Annotating a Scholarly Text

Quantitative Research

Burnout, Self-Efficacy, and Resilience in Haitian Nurses: A Cross-Sectional Study

Marie Therese Georges, PhD, MSN-RN, FNP-BC1

Lisa R. Roberts, DrPH, MSN-RN, FNP-BC, CHES, FAANP, FAAN1

Elizabeth Johnston Taylor, PhD, RN, FAAN1

Jan M. Nick, PhD, RNC-OB, CNE, ANEF, FAAN1

Salem Dehom, PhD, MPH1

1Loma Linda University

jhn

Journal of Holistic Nursing

American Holistic Nurses Association

Volume 40 Number 4

December 2022 310–325

© The Author(s) 2021

Purpose of Study: Though nursing burnout is a global problem, research on nurse burnout in Haiti is scarce. In a context of multiple personal, social, and environmental challenges, this study assessed burnout and associated factors among Haitian nurses. Design of Study: A multi-site cross-sectional study. Methods: A survey in French and Haitian Creole was conducted in five Haitian hospitals using forward and back translated scales measuring burnout (emotional exhaustion [EE], depersonalization [DP], personal accomplishment [PA]), self-efficacy, nursing work environment, resilience, and demographics. Findings: Haitian nurses (N=179) self-reported moderate EE (M=21, SD=11.18), low DP (Mdn=2.0, range=29), and high personal accomplishment (Mdn=41.0, range=33). General self-efficacy (M=32.31, SD=4.27) and resilience (M=26.68, SD=5.86) were high. Dissatisfaction with salary, autonomy, and staffing were evident. Conclusions: It is noteworthy that burnout was lower than expected given the scarce resource, difficult socio-politico-economic environment. High levels of self-efficacy and resilience likely mitigated a higher level of burnout. Adaptation enables these nurses to manage their critical conditions and practice holistic nursing, which may inspire hope among nurses in similar contexts. Keywords: burnout; nursing; resilience; self-efficacy; haiti

Article reuse guidelines: sagepub.com/journals-permissions 10.1177/08980101211065600 journals.sagepub.com/home/jhn

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312 Journal of Holistic Nursing / Vol. 40, No. 4, December

Burnout, Self-efficacy, and Resilience in Haitian Nurses / Georges et al. 311

Introduction

Nurses in Haiti live and work in a challenging context that places them at risk for burnout. Indeed, burnout exists among nurses worldwide. A meta-analysis of burnout among nurses globally demonstrated it is prevalent in high, mid, and low-income nations (Woo et al., 2020). However, such evidence is lacking among Haitian nurses. Given the consequences of nurse burnout in exacerbating the global nursing shortage (Dyrbye et al., 2017; Palazoğlu & Koç, 2019), it may be beneficial to examine burnout among Haitian nurses.

Burnout was originally conceptualized as exhaustion, manifested both physically and emotionally, resulting from a workplace that demands excessive energy, strength, and resources from its workers (Freudenberger, 1974). Building on the work of Freudenberger, Maslach suggested that burnout is a psychological syndrome arising from long-term work stress. Maslach then described the psychological syndrome of burnout among healthcare workers as comprised of three facets: a) feelings of exhaustion or energy depletion, b) sensing depersonalization (DP) toward one’s job, and c) experiencing low personal accomplishment (Maslach & Jackson, 1981).

The work of nursing, with its high demands, complex interactions, and stressful environment,

Authors’ Note: Please address correspondence to Lisa Roberts, DrPH, MSN-RN, FNP-BC, CHES, FAANP, FAAN, Research Director, Professor, School of Nursing, Loma Linda University, 11262 Campus Street, West Hall, Rm 1310A Loma Linda, CA 92350, United States; e-mail: [email protected]

places nurses at risk for burnout (Permarupan et al., 2020). Indeed, nurses may have the highest burnout rate among healthcare workers (Adams et al., 2018; Bakhamis et al., 2019; Haryanto, 2018). A systematic review of 113 studies and a meta-analysis of 61 studies among nurses (N=45,539) in 49 countries across multiple specialties found an overall pooled prevalence of burnout symptoms of 11.23% among nurses, which suggests that one-tenth globally suffered high burnout syndrome (Woo et al., 2020). Similarly, a meta-analysis of 24 studies (N=6,092) from diverse countries found an even higher prevalence of burnout among nurses (Molina-Praena et al., 2018). That is, they observed emotional exhaustion (EE) among 31% of the nurses; 24% reported high DP, and 38% reported low personal accomplishment. Unmarried nurses, with fewer years of experience and work overload experienced higher burnout (Molina-Praena et al., 2018).

Haitian nurses live and work in an environment impacted by frequent political upheaval and natural disasters. Malnutrition, lack of potable water, and lack of healthcare infrastructure further burden the chronically inadequate socio-economic system (Hashimoto et al., 2020). The precarious conditions faced by Haitian nurses put them at even higher risk of burnout than most nurses. Furthermore, Haiti has an estimated ratio of only 2.4 nurses per 10,000 citizens (Caporiccio et al., 2019). Nurses in Haiti and other low-income nations often face heavy workloads, low salary, a lack of safety, inefficient and insufficient medical facilities, and inadequate resources (Caporiccio et al., 2019; Hashimoto et al., 2020; Roberts et al., 2021; Scott et al., 2018). These issues affect nurses and place an already vulnerable public at even greater risk of receiving sub-standard care.

Thus, the purpose of this study was to assess burnout in its three dimensions (EE, DP, and PA) and to explore the relationship of these dimensions with other factors in a sample of Haitian nurses. These factors include demographics, general selfefficacy (GSE), work environment and resilience. Specifically, the following questions were addressed: (a) To what degree do nurses in Haiti experience burnout as manifested by EE, DP, and PA? (b) How do demographics, GSE, work environment, and resilience relate to the levels of burnout in the nurses?

Table 1. The Ten Caritas Processes©

1. Sustaining humanistic-altruistic values by the practice ofloving-kindness, compassion, and equanimity with self/others.

2. Being authentically present, enabling faith/hope/beliefsystem; honoring subjective inner lifeworld of self/others.

3. Being sensitive to self and others by cultivating own spiritualpractices, beyond ego-self to transpersonal presence.

4. Developing and sustaining loving, trusting-caringrelationships.

5. Allowing for the expression of positive and negative feelings;authentically listening to another person’s story.

6. Creativelyproblem-solving, ‘solution-seeking’ through caring process; full use of self and artistry of caring-healing practices via use of all ways of knowing/being/doing/becoming.

7. Engaging in transpersonal teaching and learning withincontext of caring relationship; staying within other’s frame of reference; shift toward coaching model for expanded health/ wellness.

8. Creating a healing environment at all levels; subtleenvironment for energetic authentic caring presence.

9. Reverentially assisting with basic needs as sacred acts,touching mind/body/ spirit of other; sustaining human dignity.

10. Opening to spiritual, mystery, unknowns; allowing formiracles (Watson, 2016).

Note. Reprinted from “Watson Caring Science Institute,” by

J. Watson, 2016 with author’s permission. Health Sciences Library Photograph Collection and Special Collections, University of Colorado, Anschutz Medical Campus; Publications.

Methods

This cross-sectional study consisted of a survey including demographics and four scales in a paper/ pencil format with the nurses. Study approval was received from the authors’ Institutional Review Board (#5180098). Per the Declaration of Helsinki guidelines (World Medical Association, 2013), participants were treated with respect, fairness, and justice.

Theoretical Framework

The conceptual framework used to guide the study was the Caritas© processes of Watson’s theory of Human Science/Human Caring (Watson, 2009). Human caring is essential to nurses (Sumner & Fisher, 2016). Caritas is a Latin word meaning love for humankind, and charity (Collins English Dictionary, 2014). The carative factors of Watson’s theory represent essential elements of nursing practice which protect against burnout (Woo et al., 2020) and enable nurses to remember that nursing is truly a caring science. The Caritas Processes (Table 1) interrelate with one another and present a holistic caring worldview—spiritually, emotionally, physically, and environmentally for nurses and patients.

Watson’s theory of caring guided this study through five selected Watson’s Caritas concepts: altruism, authenticity, problem-solving, healing environment, and holistically meeting basic needs through compassionate caring. These concepts represent internal and external characteristics acting as nurse resources when present or threatening nurses’ well-being when absent. Through this lens, nurses’ resources or threats may determine how the independent variables influence the dependent variable burnout (see Figure 1). Caritas (#1, 2, 6, 8, 9), as noted in the following figure, conceptually align with the validated scales GSE (Schwarzer & Jerusalem, 1995); modified Nursing Work Environment (mNWI-R) (Palmer, 2014); and Resilience (CD-RISC) (Connor &

Davidson, 2003). Caritas #1, 2 & 6 pertain to holistic self-care and caring for others, as well as critical thinking aligning with both the Self-Efficacy and Resilience scales. Caritas # 8 & 9 pertain to items of the modified nursing Work Index-Revised scale such as holistic care with relationships, and healing environment.

The conceptual model depicts Haitian nurses at the center influenced by factors such as demographics, internal and external resources/threats. When the positive factors such as internal and external resources are available, nurses are presumably experiencing less risk of burnout. However, when these resources are lacking, nurses’ well-being may suffer, and they may be more at risk of nurse burnout.

Setting and Sample

Recruitment of nurses was accomplished using convenience and snowball sampling techniques at five hospitals in five towns across Haiti. The convenience sample is a non-probability sample taken from the available nurses at the study sites. Snowball sampling consisted of study participants assisting in recruiting additional potential candidates from their respective hospitals.

Thehospitalsrangedinsizefrom10to70beds,with 14to60totalnursesineachhospital.Onlyathirdtohalf of the nurses are on duty at any given time, and staff the outpatient and ancillary departments in addition to the in-patient units. The sample consisted of registered nurses (RN) and Auxilliaires (equivalent to licensed vocational or practical nurses, LVNs or LPNs) (Caporiccio et al., 2019). In Haiti, a nurse is a person who has completed basic nursing education and is authorized by the Haitian Ministry of Health and Population (Ministère de la Santé Publique et de la Population [MSPP]) to practice nursing. The basic nursing education is recognized as a 3-year diploma program in the public sector. Private nursing schools provide a baccalaureate degree after a 4-year program. Physiciansprovideclinicalinstructionacrossspecialties, so the nurses become generalist (Partners in Health, 2016). As a generalist, nurses may engage in the full range of nursing practice such as healthcare education, supervision, and work in all hospital’s units/clinics. There are about 1,400 authorized nurses in Haiti, or about 2.4 nurses per 10,000 patients (Caporiccio et al., 2019). The shortage of nurses is partially related to high staff turnover due to low salaries, causing nurses to emigrate to better-paid settings such as the U.S. (Floyd & Brunk, 2016; Partners in Health, 2016). The problem of nurse migration experienced by Haiti is similar to other low-income nations, which are also losing staff to high-income nations (Scott et al., 2018). Nurse migration increases the remaining staff’s patient-to-nurse ratio, further contributing to nurse burnout (Dutra et al., 2018; Reith, 2018).

For this study, using an unconditional power calculation method, a sample size of N=176 was needed to achieve 80% power when the significance level (alpha) is.05 (Cohen, 1988). Criteria for participation included nurses working in the selected facilities who could read and understand French/Haitian Creole. Potential participants received the study information sheet, and any questions were answered. Interested nurses were informed that participation in the survey would serve as passive consent and reassured that their responses would be confidential. No identifying participant or hospital information was collected on the survey.

Procedure

All study materials were forward and back translated into French and Haitian Creole by committee approach (Brislin, 1970). Data were collected when nurses voluntarily completed the anonymous survey between November to December 2020.

Instruments

The dependent variable was burnout, measured with the Maslach Burnout Inventory Human Services Scale for Medical Personnel (MBI-HSSMP) (Maslach & Jackson, 1981). The independent variables included the demographics, and three

Figure 1. The percentage of nurses who endorsed “Moderately true to Exactly true” on the General Self-Efficacy scale items. Note: amNWI-R: modified Nursing Work Practice Index Scale - Revised, bCD-RISC: Connor-Davidson Resilience Scale, GSE: General Self-Efficacy Scale, dMBI-HSS-MP (BO): Maslach Burnout Inventory - Human Services Scale (Burnout Scale) with EE: Emotional Exhaustion, DP: Depersonalization, and PA: Personal Accomplishment subscales.

validated scales: the GSE scale (Schwarzer & Jerusalem, 1995), the modified Nursing Work Index Revised (MNWI-R) (Palmer, 2014), and the ConnorDavidson Resilience Scale (CD-RISC-10) (CampbellSills & Stein, 2007; Connor & Davidson, 2003).

Prior to commencing this study, preliminary work included testing a pilot instrument for cross-cultural equivalence and language with seven nurses in Haiti to evaluate both the French and Haitian Creole versions. The findings indicated that these translated scales were acceptable in terms of language, readability, comprehensibility.

Maslach Burnout Inventory Human Services Scale for Medical Personnel (MBI-HSS-MP)

The 22-item MBI-HSS-MP consists of three subscales, which measure Emotional Exhaustion, Depersonalization, and low personal accomplishment. Each subscale is scored separately and summed (Maslach et al., 1986). Response options on a 7-point Likert scale are: Never=0, A few times a year or less=1, Once a month or less=2, A few times a month=3, Once a week=4, A few times a week=5, Every day=6 (Maslach et al., 1986).

Emotional Exhaustion (EE) Subscale. EE measures an individual’s feelings of being drained by their job and includes nine items which are summed so that higher scores indicate greater EE. Possible scores range from 0 to 54 (Maslach & Jackson, 1981;

Poghosyan et al., 2009).

Depersonalization (DP) Subscale. This subscale measures a participant’s lack of feeling, which may evoke an impersonal response to the patient. The DP subscale is calculated by summing five items for a possible score of 0 to 30. Higher scores indicate a higher degree of DP (Maslach & Jackson, 1981; Poghosyan et al., 2009).

Personal Accomplishment (PA). The final subscale with a low level, measures feelings of embarrassment among medical staff due to their perceived lack of professional success. PA includes eight items which are summed, so that a higher score indicates greater personal accomplishments. Possible scores range from 0 to 48 (Maslach & Jackson, 1981; Maslach et al., 2018; Poghosyan et al., 2009).

In previous studies, the internal reliability of the MBI-HSS using Cronbach’s alphas were reported as.90 for EE,.79 for DP, and.71 for personal accomplishment (Maslach & Jackson, 1981; Maslach et al., 1996). No internal reliability has been reported as yet in the literature for MBI-HSS-MP. In the current study, Cronbach’s α for EE, DP, and PA were α=.77,.42, and.62 respectively.

General Self-Efficacy (GSE)

The GSE scale assesses a person’s general sense of perceived self-efficacy, predicting coping with daily stressors, and strategies to adapt after experiencing any stressful event (Schwarzer & Jerusalem, 1995). The 10-item GSE has been translated from German to 26 languages. Possible scores range from 10 to 40, and higher scores denote greater GSE. Response options on a 4-point Likert scale are: Not at all true=1, Hardly true=2, Moderately true=3, Exactly true=4 (Schwarzer & Jerusalem, 1995).

Internal consistency reliability, supported by evidence from 25 nations, appears to be strong, with Cronbach’s α ranging from.75 to.91 (Scholz et al., 2002). In the current study, the Cronbach’s α is.78.

Modified Nursing Work Environment –

Revised (NWI-R)

Palmer’s 9-item questionnaire stems from the Nursing Work Index-Revised questionnaire (Aiken & Patrician, 2000). In 2014, Palmer modified the NWI-R, selecting nine items emphasizing pay, reduced nursing staff, lack of recognition of nurses by the medical staff and the public, diminished work promotion, decreased autonomy, and lack of schedule flexibility, with some rewording (Palmer, 2014). The modified NWI-R-9 item uses a 4-point Likert scale for response options: Totally agree=1, Agree=2, Disagree=3, and Totally disagree=4. Higher scores denote greater nursing work dissatisfaction. Strong internal consistency was demonstrated, Cronbach’s alpha=.81 (Palmer, 2014). For the current study, scores were reversed so that lower scores indicated dissatisfaction and higher scores indicated greater satisfaction with work environment. The Cronbach’s α was.75.

Connor-Davidson Resilience Scale (CD-RISC-10)

The CD-RISC is designed to measure resilience, an individual’s ability to recover from traumatic, unexpected, and momentous life events, or natural disasters. Shortened from the original 25 items, the 10-item version is available in Canadian French and Haitian Creole (Campbell-Sills & Stein, 2007; Connor & Davidson, 2003). The possible scores range from 0–40, and higher score denotes greater resilience. Response options followed a 5-point Likert scale: Not true at all=0, Rarely true=1, Sometimes true=2, Often true=3, True nearly all the time=4 (Campbell-Sills et al., 2009). The CD-RISC-10 is a unidimensional scale with excellent psychometric properties (Cronbach’s α=.75 –.88) and is applicable for different cultures

(Campbell-Sills et al., 2009; Campbell-Sills & Stein, 2007; Notario-Pacheco et al., 2011; Scali et al., 2012; Wang et al., 2010). In the current study the Cronbach’s α is.74.

Data Analysis

We conducted quantitative analyses using the Statistical Package for the Social Sciences (Version 27). Descriptive analyses included frequencies, percentages, means, and standard deviations as well as median and range for non-normally distributed variables. Bivariable associations with burnout subscales and co-variates were explored using Pearson’s correlations for normally distributed data and

Spearman’s rho for abnormally distributed variables. Due to weak correlations and minimal variance, the multiple regression results were not found to be meaningful and are therefore not presented in the results. Subsequently, we proceeded to run item-by-item analyses to better understand the nurses’ responses on each scale and this analysis proved meaningful. These results were presented in number with percentages.

Results

Participant Demographics

The vast majority of the participants (N=179) were women (97.8%) and married (63.7%). The age range of the nurses was 24 to 67 years (M=36.27, SD 9.05). All were employed by one of the five hospitals and on average had 9.30 years of nursing experience (SD 8.51, range 5 months to 39 years). The number of hours worked per week ranged broadly, from 4 to 72 h (M=41.60, SD 11.75), with most working full-time. Surprisingly, over a quarter of the respondents (25.7%) worked an additional job. Most were RNs rather than Auxilliaires (76.4% and 23.6%, respectively). Almost half of the nurses had four years of nursing education, equivalent to a bachelor’s (BSN) degree (48.0%), while approximately a quarter of the nurses had either three years of nursing education (equivalent to an Associate degree), or a diploma (24.6% and 25.7% respectively). The majority of respondents were staff nurses (81.4%), with the remainder in various specialty positions, or administrative and educational roles. See Table 2.

Descriptive Analysis of Variables of Interest

The EE was moderate among the participating nurses (M=21.80, SD=11.18). DP was low with a median of 2.00 (range 29); and a high personal accomplishment (PA) reported with a median of 41.0 (range 33). On average, GSE was fairly high (M=32.37, SD=4.27). The modified NWI-R scale indicated that the nurses held a moderately positive view of their work environments (M=24.22, SD= 4.47). The CD-RISC-10 data analysis indicated high resilience (M=26.68, SD=5.86).

Table 2. Demographics (N=179)

Variables	N	%
Gender Male	4	2.2
Female	175	97.8
Marital Status Single	58	32.4
Currently Married	114	63.7
Previously married	7	3.9
Nursing Degree Diploma	46	25.7
Associate degree	44	24.6
Bachelors of Science in Nursing	86	48.0
Master of science	3	1.7
Health Qualification Licensed Practical Nurse (Auxiliaire)	42	23.6
RN	136	76.4
Position Staff nurse	136	81.4
Charge nurse	9	5.4
Supervisor	8	4.8
Nurse educator	2	1.2
Other positions	13	7.2
Additional job No	133	74.3
Yes	46	25.7

Note. Other positions included anesthetist, community nurse, emergency room nurse, surgical nurse, and ancillary services.

Item Analyses. To better understand and capture the nuances of the data, descriptive analysis of individual items from the validated scales are provided. Item-by-item analysis captures variances otherwise obscured by summative scores.

Emotional Exhaustion (EE) Frequencies. Response options were collapsed into three categories; (1) never, (2) a few times a month or less, and (3) once a week or more. The majority of nurses experienced EE to some degree a few times a month or less than once a week or more (Figure 1). The two items most frequently endorsed by the nurses were “I feel used up at the end of the working day” and “I feel fatigued when I get up in the morning and have to face another day on the job,” with 98% and 90% respectively, indicating feeling this way. Approximately one-third of the nurses endorsed “I feel emotionally drained from my work,” “working with people all day is really a strain for me,” “I feel burned out from my work,” “I feel frustrated by my job,” and “I feel I am working too hard on my job.” Just about half (50%) of the respondents indicated that they felt that working with people directly puts too much stress on them. Almost 60% of the nurses indicated they were at the end of their rope a few times a month or less or once a week or more. See Figure 2.

Depersonalization (DP) Frequencies. Figure 3 shows “never” responses to DP items ranged from about 55% to 89%. The nurses’ responses to the DP subscale indicate that this is not an aspect of burnout they generally experience. Nevertheless, approximately 12% of the nurses felt they treated patients as if they were impersonal objects and became callous toward people since they took the job. About 27% don’t really care what happens to some patients and 33% of the nurses worry that the job is hardening them emotionally. Approximately 45% reported patients blaming them for what happened to them.

Personal Accomplishment (PA) Frequencies. The vast majority of respondents indicated high Personal Accomplishment. Positive responses to PA subscale items ranged from 82% to 97% endorsed as once a week or more often. The highest percentages were for items “I feel exhilarated after working closely with my patients” and “I have accomplished many worthwhile things in this job” (97% each). Approximately 18% did not think that they could deal with their emotional problems calmly, and unfortunately, 12% did not feel they were influencing someone’s life positively through their work. See Figure 4.

General Self-Efficacy (GSE) Frequencies. On average, GSE was high, with 78% – 95% endorsing moderately true or exactly true for all ten GSE scale items. Approximately 22% did not think they could find the means and ways to get what they want if someone opposes them, nor remain calm when facing difficulties. Figure 5.

Modified Nursing Work Environment Index-Revised (NWI-R) Frequencies. Responses agree and totally agree were collapsed into the agree category. Overall, 60% of the nurses positively endorsed their work environment by agreeing on six items.

Approximately 80% agree that the supervisors collaborate with and help the nurses, and 90% felt that the nurses are a valued part of the hospital. About 63% felt that the public appreciates and values the nurses, and 84% perceived teamwork between physicians and nurses. Flexibility with schedule was endorsed by 67% of the nurses, and 63% agreed that there are sufficient opportunities to advance in the work environment. The three remaining items that fell below 60% were “I have autonomy to make clinical decisions” (46%), “There are sufficient nurses to provide excellent care at work” (34%), and “I am satisfied with my pay” (19%). Roughly 40% were dissatisfied with at least some work environment parameters. See Figure 6.

Resilience (CD-RISC-10) Frequencies. Responses Sometimes true to True nearly all the time were collapsed to show the high level of resilience endorsed by the majority of nurses. Overall, participants endorsed resilience as true of them on all items (80–95%) except one item falling below 60% “I tend to bounce back after illness, injury, or other hardships.” See Figure 7.

Bivariate Correlation Analysis

The total sum of each variable was used when calculating the correlations among the variables. The three subscales of the MBI-HSS-MP (EE, DP, and PA) were bivariably analyzed with all independent variables; however, only the significant correlations are presented here. EE was weakly negatively correlated with work environment (r [179]=-.30, p <.001) and resilience (r [179]=-.17, p=.023). Low Personal Accomplishment (more burnout) was weakly negatively correlated with self-efficacy (r [179]=-.21, p=.006), resilience, (r (179)=-.26 p <.001), and weakly positively correlated with age (r [175]=.22, p=.003). All the correlations were weak with r less than.39 (Schober et al., 2018). See Table 3.

Discussion

This multi-site study is groundbreaking in the sense that, to our knowledge, it is the first study quantifying Haitian nurse responses to work perspectives. This study evaluated self-efficacy, work environment, and resilience as possible correlates of burnout. As caring is central to nursing, five of Watson’s 10 Caritas© processes influenced the conceptual framework guiding the study design. Nursing burnout is a phenomenon of concern in much of the world, and given the low-resource, complex environment in which Haitian nurses work, we hypothesized that these nurses were at increased risk for burnout. However, our results show that while moderately prone to EE, DP is low, and PA is high.

EE is the stress aspect of burnout theory caused by nurses feeling worn out through the routine of a demanding job (Maslach, 1993). Researchers report that nurses are prone to burnout when emotionally

Figure 2. The frequency of Emotional Exhaustion endorsed.

exhausted, which may negatively affect their wellbeing, health, and job satisfaction. Patient satisfaction and the quality of patient care may also be negatively affected (Hailay et al., 2020; Khamisa et al., 2017; Poku et al., 2020; Ugwu et al., 2017). However, the Haitian nurses in our study showed they continued to function and even demonstrate compassionate caring as postulated in Watson’s Caritas. Perhaps because they themselves experience hardships, these nurses were able to be compassionate towards themselves and others, reducing their stressors and risk for burnout.

DP is characterized as a detachment and a tendency to becoming insensitive towards patients (Galletta et al., 2016; Maslach et al., 1986)—the opposite of compassionate caring. The majority of the nurses in our study did not endorse DP as reflective of their experience. This result contrasts with findings among nurses in Egypt, and sub-Saharan Africa which indicated moderate to high levels of burnout at all three dimensions (Anwar & Elareed, 2017; Dumit & Honein-AbouHaidar, 2019; Owuor et al., 2020). A previous study indicated that the public regards nurses favorably in Haiti (Roberts et al., 2021), which may cause Haitian nurses to feel valued, thus decreasing the risk of burnout.

Additionally, 82–97% of the participating nurses indicated feelings of high personal accomplishment. These results reflect commitment and a sense of fulfillment in caring holistically for patients, which aligned with the Watson’s Caritas processes pertaining to authentic presence, trusting-caring relationships, and human dignity (Watson, 2009). In Haiti, some consider nursing a sacred calling, and in this society, nurses are generally held in high esteem (Roberts et al., 2021).

Figure 3. The percentage of nurses who chose response option “Never” for the Depersonalization subscale items.

Figure 4. The percentage of nurses who responded “At least once a week” for the Personal Accomplishment subscale items.

Figure 5. The percentage of nurses who endorsed “Moderately true” to “Exactly true” on the General Self-Efficacy scale items.

The nurses’ GSE, work environments, and resilience were also examined as possible correlates of burnout. The strength of these correlations was weak but nonetheless provide directional information pertaining to their influence on the components of burnout (EE, DP, PA) (Schober et al., 2018).

Overall, the nurses rated their self-efficacy as high, which fits with their perception of personal accomplishment and is reflected in the significant correlation between GSE and PA. Furthermore, these findings are congruent with the literature as selfefficacy tends to have a protective effect on nursing burnout. When self-efficacy increases, stressors are reduced (Yao et al., 2018) as well as burnout. The current study suggests that the high level of selfefficacy protected these nurses from burnout and boosted their sense of personal accomplishment.

The nurses’ perceptions of their work environment with EE were inversely and weakly correlated. The negative direction of the correlation indicates that nurses’ EE increases when they are dissatisfied with their work environment. While overall the nurses positively endorsed their work environment, most were not satisfied with their salary, staffing ratios, or level of autonomy. Thus, our findings are consistent with other studies that found nurse burnout associated with job dissatisfaction factors, including low salary and a shortage of nurses (Dyrbye et al., 2017; Guo et al., 2018; McHugh et al., 2020; Pisanti et al., 2016; Shin et al., 2018; Woodhead et al., 2016).

The other factor that influenced burnout in this sample of nurses was resilience. Although the correlation of resilience with EE was weak, it was significant. As resilience increased, EE decreased, indicating that resilience may act as a protective factor, which is consistently confirmed in the literature (Marie et al., 2017; Ngoasong & Groves, 2016; Ramalisa et al., 2018; Rushton et al., 2015). Resilience was also negatively correlated with low personal accomplishment, although weakly. Resilient nurses can usually adapt to their circumstances, manage their challenging roles, and retain their sense of personal and professional accomplishments (Robertson et al., 2016). Thus, it appears that resilience may enhance the ability of the nurses in Haiti to avoid burnout, as it may have mitigated some of the identified risks for burnout syndrome.

Figure 6. Percentage of “Agree” to “Totally agree” responses to modified Nursing Work Index-Revised scale items.

Strengths and Limitations

This study provides evidence about burnout among nurses in Haiti, a novel research topic in this population. The selected validated scales have been used in many countries allowing comparison to other studies. The data, having been collected in various hospitals from the North to the South of Haiti, including the capital’s vicinity, engenders trust in the findings as fairly representative.

Nevertheless, there are also some limitations to consider. The convenience sample limits generalizability, and the cross-sectional design does not permit the determination of cause-and-effect relationships. Moreover, social desirability bias may have inflated positive responses, particularly personal accomplishment, self-efficacy, and resilience. At the same time, participants might not have trusted that their responses would remain confidential, therefore, fearing possible supervisor/employer retribution if they shared negative views -- particularly regarding EE, DP, and work environment.

Other potential limitations are research naivete in this sample, and differences between the written and spoken language familiar to the nurses. Although the participants speak and read French, the French-Canadian version of two scales (MBI-HSS-MP and CD-RISC-10) did seem to present some difficulties in transliteration.

The internal reliability for the DP subscale was lower than desirable (Cronbach’s α=.42). It is possible that the overall concept of DP does not fit culturally. Haitian culture may deter negatively thinking about patients, who, like them, suffer chronically difficult living conditions, therefore fostering a genuine desire to help community members and show compassion in caring (Percy & Richardson, 2018; Sinclair et al., 2016; Watson, 2009).

Implications for Advancing Knowledge

Owing to the precarious conditions where Haitian nurses practice and live, it was critical to understand burnout syndrome in their setting. This new knowledge may inform future interventions to improve their well-being, thus promoting quality of care for the patients.

Figure 7. Nurses who endorsed “Sometimes true” to “True nearly all the time” to the CD-RISC-10 scale items.

This novel study’s contribution to the nursing discipline is the Haitian Creole version of the Maslach-Burnout Inventory Health Service Survey for Medical Professionals (MBI-HSS-MP). This version is now available online for future research at https://www.mindgarden.com. Furthermore, this study adds to the limited literature on Haitian nurses’ burnout pertaining to its correlates and provides evidence that the attributes of resilience and self-efficacy are means to mitigate nursing burnout.

Implications for Clinical Practice Environment

Studies have shown that self-efficacy, resilience, and PA are protective factors that alleviate nurse burnout, thus, programs to enhance these attributes are warranted. Programs such as mindfulness exercises, positive thinking, altruism, and supportive interpersonal relationships are personal interventions for holistic practice (Montanari et al., 2019; Wei et al., 2019). Encouraging nurses’ growth and building on their strengths are administrative interventions that may be effective as well (Wei et al., 2019). Resilient nurses are able to maintain their well-being and thereby achieve better patient care outcomes. Additionally, understanding nurses’ dissatisfaction with their work environment, provides direction for strategic planning.

Implications for Nursing Research and Education

Future research to include pre-and-post interventional studies on strengthening nurses’ self-efficacy and resilience to lessen EE, a component of

Table 3. Correlates of Independent Variables with the Three Subscales of Burnout Measure EE p-value DPa p-value PAa p-value GSE −.137 .067 .040 .592 −.205 .006 Modified NWI-R −.297 <.001 −.052 .486 .038 .611 CD-RISC-10 −.170 .023 −.007 .924 −.263 <.001 Age in years −.057 .452 .055 .472 .224 .003 Note. aSpearman’s rho correlation used with PA (Personal Accomplishment), and DP (Depersonalization), as these variables were not

normally distributed.

burnout, is warranted. Mitigating nurse burnout will likely increase effective, holistic, quality care for the patients.

Furthermore, understanding the protective effects of self-efficacy and resilience, provides insight pertaining to strengths to build on and support of further studies on holistic caring. Educators may also choose to integrate the concepts of self-efficacy, resilience, and Watson’s Caritas© processes, as ways to strengthen the preparation of future nurses. Strengthening these areas in the curriculum may decrease future risk of burnout for new nurses.

Conclusion

This study examined burnout among Haitian nurses, a novel and important contribution to the literature. The finding of lower-than-expected symptoms of burnout (primarily moderate EE) is noteworthy given the low resource context aggravated by a difficult socio-politico-economic environment. It seems that these nurses have developed a degree of adaptation that permits them to manage their critical conditions. The findings provide tentative evidence that the high resilience with high self-efficacy may have buffered precarious conditions and contribute to nursing strength in caring for others holistically. While facing their own lack of the basic needs of life, their performance in high levels of resilience, self-efficacy and personal accomplishment is quite remarkable and commendable. Haitian nurses seem to possess a caring nursing worldview which galvanized them to empathize with others despite adversities. This worldview aligns well with the conceptual model of Human Caring/Human Science of Jean Watson and her carative factors (Watson, 2009). Watson’s Caritas Processes portrays the holistic vision of nursing healthcare in order to avoid burnout. Haitian nurses are in a good position to be examples for others in promoting an environment conducive to holistic restoration of their fellow citizens.

Acknowledgments

We wish to thank the medical directors, nursing supervisors and participating nurses at each of the five hospitals in Haiti.

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) received no financial support for the research, authorship and/or publication of this article.

ORCID iDs

Marie Therese Georges https://orcid.org/0000-0002-7167-

3347

Lisa R. Roberts https://orcid.org/0000-0003-3722-8634

References

Adams, J. M., Zimmermann, D., Cipriano, P. F., Pappas, S., & Batcheller, J. (2018). Improving the work life of health care workers: Building on nursing’s Experience. Medical Care, 56(1), 1–3. https://doi.org/10.1097/MLR.0000000000000839

Aiken, L. H., & Patrician, P. A. (2000). Measuring organizational traits of hospitals: The revised nursing work index. Nursing Research, 49(3), 146–153. https://journals.lww. com/nursingresearchonline/Fulltext/2000/05000/Measuring_ Organizational_Traits_of_Hospitals__The.6.aspx https://doi.

org/10.1097/00006199-200005000-00006

Anwar, M. M., & Elareed, H. R. (2017). Burnout among Egyptian nurses. Journal of Public Health, 25(6), 693– 697. https://doi.org/10.1007/s10389-017-0831-2

Bakhamis, L., Paul, D. P.III, Smith, H., & Coustasse, A. (2019). Still an epidemic: The burnout syndrome in hospital registered nurses. The Health Care Manager, 38(1), 3– 10. https://doi.org/10.1097/HCM.0000000000000243

Brislin, R. W. (1970). Back-translation for cross-cultural research. Journal of Cross-Cultural Psychology, 1(3), 185– 216. https://doi.org/10.1177/135910457000100301

Campbell-Sills, L., Forde, D. R., & Stein, M. B. (2009). Demographic and childhood environmental predictors of resilience in a community sample. Journal of Psychiatric Research, 43(12), 1007–1012. https://doi.org/10.1016/j. jpsychires.2009.01.013

Campbell-Sills, L., & Stein, M. B. (2007). Psychometric analysis and refinement of the connor–davidson resilience scale (CD-RISC): Validation of a 10-item measure of resilience. Journal of Traumatic Stress: Official Publication of The International Society for Traumatic Stress Studies, 20(6), 1019–1028. https://doi.org/10.1002/jts.20271

Caporiccio, J., Louis, K. R., Lewis-O’Connor, A., Son, K. Q., Raymond, N., Garcia-Rodriguez, I. A., Dollar, E., & Gonzalez, L. (2019). Continuing education for Haitian nurses: Evidence from qualitative and quantitative inquiry. Annals of Global Health, 85(1), 93–100. https://

doi.org/10.5334/aogh.2538

Cohen, J. (1988). Statistical power analysis for the behavioral sciences, 2nd edn. Á/L. Erbaum Press.

Collins English Dictionary, C. E. D. (2014). Collins english dictionary. Complete & Unabridged.

Connor, K. M., & Davidson, J. R. (2003). Development of a new resilience scale: The connor-davidson resilience scale (CD-RISC). Depression and Anxiety, 18(2), 76–82. https://doi.org/10.1002/da.10113

Dumit, N. Y., & Honein-AbouHaidar, G. (2019). The impact of the Syrian refugee crisis on nurses and the healthcare system in Lebanon: A qualitative exploratory study. Journal of Nursing Scholarship, 51(3), 289–298. https://

doi.org/10.1111/jnu.12479

Dutra, H. S., Cimiotti, J. P., & de Brito Guirardello, E. (2018). Nurse work environment and job-related outcomes in Brazilian hospitals. Applied Nursing Research, 41, 68–72. https://doi.org/10.1016/j.apnr.2018.04.002

Dyrbye, L. N., Shanafelt, T. D., Sinsky, C. A., Cipriano, P. F., Bhatt, J., Ommaya, A., West, C. P., & Meyers, D. (2017). Burnout among health care professionals: A call to explore and address this underrecognized threat to safe, high-quality care. NAM perspectives. Discussion Paper, National Academy of Medicine, Washington, DC. https:// nam.edu/burnout-among-health-careprofessionals-a-call to-explore-and-address-this-underrecognized-threat-to-sa fe-high-quality-care

Floyd, B. O. M., & Brunk, N. (2016). Utilizing task shifting to increase access to maternal and infant health interventions: A case study of midwives for Haiti. Journal of Midwifery & Women’s Health, 61(1), 103–111. https://

doi.org/10.1111/jmwh.12396

Freudenberger, H. J. (1974). Staff burn-out. Journal of Social Issues, 30(1), 159–165. https://doi.org/10.1111/j.1540 4560.1974.tb00706.x

Galletta, M., Portoghese, I., D’Aloja, E., Mereu, A., Contu, P., Coppola, R. C., Finco, G., & Campagna, M. (2016). Relationship between job burnout, psychosocial factors and health care-associated infections in critical care units. Intensive and Critical Care Nursing, 34, 59–66. https://doi.org/10.1016/j.iccn.2015.11.004

Guo, Y. f., Luo, Y. h., Lam, L., Cross, W., Plummer, V., & Zhang, J. p. (2018). Burnout and its association with resilience in nurses: A cross-sectional study. Journal of Clinical Nursing, 27(1–2), 441–449. https://doi.org/10.1111/jocn. 13952

Hailay, A., Aberhe, W., Mebrahtom, G., Zereabruk, K., Gebreayezgi, G., & Haile, T. (2020). Burnout among nurses working in Ethiopia. Behavioural Neurology, 2020.

Haryanto, M. (2018). Burnout: When It’s More than “just a Bad Day”. Orthopaedic Nursing, 37(4), 215–216. https:// doi.org/10.1097/NOR.0000000000000462

Hashimoto, K., Adrien, L., & Rajkumar, S. (2020). Moving towards universal health coverage in Haiti. Health Systems & Reform, 6(1), e1719339. https://doi.org/10. 1080/23288604.2020.1719339

Khamisa, N., Peltzer, K., Ilic, D., & Oldenburg, B. (2017). Effect of personal and work stress on burnout, job satisfaction and general health of hospital nurses in South Africa. Health SA Gesondheid, 22, 252–258.

Marie, M., Hannigan, B., & Jones, A. (2017). Resilience of nurses who work in community mental health workplaces in palestine. International Journal of Mental Health Nursing, 26(4), 344–354. https://doi.org/10.1111/inm. 12229

Maslach, C. (1993). Burnout: A multidimensional perspective. In W. B. Schaufeli, C. Maslach, & T. Marek (Eds.), Professional burnout: Recent developments in theory and research (pp. 19–32). Taylor & Francis.

Maslach, C., & Jackson, S. (1981). The measurement of experienced burnout. Journal of Occupational Behavior, 2, 99– 113. https://doi.org/10.1002/job.4030020205

Maslach, C., Jackson, S. E., & Leiter, M. P. (1996). Maslach Burnout Inventory Manual. CPP. Inc. Maslach, C., Jackson, S. E., Leiter, M. P., Schaufeli, W., & Schwab, R. (2018). Maslach Burnout Inventory. 2017. Maslach, C., Jackson, S. E., Leiter, M. P., Schaufeli, W. B., & Schwab, R. L. (1986). Maslach burnout inventory (Vol. 21). Consulting Psychologists Press.

McHugh, M. D., Aiken, L. H., Windsor, C., Douglas, C., & Yates, P. (2020). Case for hospital nurse-to-patient ratio legislation in queensland, Australia, hospitals: An observational study. BMJ Open, 10(9), e036264. https://doi.org/10. 1136/bmjopen-2019-036264

Molina-Praena, J., Ramirez-Baena, L., Gómez-Urquiza, J. L., Cañadas, G. R., & De la Fuente, E. I. (2018). Levels of burnout and risk factors in medical area nurses: A metaanalytic study. International Journal of Environmental Research and Public Health, 15(12), 2800. https://doi.org/ 10.3390/ijerph15122800

Montanari, K. M., Bowe, C. L., Chesak, S. S., & Cutshall, S. M. (2019). Mindfulness: Assessing the feasibility of a pilot intervention to reduce stress and burnout. Journal of Holistic Nursing, 37(2), 175–188. https://doi.org/10.1177/ 0898010118793465

Ngoasong, M. Z., & Groves, W. N. (2016). Determinants of personal resilience in the workplace: Nurse prescribing in an african work context. Human Resource

Development International, 19(3), 229–244. https://doi. org/10.1080/13678868.2015.1128677

Notario-Pacheco, B., Solera-Martínez, M., Serrano-Parra, M. D., Bartolomé-Gutiérrez, R., García-Campayo, J., & Martínez-Vizcaíno, V. (2011). Reliability and validity of the spanish version of the 10-item connor-davidson resilience scale (10-item CD-RISC) in young adults. Health and Quality of Life Outcomes, 9(1), 63. https://doi.org/10. 1186/1477-7525-9-63

Owuor, R. A., Mutungi, K., Anyango, R., & Mwita, C. C. (2020). Prevalence of burnout among nurses in subsaharan Africa: A systematic review. JBI Evidence Synthesis, 18(6), 1189–1207. https://doi.org/10.11124/ JBISRIR-D-19-00170

Palazoğlu, C. A., & Koç, Z. (2019). Ethical sensitivity, burnout, and job satisfaction in emergency nurses. Nursing ethics, 26(3), 809–822.

Palmer, S. P. (2014). Nurse retention and satisfaction in E cuador: Implications for nursing administration. Journal of Nursing Management, 22(1), 89–96. https://doi.org/10. 1111/jonm.12043

Partners in Health, P. i. H. (2016). Meet a leader transforming nursing in Haiti [Nursing life story]. https://www.pih.org/ article/meet-a-leader-transforming-nursing-inHaiti

Percy, M., & Richardson, C. (2018). Introducing nursing practice to student nurses: How can we promote care compassion and empathy. Nurse Education in Practice, 29, 200–205. https://doi.org/10.1016/j.nepr.2018.01.008

Permarupan, P. Y., Al Mamun, A., Samy, N. K., Saufi, R. A., & Hayat, N. (2020). Predicting nurses burnout through quality of work life and psychological empowerment: A study towards sustainable healthcare services in Malaysia. Sustainability, 12(1), 388. https://doi.org/10. 3390/su12010388

Pisanti, R., van der Doef, M., Maes, S., Meier, L. L., Lazzari, D., & Violani, C. (2016). How changes in psychosocial job characteristics impact burnout in nurses: A longitudinal analysis. Frontiers in Psychology, 7, 1082. https://doi.org/ 10.3389/fpsyg.2016.01082

Poghosyan, L., Aiken, L. H., & Sloane, D. M. (2009). Factor structure of the maslach burnout inventory: An analysis of data from large scale cross-sectional surveys of nurses from eight countries. International Journal of Nursing Studies, 46(7), 894–902. https://doi.org/10.1016/j.ijnurstu.2009. 03.004

Poku, C. A., Donkor, E., & Naab, F. (2020). Determinants of emotional exhaustion among nursing workforce in urban Ghana: a cross-sectional study. BMC nursing, 19(1), 1–10. Ramalisa, R. J., du Plessis, E., & Koen, M. P. (2018). Increasing coping and strengthening resilience in nurses providing mental health care: Empirical qualitative research. Health SA, 23(1), 1094. https://doi.org/10. 4102/hsag.v23i0.1094

Reith, T. P. (2018). Burnout in United States healthcare professionals: A narrative review. Cureus, 10(12). https://doi. org/10.18605/2175-7275/cereus.v10n2p12-25

Roberts, L. R., Georges, M., Nick, J. M., & Taylor, E. J. (2021). Dedication in a difficult context: Faith-based nursing in Haiti. Journal of Christian Nursing, 38(2), 82– 91. https://doi.org/10.1097/CNJ.0000000000000816

Robertson, H. D., Elliott, A. M., Burton, C., Iversen, L., Murchie, P., Porteous, T., & Matheson, C. (2016). Resilience of primary healthcare professionals: A systematic review. British Journal of General

Practice, 66(647), e423–e433. https://doi.org/10.3399/

bjgp16X685261

Rushton, C. H., Batcheller, J., Schroeder, K., & Donohue, P. (2015). Burnout and resilience among nurses practicing in high-intensity settings. American Journal of Critical Care, 24(5), 412–420. https://doi.org/10.4037/ajcc2015291

Scali, J., Gandubert, C., Ritchie, K., Soulier, M., Ancelin, M.-L., & Chaudieu, I. (2012). Measuring resilience in adult women using the 10-items connor-davidson resilience scale (CD-RISC). role of trauma exposure and anxiety disorders. PloS One, 7(6), e39879. https://doi.org/ 10.1371/journal.pone.0039879

Schober, P., Boer, C., & Schwarte, L. A. (2018). Correlation coefficients: Appropriate use and interpretation. Anesthesia & Analgesia, 126(5), 1763–1768. https://doi. org/10.1213/ANE.0000000000002864

Scholz, U., Doña, B. G., Sud, S., & Schwarzer, R. (2002). Is general self-efficacy a universal construct? Psychometric findings from 25 countries. European Journal of

Psychological Assessment, 18(3), 242. https://doi.org/10. 1027//1015-5759.18.3.242

Schwarzer, R., & Jerusalem, M. (1995). Generalized selfefficacy scale. Measures in Health Psychology: A user’s portfolio. Causal and control beliefs, 1(1), 35–37.

Scott, J. W., Lin, Y., Ntakiyiruta, G., Mutabazi, Z. A., Davis,

W. A., Morris, M. A., Smink, D. S., Riviello, R., & Yule, S. (2018). Contextual challenges to safe surgery in a resource-limited setting: A multicenter, multiprofessional qualitative study. Annals of Surgery, 267(3), 461–467. https://doi.org/10.1097/SLA.0000000000002193

Shin, S., Park, J.-H., & Bae, S.-H. (2018). Nurse staffing and nurse outcomes: A systematic review and meta-analysis.

Nursing Outlook, 66(3), 273–282. https://doi.org/10.1016/ j.outlook.2017.12.002

Sinclair, S., Norris, J. M., McConnell, S. J., Chochinov, H. M., Hack, T. F., Hagen, N. A., McClement, S., & Bouchal, S. R. (2016). Compassion: A scoping review of the healthcare literature. BMC Palliative Care, 15(1), 1– 16. https://doi.org/10.1186/s12904-016-0080-0

Sumner, J., & Fisher, W. (2016). Is there anything nontrivial about caring in nursing that is rigorously measureable? Journal of Physics: Conference Series, 772(1), 012044-012050). https://doi.org/10.1088/1742-6596/772/ 1/012044

Ugwu, L. I., Enwereuzor, I. K., Fimber, U. S., & Ugwu, D. I. (2017). Nurses’ burnout and counterproductive work behavior in a Nigerian sample: The moderating role of emotional intelligence. International journal of Africa nursing sciences, 7, 106–113.

Wang, L., Shi, Z., Zhang, Y., & Zhang, Z. (2010).

Psychometric properties of the 10-item connor–davidson resilience scale in Chinese earthquake victims. Psychiatry and Clinical Neurosciences, 64(5), 499–504. https://doi. org/10.1111/j.1440-1819.2010.02130.x

Watson, J. (2009). Caring as the essence and science of nursing and health care. O Mundo da Saúde São Paulo, 33(2), 143–149. https://doi.org/10.15343/0104-7809. 200933.2.2

Watson, J. (2016). Watson caring science institute. Health Sciences Library Photograph Collection and Special Collections, University of Colorado, Anschutz Medical Campus; Publications. https://digitalcollections. cuanschutz.edu/search?f%5Bcreator_display_ssim%5D%5 B%5D=Watson,%20Jean

Wei, H., Roberts, P., Strickler, J., & Corbett, R. W. (2019). Nurse leaders’ strategies to foster nurse resilience. Journal of Nursing Management, 27(4), 681–687. https://

doi.org/10.1111/jonm.12736

Woo, T., Ho, R., Tang, A., & Tam, W. (2020). Global prevalence of burnout symptoms among nurses: A systematic review and meta-analysis. Journal of Psychiatric Research, 123, 9–20. https://doi.org/10.1016/j.jpsychires.2019.12.015

Woodhead, E. L., Northrop, L., & Edelstein, B. (2016). Stress, social support, and burnout among long-term care nursing staff. Journal of Applied Gerontology, 35(1), 84– 105. https://doi.org/10.1177/0733464814542465

World Medical Association, W. M. A. (2013). World medical association declaration of Helsinki: Ethical principles for medical research involving human subjects. JAMA, 310(20), 2191–2194. https://doi.org/10.1001/jama.2013. 281053

Yao, Y., Zhao, S., Gao, X., An, Z., Wang, S., Li, H., Li, Y., Gao, L., Lu, L., & Dong, Z. (2018). General self-efficacy modifies the effect of stress on burnout in nurses with different personality types. BMC Health Services Research, 18(1), 667. https://doi.org/10.1186/s12913-

018-3478-y

Author Biographies

Marie Therese Georges, Ph.D., MSN-RN, FNP-BC, received her Ph.D. in nursing in June 2021 from Loma Linda University in Loma Linda, California. She has worked as a Registered Nurse since 1989 and as a Family Nurse Practitioner since 2007 in diverse populations, settings, and states in the US. Her teaching experiences include adjunct faculty and assistant professors at Columbia Union College in Maryland, Florida and Howard University in Washington, D.C.

Lisa R. Roberts, DrPH, MSN-RN, FNP-BC, CHES, FAANP, FAAN is the research director and a professor at Loma Linda University School of Nursing. She teaches in the PhD program and her research addresses health disparities and vulnerable populations.

Elizabeth Johnston Taylor, PhD, RN, FAAN is a professor at the Loma Linda University School of Nursing. She teaches in the doctoral programs and pursues a program of research exploring the intersection of spirituality and nursing.

Jan M. Nick, PhD, RNC-OB, CNE, ANEF, FAAN is a professor at Loma Linda University School of Nursing. She specializes in teaching and researching of informatics, evidence-based practice methodology, the open access movement, and mentoring. She is the director of the Off-campus International MS in Nursing and is lead director for the interdisciplinary LLUH Center for Evidence Synthesis.

Salem Dehom, PhD, MPH is an associate professor at the Loma Linda University School of Nursing. He teaches in the doctoral programs and his current research interests include lifestyle & disease prevention, environmental factors & health outcome, and evidence-based practice in healthcare.

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