Burnout and work-family con flict among nurses during the preparation for reevaluation of a grade A tertiary hospital

Ya-Xuan Fang

School of Health Sciences,Wuhan University,Wuhan,Hubei 430071,China

Burnout and work-family con flict among nurses during the preparation for reevaluation of a grade A tertiary hospital

Ya-Xuan Fang

School of Health Sciences,Wuhan University,Wuhan,Hubei 430071,China

a r t i c l e i n f o

Article history:

Hospital grade reevaluation

Nurse

Burnout

Work-family con flict

Objectives:To gain a better understanding of nurse burnout and work-family con flict for nurses and to help the hospital prepare for hospital grade reevaluation.

Methods:This study is a cross-sectional study,and 95 nurses participated.The questionnaires included MBI and Carlson work-family con flict questionnaires,and the data were analyzed using SPSS 17.

Results:A total of 71.6%of nurses worked over 8 h per day during the last two months before the reevaluation.The total score of burnout of nurses was 66.84±12.60,and the proportion of heavy work burnout was 44.2%.The personal accomplishment takes the heaviest portion(80.0%).The total score of work-family con flict is 55.19±9.27.The scores of work-to-family con flict are all higher than that of family-to-work con flict.The time dimension had the highest score.

Conclusions:During the preparation period,nurses suffered from a heavy workload and intense job burnout,and many aspects of work-family con flict existed.

©2017 Shanxi Medical Periodical Press.Publishing services by Elsevier B.V.This is an open access article under the CC BY-NC-ND license(http://creativecommons.org/licenses/by-nc-nd/4.0/).

1.Introduction

In China,hospital grade reevaluation,the reassessment of a grade A tertiary hospital every four years,ensures that tertiary hospitals maintain high standards of operation.If a grade A tertiary hospitalfails in the reevaluation,it loses the title of“grade A tertiary hospital”and is required to reform its institution and then apply for a new hospital grade evaluation.Hospital grade reevaluation assesses the comprehensive hospitalsystem of“hardware”(environment,facility,documentation)and“software”(structure, management,clinical pathway,regulation and implementation). Whether the tertiary hospital can successfully pass,the reevaluation in fluences the tertiary hospitals throughout operation. Additionally,the reputation of all medical workers are closely affected.Because nurses manage the clinical department of the environment,equipmentand patientcare,they mustcarry a heavy burden that other medical workers do not during the hospital grade reevaluation.Thus,nurses often have to prolong their workday to complete their own nursing work,organize documents from previous years,clean the clinical environment and restore supplementary medical goods,which causes hospital grade reevaluation to be a stressful event for nurses.During the preparation of the hospital grade reevaluation,nurses'working conditions and work attitudes in fluence their productivity and therefore need to be taken seriously.Studies have shown that the overall level of nurses'mental health during preparation of the hospital grade assessment is worse than the national norm.1The purpose of this study was to determine whether job burnout and work-family con flicts among nurses are higher than normal during the hospital grade reevaluation of tertiary hospitals.

2.Literature review

Burnout was de fi ned in the 1970s in reference to a certain reaction of human service workers,such as medical workers,to interpersonal stressors from work,and emotional exhaustion, depersonalization and senses ofa lack ofpersonalaccomplishment, which interfere with workers'moods,attitudes,self-ef fi cacy and con fi dence.2Burnout is a long-term result from the accumulation ofexcessive job demands,personalinabilities,lack ofresources and social support,excessive responsibilities,and con flicts of role boundaries.2,3Burnout can affect nurses'job satisfaction,workfamily con flicts,personal health,and turnover rate,and it can even affectinstitutionalcosts.4Many researchers allover the world have studied nurses burnout and noted that nurses are vulnerable for burnout.For example,a survey in Beijing,China,with 128nurses in a teaching hospital similar to the hospital in this study showed that nurses suffered a moderate levelof burnout,younger nurses suffered more than older nurses,and family pressure from being the only child or being married were factors of burnout.4

Work-family con flicts have been widely discussed based on its de fi nitions and mainly refer to con flicts caused by con flicts of role, time and demand.5The factors for work-family con flicts and burnout overlap.Studies support that nurses are constantly in work-family con flicts and face the dilemma of balancing work and family lives.Chinese research has shown that nurses in the emergency department,pediatric department and intensive care unit had more work-family con flicts than nurses in other department; hospital nurses suffered more work-family con flicts than community nurses.5Moreover,work-family con flicts willin fluence nurses' career development,job satisfaction,turnover rates,commitment to organizations and even psychological problems.5,6Fortunately, studies have revealed thatcontrolling stress can mitigate the effects of work-family con flicts.Individual emotional intelligence plays a criticalrole in mediating work-family con flicts.6

The preparation of hospital grade reevaluation lasted for about half a year.Nurses were overloaded with lots of extra work in addition to patient care,and they worked overtime until the hospitalgrade reevaluation ended.Nurses were in the intermediate or higher levels engaged in the work of hospital grade reevaluation, even in the operating room,7and the underlying reasons also indicated that nurses in more criticaland stressfulwork are higher engaged in than in less valuable work.8In the lastmonth before the hospital grade reevaluation,nurses and head nurses all suffered from such work stress for a prolonged period and experienced burnout.At the same time,work-family con flicts act as another stressor.Nurse managers,who want to change the situation,have recognized nurses who leave their positions during the preparation of hospital grade reevaluation.To prevent bad outcomes,protect nurses,and promote a reasonable preparation process of hospital grade reevaluation,we should fi rst understand how nurses feel during this stage,including serious problems that nurses suffered. This study is a beginning ofdeveloping an understanding ofnurses' feelings.

3.Methods

3.1.Sample and methods

This study is a cross-sectional survey to collect burnout and work-family con flicts status among nurses from three departments of cardiology,orthopedics and oncology in the last month prior to the hospital grade reevaluation.The three departments had different levels of importance in the hospital grade reevaluation; however,because they were all under the same process in the nursing department,the workload across the three departments one month before the reevaluation was identical.All the nurses who were willing to participate in this study were welcome.A total of100 questionnaires were distributed,and 95 valid questionnaires were collected.Among them,29 were from the cardiology department,26 were from the orthopedic department,and 40 were from the oncology department.

3.2.Instruments

(1)Demographic Information Questionnaire,including the clinicaldepartments,age,sex,education level,maritalstatus, length of service,type of employment,work title,monthly income,and“times of night shifts per week”and“average daily working hours”.

(2)Carlson(2000)and other research work-family con flict (work-family con flict)scale.9The Chinese version has been fi nalized,revised and implemented,and it proved to have good reliability and validity.10The scale consists of 18 items: items 1e6 were for the time dimension,7e12 for the pressure dimension,and 13e18 for the behavior dimension;the Cronbach alphas for each dimension are 0.736,0.848,and 0.757,respectively.10

(3)MBI(Maslach Burnout Inventory),MBIhas been widely used in China and developed into more than one version;many researchers have proved its reliability and validity.MBIused in this study has been published and has three subscales measuring three dimensions of job burnout:Emotional Exhaustion,Depersonalization and Lack of Personal Accomplishment;the Cronbach alphas for each dimension are 0.8577,0.7607,and 0.7571,respectively.11All entries were scored on a scale of0e6,and scores were calculated for each dimension by summation.There are 8 models or stages of burnout,but the clear division of mild,moderate and severe of the total score hasn't been decided by researchers.12However when the three dimensions all get high scores,it should be considered the highest degree of job burnout.

3.3.Participant recruitment and data collection

After receiving permission from each clinical department,the participants were informed through the head nurses one and a half months before the hospitalgrade reevaluation,and the researcher provided oral informed consent with guarantee of autonomy and anonymity before the participants agreed to answer the questionnaire.Then,the questionnaires were sent out by the head nurses when the nurses were busy preparing for reevaluation and had been working in such higher-than-normalburdened conditions for about three months.Each clinicaldepartment differed in workload, depending on the managers'and head nurses'abilities.The number ofquestionnaires sentoutto each clinicaldepartmentwas based on the totalnumber ofnurses ofeach clinicaldepartment.A two-week time frame was assigned for data collection because of the“very busy”condition,so thatthe nurses could settheir time to fi nish the questionnaires in such high-demand condition.Then,the data was sorted and calculated.There were 5 questionnaires not answered properly so they were not included in data analysis.

3.4.Data analysis

The demographic data in this study were analyzed using descriptive analysis,SPSS 17 software,to count the numbers and calculate percentages.The scores of questionnaires have been calculated according to each dimension and the severe criteria and then analyzed in the software using descriptive data analysis by means,percentage and standard deviation.Correlations have been analyzed as well to show the correlations among demographic data,job burnout and work-family con flict.

4.Results

4.1.Participants

Among the 95 nurses surveyed,5.3%were male nurses,young nurses under the age of32 accounted for 85.3%,66.3%ofnurses had a bachelor degree,and 81.1%were married nurses.A total of 77 (81.1%)were contractnurses.Nurses who had served for more than 5 years accounted for 43.2%,nurses titled with“senior nurses”or higher titles were up to 77.9%,26.3%nurses had higher than RMB6000 monthly income,and nurses with an average of 3 night shifts per week accounted for 28.4%.The average daily working hours of more than 8 h accounted for 71.6%.Additionaldetails are shown in Table 1.

4.2.Nurses burnout score

The total score of job burnout was 66.84±12.60 and the severest burnout nurses who got severe problems in all three dimensions took 44.2%.Among emotionalexhaustion(28.98±7.99), depersonalization(10.68±5.42)and lack of personal accomplishment(27.18±6.72),lack of personal accomplishment had the highest severity percentage(80.0%),followed by emotional exhaustion,depersonalization(Table 2).

4.3.Nurses'work-family con flicts score

Nurses'work-family con flicts scores during preparation of hospitalgrade reevaluation are shown in Table 3.The overallscore ofwork-family con flicts was 55.19±9.27,and among the totalscore and scores ofdimensions oftime,stress and behavior,the scores of work-to-family con flict were higher than the family-to-workcon flict scores,and time dimension received the highest score in both work-to-family and family-to-work con flicts.

Table 1 Demographic data.(n¼95).

Table 2 Totalscore of nurses burnout and the scores of moderate to severe cases.

Table 3 Mean score of each dimension and direction of nurses'work-family con flicts.

The Pearson correlation among demographic data,job burnout and work-family con flict were analyzed.The data showed that correlations existed between clinicaldepartment and average daily actualworking hours(0.239,P<0.05),years ofservice and workto-family con flict(0.267,P<0.05),job title and average daily actual working hours(0.282,P<0.05),job title and depersonalization (0.220,P<0.05),education and stress con flict(0.210,P<0.05), maritalstatus and time con flict(0.245,P<0.05),years of service and time con flict(0.205,P<0.05),average daily actual working hours and family-to-work con flict(0.229,P<0.05).Emotional exhaustion was correlated with age(0.253,P<0.05),types of employment(0.288,P<0.05),average daily actualworking hours (0.346,P<0.05),and years ofservice(0.236,P<0.05).Correlations also existed within dimensions of job burnout and the total job burnout,but emotional exhaustion and lack of personal accomplishment were not proven to be correlated in this study.Department was an important predictor of work-family con flict,as it was correlated with family-to-work con flict(0.249,P<0.05),time con flict(0.266,P<0.05),behavioral con flict(0.247,P<0.05),and work-family con flict(0.250,P<0.05).Among the dimensions and totalscores ofwork-family con flict,correlations were allsigni fi cant at the 0.05 level.Correlations between job burnout and workfamily con flicts were also signi fi cant,such as work-to-family conflict correlating with emotional exhaustion(0.515,P<0.05), depersonalization(0.315,P<0.05),lack of personal accomplishment(0.211,P<0.05)and total job burnout(0.349,P<0.05), family-to-work con flict was also correlated with all job burnout dimensions and total job burnout,as every dimension of workfamily con flict.Other detailed data are shown in Tables 4 and 5.

5.Discussion

The data showed that of the nurses in this tertiary hospital, 94.7%were female nurses,85.3%were young nurses under the age of 32,66.3%nurses have bachelor's degrees,which indicated that the overall quality and skill level of the nurses in the third-gradetertiary hospitals were higher despite years of experience.On the other hand,the percentage of married nurses was high which may lead to greater work-family con flicts,and nurses'wage levelwas at a normallevelin China even during their busy time in the year.The nurses worked more than 8 h per day during the preparation of hospital grade reevaluation and took frequent night shifts,which may affect job burnout and work-family con flicts outcomes among nurses.Compared to the norm of MBI for nurses in Hangzhou, China,the scores of job burnout of nurses prepared for hospital grade reevaluation are higher than the norm of MBI,and are higher than the overallnurses'job burnout score in other parts of China.13Compared to former study of nurses in usualworking condition in Beijing,nurses in the current study4before hospital grade reevaluation suffered higher burnout,and the emotional exhaustion 28.98± 7.99 compared to 22.75± 11.25,depersonalization 10.68±5.42 compared to 4.17±4.34,lack of personal accomplishment 27.18±6.72 compared to 33.90±8.9.So that this study proved that nurses preparing for hospitalgrade reevaluation in the tertiary hospitals were in a serious state of emotional exhaustion and depersonalization.Because lack ofpersonalaccomplishment is related to emotional exhaustion and depersonalization,the overburdened nurses with time-consuming tri fle work of arranging documents felt worn out.

Table 4 Pearson correlation within job burnout.

Table 5 Pearson correlation within work-family con flict.

It is the same for the work-family con flicts:nurses during the preparation for hospitalgrade reevaluation obtained higher scores than normal than those presented in other studies.A study10in Guangzhou showed nurses'overall average score of work-family con flicts was 50.71±9.05,Li's research14showed that overall average score of nurses'work-family con flicts was 53.31±11.94, while the results of the current study reached a higher score of 55.19±9.27.The bi-directional characteristic of work-family conflicts explained why the time dimension received the highest score over other dimensions in both work-to-family and family-to-work con flicts in this study.Meanwhile,the allocation of time is an important reason for work-family con flicts.

The higher score of job burnout and work-family con flicts of nurses and head nurses in this study is considered highly related to the stress eventofhospitalgrade reevaluation.Severalnurses could not stand the heavy workload and resigned.However,this is affected not only by the stress event but also by the inadequate workload allocation,shortage of staff in support crew and unorganized storage of working documents.For example,nurses in different clinical departments had different standards of inputting data into hospital information system although the system is the same,because the administration department has not successfully launched standards for the whole hospital,which resulted in disorganized documents,and nurses are the workers who took the additional workload for their own clinical department.These organizational and management masses were transferred to nurses.The employment types have not successfully represented nurses'quali fi cations and efforts,because employment types were decided at the beginning(a nurse was employed and hardly changed positions,which causes some inequality for those working many years but with lower educational levels).Fortunately,the hospitalapplied a performance evaluation,which can decrease the inequality.

The hospitalgrade reevaluation was a stress event with positive in fluences on a third-grade tertiary hospital.According to the standards of hospital grade reevaluation,the hospital could determine its de fi ciencies and implement promotion strategies that can continuously work.Major improvements can be achieved,and the hospitalcan work more ef fi cientand organized,which willincrease the hospital's reputation for patients and attract health workers.

Experts have proposed some approaches to prevent burnout, including constructing internal strength,capability,external support,and reinforcement.2The common strategies that can be used to prevent burnout and work-family con flicts are active coping strategies,cooperation,management practical period,improved staf fi ng and environment.Good leadership could be a supplementary strategy for consideration.According to the results ofthis study,the proposed suggestions for management and nurses in the hospital grade reevaluation period are(1)provide adequate allocated safe working hours and work tasks to improve ef fi ciency to reduce overtime working;(2)make a top-down plan as soon as possible to reduce times ofrework;(3)establish a uni fi ed standard for day-to-day work and do well in information management, equipment management and environmental management;(4) arrange special management personnel instead of nurses for themanagement of departments to reduce nurses'extra workload;(5) provide special circumstances and special treatment and improve wages or provide bonuses for nurses;and(6)provide health and psychologicalguidance,clarify meanings of the work,head nurses or other leaders should help nurses to address work-family problems or provide good advice.

6.Conclusions

During the preparation of the hospital grade reevaluation, nurses'workload was heavy,nurses felt job burnout strongly,and many aspects of work-family con flict existed,which called for reasonable arrangements and various supports from hospitals, departments and leaders.

6.1.Signi fi cance

This is a lesson of maintaining standardized Chinese hospitals, which is not the same as it is in western countries.However,the situations maybe encountered in other parts of the world.After all many nurses suffer from similar stressfulsituations and take heavy workloads as Chinese nurses around the world.The well-designed hospital system and strengthened management effectiveness are preconditions for an ef fi cient hospitaland can prevent masses and rework.Meanwhile,uncertainty should be avoided in hospital management.Moreover,incentive mechanism,staff storage and department design should be welldesigned and balanced.

6.2.Limitation

This study was only performed a cross-sectional survey about burnout and work-family con flicts among nurses during preparation of hospital grade reevaluation and discussed the differences with the norm or with levels in other research.It did not include a pre-and post-comparison,which resulted in a weak strength of comparison of burnout and work-family con flicts among nurses. Although the levelofburnout and work-family con flicts were high, we could not understand exactly the changes contributed by the work stress from hospital grade reevaluation.One more consideration is that head nurses sent out the questionnaires,so that some personal bias should be taken into consideration;however,head nurses were also the participants in the study,so that they may have the same feeling as the nurses under their supervision.Thus, further studies should be done following this one to understand the extent,to compare the stress level among different medical workers,and to determine if nurses had a higher stress level and why they did so.

Conflicts of interest

There is no con flict of interest.

Acknowledgements

Great appreciation is extended to the tertiary hospital that allowed the researcher to do the study in such a busy period and thanks is extended to the head nurses and nurses who took time to participate in the study.Thanks for Guilin Huang and Xiqian Gu who have helped researcher in the study.

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How to cite this article:Fang Y-X.Burnout and work-family con flict among nurses during the preparation for reevaluation of a grade A tertiary hospital.Chin Nurs Res.2017;4:51e55.http:// dx.doi.org/10.1016/j.cnre.2017.03.010

17 October 2016

E-mail address:jessieyiyun@sina.cn.

Peer review under responsibility of Shanxi Medical Periodical Press.

http://dx.doi.org/10.1016/j.cnre.2017.03.010

2095-7718/©2017 Shanxi MedicalPeriodical Press.Publishing services by Elsevier B.V.This is an open access article under the CC BY-NC-ND license(http://creativecommons. org/licenses/by-nc-nd/4.0/).

Received in revised form 14 December 2016

Accepted 15 January 2017

Available online 13 April 2017