Systematic Review nursing burnout
Michelle_Michy
sample.pdf
Int. J. Environ. Res. Public Health 2013, 10, 2214-2240; doi:10.3390/ijerph10062214
International Journal of
Environmental Research and
Public Health ISSN 1660-4601
www.mdpi.com/journal/ijerph
Review
Burnout in Relation to Specific Contributing Factors and Health
Outcomes among Nurses: A Systematic Review
Natasha Khamisa 1,2,
*, Karl Peltzer 3,4,5
and Brian Oldenburg 2,6
1 School of Health Sciences, Department of Public Health, Monash South Africa, 144 Peter Road,
Roodepoort, Johannesburg 1725, South Africa 2 Faculty of Medicine, Nursing and Health Sciences, Monash University, Victoria, Melbourne 3800,
Australia; E-Mail: [email protected] 3 Human Science Research Council, 134 Pretorius Street, Pretoria 0002, South Africa;
E-Mail: [email protected] 4 University of Limpopo, University Street, Turfloop, Sovenga, Polokwane 0727, South Africa
5 ASEAN Institute for Health Development, Mahidol University, Salaya 73170, Thailand
6 Monash Alfred Hospital Campus, Level 3 Burnet Tower, 89 Commercial Road, Melbourne 3004,
Australia
* Author to whom correspondence should be addressed; E-Mail: [email protected];
Tel.: +27-11-950-4450.
Received: 1 March 2013; in revised form: 16 May 2013 / Accepted: 24 May 2013 /
Published: 31 May 2013
Abstract: Nurses have been found to experience higher levels of stress-related burnout
compared to other health care professionals. Despite studies showing that both job
satisfaction and burnout are effects of exposure to stressful working environments, leading
to poor health among nurses, little is known about the causal nature and direction of these
relationships. The aim of this systematic review is to identify published research that has
formally investigated relationships between these variables. Six databases (including
CINAHL, COCHRANE, EMBASE, MEDLINE, PROQUEST and PsyINFO) were
searched for combinations of keywords, a manual search was conducted and an
independent reviewer was asked to cross validate all the electronically identified articles.
Of the eighty five articles that were identified from these databases, twenty one articles
were excluded based on exclusion criteria; hence, a total of seventy articles were included
in the study sample. The majority of identified studies exploring two and three way
relationships (n = 63) were conducted in developed countries. Existing research includes
OPEN ACCESS
Int. J. Environ. Res. Public Health 2013, 10 2215
predominantly cross-sectional studies (n = 68) with only a few longitudinal studies (n = 2);
hence, the evidence base for causality is still very limited. Despite minimal availability of
research concerning the small number of studies to investigate the relationships between
work-related stress, burnout, job satisfaction and the general health of nurses, this review
has identified some contradictory evidence for the role of job satisfaction. This emphasizes
the need for further research towards understanding causality.
Keywords: work related stress; burnout; job satisfaction; general health; staff nurses;
relationship
1. Introduction
Burnout is typically characterised by emotional exhaustion (depletion of emotional resources and
diminution of energy), depersonalization (negative attitudes and feelings as well as insensitivity and a
lack of compassion towards service recipients) and a lack of personal accomplishment (negative
evaluation of one’s work related to feelings of reduced competence) [1,2]. These three characteristics
emphasise the connection between burnout and working with people [3].
Burnout is usually thought of as an individual’s response to prolonged work related stress, which in
turn, impacts on job satisfaction and thereafter, can often affect productivity, performance, turnover
and wellbeing among health care professionals and other kinds of workers [3]. Health care
professionals in general are thought to have a high vulnerability to burnout as a result of experiencing
high levels of emotional strain, owing to stressful working environments exacerbated by sick and
dying patients to whom they provide care [4]. Nurses in particular however, have been found to
experience higher levels of burnout compared to other health care professionals [5,6], owing to the
nature of their work [7,8].
High levels of burnout among nurses have often been attributed to prolonged direct personal contact
of an emotional nature with a large number of patients [4,9,10]. This, amongst other factors such as
prolonged exposure to work related stress as well as low levels of job satisfaction, have also been
recognised as factors contributing to high levels of burnout among nurses [11,12]. Burnout in nurses
has been shown to lead to emotional exhaustion as well as a loss of compassion for others
(depersonalization) and a sense of low personal accomplishment. These experiences can have very
significant implications for the health and wellbeing of nurses [13–15].
Research has confirmed that prolonged exposure to work related stress is associated with burnout [9],
through active interactions between an individual and their working environment. During such
interaction, environmental demands exceeding individual resources may be perceived as stressful and
result in negative outcomes such as low job satisfaction, burnout and illness [16,17]. In nursing, these
demands also include role ambiguity, role conflict, responsibility for others’ lives, work overload, poor
relationships at work, inadequate salaries, lack of opportunities for advancement, a lack of personnel,
patient care, lack of support, staff issues and overtime [10,18,19].
Limited research has identified studies confirming two and three way relationships between work
related stress and job satisfaction [20], work related stress, job satisfaction and burnout [21], as well as
Int. J. Environ. Res. Public Health 2013, 10 2216
work environment and burnout [22] specifically among nurses. However, despite studies showing that
both job satisfaction and burnout are effects of exposure to stressful working environments, leading to
health consequences [23], the nature and direction of these relationships remains ambiguous (Figure 1).
Figure 1. A model illustrating relationships between contributing factors and health
outcomes of burnout among nurses.
For the purpose of this review, general health outcomes are specifically defined as being symptoms
related to anxiety, depression, somatic symptoms and/or social dysfunction [24].
Although it is already known that nurses experience higher levels of burnout compared to other
health care professionals [5,6] and that lack of job satisfaction and burnout result from the effects of
exposure to stressful working environments, leading to poor health among nurses [23], little is known
about the causal nature and direction of these relationships. Therefore, this systematic review aims to
identify those published studies that explore such relationships between work related stress, burnout,
job satisfaction and general health, specifically among nurses, while at the same time, also identifying
important evidence gaps in the published literature. This can provide a strong foundation for further
research in this field as a precursor to conducting controlled evaluations of appropriate intervention
strategies.
The review questions are as follows:
Do existing studies identify the causal nature and direction of relationships between work
related stress, burnout, job satisfaction and general health of nurses?
Do existing studies focus mostly on two and three way relationships between work related
stress, burnout, job satisfaction and general health of nurses?
2. Methods
2.1. Search Strategies
A comprehensive range of search strategies as per the CRD guidelines on EQUATOR were used to
identify relevant published studies. Firstly, all of the major public health, psychology and nursing
Stressors Burnout
Job
Satisfaction
General
Health
Work Related
Stress
Int. J. Environ. Res. Public Health 2013, 10 2217
databases were searched for combinations of keywords such as work related stress, burnout, job
satisfaction, general health, relationship and nurses. These databases consisted of CINAHL Plus,
COCHRANE Library, EMBASE, MEDLINE, PROQUEST and PsycINFO. The second strategy
involved a manual search of various journals including the ISRN Nursing, Journal of Nursing
Management and Journal of Clinical Nursing using the same combinations of keywords mentioned
above. Specific inclusion and exclusion criteria explained below were used to select articles. A third
strategy involving an independent reviewer was also used to cross validate all the electronically
identified articles. The citation for each identified article was saved using a reference program known
as End Note and the full text version was saved in specific folders.
2.2. Inclusion Criteria
This review included studies conducted between 1990 and 2012 that: (a) were published in the
English language; (b) published only in academic and scholarly journals; (c) were openly accessible
and available in full text; (d) were based on empirical studies; (e) measured the relationship between at
least two of the variables (work related stress, burnout, job satisfaction and general health); (f) focused
on studies specifically consisting of nurses as the sample; and (g) focused on nurses working in various
settings (public hospitals, private hospitals, clinics, retirement homes, hospices, mental institutions,
prison institutions in urban and rural areas).
2.3. Exclusion Criteria
This review excluded studies that: (a) involved insufficient details (such as significance of results/
p-values) of the identified relationships between work related stress, burnout, job satisfaction and
general health; (b) included samples consisting of health professionals in general (doctors, nurses,
radiologists, anesthesiologists, social workers); (c) measured different health outcomes beyond the
scope of the review (cardiovascular heart disease, diabetes and hypertension). It is believed that
exclusion based on the above criteria, allowed for the selection of articles with sufficient information
about the method, sample and findings of studies. Selected articles included in this review were
analyzed according to their findings and reported in terms of the relationships between work related
stress, burnout, job satisfaction and general health of nurses.
3. Results
Using the first strategy, a total of eighty five articles meeting the inclusion criteria were
electronically identified from six databases. However, following application of the exclusion criteria,
twenty one of the eighty five articles were excluded leaving sixty four relevant articles. Four additional
articles were identified manually and two by an independent reviewer resulting in a total of 70 articles.
This is illustrated below (Figure 2).
Int. J. Environ. Res. Public Health 2013, 10 2218
Figure 2. A flow chart describing selection of articles using inclusion and exclusion criteria.
Of the 70 identified articles, 64 articles were identified electronically, four articles were identified
manually and two articles were identified by an independent reviewer. Of these 70 identified articles,
majority were from developed countries (26 European studies, 25 North American studies, 12 Asian
studies, four Australian studies, one South African study, one Nigerian study and one East African
study).
3.1. Work Related Stress and Burnout
Ten articles confirming the relationship between work related stress and burnout were identified.
Work environment related stressors such as working place, poor peer relationships, poor nurse patient
relationships, lack of professional recognition or reward [25–27], feedback clarity and supervisor
leadership style [28] were related to one or more burnout dimensions. Work content related stressors
such as nursing role, patient care, job demands [25,26,29], job complexity [28], work overload,
working overtime [30–32], stigma and discrimination while caring for HIV positive patients [29], role
conflict, role insufficiency, role ambiguity were also related to burnout [27,30,33]. Nurses who
reported inadequate communication with doctors about patients as well as fear of not completing tasks
also reported high burnout [34]. A manual search yielded one relevant article, which revealed that
burnout (including all three dimensions) is most frequently associated with recurrent night duty among
nurses [35].
Further details about the method, sample and findings of identified articles are included in Table 1
below.
Int. J. Environ. Res. Public Health 2013, 10 2219
Table 1. Method, sample and findings of identified articles.
Method Sample Findings
Quantitative
(questionnaire
distribution at
conferences and
meetings) [25]
132 nurses (132
women & 22 men)
working in different
wards and clinics
[25]
Working place/nursing role was associated with higher burnout among
practicing nurses compared to those who had a managerial function (as
head nurse, deputy, or mentor) (t = 3.2, p < 0.01) owing to limited
support with complicated treatments, less power, lower status and lack
of variation in roles [25]
Quantitative
(extensive
questionnaire
survey) [26]
1,190 registered
nurses working in 43
public hospitals [26]
Social context related stressors (lack of professional recognition,
professional uncertainty, interpersonal and family conflicts, tension in
professional work relationships as well as tensions in nurse-patient
relationships) were all significantly associated with emotional
exhaustion (β = 0.44, p ≤ 0.01), depersonalization (β = 0.26, p ≤ 0.01)
and personal accomplishment (β = −0.33, p ≤ 0.01).
Job content related stressors including patient care responsibilities, job
demands and role conflict) also had significant relationships with
emotional exhaustion (β = 0.22, p ≤ 0.01), and personal
accomplishment (β = 0.23, p ≤ 0.01) but not with depersonalization
(β = −0.04, p ≥ 0.01) [26]
Quantitative
(questionnaire
distribution and
collection in 2
weeks) [27]
336 nurses (27 male
and 309 female) at
three hospitals
specializing in
acute treatment [27]
Emotional exhaustion positively correlated with qualitative workload
(β = 0.22, p < 0.01), quantitative workload (β = 0.42, p < 0.01) and
conflict with patients (β = 0.19, p < 0.01). Depersonalization was
positively related to conflict with other nursing staff (β = 0.28, p < 0.01),
qualitative workload (β = 0.15, p < 0.05), quantitative workload
(β = 0.19, p < 0.01) and conflict with patients (β = 0.24, p < 0.01) while
being negatively related to nursing role conflict (β = −0.17, p < 0.01).
Personal accomplishment was negatively correlated with qualitative
workload (β = −0.21, p < 0.01) and quantitative workload (β = −0.19,
p < 0.01) while being positively correlated with nursing role conflict
(β = 0.25, p < 0.01) [27]
Quantitative
(questionnaire
distribution with
reminders to non
responders [28]
492 nurses from
long stay wards at 5
psychiatric hospitals
[28]
Work environment stressors such as job complexity, feedback/clarity,
the level of performance of the patient group and social leadership style
explained 16% (adjusted R²) of the variance in emotional exhaustion.
Job complexity, feedback/clarity and social leadership style explained
12% of the variance in depersonalization. 11% of the variance in
personal accomplishment was explained by feedback/clarity and job
complexity [28]
Quantitative and
Qualitative (All
nurses received
questionnaires
with 5 being
selected to
participate in a
semi-structured
interview) [29]
30 community
clinical HIV/AIDS
nurse specialists [29]
Significant correlations were found between emotional exhaustion and
grief/loss (τ = 0.58, p < 0.05), emotional exhaustion and loss
tolerance/peer relationship (τ = 0.41, p < 0.05), personal
accomplishment and social recognition/reward (τ = 0.40, p < 0.05).
A weak but significant relationship was found between emotional
exhaustion and stigma/discrimination (τ = 0.29, p < 0.05). Qualitative
findings indicated that death of a patient and stigma/grief were related
to burnout [29]
Int. J. Environ. Res. Public Health 2013, 10 2220
Table 1. Cont.
Method Sample Findings
Quantitative
(questionnaire
distribution and
completion at 2
time points) [30]
98 nurses attending a
post-work course
towards a licentiate
degree [30]
Amount of variance explained increased (ΔR² = 0.14, p < 0.001)
when work related stressors were entered into the burnout model.
Work overload was the only stressor that significantly predicted
emotional exhaustion (β = 0.35, p < 0.01). Experience with pain and
death significantly predicted depersonalization (β = −0.38, p < 0.001)
and role ambiguity (β = 0.32, p < 0.05) while lack of cohesion
(β = 0.24, p < 0.05) significantly predicted the lack of personal
accomplishment [30]
Quantitative
(Questionnaires
posted to
members of the
Association of
Nurses in AIDs
Care) [31]
445 nurses providing
care to people living
with HIV/AIDS [31]
Findings confirmed association between perceived workload (hours
worked and amount of work) and burnout (r = 0.24, p < 0.01).
Workload accounted for 5.6% of the variance in burnout [31]
Quantitative
(questionnaire
packages were
mailed to nurses)
[32]
574 Australian
Nursing Federation
members [32]
Generally, working overtime was positively related to higher
emotional exhaustion (r = 0.21, p < 0.05). Being pressured or
expected to work overtime (involuntarily) was related to higher
emotional exhaustion (r = 0.41, p < 0.05) and depersonalization
(r = 0.22, p < 0.05); while working unpaid overtime was also
associated with higher emotional exhaustion (r = 0.13, p < 0.05) [32]
Quantitative
(questionnaire
distribution by
nominated
coordinator at
each hospital)
[33]
495 nurses from three
provincial hospitals
[33]
Role insufficiency was significantly related to exhaustion (r = 0.38,
p < 0.05), cynicism (r = 0.39, p < 0.05) and professional efficacy
(r = 0.28, p < .05). Role ambiguity was significantly related to
exhaustion (r = 0.20, p < 0.05), cynicism (r = 0.28, p < 0.05) and
professional efficacy (r = 0.27, p < 0.05). Role boundary was
significantly related to exhaustion (r = 0.29, p < 0.05), cynicism
(r = 0.34, p < 0.05) and professional efficacy (r = 0.21, p < 0.05).
Responsibility, physical environment, and role overload are all
significantly related to exhaustion (r = 0.33, p < 0.05, r = 0.31,
p < 0.05, r = 0.42, p < 0.05 respectively) and cynicism (r = 0.28,
p < 0.05, r = 0.20, p < 0.05, r = 0.30, p < 0.05 respectively) [33]
Quantitative
(questionnaire
distribution via
the hospital’s
internal mail
system) [34]
101 registered nurses,
employed at a major
specialist oncology
metropolitan hospital
[34]
Significant correlations were found between nursing stressors (lack
of support, poor communication with doctors) and emotional
exhaustion (r = 0.48, p < 0.01) as well as depersonalization (r = 0.34,
p < 0.01), but not personal accomplishment [34]
Quantitative
(questionnaire
distribution after
receiving
consent) [35]
292 nurses working at
a state hospital [35]
Doctor/nurse conflict (OR = 3.1; 95% CI, 1.9–6.3), low doctor/nurse
ratio (OR = 6.1; 95% CI, 2.5–13.2), inadequate nursing personnel
(OR = 2.6; 95% CI, 1.5–5.1) and too frequent night duties (OR = 3.1;
95% CI, 1.7–5.6) were significant predictors of emotional exhaustion.
Doctor/nurse conflict (OR = 3.4; 95% CI, 2.2–7.6), low doctor/nurse
ratio (OR = 2.4; 95% CI, 1.4– 4.1), and too frequent night duties
(OR = 2.4; 95% CI, 1.5– 4.8) significantly predicted depersonalization.
High nursing hierarchy (OR = 2.7; 95% CI, 1.5–4.8), poor wages
(OR = 2.9; 95% CI, 1.6–5.6) and too frequent night duties (OR = 2.3;
95% CI, 2.3–4.5) significantly predicted reduced personal
accomplishment [35]
Int. J. Environ. Res. Public Health 2013, 10 2221
3.2. Work Related Stress and Job Satisfaction
Sixteen articles confirming the relationship between work related stress and job satisfaction
were found. Work related stressors including pay, task requirements, well maintained up to date
resources [36–38], physical work environment [39], autonomy [40–42], peer relationships, cohesion,
feedback [40,41,43], workload, control over practice [44,45] patient outcomes and supervisor
support [36,41] recognition, independence, responsibility, authority [46], meaningfulness of work, nurse
centered communication involving humor and clarity [47], role stress [48] as well as overtime [38,41]
were related to job satisfaction. It has also been found that the interaction between workload and
autonomy best predicts job satisfaction [44]. A common conclusion was that work related stress is
significantly related to job satisfaction [49,50] and nurses who experience higher stress levels are less
satisfied with their jobs [51]. Further details about the method, sample and findings of identified articles
are included in Table 2 below.
Table 2. Method, sample and findings of identified articles.
Method Sample Findings
Qualitative (interviews,
observations and field
notes) [36]
8 nurses
selected from a
local nursing
agency [36]
Thematic analysis revealed that nurses were most satisfied with
compensation (patient outcomes, compliments, salary, incentives and
lessons learned), team spirit (working together and sharing duties),
strong support from physicians and advocacy (assisting and supporting
new nurses) [36]
Quantitative
(questionnaires were
sent out with each
nurses’ paycheck) [37]
249 nurses
employed at a
children’s
hospital [37]
In general job stress was found to be significantly associated with job
satisfaction (r = 0.64, p < 0.05). Pay (r = 0.40, p < 0.05, r = 0.43,
p < 0.05), interaction/cohesion (r = 0.44, p < 0.05, r = .41, p < 0.05) and
task requirements (r = 0.53, p < 0.05, r = 0.67, p < 0.05) were
significantly associated with both job stress and job satisfaction
respectively [37]
Quantitative
(questionnaires were
mailed to nurses) [38]
944 RN’s
working in rural
and remote
hospital settings
[38]
Workplace stressors explained 32% of the variance in job satisfaction.
Having available, well maintained and up-to-date equipment and
supplies was highly related to job satisfaction, accounting for 17% of
the total variance. Greater scheduling and shift satisfaction (no
overtime) as well as lower psychological job demands (fewer time
constraints, less excessive workloads) were strong predictors of job
satisfaction (accounting for 12% of the variance) [38]
Quantitative (survey
packets with
instructions were placed
in staff mailboxes) [39]
116 medical-
surgical nurses
working in
acute-care
settings [39]
Only one environmental factor, noise, was significantly associated with
perceived stress (r = −0.18, p = 0.05). Perceived stress was directly
related to job satisfaction (r = 0.55, p = 0.00) [39]
Quantitative (survey
distribution via the
hospital’s internal mail)
[40]
135 nurses
employed in a
170 bed hospital
[40]
Work content stressors including variety, autonomy, task identity and
feedback are all strongly correlated with job satisfaction (r = 0.35–0.50,
p < 0.001). Work environment stressors including collaboration with
medical staff and cohesion among nurses are also strongly correlated
with job satisfaction (r = 0.37–0.45, p < 0.001). Job satisfaction was
mostly predicted by variety, feedback and collaboration with medical
staff (r = 0.55, R² = 0.30) [40]
Int. J. Environ. Res. Public Health 2013, 10 2222
Table 2. Cont.
Method Sample Findings
Quantitative (E-mails
containing a $5 e-mail
gift certificate and a
web link to the survey
instrument were sent.
Reminder e-mails were
sent to non responders)
[41]
362 registered
nurses in a large
metropolitan
hospital [41]
Job satisfaction was positively and significantly correlated with
physical work environment (r = 0.26, p < 0.01). Significant positive
predictors of job satisfaction from the baseline model were autonomy
(β = 0.09, p < 0.05), supervisor support (β = 0.05, p < 0.05),
workgroup cohesion (β = 0.09, p < 0.05), working in a unit other than
the intensive care unit (β = 0.67, p < 0.05), working in a step-down
unit or general medical surgical unit (β = 0.31, p < 0.05), and number
of hours of voluntary overtime worked in a typical work week
(β = 0.05, p < 0.05). A negative significant predictor was working a
12-hour shift (β = −0.83, p < 0.05) [41]
Quantitative
(questionnaire
distribution through the
nurse manager of each
unit) [42]
431 critical care
nurses, all of whom
were RN’s working
at 16 different
hospitals [42]
Professional autonomy had a moderate positive correlation with
reported role conflict and role ambiguity (r = 0.33, p < 0.001).
A positive moderate correlation between professional autonomy and
job satisfaction was found (r = 0.33, p < 0.001) [42]
Quantitative
(anonymous
questionnaire
distribution) [43]
117 Registered
Nurses (77 Army
RNs – 40 Civilian
RNs) [43]
Work related stress was inversely correlated with job satisfaction for
both civilian (r = −0.32, p < 0.05) and army (r = −0.23, p < 0.05)
nurses. Army nurses were most stressed and least satisfied by their
working relations with colleagues (r = −0.40, p < 0.01), while civilian
nurses were most stressed and least satisfied with their physical
working environments (r = 0.32, p < 0.05) [43]
Quantitative
(participants were
invited by e-mail to
attend a one-day event
where they completed
surveys) [44]
271 public health
nurses [44]
Control-over-practice (x² = 7.22, p = 0.01; OR = 1.01, 95% CI 1.00–1.02)
and workload (x² = 15.04, p < 0.01; OR = 0.90, 95% CI 0.86–0.95)
significantly predicted job satisfaction.
The strongest association was found between workload and job
satisfaction, whereby a one-unit increase on the work overload scale
decreased the odds of job satisfaction by nearly 10%. The interaction
between autonomy and workload was a significant predictor of job
satisfaction (x² = 15.87, p < 0.01) [44]
Quantitative (voluntary
completion of
standardized
questionnaires) [45]
129 qualified nurses
[45]
Results showed that workload was the highest perceived stressor in
the nurses’ working environment (M = 1.61, SD ± 0.88). Nursing
stress was found to be negatively and significantly correlated with job
satisfaction (r = −0.22, p < 0.05). Nurse stress predictor variables
combined accounted for 17% of the variance in job satisfaction
(R² = 0.17, F (3, 123) = 8.9, p < 0.001) [45]
Quantitative
(distribution of
questionnaire packets)
[46]
140 registered
nurses from
medical-surgical,
management and
home health nursing
specialties [46]
There was a significantly positive correlation between job satisfaction
and perceived autonomy (r = 0.538, p < 0.05) [46]
Quantitative (surveys
were made available in
each unit and were also
distributed to nurses
during unit meetings
with incentives) [47]
205 nurses
employed at a at a
large women and
children’s hospital
[47]
Nurses’ perceptions of physicians’ nurse centered communication was
significantly related to job satisfaction (r = 0.23, p = 0.002).
Physicians’ nurse centered communication behaviors examined as
predictors of nurses’ reported job satisfaction revealed a significant
model (F (5, 160) = 3.86, R² = 0.11, p = 0.003, with humor and clarity
being the most significant predictors of job satisfaction). Work
environment, meaningfulness of work, and stress also significantly
predicted job satisfaction in another model (F (7, 188) = 27.40,
R² = 0.51, p = 0.001) [47]
Quantitative
(anonymous
questionnaire
distribution and
collection) [48]
532 nurses with job
rotation experience
[48]
Structural equation modeling revealed a negative relationship between
role stress and job satisfaction (γ = 0.52, p < 0.01) [48]
Int. J. Environ. Res. Public Health 2013, 10 2223
Table 2. Cont.
Method Sample Findings
Quantitative (survey
distribution by nurse
managers. Follow up
surveys were
redistributed after 2
weeks to boost
response rate) [49]
287 registered nurses
employed in state
prison health care
facilities [49]
The nursing stress score was the strongest explanatory variable,
accounting for 30.3% of the variance in job satisfaction. An inverse
relationship between nursing stress and job satisfaction was confirmed
(β = −0.55, p < 0.01) [49]
Quantitative
(questionnaire
distribution by
graduate students and
administrative staff to
nurses’ onsite
mailboxes) [50]
464 RNs employed in
five acute care
hospitals [50]
Work related stress (including personal stressors (r = −0.11, p < 0.05)
as well as situational stressors (r = −0.30, p < 0.05)) were negatively
correlated with job satisfaction. Regression analysis further confirmed
that work related stress (personal stressors (R² = 0.29, p < 0.05) as
well as situational stressors (R² = 0.29, p < 0.05)) is a significant
predictor of job satisfaction [50]
Quantitative
(questionnaire
distribution by nurse
administrators)
285 nurses from six
hospitals
The strongest association was found between job related stress and job
satisfaction, which were inversely related (rs = −0.331, p < 0.05).
It was concluded that nurses who experience higher stress levels are
less satisfied with their jobs.
3.3. Work Related Stress and General Health
Six articles confirmed the relationship between work related stress and general health of nurses.
The frequency of exposure to stressful situations including emotionally provoking tasks and a lack of
social support from peers were related to psychosomatic health complaints [52]. Nurses with work
overload and negatively perceived health status reported higher occurrence of headaches [53].
Furthermore, high job demands, low job control and lack of social support at work were related to mental
distress even after controlling for age, smoking, alcohol consumption and physical activity [54]. Other
work stressors related to physical and mental health include physician conflict and nurse conflict,
negative patient outcomes, treatment uncertainty and inadequate preparation [55]. In general, work
related stress is negatively related to psychological wellbeing [56] and poor health [57] among nurses.
Further details about the method, sample and findings of identified articles are included in Table 3
below.
Table 3. Method, sample and findings of identified articles.
Method Sample Findings
Quantitative
(distribution of self
administered
questionnaires) [52]
420 registered nurses and
student nurses from public
hospitals [52]
The frequency of stressful situations and emotionally
provoking problems as well as the lack of social support from
peers were the only factors significantly associated with
psychosomatic health complaints among registered nurses
(R² = 0.11, p < 0.01) and student nurses (R² = 0.06, p < 0.05),
after controlling for other variables [52]
Quantitative and
qualitative (distribution
of questionnaires and
interviews by a
neurologist) [53]
779 nursing staff at a
tertiary medical center [53]
Work overload (M = 3.32, SD ± 0.74, p < 0.001) and health
status (M = 2, SD ± 1.16, p < 0.001) were the most significant
stressors among headache sufferers [53]
Int. J. Environ. Res. Public Health 2013, 10 2224
Table 3. Cont.
Method Sample Findings
Quantitative
(questionnaire
distribution at an event)
[54]
372 community nurses
[54]
High job demands (OR = 2.15; 95% CI, 1.07–4.30), low job
control (OR = 1.22; 95% CI, 0.64–2.31) and job strain/low
social support at work (OR = 3.78; 95% CI, 2.08–6.87) were
related to mental distress. In conclusion, mental distress
among the nurses is associated with occupational stress
elicited by adverse psychosocial job characteristics [54]
Quantitative
(questionnaire packets
distributed by head
nurse for each unit)
[55]
480 hospital nurses from
five hospitals in three
major cities [55]
The most frequently occurring workplace stressor was
workload (M = 9.18, SD ± 3.93). Work place stressors
including workload (r = −0.21, p < 0.01, r = −0.30, p < 0.01),
physician conflict (r = −0.24, p < 0.01, r = −0.25, p < 0.01),
death/dying (r = −0.18, p < 0.01, r = −0.17, p < 0.01), nurse
conflict (r = −0.27, p < 0.01, r = −0.28, p < 0.01), lack of
support (r = −0.11, p < 0.01, r = −0.14, p < 0.01), inadequate
preparation (r = −0.17, p < 0.01, r = −0.23, p < 0.01) and
treatment uncertainty (r = −0.25, p < 0.01, r = −0.26,
p < 0.01) were all significantly correlated with physical and
mental health respectively. Work place stress is related to
physical and mental health [55]
Quantitative
(questionnaire
distribution by
principal nursing
officers in each unit)
[56]
1,043 nurses of different
grades/ranks/departments
[56]
Work stress was found to be negatively related to
psychological well-being of the nurses, with stronger effects
on anxiety and depression (r = −0.44, p < 0.001) [56]
Quantitative (online
surveys with email
reminders to non
responders) [57]
3,132 registered nurses
from five multi-state
settings [57]
Perceived work stress levels was confirmed as a strong
predictor of poor health among nurses (OR = 1.09;
95% CI, 1.05–1.13) [57]
3.4. Work Related Stress, Burnout and Job Satisfaction
Nine articles confirmed the relationship between work related stress, burnout and job satisfaction.
Nurses providing direct care while working in poor environments report higher burnout and lower job
satisfaction [58]. It has also been found that improving working environments reduced job
dissatisfaction and burnout among nurses [59]. Poor relations with physicians, difficulty meeting
patients’ needs, high workload and low job satisfaction are all related to burnout [60]. Nurse staffing
was also found to be related to job satisfaction and burnout [61], with increased patient to nurse ratios
relating to higher burnout and lower job satisfaction [62] following an increase in the ratio by one
patient per nurse [7].
Although work related stressors including nurse physician relationships, management styles and
organizational support were found to be related to burnout and job satisfaction [63], further analysis
indicated that work related stress is linked to job satisfaction through burnout [64].
These findings suggest that burnout plays a mediating role in the relationship between work related
stress and job satisfaction. Furthermore, work related stress and burnout were not only associated with
job satisfaction, but were strongly predictive [65].
Int. J. Environ. Res. Public Health 2013, 10 2225
A manual search led to the identification of an additional article confirming that work related stress,
burnout and job satisfaction among nurses are significantly related [66]. Further details about the
method, sample and findings of identified articles are included in Table 4 below.
Table 4. Method, sample and findings of identified articles.
Method Sample Findings
Quantitative (nurses were
sent surveys at their home
mailing address) [58]
95,499 nurses from
614 hospitals in
four states [58]
Nurses providing direct care for patients reported higher burnout
(94%) and job dissatisfaction (64%). A third of nurses working in
poor environments were dissatisfied with their jobs. Nurses who were
satisfied with their jobs were twice as high for those working in better
environments. It was concluded that nursing roles and working
environments affect burnout and job satisfaction among nurses [58]
Quantitative (Surveys were
delivered to nurses by nurse
managers) [59]
1,104 bedside
nurses in 89
medical, surgical
and intensive care
units at 21 hospitals
[59]
Improving the work environments of nurses (from poor to better) was
associated with a 50% decrease in job dissatisfaction and a 33%
decrease in burnout. The chances of higher burnout and job
dissatisfaction were lower among nurses working in good
environments than those working in poor environments, by OR = 0.67
and 0.50, respectively. Nurses working in poor environments were
1.5 and 2 times more likely than those working in good environments
to experience burnout and job dissatisfaction [59]
Quantitative (the
questionnaires were hand
delivered to participants and
collected within a week)
[60]
60 nurses from 3
hospitals [60]
Non satisfactory relations with physicians (M = 30.2, SD ± 6.6,
M = 10.8, SD ± 4.8, M = 25.9, SD ± 10) and high difficulty in
meeting patient care needs (M = 32.8, SD ± 6, M = 12.2, SD ± 5.1,
M = 25.3, SD ± 11.7) as well as low work satisfaction (M = 27.5,
SD ± 8, M = 9.3, SD ± 4.5, M = 28.1, SD ± 10.6) were all
significantly associated with higher emotional exhaustion, and
depersonalization as well as low personal accomplishment
respectively. High nursing workload (M = 17.2, SD ± 7.1, M = 35.3,
SD ± 8.2) was associated with higher emotional exhaustion and
depersonalization respectively [60]
Quantitative (questionnaire
distribution and return in
sealed envelopes) [61]
1,365 nurses from
65 intensive care
units at 22 hospitals
[61]
Perceived adequate staffing was related to decreases in the odds
of dissatisfaction (OR = 0.30; 95% CI, 0.23–0.40) and burnout
(OR = 0.50; 95% CI, 0.34–0.73) [61]
Quantitative (questionnaires
were distributed through the
hospitals internal mail
systems [62]
5,006 English
nurses and 3773
Scottish nurses [62]
Significant relationships were confirmed between nurse staffing
(nurse to patient ratio) and burnout (odds ratios for burnout increased
from 0.57 to 0.67 to 0.80 to 1.00 as the number of patients a nurse
was responsible for increased from 0–4 to 5–8 to 9–12 to 13 or
greater). The relationship between nurse staffing and job
dissatisfaction was also significant (OR = 0.81; 95% CI, 0.71–0.93)
[62]
Quantitative (nurses were
invited to voluntarily
complete questionnaires
distributed by an assigned
person) [63]
401 staff nurses
across 31 units in
two hospitals [63]
The improved model confirmed the mediating role of burnout
(depersonalization and personal accomplishment) in the relationship
between nurse practice environment related stress (nurse-physician
relationship, nurse management, hospital management and
organizational support,) and job outcomes (including job satisfaction)
(x² = 548.1; d.f. = 313; p < 0.001; CFI = 0.906; IFI = 0.903; RMSEA = 043) [63]
Int. J. Environ. Res. Public Health 2013, 10 2226
Table 4. Cont.
Method Sample Findings
Quantitative (nurses were
invited to voluntarily complete
questionnaires distributed by
an assigned person) [64]
155 medical,
surgical and surgical
intensive care unit
nurses across 13
units in three
hospitals [64]
Nurse–physician relations had a significant positive association
with nurse job satisfaction (OR = 7.7; 95% CI, 2.6–22.7) and
personal accomplishment (OR = 3.5, S.E. ± 0.8), nurse
management at the unit level had a significant positive
association with the nurse job satisfaction (OR = 3.6; 95% CI,
1.3–10) and personal accomplishment (OR = 2.7, S.E. ± 0.1.1),
hospital management and organizational support had a significant
positive association with personal accomplishment (OR = 2.1,
S.E. ± 1). Nurse–physician relations (OR = −3.9, S.E. ± 1.2) and
nurse management (OR = −3.6, S.E. ± 1.6) had a significant
negative association with emotional exhaustion, while hospital
management and organizational support had a significant
negative association with depersonalization (OR = −2.0,
S.E. ± 0.8) [64]
Quantitative (nurses were
invited to voluntarily complete
questionnaires) [65]
546 staff nurses
from 42 units in four
hospitals [65]
Emotional exhaustion is the strongest predictor of job satisfaction
(OR = 0.89, 95% CI 0.85–0.94). Positive ratings on the nurse
work practice environment dimensions including nurse-physician
relations (Slope = −4, SE ± 0.7, Slope = −1.3, SE ± .4, Slope = 2.2,
SE ± 0.5), nurse management (Slope = −8.5, SE ± 1.2, Slope = −3.1,
SE ± 0.6, Slope = 4.32, SE ± 0.8) as well as hospital management
and organizational support (Slope = −9.5, SE ± 1.1, Slope = −3.9,
SE ± 0.6, Slope = 4.7, SE ± 0.8) were significantly correlated
with lower emotional exhaustion and depersonalization as well as
high personal accomplishment respectively.
Hospital management and organizational support is significantly
associated with job satisfaction (OR = 10.7, 95% CI 3.1–37) [65]
Quantitative (fieldworkers
appointed by hospital
management for private
hospitals and by the affiliated
university for public hospitals
were
trained to distribute and collect
questionnaires) [66]
935 registered nurses
working in critical
care units of selected
private and public
hospitals [66]
Significant correlations were found for all the subscales of the
practice environment (including nurse manager leadership, ability
and support, nurse physician relations, staffing and resource
adequacy, nurse participation in hospital affairs) with job
satisfaction (rs = 0.30 to .65, p < 0.01) and burnout (rs = −0.41 to
0.26, p < 0.01). Job satisfaction was also significantly associated
with burnout (rs = −0.46 to 0.23, p < 0.01) [66]
Quantitative (surveys were
mailed to nurses who were
members of the Board of
Nursing) [7]
10,184 staff nurses
providing adult acute
care at 210 general
hospitals [7]
An increase of one patient per nurse was found to increase
burnout by 1.23 (95% CI, 1.13–1.34) and job dissatisfaction by
1.15 (95% CI, 1.07–1.25) confirming an association between
these variables. Nurses working in hospitals with 1:8 patient
ratios were found to be 2.29 times more likely to experience
burnout and 1.75 times more likely to be dissatisfied with their
jobs.
Lower staffing increases the likelihood of nurses experiencing
burnout and job dissatisfaction [7]
Int. J. Environ. Res. Public Health 2013, 10 2227
3.5. Work Related Stress, Burnout and General Health
Six articles confirmed the relationship between work related stress, burnout and general health.
Anxiety, depression and somatization are linked to work related stress and burnout [67]. Specific
stressors such as higher physical and emotional demands [68] as well as work overload, role stress,
hostility with physicians and patients are directly and indirectly related to burnout and psychosomatic
complaints [69]. In another study, physical tiredness, working with demanding patients, losing a
patient, lack of free time and burnout were also found to be related [70]. Further analysis indicated that
burnout plays an intervening role in the relationship between work related stress and health [71]. This
was supported, in that, work related stress has been found to be indirectly related to burnout, which
was directly related to the health of nurses [72].
Additionally, an article identified by an independent reviewer confirmed that work related stress is
significantly related to burnout and mental health [73]. Further details about the method, sample and
findings of identified articles are included in Table 5 below.
Table 5. Method, sample and findings of identified articles.
Method Sample Findings
Quantitative (distribution
of survey packets by
head nurses/charge
nurses) [67]
237 paid staff nurses
employed on 18 units
in 7 hospitals [67]
More health complaints (anxiety, depression and somatization) were
associated with higher work related stress and emotional exhaustion
(rs = 0.21 to .42, p < 0.001). Work related stress, burnout and health
are related [67]
Quantitative
(questionnaires were sent
to nurses’ home address)
[68]
69 nurses from a
nursing home [68]
High physical demands had adverse effects on physical complaints
(β = 0.2, SE ± 0.1) and emotional demands affected emotional
exhaustion (β = 0.4, SE ± 0.1) [68]
Quantitative (self
reported questionnaire
distribution) [69]
1,636 unionized
registered nurses
(RNs) working in the
public health care
sector [69]
Demands including overload (γ = 0.57, p < 0.001), role stress (γ = 0.08,
p < 0.05), hostility with physicians (γ = 0.12, p < 0.001) and hostility
with patients (γ = 0.11, p < 0.01) are the most significantly important
determinants of emotional exhaustion which indirectly affect
depersonalization via emotional exhaustion (γ = 0.36, p < 0.001).
Emotional exhaustion (γ = 0.71, p < 0.001) and depersonalization
(γ = 0.22, p < 0.001) are significantly associated with psychosomatic
complaints [69]
Quantitative (All of the
centers were sent
questionnaires for each
one of their nurses) [70]
229 professional
nurses from medical
centers [70]
High emotional exhaustion was found to be directly associated with
physical tiredness (OR = 2.01; 95% CI, 1.12–3.61) and health
(OR = 1.47; 95% CI, 1.32–1.63). High depersonalization was found
to be associated with health (OR = 1.17, 95% CI 1.07–1.28). Low
personal accomplishment was found to be inversely related to losing a
patient (OR = 0.46; 95% CI, 0.22–0.97) and lack of free time
(OR = 0.43, 95% CI, 0.20–0.93).
Physical tiredness and working with demanding patients are
associated with burnout. Burnout is associated with poor health [70]
Int. J. Environ. Res. Public Health 2013, 10 2228
Table 5. Cont.
Method Sample Findings
Quantitative
(questionnaires were
sent to nurses) [71]
297 nurses at a
large university
hospital [71]
Nursing stress was directly associated with burnout as well as health
(affective and physical symptoms), whereby nursing stress predicted
burnout which predicted affect and physical symptoms (x² = (3, n = 259) =
19.07 (RMSR = 0.05, CFI = 0.92). Burnout was confirmed as an intervening
variable between work stress and affective and physical symptomatology
(x² = (1, n = 259) = 5.45 (RMSR = 0.01, CFI = 0.98) [71]
Quantitative
(questionnaire
distribution by nurse
managers) [72]
126 registered
nurses were
recruited from
area hospitals
[72]
Emotional exhaustion (R 2 = −0.407; p < 0.0001) and depersonalization
(R 2 = −0.034; p < 0.05) were inversely predictive of health outcomes
whereas personal accomplishment (R 2 = 0.03; p < 0.05) was positively
predictive of health outcomes. Work stress is indirectly related to burnout
(through mediation by hardiness) and burnout is directly related to health
outcomes [72]
Quantitative
(questionnaire
distribution followed
by reminders) [73]
1,891 nurses
from 6 acute care
hospitals [73]
Work stress was significantly associated with burnout (OR = 5.77; 95% CI,
3.92–8.5) and mental health (OR = 2.34; 95% CI, 1.62–3.36) [73]
3.6. Work Related Stress, Job Satisfaction and General Health
Six articles confirmed the relationship between work related stress, job satisfaction and general
health. Work related stressors including job complexity, feedback/clarity, leadership styles,
opportunities for promotion and growth, autonomy, workload [74–76], relations with the head nurse,
peers and physicians, job conflict, cooperation, expectations and demands, development and
motivation are related to job satisfaction and health complaints [77,78]. Contrary to this, other findings
suggest that higher stress levels among nurses were associated with more health complaints but not
with job satisfaction [79].
An additional article identified by an independent reviewer revealed that work related stressors are
associated with job satisfaction and psychosomatic complaints among nurses [80]. Further details
about the method, sample and findings of identified articles are included in Table 6 below.
Table 6. Method, sample and findings of identified articles.
Method Sample Findings
Quantitative
(questionnaire
distribution to nurses)
[74]
475 senior nurses
[74]
Stressors accounted for the largest portion of the variance explaining job
satisfaction (career stress = 22% and organizational stress = 3%). Job
stress was found to be significantly predictive of job satisfaction
(F (6, 468) = 31.8, p < 0.001). Only stress associated with workload was
found to be a predictor of mental health (accounting for 4% of the
variance) [74]
Quantitative
(questionnaire
distribution to nurses)
[75]
561 trained staff
nurses from 16
randomly chosen
hospitals [75]
Various work dimensions such as job complexity, feedback/clarity, work
pressure, autonomy, promotion/growth as well as supervisors’ leadership
style are related to job satisfaction (r = 0.18–0.61, p < 0.01) and health
complaints (r = 0.20–0.34, p < 0.01). 59% and 20% of variance in job
satisfaction and health complaints is explained by the selected predictors
(work dimensions) [75]
Int. J. Environ. Res. Public Health 2013, 10 2229
Table 6. Cont.
Method Sample Findings
Quantitative
(questionnaire
distribution to nurses)
[74]
475 senior nurses
[74]
Stressors accounted for the largest portion of the variance explaining job
satisfaction (career stress = 22% and organizational stress = 3%). Job
stress was found to be significantly predictive of job satisfaction
(F (6, 468) = 31.8, p < 0.001). Only stress associated with workload was
found to be a predictor of mental health (accounting for 4% of the
variance) [74]
Quantitative
(questionnaire
distribution to nurses)
[75]
56l trained staff
nurses from 16
randomly chosen
hospitals [75]
Various work dimensions such as job complexity, feedback/clarity, work
pressure, autonomy, promotion/growth as well as supervisors’ leadership
style are related to job satisfaction (r = 0.18–0.61, p < 0.01) and health
complaints (r = 0.20–0.34, p < 0.01). 59% and 20% of variance in job
satisfaction and health complaints is explained by the selected predictors
(work dimensions) [75]
Quantitative
(following invitation
and awareness
questionnaires were
distributed) [76]
155 nurses from
nine units in two
general hospitals
[76]
Autonomy and workload are significantly associated with job satisfaction
(r = 0.46, p < 0.01 and r = −0.33, p < 0.01, respectively) and health
complaints (r = −0.17, p < 0.05 and r = 0.25, p < 0.01, respectively). The
correlation between complexity of care and job satisfaction was no longer
significant (p = 0.38) when workload was corrected for. Workload
mediates the relationship between complexity and job satisfaction [76]
(Quantitative
(questionnaire
distribution for
completion at own
convenience) [77]
376 female hospital
nurses working full
time at an urban
university teaching
hospital [77]
In descending order, perceived relations with the head nurse (β = 0.24,
p ≤ 0.001), job conflict (β = −0.19, p ≤ 0.001), relations with coworkers
(β = 0.17, p ≤ 0.01), relations with physicians (β = 0.15, p ≤ 0.01), and
other units/departments (β = 0.13, p ≤ 0.01) were significant predictors of
job satisfaction. Job conflict (β = 0.12, p ≤ 0.05), along with the relations
with the head nurse (β = −0.12, p ≤ 0.05) and physicians (β = 0.09,
p ≤ 0.05), were predictors of psychological distress.
The relations with the head nurse and physicians as well as job conflict,
were predictors of both satisfaction and health [77]
Quantitative
(questionnaire
distribution) [78]
299 staff working
in different forms
of elderly care [78]
Stressors including workload, cooperation, age, expectations and
demands, personal development and internal motivation explained 41% of
the variance in perceived stress symptoms. Job satisfaction was positively
and significantly associated with perceived stress symptoms including
sleep disturbance, depression, headaches and stomach disorders. This
model was significant (F(6/280) = 32.54, p < 0.001) [78]
Quantitative (self
administered
questionnaire
distribution) [79]
218 female nurses
from public
hospitals [79]
Nurses with the highest level of stress reported significantly higher
frequency of tension headache (32.4%, p < 0.001), back-pain (30.1%,
p < 0.05), sleeping problems (37%, p < 0.001), chronic fatigue (59.5%,
p < 0.001), stomach acidity (31.5%, p < 0.01) and palpitations (32.4%,
p < 0.01).
The frequency of psychosomatic symptoms is an indicator of nurse related
stress. No relationship was confirmed between job satisfaction and stress
[79]
Quantitative
(distribution of self
administered
structured surveys)
[80]
254 nurses working
in 15 emergency
departments of
general hospitals
[80]
Work-time demands were found to be important determinants of
psychosomatic complaints (β = −0.31, p < 0.001) and fatigue (β = −0.21,
p < 0.01) in emergency nurses. Decision authority (β = 0.138, p < 0.05),
skill discretion (β = 0.17, p < 0.01), perceived reward (β = 0.25, p < 0.001)
and social support by colleagues (β = 0.16, p < 0.01) were found to be
strong determinants of job satisfaction. Work related stress explained 21%
of the variance in psychosomatic complaints and 34% variance in job
satisfaction [80]
Int. J. Environ. Res. Public Health 2013, 10 2230
3.7. Burnout and Job Satisfaction
Only one article confirming the relationship between burnout and job satisfaction was identified.
It has been found that a two factor model including burnout and job satisfaction was a better fit
providing evidence of a negative association between job satisfaction (particularly with supervisors
and coworkers) and burnout [81].
Following a manual search, an additional article confirmed that job satisfaction is a significant
predictor of burnout among nurses [11]. Further details about the method, sample and findings of
identified articles are included in Table 7 below.
Table 7. Method, sample and findings of identified articles.
Method Sample Findings
Quantitative
(questionnaire
distribution by
administrative
officer) [81]
248 nurses
from five
hospitals [81]
Satisfaction with supervisors and coworkers was significantly negatively
associated with emotional exhaustion (r = −0.50, p < 0.01 and r = −0.34, p < 0.01,
respectively) and depersonalization (r = −0.41, p < 0.01 and r = −0.29, p < 0.01,
respectively) while being positively correlated with personal accomplishment
(r = 0.19, p < 0.01 and r = 0.19, p < 0.01, respectively). This two-factor model
compared to the single-factor model was a better fit (Δχ² (1) = 572.533,
p < 0.001) [81]
Quantitative
(questionnaire
distribution in a quiet
room within the
hospital) [11]
203
employed
nurses [11]
Through path analyses, it was found that job satisfaction had a direct negative
effect on emotional exhaustion (−0.97, p < 0.01) and on depersonalization
through emotional exhaustion (−0.58, p < 0.01).
Job satisfaction is a significant predictor of burnout in nurses [11]
3.8. Burnout and General Health
Two articles revealing a weak but significant relationship between burnout and depression were
identified [82,83]. Further details about the method, sample and findings of identified articles are
included in Table 8 below.
Table 8. Method, sample and findings of identified articles.
Method Sample Findings
Quantitative (anonymous
distribution of self
reported questionnaires)
[82]
368 members of the nursing
staff [82]
A weak but significant relationship between burnout and
depression was found (χ² (3) = 12.093, p < 0.01) Younger
nurses were found to suffer from burnout and depression
(χ² (3) = 13.337, p > 0.01), more than elderly nurses
(χ²(3) = 5.685, p < 0.01) [82]
Quantitative
(questionnaire
distribution and
collection in one sitting)
[83]
17 male and 62 female
nurses in general internal
medicine, general surgery
and respiratory medical
wards [83]
Depression was correlated with burnout to a lesser degree
(r = −0.38 to 0.27, p < 0.05) than sense of coherence (r = −0.55
to 0.44, p < 0.05), which was correlated to a higher degree with
depression (r = −0.58, p < 0.05). The relationship between
burnout and depression may be a product of the relationship
between depression and sense of coherence [83]
Int. J. Environ. Res. Public Health 2013, 10 2231
3.9. Burnout, Job Satisfaction and General Health
One article confirming the relationship between burnout, job satisfaction and health was identified.
Job satisfaction was found to be a significant predictor of both burnout and depression, with burnout
also significantly predicting depression. Further analysis revealed that job satisfaction moderates the
relationship between burnout and health [84]. Further details about the method, sample and findings of
identified articles are included in Table 9 below.
Table 9. Method, sample and findings of identified articles.
Method Sample Findings
Quantitative
(questionnaire
distribution) [84]
239 nurses in
Japan and 550
nurses in
mainland China
[84]
Job satisfaction among Japanese nurses was found to be a significant predictor of
depersonalization (ΔR² = 0.22, p < 0.001; β = −0.21, p < 0.01), diminished
personal accomplishment (ΔR² = 0.10, p < 0.001; β = −0.28, p < 0.01), and
depression (ΔR² = 0.37, p < 0.001; β = −0.30, p < 0.001). Among Chinese nurses
job satisfaction also significantly predicted depersonalization (ΔR² = 0.11,
p < 0.001; β = −0.12, p < 0.05), diminished personal accomplishment (ΔR² = 0.08,
p < 0.001; β = −0.25, p < 0.001), and depression (ΔR² = 0.24, p < 0.001;
β = −0.18, p < 0.001). Emotional exhaustion was found to significantly predict
depression in Japanese (ΔR² = 0.37, p < 0.001; β = 0.43, p < 0.001) as well as
Chinese nurses (ΔR² = 0.24, p < 0.001; β = 0.38, p < 0.001). Absenteeism was
not significantly predictive of burnout or job satisfaction. Job satisfaction was
found to moderate the relationship between emotional exhaustion and
absenteeism in predicting depression among Japanese (ΔR² = 0.03, p < 0.01;
β = −3.9, p < 0.01) and Chinese nurses (ΔR² = 0.02, p < 0.05; β = −4.2,
p < 0.05) [84]
3.10. Job Satisfaction and General Health
One article was identified confirming the relationship between job satisfaction and health among
nurses by showing that increased job satisfaction was related to poor psychological health among
nurses [85]. Further details about the method, sample and findings of identified articles are included in
Table 10 below.
Table 10. Method, sample and findings of identified articles.
Method Sample Findings
Quantitative and qualitative (following a
medical pre-examination of mental
health as well as interviews about
shifts/tasks, questionnaires were
distributed to eligible participants) [85]
101 nurses enrolled
at a clinic of
occupational
medicine [85]
Increase in job satisfaction was associated with
decreased psychological distress measured using
several indicators including perceived stress (r = −0.44,
p < 0.05) and general health (r = −0.24, p < 0.05)
scores.
Job satisfaction is inversely associated with reduced
psychological distress [85]
3.11. Work Related Stress, Burnout, Job Satisfaction and General Health
Six articles exploring all variables were identified. As was the case with the findings discussed
above, most of these explored two and three way relationships between work related stress and
Int. J. Environ. Res. Public Health 2013, 10 2232
burnout [23,86], work related stress and job satisfaction [23,86,87], work related stress and
health [23,86–88], burnout job satisfaction and health [89,90] as well as job satisfaction and health [90].
Few of these studies exploring more complex relationships showed that work related stress was not
significantly predictive of burnout [90] and only indirectly related to job satisfaction [86].
Additionally, work related stress was found to be a mediator rather than an independent variable
predicting burnout, job satisfaction and health among nurses [88].
An additional article identified through a manual search revealed predictive relationships between
stressors including information provision, social support, physical conditions and burnout, job
satisfaction, somatic complaints respectively. However, the relationship between burnout, job
satisfaction and somatic complaints was not empirically explored [91]. Further details about the
method, sample and findings of identified articles are included in Table 11 below.
Table 11. Method, sample and findings of identified articles.
Method Sample Findings
Quantitative
(structure
questionnaires
were mailed with
nurses’
paychecks) [23]
173 nurses
[23]
Job stress was significantly associated with burnout (r = 0.56, p < 0.01) and job
satisfaction (r = −0.34, p < 0.01). Job stress was significantly associated with
psychosomatic health problems (r = 0.55, p < 0.01). The only significant interaction
was found between job stress and psychosomatic health problems accounting for
5% of the variance (p < 0.05) [23]
Quantitative
(questionnaire
distribution
following
invitation letters)
[86]
1,204 nurses
working in
general
hospitals
[86]
The variance explaining job satisfaction was high (R² = 0.44). High job satisfaction
was significantly (p < 0.05) predicted by high social support (β = 0.33), low workload
(β = −0.21), low role ambiguity (β = −0.19), low role conflict (β = −0.14) and high
autonomy (β = 0.09). Psychosomatic health complaints were explained by high
workload (β = 0.20, p < 0.05); low social support (β = −0.10, p < .05), and high role
conflict (β = 0.09, p < 0.05). A two-way interaction effect was found between
workload and social support (β = −0.08) thereby suggesting that higher levels of
social support buffer the negative effects of workload on emotional exhaustion.
Results also indicated that high levels of social support would buffer the negative
effects of workload on job satisfaction (β = 0.08, p < 0.05). High complexity was
indirectly predictive of burnout (ΔR² = 0.01, p < 0.05; β = −0.08, p < 0.05) through
mediation by workload (ΔR² = 0.29, p < 0.05; β = 0.37, p < 0.05) [86]
Quantitative
(questionnaires
were sent to
nurses’ home
address) [88]
The sample
consisted of
807
registered
nurses
working in
an academic
hospital [88]
Organizational and environmental conditions explained significant variance in job
characteristics, ranging between 14% in social support colleagues and 41% in
workload. Job characteristics explained significant variance in outcomes, ranging
between 13% in somatic complaints and 38% in job satisfaction whereas
organizational/ environmental conditions explained significant variance in all
outcomes: 4% in somatic complaints, 5% in psychological distress, 11% in
emotional exhaustion, and 26% in job satisfaction.
Occupational stressors overall predict large amounts of the variance in the outcome
measures, especially in job satisfaction (44%) and emotional exhaustion (25%).
In conclusion, job characteristics (job stressors) mediate the relationship between
organisational and environmental conditions and outcomes (burnout, job
satisfaction and health) [88]
Quantitative
(questionnaire
administration)
[87]
1,697
registered
nurses [87]
Increase in job satisfaction was predicted by emphasis on patient care, recognizing
importance of personal lives, satisfaction with salary/benefits, job security and
positive relationships with other nurses and managers. Decrease in job satisfaction
was predicted by high levels of stress to the point of burnout. Physical health
predicted satisfaction with nursing as a career [87]
Int. J. Environ. Res. Public Health 2013, 10 2233
Table 11. Cont.
Method Sample Findings
Quantitative
(questionnaire
distribution with
instructions to
return by mail)
[89]
175 nurses
working in a
psychiatric
hospital [89]
Job satisfaction was moderately associated with burnout (r = −0.56, p < 0.05),
which was also moderately associated with psychosomatic health problems (r = 0.45,
p < 0.05). With shift time as a stressor, significant differences were found in
psychosomatic health problems between day and evening shifts (t = 2.2, p < 0.05),
evening and rotational shifts (t = −2.3, p < 0.05) as well as night and rotational
shifts (t = −2.10, p < .05). For job satisfaction, significant differences were found
between day and night shifts (t = 2.97, p < .05), evening and night shifts (t = 2.68,
p < 0.05) as well as rotational and night shifts (t = 3.13, p < 0.05). Generally, night
shift nurses’ wellbeing seemed to be affected more seriously than nurses working
other shifts. Only one interaction effect was found to be significant leading to the
conclusion that female nurses on rotating shift experience more health problems
than other nurses (F = 3.85, p < 0.05) [89]
Quantitative
(questionnaire
distribution with
letter explaining
the study) [90]
404 nurses (
77 male and
317 female)
[90]
Job characteristics reflected emotional exhaustion (r = −0.17 to −0.38, p < 0.001)
but did not explain it. Emotional exhaustion was most highly correlated with job
satisfaction (r = −0.55, p < 0.001). Both emotional exhaustion (r = 0.25, p < 0.001)
and job satisfaction (r = −0.12, p < 0.05) were related to sickness absence. Job
satisfaction was found to be a strong predictor of emotional exhaustion (β = −0.42,
p = 0.001). The most prominent predictor of sickness absence was emotional
exhaustion (β = 0.29, p = 0.001) [90]
Quantitative
(questionnaire
distribution by the
matron and
researchers in
each ward) [91]
309 female
nurses
working in
private and
public
hospitals in
3 countries
[91]
Burnout is most strongly predicted by problems with information provision
(ΔR² = 0.17, p < 0.001; β = −0.20, p < 0.001), job satisfaction by lack of social
support form supervisors (ΔR² = 0.36, p < 0.001; β = 0.21, p < 0.001) and somatic
complaints by physical working conditions (ΔR² = 0.08, p < 0.01; β = 0.16,
p < 0.05) [91]
4. Discussion
The majority of the articles included in this review have revealed that high levels of work related
stress, burnout, job dissatisfaction and poor health are common within the nursing profession. This is
supported by literature suggesting that nurses experience longer working hours as well as frequent
direct, personal and emotional contact with a large number of patients in comparison with other health
professionals [10,91].
Although a number of articles identified in this review have confirmed significant relationships
between work related stressors and burnout [25–34,59,60,77,78], job satisfaction [11,36–51,58–66,81]
as well as general health, these relationships are predominantly two way relationships with only a
handful of studies confirming three way relationships [64,65,71,84]. Among the studies confirming
two way relationships, only one study confirming the relationship between job satisfaction and general
health [85] was identified. Similarly, only one study confirming the three way relationship between
burnout, job satisfaction and general health [84] was identified. This demonstrates the limited
availability of studies exploring certain relationships.
Among the handful of studies confirming three way relationships findings suggest that work related
stress significantly predicts burnout, which is significantly predictive of physical and mental health
symptoms. This means that burnout plays an intervening role in the relationship between work related
Int. J. Environ. Res. Public Health 2013, 10 2234
stress and general health among nurses [71]. Although such findings provide strong support for the
relationship between work-related stress, burnout and general health, little is known about the role of
job satisfaction. Within the literature, ample evidence confirming significant two way relationships
between work related stress and job satisfaction [49–51], burnout and job satisfaction [81] as well as
general health and job satisfaction [78,85] is available. However, limited evidence to account for
mediation and moderation in the relationship between all variables could be found.
Furthermore, within studies confirming three way relationships, available evidence regarding the
role of job satisfaction is conflicting in that one study reveals that job satisfaction is a significant
predictor of burnout among nurses, [11] whereas another study reveals that job satisfaction is the
outcome variable predicted by work related stress and burnout [64]. Contradictory to this, it has also
been found that job satisfaction is the intervening variable in the relationship between burnout and
general health [84]. Therefore, despite work related stress, burnout, job satisfaction and general health
being inter-related, the complexity of these relationships can only be well understood if all variables
are explored simultaneously.
4.1. Limitations
Limitations of the studies included in this review involve predominant exploration of two and three
way relationships between work related stress, burnout, job satisfaction and general health of nurses,
while focusing less on the relationship between all four variables. Furthermore, majority of the studies
included in this review have used cross-sectional study designs with only a few longitudinal studies;
hence the evidence base for causality is still limited. As such, there is minimal evidence supporting the
causal nature of relationships between all four variables. Moreover, the use of different measuring
instruments, biased samples and in some cases poor response rates compromise the generalisability of
findings. Limitations of the review with regards to the inclusion of studies published only in English,
introduces a language bias. Additionally, most studies included in this review were conducted in
developed countries, thereby limiting generalizability to nurses in developing countries.
4.2. Implications
Comprehensive review of all variables, revealed some contradictory evidence for the role of job
satisfaction in the relationship between work related stress, burnout and general health, indicating the
need for further research confirming the role of job satisfaction. Although it was found that the nature
and direction of relationships between these variables is ambiguous, identification of this gap in
findings emphasizes the importance of simultaneously exploring the relationship between all four
variables towards understanding causality.
5. Conclusions
Identified relationships in this review were mostly two- and to a lesser extent three-way
relationships, with minimal focus on the causal nature and direction of relationships. Further research
exploring mediating and moderating effects of relationships between work related stress, burnout, job
satisfaction and general health over longer periods of time are necessary for establishing causality.
Int. J. Environ. Res. Public Health 2013, 10 2235
Understanding causality will allow for specific and appropriate strategies to address challenges of
work related stress, burnout, job dissatisfaction and poor general health among nurses, such as low
productivity, poor service delivery and adverse patient outcomes [92,93].
Conflict of Interest
The authors declare no conflict of interest.
References
1. Maslach, C.; Jackson, S.E. The measurement of experienced burnout. J. Occup. Behav. 1981, 2,
99–113.
2. Maslach, C.; Jackson, S.E. Maslach Burnout Inventory: Manual, 2nd ed.; Consulting
Psychologists Press: Palo Alto, CA, USA, 1986.
3. Vanyperen, N.W.; Buunk, B.P.; Schaufeli, W.B. Communal orientation and the burnout syndrome
among nurses. J. Appl. Soc. Psychol. 1992, 22, 173–189.
4. Maslach, C. Burnout: The Cost of Caring; Malor Books: Cambridge, MA, USA, 2003; pp. 25–121.
5. Chopra, S.S.; Sotile, W.M.; Sotile, M.O. Physician burnout. J. Am. Med. Assoc. 2004, 291, 633,
doi: 10.1001/jama.291.5.633.
6. Rada, R.E; Johnson-Leong, C. Stress, burnout, anxiety and depression among dentists. J. Am.
Dent. Assoc. 2004, 135, 788–794.
7. Aiken, L.H.; Clarke, S.P.; Sloane, D.M.; Sochalski, J.; Silber, J. Hospital nurse staffing and
patient mortality, nurse burnout, and job dissatisfaction. J. Am. Med. Assoc. 2002, 288, 1987–1993.
8. Engelbrecht, M.; Bester, C.L.; Van Den Berg, H.; Van Rensburg, H.C.J. The Prediction of
Psychological Burnout by Means of the Availability of Resources, Time Pressure or Workload,
Conflict and Social Relations and Locus of Control of Professional Nurses in Public Health
Centres in the Free State. In proceedings of the European Applied Business Conference (EABR)
and Teaching and Learning Conference (TLC), Rothenburg, Germany, 8–11 June 2008.
9. Jennings, B.M. Work Stress and Burnout among Nurses: Role of the Work Environment and
Working Conditions. In Patient Safety and Quality: An Evidence Based Handbook for Nurses;
Hughes, R.G., Ed.; Agency for Healthcare Research and Quality: Rockville, MD, USA, 2008;
Volume 2, pp. 137–158.
10. Levert, T.; Lucas, M.; Ortlepp, K. Burnout in psychiatric nurses: Contributions of the work
environment and a sense of coherence. S. Afr. J. Psychol. 2000, 30, 36–41.
11. Kalliath, T.; Morris, R. Job satisfaction among nurses: A predictor of burnout levels. J. Nurs.
Admin. 2002, 32, 648–651.
12. Turnbull, J.M. Stress in Nursing Care. In Alzheimer’s Disease: A Handbook for Caregivers, 2nd
ed.; Hamdy, R.C., Turnbull, J.M., Clark., W, Lancaster, M.M. Eds.; Mosby: Boston, MA, USA,
1994; pp. 319–327.
13. Demeuroti, F.; Bakker, A.R.; Nachreiner, F.; Schaufeli, W.B. A model of burnout and life
satisfaction among nurses. J. Adv. Nurs. 2000, 32, 454–464.
14. Lim, J.; Bogossian, F.; Ahern, K. Stress and coping in Australian nurses: A systematic review. Int.
Nurs. Rev. 2010, 57, 22–31.
Int. J. Environ. Res. Public Health 2013, 10 2236
15. Nolan, P.; Smojkis, M. The mental health of nurses in the UK. Adv. Psychiatr. Treat. 2003, 9,
374–379.
16. Coyle, D.; Edwards, D.; Hannigan, B.; Fothergill, A.; Burnard, P. A systematic review of stress
among mental health social workers. Int. Soc. Work 2005, 48, 201–211.
17. Kohler, J.M.; Munz, D.C.; Grawitch, M.J. Test of a dynamic stress model for organisational
change: Do males and females require different models? Appl. Psychol. Int. Rev. 2006, 55, 168–191.
18. Peltzer, K.; Mashego, T.; Mabeba, M. Short communication: Occupational stress and burnout
among South African medical practitioners. Stress Health 2003, 19, 275–280.
19. Rothmann, S.; Van Der Colff, J.J.; Rothmann, J.C. Occupational stress of nurses in South Africa.
Curationis 2006, 29, 24–25.
20. Lu, H.; Barriball, K.L.; Zhang, X; While, A.E. Job satisfaction among hospital nurses revisited:
A systematic review. Int. J. Nurs. Stud. 2012, 49, 1017–1038.
21. Toh, S.G.; Ang, E.; Devi, M.K. Systematic review on the relationship between the nursing
shortage and job satisfaction, stress and burnout levels among nurses in oncology/haematology
settings. Int. J. Evid. Based Healthc. 2012, 10, 126–141.
22. O’Mahony, N. Nurse burnout and the working environment. Emerg. Nurse 2011, 19, 30–37.
23. Jamal, M.; Baba, V.V. Job stress and burnout among Canadian managers and nurses:
An empirical examination. C. J. Public Health 2000, 91, 454–458.
24. Goldberg, D.P.; Hillier, V.F. A scaled version of the General Health Questionnaire. Psychol. Med.
1979, 9, 139–145.
25. Chayu, T.; Kreitler, S. Burnout in nephrology nurses in Israel. Nephrol. Nurs. J. 2011, 38, 65–78.
26. Lee, J.S.Y.; Akhtar, S. Effects of the workplace social context and job content on nurse burnout.
Hum. Resource Manage. 2011, 50, 1–19.
27. Ohue, T.; Moriyama, M.; Nakaya T. Examination of a cognitive model of stress, burnout and
intention to resign for Japanese nurses. Jpn. J. Nurs. Sci. 2011, 8, 76–86.
28. Melchior, M.E.W.; Van Den Berg, A.A.; Halfens, R.; Huyer Abu-Saad, H.; Philipsen, H.;
Gassman, P. Burnout and the work environment of nurses in psychiatric long-stay care settings.
Soc. Psych. Psych. Epid. 1997, 32, 158–164.
29. Hayter, M. Burnout and AIDS care related factors in HIV community nurse specialists. J. Adv.
Nurs. 1999, 29, 984–993.
30. Garrosa, E.; Rainho, C.; Moreno-Jimenez, B.; Monteiro, M.J. The relationship between job
stressors, hardy personality, coping resources and burnout in a sample of nurses: A correlational
study at two time points. Int. J. Nurs. Stud. 2010, 47, 205–215.
31. Gueritault-Chalvin, V.; Kalichman, S.C.; Demi, A.; Peterson, J.L. Work-related stress and
occupational burnout in AIDS caregivers: Test of a coping model with nurses providing AIDS care.
AIDS Care 2000, 12, 149–161.
32. Patrick, K.; Lavery, J.F. Burnout in nursing. Aust. J. Adv. Nurs. 2007, 24, 43–48.
33. Wu, S.; Zhu, W.; Wang, Z.; Wang, M.; Lan, Y. Relationship between burnout and occupational
stress among nurses in China. J. Adv. Nurs. 2007, 59, 233–239.
34. Barnard, D.; Street, A.; Love, A.W. Relationships between stressors, work supports and burnout
among cancer nurses. Cancer Nurs. 2006, 29, 338–345.
Int. J. Environ. Res. Public Health 2013, 10 2237
35. Lasebikan, V.O.; Oyetunde, M.O. Burnout among nurses in a Nigerian general hospital:
Prevalence and associated factors. ISRN Nurs. 2012, 2012, 1–6.
36. Archibald, C. Job satisfaction among neonatal nurses. Pediatr. Nurs. 2006, 32, 176–179.
37. Ernst, M.; Franco, M.; Messmer, P.R.; Gonzalez, J.L. Practice applications of research. Nurses’
job satisfaction, stress and recognition in a pediatric setting. Pediatr. Nurs. 2004, 30, 219–227.
38. Penz, K.; Stewart, N.J.; D’Arcy, C.; Morgan, D. Predictors of job satisfaction for rural acute care
registered nurses in Canada. Western J. Nurs. Res. 2008, 30, 785–800.
39. Applebaum, A.; Fowler, S.; Fiedler, N.; Osinubi, O.; Robson, M. The impact of environmental
factors on nursing stress, job satisfaction and turnover intention. J. Nurs. Admin. 2010, 40, 323–328.
40. Chaboyer, W.; Williams, G.; Corkill, W.; Creamer, J. Predictors of job satisfaction in remote
hospital nursing. Can. J. Nurs. Leadersh. 1999, 12, 30–40.
41. Djukic, M.; Kovner, C.; Budin, W.C.; Norman, R. Physical work environment: Testing an
expanded model of job satisfaction in a sample of registered nurses. Nurs. Res. 2010, 59,
441–451.
42. Iliopoulou, K.K.; While, A.E. Professional autonomy and job satisfaction: Survey of critical care
nurses in mainland Greece. J. Adv. Nurs. 2010, 66, 2520–2531.
43. Malliarou, M.; Sarafis, P.; Moustaka, E.; Kouvela T.; Constantinidis, Τ.C. Greek registered
nurses’ job satisfaction in relation to work-related stress. A study on army and civilian RNs.
Global J. Health Sci. 2010, 2, 44–60.
44. Graham, K.; Davies, B.; Woodend, K.; Simpson, J.; Mantha, S. Impacting Canadian public health
nurses’ job satisfaction. C. J. Public Health 2011, 102, 427–431.
45. Healy, C.; McKay, M.F. Nursing stress: The effects of coping strategies and job satisfaction in a
sample of Australian nurses. J. Adv. Nurs. 2000, 31, 681–688.
46. Zurmehly J. The relationship of educational preparation, autonomy, and critical thinking to
nursing job satisfaction. J. Contin. Educ. Nurs. 2008, 39, 453–460.
47. Wanzer, M.; Wojtaszczyk, A.M.; Kelly, J. Nurses’ perceptions of physicians’ communication:
The relationship among communication practices, satisfaction and collaboration. Health Commun.
2009, 24, 683–691.
48. Ho, W.H.; Chang, C.S.; Shih, Y.L.; Liang, R.D. Effects of job rotation and role stress among
nurses on job satisfaction and organizational commitment. BMC Health Serv. Res. 2009, 9, 8,
doi:10.1186/1472-6963-9-8.
49. Flanagan, N.A.; Flanagan, T.J. An analysis of the relationship between job satisfaction and job
stress in correctional nurses. Res. Nurs. Health 2002, 25, 282–294.
50. Larrabee, J.H.; Wu, Y.; Persily, C.A.; Simoni, P.S.; Johnston, P.A.; Marcischak, T.L.; Mott, C.L.;
Gladden, S.D. Influence of stress resiliency on RN job satisfaction and intent to stay. Western J.
Nurs. Res. 2010, 32, 81–102.
51. Cangelosi, J.; Markham, F.; Bounds, W. Factors related to nurse retention and turnover:
An updated study. Health Mark. Q. 1998, 15, 25–43.
52. Piko, B.F. Psychosocial work environment and psychosomatic health of nurses in Hungary. Work
Stress 2003, 17, 93–100.
53. Lin, K.C.; Huang, C.C.; Wu, C.C. Association between stress at work and primary headache
among nursing staff in Taiwan. Headache 2007, 47, 576–584.
Int. J. Environ. Res. Public Health 2013, 10 2238
54. Malinauskienė, V.; Leišytė, P.; Malinauskas, R. Psychosocial job characteristics, social support,
and sense of coherence as determinants of mental health among nurses. Med. Lith. 2009, 45, 910–917.
55. Lambert, V.A.; Lambert, C.E.; Petrini, M.; Li, X.M.; Zhang, Y.J. Predictors of physical and
mental health in hospital nurses within the People’s Republic of China. Int. Nurs. Rev. 2007, 54,
85–91.
56. Boey, K.W.; Chan, K.B.; Ko, Y.C.; Goh, C.G.; Lim, G.C. Work stress and psychological well-being
among nursing professionals in Singapore. Singap. Med. J. 1997, 38, 256–260.
57. Tucker, S.J.; Harris, M.R.; Pipe, T.B.; Stevens, S.R. Nurses’ ratings of their health and
professional work environments. Am. Assoc. Occ. Health Nurses J. 2010, 58, 253–267.
58. McHugh, M.D.; Kutney-Lee, A.; Cimiotti, J.; Sloane, D.M.; Aiken, L.H. Nurses’ widespread job
dissatisfaction, burnout, and frustration with health benefits signal problems for patient care.
Health Affair. 2011, 2, 202–210.
59. Liu, K.; You, L.M.; Chen, S.X.; Hao, Y.T.; Zhu, X.W.; Zhang, L.F.; Aiken, L.H. The relationship
between hospital work environment and nurse outcomes in Guangdong, China: A nurse
questionnaire survey. J. Clin. Nurs. 2012, 21, 1476–1485.
60. Kiekkas, P.; Spyratos, F.; Lampa, E.; Aretha, D.; Sakellaropoulos, G.C. Level and correlates of
burnout among orthopaedic nurses in Greece. Orthop. Nurs. 2010, 29, 203–209.
61. Cho, S.H.; June, K.J.; Kim, Y.M.; Cho, Y.A.; Yoo, C.S.; Yun, S.C.; Sung, Y.H. Nurse staffing,
quality of nursing care and nurse job outcomes in intensive care units. J. Clin. Nurs. 2009, 18,
1729–1737.
62. Sheward, L.; Hunt, J.; Hagen, S.; Macleod, M.; Ball, J. The relationship between UK hospital
nurse staffing and emotional exhaustion and job dissatisfaction. J. Nurs. Manage. 2005, 13,
51–60.
63. Bogaert, P.V.; Meulemans, H.; Clarke, S.; Vermeyen, K.; van de Heyning, P. Hospital nurse
practice environment, burnout, job outcomes and quality of care: Test of a structural equation
model. J. Adv. Nurs. 2009, 65, 2175–2185.
64. Bogaert, P.V.; Clarke, S.; Vermeyen, K.; Meulemans, H.; van de Heyning, P. Practice
environments and their associations with nurse-reported outcomes in Belgian hospitals:
Development and preliminary validation of a Dutch adaptation of the Revised Nursing Work
Index. Int. J. Nurs. Stud. 2009, 46, 55–65.
65. Bogaert, P.V.; Clarke, S.; Roelant, E.; Meulemans, H.; van de Heyning, P. Impacts of unit-level
nurse practice environment and burnout on nurse-reported outcomes: A multilevel modelling
approach. J. Clin. Nurs. 2010, 19, 1664–1674.
66. Klopper, H.C.; Coetzee, S.K.; Pretorius, R.; Bester, P. Practice environment, job satisfaction and
burnout of critical care nurses in South Africa. J. Nurs. Manage. 2012, 20, 685–695.
67. van Servellen, G.; Topf, M.; Leake, B. Personality hardiness, work-related stress, and health in
hospital nurses. Hosp. Top. 1994, 72, 34–39.
68. van Tooren, M.; de Jonge, J. Managing job stress in nursing: What kind of resources do we need?
J. Adv. Nurs. 2008, 63, 75–84.
69. Jourdain, G.; Chenevert, D. Job demands-resources, burnout and intention to leave the nursing
profession: A questionnaire study. Int. J. Nurs. Stud. 2010, 47, 709–722.
Int. J. Environ. Res. Public Health 2013, 10 2239
70. Bressi, C.; Manenti, S.; Porcellana, M.; Cevales, D.; Farina, L.; Felicioni, I.; Meloni, G.; Milone, G.;
Miccolis, I.R.; Pavanetto, M.; et al. Haemato-oncology and burnout: An Italian survey. Brit. J.
Cancer 2008, 98, 1046–1052.
71. Hillhouse, J.J.; Adler, C. Evaluating a simple model of work, stress, burnout, affective and
physical symptoms in nurses. Psychol. Health Med. 1996, 1, 297–306.
72. Sortet, J.; Banks, S. Hardiness, job stress and health in nurses. Hosp. Top. 1996, 74, 28–33.
73. Bourbonnais, R.; Comeau, M.; Vézina, M.; Dion, G. Job strain, psychological distress, and
burnout in nurses. Am. J. Ind. Med. 1998, 34, 20–28.
74. Baglioni, A.J., Jr.; Cooper, C.L.; Hingley, P. Job stress, mental health and job satisfaction among
U.K. senior nurses. Stress Med. 1990, 6, 9–20.
75. Landerweerd, J.A.; Boumans, N.P.G. The effect of work dimensions and need for autonomy on
nurses’ work satisfaction and health. J. Occup. Organ. Psych. 1994, 67, 207–218.
76. Tummers, G.E.R.; Landeweerd, J.A.; Merode, G.V. Organization, work and work reactions:
A study of the relationship between organizational aspects of nursing and nurses’ work
characteristics and work reactions. Scand. J. Caring Sci. 2002, 16, 52–58.
77. Decker, F.H. Occupational and non occupational factors in job satisfaction and psychological
distress among nurses. Res. Nurs. Health 1997, 20, 453–464.
78. Engström, M.; Ljunggren, B.; Lindqvist, R.; Carlsson, M. Staff satisfaction with work, perceived
quality of care and stress in elderly care: Psychometric assessments and associations. J. Nurs.
Manage. 2006, 14, 318–328.
79. Piko, B.F. Work related stress among nurses: A challenge for health care institutions. J. R. Soc.
Promo. Health 1999, 119, 156–162.
80. Adriaenssens, J.; Gucht, V.M.J.; Doef, M.P.; Maes, S. Exploring the burden of emergency care:
Predictors of stress-health outcomes in emergency nurses. J. Adv. Nurs. 2011, 67, 1317–1328.
81. Önder, C.; Basim, N. Examination of developmental models of occupational burnout using
burnout profiles of nurses. J. Adv. Nurs. 2008, 64, 514–523.
82. Iacovides, A.; Fountoulakis, K.N.; Moysidou, C.; Ierodiakonou, C. Burnout in nursing staff:
Is there a relationship between depression and burnout? Int. J. Psychiat. Med. 1999, 29, 421–433.
83. Tselebis, A.; Moulou, A.; Ilias, I. Burnout versus depression and sense of coherence: Study of
Greek nursing staff. Nurs. Health Sci. 2001, 3, 69–71.
84. Tourigny, L.; Baba, V.V.; Wang, X. Burnout and depression among nurses in Japan and China:
The moderating effects of job satisfaction and absence. Int. J. Hum. Resour. Man. 2010, 21,
2741–2761.
85. Amati, M.; Tomasetti, M.; Ciuccarelli, M.; Mariotti, L.; Tarquini, L.M.; Bracci, M.; Baldassari, M.;
Balducci, C.; Alleva, R.; Borghi, B.; et al. Relationship of job satisfaction, psychological distress
and stress-related biological parameters among healthy nurses: A longitudinal study. J. Occup.
Health 2010, 52, 31–38.
86. Tummers, G.E.R.; Landeweerd, J.A.; van Merode, G.G. Work organization, work characteristics
and their psychological effects on nurses in the Netherlands. Int. J. Stress. Manage. 2002, 9, 183–206.
87. Buerhaus, P.I.; Donelan, K.; Ulrich, B.T.; Kirby, L.; Norman, L.; Dittus, R. Registered nurses’
perceptions of nursing. Nurs. Econ. 2005, 23, 110–118.
Int. J. Environ. Res. Public Health 2013, 10 2240
88. Gelsema, T.I.; van Doef, M.; Maes, S.; Akerboom, S.; Verhoeven, C. Job stress in the nursing
profession: The influence of organizational and environmental conditions and job characteristics.
Int. J. Stress Manage. 2005, 12, 222–240.
89. Jamal, M.; Baba, V.V. Shiftwork, burnout and well-being: A study of Canadian nurses. Int. J.
Stress Manage. 1997, 4, 197–204.
90. Bekker, M.H.J.; Croon, M.A.; Bressers, B. Childcare involvement, job characteristics, gender and
work attitudes as predictors of emotional exhaustion and sickness absence. Work Stress 2005, 19,
221–237.
91. Van Der Doef, M.; Mbazzi, F.B.; Verhoeven, C. Job conditions, job satisfaction, somatic
complaint and burnout among East African nurses. J. Clin. Nurs. 2012, 21, 1763–1775.
92. Maslach, C.; Leiter, M.P. The Truth About Burnout: How Organisations Cause Personal Stress
and What To Do About It; Jossey-Bass: San Francisco, CA, USA, 1997.
93. Hickman, D.; Severance, S.; Feldstein, A. The Effect of Health Care Working Conditions on
Patient Safety; Agency for Healthcare Research and Quality: Rockville, MD, USA, 2003.
© 2013 by the authors; licensee MDPI, Basel, Switzerland. This article is an open access article
distributed under the terms and conditions of the Creative Commons Attribution license
(http://creativecommons.org/licenses/by/3.0/).
