Walden University

COLLEGE OF HEALTH SCIENCES

This is to certify that the doctoral dissertation by

Prisca Regis-Andrew

has been found to be complete and satisfactory in all respects,

and that any and all revisions required by
the review committee have been made.

Review Committee
Dr. Cheryl Anderson, Committee Chairperson, Health Services Faculty
Dr. Amany Refaat, Committee Member, Health Services Faculty
Dr. Monica Gordon, University Research Reviewer, Health Services Faculty

Chief Academic Officer

Eric Riedel, Ph.D.

Walden University
2012
 Abstract
Nursing Burnout at a General Healthcare Facility and a Mental Healthcare Institution in

the Caribbean

by

Prisca Regis-Andrew

MA, University of Edinburgh, 2007

Dissertation Submitted in Partial Fulfillment

of the Requirements for the Degree of

Doctor of Philosophy

Health Services

Walden University

November 2012
 Abstract

Globally, health care services share a concern about the effect of burnout among nurses.

Although burnout is a personal experience for the nurse, the result impacts negatively on

the quality of care delivered while increasing the cost of care. The purpose of this study

was to compare the level of burnout among registered nurses employed at two facilities in

a Caribbean island: a general healthcare facility and a psychiatric institution. Burnout, the

result of variance between the nursess job requirements and the work environment,

affect both the mental and physical well-being of the nurse. Grounded in Lazaruss

transactional theory of stress, this study employed a quantitative, cross sectional, survey

design. The total population of registered nurses employed at the participating institutions

was 132. Fifty eight participated in the study. Nurses completed the Maslach Burnout

Inventory-Human Service Survey and a demographic questionnaire. Independent-samples

t-tests showed an unexpected higher level of emotional exhaustion and burnout among

the nurses at the general healthcare facility. Linear regression analysis on the random-

effect model suggests no relationship between burnout and age and years of service at

either institution. This study provides evidence that burnout is affecting nurses in the

Caribbean, more so in the general than in the mental care facility. Implications for

positive social change include the need to improve work environments for nurses and

thus improve the quality of care for the general population. This study also has

implications for healthcare delivery and policy development in the Caribbean region.
Nursing Burnout at a General Healthcare Facility and a Mental Healthcare Institution in

the Caribbean

by

Prisca Regis-Andrew

MA, University of Edinburgh, 2007

Dissertation Submitted in Partial Fulfillment

of the Requirements for the Degree of

Doctor of Philosophy

Health Services: Management and Policy

Walden University

November 2012
 UMI Number: 3544943

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 Dedication

This dissertation is dedicated to the 5 most important men in my life and to my

grandson. To my father, Francis Regis, who taught me the importance of always doing

my best. To my husband, James, thanks for supporting me by sharing the best as well as

the worst moments of this journey. To my sons, Jeshurun, Precious, and Philemon, whose

very presence in my life has been my greatest motivation for success. Lastly, to my

grandson, Joachim, whose arrival brought me the timely distraction I needed so as not to

neglect family.
 Acknowledgements

I wish to acknowledge Dr. Cheryl Anderson for her support and encouragement,

first as a committee member then as chairperson of my dissertation committee. Thank

you for stepping up in my moment of crisis. Thanks to Dr. Nancy Rea, who stepped in as

a committee member and helped me to make a smooth transition from one committee to

another. I express gratitude to Dr. Refaat, who accepted the challenge of joining my

dissertation committee during the fine tuning stage. My appreciation to Dr. Monica

Gordon, university research reviewer, who ascertained this study, was stamped with the

desired quality. It would be remiss of me not to acknowledge and say thanks to Dr. John

Kowalczyk, who started this long journey with me, but alas, could not complete it. My

prayers go up on your behalf.

I say thanks to my siblings, extended family members, and friends for allowing

me the space and time needed to focus on completing this feat. Thanks also to the nursing

directors of the participating institution who readily agreed to allow this study. A special

thank you to the participating nurses who made this study feasible. Last but not least, I

thank God almighty, who allowed this process to go as it went, thus drawing me closer to

him. I thank you, father, for your unfailing guidance and direction. You have taught me, I

can do all things through your strength.

 Table of Contents

List of Tables ..................................................................................................................... vi

List of Figures .................................................................................................................. viii

Chapter 1: Introduction to the Study....................................................................................1

Study Background ..........................................................................................................4

Problem Statement .........................................................................................................5

Purpose of the Study ......................................................................................................6

Nature of the Study ........................................................................................................7

Research Questions and Hypotheses ...................................................................... 8

Theoretical Base...........................................................................................................12

Conceptual Framework ................................................................................................15

Operational Definitions ................................................................................................17

Assumptions.................................................................................................................18

Limitations ...................................................................................................................18

Delimitations ................................................................................................................19

Significance of the Study .............................................................................................19

Summary ......................................................................................................................20

Chapter 2: Literature Review .............................................................................................23

Burnout: Theoretical Perspectives ...............................................................................24

Causes of Burnout ........................................................................................................25

Work Load and Job Control .................................................................................. 26

Fairness, Recognition, and Compensation ............................................................ 27

i
 Interpersonal Relationship and Personal Values................................................... 28

Burnout Signs and Symptoms ......................................................................................29

Demography and Burnout ............................................................................................30

Gender32

Age33

Marital Status ........................................................................................................ 33

Ethnicity ................................................................................................................ 34

Education .............................................................................................................. 34

Incidence ......................................................................................................................35

Burnout among Teachers ...................................................................................... 36

Effect of Burnout among Police Officers ............................................................. 37

Prevalence of Burnout among Physicians............................................................. 38

Burnout Experience Among Members of the Clergy ........................................... 39

Social Workers, Burnout, and Public Practice ...................................................... 39

Nurses and Burnout......................................................................................................40

Workload............................................................................................................... 41

Job Control ............................................................................................................ 42

Job Compensation and Recognition...................................................................... 44

Interpersonal Relationships ................................................................................... 46

Perception of Fairness ........................................................................................... 47

Personal Values ..................................................................................................... 48

Comparison between Nursing Specialty Environments ..............................................49

ii
 Effects of Burnout ........................................................................................................51

Quality of care....................................................................................................... 52

Cost of care ........................................................................................................... 53

Burnout Prevention ......................................................................................................53

Onboarding ........................................................................................................... 54

Employee Rounding.............................................................................................. 55

Social Networking ................................................................................................ 56

Employee Recognition .......................................................................................... 57

Developmental Stretch Assignments .................................................................... 57

Personality Traits and Mindset ............................................................................. 58

Recovering from Burnout ............................................................................................60

Psychological Stress Theory ........................................................................................60

Research Methods ........................................................................................................63

Summary ......................................................................................................................64

Chapter 3: Research Methodology.....................................................................................67

Introduction ..................................................................................................................67

Research Design and Approach ...................................................................................70

Setting and Sample ......................................................................................................72

Instrumentation and Materials .....................................................................................75

Interpretation of Results ........................................................................................ 77

Reliability and validity.......................................................................................... 78

Data Collection and Analysis.......................................................................................80

iii
 Data Collection ..................................................................................................... 80

Data Analysis ........................................................................................................ 81

Protection of Participants .............................................................................................83

Summary ......................................................................................................................84

Chapter 4: Results ..............................................................................................................85

Data Collection ............................................................................................................85

Characteristics of Sample ............................................................................................86

Data Analysis ...............................................................................................................89

Other Data Analysis ...................................................................................................111

Reasons for Employment .................................................................................... 111

Issues of Concern ................................................................................................ 112

Summary ....................................................................................................................112

Chapter 5: Discussion, Conclusion, and Recommendations ...........................................113

Interpretation of Findings ........................................................................................1155

Conclusions From Findings .......................................................................................118

Implications for Social Change ................................................................................1211

The Nurse .......................................................................................................... 1211

The Organization .............................................................................................. 1222

The Service User ................................................................................................. 122

The Community ................................................................................................ 1233

Recommendations for Action ..................................................................................1234

Limitations and Recommendations for Further Study ...............................................124

iv
 Limitations .......................................................................................................... 124

Recommendations for Further Study .................................................................. 125

Reflection .................................................................................................................1266

References ........................................................................................................................127

Appendix A: Research Notification Flyer .......................................................................145

Appendix B: Research Participant Invitation Flyer .........................................................146

Appendix C: Permission to Use Data Collection Instrument ..........................................147

Appendix D: Demographic Questionnaire Sample..........................................................148

Appendix F: Sample Questions From Maslach Burnout Inventory.................................152

v
 List of Tables

Table 1. Frequency Distribution of Participantss Institution of Work....86

Table 2. Frequency Distribution of Participantss Gender........87

Table 3. Frequency Distribution of Participantss Age.....88

Table 4. Frequency Distribution of Participants Length of Service.89

Table 5. Comparison of Mean Level of Emotional Exhaustion Between Institutions..92

Table 6. Categorization for Emotional Exhaustion Scores for Human Services...92

Table 7. Group Statistics of Independent t Test for Emotional Exhaustion cores.93

Table 8. Independent-samples t Test of Emotional Exhaustion Scores.94

Table 9. Comparison of Mean Level of Depersonalization Between Institutions. ...96

Table 10. Comparison of Mean Scores of Depersonalization Between Institutions.96

Table 11. Categorization for Depersonalization Scores for Human Services...97

Table 12. Independent-samples t Test of Depersonalization Scores 98

Table 13. Mean Level of Personal Accomplishment Between Institutions ..99

Table 14. Categorization for Personal Accomplishment Scores for Human Services100

Table 15. Mean Score of Personal Accomplishment Between Institutions.100

Table 16. Independent-samples t Test of Personal Accomplishment Scores..101

Table 17. Frequency of Burnout Level Among Participating Registered Nurses.......102

Table 18. Comparison of Mean Level of Burnout Between Institutions.103

Table 19. Independent-samples t Test of Level of Burnout.104

Table 20. ANOVA of Linear Regression of Age of Participants and Level of

Burnout..105

vi
Table 21. Coefficients of Linear Regression of Age of Participants and Level of

Burnout105

Table 22. ANOVA of Linear Regression of Length of Service of Participants and Level

of Burnout...108

Table 23. Coefficients of Linear Regression of Age of Participants and Level of

Burnout110

vii
 List of Figures

Figure 1.Visual Model of Study Variables............................................16

Figure 2. Percentage of Participantss Level of Emotional Exhaustion .......91

Figure 3. Percentages of the Levels of Depersonalization of Participants ...........95

Figure 4. Regression Scatterplot between Burnout Level and Age of Participants ...106

Figure 5. Regression Scatterplot between Level of Burnout and Length of Service of

Participants..110

viii
 1
Chapter 1: Introduction to the Study

Nurses all over the world have been experiencing burnout (Maslach, 2003). From

China to Spain, Japan to Canada, the United States to the United Kingdom, research has

been conducted regarding various aspects of burnout among nurses (Garrosa, Rainho,

Moreno-Jimenez, & Monteiro, 2010; Grau-Alberola, Gil-Monte, Garcia-Juesas, &

Figueiredo-Ferraz, 2010; Lei, Hee, & Dong, 2010; Kanai-Pak, Aiken, Sloane, &

Poghosyan, 2008; McGilton, McGills, Wodchis, & Petroza, 2007). Researchers in the

United Kingdom, Canada, and Japan have investigated the link between aspects of the

work environment and the three main components (emotional exhaustion,

depersonalization, and diminished personal accomplishment) of burnout (Garrosa et al.,

2010; Kanai-Pak et al., 2008; McGilton et al., 2007). The incidence of burnout has been

studied among nurses in Spain (Grau-Alberola et al., 2010), while the causes and

prevention of burnout have been investigated in China (Lei et al., 2010). Yet, there

remains a paucity of research about nurses in the English-speaking Caribbean community

(CARICOM). Specifically, no research has been conducted among nurses in Caribia (a

pseudonym) on the topic of burnout.

The term burnout was originally applied to engines and was defined as a

diminished ability to function (Felton, 1998). Burnout became associated with human

beings during the decade of the 1970s when psychiatrist Herbert Freudenberger (1974)

described his personal experience, as well as that of colleagues who volunteered at a

clinic providing free mental health care. Freudenberger associated burnout with human

service professions that allow members to over utilize personal resources to the point of
 2
depletion. Depleted personal resources are then manifested by physical and behavioral

signs. Much investigation into the burnout phenomenon among nurses in the United

States has since been carried out by researchers, including Christina Maslach, a social

psychologist (Wicks, 2006). Maslach and Leiter (1997) have linked the work

environment aspects of inadequate compensation, work overload, and value conflict to

burnout among nurses and the nurses intention to leave the employment or the

profession.

Caribbean nurses have been subsidizing the supply of nurses for countries such as

the United States, Canada, and the United Kingdom (World Bank, 2009). This outward

migration has worsened the shortage of nurses in the Caribbean that is compounded by a

phenomenon known as brain drain. Brain drain occurs when the most intelligent, highly

trained, and productive individuals migrate from their country of origin in search of

employment elsewhere (World Bank, 2009). A deficient work environment similar to that

identified by Maslach and Leiter (1997) has been noted as the main reasons for the

migration of nurses from the Caribbean. This deficient work environment includes

aspects of work overload, inadequate remuneration, and value conflicts resulting from a

lack of opportunity for career development (World Bank, 2009). In Caribia as well as the

other English-speaking CARICOM, the average nurse per population ratio in 2009 was

.55 to 3 per 1,000. Compared to a U.S. nurse ratio of 7.7, the CARICOM environment is

experiencing a greater nurse shortage that increases the risk of nurses developing burnout

(World Bank, 2009).

 3
The work environment comprises both the physical structure and conditions of

work at the institution (Hiscott, 1998). Conditions of work include working hours and

schedules, remuneration and benefit packages, administrative support and leadership, as

well as quantity of work and availability of resources (Hiscott, 1998). According to

Hiscott (1998), a shortage of nurses worsens certain aspects of the work environment and

increases the risk of burnout. The opposite is also true; burnout influences a nurses

decision to leave the profession and increases sick days, thereby worsening shortage of

nurses (Thomas, 2004); thus, a cycle results. Further discussion regarding the cyclical

relationship between nurse shortage and burnout will be discussed in Chapter 2.

Burnout research conducted among nurses has addressed areas that include

personality traits, coping mechanisms, and strategies (Garrosa et al., 2010; Lei et al.,

2010). Research has also included burnout incidence at various health institutions and

among specialties (Grau-Alberola et al., 2010; McGilton et al., 2007) and the relationship

among burnout, work environments, and quality of nursing care provided (Kanai-Pak et

al., 2008). The impact of various support mechanisms on burnout (Lei et al., 2010), as

well as, the effect of burnout on patientss safety, has also been investigated (Teng, Shyu,

Chiou, Fan, & Lam, 2010). Regardless of the many studies conducted globally, there

remains a deficit of investigations addressing a comparison of burnout between medical

and psychiatric nurses. Nurses in Caribia regard the psychiatric institutions work

environment as a greater risk of developing burnout than that of medical institutions

work environment The concern regarding the comparison of burnout between nurses who
 4
work in medical compared to psychiatric institutions will be discussed in greater detail in

Chapter 2.

Study Background

Caribia is a tropical, Eastern Caribbean island located between the Caribbean Sea

and the Atlantic Ocean. It is a member of the English-speaking CARICOM and is

considered as a middle income country. The majority of nurses in Caribia (75-8-%) are

employed in the public service. Retirement age in the public service is 55 years (World

Bank, 2009). Thereafter, a retired nurse may return to work as a temporary employee

until the age of 60 years. The construction of weekly work schedules for nurses is the

responsibility of individual work unit managers and is not the decision of the nurse

(World Bank, 2009). The Ministry of Health has overall responsibility for allocation and

organization of resources for health care delivery (Government Website, 2009).

The population of Caribia is estimated at 161,557 and is made up of an ethnic

blend (Government Website, 2011). African descent accounts for the majority at 90%,

Europeans make up 1%, and East Indians contribute 3%, while combinations of these

ethnic origins make up a further 6% (Government Website, 2011). The vast majority of

nurses in the Caribbean are of African descent. A registered nurse employed in the

Caribbean earns between U.S. $1,380 and U.S. $1,600 monthly (World Bank, 2009).

Despite the construction of a new mental health institution in Caribia, registered

nurses seem reluctant to accept employment at the institution (WHO, 2009). Registered

nurses in Caribia claim the mental health work environment to be a greater risk of

developing burnout than the environment of the medical institution. This opinion is
 5
supported by research conducted in Iran, where higher levels of emotional exhaustion and

depersonalization were noted among nurses in the psychiatric work environment

(Sahraian, Fazelzadeh, Mehdizadeh, & Toobaee, 2008).

Mental health care in Caribia is delivered at a standard desirous of improvement

and is not guided by an established policy. The standards are founded on the Mental

Hospital Act that is a consolidation of two mental hospital regulations enacted in the late

1800s to early 1900s. The lack of guidelines compromises the delivery of care at a time

when mental health reform is being implemented (Government Website, 2010). A further

compromise in the delivery of care because of registered nurses refusal of employment

at the mental health institution will have serious ramifications for service users. Thus, an

association between the mental health work environment and increased risk of

developing burnout poses a threat to the standard of mental health care delivery in

Caribia.

Problem Statement

In Caribia, research was needed to determine the existence and levels of burnout

and burnout components and their relationship with the mental and medical health

institutionss work environment. The registered nurses reluctance to accept employment

has resulted in the increased employment of nursing assistants at the mental healthcare

institution in Caribia (WHO, 2009). Nursing assistants are required to work under the

supervision of registered nurses (International Council of Nurses, 2008). A shortage of

registered nurses can result in situations where nursing assistants work without

supervision, therefore, potentially compromising delivery of mental health care.

 6
Burnout as a phenomenon that adversely affects the physical and psychological

health of nurses should be a concern to both the profession and the Ministry of Health in

Caribia. Burnout comprises constructs of emotional exhaustion, depersonalization, and

personal accomplishment at varying levels and negatively affects the productivity of the

nurse (Maslach, Jackson, & Leiter, 1996). Nurses make up the majority of persons

responsible for delivering direct patient care (DAntonio, Baer, Rinker, & Lynaugh

2006). Nurses are involved in health education, disease prevention, health promotion,

rehabilitation, and curative care. Therefore, nurses are positioned to influence not just the

quality of care but the level of health enjoyed by society (DAntonio, 2006). As such, it is

of vital importance that conditions noted to affect the health and productivity of the nurse

adversely be addressed with urgency.

Purpose of the Study

This study was conducted to determine the existence and level of burnout among

registered nurses employed at a general health care facility and a mental health institution

in Caribia. The levels of the three constructs of burnout were also investigated. Included

in the purpose was a comparison of the level of burnout and the constructs of burnout

among the nurses as it relates to the work environment. The relationship between age and

length of service and the level of burnout was also included in the purpose. Registered

nurses in Caribia hold the opinion that the psychiatric work environment is associated

with a greater risk of developing burnout. Lazaruss (1990) psychological transactional

theory of stress was used to explain the development of burnout as a result of dissonance

between the nurse and the work environment. This study provided the evidence needed to
 7
refute or support the opinion held by the registered nurses in Caribia and provided

information on the effect of the two work environments on the nurse.

Nature of the Study

A cross sectional research design was used to answer the research questions in

this study. The population included registered nurses who were currently employed at the

general healthcare facility and the mental healthcare institution in Caribia. Participants of

the study had been employed at the participating institutions for one year or more. This

employment criterion was guided by the concept that symptoms of burnout become

evident about one year after continuous exposure to at-risk conditions (Freudenberger,

1974). Although the background and description for this study is factual, the name

Caribia is used throughout this discourse as a pseudonym. This strategy is employed in an

effort at protecting the efficacy of the healthcare environment of the country involved in

this study.

Details of the research design will be discussed in Chapter 3. The Maslach (1996)

Burnout Inventory was used to collect data for this study. Burnout was assessed under the

components of emotional exhaustion, depersonalization, and personal accomplishment.

The participating general healthcare facility is made up of pediatric, surgical, medical,

intensive care, and accident and emergency units. Only registered nurses are employed at

the general healthcare facility. The participating mental healthcare institution is the only

public psychiatric care facility in Caribia. It provides acute and rehabilitative care for

teenagers and adults and employs both registered nurses and nursing assistants.
 8
Research Questions and Hypotheses

Acknowledgement of the existence of burnout among nurses of different health

institutions will allow for the development of needed policy to guide the workplace

environment in Caribia. This quantitative research included the independent variables of

age, years of service, mental health, and general health care institutions. Dependent

variables of level of burnout and components of burnout (emotional exhaustion,

depersonalization, and decreased personal accomplishment) were also included.

Independent variables are differing characteristics that can be manipulated to affect the

outcome of the research. Independent variables can be represented by assigned groups

such as registered nurses working at a particular institution. Dependent variables respond

to changes in the independent variable and are viewed as the outcome of manipulating the

independent variable (Creswell, 2009; Salkind, 2009).

Answers were sought for six research questions that are discussed below. The

research questions enabled the testing of six hypotheses. The first three questions

addressed the incidence of burnout components (emotional exhaustion, depersonalization,

and personal accomplishment) among individual nurses. The fourth question related to

the general existence of burnout among registered nurses at the institutions involved in

the study. The fifth and sixth research questions examined the effect of age and years of

service on the level of burnout. The research questions and corresponding hypotheses

were as following.
 9
Question 1: What is the level of the burnout component of emotional exhaustion

among registered nurses employed at a general healthcare facility as compared to

registered nurses employed at a mental healthcare institution in the Caribbean?

Null Hypothesis (Ho) :There is no difference between the levels of emotional

exhaustion among registered nurses employed at a general healthcare facility as

compared to registered nurses employed at a mental healthcare institution in the

Caribbean. Levels of emotional exhaustion will be measured by the sum of the numerical

value of responses to questions assigned in the data gathering instrument, to assess the

participantss emotional state.

Alternate Hypothesis (H1): The level of emotional exhaustion among registered

nurses employed at a general healthcare facility is different as compared to registered

nurses employed at a mental healthcare institution in the Caribbean.

Question 2: What is the level of the burnout component of depersonalization

among registered nurses employed at a general healthcare facility as compared to

registered nurses employed at a mental healthcare institution in the Caribbean?

Ho: There is no difference between the levels of depersonalization among

registered nurses employed at a general healthcare facility as compared to registered

nurses employed at a mental healthcare institution in the Caribbean. The levels of

depersonalization will be measured by the sum of the numerical value of responses to

questions assigned to assess the participantss experience of depersonalization.

 10
H1: The level of depersonalization among registered nurses employed at a general

healthcare facility is different as compared to registered nurses employed at a mental

healthcare institution in the Caribbean.

Question 3: What is the level of the burnout component of personal

accomplishment among registered nurses at a general healthcare facility as compared to

registered nurses employed at a mental healthcare institution in the Caribbean?

Ho: There is no difference between the levels of personal accomplishment among

registered nurses employed at a general healthcare facility as compared to registered

nurses employed at a mental healthcare institution in the Caribbean. The levels of

personal accomplishment will be measured by the sum of the numerical value of

responses to questions, assigned in the questionnaire, to assess the participantss sense of

personal accomplishment.

H1: The level of personal accomplishment among registered nurses employed at a

general healthcare facility is different as compared to registered nurses employed at a

mental healthcare institution in Caribbean.

Question 4: What is the level of burnout experienced by registered nurses

working at a general healthcare facility as compared to registered nurses working at a

mental healthcare institution in the Caribbean?

Ho: There is no difference in the level of burnout experienced by registered

nurses employed at a general healthcare facility as compared to registered nurses working

at a mental healthcare institution in the Caribbean. The level of burnout will be computed
 11
based on the determined levels of emotional exhaustion, depersonalization, and personal

accomplishment.

H1: The level of burnout among registered nurses employed at a mental

healthcare institution is higher than the level of burnout of registered nurses employed at

a general healthcare facility in the Caribbean island.

Question 5: What is the relationship between age and the level of burnout

experienced by registered nurses employed at a general healthcare facility as compared to

registered nurses working at a mental healthcare institution in the Caribbean island?

Ho: Age has no relationship with the level of burnout experienced by registered

nurses employed at a general healthcare facility as compared to registered nurses working

at a mental healthcare institution in the Caribbean island. The computed level of burnout

will be analyzed in relation to the participantss age.

H1: Age is negatively correlated to the level of burnout experienced by registered

nurses employed at a general healthcare facility as compared to registered nurses working

at a mental healthcare institution in the Caribbean island?

Question 6: What is the relationship between years of service and the level of

burnout experienced by registered nurses employed at a general healthcare facility as

compared to registered nurses working at a mental healthcare institution in the

Caribbean?

Ho: Years of service has no relationship with the level of burnout experienced by

registered nurses employed at a general healthcare facility as compared to registered

 12
nurses working at a mental healthcare institution in the Caribbean. The participantss

years of service will be analyzed in relation to the computed level of burnout.

H1: Years of service is negatively correlated to the level of burnout experienced

by registered nurses employed at a general healthcare facility as compared to registered

nurses working at a mental healthcare institution in the Caribbean?

Theoretical Base

According to Freudenberger (1974), burnout usually manifests itself after an

individual has been working in the high-risk environment for about one year.

Freudenberger believed that by then, many burnout contributing factors would

sufficiently impact on the individual, who would display signs of burnout. These signs

vary in amount and aspects of orientation, as well as intensity, giving rise to various

levels of burnout. Burnout is related to stress but not that which is personal. Instead,

burnout is associated primarily with stress generated by an individuals work

environment (Maslach & Leiter, 1997).

The word stress was first used by Hans Selye in1956 to describe an organisms

reaction to stimuli. Further research into the stress phenomenon resulted in many theories

including that of psychological stress that forms the basis for this study. The

psychological theory of stress, referred to as the transactional or psychological

transactional theory of stress, was first purported by Lazarus in 1966. Lazarus described

psychological stress as an association between an individual and the environment

(Lazarus, 1966). This association is viewed by the individual as threatening and beyond

that of personal coping mechanisms. These continuous associations, termed transactions,

 13
suggest that stress is not inherent in the individual or the environment (Lazarus, 1990, p.

3). Instead, this psychological stress results from a disagreement between an individuals

personal beliefs and that of his or her environment (Lazarus, 1990). Psychological stress

can be compared to the phenomenon of burnout that is stress resulting from dissonance

between an individual and the work environment (Maslach & Leiter, 1997). This study,

therefore, compared the level of psychological stress experienced by registered nurses

employed at a general health care and a mental health care institution. Organizational

value and an employees personal beliefs are regarded as an aspect of the work

environment where dissonance may exist (Maslach 2003, Thomas, 2004).

Nurses who work in settings such as emergency and cancer care have been

identified by researchers as having higher levels of stress compared with nurses who

work in other departments (Hooper, Craig, Janvrin, Wetsel, & Reimels, 2009; Trufelli et

al., 2008). Researchers have also identified intensive and palliative care units, as well as

mental health institutions, as high level stress settings where nurses are more likely to

experience burnout (Iglesias, de Bengoa Vallejo, & Fuentes, 2010; Jenkins & Elliott,

2004; Lobb et al., 2010). Although these environments have all been identified as areas

prone to high levels of stress, the stress-producing factors vary, are perceived differently,

and thus impacts differently on the nurse (Wicks, 2006).

The psychological theory of stress regards stress as a subjective experience with

input from the environment and output expressed by the individual (Lazarus, 1990). To

experience psychological stress an individual must first assess an environment as being

demanding, a threat to personal welfare, and beyond coping. This individual perception
 14
of ones environment as being stressful is anchored on cognitive appraisal that is a basic

tenet of the psychological theory of stress (Lazarus & Folkman, 1984, p.31). Cognitive

appraisal requires an individual to perform a self-analysis similar to that which was

performed by participants of this study. Participants who work in a similar environment

may perceive the work environment differently. Cognitive appraisal allows for the

collection of subjective data and may be conscious or unconsciously performed (Lazarus

& Folkman, 1984).

Six aspects of the work environment have been implicated in the development of

burnout and as stress-producing stimuli (Thomas, 2004). Burnout includes the

components of emotional exhaustion, which is closely associated with an emotionally

demanding environment (Maslach, 2003). An emotionally demanding environment leads

to depersonalization as the nurse withdraws from the situation. This withdrawal from the

work environment and thus those who seek care inadvertently results in a reduction of

efficiency, producing a sense of lowered personal accomplishment (Maslach, 2003). The

resulting feeling of being overwhelmed is frequently demonstrated by anger which is

often expressed to recipients of care (Thomas, 2004).

Freudenberger (1974) and Maslach and Leiter (1997) agreed that an increased risk

for developing burnout exists in human service work environments. These giving

professions often have highly stressful work environments as related to dissatisfaction of

employees. Maslach and Leiter (1997, p. 10) identified work overload as insufficient

supplies to meet increased work demands in limited time. Thus, work overload is
 15
recognized as the primary culprit for burnout. Work overload is an experience frequently

expressed by nurses as being an aspect of the work environment (Thomas, 2004).

Early research on burnout supported the idea that individuals employed in human

service professions such as nurses are at greater risk of burnout. This idea of increased

burnout risk among human service professions formed the groundwork for development

of a scale used to identify and measure the existence of burnout; the Maslach Burnout

Inventory Human Service Survey (MBI-HSS; Maslach, Jackson, & Leiter, 1996). The

MBI-HSS was used to collect data for this study. The purpose of the study was to

associate level of burnout identified by the MBI-HSS to the work environment of either

general care or mental health care. Further discussion regarding the psychological theory

of stress and its relation with this study is presented in Chapter 2.

Conceptual Framework

Many previous studies conducted on burnout have not used a conceptual

framework as they are usually underpinned by one selected theory, as is the case of this

study (Parahoo, 2006). According to Parsons and Shilss four levels of theories (as cited

in Frankfort-Nachmias & Nachmias, 2008), conceptual frameworks are classified as a

third level. Conceptual frameworks bring various theories together to direct a study and

use a broad, well-defined scheme to forecast results and provide clarification. Often

conceptual frameworks are diagrammatically presented (Frankfort-Nachmias &

Nachmias, 2008).

This study was guided by a taxonomy which is classified as a second level theory.

Taxonomies allow a researcher to explain relationships among groups during which

 16
comparisons can be made (Frankfort-Nachmias & Nachmias, 2008). Although a

conceptual framework was not used to guide this study, the variables investigated may be

presented as a visual model (Figure 1). Independent variables (IV) for this study included

mental health institution, general healthcare facility, age, and length of service, with the

latter two regarded as intervening variables. Emotional exhaustion (EE),

depersonalization (DP), personal accomplishment (PA), and burnout were the dependent

variables (DV) for this study. Visual models allow for a better understanding of the

associations between the variables being studied and may represent a conceptual model

where other theory levels guide the study (Creswell, 2009).

DVs

EE Age (intervening IV)

Mental health institution (IV)

DP Burnout (DV)

General health facility (IV)

PA Length of service
(intervening IV)

Figure 1. Visual model of study variables.

 17
Operational Definitions

Brain drain: The resulting state experienced by a country when many skilled,

trained, educated, and productive individuals migrate in search of more attractive

employment (World Bank, 2009).

Burnout: A sequela of high levels of emotional fatigue, an uncaring attitude, and a

reduction in efficiency and effectiveness (Maslach, 2003).

Charge nurse: A senior registered nurse employed to function in a supervisory

position of a ward or unit in a health facility (Golden Hope Hospital, 2009).

Cynicism: An uncaring and unfeeling attitude towards ones work (Maslach et al.,

1996).

Depersonalization: An unfeeling and impersonal response towards recipients of

ones service, care, treatment or instructions (Maslach et al., 1996).

Emotional exhaustion: Feeling of being emotionally overextended and fatigued

by ones work (Maslach et al., 1996).

Nursing assistant: An individual licensed to practice in the Caribbean island of

interest after successful completion of a recognized 18-month training program in

nursing. An individual can also be licensed to practice as a nursing assistant if successful

at the 3-year training program offered at local community college but unsuccessful at the

regional examination. Nursing assistants work along with or under the supervision of a

registered nurse (Government Website, 2009).

Personal accomplishment: Feelings of competence and achievement of ones

work with people (Maslach et al., 1996).

 18
Registered nurse: A nurse licensed to practice after successful completion of a 3-

year nurses program and the regional examination (Golden Hope Hospital, 2009).

Assumptions

For the purpose of this study, I assumed that burnout did exist among registered

nurses employed at the general healthcare facility and the mental healthcare institution in

Caribia. I further assumed that the registered nurses employed at the identified

institutions would be willing to participate in the study to allow for feasibility and

significant analysis of data.

Limitations

Data collection for this study used a self-reporting strategy. The survey was self-

administered and used to gather information regarding the frequency of which personal

feelings are experienced. This strategy limits the data to possible subjective responses;

thus anonymity of data collection must be ensured. Results of this study will only be

applicable to registered nurses employed at government-controlled general and mental

health institutions in the Caribbean. I did not participate in the direct recruitment of

participants or dissemination and collection of questionnaires.

The Maslach Burnout Inventory has been tested for validity and reliability;

therefore, no piloting or pretesting of the instrument was undertaken (Maslach et al.,

1996). Participants were encouraged to fill out the questionnaires completely and

privately. Participants were also encouraged to avoid the influence of coworkers, family

members, partners and friends when answering the questionnaire. Paper questionnaires

were used as Internet service is not readily available to participants.

 19
Delimitations

This study included only registered nurses employed at the government-controlled

general health and mental health institutions. The work environment is different from that

of private institutions and institutions which are subsidized by the government. Nursing

assistants were not included in this study as their training and level of responsibility is not

equivalent to that of registered nurses. Nursing assistants are employed only at the mental

health institution and not at the general healthcare facility. Other general health care

institutions in the Caribia were not invited to participate as they are community hospitals

and do not have a continuous flow of inpatients as do the two institutions involved in the

study.

Significance of the Study

Results of the study are intended to guide the construction of policy relating to the

work environment. This policy will aim at improving the work environment to assist with

reducing the development of burnout among nurses. Results are also meant to generate

awareness among nurses in Caribia, as well as the wider Caribbean, of the existence of

burnout. An awareness of burnout created among nurses is intended to motivate nurses to

employ coping mechanisms to reduce the risk of developing the phenomenon.

Ultimately, changes may be enacted at the institutions under study to support the

reduction of risks associated with burnout.

Burnout affects the nurses productivity, as well as the ability to function

(Maslach & Leiter, 1997). Therefore, reducing the incidence of burnout will indirectly

improve the quality of care delivered by the nurse. Addressing the risk factors
 20
contributing to the development of burnout among nurses can impact positively on the

health of society in general. Nurses comprise the majority of persons responsible for

direct patient care (DAntonio, 2006). Thus, ensuring the positive mental health of nurses

is a means of improving safe delivery of health care to their patients.

Implications for positive social change include improvement in the quality and

safety of health care delivery along with improvement in the health of individuals,

family, and communities. Implications also include creating an awareness of the need to

review the work environments of other healthcare organizations. The need for further

research was highlighted as new questions were generated. The promotion of positive

social changes in the life of the nurse as it relates to the work environment will have a

domino effect on family members, healthcare service users and society.

This study generated information about the level of burnout as well as the levels

of the components of burnout among registered nurses employed at the general healthcare

facility and a mental healthcare institution in a Caribia. Results provide a rationale for

rotation of nurses, training, and scheduling which all relate to the work environment. The

study also represents a step in alleviating the paucity of existing research relating to

burnout among nurses in the Caribbean, thus providing information for that gap in the

literature.

Summary

Burnout is a phenomenon associated with the work environment and is closely

linked to persons involved with human service professions (Freudenberger, 1974). The

work environment includes the physical structure as well as conditions of work.

 21
Remuneration, workload, work schedules, and resources are all included in the conditions

of work (Hiscott, 1998). According to the psychological theory of stress an environment

that is perceived by an individual as being threatening will, during its interaction with

that individual, produce psychological stress (Lazarus, 1990). This study determined the

existence and level of burnout among registered nurses employed at a general healthcare

facility and a mental healthcare institution in Caribia. In so doing, a comparison between

the two facilities were undertaken. No previous investigation has been conducted on

burnout and burnout components in Caribia.

A lack of awareness of the existence of the burnout phenomenon by nurses,

policy makers, and management hinders addressing concerns related to the work

environment and its effect on health care delivery. Results from this study are intended to

guide policy construction as it relates to improvement of the work environment. As such,

the study enabled six research questions to be answered. The first three address the

components of burnout and the fourth addresses the level of burnout. The fifth and sixth

research questions address the relationship between age and burnout, and years of service

and burnout. Burnout comprises components of emotional exhaustion, depersonalization,

and decreased personal accomplishment.

Chapter 2 will provide a comprehensive review of the literature on burnout,

paying special attention to its effect on nurses and health care delivery. The impact of the

work environment on the development of burnout will also be presented, and information

regarding burnout and other human service professions will be discussed. Chapter 3 will

present a detailed description of the methodology to be employed during this study.

 22
Information regarding the population of interest and data gathering instruments to be

utilized will also be provided. Chapter 4 will present the results of the study. Chapter 5

will include a discussion of the results of the study as it relates to the research questions

and hypotheses, as well as recommendations and the implications for social change.
 23
Chapter 2: Literature Review

This study allowed for the comparison of the levels of burnout and the

components or constructs of burnout among registered nurses employed at a general

health care facility and a mental health care institution. The relationship between the level

of burnout and the age and years of service of the nurse was also investigated. The

following discourse will present information regarding the burnout phenomenon: effects,

prevalence, prevention and coping mechanisms. A comparison will be made between the

incidences of burnout among different health care-providing environments. The effects

and incidence of burnout among other human service professions will be discussed, as

well as, burnouts relationship to gender, age, marital status, education, ethnicity, and

years of service. The possible positive effects with which burnout can be associated will

be presented. Information will also be presented on the role of the components of burnout

in determining the overall level of burnout.

Research studies conducted from 2007 to the present will be discussed as they

relate to the identification of burnout among nurses coupled with aspects that were

previously mentioned. The causes of burnout will be presented generally and then in

further detail in relation to nurses. The literature review will provide a background and

foundation information in support of the need for conducting this study. During this

study, I sought to compare the level of burnout among registered nurses employed at a

general care facility to the level of burnout among registered nurses employed at a mental

health facility. It was hoped that results will reveal the existence of any association
 24
between the work environment (general care or psychiatric care) and the level of burnout

among registered nurses.

A literature search was conducted under the general theme of health services and

nursing among peer-reviewed scholarly journals from databases available through the

Walden University Library. MEDLINE, CINAHL, Nursing and Allied Health Source,

Ovid nursing journals, SAGE, SocINDEX, and Health and Medical Complete databases

were searched. Terms used for searching include burnout, nurses, emotional exhaustion,

and depersonalization. Search terms of personal accomplishment, nurses and burnout,

work environment, and human service were also used. E-books available from the

Walden University library through eBrary were also accessed along with other relevant

sources. The discourse will include a critical analysis of findings from previous studies

identified through the databases searched.

Burnout: Theoretical Perspectives

The compound word burnout comprises two words, both of which carry a

negative connotation. The word burnout was coined in the 1940s, to describe the point at

which an engine ceased to function as it was originally intended (Fenton, 1998). Thirty

years later, Freudenberger (1974) used the word burnout to describe human beings in a

similar situation as it related to the work environment. The work environment includes

workload, job control, fairness, interpersonal relationship, job recognition and

compensation, and personal values. These aspects of the work environment play a

significant role in the development of burnout and have been implicated in the cause of

burnout (Hiscott, 1998).

 25
The work environment influences an employees relationship with work or the

job. Disharmony between human service providers, such as nurses, and the work

environment may lead to emotional exhaustion, decreased personal accomplishment, and

depersonalization that are the main components of burnout (Thomas, 2004). Components

of burnout are demonstrated or experienced through physical and/or psychological signs

and symptoms and are closely related to symptoms of stress (Potter 1996). The

phenomenon of burnout can be viewed from the perspective of the psychological theory

of stress with the work environment being an important variable for both.

Causes of Burnout

Norcross and Guy (2007) explained the occurrence of burnout as more likely

where the employee and the job are incongruent. An unhealthy relationship between the

work environment and the individual is regarded as the primary cause. Others hold a

different view and regard burnout as a weakness of mind set, which is manifested where

there is a deficiency in resilience (Brooks & Goldstein, 2004). Wicks (2006) identified

the common characteristic of scarcity, lack, or insufficiency that leads to frustration or

dissatisfaction in most situations of burnout. Matching of the employee and the job

includes aspects of the projected quantity of work to be accomplished and control over

job activities (Thomas, 2004). Low control over job activities coupled with work

overload is possible where a shortage of nurses exists.

Employee and job matching also includes recognition and compensation for work

accomplished, as well as fairness. A healthy relationship between employees and

agreement between the values of the organization and that of the employee also form part
 26
of matching the employee and the job (Maslach & Leiter, 1997). Burnout does not only

occur in organizations or institution but may develop among home-based caregivers,

including family members (Gill, Greenberg, Moon, & Margraf, 2007). Causes of burnout

as it relates generally to aspects of the work environment are presented here but will be

discussed later in further detail as it relates to nurses.

Aspects of the work environment implicated in the cause of burnout include

workload, job control, fairness, interpersonal relationship, job recognition and

compensation, and personal values (Hiscott, 1998). These aspects of the work

environment are not measured directly by this study. Instead, the survey consists of items

that relate to these aspects of the work environment and are assigned to assessing the

three main components of burnout (emotional exhaustion, depersonalization, and

personal accomplishment).

Work Load and Job Control

Work overload may occur in any work environment (Wicks, 2006). According to

Maslach and Leiter (1997), Work overload is perhaps the most obvious indication of a

mismatch between the person and the job (p. 10). Long hours, unmet job demands or

expectations, poor and/or dangerous physical working conditions, and unrealistic job

responsibilities all contribute to work overload (Ornelas & Kleiner, 2003; Wicks, 2006).

A shortage of nurses provides an environment that is prone to work overload (Hiscott,

1998). Coupled with poor autonomy and a culture that expects nurses to follow the

physicians orders; nurses often have little control over job-related activities (Tabak &

Koprak, 2007).
 27
These conditions result in stress which becomes chronic because the conditions

are maintained over a long period. Chronic stress eventually leads to exhaustion (Ornelas

& Kleiner, 2003). It is important to have time away from work whether it is in the form

of days off or vacation as a means of coping with work-related stressors (Wicks, 2006).

Being overworked may be compounded when the work environment allows no or little

control over job-related duties and task.

Work environments where there exists no opportunity for upward mobility or

training generates a powerless feeling among employees. This powerless feeling is also

experienced in organizations where employees are not involved with decision making

and communication between managers and subordinate staff is poor (Ornelas & Kleiner,

2003). Such conditions contribute to what is regarded as a lack of job control (Norcross

& Guy, 2007). Although employees may be qualified for the post in which they function,

task related decision making may not be forthcoming. Instead, the employee must follow

instructions which often are not the most resourceful and successful way to achieve

desired results (Ornelas & Kleiner, 2003). Working under such conditions can prove to

be frustrating and dissuading and does not encourage self-development but instead leads

to a lack of interest and ability to use skills (Potter, 1996).

Fairness, Recognition, and Compensation

Lack of recognition at work is regarded as a demotivating factor to employees and

includes feelings of being underpaid and underutilized (Potter, 1996). Maslach and Leiter

(1997) described the effect of lack of recognition as having a double negative impact in

that it devalues both the employee and the work accomplished. Recognition can assume
 28
either verbal or written acknowledgement and/ or adequate financial compensation for

work done (Potter, 1996). A devalued employee experiences a sense of reduced personal

accomplishment and is likely to be less productive (Maslach & Leiter, 1997). Employees

frequently compare job compensation with other colleagues and may regard existing

differences as being unfair (Thomas, 2004).

An employees perception of fairness is influenced by personal experience, as

well as the observed treatment of colleagues. Trust in the management of an organization

is based on an employees perception of the existence of fairness. It is hardly possible for

employees to commit to or demonstrate engagement with the job where a perceived lack

of fairness or justice exists (Thomas, 2004).

Interpersonal Relationship and Personal Values

A work environment where employees feel overwhelmed does not enhance

interpersonal relationships. Instead, such overwhelmed employees display a quickness to

react to coworkers and clients in an inappropriate, aggressive or emotional manner

(Potter, 1996). This aggressive behavior may spill over into relations with family and

friends and obstructs effective communication with colleagues and service users.

Negative emotions associated with burnout are expressed via interpersonal relationships

and are manifested by irritability, sarcasm and other unpleasant social actions. These

unpleasant actions cause similar reactions among colleagues giving the impression that

burnout is communicable (Maslach & Leiter, 1997). Interpersonal relations may also be

influenced by personal values (Potter, 1996).

 29
When an employees personal belief of what is right and wrong is frequently at

odds with the instructions and expectations of the organization, value conflict exists. This

value conflict may be accompanied by overt societal disapproval, causing the employee

to question job activities and belief (Potter, 1996). Value conflicts often result in

employees going against standards which they consider important to their moral beliefs,

causing guilt and disengagement with work (Borysenko, 2011).

Burnout Signs and Symptoms

Burnout comprises the three major components of emotional exhaustion,

depersonalization, and reduced personal accomplishment (dependent variables of this

study). Each component is characterized by a variety of symptoms. Symptoms include

both physical and psychological presentations (Potter, 1996). Burnout is usually assessed

as being high, moderate, or low, and each component can be assessed individually

(Maslach et al. 1996). The existence of burnout depends on the presence of emotional

exhaustion (Wicks, 2006). Thus, it is safe to conclude that the presence of emotional

exhaustion is most important in assessing the presence of burnout.

Although of a mental origin, emotional exhaustion can be manifested both

emotionally and physically but is not relieved by rest or sleep (Glouberman, 2003).

Headache, sleep disturbances and persistent elevated blood pressure may be manifested

(Wicks, 2006). Emotional exhaustion is referred to as compassion fatigue and can lead to

frequent negative thoughts and a conspicuous absence of positive contemplations. These

negative thoughts are accompanied by low self-esteem (Shelton, 2007). Emotional

outburst and hostility becomes the normal reaction (Potter, 1996).

 30
Relationships deteriorate while frequent minor illnesses persist, due to lowered

immune system activity (Potter, 1996). Failing health and deteriorating relationships are

likely to result in isolation. Further withdrawal due to depersonalization occurs as ones

stress level increases. Sometimes referred to as cynicism, depersonalization causes

withdrawal which results in an unapproachable demeanor (Shelton, 2007). Loss of

interest and concern for service users by giving or helping professionals is a sign of

depersonalization. Often there is increased use of alcohol, drugs or other habit forming or

addictive chemical and or activities (Potter, 1996).

Misuse or abuse of habit forming chemicals along with dwindling innovation and

motivation is mostly demonstrated as a reduction of personal accomplishment (Potter,

1996). A fall in work standards and quality, unprompted resignation, increased

absenteeism, and difficulty concentrating on work all speaks of a reduction in personal

accomplishments (Potter, 1996). Persons displaying symptoms of reduced personal

accomplishment lose the satisfaction, enthusiasm, interest, and fulfillment which were

once experienced in work. The efficiency of such individuals declines (Shelton, 2007).

Although burnout is primarily associated with human service professions, it is important

to realize that its occurrence is not constrained to these professions only, and it is possible

in any organization (Potter, 1996).

Demography and Burnout

Maslach (2003) described a pattern of the prevalence of burnout as it relates to

gender, ethnicity and age. Results from research suggest interplay between demographic
 31
variables and their relationship to burnout (Norlund et al., 2010; Soares, Grossi, &

Sundin, 2007). Thus, burnout among gender may be influenced by age.

Gender

According to Maslach (2003), men and women have similar experiences

regarding the level of burn out but may present a difference in the components of

burnout. Women are more apt to show signs of emotional exhaustion while men are more

likely to experience depersonalization. These differences may be ascribed to the general

orientation of women to be nurturers (Glassman & Haddad, 2009) and thus are more

likely to become emotionally involved with service users. Men are mostly cultured to be

hard and may transmit these feelings into an unsympathetic behavior (Maslach, 2003).

The difference in burnout components may also be regarded as a result of

choosing a profession which may be more oriented to the opposite gender, such as male

nurses or female police officers (Maslach, 2003). Contrary to Maslachs conclusion, a

result from a general study conducted in northern Sweden suggests the existence of a

higher level of burnout among women. This higher level was influenced by

dissatisfaction with job compensation and recognition and was most significant among

the 35-44 years age group (Norlund et al., 2010). Among a randomly selected sample of

women in Stockholm County, researchers observed a higher level of burnout among

younger than older women. Stockholm women in that study showed a decrease in the

level of burnout as age increased (Soares et al., 2007).

Globally the nursing profession is female dominated with 5.7% male nurses in the

United States in 2004 (American Nurses Association, n.d.). In Caribia, male nurses
 32
contribute 12.5% of the registered nurses employed at the mental healthcare institution

and 5.5% at the general healthcare facility (Government Website, 2009). Because

research results suggest a higher level of burnout among women, it may be safe to

conclude that the female dominated nursing profession is likely to display higher levels

of burnout.

Age

Burnout appears to be higher among younger than older professionals. Older

individuals are more likely to have acquired coping skills over the years. It is also

possible that the survivors of burnout are encountered in the profession in their later

years, as older persons (Maslach, 2003). The higher incidence of burnout among younger

individuals is supported by previous research conducted among physicians, social

workers, and members of the clergy (Peisah, Latif, Wilhelm, & Williams, 2009; Randall,

2007, Schwartz, Tiamiyu, & Dwyer, 2007). Yet among nurses, results from research

suggest a higher level of burnout among older nurses. These nurses were over 30 years

old or had over 10 years of experience working in departments such as intensive care

units (Iglesias et al., 2010). It may be that the effect of age and experience on the

decreasing levels of burnout is related to the profession, specialty of work, or the culture.

Research conducted in Finland among the general population suggests an increasing level

of burnout as age increased (Ahola et al., 2006).

This effect may be explained by the difficulty of keeping up with modern issues

and education experienced by older employees (Ahola et al., 2006). Retirement age for

government employees including nurses in Caribia is 55 years. Shortage experienced in

 33
the nursing profession has encouraged many nurses to return to the workforce after

retirement until the allowed age of 60 years (World Bank, 2009). There after nurses are

employed on a session basis as the need arises. The higher level of burnout among older

nurses and nurses assigned to stressful environments for many years may be an important

factor for scheduling and assigning of nurses.

Marital Status

Research results suggest burnout levels to be higher for single and childless

individuals than for the married and those with children (Evans, Bryant, Owens, &

Koukos, 2004). Persons who are divorced experience high levels of emotional exhaustion

near to that presented by singles. Divorced individuals can also identify with married

individuals with their experience of low depersonalization. Families are considered a

source of emotional support and a burnout buffer (Ahola et al., 2006).

A higher level of maturity seen among persons with family is thought also to

serve as a buffer for burnout. This higher level of maturity together with the experience

of dealing with emotional situations with spouse and children allows for better coping

with burnout risk situations (Maslach, 2003). Yildirm (2008) disagreed with Maslach, as

results coming out of research conducted among school counselors in Turkey suggest no

significant relationship between their union status and scores of the three components of

burnout. Yet, results from research conducted among nurses suggest a lower level of

burnout in married nurses than in their divorced colleagues (Abushaikha, & Saca-

Hazboun, 2009).
 34
Ethnicity

African Americans in the helping professions are noted to experience lower levels

of burnout as it relates to emotional exhaustion and depersonalization. The levels of

personal accomplishment are also observed to be lower (Maslach, 2003). Social and

family networks, past experiences of depravity and inequity, and dealing with emotional

encounters may have inculcated a sense of hardiness among African Americans, which

enables coping with burnout risk situations (Maslach, 2003). There exists a paucity of

studies over the last 4 years involving ethnic comparison of burnout and cultural

diversity. A study conducted in Florida among female providers of child care revealed

results which were contrary to that purported by Maslach (Evans et al., 2004).

Evans, Bryant, Owens, & Koukos (2004) reported higher levels of

depersonalization and emotional exhaustion among African American than among

European American women. African American women in this study were more likely to

be participants of interventions aimed at coping with burnout. A greater majority of the

African American participants of this study were unmarried, a status previously discussed

as being associated with high levels of burnout (Evans et al., 2004). In another study

comparing burnout among Jews and Moslem Arabs living in Israel, results suggest

similar mechanisms to be responsible for the generation of burnout, along with similar

levels, among dual earning families of the two cultures (Liat, 2009).

Education

Generally speaking, human service providers with less education experience a

lower level of burnout, especially in situations where college was not completed. Maslach
 35
(2003) purported an association between higher levels of education, higher expectations,

and a higher level of burnout. Unmet high expectations are likely to result in

disenchantment, depersonalization, and a corresponding high level of burnout. In Finland,

results from research conducted among the general public suggest differently. A higher

level of burnout among women with lower levels of education and social economic status

was observed (Ahola et al., 2006).

Education in Caribia is compulsory for all children from the age of 5 to 16 years

old. The island has one tertiary education institution with two campus sites. The tertiary

education institution offers the three year training program for nurses (World Bank,

2009). On successful completion of this program, persons are eligible to write the

regional examination along with other CARICOM nationals. Success at this exam deems

the nurse suitable for licensure with the General Nursing Council of Caribia and allows

the use of the title of registered nurse.

Incidence

Burnout, sometimes referred to as chronic secondary stress, is not a phenomenon

which develops overnight. The word chronic suggests a prolonged and building up of

intensity, as well as late recognition (Wicks, 2006). Freudenberger (1974) highlights the

idea of a build up by observing the exhibition of burnout signs after about one year of

being exposed to contributing factors. Although Freudenberger observed persons

involved with volunteer work in mental health, he associated burnout with individuals

who are devoted and highly enthusiastic. Such persons appear to begin their involvement

fired up for the task ahead but ended up burnt out along the way.
 36
Like Potter (1996), Wicks (2006) agreed to the buildup of stress and its

relationship with burnout. Potter purported the idea of increased risk of human service

professions but includes other job characteristics. Activities of specific detail, interaction

with the dying, and challenging work hours are job characteristics, which are included, as

high risk (Potter, 1996). Included in the high risk category are jobs which are subjected to

high social critique and professionals who are engaged in lucrative but mentally

unrewarding jobs (Berglas, 2009; Potter, 1996).

The variety of job characteristics implicated with the burnout phenomenon places

many individuals in at-risk situations (Potter, 1996). Burnout is not confined to any level

in an organization. It is possible for apparently successful individuals in managerial

positions to lose their sense of job satisfaction to what is referred to as supernova burnout

(Berglas, 2009). Burnout has been observed globally among human service professions

such as teachers (Betoret & Artiga, 2010; Zhong et al., 2009), police officers (Aranda,

Pando, Salazar, Torres, & Aldrete, 2009; Schaible, & Gecas, 2010), physicians (Peisah et

al., 2009; Yoon, Rasinski, & Curlin, 2010), social workers (Abdallah, 2009; Schwartz et

al., 2007), members of the clergy (Miner, 2007; Randall, 2007), and nurses (Garrosa et

al., 2010; Lei et al., 2010).

Burnout among Teachers

In a study conducted among a sample of three hundred university teachers,

burnout was evident. Burnout was also implicated in the path to poor physical health and

worsened of depression experienced by participants (Zhong et al., 2009). The study

highlighted the findings that burnout was not inevitable but could be prevented if coping
 37
strategies were used to handle its contributing factors (Zhong et al., 2009). Another study

involving primary and secondary school teachers supported the importance of coping

mechanism as a deterrent for burnout which existed among the sample (Betoret & Artiga,

2010). Results from this second study suggest that strategies which decrease

depersonalization and increase personal accomplishment decreased burnout among

teachers (Betoret & Artiga, 2010). The studies conducted by Zhong et al. and Betoret and

Artiga both used Maslach Burnout Inventory along with other instruments for data

collection. The teaching profession is often under scrutiny by society similarly to the

human service profession of police officers (Aranda et al., 2009).

Effect of Burnout among Police Officers

Fifty-four percent of the 836 traffic police officers who participated in a study in

Mexico were found to be experiencing burnout. Police work has been associated with a

high level of job related stress which according to the study was not adequately handled

by the existing social supports (Aranda et al., 2009). Results of a survey study conducted

among police officers in the Pacific Northwest suggest conflict between the officerss

values and that of the department as responsible for the presence of burnout (Schaible, &

Gecas, 2010). The study further noted the frequent use of depersonalization as a coping

mechanism which inadvertently increased burnout. Depersonalization has been

recognized as a component of the burnout phenomenon (Schaible, & Gecas, 2010).

Nurses who work in departments which provide end of life care may also use

depersonalization as a crisis coping mechanism. Depersonalization as a coping

mechanism allows police officers, and other human service providers such as physicians,
 38
to remain emotionally unattached to situations of crisis which are dealt with daily

(Maslach & Leiter, 1997).

Prevalence of Burnout among Physicians

Obstetrician gynecologists from the United States participated in a survey meant

to assess burnout experienced during practice. Although, for this study, only the

emotional exhaustion component was used as representative of burnout, 36% of the

participating 1,154 physicians, experienced high levels. Twenty four percent experienced

moderate levels of burnout and forty percent experienced low levels (Yoon et al., 2010).

These statistics revealed the alarming fact that all participants of this study experience

burnout to some degree during their practice. Doctors as members of the health care

providing team enjoy greater job control when compared to nurses (Thomas, 2004). Yet

results suggest that this positive aspect of the work environment was insufficient to

prevent burnout (Yoon et al., 2010).

In another study, Peisah, Latif, Wilhelm, & Williams (2009), noted a higher level

of burnout among younger doctors than their older colleagues. Participants of the study

expressed the view that doctors with many years of experience were more aware of the

risk and associated factors of burnout. This awareness of burnout risk factors allowed for

the development of coping mechanism and strategies to avoid the phenomena. The word

older was used during the study, to mean years of practice and not chronological age

(Peisah et al., 2009). In burnout studies conducted among members of the clergy, the

word older carries a different meaning from that of physicians (Randall, 2009).
 39
Burnout Experience Among Members of the Clergy

Members of the clergy are not exempted from burnout (Miner, 2007; Randall,

2007). Research conducted among members of the Anglican clergy in England and

Wales, suggest a higher level of burnout among younger members as compared with

those who are older. In this study, the term younger referred to ones chronological age

and not the number of years served in the clergy. Younger members of the participating

clergy were assessed as having higher levels of emotional exhaustion and

depersonalization (Randall, 2007). Contrary to results from the Randall study, a study

conducted by Miner (2007) in Australia suggested the opposite. Protestant clergy

participating in this Australia study revealed an increasing level of burnout after one year

in the clergy compared to the level at graduation. These results were obtained regardless

of the participants age. Maslach Burnout Inventory was used to determine the level of

burnout among participants (Miner, 2007). Similarly to nurses, clergy members are called

upon, to interact with both the terminally ill and the dying. Members of the clergy

interact daily with individuals experiencing societal ills as do social workers (Miner,

2007).

Social Workers, Burnout, and Public Practice

Burnout exists among social workers and is associated with their age and work

place setting. Results from a study conducted in the United States by Schwartz, Tiamiyu,

and Dwyer (2007) suggest a lower level of burnout among social workers involved with

private practice compared to public practice. Burnout level decreased as years of service

in private practice increased; while the opposite was true for public practice. The higher
 40
level of burnout observed in public practice may be associated with the possibility of

poorer work environments than that which exists in private practice. Interestingly,

though, burnout levels were noted to decrease generally as chronological age of the social

worker increased (Schwartz et al., 2007).

It may be that similar to physicians, increased age brings with it wisdom which

the invincible-thinking youth does not possess. This acquired wisdom accompanied by

exposure to the situation allows for the development of coping mechanisms (Peisah et al.,

2009). Another study among social workers in Palestine identified high levels of

emotional exhaustion among 46% of participants (Abdallah, 2009). The component of

personal accomplishment was most significant, as 53% experienced a lack. The study

used Maslach Burnout Inventory (Maslach et al., 1996) for assessment of burnout and

noted lower levels among older social workers (Abdallah, 2009). Nurses, like social

workers, can experience a low level of personal accomplishment as they are faced with

situations in which a sense of powerlessness prevails (Thomas, 2004).

Nurses and Burnout

The main causes of burnout were previously identified as work overload, lack of

job control, lack of job recognition and or inadequate job compensation, poor

interpersonal relationship, lack of fairness, and conflict between the employees personal

values and that of the organization (Maslach & Leiter 1997). Global shortage of nurses

accompanied by an increase in demand for quality care has increased the quantity of

work expectations (Wunderlich, Sloan, & Davis, 1996). Thus, while the shortage of

nurses contributes to the increase in quantity of work, work overload increases the risk of
 41
burnout and the nurses intention to leave the profession (Leiter & Maslach, 2009). When

nurses leave the profession the crisis of nurse shortage is further compounded.

The relationship between work overload and burnout can therefore, be regarded as

cyclical. Leiter and Maslach, (2009) in their research among nurses, found that nurses

intention to leave their job was greatly influenced by a lack of involvement in work. This

lack of involvement was manifested by cynicism or depersonalization, a component of

burnout whose primary construct is that of exhaustion due to work overload (Thomas,

2004).

Workload

An employees work load is regarded as the quantitative component of work

demand (Jourdin, & Chnevert, 2010). When the amount of work assigned, is in excess

of what is deemed possible to accomplish, work overload exist (Ornelas, & Kleiner,

2003; Wicks, 2006). Absenteeism is viewed as a warning sign of burnout, an increase of

which is associated with work overload. This absenteeism is often due to an increase in

health problems associated with a declining function of the immune system resulting in

poor resistance to minor infections (Potter, 1996). Results from research conducted

among Finnish nurses suggest an increase in absenteeism among nurses with a heavy

workload. This workload was above the optimum level of work as assessed by the Rainio

Fagerstrom Rauhala (RAFAELA) patient classification system. The RAFAELA patient

classification system is validated and widely used in Finland (Rauhala et al., 2007).

Jourdin and Chnevert (2010) based on their findings during research among

registered nurses working in Canada concluded that a high demand in quantity of work
 42
was linked to emotional exhaustion, which could result in depersonalization. Emotional

exhaustion and depersonalization are both primary constructs of burnout (Maslach et al.,

1996). Historically the nursing profession has been female dominated, a trend which is

still evident today (Brown, Nolan, & Crawford, 2000). Women compared to men have

been noted to have higher levels of absence from work due to sickness (North, Syme,

Feeney, Shipley, & Marmot, 1996). This combination of factors and the addition of work

overload increase the risk of burnout among nurses. According to Karasek (1979) job

strain model, work overload or a high workload accompanied by poor or low job control

give rise to a high-strain job.

Job Control

Described as the amount of work activity decision making, possessed by an

employee, job control can be regarded as the catalyst for translating work overload to

burn out (Karasek, Baker, Marxer, Ahlbom, & Theorell, 1981). Employees can cope with

the burnout risk associated with high workload or work overload if in possession of high

job control; a situation which will result in an active job. A low workload accompanied

by low job control results in a passive job; while a low workload along with a high job

control will result in a low-strain job (Karasek et al., 1981).

Research conducted to investigate the relationship between job strains and

cardiovascular disease suggests a greater risk among persons with high-strain jobs. Low

job control as it relates to aspects of work scheduling and opportunity for innovative and

use of skills were noted to be of significance (Karasek et al., 1981). Nurses who are

employed at institutions work various shift schedules so as to provide health care twenty
 43
four hours a day (Wunderlich et al., 1996). Elovainio, Kuusio, Aalto, Sinervo, and

Heponiemi (2009) found in their research, a close association of increased psychological

stress and shift work among nurses. Nurse-physician relationship also poses a source of

stress. The nurse and the physician utilize a different approach to care which frequently

result in conflict and little opportunity for the use of innovation by the nurse (Tabak &

Koprak, 2007).

These two work environment issues may promote the perception of direct clinical

nursing as a position with low or poor job control and inadvertently a high-strain job.

Chiu, Chung, Wu, and Ho (2009), in their research among Taiwanese clinical care nurses,

found that nurses involved in high-strain jobs, entertained thoughts of leaving their job.

Nurses, who function in high workload areas with social support and decision-making

opportunities, did not. Results from other research among nurses providing geriatric care

supported the perception of nursing being a high-strain job as a result of high workload

and poor or low job control (Schmidt & Dieste, 2009).

Findings from the Schmidt and Dieste (2009) study lead to the further conclusion

that high workload and low job control resulted in emotional exhaustion; a component of

burnout. The studys findings also suggested that high workload coupled with low job

control can be used to foretell the level of job satisfaction among the nurses (Schmidt &

Dieste, 2009). Job satisfaction is frequently influenced by job recognition and

compensation. Lack of job recognition and or perceived inadequate compensation robs

employees of the eagerness, delight and commitment which are present in the absence of

burnout (Norcross & Guy, 2007).

 44
Job Compensation and Recognition

Many countries are engaging in financial cutbacks as it relates to healthcare

(Thomas, 2004). These activities are reflected by wage freeze, decrease financial and

human resource allocation cutbacks and downsizing. Thus, while more is expected of

health care employees, compensation in the form of remuneration frequently remains

stagnant (Thomas, 2004). Stagnant remuneration may cause dissatisfaction and anger

originating from frustration. Among mental health registered nurses in New England,

Sharpe (2008) noted satisfaction with compensation to have the lowest percentage

compared to other aspects of the job. Aspects of the job considered were opportunities to

use abilities, relationship with coworkers, sense of achievement, and remuneration.

Remuneration scored the highest percentage of job dissatisfaction. Inadequate

compensation was identified by Leiter and Maslach (2009) as one of the most significant

components of the work life of nurses which impacted on depersonalization resulting in

intention to turnover.

Overall job dissatisfaction as a result of hospital merger and dissatisfaction with

remuneration is not only rampant among registered nurses but is also experienced among

supervisors or managers. Results from a study conducted among nursing managers

identified dissatisfaction with pay and poor interpersonal relationship as reasons for

leaving. Poor relationships especially with the head of the department and difficulties

associated with mergers were also identified as reasons for leaving (Skytt, Ljunggren, &

Carlsson, 2007). Change initiatives will produce dissatisfaction among employees unless

the change facilitator is prepared to encourage employees during implementation of

 45
change. Encouragement of employees can be accomplished by positive affirmations such

as verbal recognition for job accomplishments; as a means of building morale (Maginn,

2004).

Results from a study conducted in Australia among registered nurses suggest a

direct link between personal morale and professional recognition. Nurses who reported

higher levels of recognition of job accomplishments scored higher levels of personal

morale and ability to cope with day to day job requirements (Day, Minichiello, &

Madison, 2007). Instead of receiving recognition for work accomplished nurses complain

of being treated with a lack of respect which undermines personal morale and a sense of

efficiency (Thomas, 2004). Low personal morale and a sense of inefficiency among

nurses are stepping stones towards the burnout component of low personal

accomplishment (Borysenko, 2011).

During a study among Chinese registered nurses, results indicated the importance

of professional recognition as a construct of empowering nurses to experience job

satisfaction and a high level of proficiency. The importance of building cordial and

supportive interpersonal relationships through effective communication was emphasized

(Ning, Zhong, Libo, & Qiujie, 2009). Respect for autonomy is a guiding principle of

ethical health care delivery as it relates to bioethics (Beauchamp & Childress, 2001). Its

importance is not only in regards to the health care seeker but is also applicable to the

nurse. Nurses who work in an environment of no autonomy are prone to burnout and are

greatly affected by perceived lack of respect (Fabre, 2009).

 46
Interpersonal Relationships

Provision of clinical care utilizes many relationships of various levels. The nurse

must maintain positive relationships with service users, nurse colleagues, supervisors,

and members of other health related professions; the demands of which may result in an

overload of interpersonal relationship (Thomas, 2004). Results from a study among

Canadian registered nurses implicated poor interpersonal relationship with supervisors as

a contributing factor to job dissatisfaction (Laschinger, Leiter, Day, & Gilin, 2009). Other

factors included lack of empowerment and depersonalization. Findings from the study

further identified poor interpersonal relationship with supervisors along with emotional

exhaustion and depersonalization as factors which contribute to the registered nurses

decision to leave the profession (Laschinger et al., 2009).

Interpersonal relationship is not only important between the registered nurse and

the supervisor but between nurses of similar level. Positive relationships between

registered nurses, managers, and doctors, who worked in an oncology setting, in Canada,

were observed to impact positively on the work environment and the sense of job

satisfaction (Cummings et al., 2008). Poor interpersonal relationships have been

identified as a leading cause of work place associated stress, and is a factor to be

addressed as it relates to the burnout phenomenon. During one such attempt, Scarnera,

Bosco, Soleti, and Lancioni (2009), conducted training sessions with frontline mental

health workers including nurses.

This training was aimed at improving interpersonal relationships and focused on

topics such as effective communication, handling ones negative feelings and thoughts,
 47
and relationship building with colleagues. Findings noted an improvement in the scores

of depersonalization after the training, as well as stabling of the emotional exhaustion and

personal achievement scores (Scarnera et al., 2009). Poor interpersonal relationships are

directly linked to the burnout component of depersonalization and are often associated

with feelings of work place injustice (Sherbun, 2006).

Perception of Fairness

An organization will be perceived as being fair if it creates a work environment

where reliance, transparency, and respect exist. Honesty is expected within such an

environment as employees show and receives respect (Maslach & Leiter, 1997). In 1990,

Greenberg discussed the term organizational justice to refer to a combination of

procedural and distributive justice which is perceived by employees. Distributive justice

includes aspects of fairness of remuneration, promotion performance appraisal, conflict

resolution and decisions regarding cutbacks and downsizing (Greenberg, 1990). Lack of

perceived fairness by employees is a source of stress, frustration, anger, and job

dissatisfaction, which invariable, leads to the burnout component of depersonalization

(Maslach, & Leiter, 1997).

The absence of fairness at work is associated with poor health, which is displayed

by obesity and lowered function of the immune system. Elovainio et al. (2009) found in

their study that a perception of unfair treatment at work may result in sleep problems,

which is associated with obesity and lowered resistance to infections. Research conducted

among nurses scrutinized the four constructs of organizational justice and concluded that

a lack may contribute to the development of two components of burnout; namely

 48
depersonalization and emotional exhaustion (Rodwell, Noblet, Demir, & Steane, 2009).

This research specifically related a low perception of interpersonal, distributive, and

procedural fairness to be associated with increased psychological stress, job

dissatisfaction, and a lack of commitment to the organization, respectively (Rodwell et

al., 2009).

Present day nursing work environment can be closely associated with constructs

of organizational injustice (Thomas, 2004). Work overload and lack of training may be

perceived as distributive injustice, while poor support from supervisors along with lack of

job recognition may be viewed as procedural and interpersonal injustice (St Pierre &

Holmes, 2010). Fairness in an organization is directly linked to the values held by the

organization, which may conflict with the values and beliefs of employees (Borysenko,

2011).

Personal Values

The nursing profession is guided by professional ethics, which along with clinical

and business ethics comprise healthcare organizational ethics (Spencer, Milles, Rorty, &

Werhane, 2000). Organization ethics refers to the morals and values adopted by an

organization, which are utilized as a guide for its decision making Thus, where a conflict

exists between the organizationss values and that of the employee, moral distress will

ensue (Spencer et al. 2000). In 1984, Jameton purported the meaning of moral distress

among nurses as a psychological disharmony which results from not acting on what is

considered to be the correct course of action. This inability to carry out the action
 49
considered being correct is usually due to of lack of resources, insufficient time, or

organization policy or guidelines (Thomas, 2004).

According to research results, moral distress has a high occurrence among nurses

who work in acute medical and surgical departments. Incidence appears to increase with

length of service in the department (Rice et al., 2008). The concentration of moral

distress appears greater as it relates to ineffective care and caregiving practices of doctors

and nurses. Generators of moral distress include organizational factors, deception, and the

deliberate decision to end life. Moral distress associated with futile care and deception

was noted to be of a greater frequency (Rice et al, 2008). Moral distress is linked to job

dissatisfaction, which is implicated in the burnout component of emotional exhaustion

(Potter, 1996).

Leiter and Maslach (2009) purported the notion of value conflicts as one of the

most significant components of the work life of nurses which impacted on

depersonalization. Previous research results has concluded that work related moral stress

experienced by nurses is influenced by the moral climate of the health care organization

(Ltzn, Blom, Ewalds-Kvist, & Winch, 2010). An organizations moral climate is

influenced by the ethical and moral values of the organization. Used by the leaders,

ethical and moral values guide decisions, and conflict resolution; and influence the

employees perception of honesty, fairness, openness and justice (Hatcher, 2002).

Comparison between Nursing Specialty Environments

There appears to be disagreement among researchers regarding the specialty work

environment of nurses which mostly contributes to the development of burnout. Some

 50
studies implicate psychiatric care environments (Sahraian et al., 2008), others claim

medical (Schulz et al., 2009), while others identified acute care work environments

(Hanrahan, McClaine, & Hanlon, 2010). Wicks (2006) identified three levels of burnout

and theorized that all nurses experience the first level intermittently. First level burnout is

easily resolved and is characterized by mild symptoms over short periods. Nurses with

level two burnout display symptoms which are better established, requires an effort to

resolve, and last for longer periods. At level three, nurses display signs of illness,

symptoms are chronic, and the condition is well established.

Sahraian et al. (2008), during their study in Iran, identified higher level of

emotional exhaustion and depersonalization among nurses in the psychiatric work

environment. The presentation of these constructs is representative of high level of

burnout. Schulz et al. (2009) concluded differently based on results from their research

conducted in Germany. Nurses working in medical departments in Germany portrayed a

higher level of burnout as it relates to all three components; along with higher scores of

effort-reward imbalance. Although workload has increased for nurses, the improvement

of the community psychiatric programs have allowed psychiatric institutional care work

environments to improve in Germany; enforcing the importance of the workload aspect

of the work environment in relation to burnout.

A higher level of burnout was observed by Hanrahan, McClaine, and Hanlon

(2010) among nurses working in the acute care environment compared with those in the

psychiatric care environment. The researchers noted lower patient to nurse ratios and

healthy nurse physician relationships. Skilled and competent unit managers providing
 51
leadership and better work environments were also noted at the psychiatric facility. It

appears that the organizations work environment may be more important than the

nursing specialty or nature of care provided as it pertains to the experience of burnout

(Hanrahan et al., 2010).

Yet research conducted among nurse practitioners, nurse managers and

emergency nurses indicate that nursing specialty impacts on the job-control aspect of the

work environment. Nurse practitioners were noted to have the lowest level of burnout

accompanied by the highest level of job control. Emergency nurses had the highest level

of burnout and the lowest level of job control (Browning, Ryan, Thomas, Greenberg, &

Rolniak, 2007). Nurses practitioners are nurses who have had advanced training in

assessment and diagnosis, is able to function independently; and hold prescriptive rights

in many countries (Allen, Hughes, Jordan, Prowse, & Snelgrove, 2002).

Effects of Burnout

Whereas burnout affects the physical and psychological aspects of health of the

nurse, its effects spill over to the service user (Wicks, 2006). Results from research

conducted by Teng et al. (2009) suggest a positive influence of job commitment, on many

aspects of care delivered. These aspects of care include safety; demonstration of empathy

by the nurse; and sensitivity to patients needs, as well as the patientss view of the

quality of care which they receive. Thus, when nurses experience burnout, evident by the

absence of commitment to work, these aspects of care are compromised (Wicks, 2006).

Previous research has suggested an increase in sick days and absenteeism, as well as

substandard job performance when employees experience burnout (Rauhala et al., 2007).
 52
Such a situation has implication for the quality, as well as the cost of care provided and

delivered to seekers (Sherbun, 2006).

Quality of care

Quality of care is negatively impacted by poor interpersonal relations among the

health care team via which care is provided. These teams usually comprise nurses and

physicians among whom burnout frequently exist (Wicks, 2006). Quality of care is also

influenced by the occurrence of errors in two ways. First the burnt out nurse is prone to

errors as work efficiency drops and second the existence of burnout increases the

challenge of identify that an error has occurred. Findings of research conducted by

Halbesleben, Wakefeld, Wakefeld, and Cooper (2008) suggest an association between

burnout and a perception of a less safe environment for patients, as well as a decrease in

reporting of errors.

The care environment of the organization, as well as the level and nurse to patient

ratio or workload, affects the quality of care (Thomas, 2004). Research carried out by

Aiken, Clarke, Sloan, Lake, and Cheney (2008) found better work environment, nurse to

patient ratio of 4:1, along with a majority percentage of higher educated nurses, to be

directly linked to a lower mortality rate. Rapid turnover of nurses equates to nurses who

are new to the organization, possible inexperienced, and need training and time to adjust

to their environment. Thus, burnout, which often causes turnover among nurses, may

result in a lowering of the quality of care and an increase in the cost associated with

training (Wicks, 2006).

 53
Cost of care

Burnout increases the cost of care to both the nurse and the health care

organization (Maslach, 2003). The nurse must cope with the extra financial cost incurred

from frequent illnesses while family members cope with the psychological impact

(Maslach, & Leiter, 1997). Inability to sleep, gastrointestinal problems, headache,

hypertension and its related chronic diseases, and poor self-esteem are included among

the physical and psychological issues with which the nurse must cope (Maslach, 2003;

Wicks, 2006). The healthcare organization must continuously train new nurses while

burnt out nurses who remain are less capable of the quantity and quality of care expected

(Wicks, 2006). The cost to the organization associated with medical errors can be

horrendous where litigation is involved and may also cost the nurse a career. The need for

constant, temporary replacements to cover nurses during absenteeism and sick days also

increases the cost of health care delivery (Wicks, 2006).

Burnout Prevention

As applicable to illness and disease conditions, prevention of burnout is better

than cure; and where prevention fails early detection is the best option (Maslach, 2003).

The primary cause of burnout has been identified as the work environment. Issues

regarding the work environment must be addressed, in an attempt at decreasing the

occurrence of burnout. As previously mentioned, burnout influences the nurses decision

to leave which in turn increases the workload of remaining nurses and the increased risk

of burnout. Therefore, interventions aimed at influencing the nursess decision, not to

turnover, will decrease the risk of burnout (Sherbun, 2006). Although changing jobs is an
 54
option for preventing and handling burnout, it is important for the nurse to recognize the

environmental factors of the present organization which contribute to burnout so as to be

equipped for assessing the new work environment (Potter, 1996).

Hinson and Spatz (2011) during their research implemented five areas of change,

which resulted in, a reduction of nurses leaving the employment, along with a notable

financial gain to the organization. These areas included onboarding, employee rounding,

social networking, employee recognition, and developmental stretch assignments.

Prevention of burnout requires an effort from both the employee and the organization and

is less costly to both parties than dealing with the effects of burnout and its recovery.

Reducing the possibility of the occurrence of the mismatches between the employees and

the job will prevent burnout and result in job engagement (Maslach & Leiter, 1997).

Onboarding

A process used to help new employees adjust to the environment of the

organization is referred to as on boarding. Hinson and Spatz (2011) during their research

used on boarding strategies such as welcoming, assignment of older nurses as mentors,

and the conducting of orientation sessions with newly employed nurses. Members of the

orientation team were available on all shifts and discussions were held on pertinent topics

such as coping with your first experience of death. On boarding extended over a period of

many months and allowed for the development of healthy interpersonal relationships. On

boarding also fostered an enthusiasm and commitment for work and built the self-esteem

of members of the orientation team as well as mentors (Hinson & Spatz, 2011).
 55
Previous research conducted among registered nurses in Australia reported results

which indicated that healthy relationships among health care team members impacted

positively on the quality of care provided (Day et al., 2007). According to Wicks (2006)

employees should be well oriented to the expectations of the organization, as well as to

available support systems, from the inception. Being forewarned about existing situations

and challenges, which the job entails, allows for the opportunity to forearm oneself and

so as to cope with the workload (Maslach, 2003). Continuous education and periodic self-

evaluation about burnout will assist nurses to be constantly aware of and prevent the

hazards of burnout (Norcross & Guy, 2007).

Employee Rounding

The mainstay of employee rounding during the Hinson and Spatz study was the

development of communication between colleagues, as well as unit managers. Monthly

meetings were conducted during which the issues and concerns of the nurses were

discussed and addressed. Discussion of care plan and assignment of simple educational

task formed part of the rounding process; for which success was recognized with a simple

token. Employee rounding provided the opportunity for nurses to express concerns, and

build trust and respect and develop mechanisms for coping with assigned work (Hinson

& Spatz, 2011).

Nurses must have the opportunity to express concerns to managers in a civil

manner without the threat of judgment and repercussions (Wicks, 2006). It is important

for nurses to perceive the health organization as fair, a lack of which will contribute to

the development of depersonalization (Maslach & Leiter. 1997). This effect of a lack of
 56
perceived organizational justice that is observed among employees is not constrained to

nurses only. Results from a study conducted among Swedish employment officers

suggest an association between a low level of burnout and high perception of the

existence of fairness at the workplace (Liljegren & Ekberg, 2009).

Social Networking

The primary purpose of social networking is to encourage relationships which

would provide much needed social support for each other. Social events can be planned

in accordance with unit highlights, health oriented days such as world aids day; as well as

calendar and seasonal changes and celebrations (Hinson & Spatz, 2011). Chiu et al.,

2009) during analysis of their research results observed a negative association between a

high level of social support and nursess intention to leave the profession in Taiwan.

When the nurse perceived to receive a high level of social support, thoughts of leaving

the profession were not entertained.

One must be supportive to receive support (Wicks, 2006). Nurses must be

supportive of the goal and objectives of colleagues to receive support in return when

needed (Potter, 1996). The development of a circle of support is a skill possessed by

individuals who are resilient (Maddi, & Khoshaba, 2005). Mechanisms of coping with

stress related to work should include strategies of relaxation, debriefing, exercise, humor

shared with and not about colleagues, and socializing (Maslach, 2003). Social networking

provides an opportunity for development of healthy interpersonal relationships; an

absence of which increases the risk of burnout (Wicks, 2006).

 57
Employee Recognition

Recognition of the efforts of nurses was identified as paramount for developing

work engagement and engendering an environment of fairness (Wicks, 2006). Strategies

included public recognition at organized dinners or lunch, personalized electronic or

paper cards, verbal acknowledgement at unit meetings, or small certificates, which could

have been redeemed, for meals or tokens (Hinson & Spatz, 2011). Recognition of the

nurses effort will build self-esteem necessary for preventing the burnout component of

decreased personal accomplishment (Thomas, 2004). Recognition can also be

incorporated into rewards, which may be given as time off from work. Efforts which are

highlighted in written evaluations, may result in recognition and rewards, in the form of

promotion, for the nurse (Sherbun, 2006).

Developmental Stretch Assignments

Developed out of employee rounding, stretch assignments allowed nurses to

construct detailed plans aimed at addressing concerns or enhancing specific areas of the

unit or the care provided (Hinson & Spatz, 2011). These proposals were not to be

initiated by unit managers but were the responsibility of the subordinate nurses who were

expected to implement their well-structured ideas after discussion and approval. These

projects generated a feeling of fulfillment and allowed for engagement with work which

resulted in satisfaction. This empowering opportunity allowed for the autonomous

expression of nurses and generated a feeling of job satisfaction (Hinson & Spatz, 2011).

This strategy is supportive of results coming out of a study by Schmidt, and

Dieste (2009), which noted an increase in job satisfaction as job control increased; along
 58
with a decrease in the level of emotional exhaustion. Ning, Zhong, Libo, and Qiujie

(2009) during their research among Chinese nurses observed a positive correlation

between the experience of job satisfaction and empowerment. A lack of job satisfaction is

associated with the burnout component of depersonalization (Maslach & Leiter, 1997).

Personality Traits and Mindset

Regardless of the environmental risk for burnout which exists in an organization,

employees may not all experience burnout (Maddi & Khoshaba, 2005). Results from a

study conducted among health care workers employed with the same organization;

identified characteristics of high self-esteem, emotional stability, tolerance, ability to

adapt, and resilience among the non-burnout group (Gustafsson, Parsson, Eriksson,

Norberg & Strandberg, 2009). The personality trait of hardiness has also been identified

as necessary for coping with burnout risk environments and preventing burnout (Maddi &

Khoshaba, 2005). Garrosa et al. (2010) during a study among nurses; identified a

personality with the characteristics of hardiness as useful to the nurse for lowering

susceptibility to burnout.

Characteristics associated with a hardy personality may be inbred but can also be

learnt or developed as a mindset. Hardiness is considered the foundation of resilience,

which is needed for coping, surviving, managing or thriving in the presence of stressful

situations such as is present in burnout risk environments (Maddi & Khoshaba, 2005).

Resilience is the ability to recover from adverse occurrences and achieve a measure of

success (Neenan, 2010). Resilient persons display attitudes of commitment, challenge,

and control, through which they develop skills of transformational coping and the ability
 59
to form a circle of social support. The skill of transformational coping will allow the

resilient individual to use stressful situations for self-benefit (Maddi & Khoshaba, 2005).

Committed individuals regard their work as vital and use every means to remain

involved in work activities and are attentive to the work process (Maddi & Khoshaba,

2005). The attitude of control equips persons to seek opportunity through which they are

able to influence the changes around so as to be beneficial to self. Persons who possess

the resilient attitude of challenge have embraced the reality of constant change, and

continuously endeavor to use change as learning opportunities (Maddi & Khoshaba,

2005). Another personality trait associated with the ability to deal successfully with

stressful situations is a sense of coherence (Nordang, Hall-Lord, & Farup, 2010; Van der

Colff & Rothmann, 2009).

Antonovsky as cited in Van der Colff and Rothmann (2009) introduced the term

sense of coherence to mean the ability to view stress as manageable and cope in a manner

which preserves health. Sense of coherence comprises constructs of comprehensibility,

meaningfulness, and manageability and allows individuals to rationalize stressful

situations and identify meaningful resolutions. Research conducted among nurses during

a stressful period of reorganizing and downsizing of the health care organization,

revealed a noticeable progress of burnout, which was associated with a low level of sense

of coherence (Nordang, Hall-Lord, & Farup, 2010). Another study among registered

nurses employed at both private and public health institutions in South Africa identified a

weak sense of coherence as a fore runner of a high level of emotional exhaustion and

depersonalization and, therefore, burnout (Van der Colff, & Rothmann, 2009).
 60
Recovering from Burnout

A burnout experience does not have to be the end of ones world (Berglas, 2009).

As with any problem the first step towards resolution is to be honest with ones self and

admit the existence of the problem. From there, burnout can provide the opportunity for a

fresh start (Glouberman, 2003). Similar to developing burnout, recovery does not happen

overnight. A fresh start comes with developing new habits while breaking away from the

old (Glouberman, 2003). A fresh start involves reviewing personal beliefs and values,

managing time differently, and taking care of physical health. During recovery learning

to say no becomes vitally important as a means of allowing time for self-care and

rejuvenation (Lewis, 2002). During the healing process acquiring the hardy skills of

commitment, challenge and control will prepare for future encounters with burnout risk

work environments (Maddi, & Khoshaba, 2005). Sharing your experience with others

will serve as a reminder for yourself, as well as a warning for others (Lewis, 2002).

Psychological Stress Theory

The psychological stress theory is a cognitive stress theory, which identifies stress

as a specific type of affiliation or association between the environment and an individual

(Lazarus, 1990) and was utilized to guide this study. The psychological stress theory is

regarded as taxonomy or second level theory that relates directly to burnout that develops

as a result of dissonance between an individual and the work environment (Creswell,

2009; Maslach, 2003). According to Center for Disease Control and Prevention (CDC),

the establishment of work process in recent times has increased the level of job related

stress experienced by employees. This work process includes the procedures, plan, and
 61
format, of accomplishing work related activities as well as the accompanying supervision

(National Institute for Occupational Safety and Health [NIOSH], 2002). Referred to as

organization of work, this work environment incorporates external organizational and

work contexts (NIOSH, 2002, p.2).

The external context includes global influences while organizational context

refers to guidelines and supervision methods. Work context includes workload, job

responsibilities, interpersonal relationships and opportunity for personal advancement

(NIOSH, 2002). The psychological theory of stress purports two main variables which

impact on the stress experience; the environment and personal characteristics (Lazarus,

1999). This study investigated the environment variable and specifically the work

environment as an independent variable. According to Lazarus (1999), the variable,

environment can be broken down into four basic variables namely demand, opportunity,

culture, and constraint (p.61).

Demands from the environment oblige individuals to conform to rules and

regulations and includes the morals and values upheld by an organization (Lazarus,

1999). The demand variable can be a source of conflict with an individuals personal

beliefs and thus contribute to dissonance with the work environment; an aspect

implicated in burnout (Lazarus, 1999; Maslach, 2003). The environmental variable of

constraint impacts on coping mechanisms available to deal adequately with situations

such as work overload and poor supervision (Lazarus, 1999). These concepts have been

identified as contributors to the development of psychological stress as well as

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components of the work environment which increases an individuals risk of developing

burnout (Lazarus, 1999; Thomas, 2004).

The opportunity variable engages individuals in assessment; requires alertness to

timing and requires judgment in making a decision regarding choices (Lazarus, 1999).

The psychological stress variable of opportunity is implicated in the burnout component

of reduced personal accomplishment, a dependent variable of this study. The variable

also influences the compensation and job recognition aspects of the burnout environment

(Lazarus, 1999; Thomas, 2004). The last psychological stress environment variable is that

of culture, which speaks of customs and habits (Lazarus, 1999). The manner in which the

work environment conducts appraisal, handles conflict, and conducts supervision is

influenced by the organization's culture and influences the development of burnout

(Maslach, 2003).

The second main variable identified by Lazarus (1999) is that of personal

characteristics relating to cognition or ones mental ability. This variable may be

regarded as the most important, as an individuals experience of psychological stress

relates directly to that individuals mental evaluation of the environment (Lazarus &

Folkman, 1984). This mental evaluation referred to as cognitive appraisal is conducted

in two phases (Lazarus & Folkman, 1984, p 31). During phase one, an individual assesses

the environment while, during the second phase, ones coping resources is appraised

(Lazarus, 1999; Lazarus & Folkman, 1984). As persons cognitive abilities and

perception vary so too do individual perception of stress and indirectly the level of stress
 63
experienced. An environment assessed as being overwhelming to personal coping

mechanisms will be perceived as being stressful (Lazarus & Folkman, 1984).

The psychological stress theory proposes strategies for coping. Coping is referred

to as continued intellectual and interactive activity aimed at managing psychological

stress (Lazarus, 1993). Coping utilizes two main strategies. The first and most successful

coping strategy is that of changing the individual-environment relationship. The second

strategy involves avoiding, ignoring, or distancing self from the stress producing

environment (Lazarus, 1993). According to research results this second strategy is used

by police officers and other human service providers and is referred to as

depersonalization; a component of the burnout phenomenon (Maslach & Leiter, 1997;

Schaible, & Gecas, 2010).

Research Methods

Research about burnout and its related variables conducted among human service

professions frequently uses the Maslach Burnout Inventory (Gonzalez-Morales,

Rodrguez, & Peiro, 2010; Rice, Rady, Hamrick, Verheijde, & Pendergast, 2008;

Scarnera, Bosco, Soleti, & Lancioni, 2009). The inventory is used singly or along with

other data collecting instruments excluding demographic questionnaires. Often

researchers seek to investigate the level of burnout and may include the main components

of emotional exhaustion, depersonalization and personal accomplishment (Halbesleben et

al., 2008; Schulz et al., 2009). Although studies use a qualitative method where

description of the burnout experience is sought (Ablett, & Jones, 2007; Gustafsson,

Norberg, & Strandberg, 2008), the majority of studies employ a quantitative design.
 64
These studies seek to answer research questions based on relationships between

variables or hypothesis testing and often seek to associate the components of burnout

with specific aspects of the work environment (Chiu et al., 2009; Jourdin, & Chnevert,

2010). Through the use of quantitative methods (Aranda et al., 2009; Schaible, & Gecas,

2010) such as cross-sectional surveys and correlational studies, researchers have sought

to investigate the relationship among burnout, job stressors, and personality. The effects

of burnout on quality of health care delivered have also been investigated (Garrosa et al.,

2010; Teng et al, 2009).

Cross sectional studies have been used to investigate the level and existence of

burnout among specific nursing populations. Such studies also provided information

regarding the effect of burnout on health care and the coping mechanisms and strategies

employed by both the organization and the nurse (Garrosa et al., 2010; Teng et al., 2009;

2010). Surveys often form part of the research design (Liat, 2009; Schmidt & Dieste,

2009; Van der Colff & Rothmann, 2009) while experimental studies (Nordang, Hall-Lord

& Farup, 2010) are infrequently used.

Summary

Burnout is a phenomenon primarily caused by chronic stress related to the work

environment especially for those of human service profession. The phenomenon has its

base in the psychological theory of stress which describes stress as a relationship between

an individual and the environment. Burnout is accentuated by a deficit of hardy

individual personality traits which include commitment, challenge and control. Burnout is

also associated with a low sense of coherence. These deficits in personality traits, which
 65
assist individuals to cope with high levels of stress, increase the susceptibility of

individuals to the burnout risk of the work environment. Burnout is made up of three

main components; namely emotional exhaustion, depersonalization, and low personal

accomplishment. Burnout is rooted in mismatches between an individual and their job

(Potter, 1996). These mismatches include work load, work control, values, job

recognition and compensation, interpersonal relationships, and fairness. Burnout can

occur among individuals engaged in any work but is frequently observed among human

service professionals such as nurses, police officers, doctors, social workers, and

members of the clergy.

Nurses are believed to have an increased risk of burnout because of the work

environment, which allows for the experience of the six identified mismatches. Research

on burnout often involves the use of the Maslach Burnout Inventory (Maslach, Jackson,

& Leiter, 1996) for an assessment of the level and components of burnout. Burnout

among nurses negatively impacts the quality of health care provided, increases the cost of

health care while damaging the health of the nurse. Prevention of burnout is regarded as a

more cost effective strategy compared to dealing with effects and recovery. The level of

burnout as it relates to psychiatric or medical work environments cannot be generalized.

Each situation must be individualized as countries may develop one area of health care

and its work environment more than another.

Research has linked these six identified causes referred to as mismatches to

specific components of burnout which are the dependent variables for this study. The

component of emotional exhaustion and depersonalization together has been linked to an

 66
environment where work overload and poor job control prevails. Poor job compensation

and or recognition are noted to increase depersonalization and decrease a feeling of

personal accomplishment. Poor interpersonal relationships will impact all three

components of burnout but has its greatest effect by increasing depersonalization. A

perception of injustice in the organization greatly increases the component of emotional

exhaustion, similarly to the mismatch of personal values. Perceived injustice is also

linked to an increase in the burnout component of depersonalization.

Coping mechanism for burnout comprises strategies implemented by both the

organization and the professional or employee. Knowledge of the possibility of

developing burnout is important to addressing the phenomenon. Awareness of the

existence and domino effect of burnout among nurses is important for prevention.

Burnout impacts negatively on the quality and cost of healthcare and thus the health of

society.

It is important that both the nurse and the work organization be cognizant of the

existence of burnout when it occurs. Research into the level of burnout experienced by

nurses, will provide vital information for the organization towards the need for reviewing

of the work environment, which has been implicated in the cause of burnout. Such a

study will also create awareness among nurses, allowing them the opportunity to employ

preventative and coping mechanisms. The following chapter provides a detailed

description of one such study, conducted to compare the level of burnout and burnout

components at two different health care provision environments.

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Chapter 3: Research Methodology

Introduction

I compared the level of burnout and the relationship among burnout, age, and

years of service among registered nurses in Caribia. The levels of emotional exhaustion,

depersonalization, and personal accomplishments (components of burnout) were also

investigated. The study focused on registered nurses involved with the delivery of patient

care in a government-controlled general healthcare facility and a mental health

institution. The psychological stress theory (Lazarus, 1966) formed the basis of this

study. A comparison of the level of burnout among the nurses was investigated in an

effort to answer the following six research questions and test the corresponding

hypotheses. The research questions emerged from the refusal of registered nurses to work

at the mental health institution and an observed poor level of mental health care delivery

in Caribia.

Question 1: What is the level of the burnout component of emotional exhaustion

among registered nurses employed at a general healthcare facility as compared to

registered nurses employed at a mental healthcare institution in a Caribbean island?

Null Hypothesis (Ho): There is no difference between the levels of emotional

exhaustion among registered nurses employed at a general healthcare facility as

compared to registered nurses employed at a mental healthcare institution in a Caribbean

island. Levels of emotional exhaustion will be measured by the sum of the numerical

value of responses to questions assigned in the data gathering instrument, to assess the

participantss emotional state.

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Alternate Hypothesis (H1): The level of emotional exhaustion among registered

nurses employed at a general healthcare facility is different as compared to registered

nurses employed at a mental healthcare institution in a Caribbean island.

Question 2: What is the level of the burnout component of depersonalization

among registered nurses employed at a general healthcare facility as compared to

registered nurses employed at a mental healthcare institution in a Caribbean island?

Ho: There is no difference between the levels of depersonalization among

registered nurses employed at a general healthcare facility as compared to registered

nurses employed at a mental healthcare institution in a Caribbean island. The levels of

depersonalization will be measured by the sum of the numerical value of responses to

questions assigned to assess the participantss experience of depersonalization.

H1: The level of depersonalization among registered nurses employed at a general

healthcare facility is different as compared to registered nurses employed at a mental

healthcare institution in a Caribbean island.

Question 3: What is the level of the burnout component of personal

accomplishment among registered nurses at a general healthcare facility as compared to

registered nurses employed at a mental healthcare institution in a Caribbean island?

Ho: There is no difference between the levels of personal accomplishment among

registered nurses employed at a general healthcare facility as compared to registered

nurses employed at a mental healthcare institution in a Caribbean island. The levels of

personal accomplishment will be measured by the sum of the numerical value of

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responses to questions, assigned in the questionnaire, to assess the participantss sense of

personal accomplishment.

H1: The level of personal accomplishment among registered nurses employed at a

general healthcare facility is different as compared to registered nurses employed at a

mental healthcare institution in a Caribbean island.

Question 4: What is the level of burnout experienced by registered nurses

working at a general healthcare facility as compared to registered nurses working at a

mental healthcare institution in a Caribbean island?

Ho: There is no difference in the level of burnout experienced by registered

nurses employed at a general healthcare facility as compared to registered nurses working

at a mental healthcare institution in a Caribbean island. Burnout levels will be computed

based on the determined levels of emotional exhaustion, depersonalization, and personal

accomplishment.

H1: The level of burnout among registered nurses employed at a mental

healthcare institution is higher than the level of burnout of registered nurses employed at

a general healthcare facility in a Caribbean island.

Question 5: What is the relationship between age and the level of burnout

experienced by registered nurses employed at a general healthcare facility as compared to

registered nurses working at a mental healthcare institution in a Caribbean island?

Ho: Age has no relationship with the level of burnout experienced by registered

nurses employed at a general healthcare facility as compared to registered nurses working

 70
at a mental healthcare institution in a Caribbean island. The computed level of burnout

will be analyzed in relation to the participantss age.

H1: Age is negatively correlated to the level of burnout experienced by registered

nurses employed at a general healthcare facility as compared to registered nurses working

at a mental healthcare institution in a Caribbean island?

Question 6: What is the relationship between years of service and the level of

burnout experienced by registered nurses employed at a general healthcare facility as

compared to registered nurses working at a mental healthcare institution in a Caribbean

island?

Ho: Years of service has no relationship with the level of burnout experienced by

registered nurses employed at a general healthcare facility as compared to registered

nurses working at a mental healthcare institution in a Caribbean island. The participantss

years of service will be analyzed in relation to the computed level of burnout.

H1: Years of service is negatively correlated to the level of burnout experienced

by registered nurses employed at a general healthcare facility as compared to registered

nurses working at a mental healthcare institution in a Caribbean island?

Research Design and Approach

Quantitative research design is used for conducting investigations directed at

determining the relationship between variables and thus tests hypotheses (Creswell,

2009). Quantitative research is also best suited for comparison between groups (Creswell,

2009), as was the purpose of this study. In so doing, I scrutinized the relationship

between the independent variables (institution of work, age, and years of service) and the
 71
dependent variable (level of burnout). I also examined the relationship between the

independent variable institution of work and the dependent variables of burnout

components (emotional exhaustion, depersonalization and reduced personal

accomplishment). A cross sectional survey design was used for this study. Surveys are

usually used to gather information about distinguishing features of an identified

population. Surveys allow researchers to assess attitudes and associations between mental

and social variables of specific populations (Salkind, 2009).

I gathered information directly from the identified population of registered nurses

regarding distinguishing features of burnout. Registered nurses in Caribia claim the

mental health work environment to be a greater risk of developing burnout than the

environment of the medical institution. This opinion held by registered nurses has

influenced their decision to refuse employment at the mental health institution. The

refusal of employment by registered nurses has resulted in increased employment of

nursing assistants at the mental health institution (World Bank, 2009).

Nursing assistants are required to work under the supervision of registered nurses

(International Council of Nurses, 2008). Thus, a shortage of registered nurses employed

at the mental health institution may lead to a compromise in the standard of health care

provided. This study contributed information required to refute or support the claim made

by registered nurses. Results from this study also generated an awareness of burnout

among nurses in Caribia and provided vital information for health care managers towards

positive social change of the work environment.

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A cross-sectional method provides the opportunity for researchers to examine

more than one group of individuals at a specific time, as was done for this study (Salkind,

2009). Cross sectional designs are not used to identify causes but instead to identify

patterns and relationships between variables (Frankfort-Nachmias & Nachmias, 2008).

Similarly, this study was not used to identify the causes of burnout. Instead, I sought to

discover the existence and component patterns of burnout as they relate to the institution

of work. I was responsible for informing nurses employed at the participating institutions,

of the impending research. It was also my responsibility to obtain consent from the

participants and to ensure ethical execution of the study. Permission to conduct the study

was first sought and received from the management of the institutions (Appendix A & B).

Setting and Sample

Dissemination of information to nurses regarding the intended study was

accomplished through the use of research notification flyers (Appendix A), distributed

throughout the two health care institutions involved with this study. Research notification

flyers were circulated before the actual data collection was carried out. Information

regarding the intended research was also provided to the professional association of

nurses. Participant invitation flyers (Appendix B) were used to invite registered nurses to

participate in the study. Participant invitation flyers along with data collecting packages

were distributed to every unit where registered nurses are assigned at the participating

institutions. This advertisement strategy allowed for a convenience sampling of the

population of registered nurses at the institutions.

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Permission to conduct this study was sought and received from the Institutional

Review Board (IRB) of Walden University. The approval number is 03-28-12-0194514.

The institutions under study do not have an ethics committee or review board. Thus,

written permission and approvals were sought and obtained from the nursing director and

principal nursing officer, who have overall responsibility for nurses at their assigned

institution. A research ethics committee was established in Caribia after permission was

received from the management of the participating institutions. The committee functions

as a subcommittee of the islands Medical and Dental Health Council and is responsible

for assuring ethical conduct of research studies as it relates to non-maleficence and

beneficence. Permission to conduct the study was sought from this local research ethics

committee and received.

The population was registered nurses who have been employed for a year or more

at the general healthcare facility and the mental healthcare institution. Both institutions

are located in the capital, which has a population of 67,000. The total population of the

island is estimated at 161,557. The total population of registered nurses working in these

two organizations is 132 (Government Website, 2011). All were invited to participate.

Convenience sampling method was used to obtain participants that made up the sample.

The sampling method can also be regarded as volunteer sampling as although the entire

population was invited to participate, participation was voluntary and volunteers were

accepted as part of the sample. The nursing population of the general healthcare facility

comprised 118 registered nurses while the mental healthcare institutions population is

14, for a total of 132 possible registered nurses for this research sample.
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Convenience sampling is a nonprobability sampling strategy during which

available members of the population are sampled (Creswell, 2009). Therefore, the sample

size confidence interval and confidence level could not be projected. Confidence interval

speaks of the margin of error of the results while confidence level speaks of the

researchers sureness that the obtained results are applicable to the population under

study. Researchers often use confidence intervals of 90%, 95%, or 99%, which is

regarded as evidence of the usefulness of the research results (Creswell, 2009).

Although the sampling strategy did not require a projected confidence interval

and confidence level, data will be statistically significant only if the number of

participants meet certain parameters. Based on a 90% confidence level, a confidence

interval of 10, and a distribution response of 50%, 12 members of the population of 14

would generate statistically significant data from the mental health institution. The

general healthcare institution required 44 participants from the population of 118.

The general healthcare facility is a 150-bed hospital, with pediatric, surgical,

medical, intensive care, theatre, and accident and emergency departments where

registered nurses are employed. This institution is the main public provider of health care

services to the island, and its nursing division is under the supervision of a nursing

director. The overall function and responsibility of the facility is that of the Ministry of

Health (Government Information Service Website, 2007). The levels of burnout at the

general healthcare facility were not compared between departments because although

nurses are assigned to specific specialties, session work is carried out in other

departments due to shortage of nurses. Registered nurses employed at the general

 75
healthcare facility work a combination of three shifts, a total of 37.5 hours weekly and

are not assigned to any particular work shift schedule (Government Website, 2010).

The mental healthcare institution is also the responsibility of the Ministry of

Health. It is the only mental health facility on the island and has a total bed capacity of

108; 84 are designated to mental health while the other 24 (not currently in use) are to be

used by neurology (Government Information Service Website, 2010). The institution is a

six unit facility where shortage of nursing also exists, demanding nurses to work on

assigned units, as well as other units as the need arises. Patients are assigned to the

various units based on their stage of illness and their nursing care needs (Government

Information Service Website, 2010).

Registered nurses employed at the mental health institution work a total of 35.5

hours weekly as a combination of three different shifts (Government Website, 2009). The

nursing division is under the direct supervision of the principal nursing officer. The

principal nursing officer and the nursing director were not invited to participate in the

study. Although they are registered nurses, they do not share a similar work environment

with registered nurses involved with direct patient care; which comprise the population

under study.

Instrumentation and Materials

The Maslach Burnout Inventory (MBI; Maslach, Jackson, & Leiter, 1996) was

used as the main data gathering instrument. Permission (Appendix C) had been sought

and received from the entity responsible for its use. A questionnaire constructed by the

researcher (Appendix D) was used to collect demographic data, which included age,
 76
gender, years of service, and institution of employment. The demographic questionnaire

also allowed each participant to comment on an issue of concern about his or her

institution of work and to identify reasons for refusing or accepting employment at the

mental health institution. This demographic questionnaire allowed for collection of a

limited amount of qualitative data for descriptive purposes.

Three versions of the MBI are available: Human Service Survey (HSS), General

Survey (GS), and Educators Survey (ES). The Maslach Burnout Inventory-Human

Service Survey (MBI-HSS) is the original instrument designed for assessment of burnout

among professionals employed in the human services (Maslach et al., 1996). Sample

questions of the survey are provided in Appendix E. The MBI-HSS is designed to

measure emotional exhaustion (EE), depersonalization (DP) and personal

accomplishment (PA) that are recognized as the main components of burnout (Maslach et

al., 1996). The instrument was self-administered and required 10 to 15 minutes for

completion (Maslach et al., 1996). The demographic questionnaire was attached to the

MBI-HSS scale and presented as a combined data collection package.

The Maslach Burnout InventoryHuman Service Survey (MBI-HSS) is a Likert

scale with six choices ranging from never to every day; comprising a total of twenty two

items. A numeric value is assigned to each of the six choices allowing for the collection

of quantitative data. Five items are assigned to assessing depersonalization, nine allocated

for the assessment of emotional exhaustion and eight utilized for assessing personal

accomplishment. Although items of the MBI-HSS gather information about feelings and

experiences, questions seek the participants frequency of experiencing specific feelings.

 77
A numerical value is assigned to the frequency of each experience; thus the survey

gathers numerical data.

The structure of the instrument allows for assessment of each component for each

participant. Arriving at a cumulative score is not the purpose of using the MBI-HSS

(Maslach et al, 1996). Instead, the total numeric value of each burnout component is

computed and assessed. The MBI-HSS is frequently used for data collection during

research involving nurses and burnout (Jenkins & Elliott, 2004; Kanai-Pak et al., 2008;

Schultz et al., 2009; Teng et al., 2010). According to the literature search the MBI is the

most commonly used tool in research, for measuring the level of the three components of

burnout, as well as the level of burnout itself.

Interpretation of Results

Each burnout component was scored independently thus three subtotals resulted.

Emotional exhaustion (EE) measures the effect of work on an individuals emotion.

Depersonalization (DP) assesses the professionals feeling towards service users and

personal accomplishment (PA) evaluates feelings of efficiency. Each subscale is

evaluated using a range of six (Appendix E), and total numeric scores for each

component are regarded as being high, average, or low (Maslach et al., 1996). High

scores are in the upper third, average in the middle third, and low, in the lower third.

Burnout is assessed in a similar manner of being high average or low. A high degree of

burn out is equated to high EE and DP scores coupled with a low PA score (Maslach et

al., 1996). An average degree of burnout is represented by average scores of all three
 78
components. A low degree of burnout is reflected by a high PA score coupled with low

scores for EE and DP (Maslach et al., 1996).

Reliability and validity

The reliability of a data gathering instrument is its ability to measure repeatedly,

the same constructs and give similar results (Frankfort-Nachmias & Nachmias, 2008;

Salkind, 2009). The MBI-HSS has maintained consistency within subscales for

longitudinal studies, as well as when used for test and retest. Studies were conducted for

interval periods of one month, three months and up to one year during which consistency

of results examined (Maslach et al., 1996). The emotional exhaustion component

subscale had a reliability coefficient of .90, depersonalization .79, and personal

accomplishment .71. Data gathering instruments must be characterized by validity which

is of three types; content, empirical and construct. Validity of a data-gathering instrument

speaks of its ability to measure the constructs that the researcher intends to measure

(Frankfort-Nachmias & Nachmias, 2008).

Content validity. According to Salkind (2009), content validity of a data

gathering instrument tells how well the variables to be measured correspond with the

instrument. Research carried out by Maslach and Johnson using the MBI produced data

that confirmed the link between various job features and burnout. Research conducted

with physicians found a higher emotional exhaustion level among those in prolonged,

direct contact with patients as compared to those who were not. This higher emotional

exhaustion was accompanied by low scores of personal accomplishment and high scores

of depersonalization (Maslach et al., 1996).

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Empirical validity. The relationship between the results obtained by the

instruments and results in the normal setting should be similar. This can be ascertained by

allowing a colleague to provide an objective assessment of an individual and compare

results to that which is obtained by the data gathering instrument (Frankfort-Nachmias &

Nachmias, 2008). Referred to as convergent validity; MBI self-rating results correlated to

scores obtained from peer appraisals among mental health workers in a previous study.

Significant correlation were obtained as evident by a peers rating of colleagues as being

physically and emotionally tired and high scores of emotional exhaustion and

depersonalization (Maslach et al., 1996). Emotional exhaustion and depersonalization are

main components of burnout (Hiscott, 1998).

Construct validity. Researchers usually connect the data gathering instrument to

a theoretical framework to ensure construct validity (Frankfort-Nachmias & Nachmias,

2008). Based on previous research Maslach, Jackson and Leiter (1996) were able to

confirm the hypothesized link between individuals experiencing burnout and their

personal reactions as it relates to growth and development. Research conducted among

nurses, and other health care providers revealed a positive correlation between

satisfaction with opportunities for growth and development, and personal

accomplishment (PA). A negative correlation between satisfaction with opportunities for

growth and development, and emotional exhaustion (EE) and depersonalization (DP) was

also revealed. These results provided support for the hypothesis and construct validity.

Opportunities for growth and environment are important constructs of the work

environment (Hiscott, 1998).

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Data Collection and Analysis

Maslach et al. (1996) advised against sensitizing participants about burnout before

collecting data. This security measure is recommended to preserve the objectivity of

participants responses and avoid personal opinions from influencing responses. As such

participants were encouraged to complete the survey privately. In support, the data

gathering instrument was named and referred to as the Human Services Survey.

Data were collected after permission for conducting the study had been received

from the IRB of Walden University, as well as the two hospitals involved. Data collection

packages were distributed to each ward or unit throughout the two-week data collection

period. A secured receptacle was made available on each unit or ward, into which

participants were instructed to deposit completed data collection packages. Upon

collection, I assigned each data collection package a unique number to facilitate ease of

analysis. Flyers (Appendix C & D) were used to advertise the study and to recruit

participants.

Data Collection

The data collection package included the Maslach Burnout Inventory-Human

Service Survey (MBI-HSS; Maslach et al., 1996) and attached demographic

questionnaire; and an invitation letter and consent form. I made no attempt at recruiting

participants, because of the previous post held as principal nursing officer of the mental

healthcare institution. Invitation to participate in the study was accomplished by means of

circulating flyers at the institutions and data collecting packages were made available at

individual units. This measure serves to avoid the possibility of undue coercion that may
 81
be imposed on participants. I collected completed MBI-HSS and demographic

questionnaires (data collection package) from the provided sealed receptacles

periodically. These completed packages were stored in a locked receptacle away from the

institutions. The supply of data collection packages were also replenished periodically.

The paper data will be preserved for a period of five years after analysis, and then

destroyed using a shredder. Flyers continued to be available on each unit or ward

throughout the two-week data collection period reminding nurses of the ongoing study

and the importance of participating.

Data Analysis

Descriptive analysis was conducted on the demographic data, as well as to

compute the level of burnout for every participant. SPSS 18.0 was used for computation.

The level of significance was taken as .05, and in each instance, the dependent variable

produced nominal data. The independent- sample t test was used to provide a rationale

for accepting or rejecting the null hypothesis for the first four research questions. The

independent- samples t test allows the researcher to evaluate the significance of the

difference of the means between two independent groups. The independent-samples t test

was conducted on the raw score of the components of burnout and not the levels. An

independent-sample test computed using raw scores has greater power than a test of

correlation with a dichotomized variable such as levels (Green and Salkind, 2008).

Burnout levels were used to conduct the independent-samples t test for the burnout

variable only because no raw score was generated.

Three assumptions are associated with the independent-sample t test. They are:
 82
1. The test variable is normally distributed in each of the two populations as

defined by the grouping variable (Salkind & Green, 2008, p. 176). The

grouping variable is that of institution of work with sample sizes of 46

and 12 which is sufficiently large to provide accurate p values.

2. The variances of the normally distributed test variable are equal

(Salkind & Green, 2008, p. 176). However, further explanation

indicates the calculation of an approximate value where the variances

are not assumed equal.

3. The cases represent a random sample from the population and scores on

the test variable are independent of each other (Salkind & Green, 2008,

p. 176). Although the sample for this study was not a random sample,

further explanation of the assumption identifies the independence of the

scores as the most crucial factor. For this study, the scores generated for

the burnout components are independent of each other.

Linear regression was conducted to respond to null hypotheses relating to

questions five and six. Linear regression analysis was conducted on the random-effect

model which is more appropriate for studies such as this study, which is nonexperimental

(Salkind & Green, 2008). The assumptions are:

1. The X and Y variables are bivariately normally distributed normally

distributed in the population (Salkind & Green, 2008, p. 277).

2. The cases represent a random sample from the population and the scores

from each variable are independent of other scores on the same variable
 83
(Salkind & Green, 2008, p. 277). Although the sample for this study was not

randomly selected the test is accurate because further explanation of this

assumption identifies the independent component as the factor capable of

rendering accuracy for the p value (Salkind & Green, 2008).

For each analysis conducted, the p value was compared to the level of

significance (.05). If the p value was less than the level of significance, I rejected the null

hypothesis. Results are presented by means of tables, a line graph, a bar chart, and a

scatter plot. Numerical data will be stored on a mass storage device belonging to the

researcher for a period of five years after analysis and then deleted.

Protection of Participants

I did not participate in direct distribution and collection of questionnaires to or

from participants. This method sought to protect participants from undue coercion to

participate which may be inferred by the presence of the researcher. The data collection

package included an invitation letter and consent form which cautioned participants

against including identifying data on the package. Use of these measures ensured

anonymity and confidentiality of data collection and served to inform participants of their

freedom to withdraw from the study at any time should they so desire. The consent form

also explained the importance of completing the survey privately, without the influence

of relatives, friends and colleagues.

Participants were not required to submit the signed consent form. Return of the

completed questionnaire was regarded, as an indication of consent to participate in the

study. My contact details were included on the invitation letter to participants. I

 84
conducted impromptu discussions with available members of the population at each

institution during dissemination of notification flyers to explain the purpose of the

research. My curriculum vitae, references and in text citations with inference to the

Caribbean island involved in this study, and proof of permission to conduct the study

were removed from this discourse, to protect the identity of the island and the efficacy of

the health service.

Summary

This quantitative study employed a cross sectional survey design to answer the

research questions. The population of interest was registered nurses who have been

employed at the general healthcare facility and the mental healthcare institution for a

period of one year and more. All members of the population were invited to participate in

the study. A convenience sampling strategy was used. Maslach Burnout Inventory-

Human Service Survey (Maslach et al., 1996) was the primary data collection instrument.

Data collection adhered to an anonymous and confidential process, and data was

subjected to statistical and inferential analysis. Results of the study will be discussed and

presented in the following chapter.

 85
Chapter 4: Results

Presented in this chapter are the results of the study I conducted to compare the

level of burnout among registered nurses employed at a general healthcare facility and a

mental healthcare institution in the Caribbean. The study was conducted among

registered nurses who voluntarily participated upon invitation.

Data Collection

Data collection extended over a period of 3 weeks, from March 29, 2012 to April

18, 2012. Data collection was preceded by a one week period of sensitization during

which the intended study was advertised through the use of a flyer (Appendix C). The

sensitization period provided the opportunity to explain the study and process of data

collection to interested persons. The population of interest consisted of 132 registered

nurses; 118 were employed at the general healthcare facility and 14 at mental health

institution. A total of fifty eight registered nurses participated in the study by returning

completed questionnaires (Table 1). Twelve represented the mental health institution

while forty-six were employed at the general healthcare facility.

 86
Table 1

Frequency Distribution of Participants Institution of Work

Institution of work Frequency Percent Valid Cumulative

percent percent

Valid General healthcare 46 79.3 79.3 79.3

facility

Mental healthcare 12 20.7 20.7 100.0

institution

Total 58 100.0 100.0

For this study, a confidence level of 90%, a confidence interval of 10, and a

distribution response of 50% was regarded as generating statistically significant data.

Prior to applying linear regression and independent-samples t test to the data, the level of

burnout and its components (emotional exhaustion, depersonalization and personal

accomplishment) was computed for each participant using the numerical guide provided

with the survey. This process comprised two steps. Numerical data generated for the

components were first categorized into low, moderate, and high levels. The level of each

component was then used to arrive at a level for burnout. Participants responded to every

item; thus no missing data resulted.

Characteristics of Sample

Collected data were first subjected to descriptive analysis. Table 2 provides

information on the gender of participants. The majority of participants (91.4%) were

 87
women while men accounted for 8.6%. According to the governments website (2009)

this gender make-up is similar to the mean of 9% that exists among the combined

population of nurses employed at the two institutions.

Table 2

Frequency Distribution of Participants Gender

Participantss Frequency Percent Valid percent Cumulative

gender percent

Valid Men 5 8.6 8.6 8.6

Women 53 91.4 91.4 100.0

Total 58 100.0 100.0

The most common age range of participants was 25-29 years, represented by just over

two fifths (41.4%) of the population (Table 3). This reflects a youthful sample,

representative of the employment force of the institutions. Results from research

conducted among nurses suggest a higher level of burnout among older nurses (Iglesias

et al., 2010). Not surprisingly the length of service (Table 4) also reflected a

corresponding commonality (44.8%) in the lower category of 1-4 years. Nevertheless the

majority of participants (55.2%) had more than five years of experience.

 88
Table 3

Frequency Distribution of Participantss Age

Participantss Frequency Percent Valid percent Cumulative

age percent

20-24yrs 3 5.2 5.2 5.2

25-29yrs 24 41.4 41.4 46.6

30-34yrs 12 20.7 20.7 67.2

35-39yrs 4 6.9 6.9 74.1

40-44yrs 7 12.1 12.1 86.2

50-54yrs 5 8.6 8.6 94.8

55-63yrs 3 5.2 5.2 100.0

Total 58 100.0 100.0

 89
Table 4

Frequency Distribution of Participantss Length of Service

Participantss length Frequency Percent Valid percent Cumulative

of service percent

Valid 1-4yrs 26 44.8 44.8 44.8

5-9yrs 11 19.0 19.0 63.8

10-14yrs 10 17.2 17.2 81.0

15-19yrs 3 5.2 5.2 86.2

20-24yrs 1 1.7 1.7 87.9

30-34yrs 5 8.6 8.6 96.6

35+yrs 2 3.4 3.4 100.0

Total 58 100.0 100.0

Data Analysis

Prior to applying linear regression and independent-samples t test to the data, I

computed the levels of burnout and its components (emotional exhaustion,

depersonalization and personal accomplishment) for each participant using the numerical

guide provided with the survey. This allowed me to answer the following six research

questions and reject or accept the corresponding hypotheses.

Question 1: What is the level of the burnout component of emotional exhaustion

among registered nurses employed at a general healthcare facility as compared to

registered nurses employed at a mental healthcare institution in a Caribbean island?

 90
Null Hypothesis (Ho): There is no difference between the levels of emotional

exhaustion among registered nurses employed at a general healthcare facility as

compared to registered nurses employed at a mental healthcare institution in a Caribbean

island.

Alternate Hypothesis (H1): The level of emotional exhaustion among registered

nurses employed at a general healthcare facility is different as compared to registered

nurses employed at a mental healthcare institution in a Caribbean island.

To answer Question 1, the computed levels of emotional exhaustion for each

participant were compared between institutions. Although the majority of participants

(39.7%) experienced a low level of emotional exhaustion (Figure 1), more than one

quarter (27.6%) experienced a high level.

 91

Figure 2. Percentage of participants level of emotional exhaustion.

A comparison of the mean level of emotional exhaustion at the participating

institutions revealed a higher mean at the general healthcare facility than at the mental

health care institution (Table 5). A low level of emotional exhaustion is represented by 1,

a moderate level by 2 and a high level by 3. Thus, the mean level of 2.04 at the general

healthcare institution is representative of a moderate level with a score range of 17-26

(Table 6). The mean level of emotional exhaustion at the mental health institution (Table

5) is low (1.25), represented by a score range of 0-16 (Table 6).

 92
Table 5

Comparison of Mean Level of Emotional Exhaustion Between Institutions

Institution of work M N SD

General healthcare facility 2.04 46 .815

Mental healthcare institution 1.25 12 .452

Total 1.88 58 .818

Table 6

Categorization for Emotional Exhaustion Scores for Human Services

Level Frequency

High 27 OR OVER

Moderate 17-26

Low 0-16

Note. From Maslach Burnout Inventory Manual by Maslach, Jackson, Leiter, 1996,
p11. Retrieved from www.mindgarden.com. Reprinted with permission.

An independent-samples t test was conducted to determine the significance of the

difference between the emotional exhaustion scores. The mean (22.59) and standard

deviation (12.02) of emotional exhaustion scores for participants from general healthcare

facility (Table 7) are proportionally comparative to that of the normative data for the

MBI-HSS. The MBI-HSS normative data for emotional exhaustion scores for nurses

employed at a general care facility is represented by a mean (M) of 22.41 and a standard

deviation (SD) of 11.91. The mean (12.08) and standard deviation (6.96) of emotional
 93
exhaustion scores for participants from the mental healthcare institution (Table 7) are also

proportionally comparative to that of the normative data for the MBI-HSS. The MBI-

HSS normative data for emotional exhaustion scores for nurses employed in mental

healthcare is represented by a mean of 16.89, and a standard deviation of 8.90. The

independent-samples t test equal variances not assumed, revealed a significance

difference, t (30) = 3.9, p = .000 (Table 8), thus, I rejected the null hypothesis.

Table 7

Group Statistics of Independent-Samples t Test for Emotional Exhaustion Scores

Variable Institution of N M SD SEM

work

Emotional General 46 22.5870 12.02327 1.77273

exhaustion score healthcare

facility

Mental 12 12.0833 6.96039 2.00929

healthcare

institution
 94
Table 8

Independent-samples t Test of Emotional Exhaustion Scores

Emotional exhaustion score

Equal variances Equal variances
assumed not assumed

Levene's Test F 5.211

for equality of Sig. 0.026
variances

t-test for T 2.89 3.92

equality of Df 56 30.302
means Sig. (2-tailed) 0.005 0
Mean difference 10.503 10.504
Std. error difference 3.634 2.67952
90% confidence Lower 4.426 5.95722
interval of the Upper 16.581 15.05003
difference

Question 2: What is the level of the burnout component of depersonalization

among registered nurses employed at a general healthcare facility as compared to

registered nurses employed at a mental healthcare institution in a Caribbean island?

Ho: There is no difference between the levels of depersonalization among

registered nurses employed at a general healthcare facility as compared to registered

nurses employed at a mental healthcare institution in a Caribbean island.

H1: The level of depersonalization among registered nurses employed at a general

healthcare facility is different as compared to registered nurses employed at a mental

healthcare institution in a Caribbean island.

 95
Answering the second research question required using the computed levels of

depersonalization for each participating registered nurse. The majority displayed a low

level of depersonalization but more than 1/3 of the sample (34.5%) had a moderate level

(Figure 3).

Figure 3. Percentages of the levels of depersonalization of participants.

 96
Table 9

Comparison of Mean Level of Depersonalization Between Institutions

Institution of work M N SD

General healthcare facility 1.46 46 .622

Mental healthcare institution 1.42 12 .515

Total 1.45 58 .597

A comparison between registered nurses employed at the participating institutions

showed mean levels of less than 2 (Table 9). A low level of depersonalization is

represented by 1 and a moderate level by 2. A high level of depersonalization is

represented by 3. The mean depersonalization scores between institutions were analyzed.

Results (Table 10) indicate mean scores for both institutions within the low

depersonalization level of 0-6 (Table 11).

Table 10

Comparison of Mean Scores of Depersonalization Between Institutions

Institution of work M N SD

General healthcare facility 5.6087 46 5.28511

Mental healthcare institution 5.4167 12 3.82476

Total 5.5690 58 4.98810

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Table 11

Categorization for Depersonalization Scores for Human Services

Level Frequency

High 13 OR OVER

Moderate 7-12

Low 0-6

Note. From Maslach Burnout Inventory Manual by Maslach, Jackson, Leiter, 1996,
p11. Retrieved from www.mindgarden.com. Reprinted with permission.

The mean level and mean scores for depersonalization indicate a low level at both

institutions although a difference is evident. An independent-samples t test was

conducted to evaluate the difference (Table 12). The independent-samples t test equal

variances not assumed, revealed a nonsignificant difference, t (23) = 0.142, p = .888.

Based on this analysis I rejected the null hypothesis.

 98
Table 12

Independent-samples t Test of Depersonalization Scores

Depersonalization score
Equal variances Equal variances
assumed not assumed

Levene's Test F 1.114

for equality of Sig. 0.296
variances

t-test for T 0.118 0.142

equality of Df 56 23.276
means Sig. (2-tailed) 0.907 0.888
Mean difference 0.19203 0.19203
Std. error difference 1.63106 1.3514
90% confidence Lower -2.53595 -2.12295
interval of the Upper 2.92001 2.50701
difference
 99
Question 3: What is the level of the burnout component of personal

accomplishment among registered nurses at a general healthcare facility as compared to

registered nurses employed at a mental healthcare institution in a Caribbean island?

Ho: There is no difference between the levels of personal accomplishment among

registered nurses employed at a general healthcare facility as compared to registered

nurses employed at a mental healthcare institution in a Caribbean island.

H1: The level of personal accomplishment among registered nurses employed at a

general healthcare facility is different as compared to registered nurses employed at a

mental healthcare institution in a Caribbean island.

Responding to the third research question required using the computed levels of

personal accomplishment for each participant. Results revealed a high level of personal

accomplishment experienced by all registered nurses of the general healthcare facility as

was evident by a mean level of 3 and a standard deviation of 0.00 (Table 13). The mean

level of personal accomplishment at the mental health institution was lower at 2.92 and

was representative of a moderate level of personal accomplishment (Table 14).

Table 13

Mean level of personal accomplishment between institutions

Institution of work M N SD

General Healthcare 3.00 46 .000

Mental Healthcare 2.92 12 .289

Total 2.98 58 .131

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Table 14

Categorization for personal accomplishment scores for human services

Level Frequency

High (3) 0-31

Moderate (2) 32-38

Low (1) 38 or over

Note. From Maslach Burnout Inventory Manual by Maslach, Jackson, Leiter, 1996,
p11. Retrieved from www.mindgarden.com. Reprinted with permission.

The mean score of personal accomplishment was computed (Table 15) generating

results which indicate mean scores, though different, falling into the same range

representative of a high level; 0-31(Table 14). Further analysis was conducted to evaluate

the significance of the differences. The scores for depersonalization were subjected to an

independent-samples t test. The independent-samples t test equal variances not assumed,

revealed a nonsignificant difference, t (14) = -1.22, p = 0.244 (Table 16). The negative t

result further supports the lack of significance; thus the null hypothesis is not rejected

although the mean levels are different.

Table 15

Mean Score of Personal Accomplishment Between Institutions

Institution of work M N SD

General healthcare facility 9.1304 46 6.04652

Mental healthcare institution 12.4167 12 8.82618

Total 9.8103 58 6.76020

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Table 16

Independent-samples t Test of Personal Accomplishment Scores

Personal accomplishment score

Equal variances Equal variances
assumed not assumed

Levene's Test F 0.727

for equality of Sig. 0.397
variances

t-test for T -1.517 -1.217

equality of Df 56 13.808
means Sig. (2-tailed) 0.135 0.244
Mean difference -3.28623 -3.28623
Std. error difference 2.16673 2.69937
90% confidence Lower -6.91014 -8.04534
interval of the Upper 0.33768 1.47287
difference

Question 4: What is the level of burnout experienced by registered nurses working

at a general healthcare facility as compared to registered nurses working at a mental

healthcare institution in a Caribbean island?

Ho: There is no difference in the level of burnout experienced by registered

nurses employed at a general healthcare facility as compared to registered nurses working

at a mental healthcare institution in a Caribbean island.

H1: The level of burnout among registered nurses employed at a mental

healthcare institution is higher than the level of burnout of registered nurses employed at

a general healthcare facility in a Caribbean island.

 102
The level of emotional exhaustion (EE), depersonalization (DP), and personal

accomplishment (PA) was used to compute the level of burnout for each participant. A

high degree of burn out is equated to high EE and DP scores coupled with a low PA score

(Maslach et al., 1996). An average degree of burnout is represented by average scores of

all three components. A low degree of burnout is reflected by a high PA score coupled

with low scores for EE and DP (Maslach et al., 1996).

The majority of registered nurses experienced a low level of burnout (Table 17),

while a high level of burnout was not experienced by any. Further frequency analysis

showed the burnout mean level to be greater among registered nurses at the general

healthcare facility than at the mental health care institution (Table 18). A low level of

burnout is represented by 1; a moderate by 2, while 3 is representative of a high level of

burnout.

Table 17

Frequency of Burnout Level Among Participants Registered Nurses

Level Frequency Percent Valid percent Cumulative

percent

Valid Low (1) 49 84.5 84.5 84.5

Moderate 9 15.5 15.5 100.0

(2)

Total 58 100.0 100.0

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Table 18

Comparison of Mean Level of Burnout Between Institutions

Institution of work M N SD

General healthcare facility 1.20 46 .401

Mental healthcare institution 1.00 12 .000

Total 1.16 58 .365

The standard deviation for the mental healthcare institution is 0.000, while the mean is

1(Table 18). This allowed for the conclusion that all registered nurses at the mental

healthcare institution were assessed as experiencing a low level of burnout. Therefore,

the identified participants (15.5% of the sample) experiencing a moderate level of

burnout are employed at the general healthcare facility and represents 19% of that

institutions sample. An independent- samples t test was conducted to evaluate the

significance of the mean difference. The test was significant t (45) = 303.09, p = 0.002

(Table 19). I therefore rejected the null hypothesis of no difference in the level of

burnout between the institutions.

 104
Table 19

Independent-samples t Test of Level of Burnout

Level of burnout
Equal variances Equal variances
assumed not assumed

Levene's test F 19.685

for equality of Sig. 0
variances

t-test for T 1.679 3.308

equality of Df 56 45
means Sig. (2-tailed) 0.099 0.002
Mean difference 0.196 0.196
Std. error difference 0.117 0.059
90% confidence Lower 0.001 0.096
interval of the Upper 0.391 0.295
difference

Question 5: What is the relationship between age and the level of burnout

experienced by registered nurses employed at a general healthcare facility as compared to

registered nurses working at a mental healthcare institution in a Caribbean island?

Ho: Age has no relationship with the level of burnout experienced by registered

nurses employed at a general healthcare facility as compared to registered nurses working

at a mental healthcare institution in a Caribbean island.

H1: Age is negatively correlated to the level of burnout experienced by registered

nurses employed at a general healthcare facility as compared to registered nurses working

at a mental healthcare institution in a Caribbean island?

Statistical analysis of bivariate linear regression was applied to the data for

participants age and level of burnout, and compared between institutions. The analysis
 105
evaluates whether the independent variable of age predicts the dependent variable of level

of burnout. This test appears in the F test as part of ANOVA (Table 20) and in the t test

in the coefficients (Table 21). The tests are alike and resulting p values are the same: F

(1, 56) = .22, p >.05 and t (56) = 1.24, p > .05. The independent variable, therefore,

does not predict the dependent variable.

Table 20

ANOVA of Linear Regression of Age of Participants and Level of Burnout

Model SS Df MS F Sig.

1 Regression .202 1 .202 1.526 .222a

Residual 7.402 56 .132

Total 7.603 57

Table 21

Coefficients of Linear Regression of Age of Participants and Level of Burnout

Model Unstandardized Standardized T Sig. 90.0%

coefficients coefficients Confidence

interval for B

B Std. Lower Upper

Error Bound Bound

1 (Constant) 1.259 .097 12.985 .000 1.097 1.422

Age -.031 .025 -.163 -1.235 .222 -.072 .011

Note. Dependent Variable: Level of burnout

 106
Examination of the regression scatter plot (Figure 4) show a small number of age

points near the line while that of level of burn out away from the line in entirety,

indicating no relationship. The 90% confidence interval for the slope, -.072 to

.011contains the value of zero (Table 21) and therefore, supports my decision to accept

the null hypothesis.

Figure 4. Regression scatterplot between burnout level and age of participants.

 107
Question 6: What is the relationship between years of service and the level of

burnout experienced by registered nurses employed at a general healthcare facility as

compared to registered nurses working at a mental healthcare institution in a Caribbean

island?

Ho: Years of service has no relationship with the level of burnout experienced by

registered nurses employed at a general healthcare facility as compared to registered

nurses working at a mental healthcare institution in a Caribbean island.

H1: Years of service is negatively correlated to the level of burnout experienced

by registered nurses employed at a general healthcare facility as compared to registered

nurses working at a mental healthcare institution in a Caribbean island?

Statistical analysis of bivariate linear regression was also applied to the data for

length of service of participants and level of burnout, and compared between institutions.

The analysis evaluates whether the independent variable of length of service predicts the

dependent variable of level of burnout. This test appears in the F test as part of ANOVA

(Table 22) and in the t test in the coefficients (Table 23). The tests are alike and resulting

p values are the same: F (1, 56) = .677, p > .05 and t (56) = .823, p > .05. The

independent variable therefore does not share a relationship with the dependent variable.
 108
Table 22

ANOVA Result of Regression Analysis of Length of Service of Participants and Level of

Burnout

Model Sum of Df Mean square F Sig.

squares

1 Regression .091 1 .091 .677 .414a

Residual 7.513 56 .134

Total 7.603 57

Examination of the regression scatterplot (Figure 5), show the majority of the

length of service points falling away from the line along with all level of burnout points,

indicating no relationship between the scrutinized variables. In addition, the 90%

confidence interval for the slope is -.059 to .020 and includes the value of zero (Table 23)

thus the null hypothesis is accepted.

 109
Table 23

Coefficients of Linear Regression of Age of Participants and Level of Burnout

Model Unstandardized Standardized T Sig. 90.0%

coefficients coefficients Confidence

Interval for B

B Std. Lower Upper

error bound bound

1 (Constant) 1.204 .077 15.709 .000 1.076 1.333

Length of -.020 .024 -.109 -.823 .414 -.059 .020

service
 110

Figure 5. Regression scatterplot between level of burnout and length of service of

participants.
 111

Other Data Analysis

Participants had an opportunity to identify an issue of importance as it relates to

their institution of work. Opportunity was also provided to give reasons for employment

at their present institutions while highlighting reasons for refusal of employment at the

mental health institution.

Reasons for Employment

Participants who were employed at the mental health institution cited love for

psychiatric nursing as the most common reason for their choice of work institution. Two

participants (16.67%) expressed their choice as being inevitable as these were the only

vacancies for registered nurses available on the island. Interestingly five (41.67%) of the

participants employed at the mental health institution viewed their institution of

employment as being less stressful than that of the general healthcare facility.

Participants employed at the general healthcare facility held a vastly different opinion.

Of the forty six participants employed at the general healthcare facility, twelve

(26.9%) indicated their willingness to be employed at the mental healthcare institution.

The remaining 73.1% (32) cited three main reasons for their disinterest in employment at

the mental healthcare institution. The first two reasons were dislike of psychiatric

nursing, identified by 65.62%, and disorganization of mental healthcare was cited by

28.13%. The third reason for disinterest in employment at the mental healthcare

institution was cited as too stressful and was identified by 6.25% of the disinterested

participants.
 112
Issues of Concern

Participants employed at the mental health institution main concern was related to

safety and security, a lack of concern for mental health services and neglect of patients by

family members. A greater variety of issues were highlighted by participating registered

nurses employed at the general healthcare facility. The issues included poor interpersonal

relationship (17.39%), work overload expressed as inadequate staffing (21.74%), lack of

resources (8.70%) poor mechanism for promotion (17.39%), lack of institutional policies

and training opportunities (12.24%). Poor work conditions and burnout (8.70%); lack of

policy, poor management and conflict resolution (13.84%) were also identified.

Summary

Inferential and descriptive analyses were applied to the collected data with a goal

to answer the six research questions. I rejected the null hypothesis for Questions 1and 4

and accepted the null hypothesis for Questions 2 and 3 after conducting independent-

samples t test analysis on the relevant data. The fifth and sixth research questions were

subjected to bivariate linear regression statistical analysis. Results were indicative of no

relationship between age and burnout and length of service and burnout among the

sample; thus I accepted the corresponding null hypothesis.

Results of the study in light of previous research will be presented in the

following chapter. Interpretations of the results will be presented and recommendations

for action put forward. Conclusions will be drawn and recommendations made for further

research. The studys implications for social change will also be presented.
 113
Chapter 5: Discussion, Conclusion, and Recommendations

This final chapter begins with an overview of the reasons for conducting the study

as well as the manner in which it was performed. The chapter focuses on the

interpretation of the studys findings as related to the research questions and previous

studies. This chapter includes recommendations for actions and further study and the

implications of social change.

This study was conducted to determine the existence and level of burnout among

registered nurses employed at a general health care facility and a mental health institution

in Caribia. The levels of the three constructs of burnout were also investigated. Included

in the purpose was a comparison of the level of burnout and the constructs of burnout

among the nurses as it relates to the work environment. The relationship between age and

length of service and the level of burnout was also included in the purpose.

Burnout is more likely to occur where incongruence exists between the employee

and the job. An unhealthy relationship between the work environment and the individual

is regarded as the primary cause (Norcross & Guy, 2007). The work environment is not

necessarily the physical structure but instead includes aspects of workload, job control,

fairness, interpersonal relationship, job recognition and compensation, and personal

values (Hiscott, 1998). Although burnout can occur in any individual, persons involved in

human service professions such as nurses are identified as having a greater risk of

development as it pertains to their work environment (Potter, 1996).

This increased risk is also associated with activities of specific detail, interaction

with the dying, and challenging work hours (Potter, 1996). Included are jobs that are
 114
subjected to high social critique and professionals who are engaged in lucrative but

mentally unrewarding jobs (Berglas, 2009). Nursing as a profession is recognized as high

stress. The need to pay attention to detail and an increased opportunity for work overload

associated with nurse shortage contribute to the heightened stress level (Thomas, 2004).

Results from studies conducted in the United States (Larrabee et al., 2010), China

(Lei et al., 2010), Canada (Grau-Alberola et al., 2010), and the United Kingdom (Garrosa

et al., 2010) suggest the existence of burnout among nurses as a phenomenon of grave

concern. Although much research has been conducted on burnout, there remains a dearth

of studies conducted in the Caribbean and specifically in Caribia. This lack of knowledge

on burnout as it relates to the Caribbean does not allow for evidence-based decisions

about the burnout topic.

The aim of this study was to determine the level of burnout and its components

among registered nurses at a government-controlled mental health institution and a

general healthcare institution. Guided by the transactional or psychological transaction

stress theory (Lazarus, 1966) that views stress as a result of an association between an

individual and the environment; I used this study to compare the level of burnout between

the two different work environments. In so doing, the six research questions were

answered. The 22-item Maslach Burnout Inventory-Human Service Survey (Maslach et

al., 1996) was used as the main data collecting instrument. I also used a demographic

questionnaire that allowed participants to identify one area of concern as well as express

reasons for choosing or not choosing the mental healthcare institution for employment.
 115
Interpretation of Findings

Descriptive analyses conducted on the level and scores for the burnout component

of emotional exhaustion indicated a difference in the means. An independent-samples t

test revealed a significant difference; thus I rejected the null hypothesis. The mean

differences represent a mean low level of emotional exhaustion among registered nurses

at the mental health institution compared to a moderate level at the general healthcare

facility. In answer to Question 1, results from this study suggest a difference in the level

of emotional exhaustion among registered nurses employed at the general healthcare

facility compared to the mental healthcare institution.

Previous research conducted comparing the level of emotional exhaustion among

nurses at medical or general health care facilities and mental health or psychiatric

institutions have proved to be inconclusive. An Iranian study indicated mental health as

having higher levels of emotional exhaustion while, in Germany, medical environments

had higher levels (Sahraian et al., 2008; Schulz et al., 2009). Work overload has been

identified as influencing the development of emotional exhaustion (Wicks, 2006). It is

possible that the workload of registered nurses employed at the mental healthcare

institution in Caribia is lower than that of registered nurses working at the general

healthcare facility.

Data related to the burnout component of depersonalization levels were first

analyzed by descriptive statistics to answer Question 2. The mean level was computed as

1.46 for the general healthcare facility and 1.42 for the mental healthcare institution. A

low level of depersonalization was represented by one. Analysis of the depersonalization

 116
scores resulted in a mean of 5.6 for the general healthcare facility and 5.41for the mental

healthcare institution. A low level of depersonalization is represented by scores within a

range of 0 to 6. As such, it is correct to evaluate the levels of depersonalization at both

institutions to be of a low level accepting the null hypothesis relating to question two.

Depersonalization as a component of burnout is grounded in emotional

exhaustion. According to the literature review emotionally exhausted individuals often

harbor negative thoughts that are frequently projected unto recipients of service and often

manifested in behaviors such as withdrawal (Shelton, 2007). Because the length of time

between the development of emotional exhaustion to progression to depersonalization is

unsure, the levels of the two components may differ at any one point (Potter, 1996).

Previous research conducted among nurses suggested an association between poor

interpersonal relationship and perceived organizational injustice with the development of

depersonalization (Elovainio et al., (2009).

Analysis of qualitative data collected during this study revealed 17.39% of

respondents from the general healthcare facility, to be concerned about poor interpersonal

relationships. Concerns regarding poor management and conflict resolution accounted for

another 13.84%. These areas of concern were not identified by respondents employed at

the mental healthcare institutions. The presence of these risk factors is indicative of the

need to monitor the levels of depersonalization among registered nurses at the general

healthcare facility. As depersonalization increases, it impacts negatively on the nurses

output, resulting in lowered personal accomplishment (Potter, 1996). Contrary to my

 117
expectations, data analysis of the personal accomplishment component of burnout did not

show a similar pattern to that of depersonalization.

Question 3 addressed a comparison of the levels of personal accomplishment. The

mean level of personal accomplishment was lower at the mental healthcare institution.

The mean level was moderate compared to a high level at the general healthcare facility,

in answer to Question 3. Results of the study indicated this difference in the level as

being insignificant. According to Shivers (2008) the nurse who delivers mental

healthcare, uses the therapeutic relationship as the main tool in the delivery of care. The

underutilization of medical skills may result in a decrease in the sense of personal

accomplishment for nurses, who are employed at a psychiatric institution. The level of

personal accomplishment does not relate directly to the level of burnout as does the level

of emotional exhaustion (Leiter & Maslach, 2009).

Results from this study suggest a mean low level of burnout among registered

nurses at both institutions, in answering Question 4. There exists though, a difference in

the levels, with the general healthcare facility depicting higher mean levels similar to that

of emotional exhaustion. These results that link the level of burnout to the level of

emotional exhaustion are in keeping with previous studies (Hamaideh, 2011; Van der

Colff, & Rothmann, 2009). The suggestion of higher mean levels of burnout at the

general healthcare facility is contrary to that suggested by Sahraian et al. (2008), whose

study suggests a higher mean level of burnout among psychiatric nurses. According to

Wicks, (2006) the existence of burnout depends on the presence of emotional exhaustion;

thus the presence of emotional exhaustion is most important in assessing the presence of
 118
burnout. Results from the study further indicate that every study participant experienced a

certain level of burnout. According to Lazarus (1999) The environmental variable

referred to as constraint, impacts on coping mechanism available to deal adequately with

situations such as work overload and poor supervision; giving rise to psychological stress

(Lazarus, 1999). This psychological stress is regarded as burnout (Maslach, 2003).

According to results from the study, length of service alone did not predict the

level of burnout among registered nurses at either institution. Age of nurse also did not

predict the level of burnout. Previous research among nurses suggests a higher level of

burnout among older nurses with ten and more years of experience (Iglesias et al., 2010).

Another study by Kowalski et al. (2010), agrees with the results of this study in

suggesting there was no relationship between burnout and length of service; and burnout

and age, in answering research questions five and six. Among other healthcare providers

such as physicians, the opposite appeared to be true. Older professionals with more years

of service seemed to have developed coping mechanisms and displayed a lower level of

burnout (Maslach, 2003).

Conclusions From Findings

Results from the study suggest a higher level, of the emotional exhaustion

component of burnout, among registered nurses employed at the general health care

facility compared to the mental health care institution. The mean level for registered

nurses at the general healthcare facility was moderate compared to a low level at the

mental healthcare facility. Results from previous research have proven to be inconclusive

and point to low levels in environments that have addressed the issues of work over load
 119
(Schulz et al., 2009). The component of emotional exhaustion has been identified as the

main influence of the level of burnout (Maslach, Jackson, & Leiter, 1996) and also as an

influence in the development of depersonalization (Figure 1). According to Lazaruss

(1999) theory of psychological stress work overload is an environment variable of

constraint, that may overwhelm an individuals coping mechanism. Such dissonance

between individual and work environment will result in burnout (Maslach, 2003).

Wicks (2006), in his writings speculated that all nurses intermittently experience a

first or low level of burnout, characterized by mild symptoms and lasting a short period.

Results from my study support this speculation as all participants displayed burnout to

some degree, with a higher level among registered nurses employed at the general

healthcare facility. The study indicates a link between the higher level of emotional

exhaustion and the higher level of burnout at the general health care facility. Previous

studies also link the level of emotional exhaustion to the overall level of burnout

(Hanrahan, McClaine, & Hanlon, 2010; Sahraian et al., 2008).

The link between the level of depersonalization and burnout is less pronounced.

Depersonalization is often influenced by emotional exhaustion (Figure 1) and in turn

influences the component of personal accomplishment (Maslach, 2003). Results from the

study suggest similar low levels of depersonalization being experienced by registered

nurses employed at both institutions. Inadequate compensation has been identified as

playing a significant role in the level of depersonalization (Leiter & Maslach, 2009).

Participants of the study are all employed through the public service and enjoy similar
 120
remuneration (World Bank, 2009) that may have impacted the similarity of the level of

depersonalization.

Similarity of levels of personal accomplishment was evident between the general

health care facility and the mental health care institution in this study. A mean high level

of personal accomplishment was experienced by participants of both institutions. This is

indicative of similar aspects of the work environment as it relates to recognition for work

accomplished; sense of efficiency; resulting in high personal morale of participants

(Thomas, 2004; Borysenko, 2011). Results from a previous study conducted among

nurses highlighted the importance of job recognition in building high personal morale and

thus building a high level of personal accomplishment (Ning, Zhong, Libo, & Qiujie,

2009). Nurses who experience a high level of personal accomplishment are thought to

remain in the profession for a longer period than those who do not (Leiter & Maslach,

2009).

Yet results from this study suggest neither age nor length of service as predictors

of the level of burnout. Previous research suggests a higher level of burnout among older

nurses as well as among those with more than ten years of service (Iglesias et al., 2010).

Because outward migration has been one of the main causes of attrition among nurse in

the Caribbean (World Bank, 2009) it would be correct to conclude that nurses who have

remained in the Caribbean have developed coping mechanisms and may not experience a

high level of burnout.

Previous research among other healthcare service providers suggests a lower level

of burnout among older physicians (Peisah et al., 2009). Interestingly, among social
 121
workers, burnout level decreased with increased years of service in private practice but

not in public service (Schwartz et al., 2007). This supports the implication of aspects of

the work environment as the most important influence on the development of burnout or

psychological stress as purported by Lazarus (1999).

Implications for Social Change

This study has implication for social change that would benefit the nurse and the

organization as well as the service users and the community. Most important is the

foundation laid down for further investigation by creating an awareness of the existence

of burnout among registered nurses in the Caribbean.

The Nurse

The first course of action in addressing a problem is the identification and

acknowledgment of the existence of the problem (Creswell, 2009). As such, the evidence

generated by this study will allow nurses the opportunity to confront burnout as a real

problem existing in the workplace. Awareness of the existence of burnout will prompt

nurses into adopting a vigilant state towards its existence in both self and colleagues.

Knowledge of the effects of burnout on self has the ability to generate a need to prevent

its development by learning coping and preventative measures. Evidence from this study

suggesting a lower level of burnout at the mental healthcare institution permits the

registered nurse to make an informed choice regarding an organization of employment.

This choice will not be guided by fear of developing burnout and will allow for the

opportunity of better staffing components at the mental healthcare institution.

 122
The Organization

Evidence based management and policy making is a much needed climate for

healthcare organizations (Walshe & Smith, 2006). The evidence provided by this study

should prompt management of the participating institutions into implementing proactive

measures in an effort at preventing both the development and the worsening of burnout.

Emotional exhaustion among nurses is manifested by both physical and psychological

symptoms, and previous research has linked burnout to increased absenteeism (Rauhala

et al., 2007). Absenteeism among nurses increases the cost of care by its generation of

replacement staff or overtime by those present (Wicks, 2006). Burnout negatively affects

the performance of the nurse causing a fall in the quality of nursing care delivered

(Rauhala et al., 2007). In previous research conducted burnout was associated with an

increase in errors and a decrease in the identification of errors (Halbesleben et al., 2008).

Medical errors further increase the cost of care through law suits and corrective measures

(Kohn, Corrigan, & Donaldson, 2000). Management of the participating institutions,

therefore, is provided with the opportunity to prevent an increase in the cost of healthcare

and a fall in the quality of care by acting on the evidence provided by this study.

The Service User

The ultimate beneficiaries of healthcare are those individuals who access the

service and depend on the providers for quality care (Kohn et al., 2000). Prompt action

based on evidence generated from this study will preserve or improve the quality of care

received. The action should originate from both the nurse and management of the

participating organization as previously discussed. Activities geared at both preventing

 123
the development and increase in burnout will allow the service user to enjoy a safer

healthcare environment and a better quality of care. This effect will spill over to the

general community.

The Community

Family members of service users will benefit from the improvement in quality

care by being able to trust healthcare providers. A sense of trust between the community

and the healthcare provider enables a harmonious and effective delivery of care (Kohn et

al., 2000). Stability of cost of care will benefit the economy of the Caribbean where many

countries are regarded as developing (American Mathematical Society, 2012). Acting on

the evidence generated by this study in an effort at reducing absenteeism or sick days

associated with burnout, will also benefit the economy and indirectly the community.

Results from this study will also benefit healthcare providers of other facilities as the

awareness of the existence of burnout can serve as a warning and arouse a need to

employ coping mechanism for prevention.

Recommendations for Action

Dissemination of the results generated from this study should be the first course

of action as awareness cannot be created unless the evidence is publicized. Results should

be disseminated to all stake holders including the management of the participating

organizations, management of the Ministry of Health, the professional organization of

nurses, and most importantly, the nurse. Ideally this should take the form of a face to face

presentation to allow for discussion. An important coping mechanism for burnout

includes changing the individual-environment relationship (Lazarus, 1993). Having time

 124
away from work in the form of days off or vacation is a simple strategy of changing the

individual-environment relationship as a means of coping with work related stressors

(Wicks, 2006). Management of the healthcare organization may need to review the

policies regarding vacation and utilization of time off for extra work.

The nurse patient ratio is an important contributing factor to work overload that is

an aspect of the work environment implicated in the development of burnout (Maslach &

Leiter, 1997). The aspect of the nurse-patient ratio must be addressed as it impacts on

both work overload and the individual-environment relationship (Wicks, 2006). The

need for further research into the phenomenon of burnout among other categories of

healthcare providers should be supported by the management of the participating

institutions. A collaborated effort between the employee and the employer is best suited

for the control of burnout and its effects (Wicks, 2006).

Limitations and Recommendations for Further Study

Nurses are encouraged to deliver care that is culturally friendly (Longest & Darr,

2008). In a similar manner, the successful carrying out of research must utilize

mechanisms that are culturally sensitive to its participants. Nursing as a profession must

deliver care that is evidenced based in keeping with issues and trends. Based on this

principle, the need for research among nurses becomes paramount (Parahoo, 2006).

Limitations

The limitations for this study include the sampling strategy used and possible

bias. The convenience sampling strategy used does not allow for random sampling of the

population and therefore, limits credibility of the results for certain statistical analyses.
 125
The nature of the questions asked may prompt the action of under or over reporting due

to the need to provide socially acceptable responses, introducing bias into the study.

Because the development of burnout maybe influenced by personality traits such as

hardiness or resilience, it is possible for the hardy or resilient individual to display a low

level of burnout that is contrary to the characteristics of the environment (Garrosa et al.,

2010; Lei et al., 2010). This study did not evaluate the personality traits of the

participants that may or may not affect the development of burnout, allowing for the

introduction of bias.

Recommendations for Further Study

Further study of the personalities of registered nurses employed at the two work

environments is necessary. Resilience is a personality trait that can be developed and

used as a coping mechanism for burnout (Maddi, & Khoshaba, 2005). Evidence of the

positive effect of resilience among members of the population would provide a rationale

for the need for training. Important also is an investigation into the two work

environments. Six aspects of the work environment have been identified as areas where

congruence with the nurse may exist, posing a risk for the development of burnout. These

include workload, job control, recognition, fairness, compensation, interpersonal

relationship, and personal values (Maslach & Leiter, 1997). Results of an investigation

into the work environments would provide information for policy holders regarding the

specific areas of burnout risk development that needs addressing.

 126
Reflection

This study has contributed to the gap in the literature regarding comparison of

burnout levels between registered nurses employed at a mental healthcare institution and

a general healthcare facility. More so is its significance as it relates to the English

speaking Caribbean. Results from this study have made the phenomenon of burnout a

reality by providing documented evidence of its existence at two main healthcare

facilities in the Caribbean.

The evidence suggests a higher mean level of emotional exhaustion and burnout

at the general healthcare facility than at the mental healthcare institution. Improving the

condition of civilization or society can only be effected by positive social change that is

best implemented based on evidence supported by research (Creswell, 2009). No longer

is burnout just a read-about topic in research journals. It has now come home and is

begging for the attention of all stakeholders of healthcare provision. A phenomenon with

the ability to affect the physical and psychological health of the nurse, negatively impact

on the ability to provide quality care, and is detrimental to the economy is worthy of

immediate attention.
 127
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Appendix A: Research Notification Flyer

COMING SOON!
A study to investigate how registered nurses view their service as
it relates to the work environment after one year or more of
employment. Express your opinion via this study as a means of
influencing positive social change for service users, the community
and self.

Participation is voluntary!

Be a client/patient advocate

Plan to participate!

For further information contact Prisca Regis-Andrew at 2869491 or prisca.regis-

andrew@waldenu.edu
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Appendix B: Research Participant Invitation Flyer

ITS HERE
Prisca Regis-Andrew (Family Nurse Practitioner), in
collaboration with Walden University and in partial fulfillment of
doctoral studies is conducting a study.

Are you a Registered Nurse?

Have you been employed for one year and more?
If you are
Then you are invited to participate.
Surveys are available on every unit/ward.
Every item is to be completed privately.
Your personal opinion is important.

Participation is Voluntary!
For further information contact Prisca Regis-Andrew at 2869491 or prisca.regis-
andrew@waldenu.edu
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Appendix C: Permission to Use Data Collection Instrument
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Appendix D: Demographic Questionnaire Sample

Walden University Doctoral Research Study

Demographic Questionnaire

Please answer every item of this questionnaire truthfully, by placing an X next to the

most appropriate response. Do not write your name or any other identifying data on this

questionnaire.

1. What is your gender? Male ( )

Female ( )

2. At which institution are you employed? General healthcare facility ( )

Mental healthcare institution ( )

3. For persons working at the general healthcare facility: Would you work at the mental

healthcare institution Yes ( )

National Mental Wellness Centre? No ( )

4. If you answered no to question three, indicate your reasons below by ticking all that

apply:

(a) I do not like psychiatric nursing ()

(b) The institution is too far away ()

(c) Working at the institution is too stressful ()

(d) Mental healthcare is too disorganized ()

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5. For persons working at Mental healthcare institution: Why are you employed at this

institution? Indicate your reasons below by ticking all that apply.

(a) I like psychiatric nursing ()

(b) This was the only available vacancy ()

(c) The institution is easy to access ()

(d) Working at the institution is less stressful than general healthcare ()

6. To which age group do you belong? 20-24 yrs. ( )

25-29 yrs. ( )

30-34 yrs. ( )

35-39 yrs. ( )

40-44 yrs. ( )

45-49 yrs. ( )

50-54 yrs. ( )

55-63 yrs. ( )

7. For how long have you been employed? 1-4 yrs. ( )

5-9 yrs. ( )

10-14 yrs. ( )

15-19 yrs. ( )

20-24 yrs. ( )

25-29 yrs. ( )

30-34 yrs. ( )

35 + yrs. ( )
150
 151
8. Kindly comment on one issue of importance to you about your institution of

employment.

________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________

Thank you for your participation.

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Appendix F: Sample Questions From Maslach Burnout Inventory