A cross-sectional multicentre qualitative study exploring attitudes and burnout knowledge in intensive care nurses with burnout

Burnout is a response to long-term emotional and interpersonal stressors, usually in the context of the workplace, and is largely determined by work environment and workload (1, 2). ICUs are a specific environment characterised by high-tech devices, high levels of responsibility, rapid patient turnover, and stress (3). Nurses employed in ICUs are exposed to work-related stress (4) and burdened with high levels of burnout (5, 6, 7, 8), which can lead to frequent physical illness, reduced well-being (e.g. insomnia and irritability), eating problems and depression, and increased turnover, absenteeism and sick leave (6, 9). Moreover, burnout in nurses can affect the quality of patient care they are able to offer (10). Several factors have been found to be associated with the development of burnout syndrome: personal characteristics, working conditions (prolonged overload), conflicts with patients, families or other staff members, lack of support, and a feeling that the work is not useful (11, 12, 13).

Numerous studies have determined the prevalence and assessment of burnout in ICU healthcare providers, the risk factors, and the organisational impact, yet burnout therapies have been relatively unexplored (13, 14). There have been several studies conducted on nurses diagnosed with burnout aimed at identifying measures to strengthen workplace well-being (15), interventions for reducing burnout symptoms, and the application of coping strategies (16). ICU nurses’ well-being was shown to be better when they re-focused on their own resources using yoga and mindfulness, together with organisational support (e.g. peer supervision, official conversation, and teamwork (16)).

This study was conducted to fill the gap in information on the attitudes and experience of burnout in participants previously assessed as burnt out. The approach also targeted the sense of knowledge among ICU nurses, e.g. describing their own knowledge as sufficient, superficial, non-existent etc. The findings could be of the utmost importance when planning burnout prevention, and could provide a better understanding of the phenomenon, which has been clearly recognised as a current problem in all healthcare systems. They might, therefore, be of international relevance.

The study had a qualitative phenomenological design with semi-structured interviews, and is reported in accordance with the Consolidated Criteria for Reporting Qualitative Research checklist. The inductive approach enabled the researchers to develop a thematic framework emerging from the data (“from the ground up”), while a semantic approach was needed to explore the participants’ experiences, beliefs and views (17).

There were 4 (14%) male and 24 (86%) female nurses aged between 18 and 25 (n=6 (21%)), 26 and 36 (n=10 (36%)), and 36 and 45 (n=11 years (40%)), with one person over 45 years of age. They were mostly single (n=18 (64%)), with one divorced person, and had secondary levels of education (n=12 (43%)) or higher. Of the total number, 11 (40%) had less than five years’ work experience, while the others reported between five and ten years (n=5 (18%)), 11 to 15 years (n=3 (11%)), 16 to 20 years (n=6 (21%)) or 21 or more years of professional experience (n=3 (11%)). They were employed at Zagreb university hospitals (n=17 (61%)), Sestre Milosrdnice (n=4 (14%)), Sveti Duh (n=3 (11%)), Merkur (n=3 (11%)) and Dubrava (n=1 (3%)).

For each question, the analysis displayed the main themes that recurred throughout the conversation. An inventory of the themes, including the codes, is presented in Tables 1–4.

There were four research questions. These covered different areas of the interviewees’ experience. The data collected was organised into three sub-levels: code(s), sub-theme(s) and main theme(s). The answers to each question were organised into one or two main themes. All the themes had sub-themes based on several codes, with the number of codes per sub-theme varying from two to five.

There was one main theme identified in the answers to this question (Table 1), Private life compromised, with five sub-themes (lack of leisure time, strained relationships, projecting dissatisfaction onto family, inadequate coping and the effects). With regard to the main theme Private life compromised, the participants most often mentioned two sub-themes, namely a lack of leisure time, and strained family relationships (“I rarely see my family” or “Sometimes I get calls late in the afternoon outside working hours and I have to do something for work before I go there the next time”). On the one hand, work-related stress manifests itself in a limited amount of leisure time (due to the long working hours and sometimes also due to work assignments/telephone calls outside working hours); on the other hand, work affects nurses’ mood and mental state in such a way that they seclude themselves from family members or they pass their stress on to their families (“I bring home the things that happen at work and I mull over them and cannot devote myself to my family as normal”).

The participants tried to alleviate the negative effects on their families as much as possible, yet most of them stated that they did not have an efficient method of achieving that goal. The two sub-themes were therefore labelled Inadequate coping and Projecting dissatisfaction onto family, due to the participants’ lack of constructive coping strategies, so they ended up projecting dissatisfaction at home and felt mentally and physically tired. The participants felt that stress in their private lives stemmed from a lack of sleep (primarily because of night shifts) and long shifts (“I am privately strained because of fatigue, chronic stress, insufficient rest between shifts and so on”) and also from the difficulty of the job itself. The fifth sub-theme covered the Effects, derived from the codes “no” and/or “occasional negative effects” and “some positive influence”, for the participants who said they experienced them. Very few participants (three in all) said they did not feel any negative consequences from work stress, or even had positive impacts (resisting stress) on their private lives.

The participants’ answers were grouped around two main themes: Stressful work demands (sub-themes: objective working conditions, psychological strain, interpersonal relationships) and Stress-reduction options with two sub-themes, i.e. spontaneously applied and management-related (Table 2). All agreed that their work was extremely stressful and demanding. Besides its objectively demanding characteristics, such as unpredictability, great responsibility and extreme workload, the participants also reported objective stressors, such as responsibility and rapid decision-making about human lives (“Too much to do, not enough staff, you try to do everything you need”). Being surrounded by human suffering, death and dying also makes the job emotionally demanding/tiring. The third cause of workplace stress is poor workplace environment and poor interpersonal relationships (“It’s not fair” or “I think some people work a lot more and a lot better than others do, and for practically the same amount of money”).

Besides talking about the presence of stress at work, some participants spontaneously mentioned certain techniques to reduce stress (second theme, Stress reduction options). They suggested means of stress relief and work environment improvements that were already in place on their wards, e.g. socialising outside work, or creating smaller work groups on the ward that encourage teamwork and cooperation (“I think it is important to foster a good team spirit in various ways”). Unfortunately, there was just a handful of examples of these successful strategies. Most proposals made by the nurses were wishes and unfulfilled needs, but they included very specific guidelines on stress relief in the workplace: “The only thing that comes to my mind is to increase the medical staff. I think everyone here gives the best that they can, but sometimes they can’t do what’s best because they simply don’t have enough time” or “For example, they could provide us with the supplies needed for work that we often don’t have... Providing enough equipment and supplies, providing enough staff, all of that relieves stress”. These are all management-related.

When asked directly about the role of the employer, the nurses gave suggestions that fall into one major theme called Protective workplace measures, and four sub-themes (Table 3). The first sub-theme was leadership: “Creating a positive work environment, having teams that work well together, whose members work well together, because if the environment is positive, if people communicate well, then it’s easier to bear it all”. The second sub-theme was creating preventive and psychosocial support. The employer needs to provide education/training on stress prevention for employees, as well as a support system when the negative impacts of stress appear: “In the sense of support for various programmes and training in stress prevention, it doesn’t exist here, so you’re left to yourown devices when it comes to coping”. As the third sub-theme, Organisational measures, states, prerequisites for stress reduction are better working conditions in the sense of improved staff education (“The better the staff are educated, the less insecurity at work”), and better-equipped wards. Finally, the fourth sub-theme recognises that rewards and quality control are also important – it seems that the existing system of rewards is not satisfying because of a lack of unified criteria for quality assessment. Nurses are aware of the differences in work quality, and feel it is both necessary and encouraging to reward better nurses and give them some privileges.

The main theme is one of the recurring themes on burnout (Table 4), Sense of knowledge of burnout, with five sub-themes (recognising and being acquainted with burnout, being able to describe it, ideas about burnout relief, and possible sources of information). The participants’ personal experience varies: most stated that they had some notion about what burnout might be, but insufficient knowledge, while a lower number stated that they were already feeling the symptoms of burnout (“I think I have felt the full scope of burnout and that it struck because I thought it could not happen to me and that I could control it. I did not have support, but it wasn’t until I realised that I couldn’t function, that I couldn’t sleep, that I couldn’t function privately, that I realised I had a problem”). This is an indicative finding, since the interviews were carried out only with those with burnout (MBI^TOT) and those who had stated a higher level of negative stress influence.

In line with this, it was generally acknowledged in the second sub-theme that other nurses also did not know enough about burnout syndrome, but that they could only say what it was on purely a superficial level: “I think knowledge is insufficient and most do not understand what it means at all”. Only a few individual participants felt that nurses were sufficiently well-informed.

How nurses feel about burnout syndrome and what they know about it is best seen through their own words: “For me, it represents a state where I no longer have the willpower to go to work after a while when a lot of these things have accumulated”.

The two additional sub-themes were burnout relief and sources of information, which vary (although it seems that they are primarily found at work). Some nurses had heard about the syndrome at college/school, but most had reportedly heard of it for the first time at work (from coworkers, through organised courses). There is definitely a need for certain strategies, i.e. information, awareness-raising and specific guidelines about who to turn to for help and how to proceed. An important role is attributed to the team leader/head nurse (“The head nurse knows best what interpersonal relations are like and what kind of a work place this is, so I think she should take up a bigger role here, since she knows everything, and she should encourage people to talk to each other, to get frustrations out in a civilised manner, to just talk”).

The aim of this study was to explore intensive care nurses’ experience of and attitudes towards burnout, and to identify their sense of knowledge about this syndrome. Five main themes were generated from a rich amount of data, including, inevitably, a reflection of the authors’ perspective: Compromised private life with five sub-themes (lack of leisure time, strained relationships, projecting dissatisfaction onto family, inadequate coping and the effects); Stressful work demands (sub-themes: objective working conditions, psychological strain, interpersonal relationships) and Stress reduction options with two sub-themes (spontaneously applied and management-related); Protective workplace measures with four sub-themes (leadership, prevention and psychosocial support, organisational measures, and quality control and rewards) and Sense of knowledge of burnout with five sub-themes (recognising and being acquainted with burnout, being able to describe it, ideas about burnout relief and possible sources of information).

The study tried to present what a group of ICU nurses felt, experienced and knew about burnout. Their perceptions and perspectives were all analysed, and then used to create an understanding of this part of their professional experience in a broader sense. The nurses’ expectations and proposals for protective workplace measures, e.g. leadership, prevention and psychosocial support, organisational measures, and quality control and rewards are among the very illustrative findings of this study (Table 3). In addition, the results also showed that participants had a poor sense of knowledge about burnout (Table 4).

High dependency departments are very stressful environments and can lead to a greater incidence of burnout, especially by way of emotional exhaustion and poor personal accomplishment. Nurse education has been increasing in the past decade, but it has not been followed by more competencies and greater autonomy (23). This study aimed to provide an insight into the attitudes towards and knowledge of burnout among ICU nurses with burnout. A poor sense of knowledge of burnout was identified in the participants (Table 4). The participants tried to alleviate the adverse effects on their families as much as possible, yet most of them stated that they did not have an efficient method of achieving that goal (Table 1). This accords with Shanafelt et al. (10), who reported poor communication with families, with the effects of work spilling over into personal life in healthcare providers who came home upset and unhappy.

The participants felt that the causes of the adverse effects (Theme 3, Table 1) and stress in their private lives stemmed not only from a lack of sleep (primarily because of night shifts) and long shifts, but also from the difficulty of the job itself (Table 2). Research has shown that high stress contributes to the development of lethargy, which can worsen further due to difficulty sleeping (24, 25). The participants reported an array of difficulties, and the study’s findings confirmed that ICU nurses considered their work to be extremely stressful and emotionally demanding (Table 3). The interviewees reported objective stress sources, such as responsibility and rapid decision-making about human lives (Table 3), similarly to Donchin (26), who described the ICU as an extremely stressful environment, and other authors who focused on workload as an independent factor in the development of burnout (5). Research exploring a reduction in burnout levels has shown promising results for burnout recovery when combined with individually and professionally focused activities (27, 28). An improvement in work organisation has been shown to be the most important factor for reducing stress (29), and the need for a balanced interaction between job demands and resources in order to prevent burnout in hospital nurses has been confirmed among Croatian hospital nurses in previous research (30).

In this study, one frequently mentioned cause of workplace stress was an unpleasant or poor work environment and poor interpersonal relationships (Table 3). Others have also confirmed that the work environment and interpersonal relationships are linked to burnout (1, 9, 31). This study participants suggested some solutions to address occupational stress, including changes in organisational and working conditions, refining interpersonal communication, and obliging supervisors/superiors/head nurses to implement them (Table 4), which accords with research findings that stress in hospital nurses is related to the organisation of work (32, 33). In their cross-sectional survey conducted in 2006-2007, Golubić et al. identified several major groups of occupational stressors in hospital nurses: organisation of work and financial issues; public criticism; hazards and interpersonal conflicts in the workplace; shift work; and professional and intellectual demands. They advised hospital managers to develop strategies to address and improve the quality of working conditions for nurses in Croatian hospitals (34). Other authors have also proposed that head nurses be encouraged to accept suggestions from staff, given how employees feel about their work and how personal relationships in the workplace affect their well-being (35). This is similar to this study participants’ expectations and proposals (Tables 3, 4). Providing specialist help and awareness-raising workshops (Table 4) could help to reduce nurses’ occupational stress levels and staff turnover (Table 4, “Leaving for an easier workplace”), and enable nurses to maintain their capacity to work.

This study showed that there was an insufficient sense of knowledge of burnout syndrome, with information coming from a variety of sources (Table 4). This makes it difficult to diagnose burnout early, and to prevent and possibly treat it. However, the ICU environment should primarily target the prevention of burnout (36). This could be accomplished by developing capacity-building to help staff become more aware of the issue, and encouraging them to talk about it (37). It has already been suggested in Croatia that developing prevention plans and including psychological education as an intervention would greatly reduce both the incidence and the adverse effects on the health system (38). Given that differences in job satisfaction and psychological and subjective well-being have been found to be conditioned by level of education, i.e. nurses with a higher level of education are more satisfied with their jobs (35), continuing education could affect both burnout and job satisfaction. Within continuous education, lectures should provide information about coping skills (39). There is definitely a need for certain strategies for ICU nurses, i.e. information, awareness-raising and specific guidelines about who to turn to for help and how to proceed (Table 4).

To produce more conclusive findings with an international impact, it is of the utmost importance that research using a mixed (quantitative and qualitative) methodology is carried out again in the region, in hospitals with similar organisational set-ups and conditions. Aside from this, absenteeism and career changes related to working conditions and demands in ICU nurses should be taken into account when planning further research.

In order to prevent or reduce burnout syndrome levels, compromised private life and stressful work demands, the various levels of the nursing education system should address stress reduction options, protective workplace measures and the poor sense of knowledge among ICU nurses. These should also be addressed within administrative and institutional settings. The information provided can help ICU nurses, and nurses in general, to understand how burnout affects their professional and family lives, and offers a variety of methods aimed at mitigating these harmful effects. Finally, the findings can motivate healthcare professionals with limited skills and/ or knowledge of burnout to at least accept the necessity to modify their coping strategies so that they are more problem-oriented and constructive.