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Effects of cognitive-behavioral stress management training on the syndrome of burnout in employed women nurses: a case study in hospitals of Ahvaz University of Medical Sciences.

Introduction

Burnout has gained widespread attention by researchers following its introduction into research literature in the mid seventies [14]. Burnout was first observed among those involved in helping professions such as nurses, social workers, and the police force; however further research revealed it can be observed among other professions as well [15]. The syndrome is the result of a combination of various factors such as distress, despair, disillusionment, negative self-perception, and negative attitudes towards working, people and life. Maslach et al., [15] showed burnout may lead to the reduction of the quality or accuracy of the services the employees provide. It appears burnout is one of the factors involved in quitting a job, absence, and low morale. It is also linked to personal disorders, increased drinking, drug abuse, and matrimonial and family problems [21]. Research also indicates burnout is a psychological syndrome frequently seen in careers requiring regular contact with people. [22]. Maslach et al.,'s [15] taxonomy of burnout involves three dimensions, namely emotional exhaustion, depersonalization, and personal accomplishment [22].

High emotional exhaustion and depersonalization, along with lowered personal accomplishment are the symptoms of burnout [22]. Researchers studying the factors giving rise to the development of burnout among nurses have mainly adopted three approaches: personal, interpersonal, and organizational.

As the degree of burnout varies among people who work under the same working conditions, a group of researchers emphasize the role of personal factors in the formation of the syndrome [24,8,11]. It is crystal clear that both a safe working environment (as an organizational factor) and having the privilege of support from others (as an interpersonal factor) can impede the progress of burnout to a great extent and protect one against negative feelings induced by stressful working conditions; [27] yet, people may have to rely on self-protective strategies in case none of these factors are not readily available. [10]. In such circumstances, the individual focuses on inner factors--rather than external factors such as blaming the system or the working conditions or other people--to initiate an ongoing and perpetual improvement process. Therefore, one can argue instruction of skills for coping with stress is among the most important factors which can buffer distress and other mental problems hypothesized to accelerate job burnout[6].

Cognitive Behavioral Stress Management (CBSM) focuses on the CBSM techniques such as cognitive reconstruction, problem solving, self-instruction, and progressive muscle relaxation [5].

Considering the daily pressure most nurses bear everyday, it is highly probable that they fall into negative thought patterns; the patterns which greatly affect their perceptions of their work environment and of their home. Mimura & Griffiths [17] suggest cognitive behavioral intervention and progressive muscle relaxation as two effective methods to reduce distress. Cognitive behavioral intervention method has been designed to help people live longer, feel better, and prevent negative thoughts.

Kravits et al., [13] carried out a research with the objective of developing and assessing a psycho-educational intervention program to reduce nurses' stress to prevent the development of the burnout syndrome. The research adopted self-care strategies to help nurses, and to develop stress management programs. The research took the importance of studying the nursing risk factors, using muscle relaxation techniques and art into account. The results showed positive effects on reducing emotional exhaustion.

Richardson & Rothstein [20] carried out a meta-analysis to determine the effect of stress management intervention in work environments. The interventions were coded as follows: cognitive- behavioral, muscular relaxation, organizational, multimodal, and alternative. The results introduced the cognitive-behavioral program as the most effective intervention method. Muscular relaxation was the intervention method used by most of the subjects, while the organizational interventions were rarely followed. The interventions were mostly effective on psychological variants, and the study of the other modifiers such as the duration of the therapy showed no significant changes in the effectiveness of the intervention methods.

Burnout greatly affects nurses' profession in all domains. According to Aiken et al., [1] 40% of hospital nurses are affected by burnout to some degree, which is above the norm for the health care staff [4]. Burnout occurs in all clinical domains; from intensive care to mental health units [9,2]. According to National Institution of Health (2002) 43% of the nurses affected by burnout quit their job in a year. Thus, the manifestations of work place stress including shocks and burnout can be prevented by programming [3].

The indicators of burnout include overwork, frustration, emotional drainage, and less productivity. Burnout leads to interpersonal conflicts, physical symptoms, obsessional operations, reduction of efficiency, and negative emotions. Those who are affected by burnout believe that they cannot change their conditions. Burnout is increasingly epidemic among the healthcare staff [7]. Having recognized the causes of burnout, one can overcome it [4].

Nursing is a stressful profession. Research shows that the syndrome of burnout is epidemic among nurses, for which a variety of therapies have been suggested. The present research attempts to study the effect of Cognitive-Behavioral Stress Management (CBSM) training in reducing the indicators of burnout (emotional exhaustion, depersonalization, and diminished personal accomplishment and job performance). Therefore, regarding the purpose and the background of the study, the following hypotheses were proposed and tested.

Research Hypotheses:

1. Cognitive-Behavioral Stress Management (CBSM) training leads to the reduction of emotional exhaustion and depersonalization, and the increase of the sense of personal accomplishment in women nurses.

2. Cognitive-Behavioral Stress Management (CBSM) training leads to the lasting reduction of emotional exhaustion and depersonalization, and the increase of the sense of personal accomplishment in women nurses in the one month follow-up.

The Statistical Population, Sample, And The Method Of Sampling:

The statistical society of the present research included the women nurses employed in the hospitals of Ahvaz University of Medical Sciences. The samples were chosen by the method of random sampling. The burnout questionnaire was given out to all the women nurses employed in the three aforementioned hospitals. Then the women nurses with at least one year of clinical experience and one standard deviation up the mean burnout score (126 samples) were chosen. Thirty nurses were randomly chosen from this group. Then they were randomly divided into two groups of experimental and control, having matched them regarding their marital status.

Having chosen the experimental and the control group (with 15 samples for each), the experimental intervention was carried out for the experimental group, while the control group received no intervention. Having finished the intervention process, both groups were post-tested. In the follow-up, one month after the post-test, the samples of the experimental and the control group reanswered Maslach Burnout Inventory.

Instruments:

The present research uses Maslach Burnout Inventory (MBI) as the means of collecting the data related to the variable of the study. The results of Maslach's study [16] on the psychological assessment of the syndrome of burnout have become a measurement unit called Maslach Burnout Inventory (MBI).

This standardized questionnaire includes validated components: emotional exhaustion (a feeling of inability to nurse others), depersonalization (treating people as objects), and personal accomplishment (gaining self-satisfaction from one's job) [28].

The questionnaire includes 22 propositions in the form of statements about personal attitudes or feelings. The examinee has to determine the degree of his/her agreement with the statements in a scale ranging from zero (= never) to 6 (= everyday).

Kim et al., [12] have used Cronbach's Alpha to calculate the reliability of Maslach's questionnaire in the three components of emotional exhaustion ([alpha] = 0/86), depersonalization ([alpha] = 0/80), and personal accomplishment ([alpha] = 0/69).

MBI has been used as a means of measuring burnout in different professions in many countries [19,22,25].

Research Findings:

Descriptive Results:

This part of the research provides the results regarding the mean, the standard deviation, the highest and the lowest scores in the three components of burnout (emotional exhaustion, depersonalization, and personal accomplishment) in the samples of the experiment.

Table 1 provides the results regarding the mean, the standard deviation, the highest and the lowest small scale score for emotional exhaustion, depersonalization, and personal accomplishment in the first sample of 233 nurses.

Table 1 shows that all the samples gained a higher mean in the small scale of personal accomplishment, in comparison with the two other small scales.

Table 2 shows the mean and the standard deviation of the small score of emotional exhaustion in the samples of the experimental and the control group in the pre-test, the post-test and the follow-up.

As the contents of Table 2 demonstrate, there is a slight difference in the mean score of emotional exhaustion of the experimental group in the post-test and the follow-up, in comparison with the pre-test scores; the same is also true in case of the control group. The significance of this difference will be studied in the hypothesis related research findings of the present study.

Table 3 shows the mean and the standard deviation of the depersonalization score of the samples in the pre-test, the post-test, and the follow up.

The contents of table 3 show a difference between the mean score of depersonalization in the experimental group in the post-test and the follow-up in comparison with the pre-test. The depersonalization score of the experimental group is lower in the post-test and the follow-up, in comparison with the pre-test scores. However, there is no change in the scores of the control group. The significance of this difference will be studied in the hypothesis related research findings of the present study.

Table 4 shows the mean and the standard deviation of the personal accomplishment scores of both groups in the pre-test, the post-test, and the follow-up.

The contents of Table 4 show a difference between the mean score of personal accomplishment in the experimental group in the post-test and the follow-up in comparison with the pre-test. The personal accomplishment score of the experimental group is higher in the post-test and the follow-up, in comparison with the pre-test scores. However, there is no change in the scores of the control group. The significance of this difference will be studied in the hypothesis related research findings of the present study.

Hypothesis -Related Research Findings:

Hypothesis 1- Cognitive-behavioral stress management training can reduce emotional exhaustion and depersonalization, and increase personal accomplishment in women nurses.

The results of studying the first hypothesis are represented in table 5 and 6.

Table 5 shows the results of MANCOVA on the mean post-test score of emotional exhaustion, depersonalization, and personal accomplishment of the experimental and the control group, with the pretest scores as the control.

The contents of table 5 show a significant difference between the experimental and the control group, regarding the dependent variants at the level of P < 0.001. Thus, the first hypothesis of the present research is confirmed. So, it can be claimed that there is a significant difference between the two groups in at least one dependent variant (emotional exhaustion, depersonalization, and personal accomplishment). In order to find this difference, three MANCOVA analyses were carried out, the results of which are represented in table 6. Table 6 shows the results of the MANCOVA on the mean post-test scores of emotional exhaustion, depersonalization, and personal accomplishment of the experimental and the control group.

As the contents of table 6 show, the column for the level of significance represents a significant difference between the experimental and the control group, regarding the depersonalization (F=12.01, P = 0.002), and the personal-accomplishment variant (F = 17.63, P = < 0.001), but there is no significant difference regarding emotional exhaustion at the level of P < 0.001. Based on these findings, it can be claimed that the first hypothesis of the present research is confirmed.

Hypothesis 2: Cognitive-behavioral stress management training can lead to the long-term reduction of emotional exhaustion and depersonalization, and increased personal accomplishment in women nurses in the one-month follow-up.

Table 7 shows the results of MANCOVA on the mean follow-up score of emotional exhaustion, depersonalization, and personal accomplishment of the experimental and the control group, with the pretest scores as the control.

As the contents of Table 7 show, the column for the level of significance represents a significant difference between the experimental and the control group, regarding their follow-up score of emotional exhaustion, depersonalization, and personal accomplishment at the significant level of p < 0.001. Therefore, the second hypothesis of the present research is confirmed. The significant level of p < 0.001 shows that there is a significant difference between the experimental and the control group, in at least one dependent variant (emotional exhaustion, depersonalization, and personal accomplishment). In order to find this difference, three MANCOVAs were carried out, the results of which are represented in table 8.

Table 8 shows the results of MANCOVA on the mean follow-up score of emotional exhaustion, depersonalization, and personal accomplishment of the experimental and the control group.

As the contents of table 8 show, the column for the level of significance represents a significant difference between the experimental and the control group in the follow-up, regarding the variants of depersonalization (F = 19.88, P < 0.001), and personal accomplishment (F = 33.69, P < 0.001), but there is no significant difference between the experimental and the control group, regarding the variant of emotional exhaustion at the significant level of P < 0.001. Based on these findings, it can be claimed that the second hypothesis of the present research is confirmed.

Conclusion and Discussion:

As it was already mentioned, there is a significant difference between the burnout component (depersonalization and personal accomplishment) scores of the experimental and the control group, at the level of P < 0.001. Therefore, cognitive behavioral stress management training has lead to the reduction of depersonalization and the increase of the personal accomplishment of the nurses in the experimental group, in comparison with those in the control group. The follow-up demonstrated the long-lasting positive effect of stress management training on the above components. The results of the research showed no significant difference between the experimental and the control group regarding the variant of emotional exhaustion. The result was confirmed in the follow-up. Therefore cognitive behavioral stress management training has not led to decreased emotional exhaustion in the experimental group in comparison with the control one. However the results of the present research based upon the ineffectiveness of cognitive behavioral stress management training on emotional exhaustion, and its effectiveness on reducing depersonalization and increasing personal accomplishment confirms the results of Taormina & Law's research [26]. In their study, Taormina & Law compared the approach of personal stress management and that of organizational socialization to overcome burnout, and found a strong negative relationship between the domains of professional training, organizational recognition, the colleagues' support, and looking forward to the future; and the components of burnout. In addition, there was a strong negative relationship between personal stress management assessment (interpersonal skills, self-management skills, and psychological preparedness); and the reduction of depersonalization and the increase of personal accomplishment; however it had no relationship with emotional exhaustion. As Taormina & Law [26] suggest: "The results show the necessity of defining burnout in both aspects; personal and organizational. Thus, in order to overcome burnout, more comprehensive programs must be developed. The foundations of such programs must rest on providing nurses with personal stress management skills and managers' support, so that they would be able to overcome each and every component of burnout."

The present research placed great emphasis upon teaching efficient patterns of interaction and interpersonal skills; using muscle relaxation techniques in the work environment as well as the daily life; and challenging and experimenting recognition errors. These methods show the effect of stress management training on the two components of depersonalization and personal efficiency in the research samples, although they enjoyed no organizational support during the course. The remarkable results of Taormina & Law's [26] study demonstrate an organizational variant as the only anticipant of emotional exhaustion. This can explain why the approach of the present research has not been effective in preventing emotional exhaustion in nurses. A nurse's mistake due to low skill level may lead to catastrophic results for patients. Low skill level caused anxiety, and the latter leads to emotional exhaustion. Broadening professional skills through developing the nurses' ability to take over their potential responsibilities will reduce the probability of making professional mistakes. This results in stress reduction, and thus lower levels of emotional exhaustion. The chance for future success is another organizational variant which has a strong relationship with emotional exhaustion; future success refers to the rewards one may look forward to receive. If there is no reward, the employee feels that all his/her struggle has been in vain. The absence of promotions or other forms of appreciation results in a feeling of uselessness and frustration which emotionally harasses the employee. On the other hand, showing genuine appreciation for one's services prevents emotional exhaustion by suppressing such negative feelings. The results of regression analysis in Taormina & Law's [26] study also determined the positive effects of interpersonal skills on developing personal accomplishment. Successful interaction in tension is an advantage which helps one feels better able to control countless environmental demands. Having gained such a control power, one enjoys more freedom and gives more time to his/her commitments and success.

Colleagues' support is a valuable facilitator which helps prevent burnout. Receiving this support from colleagues fulfills one's need for respect, credibility and belonging to somewhere; there is a negative relationship between the fulfillment of such needs, and the development of the burnout syndrome. Receiving the colleagues' emotional support and help, raises one's hope for success. Colleagues' support affects all the three components of burnout, especially that of increased personal accomplishment. The present research tried to give the subjects an opportunity to receive this support: they were given an opportunity to provide each other with a positive feedback by talking about their emotional problems (interpersonal problems with colleagues, patients, etc) their mistakes made in the work environment, and the guilt and the stress they have experienced. Providing each other with such positive feedback led to the reduction of depersonalization and the increase of personal accomplishment in the experimental group samples.

References

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(1) Somaye Karimi, (2) Mohadese Hasani and (2) Mohammad Reza Dalvand

(l) ACECR, Iranian Academic Center for education culture and research, Khuzestan branch.

(2) Zahedshahr Branch, Islamic Azad University, Zahedshahr, Iran.

Corresponding Author

Somaye Karimi, ACECR, Iranian Academic Center for education culture and research, Khuzestan branch, Iran.
Table 1: The descriptive statistics of burnout components (emotional
exhaustion, depersonalization, and personal accomplishment).

 Scales Mean Standard Deviation Lowest

 Emotional Exhaustion 20.25 0.18 4
 Depersonalization 6.66 4.36 0
 Personal Accomplishment 34.64 8.37 5

 Scales Highest Number

 Emotional Exhaustion 44 233
 Depersonalization 21 233
 Personal Accomplishment 48 233

Table 2: The Mean and the standard deviation of the small score of
emotional exhaustion.

 Stage Groups Mean Standard Number
 Deviation

 Pre-Test Experimental 32.2 5.58 15
 Control 29.2 9.35 15

 Post-Test Experimental 30.06 9.38 15
 Control 31.26 9.12 15

 Follow-Up Experimental 31.33 9.83 15
 Control 32.73 9.63 15

Table 3: The mean and the standard deviation of the depersonalization
score of the samples.

 Stage Groups Mean Standard Number
 Deviation

 Pre-Test Experimental 11.46 4.12 15
 Control 9.13 6.16 15
 Post-Test Experimental 8.6 4.61 15
 Control 13.8 9/08 15
 Follow-Up Experimental 7.9 3.97 15
 Control 14.73 9.05 15

Table 4: The mean and the standard deviation of the personal
accomplishment scores.

 Stage Groups Mean Standard Number
 Deviation

 Pre-Test Experimental 31.26 8.59 15
 Control 27.8 9.15 15
 Post-Test Experimental 38.2 8.95 15
 Control 26.73 5.75 15
 Follow-Up Experimental 38.53 7.58 15
 Control 25.4 5.35 15

Table 5: The results of MANCOVA.

 Test Value F-Statistics [df.sub.Hypothesis]

 Pillai's Trace 0.464 6.634 3

 Wilks'Lambda 0.536 6.634 3

 Hotelling's Trace 0.865 6.634 3

 Roy's Largest Root 0.865 6.634 3

 Test [df.sub.Error] Significant level

 Pillai's Trace 23 0.002

 Wilks'Lambda 23 0.002

 Hotelling's Trace 23 0.002

 Roy's Largest Root 23 0.002

Table 6: The results of three MANCOVA context analyses.

 Test Sum of df mean of
 squares squares

 Emotional Exhaustion 111.893 1 111.893

 Depersonalization 325.512 1 325.512

 Personal accomplishment 462.3 1 462.3

 Test F statistics Significant
 level

 Emotional Exhaustion 2.717 0.11

 Depersonalization 12.01 0.002

 Personal accomplishment 17.63 0.001

Table 7: The results of MANCOVA on the mean score of emotional
exhaustion, depersonalization, and personal accomplishment.

 Test Value F-Statistics [df.sub.Hypothesis]
 Pillai's Trace 0.625 12.804 3
 Wilks'Lambda 0.375 12.804 3
 Hotelling's Trace 1.67 12.804 3
 Roy's Largest Root 1.67 12.804 3

 Test [df.sub.Error] Significant level
 Pillai's Trace 23 0.001
 Wilks'Lambda 23 0.001
 Hotelling's Trace 23 0.001
 Roy's Largest Root 23 0.001

Table 8: The results of MANCOVA on the mean score of emotional
exhaustion, depersonalization, and personal accomplishment.

 Test Sum of squares df mean of squares

 Emotional Exhaustion 61.063 1 61.063
 Depersonalization 493.262 1 493.262
 Personal accomplishment 737.196 1 737.196

 Test F statistics Significant level

 Emotional Exhaustion 0.825 0.37
 Depersonalization 19.885 < 0.001
 Personal accomplishment 33.690 < 0.001
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Title Annotation:Original Article
Author:Karimi, Somaye; Hasani, Mohadese; Dalvand, Mohammad Reza
Publication:Advances in Environmental Biology
Article Type:Report
Geographic Code:7IRAN
Date:Jan 1, 2012
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