Relationship between occupational burnout and demographic variables among nurses in Jahrom, Iran

Introduction Occupational burnout is a psychological syndrome caused by the accumulation of work-related stress and characterized by intolerance, high levels of emotional exhaustion, depersonalization, and the perception of low personal accomplishment. The present study aimed to evaluate the relationship between occupational burnout and all demographic variables among the nurses in Jahrom, Iran. Methods The present descriptive-analytical study was carried out during 2016 among nurses employed at Motahari Hospital and Peymanieh Hospital, both affiliated to Jahrom University of Medical Sciences (Iran). Based on the inclusion criteria, a total of 250 participants were selected. The data collection instruments included a demographic questionnaire and the Maslach burnout inventory. The data were analyzed using the SPSS statistical software (version 16.0) by descriptive statistics and Spearman's test. Results Among the participants, 223(89.2%) nurses suffered from a moderate to high level of occupational burnout. There was a significant correlation between personal accomplishment and age (r=0.21, P=0.002) and education level (r=-0.16, P=0.01). Additionally, income level had a significant correlation with emotional exhaustion (r=-0.38, P=0.001), depersonalization (r=-0.3, P=0.001), and personal accomplishment (r=0.35, P=0.001). A significant relationship was also found between sex and depersonalization (r=-0.15, P=0.02). However, there was no significant relationship between occupational burnout subscales and the number of children, type of hospital ward, type of employment, and marital status (P>0.05). Conclusion A significant positive correlation was found between the subscales of occupational burnout and younger age, low income, high education, and male nurses.


Introduction
Occupational burnout (OB) is a psychological syndrome caused by the accumulation of work-related stress and characterized by intolerance, high levels of emotional exhaustion, depersonalization, and the perception of low personal accomplishment. OB can adversely affect the physical and mental health, performance at work, and even lead to loss of valuable workforce. It occurs in any profession, but particularly among health care workers due to the heavy workload [1][2][3]. It is estimated that OB in health care centers has been the cause of 30% workers' illnesses and absence from work; at an annual cost of 300-400 million US dollars. Various studies have reported that among all health professionals, nurses are at a higher risk of OB [4,5]. The incidence of OB has been estimated at a staggering level of >40% among professional nurses [6], particularly emergency room nurses, as they are daily exposed to the suffering and discomfort of patients as well as death. Additionally, they suffer from insomnia, stress and anxiety due to the working conditions in hospitals, or from working in a negative competitive workplace.
Anxiety among nurses not only negatively affects their relationship with patients, but is also one of the reasons for the reduced efficiency of the health care system [7]. Studies have indicated that positive experiences in the workplace enhance professional commitment and reduce occupational stress, while negative perceptions and long-term workplace stresses result in nurse burnout [8]. A previous study has reported that the prevalence of OB was significantly related to early life stress, living alone, not having children, and not using coping strategies against problems [9]. Another study reported that high levels of personal accomplishment could improve the physical and mental well-being of nurses and encourage them to provide highquality care to patients [10]. In light of the above, a number of studies have been conducted to evaluate the prevalence of nurse burnout and to recommend measures to prevent its occurrence. A study among Spanish nurses reported that OB was significantly correlated with demographic and personality-related variables [4]. They recommended the need for more information gathering about nurse burnout prevalence and its risk factors to determine the best intervention method to prevent this phenomenon. Studies conducted in different countries have reported a significant difference among Irish, Greek, Italian, Polish, and Dutch nurses with respect to emotional exhaustion and depersonalization [3,11]. The difference was attributed to dissimilarities between the professional environment and the role nurses play in various health care systems. Some related studies have also been conducted on this topic in Iran, however, they did not include all relevant demographic variables affecting the occurrence of nurse burnout [12,13]. To complement previous studies, we aimed to evaluate the relationship between OB and demographic variables among the nurses in Jahrom, Iran.  Table 3. The correlation between OB subscales and demographic variables are shown in Table 4. There was a significant correlation between personal accomplishment and age

Discussion
The demographic characteristics of the participants in the present study were comparable to those in Kravits et al. study [16].  [19]. In contrast to the results of the present study, the above-mentioned studies reported a lower mean OB, which might be due to the differences in the mean age of the participants. The results showed that the majority of the participants experienced a moderate to high level of OB. In line with our result, a study on OB among Indonesian nurses reported that OB was highly prevalent and its level was higher than the average among the nurses [4]. Some other studies also reported a high prevalence of OB among nurses [3,20,21]. It has been reported that nurse burnout is the result of occupational stress and that there is a strong relationship between OB, environmental stress, and personality traits [21]. Therefore, the prevalence of OB could be the result of being faced with job-related stress as well as factors such as role ambiguity, role conflict, work pressure, and inadequate workplace conditions [20,22]. Additional causes could be due to being left out of the decision-making process, lack of accountability by officials, and lack of cooperation between nursing units and other wards [19,23]. We found that the majority of the participants had a high to moderate level of emotional exhaustion and depersonalization, and a low level of personal accomplishment.

Momeni et al. reported a high degree of emotional exhaustion and
depersonalization, and a low degree of personal accomplishment among nurses [12]. Similar results in the UK were reported by Adriaenssens et al. [3]. In contrast, a significantly lower level of nurse burnout was reported in Iran (Mashhad) [24], Scotland [25], and in China [26]. Such differences could be related to the working conditions and the role of nurses in various health care systems around the world. They could also be attributed to the level of independence at work, the span of control, partnership, and the level of communication between nurses in the workplace [27]. The results showed a significant relationship between personal accomplishment and age. Personal accomplishment improved with age and was associated with a lower OB score. Spooner reported a negative correlation between age and depersonalization such that younger nurses suffered a higher level of nurse burnout [28]. Momeni et al.
also reported different depersonalization scores with respect to different age groups. Based on the above, it seems that age could have an adverse effect on some OB subscales. Since the ability to handle occupational issues improved with higher age and experience, therefore, more experience could be associated with effective solving of unpredictable situations [12].
In line with Cañadas-De la Fuente et al. study [4], our results also showed a significant difference between male and female nurses in terms of the mean depersonalization score. Male nurses achieved a higher score, which indicated a personality difference between male and female nurses. A statistically significant correlation was found between OB subscales and income level. Other studies also reported that nurses consider low income as an important cause of workrelated stress [19,29]. Anderson and Brooks also reported that only 57% of the nurses were satisfied with their income level [22].
Consequently, low income level could be considered as a cause of nurse burnout. In line with the findings of Lin et al. [30], we also found no statistically significant difference between marital status and OB subscales. However, it was observed that married female nurses experienced a higher level of emotional exhaustion due to additional responsibilities as a housewife. On the other hand, they had a sense of higher personal accomplishment due to family support. In contrast, another study reported a relationship between marital status and emotional exhaustion and stated that marital status was the predictor of at least one OB subscales [4]. The difference between these results might be due to different sample sizes. Moreover, it seems that emotional exhaustion could also be associated with other variables such as personality traits. In a study by Abarghouei et al they concluded that the stress resulting from the loss of job by some employees had a ripple effect on others. In other words, not only the employees who had lost their jobs were stressed, but those who witnessed the event were also stressed due to the concern about their own job security [5]. In contrast, we found no significant relationship between OB subscales and employment status. This could be due to the fact that the Iranian insurance system provides equal support to people irrespective of the employment status. Therefore, employment status did not affect OB. The results of the present study showed no significant relationships between OB subscales and working in different hospital wards (general ward or intensive care unit).
Hooper et al. reported that about 82% of nurses working in the emergency wards had a moderate to high level of nurse burnout.
However, they found no significant difference between the nurses on emergency wards and those on oncology, nephrology, and special wards in terms of compassion satisfaction, job burnout, and compassion fatigue [31]. Irregularities, unpredictable situations, stressful conditions, lack of control, a limited time frame for assessing the effect of therapeutic interventions on the patients, and frequent contact with patients with pain and anxiety and stressful conditions have also been considered to be stressful issues for nurses working in emergency departments [32]. In the same vein, Cabera et al. found that working on a specific type of ward was associated with nurse burnout, which is in contrast to the present study [33]. The difference in the results could be due to the way we categorized the wards since

Conclusion
The results of the present study showed a high prevalence of OB among the nurses in Jahrom, Iran. Furthermore, OB subscales were significantly correlated with age, income level, sex, and education level. Younger age, low income, high education, and male nurses were positively correlated with OB subscales. Identification of those factors affecting nurse burnout plays an important role in preventing this phenomenon among nurses.

What is known about this topic
• Nurses experience occupational burnout; • Some demographic factors affect nurses' occupational burnout.

What this study adds
• Increase in age may be effective in decreasing depersonalization and enhancing personal accomplishment among nurses; • Nurses with higher education levels may experience higher occupational burnout. Table 1: degrees of occupational burnout subscales