Víctor Ramón Miranda-Lara,1 Gloria Monzalvo-Herrera,2 Briseida Hernández-Caballero,3 Moisés Ocampo-Torres4
1Investigación en Salud Mental; 2Investigación en Salud Reproductiva; 3Investigación en Enfermedades Crónico-Degenerativas; 4Investigación en Epidemiología. Coordinación Estatal de Investigación de los Servicios de Salud, Pachuca, Hidalgo, México
Correspondence: Víctor Ramón Miranda-Lara
Received: August 12th 2014
Judged: January 21st 2015
Accepted: May 20th 2015
Introduction: Burnout syndrome is a disorder that is increasing in nursing staff; it occurs due to prolonged exposure to stress, as well as the imbalance between professional demands and the ability to carry them out.
Objective: To determine the prevalence of burnout syndrome in nurses working in two institutions of health services in the state of Hidalgo.
Methods: Cross-sectional study in which 535 surveys were applied to nurses working in in-patient services of the Secretaría de Salud (193) and the Instituto de Seguridad y Servicios Sociales de los Trabajadores del Estado (ISSSTE). For the analysis of the information, a database was created and descriptive statistics of the different variables of the study was applied.
Results: The ratio of staff burnout syndrome was 33.8 % (181 of 535), 6.7 % (36 of 535) presented a high level of this syndrome. It was found that 44.1% had emotional exhaustion; 56.4% depersonalization and 92.9 % low personal accomplishment.
Conclusions: It is necessary to create a strengthening program that operates at the state level and that can improve working conditions for nurses.
Keywords: Professional burnout; Prevalence; Nursing staff
Work activity generates stress in and of itself because it determines the employee's exposure to certain stressors, which, as they are incurred, determine individual response, which may be adaptive and involve learning, or maladaptive, which will bring fatigue and dissatisfaction.1
Some studies have described certain characteristics that influence the health of workers; these include the size of the company, the responsibility one has, role dysfunctions, and lack of participation in decision-making.2 Thus, by linking stress and work, demands emerge such as the need for satisfaction, self-esteem, and personal accomplishment, which play an important role to make sense of the activity being done. This is how occupational stress can be defined as the perceived imbalance between professional demands and the person’s ability to carry them out.3
In Spanish, burnout means "burning", "professional burnout syndrome " or "professional burning". According to Torres, referring to the dictionary of the Real Academia Española, burnout refers to one becoming irritated or anxious, spent, running out of resources or opportunities in any activity; about burning, it says that this "refers to the moral anxiety of a desire not achieved"; that is, it implies that one is unhappy and dissatisfied with one’s work. It even generates symptoms of depression such as low morale, increased irritability, avoidance of interpersonal and professional relationships, low productivity, and inability to withstand pressure.4
The term burnout was first used in the context of medicine in 1974 by Herbert Freudeberger, a psychiatrist who, when he tried to explain the deterioration of professional care and attention to users of health services, noticed the presence of emotional disturbances in his colleagues.5 In 1976 Cristina Maslach used the term burnout as the syndrome of "burning out at work", which is characterized by the worker presenting physical, psychological, and emotional exhaustion, low motivation, negative attitudes towards self and others, as well as a feeling of inadequacy in their professional work. All this leads workers to formulate criticisms and complaints regarding the conditions in which they work, their interpersonal relationships, and obstacles to their organizational career.6
In 1977, Maslach publicly unveiled this word at the annual meeting of the American Psychological Association (APA); he described burnout as a phenomenon of exhaustion of workers who worked with and for people, in what he called "human service workers", that is, professionals who maintain a constant and direct contact with people who are beneficiaries of the work itself: teachers, health workers, social services, and public safety. In that sense, he used the term to refer to a state of exhaustion, emotional weariness, or mental wear or fatigue at work, which produce decreased personal fulfillment, as well as the quantity and quality of work, plus producing a loss of energy, which surpasses and exhausts the worker's ability to cope adaptively with a labor, family, or social situation.
In the early eighties, burnout syndrome was almost exclusively studied in the United States. English-speaking countries like Canada and Britain then joined the study; currently, we can find studies worldwide.
Burnout syndrome can be studied from two perspectives: clinical and psychosocial. Maslach and Jackson define the latter perspective as a three-dimensional syndrome of emotional exhaustion, depersonalization, and low personal fulfillment at work.
Thus, this syndrome may also be recognized as a response to chronic occupational stress that affects people whose job is to help and support others, which produces symptoms in the professional ranging from physical, mental, and emotional exhaustion, to conflictive interpersonal relations.
The most widely-accepted definition is the one coined by the aforementioned authors, who began to study and identify the different working conditions leading to burnout syndrome from a psychosocial perspective: it is a chronic stress caused by contact with clients, which leads to exhaustion and emotional distance with the beneficiaries of their work;7 the definition was completed in the eighties as a gradual loss of concern and all emotional feeling towards the people with whom one works; this loss leads to isolation or dehumanization. The basic aspects that make up burnout syndrome are emotional exhaustion, depersonalization, and decreased personal fulfillment.8
The symptoms of emotional exhaustion involve loss of energy, physical and mental exhaustion, fatigue, wear, and feelings of being at one’s limit. This happens when emotional strength is used up and the professional sees their capacity to give to others emptied, on a personal, physical, and psychological level.
Depersonalization involves the appearance of negative feelings and even cynical attitudes about the subject with whom one works, with emotional detachment, irritability, and rejection. This process leads to workers’ hardening and dehumanization towards the users they serve, as they begin sometimes to treat them as simple objects, numbers, or even considering them deserving of their own problems.
As for the decline in personal fulfillment, workers often evade confrontation and turn to joking or some other indirect form of communication, resulting in disqualification and aggression towards people.
Thus, starting in the eighties, a variety of books and articles emerged that raised explanatory models, proposed intervention ideas, and presented several ways to corroborate their evidence through questionnaires, interviews, and clinical case studies.
From some studies related to burnout syndrome may identify several features that allow us to approach our research more comprehensively.
368 subjects were studied in the city of Mexicali, Baja California, in the Hospital de Gineco-pediatría No. 31 with Family Medicine and Hospital General No. 30; of these, 345 (93.75%) were women, with an average age of 41.21 years (standard deviation [SD]: 6.59); work experience was 15.87 years (SD 6.12). The prevalence of burnout in nurses of the two hospitals was 6.79%. It was concluded that the prevalence rate was lower than that reported in other studies in Mexico.9
A study was conducted concerning burnout syndrome in nurses in the Hospital de las Culturas in Chiapas; surveys with dimensions of this syndrome were applied to a total of 82 workers. They found high emotional burden (95%), high depersonalization (47%), and low personal fulfillment (100%), so it was suggested to develop a management program to reduce stress, as previous data show that this situation is reflected in poor quality of care given to service users.10
A study conducted at the Hospital General de Pachuca in the emergency department found one case with a high rate of emotional exhaustion, while the rest of the staff studied showed a lack of personal fulfillment. The ages of nurses ranged between 30 and 59 years old. The highest scores from the Maslach Burnout Inventory were in the Dysplasia Clinic, the Equipment and Sterilization Center, Pediatrics, General Surgery, and the Emergency Department in the morning, evening, and night shift A and B. Meneses stated that stressors from the workplace itself are decisive and generate the onset of burnout syndrome in this group of health professionals, due to their constant workload, having two jobs, and presenting emotional weariness from relationships in the workplace. The author concludes that even a low level of burnout is a defense mechanism.8
Studies in other countries indicate that nurses are continually exposed to stressful situations in the services where they are assigned, such as the case of intensive care units, where they must continually make major decisions in emergency patient care. Facing this particular type of situation causes depression, anxiety, risk of compassion fatigue, and burnout, according to a study in Cartagena.11
Working in an environment of continuous contact with suffering and death, as well as a large number of direct and indirect actions before which nurses cannot express their feelings, produces negative health consequences. Another study also conducted in Cartagena found that job dissatisfaction in those under age 40 is associated with burnout, and burnout prevalence was 26.6%.
In a study in Chile to determine the presence of chronic occupational stress and its probable relationship to social and occupational factors in nurses working in emergency health care services, the results showed that more than 50% were young adults, single, without children, and had under 10 years of work experience; moreover, most of them had up to four shifts back-to-back.12
The group of professionals showed that burnout syndrome was presented with intermediate intensity, which would mainly be influenced by variables such as perceived insufficient labor resources and too many work shifts. At the same time, the older group showed more emotional exhaustion, and widowed or separated people had less depersonalization than the rest of those surveyed.13
A study in Madrid showed that the prevalence of back pain in the hospital sector was 85.8%, which mostly involved medical visits (43%), medication (36%), physical therapy (27.8%), and interference in daily work (24.6%). Pain episodes happened repeatedly (62.2%) and progressively (52%); their location by area was as follows: lower back 55.2%, neck 43.8%, and upper back 42%.14
Other studies report the incidence of needlestick events associated with burnout syndrome. 21.6% had at least one event; of these, 86.1% involved sharps, and 13.8% mucocutaneous exposure. Accidents occurred mainly in the morning shift with 49%, in the first four hours of work in 69.1%, at the medication preparation table in 81.1%, during medication administration in 55.4%, and before the activity in 54.4%. In the needlestick events, 41% was from glass from the vial, 89.9% occurred in the fingers, and in 12.5% there was presence of contaminated blood. Of mucocutaneous exposure accidents, 85.7% involved splashing into eyes, and 77.8% contact with urine, saliva, or secretions. 10% of the injured reported the event, and a relationship was established between the events and an average age of 32.9 years, as well as between accidents and time of service of 7.5 years.
Thus, the crude rate of work accidents in nurses was 215.9 per 1,000 people, and the highest rates occurred in the group of nurse practitioners and those working in the surgery department.15
A study in Mexico analyzed 288 reports of exposure to occupational accidents, in which nurses predominated, followed by physicians. Accidents for cleaning staff accounted for 19.09%. Dentists and X-ray staff made reports eventually.16
In Havana, Cuba, a study was done about health workers’ occupational risk of exposure to sharps, through a survey on accidental injuries and punctures applied to 1208 workers in eight health units. Of these, 22% reported accidents with needlesticks, and the workers most at risk were surgeons, nurses, laboratory technicians, and dentists. 20.9% of health workers had acquired some contagious disease in relation with patients; 10.8% reported having had hepatitis, and 3.06% hepatitis B and C. This occupational risk is frequently reported by health personnel and is a significant cause of occupational morbidity.17
For decades it has been recognized that the work of nurses in the hospital setting has different effects on physical and mental health, which are associated with workloads, the complexity of the procedures performed, proximity or confrontation with patient death (which generates prolonged job stress and the risk of health problems from the comprehensive care of patients with infectious and contagious diseases during work). It has been observed that nurses mostly present clinical manifestations of burnout syndrome due to responsibility at work; for example, in emergency situations, they take on responsibilities they are not fully trained for due to the absence of medical staff.18
Other causes are linked to specific aspects of the infrastructure, such as poor lighting in night shifts, inadequate or insufficient space to do the work, ambiguity in assigning roles to nurses, lack of staff to provide adequate attention to users, and, sometimes, continuous criticism of their work from other health professionals.
It is considered that during their daily work nurses engage in activities that expose them to musculoskeletal injuries and harm from physical overwork. In surgical areas, the risks are related to the workplace, microclimate, lighting, radiation, biological hazards, ergonomics, stress, adopting difficult positions in very complicated procedures, or working on flooring with heavy material in torsion. In intensive care services, nurses also have the risk of some infectious diseases from the comprehensive management of patients with problems of this nature. It is important to note the existence of a significant percentage of accidents related to so-called effort injuries, from the continuous mobilization of patient for tests or changing their position in bed. Nurses are also exposed to psychosocial risks arising from night work; regarding years of service, this is greater among staff starting at two years and decreases after 21 years of work.
If we analyze that humans over millions of years have gradually evolved in tune with the rhythms and cycles of nature, it results that nurses with fixed night shifts are at risk of desynchronization of their circadian biological rhythms, which can cause alterations in digestive, cardiovascular, and mental disorders, which reduces the duration and quality of sleep, in addition to producing familial disturbances. It is important to note that these symptoms, like musculoskeletal symptoms from repetitive strain, are hardly recognized in occupational cases.
A cross-sectional study was conducted to determine the prevalence of burnout syndrome in nurses working in 16 hospitals of the Secretaría de Salud and in five hospitals in the Instituto de Seguridad y Servicios Sociales de los Trabajadores del Estado (ISSSTE) in the State of Hidalgo. A survey was applied to 535 nursing workers, which included Maslach Burnout Inventory (MBI). The sample was calculated with Open Epi program, version 3.01, based on the formula for proportions and a reliability of 95%, 40% prevalence, and sampling error of 0.05. The criteria for selecting subjects were: active nursing staff at the designated hospitals, having work experience of more than two years, and voluntarily agreeing to participate in the study.
Before collecting the information, necessary steps were taken with the hospital directors and head nurses, and fieldwork logistics were established, which would allow a representative sample of all nurses working in the hospital regardless of the shift and service that they work.
Surveys were self-administered after signing the informed consent. SPSS version 19 was used for analysis. Statistical analysis was performed at a descriptive level for numerical and categorical variables, plus Chi-squared tests for categorical variables.
The study followed the provisions of the Reglamento de la Ley General de Salud in research; in addition, the protocol was previously approved by the Research Committee and the Ethics and Biosafety Committee.
During the study period 535 surveys were applied to nurses in hospitals of the Secretaría de Salud and ISSSTE. Regarding gender, 93.8% were women and 6.2% men. The mean age was 37.8 ± 9.4 years. As for marital status, 44.3% were married; 29.3% were single; 18.4% cohabiting; 5.6% were divorced; and 2.5% widowed. 79.2% had children; of these, 27.6% had one child, 43.9% two children, 23.7% three children.
The distribution of staff by service at the hospital was as follows: 18.7% in Emergency Medicine; 18.5% Hospitalization; and 8.6% Outpatient, while a minority was in the services of Chemotherapy, Endoscopy, and Neonatal Intensive Care. As for the distribution by shift, 32% belonged to the night shift; 29.4% to the morning shift; 20.2% to the special shift, and 18.4% to the evening shift. The average years of work experience was 15 ± 9.1 years. Clustered, the group with 0 to 5 years was 17.57%; 6 to 10 years, 19.62%; 11 to 15 years, 18.31%; and 16 to 20 years, 14.01%.
The ratio of staff burnout syndrome evaluated with the MBI instrument was 33.8% (181 of 535), of which 6.7% (36 of 535) presented a high level of burnout. From the indicators established by the Maslach scale, it was found that 44.1% had emotional exhaustion; 56.4% depersonalization, and 92.9% reduced personal fulfillment.
As for the bivariate analysis, the following results were found: there was no significant difference regarding burnout in relation to sex, marital status, and shift; however, age, service in which the nurse worked (if their workload involved increased stress), and unjustified absence showed significant differences (p < 0.05) (Table I).
|Table I Prevalence of burnout syndrome in nurses in two health institutions|
n = 181 (33.8%)
n = 354 (66.2%)
|Age (in years)||36 ± 9.3 (27-45)||38.7 ± 9.4 (30-48)|
As to the different dimensions of burnout, emotional exhaustion had a greater proportion among nurses with this syndrome (44.1% vs. 10.3%); depersonalization was also higher in nurses with burnout (56.4% vs. 22.6%); finally, personal fulfillment also had a greater proportion (92.9% vs. 59.1%); all were statistically significant (p < 0.05) (Table II).
|Table II Prevalence of burnout syndrome in nurses in two health institutions|
n = 181 (33.8%)
n = 354 (66.2%)
|Time in current service (in years)|
|Number of children|
14.3% worked for some other institution, while the rest only worked at one (Table III). Regarding the means of transport, 47.2% used public transport, 37% used private cars, 4.4% used taxi or other, and 4.4% went to work on foot. As for the commute time from home to hospital, 26.5% took less than 15 minutes; 32.1% between 16 and 30 minutes; 8.8% between 31 and 45 minutes; 11.1% of 46 to 60 minutes, 7.1% of 60 to 90 minutes, 8.6% of 91 to 120 minutes, and 5.6% more than two hours.
|Table III Prevalence of burnout syndrome in nurses in two health institutions|
n = 181 (33.8%)
n = 354 (66.2%)
|13.1 ± 7 (6-20)||16.1 ± 9.3 (7-25)|
|Working at another institution|
|Participating in critical areas|
19.1% found the work environment unfavorable; 56.8% said that their income was not enough; on the other hand, 53.4% stated that their colleagues’ absenteeism greatly affected their performance; 16.5% mentioned that it affected them little, and 30.1% said it did not affect them at all. Finally, 71.3% considered it necessary to have a decent place to rest.
The frequency of burnout found in hospitals of the Secretaría de Salud and ISSSTE is high (33.8%) compared to studies in other hospitals in the world.
Factors that were associated (statistically significant) were female nurses with two or more children, 38 years of age or younger, working in critical areas and, moreover, with unexcused absences. There were also other factors, such as working the night or morning shift, having less than five years of experience in the current service, and less than 20 years of work experience.
A reinforcement program is needed for nurses who work at the state level, as well as improvement of conditions under which nurses are currently working. It is specifically suggested to have rest areas; train staff with the implementation of courses and workshops (e.g., stress management, motivation and self-improvement, improvement of interpersonal relations, working environment, and assertive communication); hire more staff; recognize their work; support them psychologically and therapeutically; and ultimately achieve greater institutional identification.