Job Satisfaction, Burnout and Associated Factors Among Nurses in Health Facilities, Dubai, United Arab Emirates, 2013
Ismail L. S.1, Al Faisal W.2, Hussein H.2, *, Wasfy A.2, Al Shaali M.2, El Sawaf E.2
1Primary Health Care Services Sector, Dubai Health Authority, Dubai, UAE
2Staff Development, Health Centers Department, Primary Health Care Services Sector, Dubai Health Authority, Dubai, UAE
Background: Health care workers job satisfaction and burnout are constant public health concerns. Burnout predispose to rapid staff turnover, absenteeism or illness that ends in decreased job satisfaction. Burnout and satisfaction among nurses are serious conditions that threaten their own and patients health. Objectives: To explore levels and determinants of job satisfaction and burnout among nurses working in Primary Health Care facilities, Dubai Health Authority, Dubai, UAE. Methods: A cross sectional study targeting all nurses working at PHC centres (400) was carried out using self-administered questionnaires containing socio-demographic, work related, personal health status, burnout (emotional exhaustion, depersonalization, and personal accomplishment) and satisfaction variables. Results: Overall nurses reported moderate satisfaction levels and low burnout state. Correlation between burnout and job satisfaction was significant, weak and of opposite course. Burnout increased in older and divorced nurses. Emotional exhaustion related significantly to high income level, performing physical activity and nurses’ intention to leave. Emotional exhaustion had intermediate correlation to job satisfaction. Depersonalisation was higher in nurses with chronic disease and had negative association to job satisfaction. Personal accomplishment had significant positive correlation to nurses’ job satisfaction. Perception of personal accomplishment increased with age, high BMI levels and in nurses with chronic disease. Conclusion: Findings from this study contributes to the understanding of the relationship between nurses' job satisfaction and burnout syndrome and points out that nurses burnout is not uncommon among nurses working in PHC in Dubai. Nurses burnout and satisfaction levels proved to have special characteristics relating to the unique composition of health care in the UAE. The study also indicates that some dimensions of job satisfaction and burnout had proven to be relevant to nurses’ turnover tension. Recommendations: There is a need to develop periodic screening for signs of distress, burnout or dissatisfaction, and to establish preventive strategies that are practical and can be implemented within the current healthcare structure. This will result in increasing nurses’ satisfaction, commitment and motivation which will in time reflect on the quality of healthcare services and daily performance indicators.
Job Satisfaction, Burn Out, Nurses, Dubai
Received:May 3, 2015
Accepted: May 20, 2015
Published online: June 28, 2015
@ 2015 The Authors. Published by American Institute of Science. This Open Access article is under the CC BY-NC license. http://creativecommons.org/licenses/by-nc/4.0/
Health care workers job satisfaction and burnout are constant public health concerns. Burnout predispose to rapid staff turnover, absenteeism or illness that ends in decreased job satisfaction. Ultimately, discontented nurses compromise quality of care and patients satisfaction. Burnout is defined as a psychological syndrome of emotional exhaustion, depersonalization and reduced personal accomplishment that occurs among individuals who work with other people, particularly in conflicting or otherwise critical situations(1). Especially worth noticing is that burnout among nurses is a serious condition that threatens their own health and that of their patients. Nursing is perceived as the most stressful profession among healthcare providers. Results of studies in western countries ascertain that nurses have higher rates of mortality, suicide, burnout, stress related diseases when compared to general population(2). Studies of health professionals in Arab countries are insufficient. Nurses at primary health care (PHC) facilities are porn to develop burnout syndrome as a result of overwhelming demand to provide comprehensive patient care. They coordinate health services provided to patients along with their health promotion advisory role. Their responsibilities extend beyond clinics to include homes, nursing homes, schools and other community facilities. Variable stress levels and changing tasks predispose nurses to burnout syndrome(3).Job satisfaction is defined as ‘the positive sentimental orientation towards a job(4).A meta-analysis of data from 48 studies with a total of 15,048 subjects revealed that job satisfaction was most strongly associated with stress and organizational commitment. The need for the analyses of the growing literature related to job satisfaction among nurses is its significance to develop nurse retention pathways. The recent nursing shortage and turnover affect the efficiency and effectiveness of any health-care delivery system. This is the reason why nurse’s job satisfaction is of huge concern in several countries as well as in United Arab Emirates (UAE) where problems related to job satisfaction, recruitment and maintenance of nurses are persistent. The principal point of argument is that improvement intervention is limited by the absence of an updated model that combines organizational, professional and individual variables to achieve harmonious satisfaction among nurses and health care organizations(5).
To explore job satisfaction and burnout among nurses working in PHC, Dubai Health Authority, and to examine the relationship between demographic factors, job status and health status and nurses’ job satisfaction and burnout.
A cross sectional study was carried out on convenient sample of 400 nurses working at Dubai health Authority primary heath care centers. Self-administered questionnaire was used to evaluate socio-demographic data, job characteristics of nurses Burnout inventory [Maslach burnout inventory (MBI)](6)and employee satisfaction level [Minnesota satisfaction questionnaire (MSQ)](7). Burnout syndrome and satisfaction score was calculated and nurses was classified and compared accordingly.
Table (1) illustrates burnout of Nurses in Primary Health Centers, Dubai Health Authority in UAE during the study period in 2013. Regarding emotional exhaustion, (68.4%) of the study nurses recorded low levels, (15.6%) of them recorded moderate exhaustion and only (16.0%) complained of high exhaustion level. Mean score for Emotional exhaustion was also low; (15.19), which is lower than the average value (22.19) for the category of health care professionals confirming low emotional exhaustion in the sample. As for depersonalization, about two thirds of the sample nurses had low levels of depersonalization, (21.6%) were with moderate depersonalization level and (16.4%) had high depersonalization. Mean score for depersonalization was (4.8), which is lower than the average value (7.12) for the category of health care professionals reflecting low depersonalization state. Considering personal achievement, results of (44.8%) of the nurses were low, (27.2%) recorded moderate personal achievement and (28.0%) had high personal achievement level. Mean score for Personal accomplishment was (33.07); this value is lower than the average reference value (36.53) for the category of health care professionals which reflect low personal accomplishment in our sample. Overall low burnout was recorded among (49.2%) of the nurse and (44.4%) of the nurses recorded moderate burnout while only (6.4%) had high level of burnout.
|Emotional exhaustion (M=15.19- SD= 10.1)||171||68.4||39||15.6||40||16.0|
|Depersonalization (M=4.8- SD= 4.7)||155||62.0||54||21.6||41||16.4|
|Personal Achievement (M=33.07- SD=12.15)||112||44.8||68||27.2||70||28.0|
|Burnout total (M= 53- SD= 17.5)||123||49.2||111||44.4||16||6.4|
Table (2) shows distribution of total burnout by socio demographic data of nurses in Primary Health Centers, Dubai Health Authority in Dubai, UAE during the study period in 2013. it is clear that nurse with different ages recorded nearly the same level of high burnout (6.7%) for those less than thirty and (5.4%) for those more than forty with statistically insignificant value (P=0.596). Likewise males and females were nearly equal (6.6%) for females compared to (4.2%) for males. Difference in burnout levels was recorded based on nationality. (20.0%) of local nurses had high burnout compared to (5.8%) of other nationalities but this was statistically insignificant (P=0.198). As for education, only (4.1%) of those with nursing diploma had high burnout level compared to (8.0%) of nurse with bachelor degree and (7.1%) of nurses with master degree. None of the widowed females had high burnout level compared to (40.0%) of divorced nurses and only (5.0%) of married. Marital status differences were statistically significant (P=0.023). As for number of children and residence the level of high burnout ranged from (5.4%) for nurse with 1-3 children to (10.4%) for those who had no children without statistical significance for either number of children or place of residence.
|Socio demographic data||Burnout total||X2||P|
|No. of Children||3.7||0.455|
^ P value based on Mont Carlo exact probability * P < 0.05 (significant)
Table (3) illustrates distribution of total burnout by work related data of nurses in Primary Health Centers, Dubai Health Authority in Dubai, UAE during 2013. Regarding time needed to reach work, it is clear that there is no high burnout rate for nurses who reach their works in less than 10 minutes while (9.5%) for those who reach within 30 minutes but had high rate of burn out. This was statistical insignificant. Considering experience years, the high burnout rate ranged from (3.3%) among highly experienced nurses to (11.1%) among the nurses with experience was less than 5 years but this recorded trend wasn't statistically significant. Also regarding DHA experience, none of the nurses with DHA experience of more than 26 years recorded high burnout compared to (9.1%) of nurses with experience for less than 5 years. also these differences were found to be statistically insignificant. As for work nature, None of those at administrative position had high burnout compared to (6.7%) of those who work for 8 hours weekly and (7.9%) for nurses who had two shifts weekly. About (12.0%) of the nurses who had higher salaries (>25000Dirhams) recorded high burnout compared to only (5.0%) of those with lower salary range. This was without any statistical significance. With regard to intention to leave, (15.4%) of those who intend to leave their units had high burnout degree compared to (3.8%) of those who refuse to leave with a recorded statistical significance (P=0.005). Only (13.3%) of the nurses who classified nursing as a job recorded high burnout.
Table (4) illustrates distribution of burnout total by habits and medical data of nurses in Primary Health Centers, Dubai Health Authority in UAE during 2013. Considering smoking, only (9.1%) of smokers had high burnout compared to (6.3%) of nonsmokers but this difference wasn't statistically significant. None of the nurses who have alcohol recorded high burnout while (6.9%) of those who didn't have alcohol did also without statistical significance. (8.0%) of nurses who practice sports had high burnout level compared to (6.0%) of others. Regarding BMI, high burnout rate changed from (3.7%) among obese nurses to (14.3%) among nurses with underweight but no statistical significance was recorded. also (7.1%) of nurses complaining of any of the chronic diseases were highly burnout compared to (6.35) of healthy.
Table (5) Results of multiple stepwise logistic regressions for the risk factors of burnout among nurses in Primary Health Care centers, Dubai Health Authority. The model included all studied risk factors that showed either statistical significance or border line significance including intention to leave within 5 years and existence of chronic diseases were found to be the most important predictors for burnout keeping all other factors constant.
As for intention to leave, nurses who intend to leave their current unit were about 5 times more liable to have burnout than those who had no intention to leave work (OR=4.6; 95% CI: 2.0-10.6) while nurses who intend to leave their facility have a doubled risk for burnout compared to those who had no intention to leave their current facility (OR=1.98; 95% CI: 1.0-4.1). Keeping all other factors constant; nurses known to have any chronic health problem recorded about doubled risk for burnout when compared to healthy nurses (OR=2.0; 95% CI: 1.1-4.1).
Table (6) illustrates multiple stepwise logistic regressions for the risk factors of satisfaction among nurses in Primary Health Care center. It included all studied risk factors that showed either statistical significance or border line significance among which intention to leave within 5 years and shift duties per week were found to be the most important predictors for satisfaction keeping all other factors constant. As for intention to leave, nurses who intend to leave their current unit recorded 60% lower probability for being satisfied than those who choose not to leave. (OR=0.40; 95% CI: 0.18-0.88) while those who intend to leave their facility recorded 62% lower probability for being satisfied compared to nurses who had no intention to leave.(OR=0.38; 95% CI: 0.17-0.82). Concerning shift duties per week, nurses who had at least two shifts weekly recorded 55% lower probability for being satisfied compared to others who didn't work shift duties (OR=0.45; 95% CI: 0.23-0.88) keeping all other factors constant.
|Work related data||Burnout total||X2||P|
|Time to work||4.3||0.636^|
|≤ 50 min||47||48.0||45||45.9||6||6.1|
|≥ 51 min||34||45.3||37||49.3||4||5.3|
|Nursing experience in years||4.2||0.653^|
|DHA experience in years||7.1||0.312^|
|Work day hours||2.1||0.353^|
|Days at work||2.2||0.707^|
|Intention to leave in 5 years||18.7||0.005*^|
|Field of nursing||22||55.0||16||40.0||2||5.0|
|Consider Nursing as||1.5||0.474|
^ P value based on Mont Carlo exact probability * P < 0.05 (significant)
|Habits & medical data||Burnout total||X2||P|
|Underweight ( <18)||2||28.6||4||57.1||1||14.3|
|Overweight (25- 29.9)||54||48.2||49||43.8||9||8.0|
|Obese (> 30)||13||48.1||13||48.1||1||3.7|
^ P value based on Mont Carlo exact probability * P < 0.05 (significant)
|Iteration||Risk factor||B||S.E.||P||OR||95.0% C.I for OR|
|Step 1||Intention to leave||0.002|
|Field of nursing||0.11||0.36||0.764||1.12||0.55||2.28|
|Step 2||Intention to leave||0.002|
|P value for the model||0.002*|
B: regression coefficient SE: Standard Error OR: Odds ratio C.I: Confidence interval * Significant OR
|Iteration||Risk factor||B||S.E.||P||OR||95.0% C.I for OR|
|Step 1||Intention to leave||0.043|
|Field of nursing||-0.59||0.38||0.117||0.56||0.27||1.16|
|Step 2||Intention to leave||0.016|
|Two shift duties /wk.||-0.80||0.34||0.020||0.45*||0.23||0.88|
|P value for the model||0.008*|
B: regression coefficient SE: Standard Error OR Odds Ratio C.I : Confidence interval * Significant OR
Table (7) represents the correlation between burnout and satisfaction illustrates that there is a significant inverse intermediate correlation between emotional exhaustion of the nurses and their satisfaction (r=-0.36). Also depersonalization of the study nurses was significantly inversely rated with their satisfaction (r=0.18). Regarding personal accomplishment, in contrast it showed a significant positive correlation with satisfaction while burnout as a total was significantly of weak inverse correlation with satisfaction.
r: Pearson's correlation co efficient * P < 0.05 (significant)
The mean values on the three burnout components were as follows: emotional exhaustion (15.19), Depersonalization (4.88), and Personal accomplishment (33.07). Thus this nursing sample had relatively low levels of emotional exhaustion and depersonalization as well as low perception of personal accomplishment when compare to the reference values of each of the components of burnout; (EE 20.99- DP 8.73- PA 34.58)(8). Participants reported low levels of burnout and moderate levels of satisfaction, which is unlike to the inverse relationship between the 2 concepts reported in the literature. Maslach’s classification supports the notion that high personal achievement will most probably associate with low levels of other burnout components, depersonalization and emotional exhaustion (1-5,8-13). The cause could be due to the fact that the majority of health personnel are expatriates and this leads to instability in the workforce. Ministry of health (MOH) published in 2007 that (43 %) of the MOH’s manpower were nurses and local nurses comprise mere (4-7%)(14).Expatriates use their job experience in UAE as the jump-off point to go to western countries(15). Similar experience have been published in Saudi Arabia by Al Amri et al. Al Amri, 2006, stated that expatriate nurses leave Saudi Arabia as soon as they have obtained sufficient experience to work in developed countries(16). Before endorsing Maslach cut-off points, one must reflect that these values can vary as a result of social or cultural influences. This calls for further efforts to establish and adopt national cut-off points to suite the health care structure within the Emirati culture.(57.8%) of nurses aged less than 30 years and half of the nurses in the age group 30-40 years reported low levels of burnout. While majority of nurses aged ≥40, had a moderate burnout score, which means that older nurses scored higher burnout levels than the younger age groups of the sample. Similar results were reported by Koivula, 2005(17)as well asLin, et al , 2009(18). The rationale for the results was the fact that most nurses from young generation live with their parents and have better social support and less social responsibilities. While older nurses may be responsible for families and social obligations(18).This finding, however, remains different from results of previous studies which established an inverse correlation between age and burnout syndrome(8,19,20). Though burnout rates can change depending on the organizational context and specific samples, many studies reported high levels of burnout in young nurses. Al-Turki, 2010, reported that "younger age was a predictor of emotional stress and burnout in nurses(21)because older nurses are believed to be equipped with rich experience in handling challenging situations and higher ranking that earns them more respect from others, better economic reward, and less requirement of shift work. Therefore, they are presumed to have lower level of burnout (20,22.23). Burnout in relation to nurses’ personal and job characteristic was further explored. Marital status was found to be statistically significant influence on burnout syndrome (P=0.023). 49.5% of married nurses reported low burnout, while 60% of divorced nurses reported a moderate burnout level and the concluding 40% of the divorced sample reported high levels of burnout. Two thirds of the single nurses reported low burnout levels and widowed nurses were 50% at low burnout category and 50% at moderate burnout category. In Asir-KSA, 2013, Burnout prevalence study confirms that interaction between personal and environmental factors are the most obvious causes of precipitating burnout syndrome in health care professionals.(24)Comparably, a cross sectional study in Egypt, conductd in 2012, has reported similar findings. It confirms that marital status significantly associated with having low scores of burnout among married health workers. This was justified by stating that husbands provide social support and buffers the effect of stressful event in married females rendering their low burnout status(25). In the same study,Mortada, et al, counteract the conclusion provided by the Saudi study. In Egypt workers in the field of health care have professional characteristics steering the pathway to burnout and dissatisfaction rather than personal characteristics.
Unlike western culture, burnout determinants in UAE were unique to the composition of its healthcare structure. Old and divorced nurses exhibit higher burnout levels. Emotional exhaustion was found to relate significantly to higher income, performing physical activity and intention to leave within five years. Depersonalization seemed to be lower in satisfied nurses. Nurses known to have chronic disease revealed greater depersonalization towards their patients. Personal accomplishment increases with increasing age, weight and in nurses with known chronic disease. Overall satisfaction levels were moderate among nurses in DHA PHCC.
There is a need to develop periodic screening systems to recognize early signs of impairment and distress of PHC nurses using components of the MBI questionnaire. Also a practical strategy should be sought for preventing burnout. Emphasis should be placed on effective supervision, empowerment, and a better reward system.