Original Article

Nurses in double trouble: Antecedents

of job burnout in nursing profession
Mirza Naveed Shahzad 1,
Mirza Ashfaq Ahmed 2, Bushra Akram 3
ABSTRACT
Objective: To understand the most prominent factors contributing to job burnout in the nursing profession.
Methods: Mixed method design was used in this study. In the qualitative part of the study, a focus group
discussion approach was used to determine the major factors contributing in nurses’ job burnout. The
quantitative part was conducted by using a questionnaire based on the theme generated in the qualitative
part along with other demographic information. The data was collected from 93 nurses with 90.3% response
rate.
Results: The proposed logistic regression model was able to correctly classify the 96% job burnout cases
using factors mutually agreed in the focus group discussion. All the factors are significantly contributing to
job burnout. However, the unfavourable work environment contributes more to job burnout as compared
to the unfavourable support from family.
Conclusion: unfavourable support of work environment and unfavourable support from family are the main
contributors in the job burnout of nurses. Therefore, an equal improvements in both areas should be made
on the priority basis to retain the happy nurses to deliver excellent healthcare services.
KEYWORDS: Family support, Job burnout, Nursing profession, Working environment.
doi: https://doi.org/10.12669/pjms.35.4.600
How to cite this:
Shahzad MN, Ahmed MA, Akram B. Nurses in double trouble: Antecedents of job burnout in nursing profession. Pak J Med Sci.
2019;35(4):934-939. doi: https://doi.org/10.12669/pjms.35.4.600
This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0),
which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

INTRODUCTION

1. Dr. Mirza Naveed Shahzad,

Superior performance is directly and strongly
Assistant Professor, linked to the psychological well-being of the
Department of Statistics, employees. Happy and satisfied employees remain
2. Dr. Mirza Ashfaq Ahmed,
Assistant Professor,
engaged and put in sincere efforts to reach the
Department of Management Sciences, highest standards of performance. However, in the
3. Dr. Bushra Akram, healthcare services, the employees’ performance
Assistant Professor,
Department of Psychology,
becomes more challenging as the nature of the
1-3: University of Gujrat, job requires a high level of sensitivity and utmost
Gujrat - Pakistan. accuracy where a small mistake can lead to
Correspondence: severe consequences.1 In nursing profession, job
Dr. Mirza Ashfaq Ahmed,
performance is even more crucial because the
Department of Management Sciences, patients’ recovery and safety depend mainly on the
Hafiz Hayat Campus, level of care and services provided by the nurses.2
University of Gujrat,
Office A-108, Al-Farabi Block,
Therefore, job satisfaction and engagement become
Gujrat, Pakistan. the key points of discussion in the recent literature
Email: [email protected] of nursing profession because nursing is the spine
* Received for Publication: February 22, 2019 of healthcare services. Special emphasis is put on
* Accepted for Publication: May 16, 2019 the enhancement of the psychological well-being of

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 Mirza Naveed Shahzad et al.

the nurses for the speedy recovery of the patients. seventeen themes, four were individual themes and
Despite the sensitivity of the profession and all the thirteen others were grouped together into two
efforts made, the increasing rate of job stress and main factors. The main factors were ‘unfavourable
burnout has become a global challenge.3 This is support from family’ and ‘unfavourable support
mainly due to the unique nature of the nursing from the working environment’, with six and seven
profession where work schedules, heavy workloads, themes, respectively.
peers’ behaviour, environmental factors, patient At the second stage of the study, a quantitative
support, organizational characteristics, nature of approach was used in which a questionnaire was
diseases and family pressure directly influence developed on the basis of seventeen initial themes
the job performance.4,5 Therefore, the nurses, as an that were generated via the results of a focus
employees and a family members, are pressurized group. The English language was used in both
to justify both roles simultaneously. These mutually themes discussed in the Focus Group Discussion
incompatible roles along with inconsistent and and questions extracted from themes. The
behavioural demands contribute immensely to the questionnaire comprised two parts. Part 1 included
job burnout rate.6,7 Therefore, job burnout leads to the demographic information and part 2 included
the shortage of nurses all over the world and creates the thirteen statements categorized into two factors.
a huge gap between the needed and the available Four other questions, including choice of the job, the
nurses to cater to the demands of the healthcare
problem faced during the night shift, embarrassing
services.8
feelings of the family due to nursing and satisfaction
The shortage of qualified and well-trained work-
with current salary structure were also included in
force of the healthcare services in Pakistan has
the questionnaire other than the two main factors
been highlighted at various forums to address this
considering their strong impact on job burnout in
serious matter.9-11 Another very important aspect
Pakistani context as indicated by literature review.12
associated with this shortage is the reluctance
The questionnaire was presented to the panel of
of females to join this profession and at the same
time, the growing tendency to leave this profession five psychologists for establishing the content and
due to the aforementioned factors. Considering construct validity of the items. The questionnaire
the facts described, the purpose of this study was given to 103 nurses from the registered private
was to understand the problems associated with hospitals operating in Gujrat city and offering multi-
the nursing profession and to find out the most specialty services. The participants were recruited
prominent factors contributing to the job burnout through proportionate probability sampling
in the nursing profession. technique. The total number of nurses on the
hospital’s payroll was treated as the research frame
METHODS (the research frame consisted of 147 nurses). 103
This study was conducted in two stages with nurses were included on the basis of proportional
mixed method design. At the first stage qualitative allocation (N=103, 70% of the population from each
approach was used in which one focus group was hospital). The inclusion criteria include, worked in
conducted to deeply understand the perception of both morning and night shifts, five years and above
the nursing profession in Pakistan and to determine work experience, and worked at more than one
the major contributors of job burnout associated hospital. Questionnaires were handed to nurses to
with this profession. For this purpose, nine nurses register the responses themselves. The reliability of
were selected. The inclusion criterion was the the factors and questionnaire was tested through
work experience of at least 10 years, working both Cronbach’s alpha.
in morning and night shifts and in at least five All the considered factors were highly reliable13,
different departments. The researcher coordinated as the Cronbach’s alpha coefficient of the two
the focus group discussion and finalized the key factors was 0.916 and 0.871, respectively. The
problem areas related to the nursing profession questionnaire was also proven reliable on the
by following the modified Delphi Method used basis of the value obtained through Cronbach’s
in the healthcare sector. Firstly, initial coding was alpha coefficient of 0.849. With this, confirmatory
done and a total number of 29 statements were factor analysis (CFA) was also employed and
generated. In Round-2, the similar statements were the analysis proved that the questions in the two
grouped together and reduced to 21. In Round-3, considered factors were highly significant and
seventeen initial themes reached consensus. In these those factors followed the recommended goodness

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 Burnout in nursing profession

Table-I: The Model fit indices Goodness of Fit values.

Factors chi/d.f GFI AGFI RMSEA
Model fit indices <3 >0.90 >0.90 <0.08
Unfavourable support from family 0.162 0.926 0.934 0.047
Unfavourable support from working environment 1.827 0.918 0.907 0.069
Chi/d.f: Ratio of Chi-Square with Degree of Freedom, GFI: Goodness of Fit Index,
AGFI: Adjusted Goodness of Fit Index, RMSEA: Root Mean Square Error of Approximation.

of fit indices.14 for CFA, as reported in the Table-I. and only 9% were married. To estimate the risk
Further demographic detail of the sample is factors for job burnout potential confounders were
presented in the Table-II. entered into the logistic regression model including
All of the research ethical standards were followed age, job by selection (by choice vs. by force),
in the course of the study. The Questionnaire was problem in night shift, family feel embarrassment,
withdrawn in case of an emergency and another satisfaction with salary, unfavorable support from
meeting was scheduled. Utmost efforts were made family and unfavorable support from working
to avoid the respondents suffering from extreme environment. All the considered risk factors were
tiredness, long working hours, and an unpleasant statistically significant (p-value ≤ 0.05) in the final
situation caused by their interaction with patients, logistic regression model. The odd ratios with other
visitors or hospital management. Similarly, results of the model are presented in Table-III.
respondents were not persuaded in case of refusal Odd ratio of age indicates, age after 30 year creates
to participate in the study. Consequently, 93 nurses 23% more significant risk to get job burnout as
completed the provided questionnaire with 90.3% compared to below 30 years. The respondents who
response rate. Each questionnaire was assigned a have opted nursing profession by force are more
unique code for traceability and entered in the SPSS likely to have job burnout than those who opted
for analysis purpose. The entered data was screened by choice. The value of the odd ratio for this risk
before applying the statistical analysis. factor is 0.3837 with negative coefficient (-0.958),
that reveals, if nursing profession was selected
RESULTS
by choice then it will decrease the job burnout.
Mixed Method design was used and a Similarly, ‘satisfaction with salary’ is protective
questionnaire was developed on the basis of the against job burnout. The odd ratios of problems
themes finalized in the focus group discussion. Using during night shift and family feeling embarrassed
the questionnaire 103 nurses were interviewed in due to the nursing job are 1.363 and 1.815 with
which ten questionnaires were discarded from the positive coefficients 3.9079 and 6.1411, respectively,
analysis due to incomplete information. The initial therefore the presence of these risk factors, chances
analysis is listed in Table-II, it reflects that more of job burnout in a nurse is increased by the odd
than 80% respondents were above 21 year of age ratio times.

Table-II: Demographic characteristics of the respondents.

Characteristics Category N % Characteristics Category n %
Marital Status Single 83 89.2 Father’s Profession Farmer 16 17.2
Married 8 8.6 Labor 30 32.3
Divorced 2 2.2 Business 20 21.5
Age (Years) Below 20 6 6.6 Teaching 8 8.6
21-25 60 65.9 Free at home 9 9.7
26-35 20 22.0 Shopkeeper 5 5.4
36-40 1 1.1 Late 5 5.4
Above 40 3 3.3 Mother’s Profession housewife 86 92.5
Salaries below 10000 6 6.5 Heath worker 5 5.4
10001-15000 52 55.9 Late 2 2.2
15001-20000 22 23.7 Duty in Ward No 21 22.6
20001 and above 13 14.0 Yes 72 77.4
Total Number of respondents: 93.

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 Mirza Naveed Shahzad et al.

Table-III: Logistic Regression for Nurses Job Burnout.

β SE(β) Wald p-value OR 95% C. I
Lower Upper
Age (X1 ) 0.2080 0.0510 16.6336 0.0000 1.2312 1.1141 1.3606
Job by choice (X2 ) -0.958 0.173 30.6647 0.0005 0.3837 0.2733 0.5385
Problem in night shift (X3 ) 1.363 0.411 10.9979 0.0142 3.9079 1.7462 8.7457
Family feel embarrassment (X4 ) 1.815 0.226 64.4965 0.0136 6.1411 3.9434 9.5636
Satisfaction with salary (X5 ) -0.469 0.112 17.5352 0.0163 0.6256 0.5023 0.7792
US from family (X6 ) 1.364 0.517 6.9606 0.0000 3.9118 1.4200 10.776
US from working environment (X7 ) 1.685 0.431 15.2843 0.0371 5.3925 2.3169 12.550
Constant -1.609 1.867 0.7427 0.0000
Note: Tests are two-tailed, Confidence Interval (C.I), Odd ratio (OR), Unfavourable support (US), age <30=0 , >30=1,
Job joined by choice No =0, Yes=1, Face problem in night shift No =0, Yes=1, Family members feel embarrassment
(due to my nursing job) No =0, Yes=1, Satisfaction with salary No =0, Yes=1.

The factors ‘unfavorable support from family’ Gender-based earning difference also exists in
and ‘unfavourable support of the working the local context and females are discriminated
environment’ have positive association in on earning and job status basis as compared to
developing job burnout as the odd ratios show that males.16 Social Closure Theory argues that males
the nurses who have the ‘unfavorable support from have a better chance of getting good job positions
family’ have 3.9118 times more risk of getting job and higher salaries whereas similar opportunities
burnout as compared to those who have favorable are unavailable to females.17 Therefore, the salary
family support. A similar interpretation is made based discrimination increases the chance of job
for the ‘unfavourable support of the working burnout. Respondents of the study believe that
environment’, however, its impact is relatively earning plays an important role in the longevity
higher in job burnout. Finally, the combine effect of service as their satisfaction with earning has
of all considered factors indicates that model is negative associations with job burnout.18 In
adequately fit and classified the cases with 96% the later stages of their career, they face more
accuracy. financial pressure to survive with less salary due
DISCUSSION to increased family demands and a higher rate of
inflation. Therefore, with the passage of time, the
In Pakistan, nurses are mostly young, in early financial pressure becomes the key contributor to
stage of their careers and agreed to work on bad health and job stress for nurses.
low wage rate. However, on the other side, the Females are unable to perform their job
experienced nurses were dissatisfied with their effectively without the support of their families.
current salary growth and are inflexible to adapt Work-family conflict is more obvious in females
themselves as per the requirements of business- as compared to males.19 because females have to
oriented hospitals. Similarly, when age of the manage the family duties along with their work
nurses corss the thirty years and they are not in requirements. In the healthcare services, the
this profession by choice then the chance of job job requires more concentration, higher level of
burnout increases many times. This issue was accuracy, empathetic behaviour and alertness.
loudly raised in the focus group discussion. Young Theory of Role Strain argues that each role being
age and profession opted unwillingly create performed by individual demands a specific set
another set of problems for nurses to perform their of psychological, emotional and physical energy
duties at night. The male dominant society and resources. However, the individuals are low on
the social set-up do not encourage the females to such energy resources. Allocation of resources to
stay out and perform their jobs at night. Especially one role minimizes the same resources available
for young and unmarried nurses, night shifts are for another role. Therefore, nurses are stuck
highly undesirable as they feel more vulnerable to between maintaining the full-time employment
harassment. Similarly, night shifts are considered and meeting the caring and financial demands
a nightmare by nurses having kids as it directly of their families. Nurses are exhausted due to
affects their family.15 depletion of available resources after performing

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 Burnout in nursing profession

full-time duties and need rest and psychological Acknowledgment: We are grateful to all the
support from family to gain energy for other tasks participants, management of hospitals and faculty
associated with their families. However, failure in members of the Nawaz Sharif Medical College,
gaining the favourable support from the family University of Gujrat, for their facilitations.
results in the stressful impact on the work-family
Conflict of interest: None.
role balance.19-21 Therefore, the favourable support
from family plays a crucial role in the career Grant Support & Financial Disclosures: None.
length and psychological well-being in the nursing
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