Emergency. 2018; 6 (1): e41 OR I G I N A L RE S E A RC H Job Burnout, Stress, and Satisfaction among Emergency Nursing Staff after Health System Transformation Plan in Iran Nader Tavakoli1, Seyed Hosein Shaker1, Siamak Soltani2, Mohsen Abbasi1, Milad Amini3, Ali Tahmasebi3, Seyed Mohammad Hosseini Kasnavieh1∗ 1. Department of Emergency Medicine, Iran University of Medical Sciences, Tehran, Iran. 2. Department of Forensic Medicine, Iran University of Medical Sciences, Tehran, Iran. 3. Trauma and Injury Research Center, Iran University of Medical Sciences, Tehran, Iran. Received: May 2018; Accepted: July 2018; Published online: 13 July 2018 Abstract: Introduction: Job burnout, stress, and satisfaction are linked to quality of care, patient outcomes and retention of staff. This study was conducted to determine the mentioned issues among emergency nurses. Methods: This cross-sectional study was conducted on all nurses working in the emergency departments of 10 hospitals in Tehran, Iran, in 2017. Standard questionnaires were used for gathering the data of participants regarding job burnout, stress, and satisfaction. Results: 709 (90%) participants returned the completed questionnaires (58.9% female). The mean age of the nurses was 33 (SD = 7) years. The level of job burnout was moderate in 76.1%, low in 22.5%, and high in 1.4% of the nurses. The level of burnout in the married nursing staff was lower than single nurses (3.78 ± 0.98 versus 4.14 ± 0.58, p = 0.049). The level of job satisfaction was moderate in 61.1%, low in 22.2%, and high in 16.7%. There was a significant correlation between age and job satisfaction (p = 0.027, r = 0.3). Job burnout was directly correlated with job stress (p ≤0.001, r = 0.57) and job burnout was negatively correlated with job satisfaction (p = 0.001, r = -0.41). Conclusion: More than 60% of the studied emergency nurses had moderate levels of job burnout, stress, and satisfaction. Job burnout had a direct correlation with job stress and indirect correlation with job satisfaction. Planning to reduce burnout of the emergency nursing staff seems to be necessary. Keywords: Burnout, Professional; occupational Stress; Job Satisfaction; nurses; emergency responders; hospitals © Copyright (2018) Shahid Beheshti University of Medical Sciences Cite this article as: Tavakoli N, Shaker Seyed H, Soltani S, Abbasi M, Amini M, Tahmasebi A, Kasnavieh Seyed M. Job Burnout, Stress, and Satisfaction among Emergency Nursing Staff after Health System Transformation Plan in Iran. Emergency. 2018; 6(1): e41. 1. Introduction E mergency nursing staff deal with life and death situa- tions every day and they have to provide skilled, qual- ity care for patients (1). High patient loads, long shifts, demanding physicians, a fast-paced environment, and work- ing in an environment with emotional and physical chal- lenges can cause problems for nurses in the emergency de- partment (2). One critical problem in the modern work- ing environments is job burnout, which has become preva- ∗Corresponding Author: Seyed Mohammad Hosseini Kasnavieh. Rasoul Akram Hospital, Niaiesh St, Satarkhan St, Tehran, Iran. Email: hosseinikas- navieh.sm@iums.ac.ir Phone number: 00982166539233 lent dramatically over the past decade (3, 4). Although job burnout may occur in any job, it can be more common in jobs that are related to helping people (such as health depart- ment staff ) (5-7) and among health department staff, nurses are more at risk of job burnout than others (8). The effects and consequences of burnout can be examined from three aspects including the nurse, client (patient), and organiza- tion (9). The cost of nursing turnover (due to burnout) can reach as high as 150% of an employee’s annual compensa- tion. This can cause a decrease in safety of patients (10), rais- ing the patient’s negative attitude towards the nursing staff (11), and decreasing the quality of healthcare (12). Patient satisfaction can also be related to job burnout among the hospital staff and thus, should be considered. Higher levels of job satisfaction among nurses have been positively This open-access article distributed under the terms of the Creative Commons Attribution NonCommercial 3.0 License (CC BY-NC 3.0). Downloaded from: www.jemerg.com N. Tavakoli et al. 2 linked to improved quality of care, patient outcomes (13) and retention of staff (14). Job stress is also serious among helping professions (15). Some of the stressors in the emergency department include aggression and violence at work (16), work overload (17) and others. Given that national projects such as the Health System Reform Plan are being implemented in Iran (the plan has increased the workload among nurses) and since there is a shortage of nursing staff in Iran, addressing these issues ap- pears to be of great importance. This study was conducted to determine the status of job burnout, stress, and satisfaction and their relationship. 2. Methods 2.1. Study design and setting This prospective cross-sectional study was conducted in March 2017 in ten public educational hospitals of Tehran, Iran. The ten hospitals were general public hospitals affili- ated to Iran University of Medical Sciences and were among the most important hospitals in affiliation with this univer- sity. The necessary permissions were obtained from the Med- ical Ethics Committee (IR.IUMS.REC 1394. 27240). More- over, the subjects were assured of the right to withdraw from participation at any time and confidentiality of their re- sponses. 2.2. Participants Using census sampling, all nursing staff members working in the emergency departments of the above-mentioned hos- pitals were included for being evaluated regarding the pur- poses of this study. A total of 788 nurses were employed in the emergency departments of the ten hospitals. 2.3. Data gathering Four questionnaires were used in this study. At the beginning of the first questionnaire, the objectives of the study were generally explained to the respondents. In the first questionnaire, demographic information of the nurses such as age, sex, marital status, education level, em- ployment type and work experience was questioned. An as- sessment of burnout was made using the Maslach Burnout Inventory (MBI)(18). MBI is the most widely used measure of burnout, which consists of 22 questions relating to the three components of burnout; emotional exhaustion, depersonal- ization and personal accomplishment. All items were scored on a seven-point rating scale (1= never, 7 = every day). Higher scores indicate higher levels of burnout. Previous research using MBI among nurses suggests that it is highly reliable (e.g., Laschinger& Leiter, 2006, reported Cronbach’s Îś level of 0.91 for emotional exhaustion and 0.80 for depersonaliza- tion) (19). The hospital stress scale (HSS-35) was used to measure job stress. The scale consisted of 35 items, which were scored based on a 5-point Likert scale, allocated points were: never (score 1), rarely (score 2), sometimes (score 3), mostly (score 4) and always (score 5). The mean scores represented the measured stress levels, which ranged from 1 to 5, with 1 being desirable (insignificant stress) and 5 being undesirable (se- vere stress). The reliability and validity of the scale developed by Badiqi et al. have been confirmed and the scale has been frequently used in numerous studies in Iran (20, 21). The Job Descriptive Index ( JDI) scales was used for measure- ment of job satisfaction (22). The JDI measures five areas of a job to assess satisfaction: type of work, payment, promo- tion opportunities, supervision, and co-workers. The JDI has been the target of numerous validation and reliability stud- ies. All of the scales are reported to have corrected split-half internal consistency coefficients exceeding 0.80, and average test-retest reliabilities of 0.57 (23). An individual acted as an interviewer in this study, who received preliminary trainings. 2.4. Statistical Analysis The data of the questionnaires were coded and then ana- lyzed via SPSS software version 21 in two levels of descriptive and analytical statistics. In descriptive statistics, parameters such as frequency, frequency percentage, and standard deviation were used. To conduct analytical tests, tests such as the independent samples test as well as one-way ANOVA were used, whereas the Pearson Correlation coefficient was used to examine the relationship between the three variables including job burnout, stress, and satisfaction. The significance level in all the analytical tests was 0.05. 3. Results 3.1. Baseline characteristics of studied nurses 788 nursing staff members working in the emergency de- partment of the 10 surveyed hospitals were questioned. 709 (90%) participants returned the completed questionnaires (58.9% female, 65.3% married). The mean age of the nurses was 33 (SD = 7) years and 57.4% were in the range of 23-32 years. With regard to work experience, 48.4% of the nurses had 1-7 years of experience with the mean work experience of 9 (SD = 7) years. Most of the nursing staff members (55.7%) had undergraduate education. Other demographic charac- teristics are presented in Table 1. 3.2. Job burnout The level of job burnout was moderate in 76.1%, low in 22.5%, and high in 1.4% of the nurses. The only demographic vari- This open-access article distributed under the terms of the Creative Commons Attribution NonCommercial 3.0 License (CC BY-NC 3.0). Downloaded from: www.jemerg.com 3 Emergency. 2018; 6 (1): e41 Table 1: Baseline characteristics of the studied nurses Variables Number (%) Sex Female 418 (58.9) Male 291 (41.1) Age (year) 23-32years 406 (57.4) 33-42years 230 (32.4) 43-54 years 73 (10.3) Marital status Single 246 (34.7) Married 463 (65.3) Educational level Diploma 142 (20) Associate Degree 142 (20) Bachelor’s degree 395 (55.7) Master’s degree 21 (2.9) PhD 10 (1.4) Employment status Permanent 172 (24.2) Fixed-term 57 (8.1) Contractual 412 (58.1) Casual 46 (6.5) Corporate 23 (3.2) Work experience (year) 1-7 343 (48.4) 8-14 211 (29.7) 15-21 100 (14.1) 22-28 55 (7.8) able related to job burnout was the marital status (table 2). The level of burnout in the married nursing staff was lower than single nurses (3.78 ± 0.98 versus 4.14 ± 0.58, p = 0.049). 3.3. Job stress The level of job stress was moderate in 80.3%, low in 10.5%, and high in 9.2% of the nurses. The relationship between job stress and demographic characteristics has been investigated in table 2. No significant relationship was found between job stress and demographic characteristics (P-value> 0.05). 3.4. Job satisfaction The level of job satisfaction was moderate in 61.1%, low in 22.2%, and high in 16.7% of the nurses. The relation- ship between job satisfaction and demographic characteris- tics showed that age had a significant relationship with job satisfaction (p = 0.039). There was a significant and positive correlation between age and job satisfaction score (p = 0.027, r = 0.3). Job satisfaction increased with increase in age, as was also confirmed by post hoc tests. However, other demo- graphic variables did not show any significant relationship with job satisfaction (Table 2). 3.5. Correlation of job stress, satisfaction, and burnout Examining the relationship between the main variables showed a significant correlation between the three main vari- ables. Job burnout was directly correlated with job stress so that burnout rate increased with job stress increasing (p ≤0.001, r = 0.57). On the other hand, job burnout was neg- atively correlated with job satisfaction, indicating that with increase in the level of job satisfaction, the rate of burnout decreased (p = 0.001, r = -0.41). There was a negative corre- lation between job satisfaction and job stress (p ≤0.001, r = -0.43, table 3). 4. Discussion The findings showed that more than 60% of the studied emer- gency nurses had moderate levels of job burnout, stress, and satisfaction. Significant correlation was found between job burnout and marital status, as well as job satisfaction and older age. Job burnout had direct correlation with job stress and indirect correlation with job satisfaction. There is a shortage of nursing staff around the world and Iran is no exception. According to a census (2014), Iran (with a population of 75 millions) requires about 240000 nursing staff; however, the number of nursing staff in Iran now is about 100000 (24). Majidi et al. (2017) concluded that the number of patients referred to the emergency department has increased following the implementation of the Health System Reform Plan (25). In such a situation, maintenance of human resources in hospitals was a priority and nurses who were pioneers in terms of providing services to patients were exposed to high workload and consequently burnout and dissatisfaction. In support of this claim, Nakhaei et al. in 2017 indicated that the low level of nursing staff satisfaction with the Health System Reform Plan was due to the increase in the number of patients (26). Hence, an investigation of job burnout seems to be of essence. Aiken et al. proved that each additional patient per nurse was associated with a 23% in- crease in the odds of burnout and 15% increase in the odds of job dissatisfaction (6). In the emergency departments of the hospitals evaluated in this study, a large number of nurs- ing staff had a low and moderate level of burnout and only 1.4% of the nursing staff had a high level of burnout. Despite the fact that a small number of nurses reported high burnout levels, 76% of nurses revealed a moderate level of burnout and this should receive more attention. There are similarities and differences between the findings in this study and the results of some other studies. Like the current study, some studies announced a moderate level of burnout. In 2016, Tarcan et al. surveyed 250 emergency service staff. In this study, the burnout level was evaluated to be moderate (27). Job burnout had a significant relationship with the employ- This open-access article distributed under the terms of the Creative Commons Attribution NonCommercial 3.0 License (CC BY-NC 3.0). Downloaded from: www.jemerg.com N. Tavakoli et al. 4 Table 2: Relationship of job burnout, stress and satisfaction with demographic variables of the nursing staff Variable Stress P Satisfaction P Burnout P Sex Female 3.03 ± 0.49 0.66 2.95 ± 0.66 0.75 4.01 ± 0.82 0.3 Male 2.98 ± 0.44 2.9 ± 0.63 3.79 ± 0.98 Marital Status Single 3.04 ± 0.32 0.554 3.1 ± 0.63 0.134 4.14 ± 0.58 0.049 Married 2.98 ± 0.52 2.85 ± 0.64 3.78 ± 0.98 Educational level Diploma 3.16 ± 0.45 2.79 ± 0.76 3.83 ± 0.99 Associate Degree 2.93 ± 0.53 2.8 ± 0.62 4.12 ± 4.12 Bachelor 2.98 ± 0.46 0.362 3.01 ± 0.62 0.635 3.91 ± 3.91 0.48 MA 3.51 ± 0.61 2.54 ± 0.61 4.91 ± 4.91 PhD 2.77 ± NA 2.61 ± NA 4 ± NA Age (year) 23-32 3.04 ± 0.45 2.9 ± 0.61 3.97 ± 0.71 33-42 2.97 ± 0.52 0.582 2.86 ± 0.66 0.039 3.79 ± 1.05 0.61 43-54 2.97 ± 0.55 3.53 ± 0.43 3.62 ± 1.09 Work experience (year) 1-7 3.07 ± 0.51 2.86 ± 0.66 4.14 ± 0.87 8-14 2.91 ± 0.5 0.704 2.95 ± 0.58 0.119 3.72 ± 0.72 0.184 15-21 3.02 ±0.26 2.88 ± 0.76 3.45 ± 1.26 22-28 2.86 ± 0.67 3.61 ± 0.42 3.67 ± 1.02 Table 3: Correlation between job burnout, job stress, and job satisfaction among studied nurses Variables Stress Satisfaction Burnout Stress Correlation 1 -0.43 0.57 P-value — ≤0.001 ≤0.001 Satisfaction Correlation -0.43 1 -0.41 P-value ≤0.001 — 0.001 Burnout Correlation 0.57 -0.41 1 P-value ≤0.001 0.001 — ees’ marital status and the level of burnout in single employ- ees was higher than that in married ones. Many studies have counted being single as a risk factor for burnout in nurses (27-30). Seo et al. found that single nurses are 6 times more likely than married nurses to feel burnout (31). According to the findings of this study, there was a significant relationship between the nursing staff’s age and job satisfaction and their job satisfaction improves with increase in age. This result was in line with the findings of two other studies, both of which were carried out on nurses at the emergency department (27, 32). According to the findings, burnout had a significant re- verse correlation with job stress. Such a relationship is con- firmed by various studies in different fields (28, 33, 34). A point to be noted is that high level of job stress among the staff does not necessarily imply having burned out staff. Var- ious investigations have shown that job satisfaction plays a critical role in moderating the effect of stress on resulting in job burnout (30). Job burnout had a significant and inverse correlation with job satisfaction of the nursing staff in the emergency depart- ments so that burnout rates increased linearly with a de- crease in job satisfaction. A majority of studies had found similar results to the findings of this study (27-29, 32, 34). 5. Conclusion The findings showed that more than 60% of studied emer- gency nurses had moderate levels of job burnout, stress, and satisfaction. A significant correlation was found between job burnout and marital status, and also between job satisfac- tion and nurses’ older age. Job burnout had direct correlation with job stress and indirect correlation with job satisfaction. Planning to reduce burnout of the emergency nursing staff seems to be necessary. This open-access article distributed under the terms of the Creative Commons Attribution NonCommercial 3.0 License (CC BY-NC 3.0). Downloaded from: www.jemerg.com 5 Emergency. 2018; 6 (1): e41 6. Appendix 6.1. 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Linking com- muting stress to job satisfaction and turnover intention: The mediating role of burnout. Journal of Workplace Be- havioral Health. 2016;31(2):104-23. This open-access article distributed under the terms of the Creative Commons Attribution NonCommercial 3.0 License (CC BY-NC 3.0). Downloaded from: www.jemerg.com Introduction Methods Results Discussion Conclusion Appendix References