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Running head: PREVENTING AND REDUCING BURNOUT
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Sinclair School of Nursing
UNIVERSITY OF MISSOURI MASTER’S EXAMINATION Fall 2010 1. 2. My identification number is: FS2010 – 1278 Master’s Examination Option (please check one): ‰
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3. 4. Literature Review Problem Solving Exam Research Proposal Clinical Guideline Paper My area of specialization is: Leadership in Nursing and Health Care Systems The problem, within my area of specialization, which I have addressed, is Preventing and Reducing Burnout Among Staff Nurses Faculty readers are chosen on shared specialties, exam topics and availability This blinded number/cover sheet must be attached to your exam when electronically submitted. DO NOT place your name on this cover sheet. RM/tjb‐FS2010 PREVENTING AND REDUCING BURNOUT
Preventing and Reducing Burnout Among Staff Nurses: A Literature Review
FS2010-1278
University of Missouri
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Abstract
The purpose of this paper is to provide a better understanding of why burnout develops
in order to guide interventions to prevent and reduce burnout among staff nurses. The
Cumulative Index to Nursing and Allied Health Literature (CINAHL), Ovid, and
PsycINFO databases were searched for articles regarding the causes, effects, and
treatments of burnout. The author reviews and discusses 27 articles based on the
theory of burnout described by Maslach and Leiter (1997) and Maslach, Schaufeli, and
Leiter (2001). This literature review explores contributing factors of burnout, areas of
nursing most impacted by burnout, and methods of reducing burnout as well as
analyzes strengths and weaknesses of current burnout literature. The paper concludes
with suggestions for future research.
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Preventing and Reducing Burnout Among Staff Nurses: A Literature Review
Freudenberger (1974) first acknowledged the importance of recognizing,
preventing, and overcoming burnout over 35 years ago. Since then, staff burnout has
been an area of concern and a popular research topic in the professional world. This
psychological condition is characterized by work-related emotional exhaustion,
depersonalization, and reduced personal accomplishment (Maslach, 1982; see also
Maslach & Leiter, 1997; Maslach, Schaufeli, & Leiter, 2001). Nurses and other service
professionals are at an increased risk because of the emotionally demanding nature of
helping other people (Maslach). A 1998-1999 study of 13,471 Pennsylvania nurses
found 43.2% of participants were experiencing high levels of burnout (Aiken et al.,
2001). Burnout has also become a popular research topic in health care because of its
impact on nurse retention and patient outcomes (Aiken, Clarke, Sloane, Sochalski, &
Silber, 2002). Multiple studies have found that nurses experiencing high levels of
burnout often plan to leave their current jobs or the nursing profession altogether (Aiken
et al., 2001; Aiken, Clarke, Sloane, et al., 2002; Leiter & Maslach, 2009; Vahey, Aiken,
Sloane, Clarke, & Vargas, 2004). Aiken, Clarke, Sloane, et al. (2002) found 43% of
nurses experiencing high levels of burnout intend to leave their current positions within
a year. Patients of nurses suffering from burnout experience significantly lower levels of
satisfaction with their care (Vahey et al.) and higher mortality rates (Aiken, Clarke,
Sloane, et al., 2002).
The purpose of this paper is to provide a better understanding of why burnout
develops in order to guide interventions to prevent and reduce burnout among staff
nurses. This literature review will explore contributing factors of burnout, areas of
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nursing most impacted by burnout, and methods of reducing burnout as well as analyze
strengths and weaknesses of current burnout literature. The Cumulative Index to
Nursing and Allied Health Literature (CINAHL), Ovid, and PsycINFO databases were
searched for articles regarding the causes, effects, and treatments of burnout. The
results were limited to peer-reviewed research articles published in the English
language. Articles were selected based on their relevance to the research topic.
Studies conducted in other countries were evaluated for relevance and generalizability
to nursing as a profession. Articles focusing specifically on nursing care in countries
other than the United States were excluded. Although no limits were placed on the
years of publication, it should be noted that all of the reviewed articles were published
since 2000. This indicates that this topic is relatively new in the realm of nursing
research. Twenty-seven articles were included.
This literature review presents a thorough description of current burnout
research. However, this review also reveals several gaps in knowledge regarding the
prevalence of burnout in different areas of nursing as well as possible methods of
reducing burnout among staff nurses. A discussion of research methods and findings
pertaining to the contributing factors of burnout, areas of nursing most impacted by
burnout, and methods to reduce burnout will be explored followed by an analysis of
strengths and weaknesses of current burnout research. Inconsistencies between
studies and suggestions for future research will also be discussed.
Theoretical Framework
This literature review is based on the theoretical framework of burnout presented
by Maslach and Leiter (1997) as well as Maslach et al. (2001). This framework is based
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on the idea that a person’s degree of job burnout is based on the degree of match or
mismatch of the person with his or her work environment. The person is less likely to
experience burnout when he or she experiences a better match with the work
environment. Unlike other similar frameworks that link the degree of fit directly to work
outcomes, this theory links the degree of fit to burnout and the degree of burnout to
work outcomes. This model identifies six specific areas of mismatch that lead to job
burnout: workload, control, reward, community, fairness, and values.
Burnout is characterized by emotional exhaustion, depersonalization (also
referred to as cynicism), and reduced personal accomplishment (Maslach, 1982). The
six proposed mismatches in the framework by Maslach and Leiter (1997) and Maslach
et al. (2001) influence these three components of burnout. In this framework, workload
encompasses physical and emotional demands as well as the type of work and skills
required. Control relates to the authority and resources to complete a job efficiently and
responsibly. A mismatch in reward indicates inadequate financial and social recognition
for work. Community entails positive connections and a shared sense of values with
coworkers while fairness involves respect and equity. Values entail ethics and
aspirations and may influence the other five areas. The degree to which mismatches in
each of these six areas influence emotional exhaustion, depersonalization, and reduced
personal accomplishment varies from person to person. In the literature review section
of this paper, the author will link the six areas of mismatch described by this theory with
contributing factors to burnout identified by current research studies.
Review of Literature
Contributing Factors to Burnout
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Workload.
Studies have repeatedly shown that nurses experiencing burnout have
undergone long periods of work-related stress. This stress is often linked to workload
and staffing levels. Workload is one of the six areas of mismatch identified by Maslach
and Leiter (1997) and Maslach et al. (2001) that contribute to mismatch. In a landmark
study Aiken, Clarke, Sloane, et al. (2002) mailed surveys to a random sample of
Pennsylvania nurses asking about work history, workload, job satisfaction, and
perceived levels of work-related burnout. These surveys consisted of a four-point
Likert-type scale for job satisfaction and the emotional exhaustion subscale of the
Maslach Burnout Inventory (MBI) (Maslach & Jackson, 1986). Results from the 10,184
returned completed surveys showed that each patient added to a nurse’s base workload
of four patients increases the odds of burnout by 23% and the odds of job
dissatisfaction by 15%. The researchers also analyzed data from 168 of the 210 adult
acute care Pennsylvania hospitals in 1999. These 168 hospitals were selected based
on having discharge data for surgical patients from the targeted diagnosis related
groups (DRGs), structural characteristics reported in the American Hospital Association
Annual Survey or Pennsylvania Department of Health Hospital Questionnaire, and at
least 10 survey responses from staff nurses. Researchers evaluated the outcomes of
232,342 general surgical, orthopedic, and vascular patients aged 20 to 85 who had
undergone procedures at the 168 studied hospitals between April 1, 1998, and
November 30, 1999. Analysis of the hospital data revealed that each patient added to a
nurse’s base workload of four patients increases the odds of patient mortality by 7%.
These findings provide scientific evidence that inadequate nurse staffing can have
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detrimental effects on both nurse and patient outcomes. The study’s theoretical
framework was not described.
The results from the study by Aiken, Clarke, Sloane, et al. (2002) linking nurse
staffing to burnout prompted other researchers to conduct similar studies. Halm et al.
(2005) conducted a cross-sectional, correlational study at a 572-bed acute care hospital
in the greater Twin Cities area. Unlike Aiken et al. who based their results on data from
10,184 nurses, 232,342 patients, and 168 general hospitals across Pennsylvania, Halm
et al. only used data from 2,709 patients and 140 registered nurses (RNs) on staff at
one hospital. Halm et al. measured job satisfaction by asking nurse participants to rank
their overall job satisfaction on a 4-point Likert scale. Halm et al. also asked the
participants if they planned to leave their current jobs within the year. Burnout was
measured using the MBI (Maslach, Jackson, & Leiter, 1996). No theoretical framework
was discussed.
The study by Halm et al. (2005) had considerably different findings than the study
by Aiken, Clarke, Sloane, et al. (2002). Seventy percent of the nurse participants
indicated they were satisfied or very satisfied with their jobs. While 43% of participants
in the Aiken et al. study had high emotional exhaustion scores, only 25% of participants
in the Halm et al. study had high emotional exhaustion scores. Although their estimated
staffing levels for 2002 prevented them from linking emotional exhaustion to nursepatient ratios like in the Aiken et al. study, Halm et al. were able to link emotional
exhaustion to years of service. For these participants, every year of employment was
associated with a 5.2% increase in their risk of emotional exhaustion. When
considering the differences between the Aiken et al. study and the Halm et al. study, it is
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important to consider the differences in sampling and data collection procedures. It
should also be noted that the researchers in the Halm et al. study were conducting an
in-house study, so there is a potential for bias. Participants may have been
uncomfortable or unwilling to provide unfavorable responses to researchers from their
own hospital, and the researchers may have interpreted their findings based on a desire
to improve their hospital’s image.
One of the biggest differences between the studies by Aiken, Clarke, Sloane, et
al. (2002) and Halm et al. (2005) was the timing of data collection regarding patient
information and nurse staffing levels. Aiken et al. collected hospital data at the time of
the study and measured staffing levels by asking nurse participants how many patients
they were assigned during their last shift. Halm et al. collected hospital data
retrospectively based on hospital and death records from 2002. Staffing levels for 2002
were calculated based on the average nurse-to-patient ratio for each of the 52 weeks
for every nursing unit.
Job demands.
Similar to workload, job demands can also contribute to work-related stress.
Demerouti, Bakker, Nachreiner, and Schaufeli (2000) distributed surveys to 185
German nurses working at a particular hospital or one of two nursing homes. The study
was based on general stress theories (Lazarus & Folkman, 1984; Hobfoll, 1989) and the
framework that job demands and job resources contribute to stressful working
conditions for nurses. The surveys measured life satisfaction, burnout, job demands,
and job resources using a four-item life satisfaction survey (Rice, 1984), the Oldenburg
Burnout Inventory (OLBI) (Ebbinghaus, 1996), and a 21-item working condition
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assessment. The results of the 109 completed surveys linked high job demands to
emotional exhaustion and a lack of resources to disengagement. The results also
showed that burnout has a negative impact on life satisfaction.
In a similar study also conducted in Germany, Bakker, Killmer, Siegrist, and
Schaufeli (2000) investigated how efforts and rewards affect burnout based on the
effort-reward imbalance framework (Siegrist, 1996). A sample of 204 nurses working at
a university hospital completed the MBI (Maslach & Jackson, 1986) and three unnamed
questionnaires to measure extrinsic efforts (Siegrist & Peter, 1996), intrinsic efforts
(Matschinger, Siegrist, Siegrist, & Dittmann, 1986), occupational rewards, and effortreward imbalance (ERI). The results linked ERI to emotional exhaustion,
depersonalization, and reduced personal accomplishment, especially among nurses
with high levels of intrinsic effort. These results support the theoretical framework by
Maslach and Leiter (1997) and Maslach et al. (2001) that identified reward as one of the
six areas of mismatch that lead to job burnout.
Work environment.
The work environment can also increase stress and lead to burnout. Aiken,
Clarke, Sloane, Lake, and Cheney (2008) studied how the hospital care environment
affects nurse outcomes. The researchers did not use a theoretical framework. The
study was based on 168 of the 210 adult acute care Pennsylvania hospitals in 1999.
These 168 hospitals were selected based on having 100 or more surgical discharges
studied by the Pennsylvania Health Care Cost Containment Council, structural
characteristics reported in the American Hospital Association Annual Survey or
Pennsylvania Department of Health Hospital Questionnaire, and having an adequate
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number of nurse survey respondents to provide a reliable assessment of the care
environment. Researchers evaluated the outcomes of 232,342 general surgical,
orthopedic, and vascular patients aged 20 to 85 who had undergone procedures at the
168 studied hospitals between April 1, 1998, and November 30, 1999. Nurse
participants were recruited based on surveys mailed to a 50% random sample of
Pennsylvania registered nurses. Over 40,000 completed surveys were returned. Of
these, 10,184 surveys from nurses currently working at the studied 168 hospitals were
analyzed. Hospital data were collected using the 1999 American Hospital Association
Annual Survey and the 1999 Pennsylvania Department of Health Hospital Survey.
Nurse participants completed the Nursing Work Index (PES-NWI) (Lake, 2002),
emotional exhaustion subscale of the MBI (Maslach & Jackson, 1986), and unnamed
surveys measuring job dissatisfaction, intent to leave within the next year, and
perceptions of quality of care.
Aiken et al. (2008) found nurses in hospitals with care environments ranked
“poor” on the PES-NWI experienced higher levels of burnout and job dissatisfaction and
were more likely to leave their current positions within the next year. Findings also
showed that each patient added to a nurse’s mean workload increased the odds of
burnout by one-fifth. Although it is not addressed in the article, the research methods
used in this study are identical to those described by Aiken, Clarke, Sloane, et al.
(2002), thus suggesting that the same data were used for both studies despite a sixyear difference in publication dates.
Instead of evaluating the work environment as a whole like Aiken et al. (2008),
some researchers have chosen to evaluate specific aspects of the work environment.
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In a study by Sadovich (2005), 106 commissioned nurse officers and federal civil
service nurses accessed a website to complete the Work Excitement Tool (ErbinRoesemann & Simms, 1995) and MBI (Maslach et al., 1996). Sadovich recruited these
participants using the Public Health Service Nursing Professional Advisory Committee
listserv. The study was based on the work excitement model (Simms, ErbinRoesemann, Darga, & Coeling, 1990). This model indicates work arrangements,
growth and development, variety of experiences, and working conditions impact work
excitement, which is necessary for quality care and outcomes. The results of the study
showed that emotional exhaustion and depersonalization decrease as work excitement
increases and personal accomplishment increases as work excitement increases.
A study by Vahey et al. (2004) also researched how nurse work environments
affect nurse burnout levels and patient satisfaction. The researchers did not base their
study on a theoretical framework. Participants included 820 nurses and 621 patients
from 20 hospitals across the United States. Nurses completed the revised Nursing
Work Index (NWI-R) (Kramer & Hafner, 1989), MBI (Maslach & Jackson, 1986), and La
Monica-Oberst Patient Satisfaction Scale (LOPSS) (Aiken, Sloane, Lake, Sochalski, &
Weber, 1999) regarding personal characteristics, unit and hospital characteristics,
burnout, and intent to leave. Patients were interviewed about their medical history, care
preferences, satisfaction with nursing care, and care measures. The results showed
nurses were more likely to experience emotional exhaustion, depersonalization, and
intent to leave in work environments with inadequate staffing, poor administrative
support, and poor nurse-physician relationships. Patient satisfaction was also
negatively impacted by these nurse work conditions in addition to the overall level of
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nurse burnout. The findings regarding the impact of administrative support and nursephysician relationships on emotional exhaustion, depersonalization, and intent to leave
support the theory that mismatches in the area of community contribute to burnout
(Maslach & Leiter, 1997; Maslach et al., 2001).
Also concerned about how the work environment impacts nurses, Garrett and
McDaniel (2001) studied how environmental uncertainty and social climate affect nurse
burnout. They based their research on the conceptual framework by Elliott and
Eisdorfer (1982) that explains how perceived environmental uncertainty leads to
professional burnout and how this response is mediated by a nurse’s personal
characteristics. Garrett and McDaniel collected data regarding admissions, discharges,
transfers, and midnight census at a 493-bed acute care hospital in the Midwestern
United States. Seventy-seven full-time registered nurses completed the Work
Environment Scale (Moos, 1994), MBI (Maslach et al., 1996), and Perceived
Environmental Uncertainty Scale (Salyer, 1996) regarding social climate and burnout.
Results showed that perceived environmental uncertainty increases the likelihood of
burnout and supervisor support reduces the likelihood of emotional exhaustion and
depersonalization.
The findings by Vahey et al. (2004) and Garrett and McDaniel (2001) that
supervisor support reduces the likelihood of emotional exhaustion and
depersonalization are supported by a 2007 study by Kanste, Kyngas, and Nikkila. This
study was based on the multifactor leadership theory (Bass, 1985; Bass & Avolio,
1997), which describes five transformational leadership styles, three transactional
leadership styles, and a non-transactional laissez-faire leadership style. Kanste et al.
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used a non-experimental survey design to investigate how these nine leadership styles
affect burnout. A stratified random sample of 601 Finnish nurses, public health nurses,
and head nurses completed the MBI-Human Services Survey (Maslach et al., 1996) in
addition to the Multifactor Leadership Questionnaire (Bass & Avolio) based on the
leadership styles of their immediate supervisors. Results indicated that rewarding
transformational leadership helps prevent depersonalization, as does active
management-by-exception. Management-by-exception also helps increase personal
accomplishment. Conversely, passive laissez-faire leadership increases the risk of
emotional exhaustion and reduced personal accomplishment. Nurses under the age of
40 are more likely to experience depersonalization, and supervisors and nurses working
irregular shifts (e.g. night shifts) are more likely to experience reduced personal
accomplishment. While Vahey et al. and Garrett and McDaniel demonstrated how
supervisor support can help reduce burnout, Kanste et al. demonstrated how a
supervisor’s leadership style can have a positive or negative effect on burnout.
Inadequate coping skills.
Multiple studies have demonstrated that work-related stress is more likely to lead
to burnout when nurses lack adequate coping skills. Garrosa, Rainho, MorenoJiménez, and Monteiro (2010) investigated how job stressors, hardy personality, and
coping resources impacted burnout levels. The study was not based on a theoretical
framework. A convenience sample of 98 baccalaureate-prepared Spanish nurses
attending a post-work course completed the Nursing Burnout Scale (NBS) (Garrosa,
Moreno-Jiménez, Liang, & González, 2008; Moreno-Jiménez, Garrosa, & GonzálezGutiérrez, 2000), which measures burnout, job stressors, hardy personality, and coping.
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Unlike the other cross-sectional studies included in this literature review, Garrosa et al.
(2010) attempted to reduce common method bias by asking participants to complete the
surveys again four weeks later to evaluate for temporal effects. Results linked active
coping with lower depersonalization and higher personal accomplishment, and higher
levels of control and social support were linked to lower levels of emotional exhaustion.
This finding supports the theory that a mismatch in the area of control can lead to
burnout (Maslach & Leiter, 1997; Maslach et al., 2001). Garrosa et al. also found that
role ambiguity and lack of cohesion are negatively related to personal accomplishment.
Female participants were more likely to experience feelings of reduced personal
accomplishment than male participants. The finding linking a lack of cohesion to
reduced personal accomplishment supports the theory by Maslach and Leiter (1997)
and Maslach et al. (2001) that a mismatch in community can lead to burnout.
The findings by Garrosa et al. (2010) regarding role ambiguity are similar to
those of Tunc and Kutanis (2009). Tunc and Kutanis analyzed the correlations between
burnout, role conflict, and role ambiguity. No theoretical framework was used.
Participants included 170 physicians and 81 nurses working at a 220-bed university
hospital in the western Black Sea region of Turkey. The participants completed the MBI
and Rizzo’s Role Conflict and Role Ambiguity Scales (Rizzo, House, & Lirtzman, 1970).
Results demonstrated a strong relationship between high scores on both instruments,
thus indicating a positive correlation between role conflict, role ambiguity, and burnout.
The nurse participants scored higher levels of role conflict, role ambiguity, and burnout
than the physician participants.
Glasberg, Eriksson, and Norberg (2007) also explored the relationship between
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coping, personality, social support, and burnout. More specifically, they investigated
how “stress of conscience”, personal and work variables, social support, and resilience
affect emotional exhaustion and depersonalization. They based their study on the
theoretical assumptions that “stress of conscience”, social support, resilience, and
personal and work demographics impact burnout. A sample of 423 Swedish health care
personnel with patient contact completed a Swedish version of the MBI (Maslach et al.,
1996), Perception of Conscience Questionnaire (Dahlqvist et al., 2007), Stress of
Conscience Questionnaire (Glasberg et al., 2006), Social Interactions Scale (Lindström
et al., 2000), and the Resilience Scale (Wagnild & Young, 1993). The results of these
questionnaires revealed that “stress of conscience” related to work demands such as
time and “having to deaden one’s conscience” increases emotional exhaustion and
depersonalization. This supports the theory that a mismatch in the area of values can
lead to burnout (Maslach & Leiter, 1997; Maslach et al., 2001). From a more social
standpoint, Glasberg et al. found that participants who felt unable to live up to others’
expectations experienced more depersonalization.
Also interested in how coping skills affect burnout, Montoro-Rodriguez and Small
(2006) conducted a study based on the stress models used by Ramirez, Teresi,
Holmes, and Fairchild (1998) and Cohen-Mansfield and Noelker (2000). The stress
model by Ramirez et al. indicates that work demands and resources influence nursing
outcomes including job satisfaction and burnout. The stress model by Cohen-Mansfield
and Noelker is more complex and explains how job satisfaction and stress are impacted
by organizational features, unit organization, relationships with and care of patients and
families, and staff members’ personal lives. The theory goes on to explain how staff
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dissatisfaction and stress have a negative impact on patient outcomes. MontoroRodriguez and Small had a convenience sample of 161 nurses from five nursing homes
in Ohio and two nursing homes in Vancouver complete and mail in a shortened version
of the Psychiatric Epidemiology Research Instrument (Dohrenwend, Shrout, Ergie, &
Mendelshon, 1980), MBI (Maslach et al., 1996), and staff job satisfaction survey (Cantor
& Chichin, 1990) to determine how individual characteristics, work demands, work
resources, and conflict resolution styles affect staff morale, burnout, and job
satisfaction. They found that staff who use confrontational or avoidance conflict
resolution styles are more likely to experience lower morale. The results also showed
that confrontational conflict resolution styles increase emotional exhaustion and
depersonalization.
While Montoro-Rodriguez and Small (2006) studied the effects of avoiding
conflict, Iglesias, Vallejo, and Fuentes (2010) studied the effects of avoiding certain
negative experiences in general, a phenomenon known as experiential avoidance.
Iglesias et al. evaluated the relationships between burnout, experiential avoidance,
health habits such as smoking, sociodemographic factors, and job related factors. No
theoretical framework was used. Eighty full-time critical care nurses who had worked
for at least a year in a critical care unit in one of five major hospitals in the Northern
State of Spain participated. Participants completed the MBI (Maslach & Jackson,
1981), Acceptance and Action Questionnaire (AAQ) (Hayes, Strosahl, & Wilson, 1999),
and a survey regarding age, gender, marital status, hospital type, years of critical care
experience, nurse-patient ratio, and tobacco dependence greater than six months.
Overall, the participants demonstrated high levels of emotional exhaustion, moderate
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levels of depersonalization, and low levels of personal accomplishment. High scores on
the AAQ were correlated with high emotional exhaustion and depersonalization scores
and low personal accomplishment scores on the MBI. Participants over the age of 30
who had more than 10 years of critical care experience were more likely to experience
emotional exhaustion. Participants who smoked were more likely to experience
depersonalization. Gender was not related to scores on the MBI or AAQ. Married
nurses tended to score higher on the personal accomplishment subscale of the MBI
than single nurses.
Areas of Nursing Impacted by Burnout
Comparison of burnout levels among different nursing specialties.
Very few researchers have compared burnout levels among different nursing
specialties. Scores on the MBI-General Survey (Schaufeli, Leiter, Maslach, & Jackson,
1996), Primary and Secondary Control Scale (Maher, Misajon, Heeps, & Cummins,
2001), and 12 neuroticism items from the NEO Five-Factor Inventory (Costa & McCrae,
1992) from 104 Australian nurses regarding burnout, control, and neuroticism revealed
that there is no difference in burnout or neuroticism levels between acute and chronic
care nurses (Allen & Mellor, 2002). The study was not based on a theoretical
framework. Scores on the MBI (Maslach et al., 1996) and 28-item version of the
General Health Questionnaire (Hare, Pratt, & Andrews, 1988) from 180 nurses working
at five hospitals in Shiraz, Iran, revealed that nurses working on psychiatric wards are
more likely to experience burnout than nurses working on burn, surgery, or internal
medicine wards (Sahraian, Fazelzadeh, Mehdizadeh, & Toobaee, 2008). No theoretical
framework was described.
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Burnout levels in individual specialty areas.
Some researchers have chosen to explore the incidence of burnout among
individual specialty areas without comparing them to other specialties. Building on the
results of Sahraian et al. (2008) and others who have found mental health nurses
experience high levels of burnout, Hanrahan, Aiken, McClaine, and Hanlon (2010)
studied how the psychiatric nurse work environment affects psychiatric nurses’ burnout
levels. The study was not based on a theoretical framework. Hanrahan et al. reviewed
the data from the study by Aiken, Clarke, Sloane, et al. (2002) and extracted the data
from 353 psychiatric nurses providing direct patient care at one of 67 general hospitals
with psychiatric inpatient units with a minimum of six psychiatric beds and three
psychiatric nurses. Based on the survey results from these nurses during the Aiken et
al. study, Hanrahan et al. reaffirmed the relationship between better nurse work
environments and lower levels of emotional exhaustion and depersonalization. They
also confirmed that manager skill and leadership are negatively related to emotional
exhaustion and depersonalization.
Similar to the results from the Vahey et al. (2004) study, Hanrahan et al. (2010)
found emotional exhaustion and depersonalization were strongly linked to poor nursephysician relationships. This finding further supports the theoretical framework that a
mismatch in community contributes to burnout (Maslach & Leiter, 1997; Maslach et al.,
2001). Hanrahan et al. also confirmed the findings from the Aiken, Clarke, Sloane, et al.
(2002) study linking inadequate nurse staffing with an increased risk for burnout, thus
providing additional evidence for Maslach and Leiter (1997) and Maslach et al.’s (2001)
theory that mismatches in workload also contribute to burnout.
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Focusing on a more specific area of nursing, Flynn, Thomas-Hawkins, and
Clarke (2009) explored burnout among chronic hemodialysis nurses based on the
nursing organization and outcomes model (Aiken, Clarke, & Sloane, 2002). The nursing
organization and outcomes model describes how nurse staffing levels/workloads, work
environments, and care processes affect patient and nurse outcomes. Flynn et al.
mailed survey packets to 2,000 registered hemodialysis staff nurses based on a random
sample of American Nephrology Association members. Of the 1,015 nephrology nurses
who returned the survey, 422 nurses from 47 states who currently worked in dialysis
facilities were included in the study sample. The survey packets included the emotional
exhaustion subscale of the MBI (Maslach & Jackson, 1986), surveys regarding intent to
leave their current position or employer, workload subscale of the Individual Workload
Perception Scale (Cox, 2003), practice environment scale of the Nursing Work Index–
Rev (PES-NWI) (Lake, 2002), and surveys derived from previous studies (Aiken et al.,
2001; Sochalski, 2001) asking which of seven nursing activities they had left not
completed during their last shift because they did not have time to do them. Thirty-one
percent of participants experienced high levels of emotional exhaustion. Participants
with the highest workloads were five times as likely to experience burnout compared to
those with the lowest workloads, and participants with the least supportive environments
were four times as likely to experience burnout compared to those with the most
supportive environments.
Choosing a much smaller and more specialized area, Gallagher and Gormley
(2009) explored burnout among pediatric bone marrow transplant nurses using a
descriptive non-experimental design. They surveyed a convenience sample of 30 bone
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marrow transplant nurses at a large pediatric medical center in the United States. This
study was not based on a theoretical framework. Participants completed the MBI
(Maslach et al., 1996) and a demographic informational questionnaire about work
experience, work-related stress, and support systems in the unit. Results showed
73.7% of participants experienced moderate to high levels of emotional exhaustion, and
33.3% of participants experienced moderate levels of depersonalization. Day shift
nurses felt more socially supported at work than night shift nurses. Emotional
exhaustion and depersonalization decreased and personal achievement increased as
years of nursing and bone marrow transplant experience increased. This is in direct
contrast to the finding by Halm et al. (2005) that every year of employment was
associated with a 5.2% increase in their risk of emotional exhaustion.
Impact of burnout on nurses working in private vs. public hospitals.
Expanding on burnout research into individual specialty areas, Ersoy-Kart (2009)
explored not only how burnout affects emergency nurses, but how burnout affects
emergency nurses working in the private sector compared to those working in the public
sector. Her study also evaluated the relationship between burnout, anger, and
perceived social support. This study was not guided by a theoretical framework. The
participants consisted of 53 emergency room nurses working in public hospitals and 47
emergency room nurses working in private hospitals in Ankara, Turkey. Each
participant completed the Turkish adaptation of the MBI (Maslach & Jackson, 1981),
Turkish adaptation of the Trait-Anger and Anger Expression Scale (Spielberger, Jacobs,
Dussel, & Crane, 1983), Multidimensional Scale of Perceived Social Support (Zimet,
Dahlem, Zimet, & Farley, 1988), and a demographic information form. Results showed
PREVENTING AND REDUCING BURNOUT
21
that both private and public emergency room nurses are able to express their anger
more easily when they perceive higher levels of social support. Both groups were also
similar in the fact that depersonalization was linked to high internal anger scores.
However, private emergency room nurses have better control of their anger and do not
express their anger as easily. Public emergency room nurses who do not successfully
control their anger experience lower feelings of personal accomplishment. Public
emergency room nurses with high trait anger scores experience more emotional
exhaustion and lower levels of personal accomplishment.
Impact of burnout on nurses of different generations.
Instead of focusing on nursing specialty areas, some researchers have explored
how nurses of different generations are impacted by burnout. Leiter, Jackson, and
Shaughnessy (2009) used the same theory of burnout by Maslach and Leiter (1997)
and Maslach et al. (2001) that has guided this literature review to design their study
regarding the differences in nursing burnout, turnover intention, control, value
congruence, and knowledge sharing between Baby Boomers and Generation X. For
this study, Baby Boomers were defined as those people born between 1943 and 1960.
Generation Xers were defined as those people born between 1961 and 1981.
Participants for this Canadian study were recruited from acute care facilities in Nova
Scotia, New Brunswick, Newfoundland, and Prince Edward Island. Of the 2,436
surveys that were sent out, only 667 were returned. Surveys could be completed on
paper or online and included the MBI-General Scale (Schaufeli et al., 1996), 3-item
turnover intention survey (Griffeth & Hom, 2001), control and values subscales of the
Areas of Worklife Scale (Leiter & Maslach, 2006), and an unnamed survey regarding
PREVENTING AND REDUCING BURNOUT
22
knowledge sharing (Leiter, Day, Harvie, & Shaughnessy, 2007). The results showed
that nurses belonging to Generation X were more likely to experience burnout and quit
due to a value mismatch than nurses belonging to the Baby Boomers. Nurses in
Generation X were also more likely to experience mismatches in the area of control,
and they were less likely to participate in knowledge sharing than Baby Boomer nurses.
Santos et al. (2003) also evaluated differences between different generations of
nurses. The researchers did not use a theoretical framework. In this multi-site, mixed
methods study, three generations were considered: Matures, Baby Boomers, and
Generation Xers. The birth years for the Baby Boomers and Generation Xers were
slightly different than those used for the Leiter et al. (2009) study. Santos et al. defined
Matures as those people born between 1919 and 1945, Baby Boomers as those people
born between 1946 and 1964, and Generation Xers as those people born between 1965
and 1979. Of the 694 participants, 55 were Matures, 368 were Baby Boomers, and 246
were Generation Xers. The study used a voluntary sample of registered nurses from
four Midwest hospitals representing rural, urban, suburban, and specialty institutions.
All participants completed the Occupational Stress Inventory-Revised Edition (Osipow,
1998). Following completion of the surveys, the researchers clarified findings from the
surveys by using semi-structured interview questions with follow-up focus groups. The
study found that Baby Boomers had worse scores than the other two generations on the
role overload, role insufficiency, role ambiguity, role boundary, and interpersonal strain
subscales. Overall, the worst scores for stress and strain were for physical environment
and responsibility. Specifically, Generation Xers had worse scores for physical
environment than the other two generations. The combined findings of Leiter et al. and
PREVENTING AND REDUCING BURNOUT
23
Santos et al. demonstrate that while multiple generations are negatively impacted by
poor working environments, Generation X nurses experience more strain from
mismatches in values and control than other generations and Baby Boomer nurses
experience more strain from role-related stressors.
Interventions to Reduce Burnout
Unfortunately, few studies have investigated methods of reducing or preventing
burnout among nurses. While research has revealed much regarding what factors
contribute to the development of burnout, few studies have explored how to reduce
burnout once it has occurred. Of these, most have focused on social support as a
method of reducing burnout. This supports the theory that a mismatch in the area of
community may contribute to burnout (Maslach & Leiter, 1997; Maslach et al., 2001).
Some researchers have explored the used of group-based therapies. A randomized
controlled trial by Bittman, Bruhn, Stevens, Westengard, and Umbach (2003)
researched the use of a group-based six-session recreational music-making protocol
using drums and keyboards to reduce burnout and total mood disturbance (TMD)
among 112 long-term care workers at a retirement community in Pennsylvania. The
theoretical framework was not described. Participants completed the MBI (Maslach et
al., 1996) and Profile of Mood States (McNair, Lorr, & Droppleman, 1992) immediately
prior to the study, at the end of six weeks, and at the end of twelve weeks. Results
showed that the recreational music-making protocol reduced burnout and TMD levels.
While Bittman et al. (2003) evaluated whether a group-based activity improves
burnout, other researchers have focused on group-based discussion as a method of
decreasing burnout levels. A randomized controlled trial by Peterson, Bergstrom,
PREVENTING AND REDUCING BURNOUT
24
Samuelsson, Asberg, and Nygren (2008) investigated the use of a peer-support group
to improve nurses’ perceived health, burnout, and work conditions. They based their
study on unspecified social support, change, and communication theories. Of the 3,719
physicians, registered nurses, nursing assistants, social workers, occupational
therapists, physiotherapists, psychologists, dental hygienists, dentists, service staff,
administrators, teachers, and technicians working in a County Council area in Sweden
who completed the General Nordic Questionnaire for Psychological and Social Factors
at Work (Dallner et al., 2000) and a Swedish version of the OLBI (Demerouti, Bakker,
Nachreiner, & Schaufeli, 2001), 660 scored above the 75% percentile of the exhaustion
dimension on the OLBI. Of these, 131 participated in the study. Those in the
intervention group met for two hours every week for ten weeks. All participants
completed questionnaires at the beginning of the study as well as seven and ten
months after the intervention, and researchers analyzed qualitative session content. At
the end of the study, the intervention group reported less stress and burnout along with
other improvements.
Multiple other studies endorse the use of social support to reduce burnout. A
pilot study by Barnard, Street, and Love (2006) explored the relationship between
stress, work supports, and burnout among oncology nurses. The researchers did not
describe a theoretical framework. One hundred one registered nurses in Australia
completed an unnamed questionnaire about work supports, the Stressor Scale for
Pediatric Oncology Nurses (Hinds et al., 1990), and the MBI (Maslach et al., 1996).
Results showed that most oncology nurses’ support comes from peers and that this
support decreases stress and increases personal accomplishment. LeBlanc, Hox,
PREVENTING AND REDUCING BURNOUT
25
Schaufeli, Taris, and Peeters (2007) also studied peer support among oncology nurses.
A quasi-experimental design based on participatory action research was used. The
sample consisted of 664 physicians, nurses, and radiotherapy assistants working on 29
oncology wards of 18 hospitals in the Netherlands. Nine of the wards were randomly
selected to receive the peer-support group intervention. Participants completed a Dutch
version of the MBI’s emotional exhaustion and depersonalization scales (Maslach &
Jackson, 1986) before the program began, after the program ended, and six months
after the program ended. The results showed that the participants in the intervention
group experienced less emotional exhaustion and depersonalization following changes
in perceived job demands, job control, and social support.
Estryn-Behar et al. (2007) studied 28,561 nurses from a stratified sample of ten
European countries to determine how social work environment, teamwork
characteristics, burnout, and personal factors affect a nurse’s intent to leave. No
theoretical framework was described. Participants completed a 260-item questionnaire
developed for the NEXT research project about their work history, private lives, work
environment and demands, and future plans (Hambleton, 1994). Multiple factors
including quality of teamwork and interpersonal relationships were shown to affect
participants’ intent to leave.
Strengths of Literature
Reliable and Valid Measurement Instruments
In quantitative research, it is necessary for measurement instruments to be
reliable and valid (Polit & Beck, 2008). Most of the studies in this literature review
provided internal consistency data for the measurement instruments used. Very few of
PREVENTING AND REDUCING BURNOUT
26
these had Cronbach alpha values less than 0.7, thus indicating that the measurement
instruments used by these studies were reliable. Many of the studies also provided intext citations for studies demonstrating the validity of the instruments. It is important to
note the high majority of studies that used all or part of the MBI. This consistency in
measurement instruments makes it easy to compare findings among various studies
and provides a firm precedent for future burnout research.
Consistency of Results
Research regarding contributing factors to burnout has yielded consistent results.
Although Gallagher and Gormley (2009) and Halm et al. (2005) disagree about the
impact of years of experience on emotional exhaustion, other studies have had similar
findings concerning the impact of workload (Aiken, Clarke, Sloane, et al., 2002;
Hanrahan et al., 2010), job demands (Bakker et al., 2000; Demerouti et al., 2000), work
environment (Aiken et al., 2008; Garrett & McDaniel, 2001; Sadovich, 2005; Vahey et
al., 2004), supervisor support (Garret & McDaniel; Kanste et al., 2007; Vahey et al.),
nurse-physician relationships (Hanrahan et al.; Vahey et al.), and coping skills (Garrosa
et al., 2010; Glasberg et al., 2007; Iglesias et al., 2010; Montoro-Rodriguez & Small,
2006; Tunc & Kutanis, 2009) on burnout levels. This consistency in results as to the
contributing factors of burnout provides a solid basis for future intervention studies.
Current Studies
As mentioned at the beginning of this paper, all of the studies included in this
literature review have been published since 2000. Although the concept of professional
burnout was first described over 30 years ago (Freudenberger, 1974), the topic of
burnout in nursing is much more contemporary. The studies in this literature review
PREVENTING AND REDUCING BURNOUT
27
provide current evidence for interventions to prevent and reduce burnout among today’s
staff nurses.
Weaknesses of Literature
Reliance on Self-Report Instruments
All of the studies included in this literature review used self-report questionnaires
to measure burnout and other variables. These questionnaires allow researchers to
measure participants’ feelings and beliefs in a quantifiable manner, but it is impossible
to know if the participants are answering questions truthfully (Polit & Beck, 2008). The
psychological and social aspects of these studies may have led some participants to
answer questions in ways they felt were more compatible with professional and public
expectations, thus increasing the risk for social desirability response bias (Polit & Beck).
Lack of Generalizability
Several of the reviewed studies were conducted outside of the United States.
Several studies were conducted in European countries including Finland (Kanste et al.,
2007), Germany (Bakker et al., 2000; Demerouti et al., 2000), the Netherlands (LeBlanc
et al, 2007), Spain (Garrosa et al., 2010; Iglesias et al., 2010), Sweden (Bittman et al.,
2003; Glasberg et al., 2007), and Turkey (Ersoy-Kart, 2009; Tunc & Kutanis, 2009).
Estryn-Behar et al. (2007) included nurses from ten European countries in their study.
Other countries outside of the United States and Europe included Australia (Allen &
Mellor, 2002; Barnard et al., 2006), Canada (Leiter et al., 2009), and Iran (Sahraian et
al., 2008). While this literature review focused on the nursing profession in general and
was not limited to studies conducted in the United States, the results of these
international studies may have been affected by cultural differences and therefore may
PREVENTING AND REDUCING BURNOUT
28
not be entirely applicable to nursing in the United States.
Lack of Theoretical Frameworks
Of the 27 reviewed studies, only 11 were based on theoretical frameworks.
None of these 11 used the same theoretical framework to guide their research. Polit
and Beck (2008) state that while some studies do not require theoretical frameworks
because they have obvious practical goals, it is often difficult to integrate isolated
nursing studies that lack theoretical foundations. The theoretical framework by Maslach
and Leiter (1997) and Maslach et al. (2001) that guided this literature review provided a
basis for assimilating the results of all 27 studies, but it would have been otherwise
difficult to combine all of these results into a guide for preventing and reducing nurse
burnout without understanding the conceptual framework behind most of the studies.
Studies Not Limited to Nursing
While most of the reviewed studies focused solely on the nursing profession or
considered nurses separately from other groups of participants, some studies included
many types of health care workers. Glasberg et al. (2007) included all health care
personnel with patient contact. The study by Peterson et al. (2008) included physicians,
registered nurses, nursing assistants, social workers, occupational therapists,
physiotherapists, psychologists, dental hygienists, dentists, service staff, administrators,
teachers, and technicians. LeBlanc et al. (2007) studied physicians, nurses, and
radiotherapy assistants. Because the results of these studies are based on all of the
participants and not just nurses, the results may not be as applicable as the results of
those studies that focused solely on nursing.
Convenience Sampling
PREVENTING AND REDUCING BURNOUT
29
Most of the studies included in this literature review used convenience samples.
Although it is the most common form of sampling, convenience sampling is also the
weakest (Polit & Beck, 2008). The results of these studies would have been
strengthened if participants had been randomly selected.
Low Response Rates
In addition to poor sampling methods, several studies suffered from low response
rates. Polit and Beck (2008) state that a response rate greater than 65% is usually
necessary to minimize nonresponse bias. Nonresponse bias occurs when low
response rates lead to samples that are not representative of the entire population, thus
limiting the generalizability of the results. Many of the studies included in this literature
review had response rates less than 65%: 59% (Demerouti et al., 2000), 56% (Barnard
et al., 2006), 52% (Aiken et al., 2008; Aiken, Clarke, Sloane, et al., 2002; Allen & Mellor,
2002; Flynn et al., 2009; Hanrahan et al., 2010; LeBlanc et al., 2007), 42% (Halm et al.,
2005), 27% (Leiter et al., 2009), 26% (Garrett & McDaniel, 2001), and 24% (Sadovich,
2005). The studies by Bakker et al. (2000), Ersoy-Kart (2009), Estryn-Behar et al.
(2007), Gallagher and Gormley (2009), Montoro-Rodriguez and Small (2006), and
Santos et al. (2003) did not provide response rate data, thus hampering the ability to
determine if these were representative samples.
New Studies Using Old Data
While all of the 27 reviewed studies were published since 2000, some of the data
used in these studies are more than 10 years old. For example, the study by Vahey et
al. (2004) analyzed data that was collected in 1991. The studies by Aiken et al. (2008);
Aiken, Clarke, Sloane, et al. (2002); and Hanrahan et al. (2010) were all based on the
PREVENTING AND REDUCING BURNOUT
30
same data collected between 1998 and 1999. Although these studies were all
published recently, their conclusions based on old data may not be entirely applicable to
today’s nurses.
Single Site Studies
Several of the reviewed studies were conducted at a single hospital or facility
(Bakker et al., 2000; Bittman et al., 2003; Garrett & McDaniel, 2001; Gallagher &
Gormley, 2009; Halm et al., 2005). Future studies would be strengthened by recruiting
participants from multiple facilities. Multisite studies provide larger, more diverse
samples that increase the generalizability of results (Polit & Beck, 2008).
Suggestions for Future Research
Randomized Controlled Studies
Of the 27 studies reviewed, most were descriptive studies. The high proportion
of descriptive studies is typical for nursing research, but correlational research does not
allow researchers to demonstrate causal relationships (Polit & Beck, 2008). Polit and
Beck credit experimental designs with producing the strongest evidence of causal
relationships, but there is a limited number of experiments regarding burnout in nursing.
Of the studies reviewed, only Bittman et al. (2003) and Peterson et al. (2008) performed
randomized controlled trials, and LeBlanc et al. (2007) conducted a quasi-experiment.
While correlational studies are needed to evaluate relationships between burnout and
possible contributing factors, more experiments are needed to identify methods of
preventing and reducing burnout.
Longitudinal Studies
More longitudinal studies are also needed. Gallagher and Gormley (2009) and
PREVENTING AND REDUCING BURNOUT
31
Halm et al. (2005) disagree regarding whether years of experience are associated with
an increase or decrease in emotional exhaustion. This topic would benefit greatly from
a longitudinal design in order to track changes in emotional exhaustion over time rather
than relying on cross-sectional data.
Differences in Burnout Between Male and Female Nurses
There is a major gap in the literature regarding the differences between how
male nurses experience burnout compared to female nurses. The only articles found on
this topic were excluded from this literature review because they focus on nursing in
specific countries rather than nursing as a profession. Al Ma’aitah, Cameron,
Armstrong-Stassen, and Horsburgh (1999) explored the impact of gender on nurses’
quality of work life in Jordan, a country where nursing is viewed as a low-status
profession. Hsu, Chen, Yu, and Lou (2010) investigated job stress and burnout among
male nurses in Taiwan, where only 0.8% of nurses are male. Currently, 6.6% of nurses
in the United States are male, and this number is growing (U.S. Department of Health
and Human Services Health Resources and Services Administration, 2010). Future
research should evaluate the differences in burnout levels between male and female
nurses in the United States and other countries where nursing is viewed as a more
respectable profession for both genders.
Summary and Conclusions
Burnout is characterized by emotional exhaustion, depersonalization, and
reduced personal accomplishment (Maslach, 1982; see also Maslach & Leiter, 1997;
Maslach, Schaufeli, & Leiter, 2001). The degree of job burnout a person experiences is
based on the degree of match or mismatch with the work environment. Six areas of
PREVENTING AND REDUCING BURNOUT
32
mismatch include workload, control, reward, community, fairness, and values (Maslach
& Leiter; Maslach et al.). These six areas are influenced by staffing (Aiken, Clarke,
Sloane, et al., 2002; Hanrahan et al., 2010), job demands (Bakker et al., 2000;
Demerouti et al., 2000), work environment (Aiken et al., 2008; Garrett & McDaniel,
2001; Sadovich, 2005; Vahey et al., 2004), supervisor support (Garret & McDaniel;
Kanste et al., 2007; Vahey et al.), nurse-physician relationships (Hanrahan et al.; Vahey
et al.), and coping skills (Garrosa et al., 2010; Glasberg et al., 2007; Iglesias et al.,
2010; Montoro-Rodriguez & Small, 2006; Tunc & Kutanis, 2009).
Limited research is available regarding which nursing specialties are impacted
most by burnout. Generation X nurses are more likely to experience burnout related to
mismatches in the areas of values and control than Baby Boomer nurses (Leiter et al.,
2009). Matures, Baby Boomers, and Generation Xers all experience strain from poor
working environments. Baby Boomers experience more strain related to their roles
(Santos et al., 2003). There is little research available regarding interventions to reduce
burnout. Most successful burnout interventions are based on increasing social support
(Bittman et al., 2003; LeBlanc et al., 2007; Peterson et al., 2008).
Most studies regarding burnout in nursing have focused on contributing factors to
burnout. Future research should focus on burnout among different genders and nursing
specialties in order to identify those areas that are most at risk in order to focus
interventions to prevent burnout from occurring. Future studies should also evaluate
methods of reducing burnout such as the peer-support group described by Peterson et
al. (2008) using longitudinal, multi-site experimental designs.
PREVENTING AND REDUCING BURNOUT
33
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