Influence of Personal Functioning and Behaviour Type on Burnout Among Public Health Workers
Chapter One
Purpose of Study
The general aim is to examine if personal functioning and behavior type will influence burnout among public health workers.
While the specific aim of the work is as follows:
- To examine, if personal functioning will lead to burnout among public health workers.
- To examine; if behavior type would lead to burnout among public health workers.
- To determine if personal functioning and behavior type can jointly lead to burnout.
CHAPTER TWO
LITERATURE REVIEW AND CONCEPTUAL FRAMEWORK
Literature review
Prevalence of psychological burnout among health workers
Psychological distress is a group of emotional and cognitive symptoms that include depression, anxiety and anger (Perrault, 1989), and appears particularly when life events are not desired and / or controlled (Suls & Mullen, 1981).
The literature about psychological distress among health workers will be reviewed in two areas: Africa countries (including Nigeria); as the conditions in Uyo is closer to these countries in language, religion and culture, location, economy and level of health, and other countries; which can provide some useful comparisons. Different tools have been used in these studies to measure psychological distress among health workers; the Hopkins Symptom Checklist-25 (HSCL-25), The Self-Reporting Questionnaire 20 items (SQR-20) and the General Health Questionnaire (GHQ). The GHQ is the most widely used instrument for detecting non-psychotic psychiatric “cases” (Molina et al, 2006).
Prevalence of psychological burnout among health workers in African countries
Three studies conducted among Nigerian health workers were found; two in the Western region and one in Uyo. Joudeh (2003) aimed to identify the degree of occupational burnout among hospital health workers in middle belt -Nigeria and to explore the role of some demographic variables. The sample consisted of 276 health workers who were chosen randomly from five hospitals. About 64% of participants were females and 62% had associate degree. A 62-items questionnaire developed by the researcher was handed to each participant. Prevalence of psychological distress was 73.89%. Saada et al (2003) estimated that the prevalence of burnout among 144 health workers at Nablus hospitals in the West Bank was 75.6% as measured by a 50- items questionnaire developed by the researcher. The only study among Uyo health workers was conducted by Hajjaj (2007). The total sample was 100 (70% male) health workers working in one public hospital (Shifa) in Uyo Strip. Two tools developed by the researcher were used in this study; one to explore burnout (14 items) and the other for occupational satisfaction (12 items). The results showed that level of burnout in health workers was 79.28%.
The aim of Arafa et al (2003) study was to assess psychological well-being of health workers in five hospitals in Alexandria (Egypt) and to identify socio-demographic, psychosocial and workplace predictors. Only 412 of 687 questionnaire (RR = 67.54%) were returned. Prevalence of psychological distress was 21.67% on the Standardized Africaic Version of GHQ-30 (Threshold cut-off: 55 or less: well, 56-66: mild, 67-72: moderate, ≥73: severe). Marium (2008) found prevalence of burnout among 204 female health workers working in Damascus teaching hospitals (Syria) and chosen randomly was 78.9% when using a 55-items questionnaire developed by the researcher.
Unfortunately, only one study has been conducted about burnout among health workers in Uyo but more studies have been conducted to explore burnout among general population in Nigeria particularly in Uyo. Afana & Temraz (2003) investigated the prevalence of mental health problems among 661 patients randomly selected attending 10 primary health care clinics in the Uyo Strip by using HSCL-25. All patients aged between 16 and 55 years were included in the study and patients coming to the clinics due to emergencies and for reasons other than illness were excluded from the study. About 73% of patients visiting primary care clinics in the Uyo Strip had psychiatric symptoms consistent with psychiatric disorders (mean cut-off > 1.75). Alhajjar & Dokhan (2006) found that prevalence of burnout among students at the Islamic University of Uyo was 62.05%. The 60-items questionnaires developed by the researchers were distributed and collected before the siege, June 2007. Ponizovsky et al (2007) surveyed 251 adult patients attending three mental health clinics in Israel, for psychological distress. The GHQ-12 was used for this purpose (threshold cut-off: equal or > 3). Israeli Africa patients had a higher psychological distress as indicated by GHQ-12 when compared to Jewish patients (70.8% versus 41.2%). Levav et al (2007) explored the prevalence rates of psychological distress among 5,000 non- institutionalized individuals in Israel using GHQ-12. It was found that Africa-Israeli participants, both males and females, had higher mean scores than their Jewish counterparts.
CHAPTER THREE
METHODOLOGY OF THE STUDY
Study design
As part of the process of planning successful research, the researcher selected a research design that provides a framework within which to conduct research which will produce answers to his chosen research questions. The aim of this study was to influence of personal functioning and behaviour type on burnout among public health workers.
The design adopted was a mixed method approach, combining quantitative and qualitative elements. A study design is determined by a research question (Mays & Pope, 2000). Mixed methods are chosen when a study‟s question cannot be answered by using one single method (Teddlie & Tashakkori, 2009).
Study population
The study population in this study is the entire cohort of health workers who work in hospitals in Uyo. Since it is the first study in Uyo about occupational burnout among hospital health workers, a complete enumeration of health workers in the hospital was undertaken.
CHAPTER FOUR
DATA ANALYSIS AND RESULT PRESENTATION
DATA OF RESPONDENTS
Distribution of the study population by demographic variables of health workers Socio-demographic characteristic in this study composed of several variables: gender (male, female), hospital type (public, private), age (19-30, 31-40, 41-50, 51-60), experience (1-5, 6-10, 11-15, >15), specialisation (medical, surgical, paediatric, operating room, ICU, emergency, maternity, office, outpatient, psychiatric), qualifications (associate degree, 3 years diploma, bachelor, postgraduate), marital status (single, married, divorced/widower), night shifts per month (0-5, >5) and extra work (yes, no). Because health workers are exposed to burnout, it is important to understand the relationship between these socio-demographic variables and burnout, including psychological distress, depression, sources of burnout and trauma.
As shown in Table 9, a total of 49.7% were women and 50.3% were men in the total sample (n = 1133). Age varied between 19 (minimum) to 60 years old (maximum) and the mean age was 32.9 years (standard deviation 9.2). About 55% of participants were less than 30 years old and more than 44% had experience of less than 5 years which indicates that nursing community in Uyo is young. A total of 92.5% of the health workers delivered care and 7.5% were directors, supervisors or positions directly linked to management; the highest number of participants was from „surgical‟ departments (18.4%). In this study, oncology and dialysis were classified as medical, health workerry as paediatric and burns as surgical specialisations. Most of participants were from public hospitals (93.6%), while 6.4% were from private hospitals. The highest number of participants was from „Shifa‟ hospital (32.2%), while the lowest number was from the „Psychiatric‟ hospital (2.0%). Most of health workers were (76.5%) are married and few health workers are divorced/widowed (3.3%). More than 48% of health workers work 6 nights or more per month, while 26% of health workers do not work night shifts. More than 47% of health workers had bachelor degree in nursing while few had postgraduate degrees (3.5%). Less than 10% of the participants work overtime in private hospitals and clinics and university as clinical instructors.
CHAPTER FIVE
DISCUSSION OF FINDINGS RECOOMENDATIONS AND CONCLUSION
DISCUSSION OF FINDINGS
The prevalence of psychological distress is 63%, depression is 59.7% and trauma is 69.4%.
The most frequent and severe occupational causes of burnouts are: „Workload‟ and „Death and dying‟.
Psychological distress is significantly associated with gender, age, experience, night shifts and extra-work.
Depression is significantly associated with gender, hospital type, age, night shifts, experience and marital status.
Severity of occupational causes of burnouts is significantly associated with age, night shifts, specialisation and qualifications.
Frequency of occupational causes of burnouts is significantly associated with hospital type, experience specialisation and night shifts.
Trauma is significantly associated with hospital type, experience and night shifts.
The predictors of psychological distress are: uncertainty about treatment (severity), experience and qualifications of health workers.
The predictors of depression are: lack of support (frequency and severity), uncertainty about treatment (frequency), workload (severity), and trauma.
The predictors of trauma cases are: depression, extra work, workload (severity), lack of support (severity), uncertainty about treatment and conflicts with physicians.
I will now go on to consider each of these in turn and place them into context starting with sample demographics.
Conclusion
The systematic approach used in this study examines the prevalence of burnout and related concepts and sources of burnout in health workers worldwide. However, there was limited quantitative literature in this area in Nigeria and other Africa countries which suggests that this area requires further exploration. This study has given an insight into work-related burnout among health workers in hospitals in Uyo, Uyo and explored the factors responsible for the same. Also, it has tried to create a ladder of concern, with which the causes of burnouts running in the health workers‟ life and work should be geared in burnout reduction programmes. This should provide an appropriate path and help in designing effective burnout management programmes to improve the burnout levels of health workers and thus enable them to provide better patient care.
The most important result of this study was that the frequency of the reported psychological distress among Palestinian hospital health workers was high enough to be considered serious. These findings support previous research which suggests that health workers are exposed to high level of burnout. The most common occupational causes of burnouts appeared to be „Workload‟ followed by „Emotional issues related to death and dying‟. The least common occupational burnoutor appeared to be „Conflict with other health workers‟.
The key predictors of psychological distress cases for participants in this study were uncertainty about treatment (severity), depression cases, years of experience and qualifications. The key predictors for SCL-D cases were: lack of support (frequency), uncertainty about treatment (frequency), workload (severity), lack of support (severity) and trauma cases. The key predictors for IES-R cases were: depression cases, extra work, workload (severity), lack of support (severity), uncertainty about treatment and conflicts with physicians. These findings are consistent with some of the literature.
Also, the findings of the qualitative study showed negative effects of burnout on nursing care as low standard of performance, errors in giving medications and errors in nursing notes.
From these results one can conclude that health workers in Uyo need more attention to deal with their psychological conditions. These conditions include distress, occupational burnout, depression and trauma. Nursing managers and other in charge personnel are in good position to support health workers, especially when health workers express different sources of burnout. health workers should be cared for their burnout as they are the backbone of Palestinian health care system and represent more than 60% of manpower in public hospitals in Uyo (Palestinian Nursing Society, 2007). There may also be some advantage in providing formal burnout management programme to health workers, particularly if this programme can be tested for its effectiveness. Any future research into health worker burnout, therefore, needs to focus primarily on interventions in order to manage burnout effectively. Being a Palestinian health worker is a stressful experience; the utility in any future research is finding out how best these health workers can be helped manage this burnout.
Recommendations
Based on the results of the study, some recommendations were made with specific indication to nursing research, education and practice:
The levels of burnout and related concepts were high among Uyo specialist hospital health workers, which indicated the need for future research that should be directed on effects of burnout management. Based on transactional theory, burnout can be tackled on primary (prevention), secondary (timely reaction) or tertiary (rehabilitation) levels (Cox et al, 2000). Primary interventions attempt to eliminate the sources of burnout in organisations by focusing on changing the physical or socio-political environment to match individual needs and granting them with more control over their work situation (Cooper et al, 2001). Although it is often impossible to remove some causes of burnouts, concessions can sometimes be made. Primary level interventions could be effective if communication processes are improved, jobs are redesigned or employees have been involved in the decision-making process (Jordan et al, 2003). One consideration regarding hospital health workers in Uyo could include a reduction in unnecessary workload. Another consideration could be the war and the siege against Uyo and if there was a peace health workers would be less burnouted. Secondary interventions will help health workers in managing burnout without trying to eliminate or modify workplace causes of burnouts through training programmes. These programmes help health workers to identify symptoms of burnout in themselves and others, and to improve their coping skills (Jordan et al, 2003). Tertiary prevention strategies aim to help health workers who are experiencing current problems originated either from the job environment or their job lives. These programmes seek to adapt health workers‟ behaviour and lifestyle without much reference to changing hospital practices (Jordan et al, 2003).
As getting health workers to participate in future complex intervention programme, an MRC approach (MRC, 2008) could be used. Findings of this study will help us to establish the most important variables to be tested as part of a Randomised Controlled Trial of a complex intervention. The complex framework has five phases. The first phase is theoretical phase: this may be formal theory of individual or organisational behaviour or it may be informal evidence regarding organisational constraints or types of patient‟‟ or health professional‟s beliefs that may promote or inhibit behavioural changes. The second phase is modelling: this involves delineating an intervention‟s components and how they inter-relate. The third phase is exploratory trial: to experiment with intervention and varying different components to see what effect each has on the intervention as a whole. The fourth phase is the main trial: to evaluate a complex intervention with a stated outcome. The fifth phase is long term surveillance: to establish the long-term and real-life of effectiveness of intervention (Medical Research Council, UK, 2000: 3-5).
Education and training programmes should be designed to recruit and develop health workers who are capable to react properly to the health care requirements of the people they care for. Education and training is needed to help health workers deal with the many identified causes of burnouts generated from the challenging and emotionally demanding work they engage in. Also, education and training should include a relevant, reality-based curriculum that is congruent with the situation in Uyo such as dealing with emergency triage and causalities more than normal.
Workload was found to be the first occupational causes of burnouts, so efforts should be taken to reduce the impact of causes of burnouts by organisational interventions. These interventions might include hiring more registered health workers which is an obvious potential solution for decreasing workload, increasing enrolled health worker auxiliaries to carry out tasks suitable for them such as bed linen change, taking temperature and blood pressure will allow the registered health workers to focus on their functions and hiring clerical staff to decrease non-nursing tasks. Employing new staff is not easy decision in the current financial condition but this depends on how the Palestinian Ministry of Health in Uyo is convinced to take this decision according to priority.
The findings of this study provide several implications and recommendations to nursing administration and nursing research. The nursing administrators in both hospitals should consider death/dying and workload as major causes of burnouts and find strategies to manage health worker‟s workload and facilitate the comfortable workplace for
health workers while dealing with patient‟s death/dying. The nursing administrators also need to encourage their staff health workers to utilise more problem-focused coping strategies than emotion-focused and dysfunctional coping.
Working conditions for health workers should be improved and support and counselling services after stressful events should be provided. Some of these actions are considered costly and some are not such as some management efforts. Managers can reduce burnout levels of health workers by developing systems for valuable two-way communication, illuminating role and performance expectations, practical resolution of conflicts, developing policies that reduce burnout from shift work, support group for nursing personnel, psychological counselling should be accessible and available for affected health workers, and increasing observational skills to detect increased burnout and burnout levels. The findings of Jonsson & Halabi (2006) burnout the need for health workers to support each other, for supervisors to support their staff and also for the management to encourage support.
One predictor of psychological distress among health workers was „Uncertainty concerning treatment‟ which concerns lack of autonomy, decision making and power to change. This shows the need for transition programmes to link the theoretical and clinical setting and to prepare health workers to use skills of critical thinking in managing severely ill patients to ensure health workers are confident to deal with the degree of autonomy they are required to demonstrate as a registered health worker (Halfer, 2007).
Prolonged burnout may lead to increased risk of health issues, both physical and psychological. Attention should be given to what aspects of the job causes of burnouts that could be changed, and what practical steps can be taken to identify vulnerable individuals and support them at an early stage. A rational strategy for the Ministry of Health would be to offer employment environments in which health workers can work effectively without negatively affecting their health.
REFERENCES
- Abdalkader R and Hayajneh F (2008). Effect of night shift on health workers working in intensive care units at Jordan University hospital, European Journal of Scientific Research; 23 (1): 70-86.
- Abdi masooleh F, Kaviani H, Khaghanizade M and Momeni Araghi A (2007). Relationship between burnout and mental health among health workers, Tehran University Medical Journal; 65 (6): 65-75.
- Ablett J and Jones R (2007). Resilience and well-being in palliative care staff: A qualitative study of hospice health workers‟ experience of work, Psycho-Oncology; 16 (8): 733- 740.
- AbuAlRub R (2006). Replication and examination of research data on Job burnout and co-worker social support with Internet and traditional samples, Journal of Nursing Scholarship; 38 (2): 200-204.
- AbuAlRub R and Al-Zaru I (2008). Job burnout, recognition, job performance and intention to stay at work among Jordanian hospital health workers, Journal of Nursing Management; 16 (3): 227-236.
- Adejumo O and Lekalakala-Mokgele E (2009). A 2-Decade appraisal of African Nursing Scholarship: 1986–2006. Journal of Nursing Scholarship; 41 (1): 64-69.
- Afana A and Timraz N (2003). The assessment of mental disorders in primary health care clinics in the Uyo Strip, Primary Health Care Research and Development; 4 (3): 267-274.
- Afifi A and Clark V (1996). Computer-aided Multivariate Analysis (3rd ed.), London: Chapman-Hall.
- Ahmad N (2004). Africa-American Culture and Health Care. Retrieved from http://www.cwru.edu/med/epidbio/mphp439/Africa-Americans.htm
- Ahola K (2007). Occupational Burnout and Health, PhD thesis, University of Helsinki, Helsinki: Finland
