research
Perspect Psychiatr Care. 2021;57:583–596. wileyonlinelibrary.com/journal/ppc © 2020 Wiley Periodicals LLC | 583
Received: 22 February 2020 | Revised: 1 July 2020 | Accepted: 5 July 2020
DOI: 10.1111/ppc.12581
OR I G I N A L AR T I C L E
The effect of role‐related stressors on nurses' burnout syndrome: The mediating role of work‐related stress
İrfan Akkoç PhD1 | Olcay Okun PhD2 | Aysun Türe PhD3
1Organizational Behaviour, Izmir, Turkey
2Organizational Behaviour, Van, Turkey
3Department of Nursing Management, Faculty
of Health Sciences, Eskisehir Osmangazi
University, Eskisehir, Turkey
Correspondence
İrfan Akkoç, PhD, Hürriyet mah. Melahat
Aksoy cad. Yıldıray Apt. No:3/3, 35900, Tire/
İzmir, Turkey.
Email: dr.irfanakkoc@gmail.com
Abstract
Purpose: This study sought to investigate the effects of role conflict, role ambiguity,
and workload on burnout syndrome among clinical nurses working in university
hospitals and the mediating role of work‐related stress in these effects.
Design and Methods: Cross‐sectional questionnaire‐based survey was conducted.
Data from 386 nurses were evaluated. The research variables were analyzed using
statistical methods such as factor analysis, correlation analysis, regression analysis,
Sobel tests, and bootstrapping method.
Findings: It was determined that role conflict, role ambiguity, workload, and work‐ related stress affect nurses’ burnout significantly and work‐related stress has a
mediator role between burnout and the independent variables.
Practice Implications: Nurses' burnout syndrome can be prevented if managerial
practices to reduce the sources of role‐related stressors and work‐related stress are
implemented by managers.
K E YWORD S
burnout, role ambiguity, role conflict, workload, work‐related stress
1 | INTRODUCTION
Hospitals are high‐tech institutions that provide high‐level and specia-
lized services in terms of service type and quality, that is, specialized
health services. Although the technologies used in hospitals are ad-
vanced, employees remain the most important factor in their success. It
is important to note that working life has a different meaning for each
individual. For some, economic gain is the priority, and for others, it is
the pleasure and social status at work that are essential.1 It is a known
fact though that individuals who enjoy their work are the most suc-
cessful in it. However, this requires a healthy and good working en-
vironment. World Health Organization2 defines a healthy workplace as
a work environment in which health, safety and improvement processes
are provided to the staff. This helps to protect and improve the health,
safety, and welfare of employees and promote the sustainability of the
workplace.3 Workplace policy‐makers recognize that quality of work
and the working environment are vital for the health of employees.
Poor quality work characterized by severe working conditions (eg, long
working hours) can be harmful to health.4
World over, organizations focus on productivity of their em-
ployees but remain insensitive to the work‐related stress of em-
ployees which, among other consequences, significantly affect their
health. Work‐related stress is trending upwards and many employees
across the globe suffer in silence. World Health Organization5 de-
fines work‐related stress as the people's response when presented
with work demands and pressures beyond their coping abilities. It is a
structural problem that has an individual impact on each employee.6
Ehsan and Ali7 assert that several employees suffer from anxiety,
depression and stress‐related illnesses and each affected employee
loses about 16 working days every year. Stress therefore leads to
lower organizational and employee performance, high error rates,
staff turnover, and absenteeism as a result of health problems such
as anxiety, emotional disorder, depression, among other ailments.8 It
has also been mentioned that work stresses lead to a psychological
reaction affecting beliefs such as organizational outcomes and job
attitudes.9 The issue of work‐related stress is so serious that it is
currently being evaluated in the legislation of many countries in
Europe.10 For instance, European stakeholders have acted on the
issue by producing documents such as position papers and govern-
ment regulations.11
In a wider perspective it is often useful to study role‐related stressors along with work‐related stress. A stressor is a prevailing
condition that causes stress. Workplace role‐related stressors are
those that relate to the role requirements of that work.12 Role‐ related stressors are often conceptualized under role ambiguity, role
conflict, and work overload because employees experience them
continuously (chronic).13‐16 All these three role‐related stressors
significantly affect anxiety and thus the level of commitment to task
performance. Role stress is a reaction that occurs when employees
are presented with job demands that do not match their knowledge
and skills and thus challenge their coping ability.17
Exposure to stressors for a long time and inability to cope with
prolonged stress causes burnout.18 A burnout syndrome is especially
common among nurses.19‐21
A study conducted in Turkey,22 revealed that hospitals face
serious challenge of shortage of nurses as the number of nurses per
patient is inadequate. This small nurse‐patient ratio has direct ne-
gative impact on both the patient and the nurse, the hospitals, and
ultimately the whole country. There is need to study and clearly
understand the relationships mong work role stress factors, work‐ related stress, and burnout in the nursing profession and the med-
iating effect of work‐related stress in these relationships. The main
purpose of this study is to test the theoretical relationships between
variables on the model (Figure 1). In the model that puts forward the
precursors of burnout syndrome, it is intended to identify the
elements of work stress (role conflict, role ambiguity, workload,
work‐related stress) and to examine their effects on nurses; to
examine the relationships among the variables, and to analyze the
mediator role of work‐related stress in the relationships.
1.1 | Role‐related stressors
Role ambiguity is a common phenomenon in many organizations. It
entails a lack of clarity, certainty, and/or predictability one expected
with regard to behaviour in a job, for instance, due to an ill‐defined job description and/or uncertain organizational objectives.23 It is a
state of uncertainty from the point of view of employee. Settles
et al15,24 Schmidt et al25 agree that role ambiguity is broadly con-
sidered to include uncertainties about role definition, expectations,
responsibilities, tasks, and behaviors involved in the task environ-
ment. Role ambiguity is one of the sources of stress in the work-
place.26 Role ambiguity in the nursing profession can be defined as
unclear situations about what to do for a particular patient due to
conflicting messages given to them by different authorities. When
nurses experience role ambiguity while handling the patient, they are
not clear about what behaviors are expected of them. These condi-
tions lead to producing negative results for patients.27
Nurses in hospitals often receive conflicting demands from man-
agers and patients. They are also required to adhere to the simulta-
neous realization of multiple roles in managerial tasks entrusted to
them.28,29 This condition makes them to give more weight to one of the
roles. Hence the situation leads to role conflict.26 Role conflict is related
to business content and tasks and is a typical source of stress to nurses.
Employers with low work efficacy have been reported empirically to
have more role conflicts than those with high work efficiency.15
One of the major challenges nurses face in their profession is the
heavy workload because in most hospitals they are few yet their job
is very demanding. Workload is defined as finishing a certain amount
of work by the given time30 and is one of the major internal stress
sources.31 Nurses’ workload entails the procedures carried out in the
patient care and the time given for these procedures.32 Nurses have
a heavy workload because they attend to large number of patients
and take responsibility for them. Their work overload prevents them
from performing their tasks properly.33‐36
1.2 | Work‐related stress
Stress is the adaptive behavior shown by individual differences and
psychological processes, and any external and internal movement,
situation, or event that causes extreme psychological and physical
F IGURE 1 Study concept model [Color figure can be viewed at wileyonlinelibrary.com]
584 | AKKOÇ ET AL.
pressures on the person.37 Work‐related stress is perceived as having
more work than the employee's ability, thus the worker becomes af-
fected psychologically and physiologically.38 Working in a hospital en-
vironment increases work stress.39,40 Among health workers, nursing is
considered one of the high‐risk professions for physical and mental
diseases.41 The nursing profession is inherently stressful due to long and
intensive working hours. Stress affects the quality of life and health of
nurses, their workload, and their relationship with patients.42
1.3 | Burnout
Burnout is a syndrome of emotional exhaustion and cynicism fre-
quently seen in working individuals, and can lead to incompetence
and low productivity at work. It consists of three sub‐dimensions:
emotional exhaustion, depersonalization, and low personal accom-
plishment.17,43 Employees experience emotional exhaustion when
they feel their psychological and emotional resources are exhausted.
Also, it is a feeling that is manifested by physical fatigue.44 Low
personal accomplishment is the tendency of employees to assess
themselves negatively. The employee is not satisfied with the success
of his/her work. Depersonalization is the attitude and behavior of the
employee who lacks emotion in the workplace.45
Currently employees are gaining experience in handling work-
place stressors as they progress in their careers and acquire more
resources to combat strains such as burnout.46 WHO2 officially de-
fined the burnout syndrome as professional deformation.
1.4 | Role‐related stressors and work‐related stress as predictors of burnout: Theoretical background, proposed model, and hypotheses
Conservation of resources (COR) theory47 and the affective events
theory (AET)48 provided the theoretical background for this study.
The fundamental principle of COR theory states that individuals
strive to protect, build, and retain the resources they value, from the
threat of potential or actual loss. The well‐being of the individual
depends on the acquisition and protection of these resources. There
are four sources of resources in the resource protection model. In-
dividuals get their object resources (home, car…), personal char-
acteristics (personal respect, etc), condition resources (being married,
living with someone who is providing financial support, etc) and en-
ergy resources (time, money, information, etc) to work and to pro-
tect. When faced with stress sources, individuals react to minimize
the loss of resources according to the theory. That individuals employ
resources in the stress‐coping process and this depletes these re-
sources. Based on the COR theory, it is reasonable to assume that
organizational changes associated with the increase in work stress
factors may exhaust the psychological resources of employees and
consequently create a sense of burnout.49 According to the theory,
the inter‐role conflict between the individual and the job may lead to
tension because the individual may lose resources for the sake of
success in work. The loss of these resources can lead to dissatisfac-
tion, depression, anxiety, or psychological tensions.47
Organizational behavior variables are frequently explained in the
literature with AET.48 AET theory broadens our understanding of
COR theory in the context of workplace stressors and strains. It
explains the positive and negative emotional responses that em-
ployees give to the effects of events and processes at work. The AET
states that workplace stress sources, such as workload, role conflict,
and role ambiguity affect employees' feelings for work.50
Stress and burnout are important risks for healthcare workers and
are associated with a decline in health care quality, attrition, and re-
duced commitment.51 When there is a conflict of value in the profession
and therefore a gap between individual and organizational values, em-
ployees will find themselves in a dilemma, resulting in greater
burnout.52 In a survey covering 314 nurses (243 nurses responded to
the questionnaire, a response rate of 73.4%) in Turkey (city center of
Kastamonu) in 2014, it was found that experienced nurses and surgical
clinics’ nurses faced more role conflicts than unexperienced and other
clinics’ nurses.53 In a study conducted in Turkey in Bitlis, 36.88% (52) of
nurses reported that they take responsibility beyond their duties.54
In light of these two theories, Figure 1 theoretical model has
been developed to deeply understand the role conflict, role ambi-
guity, workload, work‐related stress and burnout relationships
Hypothesis 1. Perceived role ambiguity is significantly and positively
related to nurses' burnout levels.
Hypothesis 2. Perceived role conflict is significantly and positively
related to nurses' burnout levels.
Hypothesis 3. Perceived workload is significantly and positively related
to nurses' burnout levels.
Hypothesis 4. Perceived work‐related stress is significantly and
positively related to nurses' burnout levels.
Hypothesis 5. Perceived role ambiguity is significantly and positively
related to work‐related stress.
Hypothesis 6. Perceived role conflict is significantly and positively
related to work‐related stress.
Hypothesis 7. Perceived workload is significantly and positively related
to work‐related stress.
Hypothesis 8. Perceived work‐related stress has a mediator role
between role ambiguity and nurses’ burnout levels.
Hypothesis 9. Perceived work‐related stress has a mediator role
between role conflict and nurses'burnout levels.
Hypothesis 10. Perceived work‐related stress has a mediator role
between workload and nurses’ burnout levels.
AKKOÇ ET AL. | 585
2 | METHODS
2.1 | Research design
2.1.1 | Procedure and data analysis
Questionnaire‐based survey was conducted. Data were obtained from
full‐time nurses of a public üniversity hospital in Eskişehir city in Turkey.
The questionnaires were administered personally by the researcher and
there was face to face interaction with the participants. Demographic
variables included education level, gender, marital status, age, and work
experience. The survey contained a total of 48 five‐point Likert scale
items (work‐related stress, role conflict, role ambiguity, workload, and
burnout) ranging from 1, being “strongly disagree”, to 5, being “strongly
agree”. Analyses of the causal steps approach proposed by Baron and
Kenny55 and bootstrapping method56 were done and SPSS 22 software
and PROCESS macro were also used.
2.1.2 | Data collection technique and participants
Ethical approval was obtained from the Non‐Interventional Clinical
Research Ethics Committee of Eskişehir Osmangazi University (approval
number: 254033353‐050.99‐E.1455668, date of approval: 10//12/
2019). In addition, permission for the study was obtained from the
institution where the study was conducted. Nurses voluntarily partici-
pated in this study and their oral consent was obtained. Due to the high
workload, a study group of 550 nurses working in a university hospital
(included all clinics in Eskişehir was selected. Survey questionnaire were
administered to 500 nurses randomly selected by sampling method, and
403 questionnaires were returned. However, 9 questionnaires were
excluded from the analysis because of missing data and 394 (78.8%)
were found suitable for analysis (collected the data in December 2019).
The data obtained were checked for outliers, skewness, normality, lin-
earity, homoscedasticity, and multiple connections. As a result, eight
data were extracted in the extreme value analysis57 leaving 386 ques-
tionnaires suitable for evaluation. The demographic characteristics of
participants can be seen in Table 1.
As seen in Table 1, 29,3% (n = 113) of the sample were high
school graduates, 13,7% (n = 53) associate degree graduates, 48.4%
(n = 187) university degree graduates, 7.3% (n = 28) had master's
degree and 1.3% (n = 5) had a doctorate degree. 71.5% (n = 276) of
the sample were female and 28.5% (n = 110) were male. 48.7%
(n = 188) of the sample were married and 51.3% (n = 198) were sin-
gle. The mean age of the sample was 31.1 years (SD = 8.051) and the
mean work experience was 8.57 years (SD = 7.245)
2.2 | Data collection tool
Information about the scales used in the research is given below.
Cronbach α reliability coefficients of the scales were analyzed with
the use of the SPSS package program.
2.2.1 | Role Ambiguity Scale
Perceived role ambiguity levels measured by a 6‐item (ie, “I feel
certain about how much authority I have”) scale which was cre-
ated by Rizzo et al58 then used by House et al59 and Schuler
et al60 Cronbach's α reliability coefficient of the scale was found
to be .87 by Rizzo et al58 From the scale, answers were obtained
with a 5‐point Likert scale (1 = Strongly disagree; upto 5 = Strongly
agree).
2.2.2 | Role Conflict Scale
To determine the levels of role conflict, an 8‐item (ie, “I have to do
things that should be done differently”) scale created by Rizzo
et al58 was used. The scale was also used by Schuler et al60 and
House et al59 Cronbach's α reliability coefficient of the scale was
found to be .82 by Rizzo et al58 From the scale, answers were
obtained with a 5‐point Likert scale (1 = Strongly disagree; upto
5 = Strongly agree).
2.2.3 | Quantitative workload inventory
The 5‐item (ie, “I have not enough time to complete my work”)
scale, which was developed by Spector and Jex61 and whose re-
liability coefficient was determined as 0.82, was used. A Turkish
validation study was conducted by Keser62 and the reliability
coefficient of the scale was 0.78. From the scale, answers were
obtained with a 5‐point Likert scale (1 = Strongly disagree; upto
5 = Strongly agree).
TABLE 1 General characteristics of the participants (N = 386)
Characteristic N %
Educational level
High school 113 29.3
Associate degree 53 13.7
University 187 48.4
Master's degree 28 7.3
Doctorate 5 1.3
Sex
Female 276 71,5
Male 110 28.5
Marital status
Married 188 48.7
Single 198 51.3
Age, y Lowest Highest M SD
18 55 31.1 8.051
Work tenure, y Lowest Highest M SD
1 35 8.57 7.245
Abbreviations: M, mean; SD, standard deviation; y, years
586 | AKKOÇ ET AL.
2.2.4 | Work‐Related Stress Scale
The level of work‐related stress was measured by 7 items (ie, “I feel
fidgety or nervous because of my job”)scale developed by House and
Rizzo.63 The scale was translated into Turkish by Efeoğlu64 and ap-
plied in the pharmaceutical sector. The Cronbach's α reliability
coefficients were reported to range between .71 and .89. From the
scale, answers were obtained with a 5‐point Likert scale (1 = Strongly
disagree; upto 5 = Strongly agree).
2.2.5 | Burnout Scale
Maslach Burnout Inventory developed by Maslach and Jackson45
consisting of 22 items and three subscales was used. The first sub-
scale of the Maslach Burnout Inventory is the emotional exhaustion
of 9 items (ie, “I feel frustrated by my work”), the second is the
depersonalization of 5 items (ie, “I've become more callus toward
people since I took this job”) and the third is the decrease in the low
personal accomplishment of 8 items (ie, “I feel very energetic”).
Cronbach's α reliability coefficients were .83, .65, and .72, respec-
tively. From the scale, answers were obtained with a 5‐point Likert scale (1 = Strongly disagree; upto 5 = Strongly agree).
3 | RESULTS
The data were analyzed with SPSS 22 and PROCESS macro. As
shown in Table 2, sufficient evidence was obtained for the validity of
the study scales. Mean, standard deviations, and correlations of study
variables are presented in Table 2.
As seen in Table 2, there are significant relationships between all
dependent and independent variables. Therefore, significant effects
can be predicted among the variables.
Collinearity was also examined to determine whether there is a
multiple linear connection problem in the data set. Tolerance and VIF
values gave results confirming that there was no multicollinearity
between variables (Tolerance > 0.2, VIF < 3).
The relationship between variables and mediation effect was
analyzed with the causal steps approach proposed by Baron and
Kenny.55 Findings of hierarchical regression analysis, Sobel tests, and
mediation tests are presented in Tables 3, 4, and 5. respectively. For
the mediation effect, four conditions are expected to occur.
(1) Independent variable must affect the dependent variable.
(2) Independent variable must affect the mediator variable.
(3) Mediator variable must affect the dependent variable.
(4) When the mediator variable is included in the regression analysis
with the independent variable, the effect of the independent
variable on the dependent variable decreases, and the mediator
variable has a significant effect on the independent variable.
When the mediator variable is included in regression analysis, if the
effect of the independent variable on the dependent variable is entirely
through the mediator variable then it is a case of full mediation. How-
ever, if there is a decrease in the relationship between the independent
variable and the dependent variable, then it is a case of partial mediation.
As shown in Table 3 in Stage 1 of the mediation test, the re-
lationship between the independent variable role ambiguity and
burnout was examined.
Table 3: In Step 1 role ambiguity was found to have a significant
effect on burnout (β = −.31; P < .001). In Step 2 role ambiguity was
found to have a significant effect on work‐related stress (β = −.12;
P < .05). In Step 3 work‐related stress was found to have a significant
effect on burnout (β = .69, P < .001). In the last step of this stage role
ambiguity and mediator work‐related stress were analyzed together
and their effects on burnout were examined. Results showed that the
effect of role ambiguity on burnout continued and decreased
(β = −.23; P < .001), while the effect of work‐related stress on burnout
continued (β = .66; P < .001). Following these steps, the Sobel test was
performed to confirm the mediation effect and Sobel (z) was sig-
nificant (z = −2.42; P < .05). This finding shows that work‐related
TABLE 2 Average scores, correlation analysis of the variables and their
subdimensions
M SD 1 2 3 4 5 6 7 8
1. RA 3.91 .82 (0.90)
2. RC 3.40 .72 .03 (0.77)
3. W 3.53 .89 ‐0.03 .59** (0.81)
4. WRS 3.28 .91 ‐0.14** .61** .69** (0.88)
5. B 2.75 .69 ‐0.33** .47** .52** .72** (0.84)
6. EE 3.05 1.03 ‐0.26** .44** .48** .71** .91** (0.95)
7. D 2.80 .96 ‐0.20** .45** .49** .64** .83** .71** (0.87)
8. LPA 2.32 .64 ‐0.33** .14** .17** .20** .45** .16** .11* (0.86)
Note: α Reliability coefficients are shown in bold parentheses.
Abbreviations: B, bornout; D, depersonalization; EE, emotional exhaustion LPA, low personel
accomplishment; RA, role ambiquity; RC, role conflict; SD, standard deviation; W, workload; WRS,
work‐related stress.
*P ≤ .05.
**P ≤ .01.
AKKOÇ ET AL. | 587
stress plays a partial mediating role in the effect of role ambiguity on
burnout. From this section's analysis, it is seen that while
Hypothesis 1 and Hypothesis 5 were rejected, Hypothesis 4 and the
mediation hypothesis (Hypothesis) 8 were supported.
As shown in Table 3, in Stage 2 of the mediation test, sub‐ dimensions of burnout; emotional exhaustion, depersonalization, and
low personal accomplishment variables and hypothesis variables
were analyzed.
Hypothesis 1a. Perceived role ambiguity is significantly and positively
related to nurses' emotional exhaustion levels.
Hypothesis 4a. Perceived work‐related stress is significantly and
positively related to nurses' emotional exhaustion levels.
Hypothesis 8a. Perceived work‐related stress has a mediator role
between role ambiguity and nurses’ emotional
exhaustion levels.
Hypothesis 1b. Perceived role ambiguity is significantly and positively
related to nurses' depersonalization levels.
Hypothesis 4b. Perceived work‐related stress is significantly and
positively related to nurses' depersonalization levels.
Hypothesis 8b. Perceived work‐related stress has a mediator role
between role ambiguity and nurses’ depersonalization levels.
Hypothesis 1c. Perceived role ambiguity is significantly and positively
related to nurses' low personal accomplishment levels.
Hypothesis 4c. Perceived work‐related stress is significantly and
positively related to nurses' low personal accomplishment
levels.
Hypothesis 8c. Perceived work‐related stress has a mediator role
between role ambiguity and nurses' low personal
accomplishment levels.
In Step 1, role ambiguity was found to have a significant effect on
emotional exhaustion (β = −.24; P < .001). In Step 2, role ambiguity
was found to have a significant effect on work‐related stress
(β = −.12, P < .05). In Step 3, work‐related stress was found to have a
significant effect on emotional exhaustion (β = .67; P < .001). In the
last step of this stage role ambiguity and mediator work‐related stress were analyzed together and their effects on emotional
exhaustion were examined. Results showed that the effect of
role ambiguity on emotional exhaustion continued and decreased
TABLE 3 Hierarchical regression analysis predicting RA and WRS
1 2 3 1 2 3
B WRS B EE WRS EE
Step β β β Step β β β
RA −0.31*** −0.12* −0.23*** RA −0.24*** −0.12* −0.16***
WRS .66*** WRS .65***
Age .161 .170 .048 Age .156 .170 .045
Work tenure −0.496 −0.371 −0.160 Work Tenure −0.409 −0.371 −0.168
ΔR2 .194s .081 .595 ΔR2 .153 .081 .542
F 30.6*** 11.2*** 140.1*** F 23.1*** 11.2*** 112.7***
Sobel Test(z) −2.42* Sobel Test(z) −2.41*
1 2 3 1 2 3
D WRS D LPA WRS LPA
Step β β β Step β β β
RA −0.19** −0.12* −0.12** RA −0.32*** −0.12* −0.30***
WRS .59*** WRS .16**
Age .314 .170 .214 Age −0.140 .170 −0.067
Work tenure −0.502 −0.371 −0.275 Work Tenure .073 −0.371 .134
ΔR2 .131 .081 .435 ΔR2 119 .081 .143
F 15.6*** 11.2*** 140.1*** F 17.2*** 11.2*** 15.8***
Sobel Test(z) −2.40* Sobel Test(z) −2.06*
Abbreviations: B, burnout; D, depersonazalition, EE, emotional exhaustion, LPA, low personal accomplishment; RA, role ambuqiuty; WRS, work related stress.
*P ≤ .05.
**P ≤ .01.
***P ≤ .001.
588 | AKKOÇ ET AL.
(β = −.16; P < .001), while the effect of work‐related stress on emo-
tional exhaustion continued (β = .65; P < .001). Following these steps,
the Sobel test was performed to confirm the mediation effect and
Sobel (z) was significant (z = −2.41; P < .05). This finding shows that
work‐related stress plays a partial mediating role in the effect of role
ambiguity on emotional exhaustion. From this section's analysis, it is
seen that while Hypothesis 1a was rejected, Hypothesis 4a and the
mediation hypothesis (Hypothesis 8a) were supported.
In Step 1 role ambiguity was found to have a significant effect on
depersonalization (β = −.19; P < .01). In Step 2 role ambiguity was
found to have a significant effect on work‐related stress (β = −.12;
P < .05). In Step 3 work‐related stress was found to have a significant
effect on depersonalization (β = .60; P < .001). In the last step of this
stage role ambiguity and mediator work‐related stress were analyzed
together and their effects on depersonalization were examined. Re-
sults showed that the effect of role ambiguity on depersonalization
continued and decreased (β = −.12; P < .01), while the effect of work‐ related stress on depersonalization continued (β = .59; P < 0.001).
Following these steps, the Sobel test was performed to confirm the
mediation effect and Sobel (z) was significant (z = −2.40; P < .05). This
finding shows that work‐related stress plays a partial mediating role
in the effect of role ambiguity on depersonalization. From this sec-
tion's analysis, it is seen that while Hypothesis 1b was rejected,
Hypothesis 4b and the mediation hypothesis (Hypothesis 8b) were
supported.
In Step 1, role ambiguity was found to have a significant effect on
low personal accomplishment (β = −.32, P < 0.001). In Step 2, role
ambiguity was found to have a significant effect on work‐related stress (β = −.12; P < .05). In Step 3, work‐related stress was found to
have a significant effect on low personal accomplishment (β = .20;
P < .001). In the last step of this stage role ambiguity and mediator
work‐related stress were analyzed together and their effects on low
personal accomplishment were examined. Results showed that the
effect of role ambiguity on low personal accomplishment continued
and decreased (β = −.30; P < .01), while the effect of work‐related stress on low personal accomplishment continued (β = .16; P < .001).
Following these steps, the Sobel test was performed to confirm the
mediation effect and Sobel (z) was significant (z = −2.06; P < .05). This
finding shows that work‐related stress plays a partial mediating role
in the effect of role ambiguity on low personal accomplishment. From
this section's analysis, it is seen that while Hypothesis 1c was re-
jected, Hypothesis 4c and the mediation hypothesis (Hypothesis 8c)
were supported.
Table 4: As shown in Table 4 in Stage 1 of the mediation test, the
relationship between the independent variable role conflict and
burnout was examined.
TABLE 4 Hierarchical regression analysis predicting RC and WRS
1 2 3 1 2 3
B WRS B EE WRS EE
Step β β β Step β β β
RC .45*** .60*** .06 RC .42*** .60*** .03
WRS .65*** WRS .65***
Age .088 .117 .012 Age .096 .117 .019
Work tenure −0.354 −0.310 −0.153 Work Tenure −0.363 −0.310 −0.161
ΔR2 .301 .425 .545 ΔR2 .272 .425 .518
F 93.4*** 93.4*** 140.1*** F 47.6*** 93.4*** 47.6***
Sobel Test(z) 12.04*** Sobel Test(z) 11.70***
1 2 3 1 2 3
D WRS D LPA WRS LPA
Step β β β Step β β β
RC .43*** .60*** .12* RC .14** .60*** .02
WRS .53*** WRS .19**
Age .261 .117 .199 Age −0.195 .117 −0.217
Work tenure −0.455 −0.310 −0.291 Work Tenure .094 −0.310 .142
ΔR2 .282 .425 .444 ΔR2 119 .425 .055
F 49.9*** 93.4*** 15.8*** F 4.6** 93.4*** 5.5***
Sobel Test(z) 10.80*** Sobel Test(z) 3.79***
Abbreviations: LPA, low personal accomplishment; RC, role conflict; WRS, Work‐Releated Stress; B, Burnout; D, deporsonazalition; EE, Emotional
Exhaustion.
*P ≤ .05.
**P ≤ .01.
***P ≤ .001.
AKKOÇ ET AL. | 589
In Step 1 role conflict was found to have a significant effect on
burnout (β = .45; P < .001). In Step 2 role conflict was found to have a
significant effect on work‐related stress (β = .60; P < .001). In Step 3
work‐related stress was found to have a significant effect on burnout
(β = .69; P < .001). In the last step of this stage role conflict and the
mediator work‐related stress were analyzed together and their ef-
fects on burnout were examined. As a result of this analysis, the
effect of role conflict on burnout was eliminated (β = .06; P < .146),
while the effect of work‐related stress on burnout persisted (β = 0.65;
P < .001). Following these steps, the Sobel test was performed to
confirm the mediation effect and Sobel (z) was significant (z = 12.04;
P < .001). This finding shows that work‐related stress plays a full
mediation role in the effect of role conflict on burnout. From this
section's analysis, it is seen that Hypothesis 2, Hypothesis 6 and
mediation hypothesis (Hypothesis 9) are supported.
As shown in Table 4, in Stage 2 of the mediation test, sub‐ dimensions of burnout; emotional exhaustion, depersonalization, and
low personal accomplishment variables and hypothesis variables
were analyzed.
Hypothesis 2a. Perceived role conflict is significantly and positively
related to nurses' emotional exhaustion levels.
Hypothesis 9a. Perceived work‐related stress has a mediator role
between role conflict and nurses’ emotional
exhaustion levels.
Hypothesis 2b. Perceived role conflict is significantly and positively
related to nurses' depersonalization levels.
Hypothesis 9b. Perceived work‐related stress has a mediator role
between role conflict and nurses’ depersonalization
levels.
Hypothesis 2c. Perceived role conflict is significantly and positively
related to nurses' low personal accomplishment levels.
Hypothesis 9c. Perceived work‐related stress has a mediator role
between role conflict and nurses’ low personal
accomplishment levels.
In Step 1 role conflict was found to have a significant effect on
emotional exhaustion (β = .42; P < .001). In Step 2 role conflict was
found to have a significant effect on work‐related stress (β = .60;
P < .001). In Step 3 work‐related stress was found to have a sig-
nificant effect on emotional exhaustion (β = .67; P < .001). In the last
step of this stage role conflict and the mediator work‐related stress
were analyzed together and their effects on emotional exhaustion
were examined. From this analysis, the effect of role conflict on
emotional exhaustion was eliminated (β = .03; P < .523), while the
effect of work‐related stress on emotional exhaustion persisted
(β = .65; P < .001). Following these steps, the Sobel test was per-
formed to confirm the mediation effect and Sobel (z) was significant
(z = 11.70; P < .001). This finding shows that work‐related stress plays
a full mediation role in the effect of role conflict on emotional ex-
haustion. From this section's analysis, it is seen that Hypothesis 2a,
and mediation hypothesis (Hypothesis 9a) are supported.
In Step 1 role conflict was found to have a significant effect on
depersonalization (β = .43; P < .001). In Step 2 role conflict was found
to have a significant effect on work‐related stress (β = .60; P < .001).
In Step 3 work‐related stress was found to have a significant effect
on depersonalization (β = .60; P < .001). In the last step of this stage
role conflict and mediator work‐related stress were analyzed to-
gether and their effects on depersonalization were examined. Results
showed that the effect of role conflict on depersonalization con-
tinued and decreased (β = .12; P < .01), while the effect of work‐ related stress on depersonalization continued (β = .53; P < .001).
Following these steps, the Sobel test was performed to confirm the
mediation effect and Sobel (z) was significant (z = 10.80; P < .05). This
finding shows that work‐related stress plays a partial mediating role
in the effect of role ambiguity on depersonalization. From this sec-
tion's analysis, it is seen that Hypothesis 2b and mediation hypothesis
(Hypothesis 9b) are supported.
In Step 1 role conflict was found to have a significant effect on
low personal accomplishment (β = .14; P < .001). In Step 2 role conflict
was found to have a significant effect on work‐related stress (β = .60;
P < .001). In Step 3 work‐related stress was found to have a sig-
nificant effect on low personal accomplishment (β = .20; P < .001). In
the last step of this stage role conflict and mediator work‐related stress were analyzed together and their effects on low personal ac-
complishment were examined. As a result of this analysis, the effect
of role conflict on low personal accomplishment was eliminated
(β = .02; P < .707), while the effect of work‐related stress on low
personal accomplishment persisted (β = .19, P < .001). Following these
steps, the Sobel test was performed to confirm the mediation effect
and Sobel (z) was significant (z = 3.79; P < .05). This finding shows that
work‐related stress plays a full mediating role in the effect of role
ambiguity on low personal accomplishment. From this section's
analysis, it is seen that Hypothesis 2c and mediation hypothesis
(Hypothesis 9c) are supported.
As shown in Table 5 in Stage 1 of the mediation test, the re-
lationship between the independent variable workload and burnout
was examined.
Table 5: In Step 1 workload was found to have a significant effect
on burnout (β = .49; P < .001). In Step 2 workload was found to have a
significant effect on work‐related stress (β = .66; P < .001). In Step 3
work‐related stress was found to have a significant effect on burnout
(β = .69; P < .001). In the last step of this stage workload and mediator
work‐related stress were analyzed together and their effects on
burnout were examined. As a result of this analysis, the effect of
workload on burnout was eliminated (β = .05; P < .295), while the
effect of work‐related stress on burnout persisted (β = .66; P < .001).
Following these steps, the Sobel test was performed to confirm the
mediation effect and Sobel (z) was significant (z = 13.16; P < .001).
This finding shows that work‐related stress plays a full mediation role
in the effect of workload on burnout. From this section's analysis, it is
590 | AKKOÇ ET AL.
seen that Hypothesis 3, Hypothesis 7, and mediation hypothesis
(Hypothesis 10) are supported.
As shown in Table 5, in Stage 2 of the mediation test, sub‐ dimensions of burnout; emotional exhaustion, depersonalization, and
low personal accomplishment variables and hypothesis variables
were analyzed.
Hypothesis 3a. Perceived workload is significantly and positively
related to nurses' emotional exhaustion levels.
Hypothesis 10a. Perceived work‐related stress has a mediator role
between workload and nurses'emotional exhaustion
levels.
Hypothesis 3b. Perceived workload is significantly and positively
related to nurses' depersonalization levels.
Hypothesis 10b. Perceived work‐related stress has a mediator role
between workload and nurses’ depersonalization
levels.
Hypothesis 3c. Perceived workload is significantly and positively
related to nurses' low personal accomplishment
levels.
Hypothesis 10c. Perceived work‐related stress has a mediator role
between role workload and nurses’ low personal
accomplishment levels.
In Step 1 workload was found to have a significant effect on emo-
tional exhaustion (β = .44; P < .001). In Step 2 workload was found to
have a significant effect on work‐related stress (β = .66; P < .001). In
Step 3 work‐related stress was found to have a significant effect on
emotional exhaustion (β = .67; P < 0.001). In the last step of this stage
workload and mediator work‐related stress were analyzed together
and their effects on emotional exhaustion were examined. As a result
of this analysis, the effect of workload on emotional exhaustion was
eliminated (β = .003; P < .940), while the effect of work‐related stress
on emotional exhaustion persisted (β = .67; P < .001). Following these
steps, the Sobel test was performed to confirm the mediation effect
and Sobel (z) was significant (z = 12.72; P < .001). This finding shows
that work‐related stress plays a full mediation role in the effect of
workload on emotional exhaustion. From this section's analysis, it is
seen that Hypothesis 3a and mediation hypothesis (Hypothesis 10a)
are supported.
In Step 1 workload was found to have a significant effect on
depersonalization (β = .46; P < .001). In Step 2 workload was found to
have a significant effect on work‐related stress (β= .66; P< .001). In Step
3 work‐related stress was found to have a significant effect on
TABLE 5 Hierarchical regression analysis predicting W and WRS
1 2 3 1 2 3
B WRS B EE WRS EE
Step β β β Step β β β
W .49*** .66*** .05 W .44*** .66*** .003
WRS .66*** WRS .67***
Age .091 .121 .012 Age .099 .121 .018
Work tenure −0.315 −0.255 −0.148 Work Tenure −0.328 −0.255 −0.156
ΔR2 .327 .498 .543 ΔR2 .290 .498 .517
F 62.0*** 126.3*** 113.3*** F 52.0*** 126.3*** 102.0***
Sobel Test(z) 13.16*** Sobel Test(z) 12.72***
1 2 3 1 2 3
D WRS D LPA WRS LPA
Step β β β Step β β β
W .46*** .66*** .11* W .16** .66*** .05
WRS .53*** WRS .16*
Age .264 .121 .201 Age −0.195 .121 −0.215
Work tenure −0.419 −0.255 −0.284 Work Tenure .109 −0.255 .150
ΔR2 .301 .498 .442 ΔR2 .043 .498 .056
F 54.8*** 126.3*** 75.3*** F 5.7** 126.3*** 5.6***
Sobel Test(z) 11.59*** Sobel Test(z) 3.82***
Abbreviations: B, burnout; D, depersonalization; EE, emotional exhaustion, LPA, low personal accomplihsment; W, workload; WRS, work‐related stress.
*P ≤ .05.
**P ≤ .01.
***P ≤ .001.
AKKOÇ ET AL. | 591
depersonalization (β= .60; P< .001). In the last step of this stage work-
load and mediator work‐related stress were analyzed together and their
effects on depersonalization were examined. Results showed that the
effect of workload on depersonalization continued and decreased
(β= .11; P< .01), while the effect of work‐related stress on depersonali-
zation continued (β= .53; P< .001). Following these steps, the Sobel test
was performed to confirm the mediation effect and Sobel (z) was sig-
nificant (z=11.59; P< .001). This finding shows that work‐related stress
plays a partial mediation role in the effect of workload on depersonali-
zation. From this section's analysis, it is seen that Hypothesis 3b and
mediation hypothesis (Hypothesis 10b) are supported.
In Step 1 workload was found to have a significant effect on low
personal accomplishment (β = .16; P < .001). In Step 2 workload was
found to have a significant effect on work‐related stress (β = .66;
P < .001). In Step 3 work‐related stress was found to have a
significant effect on low personal accomplishment (β = .20; P < .001). In
the last step of this stage workload and mediator work‐related stress
were analyzed together and their effects on low personal accomplish-
ment were examined. As a result of this analysis, the effect of workload
on low personal accomplishment was eliminated (β = .05; P < .435), while
the effect of work‐related stress on low personal accomplishment
persisted (β = .16; P < .05). Following these steps, the Sobel test was
performed to confirm the mediation effect and Sobel (z) was significant
(z =3.82; P < .05). This finding shows that work‐related stress plays a full
mediation role in the effect of workload on low personal accomplish-
ment. From this section's analysis, it is seen that Hypothesis 3c and
mediation hypothesis (Hypothesis 10c) are supported.
According to the results of the hierarchical regression analysis, it
was determined that all independent variables affected the mediator
variable and significantly increased burnout and subdimensions in
work‐related stress.
In this study, total, direct, and indirect effects between the
dependent variables and the independent variables were tested using
the bootstrap method with 5000 resampling and 95% symmetric con-
fidence interval with deviation correction.65 The mediating role has
been assumed as statistically significant when the lower limit (BootLLCI)
and upper limit (BootULCI) of bootstrap results in 95% confidence in-
terval are both below or above zero.66 Findings obtained as a result of
the analysis are shown in Table 6. As shown in Table 6, Model 1,
Completely Standardized Indirect Effect line in the lower level con-
fidence (95%) range −.1170 and in the upper level confidence (95%)
range −.0074 (below zero). Model 2 in the lower level confidence (95%)
range, 3147 and in the upper level confidence (95%) range, 4874 (above
zero). Model 3 in the lower level confidence (95%) range, 3519 and in
the upper level confidence (95%) range, 5675 (above zero).
4 | DISCUSSION AND CONCLUSION
This study sought to reveal the relationship between role‐related stressors and burnout levels of nurses working in Eskişehir University
Training and Research Hospital and the mediator effect of work
stress in this relationship. Consistent with previous studies67‐69 role
ambiguity is a cognitive‐attitudinal response and is a strong predictor
of all the three components of burnout syndrome. The results in-
dicate that role ambiguity negatively and significantly reduced
burnout and its sub‐dimensions (emotional exhaustion, depersonali-
zation, and low personal accomplishment). According to the theory,
role ambiguity is expected to positively affect and increase burnout
and its sub‐dimensions. However, the opposite result was obtained in
this study. Role‐stressors vary between cultures and within the cul-
tural context.17 Hofstede's70 research revealed that Turkish culture
had high‐power distance, collectivist, high uncertainty avoidance, and
feminist characteristic. This situation is thought to cause the nurses
to react in the opposite direction with a unique difference in Turkish
Culture. It is considered that nurses cause their feelings of respon-
sibility to diminish when they experience role ambiguity, thus redu-
cing the work‐related stress and anxiety that may arise from work
and causing psychological relief. These results indicate that culturally
different organizational environments cause job‐related stressors to
be felt differently. The consequences of job‐related stressors should
not be evaluated independently of the cultural context.
Role conflict is a significant predictor of burnout;71,72 Phillips
et al73 This study established that role conflict is associated with
burnout and increases burnout and its sub‐dimensions positively and
significantly. Nurses who have role conflicts lose their ability to de-
termine the needs of the patients, to perform the expected nursing
practices, and to provide efficient health care services. This raises
their burnout levels.
Burnout syndrome is a common phenomenon that threatens em-
ployees' well‐being.74 It can be considered as a symptom of chronic
workload and employee capacity imbalance.75 The study revealed that
workload is associated with burnout and increases burnout and its sub‐ dimensions positively and significantly. Nurses play an important role in
the quality of health care provided, patient safety, treatment process,
and hospital performance. However, with increase in workload they will
not be able to perform these roles effectively within the required time
and this will lead to increased levels of burnout.
The prior studies indicated that work‐related stress could sig-
nificantly predict burnout.76,77 High levels of work stress are asso-
ciated with high burnout syndrome.78,79 It was determined that
work‐related stress is associated with burnout and increases burnout
and its sub‐dimensions positively and significantly. Work stress is a
major source of burnout and it influences employees to evaluate
themselves negatively, lose interest in other employees’ emotions,
become negligent, develop hostile behavior, and feel unable to fulfill
the job requirements.
It was determined that role ambiguity, role conflict, and work-
load were associated with work‐related stress and increased it po-
sitively and significantly. It can therefore be concluded that the most
important variables that increase the work‐related stress of nurses
are role ambiguity, role conflict, and workload.
It is thought that role ambiguity, role conflict, and workload have
an effect on burnout and its sub‐dimensions, and this effect may be
reflected in output variables through some variables. The study
sought to investigate the role of work‐related stress in the effect of
592 | AKKOÇ ET AL.
perceived role ambiguity, role conflict, and workload on burnout. The
results showed that work‐related stress has a partial mediating role
in the effect of role ambiguity on burnout and its subdimensions. It
was found that work‐related stress plays a fully mediating role in the
effect of role conflict on burnout. In the effect of role conflict on the
dimensions of burnout; it was found that there was a full mediating
role in the dimension of emotional exhaustion, a partial mediating
role in depersonalization, and decreased sense of personal accom-
plishment. The study established that work‐related stress has a full
mediating role in the effect of workload on burnout. In the effects of
work‐related stress on the dimensions of burnout, it was found that
there was a full mediating role in the dimension of emotional ex-
haustion, and a partial mediating role in depersonalization, and low
personal accomplishment. Health care professions, especially nursing,
have outstanding and distinctive values as dynamic phenomena.80
They establish intense emotional relationships with their patients.
The greatest obstacle for nurses to be able to commit themselves to
their work, to have increased motivation, to show their abilities such
as creativity and problem solving, and to increase their self‐ confidence in their specialties is burnout. Work stress is a variable
that has a significant effect on burnout.76,77
This study has contributed to the theory in the sense that it has
established that work‐related stress can be increased by mediating
role in the effect of role ambiguity, role conflict, and workload on
burnout, which is an important output variable. Secondly, there has
never been a study investigating the mediating effect of work‐related stress in the relationship of these three independent variables with
burnout. This finding of the positive effect of work‐related stress on
role ambiguity, role conflict, and increasing workload on burnout is
important as the first evidence of scientific knowledge about the role
of work‐related stress. Thirdly, unlike the results of the other studies,
the role ambiguity in Turkish culture reduces burnout levels. This
realization indicates that the effects of role ambiguity on burnout can
vary from one cultural environment to another.
Nurses' burnouts have significant negative impact on the quality of
health care provided, patient safety, treatment process, and hospital
TABLE 6 Total, direct, and indirect effects
Role ambiguity (X) (work)−related stress (M) (burnout)(Y)
Model 1 β SE t P LLCI ULCI
Total effect −.1080 .0386 −2.7987 .0054 −.1839 −.0321
Direct effect −.0400 .0294 −1.3607 1744 −.0978 .0178
β BootSE BootLLCI BootULCI
Indirect effect −.0680 .0348 −.1409 −.0053
Partially standardized indirect effect −.1080 .0550 −.2222 −.0083
Completely standardized indirect effect −.0890 .0436 −.1770 −.0074
Role conflict (X), work−related stress (M), burnout (Y)
Model 2 β SE t P LLCI ULCI
Total effect .3685 .0402 9.1747 .0000 .2895 .4474
direct effect .0257 .0419 .6139 .5397 −.0567 .1081
β BootSE BootLLCI BootULCI
Indirect effect .3428 .0441 .2640 .4358
Partially standardized indirect Effect .5441 .0636 .4306 .6789
Completely standardized Indirect effect .3944 .0443 .3147 .4874
Workload (X), work−related stress (M), burnout (Y)
Model 3 β SE t P LLCI ULCI
Total effect .3242 .0322 10.0782 .0000 .2610 .3875
Direct effect .0032 ,0372 .0853 .9321 −.0699 .0763
β BootSE BootLLCI BootULCI
Indirect effect .3210 ,0443 .2414 .4129
Partially standardized indirect effect .5096 .0657 .3921 .6495
Completely standardized indirect effect .4529 .0553 .3519 .5675
Note: X, independent variable; Y, dependent variable; M, mediating variable; BootLLCI, lower limit of the bootstrap confidence interval with %95;
BootULCI, upper limit of the bootstrap confidence interval with %95; Bootstrap sampling size, 5000.
AKKOÇ ET AL. | 593
performance. Therefore, when nurses perceive role conflict, workload,
and work‐related stress in their functions, it is considered that burnout
levels may increase and negatively affect the whole institution.
5 | LIMITATIONS
In this research, the questionnaire was used as a data collection tool and
the data obtained were based on personal statements. It is possible that
participants did not reflect what actually happened but rather gave the
researcher responses they thought were ideal for the questions asked.
The research was also limited in scope because the data were collected
in a specific period of time, that is December 2019, and covered only
the nurses working at Eskişehir University Training and Research
Hospital. Different findings could be obtained with the data collected in
different periods and in a different geographical location. Finally, the
sample size used was not adequate for the proposed model which
contained multiple variables. This necessitated need to collect evidence
of validity on the proposed model by testing it on more samples.
ACKNOWLEDGMENTS
The author holds country's registered Nurse license (RN).
CONFLICT OF INTERESTS
The authors declare that there are no conflict of interests.
ORCID
İrfan Akkoç http://orcid.org/0000-0002-5653-0508
Olcay Okun http://orcid.org/0000-0002-7096-5794
Aysun Türe http://orcid.org/0000-0003-2513-0904
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How to cite this article: Akkoç İ, Okun O, Türe A. The effect
of role‐related stressors on nurses' burnout syndrome: The
mediating role of work‐related stress. Perspect Psychiatr Care.
2021;57:583–596. https://doi.org/10.1111/ppc.12581
596 | AKKOÇ ET AL.
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