







































 Humanities and Social Science Research; Vol. 6, No. 1; 2023 

ISSN 2576-3024   E-ISSN 2576-3032 

https://doi.org/10.30560/hssr.v6n1p1 

 1 Published by IDEAS SPREAD 

 

Targeting Burnout and Emotional State in Nurses within a Mental 

Health Care Setting: A Quasi-Experimental Study 

Josianne Scerri1,2, Alexei Sammut,1 Margaret Mangion3, Michael Galea1, Paulann Grech1, Sarah Cilia Vincenti1 

& Liberato Camilleri4 

1 Department of Mental Health, Faculty of Health Sciences, University of Malta 

2  Faculty of Health, Science, Social Care and Education, Kingston University 

3 The Edward de Bono Institute for Creative Thinking and Innovation, University of Malta 

4 Department of Statistics and Operations Research, Faculty of Science, University of Malta 

Correspondence: Josianne Scerri, Department of Mental Health, University of Malta, Msida, Malta, MSD 2080. 

Email: josianne.scerri um.edu.mt 

 

Received: November 26, 2022; Accepted: December 26, 2022; Published: December 29, 2022 

 

Abstract 

Nurse burnout is a widespread phenomenon that may impact their quality of life, work efficacy and organisational 

commitment. Hence, the need for interventions that enhance nurse well-being, and which target the needs and 

concerns of professionals working in a complex and dynamic context. The aim of this study is to examine the 

effectiveness of an intensive intervention for nurses providing care to persons with mental illnesses. A quasi-

experimental study was conducted with 120 nurses. Sixty-eight nurses received the intervention, and fifty- two 

nurses were in the control group. The intervention incorporated sessions on: (i) critical and creative thinking; (ii) 

mindfulness; (iii) legal issues; (iv) documentation and (v) expressive arts. Participants completed the Maslach 

Burnout Inventory and the DASS-21 at pre- and post- test. The single day intervention was repeated for 4 

consecutive times. Data were analysed using the Pearson’s chi square test, Wilcoxon sign test, Mann–Whitney U 

test, Spearman’s rank order correlation and a general linear model. Significant decreases in burnout-

depersonalisation, stress and anxiety were identified post intervention. Stress, personal accomplishment (burnout), 

gender and age-group were predictors of the burnout domain- depersonalisation. Interventions incorporating 

critical and creative thinking and legal issues in addition to cognitive and expressive art sessions, are efficacious 

in reducing burnout, anxiety, and stress in nurses 

Keywords: critical thinking; nursing; burnout; depression, stress; anxiety; quasi- experimental design 

1. Introduction 

Numerous empirical studies addressing burnout in healthcare providers, have accumulated since it was initially 

construed in the early 1970s. A meta-analysis conducted by Zeng et al. (2020) has demonstrated that burnout is 

notably common among mental health nurses, particularly those with less working experience and is associated 

with a decreased quality of life, increased depressive symptoms, anxiety, sleep problems, impaired memory, back 

pain and alcohol consumption. The additional costs of burnout to organizations are also documented and include 

negative attitudes, absenteeism and high staff turnover (Ohue et al., 2021). According to Johnson et al. (2018) 

burnout is usually caused by an imbalance of demands and resources between helpers and help recipients, and 

factors contributing to this imbalance include the ‘emotional labour’ of caring for persons with mental illness, 

inadequate staffing, underfunding of mental health services, detaining, and treating patients against their will and 

encountering higher levels of violence. Despite the identification of these potential triggering factors, extant 

research on burnout among mental healthcare providers staggers when compared to other occupational groups. 

The current global evidence of burnout among mental health nurses, highlights the need for interventions that 

target emotionality inherent in their everyday practice (Alenezi et al., 2019). Interventions targeting burnout have 

been categorized into individual and organisational based person-directed interventions. These typically comprise 

classic cognitive-behaviour principles (e.g., cognitive restructuring) or third-generation cognitive-behavioural 

techniques (e.g., meditation, mindfulness), whilst organization-directed interventions include educational 

interventions, work scheduling changes and co-worker support groups (Johnson et al., 2018). A meta-analysis of 

burnout intervention studies among mental health providers demonstrated that the intervention subtypes (i.e., 



hssr.ideasspread.org   Humanities and Social Science Research Vol. 6, No. 1; 2023 

 2 Published by IDEAS SPREAD 

 

person directed/organization directed/combined) did not differ significantly in remediating composite burnout 

(Dreison et al., 2018). However, person-directed interventions have been found to be more effective in addressing 

the emotional exhaustion component of burnout. Whilst a systematic review of the effect of mindfulness-based 

person-directed programmes for burnout syndrome in nursing highlight, that programmes with shorter durations 

are equally effective and attenuate drop-out rates (Suleiman-Martos et al., 2020). 

A critical review of burnout interventions among mental health providers demonstrates the heterogeneity of studies 

relating to study designs, outcome measures, types and durations of interventions that hamper comparisons and 

conclusions (Alenezi et al., 2019). Most studies tend to include cross-sectional or correlational designs which yield 

less robust results than longitudinal designs, whilst effect sizes are not always indicated in studies (Salvado et al., 

2021). Moreover, although the Maslach Burnout Inventory (MBI) remains the most widely used instrument in 

assessing burnout in nurses, comparisons between studies using this tool are encumbered by a heterogenous use 

of the tool, whereby different versions and scale items are used (Khatatbeh et al., 2022).  The current research 

uses the MBI-Human Services Survey (MBI-HSS) that is designed specifically for professionals in the human 

services and consists of the following sub scales: ‘emotional exhaustion’; ‘depersonalisation’ (conceptualized as 

the impersonal response towards recipients of one’s care) and ‘personal accomplishment’ in one’s work.  

Various recommendations relating to nursing interventions on burnout and emotional state have been made. These 

include addressing participants’ needs and cultural contexts when formulating interventions (Ruiz-Íñiguez et al., 

2021) and the inclusion of additional outcome measures that complement the MBI in studies (Dreison et al., 2018). 

This was addressed in the present research through the collection of additional data on anxiety, depression and 

stress in nurses using the Depression, Anxiety, Stress Scale (DASS-21) (Lovibond & Lovibond, 1995). Another 

recommendation cited relates to the inclusion of new content apart from mindfulness in interventions (Zeng et al., 

2020). The present study addressed this recommendation through the additional inclusion of sessions on critical 

and creative thinking skills; legal issues; documentation and expressive arts. Critical and creative skills were 

included in the intervention, as they foster a sense of freedom and autonomy in the person. They also provide space 

for the generation of ideas, whilst also instilling a greater willingness for care providers to confidently step outside 

of their comfort zone (Ma et al., 2018).  This notion of critical thinking was approached using the critical thinking 

model for nursing judgement as outlined by Kataoka-Yahiro and Saylor (1994). In this model different levels and 

components of critical thinking were used to build practical examples stimulating reflection and discussion. This 

enabled the participants to focus on the importance of seeking alternatives to move away from functional fixedness, 

thus shifting of their perspectives to change problems into opportunities. A session on legal issues was also 

included to address nurse vulnerability in relation to a lack of knowledge on patients’ rights and the signing of 

legal documents (Shenai et al., 2019; Xavier et al., 2019), whilst the session on documentation targeted what 

Bjerkan et al. (2021) describe as the lack of knowledge and a sense of insecurity regarding correct documentation 

procedures in healthcare professionals. The decision to include expressive arts was influenced by the role of 

creativity as a means of reducing nursing stress, thus positively targeting their well-being (Phillips & Becker, 

2019). 

With these considerations in mind, the current quasi-experimental design addressed the following research 

question: What is the impact of an intervention that incorporates critical and creative thinking, legal issues, 

mindfulness, documentation and the expressive arts on nurses’ levels of burnout, depression, anxiety and stress? 

2 Method 

2.1 Study Design 

A non-equivalent control group pretest-posttest quasi-experimental research design was used. This choice of 

design enabled the evaluation of the intervention by examining levels of burnout, anxiety, depression and stress 

prior to commencing the intervention (T1) and then on completion (T2). The intervention consisted of a full day 

workshop with a duration of 7 hours. The workshop was held over a single day as this would prove less challenging 

for nurses to attend. The intervention was conducted outside their workplace setting, on university premises. 

2.2 Participants 

The target population consisted of all nurses working within the main psychiatric hospital. Inclusion criteria for 

the study included full-time qualified nurses who provided care to persons with mental health conditions. A total 

of 120 participants agreed to partake in the study (i.e., within the intervention or control group) from a total of 230 

nurses working in the mental health sector providing a margin of error of 6.2% assuming a 95% confidence level. 

An a priori power analysis was also conducted using G*Power version 3.1.9.7 (Faul et al., 2007) to determine the 

representative sample size required to test the study hypothesis. Results indicated the required sample size to 

achieve 80% power for detecting a medium effect size (d = 0.472), at a significance criterion of α=0.05 was N = 



hssr.ideasspread.org   Humanities and Social Science Research Vol. 6, No. 1; 2023 

 3 Published by IDEAS SPREAD 

 

120 participants for the Mann Whitney test. Using an allocation ratio of 1.308, a sample of 68 participants in the 

experimental group and 52 participants in the control group was deemed adequate to test the study hypotheses. 

In the present study 37.5%, 50% and 35% of nurses experienced some degree (i.e., 

mild/moderate/severe/extremely severe levels) of stress, anxiety and depression respectively at baseline. Whilst 

for burnout scores by total sample, approximately half of the study participants perceived themselves as 

emotionally exhausted (55.8%) and withdrawn from work (52.5%) and 74.2% expressed a sense of personal 

accomplishment at baseline. 

2.3 Procedure 

A total of four workshops were organised with a maximum number of 18 participants within each workshop. The 

number of participants in each workshop was restricted to enable effective interaction with the professionals 

delivering the intervention. Participants were also informed that the workshops would be held over 4 consecutive 

days. Those nurses who could attend on any one of these 4 days were assigned to the intervention group. Whilst 

those nurses who were willing to participate in the study but could not attend any one of the 4 days assigned, 

accepted to form part of the control group. Hence, the intervention group consisted of 68 nurses and the control 

group of 52 nurses. Participants in the intervention group were instructed not to discuss details pertaining to the 

intervention with other colleagues outside their specific workshop. 

The single day intensive workshop consisted of face-to face sessions on the following topics. The number in the 

brackets represents the duration of each session. 

(i) mindfulness (1.5 hours) 

(ii) expressive arts (1.5 hours) 

(iii) documentation in the mental health nursing context (1 hour) 

(iv) critical and creative thinking skills (1.5 hours) 

(v) legal issues (1.5 hours) 

2.4 Measures 

Anonymous data were collected both at pre- (T1) and post- test (T2) using a socio-demographic questionnaire; the 

Maslach Burnout Scale (Maslach et al., 1996) and the Depression, Anxiety, Stress Scale (DASS-21) (Lovibond & 

Lovibond, 1995). 

(i) The socio-demographic questionnaire collated data regarding gender and clinical attributes such as the level of 

nursing education, years of professional experience in a general nursing and in a mental health setting and the 

clinical area where the nurse currently worked (e.g., acute/chronic/community). 

(ii) Burnout was measured using a self-rating scale developed by Maslach et al. (1996). The tool consisted of 22 

items and three subscales namely: emotional exhaustion (EE), depersonalisation (DP), and personal 

accomplishment (PA). All MBI items are scored on a 7-point Likert Scale from 0 (never) to 6 (experiencing that 

every day).  In the EE subscale, nine items were related to compassion fatigue and the reduction of emotional 

energy with a score range of 0–54 (a score of < 19 was considered low burnout, 19–26 reflected moderate burnout, 

and > 26 reflected high burnout). In the DP subscale, five items reflected the extent to which a person was removed 

emotionally towards those being cared for, with a score range of 0–30 points (< 6 reflected low burnout, 6–9 

reflected moderate burnout, and > 9 indicated high burnout). In the PA dimension, eight items defined the person’s 

sense of satisfaction at work, with a score range of 0–48 points (> 39 reflected low burnout, 34–39 indicated 

moderate burnout, and < 34 reflected high burnout). Higher score for EE and DP and lower scores on personal 

accomplishment were associated with an increased risk of burnout. The internal reliability coefficients with a 

nursing population were satisfactory for the following MBI subscales: 0.85 for emotional exhaustion, 0.71 for 

depersonalization and 0.76 for personal accomplishment (Moalemi et al.,2018). 

(iii) The third questionnaire, the Depression, Anxiety, Stress Scale (DASS-21; Lovibond & Lovibond, 1995) 

comprises 21 items consisting of 3 subscales each with 7 items, measuring depression, anxiety and stress symptoms 

respectively.  Participants were asked to indicate the degree to which each statement applied to them in the last 

two weeks. The DASS-21 uses a 4-point rating scale (0 = did not apply to me at all to 3 = applied to me very much, 

or most of the time). The DASS-21 scale has good Cronbach's alpha coefficients for depression, anxiety and stress 

of 0.93, 0.88, and 0.82 respectively in a large sample (n=1, 794) in England (Henry & Crawford, 2005). It also has 

adequate convergent and discriminant validity with other measures of anxiety and depression (Brown, Chorpita, 

Korotitsch, & Barlow, 1997). 



hssr.ideasspread.org   Humanities and Social Science Research Vol. 6, No. 1; 2023 

 4 Published by IDEAS SPREAD 

 

2.5 Data Analysis 

An alpha level was set at .05 for all analyses conducted in this study. The statistical procedures were computed 

with the software IBM SPSS (version 26). Normality of scores were determined using the Shapiro–Wilk test and 

scale scores were identified to be skewed. The Pearson’s chi-square test was used to assess the association between 

two categorical variables, while the Cramer’s V index and the phi coefficient were used to quantify the strength 

of the association between the variables. The Wilcoxon signed-rank test was used to compare pre and post 

intervention scores, whilst the Mann Whitney ‘U’ test was computed to examine baseline scores between the 

intervention and control group. Intercorrelations using Spearman’s correlation coefficient were used to examine 

significant interrelationships between the subscales on the Maslach’s Burnout Inventory and the DASS-21 tool. A 

General linear model was conducted to examine several predictors of an outcome measure when predictors 

consisted of both categorical and continuous variables.  A backward stepwise procedure was then used to identify 

the parsimonious models that includes solely the significant predictors. 

2.6 Ethics 

Ethical approval was granted by the relevant university research ethics committee. To avoid coercion, potential 

participants were approached by practice nurses (intermediaries) who provided information letters describing the 

nature of the study. Posters with details regarding the research were also placed on staff notice boards. Those 

nurses who were willing to participate in the study were invited to contact the research team. Participants were 

also provided with questionnaires to be filled in at pre and posttest. These questionnaires had the same code; 

however, the questionnaires were to be filled in anonymously.  On completion of the questionnaires, participants 

were requested to place them in a box provided.  

3. Results 

3.1 Sample Characteristics 

The demographic characteristics of study participants are presented in Table 1. Most of the participants were 

female (n=68, 56.7%) with a modal age group of 20-29 years (n=45, 37.5%). Most participants worked in an acute 

(n=44, 42.7%) or chronic (n=40, 38.8%) ward setting; had an undergraduate degree in nursing (n= 55, 45.8%) and 

had been working in a mental health setting for less than 10 years (n=89; 74.2%). 

No statistically significant differences between participants in the intervention and control groups by 

sociodemographic and career related variables were identified (Table 1). 

A Mann Whitney U test was conducted to determine whether there were significant differences on the MBI and 

DASS domains between the intervention and control group at baseline. No significant differences (p>.05) were 

detected between the intervention and control group on the burnout, depression, anxiety and stress subscales (Table 

2). 

 

Table 1. The sociodemographic and career attributes of participants  

Participant characteristics 

Sample 

size 

n (%) 

Group 1 Experimental 

Group n=68 

 Group 2 Control 

Group n=52 Test statistic 

Gender 
Females  66 (55.0) 42 24 χ2(1) = 2.9, p=.09 

Phi=.16 Males   54 (45.0) 26 28 

Age groups (years) 

20-29 45 (37.5) 24 21 

χ2(3) =4.48, p=.21, 

Cramer’s V=.19 

30-39 16 (13.3) 12 4 

40-49 27 (22.5) 12 15 

50+ 32 (26.7) 20 12 

Educational Level 

Diploma 51 (42.5%) 23 28 

χ2(2) =.117, p=.94, 

Cramer’s V=.03 

Undergraduate 

degree i.e., B.Sc 
55 (45.8%) 23 32 

Postgraduate degree 

i.e., MSc, PhD  
14(11.7%) 6 8 

Years of nursing 

experience 

<10 33 (27.5%) 19 14 
 χ2(2) =.069, p=.97, 

Cramer’s V=.02 
11-20 17 (14.1%) 10 7 

21+ 70 (58.4%) 39 31 

>10   89 (74.2%) 50 39 



hssr.ideasspread.org   Humanities and Social Science Research Vol. 6, No. 1; 2023 

 5 Published by IDEAS SPREAD 

 

Years working in 

mental health setting 

11-20 14 (11.6%) 6 8 χ2(2) =2.44, p=.29 

Cramer’s V=.30 21+ 17 (14.2%) 12 5 

Clinical setting * 

Acute  44 (42.7%) 27 17 
 χ2(2) =.350, p=.84,, 

Cramer’s V=.06 
Chronic  40 (38.8%) 22 18 

Community 19 (18.5%) 11 8 

[N.B:* Variable ‘Clinical setting’ not all participants indicated their work setting] 

 

Table 2. Mean ranks for the intervention and control group on the Maslach Burnout Inventory (MBI) and 

Depression, Anxiety, Stress Scale-21 (DASS-21) subscales at baseline (T1) 

Subscale Mean Rank Experimental Group   

(n=68) 

Mean rank Control Group (n=52) Mann Whitney U test  P value 

MBI 

Personal Accomplishment 57.82 64.00 1586.00 .34 

Depersonalisation 61.49 59.20 1700.50 .72 

Emotional exhaustion 65.24 54.31 1446.00      .09 

DASS-21 

Depression 64.03 55.88 1528.00 .20 

Anxiety 62.35 58.09 1642.50 .50 

Stress 65.66 53.75 1417.00 .06 

 

Wilcoxon signed-rank tests were then conducted to identify any significant differences between scores at pre and 

post intervention for a related sample. Table 3 presents the median (Mdn), interquartile range (IQR), z scores and 

effect sizes (r) for each domain of the MBI and DASS-21 at pre-(T1) and post- test (T2), for both the intervention 

and control group. A significant improvement at T2 was identified for the intervention group in the following 

subscales namely: burnout- depersonalisation [pre-test (Mdn = 6.00), post-test (Mdn = 5.50), z = - 2.152, p =.03, 

r = .18]; DASS-anxiety  [pre-test (Mdn = 4.00), post-test (Mdn = 3.00), z = - 2.116, p =.03, r = .18] and DASS-

stress [pre-test (Mdn = 7.00), post-test (Mdn = 5.00), z = - 4.185, p <.001, r = .36]. For the control group there 

were no significant changes in scores between pre and post- test on any of the domains. 

 

Table 3. Comparison of scores between pre (T1) and post- test (T2) by experimental and control group  

  Experimental group Control group 

Tool and Subscales  
Median 

(IQR) 
Z score 

P 

value 

Effect size 

‘r’ 
Median (IQR) Z score 

 

P value 

 

Effect 

Size 

‘r’ 

MBI 

Personal Accomplishment 

T1 
32.00  

(12.50) 
-0.62 .54 .05 

36.00 (13.25) 

-0.20 .84 .019 

T2 
34.00  

(13.00) 
35.50 (11.75) 

Depersonalisation 

T1 
6.00  

(7.75) 
-2.15 .03 .18 

5.50  

(8.00) 
-0.07 .94 .0007 

T2 
5.50  

(8.00) 
5.50 (8.75) 

Emotional exhaustion T1 20.50  -1.56 .12 .13 17.50 (14.75) -0.78 .44 .007 



hssr.ideasspread.org   Humanities and Social Science Research Vol. 6, No. 1; 2023 

 6 Published by IDEAS SPREAD 

 

(13.75) 

T2 
19.00  

(17.00) 
17.50 (13.75) 

DASS-21 

Depression  

T1 
3.00   

(6.75) 
-0.97 .33 .08 

3.00  

(5.00) 
-1.88 .06 .018 

T2 
3.00  

(7.00) 

2.00  

(3.75) 

Anxiety 

T1 
4.00  

(5.75) 
-2.12 .03 .18 

3.00  

(4.75) 
-1.37 .17 .013 

T2 
3.00  

(5.00) 

3.00  

(5.00)  

Stress 

T1 
7.00  

(6.00) 
-4.19 <.001 .36 

5.50 

(4.75) 
-1.70 .09 .016 

T2 
5.00  

(6.00) 

5.50  

(3.00) 

[N.B: P values listed in bold indicate significance] 

 

Table 4 presents the intercorrelations between the various burnout subscales and those for stress, anxiety and 

depression. Higher depression scores were positively correlated with higher scores on two burnout scales:  DP 

(rho:.364, p=.003) and EE (rho=.395, p=.001) and on the DASS subscales for stress (rho=.695, p<.001) and anxiety 

(rho=.635, p<.001). Whilst higher scores on PA were negatively correlated with depression (rho=-.327, p=.007); 

DP (rho=-.327, p=.006); anxiety (rho=-.328, p=.007); and stress (rho=-.286, p=.020). Scores for EE were 

positively correlated with DP (rho=.619, p<.0001); stress (rho=.364, p=.003); and anxiety (rho=316, p=.01). 

Higher scores for the burnout subscale DP is positively associated with EE (rho=.619, p=<.001) and stress 

(rho=.251, p=.042). Stress is positively associated with anxiety (rho:.72, p<.001) 

 

Table 4. Intercorrelations amongst the subscales for the MBI and the DASS-21   

 MBI 

DP2 

MBI 

PA2 

MBI 

EE2 

DASS 

Depression 2 

DASS 

Anxiety 2 

DASS 

Stress 2 

MBI 

DP 2 
--- -.327** .619*** .364** .203 .251* 

MBI 

PA 2 
-.327** --- -.057 -.327** -.328** -.286* 

MBI 

EE 2 
.619*** -.057 --- .395*** .316** .364** 

DASS 

Depression 2 
.364** -.327** .395*** --- .635*** .695*** 

DASS 

Anxiety 2 
.203 -.328** .316** .635*** --- .720*** 

DASS 

Stress 2 
.251* -.286* .364*** .695*** 

.720*** 
--- 

[N.B: *p ≤ 0.05; **p ≤ 0.01; ***p ≤ 0.001] 

 

A General linear regression was conducted to examine whether staff emotional adjustment response (i.e., stress, 

anxiety, depression), demographic and career related variables were predictors of post-test scores (T2) on the DP 

burnout domain. This outcome measure was selected as the intervention positively impacted this burnout domain. 



hssr.ideasspread.org   Humanities and Social Science Research Vol. 6, No. 1; 2023 

 7 Published by IDEAS SPREAD 

 

Those variables that were significantly correlated with the outcome measure (i.e., DP) and that were of high 

theoretical importance were included in the model. 

The regression model (Table 5) demonstrates that stress, PA (burnout), gender and age-group were all significant 

predictors of DP (burnout). The 4-predictor model explained 30% of the total variation in the DP score. Assuming 

that other effects were kept constant, for every 1-unit increase in the stress score, the DP score was expected to 

increase by 0.321. Males were expected to score 1.679 points higher in DP than females. Whilst for every 1-unit 

increase in the PA score, the DP score was expected to decrease by 0.214 and individuals aged 31-40 years were 

expected to score 4.704 points higher in DP than their older counterparts aged over 50 years. 

 

Table 5. General linear regression for the burnout domain -DP at T2 

Parameter B Std. Error t P-value 
95% Confidence Interval 

Lower Bound Upper Bound 

Intercept 9.300 2.133 4.361 0.000 5.074 13.526 

DASS-stress T2 0.321 0.115 2.778 0.006 0.092 0.549 

PA T2 -0.214 0.051 -4.197 0.000 -0.315 -0.113 

Gender 
Male 1.679 0.798 2.104 0.038 0.098 3.260 

Female 0 . . . . . 

Age Group 

20-30 years 1.514 1.008 1.502 0.136 -0.483 3.510 

31-40 years 4.704 1.318 3.569 0.001 2.092 7.315 

41-50 years 1.464 1.129 1.298 0.197 -0.772 3.701 

More than 50 years 0      

 

4. Discussion 

4.1 Discussion of Key Findings 

According to Lopez-Lopez et al. (2019) burnout is described as notably problematic among mental healthcare 

providers and hence the need for interventions that can target this issue. The current study contributes to the extant 

literature by exploring the impact of an intervention that included mindfulness and the supplemental introduction 

of sessions on critical and creative thinking skills, legal issues, documentation, and expressive arts. The session on 

mindfulness was included as it has been identified as efficacious in addressing the EE domain, whilst the 

supplementary components were carefully selected to match the perceived stressors of the study population.  

In the present study, significant improvements in the DP component of burnout, stress and anxiety were identified 

following the intervention at T2. The critical and creative thinking skill component provided in the present 

intervention could have contributed to an improvement in DP as imaginative nurses were identified as less likely 

to develop negative, cynical attitudes, and feelings about their patients (Li et al., 2019). 

The present study also highlights that being male, being aged between 31 to 40 years, having lower levels of PA 

and higher levels of stress were all significant predictors of DP. The gender differences associated with the 

different dimensions of burnout are accented by a growing body of evidence suggesting that males are more 

susceptible to high DP (Ortega et al., 2018). With regards to age, extant research suggests that nurses’ DP is 

inversely associated with increased age (Xie et al., 2011) and this may arise as younger nurses are more prone to 

burnout since they exhibit greater professional activity, exploiting their strength and commitment excessively 

(Bartosiewicz & Januszewicz, 2019). Hence, it is possible that nurses aged between 31 to 40 years in the present 

study were more prone to higher scores on DP than their colleagues aged 50 years, due to heightened professional 

activity during those years. 

The identification of stress as a predictor of DP concurs with findings from various research studies (De Clercq et 

al., 2020; Liu and Aungsuroch, 2019; Lopez-Lopez et al., 2019). Although comparisons are hampered due to 

different scales being used in these studies to measure stress, one can also deduce that the relationship between 

stress and DP is so strong that it is effectively and consistently captured with different stress tools. De Clercq et al. 

(2020) propose that employees experiencing job related stress and anxiety leave less room for positive and caring 

behaviours to conserve valuable energy resources. Furthermore, the inclusion of legal issues in the intervention 

may also have contributed to target both stress and anxiety in participants.  In fact, Morrissey and Higgins (2019), 

in their study on the legal apprehensions amongst mental health nurses, identified that these care providers worked 

in a perceived pervasive environment of legal anxiety and fear. They further recommended that stress and anxiety 



hssr.ideasspread.org   Humanities and Social Science Research Vol. 6, No. 1; 2023 

 8 Published by IDEAS SPREAD 

 

in care providers needed to be mitigated via thorough and regular training sessions on legal issues and in relation 

to the conscientious documentation of care. 

The expressive arts component in the present intervention may also have contributed to the significant 

improvements in anxiety and stress. A systematic review examining the effectiveness of expressive arts 

interventions and psychosocial stress in health care workers, provided preliminary evidence for the effectiveness 

of expressive arts in targeting stress (Phillips., 2019). Moreover, more pronounced improvements were noted in 

those studies that included an additional psychoeducational component to the expressive arts component. The 

clinical and creative skills component provided may also have contributed to target stress as creativity in nursing 

care includes the acceptance of new ideas for patient care in such a way that the new methods are simple, useful, 

efficient, affordable, and safe and less conducive to stress (Cheraghi et al., 2021).  

Although a positive correlation was identified in the present study between anxiety, stress and PA, the intervention 

resulted in no significant improvement for the burnout domain of PA. Dreison et al. (2018) outline that PA is the 

burnout component for which intervention effects are overall not significant in studies. This may arise as PA might 

be conceptualized as more of a consequence of burnout rather than a core component (Demerouti et al., 2003). 

4.2 Implications and recommendations 

This research provides meaningful ramifications for mental health nursing practice, education and research. 

Educational institutions need to inculcate the paramountcy of self-care and mindfulness more effectively for 

mental health nurses and to foster a creative mindset and a critical thinking ethos. The role of participation in the 

arts assists in the forging of deep relational bonds on the workplace and should also be acknowledged by 

managerial staff. Such initiatives require in concert regular, systemic efforts on the workplace. Organizations must 

support positive nursing self-care behaviours such as mindfulness, which improve emotional adaptation, and 

commit to unravel workload issues, conflict and other challenges. Mental health nurses would benefit from feeling 

better supported in making decisions to solve or adapt to challenging situations. For this to happen a culture where 

negative experiences are viewed as learning opportunities and exploited to generate growth is vital. 

This research study also contributes to extant literature pertaining to burnout interventions for mental healthcare 

providers. The intervention components in this study were both grounded in the literature and selected in relation 

to the specific needs of the study population. Transparency in the reporting of sample descriptive data and specific 

details pertaining to the intervention were adhered to, thus enabling sound comparisons with other studies. The 

MBI was complemented with the DASS-21 to circumvent limitations originating from the use of a single measure 

and effect size computations were reported in the data analysis. 

In relation to future burnout studies, it is advised that such studies should address the needs and concerns of study 

populations. These interventions would be best assessed by random sampling of study participants into an 

intervention and control group and an exploration of the effects of the intervention at different time points i.e., 

after one month, three months, and six months to provide a better insight into outcomes. There is also a need to 

ascertain by research whether refresher/booster sessions would be empowering to staff and whether positive results 

are extending beyond individual nurses and being reflected in improved quality of care.  

A limitation of the current study relates to the research design. Random assignment of participants into the 

intervention and control group would have augmented the robustness of the results. Additionally, inferences about 

the sustainability over time of the improvements post intervention reported in this study cannot be made as the 

outcome measures were determined once shortly after the intervention i.e., at T2. 

5. Conclusions 

Burnout interventions comprising cognitive-behavioural components, critical and creative thinking skills and 

didactic components (such as documentation and legal issues) based on participants’ needs remediate burnout 

more comprehensively and yield significant improvements in depersonalisation, anxiety and stress in nurses. There 

is a need to acknowledge and provide such sessions and their cost (monetary or otherwise) should be perceived as 

an investment. Participation in burnout remediating training sessions or intervention research needs to be actively 

encouraged and facilitated by managers.   

References 

Alenezi, A., McAndrew, S., & Fallon, P. (2019). Burning out physical and emotional fatigue: Evaluating the effects 

of a programme aimed at reducing burnout among mental health nurses. International journal of mental 

health nursing, 28(5), 1045-1055. https://doi.org/10.1111/inm.12608 

Bartosiewicz, A., & Januszewicz, P. (2019). Readiness of polish Nurses for prescribing and the level of 



hssr.ideasspread.org   Humanities and Social Science Research Vol. 6, No. 1; 2023 

 9 Published by IDEAS SPREAD 

 

professional burnout. International journal of environmental research and public health, 16(1), 35. 

https://doi.org/10.3390/ijerph16010035 

Bjerkan J, Valderaune V and Olsen RM (2021) Patient Safety Through Nursing Documentation: Barriers Identified 

by Healthcare Professionals and Students. Frontiers in Computer Science. 3:624555. 

https://doi.org/10.3389/fcomp.2021.62455 

Brown, T. A., Chorpita, B. F., Korotitsch, W., & Barlow, D. H. (1997). Psychometric properties of the Depression 

Anxiety Stress Scales (DASS) in clinical samples. Behaviour research and therapy, 35(1), 79-89. 

https://doi.org/10.1016/s0005-7967(96)00068-x 

Cheraghi, M. A., Pashaeypoor, S., Dehkordi, L. M., & Khoshkesht, S. (2021). Creativity in Nursing Care: A 

Concept Analysis. Florence Nightingale Journal of Nursing, 29(3), 389. 

https://doi.org/10.5152%2FFNJN.2021.21027 

Cottrell, S. (2017). Critical thinking skills: Effective analysis, argument and reflection. Bloomsbury Publishing. 

De Clercq, D., Haq, I. U., & Azeem, M. U. (2020). The relationship between workplace incivility and 

depersonalization towards co-workers: Roles of job-related anxiety, gender, and education. Journal of 

Management & Organization, 26(2), 219-240. https://doi.org/10.1017/jmo.2019.76 

Demerouti, E., Bakker, A. B., Vardakou, I., & Kantas, A. (2003). The convergent validity of two burnout 

instruments: A multitrait-multimethod analysis. European Journal of Psychological Assessment, 19(1), 12. 

https://doi.org/10.1027/1015-5759.19.1.12 

Dreison, K. C., Luther, L., Bonfils, K. A., Sliter, M. T., McGrew, J. H., & Salyers, M. P. (2018). Job burnout in 

mental health providers: A meta-analysis of 35 years of intervention research. Journal of occupational health 

psychology, 23(1), 18. https://doi.org/10.1037/ocp0000047 

Faul, F., Erdfelder, E., Lang, A. G., & Buchner, A. (2007). G* Power 3: A flexible statistical power analysis 

program for the social, behavioral, and biomedical sciences. Behavior research methods, 39(2), 175-191. 

https://doi.org/10.3758/bf03193146 

Henry, J. D., & Crawford, J. R. (2005). The short‐form version of the Depression Anxiety Stress Scales (DASS‐

21): Construct validity and normative data in a large non‐clinical sample. British Journal of Clinical 

psychology, 44(2), 227-239. https://doi.org/10.1348/014466505X29657. 

Johnson, J., Hall, L. H., Berzins, K., Baker, J., Melling, K., & Thompson, C. (2018). Mental healthcare staff well‐

being and burnout: A narrative review of trends, causes, implications, and recommendations for future 

interventions. International Journal of Mental Health Nursing, 27(1), 20-32. 

https://doi.org/10.1111/inm.12416 

Kataoka-Yahiro, M., & Saylor, C. (1994). A critical thinking model for nursing judgment. Journal of Nursing 

Education, 33(8), 351-356. https://doi.org/10.3928/0148-4834-19941001-06 

Khatatbeh, H., Pakai, A., Al‐Dwaikat, T., Onchonga, D., Amer, F., Prémusz, V., & Oláh, A. (2022). Nurses’ burnout 

and quality of life: A systematic review and critical analysis of measures used. Nursing Open, 9(3), 1564-

1574. https://doi.org/10.1002/nop2.936 

Li, Y., Wu, Q., Li, Y., Chen, L., & Wang, X. (2019). Relationships among psychological capital, creative tendency, 

and job burnout among Chinese nurses. Journal of advanced nursing, 75(12), 3495-3503. 

https://doi.org/10.1111/jan.14141 

Liu, Y., & Aungsuroch, Y. (2019). Work stress, perceived social support, self‐efficacy and burnout among Chinese 

registered nurses. Journal of nursing management, 27(7), 1445-1453. https://doi.org/10.1111/jonm.12828 

López‐López, I. M., Gómez‐Urquiza, J. L., Cañadas, G. R., De la Fuente, E. I., Albendín‐García, L., & Cañadas‐

De la Fuente, G. A. (2019). Prevalence of burnout in mental health nurses and related factors: a systematic 

review and meta‐analysis. International journal of mental health nursing, 28(5), 1035-1044. 

https://doi.org/10.1111/inm.12606 

Lovibond, P. F., & Lovibond, S. H. (1995). The structure of negative emotional states: Comparison of the 

Depression Anxiety Stress Scales (DASS) with the Beck Depression and Anxiety Inventories. Behaviour 

research and therapy, 33(3), 335-343. https://doi.org/10.1016/0005-7967(94)00075-U 

Ma, X., Yang, Y., Wang, X., & Zang, Y. (2018). An integrative review: Developing and measuring creativity in 

nursing. Nurse Education Today, 62, 1-8. https://doi.org/10.1016/j.nedt.2017.12.011 



hssr.ideasspread.org   Humanities and Social Science Research Vol. 6, No. 1; 2023 

 10 Published by IDEAS SPREAD 

 

Maslach, C., Jackson, S. E., & Leiter, M. P. (1996). MBI: Maslach burnout inventory: CPP, incorporated Sunnyvale 

(CA).  

Moalemi, S., Kavosi, Z., Beygi, N., Deghan, A., Karimi, A., & Parvizi1, M.M. (2018). Evaluation of the Persian 

Version of Maslach Burnout Inventory-Human Services Survey among Iranian Nurses: Validity and 

Reliability. Galen Medical Journal, 7: e995. https://doi.org/10.22086%2Fgmj.v0i0.995 

Mednick, S. (1962). The associative basis of the creative process. Psychological review, 69(3), 220. 

https://doi.org/10.1037/h0048850 

Morrissey, J., & Higgins, A. (2019). “Attenuating Anxieties”: A grounded theory study of mental health nurses’ 

responses to clients with suicidal behaviour. Journal of clinical nursing, 28(5-6), 947-958.  

https://doi.org/10.1111/jocn.14717 

Ohue, T., Aryamuang, S., Bourdeanu, L., Church, J. N., Hassan, H., Kownaklai, J., ... & Suwannimitr, A. (2021). 

Cross‐national comparison of factors related to stressors, burnout and turnover among nurses in developed 

and developing countries. Nursing open, 8(5), 2439-2451. https://doi.org/10.1002/nop2.1002 

Ortega, E., Cañadas-De la Fuente, G. A., Ramirez-Baena, L., De la Fuente-Solana, E. I., Vargas, C., & Gómez-

Urquiza, J. L. (2018). Gender, marital status, and children as risk factors for burnout in nurses: A meta-analytic 

study. International journal of environmental research and public health, 15(10), 2102. 

https://doi.org/10.3390/ijerph15102102 

Partnership for 21st Century Learning (2015). P21 framework definitions. www.p21.org/our-work/p21-framework 

Phillips, C. S., & Becker, H. (2019). Systematic Review: Expressive arts interventions to address psychosocial 

stress in healthcare workers. Journal of Advanced nursing, 75(11), 2285-2298. 

https://doi.org/10.1111/jan.14043 

Ruiz-Íñiguez, R., Pérez-Díaz, R., García-Jacomino, J. C., Carralero-Montero, A., & Santed, M. Á. (2021). 

Acceptability and effectiveness of a mindfulness-based intervention for reducing stress and burnout among 

mental health professionals: A mixed-methods pilot study conducted in Cuba. Current Psychology, 1-12. 

https://doi.org/10.1007/s12144-021-01388-1 

Salvado, M., Marques, D. L., Pires, I. M., & Silva, N. M. (2021, October). Mindfulness-Based Interventions to 

Reduce Burnout in Primary Healthcare Professionals: A Systematic Review and Meta-Analysis. In 

Healthcare (Vol. 9, No. 10, p. 1342). MDPI. https://doi.org/10.3390/healthcare9101342 

Shenai, N. A., Joseph, J., & Kachappillil, A. J. (2019). Knowledge of staff nurses regarding legal aspects of patient 

care. Asian Journal of Nursing Education and Research, 9(1), 143-145. https://doi.org/10.5958/2349-

2996.2019.00029.6 

Suleiman‐Martos, N., Gomez‐Urquiza, J. L., Aguayo‐Estremera, R., Cañadas‐De La Fuente, G. A., De La Fuente‐

Solana, E. I., & Albendín‐García, L. (2020). The effect of mindfulness training on burnout syndrome in 

nursing: a systematic review and meta‐analysis. Journal of advanced nursing, 76(5), 1124-1140. 

https://doi.org/10.1111/jan.14318 

Xavier, K. F., Mmusi-Phetoe, R., & Thupayagale-Tshweneagae, G. (2019). Nurses' Perception of Ethics and Legal 

Training of Nurses in Ghana. International Journal of Nursing Education, 11(4). 

https://doi.org/10.5958/0974-9357.2019.00117.X 

Xie, Z., Wang, A., & Chen, B. (2011). Nurse burnout and its association with occupational stress in a cross‐

sectional study in Shanghai. Journal of Advanced nursing, 67(7), 1537-1546. https://doi.org/10.1111/j.1365-

2648.2010.05576.x 

Zeng, L. N., Zhang, J. W., Zong, Q. Q., Chan, S. W. C., Browne, G., Ungvari, G. S., ... & Xiang, Y. T. (2020). 

Prevalence of burnout in mental health nurses in China: A meta-analysis of observational studies. Archives of 

Psychiatric nursing, 34(3), 141-148. https://doi.org/10.1016/j.apnu.2020.03.006 

 

Copyrights 

Copyright for this article is retained by the author(s), with first publication rights granted to the journal. 

This is an open-access article distributed under the terms and conditions of the Creative Commons Attribution 

license (http://creativecommons.org/licenses/by/4.0/). 


