Burnout and work environment impacts on Saudi Arabian registered nurses

Burnout and Work Environment on Job Satisfaction, Intent to Leave, Quality of Care among Registered Nurses in Saudi Arabia

To investigate the impact of burnout and work environment on job satisfaction, intent to leave, quality of care among Registered Nurses in Saudi Arabia. Background: A healthy work environment plays a critical role in health care system. This research enhances a greater understanding how the work environment and burnout play a critical role in the quality of patient care, intent to leave and job satisfaction among nursing professionals.

The study uses the descriptive-correlation quantitative technique to collect and analyze data. The study collects data from a total of number 545 Registered staff nurses in three governmental hospitals in Riyadh Saudi Arabia, and the sample size is based on a 0.05 margin of error and a 95% confidence interval.

Results: The findings confirm that nurses experience a moderate level of burnout, and 88% of participants are satisfied with their current job, however 64% have no intention to intent to stay despite that quality of care is excellent.

Conclusion: The findings agree with the previous research showing that burnout has a strong influence on nurses' intention to stay in their current job. Thus, healthcare organizations are required to implement a policy that will reduce the burnout in the healthcare working environment.

INTRODUCTION

1. Background of the Study

A healthy work environment plays a major role in today's health care system for better patient outcome. Ives, (2010) stresses that an importance of healing environments for patients has a momentous influence on the development of the fundamental values of healthy work environments. Dieleman, & Harnmeijer, 2006) describe the work environment as an essential factor in the recruitment and retention of health professionals where the characteristics of the work environment affect the overall nurses' job outcomes. The International Council of Nurses and other affiliated organizations suggest that due to the present global health workforce crisis, establishing positive practice environments across health sectors worldwide is of paramount importance for patient's safety and well-being of health care providers. (ICN, 2008). Although, there is a good reason to believe that nursing profession shares commonalities across sectors, there are also some important differences between nursing professions and other professional settings that have been understudied. Aboshaiqah (2015) mentioned that little is known about the patient safety and safety culture from a nursing perspective in the Saudi Arabian healthcare system. In addition, studies on work environment and its impact on the job outcomes among Registered Nurses in Saudi Arabia is lacking.

1.1. Statement of the Problem

Changes in health status of population, increase of morbidity among the health care workforce, and changes in the health care delivery have led to significant changes in the health care workplace. One important area of health care delivery is the nursing care environment, which should be more conducive to providing adequate support to nurses. The work environment can also have an influence on the quality of care. The Institute of Medicine (2004) identified key aspects of the work environment for nurses that are likely to have an impact on patient safety; and potential improvements in health care working conditions that might increase patient safety. Kirwan, Matthews and Scott (2003) supports their research findings indicating that a positive practice work environment enhances patient safety. The author explores the relationship between the health environment where nurses' practice and patient safety outcomes using ward level variables as well as nurse level variables. The outcomes were nurse-reported patient safety levels in the wards where they work, and numbers of formal adverse event reports submitted by nurses.

1.3: Design

The cross-sectional quantitative study was carried out within a European FP7 project: Nurse Forecasting: Human Resources Planning in Nursing (RN4CAST) project. All nurses in direct patient care in the study wards were invited to participate. Data of 1397 nurses were used in this analysis. A nurse survey was carried out using a questionnaire incorporating the Practice Environment Scale of the Nursing Work Index (PES-NWI). Multilevel modeling was carried out to examine the impact of ward level factors on patient safety. These included proportions of nurses on the ward educated to degree level, and aggregated ward-level mean was used for PES-NWI scores. The results support other research findings indicating that a positive practice environment enhances patient safety. Specifically, at ward level, factors such as the ward practice environment and the proportion of nurses with degrees were found to significantly impact safety outcomes.

2. Literature Review

According to American Association of Critical-Care Nurses (2005), establishing and sustaining healthy work environments must be a priority if nurses are going to make their optimal contributions in caring for patients and their families. Typically, there is a strong evidence that supports a positive relationship between nursing professional practice and patient outcomes. Mcgillis & Doran (2007) underscore the importance of examining the environment in which nurses' work as a potential factor that influences outcomes experienced by patients and nurses.

An effective hospital nurse work environment is essential to assist nursing leadership providing the right structures, practices, and people. This enables nurses to do the right things correctly, thus producing desired outcomes for patients, staff, and the organization. Researchers at magnet hospitals have identified the following factors to achieve positive nursing environment: Leadership attributes of nursing administrators (e.g., vision and responsiveness), professional attributes of the staff nurses (e.g., nurse autonomy and control, ability to establish and maintain therapeutic nurse -- patient relationships, and collaborative nurse -- physician relationships), and an environment that supports professional practice (Scott, Sochalski& Aiken, 1999).

Several studies suggest that staff nursing job satisfaction, turnover intentions and the factors influencing them are linked to predictors of the quality and safety of patient care (Laschinger et al. 2001, Aiken et al. 2008). Hospitals with poorer staffing and less adequate resources tend to be associated with higher levels of nurses' dissatisfaction and poorer quality patient care. Hospitals with poor care environments had a higher percentage of nurses reporting high burnout levels and dissatisfaction with their jobs (Aiken, Clarke & Sloane, 2008). Self-reported collaboration between medical intensive care unit nurses and physicians was linked to improved patient outcomes. The care environment and nurse staffing were found to have significant effects on burnout and job dissatisfaction. Nurse retention and patient outcomes are improved when the nurse leaders improve staffing environment. (Aiken, Clarke & Sloane, 2008). Moreover, higher ratings of nurse staffing and resources adequacy were related to lower emotional exhaustion scores (Rocheforte & Clarke, 2010). Each 10% increase in inexperienced nurses and each unit decrease in staffing-resource adequacy and nurse-physician relations increases the odds in nurses exhibiting high nurse burnout, job dissatisfaction and the odds of their reporting lead to poor or fair quality of care. According to the survey carried out by Kanai-Pak, Aiken, Poghosyan et al. (2008), 39% of participants reported that there were insufficient Registered Nurses to provide quality patient care and inadequate nurse staffing was identified as a predictor of job dissatisfaction.

A number of investigators have used the Revised Nursing Work Index as a measure of the work environment. The NWI-R grew out of the Magnet Hospital research used to measure nurse autonomy, control over practice, nurse-doctor relations, nursing leadership, and resource adequacy. Hospital wards with higher subscale scores demonstrated higher patient satisfaction, lower nurse emotional exhaustion and lower incidence of needle stick injuries. In one study using NWI-R at the ward level, nurses' perceptions of control of practice, autonomy/collaboration, and continuity/specialization were associated with a lower incidence of urinary tract infections, pneumonia, cardiac arrest, and shorter length of stay. Higher levels of nurse management support were associated with lower rates of mortality and pressure ulcers. Improved collegial relationships between nurses and doctors, along with better-educated nurses and richer skill mix have been linked with a decrease in patient mortality (Aiken, Clarke & Sloane, 2008).

Mitchell (2009) explores a relationship between demographic characteristics, work environment factors, hospital characteristics (linked to job satisfaction) and burnout among foreign-trained nurses living and working in Saudi Arabia. A mixed-method study using correlation and triangulation designs explored the associations between demographic factors and work environment factors using the subscales for job satisfaction (Nursing Work Index-Revised and the Practice Environment Scale) and burnout (Maslach Burnout Inventory). A total of 453 full-time nurses (FTNs) participated in the surveys and 25 FTNs participated in focus group sessions. Overall scores showed a higher rate of burnout for depersonalization, emotional exhaustion, and an average feeling of burnout for personal accomplishment. Scores also indicated that foreign-trained nurses had neutral feelings for a professional work environment. Important issues for foreign-trained nurses included staffing, policies and procedures, status, security, support for nursing, continuing education, and communication. Foreign-trained nurses also raised issues unique to the nature of work in Saudi Arabia that need improvement. If the work environment improves, job satisfaction may increase, burnout may decrease, and tenure may improve. Nursing leaders in all sectors must be empowered to effect change in the professional work environment through collaboration, cooperation, and transformational leadership in order to recruit and retain qualified foreign-trained nurses.

Kazanjian, Green, Wong & Reid (2005) conducted a systematic review of studies linking nursing work environment characteristics to patient mortality. The authors concluded based on the evidence from 27 studies revealed a link between inpatient mortality and variables that include autonomy, good nurse/physician relationships, reasonable workloads, care based on nursing standards, positive manager attributes, and professional development opportunities.

Aikens et al. (2008) research was the first study to link nursing work environments to patient outcomes revealing that nurses in the Magnet hospitals have lower levels of burnout, greater job satisfaction and lower turnover intentions because these hospitals support professional nursing practice by ensuring nurse autonomy, control over the practice setting, and strong nurse/ physician relationships. Job satisfaction and turnover rates in the rural and urban nursing units are associated with both nursing unit characteristics and the work environment (Bernholdt & Mark, 2009).

A large body of literature describes burnout as a consequence of organizational factor, a driver of suboptimal well-being and productivity. The dominant approach in this field has been to model simple sets of relationships whereby practice environment factors are hypothesized to influence outcomes through unspecified or untested mechanisms. (Kazanjian, Green, Wong & Reid, 2005). Moreover, work environments associated with high burnout are those that demand high personal adherence to work through restrictions of worker freedom or flexibility, de-emphasize planning and efficiency for the task at hand. Other work environments related to higher levels of burnout are those in which job expectations are vague or ambiguous, where management imposes extensive rules and regulations, and in which support and encouragement for new ideas and procedures are low. Maslach et al. (1996) suggested that a reduced stability on the organizational level is likely to have an impact on burnout. According to Maslach et al. (1996), organizational settings that undermine staff members' autonomy reduce their potential for significant accomplishments and increase their tendency to become cynical and distant from their work. The most commonly cited sources of pressure found in the study where lack of resources followed by work overload, bureaucracy and management.

Typically, burnout is increasingly being recognized as being a serious problem affecting many people, particularly those in the human service industry. Job burnout is a prolonged response to chronic emotional and interpersonal stressors on the job. In the multidimensional, there are three key dimensions to the burnout phenomenon. These include exhaustion, the feeling of cynicism, detachment from the job, a sense of ineffectiveness and lack of accomplishment. According to Maslach, Jackson, & Leiter (1996), burnout differs from occupational stress in that it is specific to work that requires intense involvement.

Burnout has been associated with absenteeism, ineffectiveness, interpersonal conflicts, lower productivity, job dissatisfaction, reduced organizational commitment, and turnover. The emotional exhaustion component of burnout has been associated with stress-related health outcomes. Emotional exhaustion predicts an increased rates of illness, fatigue, substance misuse, depression, anxiety, and irritability (Ducharme et al. 2008). Turnover among human service occupations has adverse implications not only for the organization, but also for the clients. Clients may suffer setbacks such as loss of trust when their clinical services are disrupted by their therapists. Turnover can intensify stress among the remaining therapists whose caseloads increase making the organization to hire temporary staff or newer less-experienced to fill the vacant positions (Ducharme et al.2008). Replacing staff is time-consuming and costly. There are costs associated with recruitment, training, and supporting new employees until their performance reaches a satisfactory level. Turnover causes a disruption in service provision and in the client-provider relationship.

Evidence suggests that a good work environment is an important factor in the recruitment and retention of health workers. Furthermore, the work environment can influence the quality of care and patient safety. As a working definition, an attractive and supportive workplace in this case can be described as an environment that attracts individuals into the health professions, encourages them to remain in the health workforce and enables them to perform effectively.

3 METHODOLOGY

3.1. Research Design

This study uses a quantitative descriptive-correlation to determine the impact of work environment on a quality of care, intent to leave, burnout and job satisfaction among Registered Nurses in Saudi Arabia.

3.2. Sample and Population

After obtaining the IRB approval from the hospitals, a convenience sampling method was used to recruit Registered Nurses working in the different departments in the hospitals. A total of 545 Registered staff nurses in three governmental hospitals in Riyadh Saudi Arabia with more than one-year work experience consented to participate in the study. This sample size is based on a 0.05 margin of error and a 95% confidence interval.

3.3. Instrument

Registered nurses were asked to fill out a form to provide their demographic characteristics such as age, gender, civil status, the highest degree of education, area of assignment and employment status.

3.3.1. Nurse work environment.

Nurse work environment will be assessed by the Practice Environment Scale of the Nursing Work Index (Lake, 2002), which is the most widely reported measure used to gauge the quality of nursing practice environment. The PES-NWI is composed of 31 items that have been organized into five subscales: nurse participation in hospital affairs; nursing foundations for quality of care; nurse managerial ability, leadership, and support for nurses; staffing and resource adequacy; and collegial nurse-physician relations. The potential scores ranged from 1 (strongly disagree) to 4 (strongly agree) on a 4-point Likert scale. Higher scores indicated more agreement that the subscale items were present in the current job. Nurse responses in each item will be aggregated for each subscale to create a hospital-level mean of the subscales. The Cronbach's α coefficient of the PES-NWI in subscales 1 to 5 are 0.87, 0.90, 0.87, 0.91, and 0.85, respectively. Its discriminant validity has been shown in its ability to detect differences in the nurse practice environments of hospitals.

3.3.2. Job Outcomes

The categories that measure nurses' job outcome are job satisfaction, intention to leave, burnout and nurse-assessed quality of care. Job satisfaction is measured by a single item that asked nurses' perception about their satisfaction with their present jobs. The response categories ranged from 1 (very satisfied) to 4 (very dissatisfied) on a Likert scale. Higher scores indicate that nurses are dissatisfied with their current job. Reliability of published tests for a single item of nurse job satisfaction was in the range of 0.70 (Wanous, Reichers, &Hudy, 1997).

Burnout will be measured with the Maslach Burnout Inventory-Human Service Survey (MBI) (Maslach et al.,1996), using 20 items tapping three separate dimensions: emotional exhaustion (8 items), depersonalization (5 items) and personal accomplishment (7 items). Respondents are rated based on the frequencies with which they experience various job-related feelings on a 7-point scale ranging from 0 ('never experienced such a feeling') to 6 ('experience such feelings every day'). High scores on emotional exhaustion and depersonalization and low scores on personal accomplishment scale are considered indicative of burnout. Reliability coefficients are .88 for Emotional Exhaustion (EE), .70 for Depersonalisation (DP), and .83 for Personal Accomplishment (PA).

Regarding "intention to leave," nurses will be asked the following question: "Are you planning to leave your present job in the next year?" "Yes" is graded as 1; "No" is graded as 2. (Stone, Mooney-Kane, Larson, et al. 2007)

The variable of "nurse-assessed quality of care" is measured by a single item that asked nurses' perception about the quality of nursing care delivered to their unit. The response categories ranged from 1 (excellent) to 4 (poor) on a Likert-scale, with higher scores indicating poorer levels of quality. This single-item measure has been used extensively in international work and has established predictive validity (Aiken, Clarke, & Sloane, 2008) with Cronbach's coefficients in the range of 0.92 to 0.94. Single item measurements are useful when the construct is unambiguous (Wanous, Reichers, & Hudy, 1997) or when a holistic impression is informative. Single item measures are used because of their convenience, and are useful when participants are busy or perhaps dismissive of the academic pedantry that multiple item measures manifest (Wanous, Reaches, & Hudy, 1997).

3.4. Data Collection Procedures

After the Institution Review Board (IRB) approval the questionnaires were distributed and explained to the target respondents with a consideration of the inclusion and exclusion criteria. All data collected were coded and entered in the Excel software for the analysis.

3.5. Data Analysis methods

The statistical Program for Social Sciences (SPSS, Version 17) was used for the data analysis. The simple percentage was used to present the demographic profile of the respondents such as age, gender, civil status, educational attainment, the area of assignment and length of hospital experience. Chi-square test was used to establish the relationship among variables of the study.

4.RESULTS

Number of participants (N=545) were female (n=483/545; 88.62%) while males comprised 11% (n=62/545). The majority of the participants were married (n=374/545; 68.62%) while less than one-third (n=171/545; 32%) were single. The majority of the participants were BSN degree holders (n=491/545; 90%). Those with BSN graduates and post graduate studies are 10% (54/545). More than half of the participants have combined tenure of fewer than five years (n=285/545; 52%) while 48% (n= 260/545) have more than five years of tenure. Most of the participants were assigned to various units (n=243/545; 44.5%) while at least 10% (n=±54/545) were assigned either to the Medical-surgical ward, OB-GYN. or intensive care Unit (ICU).

Overall, the results show that nurses in this study perceived having good nursing foundations for providing quality of care. However, there is an evidence that administration is not listening to the employee's demand concerning the inadequacy staffing.

Table 1. Practice environment

4.1. Burnout

The results in Table 2 show that emotional exhaustion is experienced a few times a month (Mean=2.57; SD 1.81); depersonalization a few times a year or less (Mean=1.38; SD 1.56); personal accomplishment a few times a week (Mean=4.39; SD 1.56); and burnout a few times a month (Mean=2.76; SD 1.11).

Table 2. Burnout

4.2. Job satisfaction

Most of the nurses in this study were satisfied with their jobs (combined satisfied and very satisfied: n=468/545; 86%) while only 14% (n=77/545) were either dissatisfied or very dissatisfied.

4.3. Intent to stay

Almost two-thirds (n=348; 64%) expressed no intention to stay with their jobs while more than a third (n=197/545; 36%) has the intention to stay.

4.4. Quality of nursing care

The participants perceived that good quality of nursing care was provided (combined good and excellent: n=480; 88%) as shown in Figure 8 while 11% (n=59/545) perceived that the quality of nursing care was fair.

4.5. Correlations

Bivariate correlations were tested using Spearman rank correlation coefficient to determine the presence of an association between practice environment subscales and as a whole with job satisfaction, intent to stay, quality of nursing care, and burnout as shown in Table 3.

The results show that nurse participation in hospital affairs (rs=-0.44;p<0.001); nursing foundations for quality of care (rs=-0.35;p<0.001); nurse manager ability, leadership, and support (rs=-0.38;p<0.001); staffing and resource adequacy (rs=-0.35;p<0.001); collegial nurse-doctor relations (rs=-0.29;p<0.001); and overall practice environment (rs=-0.44;p<0.001) were negatively associated with job satisfaction. This means that negative issues in a practice environment influence a decline in job satisfaction.

The results also show that nurse participation in hospital affairs (rs=0.25;p<0.001); nursing foundations for quality of care (rs=0.18;p<0.001); nurse manager ability, leadership, and support (rs=0.26;p<0.001); staffing and resource adequacy (rs=0.29;p<0.001); collegial nurse-doctor relations (rs=0.18;p<0.001); and overall practice environment (rs=0.31;p<0.001) were positively associated with intent to stay. This means that healthy or positive practice environment influence the decisions of nurses to stay with their jobs.

The results also show that nurse participation in hospital affairs (rs=-0.22;p<0.001); nursing foundations for quality of care (rs=-0.36;p<0.001); nurse manager ability, leadership, and support (rs=-0.22;p<0.001); staffing and resource adequacy (rs=-0.27;p<0.001); collegial nurse-doctor relations (rs=-0.27;p<0.001); and overall practice environment (rs=-0.33;p<0.001) were negatively associated with quality of nursing care. This means that negative factors or issues in practice environment influence decrease in quality of nursing care.

The results also show that nurse participation in hospital affairs (rs=-0.32;p<0.001); nursing foundations for quality of care (rs=-0.22;p<0.001); nurse manager ability, leadership, and support (rs=-0.31;p<0.001); staffing and resource adequacy (rs=-0.31;p<0.001); collegial nurse-doctor relations (rs=-0.22;p<0.001); and overall practice environment (rs=-0.36;p<0.001)were negatively associated with burnout. This means that negative factors or issues in practice environment influence burnout among nurses.

5. Discussion

The results show a positive relationship between working environment and job satisfaction. The results support that all study participant's agreed that working environment plays important role in attaining nurses job satisfaction and patient's outcome. The findings are consistent with a study (Aiken, Clarke and Sloane, 2008) that shows that job satisfaction is increased in a conducive and good work environment. This means that healthy or positive practice environment influences the decisions of nurses to stay with their jobs. Most of the nurses in this study were satisfied with their jobs while only 14% were either dissatisfied or very dissatisfied. Our findings support that increased in work complexity and stressfulness is associated with higher turnover. Emotional exhaustion was experienced few times a month, depersonalization a few times a year or less personal accomplishment a few times a week with burnout being experienced a few times a month. The results also showed that nurse participation in hospital affairs is a foundation for quality of care, nurse managerial ability, leadership, support staffing and resource adequacy collegial nurse-doctor relations and overall practice environment was positively associated with intent to stay. The result showed that negative factors or issues in practice environment influence burnout among nurses. Maslach et al. (1996) suggested that reduced stability on the organizational level is likely to have an impact on burnout.

6.Conclusions

This research provides additional evidence on the importance of the link between work environment, Job Satisfaction, Intent to Leave, Burnout and Quality of Care. Employees are significantly less likely to leave their job if they perceive a good working environment. Most employees who think of leaving their job perceived their workplace environment to be unhealthy. Work environment has a significant influence on employee job satisfaction. Based on the outcome of this research, it is certain that there is a significant influence of work environment on employee's job satisfactions, nurses' job satisfaction which influence nursing administrations to pay more attention to the work environment. The result indicates that workload, stress, overtime, fatigue, boredom is some of the factors that may increase job dissatisfaction. On the other hand, good working conditions, refreshment & recreation facilities have a positive impact on the job satisfaction. Bad working conditions restrict employees from portraying their capabilities and attaining their full potential. Therefore, for all hospitals, it is prudent to examine the work environment as part of an overall plan to improve nurse satisfactions and patient's outcomes. In most studies it was evident that there is a positive relationship between nursing professional practice environment and job satisfaction.

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