11993 - 2p - 12 hrs

lable at ScienceDirect

European Journal of Oncology Nursing 15 (2011) 347e350

Contents lists avai

European Journal of Oncology Nursing

journal homepage: www.elsevier.com/locate/ejon

Burnout syndrome in surgical oncology and general surgery nurses: A cross-sectional study

Ilona Ksią_zek a,c, Tomasz J. Stefaniak a,b,c,*, Magdalena Stadnyk b,c, Janina Ksią_zek d,c

a Dept. of General, Endocrine and Transplant Surgery, Medical Univ. of Gdansk, 7 Debinki Str., PL-80-210, Gdansk, Poland b Laboratory of Psychology of Surgery and Psychosomatics (LOPSAP), Dept. of General, Endocrine and Transplant Surgery, Medical Univ. of Gdansk, 7 Debinki Str., PL-80-210, Gdansk, Poland c Dept. of Surgical Nursing, Medical Univ. of Gdansk, 7 Debinki Str., PL-80-210, Gdansk, Poland d Dept. of Thoracic Surgery, Medical Univ. of Gdansk, 7 Debinki Str., PL-80-210, Gdansk, Poland

Keywords: Burnout syndrome Nurse Surgery Oncology Surgery Surgical nursing Emotional tiredness

* Corresponding author. Dept. of General, Endocr Medical Univ. of Gdansk, 7 Debinki Str., PL-80-210, 349 24 10.

E-mail address: wujstef@amg.gda.pl (T.J. Stefaniak

1462-3889/$ e see front matter � 2010 Elsevier Ltd. doi:10.1016/j.ejon.2010.09.002

a b s t r a c t

Purpose: The occurrence of burnout syndrome is strongly associated with and modulated by multiple personality and environmental factors. In Poland, nurses experience a discrepancy between the demands, expectations and social status of the position of their profession and low salaries. Such a situation provokes frustration and depression, and further leads to problems of adaptation including burnout syndrome. The aim of this study was to evaluate the occurrence of burnout syndrome among nurses working in general surgery and surgical oncology specialties. Methods: The study was designed as a cross-sectional questionnaire survey. It was undertaken in the largest Hospital in the Pomeranian region of Poland. The participants included 60 nurses working in two departments: General Surgery and Surgical Oncology. The study was based upon an anonymous self-test composed of a questionnaire and three psychological measures: Maslach Burnout Inventory (MBI), Psychological Burden Scale and a self-constructed questionnaire on job satisfaction. Results: Intensity of burnout syndrome was significantly higher among oncology nurses than among surgical ones. There was also a strong but not significant trend towards higher Psychological Burden Scale in the group of oncology nurses. Conclusions: The study revealed a high degree of emotional burden and burnout in nurses working in the study hospital suggesting that nurses are at great occupational risk. The findings of the study provide evidence of the potential need to restructure the system and suggest that nurses need more control of their work including a higher degree of involvement in clinical decision-making.

� 2010 Elsevier Ltd. All rights reserved.

Introduction

Contemporary nursing demands constant intellectual and emotional effort, physical strength, technical skill, warmth, friend- liness and assertiveness (Cabrera-Gutierrez et al., 2005; Escriba- Aguir et al., 2006; Hall, 2001; Marjanovic et al., 2006; Poncet et al., 2007). However, excessive activity, increased concentration and psychological processing lead to high levels of tension during and after work (Cabrera-Gutierrez et al., 2005; Escriba-Aguir et al., 2006; Hall, 2001; Marjanovic et al., 2006; Poncet et al., 2007). This overload results in tiredness and fatigue. Moreover, frequently the

ine and Transplant Surgery, Gdansk, Poland. Fax: þ4858

).

All rights reserved.

nurse experiences discrepancy between the demands and expec- tations and social status of the nursing as a profession. In Poland, despite the access to the European Community, the professional prestige and salaries of nurses are still very low, leading to signifi- cant immigration. This state of things can lead to frustration and thus to depression, and further to health problems, as well as adaptation problems including burnout syndrome.

The concept of burnout was first developed and described by Herbert Freudenberger (1974). Freudenberger and Richelson have defined burnout as the state of fatigue and frustration caused by long-lasting sacrifice without leading to expected reward (Anczewskaet al.,2005). Freudenbergerhas referredtoit as a state of emotional, physical and mental tiredness due to unfavourable work conditions (Martinez et al., 2008). Maslach (1993) has described burnout as a psychological syndrome of emotional exhaustion, depersonalization and reduced personal accomplishment that can occur among individuals who work with other people.

I. Ksią_zek et al. / European Journal of Oncology Nursing 15 (2011) 347e350348

Burnout syndrome includes three different components (Maslach et al., 1997):

i) emotional burnout e mostly characterised by psychosomatic problems including headaches, sleeplessness, fatigue, lack of energy and lack of happiness of life or impulsive reactions;

ii) depersonalization e specific attitude towards the patients demonstrated by negative, cynic attitude, increasing distance to the patients in interpersonal contacts;

iii) decreased sense of personal achievements e reaction to inadequate coping with occupational stress, feeling of low achievements and lack of competence and tendency to eval- uate oneself negatively. It is often described as the ‘terminal stage of burnout’ and is associated with lack of ability to solve problems arisen by previous episodes of burnout. For a person affected, work becomes a source of deep suffering, frequently soothed by alcohol abuse.

Burnout can be visualized as a flame or fire that is about to end: thefuelfinishes andall thatisleft aretheashes.Thisphenomenoncan be observed in almost every profession associated with providing help to others. The essential tools used in caregiving are, apart from the knowledge, interpersonal abilities, personality, systems of values, motivation and self-confidence (Cabrera-Gutierrez et al., 2005; Poncet et al., 2007). Burnout syndrome is considered to be an effect of chronic, continuous emotional overload (Collins, 1996; Karasel and Theorell, 1999; Moore, 1996; Shirom, 1989; Wagner and Jason, 1997). Nurses start their work as dedicated, energetic and open-hearted. They continue giving and giving, and suddenly it turns out there is nothing left to give anymore (Hall, 2001; Marjanovic et al., 2006; Poncet et al., 2007).

It is characteristic of the burnout syndrome to develop imper- ceptibly and is not recognized by the affected person until it is too late. Initially, it is associated with fatigue, increased nervousness and anxiety (Collins,1996; Karasel and Theorell,1999; Moore,1996; Shirom, 1989; Wagner and Jason, 1997). Daily contact with disease, low control of surrounding reality, highly hierarchical professional relations, and specificity of work due to different ward character- istics are the most important factors that may play a role in the occurrence of burnout syndrome among nurses (Maslach, 1993). Different types of nursing specialty may be associated with various level of burnout syndrome. Schraub and Marx (2004) have shown that oncology nurses report a higher level of burnout syndrome than palliative care staff.

The aim of this study was to evaluate different aspects of burnout syndrome among different types of nurses: those working in general surgery and those in surgical oncology departments of a large university hospital in Northern Poland. The second aim was to describe different patterns of burnout and the extent of the problem in the context of Polish financial conditions for nurses.

Material and methods

Sixty nurses took part is a study that was conducted in April and May 2004 at the Department of General, Endocrine and Transplant Surgery (30 nurses), and the Department of Thoracic Oncologic Surgery (30 nurses), Medical University of Gdansk, Poland. The study was based upon an anonymous self-test composed of a set of questionnaires which included the following measures:

1. The questionnaire which was constructed by the first author included three parts: 14 items concerning demographical details, 5 items about education, and 18 items concerning the nurses’ subjective perception of burnout syndrome.

2. The Maslach Burnout Inventory (MBI) which is a 22-item, 7- level Likert scale (Maslach, 1993; McDowell and Newell, 1987). The MBI comprises of three subscales: (i) emotional exhaustion [EE] (having no capacity left to offer psychological support to others), (ii) tendency to depersonalize others [DP] (having a negative or callous attitude toward colleagues or patients), and (iii) diminished feelings of personal accomplishment in working with others [PA] (Maslach, 1993; McDowell and Newell, 1987). Internal consistency (Cronbach’s alpha) for the subscales are: 0.90 for Emotional Exhaustion, 0.79 for Deper- sonalization and 0.71 for Personal Accomplishment (Maslach et al., 1997). The MBI include items which are written in the form of

statements about personal feelings or attitudes (e.g. “I feel emotionally drained from my work”, “I don’t really care what happens to some recipients”). Respondents are instructed to answer each time according to the degree to which each MBI statement was like or unlike their reactions to work. The scale used is 1 ¼ very unlike me, through to 7 ¼ very much like me. A high degree of burnout is reflected in high scores on the emotional exhaustion and depersonalization scales and in low scores on the personal accomplishment scale (Maslach et al., 1997).

3. The Psychological Burden Scale is a version designed for the evaluation of nurses. The scale is composed of 14 items, and it is a 4-level Likert scale (Sęk and Beisert, 1996; McDowell and Newell, 1987). The PBS measures intensity of stress and emotional burden associated with work. It considers situa- tions at work which may be stressful for respondent, such as patients behaviour, atmosphere at work or low income. Respondents evaluate each item from 1 to 4, where 1 means very strong stress and 4 no stress. Higher result is associated with more intensive stress and emotional burden. Internal consistency (Cronbach’s alpha) for the version for nurses is 0.76 (Sęk and Beisert, 1996).

4. Self-evaluation questionnaire on job satisfaction in comparison to the extent and responsibilities associated with the job per- formed. Job satisfaction was measured by self-evaluation questionnaire, which includes 14 items. It is a 5-level, 14-item Likert scale. Each item was estimated from 1 to 5, where 1 means not at all and 5 always. Higher result is associated with higher job dissatisfaction. The internal consistency (Cronbach’s alpha) has been quantified at a moderate level of 0.59.

The questionnaires were returned in sealed envelopes within two weeks. The response rate was 100%.

The statistical analysis was performed using STATISTICA 6.0. PL licensed to Medical University of Gdansk. The analyses included t-Student and ANOVA tests for parametric data, U-Mann-Whitney and H-KruskaleWallis test for non-parametric data. The analyses for binomial data were analysed using Chi2 test.

Results

All the participants were female, aging from 23 to 50, with median age of 35 years. The mean age for surgical nurses was 36 years and for oncological nurses 34 years. There was no significant difference concerning age or level of education between the two groups of nurses.

There was no significant difference concerning variables from the MBI (emotional tiredness, depersonalization and decreased sense of personal achievements) between nurses form surgical and oncology departments. The mean results and standard deviations of MBI scores are presented in Table 1.

Table 1 Intensity of psychological parameters associated with emotional burden in everyday work (presented as mean).

Variable Surgical nurses

Oncological nurses

p

Age 35.63 34.1 0.494 p > 0.05 Burnout 24.46 26.43 0.045 p < 0.05 Withdrawal 7.36 7.36 1.000 p > 0.05 Anger 9.33 9.36 0.879 p > 0.05 Other 9.5 9.63 0.410 p > 0.05 Somatization 7.16 6.76 0.125 p > 0.05 Workload 31.56 33.33 0.320 p > 0.05 Emotional exhaustion 18.6 17.16 0.345 p > 0.05 Depersonalization 6.53 6.5 0.977 p > 0.05 Sense of own achievements 27.03 25.36 0.191 p > 0.05 Work satisfaction 38.53 37.83 0.601 p > 0.05

I. Ksią_zek et al. / European Journal of Oncology Nursing 15 (2011) 347e350 349

Interestingly, overall intensity of burnout syndrome (measured as an overall result of the MBI test) was significantly higher among oncological nurses (26.43) than among surgical ones (24.46) (t-test, p ¼ 0.045).

The analysis of the Psychological Burden Scale had a non significant trend towards higher overload in the group of onco- logical nurses (33.3 vs. 31.56) (t-test, p ¼ 0.087).

The analysis also showed significant correlations between emotional burden (from PBS) and emotional tiredness (from MBI) (r ¼ �0.35; p < 0.01) and depersonalization (from MBI) (r ¼ �0.39; p < 0.01). This means that lower burden is associated with lower emotional tiredness and lower depersonalization.

Discussion

The occurrence of burnout syndrome in strongly associated with and modulated by a variety of personal and environmental factors namely high demands from oneself without realistically assessing capacities and surrounding circumstances, defensive approach to problems or perfectionism (Paisley and Powell, 2007). The multi- dimensional model of burnout, initially proposed by Maslach (1993) and Maslach et al. (2001) involves a single, main factor which is emotional exhaustion, but also adds two parallel, supportive factors: abrupt reaction to the others (depersonaliza- tion) and abrupt reaction to oneself (decreased sense of personal achievements) (Freudenberger, 1974; Maslach, 1993).

Our study showed correlations between burden and emotional tiredness among all participating nurses. It may be supposed that emotional burden and work stress is increasing emotional tiredness. Emotional tiredness is a part of burnout syndrome, therefore, stress experienced in difficult situations can promote burnout. Similar results have been also presented by Beierholm et al. (1989) among nurses and other health care professions (Poncet et al., 2007). It has been postulated that burnout is a combination of individually experienced stress and social relations that involve both self- perception and perception of the others (Karasel and Theorell,1999; Shirom, 1989; Wichowicz and Rys, 2003). In three-factorial models of burnout, the lowered perception of one’s achievement is reflect- ing self-perception, while depersonalization represents impaired interpersonal reactions. Thus, affected employees tend to avoid difficult professional situations that further increase the level of experienced stress.

Our study has also shown another correlation-that emotional burden correlates with depersonalization. It may be assumed that emotional burden which is caused by unfavourable conditions at work may cause fear to engage into interpersonal relations with patients and increase depersonalization.

The oncological nurses in the examined group expressed more symptomsofemotionalexhaustionandmoresignsofdepersonalization

than surgical nurses, though these differences did not reach statistical significance.Thisfactcanbeassociatedwithmorefrequentcontactwith sufferinganddyingontheoncologicalward.Identificationandempathy with the terminally ill patients confronts the nurses with the sense of theirownmortalityandreminds them thattheloss ofhealthandlifeare inevitable. Similar differences between levels of burnout syndrome in various types of nursing specialties have also been shown in other studies. For example oncology nurses report a higher level of burnout syndrome than nurses from other specialties (Schraub and Marx, 2004).

Modern health care emphasises the importance of professional nursing in the process of treatment and convalescence. The quality of that treatment is also believed to be associated with the ability to cope with occupational stress. The specificity of the wards that nurses work at should be considered as an important factor modifying the level and dynamics of burnout.

Finally, it should be highlighted that the sense of control with treatments and involvement in creation and modification of the therapeutic processes is considered to play an important role in coping with burnout syndrome. The sense of control enables acquiring the information from the surrounding environment and triggers adequate remedies. It also directly influences the percep- tion of one’s competence. Employees free to modify and improve their work environment tend to anticipate and understand the work-derived problems better and are less susceptible to burnout. External, superior, inflexible control, lack of manageability, lack of possibilities for co-creating a treatment plan, and limited field for decisions at work should also be seen, apart from personality factors, as important contributors to burnout syndrome.

The work conditions presented above are rarely included in the narrow model of the nursing profession in Poland who is usually perceived as a person performing procedures ordered by the doctor. Broadening the competence of the nurses will provide a new outlook in this profession that will change them into professionals who actively participate in providing multidimen- sional holistic care. It can be believed that such a change of an approach will not only prevent burnout syndrome but will also improve the quality of health care.

To summarise, the study revealed a high degree of emotional burden and burnout in nurses working in the study hospital sug- gesting that nurses in Poland are at a significant occupational risk. It can be speculated that a restructuring of the competence and responsibility system in Polish hospitals may lead to increased involvement of nurses in clinical decision-making which would be beneficial for both the quality of health care and the quality of life of the professionals involved.

References

Anczewska, M., Switaj, P., Roszczynska, J., 2005. Occupational burnout. Postepy Psychiatrii i Neurologii 14 (2), 67e77.

Beierholm, M., Tiselius, I., Ek, A.C., 1989. The risk to nurses of developing burnout syndrome. Scandinavian Journal of Caring Science 3 (1), 13e18.

Cabrera-Gutierrez, L.S., Lopez-Rojas, P., Salinas-Tovar, S., et al., 2005. Burnout syndrome among Mexican hospital nursery staff. Revista medica del Instiutio Mexicano del Seguro Social 43 (1), 11e15.

Collins, M.A., 1996. The relation of work stress, hardiness, and burnout among full time hospital staff nurses. Journal of Nursing in Staff Development 12 (2), 81e85.

Escriba-Aguir, V., Martin-Baena, D., Perez-Hoyos, S., 2006. Psychosocial work environment and burnout among emergency medical and nursing staff. International Archives of Occupational and Environmental Health 80 (2), 127e133.

Freudenberger, H.J., 1974. Staff burnout. Journal of Social Issues 30, 159e165. Hall, L., 2001. Burnout: results of an empirical study of New Zealand nurses.

Contemporary Nurse 11 (1), 71e83. Karasel, R., Theorell, T., 1999. Healthy Work. Stress, Productivity and the Recon-

struction of Working Life. Basic Books. A. Division of Harper Collins Publishers, USA.

Martinez, A.A., Aytes, L.B., Escoda, C.G., 2008. The burnout syndrome and associated personality disturbances. The study in three graduate programs in Dentistry at

I. Ksią_zek et al. / European Journal of Oncology Nursing 15 (2011) 347e350350

the University of Barcelona. Medicina oral, patologia oral y cirugia bucal 13 (7), 444e450.

Maslach, C., 1993. Burnout: a multidimensional perspective. In: Schaufeli, W.B., Maslach, C., Marek, T. (Eds.), Professional Burnuot: Recent Developments in Theory and Research. John Wiley and Sons, Washington, USA.

Maslach, C., Jackson, S.E., Leiter, M.P., 1997. Maslach burnout inventory. In: Zalaquett, C., Wood, R.J. (Eds.), Evaluating Stress London, UK.

Maslach, C., Schaufeli, W.B., Leiter, M.P., 2001. Job burnout. Annual Review of Psychology 52, 397e422.

Marjanovic, Z., Greenglass, E.R., Coffey, S., 2006. The relevance of psychosocial variables and working conditions in predicting nurses’ coping strategies during the SARS crisis: an online questionnaire survey. International Journal of Nursing Studies 44 (6), 991e998.

McDowell, I., Newell, C., 1987. Measuring Health: A Guide to Rating Scales and Questionaires. Oxford University Press, New York, USA.

Moore, S., 1996. Coping with downsizing: stresses, selfesteem and social intimacy. Nursing Management 27 (3), 28e30.

Paisley, K., Powell, G.M., 2007. Staff burn-out prevention and stress management. Child and Adolescent Psychiatric Clinics of North America 16 (4), 829e841.

Poncet, M.C., Toullic, P., Papazian, L., et al., 2007. Burnout Syndrome in critical care nursing staff. American Journal of Respiratory and Critical Care Medicine 175 (7), 698e704.

Schraub, S., Marx, E., 2004. Burnout syndrome in oncology. Bulletin du Cancer 91 (9), 673e676.

Sęk, H., Beisert, M., 1996. Wypalenie zawodowe-psychologiczne mechanizmy i uwarunkowania Poznan, Poland.

Shirom, A., 1989. Burnout in organizations. In: Cooper, C., Robertson, M. (Eds.), International Review of Industrial and Organizational Psychology. John Wiley and Sons, New York, USA.

Wagner, L.I., Jason, L.A., 1997. Outcomes of occupational stressors on nurses: chronic fatigue syndrome-related symptoms. Nursing connections 10 (3), 41e49.

Wichowicz, W., Rys, D., 2003. Initial estimation of burn-out syndrome occurrence in nurses working in Gdansk hospitals. Annales Academiane Medicae Gedanesis 33, 231e242.