice environment; enduring impact; beneficial effect (Fig.  4 ).

Themes and sub-themes derived from qualitative data

The experience of participating in the intervention was generally reported positively by both students and staff, reiterating findings from the student acceptability questionnaire that affective attitude was more positive over time. Students predominantly commented on content of the intervention and staff commented on facilitation.

Content and relevance

Most students felt the content was appropriate and relevant to their roles as student and qualified nurses, perceiving the subject matter to be a positive addition to the traditional curricula. The focus on clinical practice and skills to support transition to early career nurse was particularly welcomed.

It was everything that I felt like University hadn’t identified as important, which was actually so important in practice, you incorporated it into a three-week course. (student 9 interview)

These sentiments were echoed by the staff, who identified that the co-produced nature of the intervention lent additional credibility to the content. As highlighted in the questionnaire data related to intervention coherence, students understood the rationale behind the intervention and recognised the relevance of the content of the sessions.

Delivery and logistics

The nature of the intervention, incorporating psychological skills training, and small and large group work, encouraged facilitators to limit the sense of hierarchy in the groups, by appropriately sharing personal and work experiences. The students commented positively about the helpful and respectful approach of the facilitators, which made sharing difficult experiences in placement possible.

It just gives you time to relate to everyone else, because everyone spoke about their experiences and no one was judging anyone, everyone was just saying you know what, this is what happened in my placement...no one’s there to put you down. (student 1 interview)

The compassionate facilitation of the sessions aligns with the self-efficacy scores in the acceptability questionnaire, with students becoming increasingly confident over time that they could contribute effectively.

Identifying facilitators and overcoming barriers

Across the data, barriers and facilitators to implementation of the intervention were highlighted. Staff discussed their learning from working in partnership with a large healthcare organisation and acknowledged the complexity of trying to retrofit additional sessions into established curricula. Students discussed conflicting priorities, lack of initial confidence as they found their way in new clinical placements, and the influential nature of the clinical environment on their decision making.

Attendance, engagement and timing

Engagement with the intervention was varied. In the last trimester of the programme students had many priorities, including academic and clinical practice assessment deadlines, and full-time placement responsibilities. Staff recognised the pressures the students were under and how this affected their decision to attend.

As the pressure builds on a student through the third year … I think so does their ability to take on new things reduce because they’ve got so much going on like dissertations, final placements, clinical assessments and other coursework, things like that (staff FG 2)

Some students identified that the days provided respite from the intensity of clinical practice and the sharing of placement experience was supportive and relevant. Others felt that attendance would have been much greater when the pressures of the programme were fewer.

The problem is when we’re on placement we’re doing full time hours plus extra study sessions and then a lot of people have to work on top of that and then that doesn’t even include the people that have children and family … I find managing my life and prioritising things so challenging. (student 9 interview)

The perception of increased burden or effort to attend over time indicated by the acceptability questionnaires reflects the conflicting priorities and pressures of the final stage of the nursing programme.

Role of the practice environment

Both students and staff commented about how clinical colleagues influenced their experience. Staff found that communication across the two organisations was challenging, with misunderstanding about the nature and value of the intervention. They recognised that the busy nature of the clinical areas was influential, as patient care was central to decision making but noted that clinical staff were sometimes reluctant to release students to attend. This impacted on student motivation to negotiate attendance at the sessions.

It’s difficult because it’s supposed to be a collaboration between the [NHS organisation] and the University and the students seem to have been caught a little in the crossfire, but in most cases I think the students were able to get to attend when they needed to. (staff FG 2)

The placement, they don't like it, yeah, because it was final year placement … They keep telling us, “Well that's irrelevant ... you shouldn't be attending those. It's more important that you attend your clinical hours.” (student 6 interview)

Many of the students described their clinical experience as stressful. The intervention was therefore timely as it stimulated a realisation that the stress needed to be addressed and provided new skills and tools to support transition to a new role. Students described how they had incorporated the new techniques into their everyday practice and were seeing positive results.

The mindfulness I did find quite useful with the breathing, because the neuro placement was really hectic … I would just focus on myself and take five seconds, ten seconds to breathe and then I’ll be like OK, I’ve got to do this, this and this, and it helped me organise my head in a way. (Student 5 interview)

The narrative from both students and staff describing clinical practice as a pressurised environment relates to the acceptability questionnaire data showing an increase in perceived burden and significant increase in opportunity cost for students participating in the intervention.

Future scope

Both students and staff were unanimous in recommending that the intervention should be offered to all future students. Participants suggested that it should be introduced at the beginning of the nursing programme and continue as a fundamental aspect of learning until qualification. Both staff and students would encourage colleagues and peers to become involved with delivery and attendance. Staff strongly believed that the co-designed nature of the intervention gave it credibility as a response to the expressed needs of a changing demographic of students.

Beneficial effect

Students described many aspects of the intervention that had immediate benefit for them in both their professional and personal lives. They felt the sessions gave them insight into transition to a qualified nurse but also helped with their placement experiences as a student. Of particular benefit were the mindfulness and psychological skills and techniques, which students felt helped them to cope better with their emotions in difficult situations. Likewise, the opportunity to meet with peers in a safe environment to discuss placement experiences and strengthen networks was highly valued.

It was nice that no one thought we were negative people when we discussed negative things. Most people say we should just be positive but you taught us how to and that its okay to struggle slightly. (Child BSc Student Acceptability Questionnaire 11)

For some students the intervention was a lifeline at a difficult period of their lives.

I genuinely appreciated those sessions, as a student, and in terms of personal life as well. At one point it got quite emotional for me, because I thought, my goodness, this is really helpful. And, finally there’s a focus on us students, and our mental wellbeing. (student 7 interview)

Both students and staff highlighted personal benefits of the intervention and crucially, students recognised the need to be aware of their own wellbeing, notice how they were responding to stress and take proactive action.

You get the stress where you just brush it aside but it affects us, but the sessions made me realise it affects us a lot more than we think and that if we didn’t deal with it, it has such bad effects and I think that was the, the sessions helped me come to a realisation. (student 1 interview)

Enduring impact

Students described activity connected to time management, stress management and coping mechanisms related to both in their work and home lives. Although not all students were consistently using specific skills there was a sense that the sessions had changed their perspective and they could draw on the techniques and newly developed networks at difficult times.

I felt that the sessions helped me to cope with the stress and I have taken away skills that I can apply not just within nursing but in everyday life. (Adult BSc Student Acceptability Questionnaire 13)

Students described embedding their learning into their daily activities, for example by downloading mindfulness apps onto their phones and practising meditation or breathing exercises during their commute or at break times on the wards. Some described how they now accepted negative thoughts and were more conscious of how their behaviour could reflect their personal values and impact on colleagues, friends and family; key tenets of ACT.

Meditating I tried, but it's just so difficult when you're stressed … it's good because it made me aware of, OK my heart's racing, OK I, you know, I can't seem to breathe properly. It was great to be aware and notice your feelings, but I wasn't able to put myself in the full meditation mode. (student 6 interview)

Staff also recognised the benefits for students and felt that the intervention would have enduring impact. They noticed subtle changes in the students’ thinking and demeanour. The staff members anticipated that the new skills would support students to deal with the challenges, such as low self-esteem, helplessness and home-life responsibilities.

What they were doing as part of this study actually began to bleed through into some of their thinking about other things, which is difficult to capture objectively but … I think it was a really positive experience (staff FG 1)

Staff regarded the intervention as positive enhancement of the traditional university offer that would be beneficial to the students in their future career. This positive perception of the immediate and enduring impact of the intervention by both students and staff aligns with the acceptability questionnaire data indicating a significant increase in perception of the intervention as an effective mechanism for supporting early career nurses.

The deficit of nurses in the healthcare workforce has motivated a plethora of initiatives to encourage retention of newly qualified nurses but to date there is little published research about the acceptability of these interventions [ 10 ]. To understand more about the impact of the intervention, this study was designed to explore the experiences and perceptions of nursing students and academic staff during implementation of a novel intervention. The findings raised key points for discussion: first, the intervention was generally acceptable and scores for five of the seven specific acceptability constructs showed positive significant increases over time, indicating a sound platform for wider implementation. Second, the intervention was perceived by student nurses to equip them with skills and experience that brought enduring personal benefit in both their professional and personal lives, with the potential to influence their transition to qualified nurses, burnout and retention. Third, implementation of the intervention in partnership with an NHS organisation and within established higher education curricula added a level of complexity that influenced student attendance and feasibility.

Acceptability is increasingly being recognised as a key aspect of developing healthcare interventions [ 22 ]. Strengths of the Theoretical Framework of Acceptability [ 13 ] include the definition, the multi-faceted construct, and prospective and retrospective assessment of acceptability. Individuals may perceive an intervention differently before they experience it than after.

Students did indeed significantly change their perception of intervention acceptability over time, reinforcing the value of temporal assessment to support decisions about feasibility. For five of the seven constructs this was a positive change as they gained clarity, understanding and expertise, highlighting how clear and timely explanations about the intervention may have engendered greater participation.

Findings for two acceptability constructs indicated a less positive trend in perception of the intervention. Over time the perceived cost of participating became greater, as did the perceived effort to participate. Data from the interviews and focus groups indicated a potential relationship between the timing of the delivery of the intervention in the nursing programme and other academic and practice related priorities. This was evident in the language students used in their interviews, frequently referring to stress and pressure, compounded by accounts of busy and under-staffed placement environments. Stress related to nursing programmes is a recognised phenomenon [ 23 ], is associated with academic, clinical or personal/social stressors [ 24 ] and there is a strong relationship between stress and attrition [ 25 , 26 ]. In particular, students experience moderate to severe levels of stress during clinical practice [ 27 ], highlighting the importance of addressing both individual stress and organisational stressors [ 28 ] to mitigate the impact on students. Wider implementation would require careful planning to manage the complexity of accommodating the intervention in an established nursing programme, avoid work overload and placement anxiety and limit the impact on attendance.

Perceptions of burden and opportunity cost were also influenced by the relationship with the NHS organisation. The findings indicate that the participants were cognisant of the power difference between students and supervisors, assessors, and ward managers in the practice areas. Relationships with clinical staff are frequently cited as a stressor for nursing students [ 23 ], with effective supervision and a supportive environment critical to students feeling a sense of empowerment [ 29 ]. Where learning is not optimised, competence and confidence can be affected [ 30 , 31 ] and this may explain the difficulty students reported when deciding to engage with the intervention. For wider implementation preparatory work is essential to embed understanding about the value of the intervention and facilitate prioritisation. Consideration should be given to both student and NHS colleagues’ commitments to maximise engagement and work in partnership. Future work around feasibility should include the views of a wider range of stakeholders from the NHS organisation. Despite perceptions of increased burden and opportunity cost, all those interviewed were unanimous in recognising the future potential of the intervention to support student and early career nurses.

A key facilitator to wider implementation was the innovative nature of the content of the intervention, which drew on theories of stress and wellbeing. The effective combination of exposure to new knowledge, together with a cognitive reappraisal and relaxation techniques [ 28 ], was enhanced by additional exposure to new knowledge about early career nursing practice. Students reported enduring personal benefits at the post intervention interviews, which will have influenced perceptions of acceptability and motivated attendance but also have the potential to mitigate burnout. Strategies to enhance personal wellbeing may help to support newly qualified nurses to cope in an environment with high emotional demand, understaffing or challenges with communication [ 32 ]. If a nurse feels they are upholding their personal values in their professional work, it may offer psychological protection and increase satisfaction with the workplace [ 33 ]. Similarly, such personal benefits may impact on nurse retention by increasing motivation, perceptions of job control and individual decision making, and attachment to the profession and the organisation [ 12 ].

Strengths and limitations

The strength of this study lies in the novel approach to development and application of the intervention, spanning boundaries between nursing practice and higher education. To our knowledge, the intervention is of unique design and the findings are relevant to a range of both academic and healthcare settings. The mixed methods design, the range of participant voices and the breadth of data sources further strengthens the credibility of the acceptability and feasibility, with qualitative data adding depth and contextualisation to questionnaire data.

A potential limitation is the attendance at the intervention. Although 70 acceptability questionnaires were completed, few students attended all intervention sessions and little is known about the views of those who did nto attend. However, the qualitative data helped to contextualise the lower attendance. The single study site is a further limitation. Additional studies of feasibility are recommended across an increased number of sites with different characteristics.

Nurse retention is a global concern and focusing on preparing student nurses for their early career in order to decrease burnout and increase retention is an essential element of strategies to address the issue. This study was designed in recognition of the importance of intervention acceptability to successful implementation and offers a novel approach that explores both prospective and retrospective participant perceptions. The findings indicate that not only was the intervention perceived as acceptable but the positive perception increased over time. Although challenges of the practice environment and pressures of academic assessment impacted on attendance, the personal benefits reported by participants align with known protective factors against burnout and decisions to leave the profession. Wider implementation would require careful planning to incorporate the intervention into curricula and maximise the potential of the relationship with practice partners. Evaluating acceptability and feasibility of the intervention offers new knowledge about the value of the content and allows us to conclude that wider implementation is both recommended by participants and feasible.

Availability of data and materials

The datasets generated and/or analysed during the current study are not publicly available due to the need to maintain the anonymity of participants but are available from the corresponding author on reasonable request.

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Acknowledgements

The authors would like to acknowledge the substantial contribution made to data collection and analysis by the research fellow, Dr. Jennie Brown and research assistant, Leyla Ahmet, and the generosity of the participants who took part in the project.

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This work was supported by the Burdett Trust for Nursing [Grant number: SB\ZA\101010662\253815]. The trust played no part in the design of the study, data collection, analysis, interpretation of the data, or writing of the manuscript.

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All four authors (JB, LA, DS and JM) have made substantial contributions to conception and design, and interpretation of data. JB was involved in collection and analysis of the data. All four authors were involved in drafting the manuscript or revising it critically for important intellectual content. All four authors have read and given final approval of the version to be published.

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Brook, J., Aitken, L.M., MacLaren, JA. et al. An intervention to decrease burnout and increase retention of early career nurses: a mixed methods study of acceptability and feasibility. BMC Nurs 20 , 19 (2021). https://doi.org/10.1186/s12912-020-00524-9

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Development and validation of burnout factors questionnaire in the operating room nurses

• Esmaeil Teymoori 1 ,
• Armin Fereidouni 2 ,
• Mohammadreza Zarei 3 ,
• Saeed Babajani-Vafsi 1 &
• Armin Zareiyan 4  

Scientific Reports volume  14 , Article number:  8216 ( 2024 ) Cite this article

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• Health occupations

Nurses may experience burnout more than other professions. Occupational burnout is a serious concern considering the importance of nurses' jobs in patient care. This study was carried out with the aim of designing and validating the questionnaire of burnout factors in the operating room nurses. Mixed method study was done in two qualitative and quantitative phases in 2022 on Iranian operating room nurses. In the first stage, the concept of operating room nurses' burnout was explained using interviews and literature review, and items were generated. In the second stage, the face validity, content and construct validity of the questionnaire was examined with 342 operating room nurses, and also the reliability of the questionnaire was tested using internal consistency (Cronbach's alpha) and stability (test–retest). After conducting the interview and literature review, 65 questions were extracted. Based on face validity, 4 items were modified. After content validity, 40 items remained. In construct validity, after exploratory factor analysis, 34 items with 5 dimensions were extracted. These dimensions included Organizational, Individual, Interpersonal, Occupational Nature and Managerial factors. Cronbach's alpha and intra-class correlation coefficient were equal to 0.937 and 0.946, respectively. The designed tool based on understanding the concept of burnout in operating room nurses has appropriate and acceptable validity and reliability. Therefore, it can be used to measure burnout in operating room nurses.

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Introduction.

For the first time, burnout was defined by Freudenberger in 1974 with a state of internal fatigue in people who have the task of helping others 1 . Most nurses have experienced burnout syndrome. This syndrome may be accompanied by physical, emotional and mental fatigue and is shown by symptoms of depersonalization and reduced interest in work 2 , 3 , 4 .

Studies have shown that nurses may experience burnout more than other professions. Occupational burnout is a serious concern considering the importance of nurses' jobs in patient care 5 , 6 . Burnout can lead to mental health diseases such as hopelessness, depression and suicide of personnel 7 . Also, burnout can affect individual and professional communication and cause personnel to leave the profession 8 . The most recent study by the American Medical Association reported that two out of five nurses intend to leave their current practice 9 .

The operating room environment has unique characteristics for nurses. Operating room nurses need to work long hours in stressful surgeries with high concentration 10 . Also, operating room nurses are highly exposed to biological, chemical and physical risks. These risks include constant exposure to disinfectants, X-rays, sharp items, anesthetic gases, physical injuries caused by standing for long periods and holding surgical instruments. All these cases can lead to increased burnout in operating room nurses 11 . These negative effects may increase job pressure and reduce the quality of patient care and ultimately patient safety 12 . An extensive study in the United States in which more than 7000 health care professionals participated showed that there is a significant correlation between job burnout, medical error, and patient safety, so that reducing job burnout can improve patient safety 13 . Investigating and coping with burnout in the operating room may be a priority not only to support surgical team members, but also to improve the safety and quality of patient care 14 .

Burnout is considered a long-term response to chronic workplace stress 15 . The risk of burnout in an environment with high job stress is seven times more than in an environment with low job stress 16 . Operating room nurses endure high stress both physically and mentally 17 . This long-term stress reduces resilience and increases burnout of operating room nurses. Nurses who work in the operating room for a long time may have a negative attitude towards their workplace and become extremely nervous, so it is necessary to investigate burnout in this particular group 18 . Several factors such as anxiety, lack of empathy, high workload, work environment culture and lack of personnel support by managers may cause burnout 9 , 19 . Therefore, considering various factors in burnout, there is a need to design valid and reliable tools to measure it in operating room nurses. Several tools have been designed in the field of burnout, such as Jones Burnout scale 20 , Pines Burnout measure 21 , Geldard burnout inventory 22 , Shirom-melamed burnout Measure 23 , Oldenburg Burnout Inventory, Copenhagen Burnout Inventory and Maslach Burnout inventory 24 . The Maslach Burnout inventory has been used in Iran and many countries, but the tools are general and non-specific and have low sensitivity for measuring in health environments 25 . Since burnout can affect the performance of nurses in the operating room and ultimately affect the patient's safety, also considering the need to provide accurate and suitable tools with the work environment in order to determine the factors of burnout, therefore the present research was carried out with the aim of designing and validating the questionnaire of burnout factors in operating room nurses in Iran.

Aim and research questions

Design and validation of burnout factors questionnaire in operating room nurses.

Does the occupational burnout questionnaire of operating room nurses have face and content validity?

Has the construct validity of the occupational burnout questionnaire of operating room nurses been measured?

How is the reliability of the burnout questionnaire of operating room nurses determined?

Study design

The present study is a mixed method research that was conducted in two qualitative and quantitative stages (Item generation, questionnaire design, item reduction and instrument validation) in 2022 on Iranian operating room nurses. The study was conducted in the 7 hospitals of Iran in Tehran city (Imam Reza, Besat, Imam Khomeini,Firoozgar, Talaghani, Baqiyatallah, and Rasoul Akram). All methods were performed according to the relevant guidelines and regulations.Qualitative stage is designed based on COREQ (Consolidated criteria for reporting qualitative research) guideline 26 . Quantitative stage is designed based on COSMIN (consensus-based standards for the selection of health status measurement instruments) guideline 27 . Procedures for designing the burnout factors questionnaire of operating room nurses are shown in Fig.  1 .

Procedures for designing the burnout factors questionnair of operating room nurses.

In the qualitative phase of the study, 18 operating room nurses were interviewed until the data saturation phase. In the quantitative phase of the study, 14 nurses from the operating room were included in the study. In the content validity part, 14 operating room specialists and experts in instrument design, psychology and nursing were polled. In the construct validity part, 342 operating room nurses were asked to complete the burnout questionnaire. Also, for the reliability of the questionnaire, 342 operating room personnel were used to determine Cronbach's alpha and 30 people were used to determine test–retest. Sampling method was convenience in this study. In the following, the sampling details are explained in each step.

Stage 1: questionnaire development

This stage was done with the qualitative approach of conventional content analysis. For the interview, the first participant was included in the study based on the inclusion criteria, Including the ability to communicate properly and high work experience in the operating room, at least an associate's degree in operating room nursing, willingness to participate in the study and not suffering from history of psychological diseases and not taking drugs related to psychological diseases according to the participants' self-report.Exclusion criteria were failure to complete the interview process, and transfer to another hospital or retirement.

Next, other participants were included in the study with purposeful sampling and maximum variation until data saturation. Finally, an individual, face-to-face, in-depth and semi-structured interview was conducted with 18 operating room nurses. The duration of the interview was between 40 and 80 min on average, and sometimes some participants were re-interviewed to complete the information. The interview environment was in the rest room of the personnel or the supervisor's room and in a calm condition. The interview started with a general question such as: “Describe your experience of a stressful day in the operating room” and with probing questions such as: “Explain more about this?” or “Can you give an example?” followed based on previous answers and the purpose of the study. All interviews were fully recorded and typed in word software and entered into MAXQDA-2020 software. Then, the data analysis of the interviews was carried out using the steps suggested by Graneheim and Lundman 28 . In this method, the content of each interview was recorded and typed verbatim, and a general understanding was obtained after several readings. Then the text was divided into meaning units and a code or codes were assigned to each unit. The codes were classified into classes based on similarities and differences and were used to produce items. Then, the number of items was completed with literature review. In the present study, four criteria of credibility, dependability, confirmability, and transferability, which were presented by Guba & Linklen, were used to ensure the accuracy and validity of the data 29 . The item development steps are briefly shown in Table  1 .

Stage 2: validity and reliability

In order to prepare the primary tool, the questions resulting from the qualitative content analysis and literature review based on the comments of the research team, experts in the operating room, experts in the field of psychology and psychometrics, similar and repetitive items were removed or merged. Also, some phrases or words were re-surveyed. After the changes made, the initial questionnaire with 65 statements was prepared for the psychometric process.

Face validity

In order to check face validity, in the qualitative part of the questionnaire items were checked in terms of difficulty, irrelevancy and ambiguity. In this regard, 14 operating room nurses were asked to provide their comments after reviewing the questions to be used in the subsequent analysis. The items suggested were reviewed and corrected. Next, Item impact method was used to calculate the face validity of the questionnaire in a quantitative method. The importance of each item in a 5-point Likert scale including completely important (5 points), somewhat important (4 points), moderately important (3 points), slightly important (2 points) and not important (1 point) was investigated. In this part, if the impact score of each item was higher than 1.5, it was recognized as suitable for further analysis and was retained 30 .

Content validity

Content validity was checked with two qualitative and quantitative methods. In the qualitative part, questionnaires were given to 14 operating room specialists and specializing in instrument design, psychology and nursing. Expert comments about grammar, wording, item allocation and scaling were reviewed. In order to check content validity quantitatively, Content Validity Ratio (CVR) and Content Validity Index (CVI) were used. First, to determine CVR, 14 experts (8 nursing professor, 2 surgeon, 3 psychologists and 1 expert in psychometrics of the questionnaire) were asked to express their comments about the necessity of each item in a 3-point Likert scale (necessary—useful but not necessary and not necessary). Thus, at this stage, based on Lawshe's table, items with CVR less than 0.51 (based on the evaluation of 14 experts) were removed 31 . To determine the CVI, it was done based on the content validity index of Waltz and Basel 32 . For this purpose, the researchers provided the designed questionnaire to 12 experts (7 nursing professor, 1 surgeon, 3 psychologists and 1 expert in psychometrics of the questionnaire)) and asked them to determine the three criteria of relevance, Simplicity, and Clarity of each of the questionnaire phrase in a four-part Likert scale. CVI was calculated for items that scored 3 and 4 using the following formula 33 . According to the Lynn table, the condition for accepting the item when the number of experts is 12 is 0.79 34 .

Cohen's kappa coefficient (K*) was calculated using Polit et al.'s method and using the following formula. Based on the obtained score, kappa evaluation was done (less than 0.6 = poor, 0.6 to 0.74 = good, and above 0.74 = excellent) 35 .

K = Modified Kappa coefficient.

Pc = Probability of random correlation coefficient.

N = Number of experts.

A = Number of very important scores (3 or 4).

Construct validity

In the present study, factor analysis was used to determine the construct validity. Before doing the factor analysis, the initial internal consistency was done on 30 operating room nurses. It is also necessary to consider the adequacy of the sampling before the factor analysis. Sampling adequacy means whether the number of available data is suitable for factor analysis or not. For this purpose, the Kaiser–Meyer–Olkin (KMO) index and Bartlett's Test can be used. The score of KMO more than 0.7 is appropriate 36 . Also, the significance level of Bartlett's Test is less than 0.05 acceptable 37 . Exploratory Factor Analysis (EFA) was used as the most common method to determine construct validity. Principal component analysis (PCA) method was used to extract the factors and PROMAX rotation was used for the interpretability of the factors 38 . The minimum acceptable factor loading was considered to be 0.3 39 . The minimum sample required for exploratory factor analysis is three to ten participants per item 36 . In the present study, 370 questionnaires were distributed among operating room nurses and finally 342 questionnaires were completed and collected by the samples. Inclusion criteria included at least an associate's degree in operating room and more than one year of work experience in the operating room, willingness to participate in the study and not suffering from history of psychological diseases and not taking drugs related to psychological diseases according to the participants' self-report. Exclusion criteria were failure to complete the questionnaire, and transfer to another hospital or retirement.

Reliability

To perform reliability, two methods of internal consistency and stability of the questionnaire were used. To calculate internal consistency, Cronbach's alpha coefficient was used with a sample size of 342 personnel. Also, for stability, test–retest method was used with a sample size of 30 people and with a time interval of two weeks 40 . Cronbach's alpha acceptable for the questionnaire between 0.7 to 0.8 is 41 . The most acceptable test to calculate the level of stability is the intraclass correlation coefficient (ICC) test, if this index is higher than 0.80, the level of stability is acceptable 42 . Thus, at this stage, based on Lawshe's table, items with CVR less than 0.51 (based on the evaluation of 14 experts) were removed 31 .

Data analysis

For demographic information, descriptive analyzes including frequency and percentage were used.

For the validity of the questionnaire, face (Impact score), content (CVR and CVI) and construct validity (KMO, bartlett’s test of sphericity, a scree plot, principal component analysis and promax rotation) were used. The reliability of the questionnaire was measured using the two tests of internal consistency (Cronbach’s alpha coefficient) and stability (test–retest).

For face validity if the impact score of each item was higher than 1.5, it was recognized as suitable for further analysis and was retained 30 . For CVR, based on Lawshe's table, items with CVR less than 0.51 (based on the evaluation of 14 experts) were removed 31 . For CVI based on the Lynn table, the condition for accepting the item when the number of experts is 12 is 0.79 34 . For construct validity the score of KMO more than 0.7 is appropriate 36 . Also, the significance level of Bartlett's Test is less than 0.05 acceptable 37 . The minimum acceptable factor loading was considered to be 0.3 39 . Cronbach's alpha acceptable for the questionnaire between 0.7 to 0.8 is 41 . The most acceptable test to calculate the level of stability is the intraclass correlation coefficient (ICC) test, if this index is higher than 0.80, the level of stability is acceptable 42 .SPSS software version 2022 and MAXQDA software version 2020 were used for data analysis.

Ethical considerations

The permission of this research was approved by the ethics committee of AJA University of Medical Sciences with ethics code IR.AJAUMS.REC.1399.277 and access link https://b2n.ir/n92193 . At the beginning of the study, the research objectives were explained to the participants and written informed consent was obtained. The participants were assured about maintaining the confidentiality of the research data. In addition, it was explained to them that they have the right to withdraw from the study at any stage of the research.

The concept of burnout was determined after qualitative content analysis of interviews with 18 operating room nurses. The characteristics of the interview participants are shown in Table  2 . According to operating room personnel, burnout is a mental concept that is influenced by Organizational, Individual, Interpersonal, Occupational Nature and Managerial factors. Then, in addition to the interviews, a literature review was also conducted and the items of the questionnaire were extracted. Finally, after removing, integrating and re-surveyed similar and repetitive items and using the comments of experts, a pool of questions with 65 items was designed and prepared for psychometrics. The Likert scale of the questions was designed as 5 parts including “never, rarely, sometimes, often, always”. The lowest score for each statement is zero due to choosing the “never” option and the highest score is four due to choosing the “always” option.

Face validity: In the qualitative stage of face validity, items No. 4, 5, 37 and 51 were modified in terms of writing. And in the face validity quantitative section, all the items were retained due to the Item Impact score higher than 1.5.

Content validity: at this stage, items number 4, 6, 10, 11, 12, 14, 16, 17, 28, 30, 32, 33, 35, 53, edited, items 7, 20, 21, and items 42, 43 And 44 was merged and item 55 was merged with 56. Finally, one item was added to the collection of items. After this stage, the number of questions in the questionnaire reached 60 questions. After calculating the CVR, according to the experts' comments, a decision was made to retain or remove the item. Thus, at this stage, items with CVR less than 0.51 were removed. Based on this, 20 items were removed from the 60-item questionnaire. After calculating the CVI, considering that the scores of the items were higher than 0.79, no item was removed and a questionnaire of 40 questions was obtained. The value of Scale-CVI/Ave was also equal to 0.97. The I-CVI (K*) of the whole item was obtained from 0.83 to 1, so all the items were at an excellent level and were retained.

The initial internal consistency of the questionnaire was obtained using Cronbach's alpha coefficient equal to 0.93. The value of KMO and Bartlett's Test is specified in Table  3 . In PCA implementation of the 40-item questionnaire, factor coefficients greater than 0.3 were considered as factor loadings. After performing EFA and Promax rotation, according to Eigenvalue above one, KMO index and Scree Plot (Fig.  2 ), five factors (Organizational, Individual, Interpersonal, Occupational Nature, Managerial) with 34 items were extracted (Table  4 ).

Scree plot to determine the number of factors in the questionnaire of burnout factors in operating room nurses.

Cronbach's alpha coefficient of the whole 34-item questionnaire was equal to 0.937. In Table  5 , Cronbach's alpha of all dimensions is shown. Therefore, all dimensions have a suitable reliability coefficient. Also, the ICC of the questionnaire was obtained with test–retest, 0.946.

Burnout questionnaire of operating room nurses was designed based on the concept expressed with 34 items and in 5 dimensions. In this study, face validity (qualitative and quantitative), content validity (qualitative and quantitative), construct validity (factor analysis), internal consistency and stability of this instrument were confirmed.

In the present study, 65 items were initially designed using interviews and literature review. In the phase of determining qualitative face validity, the comments of operating room nurses were applied and four items were edited in terms of writing. Also, in the quantitative section, all the items had Item impact higher than 1.5, so all of them were retained. According to this step, the designed questionnaire has good face validity. Norful et al. 43 , Kristensen et al. 44 and Mahmoudi et al. 45 also used face validity to check the validity of the job burnout questionnaire.

To survey the content validity of the questionnaire, three parts were used, including the qualitative method, Content Validity Ratio (CVR) and Content Validity Index (CVI). At the end of the qualitative phase, 14 items were edited, 3 items were removed, 5 items were merged and one item was added. In the CVR section, 20 items were removed, and finally, all the items were retained by checking the CVI. Also, Scale-CVI/Ave of the questionnaire was calculated, which had an acceptable score (0.97). Polit et al. have recommended a score of 0.90 and above to accept Scale-CVI/Ave 33 . Mahmoudi et al. 45 , Salaree et al. 25 and Sharifi et al. 46 used CVR and CVI to check the content validity of the job burnout questionnaire and reported the results as appropriate.

The construct validity of the burnout questionnaire was checked with exploratory factor analysis on the remaining 40 items. The results of the KMO index and Bartlett's Test confirmed the factor analysis model and finally, according to the Eigenvalue, 5 factors were extracted.

In the present study, Cronbach's alpha coefficient of 0.937 along with test–retest showed the appropriate reliability of the designed tools. In line with the present study, Consiglio et al. 47 , Javanshir et al. 48 and Salaree et al. 25 investigated the construct validity and reliability of the burnout questionnaire using exploratory factor analysis and Cronbach's alpha coefficient which reported the results as acceptable.

In this study, the concept of burnout was investigated and explained from the perspective of the participants. Previous studies have shown that burnout is a mental concept and because the mind is affected by the body, so if the body is stressed for any reason like overwork, the mind also gets tired. Therefore, researchers have emphasized that when investigating burnout, checking the work environment is also very important because a high stress work environment indicates an increase in the level of burnout in personnel 49 , 50 . The present study showed that the concept of burnout in operating room nurses is a subjective concept that is influenced by Organizational, Individual, Interpersonal, Occupational Nature and Managerial factors, so that these factors play an important role as factors that cause burnout in operating room nurses. Factors name were based on the content of the items and experts' comments (nursing professor, surgeon, psychologists and expert in psychometrics of the questionnaire).

In the current study, organizational factors of job burnout had the highest factor load. The operating room is one of the most stressful environments and even a small mistake can cause serious harm to the patient. Therefore, in such a situation, if proper support is not provided by the organization, the nurses in the operating room bear a lot of pressure and may go towards burnout. In line with the present study, in previous studies, the important role of organizational factors such as lack of organizational support, organizational injustice, and inappropriate organizational performance has been emphasized in creating burnout of nurses 50 , 51 . In the dimension of individual factors, things such as job dissatisfaction, lack of motivation and tolerance of more work due to economic concerns may lead to increased burnout of operating room nurses. In line with the present study, the role of these factors in nurses' burnout has been mentioned in the research conducted by Bakaç et al. 52 and Guo et al. 53 .

According to the results of the present study, operating room nurses may experience burnout through other factors such as interpersonal factors. In line with the results of the present study, due to the importance of communication between surgeons and nurses in the stressful environment of the operating room 54 and teamwork in surgery 55 , if this dimension is not paid attention to, it may cause burnout of nurses. Also, the role of factors related to Occupational Nature and Managerial factors in creating burnout of operating room nurses should not be ignored. In line with the results of the present study, high work stress in the operating room 17 , occupational hazards in this environment 56 and inappropriate performance of managers 57 can cause burnout of nurses.

One of the most widely used tools to measure burnout in internal and external studies is the Maslach Burnout Inventory, but this tools is designed for general use and has low sensitivity for use in specific groups 25 , 58 . Therefore, in order to measure job burnout more accurately, it seems necessary to design and use specific tools.

One of the strong points of this study is the design of a specific tools for burnout factors of operating room nurses based on the concept of burnout in the mentioned society and its validity and reliability. The limitation of this study is sampling in Iran, and due to the social, cultural and geographical factors in people's experiences that were effective in the design of the tool, its generalization to other societies should be done with caution. Also, one of the other limitations of the present study is the lack of use of EFA in construct validity. In addition, the self-reporting of the participants about lack of a history of previous psychological diseases can be one of the limitations of the present study.

Conclusions

Based on the results obtained from this study, a questionnaire of job burnout factors in operating room nurses was designed with 34 items. This tool was designed using two qualitative and quantitative approaches, i.e., interview and comments of nurses and experts in different fields along with the use of different validation methods, and it has good validity and reliability. For future studies considering that the present questionnaire can be easily used to measure nurses' burnout, it is recommended researchers using the present questionnaire to measure burnout and also conducting an intervention study such as designing educational programs and necessary policies to reduce it in operating room nurses.

Data availability

The datasets used and/or analysed during the current study are available from the corresponding author upon reasonable request.

Abbreviations

Content validity ratio

Content validity index

Kaiser–Meyer–Olkin

Exploratory factor analysis

Principal component analysis

Intraclass correlation coefficient

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The authors would like to thank operating room nurses who voluntarily participated in the study.

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Esmaeil Teymoori & Saeed Babajani-Vafsi

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Teymoori, E., Fereidouni, A., Zarei, M. et al. Development and validation of burnout factors questionnaire in the operating room nurses. Sci Rep 14 , 8216 (2024). https://doi.org/10.1038/s41598-024-56272-2

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“What Is Normal?”: A Qualitative Exploration of Health Practitioners’ Reports of Treating Patients Presenting with Unpleasant Sexual Experiences

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• Published: 23 September 2024

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• Rachael Sharman   ORCID: orcid.org/0000-0002-3630-1046 1 ,
• Andrew Allen   ORCID: orcid.org/0000-0001-7873-4264 1 ,
• Kirstyn van Niekerk 1 ,
• Alexandra Coles 1 ,
• Ramesh Manocha 2 , 3 &
• Therese Foran 4  

Sexual health, including sexual pleasure, is fundamental to holistic health and well-being, and is considered an area of priority health in Australia. Despite the importance of sexual functioning, women experience significant gaps in sexual well-being compared to men and often do not seek medical care or treatment. Health practitioners are central to the identification and treatment of sexual dysfunction, including fostering sexual well-being for patients. Despite this, minimal research has explored health practitioners’ experiences in treating reports of unpleasant sex. This study aimed to explore health practitioners’ experiences, responses, and confidence in treating patients presenting for unpleasant sexual experiences. An online, mixed-methods survey was completed by 96 participants. Thematic analysis identified 11 core themes. These themes included five patient centred themes (health risks, diverse sex acts, painful vaginal intercourse, relationship breakdown and violence, unwanted sex) and six health practitioner centred themes (communication and counselling, what is normal, ongoing care and follow up, emotional response, limited practical training, and highly prevalent). Participants described a complex sexual health landscape, with social contexts impacting women’s sexual experiences and engagement in treatment. Additionally, health practitioners reported the need for a biopsychosocial approach to understanding and responding to unpleasant sexual experiences for patients, while simultaneously reporting limited education in this area. Findings reflect the need for health practitioners to be cognisant of matters related to sexual function, consent, coercion, client engagement, and treatment pathways, identifying a need for greater education and holistic approaches to sexual healthcare across medical settings.

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Introduction

Sexual health and well-being, including sexual pleasure, are important to overall health and well-being (Ford et al., 2019 ). People who report more pleasurable sexual experiences report better overall sexual health, and this is more pronounced for women than men (Klein et al., 2022 ). The World Association for Sexual Health (WAS) Declaration of Sexual Rights asserts that sexual rights are fundamental to health; all people have the right to seek, receive, and impart information regarding sexuality to support well-being in healthcare settings (Ford et al., 2019 ; Kismödi et al., 2017 ; WAS, 2014 ). Despite the importance of sexual well-being, research into Australian sexual well-being in 2012 found that 48% of men and 68% of women report at least one sexual difficulty (Richters et al., 2022 ), and broader global research into sexual pleasure consistently finds that there is a substantial gendered gap in sexual pleasure between men and women. Women experience significantly less sexual pleasure than men, with heterosexual women being most impacted (Conley & Klein, 2022 ; Frederick et al., 2018 ; Laan et al., 2021 ; Richters et al., 2022 ). This is exemplified by the “orgasm gap,” where heterosexual women report orgasms in 65% of sexual encounters, compared to heterosexual men in 95% of encounters (Frederick et al., 2018 ).

It is well understood that non-consensual sexual encounters are inherently unpleasant and significantly impactful for men and women, as are unpleasant sexual encounters resulting from medical conditions, however, unpleasant sexual experiences also occur within chosen sexual activities in the absence of medical illness (Chadwick et al., 2019 ). Research into human sexuality indicates that people engage in a diverse range of sexual behavior as part of sexual expression (Herbenick et al., 2017 , 2020 ), and that patterns of sexual behavior change over time alongside changes in social attitudes (Herbenick et al., 2022a , 2022b , 2022c ). Sexual activities that were once considered “taboo” are becoming more prevalent, and men and women are increasingly engaging in sexual acts such as anal sex, sexual choking (as a form of asphyxiation or strangulation), and rough sex as part of their sexual repertoire (Herbenick et al., 2017 , 2021 , 2022a , 2022b , 2022c , 2023 ; McBride & Fortenberry, 2010 ; Rissel et al., 2014 ; Sharman et al., 2024 ). While not always wanted or desirable, people may engage in sexual acts (and endure associated discomfort) due to coercion or to please their partner (Carter et al., 2019 ; Fahs & Gonzalez, 2014 ; Jozkowski & Peterson, 2013 ; Marston & Lewis, 2014 ; Reynolds et al., 2015 ). Women are more likely to experience this pressure, and about 50% of women do not tell their partner if they are experiencing pain or discomfort during sex (Carter et al., 2019 ).

An estimated 37% of women and 9% of men report receiving anal sex across their lifespan (Herbenick et al., 2015 ). Despite this, only 24% of men and 14% of women report anal sex as appealing, and 72% of women and 15% of men report pain during anal sex (Herbenick et al., 2015 ). Anal sex carries health risks such as heightened risk of STD transmission, abrasions, fissures, bleeding and is associated with higher rates of faecal incontinence (Hutton et al., 2013 ; Markland et al., 2016 ). Rough sex, which can include whipping and spanking, bondage, hair pulling, verbal aggression or degradation and choking, is also prevalent, rated as appealing by approximately 40% of men and women (Herbenick et al., 2017 ). Rough sex acts are considered gendered, where women are predominantly the target of rough sex acts and men take a dominant role. For example, in a nationally representative US sample ( N  = 2,227, 51.73% female), one-fifth of women reported having been choked during sexual activity (Herbenick et al., 2023 ). Some research has linked the prevalence of rough sex to exposure to violent or aggressive sexual acts in pornography (Herbenick et al., 2021 , 2023 ; Vogels & O'Sullivan, 2019 ; Wright et al., 2022 ).

There are risks associated with any rough physical acts; however, “choking” carries particularly heightened risks due to the restriction of blood flow and/or airflow which include, headaches, loss of consciousness, stroke, seizures, and even death (Bichard et al., 2022 ; Herbenick et al., 2022a , 2022b , 2022c ; Wright et al., 2022 ; Yardley, 2021 ). Strangulation risks are increased, as it is indicated that many people do not research harm reduction strategies before engaging in sexual “choking” (Herbenick et al., 2022a , 2022b , 2022c ). The variation and normalisation of diverse sexual acts involves physical and emotional health risks, and may be contributing to unpleasant, unsafe, or undesired sexual experiences for men and women. In understanding sexual pleasure as it relates to well-being, it is important to consider the prevalence of unpleasant sexual experiences, and the public health response.

While research into help-seeking for difficult/unpleasant sexual experiences is sparse, information on help-seeking for perceived sexual dysfunction provides some insight into people’s willingness to engage in sexual health care. Similar to unpleasant sexual experiences, the issue of sexual dysfunction is often unreported, unrecognised, and untreated in healthcare settings, despite being associated with poor physical health outcomes and psychological distress (Azar et al., 2013 ; Parish et al., 2019 ; Richters et al., 2022 ). Global rates of help-seeking for people experiencing sexual dysfunction indicate less than 25% of people seek treatment from a healthcare practitioner, including general practitioners, gynaecologists, psychologists, and sex therapists (Lafortune et al., 2023 ; Moreira et al., 2005 ). Barriers to help seeking include; shame or embarrassment, identification of sexual dysfunction as a medical issue, awareness of professional support available, the availability of health resources, direct questioning from health practitioners, and the effectiveness of health practitioner responses (Azar et al., 2013 ; Lafortune et al., 2023 ; Moreira et al., 2005 ; Shifren et al., 2009 ).

General practitioners are often considered the gatekeepers of the health system in Australia, with GPs being the primary source of referral to specialized health practitioners. This places GPs at the forefront of screening and treatment for sexual health and well-being concerns. Health care practitioners predominantly believe that it is important to discuss sexuality and sexual well-being with patients (Dyer & das Nair, 2013 ; Stott, 2013 ). Despite this, it indicated that 75–90% of people report health practitioners do not directly approach them about their sexual health or well-being (Wendt et al., 2007 ; Zakhari, 2009 ). GP’s report discussing sexual well-being with clients to be problematic and complex (Gott et al., 2004 ; Stott, 2013 ; Tarzia et al., 2019 ), indicating that sexual health and well-being is overlooked in primary healthcare settings. Previous research into health practitioner perspectives has suggested several reasons for this, including; limited resources, limited training, low confidence, concerns about offending the patient, limited awareness of sexual issues, and personal discomfort (Byrne & Sharman, 2022 ; Dyer & das Nair, 2013 ; Gott et al., 2004 ). International reviews indicate that GPs and other healthcare practitioners receive limited core training in sexual health, and that they are required to seek independent professional development post-graduation if they wish to increase their knowledge (Mollen et al., 2018 ; Stott, 2013 ; Wakley, 2000 ).

Despite sexual and reproductive health being considered a priority area in the National Women’s and Men’s Health Strategies 2020–2023, Australian health strategies and policies maintain a strong focus on reproductive health and sexually transmitted infection prevention, with limited focus on sexual function and well-being (with the exception of male erectile dysfunction) (Commonwealth of Australia, 2019a , 2019b ). There is limited research into health care professionals’ experiences and training in treating sexual health and well-being in an Australian context. Similarly, there is a dearth of research on Australian healthcare practitioners’ experiences, attitudes, and confidence in treating or responding to clients unpleasant or uncomfortable sexual experiences. Given the prevalence and health implications of these experiences for both men and women, this study aims to add valuable insight by exploring health practitioners’ experiences with clients reporting unpleasant sexual experiences, by answering three key research questions: (1) health practitioners' experiences with patients who present with concerns related to unpleasant sex; (2) how are health practitioners responding; and (3) how prepared do health practitioners feel in assessing and responding to sexual health concerns from their patients?

Participants and Procedure

Recruitment was facilitated by the Health Ed network who distributed the survey to their professional membership. The survey was also distributed via a snowballing approach, where a range of organisations, health services, and public health networks in North and South Brisbane were invited to distribute the survey to professional members. The survey was also distributed through social media groups, such as LinkedIn. Participation was voluntary and open to registered health practitioners in Australia. Data collection and informed consent were obtained using Qualtrics, and consenting participants completed the survey. Participants were asked to respond to demographic questions, then participants who reported experience in treating patients reporting unpleasant and/or painful sexual experiences were provided further questions related to their experiences. Due to the subjective nature of the term, “unpleasant sex” was defined as any sexual activity patients chose to engage in that was an unpleasant or uncomfortable experience for them, and examples were provided. Non-consensual sexual experiences (e.g., sexual assault) were excluded from this definition. Participant responses were anonymous, and assigned a unique identifier. The responses were analyzed using NVivo14 (2023) and quantitative data was provided by Qualtrics Survey Software.

A total of 171 participants consented to and commenced the study. Of these, 125 reported treating patients who had experienced unpleasant sexual experiences and 46 reported having no experience treating unpleasant sexual experiences. Of the 171 initial participants, ages ranged from 22 to 79 years ( M  = 51.86, SD  = 12.91) and years of professional experience ranged from 1 to 55 years ( M  = 24.57, SD  = 13.98). Participants without experience in treating unpleasant sexual experiences were then removed ( n  = 46), and participants who did not respond to further questions were removed ( n  = 29), leaving a final sample of 96 participants, 90 of whom completed all questions. Participants ( n  = 6) who provided partial responses, including demographic data, were retained in the sample to explore themes in their responses. Of the final sample of participants, ages ranged from 22 to 79 years ( M  = 51.74, SD  = 12.63) and years of professional experience ranged from 1 to 50 years of experience ( M  = 24.95, SD  = 13.15). All participants were located in Australia. Demographic data for these participants is reported in Table  1 .

This study employed a mixed-methods quantitative and qualitative design, using an online survey with 25 questions, utilizing a cross-sectional online approach. Quantitative questions were used to obtain demographic information, prevalence data, and practice information, while open-ended qualitative questions were used to gather participant-led information on the subjective experiences of health practitioners and their conceptualization and treatment of patients presenting with unpleasant sexual experiences.

An online survey was administered using Qualtrics Survey Software. Guided by Simonis et al. ( 2016 ), two general practitioners (one with a specific interest and research base in sexual health) and both affiliated in research positions within an Australian University were consulted to assist in formulating survey questions. Demographic questions included: age, identified gender, profession, and practicing location. Qualitative open-ended and quantitative Likert-scale and dichotomous questions were utilised to gather feedback on health practitioners’ experiences. Qualitative questions explored health practitioners experience of client presentations, conversations with clients about unpleasant sexual experiences, perceived risks of unpleasant sexual experiences, and treatment approaches (e.g., “What kinds of problems related to unpleasant sex do your patients/clients often present with?”). Quantitative questions ascertained perceived prevalence and demographics of clients presenting with unpleasant sexual experiences, confidence in responding to patients in these settings, and training in supporting, treating, or responding to unpleasant sexual experiences (e.g., “How confident are you in answering questions from patients/clients regarding painful or unpleasant sex?”). See Appendix 1 for full survey questions.

The qualitative methodology for this research involved thematic analysis and took a critical realism ontological stance with a subjective epistemology, applying a constructivism paradigm. This approach allows for the acknowledgement and exploration of individuals lived experiences and how the interpretation and contextualisation of these experiences within broader social and cultural contexts makes meaning for the individual, allowing understanding of individuals subjective realities. This method supports developing an understanding of the experiences of the health practitioners who participated, reflecting their subjective and contextual perspectives and interpretations and how these are influenced by broad sociocultural contexts.

Data Analytic Plan

Qualtrics Survey Software provided analysis of quantitative data and generated descriptive statistics including mean, standard deviation, range, and percentages. Qualitative data were transferred from the survey and analysed using NVivo (Lumivero, 2023 ), following Braun and Clarke’s ( 2013 ) six phases of thematic analysis. The analysis involved familiarization with the data (e.g., repetitive reading), generating codes relevant to the research questions and content similarities, and collating codes into patterns (i.e., potential themes). Authors RS, AA, and AC worked through these processes independently. The authoring team then collaboratively reviewed and refined potential themes across several meetings, conceptualising categories and subcategories. Thematic findings were discussed until discrepancies in interpretation reached a consensus, with minimal differences in interpretation between the authors. While the use of data extraction through online, open-response questions may have reduced the risk of interviewer bias, bias still exists in the thematic analysis process. Accordingly, it is worth acknowledging that the authoring team, two female-identifying psychology students (KvN and AC), one female-identifying academic (RS), one male-identifying academic and clinical psychologist (AA), one female-identifying general practitioner, and one male-identifying general practitioner may collectively have personal experiences that influenced the interpretation and analysis of the data.

Thematic Analysis

Eleven themes with several subthemes were generated (see Table  2 ), and are presented in order of prominence. Descriptive results indicated that most participants saw patients presenting with difficulties arising from unpleasant sex once every three months (28.1%) followed by once a month (22.9%), once year (22.9%), once every two weeks (15.6%), once a week (8.4%), and daily (2.1%). The majority of participants reflected that they hear about unpleasant sex from patients when they aren’t presenting for specific advice regarding unpleasant sex sometimes (52.1%), followed by rarely (35.4%), often (10.4%), and very often (2.1%). Most participants reported that patients were predominantly women, and only four comments related to male-specific issues (e.g., erectile dysfunction), which were not analysed further as it was not clear if this related to cisgender males or transgender women. Other descriptive statistics are mapped onto and discussed alongside developed themes.

Health Risks

Participants identified several health risks associated with unpleasant sexual experiences, resulting in two subthemes: physical health and mental health. Physical health emerged as the most prominent theme. Participants stated that patients discuss unpleasant sexual experiences in the context of general and sexual health checks. Participants identified that health risks could be short-term (such as tears or bruising) but that there were substantial risks of patients developing long-term health conditions (such as infections or internal scarring). One participant explained the aetiology of more serious conditions from minor injuries, stating “tearing of delicate tissue resulting in bleeding and infection of bladder” (P37) was a concern, and another identifying the risk of “long term fertility issues related to trauma or infection” (P40).

Mental health was the second reported theme regarding health risk, with participants identifying that unpleasant sex posed risks to well-being, causing distress, shame, and confusion, but also contributing to pervasive mental illness such as depression and PTSD. One participant cited “depression, anxiety, self-harm [and] in the extreme cases suicide” (P68) as potential outcomes. It was further identified that declined mental health may place patients at risk of ongoing unpleasant sex due to the “risk of developing an unintended attitude around what healthy safe sex actually constitutes” (P69), creating a cycle defined by one participant as “painful sex [leading to] anxiety [leading to] tension [leading to] painful sex” (P47).

Diverse Sex Acts

According to descriptions from participants, unpleasant sexual experiences were characterised by a range of sex acts disclosed by patients, distinct from ‘traditional’ vaginal sex. Anal sex was frequently mentioned, with participants highlighting anal sex as an act that can be considered both physically and emotionally unpleasant. This was captured by one participant who identified patients experiencing “anal sex [as] painful, degrading and unpleasant” (P25). The second most commonly discussed sexual experience was that of “rough sex,” reported by participants to include: rough penetration, choking, hitting, biting and physical restraint. One participant reflected that patients experience “rough sex when it’s really violent sex” (P70), highlighting the diverse intensity of “rough” and the apparent blurred line that may exist between a sexual act and violent one. Oral sex, public sex and group sex were also discussed, though less frequently, as unpleasant sexual experiences.

Painful Vaginal Intercourse

Participants noted painful vaginal intercourse as a common issue that patients present with. Responses reflected diverse aetiologies of pain including vaginal dryness or poor lubrication, latex allergies, uncomfortable positions, partner penis size, and recent physical trauma (such as childbirth). One participant detailed the variance in presentations, stating they see patients for “pain during sex due to dry vagina, pain due to allergy from using condoms, pain due to refusing to have sex [and] pain after childbirth, especially if she had an episiotomy” (P83). Some participants referenced existing diagnoses as contributing to painful vaginal intercourse, such as endometriosis and vaginismus, with other conditions identified by one participant who stated, “the patients I see with painful intercourse have either provoked vestibulodynia or introital stenosis due to lichen sclerosus” (P60). Of relevance to this theme is the persistence of patients in engaging in painful vaginal sex, despite reporting pain and finding the experience unpleasant.

Relationship Damage and Violence

Responses outlining relationship breakdowns and increased risks of violence were reported by participants. Participants identified that patients avoid or disengage from sex with their partner, or show less enjoyment during sex, following unpleasant sexual experiences, which can lead to reduced intimacy and conflict, straining partner relationships. One participant explained this pattern, stating it “may lead to stress in relationship and avoidance of sex [which] can lead to conflict and risk of sexual coercion” (P74) and another noted that patients’ experience “backlash from [their] sexual partner as [they’re] not seen to being enjoying sexual acts” (P44). Participant responses noted that patients’ partners may respond with sexual or financial coercion, abuse, or violence, and that patients may experience associated financial, social, and cultural consequences that reinforce patterns of coercive control, summarised by one participant as a “high risk for escalating domestic violence” (P55).

Unwanted Sex

The theme of Unwanted Sex details participants reports of patients’ engaging in sex or sexual acts due to implicit and explicit pressure from their partner, despite actively disliking the act or finding it physically or emotionally uncomfortable. Content of this theme included: obligatory or duty sex, pressured sex and giving in, pleasing a partner and engaging in sex acts to seem “normal,” detailed in Table  3 . Despite the study’s definition of unpleasant sex explicitly excluding non-consensual sex, participants still reported sexual assault, forced sex, and non-consensual removal of condoms as “unpleasant sex,” possibly reflecting disparate perceptions of consent. Participant responses to conversations related to consent are clarified in the theme: What Is Normal?

Communication and Counselling

Communication and counselling was the most reported theme by health practitioners regarding their responses to patients presenting with unpleasant sexual experiences. This theme identifies that patients are not always cognisant of their experience as problematic, feel uncomfortable disclosing and are unaware of interventions. In responding to this, health practitioners aim to take a professional stance prioritising objectivity and non-judgement so that patients feel confident in practitioners’ ability to respond, and provide emotional support to patients to increase their comfort to discuss their experiences. This was perceived to facilitate a thorough understanding of the client’s history and develop treatment responses that are sensitive to client's needs. One participant advised their response was to “reassure them that you are comfortable to discuss this and also to work towards helping resolve the issues” (P74) and another reported “active listening and explor[ing] their concerns, providing [a] safe space to express their experiences and emotions” (P46).

What Is Normal?

Sex and normality emerged as a theme identifying health practitioners’ role’s in communicating and affirming for patients what “normal” and acceptable sexual experiences are. Participants reported that patients seek advice from them to understand normal physical or emotional responses to sexual experiences, whether their experiences are normal and how to communicate boundaries and preferences to their partners. One participant outlined that patients are “wanting to confirm that they are not the only person who finds this activity unpleasant, wanting to normalise their concerns and discuss how to bring this up with partner” (P74). It was reported that patients may normalise unpleasant sexual experiences, based on repeated experiences, social feedback, or exposure to pornography. This was explained by one participant who stated:

Some present because their partners, who want sex several times a day, think they have a sexual dysfunction because they are ok with once per week. A lot of conversations are giving the woman permission to say no to the sex and explore alternative ways to be sexually intimate, and to normalize sexual disparities. (P70)

Participants identified that these perspectives can be challenged and that they take an active role in providing reassurance, education, and explicit coaching to patients across domains of sexual functioning, including physiological sexual responses, consent, and communicating sexual preferences and boundaries. One participant detailed they have learned to take proactive action, stating:

I often talk with younger female patients presenting for contraception about consent and the impact of pornography on sexual acts and body dysmorphia—as a lot of issues that patients present with tend to be related to being coerced into unpleasant sex that their (usually young male partner) has learned to be 'normal' through pornography. (P40)

Participants reported that they actively check for issues regarding consent or intimate partner violence, as outlined by one participant stating, “I would first screen for patient safety i.e., is this “merely” unpleasant, or is it coercive/nonconsensual? Is there an issue generally within the relationship that would compromise patient safety such as controlling or abusive behavior” (P61).

Ongoing Follow Up and Care

This theme emerged through participant reports of ongoing care for clients, including follow-up and referral for additional support as needed. Ongoing care was considered case-specific, requiring targeted interventions to meet the client’s specific presentation and needs. It was identified that referral is an important aspect of ongoing care, with 82.2% of participants endorsing referral to other professionals, with endorsed referral pathways detailed in Fig.  1 . Participants identified referral pathways as dependent on patient support needs, with one participant stating, “depending on the situation, sometimes referral to [a] psychologist is appropriate, sometimes patients/clients need to see a gynaecologist, a physiotherapist or a sexual therapist, or a team of health professionals” (P20). The prevalence of referral may be related to health practitioners’ perceived training and confidence, as explored in the theme Limited Practical Training.

Referral pathways Note Total responses n  = 90

Emotional Response

Participants reported a range of emotional responses regarding treating patients for unpleasant sex. Response data reflected that most participants felt comfortable (65.6%) or very comfortable (24.4%) advising patients about unpleasant sex, while a minority reported feeling not comfortable (10%) ( n  = 6 responses missing). Qualitative responses detailed emotional reflections from participants, including feelings of empathy, sadness, and concern. This was expressed by one participant as: “I feel sad for them, concerned [and] wanting to help” (P12). Participants reported that there was a sense of gratitude, relief, and honour that came with patient disclosures. One participant reported “I feel honoured that they trust me and believe in me enough to discuss this” (P42). Finally, some participants reported feelings of shock, discomfort, and overwhelm when discussing these experiences with patients, reporting a sense of ill-preparedness to respond. This was expressed by one participant as “I feel upset and sometimes at a loss of what to suggest” (P79).

Limited Practical Training

Low levels of practical training were a frequently endorsed theme. Overwhelmingly, 96.7% of participants reported receiving minimal undergraduate training related to unpleasant sex, while 1.1% reported adequate training and 2.2% reported comprehensive training ( n  = 6 responses missing). Slight improvements were noted regarding participants’ continued education, but the majority (72.2%) of participants continued to report minimal ongoing training, while 18.9% reported adequate training and 8.9% reported comprehensive training. Lack of professional training and the need for professional development were reflected in the qualitative data, with participants stating, “we need more training on this issue” (P33). Some participants reported sourcing their own training and relying on practical experience to support confident practice. Response data showed that roughly half of participants reported being completely confident (15.6%) or fairly confident (40%) in answering questions from patients in regard to unpleasant sex, with the remainder feeling somewhat confident (22.2%), slightly confident (18.9%), or not confident at all (3.3%), perhaps reflecting individual investment in professional education or learning.

High Prevalence Issue

While not as prevalent as other themes, and not directly queried in the survey, several participants provided responses reflecting the prevalence of unpleasant sexual experiences, noting it as both a significant and complex issue. This was reflected strongly by one participant stating, “this is a HUGE issue and especially in remote communities where I work” (P68). Participants reported the youngest patient age they had seen reporting unpleasant sexual experiences ranging from 12 to 55 years ( M  = 19.94 years, SD  = 6.42) and the oldest patient ranging from 20 to 86 years ( M  = 63.34, SD  = 13.94) reflecting a wide age range of patients needing treatment.

The present study aimed to investigate health practitioners’ experiences treating patients presenting with unpleasant sexual experiences, seeking to understand what health practitioners are facing, how they’re responding, and their preparedness to meet patients’ needs. Qualitative and quantitative responses resulted in 11 core themes. Throughout these themes, there was a consistent discourse reflective of the complexity of sexual health and key issues in providing a healthcare response.

Experiences of Health Practitioners

Five themes emerged in response to the first research question: health risks, diverse sex acts, painful vaginal intercourse, relationship breakdown and violence, and unwanted sex. These themes were reflective of patients reports and health practitioners’ interpretations of significant social, emotional, and physical risks related to unpleasant sexual experiences. Reports of physical health risks as a prominent theme were unsurprising, and consistent with the body of existing research reflecting the health risks of unpleasant and painful sex acts (Bichard et al., 2022 ; Hutton et al., 2013 ; Markland et al., 2016 ; Yardley, 2021 ).

Our findings reflected that health practitioners view unpleasant sex through a gendered lens, reporting women of all ages as the primary group experiencing this issue. This view is consistent with existing research that identifies women experience less pleasant sex than men (Conley & Klein, 2022 ; Laan et al., 2021 ) and experience more painful sex than men (Carter et al., 2019 ). In addition to commentary on painful and unpleasant sex, the themes of relationship breakdown and violence and unwanted sex show health practitioners’ consideration of the interplay of psychosocial factors in unpleasant sex. This perspective is supported by current research regarding female sexual dysfunction, which highlights the medical, psychological and relational/social elements implicit in the aetiology and maintenance of unpleasant sex for women (Meana & Binik, 2022 ). This lens was similarly reflected by health practitioners view of diverse sex acts, such as anal sex and rough sex, showing consistency with prior research that demonstrates that women rate diverse sex acts as less appealing than men (Herbenick et al., 2017 ), but that women engage in diverse acts despite lack of interest or appeal (Faustino & Gavey, 2022 ) and are often the recipient of acts such as anal sex, choking, or hitting (Herbenick et al., 2021 ; Vogels & O'Sullivan, 2019 ; Wright et al., 2022 ).

Health practitioners’ commentary on unpleasant sex acts as a complex issue centred in gendered social contexts aligned with prior research on gendered sexual scripts, as reflected by Ward et al. ( 2022 ) and Wright et al. ( 2021 ), where western social ideologies, media, and pornography develop and reinforce sexual attitudes placing women in roles of submission and subservience in sexual encounters, resulting in lower sexual agency, prioritisation of partner pleasure (Curtin et al., 2011 ), and greater acceptance of male sexual aggression (Papp et al., 2021 ). Topics of consent and coercion were focal points throughout this study, with health practitioners identifying issues of sexual agency, partner-pleasing, and non-consent as central to women’s engagement in unpleasant and unwanted sexual experiences.

There is a breadth of literature identifying the complexities of consent and coercion in western society, with one prominent view being that social scripts position women as ‘gatekeepers’ to sex and men as initiators (Jozkowski & Peterson, 2013 ). Existing research suggests that men prioritise implicit, non-verbal indicators of consent, reflecting the need for women to provide active verbal assertion of non-consent to cease unwanted sexual activity (Kubota & Nakazawa, 2024 ), and that assumed consent is common in long-term relationships (Humphreys, 2007 ). The present study identified that barriers to assertive non-consent may be implicated in women’s experience of unpleasant sex due to women not wanting to upset their partner, internalising blame, and due to the identified risk of relationship breakdowns or escalating relational violence. The present study highlighted that health practitioners see patients engaging in unpleasant sexual experiences due perceived and overt partner pressures and experiencing associated negative outcomes such as pain, injury, and emotional harm. The observations of health practitioners may be understood through research on sexual coercion as predictive of sexual compliance both in the moment and over time (Katz & Tirone, 2010 ), and as a factor in women’s decisions to engage in unpleasant heterosexual anal sex (Fahs & Gonzalez, 2014 ; Faustino & Gavey, 2022 ) and choking (Herbenick et al., 2022a , 2022b , 2022c ). Participants in this study referenced patients who sought permission to say ‘no’ to unpleasant sex acts, seeking an understanding of whether their dislike of a sexual experience was ‘normal’ or valid, or if the issue they were experiencing was their fault. These findings raise the importance of health practitioners having a comprehensive understanding of the wider social contexts that influence sexual health landscapes and practices, and the need to be vigilant of the risks of coercion, non-consent, and violence for participants reporting unpleasant sexual experiences.

Health Practitioner Responses

The second research question queried how health practitioners approach treating unpleasant sexual experiences, with results outlining three themes of: Communication and Counselling, What is Normal, and Ongoing Care and Follow Up. Initially, the themes highlight that health practitioners navigate reports of unpleasant sex through professional and empathetic engagement. This practice approach is consistent with past research, identified as important in both sexual health and general health strategies (Larsen & Cecchini, 2023 ) and relates to previously reported views that establishing rapport is important, before responding to sexual health matters (Hendry et al., 2018 ). Contrary to previous research (Wendt et al., 2007 ), health practitioners in this study reported that they actively discuss sexuality and abuse with patients, directly exploring issues related to sexual health, consent, and interpersonal violence. It is noted that previous research has found that professional interest in sexual health and work in sexual health services may increase health practitioners engagement in these conversations (O'Sullivan et al., 2019 ), this study may have attracted practitioners meeting these criteria given by its distribution via a professional education network (HealthEd) or, alternatively, comfort may be increasing over time due to shifts in social values.

Secondly, this study identified health practitioner efforts to address the social and relational issues that contribute to patients’ experiencing unpleasant and unwanted sex, through taking an active role in educating patients in consent, communication, normal sexual function and promoting safety and agency. Health practitioners are generally perceived as an authority, where the unique insights they provide are heard and acted upon (Larsen & Cecchini, 2023 ). This positions health practitioners in good stead to educate and empower patients, and these conversations may be particularly pertinent for patient groups who have missed out on targeted sexual education, such as older generations (Graf & Johnson, 2021 ). In the absence of any clear framework to guide health practitioners in these conversations, there is the risk that personal values and perspectives on sex and consent may bias advice, with previous research indicating that personal values can dominate professional values in practice (Hendry et al., 2018 ; Muhamad et al., 2019 ). This indicates that patient experiences can be dependent on the treating practitioner’s values, comfortability, and professional knowledge, risking inconsistent outcomes for patients and justifying the need for practice guidelines in this space.

Finally, the present study found that health practitioners consider ongoing care as central to treatment for patients, citing various referral pathways for treatment and support, reflective of medical treatment recommendations such as psychology (Alahverdi et al., 2022 ; Mestre-Bach et al., 2022 ), physiotherapy, and sex therapy (Cacchioni & Wolkowitz, 2011 ). This was consistent with the overall endorsement of a holistic approach to understanding and responding to patients reporting unpleasant sexual experiences, seeing unpleasant sex through lenses of physical health, mental health, and social contexts, responsive to the complexity of the topic which is aligned with modern views of female sexual function (Meana & Binik, 2022 ; Rosen & Barsky, 2006 ).

Preparedness to Respond

The final research question that this study aimed to answer was health practitioners perceived preparedness to meet the needs of patients reporting unpleasant sexual experiences. Three themes were identified in relation to this question: emotional response, limited practical training and highly prevalent. Despite viewing the issue as prevalent and important, the present study highlighted that health practitioners perceive substantial gaps in their undergraduate training regarding sexual health and unpleasant sexual experiences. This is consistent with previous qualitative research in Australia (Lucke, 2017 ) and overseas (Dyer & das Nair, 2013 ; Stott, 2013 ), identifying that lack of training is cited by a range of health practitioners as a barrier to both initiating and responding to conversations related to sexual health and well-being. Responses in this study found that post-graduate professional development in this area was not regularly obtained by participants, with under 25% of participants reporting intentional ongoing training.

Despite limited training, over 90% of participants in this study reported feeling comfortable discussing unpleasant sexual experiences with patients, and over 75% reported feeling confident providing advice. This was contrary to previous research, where health practitioners have routinely cited personal discomfort and the complexity of topic as a reason for not engaging with patients regarding sexual health (Dyer & das Nair, 2013 ; Gott et al., 2004 ). Regardless of comfort and confidence, health practitioners reported that discussions related to unpleasant sex carried an emotional weight, contributing to stress and sadness, but also satisfaction and pride. These findings present a professional landscape where health practitioners are trying to respond to a complex and prevalent issue, without the training to support them. This may be a pertinent consideration where diagnosis uncertainty, emotional exhaustion and job dissatisfaction are related to health practitioner’s high burnout rates (Zhou et al., 2022 ). While not reported on by participants in this study, considerations raised in previous research indicate that limited resources such as time, high caseloads and a shortfall in health practitioner numbers can make it more challenging for health practitioners to provide a thorough response to patients (Australian Medical Association, 2022 ).

Implications

This study is the first of our knowledge to explore health practitioners’ experiences of treating patients presenting to medical settings for unpleasant sexual experiences, and is considered to have several strengths. The online sampling method provided substantial reach across Australia, reflecting diverse health contexts across rural and urban Australia, while limiting the risk of researcher bias. The large sample size provided an overview of the experiences of health practitioners.

While this study took an atheoretical approach, participant responses can be understood through the biopsychosocial theory of medicine (Engel, 1977 ) and feminist theories on the social roles and historic disadvantages impacting women. Health practitioners’ perspectives consistently reinforced the need to both interpret and respond to unpleasant sexual experiences from a biological, psychological, and sociological perspective, with awareness of how women are uniquely impacted by social contexts. This approach reflects a significant and positive change from historical approaches, which viewed female sexual dysfunction as it related to their role in sexually pleasing their partner or conceiving children, and described it as “frigidity” or “psychological disturbance” with treatment approaches including hypnosis, systemic desensitization, and “re-education” (Burdine et al., 1957 ; Popenoe, 1954 ; Sotile & Kilmann, 1977 ).

The present study has several implications in understanding the experiences of health practitioners in treating women experiencing unpleasant and unwanted sex, and in providing recommendations to improve the capacity of health practitioners to respond and improve the experience of patients. The 11 themes identified in this study, alongside existing research, reflect a complex sexual health landscape that is dominated by social issues related to women’s sexual agency, such as gendered social scripts, consent education and coercion. It is indicated that health practitioners are well placed to provide education, empowerment, and treatment for patients when they have sufficient training, feel confident and comfortable and hold values consistent with best practice. These findings reinforce the need for in-depth practical training and practice guidelines for health practitioners, encompassing holistic approaches to sexual health, the psychological and social contexts that impact women’s sexual experiences, and ways to engage patients in these discussions to increase disclosure and therefore access to treatment. Health practitioners may find the findings of this study of interest, as it relates to how patients may present and ways to engage and support patients.

Limitations and Future Directions

Whilst the use of the term “unpleasant” sex was chosen specifically as a bridge between normative, subclinical, and pathological aspects of sexual activity, such a broad term is encompassing and may not have allowed for clear specificity in responses. Similarly, while the research method allowed for diverse sampling, it did limit the ability to seek clarity or elaborate on responses, which may have contributed to misinterpretations of participant responses and impacted the richness of data. As the research was situated in Australia, and the survey primarily distributed via a professional network, there are limitations to cross-cultural generalisability. Further to this, as the sample of participants was over 80% women, the results may reflect health practitioners with particularly interest or investment in female sexual health, perhaps biasing the results and limiting generalisability. As our research focused on health practitioners’ individual experiences, further research into training approaches for health practitioners may be beneficial, alongside research into screening approaches for patients to better identify and respond to unpleasant sexual experiences and the development of practice guidelines to support a best-practice approach to sexual healthcare for women experiencing unpleasant, unwanted, and painful sex.

In conclusion, health practitioners across a suite of professions are seeing patients reporting unpleasant sexual experiences, situated in complex social dynamics related to women’s sexuality, requiring a biopsychosocial response to exploration, engagement, and treatment. Health practitioners are the forefront of identification, diagnosis, and treatment for sexual function, and are well placed to provide holistic care to patients reporting unpleasant sexual experiences. This is supported when practitioners are educated, confident and aware of the biopsychosocial contributors to unpleasant sex, but it is identified that they experience barriers related to training, patient comfort in disclosing, and unclear guidelines around responding to the issue. This is an important area of healthcare research, identified as a prevalent and complex topic requiring further investment.

Data Availability

Data can be made available upon reasonable request.

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Sharman, R., Allen, A., van Niekerk, K. et al. “What Is Normal?”: A Qualitative Exploration of Health Practitioners’ Reports of Treating Patients Presenting with Unpleasant Sexual Experiences. Arch Sex Behav (2024). https://doi.org/10.1007/s10508-024-02994-3

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Impact of nurse burnout on organizational and position turnover

Lesly a. kelly.

a CommonSpirit Health, Phoenix, AZ

b Edson College of Nursing and Health Innovation, Arizona State University, Phoenix, AZ

Perry M. Gee

c Intermountain Healthcare, Salt Lake City, UT

d College of Nursing, University of Utah, Salt Lake City, UT

Richard J. Butler

e Department of Economics, Brigham Young University, Provo, UT

f Southwestern University of Finance and Economics, Chengdu, China

Associated Data

• • Burnout persists as concerning problem for more than half of nurses.
• • Burnout contributes to nursing workforce turnover, however not internal transfers.
• • Working day (vs. night) shift and increased death exposure increase burnout.
• • Hospitals must measure burnout and wellbeing to understand and address its impact.

The National Academies of Medicine describes clinician burnout as a serious threat to organizational health, including employee turnover.

To determine the relationship between resilience, burnout, and organizational and position turnover.

We surveyed direct care nurses in three hospitals 1 year apart between 2018 and 2019; 1,688 nurses completed 3,135 surveys included in analysis.

Fifty-four percent of nurses in our sample suffer from moderate burnout, with emotional exhaustion scores increasing by 10% and cynicism scores increasing 19% after 1 year. The impact of burnout on organizational turnover was significant, with a 12% increase in a nurse leaving for each unit increase on the emotional exhaustion scale, though it was not a factor in position turnover.

These findings contribute to the growing body of evidence of nurse burnout and support policies and programs for annual measurement of burnout, increased employee wellbeing support, and improved work environments.

Introduction and Background

Nursing burnout is a deleterious and consequential syndrome that affects not only the individuals, but also the organization and patients in which those nurses labor. As many as half of the nursing workforce are experiencing burnout, with likelihood of personal consequence, job dysfunction, and potential risk to patients ( Dyerbye et al., 2017 ). An increase in awareness, including the National Academy of Medicine's establishment of the Action Collaborative on Clinician Wellbeing and Resilience (National Academy of Medicine [NAM], 2020 ) has contributed to efforts to produce outcome data; however, there is a paucity of quality research with the nursing workforce and organizational outcomes. In this analysis, we examine the influence of nurses’ resilience on burnout, and how nurse burnout affects subsequent organizational and position turnover.

Because burnout is characterized through three classic symptoms of exhaustion, depersonalization (cynicism), and reduced personal accomplishment ( Maslach & Leiter, 2016 ), it stands that burnout contributes to employees leaving their positions. Burned out individuals may become exhausted doing their best to care for patients, where the chances of recovery are minimal. The burned out clinician may express cynicism in uncharacteristic negative behaviors, poor communication with others, and even incivility toward co-workers. When clinicians are burned out they feel they are not performing their job responsibilities at the highest levels, lack motivation, and have poor personal job related self-esteem. The emotional toll on health care workers, especially nurses who care for patients through death, may impact nurses’ own emotions ( Wilson & Kirshbaum, 2011 ). Nurses may feel reduced personal accomplishment and a lack of satisfaction in response to job-related stressors and eventually leave their position. In addition to the disruption to patient care, the loss of a nurse leaving their position is also associated with significant financial costs, estimated from $11,000 to $90,000 per nurse with up to $8.5 million in associated wider costs (e.g., unfilled vacancies, patient deferment, training and orientations) ( Halter et al., 2017 ).

Despite the hypothesized link, few studies have evaluated burnout and actual job turnover in the nursing workforce, instead using an individual's intention to leave their position as a proxy for turnover. A recent physician study described the relationship between clinician's actual turnover and burnout, finding physicians and advanced practice providers to be 1.5 times more likely to turnover when they had high burnout ( Willard-Grace et al., 2019 ). Moreover, virtually no attention has been given to position turnover or the associated contributing factors ( Kovner et al., 2016 ; Taylor & Covaleski, 1985 ). Since studies confirm that up to one third of nurses leave their position in the first one to two years of employment ( Unruh & Zhang, 2014 ) and nationally turnover for nurses is approximately 18% ( Nursing Solutions, Inc., 2020 ), it is critical to evaluate the role of burnout in turnover.

To fully understand clinician wellbeing, the role of resilience, or one's ability to overcome adversity, must be evaluated related to burnout and outcomes (NAM, 2018). A growing trend has emerged to generally view resilience as a method to prevent burnout; while evidence generally describes personal resilience building activities as support for decreasing stress, improving coping, and adapting ( Kamath et al., 2017 ; Rees, Breen, Cusack, & Hegney, 2015 ; Rushton, Batcheller, Schroeder, & Donohue, 2015 ). In the nursing profession, resilience is required to mitigate burnout, with many interventions aiming to increase personal resilience in order to affect organizational culture and work environment ( Rushton et al., 2015 ). Thus, the examination of personal resilience must be included in evaluating the relationship of nurse burnout and its effect on turnover. The purpose of this study is to evaluate the relationship between resilience, burnout, and both organizational and position turnover.

A quantitative nonexperimental study was conducted using a survey of direct care nurses at two points in time. Institutional review board approval was received from the health system and the partner university.

The study was conducted in three hospitals in a single health system in the United States in March 2018 and March 2019. The nonprofit health system hospitals included two community hospitals and one academic medical center with two facilities under one campus. We surveyed employed nurses from 78 units who provided direct patient care. Non-nurses and nurses whose primary role was not patient care (e.g., leaders, case management, educators) and advanced practice nurses were excluded. An estimated 3,574 eligible nurses were surveyed in 2018 and 3,528 eligible nurses in 2019.

Common validated instruments were used to measure burnout and resilience: the Maslach Burnout Inventory (MBI) ( Maslach, Schaufeli, & Leiter, 2001 ) and the Connor Davidson Resilience Scale -10 item version (CDRISC-10) ( Davidson & Connor, 2018 ), respectively. The MBI measures emotional exhaustion, cynicism, and personal accomplishment, with higher scores on the exhaustion and cynicism subscales indicating a higher burnout, whereas a lower score on personal accomplishment indicates burnout through decreased motivation ( Maslach, Schaufeli, & Leiter, 2001 ). As with previous research, we classified moderate burnout as a score of 16–26, and high burnout 27 or higher on the emotional exhaustion scale ( Lee, 2017 ; McHugh, Kutney-Lee, Cimiotti, Sloane, & Aiken, 2011 ). The CDRISC-10 measures resilience with a total score of the 10 items, with a higher total indicating increased resilience ( Davidson & Connor, 2018 ).

The survey included questions asking the nurse's age, tenure as a registered nurse, and average hours worked in a typical week. Additionally, nurses were asked their race, most common shift work (day/night), whether they held a national certification in nursing, and whether they were a member of a professional organization. To assess workplace conditions related to burnout, we asked nurses to recall the number of patients assigned to their care on their last shift, as a proxy for staffing/workload, and the number of patient deaths they were involved with in the last 30 days, to assess the number of patient deaths nurses were involved with on average. Finally, we asked nurses whether they intend to be in their position in 1 year.

Organizational turnover was defined as the nurse leaving this health care system and position turnover was defined as an individual leaving their position and accepting another position within the organization ( Kovner, Brewer, Fatehi, & Jun, 2014 ). We collected turnover data from April 2018 to June 2019.

Data Collection

We utilized a third-party honest broker to identify eligible nurses, administer the survey and collect responses, which allowed us to link year over year data via the employed nurse's unique identification code. Nurses were invited to participate in the surveys each year through their email. After accessing the survey through the emailed link, the first page of the survey included informed consent the nurse must agree to in order to participate. The same survey was repeated in both years. The survey was open for 3 weeks each year the study was conducted. Throughout the 3 weeks of data collection, response rates were provided by unit and the research team utilized rounding and multiple forms of communication to encourage participation.

Turnover data was extracted from the health systems workforce department and matched through the same employee number used for the survey. Once matched, data were deidentified by removing employee numbers and utilizing unique codes for each nurse for analysis.

Data Analysis

All survey data was transferred to the research team from the third party honest broker. All participants who completed surveys in both 2018 and 2019 were included in analysis, with standard errors clustered for each nurse to account for if the nurse took the survey in both years. We utilized a recursive regression modeling structure ( Thiel, 1971 ) to evaluate the pathways from resiliency, to nurse burnout, and then subsequently organizational and position turnover. This recursive modeling structure follows an intuitive development of resiliency to burnout through the examination of how independent variables lead to dependent variables without a feedback loop. Fixed effects (for each unit) linear regressions were used to predict nurse burnout (partially determined by resiliency) and separate regressions were used to predict organizational and position turnover (partially determined by resiliency and burnout, as measured by emotional exhaustion). We estimated organizational and position turnover using all survey data with nonmissing values, with 15 months of turnover exposure risk for 2018 survey respondents (3 months for 2019 respondents) and controlling for the exposure in measuring turnover with year fixed effects, as well as all other controls including departmental fixed effects.

Limitations

Our study is limited to one system in a single state, however, we report on a large sample of three hospitals across 78 departments. The demographics, work conditions, technology, and regional practices of the area may affect generalizability. Our response rate is average to surveys with the nursing workforce; however, response bias may be present and influence the validity of the results. Although we collected data at two points in time, continued longitudinal data may provide more information about the workforce trends over time. A limitation of all prospective analyses of turnover, including ours, is that the time frames in which a turnover is observed are right censored. In our models, we control for the differential censoring between 2018 and 2019 with year fixed effects.

In 2018, a total of 1,834 surveys (51% response rate) were returned and in 2019,1,632 surveys (46% response rate) were returned. The final analytic sample on complete outcome data was conducted on 3,135 surveys. This sample comes from 1,688 nurses in 78 units.

We find that 54% of nurses in our sample to be experiencing burnout (emotional exhaustion score above 16), with 28% of nurses experiencing high levels of burnout (score above 27). On average, nurses in all units report exposure to patient death at a rate of one death every other month (0.477 deaths per month), but variance within the sample demonstrates two high acuity areas, intensive care units and emergency departments, experience on average 1.5 deaths per month. For nurses who completed the survey both years ( n  = 1,034) we find that emotional exhaustion scores increased by 10% (from 18.95 to 20.89) and cynicism increased by 19% (from 5.50 to 6.54). Personal accomplishment remained essentially flat from an average of 36.37 in 2018 to 36.07 in 2019. Nurses reported an average resiliency score of 32.59 in 2018, with a slight decrease to 31.83 in 2019. Table 1 describes average characteristics for the regression sample means, including organizational and position turnover rates of approximately 8% per year.

Summary of Nurse Characteristics and Their Environment, 2018–2019

Nurses’ resilience scores are positively impacted by their age, tenure as a registered nurse, increased hours working, and intention to stay in their position ( Table 2 , left hand column). Additionally, nurses who engage as members of a professional organization are likely to increase resilience.

Predictors of Resilience and Burnout

Linear regression resilience and burnout. Note: Nonsignificant coefficients not shown; specification included race dummy variables, a year fixed effect, and fixed effects for each nursing unit. Full models provided in supplementary material ( n  = 3,135).

In context of nurses’ resilience and other potentially contributing variables, Table 2 (right hand column) describes the significant impact of individual and work-related characteristics in predicting burnout. Female nurses experienced roughly 9% more burnout than males, similar to physician gender differences ( Templeton et al., 2019 ). Each year of tenure increases burnout (logit coefficient of 0.058), but holding tenure constant, each additional year of age decreases burnout (−0.076), suggesting that those nurses entering the profession at an earlier age have less burnout than those entering the profession at a later age (since nurses entering the profession earlier are older for each year of tenure).

The potential exposure to secondary trauma and exposure to patient deaths, as assessed through a single item measure of number of patient deaths, is extrapolated to understand the toll over 1 year. The increase in expected burnout for a nurse who witnesses one death per month would have a 3.31 increase in burnout on the emotional exhaustion scale 1 ; compared to a nurse without any death(s), this would represent an approximate 40% increase in burnout over the course of a year. For nurses who work the day shift, where work environments may be more hectic and interactions between colleagues more likely to occur, burnout is likely to be 11.3 percent higher (2.279/20.22) 1 ( Table 2 , right hand column).

We estimate the likelihood of organizational turnover (a nurse leaving the hospital system) as a function of these same variables in the left hand column of Table 3 using logistic regression. This is a 0.953 percentage point increase in the likelihood of turnover for a one unit increase in burnout on the emotional exhaustion scale, which translates into an 11.62 percent increase in the likelihood of turnover for a unit increase in the normalized scale (0.00953/0.082 = 11.62). We find only two other factors that contribute to organizational turnover: higher education and stated intention to leave. Nurses with graduate degrees (masters or doctorate) are 68% more likely to turnover than those with associate degrees, and nurses with graduate degrees are 47% more like to turnover than those with bachelor's degrees. Nurses stated intention to leave is the highest predictor of actual turnover ( Table 3 ). For nurses who choose to leave their position, we find the only significant predictor to be nurses stated intention to leave.

Predictors of Nurse Organizational and Position Turnover

Logistic regression organizational and position turnover. Nonsignificant coefficients not shown; specification included race dummy variables, a year fixed effect, and fixed effects for each nursing unit. Full models provided in supplementary material ( n  = 3,135).

Burnout continues to be a persistent and concerning problem for the nursing workforce, with more than half of our sample experiencing moderate burnout and 28% experiencing high burnout. Although prevalence findings of burnout vary across settings, studies using the MBI and assessing nurses in the United States cite the prevalence of high burnout between 19% and 43% ( Poghosyan, Clarke, Finlayson & Aiken, 2010 ; Aiken, Clarke, Sloane, Sochalski & Silber, 2002 ; McHugh et al., 2011 ). In an effort to address the scope of the problem, the National Academy of Medicine calls on organizations to utilize validated measures to annually assess burnout and wellbeing in their workforce (National Academy of Medicine, 2019). Through these actions, health care systems can begin to collect meaningful longitudinal data in understanding the impact of burnout on their employee, quality, and financial outcomes.

Efforts to understand resilience must be taken before promoting the workforce to build resilience capacity ( Kelly, Gee, Weston, & Ryan, 2019 ). Our findings describe encouraging resilience building factors, such as fostering intent to stay in one's position (organizational commitment) and supporting professional membership organization. However, the limitations of our surveys prevent us from understanding whether nurses increased resilience is in response to negative work attributes or characteristics. For example, a nurse may demonstrate higher resilience as a result of increased hours worked, suggesting part-time nurses are less resilient; however, nurses who become acclimated to longer hours, overtime, or adding extra shifts may have developed higher resilience to unfavorable conditions that can lead to burnout. Understanding and measuring resilience, as part of clinician wellbeing, should be approached by assessing work environment factors, such as staffing, communication, recognition, workload, and leadership; clinicians may be building resilience against unfavorable work environment factors causing burnout ( Kelly et al., 2019 ; National Academies of Science, Engineering, & Medicine, 2019 ). Additionally, the role and value of staff belonging to professional nursing organizations could be explored further to understand how membership increases resilience.

Alleviating factors of burnout is a complex issue, with no one strategy to support efforts. Our study continues to support the need to create healthy work environments, especially for those more vulnerable to burnout, specifically, younger, female nurses who work the day shift. This is particularly concerning, as the nursing workforce is on average 91% female and over 60% to 80% of nursing students are under the age of 30 ( National League of Nursing [NLN], 2020 ) and tend to obtain training and preceptorship on the day shift ( Mayes & Schott-Baer, 2010 ). The increased use of nurse residency programs for new graduate nurses can, but does not always, address wellbeing. These findings emphasize the need to promote wellbeing early in nurses’ preceptorship and training.

The evidence between nurse burnout and turnover is enhanced with understanding the contribution of an individual's resilience. We find that a nurses’ lack of resilience can be a predictor of burnout, however, we do not find a lack of resilience to be a factor in turnover. We interpret these findings to describe that resilience building is a necessary component of preventing burnout, but once high burnout occurs turnover is a likely outcome. In addition to burnout, organizational turnover occurs because of other known factors, such as younger age and lack of job commitment ( Kovner et al., 2014 ). Our findings describe potential new contributors to burnout such as the turbulence of day shift work and the potential of secondary trauma exposure from increased deaths. These findings describe key areas where organizations can focus burnout intervention efforts, such as improving communication between providers or supporting critical incident stress debriefing after traumatic events.

We did not find evidence that burnout contributes to position turnover. On one hand, opportunity may be driving position turnover, as nurses may be desiring career advancement or seeking novel opportunities. While often considered controversial, placement of new graduates early into specialty positions may decrease turnover, although it comes with other financial and training challenges ( Read & Laschinger, 2017 ). On the other hand, position turnover may be influenced by negative affectivity and job satisfaction ( Kovner et al., 2016 ), and likely the role of burnout could be a factor in a unit-level analysis that includes work environment and leadership variables.

Burnout and COVID-19

Recent studies have demonstrated that stressors linked to nurse burnout are prevalent during the COVID-19 pandemic. Being overworked during COVID-19, or any pandemic, and experiencing a surplus of stressful scenarios likely increases the risk of burnout ( Gavidia, 2020 ), and nurses who treat quarantined or isolated patients, especially frequently, are more likely to experience emotional issues (Lai, Ma & Wang, 2020) . Nurse burnout is already a serious problem, however, the COVID-19 pandemic brings additional stressors, increased morbidity, and severe working conditions, which increase the likelihood of burnout. It is essential that hospitals engage in proactive measures to reduce burnout, especially during a pandemic. Some strategies to decrease workload, stress, and potential burnout during COVID-19 include improving the work schedule, encouraging self-management, and providing personal resilience building opportunities, such as mindfulness-based stress reduction and mental health awareness resources ( Fessell & Cherniss, 2020 ).

Our findings describe the significant role of burnout in nurses’ organizational turnover and provide insight that other factors contribute to why nurses may choose to change positions. We further describe the impact of resilience on burnout, providing areas for increasing wellbeing in clinicians and improving the work environment. Because of the importance of identifying and reducing burnout in the workforce, organizations must systematically measure burnout and wellbeing to understand and address the impact on their turnover.

Declarations of Interest : None.

1 percent = (coefficient)/(mean value of burnout)

Supplementary material associated with this article can be found in the online version at doi:10.1016/j.outlook.2020.06.008 .

Appendix. Supplementary materials

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