This research has explored the factors associated with nurses’ self-reported fatigue correlated with the burnout syndrome. The strength of the study was its representativeness, since 53% of the total nurses’ population in Cyprus was surveyed across all clinical settings and geographical regions. To the best of our knowledge this is the first published nationwide research of its kind in Cyprus. The implications in practice include but not limited to the development of a national action plan for the prevention and the management of burnout syndrome in Cypriot nurses in the clinical settings. The study also aimed at exploring the relation between self-reported fatigue and burnout syndrome which is also of particular interest to the international literature.
The health care clinical settings are a highly stressful environment and may therefore be associated with a high rate of burnout syndrome and fatigue especially when it comes to nurses [49
]. Yoder for example in a combined quantitative and qualitative study in nurses working in various clinical settings concluded that highly stressful environments are considered as triggers for burnout and fatigue [22
]. Similarly, Maytum et al. [51
] in a descriptive qualitative study of 20 nurses working in pediatric ward claimed that the nature of the environment and the type of patients needing care were a source of fatigue and burnout. However, preceding studies have revealed an apparent paradox that of a low degree of burnout in high stress health care environments [34
]. This research coincides with these studies, contributing to the paradox that even though nurses acknowledge their work as stressful at the same time they report average to low degree of burnout. An average degree of burnout is reflected in average scores on the three subscales, and a low degree of burnout is reflected in low scores on the EE and DP subscales and a high score on the PA subscales [8
]. A low degree of burnout therefore represents a positive psychological condition rather than the stereotypical negative condition that is widely associated with the burnout syndrome.
A total of 12.8% of the participating nurses met the Maslach’s criteria for a high degree of burnout. According to Maslach et al. [8
] a high degree of burnout is reflected in high scores on the EE and DP subscales and in low scores on the PA subscale which is rated inversely. This finding indicates the correlation between stressful working environments with high degree of burnout. This is consistent with the body of literature that supports this relationship [51
The analysis demonstrated that the percentage of nurses with high EE was 21.5%, a finding which mainly reflects the organizational and the social climate of the work environment according to Maslach et al. [43
] and Yoder [22
]. A possible interpretation of this finding might reflect the nurses’ higher ability to adapt to the demands of their clinical setting as opposed to the findings of other studies [56
What has been stressed by earlier studies [53
] that the type of ward plays an important role as to the expressed levels of burnout has also been demonstrated by this study. The levels of burnout reported by the participants varied accordingly. Nurses in the oncology departments, for example expressed the highest levels of burnout (21.9%) compared to their colleagues working in operating theatres (17.5%), in surgical wards (17.2%) and in the emergency departments (15.9%). This burnout pattern was also supported in the Yoder study [22
] demonstrating that the nature of the clinical environment (i.e. ward type) as well as the type of cases that require care can pose an influence on the levels of burnout experienced by the nurses.
In contrast to the earlier findings, the researchers found relatively low expressed levels of burnout among nurses working in the ICU units. Whilst prior work [57
] expected that ICU environments would be highly stressful and potentially burnout generating, this study showed that the nurses in Cyprus working in such environments do not necessarily express higher levels of burnout compared to colleagues working in other clinical settings. This finding can partially be explained by a number of possible reasons routed in the context of the clinical settings in Cyprus. Such reasons for example can be the type of cases cared; the amount of training received the staffing levels, the working conditions and the psychological support services available to the Cypriot nurses.
The researchers anticipated that the employment type (private vs. public sector) would have an effect on the reported burnout levels reported in this study. Their expectations were based on the fact that the nurses working in the public sector tend to enjoy better working conditions (i.e. better salary, less working hours, permanent status of employment) compared to those who are employed in the private sector. Paradoxically nurses who work in the private sector reported lower feelings of EE and overall burnout than their colleagues in the public healthcare settings (12.7% of those who work in the public sector and 12.2%). This finding can possibly be interpreted by the fact that recent changes in the national health care system in Cyprus have positively influenced some (if not all) of the perceived disadvantages in the private sector. These changes have been implemented not only as a means to increase the quality of the provided care but also to bring equilibrium between private and public healthcare sectors. The improvement in the working conditions in the private sector was also reflected on the levels of fatigue experienced by the nurses. Another issue that potentially contributed to this finding is the fact that nurses in the private sector only provide secondary care and some preventative services. Statistical analysis showed that the fatigue prevalence in the nurses who work in public sector was 92.4% as opposed to 82.2% in the private sector. The employment sector also affected the level of PA with those who worked in the public sector having lower mean PA score. This can possibly be explained by the fact that in the public sector there are less feedback mechanisms and personal accomplishments strategies in place compared to the private sector.
An important aim of this paper was to clarify whether the burnout syndrome and fatigue experienced by the nursing staff might somehow be related. This is an area that received scarce attention in the literature and therefore the findings of this study are new to the relative literature. The researchers prior the study expected that a correlation between these two variables would exist and perhaps be explained by the stressful environments in which nurses’ work [63
]. A few studies [64
], support the association between fatigue and stress. Indeed, a common finding that might offer an acceptable interpretation to the above expectation is the fact that nurses acknowledging that their job is stressful appear more susceptible to burnout and self-reported fatigue. The point prevalence for fatigue was 17% in those who believed that their job was stressful and 4.3% in those who do not believe it indicating that it is more likely that this group of nurses will experience fatigue compared to their colleagues that do not see their job as stressful. This point of prevalence is consisted with those of earlier studies [67
]. Through the multilevel logistic regression analysis “my job is stressful” is a significant predictor of burnout onset. Asking the nurses to respond to this question could be an indirect predictor of their burnout.
The analysis demonstrated that burnout is correlated with EE and DP, with females being more susceptible [68
]. Perhaps the factor that explains this phenomenon is that women often have a double and possibly conflicting role, namely the one of the healthcare professional and the other of the mother (and/or housekeeper); this may increase their levels of stress and drains their energy overall [70
This study has provided new insights into the nature of the relationship between the type of organization (private or public) and the type of ward (medical, surgical, oncology), nurse burnout, nurse self-reported fatigue, and the link between nurse burnout and nurse self-reported fatigue, however further research in the future will be needed to more fully understand the causal mechanisms that link these and other organizational features and outcomes.
The study presents several limitations especially regarding its generalisability. First, Cyprus may differ regarding factors associated with burnout syndrome and fatigue, such as relationships between physicians and nurses. However, our sample was large and representative of different types of nursing wards. The large difference in the sample size of nurses working in the public and the private sector should be taken into account. The study seems to be more representative for the public rather than for the private sector. The analysis did not take into consideration possible confounders. Another limitation of the study was that the analysis did not take into consideration the various levels (ranks) of nurses included in the study. One limitation that was attributed to the demographic details acquired by the nurses was the fact that only specific clinical settings were provided as option whilst the other settings were merged into one category namely the “other”. As a result no further information could ne attained on the nature of these other settings.
This study in the future could be methodologically improved by attempting to measure the incidence rate of burnout among nurses in the various participating department. Perhaps a way of doing this would be through a series of basic self-report questions regarding the onset of fatigue and burnout in a correlational design. In conclusion any future studies on the topic under investigation should consider issues such as the hours of work per shift, hours of work per week, voluntary or mandatory overtime, the days off per week as well as other workload measures. Based on the human factors models of Carayon and Gurses [49
] and Karsh et al. [71
] these measures fall into three types of workload namely the unit-level workload, the job-level workload and the task-level workload. These variables might have a different impact on outcomes such as quality of care, patient safety, nurse job dissatisfaction and burnout.