Abstract
Introduction:
The optimal performance of a healthcare organization is one of the effective factors in increasing the efficiency and productivity of nurses and thus reducing their burnout. The aim of this study was to investigate the role of organizational management on nurse burnout based on experiences from Iranian nurses working in psychiatric wards.
Materials and Methods:
This qualitative study was conducted on 15 nurses working in psychiatric wards selected through purposive sampling. Data collection was done through in-depth semi-structured interviews in psychiatric wards in Ahvaz (southwest of Iran) and Tehran. Data analysis was done through conventional content analysis.
Results:
The findings included one main category and three subcategories. The main category was “Providing care at an inadequate organization,” and the three sub-classes namely “Shortages of human resources,” “Shortage of physical resources,” and “Impact of management approaches to care provision” were extracted.
Conclusion:
The results of this study showed that inadequate supply of equipment and human resources along with ineffective managerial approaches in the organization could lead to mental and emotional exhaustion, negative attitudes toward the profession, decreased and poor service quality, employee turnover, and early retirement of nurses in psychiatric wards. Therefore, by adopting appropriate policies in their programs, paying special attention to the physical and mental health of nurses, and addressing their problems, managers of healthcare organizations can motivate and sustain the human resources within the organization.
Keywords: Burnout, hospital, mental health, nurses, organizational factors
Introduction
Human resources are the most valuable asset for organizations, and paying attention to human resource needs and their satisfaction can be effective in increasing the efficiency and productivity of the organization.[1] Nurses constitute the major part of human resources in hospitals and their impact on the quality of health services and achievement of the organizational goals is prominent; therefore, paying due attention to them in healthcare organizations has become increasingly important.[2] The results of different studies show a high rate of burnout among nurses.[3] Work burnout results from long-term stress in the workplace, and consists of three dimensions namely emotional exhaustion, depersonalization, and reduced personal accomplishment,[4,5] which can lead to decreased work efficiency, increased absenteeism, reduced liability and efficiency, more conflicts, job change, interpersonal conflicts with colleagues, increased health costs, personnel turnover, behavioral and physical changes, substance abuse, and reduced quality of services provided to patients followed by dissatisfaction with medical services, all of which have a negative effect on patients and clients. Therefore, identification and prevention of burnout is of paramount importance when it comes to improving the mental health of individuals and enhancing the quality of services.[6,7] The issue of burnout in nurses working in psychiatric wards is an important line of inquiry because these nurses experience high levels of emotional exhaustion and stress compared to other healthcare employees.[8,9] The main function of nurses in these wards is to provide care for patients whose condition is complex and challenging. Patients admitted in these wards suffer from the most severe diseases. Many of them have complex needs, have judicial convictions, and may have been referred to the hospital by the court of law. In addition, violence by these patients toward other patients and staff, the risk of suicide and exposure to unstable behavior of patients, and their unpredictable nature create a work environment that is replete with different demands and challenges, putting an alarmingly considerable amount of pressure on the nurses working in the psychiatric wards. In fact, these unpredictable working conditions in psychiatric wards can lead to many unpleasant and harmful outcomes such as occupational stress, tension, dissatisfaction, and burnout.[10,11]
In addition to working conditions and environment, any ignorance or weakness of organizational factors with regard to the supply of human resources, care facilities, and effective management approaches to psychiatric wards also play a decisive role in accelerating the burnout process in nurses. The organization's failure to attend to supplying adequate and specialist human resources in psychiatric wards has led to increased workload, limited time for continuous interactions with patients, mental exhaustion, and job dissatisfaction among nurses. All of these factors create obstacles to the realization of health goals and provision of high quality and timely health services.[12,13]
Other organizational factors such as exposure of nurses to nonstandard facilities for care in the workplace also challenge the care process. This is because the inappropriate facilities increase the job responsibility and stress of nurses.[14]
Organizational factors associated with the managerial approaches include managers' undesirable behaviors with regard to observing justice, avoiding discrimination, and giving rewards or incentives. These have been shown to have an important role in reducing the morale and motivation of nurses in the psychiatric ward. Studies have also shown that injustice and reduced organizational support for nurses in the psychiatric ward will increase stress and decrease their collaboration, thus decreasing the quality of care and increasing the aggressive behaviors of patients.[15] The ill-advised performance of management with respect to allocation of rewards, promotion and appointments in the psychiatric work environments has led to an increase in interpersonal conflicts and nurse burnout. Other studies have shown that organizational justice leads to cohesion while injustice causes division and discrimination in the organization.[16] Therefore, managers of organizations need to consider the issue of nurse burnout seriously, and by making informed decisions in this regard they can improve the mental health and interpersonal relationships, increase the quality of services, and reduce the costs resulting from absenteeism, early retirement, and job turnover.
Studies have shown that to investigate the phenomenon of burnout in nurses, the cultural-social aspect should be taken into account as it has a significant relationship with organizational culture.[17] Therefore, since burnout is a complex phenomenon involving human agents, the use of a qualitative study design to examine the role of organizational factors in job burnout of psychiatric ward nurses can be an important tool for assessing and recognizing the responses of nurses to different situations in their work environment. Through this study, valuable points that help the nurses in solving their problems and those of their organization will be discovered. The purpose of this study, therefore, was to scrutinize the experiences of nurses in psychiatric wards about the role of organizational factors on burnout, by adopting a qualitative approach in the context of Iranian culture.
Materials and Methods
This research has been carried out using a qualitative approach and an inductive conventional content analysis during 2017–2018 in Ahvaz, southwest of Iran.
The research population included nurses working in the psychiatric wards of Ahvaz Golestan Hospital affiliated to Ahvaz Jundishapur University of Medical Sciences and Besat General Hospital and 505 Hospital affiliated to AJA University of Medical Sciences. The participants were selected through purposeful sampling and from nurses who had at least one year work experience in the psychiatric ward, and data were saturated with 15 nurses. In-depth semi-structured interviews were used to collect data. In this research, the researcher first introduced herself to the participants, described the purpose of the study, and tried to establish a friendly relationship with the participants. Before the interview, a written consent was received from the participants for their participation in the study and for recording their voice. The participants were also assured of the confidentiality of the information they shared prior to the commencement of the interviews. The interviews were conducted individually and in a quiet environment in the psychiatric ward. The main questions asked to the nurses in this study were “Please explain your experience about the role of the organization in providing care”, “How do organizational factors affect the quality of your nursing care?”, and “Express your experience in this regard?”
In order to elicit the answers to the above questions, further heuristic and in-depth questions were asked. At the end of each interview, the participants were asked to provide to the researcher any extra or complementary information not requested during the interview. The interviews were transcribed meticulously in MS Word, and the voices were maintained in separate files. The initial analysis and coding of the data of each interview was made prior to the next interview. After each interview, the researcher scrutinized the interview like an external observer. The strengths and weaknesses of the interview were highlighted and reviewed with the help of the supervisors and advisors of the dissertation as well as experienced doctoral students. Issues that needed clarification were considered in the subsequent interviews. Given the hypotheses that were presented during the interviews, other sources of information, such as informal interviews on telephone and field notes, were also used to confirm the findings from the interviews and bridge the gaps in the interview data. The average interview time was between 60 and 75 minutes.
To analyze data, Graneheim's and Lundman's (2004) content analysis method was used.[18] Initially, the transcription of the interviews was carefully read and the semantic units (primary codes) were identified. The semantic units were extracted out of the nurses' statements which showed their experiences. Then based on similarity and proportionality, the codes were assigned in a subcategory, and then in more general categories, and the main themes of the categories were determined at an abstract interpretation level.
As with content validity, the transcription of the interview and the extracted phrases were confirmed by the participants and colleagues, and this indicated that the researcher reflected the same views of the participants. Also, for the confirmation and audit of the research, we carefully recorded and reported the steps and the research process. To determine reliability, maximum variability was considered in selecting the participants, selecting them from different centers and psychiatric wards. For replication matters, the number of participants, the date, place, and manner of data collection were fully described so that other researchers can replicate the study.
Ethical considerations
This study was approved with the following code of ethics: IR.AJUMS.REC.1395.822 issued by the Ethics Committee of the Vice-Chancellor of Research of Ahvaz Jundishapur University of Medical Sciences. To observe the ethical considerations in this study, the purpose of the research was explained to all participants. A written informed consent form and the permission to record and use information were obtained. The participants were free to withdraw from the study during the study period.
Results
The participants of this study included 7 males and 8 females. The participants were selected from a specialist center and two general psychiatric hospitals. The demographic characteristics of the participants are shown in Table 1.
Table 1.
Characteristics of the study’s participants
| Age (years) | Minimum: 28, Maximum: 54 Average: 41 |
| Gender | 7 males and 8 females |
| Work experience (years) | Minimum: 8, Maximum: 15 Average: 16 |
| Qualification | 13 Bachelor’s degree and 2 Master’s degree |
| Job Title | Nurse |
| Place of Employment | Besat Nahaja General Hospital and 505 Artesh Hospital (3 nurses each) Ahvaz Golestan Hospital (9 nurses) |
According to our analysis of the findings, one main category and three subcategories were extracted. The main category was “Providing care at an inadequate organization,” and the three subcategories were “Shortages of human resources,” “Shortages of physical resources,” and the “Impact of management approaches to care provision” [Table 2].
Table 2.
The process of formation of the primary categories, subcategories, and the main category of care in the inadequate organization)
| Main category | Subcategory | Primary category |
|---|---|---|
| Care in the inadequate organization | Shortage of human resources | Shortage of specialized staff |
| Shortage of non-specialized staff | ||
| Shortage of standard facilities for providing care | Shortage of equipment and devices | |
| Inappropriate building and area | ||
| Impact of managerial approaches on care provision | Insufficient welfare and financial facilities | |
| Exposure to discrimination and ingratitude | ||
| Officials’ insufficient support for the nurses and lack of job support | ||
| Ignorance of and flaws in in-service training | ||
| Paying little attention to and weakness in employee training |
1-Shortages of human resources
The subcategory of “Shortages of human resources” includes two main categories namely “Shortage of specialist human resources” and “Shortage of non-specialist human resources.”
The psychiatric nurses' description of their experience in the work environment involved their complaints about shortage of labor force, inappropriate staff, and mandatory overtime which brings about increased workload causing mental and physical burnout, poor quality of care provided to the patient, job hatred, and increased willingness to leave.
The experience shared by a participant is as follows:
”Most of the time, there is a shortage of manpower. It's too difficult and tiresome to do a lot of work and control a lot of patients. My workload is too high, and I cannot meet the needs of all patients. Patients make a lot of demands. In most of the shifts, I have a lot of mental and physical exhaustion. My body strength and energy have decreased. (Female, 44, Night shift).
2-Shortage of standard facilities in providing care
This subcategory includes two categories of “Shortage of tools and equipment, and “Inadequacy of the building and the area”.
The important role of standard facilities, such as modern and adequate workplace equipment, as a facilitator of nursing care and medical procedures was attested by the nurses. Inadequate equipment is one of the most important recurring obstacles in the care environment that results in disruption, neglected care, delay in the delivery of care, emotional tensions, and absence from the workplace.
One participant contributed their experiences in this regard:
”The ward beds are broken and non-standard. We have to keep the side rails up so that the patients don't fall. When the patients want to go to the bathroom we should put them down and again up. I've got neck and back pain from these beds. I do not have energy, I'm worn out and I want to get retired” (Female, 37, Night shift).
Wards with inappropriate physical environment are the cause of serious physical and psychological damage to patients and nurses.
3- The impact of management approaches on provision of care
The approaches that organizations adopt in managing psychiatric wards have been considered as one of the important factors influencing the performance of nurses and provision of standard care to patients. The results of this study showed that the ill-advised management approaches in psychiatric wards, in terms of selection of suitable employees for these wards, job support, financial and welfare facilities, in-service training, and discrimination between employees can reduce motivation, productivity, and work commitment, and increase job dissatisfaction, job resignation, absenteeism, early retirement, and poor quality of care delivery to patients.
The subcategory of “The impact of management approaches on care provision” includes the following primary classes: insufficient financial facilities, discrimination and ingratitude, officials' failure in supporting nurses and providing job support, ignorance of staff training, and employment of inappropriate staff for the psychiatric ward.
3- 1 Insufficient welfare and financial facilities
Payment gap, challenges related to wages and delayed payments, low financial incentives, and lack of welfare facilities offered by the organization all lead to exhaustion, physical problems, reduced power and energy, feelings of frustration and separation from organization, and job dissatisfaction in nurses.
One of the participants expressed his experiences as follows:
”I've been working here for 29 years, but I do not have the basic livelihoods. Justice is not done in the organization. I do not have the incentive to work. There is a lot of stress in the psychiatric ward, and considering all this stress, I really receive a low salary and cannot make ends meet. I have to work overtime. I'm thinking about a job other than nursing.” (Male, 50, Morning shift).
3-2 Exposure to discrimination and ingratitude
Participants complained about the management's discrimination and ingratitude while giving promoting incentives and rewards. They also indicated that inadequate occupational status has an impact on creating inappropriate cultural atmosphere, undermining employee morale, inaccurate relationships between employees, and a deterrent factor in nursing activities.
One of the participants expressed her experience as follows:
”There is a lot of discrimination in my work. My colleague is a newcomer and her work experience is much lower than mine, but she has a better position than I do. They're violating my rights. I objected to this but they did not care. These injustices have lowered my working morale. I want to get out of my career” (Female, 44, Night shift).
Organizational ingratitude creates a negative attitude in the staff, and leads to undesirable behaviors among employees.
3-3 Officials' inadequate support for nurses and lack of job support
The nurses in the psychiatric ward believed that the managerial approaches of the hospital and the level of support the nurses receive for providing care have a profound effect on their performance, and any failure in supporting them in the workplace reduces the quality of the professional care they provide, weakens their decision-making ability and self-confidence, and lowers their passive correlation.
One of the participants said:
”Frequently, we have been threatened by our patients outside the hospital, or been beaten by them, but the organization's management has never supported us.” The hospital director says that outside the hospital is not within our jurisdiction. I feel I am being humiliated in this nursing system. I want to change my job.” (Male, 45, Night shift).
3-4 Paying little attention to and weakness in employee training
Participants expressed dissatisfaction with the management's ignorance of the importance of the scientific and practical empowerment of nurses in psychiatric ward and the inadequate allocation of funds for conducting educational classes. This, they believe, reduces the motivation for promoting scientific level and providing care in a principled manner.
According to the participants:
”The hospital pays more attention to wards that are financially more important. For example, each year, they send some to ICU and CCU courses. But so far no one has been sent for training from the psychiatric ward, and all those who come to this ward are with no interest or training. They learn their job through experience from each other. I've lost my motivation for my career.” (F, 40, Night shift).
3-5 Employing inappropriate staff for the psychiatric ward
Participants complained about the management's negative attitude toward the psychiatric ward and about the employment of inappropriate individuals for nursing in this ward. They believed that this would contribute to the development of physical and psychological problems, creation of negative attitudes toward professional activities, and thus reduced productivity in nurses.
One of the participants said:
”The management has a negative view of our ward. No one has chosen this ward with interest. The matron sends undisciplined nurses to the psychiatric ward as a punishment” (M, 39, Night shift).
Discussion
The purpose of this study was to investigate the organizational factors affecting the burnout of nurses working in the psychiatric ward. According to our analysis of the data and research findings, we extracted the main category of “Providing care at an inadequate organization,” and its three sub-categories namely “Shortages of human resources,” “Shortages of physical resources”, and “Impact of management approaches to care provision.”
Findings of the research also showed that the ill-advised performance of organizational factors can increase the workload and stress, fatigue, and thus a sharp fall in the quality of services provided to patients.
Shortage of human resources was the first extracted subcategory. Most of the participants stated that due to the huge number of patients, they were faced with enormous workload for running the ward and, due to the frequent exhausting working shifts, they suffer from mental and physical exhaustion. Consistent with our research results, Nantsupawat et al. (2105) found that lack of staff, high workload, and longer work hours lead to high emotional exhaustion, increased error and decreased safety of the patients, reduced productivity and career advancement in nurses, increased absenteeism and job dissatisfaction, and intention to quit the job.[19]
”Shortage of standard facilities for providing care” was extracted as the second subcategory. Participants stated that equipment and facilities are features of the physical environment that influence the effectiveness and efficiency of nursing programs and services, and these shortages and inadequacies act as stressors that have been effective in increasing their physical and mental exhaustion. In agreement with the results of our study, Bordbar et al. (2014), showed that there are several factors associated with the work environment referred to as psychological pressures. They contend that if nurses were not able to cope with these factors which include physical factors such as noise, congestion, inappropriate light, etc., they will experience numerous physical and psychological complications that lead to absence associated with health problems.[20]
”Managerial approaches affecting care provision” was the third subcategory extracted. The ill-advised management of the psychiatric ward can lead to poor fulfillment of the goals and missions of the organization with no optimal performance in providing standard care to patients. In this regard, the participants stated that undesirable influencing approaches to psychiatric management in terms of financial and welfare facilities, discrimination and ingratitude, employment of the staff, training, and job support led to reduced job incentives, lack of trust in managers, job burnout, and the tendency for resignation and retirement. Valizadeh et al. (2015) found that discrimination results in inappropriate outcomes such as psychological stress, disorder, and disappointment. This negative emotion will prevent nurses from achieving their desired goals, reduce the interdisciplinary collaboration and teamwork, increase error rates, and reduce the quality of services to patients.[21]
One of the issues of interest to other participants was the ignorance of financial and welfare issues, the reduction of salaries and benefits, and the importance of appreciation and encouragement from the organization, which resulted in reduced work incentives, job hatred, resignation, dissatisfaction, and separation from the organization. The employees preferred to leave their organization and join the one that understands their problems and provides them with the right facilities. In this regard, the results of Safi et al. (2015) also confirm that lack of due attention to nurses' welfare and comfort issues contributes to their reduced job satisfaction and job burnout.[22] From the viewpoint of the participants in the current study, the management's insufficient legal support for nurses can play an important role in creating feelings of dissatisfaction, emptiness, and worthlessness among them. The results of Gupta (2016) showed that perceived organizational support to nurses leads to more involvement in work and increased organizational commitment.[23]
Another focus of attention was the lack of managerial attention and the lack of appropriate funding for organizing regular training sessions for nurses in psychiatric wards. Nurses considered training courses on developing skills in problem solving and controlling violence in patients as an influencing factor in preventing their physical and mental burnout. Consistent with our study, the results of Zaki (2016) show that training programs on how to deal positively with stressors can be effective in increasing the stress capacity at work and improving the nurses' job performance in the psychiatric ward.[24]
The results of this study showed that the ill-advised performance of the organization has an important role in the formation of the burnout process among nurses working in psychiatric wards. This is marked by their job dissatisfaction, increased physical and mental problems, reduced autonomy, reduced commitment and loyalty to the organization, and a sharp fall in the quality of providing services to patients.
Limitations
In this study, the interviews were limited only to nurses working in the psychiatric ward, while physicians and psychologists working in the ward were not included. It is suggested that future research be carried out by involving others working in the psychiatric ward.
Conclusion
The results of this study showed that by identifying the negative and positive factors affecting the quality of nursing and taking appropriate measures to improve and enhance the quality of nursing services in psychiatric wards, the stage could be set for providing high-quality services to patients in the psychiatric ward.
Declaration of patient consent
The authors certify that they have obtained all appropriate consent forms. In the form, the nurses have given their consent for their images and other clinical information to be reported in the journal. They understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
Financial support and sponsorship
Ahvaz Jundishapur University of Medical Sciences, Ahvaz, Iran.
Conflict of interest
Nothing to declare.
Acknowledgments
This study is part of a PhD thesis in Nursing at Ahvaz Jundishapur University of Medical Sciences. This study was approved by the university (NCRCCD-9522). The researchers would like to express their gratitude to all the participants who provided the research team with their experiences.
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