Occupational burnout in nurses: a concept analysis^†

Emotional strain is defined as emotional exhaustion coupling with apparent unsuccessful handling and adverse emotive responses. Emotional processing is the first response system to interact with the external environment because it coordinates and activates different physiological, cognitive, and behavioral responses to help adapt to the changes that are taking place. The literature demonstrates that emotional strain may be the most basic form of strain, preceding and developing other procedures of stress such as physiological strain.²²

Compassion fatigue was first proposed by the nursing educator Joinson in 1992,²³ which is used to describe the professional incompetence of emergency department nurses caused by emotional exhaustion in their nursing work. In 1995, Figley et al.²⁴ gave the definition of CF, which refers to the symptom that caregivers frequently and indirectly expose to traumatic events and empathize with others. As time goes by, nurses’ empathy gradually decreases and then empathy fatigue occurs, which severely affects their physical and mental health, and reduces their interest and ability to empathize with others, weakening their ability to help others. Therefore, it is also known as the “cost of caring” and “secondary traumatic stress reaction (STST).” Nursing staff, as a highly stressed professional group, often suffer from secondary trauma or involved experience due to empathy involvement, such as witnessing the suffering of patients, facing the death of patients, and providing care for “trouble” patients and families while improving patient satisfaction.^25,26

Robert, RN, has been a nurse in an acute mental health unit for about 10 years in a local hospital. Every day, he has to deal with many problems which are stressful ones such as aggression management, physical restraint, and help patients involuntary administration. However, Robert loves his job because he can handle these situations. In recent few months, however, Robert finds that he is physically exhausted, though he has not made any changes in his schedule. Recently, Robert is emotionally insensitive to patients care (emotional exhaustion), and always distanced himself from the patients and shows the indifferent and neglectful attitude toward the patients or even shouts to them (depersonalization). He loses his confidence and cannot finish the tasks which his head nurse asks him to do (low personal accomplishment).

In this case, Robert displayed symptoms of emotional exhaustion, and gradually depersonalization and finally lead to his low personal accomplishment. Therefore, all the defining attributes of burnout were portrayed in this case.

Lucia is a registered nurse working in an adult mental health unit. Despite having an emotionally challenging job, she enjoys her present position and looks forward to going to work each day. Lucia feels that she can provide adequate care that shows respect and compassion for patients even though some of them are aggressive (failed emotional exhaustion). She does not discriminate against patients but adopts an enthusiastic and positive attitude toward the patients and the environment (failed depersonalization). Moreover, she is also able to complete the tasks assigned by the nurse manager correctly and thinks that working in a mental health setting is meaningful (failed low personal accomplishment).

This case clearly reflects an absence of the attributes of burnout. Lucia was completely calm and did not experience symptoms of emotional exhaustion or display depersonalization as well as low personal accomplishment.

OB was largely influenced by demographic characteristics of nurses. These includes gender,²⁹ age,³⁰ marital status,³¹ educational level,³² years of experience,³³ professional title,^33,34 and language.³⁴

It has been found that emotional demands such as exposure to patients’ suffering or death would aggravate the symptoms of nurses’ burnout in nursing practice.¹⁸ Additionally, verbal and physical aggression by patients is contributed to OB in clinical professions.³⁵ Furthermore, higher lever burnout was prevalent among employees who work in traumatic settings, for example, psychiatric caregivers are frequently exposed to workplace violence, patients’ involuntary detentions, suicide, and the traumatic life events of psychiatric patients.^28,36 For work-related variables, years of experience, salary, and personal involvement are also found to be related to burnout.^37,38

Quantitative job demands that are associated with an increased hazard of burnout include long working hours, night shifts, increased workload, and time pressures. On the contrary, qualitative job demands such as role ambiguity and role conflict increase the risk of suffering from burnout. Moreover, the study found that interpersonal conflict is positively associated with emotional exhaustion and depersonalization, and negatively correlated with personal accomplishment. Role conflict occurs when there is a need to meet conflicting needs at work, while role ambiguity occurs when there is insufficient material to do the job well.²⁷

Job resources include organizational resources²⁷ (such as job control, participative management, inadequate opportunity for promotion, minimal opportunities for participating in decision-making, inadequate autonomy, and insufficient advice on job performance), social resources²⁷ (including support from nurse managers, colleagues, peers, and family), and physical resources (such as equipment, medicine, reward, and low incomes).³⁹ The most frequently researched job resources are social support and supervision.²⁷ Additionally, Rezaei et al.⁴⁰ announced that the employment status of nurses affects emotional exhaustion and personal achievement.

The big five traits include neuroticism, extraversion, conscientiousness and agreeableness, and openness. Some studies illustrated that four of the big-five personality characteristics are related to burnout (i.e., not Openness). For instance, burnout was positively associated with neuroticism, and extraversion, conscientiousness, and agreeableness were negatively related to burnout.^37,28,41

Additionally, consequences are actions that follow as a result of the occurrence of the concept.⁶ There are three major consequences of burnout.

The first consequence is the individual’s unfavorable quality of life, including physical health problems (weakness and insomnia, cardiovascular disorders, musculo-skeletal disorders, and impairment of the immunological system), increased mental health problems (depression, nervousness, substance abuse, or even suicide), behavioral problems (aggressiveness, irritability, and isolation), and attitude problems (hostility, indifference, and cynicism).^{37,42,43,44,45}

The second consequence is the negative impact on organizations. It has been found that burnout may lead to nurses’ reduced work appointment, absenteeism, turnover, lower levels of job satisfaction, and decreased employee self-confidence, placing a considerable burden on organizational functioning.^1,46,47

The final consequence is clients, which means that burnout can lead to poor quality of services. In the nursing profession, a high level of burnout can result in the poor quality of nursing care, medical errors,⁴⁸ and diminishing patient safety.⁵

The following diagram illustrates the relationship between attributes, antecedents, and consequences for the concept of burnout (Figure 1).

Figure 1