Theoretical Framework for Nursing Dissertation


2.1 Introduction

There are several theories explaining burnout in the work environment. The study explored the Conservation of Resource model,  Job Demands-Resources model, and Maslach theory on burnout. These theories were selected because they are suitable to illuminate the concept of nurse burnout at the workplace. Measurement and diagnosis of burnout and a discussion on the effects of burnout on nurses.

2.2 Conservation of Resources

Conservation of resources (COR) model has for over the three decades become one of the most widely cited theories in organizational psychology and organizational behavior. It has been adopted burnout, and traumatic stress work environment (Hobfoll et al., 2018). Job resources and demands are the two critical sections of the model. Job demands are the physical, psychological, and social organizations features of the job which span from the workload, work pressures, time management, conflicts, and uncertainty.

Job resources formulate the physical or social structures of the company that are positioned to help the staff perform better at the workstation. It goes beyond explaining the impact of proper leadership, management, working tools, secure working environment, good working relationships, and prospects of promotion on burnout. In this model, when the demands increase and job resources decline, then an impact to both burnout and stress among workers will be evident (Bakker and Demereouti 2018).

However, when there is high job resource, and low job demands, more positive results are bound to happen. The model emphasizes the significance of creating an equilibrium between job demands and job resources. These two aspects depend on one another to form a thriving working environment. Job resources might reverse the adverse effect of job strains. For example, proper leadership, good supervision, and improved relationship with supervisors that can assist decrease work strain.

2.3 Job Demands-Resources Model

Since its development by Professor Arnold Bakker and Evangelia Demerouti in the early twenty-first century, the model has gained high popularity among researchers studying burnout and stress in the work environment. Currently, the JD-R model is referred to as one of the best models to explain job stress and burnout. It drew inspiration from earlier models such as the Effort-Reward Imbalance and Demand Control models. The theorists contended that the already existing models were not sufficient to explain numerous job situations and that they had an aspect of simplicity in them. The Effort-Reward Imbalance model emphasized on issues such as salary while the Job Demand-Control Model centered on autonomy. Majority of work organizations and jobs are complicated, and earlier research indicates a lack of resources and high job demands which require timely solutions. The theorists decided to come up with a model that would cover all persons, companies, and jobs thus backing up the physical and emotional welfare which delivers better results at the workplace. Schaufeli (2017) supports the model by noting that the model clarifies the phenomenon of burnout, mental distancing, and decreased personal efficacy.

The model has garnered considerable empirical support from various scholars. The model presumes that job resources and demands are alienated psychological processes. They attain the fundamental psychological needs while job demands require more efforts and consume many resources. In essence, job demands are likely contributors to health impairment process while job resources enable the attainment of set objectives and therefore raise the level of commitment and engagement via a motivational process. Latest examples have found a relationship between these resources where the resources of the occupation have demonstrated to buttress high demands of the job and therefore safeguard the individual from health issues (Corin and Björk 2016).

The JD-R model is applicable in all occupations; in this case nursing. Job demands are those mental, physical, social or authoritative qualities of the activity that require supported mental or physical aptitudes and this connected with specific physiological and psychological costs. Employment assets are those social, physical, psychological or hierarchical highlights of the occupation that are either operational in achieving work objectives. Reduced work requests and connected mental costs, animate individual development, learning, and improvement hence preventing burnout (Zito et al. 2016). Because the final results of contemporary work are diverse to a range of streamlining of web indexes to the conveyance of individual social insurance, obviously working condition fluctuate among organizations.

Notwithstanding the distinction, the JD-R display proposes that all activity qualities be ordered into two principle gatherings: occupation assets and requests. These elements appreciate remarkable properties and prescient esteem. Occupation requests are the components of work that costs vitality such as current obligations, the outstanding task at hand, and struggle. While unpredictability and the outstanding task at hand can be qualified as test requests that help to perform successfully, clashes are obstacles work requests that debilitate execution. Employment assets are the components of work that help the specialists to manage work requests and achieve their set objectives. For instance, social help and an assorted variety of aptitudes are persuasive occupations attributes that offer centrality to specialists and meet the vital mental necessities self-sufficiency and competency (Bakker and Demereouti, 2018).

2.4  The Maslach Theory on Burnout

The prior research by the scholar did not involve the data of an officially existing together hypothesis and underlined on burnout; essential intrigue had been to think about ’emotions’ which then later came about to enthusiasm for occupation burnout. The past examinations and research on burnout paid attention to giving consideration occupations whereby the individual legitimizing care and the individuals accepting consideration had a relationship. The investigation has expanded to comprise different professions other than human administration. Burnout occurs when there is a confusion between the individual chipping away at finishing the activity and the activity requests. The theory suggests that the individual carrying out the responsibility and the activity requests should coordinate each other to avert burnout. Moreover, burnout comprises three elements of negativity, passionate depletion, or depersonalization and inefficacy.

Emotional weariness is the most unmistakable and distinguishable among the three measurements. Most people encountering burnout experience fatigue. Burnout is related to enthusiastic enduring manifestations including disappointment, grouchiness, fomentation which manifest as inability to endure the passionate and physical attributes of the activity. In any case, the inadequacy of feelings adversely impacts physical skill. Such situations make people act in a way that does not line up with their work, and the victims are not ready to endure the activity requests. Cynicism and depersonalization is the second dimension of the theory. Depersonalization makes persons distant to each other and the job and results to negative emotions. Such situations are occasional, and occur when the person is incapable of associating himself with the job demands resulting to nonparticipation.

Emotional exhaustion influences the second dimension. Job dissatisfaction happens in this dimension and individuals are considered as objects rather than human beings. Lastly, inefficacy is the third dimension of the theory. This dimension is more sophisticated than emotional suffering and cynicism. In this dimension, a nurse experiences a general sense of incompetence and unworthiness after self-evaluation. Due to this, there is a decrease in individual attainments. This theory points out that burnout negatively influences the nurse’s performance, turnover, and the relationship among persons. In this regard, poor job person is a result of continued work after experiencing burnout. 

The Maslach theory of burnout articulates that prolonged reactions to chronic sensors on the occupation can nurture negative emotions of incompetence, distant and negative attitudes towards the job colleagues and the employer or management. Job burnout constitutes the dimensions of depersonalization, emotional exhaustion, and decreased individual attainments which can happen among staff who work with persons in some capacities. Depersonalization is the negative, detached and distinct attitude towards work and distancing of an individual from others in the organization and outside stakeholders. As illuminated, decreased individual accomplishment is the emotions of ineptitude and an observed lack of job productivity.

The theory acknowledges six risk factors that could cause a mismatch between the job and the individual: the lack of fairness, workload, control, community, reward, and values. It is remarkable to attribute that workload is the aftermath of this deed. There has to be an equilibrium between resources and demand to satisfy the demands. Time to complete the remaining task and accessibility of assets to empower the activity requests is vital. The absence of control might be affected by the absence of active contribution in the association which makes people feel less critical or underestimated. After some time sentiments of being ‘caught’ might happen which causes anxiety to rise causing burnout. Inadequate rewards, such as the absence of acknowledgment and appraisal for positive results. Positive prizes shape conduct and construct inspiration. Steady analysis prompts low spirit and withdrawal. Breakdown of the network, working associations, is seen as a network. Elements are vital. Setting up a decent association with coworkers is critical. The breakdown in the network can prompt the absence of help, no collaboration, uncertain clashes, and work environment harassing. Nonexistence of logic, justice, and decency are essential angles in working associations that cause burnout. If there is an occurrence of absence of decency or separation, criticism may happen. Conflicting with one’s qualities on account of occupation requests can produce pressure and sentiments of skepticism.

2.5 Measurement and Diagnosis of Burnout

Burnout is a condition of physical, emotional, and psychological fatigue that is a result of extreme and extended stress. It happens when an individual feels physically and emotionally drained unable to meet expectations at the workplace, and feels overwhelmed. When an individual has burnout, they lose interest and the motivation that led them to choose a career. Exhaustion saps an individual’s energy leaving them feeling helpless, skeptical, desperate, and bitter. Hence leads the person experiencing burnout to feel like they are no longer useful in their places of work (Maslach, 1997).

The process of diagnosis, management, and treatment of burnout begins with acknowledging the existence of the problem. The most common tool used to measure burnout is the Maslach Burnout Inventory (MBI) developed in 1983 by Jackson and Maslach (Appendix 1). This tool has subtypes such as Human Service Survey (MBI-HSS) which were designed primarily for human service-related occupation such as nursing (Maslach and Jackson, 1983).

MBI is used in the occupational institution to determine and measure the risk and prevalence of burnout in workplaces. Most of the material used in this research used MBI in estimating burnout among nurses. This assessment tool comprises three sections;  part A and B have seven questions each, while part C has eight issues. The first section uses physical symptoms to identify the presence of burnout. A score of 30 and above shows the presence of high burnout level, while a score between 18 and 29 indicates a moderate level of burnout. A score below 18 indicates low burnout level. In the second section, the tool measures a persons’ negative attitude towards the work environment; such as feelings towards the colleagues and the job. It also determines a person empathy level toward the patient’s or colleagues. The much the nurse withdraws and shows a sign of low involvement, the higher the level of burnout. A score of 5 and below shows a lower level; a score above 12 shows a high level while a score between 6 and 11 indicate a moderate burnout. The third section, section C, is determined by the first two parts of the tool.

Maslach burnout inventory is a useful instrument used globally as a tool for measuring the danger of burnout globally. In this section, when the score is 30 or below, it signifies a high level of exhaustion. At this point, a person is at a ‘low point.’ At such level, the burnout is high enough to hinder the employee’s performance.  The nurse may show emotional distress characterized by low self-esteem. The score above 40 is indicating low levels of burnout while a score of 34 and 39 shows a moderate level of burnout (Jeremy et al., 2015).

2.6 Burnout and Nursing

The prevalence of stress and burnout among nurses is a common phenomenon. It is caused by a demanding and stressing work environment. The high cases of burnout in nursing are a threat to the health care system and the well-being of the patients. Many studies reveal that there is a high rate of burnout among nurses, and particularly in those serving in hospitals; Europe, Asia, and North America report a high incidence of burnout. A study done in Finland with a sample of 723 nurses, nearly half of the nurses indicated that they experienced burnout, frustration, and job dissatisfaction. Elderly, secondary level nurses and those working in psychiatric departments experienced the highest level of burnout (Jeremy et al., 2015).

A survey conducted by Zahiri et al. (2014) on a sample of 61 revealed that 24.5% of the sampled nurses experienced burnout and that only 8.19% of the participants had worked for 15 years or more which means that most nurses opt for early retirement when they can no longer handle stress at work. The levels of emotional fatigue were at 45.9%, depersonalization 40.9%, and personal inefficacy at 70.4% for nurses in this study.

There exist a link between a shortage of nurses and job dissatisfaction, burnout, and stress. In a systematic review, the findings disclosed a positive bidirectional association between the shortage of nurses and burnout among nurses working in accident and emergency section. There are two types of burnouts,  the nurses who are absent from work and those that are at work but not efficiently providing quality care. The degree of the stress, job dissatisfaction, and burnout encountered by the oncology registered nurses and their view of recruiting inadequacy varied based on their work settings and demography. Nurses who hold high positions in the sector and those who worked inpatient environment and non-Magnet hospitals were more probable to attribute insufficiency of staffs as one of the key contributing aspects of their stress, burnout, and job dissatisfaction. In essence, the burnout caused many accidents and emergency nurses to quit (Fiona et al., 2016).

2.6.1 Causes of Burnout on Nurses

According to Jeremy et al. (2015), the leading cause of burn out is the conditions in the work environment, where personal risk factors vary depending on individual vulnerability where the personal risk factors include personality traits and demographic variables. The work environment that causes burnout includes; work overload, poor interpersonal relationships with other nurses, insufficient reward, unfair treatment of nurses, conflict in value and job description, and inefficiency in job performance. Personal risk factors resulting in burnout include; family status, age, education background, gender, race, and personal traits. The workload is the primary cause of burnout caused by inadequate staffing in medical care organizations a study of 665 hospitals indicated that 20% had a patient-to-nurse ratio of seven or more, while 25% had a ratio of four or less. High patients nurse ratio consumes nurses time for innovation, research, and interact with the patients. The research shows that the patient-to-nurse ratio in England high; hence nurses work for many hours causing fatigue and stress.

            Low salary and poor management demotivate nurses and reduce performance and quality of patient care. These factors lead to high turnover, and most nurses intend to change career. Salary is a drive to motivation leading to performance. Poor management is a factor that causes nurse burnouts. Management plays an essential role in the control of health care institutions. It provides enough resources for the nurses to deliver quality care an innovation (Zvauya et al., 2017)

 According to Leiter and Maslach (2009), poor communication and collaboration increases chances of nurse burnout. If the nurses do not collaborate with others, it becomes hard for them to deliver quality care. Communication is also a factor that leads to chances of burnout. The nurses and management should take communication as a crucial factor that contributes to the running of a hospital. Without proper communication, the management cannot give clear instructions to nurses. Most nurses do not get opportunities to advance their studies due to work related commitment caused by low nurse-patient-ratio. Inability to acquire higher credentials hinders career progression.

2.6.2 Impact of Burnout on Patients

According to Hayley et al. (2015), nurse burnout contributes to infections in hospitals. Studying nurse staffing, burnout, and healthcare-associated infection, the researcher, found that there was a statistically significant difference between urinary tract infection and patient to nurse ratio (0.86; P = .02) and surgical site infection (0.93; P = .04). In a multivariate model for regulating patient severity and hospital and nurse features, only nurse burnout remained statistically significant to urinary tract infection (0.82; P = .03) and surgical site infection (1.56; P < .01). Arguably, hospitals, whereby burnout was decreased by 0.3, had a total of 6,239 fewer infections in a year. Consequently, the survey offered a plausible illumination for the link between nurse staffing and health care linked infection.

Burnout has personal, professional, and organizational consequences to the nurses (Net CE, 2018). Some of the personal consequences burnout have on nurses are poor physical and mental health as a result of stressors, low job control, work overload, minimal teamwork among nurses and other health assistants, high job demands, and job dissatisfaction. Other severe cases resulted in high rates of musculoskeletal injuries and musculoskeletal disorders were among the nurses with job dissatisfaction, poor work scheduling, poor interpersonal relationships, and decision making. 

The professional and organizational consequences caused by burnout are cases of decreased productivity during their shifts, absenteeism and in extreme situations; some leave their jobs which is a result of decreased confidence, morale and motivation. Such situations create an unsympathetic attitude, causing careless decision making, lack of innovation and fresh ideas since they do the bare minimum. Consequently, it lowers the nurse-patient ratio and raises the job turnover among nurses resulting due to job dissatisfaction, and burnout. Burnout also leads to nursing errors resulting in poor patient care where in extreme situations, patients are administered the wrong medication, or given at the wrong time. Mortality levels increase where burnout is high since, with the low nurse-patient ratio, one nurse has more than six patients. In a study done in England by Net CE, (2018), if one nurse had to attend to one or two patients, nurses would have saved an estimate of 25 lives per 1,000 hospitalized patients and 15 lives per 1,000 surgical patients.

2.6.3 Effects of Burnout among Nurses

The consequences of burnout among nurses are alarming. Leiter and Maslach, (2009) report that there are three dimensions of burnout. These are emotional suffering, depersonalization, and efficacy. When nurses encounter at least one of the aspects, then the overall job productivity reduces. The condition has resulted in daring consequences in welfare, the safety of patients, quality of life, and quality of care offered. Moreover, according to (Klein et al., 2018), burnout causes depression among nurses leading to high job turnover. A survey that involved 68, 000 registered nurses in 2007 registered inpatient nurses, nearly 43% of the nurses had a great extent of emotional suffering. The study documented that 37%, of nursing home nurses, 35% of hospital nurses, and 22%  of nurses working in other environments encountered high levels of emotional suffering.

Burnout lowers the levels of patient satisfaction in the hospital. According to Dall’ Ora et al., (2015), the patients nursed in units with sufficient employees, proper management of nursing care, and functional relationship between the nurses and physicians were more than twice likely to record high contentment with care. Also, nurses in such environment showed significantly lower exhaustion and burnout. In essence, the higher the levels of job burnout, the lower the patient satisfaction.

Burnout influences the level of job turnover among nurses. Leiter and Maslach, (2009), studied 667 Canadian nurses to understand the relationship between burnout and nurses turnover. The result showed that the working environment and social-economic factors played a significant role in job turnover. The turnover trend is a threat to both the welfare of patients and nurses. It is evident that high turnover would lower nurse-patient ratio further worsening the already bad situation. It is essential to understand the relationship between stress, job satisfaction, and burnout. Khamisa et al., (2017) conducted a study with a sample of 895. The study showed that stress is a better predictor of burnout and general health than the level of job satisfaction. The study recommended urgent measures to address personal and occupational stress in the workplace.

According to Nantsupawat et al., (2016), the emotional state of nurses is significant in determining the quality of care provided to patients. The study disclosed that 32% of nurses documented immense emotional suffering, 35% low personal attainment and 18% high depersonalization. Nonetheless, 16% of the nurses considered the quality of care on the departments as poor or fair, 14% documented infections, 11% reported medication errors, and 5% reported patient letdowns. The study linked the three subscales of the MBI to rising reporting of poor or fair quality of care, medication mistakes, infections, and a decline in patients visit. Each unit of augmenting emotional exhaustion score linked with 2.63 times increase in documenting the poor or fair quality of care, a 30% increase in patient falls, a 32% rise in infection, and 47% rise in medication errors. The finding of the study is that nurse burnout linked to the increased odds of documenting negative patient results. In essence, enforcing interventions to decrease burnout among nurses is essential in enhancing patient care.

2.6.4 Management of Burnout among Nurses

Based on available literature, the work environment is a significant factor that causes burnout and stress; modifying it has the potential to reduce burnout. Some of the ways of managing burnout is improving personal lifestyle, professional lifestyle, and organizational levels. Personal lifestyle includes; obtaining adequate sleep, proper nutrition, regular physical activities and meditation, self-reflection, identifying and maintaining priorities, recognizing own limitation, and seeking emotional assistance when necessary. Professional lifestyle includes; varying work routine, setting achievable goals, interpersonal support from other nurses, and practical communication skills. Organizational level includes; creating a good work environment, providing access to training where necessary, maintaining strong leadership roles, and participation in decision making that concern providing quality patient care. It is important to note that, it is cheaper and easier to prevent burnout that resolving it once it has occurred, thus, essential to prevent accumulation of stress.

Referring to Fryer et al., (2016), assessing the confidence of nurses and other health practitioners have and its effect on the provision of quality care. The patient’s perception showed that the level of confidence among nurses influenced the quality of services provided. Poor hospital work environment and lack of teamwork and social support affect the confidence, morale, and motivation of nurses.

2.7 Summary

Burnout affects both the emotional, social, and physical state of the nurse, as well as the provision of quality care to the patients and patient safety. Organizations and institutions should focus on creating a good work environment for nurses so that they can feel included among their colleagues and their supervisors.  Such measures ensure that nursing patterns organized for effective delivery of patient care.

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