Work-Related Stress, Burnout, and Job Satisfaction of Dialysis Nurses in Association with Perceived Relations with Professional Contacts

Work-Related Stress, Burnout, and Job Satisfaction of Dialysis Nurses in Association with Perceived Relations with Professional Contacts Fatma Arıkan, RN, MS; Can Deniz Köksal, PhD; Çig`dem Gökçe, MD, MRCP(UK) F. Arıkan is with Antalya Health School, Department of Medical Nursing, and Dr. Köksal is with the Faculty of Economics and Administrative Sciences, Akdeniz University, Antalya, Turkey. Dr. Gökçe is with Hisar Intercontinental Hospital, Istanbul, Turkey. OBJECTIVE: We set out to determine levels of job-related stress, burnout, and job satisfaction in dialysis nurses and their association with nurses perceptions regarding relations with co-workers, and co-worker opinions on the nursing profession. The subjects compared in this study were employed in the dialysis units, intensive care units (ICUs) and the most preferred (cardiology, general surgery and orthopedics wards) of three different hospitals. METHODS: This descriptive and cross-sectional study was conducted in April 2003, and included 180 nurses: 31 working in dialysis units, 100 in ICUs, and 49 in the most preferred wards of the same hospitals. The study candidates were assessed with the use of a questionnaire regarding their socio-demographic characteristics, work places, and views concerning their relations with and the opinions of their professional contacts. Other means of data collection were the Work-Related Strain Inventory (WRSI), the Maslach Burnout Inventory (MBI) and the Minnesota Work Satisfaction Questionnaire (MWSQ). Percentage estimations, the chi-square test, and variance analysis were used for statistical evaluation of the data; p 0.05 was accepted as significant. RESULT: When compared with ICU and ward unit nurses, dialysis nurses had evidence of decreased job stress and burnout as well as increased job satisfaction, accompanied by decreased intention to leave the profession and higher levels of positive views concerning their relationships with physician co-workers and the opinions of their professional contacts toward the nursing profession. CONCLUSION: This study confirmed some established predictors of job satisfaction, work-related stress, and burnout and provided data on an unexplored area. Dialysis nurses appear to be at a decreased risk for job stress, burnout and premature retirement from nursing, with higher levels of job satisfaction. Further. the quality of relationships with physician co-workers and the opinions of professional contacts regarding the nursing profession as perceived by nurses may be related to job stress, burnout and work satisfaction. The high risk for professional burnout, job-related stress and job dissatisfaction noted among nurses has led to a growing interest in the psychosocial work environment in the last few decades. 1 Burnout is a syndrome of emotional exhaustion, depersonalization, and diminished perception of personal accomplishment that has been recognized as an important occupational hazard for various people-oriented professions, such as those involving social services, healthcare, and education. 2,3 Job stress can be defined as the relationship between an individual and her work environment that can threaten the wellness of the individual and eventually exhaust her means of coping with changes and problems. 4 Work-related stress can lead to depression, anxiety, and helplessness in an individual and has negative effects such as headache, muscle tension, and sleeplessness. 5,6 Job satisfaction can exert a major influence on job-related behaviors such as professional dropout, absenteeism, and selfreported job performance. 7 Job satisfaction has a special implication for the healthcare services, and low levels lead to premature loss of trained staff from their professional environments. Nurses have been reported to have lower levels of job satisfaction when compared with other professionals. 8 Professional satisfaction is the feeling of contentment that is formed by how a job is perceived by individuals and is one of the most significant requirements for successf and productivity. 9-11 Workers are satisfied when their needs are met in keeping with their expectations. 12 Healthcare workers have been described as the professional group with the highest risk for burnout, role conflict, and job dis-satisfaction. The quality of care provided by nurses is negatively effected by problems related to job satisfaction, April 2007 Dialysis & Transplantation 1

job-related stress, and burnout. 12-14 Heavy workloads, long daily working hours, and negative perceptions of work conditions can lead to burnout. 15,16 Wallcott investigated the work site stress factors in public health nurses and reported that adverse conditions like insufficient personnel, heavy workloads, communication problems with physicians, and conflicts with families were associated with increased burnout. 17 Studies conducted on healthcare personnel have shown that many factors such as inadequate payment, lack of harmony between received education and actual work, inadequate ongoing education, lack of the possibility of job advancement and negative work conditions affect job satisfaction. 3,14,18 We hypothesized that dialysis nursing as the prototype of specialist nursing could manifest differences in job stress, burnout, and satisfaction levels and that these differences could be associated with differences in the way they interpret their relations with, and the opinions of, their professional contacts. Methods Participants This research was an observational, crosssectional, and comparative study. The candidate subject population consisted of 180 nurses: 31 dialysis nurses, 100 intensive care unite (ICU), and 49 ward nurses working in the Antalya Social Security Institution, Antalya State Hospital, and Akdeniz University Faculty of Medicine Hospital in Turkey. These hospitals cater to blue-collar workers of low to lower-middle class income levels; white- and blue-collar workers of low to lower-middle class income; and white- and blue-collar workers with middle-class to high level incomes, respectively, thus representing the entire spectrum of patients cared for in Antalya. Inclusion of the nurses of the three hospitals mentioned was planned both to avoid limiting the study to a particular group of subjects working under specific conditions and to increase the number of subjects, since the number of dialysis nurses in any single center was considered too low to allow for healthy comparisons. ICU nurses comprised the first and negative control group; they were included to allow comparison with nurses with possibly the heaviest works loads and caring for patients with medical disorders similar in severity to those of dialysis patients. Nurses from the most preferred wards of the hospitals comprised the second and positive control group. These preferred wards were determined by an initial questionnaire addressed to all nurses working in the hospitals in mention; they were asked (anonymously) to list the three wards they would most prefer to work in; the response rate of 79%. The nurse administrators of the same hospitals were also asked about requests made by nurses within the prior 2 years for in-hospital transfers to the most favorite wards. Nurse administrators confirmed that the cardiology, general surgery, and orthopedic wards were consistently listed as the most favorite wards by nurses during all internal audits. The reason for trying to ascertain the most preferred wards was to allow comparison between dialysis nurses and those working in wards with possibly the best working conditions, as perceived by the subjects themselves. After determination of the study candidates, i.e., all nurses working in the dialysis, ICU, and preferred wards of all three hospitals, they were approached by a letter stating the objectives and methods of the study, requesting their informed consent. Of the total, 31 (93.9 %) of the dialysis, 100 (94.3 %) of the ICU, and 49 (84.5 %) of the ward nurses consented to participate in the study and comprised the actual study subjects. This study was approved by the institutional ethical authorities of all three hospitals. The research was conducted between April 7 and April 25, 2003, immediately after completion of the preparatory work described above. The time period was dictated primarily by an effort to gather data rapidly while the nurses work places and conditions were constant, particularly before leaves for summer and religious holidays began. Questionnaires After we determined the study candidates, those that gave informed consent were assessed with the use of a separate questionnaire inquiring their socio-demographic Job satisfaction has a special implication for the healthcare services, and low levels lead to premature loss of trained staff from their professional environments. Nurses have been reported to have lower levels of job satisfaction when compared with other professionals. characteristics, work places, and views concerning their relations with and the opinions of their professional contacts. Other means of data collection were the Work-Related Strain Inventory (WRSI), the Maslach Burnout Inventory (MBI), and the Minnesota Work Satisfaction Questionnaire (MWSQ). The data forms consisted of 75 questions: 15 initial socio-demographic and work-related questions followed by 18 WRSI-, 22 MBI-, and 20 MWSQ-related questions. Nurses were asked to choose positive, moderate, or negative to express how they perceived their relations with co-workers and the views of their professional contacts regarding the nursing profession. The first psychometric tool used in our study was the WRSI, which is an 18-item, 4-point Likert type self-reporting tool. 19 The WRSI was translated into Turkish by Aslan et al., and its validity and reliability were first investigated in a group of nurses and confirmed subsequently for other health care workers. 20 The person answering the inventory was required to assess the statement contained in each item and denote its relevance to her/his condition by choosing one of the following options with a corresponding score of 1 to 4: completely 2 Dialysis & Transplantation April 2007

applies to me, almost completely applies to me, somewhat applies to me, and does not apply to me. The second psychometric tool used in our study was the MBI. This tool was developed by Maslach and Jackson to determine individual levels of professionrelated emotional exhaustion (EE) depersonalization (DP), and personal accomplishment (PA); validity-reliability studies of its Turkish translation were previously conducted with physicians and nurses. 21,22 The MBI contains 22 items and 3 types of subscales. Subscales relevant to burnout are the EE subscale, the aim of which is to elicit employee feelings of emotional fatigue; the DP subscale, which attempts to reveal evidence of emotional estrangement and detachment from clients; and the PA subscale, which reflects self evaluation regarding the degree of professional success. The third psychometric tool employed in our study was the WRSQ, developed by Weis, Dawis, England, and Lofquist. 23 Its validity and reliability in healt care personnel in Turkey were investigated by Ergin. 24 The WRSQ is a 20-item tool in a 5-point Likert type format that elicits the interviewee s assessment of internal and external satisfaction factors. It contains items to reflect general satisfaction (GS), internal satisfaction (IS), and external satisfaction (ES) factors. In this study the WRSI reliability coefficient was found to be = 0.77; the MBI subcategory reliability coefficients were found to be = 0.87 (EE), = 0.66 (DP), = 0.68 (PA) and the WRSQ subcategory reliability coefficients were found to be = 0.88 (GS), = 0.85 (IS) and = 0.76 (ES). Statistical Analysis The Statistical Package for the Social Sciences packet program was used for data analysis. Percentage estimation was used in the evaluation of the nurses socio-demographic and job-related characteristics and the chi-square test was used to determine the differences in the nurses opinions regarding their relations with co-workers and the views of their team members, patients, and administrators about the nursing profession. Variance analysis was used in the evaluation of relationships between individual and work characteristics and psychometric tool scores. A p-value less than 0.05 was accepted to denote statistical significance. Results Owing to the vast amount of data generated in our study, some of our findings will be summarized without giving specific numeric details. All differences and correlations listed below were found to be statistically significant. When considered collectively, the study subjects were found to have moderate degree job stress and near-high emotional exhaustion as well as moderate depersonalization, near-low (perceived) professional accomplishment and neutral job satisfaction. Job stress was positively correlated with burnout and negatively correlated with job satisfaction in all groups. Factors associated with and/or accompanying job stress, burnout, and job satisfaction were age, years of work as a nurse, hospital and unit worked in, weekly work hours and scheme, monthly number of night duties, number of patients cared for per day, number of units changed within the last 5 years, main reason for working in the current unit as well as for choosing nursing as a profession, and the intention to quit nursing. Increased age emerged as an important factor associated with psychometric test results, with nurses older than 40 having the best and nurses younger than 32 having the worst emotional exhaustion and depersonalization scores. Nurses working in the University Hospital had the highest emotional exhaustion and the lowest job satisfaction scores. Nurses within the first 10 years of their profession had the highest job stress, emotional exhaustion and depersonalization scores as well as the lowest (perceived) personal accomplishment and job satisfaction scores. Nurses working more than 49 hours per week had lower (perceived) personal success and job satisfaction scores than those working 40-48 hours. Nurses working within a rotation system with night duties had higher job stress, emotional exhaustion and depersonalization and lower (perceived) personal success and job satisfaction scores than those working only in the daytime. Those called for more than 5 night duties per month had the worst psychometric test results. Nurses caring for One of the factors associated with nurse-physician conflicts may be the insistence on traditional professional roles in an age where the boundaries between nurses and physician responsibilities are changing or blurring. fewer than 10 patients during the day had scores reflecting higher job stress, emotional exhaustion, and depersonalization and lower (perceived) personal success and job satisfaction. Nurses who had changed units fewer than 4 times within the previous 5 years had better internal satisfaction scores than those who had been subjected to frequent changes. Nurses who had voluntarily chosen their current unit had psychometric test results reflecting decreased job stress, emotional exhaustion and depersonalization as well as higher (perceived) personal accomplishment and job satisfaction. The leading reasons for voluntarily choosing a unit were found to be completion of a course or certificate program relevant to, special interest in, or admiration of the communication of the team of a particular unit. Those who had chosen nursing because they admired the profession had significantly higher job satisfaction and lower emotional exhaustion scores than those who had chosen it on consideration of the ease of finding a job after graduation. The mean emotional exhaustion score of nurses who expressed intent to leave the profession was much higher than those who intended to continue to work. Of note, 65.9 % of all study subjects declared intention to leave the profession within the near future without waiting for formal retirement. Of particular note, nurses April 2007 Dialysis & Transplantation 3

who evaluated the nurse-physician professional relationships in their unit and the views of their co-workers, patients, and administrators regarding the nursing profession as positive had lower job stress, emotional exhaustion and depersonalization scores as well as higher (perceived) personal success and job satisfaction scores than nurses who rated the same items as moderate or poor. Dialysis nurses had lower job stress and burnout as well as higher job satisfaction levels when compared with the ICU and ward nurses (Table I). With respect to the factors summarized above that were found to be significantly associated with psychometric test results in our study, dialysis nurses were older and more experienced than the other groups; their weekly work hours were not less than ICU nurses but did not involve night duties; the number of patients they cared for during the day was higher than those of the ICU and ward nurses; they had not made frequent work place changes within the last 5 years; the majority of them had voluntarily chosen their units and their profession; and they had a decreased intention to quit nursing. While 25.8 % of dialysis nurses expressed an intention to leave the profession within the near future without waiting for formal retirement, 59 % of ICU and 69.4 % of ward nurses declared the same. When compared with the ICU and ward nurses, more dialysis nurses rated their professional relationships with physicians and the opinions of their co-workers, patients, and administrators regarding the nursing profession as positive. While 64.5 % of dialysis nurses evaluated their professional relationships with physicians as positive, this ratio fell to 27 % in ICU nurses. While the majority (80.6 %) of dialysis nurses perceived the opinions of their physician teammates on the nursing profession as positive, only 18 % of ICU and 36.7 % of ward nurses expressed the same view. Similar findings were noted between dialysis nurses and the control groups when questioned how they rated the opinions of their other teammates, patients, and administrators related to the nursing profession (Table II). Discussion Nursing as a profession is currently facing its greatest crisis. Despite a rapidly aging population with the need for increasing numbers of trained nurses, professional recruitment rates are falling and dropout rates are rising around the world. Specialized nursing may provide a way of attracting highly motivated individuals to TABLE I: Differences in the mean psychometric tool scores of dialysis nurses compared with intensive care unit and ward nurses. Psychometric Tool Dialysis Nurses (1) ICU Nurses (2) Ward Nurses (3) n = 31 n = 100 n = 49 Mean SD Mean SD Mean SD P 1-2 P 1-3 P 2-3 WRSI 31.55 6.13 37.27 7.6 37.08 5.63 0.000 0.000 0.060 MBI-EE 13.19 6.12 20.21 6.41 20.31 5.68 0.000 0.000 0.929 MBI-DP 2.77 2.51 6.79 3.41 6.69 3.30 0.000 0.000 0.774 MBI-PA 22.39 3.40 19.23 4.34 19.98 3.92 0.000 0.006 0.308 MWSQ-GS 3.59 0.53 2.26 0.52 3.16 0.62 0.000 0.002 0.045 MWSQ-IS 3.86 0.48 3.18 0.59 3.29 0.68 0.000 0.000 0.321 MWSQ-ES 3.20 0.69 2.63 0.62 2.96 0.71 0.000 0.148 0.004 DP = depersonalization, EE = emotional exhaustion, ES = external satisfaction, GS = general satisfaction, IS = internal satisfaction, MBI = Maslach Burnout Inventory (MBI), MWSQ = Minnesota Work Satisfaction Questionnaire, PA = personal accomplishment, WRSI = Work-Related Strain Inventory. the profession. Dialysis nursing is the prototype of specialist nursing and can thus offer the means of studying the effects of specialized nursing on job stress and satisfaction experienced by nurses. This is, to our knowledge the first study to extensively analyze job stress, burnout, and satisfaction in dialysis nurses in comparison with ICU and ward nurses. We hope our findings will increase the interest in studying and improving the work conditions and professional interactions of nurses in different units, so that the current crisis can be dealt with. This study confirmed our hypothesis by showing that dialysis nurses had decreased job stress and burnout and increased job satisfaction as compared with ICU nurses and ward nurses. ICU nurses were chosen for comparison owing to their shared characteristics with dialysis nurses, namely, caring for patients similar in disease severity and using advanced medical techniques and equipment. ICU nurses were considered negative controls, i.e., those with the highest work load and therefore possibly the highest job stress and burnout levels. In contrast, nurses working in the most preferred wards of their hospitals were considered positive controls, i.e., those expected to have the lowest levels of job stress and burnout. In keeping with our pre-study projections, ICU nurses did have psychometric test results reflecting high job stress and burnout as well as low job satisfaction but ward nurses did not have the expected positive psychometric test results. This indicates that working in the most popular wards is not sufficient in itself to positively affect job stress, burnout, and satisfaction. When analyzed in detail, the decreased job stress and burnout and higher job satisfaction levels of dialysis nurses was not found to be due to working in dialysis units per se, but associated with their being older, more experienced and free of night duties, with fewer work place changes and increased voluntary choice of work place and profession as compared to controls. Indeed, the number of patients cared for by dialysis nurses in the daytime was higher than those of ICU and ward nurses, indicating that increased personal work load did not lead to increased stress and burnout or decreased job satisfaction if accompanied by 4 Dialysis & Transplantation April 2007

TABLE II: How dialysis nurses are viewed by members of the healthcare team and by patients. Characteristics Nurse -Physician Professional Relationship Work Area Dialysis (1) ICU (2) Ward Unit (3) n % n % n % positive 20 64.5 27 27.0 20 40.8 14.48 5.10 5.22 moderate 8 25.8 52 52.0 25 51.0 2 2 2 negative 3 9.7 21 21.0 4 8.2 0.001 0.078 0.073 Physicians Opinions.about positive 25 80.6 18 18.0 18 36.7 42.24 15.53 7.59 moderate 3 9.7 51 51.0 23 46.9 2 2 2 negative 3 9.7 31 31.0 8 16.4 0.000 0.000 0.022 Nurses Opinions about positive 23 74.2 33 33.0 14 28.6 16.66 15.92 3.05 moderate 4 12.9 42 42.0 16 32.7 2 2 2 negative 4 12.9 25 25.0 19 38.7 0.000 0.000 0.217 Support Personnel s Opinions about positive 27 87.1 41 41.0 19 38.8 2.70 18.65 0.581 moderate 4 12.9 41 41.0 23 46.9 2 2 2 negative 18 18.0 7 14.3 0.000 0.000 0.748 Patients' Opinions about positive 25 80.6 55 55.0 26 53.1 6.81 6.41 0.135 moderate 3 9.7 29 29.0 14 28.6 2 2 2 negative 3 9.7 16 16.0 9 18.4 0.033 0.041 0.935 Hospital Administrators Opinions about positive 13 41.9 18 18.0 17 34.7 11.04 1.22 6.81 moderate 13 41.9 37 37.0 19 38.8 2 2 2 negative 5 16.2 45 45.0 13 26.5 0.004 0.542 0.033 Total 31 100 100 100 49 100 x 2 sd P 1-2 x 2 sd P 1-3 x 2 sd P 2-3 factors favorably affecting these job-related parameters. The importance of having decreased job stress and burnout and higher satisfaction was underlined by the decreased ratio of intention to quit nursing found in dialysis nurses when compared with both control groups. Another finding of note was the association between psychometric results and the way nurses perceived their relations with physician co-workers and the views of their professional contacts. Nurses who thought there were positive nurse-physician professional relationships in their units and who thought that their co-workers, patients, and administrators had positive views about the nursing profession had lower work-related stress, emotional exhaustion, and depersonalization scores and higher personal accomplishment as well as general, internal, and external satisfaction scores compared with those who rated the same items as moderate or negative. These differences were particularly notable between dialysis nurses and the control groups. Our study underscores the need for improved working conditions with fewer unit changes, weekly work hours, and night duties, as well as better interactions with professional contacts in order to decrease job stress, burnout, and dropout and to increase job satisfaction in nurses. Our findings are in keeping with previous studies that have shown that physi- April 2007 Dialysis & Transplantation 5

cians are at the top of the list of sources of negative attitudes and behaviors nurses encounter in the workplace. One of the factors associated with nurse-physician conflicts may be the insistence on traditional professional roles in an age where the boundaries between nurses and physician responsibilities are changing or blurring. However, the conflict between nurses and physicians and other professional contacts has been evaluated in a very limited number of research studies. Even so, the available data shows that the difficulties experienced by nurses in the workplace are not limited to communication problems but include verbal and physical attacks and abuse directed by physicians, other coworkers including other nurses and nurse administrators, patients, and families. Changing the negative views of nursing will require cultivation of a better image of the nursing profession by other professionals, in society in general, in the media, and in nurses themselves. In parallel with our finding that nurses who thought that other nurses and nursing administrators had a negative view of the nursing profession had the worst work-related stress, burnout, and satisfaction scores, Farrell determined that Australian nurses were exposed to violence directed by other nurses and did not think that their nursing administrators protected them. 25 In a noteworthy study from Turkey, Sever determined that there was a communication breakdown and serious conflict between nurses and that these problems were the cause of increased work-related stress and deceased motivation. 26 Demir reported that positive feedback received from co-workers decreased emotional exhaustion and depersonalization in nurses. 27 In short, in order to decrease professional conflict, stress, and burnout nurses need to achieve better cooperation and communication among each other. Patients and their families appear to have significant influence in a nurse s jobrelated psychometric results. Nurses who thought that their patients had negative views about nursing as a profession had negative findings with respect to job stress, burnout, and satisfaction levels in our study, which underlines the importance of the nurse interaction with patients. One research study that supported our findings was conducted by Sofield and Salmond in the United States. They found that, after physicians, patients were the second leading source of verbal abuse directed at nurses. 28 The problem is not limited to any one country. Henderson and Lynch, et al., reported that nurses in Canada and England, respectively, were frequently exposed to the abusive attitude and/or behavior of their patients and relatives. 29,30 Verbal and physical abuse directed by patients and their relatives is without doubt a factor in the decreasing attraction of nursing as a profession. To prevent this abuse, serious changes must be made in educational and healthcare institutions to foster and support self-respect and assertiveness in nurses. Improved images of nursing in society through the elimination of negative stereotypes in popular media would also contribute to this end and should be a goal for all nursing educators and administrators if nursing is to continue to attract motivated individuals dedicated to their profession. Conclusion Our findings suggest that although dialysis nurses have decreased job stress and burnout and higher job satisfaction scores than ICU and ward nurses, this is not due to working in dialysis units per se, but to having better conditions and improved professional interactions in their work places. Continuing education for nurses would enable them to either voluntarily choose their units or to accept and identify with them, develop means to foster supportive professional relations within their units based on mutual respect and trust, avoiding overextended work hours and too many night duties, and support young and inexperienced nurses by pairing them with experienced colleagues. All of these actions could help decrease job stress and burnout and thereby increase job satisfaction in all nurses. When compared to ICU and ward nurses, dialysis nurses in our study had decreased job stress and burnout as well as increased job satisfaction and higher frequencies of positive views concerning their relations with physician co-workers and the opinions of their professional contacts toward the nursing profession. These differences were accompanied by a decreased intention to leave the profession. 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