Prevalence of burnout among nurses working at a psychiatric hospital in the Western Cape

Background Nurses are exposed to stress when working in the mental health care environment. This may be because of nurses being frontline health care providers. They develop close interpersonal relationships with mental health care users (MHCUs), which is inherent in the type of care that is provided. Mental health nursing may therefore be demanding and stressful, which could render mental health nurses susceptible to burnout. Objectives To determine the prevalence of burnout among nurses working at a selected psychiatric hospital in the Western Cape. Methods A quantitative, descriptive, survey design, by using simple random sampling was used to select 198 nurses employed at a psychiatric hospital in the Western Cape, South Africa. Maslach Burnout Inventory-Human Services Survey measuring emotional exhaustion, depersonalisation and personal accomplishment was used to collect the data. Domain scores were calculated, and the influence of the demographic variables on the domains was tested with independent samples Kruskal–Wallis tests and Mann–Whitney U tests. Results The study had a 100% response rate. Most of the respondents experienced low emotional exhaustion, low depersonalisation and high personal accomplishment. Enrolled nursing assistants reported significantly higher emotional exhaustion than did the advanced psychiatric nurses and professional registered nurses. Respondents with more than 5 years of experience scored significantly higher in depersonalisation. No respondents met the criteria for burnout on all three domains. Conclusion Maintaining a safe working environment with adequate nursing staff is recommended. Strategies to prevent burnout in the future include the provision of resources and the promotion of open communication between staff and management.


Introduction
The mental health care working environment has been identified as a stressful environment to work in (Yoshizawa et al. 2016:3). Stressful working conditions may lead to burnout (Alenezi, McAndrew & Fallon 2019:1046Alqahtani, Al-Otaibi & Zafar 2020:114;Ghavidel et al. 2019:3893;Kobayashi et al. 2020:2;Konstantinou et al. 2018:449;Looff et al. 2018:514). Burnout is defined as a psychological condition that leads to depletion of physical as well as mental energy; it is caused by chronic unresolved work-related stress and ineffective coping strategies (Konstantinou et al. 2018:450); and it is prevalent in occupations that work with humans under challenging situations (O'Connor, Neff & Pitman 2018:74). The most widely accepted definition of burnout is that it is a three-dimensional syndrome consisting of emotional exhaustion, depersonalisation and personal accomplishment (Maslach et al. 1986:192).
Burnout is common in many health care professions, especially nursing because nurses engage in close interpersonal relationships with people as part of their duties (Looff et al. 2018:507). The nursing profession is stressful, particularly mental health nursing, and therefore nurses working in this environment are more susceptible to burnout (Alenezi et al. 2019(Alenezi et al. :1046. Mental health nurses are involved in the significant interpersonal burden of taking care of Mental Health Care Users (MHCUs) with compound emotional demands and complex and challenging mental health care conditions and their families (Ghavidel et al. 2019:3894;Konstantinou et al. 2018:450). They also fulfil the conflicting roles of caring for and exercising social control in MHCUs who were admitted to hospital involuntarily (McTiernan & McDonald 2015:209-210). Mental health nurses have intense relationships with the MHCUs and their families. They restrict MHCUs from harming themselves and others and manage difficult behaviours, although the results are less tangible than other disciplines of nursing, as care mainly takes place by means of interaction (McTiernan & McDonald 2015:210). In addition, violence by MHCUs towards other patients and nurses and MHCUs that are suicidal, present with unpredictable, unstable behaviour render mental health nursing to be demanding and challenging and may result in burnout (Ghavidel et al. 2019:3894).

Problem statement
Globally, studies (Alenezi et al. 2019(Alenezi et al. :1046Ghavidel et al. 2019:3893;Kobayashi et al. 2020:2;Konstantinou et al. 2018:449;Looff et al. 2018:506) have alluded to the escalation of work-related stress, which may lead to burnout among mental health nurses. Mental health nursing is stressful because it is a helping profession that involves close interpersonal working relationships with, as well as providing nursing care to, MHCUs with severe mental illness and complex emotional demands (Lee et al. 2015). These stressful working conditions may expose nurses working in psychiatric hospitals to burnout (Lee et al. 2015).
Burnout does not only have severe negative impact on mental health nurses but also on the MHCUs they serve and the mental health settings they work in (Kobayashi et al. 2020:2). Anecdotal evidence suggests that the nurses working in the research setting may be experiencing burnout; however, given that a study of this nature has not been conducted in this setting, it is unknown whether this is the case.

Aim of the study
The aim of this study was to investigate the phenomenon of burnout among nurses working at the selected psychiatric hospital in the Western Cape.

Objectives of the study
The objective of this study was to determine the prevalence of burnout among nurses working at the selected psychiatric hospital in the Western Cape.

Definition of key concepts
Burnout is a psychological syndrome of emotional exhaustion, depersonalisation and lack of personal accomplishment that happen to people who work with many other people (Maslach et al. 1986:192). In this study burnout is when a respondent scores 27 or more in the emotional exhaustion domain, 13 or more in depersonalisation domain and 31 or less in personal accomplishment domain as stipulated in the scoring key of MBI-HSS (Maslach Burnout Inventory -Human Services Survey).
Depersonalisation is undesirable, cynical attitudes and feelings about clients; this insensitive and cruel perception of others can result workers to believe that their clients deserve their problems (Maslach et al. 1986:192). In this study depersonalisation is when a respondent scores 13 or more in the depersonalisation domain, as stipulated in the scoring key of MBI-HSS.
Emotional exhaustion occurs when emotional resources are worn out, whereby the workers feel they are no longer able to give of themselves at a psychological level (Maslach et al. 1986:192). In this study emotional exhaustion is highlighted when a respondent scores 27 or more in the emotional exhaustion domain as stipulated in the scoring key of MBI-HSS.
Lack of personal accomplishment is the tendency to see yourself negatively, regarding your work with the clients; workers may feel unhappy about themselves and dissatisfied with their accomplishments in the job (Maslach et al. 1986:192). In this study lack of personal accomplishment is highlighted when a respondent scores 31 or less in the personal accomplishment domain as stipulated in the scoring key of MBI-HSS.
A MHCU is a person who receives care, treatment and rehabilitation services or utilising a health service at a health establishment meant to improve the mental health status of a user (Republic of South Africa [RSA] 2002:6). In this study an MHCU is a patient that is admitted or was admitted for care, treatment and rehabilitation to the selected psychiatric hospital.
Nurse is defined as an individual that is registered to practise nursing or midwifery (Council, S.A.N. 2005:6). In this study a http://www.curationis.org.za Open Access nurse is a person who is registered or enrolled to practise nursing at the selected hospital.

Research design
A quantitative, descriptive survey design was conducted.

Setting
This study was conducted in one of four psychiatric hospitals in the Western Cape province, South Africa. The selected psychiatric hospital is the largest in the Western Cape and is situated in the Cape Town suburb of Mitchells Plain. The hospital has a 722-bed capacity. There are 409 nurses working at the hospital.

Population and sampling
All the nurses working at the selected psychiatric hospital formed the target population, as they were responsible for providing direct nursing care to the MHCUs. The sample size for a survey was calculated by using the following parameters: confidence level = 95%, confidence interval = 5%, percentage 50% and population size = 409, yielding an estimated sample size of 198 (Creative Research Systems 2012:1). The researcher distributed 198 questionnaires, and all the questionnaires were answered (100% response rate), of which 167 questionnaires were valid and 31 were invalid. Simple random sampling was used to select the respondents by using the duty register as the sampling frame. Respondents were randomly selected from each nursing category. A total of six respondents per ward were selected comprising two per category and two others.

Inclusion criteria
The inclusion criteria were all permanent nursing staff providing direct care.

Exclusion criteria
The exclusion criteria were the various nursing managers (director, area, operational), occupational health and safety professional nurse and the clinical coordinator, as they were not involved in direct patient care. Community service practitioners and agency nurses were also excluded as they were contract workers and, therefore, had varied tenure at the selected hospital.

Data collection instrument
A 28-item structured self-administered questionnaire was used to collect data. The questionnaire required about 10-15 min to complete. The questionnaire included six demographic variables, namely age, race, gender, nursing rank, years of experience and functional business unit and the MBI-HSS. The scale has 22 items and uses a 7-point Likert scale (rating from 'never' to 'every day') to measure three domains of burnout, namely emotional exhaustion (9 items), depersonalisation (5 items) and lack of personal accomplishment (8 items) (Maslach et al. 1986:193).

Validity and reliability
In this study, Cronbach's alpha was used to determine the reliability of the instrument. The Cronbach's alpha score for this study was 0.794. Various studies reported Cronbach's alpha scores that are between satisfactory to high when using MBI-HSS. Alqahtani et al. (2020:111)

Data collection process
Data were collected from May until June 2017 for a period of 4 weeks. The researcher visited the different wards at the selected psychiatric hospital and requested permission from the sister in charge of each ward, for access to collect data. Once permission was granted, the researcher addressed all the nursing staff to establish a suitable time to explain the study and distribute questionnaires. After explaining the study and obtaining volunteers to participate in the study, the researcher left the questionnaires, information sheets and consent forms with the participants who had agreed to complete them in their own time. This was to allow them enough time to read the information sheet, sign the consent forms and complete the questionnaires. Each respondent was provided with an envelope to insert the completed questionnaires and signed consent forms, to ensure anonymity. These were then cast into a box. The researcher collected the boxes from the various wards on the day and at the time agreed upon by the respondents.

Data analysis
The data were captured into SPSS, version 24. Age and years of experiences were recoded into categorical variables (20-29, 30-39, 40-49 and 50 and over years; and 5 years and less and more than 5 years of experience). Total domain scores were calculated and recoded by using the Maslach et al. (1986) scoring key (Table 1). For the emotional exhaustion and depersonalisation domains, high mean scores reflect high levels of burnout, and low mean scores reflect low levels of burnout, whereas for personal accomplishment domain, high mean scores reflect low levels of burnout, and low mean scores reflect high levels of burnout (Maslach et al. 1986:193). A respondent can be diagnosed with burnout syndrome, if the score is 27 or more in the emotional exhaustion domain, 13 or more in the depersonalisation domain and 31 or less in the personal accomplishment domain (see Table 1 for scoring key). Frequencies were used to the proportion of respondents scoring low, moderate and high on emotional exhaustion, depersonalisation and personal accomplishment, as well as the mean scores of emotional exhaustion, depersonalisation and lack of personal accomplishment. Independent sample Kruskal-Wallis (K) and Mann-Whitney U tests (U) were used to determine the differences in domain scores and demographic variables.

Ethical considerations
Ethical approval to conduct this study was obtained from the Bio Medical Research Ethics Committee of University of the Western Cape (UWC), and permission to conduct this study in the selected psychiatric hospital was obtained from the Research Committee of the Western Cape Department of Health. Permission to access the nurses for data collection was obtained from the Chief Executive Officer of the selected psychiatric hospital. Prior to data collection, respondents were informed that they had a right to withdraw from the study at any time, without providing reasons. Participation in the research study was entirely voluntary. All ethical principles were adhered to, and contact details of the free service for government employees namely the Independent Counselling and Advisory Service (ICAS) were given to all the respondents should they have required counselling from participating in the study. Counselling with the counsellor was prearranged by the researcher (Ethical Clearance Number: BM/17/1/4, 16 January 2017).

Demographics
The selected samples all responded to the survey, but the completion of items on the questionnaire was inconsistent. More than half of the respondents were female (120, 61.5%) and 75 (38.5%) were male.
Overall, no respondents met the criteria for burnout on all three domains.

Discussion
The results of this study revealed that the nurses at the selected psychiatric hospital did not suffer from emotional exhaustion. A study conducted with Saudi Arabian mental health nurses revealed high levels of emotional exhaustion (Alenezi et al. 2019(Alenezi et al. :1050. In Greece, a study conducted among mental health nurses revealed high emotional exhaustion (Konstantinou et al. 2018:452). In Dublin, Ireland, a study conducted among hospital and community mental health nurses revealed moderate emotional exhaustion (McTiernan & McDonald 2015:213). This study results differ from the studies mentioned. McTiernan and McDonald (2015:213) reported low levels of depersonalisation amongst nurses. These results are similar to the results of the current study. In a study performed by Alenezi et al. (2019Alenezi et al. ( :1050 in Saudi Arabian mental health nurses, it was reported that they had high levels of depersonalisation. In a study conducted with Greece mental health nurses, it was observed that most of the respondents reported moderate levels of depersonalisation (Konstantinou et al. 2018:452). The results of these studies are dissimilar to the results of this study.
In a study conducted with mental health nurses in Saudi Arabia, the results revealed low levels of personal accomplishment (Alenezi et al. 2019(Alenezi et al. :1050. A study conducted with Greece mental health nurses revealed low levels of personal accomplishment (Konstantinou et al. 2018:452). In Dublin, Ireland, a study conducted with hospital and community mental health nurses observed moderate personal accomplishment scores (McTiernan & McDonald 2015:213).
The results of these studies differ from the results of this study.
A study conducted in a Saudi Arabian mental health facility showed high levels of emotional exhaustion, high levels of depersonalisation and low levels of personal accomplishment; therefore, overall burnout score for this sample was high (Alenezi et al. 2019(Alenezi et al. :1046. Konstantinou et al. (2018:452) conducted a study in Greece mental nurses and found emotional exhaustion that was high, depersonalisation that was moderate and personal accomplishment that was low; therefore, the overall burnout score for these nurses was moderate to high. In Dublin, Ireland, a study on burnout conducted with hospital and community mental health nurses revealed that both groups scored moderate for emotional exhaustion and personal accomplishment and low for depersonalisation (McTiernan & McDonald 2015:213). Therefore, none of these study show low overall burnout levels and that indicates that they differ with the results of the current study.
There are many differences between the existing literature and the finding of the current study, and this might be because of different factors such as demographic and environmental factors; a similar study was never conducted in South Africa.
The mental health nurses of the selected psychiatric hospital might be experiencing low levels of burnout because of age, as the average age for the sample of this study was 41.7 years, which is high. El-Azzab et al. (2019:734) reported a negative correlation between burnout and age, meaning that as the age increases the burnout levels are more likely to decrease. The sample of this study might not be experiencing high levels of burnout because of the high number of females (61.5%) compared with males (38.5%). Konstantinou et al. (2018:453) state that male nurses experience more emotional exhaustion and depersonalisation, compared with female nurses. Male gender is a predictor of burnout (Kobayashi et al. 2020:2).
The nurses of this study may be experiencing low levels of burnout because of the nursing rank. Advanced professional nurses made up 21.4% of the respondents, general professional nurses made up 19.4% of the respondents, enrolled nurses made up 17.7% of the respondents and enrolled nursing assistants made up 41.3% of the respondents. This shows that the majority of the respondents were enrolled nursing assistants, which is the lowest rank compared with other ranks, and according to Kobayashi et al. (2020:2) professional seniority contributes to high levels of burnout.
The average years of experience for the mental health nurses of the selected psychiatric hospital were 9.9 years. This is a high number for years of experience, which could be another reason for the low levels of burnout in this study's sample. Alqahtani et al. (2020:111) state that more experienced mental health nurses experience less burnout than less experienced mental health nurses.
The results of the current study showed a mean of 15.05 for emotional exhaustion, and according to Scoring & Interpretation Key-MBI-HSS (1981:1), a mean score between 0 and 16 indicates low levels of emotional exhaustion, a mean score of 4.03 for depersonalisation, and according to Scoring & Interpretation Key-MBI-HSS (1981:1), a mean score between 0 and 6 indicates low levels of depersonalisation and a mean score for personal accomplishment was 40.11, and according to Scoring & Interpretation Key-MBI-HSS (1981:1), a mean score of 39 and more indicates high personal accomplishment. The mental health nurses of the selected psychiatric hospital do not experience burnout because they scored low on emotional exhaustion, low on depersonalisation and high for personal accomplishment.

Limitations
This study was conducted at one of the four psychiatric hospitals in the Western Cape; therefore, the results cannot be generalised for all nurses working in psychiatric hospitals in the Western Cape.
There is a paucity of literature regarding the prevalence of burnout among mental health nurses, with recent research studies only being conducted in Asia and Europe.

Clinical practice
Burnout can be prevented by being cognisant of the following issues: maintain a safe working environment to prevent incidents; employ adequate nursing staff to prevent work overload; provide resources to prevent stress caused by the shortage, or unavailability thereof; promote open communication to allow team work; rotate nursing staff to work in other wards for professional development, avoidance of boredom, as well as exposure to different environments and challenges, which will keep them interested to learn and perform productively; and managers should support, supervise, appreciate and value nursing staff to prevent burnout.

Nursing education
The nursing staff should attend in-service training programmes that deal with stress management to acquire the necessary skills to cope with work stress. In addition, the nursing staff should attend courses and in-service training that update their knowledge to be competent health service providers.

Research
This study should be replicated in other settings, to obtain an overview of the burnout profile of health care workers, working in health care institutions in South Africa.

Conclusion
The aim of this study was to investigate burnout among nurses working at the selected psychiatric hospital in Western Cape. According to the findings of this study, nurses working at the selected psychiatric hospital do not suffer from burnout.