The Relationship between Burnout Dimensions and Psychological Symptoms (Depression, Anxiety and Stress) Among Nurses

Seyed Valiollah Mousavi^1*, Maryam Ramezani², Iraj Salehi³, Abas Ali Hossein Khanzadeh⁴, Farzaneh Sheikholeslami⁵

¹Department of Psychology, Associate professor, School of literature and humanties, University of Guilan, Rasht, Iran

²General Psychology (MA), School of literature and humanties, University of Guilan, Rasht, Iran

³Department of psychology, Assistant professor, School of literature and humanities, University of Guilan, Rasht, Iran.

⁴Department of psychology, Associate professor, School of literature and humanities, University of Guilan, Rasht, Iran.

⁵Depatment of Nursing (Psychiatric Nursing), Instructor, School of Nursing and Midwifery, Guilan University of Medical Sciences, Rasht, Iran.

*Corresponding author: School of literature and humanties, University of Guilan, Rasht

E-mail: mousavi180@yahoo.com

Received: 2015June 21; Accepted: 2016Febriary 18            

Introduction
New management theories believe that humans need to work by nature and they try to work to meet the instinctive, physical and daily living needs [1]. Working in healthcare jobs where human communication and health are raised can cause a lot of stress. Among individuals working in health centers, nurses undergo the maximum work pressure. Nursing is a stressful and challenging profession for several reasons. Permanent confrontation with patients, having responsibility for human health, performing clinical procedures, exposure to dying patients, dealing with emergency and unpredictable situations, exposure to too much noise at workplace and shifts turnover are among stress factors affecting the nursing profession [2].

For various reasons, such as the cumbersome nature of patient care, nurses are known as a group at high risk of burnout, which can reduce the quality of care in hospitals [3]. Burnout is defined as mental health damage that is formed in workplace and has three dimensions: 1. Emotional exhaustion that is completely like psychological pressure variable and feeling of being under pressure and the loss of one's emotional resources. 2. Depersonalization is defined as negative and callous answer to people who usually receive the service from a person. This dimension refers to the negative impressions from others. 3. Reduced individual performance: It refers to reduced personal accomplishment in undertaking personal responsibilities and having negative evaluation towards work [4]. There is a general consensus that emotional exhaustion is the central or core dimension of burnout [5]. Burnout, as the main characteristic of job stress, refers to a delayed reaction to chronic stressors at work, which causes numerous adverse effects on the individual and the organization where a person(s) is working as well as on society in the long term [6, 7]. The detrimental burnout effect on nurses is so much that nurse shortage in industrial countries today is a major problem and finding a solution to it has become a priority [8].

Today, depression is one of the major medical and social issues, which ruined labor, economic and social empowerment of the individual [9, 10]. Workplace stress, depression and anxiety cause lack of confidence and frequent absenteeism. As confirmed by researchers, nurses are among occupational groups who are exposed to stress and mental health problems and these psychological symptoms are among the common complaints [11]. The estimated cost of depression has been calculated more than 8 million dollars in the United States [10]. In a study in Japan, Kawano showed that nurses are at risk of having the highest stressors compared to other occupational groups. This study reported that physical and mental health of nurses affect the quality of service and patient satisfaction [12]. Various studies have been carried out in this area, including the one by Takuda et al. that showed that burnout is negatively correlated with mental health and positively correlated with job dissatisfaction [13]. Hassanzadeh and Pouretminan also found a significant relationship among stress, anxiety and depression and burnout rate. Burnout could explain 64.8% of depression, anxiety and stress [14]. When nurses feel the burnout, they offer poorer care that ultimately causes harm to the hospital as well as patients. Therefore, organizations will pay for the cost of burnout [15]. In order to work properly, human beings should think properly and to do so, they need to be healthy. So, physical, psychological and mental health can have a major effect on manpower's productivity. Depression, anxiety and stress are important psychological issues that can cause emotional problems, spiritual fatigue and hamper mental well-being. They can also be the basis for development of burnout. It seems necessary to investigate these topics scientifically to prevent problems caused by it. Therefore, the present study aimed to determine the relationship between burnout and psychological symptoms (depression, anxiety and stress) among nurses referred to educational hospitals in Rasht.

Material and Methods

The present study, which is descriptive-analytic and cross-sectional one, was conducted during the second half of 2014. The study population consisted of all nurses who were working in various wards, including psychiatry, infectious disease, burns, obstetrics and gynecology, pediatric and cardiology of six educational hospitals affiliated to the Gilan University of Medical Sciences in Rasht.

The sample size of 270 people was considered using the Morgan table. These nurses were selected using stratified random sampling, and this was used because all nurses were equally selected from different wards. To collect data at different shifts, the researcher referred to the above centers after obtaining permission of the vice-chancellor for research and technology of Gilan University of Medical Sciences. The researcher later put the questionnaires at nurses’ disposal and received them at the end of shifts after obtaining their written consent. On the questionnaires, the researcher dealt with issues like freedom to participate in the study and confidentiality of personal information. So, all participants took part in the study with their consent and voluntarily. Data collection instruments included demographic questionnaire, depression, anxiety and stress questionnaire {Depresion Anxiety, Stress, Scale (DASS21)} and Maslach burnout inventory. Demographic questionnaire includes information on age, gender, work experience, marital status, education, employment address, shifts and employment status. In this study, DASS-21 questionnaire was used and 7 questions were considered for each of the emotional states of depression, anxiety and stress. This is a four-part questionnaire scored based on 4-point Likert scale with no, low, medium and high options scored from 0 to 3, respectively. This questionnaire was first presented by Lovibond [16]. Antony et al., analyzed this scale and obtained Cronbach's alpha coefficient values of 0.97, 0.92 and 0.95 for stress, depression and anxiety, respectively [17]. The reliability of this scale was obtained at 0.70 in a study by Showani et al. [18]. In this study, the internal consistency of the test was evaluated using Cronbach's alpha, the amount of which was 0.77, 0.77 and 0.77 respectively for depression scale, anxiety scale and stress scale.

The third part of the instrument was Maslach burnout inventory, which contains 22 questions on both intensity and frequency in three dimensions: emotional exhaustion, depersonalization and personal accomplishment. Low, average, and high occupational burnout rates in the emotional exhaustion subscale are shown respectively by scores of >17 for frequency and >25 for intensity, between18-29 for frequency and 26-39 for intensity and <30 for frequency and <40 for intensity. Low, average, and high occupational burnout rates in the depersonalization dimension are shown by scores >15 for frequency and >6 for intensity, between the range of 6-11 for frequency and 7-14 for intensity, and <12 for frequency and <15 for intensity. Low, average, and high occupational burnout rates in the personal accomplishment dimension were shown respectively by scores < 36 for frequency and < 33 for intensity, between the range of 34-39 for frequency and 37-43 for intensity, and > 40 for frequency and > 44 for intensity. Maslach et al., calculated the internal validity for each of the sub-components and internal consistency of 0.83 and 0.84 for frequency and intensity, respectively.

They also calculated the reliability coefficient of 0.82 and 0.53 for frequency and intensity, respectively. Akbari et al., in a study determined the factor validity and psychometric properties of Persian version of the Maslach burnout inventory. They obtained the reliability value of 0.76, 0.60 and 0.70 for emotional exhaustion, depersonalization and personal accomplishment subscales, respectively [19]. For statistical analysis, descriptive statistics (mean and standard deviation) and inferential statistics (Pearson correlation coefficient and simultaneous multiple regression method) was used. Data was analyzed using SPSS V20.

Results
Descriptive findings showed that the mean

age of the sample group was 34.02± 5.970 years. Female and male participants accounted for 265 (98.1%) and 5 (1.9%) of the total subjects, respectively. Also, the number of participants with BS and MS in nursing was 265 (94.4%) and 15 (5.6%) of

the respondents, respectively. Permanent, contractual and temporary nurses accounted for 98 (36.3%), 79 (29.3%) and 93 (34.4%) among the subjects, respectively.
Pearson’s correlation coefficient showed positive and significant relationship between burnout dimensions (emotional exhaustion, depersonalization and reduced personal accomplishment) and psychological symptoms (depression, anxiety and stress) (table 1). The above table shows that there is a significant positive relationship between burnout dimensions and psychological symptoms (depression, anxiety and stress, which are considered as criterion variable and has been predicted based on predictive variable (burnout) in this study. Thus, each psychological symptom was individually based on burnout). Also, to predict the psychological symptoms, simultaneous studies were undertaken based on burnout and regression analysis, the results of which have been reported in table 2.