literature review of job stress

Job Satisfaction and Job-Related Stress

• First Online: 31 July 2018

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• Elizabeth George 3 &
• Zakkariya K.A. 4  

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Job satisfaction is the employee’s positive attitude or feeling towards his or her job. It is a very important motivator for employees to remain with a job, and hence an organisation. Briefly defined, job-related stress arises when there is mismatch between the employee and the work environment. The reduction of stress levels among employees is crucial in an organization. These two concepts—job satisfaction and job-related stress—are examined in relation to psychological empowerment with theoretical and research support. Apart from stating the definitions, significance, types, models and factors determining these concepts, the authors have provided a comprehensive review of the research literature for both variables, job satisfaction and job-related stress in relation to the construct of psychological empowerment, and the consequences of job satisfaction are discussed. Various scales established by different researchers for measuring job satisfaction and job-related stress are reported and discussed.

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George, E., K.A., Z. (2018). Job Satisfaction and Job-Related Stress. In: Psychological Empowerment and Job Satisfaction in the Banking Sector. Palgrave Pivot, Cham. https://doi.org/10.1007/978-3-319-94259-9_4

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A systematic review of the job-stress intervention evaluation literature, 1990-2005

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• 1 McCaughey Centre: VicHealth Centre for the Promotion of Mental Health and Community Wellbeing, School of Population Health, University of Melbourne, Victoria, Australia. [email protected]
• PMID: 17915541
• DOI: 10.1179/oeh.2007.13.3.268

Ninety reports of systematic evaluations of job-stress interventions were rated in terms of the degree of systems approach used. A high rating was defined as both organizationally and individually focused, versus moderate (organizational only), and low (individual only). Studies using high-rated approaches represent a growing proportion of the job-stress intervention evaluation literature. Individual-focused, low-rated approaches are effective at the individual level, favorably affecting individual-level outcomes, but tend not to have favorable impacts at the organizational level. Organizationally-focused high- and moderate-rated approaches are beneficial at both individual and organizational levels. Further measures are needed to foster the dissemination and implementation of systems approaches to examining interventions for job stress.

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• Research Support, Non-U.S. Gov't
• Research Support, U.S. Gov't, P.H.S.
• Systematic Review
• Occupational Health Services
• Occupational Health*
• Research Design
• Stress, Psychological*

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Work Stress of Employee-A Literature Review

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• Published: 31 March 2022

Nurses’ job stress and its impact on quality of life and caring behaviors: a cross-sectional study

• Ali-Reza Babapour 1 ,
• Nasrin Gahassab-Mozaffari 2 &
• Azita Fathnezhad-Kazemi 3 , 4  

BMC Nursing volume  21 , Article number:  75 ( 2022 ) Cite this article

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Nursing is considered a hard job and their work stresses can have negative effects on health and quality of life. The aim of this study was to investigate the correlation between job stress with quality of life and care behaviors in nurses.

This cross-sectional survey design study was performed with the participation of 115 nurses working in two hospitals. The nurses were selected via the availability sampling method and data were collected by demographic characteristics, nurses ‘job stress, quality of life (SF12), and Caring Dimension Inventory questionnaires.

The mean (SD) total scores of job stress, quality of life and caring behavior were 2.77 (0.54), 56.64 (18.05) and 38.23 (9.39), respectively. There was a statistically significant and negative relationship between total job stress scores with quality of life ( r = -0.44, P  < 0.001, Medium effect) and caring behaviors ( r =-0.26, P  < 0.001, Small effect). Univariate linear regression showed that job stress alone could predict 27.9% of the changes in the total quality of life score (β =-0.534, SE = 0.051, R 2adj  = 0.279, P  < 0.001) and 4.9% of the changes in the total score of caring behaviors (β =-0.098, SE = 0.037, R 2adj  = 0.049 P  < 0.001).

Conclusions

Job stress has a negative effect on the quality of life related to nurses’ health. It can also overshadow the performance of care and reduce such behaviors in nurses, which may be one of the factors affecting the outcome of patients.

Peer Review reports

Job stress is an interactive situation between the job situation and the working person in that job, which leads to changes in the individual’s psychological and physiological status and affects his/her normal performance [ 1 ]. Work-related stress can damage a person’s physical and mental health and ultimately have a negative effect on job productivity by increasing stress levels [ 2 , 3 ]. Today, job stress has become a common and costly problem in the workplace and, according to the World Health Organization, a pervasive issue [ 4 , 5 ].

Stress is determined as a major cause of 80% of all occupational injuries and 40% of the financial burden in the workplace according to the American Institute of Stress [ 4 ]. Nursing is known as a stressful job since it is associated with complex job demands and needs, and high expectations, excessive responsibility, and minimal authority have been identified as the main stressors [ 6 ]. The results of studies conducted in Iran show that 7.4% of nurses are absent each week due to mental fatigue or physical disability caused by work, which is 80% higher than other professional groups [ 7 ].

According to the statistics provided by the International Council of Nurses, the costs of work-related stress are estimated at $ 200–300 million annually in the United States, and nearly 90% of employees’ medical problems are attributed to job stress [ 8 ]. Job stress among nurses may affect their quality of life, and concurrently, the quality of care. The quality of life of nurses, who deal with human lives, is of particular importance since they can provide more effective services when they have a better quality of life [ 9 ]. Nurses are in close contact with patients and such factors as employment location, variety of hospitalized cases, lack of manpower, forced overtime hours, and the attitude of the ward manager can impose tremendous stress on nurses [ 10 ]. Although stress is a recognized component of modern nursing that is useful in small amounts, in the long run, chronic diseases, such as hypertension, lead to cardiovascular disease, and therefore, affect their quality of life [ 11 ]. Moreover, job stress causes job quit, co-workers conflict, health disorders, job dissatisfaction, reduced creativity, decreased professional satisfaction, reduced correct and timely decision-making, inadequacy and depression feelings, disgust and fatigue from work, reduced energy and work efficiency, and reduced quality of nursing care [ 12 ] and these items increase the likelihood of work-related injuries [ 13 ], regarding which, the results of numerous studies have shown that job stress has a direct or indirect effect on the provision of medical services [ 14 ]. Consequently, due to the inevitability of some stressors in the nursing profession, it is necessary to prevent their psychological and behavioral effects to improve nurses’ quality of life and their care behaviors [ 15 ]. The low caring behaviors can be influenced by several factors including individual and organizational factors like abilities, skills, job design and leadership style, respectively. Work stress can affect caring behavior nurses because of nurse, s excessive activity or workload and more duty [ 16 ]. Job related stress has as a result loss of compassion for patients and increased incidences of practice errors and therefore is unfavorably associated to quality of care [ 17 ]. Numerous studies reported that it has a direct or indirect effect on the delivery of care and on patient results [ 18 , 19 ]. For instance, conflict with colleagues has been found to predict lower caring practice [ 5 ]. And another study explained Job satisfaction as personal satisfaction and satisfaction with nurse management was significantly associated with caring behavior [ 20 ]. However, in study conducted in Indonesia, the results showed that there was no association between workload and job stress with caring behaviors [ 16 ]. Data from Sarafis et al., show that work-related stress impacts nurses’ health-related quality of life negatively, furthermore, it can affect patient outcomes and they have emphasized the need for performing further research in this domain [ 5 ]. Assessment of possible basics and effects of work stress among nurses has been done [ 21 ]. However, factors such as individual differences and working conditions can affect it so that significant conflicts in work-related stress between nurses may be due to workplaces, general and cultural conditions [ 14 ].

Since nurses, as members of the healthcare system, make every effort to improve the quality of care and patients’ quality of life, it is crucial to address the factors affecting their quality of life [ 22 ] It is also important to assess the dimensions of quality of life and job stress, identify psychosocial risk factors, and plan for preventive interventions to increase the efficiency and effectiveness of nurses’ activities. According to our hypotheses, job stress leads to the decline of nurse’s physical and mental health status, while it is negatively affecting nurses’ caring behaviors. Therefore, the present study was designed to achieve the following goals:

1- Assessing the level of job stress, as well as the quality of life, and care behaviors in nurses. 2- Evaluating the relationship of between job stress with quality of life and care behaviors in nurses.

Study Design and participants

This cross-sectional study was carried out in two teaching hospitals, namely the “Artesh” and “29 Bahman” hospitals, Tabriz, Iran, which are in cooperation with a non-governmental university in Tabriz, within December-January 2020. The employed nurses with at least one year of work experience and having contact with patients were entered into the study. The exclusion criteria were unwillingness to partake and failure to complete the questionnaire.

Sample size and sampling method

The maximum sample size was considered after controlling research aims, so the highest sample size was calculated based on the study performed by Sarafis et al. [ 5 ] related to job stress scale with Considering 95% confidence coefficient, 90% statistical power, an acceptable error of 0.06 around the mean (m = 2.22), and the highest standard deviation of (0.65), therefore the necessary sample size was determined to be 96 cases. The final sample size was estimated at 115 subjects after considering a drop-out rate of 20%.

Initially, the necessary permissions were obtained to conduct the research, which was followed by selecting the samples in different shifts using the availability sampling method. Afterward, the researcher referred to the hospital, explained the objectives of the study to the nurses, controlled the inclusion criteria, and obtained the participants’ satisfaction. The researcher provided the questionnaires to the samples to complete as a self-report. The sampling process was continued until reaching the calculated sample size.

1. Demographic characteristics checklist

This instrument included information about age, gender, education, marital status, shift status, employment status, and work experience.

2. Expanded nursing stress scale (ENSS)

This 57-item scale consists of 9 subscales, measuring Death and Dying Stressors (7 items), conflict with physicians (5 items), Inadequate Emotional Preparation Stressors (3 items), Problems with Peers (6 items), Problems with Supervision (7 items), workload (9 items), Uncertainty Concerning Treatment (9 items), patients and their families (8 items), and discrimination (3 items). The items are rated on a 6-point Likert scale of 1 = I have no stress at all, 2 = sometimes I am stressed, 3 = often I am stressed, 4 = I am very stressed, and 5 = this situation does not include my duties, if a person is not faced with such a situation, the number zero is marked. The total scores are estimated at a range of 0-228, with higher scores indicating higher job stress in that particular area. To obtain the mean score of each subscale, the total score of each subscale is divided by the number of items. The range of mean values for the total score and subscales are obtained at 0–4 and no specific cut-off point is determined [ 23 ].

3. Quality of Life Questionnaire-12 (SF-12)

SF-12 was constructed as a shorter alternative of the SF-36 Health Survey. SF-12, which measures physical and mental health status was used for the quality of life assessment. SF-12 includes 12 questions: 2 concerning physical functioning, 2 regarding role limitations caused by physical health problems, 1 question about bodily pain, 1 with reference to general health perceptions, 1 on vitality, 1 in regard to social functioning, 2 in relevance to role limitations because of emotional problems and 2 questions referring to general mental health [ 18 ]. To convert this score to the range of zero to 100, the raw score difference formula obtained from the minimum possible raw score divided by the difference of the maximum possible score of the minimum possible score is used. For the first time, Ware et al. [ 24 ] investigated the reliability and validity of this questionnaire and reported respective Cronbach’s alphas of 0.89 and 0.76 for physical health and mental health dimensions. Montazeri et al. investigated the reliability and validity of this scale in Iran and the reliability of the 12 items of physical and psychological elements was reported as 0.73 and 0.72, respectively [ 25 ].

4. Caring dimension inventory (CDI-25)

The CDI consists of 25 core questions designed to gather perceptions of caring by asking subjects to indicate their agreement to statements about their nursing practice as constituting caring. The respondent is required to indicate on a 5-point Likert scale ranging from “strongly agree” to “strongly disagree” whether or not they perceive caring in this manner. Studies have shown that the CDI-25 is an instrument with acceptable psychometric properties. The tool includes five dimensions: psychosocial (10 items), physical-technical (11 items), professional (1 item), unnecessary (1 item) and inappropriate (2 items). Items 3 and 16 are scored in reverse, so that the strongly agree and strongly disagree options are given the lowest and highest scores, respectively [ 26 ].

The reliability of this instrument was determined using two methods of calculating internal consistency by Cronbach’s alpha coefficient and intraclass correlation coefficient (ICC) by test-retest on 20 nurses. The Cronbach’s alpha coefficient and ICC (confidence interval of 95%) were calculated for job stress quionnaires at 0.78 and 0.82 (0.76–0.84), for quality of life at 0.87 and 0.89 (0.82–0.92), and caring dimension 0.81 and 0.85 (0.79–0.87), respectively.

Data analysis

SPSS-22 software is used to analyze the quantitative data. Sociodemographic, ENSS, SF-12, CDI-25 questionnaires score described by frequency (percent), as well as mean (Standard Deviation). The association between Sociodemographic with ENSS, SF-12 and CDI-25 determined using the t-test, ANOVA and their nonparametric equivalents for abnormally distributed variables (Mann-Whitne U test, Kruskal-Wallis H test). The associations of two continuous variables were analyzed by Spearman correlation tests in the bivariate analysis. Then, independent variables, with P  ≤ 0.05 on bivariate tests inserted into the multivariate linear regression model (enter method). The normality of quantitative data was measured based on kurtosis and skewness, Since the SF-12 and CBI scores were not normally distributed, this values were first converted by use of a natural logarithm(Ln) transformation which yielded distributions that did not significantly deviate from normality then It was used in linear regression. All tests were 2-sided.

The statistical population of the study consisted of 115 nurses (100% response rate) with mean age and work experience scores of 31.81(8.18) and 7.95(7.35), respectively. The demographic information of the samples is presented in Table  1 . The majority of participants (61.7%) were female, more than half of the subjects were married, and more than three-quarters of them had a bachelor’s degree. The employment status of most of the participants (63.5%) was permanent and most of them worked rotating shifts. The participants were selected from a range of different departments and 39.1% were working Internal medicine department.

Mean values of the ENSS, SF-12 and CDI-25

The data related to the main study variables are tabulated in Table  2 . The mean(SD) total scores of job stress, quality of life, and caring behavior were obtained at 2.77(0.54), 56.64(18.05), and 38.23(9.39), respectively. Among the job stress subscales, the highest scores were related to death and dying stressors and inadequate emotional preparation. In this same vein, the lowest score was related to the discrimination subscale. Regarding the quality of life subscale, the highest score was obtained in the field of physical health (m = 62.97 and SD = 19.42). The evaluation of the relationship between demographic characteristics and study parameters showed that job stress had a significant relationship with age, gender, employment status, and nurse’s department. In this respect, it was found that the mean scores of job stress were higher in women than in men (2.95 vs. 2.49) and in permanent nurses than in casual ones (2.86 vs. 2.63). Also, the participants who work in ICU and emergency departments have a high level of stress compared to the others. Among the demographic characteristics, only gender had a significant relationship with the quality of life, and the total mean score of quality of life was higher in men than in women (62.18 vs. 53.21). The relationship between demographic characteristics and caring behaviors showed that the total score of caring behaviors was significantly higher in men than in women (41.64 vs. 36.11) and in single cases than in married ones (40.30 vs. 36.45) (Table  1 ).

Correlation between ENSS with SF-12 and CDI-25

The data related to the relationship between the main variables of the study are summarized in Table  3 . It was revealed that the total score of quality of life was negatively correlated with all components of job stress, which was statistically significant and moderate. Furthermore, the psychological domain of quality of life had a negative correlation with all components of job stress. It was also found that there was a significant and negative relationship between the physical domain and most dimensions of job stress, except for problems with peers and death and dying stressors (Table  3 ).

Based on the results of the study, the total score of caring behaviors had a negative correlation with the total and components scores of job stress. However, this correlation was significant merely with the total score, conflict with physicians, Problems with Supervision, and patients and their families, which was weak. In addition, a significant and negative relationship was found between most areas of caring behaviors and the dimensions of job stress. Nonetheless, this correlation was not statistically significant in between most aspects of both scale, and there was a positive relationship between most dimensions of job stress and inappropriate behaviors (Table  3 ).

The results of univariate linear regression analysis showed that job stress alone could explain 27.9% of the changes in the total score of quality of life (R 2 adj  = 0.279, P  < 0.001) and the negative relationship between these two variables indicated that an increase in the standard deviation of the total job stress score, could decrease the quality of life by 0.534 (β=-0.534, SE = 0.051, P  < 0.001). Moreover, according to the multivariate linear regression, job stress (β=- 0.514, P  < 0.001) and gender (β=-0.029, P  = 0.745) were predictive factors for quality of life, and the model 2 explained 27.4% changes in quality of life ( P  < 0.001) (Table  4 ).

Based on the findings of Table  5 , job stress was able to predict 4.9% of the changes in the total score of caring behaviors (R 2 adj  = 0.049) and there was a negative relationship between these two variables; in other words, a 1 standard deviation increase in the total score of job stress led to the 0.098 decrease of caring behaviors rate (β=-0.098, P  < 0.001). The results of multivariate linear regression showed that independent variables could explain 9.2% of the dependent variable changes ( P  = 0.002), however job stress (β=-0.059, P  = 0.146), gender (β=-0.084, P  = 0.075), and marital status (β=-0.064, P  = 0.127) weren’t significant effect of caring behaviors.

This study aimed to explore the status of job stress and examine its relationship with nurses’ quality of life and caring behavior. The results of the study indicated a negative relationship among the main components of the research. In this regard, the mean total score of job stress was higher than normal, which was slightly higher than that found in a study conducted in Greece. However, the findings of most studies have reported high levels of anxiety and stress among nursing staff. It was revealed that job stress was higher in females than in males, which could be attributed to their different roles in daily life. Nevertheless, in some studies, no significant difference was found between gender and job stress [ 27 , 28 ]. However, the lack of relationship between gender and stress levels in the mentioned studies may be due to a large number of female than men participants.

In the present study, no significant difference was found between marital status and the stress level, which was inconsistent with that of a study performed by Mehrabi et al. [ 29 ] the reason may be due to the fact that married individuals’ more involvement in life issues and the impact of other life matters that can affect job stress. In our study, an increase in stress level was also observed with aging, which may be due to the effect of job burnout in individuals. In the study of Abarghouei et al., there was no significant relationship between age and job stress, but there was a direct relationship between job stress and job history. Also, with increasing work experience, the rate of burnout was higher and there was relationship between job stress and job burnout [ 30 ]. Long-term job stress has been shown to lead to burnout which is often used by the health care personnel synonymously with occupational stress [ 31 , 32 ]. However, no relationship was found between age and stress in several studies [ 28 , 33 , 34 ], which can be attributed to the fact that, in our study, 50% of the participants were under 30 years old. In addition, the level of job stress was higher in permanent employees than in contract ones, which can be attributed to a higher sense of responsibility and more duties. Also, in the present study, no significant difference was found among different shifts. Data from Arkerstedt et al. support the idea that nighttime work is hazardous to a person’s wellbeing [ 35 ] and different work shifts are considered one of the sources of stress among nurses [ 36 ], however, the results of studies on this subject are different. So that in some studies, stress levels were reported to be high in night shift nurses [ 37 , 38 ] and in others, stress was reported to be high in morning shift nurses [ 36 , 39 ]. overall, it should be acknowledged that the sources of job stress and its level of effect are different according to the working conditions, working department, and culture of each society so nurses may have different levels of job stress and influencing factors due to different working conditions and the level of support provided.

According to the findings of our study, most occupational stressors were related to death and Death and Dying Stressors and insufficient emotional preparedness. The first occupational stressors were found to be death and suffering, which was consistent with the results of studies conducted in Greece [ 40 ] and the Philippines [ 41 ], reporting that such stress is probably rooted in the inability to prevent death. The second most important factor of job stress in the present study was found to be insufficient emotional preparedness, which in a study performed by Sarafis [ 5 ], this second cause of job stress was revealed to be the conflict with the patient and family. However, in our study, this factor was reported as the fifth cause of job stress. Insufficient emotional preparedness might have been created due to the sudden outbreak of COVID-19 at the time of performing the present study.

The third source of job stress was related to the problems with the supervisor, which was also reported as the third stressor in the study carried out by Sarafis et al. [ 5 ]. Based on the findings of a study conducted in Japan, poor support from the supervisor was associated with depression [ 42 ]. English researchers have also reported that the lack of adequate support from nursing managers leads to a significant increase in stress, whereas support with supervision causes a reduction in job stress [ 43 ]. The least stressful factor was revealed to be discrimination, which was in agreement with the results of other studies. Park and Haq introduced the lack of receiving rewards and encouragement as the main cause of stress among nurses, which can be attributed to the differences in the statistical population and used questionnaires between these two studies [ 44 , 45 ].

According to another finding of the present study, the total score of quality of life and its dimensions was obtained in the middle range, and the mean score of the psychological dimension was lower than the physical dimension. A review of the literature indicated that the mean values of the total score and dimensions of quality of life in our study were lower than those in other studies [ 7 , 46 , 47 ]. This discrepancy can be regarded as the time of performing the research, which coincided with the onset of coronavirus. Based on the findings of researchers, nurses are under various mental and physical pressures depending on their job status. The reason for such stress can be due to nurses’ workload during the day since they are responsible to take care of several patients simultaneously, the repetition of which on consecutive days causes physical and psychological damages, and ultimately, affects the quality of life [ 4 ]. There was a significant inverse relationship among all dimensions of job stress with total quality of life and psychological and physical dimensions, which was consistent with the results of other studies conducted in this domain [ 7 , 48 ]. The results revealed that job stress had a moderate and weak relationship with psychological and physical dimensions, respectively. Also, 27.9% of the changes in the total score of quality of life was related to job stress and this relation was negatively significant (β=-0.534, P  < 0.001). According to the previous report, job stress is associated with low self-esteem, depression, anxiety, and feelings of inadequacy, which is considered a major risk factor for mild psychiatric illness [ 49 ]. Moreover, it was revealed that heavy workload, long working hours, lack of support, and Inability to quit work and not having enough rest can cause physical harm to the nurses, reduce their quality of life, and increase stress and tension in the workplace [ 50 ]. Also, researchers shown that job stress was as an independent predictor of quality of life related to mental component (β=-4.98, P  < 0.001), and stress resulting from conflicts with supervisors was independently associated with mental health [ 5 ]. which is consistent with our study. According to researchers, good mental health increases trust and cooperation and control stressors [ 51 ]. Mental well-being and capacity to cope with stressful situation is important [ 52 ]. The psychological well-being is related to the higher using of the different coping strategies [ 53 ] and cultivating an environment of trust may provide organizations with a strategy to improve levels of mental health and satisfaction among their employees [ 54 ].

According to the results, nurses have paid more attention to such caring behaviors as writing reports, wearing clean and tidy uniforms, monitoring vital signs, and reporting the patient’s condition to the superior nurse, which is a technical-professional. However, assisting patients in daily activities, sitting at the patient’s bedside and talking to him/her, maintaining the patient’s privacy, maintaining professional competence, and listening to the patient were considered the least important. Overall, 4.9% of the changes in the total score of caring behaviors was related to occupational stress and the relation between to variables was negative (β=-0.098, P  < 0.001). The comparison of results of this study with those of similar studies performed in Spain and England indicated the existence of differences in the understanding of nurses’ caring behaviors [ 55 ]. However, this finding was consistent with that of studies conducted in Iran [ 56 , 57 ]. Factors influencing caring behaviors can be rooted in nursing education [ 57 ]. Paying too much attention to physical care during education, increasing the workload in the ward, a large number of patients per nurse in each shift have a great impact on the performance of nurses at the patient’s bedside [ 58 ]. Job stress were significant and independent predictors of total caring behaviors and its subscales.

Researchers have attributed these discrepancies to the cultural differences of societies [ 49 ]. The data analysis showed a weak inverse relationship between job stress and different dimensions of caring behaviors. It should be noted that the increase in scores in various dimensions of job stress had a significant negative relationship with the psychosocial domain, which was moderate. Apparently, psychosocial support of the patient decreases with an increase in such stressors as conflict with physicians, patient and family, and increased workload.

According to researchers, job stress is a physical-psychological syndrome accompanied by fatigue that leads to negative behaviors and attitudes toward oneself, work, family, and patients, and causes ineffective activity and absenteeism, immorality, and job dissatisfaction, seemingly stemming from nurses’ mental stress and lack of concentration [ 51 ]. Excessive job stress has negative impacts on nurses’ psychological well-being and reduces their work productivity. The results of the present study have been confirmed by the reports of other researchers; in this respect, the job stress of healthcare workers has a relationship with their low job satisfaction, negative attitude towards own job, and negative consequences on the quality of caregiving [ 59 , 60 ].

Limitations

One of the limitations of this study was related to the type of this research since it is not possible to correctly determine causal relationships in cross-sectional studies. Furthermore, the use of the availability sampling method can be one of the limitations of the study; however, the performance of this study in two teaching hospitals contributed to the effective generalization of the results. Moreover, the non-significant result especially between groups may be due to the low sample size and because of a small sample size, the number of predictive variables to be included in the regression models was limited. Since the present study was conducted at the time of the outbreak of COVID-19, it can be a confounding factor on the main variables of the study, namely job stress, quality of life, and caring behaviors, the effects of which have not been investigated. For future study in this area, these limitations described above have important implications for similar projects.

In general, the findings of this study showed that employed nurses had higher levels of perceived job stress that can have negative effects on their quality of life and caring behaviors. Job stress can endanger the physical and mental health of nurses, decrease energy and work efficiency, and fail to provide proper nursing care, which ultimately has a negative impact on patient outcomes. Therefore, it is required to investigate the stressors and effective planning to eliminate these factors. The provision of educational programs to the proper introduction of this profession to the community can increase awareness about the nurses’ problems and concerns, and ultimately, improve their quality of life. Nevertheless, it is recommended the initial management be performed at the organizational level. Purposeful education in university on nursing professional values is essential and hospital managers can improve nurses’ quality of life and caring behaviors by providing cognitive-behavioral intervention programs with the aim of identifying sources of stress in the workplace and providing soft skill programs such as team working, behavioral and communication skills and teaching effective coping strategies to reduce stressors.

Availability of data and materials

The datasets are available from the corresponding authors on request.

Abbreviations

Expanded Nursing Stress Scale.

Quality of Life Questionnaire-12.

Caring Dimension Inventory

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Acknowledgements

We thank the women who participated in the study. We also appreciate the support from the Islamic Azad University of Medical Sciences.

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Ali-Reza Babapour

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A. Fn-K developed the study concept and study design. Testing and data collection were performed by A.B and N.GM. Data analysis and interpretation were performed by A. Fn-K. Fn-K. and A.B drafted the manuscript, and A. Fn-K and GM. N provided critical revisions. All authors approved the final version of the manuscript for submission.

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Babapour, AR., Gahassab-Mozaffari, N. & Fathnezhad-Kazemi, A. Nurses’ job stress and its impact on quality of life and caring behaviors: a cross-sectional study. BMC Nurs 21 , 75 (2022). https://doi.org/10.1186/s12912-022-00852-y

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The current study examined reports of perceived stress, job satisfaction, and job performance ratings in a longitudinal study of 684 officers participating in the Officer Safety and Wellness (OSAW) Initiative. Officers’ stress (wave 1) was negatively associated with job satisfaction (wave 2), which in turn was positively associated with supervisory ratings of job performance (wave 3). These associations remained significant among officers reporting low to moderate baseline resilience but the association between job satisfaction and performance dissipated among officers with high resilience. Stress was negatively related to job satisfaction for officers who had easy access to agency-based wellness programs, whether they had concerns about stigma or used the programs, or not. The association between stress and job performance varied according to program access, use, and concerns about stigma associated with use. Administrators and policymakers striving to retain a high-performance police workforce may consider these results in recruiting as well as academy and in-service wellness training and program decisions. Structural equation models were estimated to examine direct effects and, in subsequent analyses, the moderating effects of officer resilience and agency wellness programming on both the stress-job satisfaction association and the job satisfaction-job performance association. Surveys were administered annually, with job performance assessed both in terms of a self-rating and a self-report of supervisory rating at each officer’s last performance review. (Published Abstract Provided)

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Burnout syndrome and work engagement in nursing staff: a systematic review and meta-analysis

Miguel Ángel vargas-benítez.

1 San Cecilio Clinical University Hospital, Granada, Spain

Francisco José Izquierdo-Espín

2 Critical Care Unit, General University Hospital of Jaén, Jaén, Spain

Nuria Castro-Martínez

3 Internal Medicine Service, General University Hospital of Jaen, Jaén, Spain

José L. Gómez-Urquiza

4 School of Health Sciences, University of Granada, Cortadura del Valle s/n, Ceuta, Spain

Luis Albendín-García

5 Casería de Montijo Health Centre, Granada-Metropolitan Health District, Granada, Spain

6 Instituto de Investigación Biosanitaria (ibs.GRANADA), Granada, Spain

Almudena Velando-Soriano

Guillermo a. cañadas-de la fuente.

7 School of Health Sciences, University of Granada, Granada, Spain

8 Brain, Mind and Behaviour Research Centre (CIMCYC), University of Granada, Granada, Spain

Associated Data

The original contributions presented in the study are included in the article/ Supplementary material , further inquiries can be directed to the corresponding author.

A difficult and demanding work environment, such as that often experienced in healthcare, can provoke fatigue, anxiety, distress, and discomfort. This study considers factors that may influence levels of burnout and work engagement among nurses and seeks to determine the relationship between these conditions.

A systematic scoping review was performed, in accordance with the PRISMA Extension for Scoping Reviews, based on data obtained from a search of the PubMed/MEDLINE and Scopus databases carried out in 2022 using the search equation: “work engagement AND nurs * AND burnout.” This search identified nine quantitative primary studies suitable for inclusion in our analysis.

Work overload, type of shift worked, and/or area of hospital service, among other elements, are all relevant to the development of burnout. This syndrome can be countered by social support and appropriate personal resources and values, which are all positively associated with work engagement. Our analysis revealed a significant correlation between work engagement and the different domains of burnout. The correlation effect size between burnout and work engagement was −0.46 (95% CI −0.58, −0.31), with p < 0.001.

Well-targeted interventions in the healthcare work environment can reduce burnout levels, strengthen work engagement, and enhance the quality of healthcare.

1. Introduction

In nursing, highly complex tasks must be performed and decisions are taken in situations that are often difficult and stressful. Moreover, appropriate attention must be provided not only to patients but also to visiting family members. The working environment can include long days, rotating shifts, a severe emotional burden, and sometimes aggression expressed by patients, their families, or even colleagues ( 1 ). If this circumstance persists for an extended period of time, it can provoke fatigue, anxiety, distress, and discomfort, any or all of which may reduce the quality of care provided and heighten the probability of error. In such a case, there may be an evident imbalance between the human resources available and the demands placed on them ( 2 ).

The tasks performed by nurses are determined, on the one hand, by the day-to-day healthcare demands encountered, and on the other hand, by the resources available—personal, situational, and organizational. This balance is reflected in the job demands–resources model (JD-R) ( 3 ). Occupational demands may be physiological and/or psychological, and each type imposes a cost on the individual. In many situations, workers are subjected to stress and heavy workloads, although these may be counteracted by the application of situational resources ( 4 ), such as companionship, autonomy, opportunities to learn, institutional recognition, and the possibility of promotion, as well as personal resources such as resilience, self-efficacy, and optimism ( 5 ). Both types of resources help the professional adapt to the work environment, fostering the ability to cope ( 6 ), generating motivation and work engagement (WE), and thus reducing the probability of burnout ( 7 , 8 ).

Burnout is a consequence of long-term harmful stress in the workplace. If the individual lacks resources to deal with this situation, the response made may be maladaptive and prolonged ( 9 ). Maslach and Leiter defined three domains of burnout syndrome: emotional exhaustion, depersonalization, and low personal accomplishment ( 10 ). It may be counteracted, however, by high levels of WE, that is, a state of satisfaction, commitment, and motivation. This, too, consists of three domains: vigor (effort, self-generated energy, and resolve), dedication (exaltation, empowerment, and active assistance), and absorption (immersion and high levels of concentration in the activity being performed) ( 11 ).

Traditionally, the concepts of burnout and WE have been considered opposing and independent. Paradoxically, however, some studies have observed the simultaneous presence of burnout ( 12 ) and WE ( 13 – 15 ), which suggests that these concepts, while independent, have a certain negative correlation ( 3 , 16 ). Nevertheless, demanding occupational conditions are associated with burnout, while the availability of appropriate resources contributes to WE ( 16 ), although the beneficial impact of these resources varies according to the population considered and the environment in question.

As members of the multidisciplinary team in critical and emergency care services, nurses play a vital role in improving the quality of care and in reducing morbidity, mortality, and their associated health costs ( 17 ). Moreover, incorporating nurses into the multidisciplinary oncology team benefits the team's overall performance and can shorten the duration of treatment ( 18 ). Therefore, a good understanding of the working conditions experienced by nurses and other health workers will facilitate an organizational approach to help prevent burnout and foster WE, thus enhancing the care provided ( 19 ).

In summary, the aim of this study is to identify and analyse the factors that affect WE and burnout in nurses and then to determine the relationship between these reactions to the occupational environment.

2.1. Search strategy

A systematic scoping review was performed, in accordance with the PRISMA Extension for Scoping Reviews ( 20 ), based on data obtained from a search of the PubMed/MEDLINE and Scopus databases carried out in September 2022 using the Medical Subject Headings (MeSH search equation: “work engagement AND nurs * AND burnout”).

2.2. Inclusion and exclusion criteria

The following inclusion criteria were applied:

• - Primary full-text sources in English or Spanish.
• - Quantitative articles with sample populations of nurses.
• - Articles that measure the correlation between WE and burnout, or establish their predictive characteristics.
• - Studies published between 2016 and 2022.

The exclusion criteria were as follows:

• - Doctoral thesis.
• - Articles with mixed samples without independent data on the nursing staff.
• - Articles whose main objective is not correlated with the subject of study.

The selection of articles for analysis was carried out in three steps: First, the titles and abstracts were read, followed by a full-text reading of those remaining for analysis. Finally, a critical reading was conducted of each text finally selected, in order to assess the method applied and to detect any publication bias.

2.3. Level of evidence

The quality of the studies included in this review was assessed in accordance with the levels of evidence and degrees of recommendation stipulated by the Oxford Centre for Evidence-Based Medicine (OCEBM) ( 21 ).

2.4. Variables, data collection, and data analysis

The following data, obtained from each study/article, are summarized in Table 1 : (1) author, year of publication, country of the study; (2) design; (3) sample; (4) results; (5) level of evidence (OCEBM); and (6) grade of recommendation ( Table 1 ). A correlation effect size meta-analysis was calculated using StatsDirect software. Random effects were used for the calculation, and heterogeneity was assessed by i 2 . The Egger test was used to test for publication bias, and a sensitivity analysis was performed to check that none of the studies significantly affected the effect size.

General information on the studies considered.

DASS21, Depression Anxiety Stress Scale-21; GR, Grade of Recommendation; JDRQ, Job demands–resources Questionnaire; LE, level of evidence; MBI, Maslach Burnout Inventory; MBI-HSS, Maslach Burnout Inventory—Human Services Survey; PINS, Professional Identity in Nursing Survey; QEEW, Questionnaire on the Experience and Evaluation of Work; QNWLS, Quality of Nursing Work Life Scale; SIMPH, Short Inventory to Monitor Psychosocial Hazards; UWES, Utrecht Work Engagement Scale; WE, Work engagement.

The literature search obtained 404 articles. After excluding duplicates and applying the inclusion and exclusion criteria, 65 remained for full-text reading. This led to a further 58 being excluded, leaving seven for the final analysis review. In addition, a reverse search performed on these articles led to another two being included. Thus, nine studies were finally reviewed ( Figure 1 ).

PRISMA flowchart of the study selection process. Adapted from Page et al. ( 31 ), licensed CC-BY-4.0.

3.1. Burnout risk factors

Among the burnout risk factors for nurses, a positive correlation was observed between emotional exhaustion (a dimension of burnout) and workload. This dimension was also aggravated by emotional demands on the nurses. The longer the nurses had been employed in the service, and the more prolonged or unstable their working hours (for example, in the form of rotating shifts), the more likely they were to suffer burnout ( 25 ). Nurses who work in critical care units are more liable to suffer burnout than those working in other departments. Other factors that are positively associated with the presence of burnout syndrome include lengthy work schedules, anxiety, depression, stress, and problems with interpersonal relationships ( 26 ). Finally, a strong correlation between burnout and workload has been reported, with the latter being a significant predictor of the syndrome ( 26 , 32 ).

3.2. Protective factors of work engagement

According to the studies analyzed, good organizational values and practices, together with support from co-workers and leaders, are positively correlated with the WE of healthcare professionals. Vigor and dedication, which both contribute to WE, are positively associated with the presence of clearly stated corporate objectives, rules, and procedures ( 28 ). Other factors that favor WE include control over one's work, decision-making powers and abilities, the development of professional skills, the perception of social support, and the existence of learning opportunities—in short, satisfactory job quality ( 25 – 27 , 32 ).

Nurses working in surgical areas tend to present greater WE than those in emergency or medical care units. Moreover, hospital nurses often have lower levels of WE than those who work in health clinics ( 28 ). The specific characteristics of the job and the work environment, and even the age of the individual may also influence the development or otherwise of WE ( 30 ).

3.3. Correlation between work engagement and the dimensions of burnout

The dimensions of burnout considered were emotional exhaustion, depersonalization, and low personal accomplishment, while those of WE were vigor, dedication, and absorption.

Low levels of vigor are associated with a high risk of developing burnout due to emotional exhaustion (a perfect linear correlation has been reported in this respect). Burnout may also arise from low personal fulfillment, even if high levels of vigor are reported. Among the professionals who present low or very low dedication, there is a very high probability (90–100%) of burnout due to emotional exhaustion ( 23 ).

In addition, vigor is a significant negative predictor of emotional exhaustion, while absorption is a significant positive predictor of this condition. On the other hand, it is not significantly predicted by dedication. With respect to depersonalization, another dimension of burnout, none of the WE domains were significant mediators or direct predictors. Finally, dedication is a positive direct predictor of personal fulfillment, but neither vigor nor absorption is a significant predictor in any sense ( 22 , 23 ).

According to several studies, WE is most frequently (around 50% of cases) classified as moderate, in terms of the three domains considered (vigor, dedication, and absorption). The correlation between WE and burnout is reported to be negative and highly significant ( 22 , 23 , 27 , 29 ).

3.4. Meta-analysis of the correlation between burnout and work engagement

Five studies were included in the meta-analysis, with a total sample size of 1,506 nurses. The correlation effect size between burnout and WE was −0.46 (95%CI −0.58, −0.31) with p < 0.001 and the heterogeneity (i 2 ) was 89%. The Egger test did not reveal any publication bias, and the sensitivity analysis did not suggest any publication that had to be excluded ( Figure 2 ).

Forestplot of the correlation between burnout and work engagement.

4. Discussion

This study aims to enhance our understanding of how personal characteristics and workplace-related factors may influence WE and trigger the presence of burnout among nurses. Given this information, appropriate measures can be adopted to reduce the risk of burnout and to foster greater participation and commitment by these workers.

Our analysis shows that nurses' WE is favored by environments in which they have autonomy of decision-making, where they are given sufficient resources to carry out their work, and where there is greater altruism among workers ( 33 ). In other words, WE benefits from a strengthening of the nursing identity, which generates pride in job performance and enhances the working experience ( 34 ). In turn, higher levels of support among nurses will decrease the burnout experienced ( 33 , 35 ). The hospital area in which a nurse work is also relevant to WE and job satisfaction, which are both affected by the emotional impact or workload experienced in different areas of health care ( 36 ). According to previous research, when WE is high, nurses are less likely to request a transfer to a different work unit or service. Moreover, favorable occupational health conditions are expected to improve relationships and collaboration among workers, which enhances the care provided, and thus generates a positive gains spiral ( 24 ).

Among the factors found to increase the risk of burnout is the hospital area in which the nurses work. Those employed in an Accident and Emergency (A&E) department are more likely to generate a psychologically distant relationship with patients, as a consequence of the high level of burnout experienced ( 16 ). This, in turn, can cause patients to have negative perceptions of the quality, effectiveness, and efficiency of the healthcare received ( 37 , 38 ). Another relevant factor is the type of work shift performed; thus, nurses who work night shifts have been shown to present higher levels of burnout. In short, professionals who undergo high levels of stress and fatigue are more liable to present detachment and dysfunctional attitudes ( 39 ). Burnout can also be caused by lengthy employment in the same medical unit/service. In response, and seeking to alleviate this condition, long-standing workers might request to be transferred elsewhere ( 40 ). In addition to the above, many other elements can influence the appearance of burnout syndrome among nurses, such as the female stereotype of the profession, the lack of recognition of the ‘invisible' tasks performed, and an excessive level of bureaucracy, as pointed out by Manzano Garcia et al. in their qualitative e-Delphi study ( 41 ). These questions have received little previous research attention.

Finally, consideration should be given to the COVID-19 pandemic, which has had a negative impact on the mental health of critical care nurses and their families, as public safety considerations have been prioritized over those of patient care. This situation has generated great unhappiness among the nurses affected, despite the support received from friends and colleagues ( 42 , 43 ).

After considering the factors relevant to burnout and WE, we then determined the relationship between them, taking into account the three dimensions of each. Our analysis confirms previous findings that there is indeed a close relationship between the two concepts, and specifically that greater WE (as concerns each of its constituent elements) reduces the risk of burnout ( 40 , 44 ).

A lack of vigor is associated with higher levels of emotional exhaustion. This is in line with the Utrecht Work Engagement Scale, according to which there is a strong interaction between these two dimensions ( 45 ). Therefore, the goal of recognizing WE among nurses and establishing strategies to promote it may be limited by the presence of emotional exhaustion ( 46 ). Conversely, dedication is inversely related to the presence and impact of burnout. Some of the studies in our analysis concluded that professionals who were unable to perform the work expected of them, or who were unable to meet the needs raised, whether by the patient or by the organization, due to decreased levels of dedication and perceptions of insufficiency, were at a high risk of developing burnout ( 47 ). In this respect, too, some authors indicate that a feeling of low personal fulfillment may arise from the view that the tasks performed are not considered important or productive. This impression would tend to reduce dedication and hence WE ( 48 ). Finally, high levels of absorption might provoke burnout, if this absorption prevents the worker from achieving an objective emotional balance ( 37 , 40 ).

Our study is subject to certain limitations, which should be acknowledged. First, by restricting the articles considered to those published in English or Spanish, we may have omitted potentially significant research findings from studies published in other languages which otherwise met the inclusion requirements. Furthermore, the studies included did not all use the same measurement instruments, so the results presented may not be homogeneous. Finally, the relationship between burnout and WE has only recently been the object of academic study, and so relatively few articles are available for consideration.

5. Conclusion

The correlation between low WE and burnout in nurses not only impacts these professionals but also has damaging consequences for patients and the health system in general.

The studies considered in our review describe varying degrees of burnout and WE. The relevant factors identified include employment conditions (such as work overload and type of shift or service area), personal characteristics (such as perceived support and the individual's own values), and organizational resources. All of these factors influence WE and hence the possibility of burnout.

The results obtained from our analysis highlight the need to design and implement effective interventions in the workplace in order to address the problematic areas identified and thus reduce the risk or degree of burnout among nursing personnel. This, in turn, would enhance levels of WE. Failure to do so might be damaging not just for the workers concerned but also for the quality and safety of public healthcare.

As a final observation, further studies in this area are needed in order to better understand the phenomenon of burnout among nursing staff.

Data availability statement

Author contributions.

MAV-B, FJI-E, and GAC-F: conceptualization. FJI-E, AV-S, and LA-G: data curation. NC-M, JLG-U, and AV-S: formal analysis. MAV-B, JLG-U, and AV-S: investigation. AV-S, JLG-U, and GAC-F: methodology. MAV-B and AV-S: resources. JLG-U: software. LA-G and GAC-F: supervision. JLG-U, NC-M, and GAC-F: visualization and validation. MAV-B, NC-M, and FJI-E: writing—original draft, review, and editing. GAC-F: funding acquisition and project administration. All authors contributed to the article and approved the submitted version.

Acknowledgments

This study forms part of the Doctoral Thesis of the FJI-E, working within the Clinical Medicine and Public Health Doctoral Programme of the University of Granada (Spain).

Funding Statement

This article has been funded by the FEDER/Consejería de Universidad, Investigación e Innovación de la Junta de Andalucía, Project P20-00627.

Abbreviations

WE, Work engagement; A&E, Accident and Emergency department.

Conflict of interest

The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

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Supplementary material

The Supplementary Material for this article can be found online at: https://www.frontiersin.org/articles/10.3389/fmed.2023.1125133/full#supplementary-material