The findings related to factors which involved in the nurses' responses to burnout are presented in this article. Analysis and interpretation of data indicated that personal characteristics and social support have involved in the nurses' responses. These factors are presented in Table .
Factors involve in nurses' responses to burnout.
Data from interviews and participant observations indicated that special personal characteristics and personality traits have involved in the nurses' emotional, attitudinal, behavioral, and organizational responses to burnout. Personal characteristics such as conscience, religious beliefs, personal philosophy, commitment, a sense of responsibility, and altruism facilitated caring behaviors. Nurses with these characteristics were more patient and empathetic. They were more cooperative and rarely justified their faults by fatigue, workload or staff shortage. Conscience, commitment, and religious beliefs such as fear of divine requital were the most prominent traits that modified the responses to burnout. One of participants stated:" God knows. I always feel it's me there on the bed. Sometimes a patient calls and I ignore, but I tell myself, what I expected if I were on this bed? I fear god and say to myself, his authority is great and whatever I do, I will see the reflection of my doings". Some of the participants pointed to interest and love in caring of burn victims. One of participants stated:" these patients are different from other ones. I have worked more than 18 years in general hospitals, I haven't worked more than 7 years in burn centers, but I think that was a blessing in disguise, I am glad because clinical work for a burn patient means love, means everything, believe me. I don't care the managers' behaviors, workload, nursing shortage and other deficiencies, because I love burn victims. Believe me". Many of the nursing staff, distanced from patients, they had immoral beliefs and demonstrated humiliation and reproach in their behaviors. They related these attitudes to fatigue, micro and macro conditions in burn centers, and loss of motivation; but participant observation indicated that, this isn't the case for all the nurses. Nurses, who had been known as good nurses, were very calm and intimate with their patients and focused on the patients' needs. The researcher wrote in one of her field notes:" she is very calm and speaks with compassion. She makes jokes and patients are relaxed with her. She follows the principles and procedures more strictly than others". Nurses in all levels were under pressure of workload, low pay, staff shortage, environmental conditions of burn units and other structural inhibitors, but as the excerpts of interviews indicated, appraisal of these inhibitors was different in the presence of specific personal characteristics.
Data indicated that in some instances, when there were a number of inhibitors and they were long stay, even positive personal characteristics couldn't work. This was often the case in infectious dressing rooms and busy wards. The worst kinds of treating patients were seen in these places. It seemed that the inhibitory factors which are persistent and too frequent interact with personal characteristics and finally overcome the positive characteristics. One of participants stated:" patients expect to receive care, expect a friendly encounter which does not happen. To tell the truth, some days I am excessively distressed and tired that I don't have the patience to answer the patient' questions and concerns. I emotionally can not do what I really want to do on a daily basis for the patients. The reason is persistent day and night problems occurring with this job". This process is displayed in Table .
Interrelationships between personal characteristics, inhibitory factors and caring behavior in burnout.
Data strongly indicated that nurses' appraisal of the patients' characteristics have influenced some aspects of their attitudinal and behavioral responses. When the appraisal was positive, the relationships improved, and when it was negative, relationships deteriorated. Positive appraisal occurred often when the patients were cooperative and motivated for recovery and in cases where they had an advantage of high socio- economic class, cultural and educational levels, or whenever they stimulated the nurses' senses of compassion and pettiness. Negative appraisal occurred often when the patients were from lower socio- cultural levels, addicts or there was a possibility of having acquired immune deficiency syndrome (AIDS) or hepatitis.
The first group was treated kindly and more respectfully. The use of humiliating words and reproach towards them diminished and as a result the aggressive behavior and physical withdrawal less occurred. One of participants stated:" ...I am more supportive and compassionate towards children, those who are very alone, who have no one to love and care for them, those who have committed self-inflicted burns, a woman whose husband caused her to burn herself and doesn't have any one to support her. In many occasions I have even paid them to buy juice from outside the hospital. I feel that these patients are needy".
The second group was treated very unethical. They encountered a humiliating, reproaching, and aggressive behavior. One of participants stated:" ...he fights when I am dressing him, he pulls his hand and leg, he isn't cooperative, and he has no class. They drain all my energy to the point that I don't want to talk to them. I think they are mentally retarded. They keep still when I shout at them just the way that the children act. I tell them I'll pull your ear, and I'll beat you up. This is the behavior that has worked with them ".
Moreover patients with extensive burns, whose survival was an improbable event, not only were badly treated, but also were sometimes ignored and received poor care. In other words, they received only those treatments which had been ordered by physicians to prevent being reprimanded by supervisors. One of the participants justified herself and stated:" if you want the truth, a patient with 90% burns can not benefit from tetracycline ointment, but it's there in his order, I prefer to spend my time with a patient who has a better chance of surviving. Right or wrong I don't apply the ointment, because I can spend that time for a patient who will survive". We can conclude that burnout has made nurses to modify their caring behaviors to fit the different type of patients they care for.
Interaction between nurses and patients' characteristics
As described later, nurse's and patient's characteristics modified the nurse's responses to burnout and altered caring behaviors. More analysis and interpreting of data indicated that interaction between these two variables resulted in a more powerful combination that alters responses to burnout and identifies the kind of caring behavior. This process is displayed in table . It is important to mention that the meaning of patient's characteristics in this study is the nurse's appraisal or perception of these characteristics and nurse is clinical nursing staff in different levels.
Interrelationships between nurses and patient's characteristics and caring behavior in burnout.
Table indicates that when both nurse's characteristics and her/ his appraisal of patient's characteristics are positive, then the nurse's caring behavior is naturally effective and efficient. In this case, patient is treated respectfully, there is an empathetic behavior, and nurses spend more time with her/his clients to value their emotional needs. When the nurse's characteristics are positive and her/ his perception or appraisal of the patient's characteristics is negative the nurse doesn't have a natural empathetic behavior. She thinks that she has to be good and behave well because of her beliefs; therefore she demonstrates a good behavior. Sometimes when the patient has been perceived as having a negative outburst, from the nurse's point of view, she/he has a very negative attitude towards the patient. This will cause ethical issues and misbehavior by the nurse. The good behavior occurs when the nurse's characteristics are negative but the appraisal of the patient's characteristics is positive. In this case, the patient's characteristics do not permit for emergence of negative characteristics of the nurse; therefore an ethical/respectful and caring behavior will result. At times when nurse's characteristics are negative and her/his perception of the patient's characteristics is also negative, non-ethical behaviors find a good opportunity to emerge. In this situation the patient encounters the worst behavior. Humiliation is intense, physical withdrawal is often seen and aggressive behavior is routine.
One of participants stated: "I take care of some patients with love and conscience and take care of the other patients only with conscience and some nurses doesn't have love at all, I take care of silent, calm and lonely patients better, I perform routine care for the other". Another participant also stated:" it seems I give positive energy to the patients to whom I am more interested and take care of them with more love. I've seen that they respond better to therapeutic measures". Therefore interaction between nurses and patients' characteristics has a very powerful effect on the nurses' responses to burnout and determines their nature of caring behavior.
Data from interviews and participant observations strongly suggested that social support influences the nurses' responses to burnout.
Supportive behavior of head nurses, nursing administrators and coworkers modified the nurses' responses. Among these, head nurse's the support was the most effective factor. Nurses believed that they do not have any motivation or desire to perform well when they are not supported well. One of participants stated:" we have a very close loving relationship with the head nurses who are supportive. In that situation I do many things for her. Her supportive attitude and caring/positive attitude helps me a lot. Do you understand?" another participant believed that he couldn't endure if the nursing administrator weren't supportive. He stated:" I have seen that she is doing a good job. I have been so stressed at times that I have thought of quitting. The nursing administrator has changed my mind during those stressful moments by being caring, loving and supportive and I have decided to stay in spite of low pay and benefits." Support from peers also modified the nurses' responses. They could tolerate more with the support of their coworkers. One of participants stated:" by god, I like every single one of them. It seems like we live together seven hours a day (major part of our day). We are so familiar with each other's character and behavior patterns. You may not believe this, these relationships has been very helpful and caused us to have a very strong unit. We care for each other in times of weakness, illness or pressure".
It is worthy of mention that the effect of social support on the nurses' responses to burnout was not as powerful as the nurses' and patients' characteristics. Social support influenced the emotional and in some cases the attitudinal responses, but it didn't have enough power to alter the organizational and behavioral responses, therefore it didn't change caring behaviors significantly. Moreover, there were not any data indicative of the modifying effect of the factors proposed in this article on the psycho- somatic responses to burnout.