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Relationship Between Nurse
Practice Environment and Burnout
of Clinical Nurses in Cambodia
Ajou University Graduate School
Nursing Science
Practice Environment and Burnout
of Clinical Nurses in Cambodia
Jin-Hee Park, RN, Ph. D, Advisor
I submit this thesis as the
Master’s thesis in
February 2018
Ajou University Graduate School
Nursing Science
Acknowledgement
First of all foremost I offer my sincerest gratitude to my supervisor, Professor Park Jin Hee, who has supported me throughout my thesis with her patience and knowledge. I attributed the level of my Master’s degree to her encouragement and effort. One simply could not wish for a better or friendlier supervisor.
I would also like to thank Professor You, Mi-Ae and Song, Ju-Eun for their support and assistance with my thesis. Their insightful comments on my thesis improved the quality of work immensely. I was truly fortunate to have them as my teachers.
Besides, I would like to thanks the authority of Ajou University for providing me with scholarship. Also, I would like to take this opportunity to thanks all professors and teaching assistants of the College of Nursing for their encouragement and instruction during my studying. In addition, I would also like to thanks to directors and head nurses who permit me for data collection from their public hospital in Cambodia. Also all staff nurses who were kindly cooperate well to complete this research data.
Specially, I would appreciate and thankful for Professor Chang Soon Book and Professor Song Sin Ja who always encourage and support all my needy. Furthermore, I would like to thanks for World Christian Nursing Foundation, President Lee Song Hee who provided full scholarship for living expense in every month for two years. This is a great owe a debt of gratitude to survive while I am study in Korea.
Finally, an honorable mention goes to my mother who gives me a free time for concentrate in study and my beloved husband who willing to encourage by physical and emotional support to complete this study in every circumstance. Otherwise, I would like to thanks to my friends who provide accommodation and transport while I was far away from home. Without helps of the particular people that mentioned above, I would face many difficulties while doing this study.
i
Aim This article describes the relationship between nurse practice environment and burnout of clinical nurse in Cambodia.
Method A cross-sectional survey using 136 clinical nurses from five public hospitals in Cambodia to complete the research instrument of Nurse Practice environment and burnout (Copenhagen Burnout Inventory, CBI).
Finding There were negative significant relationship between nurse practice environment and burnout of participant in (r = -.18, p = .032). The total of nurse practice environment was negative significantly related total of work-related burnout (r = -.24, p = .006) which indicate that the nurse practice environment has to increase more favorable to decrease the level of personal and work-related burnout. Moreover, the total of burnout was found a negative significant related to the total of nurse manager, ability leadership and support (r = -.18, p = .034), total of staffing and resource adequacy (r = -.21, p = .016), and total of nursing foundations for quality of care (r = -.25, p = .003) which indicate that the level of burnout was increase, and the nurse practice environment had decrease of favorable in their practice environment.
Conclusion Improvements to the environment, to education, and increase value of clinical nurses and relationship between nurses and physician are required to reduce the risk of nurses developing burnout and increase more patient safety in the future.
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Table of Contents
Abstract ………...…….i
Table of contents ……… …...……..……ii
List of tables ………..iv
1.Introduction……….1
1.1 Background. ……….……….1
1.2 Purpose of the study ……….……..3
1.3 Definition of Variables……….….….3
1.3.1 Nurse Practice Environment……….3
1.3.2 Burnout……….4
2.Literature reviews………5
2.1 Nurse practice environment of clinical nurses in Cambodia...…..………....…5
2.2 Burnout of clinical nurses in Cambodia ………….………..……9
2.3 Relationship between nurse practice environment and burnout of clinical nurse………... 10
3.Methods……….11
3.1 Study design ………..………...…..11
3.2 Participants ……….………...……….………...…….11
iii
General Characteristic of Clinical Nurses………..12
3.3.2 Nurse Practice Environment……….…..12
3.3.3 Burnout………..…….14
3.4 Ethical considerations ………...……….15
3.5 Data collection ………...………...………….16
3.6 Data analysis ………...………..……… 16
4.Results………...18
4.1 General characteristics of participants ………..………...….…….18
4.2 Descriptive statistics of nurse practice environment and Burnout …...….20
4.3 The difference of the level of nurse practice environment by general characteristics ……….22
4.4 The difference of the level of burnout by general characteristic ...……...….24
4.5 The relationship between nurse practice environment and burnout …...….26
5.Discussion ……….………...28
Conclusion and Recommendation………37
References ……….……..39
iv List of Tables
Table 1 General characteristics of participants………...……….………….19 Table 2 Descriptive statistics of nurse practice environment and burnout ………...21 Table 3 The difference of the level of nurse practice environment by general
characteristics……….……….23 Table 4 The difference of the level of burnout by general characteristics………...…25 Table 5 The relationship between nurse practice environment and burnout…….…..27
1 1. Introduction
1.1 Background
Public health systems in Cambodia has a well-established network, including those provincial, central, and community levels, as well as those in operational districts (CAMBODIA–WHO Country Cooperation Strategy 2016–2020). However, the outpatient’s services still remain low of utilization of public providers, therefore, the need to improve the safety and quality of health service in the public provider need to get stronger oversight and regulation, and remaining challenges (CAMBODIA–WHO Country Cooperation Strategy 2016–2020).
According to Health Metric Network (2007) indicated that nurse shortages have been experiencing in Cambodia hospital. Furthermore, Cambodian nurses’ workload environment is remaining heavy and there are poorly rewarded to a professional nurse related to their skills and experience, morale is distinguishing to be poor and degenerated, and work stress is high by. In their workplace remaining insufficient staffs and inadequate skill are mixing by Health sector strategic plan (2008-2015). The level of professional satisfaction is nurse’s majority are incapable to complete their work properly by Health sector strategic plan (2008-2015).
The previous studies of (Aiken et al., 2008) indicated that the hospitals nurses are more satisfied in their jobs with supportive nurse work environments and adequate nurses staffing and less experience nurse burnout was demonstrated by (Vahey et al., 2004), and
2
nursing care get more better quality was report by (Aiken et al., 2001). Nantsupawat et al., (2011) states that most of the research has been undertaken in North America and Western Europe. Therefore, in Cambodia has a very limitation information and research related to nurse practice environment.
Burnout of clinical nurses is very important for their work life’s quality (Van Bogaert et al., 2009). Whenever the clinical nurse get burnout, they get more stress with their work (Van Bogaert et al., 2013). More stress during working hour is lead to medical error, high risk for patient care and nurse’s turnover intension (Van Bogaert et al., 2013). Leiter et al., (2009) was survey 667 Canadian nurses in the Atlantic Province, found out the particular aspects of nurse work life and burnout were the way to lead of nurses’ intention to leaves their job. Vahey et al., (2004) was indicated the patient satisfaction was affected by the level of nurse burnout on the hospital unit. Ilhan et al., (2008) found out many factors which lead to nurse burnout such as; total working time, working hours in weekly, working shift rotation, relations with superiors seem not being happy, the job suitable is not finding, anxious feeling involved with the future, poor health was perceived, personal life and difficulties in financial course problems.
Otherwise, all the statements above point that the more unfavorable of level of nurse practice environment will increase the level of burnout of clinical nurses. Instead of this the more favorable and good nurse practice environment will be decrease the level of burnout. Furthermore, the good environment will provide the high of care quality and will decrease patient risk to be more safety. According to these finding it lead this study to be
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useful to find out how the nurse practice environment is and also how the level of burnout among nurses in Cambodia as well.
1.2 Purpose of the study
The purpose of this study was to describe the relationship between nurses practice environment and burnout among hospital clinical nurses in Cambodia. The specific aims of this study were:
1. To identify the level of nurses practice environment and burnout of clinical nurses in Cambodia.
2. To identify the difference of nurses practice environment and burnout by general characteristics of clinical nurses.
3. To identify the relationship between nurses practice environment and burnout of clinical nurses in Cambodia.
1.3 Definition of Variables
1.3.1 Nurse Practice Environment
Conceptual definition:
Nurse practice environment was defined as the characteristics of organizational related to a work setting that constrain to nursing practice as professional (Lake et al., 2002).
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Operational definition:
Nurse practice environment was operationalized using scores from practice environment scale of nursing work index (PES-NWI) developed by Lake et al., (2002) and adapted by Parken et al., (2010). The scores range from one to four; the presence of a more supportive practice environment was indicated as higher scores.
1.3.2 Burnout
Conceptual definition.
Burnout is the resulting of emotional and physical exhaustion from an associated of environmental exposure, inner stressors, sufficient coping and skills of adaption.
Operational definition
Burnout is examined based on a 19-item questionnaire have five response categories, which developed by Borritz et al., (2006). The responses are rescaled to a 0-100 metric (the value being 0-25-50-75-100) which are always or to a very high degree, often or to a high degree, sometime or somewhat, seldom or to a low degree, and never/almost never or to a very low degree. Scale score are calculated by taking the mean of the items in that scale. Also, the lower score indicated less burnout and higher scores indicated more burnout.
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2. Literature Reviews
2.1 Nurse Practice Environment of Clinical Nurses in Cambodia
Nurse practice environment is very important because it is the marrow, which shows the level of favorable of clinical nurses in their working place.
Sachiko and Damian, (2011) was indicated that in the public providers were believed of public provider were involved with being sincere, honest, good at the medical skill, gentle and sweet word, good at an explanation of each disease status, and having an efficient referral system. Moreover, the consist of government employed was the public providers, including outreach workers, health centers, provincial or district hospitals, health posts and national. The primary care was offered by health centers. The public sector in Cambodia is the primary point of contact within health centers, where 13.6% in rural areas seek care and 7.8% of people in urban areas (Demographic and Health Survey [DHS] 2005). In Cambodia, Health Metrics Network [HMN], (2007) demonstrates Health Management Information System [HMIS] was not well-performed since the acute of qualified and dedicated personnel become shortage due to particularly getting low salary and insufficient of staff motivation. This is proved by a problem statement from the Director of Planning Department, Secretary of State for Health and most of the workshop participants. Moreover, the health system or epidemiologist/Biostatistician at the central health information bureau are not found al all level of health information specialists.
Parker et al., (2010) was an investigation of the subscale analysis, the PES-NWI was appraised as an assertion of the subscale of nursing foundation for quality of care (2.85),
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nurse manager’s ability (2.64) and the relationship of collegial nurse-physician (2.87). Whereas hospital affairs of nurse participation and resource and staffing adequacy had a subscale of (2.46) and (2.35) indicated disagreement, respectively that was favorable environmental control concerned the magnitude to which nurse participates in how their environments’ work were contrived and the resources accessible to them. The composite subscale score shows that overall the environment is favorable (2.64). Analysis of workplace sectors was shown slightly different among setting with the nurses who work in the public or age-care sector nurses is less favorable than the private sector rating their environment on four of the subscales.
Bae et al., (2011) reviewed the working conditions, such as Autonomy attributes to the nurse’s sense of the freedom to take part in all activities, for instance, counseling with other about complex care issues, impacting standards of care and following up on their self-decisions with caregiving. Philosophy indicating the quality of clinical care reflects a model of nursing that accentuate a top-level standard of patient care. Nurse participation encompasses a role of participatory and nurses’ status valued in a broad organizational climate. The domain of supportive manager attributes to the nurse managers ability to support and be supervised the staff nurses. Supportive relationships with peers refer to working relationships and cohesion among nurses.
Nurse’s perception of busyness refers to the number of critical issues and what patient care needs to be taken care of that has required during their work time to be completed, and the main cause of stress among nurse is related to the heavy workload (McCormack et al., 2010). Cho et al., (2011) conducted with 817 staff nurses in 15 hospitals
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of 39 adult intensive care units in South Korea, was mention the mixed (i.e. good, moderate, poor) environments was observed as the most in the intensive care units of each hospital. In addition to the analytical approaches, Cho et al., (2011) suggested that nurse work environments are needed to be improved when the scored less than ‘good’ is found on the subscales and the composite in many hospitals and unit.
A survey of 232,342 surgical patients and 10,184 nurses in 168 Pennsylvania hospitals was conducted by Aiken et al., (2008) stated that in hospital better quality care environment, the risk of failure to rescue and death of the patient can be minimized with the criteria of fewer concerns with care quality and more positive job experience. Moreover, Aiken et al., (2009) indicated that the high-quality achievement of care required the optimization of care environment elements alongside nurse staffing and education.
The studied of 39.038 hospital staff nurses was conducted by Aiken et al., (2011). The most important of new finding was that the contingent upon the vice versa quality and nurse work environment are influenced by the impact of nurse staffing. Absent a good work environment, a costly proposition, nurse workloads were a reduction by increasing additional nurses, may result in less consequence. In the meantime, staffing improvement in hospitals is the point where work environments have to get a better effect than in hospitals with a mixed environment.
In the study of 334 registered nurses of Hinno et al., 2011 was indicated that when the evaluated of work environment characteristics were get better, the quality of care of nurse-assessed also increased and decreased linearly from intentions to leave a current job of a nurse.
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In Southeastern Michigan, the Non-experimental and descriptive design was used to aid 866 nurses who were in charge of 25 intensive care units was indicated that work environment become healthy is the most important for communication between nurse-physician. Communication between nurse and physician may not affect to all outcomes, but its influence on nurse and assessed related to medication errors, and it suggests that small but decreases the significant in medication errors can be reached when the communication between nurses and physicians is getting better (Manojlovich and Decicco, 2007).
9 2.2 Burnout of Clinical Nurses in Cambodia
Burnout is still the new concept for Cambodian nurses. Therefore, they could not know what burnout is, even though they are getting burnout with their work.
In the study of Begat et al., (2005) was concluded that the root of stress and anxiety is related to a source of job as ethical conflicts in nursing. Also, concluded that nurse’s experience has an influence on psychosocial work of having or not having control on their engagement and motivations.
The study of Michael et al., (2006), demonstrated workload get heavier, lack of resources, and visibility get decrease of fist line management has a suggestion for the nurse's health and their patient. Both environment and education have to improve as a requirement in order to decrease the risk in the future of nurses developing burnout (Nuria et al., 2011). Other study found out the manager support, age, and work by requisition was the main destructive influence cause of depersonalization. An important role as a support manager has to stay in low personal accomplishment (Li Li et al,.2015).
According to the above finding, most clinical nurses working in the hospital are suffering from burnout related to their personal, work-related, and client-related burnout with a low intention of nurse practice environment. The great challenge to the prevention of burnout has supported the responsibility of nurse manager for the health care system, because the consistently of burnout may cause enlarge nurse turnover rates and lead to medical error.
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2.3 Relationship between nurse practice environment and burnout of clinical nurses
The Cambodian nurse practice environment has also faced with unfavorable with caring many patients and lack of medical equipment or material to use in caring or treat patients. Therefore, these factors lead them to face with intention to leave. Even though, they have felt to leave but they have no other choice to get a job because of their limited education.
Therefore, I studied the topic of the relationship between nurse practice environment and burnout of clinical nurses in purpose to find out how nurse practice environment characteristic lead most clinical nurses become burnout and risk for patient life in the future. However, the clinical nurses full of skill of caring, it still leads them to get to burnout in working under pressure environment of their nurse manager and health care system. To prevent burnout all hospital, need to clarify their health care system with all nurses’ manager in order to improve nurse practice environment.
According to Kristensen et al., (2005) finding above it leads this research study to used Copenhagen Burnout Inventory (CBI) instrument to measure the level of clinical nurses’ burnout. Furthermore, the nurse practice environment (NPE-NWI) material which developed by Lake et al., (2002) is consider using to measure the favorable or unfavorable of clinical nurses for this research study. Also, an enumerate description of the PNE-NWI and CBI is given in the method and literature review section of this paper.
11 3. Methods
3.1 Study design
The study design was a cross-sectional descriptive survey to collect data from clinical nurses in Cambodia.
3.2 Participants
One hundred and thirty-six clinical nurses who met the inclusion criteria were requesting to participate in this study. Inclusion criteria were clinical nurses who currently working in the public hospital within experience in nursing at least six months. And all of them were registered nurses in both genders.
3.3 Instruments
This present study included the General Characteristics, Nurse Practice Environment Scale used of Nursing Work Index (NPES-NWI) and Burnout used of Copenhagen Burnout Inventory (CBI).
Furthermore, this study instrument questionnaire was comprised four parts. Part 1 was the informed consent form and the purpose of this study research. Part 2 was consisting of socio-demographic characteristics of subject nine items and characteristics related to working thirteen items. Part 3 and part 4 were the English version of Nurse Practice Environment (NPES from NWI) and Burnout (CBI) scale. These two scales were the English
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version initially, NPES-NWI developed by Lake et al., (2002) for nurse practice environment and CBI developed by Kristensen et al., (2005) for burnout. These two scales were translated using the back translation. First step was translated from English version to Khmer version by researcher and professional lecturer who are teaching nursing student at university and staff nurses who are working at hospital. Second step was translated from Khmer version to English version by expert English teacher. Third step was comparing the meaning of questionnaire and pilot study with ten nurses to measure their understanding. Finally, the researcher found out two questions from NPES-NWI sub domain of “Nurse Foundation for quality of care” which ask about “a clear philosophy of nursing that pervades the patients/clients/residents care environment” was exclude from this questionnaire survey. Because most of the clinical nurses had difficulty to understand and answer for this question.
3.3.1 General Characteristic of clinical nurses
Socio-Demographic characteristics were age, gender, marital status, education, and economic status. And Working related characteristics was survey about work in a week, night shift, currently position, year of experience, and departments.
3.3.2 Nurse Practice Environment
The nurse practice environment was measure by Practice Environment Scale of the Nursing Work Index (PES-NWI; Lake et al., 2002). The PES-NWI consist of 29 items in five subscales, manifesting core ascribe the nursing practice as professional. The below are the items subscales and the example such as: (1) staff nurse participation in facility affairs,
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expressed by items such as “ the staff nurse have an opportunity to attendance in policy decisions”; (2) foundations for quality care, expressed by items such as “ the administration are expected in high standards of nursing care”; (3) resource adequacy, expressed by such sample item “to get the work done must have enough staff”; (4) supportive manager, expressed by such items as “a person who have a good manager and leader skill is defined as a nurse manager”; and (5) collaborative the relationships of nurse and physician, expressed by items including “a good working relationships should meet by nurses and physicians”. Clinical nurses were requested to select the term to which they agree that each item is indicated in their current jobs on a 4-point scale, design from 1 “strongly disagree” to 4 “strongly agree”.
Lake et al., 2002 was indicated the instruction of scoring as; the more supportive practice environment show as higher scores by calculated the mean scores on each of the five subscales, and the PES-NWI (29 items) was indicated a calculated of single composite by averaging the means for all the subscales. The available scores range from 1 to 4; higher scores demonstrated the existence of a more supportive practice environment. the PES-NWI’s validity and reliability have been entrenched in assorted settings including home health agencies and hospital (Flynn et al., 2007). The each of the five subscales and total composite score’s reliability of the PES-NWI were figure for the ongoing participants. Results demonstrated to be highly internally consistent of composite score (α = 0.80), and alphas ranging from 0.64 to 0.82 of each five subscales.
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The Cronbach’s coefficient alpha had been used to estimate the internal consistency of five subscales by Lake’s (2002) PES-NWI. The internal consistency for nurse manager ability, leadership and support for nurses had been 0.84, for nurse participation in hospital affairs had been 0.83, that for adequacy of staffing and resource had been 0.80, that for the care quality of nursing foundations had been 0.80, and that for the relationship of collegial nurse and physicians had been 0.71. That for the composite measure was 0.82. In the author’s study, the internal consistency of each of the five work environment subscales was: 0.80 for the leadership and support ability of nurse manager; 0.75 for workplace of nurse participation; 0.73 for adequacy of staffing and resource; 0.67 for the care quality of nursing foundations; 0.81 for the relationship of collegial nurse and physicians; and 0.86 for the composite measure.
3.3.3 Burnout
The Copenhagen Burnout Inventory (CBI) developed by Kristensen et al., (2005) was used to measure the level of Burnout. The Copenhagen Burnout Inventory focuses on debilitation and is divided in to three sub-dimensions. Personal burnout content “six questions”, work-related burnout “seven questions”, and client-burnout “six questions”. For this research study was analysis by using the scale of each item from one as “always or to a very high degree, scoring 100%”, two as “often or to a high degree, scoring 75%”, three as “sometime or somewhat, scoring 25%”, four as “Seldom or to a low degree, scoring 25%”, and five as “never or to a very low degree, scoring 0%”. Therefore, if all the scales were positively bias, indicating that most of the participants used the response categories
15
corresponding to low burnout level. Instead of this, if all the scales were negatively bias, indicating that most of the participants used the response categories corresponding to high burnout level. Furthermore, for the reliability of the burnout of 19 items were assessed by Cronbach’s alpha.
Kristensen et al., 2007 and Borritz et al., 2005 had also been estimated the internal consistency of the three subscales by using Cronbach’s coefficient alpha. The internal consistency for personal burnout had been 0.87, for work-related burnout have been 0.87, and for client-related burnout had been 0.85. In this study, the internal consistency of each of the three burnout subscales was: 0.64 for personal burnout, 0.71 for work-related burnout, and 0.75 for client-related burnout.
3.4 Ethical considerations
The hospital’s clinical research ethics committee from the five public hospitals in Cambodia was approval the ethical research in this study. Two hospitals located in the Phnom Penh capital city and other three hospitals located in the other three provinces were chosen for this study. Each copy form was sent with an explanation the purpose of the study, duration and research method, and clear confirmation that the participation in the study has to return of a completed form of assumes consent. To build up the confidential from each participant the researcher keeps protected by not show up any information related to identification of each participants, and the data collection was coded by using Statistical Package for the Social Sciences software only.
16 3.5 Data Collection
The data were collected by using possible situation such as self-administration and interview. The self-administration was applied for young nurses who can read and understand well, and the interview process was applied for older and busy nurses.
The data collection which approval to conduct this study was obtained from the College of Nursing; the approval to collect data was obtained from the public hospitals which two publish hospitals are located in the city and other three publish hospitals are located in the province. Data were collected from July 2nd to August 23rd, 2012. The Cambodian clinical
nurses were asked their favor to participate in the study; the researcher explained the nature and the purpose of the study to the participants, with confidentiality and anonymity being assured. The participants took around 15 to 20 minutes to complete the questionnaire. The participants were also instructed that they were free for canceling to participate in the study at any time.
3.6 Data analysis
All the Data was analyses by using the IBM Statistical Package for the Social Sciences 19.0 (SPSS Inc., Chicago, IL, USA).
Descriptive statistics was used to describe the general characteristics of participants, and nurse practice environment and burnout with frequencies and percentages for categorical variables and means and standard deviations (SD) for continuous variables. Independent
t-17
test, analysis of variance (ANOVA) test and Scheffe test were performed to identify the difference in the level nurse practice environment and burnout according to the general characteristic. Cronbach’s alpha was used to calculate the reliability of the factors of the nurse practice environment and burnout. The Pearson’s correlation analyses were performed to examine the relationship between nurse practice environment and burnout.
18 4. Results
4.1 General characteristics of participants
General characteristics of the participants were shown in Table 1. One hundred and thirty-six of the participants were recruited from five public hospitals in Cambodia. Eighty-one (59.6 %) of the nurses was female. The age range of the participants was 34.6% of year group 40-49, and most of them were married (55.9 %), eighty-one (59.6 %) held associate degree, and most of them are staying in the middle of economic status (87.5 %). Ninety-one (66.9 %) worked five hours per day, most of them had duty at night shift (89.0 %), Sixty-nine (50.7 %) had position as an associate nurse or staff nurse, and thirty-three (24.7 %) were primary nurses. Among the participants sixty-six (48.5%) had experience in nursing over twenty-one years.
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Table 1.
General characteristic of participants
(N=136)
Variables Categories Frequency Percentage
Age (year) 21~29 30~39 40~49 ≥ 50 36 22 47 31 26.5 16.2 34.6 22.7 Gender Male Female 55 81 40.4 59.6
Marital Status Single Windowed Married 35 25 76 25.7 18.4 55.9 Education Bachelor degree
Associate degree Primary degree 40 81 15 29.4 59.6 11.0 Economic status Poor
Middle 17 119 12.5 87.5 Days in a week ~ 4 5 ≥ 6 32 91 13 23.5 66.9 9.6 Night shift Yes
No 121 15 89.0 11.0
Currently Position Head nurses Vice-Head nurses Associated nurses Primary nurses 17 17 69 33 12.5 12.5 50.5 24.5 Experience in Nursing (year) ~ 5 ~ 10 ~ 20 ≥ 21 38 15 17 66 27.9 11.1 12.5 48.5 Departments Emergency General ward ICU Others 18 33 34 51 13.2 24.3 25.0 37.5
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4.2 Descriptive Statistics of Nurse Practice Environment and Burnout
The level of the nurse practice environment and burnout among nurses was shown in Table 2. The total mean score of nurse practice environment was 15.00. The highest sub domain of nurse practice environment was the relationship of collegial nurse and physician (mean 3.35) and the lowest was nursing participation in the work place (mean 2.61).
Furthermore, the total mean score of burnout was 127.72. The highest sub domains of burnout were personal burnout (mean 46.08) and the lowest was work-related burnout (mean 35.87).
The subscales of workplace of nurse participation (2.61), the care quality of nursing foundations (2.86), The leadership and support ability of nurse manager (3.23), adequacy of staffing and resource (2.95), and the relationship of collegial nurse and physician (3.35) were rated as agreement. These was, favorable
of nurse participate get concerned the extent
of environmental that influences in how they managed the work environments and
the available resource to them.
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Table 2.
Descriptive Statistics of Nurse Practice Environment and Burnout
(N=136)
Variables Mean ± SD Max Min Range
Nurse Practice Environment Total (29items) 75.73 ±13.87 104 35 69
The leadership and support ability of nurse manager (8items)
24.57 ± 5.16 34 8 26 Workplace of nurse participation (8items) 17.18 ± 5.39 32 8 24 Adequacy of staffing and resource (5items) 12.53 ± 3.54 21 5 16 The care quality of nursing foundations (5items) 11.85 ± 3.48 20 5 15 The relationship of collegial nurse and
physician (3items)
9.60 ± 2.43 15 3 12
Burnout Total (19items) 51.08 ± 8.90 74 25 49
Personal Burnout (6 items) 17.16 ± 3.42 26 9 7 Work-related Burnout (7items) 17.04 ± 3.88 27 8 19 Client-related Burnout (6items) 16.99 ± 4.00 26 6 20
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4.3 The difference of the level of nurses practice environment by general characteristics
Table 3 There was the significant difference in the nurse practice environment by general characteristics was significantly related to gender (t = 11.18, p = .001). And currently position also show the significantly by (F= 3.08, p = .030) and the Sheffè test was performed and the result demonstrated clinical nurses who had primary position get more unfavorable than others clinical nurses who had high position.
Otherwise, the general characteristics There was the significant difference in the department by (F = 4.26, p = .007) and the Sheffè test was performed and the result demonstrated most of the clinical nurse who work at emergency department got more unfavorable in their practice environment that another department such as ICU, general unit, and the other unit.
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Table 3
The difference of the level of Nurses Practice Environment by general characteristics (N=136) Variables Categories n Mean ± SD t or F p Scheffè
Age (year) 21-29 30-39 40-49 ≥ 50 36 22 47 31 86.42 ± 11.99 85.90 ± 10.95 83.91 ± 8.23 88.13 ± 8.16 1.21 .308 Gender Male Female 55 81 85.62 ± 12.03 86.02 ± 8.05 11.18 .001 Marital Status Single
Windowed Married 35 25 76 85.31 ± 11.95 88.96 ± 8.62 85.09 ± 9.00 1.55 .217
Education Bachelor degree Associate degree Primary degree 40 81 15 86.83 ± 8.01 86.43 ± 10.60 80.20 ± 8.39 2.90 .058 Economic status Poor Middle 17 119 85.59 ± 9.92 88.07 ± 8.96 0.11 .742 Days in a week ~ 4 5 ≥ 6 32 91 13 85.59 ± 9.83 86.04 ± 10.16 85.23 ± 7.73 0.05 .948
Night shift Yes No 121 15 85.76 ± 7.39 85.87 ± 10.14 1.50 .223 Currently Position Head nurses a Vice-Head nurses b Associated nurses c Primary nurses d 17 17 69 33 90.35 ± 11.02 89.25 ± 7.65 85.32 ± 10.42 82.91 ± 7.70 3.08 .030 d < c c < b b < a Experience in Nursing (year) ~ 5 ~ 10 ~ 20 ≥ 21 38 15 17 66 84.63 ± 10.96 85.33 ± 12.08 89.53 ± 9.31 85.74 ± 8.63 1.01 .392 Departments Emergencya General wardb ICUc Othersd 18 33 34 51 88.17 ± 10.39 81.03 ± 8.38 85.79 ± 10.41 88.22 ± 9.17 4.26 .007 b < c c < a a < d
24
4.4 The difference of the level of burnout by general characteristic
Table 4 was show the difference of burnout by general characteristics was significantly related to days in a week (F = 4.31, p = .015). And the Sheffè test was performed and the result showed that the clinical nurses who had over five days for working in a week had more burnout which compared to other subjects.
25
Table 4
The difference of the level of Burnout by general characteristics
(N=136) Variables Categories n Mean ± SD t or F p Scheffè
Age (year) 21-29 30-39 40-49 ≥50 36 22 47 31 52.81 ± 10.73 50.77 ± 9.19 50.87 ± 8.26 49.65 ± 7.23 0.73 .530 Gender Male Female 55 81 51.29 ± 9.03 50.95 ± 8.86 0.08 .773 Marital Status Single
Windowed Married 35 25 76 51.97 ± 9.49 52.80 ± 4.56 50.12 ± 9.63 1.09 .340
Education Bachelor degree Associate degree Primary degree 40 81 15 51.85 ± 8.47 50.99 ± 9.15 49.60 ± 8.98 0.36 .700 Economic status Poor Middle 17 119 48.18 ± 9.01 51.50 ± 8.84 2.10 .150 Days in a week ~ 4a 5b ≥ 6c 32 91 13 47.41 ± 7.85 52.56 ± 8.90 49.85 ± 9.15 4.31 .015 a < b b > c Night shift Yes
No 121 15 51.35 ± 8.71 48.73 ± 10.36 1.33 .250 Currently Position Head nurses Vice-Head nurses Associated nurses Primary nurses 17 17 69 33 50.59 ± 6.66 50.47 ± 7.78 51.14 ± 9.99 51.55 ± 8.31 0.07 .974 Experience in Nursing (year) ~ 5 ~ 10 ~ 20 ≥ 21 38 15 17 66 12.33 ± 2.00 54.00 ± 6.25 46.41 ± 7.44 51.55 ± 6.93 2.22 .089 Departments Emergency General ward ICU Others 18 33 34 51 52.89 ± 10.34 52.18 ± 8.84 49.47 ± 10.42 50.82 ± 7.21 0.80 .500 * p < .05
26
4.5 The relationship between nurse practice environment and burnout
Table 5 was showed the relationship between nurse practice environment and burnout toward the total score of these tow variables. There was negative significant relationship between nurse practice and burnout of participant in (r = -.18, p = .032). The total score of nurse practice environment was negative significantly related to total score of work-related burnout (r = -.24, p = .006) which indicate that the nurse practice environment has to increase more favorable to decrease the level of personal and work-related burnout. Moreover, the total of burnout was found a negative significant related to the total of The leadership and support ability of nurse manager (r = -.18, p = .034), total of adequacy of staffing and resource (r = -.21, p = .016), and total of the care quality of nursing foundations (r = -.25, p = .003) which indicate that the level of burnout was increase, and the nurse practice environment had decrease of favorable in their practice environment.
Furthermore, the personal burnout was negative significant with adequacy of staffing and resource (r = -.22, p = .012) and nursing foundation for quality of care (r = -.26, p = .003). Also, the work-related burnout was negative significant with the care quality of nursing foundations (r = -.20, p = .017) and the relationship of collegial nurse and physician (r = -.24, p = .004).
27
Table 5
The relationship between Nurse Practice Environment and Burnout
(N=136)
Burnout
Variables Total Personal Work Client
Nurse Practice Environment r (p) r (p) r (p) r (p)
Total -.18(.032) -.16(.071) -.24(.006) -.05(.576)
The leadership and support ability of nurse manager
-.18(.034) -.15(.079) -.16(.057) -.12(.174)
Workplace of nurse
participation .02(.816) .03(.701) -.12(.168) -.15(.077) Adequacy of staffing and
resource -.21(.016) -.22(.012) -.15(.077) -.13(.145) The care quality of
nursing foundations -.25(.003) -.26(.003) -.20(.017) -.15(.093) The relationship of
collegial nurse and physician
28 5. Discussion
The quality of nurse practice environment in Cambodia is the current issue
for preventing the patient safety, nurse turn over and burnout. Inadequate human
resource and staffing were the main concern major of nurses in between positive
relationship of college of nurse and physician.
The study of Vahey et al., 2004 shown that the burnout of nurse gets high
associated with satisfaction of patient become low. This study was indicating the
difference of nurse practice environment by general characteristics was significantly
related to gender. And currently position also show the significantly and the result
demonstrated clinical nurses who had primary position get more unfavorable than
others clinical nurses who had high position.
Nuria et at., (2011) was considered the most unfavorable subscales were
adequacy of staffing and resource by 63 (98%) of the nurse participation and
respondents in hospital affairs, by 57 (89%) of them. This study indicated the
subscales of adequacy of staffing and resource (2.95) average favorable related to
the work done need to have enough staff, the patient care can be get quality by having
enough staff as registered nurses, nurse can spend time with their patients by having
enough support services, to solve the problem of patient care, the nurse need enough
29
opportunity and time to discuss with other nurses, and the nurse should be having
clinically competent in working with.
Moreover, this study was found the subscales of workplace of nurse
participation (2.61) was indicated the low favorable in their workplace related to
development of career or opportunity of clinical system, advancement get in low
opportunities, staff development or upgrade of education programmed remaining in
low active for nurse, opportunity to serve on nursing committees and hospital
remaining in low, the opportunity involved with policy decisions is remaining in low,
the hospital set a deep limitation involved with the internal governance, the newly
registered nurses has hired with limit training planned of preceptor, and the power is
unequal in a senior nursing administration and authority of the hospital executives
with the other top-level also inequality.
Look at the care quality of nursing foundations subscales (2.86) was
indicated average favorable related plans of nursing care has written, up to date for
all patients, nursing care get high standards, continuity of care applies the foster of
assignment of patient care, based on a model of nurse it leads the nursing care stay
in high batter than a model of medical, and low in active quality improvement
programmed.
30
By the way, the leadership and support ability of nurse manager showed
subscales (3.23) was indicated high favorable related to a nurse manager is good at
in managing and leading, high in decision-making skill for staff nurse even if
competition with a doctor, usable and visible keep in high concern to staff by senior
nursing administrator, mistakes are used as learning opportunities by supervisors,
criticism is not meet, the nurses is supportive by a supervisory staff, the employee
concerns has responds and listens by an administration, a job well done received
recognition and reward, and staff get a consult in daily procedures and procedure by
nursing administrators.
Nuria et al., (2011) was considered most favorable subscale of respondents,
was the relationship of collegial nurse and physician. And the mean score for the
composite measure was 2.20. In this study finding indicated the subscales of the
relationship of collegial nurse and physician (3.35) was favorable related to doctor
and nurses have good relationships in working, between nurses and doctors have
collaboration, and a lot of team work.
All subscales of nurse work environment showed favorable of nurse
participate get concerned the extent of environmental that influences in how they
managed the work environments and the available resource to them.
31
Nantsupawat et al., (2011) indicated that dissatisfied with the nurse’s job
come up almost one out of four and 40% get close to study the experience of nurses
in high burnout. Also, this study was indicating the difference of burnout by general
characteristics was significantly related to days in a week test and the result showed
that the clinical nurses who had over five days for working in a week had more
burnout which compared to other subjects. Otherwise, the general characteristics was
significantly related to and the result demonstrated most of the clinical nurse who
work at emergency department got more unfavorable in their practice environment
that another department such as ICU, general unit, and the other unit.
Nuria et al., (2011) was showed nurses were the most qualified as degree
level and had experience between 11 and 15 years. The female nurses indicated
highest burnout scores, who aged between 31 and 40 were indicated the educated to
degree level and had between one and ten years’ service.
This study was indicated the total of nurse practice environment was
negative significantly related total of work-related burnout which indicate that the
nurse practice environment has to increase more favorable to decrease the level of
personal and work-related burnout by decrease the feeling worn out at the end of the
working day, try to motivate and meditated in the morning to gain more energy in
the morning, try to work with good mood under long hour of work, and try to control
32
their emotional action.
Aiken et al. (2001) were suggested that the effects of practice decisions were
based on their knowledge, education, experience, and ability. The nurse leaders must
make sure that as a nurse has to be supported, keep in control over their practice
environments, and be positive between the relationships of nurse and physician.
The total of nurse manager, ability leadership, and support which found from
the total of burnout in this study showed a negative significant related to the nurse
who works under nurse manager who doesn’t have a good leader, low in
decision-making, always get a conflict with the doctor, low visible and accessible to staff,
always criticism their staff mistakes, never listens and responds to employee concern,
limited provide the reward and recognition for a job well done, poor in consult with
staff on daily problems and procedures.
Furthermore, the total of adequacy of staffing and resource which found
from a total of burnout in this study was indicated a negative significant related to
the poor environment, lack of staff, not enough registered nurses on staff to provide
quality of care, lack of support service allow the nurses to spend time with their
patients, not enough time and opportunity to discuss patient care problems with other
nurses, and lack of nurse who is full of clinically competent.
33
Moreover, the total of the care quality of nursing foundations which found
from a total of burnout in this study was indicated a negative significant related to
the level of burnout was increase and the nurse practice environment had decrease
of favorable in their practice environment by decrease the written up to date nursing
care plans for all patient, try to promote staff to get high education involved with
high standards of nursing care, try to establish patients care assignments that foster
continuity of care, and try to look and search a nursing model and active quality
improvement programmed. Most of the nurses in Cambodia have low motivation in
research with the active quality improvement programmed.
In addition, Nantsupawat et al., (2011) indicated that the quality of care
become poor lead to risk for adverse outcomes and preventable and the nurse practice
environment and nurse staffing having low the assessed of care quality in nursing.
Other nurse work with favorable environment lead to increase quality of practicing
in the hospital to decrease the level of burnout. Furthermore, the personal burnout
was negative significant with adequacy of staffing and resource in this study was
indicated in the real situation for Cambodian nurses always face with this problem
because of work overload with many patients. Also, the work-related burnout was
negative significant with the care quality of nursing foundations in and the
relationship of collegial nurse and physician.
34
Aiken et al., 2008 was shown the negative associated with burnout and nurse
participants. In this study demonstrated that the relationship between nurse practice
environment and burnout were negative significantly. This finding indicated that the
level of burnout was increased, and the nurse practice environment had a decrease
of favorable in their practice environment. The level of the nurse practice
environment and burnout among nurses was shown the total mean score of nurse
practice environment get the highest subdomain of nurse practice environment was
the relationship of collegial nurse and physician. The relationship of collegial nurse
and physician was indicated that most of the clinical nurse’s work dependently under
supervise from physician order. Without the order and control from a physician, the
clinical nurses will not able to be completed their work properly. Therefore, a
nurse-physician relationship has to get more favorable to fulfill the good patient outcome
and safety.
In the other hand, the lowest subdomain of nurse practice environment was
nursing participation in the workplace. This indicated the competency of the nurse’s
work environment was getting low with their workplace, such as too many patients
under one nurses control in one room, the too hot temperature in the patient’s room,
material for caring patient keep in limited, very few of personal protective equipment
for clinical nurses, poor hygiene and sterilization. All these environments lead most
of a nurse to become decrease they’re favorable in participation in their workplace.
35
Coomber and Barribal, (2007) had identified an association between nurses’
intent to leave and turnover and job dissatisfaction, (Hayes et al., 2006); nurse intent
to leaves was write down the negatively associated with satisfaction of patient (Leiter
et al., 1998). Furthermore, the total mean score of burnout in this study was indicated
the highest subdomains of burnout were personal burnout which indicates that the
most female nurses get often feel tired, physically exhausted, emotionally exhausted,
feel worn out, feel weak and susceptible to illness and lead them to think to leaves
their job because of limited education and willing of caring patients as a good nurse.
And the lowest subdomains of burnout were work-related burnout which indicated
at the end of the working a day lead their feeling get worn out, in the morning get
feeling exhausted in a whole day of work, tiring in every working hour, during
relaxation time have not enough strength with family and friends, emotionally get
exhausting with full of work, frustrate of work, and get burnt out feeling because of
their workload and complicated work.
Nurse practice environments of clinical nurses in Cambodian need to be
improved. Furthermore, practice environments need to be revised from poor to a
better environment in the purpose of reducing the unfavorable and burnout of their
clinical practice skill. Hospital management has to take action to increase the positive
work environments and this action will be leading to decrease from high to low-level
of nurse burnout and job dissatisfaction. Therefore, the improvements of nurse
36
practice environment and upgrade nurse education are needed to diminish the risk of
nurses developing burnout in the future.
37
Conclusion and Recommendation
The important of conclusions from this study are the verifying public
hospital to improve the environment of clinical nurses and upgrade the nurse staffing
education and skill as a strategy for advancing quality of care and nurse retention,
specially to decrease nurse turn over and burnout.
In conclusion, the result of this study has provided information related to the
negative significant between nurse practice environment and burnout that indicate
very clear as a mirror in the society. In the recently, Cambodian patient are facing
with unsatisfied related to the nursing care service as well as their health’s safety.
There was some limitation in this study. Most of the nurses had difficulty to
provide the true answer of each question because of the work under the pressure of
manager power and hospital policy. They were afraid to provide the true answer it
will affect to their working position and relationship with manager. It is also limited
by the study size too small, which intervene generalize of finding.
Some recommendation was considered carefully in order to improve further
research which involve with relationship between nurse practice environment and
burnout, the hospital have to improve the hospital policy involved with nurse
manager’s ability in leadership and support to nursing staffs. As well as hospital need
38
to recruit more nurses to fulfill the caring service and reduce the overload of work
also increase the quality of patient care. In addition, nurse manager has to understand
and encourage all nurses to get along well with other physician and other co-worker
in purpose to reduce personal burnout, work-related burnout, and client-related
burnout.
39
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45 Appendices Appendix A
Hello,
First of all, I would like to introduce myself, my name’s Chan Soren, I am currently studying Master of Nursing Science of College of Nursing belong to Ajou University, South Korea.
I would like to ask your favor for participate in my research study because you are the clinical nurse who is currently working for public hospital in Cambodia. Otherwise, your participation in this study is entirely voluntary.
The purpose of the study is to describe the relationship between nurse practice environment and burnout and how they effect by work and general characteristics.
All the information you provide will be kept in a safety and used only for purpose of study. Furthermore, your identification will not be included and disclosed to the public. One more thing, you are free for cancelling your participation at any time. And I will not be able to use your information further.
Finally, if you have any questions about the research, please contact me at +855-92-63-09-63. I would appreciate for your participation in my research study. Thank you so much!
July 2nd, 2012 Yours faithfully,
Chan Soren
46 Appendix B Research Questionnaires
ID Number: ……… Interview Date: ………...………. Hospital’s Name: ………... Interview By: ……….………… I. General Characteristic of Clinic Nurses:
Below are the questions inquiring your socio-demographic characteristic.
Please fill in all the items by making () marks in the appropriate boxes or fill in the blank Socio-demographic characteristic of participants
1. How old are you?
21-29 30-39 40-40 ≥50
2. What is your gender? Male Female
3. What is your marital status? Single Widowed Divorced Married
4. What is your education level? Bachelor’s Degree Associate Degree Primary Degree
47 II. Working related characteristics of participants
Below are the questions inquiring your socio-demographic characteristic.
Please fill in all the items by making () marks in the appropriate boxes or fill in the blank
6. How many days do you work in a week? 4 5 4 7. Do you have night shift? Yes No
8. What is your current position? Head Nurse Vice-head Nurse Associated Nurse Primary Nurse 9. How many years do you have experience in
nursing?
~5 ~10 ~20 ≥21
10. Which department are you working for? Emergency General Word ICU Others
48
III. Nurses Practice Environment of Clinical Nurses Please read the questions carefully and marked () as your answer
No. Subscale item Disagree Strongly
(1) Dis- agree (2) Agree (3) Strongly Agree (4) The leadership and support ability of nurse manager
1 A nurse manager or immediate supervisor who is a good manager and leader
2 A nurse manager who backs up the nursing staff in decision making. Even if conflict is with a doctor 3 A senior nursing administrator who is highly visible and
accessible to staff
4 Supervisors use mistake as learning opportunities not criticism
5 As supervisory staff that is supportive of the nurses 6 Administration to listens and responds to employee
concerns
7 Praise and recognition for a job well done
8 Nursing administrators consult with staff on daily problems and problems
Workplace of nurse participation
9 Career development/clinical ladder opportunity 10 Opportunities for advancement
11 Active staff development or continuing education programed for nurses
12 Nurses have opportunity to serve on hospital and nursing committees
13 Opportunity for nurses to participate in policy decisions 14 Nurse are involved in the internal governance of the
hospital
15 A preceptor programmed for newly hired registered nurses
16 A senior nursing administration equal in power and authority to other top-level hospital executives
49
No. Subscale item Disagree Strongly
(1) Dis- agree (2) Agree (3) Strongly Agree (4) Adequacy of staffing and resource
17 Enough staff to get work done
18 Enough registered nurses on staff to provide quality patients/clients/resident care
19 Adequate support services allow me to spend time with my patients
20 Enough time and opportunity to discuss patients/clients/ residents care problems with other nurses
21 Working with nurses who are clinical competent The care quality of nurse foundations
22 Written, up to date nursing care plans for all patients/ clients/residents
23 High standards of nursing care are expected by the administration
24 Patients/clients/ residents care assignments that foster continuity of care
25 Nursing care is based on a nursing model, rather than a medical model
26 An active quality improvement programmed The relationship of collegial nurse and physician
27 Doctors and nurses have good working relationships 28 A lot of team work between Nurses and doctors 29 Collaboration between nurses and doctors Total average score
