Burnout and absenteeism among nurses in health care management.

ABSTRACT

Nursing is cited as one of the most susceptible professions to burnout. The phenomenon is a combination of symptoms with the potential to damage the individual, other workers, the department in which the burned out nurse works, the patients and their families, the organization, and the reputation of the profession.

This study examined the relationship between burnout and absenteeism from work. The connection between these variables was hypothesized to be direct--higher levels of burnout would result in more days of absence. Specifically, it compared levels of burnout with number of days of absence from work between two hospital departments, internal medicine and intensive care. This comparison was done with the objective of demonstrating more burnout expressed in more days of absence among intensive care nurses, as predicted in other research.

The study was cross sectional and used a closed-ended questionnaire. In addition data regarding work schedules to check absence was recorded in the same time period. The hypothesis was not supported. No significant differences in burnout levels were shown between the departments and the rate of absence was higher in the intensive care units so no correlation between burnout and absence was expressed.

The results did show a clear connection between age and level of burnout. It also indicated that burnout levels are potentially affected by three other variables: marital status, level of education, and professional status. Since the association between age and burnout was strong, we recommend further investigation to confirm the results and 'burnout workshops' for nurses, particularly those over forty-five years of age, to prepare coping strategies for stress and hopefully prevent the occurrence of the phenomenon.

Keywords: Burnout, Absenteeism, Nurses

1. INTRODUCTION

The phenomenon of burnout is understood to be a significant problem in the service professions. People working in an environment, often filled with tension and unpredictable situations, are vulnerable to physical and psychological distress, and can become burnt out. The profession of nursing demands high levels of responsibility and knowledge. In addition, nurses are also frequently the target of the frustration, anger, and the suffering of the patient and his family. For nurses, as for many people working in a service profession, chronically stressful circumstances are the norm at work and impossible to avoid. These stresses can lead to burnout.

Burnout is described as physical and psychological fatigue. A person is depicted as having negative attitudes towards himself, towards his work, and towards others when he is burnt out. (Pines, 1984) Usually, burnout is considered to be the result of continuous pressure applied when there is no way out of the situation, when there is insufficient support, or when there is no available alternative.

Burnout has a significant effect on performance and is an important concern at the organizational level for three reasons. Standards of nursing care are lowered and the reputation of the profession is damaged. Employee turnover is more rapid, and there is an increase in late arrivals at work and unjustified absence from work.

Understanding burnout, its causes and results, is the first step in the search for solutions to the problems it creates. The goal of this study is to clarify the problem and promote the implementation of suitable solutions for professional nurses.

2. LITERATURE REVIEW

Today's economy and the competition among organizations have increased the demands placed on the worker. As a result, they are continually exposed to added pressure in the workplace. This can have negative results on the individual, on the organization and on the population served by the organization. It is recognized that burnout is a common, important problem in the service professions. Working with people over long periods of time can generate heavy psychological burdens. (Jamel, 1981)

Burnout occurs in many occupations, most notably in those designated as the 'helping professions'. Their major distinction from other work lies in the significant focus on the client who is receiving the service. The worker is identified as the person who provides the service, constantly gives the care, continuously provides the help and is always understanding and supportive. (Oleson, 1999) These daily demands, along with the focus on the client, are a source of disappointment and stress for the worker. Often, he has chosen a helping profession with the expectation that his contribution will be recognized and appreciated. Just as frequently, it is not. The personal characteristics of a person choosing to work in the service professions usually include a liking for human beings and a voluntary desire to help others. The oppressing amount of work to be done compared with this internalized desire to help clashes with the huge amount of work set before the nurse, or social worker, or doctor, etc., and creates internal conflicts. (Cords & Dougherty, 1993) The conflict lie between what the nurse is and what he can do. The inability to continuously cope with conditions at work and the persistent internal conflicts contribute to lowered morale and motivation, indifference and withdrawal, increased staff turnover and increased absence from work. (Maslach & Leiter, 1997)

Pines (1984) says that burnout is not a crisis that occurs in one instant. Rather it is a process that develops slowly, from psychological stress over an extended period of time. One of these stressors, inherent in nursing, is the magnitude and frequency of the insurmountable challenges. A pediatric nurse, for example, working in a pediatric intensive care, does not 'get used to' the suffering she sees every day. Certainly, she will have great satisfaction when she helps reduce or eliminate the pain and the distress, but there is always another very ill child and another family that is suffering.

Billions of dollars are lost annually due to low productivity, staff turnover and work absence caused by burnout. (Johns, G. 1987) The costs of burnout are generally felt as losses. The person may leave his job; this involves loss of manpower, learning and experience. The person may continue working but will then not work as efficiently as is usual. In both cases, standards related to the quality of care will not be maintained, so the patients feel the loss. There are losses for the organizations as well, due to the high turnover, the cost of retraining and the ineffective use of experience and talent. (Maslach & Leiter, 1997). The majority of researchers agree that burnout is a negative experience for the individual. It triggers emotional problems, interferes with interpersonal relationships, and damages his career. The symptoms of burnout include: chronic fatigue which does not disappear with rest; emotional exhaustion, general feelings of weakness and malaise, lack of energy; increased susceptibility to illness and increased psychosomatic complaints; feelings of helplessness, hopelessness and depression; negative attitudes towards the self, friends, co-workers and family; withdrawal and apathy. (Pines, Kafry, & Etzion, 1980) All of these factors are potential contributors to absenteeism from work, and this obstructs the scheduled work of the unit.

One of the pioneers of research into the subject of burnout, and the person who created the term burnout in 1972, was Dr. G.H. Freudenberger. He regarded burnout as fatigue resulting from an excessive demand of energy, strength and resources to be invested in the work. When the nature of the work necessitates high levels of self awareness and continuous coping with the problems of other human beings, when there is insufficient appreciation of the person's efforts and inadequate encouragement and support, and when the individual's expectations are unrelated to the reality of his work, he said that there could be a buildup of feelings of isolation and failure, leading to burnout. (Paine, 1982)

In his more recent investigations, he showed that burnout has an affect on every aspect of the person's life, on his personal roles and on his work roles. He also identified two main groups of people whom he considered prone to burnout. One group is comprised of individuals who label themselves followers. They are often underachievers, sensitive, passive individuals, who attach great importance to being liked. The second group is composed of people who see themselves as achievers, and who are occasionally inclined to overstep customary boundaries. They are sociable, successful and impatient. Pines (1980) addressed the same subject and added another group of workers susceptible to burnout. These are the idealistic individuals with lofty goals, high motivation and dedication.

After Dr. Freudenberger, research done by social psychologists concentrated mainly on the occurrence of burnout in the helping professions. They linked its appearance to repeated, stressful situations at work, arising from role definitions that demand constant social interaction, for example, between teacher and student. (Pines, Kafry, & Etzion, 1980; Schaufeli, Leiter, & Kalimo, 1995) They describe the burnout as a psychological reaction to the accumulating pressure of the continual stress. They identify three stages in its evolution. The first is characterized by a lack of work satisfaction and the development of negative attitudes towards the work. In the second stage there is an increase in negative attitudes, which now include people outside the work environment, i.e. family and friends. In the third and last stage, the negative attitudes are turned inward. It is during this time of full-blown burnout, that the person becomes indifferent, depressed and hopeless, unable to cope with the stresses in his life.

In 1981, published results of a study done among nurses and industrial workers indicated that role conflict combined with a lack of resources act together to produce tension and burnout, and this leads to increased absence from work. (Jamel, M.) Burnout, especially as related to absence from work, has a direct impact on our own work, so we have chosen one of its aspects to study. Our study deals with the possible influence of burnout on work absence of nurses working in hospitals, specifically focusing on a comparison between two groups: those working in intensive care and those working in medical units.

Within the working environment there are numerous factors with the potential to produce the feelings associated with burnout. These factors have been classified according to category, in four groups. The first, organizational factors, includes causes specifically related to the overall organization. The second, social factors, refers to communication and interpersonal relationships. The third group, structural factors, includes physical features of the workplace. Fourth, are the psychological factors, such as the meaningfulness of work, that are important emotional components of the work environment? The table below lists those that are important according to Pines (1984) and Liraz & Albin (1997).

Nursing is considered one of the high-risk professions with respect to burnout. The continuous exposure to patients in need, and their families, creates an environment filled with stress and can easily lead to emotional exhaustion for the nurse. The nurse must cope with a variety of tension-filled situations within which she must always act in a calm and organized way. She must provide the physical care required to treat the health problems of the patient while simultaneously and consistently being supportive of both him and his family. She must encourage, give care and teach. According to Ragsdale, Burns & Houston (1991), an additional reason for the appearance of burnout among nurses is the dual nature of their role. There is constant tension created by the clash between the professional orientation of the job, which is to treat the patient, and the bureaucratic demands of the organizational system.

Additional stressors contributing to burnout in the nursing sector include dealing with angry or confused patients, high levels of responsibility, inability to influence the working environment, lack of feedback, role conflict, excessive pressure from too high a workload, shift work and the resulting complexities of organizing private life around changing schedules, the differences between what is taught in schools of nursing and the reality of hospital nursing, chronic emotional strain and the use of sophisticated, new technologies. (Skellern, 1974; Stechmiller & Yarandi, 1993; Demerouti, Bakker, Nachreiner, & Schaufeli, 2000)

When it does happen, burnout among nurses results in personal psychological damage to the nurse, impairment in the quality of treatment for the patients and the corresponding negative effects on their recovery, lowered morale among the other staff members, increased absences from work, increased staff turnover and finally, can have an effect on the financial situation of the hospital. (Ragsdale, Burns & Houston 1991)

2.1 Nursing in Medical Departments--Nursing in Intensive Care Units

In 1978, Spicer checked the factors leading to burnout among nurses working in medical and surgical departments in hospitals in the United States. She concluded that most of the pressure placed on nurses came from the demand for high levels of knowledge and experience needed to perform the nursing tasks assigned. She noted two particular problems precipitating burnout. The first was that conditions at work include rapid changes in the condition and care of the patient, thus perpetuating high levels of stress in the working environment. The second was emotional involvement of the nurse with the patient and his family to such an extent that it interfered with her acceptance of planned treatment options. The nurses felt guilty, angry and frustrated over every omission or failure and then blamed the system for causing those feelings. More recently, Janssen, de Jonge & Bakker, (1999) did a study of 156 general hospital nurses. They concluded that the heavy workload together with the limited social support were the major causes of burnout for hospital nurses.

Intensive care units (ICU) are hospital departments filled with critically ill patients facing complex health problems. The needs of these patients are often unpredictable. There is accelerated physical activity and an atmosphere of constant tension and change. The nursing staff copes with the pressure of the work itself, with the conflicts arising from the work, and with the stresses involved working as part of a team comprised of other nurses, doctors, and technicians. (Oehler & Davidson, 1992)

The pace and tension of the work in an ICU places bio-physical-social-psychological demands on the nurses working there, burdens of pressure that promote the phenomenon of burnout. (Lenart, Bauer, Brighton, Johnson, & Stringer, 1994) According to Oehler and Davidson (1992), this burnout arises from the need for nurses working in the ICU to quickly fill all the complex, individual, nursing needs of the patient and his family while maintaining good interpersonal communication with them. Several researchers claim that extended exposure to the following factors are the cause of burnout in the ICU: the urgency of the need for care, the critical state of the patient, the need to accept and perform difficult procedures during a crisis, the need to perform painful treatments without patient cooperation, the fear of making a mistake, the 'medical' environment, excessive amount of work to do and not enough staff to do it, the impossibility of controlling the disturbances in the area, the rapid tempo of the work, and the anxiety of the families. (Corley, 1995; Flakus, 1998) They emphasize that these causes lead to burnout not because they are sometimes part of a nurse's work, but because they are the constant, daily routine for an intensive care nurse.

Goodfellow, in 1997, indicated that another factor contributing to burnout in the ICU is the interpersonal communications and interpersonal relationships between nurses and medical or para-medical personnel. Corley (1995) said that the work schedules and the shortage of nurses, accompanied by the feeling that the administration did not understand how difficult it was to accomplish all that was demanded of them, was still another reason for burnout.

2.2 Absenteeism and Its Connection to Burnout

Absence from work has significant destructive results for the organization as well as inferred ramifications related to the costs of hospitalization and the quality of treatment. Generally, in the health system, work absence is a serious problem. (Buschak, Craven, & Ledman, 1996) In hospitals, work absence intensifies the problems associated with the shortage of nursing staff. Difficulties are expressed in many ways. Replacing absent staff members adds financial burdens to the hospital budget since someone will be working overtime, while the quality of the treatment provided for the patients will not be equivalent if no substitute is found. Burnout and its resulting absenteeism from work in hospitals, itself becomes an added source of stress.

Work absence is a management problem. Although it is understood that a person who is sick should stay home, the unexpected added burden of work on those who are present is not appreciated. There are differences in attitude, both on the part of the management and on the part of the workers, when the absence is due to illness as compared to absence not due to sickness. Short-term and long-term absences are viewed differently, as are planned and unplanned absences. Absence at the beginning or at the end of a weekend or holiday is not regarded in the same way that absence in the middle of the week is.

The wide variety of stressors facing the nurse, together with the lack of sufficient physical, social and psychological resources, are the forerunners of burnout. (Demerouti, Bakker, Nachreiner, & Schaufeli, 2000) Studies done on burnout have discussed numerous causes for the syndrome along with proposed interventions to reduce its occurrence. (Cavanagh & Coffin, 1992; Janssen, de Jonge, & Bakker, 1999; Demerouti, Bakker, Nachreiner, & Schaufeli, 2000; Oehler, & Davidson, 1992; Fornes, Gallego, Barcelo, Crespi, & Guttierrez, 1994; Goodfellow, Varnam, Ress, & Shelly, 1997) The search for suitable solutions to the problems created by absenteeism in the nursing sector leads, in circular fashion, back to the problems of burnout. Finding ways to prevent the phenomenon, to recognize its earliest signs and to offer help when it does occur, should help lessen the incidence of burnout and reduce its effects. This should then lead to a reduction in absenteeism.

3. GOALS OF THE STUDY

The research will examine the relationship between burnout and frequency of absence in two hospital departments: internal medicine and intensive care.

The direct goal of the study is to determine if there are quantitative differences in burnout level between the groups of nurses of the study. The more comprehensive objective is to find ways to prevent or reduce the incidence of burnout. If a connection between burnout and absence from work is established, this will provide one more tool to use in the struggle against burnout in the nursing profession.

4. HYPOTHESES

Two hypotheses are presented: the first is that there is more burnout occurring among nurses working in the intensive care units than among nurses working in internal medical departments. The second is that a higher rate of burnout is related to a higher rate of absence from work.

This research model was chosen since it illustrates the connection between the dependent variable, burnout, and the resultant variable, absenteeism from work. The model incorporates factors, including personal and professional characteristics pertaining to nurses, with the potential to support or refute our hypothesis. The demonstration of the connections between the variables and the dynamics among them should help us understand and analyze the results of this study.

5. DEFINITION OF TERMS

5.1 Burnout

Nominal definition

A brief description of burnout is that it is a phenomenon occurring in the workplace to workers who are no longer receiving work satisfaction. The feelings demonstrated by these workers can include apathy, indifference, and even hatred of the work. There are many levels of burnout. For nurses, burnout is often seen as loss of interest in the patient and 'distancing' from the treatment or treatment results. (Maslach & Jackson, 1982)

Operational definition

Measurements are made according to indices of the questionnaire on burnout. These include the following:

* level of psychological fatigue

* understanding of the work environment

* level of motivation

* quantity and quality of the burden at work

* role conflicts

* level of responsibility for the patients and/or for the members of the staff

* level of social and professional support

5.2 Work Absence

Nominal definition

Absence from work means the non-appearance of the worker when he was expected to be at work. This does not include holidays or any other day when the worker is not expected. (Van der Merwe & Miller, 1971)

Operational definition

Records for the first six months of 2004 were examined. Absence, both in the intensive care units and internal medical departments, will be checked according to computerized work sheets, and manually according to the work schedules of each department. Absence, by operational definition, is confined to a range of from one to three days of work. It is the number of workers who are missing, not the number of days a worker is absent. The data for burnout is individual while the data collected for absence is by department. It is not a function of the reasons for the absence and is an independent variable. According to the hypothesis of the study, absence for more than three days is indicative of serious illness.

5.3 Additional Variables (as operational definitions according to the questionnaire)

* age

* gender

** family status

* education

** work experience

** professional status

** number of hours of employment

5.4 Participants

A total of two hundred and seventy-three nurses working in a major hospital in Israel, comprise the population of the study. One hundred eighty- three work in seven of the internal medicine departments of the hospital; ninety work in four of the intensive care units. The study population includes all the nurses currently working in these departments during the first six months of 2004.

6. RESEARCH METHODS

Measurement of the variables was be done using a structured questionnaire on burnout. Validity of the questionnaire was established according to the Lickert Scale and it was used in a previous study in 1985 at the University of Tel Aviv. The burnout scale was constructed and validated by Y. Azrachi (1985). Answers to the questions are confidential and will be used only for the purpose of the study. There are two sections and a total of seventy-six questions. The first section has eleven questions; it supplies the demographic information needed. The second section is composed of closed-ended questions, using a Lickert Scale of 1 to 5, on the subject of burnout. Reliability of the indices will be tested according to Cronbach's Coefficient Alpha, which determines the internal consistency of the questionnaire. A high level of reliability is indicated by results between 0.7 and 1.0. (Hays, 1972).

6.1 Independent Variables

Workload, role conflict, responsibility

Reliability of the measurements lies between good to very good.

Measurement of pressure at work--independent variable.

Measurement of workload, role conflict and responsibility--independent variables

a) Workload, on a quantitative basis, is measured using three questions. Reliability of the index: [alpha] = 0.69; independent variable

b) Workload, on a qualitative basis, is measured using seven questions. Reliability of the index: [alpha] = 0.75; independent variable

c) Role conflict is measured using six questions. Reliability of the index: [alpha] = 0.87

d) Responsibility is an independent variable. It is measured using five questions with respect to responsibility for patients, one question with respect to responsibility toward the staff members, and two questions related to responsibility for the equipment. Reliability of the index: [alpha] = 0.80

e) One question is used to measure overall tension produced by the three independent variables together.

Reliability of the index without including responsibility: [alpha] = 0.91

Reliability of the index including responsibility: [alpha] = 0.90

6.2 Dependent Variable: Burnout

The scale for burnout was constructed and tested for validity by Y. Azrachi. (1985). Seven questions address burnout and eight questions address the feelings of fatigue. Reliability if the index is: [alpha] = 0.90

6.3 Social support

Social support is measured in two fields, effective and instrumental, with twelve questions related to active support and ten related to instrumental support. (Thoits, 1982) Reliability of the index: [alpha] = 0.90

Note: Two minor changes were made to the original questionnaire. The first is in question number eight where 'internal medical department' and intensive care unit' were substituted for 'kibbutz clinic' and 'public clinic'. The second is in question number twenty-five, where 'departmental head' was substituted for 'regional doctor in charge'.

6.4 Absence Check

This is an objective measurement. Work schedules were examined from January through to June, 2004 in seven internal medicine departments and in four intensive care units. The measurement is the standard number of nurses assigned to each unit along with the number of nurses actually working in that unit for each day. In addition, distribution of the absence from work noted in these departments was examined according to age groups: under forty years and forty years of age and over.

6.5 Procedure

The questionnaires were be distributed and collected in the eleven units within the six months of the study. Each questionnaire was completed by the nurses in the presence of a student for two reasons. The first is to verify that the nurse filling in the answers works in the department being investigated. (nurses are sometimes sent to help in departments other than their own). The second reason is to ensure that the nurse fills in the complete questionnaire.

In order to obtain the maximum number of responses, every third visit to each department was during evening, night or weekend shifts. In this way, nurses working part time, evenings or nights, or just on weekends, were identified and allocated questionnaires.

7. RESULTS

The total research population was 273 nurses, 183 working in internal medical departments and 90 in intensive care units. 259 answered the questionnaires, 170 from internal medicine and 89 from intensive care.

7.1 Descriptive Analysis of Study Sample

Demographic variables

As expected from national data, most participants were women. They comprised 89.4% and 91.0% of the internal medical departments and the ICU, respectively. Participants from both departments had similar age distribution with a mean (SD) of 36.4 (9.45) for medical departments and 37.1 (10.39) for the ICU. A higher proportion, 8.0%, of nurses in the internal medical departments were parents of four children of more, compared to 3.0% among the ICU nurses. However this difference did not reach statistical significance (p=0.13). The single demographic variable, which distributed significantly (p<0.001) between study groups was marital status. Currently married nurses comprised 63.5% of the internal medical department group compared to 84.3% among ICU nurses. Reciprocally the internal department group had a higher proportion of nurses who had never married or were divorced. All three widowed nurses in the study were from the internal medical department. (Table 1)

7.2 Professional Characteristics

A significantly (p<0.001) higher proportion of nurses with BA degrees was recorded among ICU nurses (57.3%) compared to medical department nurses (24.7%). Even more distinctive (p<0.001) differences were found in the comparison of nurses who had participated in advanced nursing courses. While more than two thirds of the ICU nurses had taken such a course, only 15.9% of the nurses working in internal medical departments had done so.

Similar distribution of work duties was found in both departments. In both, more than three quarters classified themselves as "staff nurse". A higher proportion of nurses in the ICU reported working full-time, (76.4%), compared to the internal medical departments (60.9%). In both groups, two thirds of the nurses reported working morning, evening and night shifts. Internal medical department nurses were employed for significantly (p=0.04) longer time in their current department (9.96 years vs. 7.94 years). They also had more years of professional experience compared to ICU nurses (13.11 years and 11.72, respectively), although not reaching significance (p=0.25).

7.3 Burnout Scores

The sum of the questions associated with burnout showed higher mean ([+ or -] SD) score for internal medical department (139.2 [+ or -] 17.0) compared to ICU nurses (135.8 [+ or -] 14.9). These differences were not significant (p=0.1) with a mean difference of 3.40 (90%CI: 0-6.79).

Potential demographic confounders

Age (in years) significantly correlated with burnout score with a Pearson correlation of 0.235 (p>0.001). Similar scores were obtained for men and women. Divorced nurses had higher burnout scores compared to other participants although not reaching statistical differences (p=0.12). Number of children showed no clear linear correlation with burnout score. However, parents of four children and above had higher scores (Table 3).

7.4 Potential Professional Confounders

Both years of professional duties and years in the current department correlated significantly (p<0.01) with burnout scores (Pearson coefficient= 0.20 and 0.18, respectively). Practical nurses showed significantly (p<0.001) higher burnout scores compared to all other nurses. Similarly, the burnout scores calculated for nurses with more tasks were significantly (p=0.008) lower compared to staff nurses or team leaders. Working shifts, advanced courses and part time jobs did not show significant differences in burnout scores (Table 4).

7.5 Perceived Professional Authority

In both departments most named the head of the department and the head nurse as the most likely to assist in case of a problem, as shown in Table 6. In both departments approximately two thirds regard the probability of getting assistance from colleagues as high and highest.

The distribution of answers to the question: "what is the probability that you would turn to the following person if you face professional difficulty?" is given in Table 7. Answers show that in both groups the head nurse and nursing colleagues are the preferred address for discussing professional difficulties. However, ICU nurses prefer their head nurse compared to internal medical department nurses with a borderline significance (p=0.095). Both in internal medical and ICU departments turning to the director of nursing or to the supervising nurse were the least favorable options as only 2.2% regarded them as the most likely option.

7.6 Multivariate Analysis 

Age was the variable with the strongest association with burnout score, as every year of age increases the score in 0.39 points (95%CI: 0.18-0.59). Practical nurses also show adjusted increase burnout score (7.63; 95%CI: 2.47-12.79). In contrast, the multivariate analysis reveals that assistant head nurses and team leaders have lower than expected burnout scores. Married nurses also have significantly lower scores compared to all other nurses, after adjustment of age, professional status, and marital status. (Table 8).

7.7 Absenteeism

Data for absenteeism from January to March, 2004, among nurses working in internal medical departments (97/183) compared to nurses working in ICU (26/90) is 2.07 are presented in Table 9a and 9b.

8. DISCUSSION

Current scientific literature and research studies indicate that stress and the phenomenon of burnout are prevalent in the population of nurses wherever they work and irrespective of their position. Our study has concentrated on one aspect of burnout,--its connection with external factors, especially absence from work. We have tried to compare this dimension of burnout in two different areas of nursing, internal medical departments and intensive care units.

The principle hypothesis we have proposed consists of two parts: There is a higher level of burnout among nurses working in intensive care units than among those working in internal medical departments and this higher level of burnout among intensive care nurses is reflected in the higher levels of absenteeism from their work.

We based our study on a theoretical model presented in diagrammatic form. The model displays the connections between the variables, the factors contributing to the dependent variable, burnout, and the resultant variable, absence from work. Statistical analysis of the findings focuses mainly on the measure of the variables, and the correlation among them, relevant to the support or repudiation of the hypothesis.

8.1 Analysis of the Results

The results of our research did not show a difference in the level of burnout between nurses working in internal medical departments and nurses working in intensive care units. (Results: Figure 1: adjusted and unadjusted burnout scores). We expected higher levels of burnout in the population of intensive care nurses based on the factors described in the literature. The responsibility of the intensive care nurse for an ever-increasing range of work, multiple nursing tasks and functions, the constant demand to perform complex procedures, and the continual stress of the rapid, unpredictable changes in the condition of the patients, are all causes of burnout for the nurse working in the ICU.

The findings of our study show that the rate of absence in the internal medical departments was higher than in the intensive care units. Since levels of burnout for the internal medical departments were not correspondingly higher, our hypothesis was not supported.

The findings show that the level of burnout noticeably rises with increasing age in both departments, a rise of 0.39 for every additional year of age. According to the distribution of age with burnout in Table 5 and Personal Characteristics and Burnout Scores in Table 3, the highest levels of burnout are found among the group of nurses over 45 years of age, irrespective of the department in which they work. Again, the literature available on the subject, supports the opposite result. There should be a higher rate of burnout among younger nurses. The change from the high ideals and standards of nursing in learning institutions to the real environment of work in a hospital is said to cause 'reality shock'. The need to cope with the demands of the organization and the professional standards on one side, along with the immediate demands of the work on the other, results in higher numbers of young nurses suffering from burnout as compared to more experienced, older nurses. (Pines, Kafri, & Etzion, 1980; Kramer, 1974) Another result we expected from our study was a direct correlation between higher education levels of the nurse and higher levels of burnout. The professional demands in the area of decision making, both in accepting treatment decisions concerning the patients and making nursing decisions, coping with new technologies and complex equipment, and case management, are all expected to be factors contributing to burnout among the population of registered nurses. None of these demands is placed on the practical nurse (Flakus, 1998). Contrary to our expectations, the findings of our study clearly (P>0.001) showed that more years of education results in less burnout. (Table 4).

With respect to professional standing, the findings of the study clearly show (P>0.008) that the higher the level of professional standing, the lower the level of burnout. (Table 4) Once again, this is contrary to expectations. According to previous studies, the majority of professional nurses in senior positions feel overburdened with the responsibility they have for the patients and their families, as well as for the staff members over whom they have authority. In addition, they experience continuing conflict between the demands of their role according to the organization and their professional responsibility to the patient. (Kramer, 1974).

The results of the comparison of family status and burnout clearly (P< 0.001) indicate that there is less burnout in the population of married nurses when compared with single nurses (single including unmarried, divorced and widowed) irrespective of the number of children. Social support, outside of the working environment, is not a significant factor related to burnout according to a study done by Demerouti, Bakker, Nachreiner, & Schaufeli, (2000). Yet, a study done by Leiter & Durup, (1996), states that the only important predictor of emotional exhaustion, aside from factors at work, is work that interferes with the family. Statistical analysis of the findings of this study indicates that family support is a potential factor related to burnout.

No clear results were achieved with reference to shift work or hours of employment. The distribution of these variables in the departments chosen for the study did not demonstrate any significance. Almost all the research concerned with environmental conditions at work for nurses point to shift work as a cause of physical ill health, disruption of social life, and family stress. This was not tested in our study.

The findings indicated that in the majority of cases, staff nurses approached the head nurse, not a member of the hospital management, when there was a problem (Table 7). No connection was shown between management support and level of burnout. The level of burnout was low in both groups of departments in the study. Corley (1995) states that nurses tend to go to their colleagues for help. In many cases, nurses feel that the management of the hospital is unaware of the difficulties experienced in the department, and hesitate to approach them for help.

Conclusions

Several important results of this study should be noted despite the lack of support for the main hypothesis:

-- The age of the nurse was shown to be the most important factor influencing the level of burnout.

-- Our findings indicate that married nurses are less susceptible to burnout than single nurses, regardless of the number of children. In addition, higher education and professional status were shown to improve defenses against burnout.

-- Since no difference in levels of burnout was found between the two types of hospital departments, we must consider the possibility that burnout is a universal phenomenon in the nursing profession. If the department where the nurse works is negligible, the other factors considered to cause burnout, such as age, family status, and personal characteristics, must be given more weight and investigated accordingly.

-- In our study, absence does not appear to be related to burnout. In the literature, absence is part of a distressing circle. Burnout is considered to be a cause of absence and absence, itself, a source of additional stress and burnout in the group of nurses left to work under conditions that become harsher due to the absence of a member of the team. (Buschak, Graven & Ledman, 1996) Instead, it is possible that the absence of the nurses in the departments of our study helped them prevent burnout. Not going to work for a few days may allow the nurse to 'ventilate', to revive her positive attitudes and return to work with renewed strength.

Since absenteeism was higher among younger nurses, married nurses, and nurses with higher education levels while burnout scores were lower in these same populations, factors such as coping with raising small children, loyalty to the organization and obligations to the nursing team, possible study days off, and commitment to work should be investigated with the goal of reducing absenteeism and possibly burnout as well.

9. LIMITATIONS OF THE STUDY

In general, the group of nurses working in internal medical departments in Israel are characterized by being older than those working in other areas of nursing. Moreover, the group of nurses working in intensive care units are characterized by being younger in age (under 45 years). The majority of the latter group also has more education than the majority of the former, where there is a large proportion of practical nurses. This data could have influenced the results of our study to produce equivalent levels of burnout in the two areas of work.

In Israel, working full-time and working different shifts during the twenty-four hours of the day is a commonly accepted practice, particularly as regards the nursing profession and especially because nursing salaries are higher for evenings and night shifts. We can assume that this influenced the results of our study by neutralizing some of the effect of shift work on measurements of burnout.

An additional influence on the results of the study may stem from the tendency of nurses to consider nursing in intensive care units as more advanced and prestigious. The feelings of respect accorded to that group of nurses may reduce the amount of burnout suffered in those units since the positive feedback received and the psychological feelings of well-being attached to that respect contribute to positive feelings about work.

The source of an additional explanation for the lack of differences in levels of burnout between the departments of the study is the organizational change currently taking place in most internal medical departments. New small intensive care units have been opened in these departments to take care of patients with more complicated treatment programs or patients who are receiving artificial respiration. This creates a new demand. Some of the nurses working in the department must take intensive care courses (enrichment programs of study in nursing) and this may blur some of the differences between the two different areas of nursing.

The process of converting to computerized work schedules has not been entirely completed in the hospital where we did our study. Although the data sheets concerned with the presence or absence of a nurse are available, there is still no program coordinating the personal details of the nurse with her schedule. We were therefore unable to match the demographic variables against absence from work for each individual nurse.

9.1 Methodological limitations

The study is cross sectional and checks the variables at one particular point in time. Therefore, the causal relationship between one variable and another could not be tested. Moreover the data was collected at specific times within a short time period and this may have contributed to skewed results. If measured over a longer period of time, the findings might have demonstrated different results. Moreover, it would require checking the same data over an extended period of time to show if burnout results in absence or if absenteeism creates burnout.

The study was completed in the internal medical departments and intensive care units of only one hospital in central Israel. We could not carry it out in other public hospitals, with approximately the same division of departments, due to the constraints imposed by time and lack of accessibility. It seems reasonable to assume that the results of the study may have been altered because of the basic differences in hospital policies and philosophies concerning human resources.

Bias in the answers to the questionnaires is another limitation. For instance, nurses with high-level managerial functions could deliberately choose to answer those questions indicating clear symptoms of burnout in the negative, and this would have influenced some of the results, for example, the result "the burnout scores calculated for nurses with more duties were significantly (p=0.008) lower compared to staff nurses or team leaders".

9.2 Absenteeism

The operational definition of absenteeism on which the study was based, was non-appearance at work from one to three days, on the assumption that absence for more than three days indicated serious illness. We measured days of absence by comparing the planned daily roster of nurses with the numbers of nurses who were actually at work for that same day. We did not investigate the reason for the absence, nor did we check the doctors' notes naming that reason.

Because of the anonymity of the questionnaire, there was no way to cross check the distribution of absence with the indices of burnout for the same nurse. Statistical analysis of the answers to the questionnaire could only compare the distribution of absence in the different departments. It was not possible to evaluate the connections between absence from work and distribution by age, family status, etc.

Of the three hundred questionnaires distributed, two hundred and sixty were answered, so we must assume that the answers not supplied by the forty nurses who were absent during the period when we distributed and collected them, could have influenced the measures of burnout in the study.

10. RECOMMENDATIONS

We recommend doing a prospective/retrospective comprehensive study in a number of public hospitals in Israel to check the contributory connections between burnout and absenteeism. Comparison of levels of burnout among nurses in several different departments of the hospitals should also be considered.

Four groups of nurses were shown to be at risk for burnout,--nurses over forty-five years of age, practical nurses, staff nurses, and single nurses. Intervention programs, applicable to these four groups, should be planned and applied to prevent or reduce the appearance of burnout. Recommended intervention programs include:

* burnout prevention workshops

* changing hospital policy related to the encouragement and promotion of nurses, as well as financial incentives to encourage further relevant courses of study

* finding ways to include single nurses in departmental extra curricular activities with the objective of providing increased social support

An example of a workshop to prevent burnout modeled on workshops designed by Weisman (1993) called "Preparation for coping with stressful situations or emergencies". The principle subjects of the workshop are:

* explanation of burnout

* self-awareness 

* personal strategies for coping with burnout

It is known that in Israel, as in all western countries, admitting to weakness or to having problems at work is not customary. In the framework of a workshop, it is possible for staff members to involve others in their problems, to get help in identifying the causes of those difficulties, and to solve them together. During workshops, positive feedback and reinforcement can be given for all that the nurses do contribute to their department and to their patients. The friendly atmosphere and encouragement will help reduce the physical tensions and lower stress levels. Workshops should be led by accredited professionals and held after working hours in a neutral area, such as a rented hall or a home.

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Yehudit Bagan has a Master's degree in Health Care Management and is a professional nurse in the Central Health Services, Tel-Aviv, Israel.

Yacov Kedem, Shenkar College of Engineering and Design, Ramat Gan, ISRAEL

Yehudit Bagan, Central Health Services, ISRAEL

Dr. Yacov Kedem is currently a professor of management at Shenkar College of Engineering and Design and at Polytechnic University of New York Extension in Israel. He has served as the Chair of the Department of Industrial Engineering and Management at Shenkar College. He serves on the editorial board of Contemporary Management Research (CMR). He is the President of INTEPRO-an international private institute for research and strategy.

TABLE 1. CHARACTERISTICS OF THE WORK
ENVIRONMENT ASSOCIATED WITH BURNOUT

ORGANIZATIONAL     SOCIAL            STRUCTURAL        PSYCHOLOGICAL

Role conflict      Number of         The building      Amount of
                   patients/                           independence
                   clients

Role ambiguity     Personalities     Space available   Variety
                   and problems of   and the amount
                   patient/client    of crowding

Footdragging       Interpersonal     Noise levels      Workload
                   communications
                   between
                   caretaker/
                   patient

Organizational     Interpersonal     Flexibility       Meaningfulness
policy and         communications    according to      of work
influence on       among staff       needs
policies

Organizational     Staff             Flexibility       Possibility of
expectations       cooperation       according to      self expression
                                     personal tastes

Paperwork          Time when there                     Potential
                   is relief from                      to advance
                   the stress                          professionally

Procedures and     Staff support
Rules

No choice of       Feedback and
work assignments   support from
                   the supervisors

Organizational     Rewards
standing

TABLE 1: DEMOGRAPHIC CHARACTERISTICS OF STUDY SAMPLE

                 internal     ICU          Chi-     df      p
I.               N     %      N     %      square

Gender
Women            152   89.4   81    91.0   0.04     1       0.85
Men              18    10.6   8     9.0

Children
None             43    25.3   19    21.3   11.24    7       0.13
1                21    12.4   19    21.3
2                60    35.3   27    30.3
3                31    18.2   21    23.6
4                12    7.1    1     1.1
5                2     1.2    1     1.1
6                1     0.6          0.0
7                      0.0    1     1.1

Marital status

Married          106   63.5   75    84.3   13.89    3       >0.001
Single           39    23.4   12    13.5
Divorced         19    11.4   2     2.2
Widowed          3     1.8          0.0

TABLE 2: PROFESSIONAL CHARACTERISTICS OF STUDY SAMPLE

                       internal       ICU         Chi-     df    p
II.                    N       %      N           square

Degree
P.N.                   43      25.3   2    2.2    36.57    3     >0.001
R.N.                   75      44.1   33   37.1
B.A                    42      24.7   51   57.3
M.A.                   10      5.9    3    3.4

Job percent
100%                   103     60.9   68   76.4   6.56     3     0.09
88%                    12      7.1    4    4.5
75%                    37      21.9   13   14.6
50%                    17      10.1   4    4.5

Advanced course
No                     143     84.1   29   32.6   69.55    1     >0.001
Yes                    27      15.9   60   67.4

Professional duty
Head nurse             7       4.1    5    5.6    5.95     4     0.20
Assistant head nurse   7       4.1    5    5.6
Nurse Clinician        5       2.9    1    1.1
Team leader            22      12.9   4    4.5
Staff nurse            129     75.9   74   83.1

Working shifts
Morning only           32.0    18.8   13   14.6   2.8      3.0   0.42
Evening only           10.0    5.9    10   11.2
Night only             15.0    8.8    7    7.9
All shifts             113.0   66.5   59   66.3

TABLE 3: PERSONAL CHARACTERISTICS AND BURNOUT SCORES

                    n       Mean       SD         p

Age                                             0.009
<45                136      135.0      15.2
45-55               67      139.9      16.5
55-65               41      143.2      19.9
65+                 15      143.6      10.1

Gender                                          0.63
Women              233      138.2      16.6
Men                 26      136.6      14.8

Children                                        0.235
None                62      137.4      17.0
1                   40      133.6      15.7
2                   87      138.5      15.0
3                   52      139.7      16.5
4 or more           18      143.3      20.7

Marital Status                                  0.12
1                  181      137.5      15.4
2                   51      136.1      16.2
3                   21      145.7      21.1
4                    3      141.0       7.0

TABLE 4: PROFESSIONAL CHARACTERISTICS OF STUDY SAMPLE

                   n    Mean         (a)SD     95%CI        P
Degree                               (b)    Low    High

P.N.               45   146.6  19.9         140.7  152.6  >0.001
R.N.               108  138.2  14.5         135.4  140.9
B.A                93   134.5  14.9         131.5  137.6
M.A.               13   132.5  18.4         121.3  143.6

Professional duty
Head nurse         12   127.4  13.5         118.8  136.0  0.008
Assistant Head
Nurse              12   130.8  13.1         122.5  139.2
Nurse Clinician    6    123.8  10.1         113.3  134.4
Team leader        26   141.1  15.8         134.7  147.5
Staff nurse        203  139.1  16.5         136.8  141.4

Shift
Morning only       45   135.7  17.2         130.6  140.9  0.673
Evening only       20   140.5  16.9         132.6  148.4
Night only         22   139.6  15.2         132.8  146.3
All shifts         172  138.2  16.3         135.7  140.6

Job percent
100%               171  137.5  16.4         135.0  140.0  0.741
88%                16   137.3  20.2         126.5  148.1
75%                50   138.6  16.0         134.1  143.1
50%                21   141.6  14.8         134.9  148.3

TABLE 5: DISTRIBUTION OF AGE WITH BURNOUT

Age       N      STAI       SD         P

<35       92     134.17     15.07      0.39
          44     136.59     15.4

35-45     41     143.66     14.86      0.03
          26     134.04     17.49

45-55     28     146.89     22.25      0.08
          13     135.23     9.91

55-65     9      146.56     9.88       0.17
          6      139.17     9.45

TABLE 6: ANSWERS TO THE QUESTION: WHEN THERE IS A PROBLEM
AT WORK, EACH OF THE FOLLOWING IS PREPARED TO LISTEN TO ME

                       Internal      ICU           Chi      df   p
                       dept.                       square

                       N     %       N     %

Director                                           6.36     4    0.2
of Nursing   Highest   5     2.9     6     6.7
             High      34    20.0    9     10.1
             Medium    45    26.5    23    25.8
             Low       34    20.0    23    25.8
             Lowest    52    30.6    28    31.5

Nursing                                            3.19     4    0.8
Supervisor   Highest   8     4.7     6     6.7
             High      32    18.8    15    16.9
             Medium    56    32.9    26    29.2
             Low       35    20.6    17    19.1
             Lowest    39    22.9    25    28.1

Head Nurse                                         6.36     4    0.17
             Highest   48    28.2    39    43.8
             High      54    31.8    31    34.8
             Medium    40    23.5    13    14.6
             Low       10    5.9     2     2.2
             Lowest    18    10.6    4     4.5

Assistant                                          5.80     4    0.2
head nurse   Highest   23    13.5    10    11.2
             High      45    26.5    25    28.1
             Medium    35    20.6    20    22.5
             Low       34    20.0    9     10.1
             Lowest    33    19.4    25    28.1

Head of                                            3.40     4    0.5
department   Highest   50    29.4    23    25.8
             High      72    42.4    33    37.1
             Medium    31    18.2    25    28.1
             Low       5     2.9     2     2.2
             Lowest    12    7.1     6     6.7

Colleagues                                         3.40     4    0.5
             Highest   50    29.4    23    25.8
             High      72    42.4    33    37.1
             Medium    31    18.2    25    28.1
             Low       5     2.9     2     2.2
             Lowest    12    7.1     6     6.7

TABLE 7: ANSWERS TO THE QUESTION: WHEN THERE ARE DIFFICULTIES
AT WORK, I WILL RECEIVE HELP AND GUIDANCE FROM THE FOLLOWING

                      Internal    ICU         Chi-     df    P
                                              Square

Director of Nursing   n    %      n    %      1.72     4    0.786

Highest               8    4.7    2    2.2
High                  30   17.6   13   14.6
Medium                49   28.8   25   28.1
Low                   31   18.2   19   21.3
Lowest                52   30.6   30   33.7

Nursing Supervisor                            1.37     4    0.850
Highest               8    4.7    2    2.2
High                  37   21.8   19   21.3
Medium                55   32.4   27   30.3
Low                   31   18.2   19   21.3
Lowest                39   22.9   22   24.7

Head Nurse                                    7.91     4    0.095
Highest               53   31.2   40   44.9
High                  51   30.0   28   31.5
Medium                39   22.9   14   15.7
Low                   11   6.5    4    4.5
Lowest                16   9.4    3    3.4

Head of department                            3.80     4    0.434
Highest               18   10.6   14   15.7
High                  44   25.9   25   28.1
Medium                48   28.2   18   20.2
Low                   25   14.7   10   11.2
Lowest                35   20.6   22   24.7

                                              0.55     4    0.969
Highest               44   25.9   23   25.8
High                  75   44.1   37   41.6
Medium                32   18.8   20   22.5
Low                   11   6.5    5    5.6
Lowest                8    4.7    4    4.5

TABLE 8: MULTIVARIATE MODEL TO EXPLAIN BURNOUT SCORE

                   Unstandardized      Standardized
                    Coefficients       Coefficients

                 B          Std.       Beta
                            Error

Constant         126.48     3.87

Age              0.39       0.10       0.23

Practical        7.63       2.62       0.18
nurses

Assistant
Head Nurses      -11.97     4.63       -0.15

Team Leaders     -13.32     6.41       -0.12

Married          -4.48      2.15       -0.13

                 t          p           95% Confidence
                                        Interval for B

                                       Lower      Upper
                                       Bound      bound

Constant         32.65      >0.001     118.85     134.11

Age              3.74       >0.001     0.18       0.59

Practical        2.91       >0.001     2.47       12.79
nurses

Assistant
Head Nurses      -2.58      0.01       -21.09     -2.84

Team Leaders     -2.08      0.04       -25.95     -0.69

Married          -2.08      0.04       -8.72      -0.25

TABLE 9A: ABSENTEEISM

                          Nurses absent 1-3 days

Dept.            Nurses   1/04       2/04       3/04

Internal A       29       4          2          1
Internal B       26       6          1          4
Internal C       28       4          3          1
Internal D       26       6          8          10
Internal E       26       7          3          3
Internal F       29       8          6          4
Internal G       19       9          4          3
Total            183      44 (24%)   27 (15%)   26 (14%)
ICU (preemie)    20       2          0          2
ICU (cardio a)   23       2          2          2
ICU (general)    24       3          2          4
ICU (cardio b)   23       3          2          2
Total            90       10 (11%)   6 (7%)     10 (11%)

TABLE 9B: ABSENTEEISM: TOTAL PERCENTAGE

                          Absenteeism     %

Internal Medical Dept     97/183          53%
ICU                       26/90           29%

TABLE 10: ABSENTEEISM IN BOTH DEPARTMENTS ACCORDING TO AGE

                               under 40 yrs.   40 yrs. & over

Internal medical departments   60              37
Intensive care units           18              8

n=273