A Study to Assess the Extent of Burnout Among Nursing Professionals Working at Various Secondary and Tertiary Health Care Institutions of Jammu and Kashmir

Work Stress is “a particular relationship between the person and the work environment that is appraised by the person as taxing or exceeding his or her resources and endangering his or her well-being” [1]. Burnout refers to the “workers’ reactions to the chronic stress common in occupations involving numerous direct interactions with people” [2]. Work stress and burnout remain significant concerns in nursing, affecting both individuals and organizations. Despite lacking absolute clarity, there is a body of research addressing work stress that spans more than 50 years in the nursing profession. Stress is pervasive in nursing and health care. Burnout is conceptualized as a syndrome characterized by emotional exhaustion, depersonalization, and reduced personal accomplishment. Nursing profession is super stress-filled voyage subjected to tides of human suffering, physical labor, work hours, staffing, and interpersonal relationships that are central to the work nurses do. Contemporary nursing profession is subjected to escalating burnout due to the inefficient staffing policies, increased nurse-patient ratio, Incompetent regulatory bodies, increasing use of technology, continuing rises in health care costs, and turbulence within the work environment. Burnout has implications in general on individual staff and organization; and in particular on patient safety and outcomes. For individuals sustained burnout causes mental, physical and emotional exhaustion which compromises the quality of care given the unit. Hence organizational efficiency is threatened through indicators like absenteeism, turnover, performance deterioration, decreased productivity and job dissatisfaction. These outcomes impede the quality of care and ultimately cost the organization in its own selfish shell of lacking self -care motivation with respect to emotional support, guidance, separating work and professional life, proper staffing policies, arranging for proper remuneration ,hostel facility, transport facility  diet ,exercise programs and renewal of staff members. By working out the essential components of the burnout in nursing profession, toxic work environments can be manipulated into healthy work places and improved patient safety and quality can be realized in letter and spirit. Meta-analysis examined higher levels of burnout associated with lower reported quality and safety. Although the effects are modest in magnitude, their consistency demonstrates the importance of addressing burnout in order to improve many aspects of patient safety [3]. 

The super specialty hospital where the researchers of the current study practice nursing barely meets minimum standards for professional nursing staffing and nurse-patient ratio is as high as 1:32 in all general wards. Moreover, there appears to be little chance of improving the nurse-patient ratio the near future. As a result, all of the nurses in the super specialty hospital have been working at least 48 hours per week throughout their tenure; many have been working several double shifts and putting in many overtime hours. Morale is deteriorating, and the staff has been complaining since last decade. Most of the staff are feeling burned out and demotivated. Staff nurses feel a responsibility to the patients, community, and organization and have continued to work the extra hours, but we are exhausted as well. Staff nurses feel conflicting loyalties to the unit, patients, supervisor, and themselves. Burnout has taken a negative toll on our health, professional hale pomp and organizational effectiveness in terms of decreased patient satisfaction, decreased patient safety and reduced quality of care outcomes. Morale of the staff is rapidly plummeting, and relationships are becoming increasingly competitive rather than cooperative in reaction to the information passed through hospital grapevine. 

Research has demonstrated that Burnout is a significant predictor of the physical consequences like hypercholesterolemia, type 2 diabetes, coronary heart disease, and hospitalization due to cardiovascular disorder, musculoskeletal pain, changes in pain experiences, prolonged fatigue, headaches, gastrointestinal issues, respiratory problems, severe injuries and mortality below the age of 45 years. The psychological effects are insomnia, depressive symptoms, use of psychotropic and antidepressant medications, hospitalization for mental disorders and psychological ill-health symptoms. Job dissatisfaction, absenteeism, new disability pension, job demands, job resources and presenteeism identified as professional outcomes Salvagioni [4]. Role-related stressors are significantly related to all burnout dimensions. The results of regression analysis has revealed that role overload and role insufficient are significant predictors of emotional exhaustion. Role overload, role insufficient and role ambiguity are found to be significant predictors of depersonalization. The significant predictors of personal accomplishment are role insufficient, role ambiguity and role boundary [5]. The odds of intent to leave are approximately 13 times greater for those with above-median emotional exhaustion, and more than 6 times lower for those with above-median sense of personal accomplishment. Emotional exhaustion and low sense of personal accomplishment are key factors influencing emergency nurses' intent to leave [6].   

Numerous recent studies have explored burnout among nursing personnel in many countries reflecting the effects of stress and burnout among nurses on patient outcomes in relation to increased mortality, failure to rescue and patient dissatisfaction. Based on current empirical evidence on burnout in nursing, there is difficulty in making recommendations regarding how to enhance patient safety. Practice implications are also unclear regarding the effects of work stress on nursing staff. 

Thus, the present research problem was taken to generate evidence based practice for the healthcare organizations that can no longer ignore findings that burnout is affecting patients and staff and inculcate a realization for action to alter unhealthy situations through interventions to mitigate work stress. This study will serve as a problem-solving approach to burnout in clinical practice and integrate the most relevant evidence with clinical expertise and patient preferences and values, to mitigate burnout through professional and informed decision making. 

Qedair Jumanah et al. [7] conducted a single-institution cross-sectional study Prevalence and factors associated with burnout among nurses in Jeddah. Out of the 1300 nurses working in KAMC-JD, 250 completed the survey. Burnout had been detected in 112 nurses (44.8%). Out of the 250 nurses, 26.4% were found to be at a high risk of burnout, which means they have high or moderate scores of Emotional Exhaustion and Depersonalisation. The majority of the participants had high burnout levels in each of the burnout components, and 99.6% of them scored high in at least one of the three dimensions. Level of burnout was significantly correlated to certain demographic factors which were the nationality (p-value = 0.01) and working unit (p-value = 0.02). On the other hand, there was no significant association between burnout and age, gender, or marital status. 

Salyers et al [3] conducted a meta-analysis to examine the relationship between professional burnout and quality and safety in healthcare. Investigators identified 82 studies of burnout and quality or safety. Most studies were cross-sectional and measured safety and quality by self-report. In the pooled analysis, higher levels of burnout were associated with lower reported quality and safety. These relationships were present across a range of outcomes and study types. Although the effects were modest in magnitude, their consistency demonstrates the importance of addressing burnout in order to improve many aspects of patient safety.

Brand et al [10] conducted a study to find associations between satisfaction with life, burnout-related emotional and physical exhaustion, and sleep complaints. Emotional and physical exhaustion was related to sleep complaints, whereas sleep complaints were not related to depressive symptoms and pessimism. Satisfaction with life was related to low sleep complaints, though mediated via low emotional and physical exhaustion, and low pessimism.

A Non-probability sampling technique was used in this study to assess the level of burnout among nursing professionals working at secondary and tertiary health care levels in Jammu and Kashmir. Nursing professionals of Jammu & Kashmir were contacted through an online google survey form via whatsapp groups and other contacts. These nursing professionals working in SKIMS Soura, GMC srinagar, GMC Anantnag, GMC Baramulla, GMC Jammu, SDH Tangmarg, SDH Sopore, SDH pulwama. The Maslach Burnout Inventory-Human Service Survey (MBI-HSS; Maslach & Jackson, 1996) was used in order to measure the burnout among nursing professionals of Kashmir in the present study. The Maslach Burnout Inventory-Human Service Survey consists of 22 statements describing the feelings an individual might have as a result of being over-stressed or burnout. Respondents were asked to indicate the frequency at which they experienced these feelings by selecting from six response choices that ranged from 0 (Never) to 6 (Everyday). The Maslach Burnout Inventory-Human Service Survey measures burnout on three subscales in the form of following sections: 

Section A: Depressive Anxiety Syndrome subscale or Emotional exhaustion-A feeling of being unable to give of oneself at a psychological level due to a depletion of emotional resources, physical symptoms, troubled sleep, chronic fatigue etc. Here a total score of 17 or less depicted low-level burnout, a score between 18-29 depicted moderate level burnout and a score of more than 30 showed high-level burnout. 

Section B: Depersonalization (DP): The development of impersonal or dehumanization, cynical feelings toward recipients of one’s services. This subscale was scored as a respondent having a score of 5 of less have low burnout, a score in between 6-11 depicted moderate level burnout and a score of 12 or above showed high level burnout. 

Section C: Personal Accomplishment (PA): 

A diminished feeling of competence and achievement in working with others. A high score in the first two sections and a low score in the last section may indicate burnout. This subscale was scored as high-level burnout if a respondent scored 33 or less, moderate level burnout if respondent scored in between 34-39 both values inclusive and low-level burnout if a respondent scored above 40 score.

Analysis and interpretation was done in accordance with the objectives laid down for the study. The purpose of analysis is to make data meaningful and interpretable. This data should be available as a valued piece of information for other researchers to come. 

The data presented in (Table 1) depicted that 61.43% (129) were female and 38.57% (81) were males. It also represented that a maximum 82.86% (174) were in the age group of (21-30) years, followed by 17.71% (33) in the age group of 31-50 and just 1.43% (03) in the age group of 41-50 years. The table also showed that a maximum 91.43% (192) were having 1-10 years of working experience followed by 7.15% (15) were having (11-20) years of working experience followed by just 1.43% (3) who were having 21-30 years of working experience. The table also represented that majority of the study subjects 75.71% (159) were having BSc Nursing as their educational qualification, followed by 18.58% (39) having MSc Nursing as educational qualification, followed by just 5.71% (12) having Diploma in General Nursing and midwifery. 

N=210 

Table 1: Frequency and percentage distribution of study subjects as per their demographic variables.

The data presented in the (Table 2) represented that the majority of the study subjects were suffering from burnout in the secondary and tertiary health care institutions of Jammu and Kashmir. The data revealed that 43.34% (91) were having high level burnout, followed by 30% (63) having moderate level burnout and just 26.66% (56) were having low level burnout in the domain of depressive and anxiety syndomes. The table also depicted that majority 75.24% (158) were having high level burnout, followed by 13.80% (29) having low level burnout and just 10.96% (23) were having moderate level burnout in the subsection of burnout inventory named as depersonalisation. The table also revealed that maximum 45.72% (96) had low personal achievement (satisfaction) while as 34.28% (42) were having low burnout level and thus were having good personal achievement or satisfaction with job while as 20% (42) were having moderate level burnout in the domain of personal achievement subscale. 

N=210 

Table 2: Burnout levels by all three subscales of Maslach Burnout Inventory scoring. 

In order to analyze the association of burnout Levels and of their subscales with selected demographic null hypothesis was framed as 

H₀₁: there is no significant association between burnout levels (depressive anxiety syndrome) and selected demographic variables (age, gender, years of working experience and educational qualification) at 0.05 level of significance. 

H₀₂: there is no significant association between burnout levels (depersonalisation) and selected demographic variables (age, gender, years of working experience and educational qualification) at 0.05 level of significance. 

H₀₃: there is no significant association between burnout levels (personal achievement) and selected demographic variables (age, gender, years of working experience and educational qualification) at 0.05 level of significance. 

In the above (Table 3) we are able to see that chi square calculated  is more than chi square tabulated with p value given against each in the variables pertaining to age (p=0.009), years of working experience (p=0.01), and educational qualification (p=0.00) except gender (p=0.085).

So, we reject the null hypothesis H₀₁ in terms of age, years of working experience, and educational qualification and fail to reject the null hypothesis in terms of gender.

Thus, the study has shown that there is significant association between burnout levels (depressive anxiety syndrome) with selected demographic variables [age (p=0.009), years of working experience (p=0.01), and educational qualification (p=0.00)]. 

N=210 

Table 3: Association of Burnout level (Depressive Anxiety Syndrome) with selected demographic variables.

In the above (Table 4) we are able to see that chi square calculated is more than chi square tabulated with p value given against each in the variables pertaining to educational qualification (p=0.02) except gender (p=0.466), age (p=0.187), years of working experience (p=0.166). 

So, we reject the null hypothesis H₀₂ in terms of educational qualification and fail to reject the null hypothesis in terms of gender, age, years of working experience. 

Thus, the study has shown that there is significant association between burnout levels (depersonalisation) with selected demographic variables [educational qualification (p=0.02)]. 

N=210 

Table 4: Association of Burnout level (Loss of Empathy) with selected demographic variables:

In the above (Table 5) we are able to see that chi square calculated is more than chi square tabulated with p value given against each in the variables pertaining to years of working experience (p=0.005), and educational qualification (p=0.01) except gender (p=0.067), age (p=0.101). 

So, we reject the null hypothesis H₀₃ in terms of years of working experience, and educational qualification and fail to reject the null hypothesis in terms of gender and age. 

Thus, the study has shown that there is significant association between burnout levels (personal achievement) with selected demographic variables [years of working experience (p=0.005), and educational qualification (p=0.01)]. 

N=210 

Table 5: Association of Burnout level (Personal Achievement) with selected demographic variables:

The key findings of the study revealed that 61.43% (129) were female and 38.57% (81) were males. It also represented that a maximum 82.86% (174) were in the age group of (21-30) years, followed by 17.71% (33) in the age group of 31-50 and just 1.43% (03) in the age group of 41-50 years. The table also showed that a maximum 91.43% (192) were having 1-10 years of working experience followed by 7.15% (15) were having (11-20) years of working experience followed by just 1.43% (3) who were having 21-30 years of working experience. The table also represented that majority of the study subjects 75.71% (159) were having BSc Nursing as their educational qualification, followed by 18.58% (39) having MSc Nursing as educational qualification, followed by just 5.71% (12) having Diploma in General Nursing and midwifery. 

The study has shown that there is significant association between burnout levels (depressive anxiety syndrome)  with selected demographic variables [age (p=0.009), years of working experience (p=0.01), and educational qualification (p=0.00)].The study has shown that there is significant association between burnout levels (depersonalisation)  with selected demographic variables [educational qualification (p=0.02)].Moreover the study has depicted that there is significant association between burnout levels (personal achievement)  with selected demographic variables [years of working experience (p=0.005), and educational qualification (p=0.01)]. 

Mudallal RH, Othman WM, Al Hassan NF [11] conducted a study on Nurses' Burnout: The Influence of Leader Empowering Behaviors, Work Conditions, and Demographic Traitstotal of 407 registered nurses participated in the study. Approximately 57% (n = 233) of the participants were female. The mean age of the nurses was 29.78 years (SD = 6.51) and ranged from 22 to 53 years. The nurses had approximately 7.22 mean years (SD = 6.20) of experience, and approximately half of the nurses were married (n = 216, 53.07%). Most of the nurses in the study (n = 373, 91.65%) had a baccalaureate degree. 

The study also represented that the majority of the study subjects were suffering from burnout in the secondary and tertiary health care institutions of Jammu and Kashmir. The data revealed that 43.34% (91) were having high level burnout, followed by 30% (63) having moderate level burnout and just 26.66% (56) were having low level burnout in the domain of depressive and anxiety syndromes. The table also depicted that the majority 75.24% (158) were having high level burnout, followed by 13.80% (29) having low level burnout and just 10.96% (23) were having moderate level burnout in the subsection of burnout inventory named as depersonalisation. The table also revealed that maximum 45.72% (96) had low personal achievement (satisfaction) while as 34.28% (42) were having low burnout level and thus were having good personal achievement or satisfaction with job while as 20% (42) were having moderate level burnout in the domain of personal achievement subscale. 

The study has shown that there is significant association between burnout levels (depressive anxiety syndrome) with selected demographic variables [age (p=0.009), years of working experience (p=0.01), and educational qualification (p=0.00)]. The study has shown that there is significant association between burnout levels (depersonalisation) with selected demographic variables [educational qualification (p=0.02)]. The study has shown that there is significant association between burnout levels (personal achievement) with selected demographic variables [years of working experience (p=0.005), and educational qualification (p=0.01)]. 

The findings of our study are supported by Qedair Jumanah et al.  [7] conducted a single-institution cross-sectional study Prevalence and factors associated with burnout among nurses in Jeddah.Out of the 1300 nurses working in KAMC-JD, 250 completed the survey. Burnout had been detected in 112 nurses (44.8%). Out of the 250 nurses, 26.4% were found to be at a high risk of burnout, which means they have high or moderate scores of EE and DP, with low ones in PA. The majority of the participants had high burnout levels in each of burnout components, and 99.6% of them scored high in at least one of the three dimensions. Level of burnout was significantly correlated to certain demographic factors which were the nationality (p-value = 0.01) and working unit (p-value = 0.02). On the other hand, there was no significant association between burnout and age, gender, or marital status. 

The findings are also supported by Haifa Al-Turki et al. [9] conducted a study to assess the prevalence of Burnout Syndrome among a multinational nursing workforce in Saudi Arabia. Forty-five percent (89) had high Emotional Exhaustion (EE) and 28.9% (57) had moderate suffering with Emotional Exhaustion. Staff who were on the job for longer duration had a lesser frequency of EE (P ≤ 0.001). The frequency of depersonalization (DP) was 83 (42%) and was graded as high and 61 (30.8%) were moderately affected. Personal accomplishment (PA) was moderate to low in the majority of the nurses (71.5%).

Burnout and stress is a proven factor through the evidence base among nursing professionals of Kashmir. More studies are desirable to move beyond descriptive design and study the relationship between burnout and patient outcomes in our settings. By reducing the stressful nature of the nursing professional’s work, nursing professionals could be more satisfied in their positions and involving them in decision-making regarding their own profession and letting them to lead and administer their own profession by working at higher posts will help. The working conditions and the environment should be viable and favorable for nursing professionals and should not be made to work like laborers all day and should have some time for refreshments in between. They must have a proper place in every working unit for fulfilling human and professional needs and requirements respectively. There must be place for workplace empowerment of nursing professionals and policy makers should involve nursing leaders before making any decision. The professionals should be asked to give their suggestions before coming to any conclusion regarding policy matters. This appealing satisfaction, in turn, could lead to enhancing those professional behaviors that improve the performances of nursing professionals; which will eventually improve patient safety and quality care outcomes. Last but not least, improved working conditions for nursing professionals might make the nursing profession more appealing and reflect bright and straight on professional visibility.

The study has revealed that burnout is more prevalent in nursing officers of Kashmir and the main reason for this is improper nurse patient ratio and work overload of the nursing professionals being highly educated and having less avenues of career progression. The study has not considered variables such as nurse patient ratio, career progression and workload in the study but were provided as additional input by the respondents.

The study was conducted on a smaller sample and only the areas and subsections of burnout were measured thus needs to be replicated on a larger scale in Jammu and Kashmir. The same need to be assessed along with coping strategies, fatigue and Resilience of nursing officers

Stress and burnout are concepts that are highly relevant to the workforce in general and nursing in particular. Despite this relevance, the effects of burnout on patient outcomes, patient safety, and quality care are not well defined by evidence. Hence in this respect, it is inevitable to move beyond descriptive design and acute care settings to study this problem with subjects as nursing professionals.

• SKIMS Soura= Sher e Kashmir Institute of Medical Sciences
• GMC= Government Medical College
• SDH= Sub District Hospital
• MBI-HSS= Maslach Burnout Inventory-Human Service Survey
• KAMC-JD= King Abdullah Medical City Jeddah
• EE= Emotional Exhaustion
• DP= Depersonalization
• PA= Personal Accomplishment

The researchers are working as independent nursing researchers in addition to their own work for higher contribution to the profession. A Google form was developed by one of the researchers and the same was forwarded in whatsapp and telegram groups. The form itself contained information and purpose regarding the project, consent to be the participant. The form was devised in such a manner that no contact details were collected from the participants. They were given the choice to take their time to fill and submit the form. The submitted forms got synced with google sheets/drive automatically.

The authors have provided consent to be the corresponding author and are in unison to get the article published.

Online forms were used to collect the data and google forms were used for same.

None

Self

Each author has contributed equally in the study on parallel basis. The authors have contributed in each and every section equally.

 Participants of the study are acknowledged for their time, patience and response.

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