Burnout and psychological distress among nurses in a Nigerian tertiary health

institution

Okwaraji FE1Aguwa EN2

1. Department of Psychological Medicine, College of Medicine, University of Nigeria Nsukka.

2. Department of Community Medicine, College of Medicine, University of Nigeria Nsukka.

Abstract
Background: The role of nurses in the health care delivery system cannot be overemphasized. Nurses are needed at all
levels of healthcare and the profession requires a lot of dedication, time and energy with regards to patient management and
service delivery. This time investment and dedication to duty is likely to lead to burnout and psychological distress among
the nurses.
Objective: This study assesses the prevalence of burnout and psychological distress among nurses working in Nigerian
tertiary health institution.
Method: The Maslach Burnout Inventory (MBI) and the General Health Questionnaire (GHQ-12) were used to assess 210
nurses working in this health institution for symptoms of burnout and psychological distress.
Results: High levels of burnout were identified in 42.9% of the respondents in the area of emotional exhaustion, 47.6% in
the area of depersonalization and 53.8% in the area of reduced personal accomplishment, while 44.1% scored positive in
the GHQ-12 indicating presence of psychological distress.
Conclusion: Prevalence of burnout and psychological distress is high among nurses.
Key words: Burnout, psychological distress, stress management.
African Health Sciences 2014;14(1): 237-245 http://dx.doi.org/10.4314/ahs.v14i1.37

Introduction treatment of ones clients in the work place; and reduced

The concept of burnout was first introduced by Herbert personal accomplishment which has to do with lack of
Freudenberger who described burnout as a condition feelings of competence and achievements in ones work
characterised by such feelings as emotional exhaustion, with people. According to Embriaco et al. 6 some of
disillusionment and withdrawal which he initially the clinical symptoms of burnout include tiredness,
noticed among voluntary health workers1. Burnout is a headache, eating problems, insomnia, irritability,
psychological term for the negative response to chronic emotional instability and rigidity in relationship with
job-related stress. It is said to occur when people give other people.
too much of their time, energy and effort on their
job over a long period of time without enough time Many researches had been conducted on burnout
to recover physically or emotionally2. Ibikunle et al.3 syndrome among various professional groups including
defined burnout as a state of physical, emotional and nurses. For instance, Thorsen et al. 2 in a study of
mental exhaustion caused by long term involvement high rates of burnout among maternal health staff in
in situations that are emotionally demanding. The Malawi reported that 72% of their subjects reported
development of the Maslach Burnout Inventory (MBI) emotional exhaustion, 43% reported depersonalization
4,5
which is the most widely used instrument to measure while 74% reported reduced personal accomplishment.
burnout has long settled the question of how to define They concluded that burnout appeared to be common
burnout. Maslach5 defined burnout as having three among maternal health staff that participated in the
components as follows: emotional exhaustion which study when compared with their colleagues working in
according to him is the feelings of fatigue and of being other medical settings. Embriaco et al.6 in their review
drained by ones work; Depersonalization which he said of Burnout syndrome among critical care healthcare
is the negative attitude towards and a dehumanizing workers observed that Burnout syndrome as measured
by the Maslach Burnout inventory is present in about
50% of critical care physicians and in one third of critical
Correspondence author: care nurses with severity of burnout being related to the
Okwaraji FE number of working hours of the critical care staff. The
Department of Psychological Medicine, College higher the working hours the more severe the burnout
of Medicine, University of Nigeria Nsukka syndrome experienced. Abdulla et al. 7 looked at the
E-Mail: Friday.okwaraji@unn.edu.ng prevalence and determinants of burnout syndrome

African Health sciences Vol 14 No. 1 March 2014 237

among primary health care physicians in Qatar and Lasebikan and Oyetunde 8 have argued that the incidence
reported that 12.6% of all the general practitioners of occupational stress related burnout among nurses is
who took part in the study experienced burnout. very high. The factors they pointed out to be associated
Lasebikan and Oyetunde 8 in their study on burnout with burnout among nurses include age of the nurse,
among nurses in a Nigerian general hospital found a number of years on the nursing job, the rank of the
high level of burnout in 39.1% of their respondents nurse in the establishment as well as inadequate staff
in the area of emotional exhaustion, 29.2% in the area to patient ratio. They further observed that a growing
of depersonalization and 40.0% in the area of reduced recognition of job stress leading to dissatisfaction
personal accomplishment. among registered nurses in Nigerian hospitals is a major
contributory factor to current problems associated with
They recommended that government needs to look recruitment and retention of nurses in the country.
into the factors that will enhance nurses recruitment They therefore suggested that if nurse administrators
and retention for effective healthcare delivery system can identify these factors, nurses turnover rate will
in Nigeria. In a related study with physiotherapists decrease thereby increasing recruitment and retention
Ibikunle et al.3 reported that 66.2% of their subjects of nurses in the country. Equally Lambert et al. 16 had
exhibited emotional exhaustion, 65.2% showed high observed high incidences of occupational stress related
levels of depersonalization and 75.6% showed high burnout among nurses in Paris. Jenkins and Elliot17 in
levels of reduced personal accomplishments on the London noted that factors such as age, years of work
Maslach burnout inventory. Variations in the prevalence and the rank of the nurse in the organization are also
of burnout syndrome in healthcare professionals have associated with the level of burnout and psychological
been documented. These include doctors 9, nurses 10, distress experienced by nurses. Other factors like
oncologists 11, and physicians caring for patients with inadequate staff, handling difficult patients, inadequate
AIDS 12 and community health personnel of primary clinical supervision, excess workload, emotional stress,
care units 13. conflict with staff and lack of adequate social support
have also been identified by various researchers to be
The role of nurses in the healthcare delivery system in related to burnout and psychological distress among
Nigeria and indeed all over the world is very significant; nurses18,19,20.
nurses occupy a central role in health delivery of every
country, though many countries may have different Though many studies had been conducted on burnout
health care systems and payment options. Nursing as a among nur ses in Nigeria, but most of these studies
profession requires investing a lot of time and energy had not critically looked at burnout and psychological
in relationship with people seeking treatment and care, distress among this professional group. The present
often in trying circumstances. Burnout is likely to be study is therefore an attempt to explore burnout and
heightened in these potentially intense and demanding psychological distress among nurses in a Nigerian
circumstances. Furthermore the nursing environment tertiary health institution with a view to making
also has elements that are likely to increase the feelings recommendations on how to reduce the negative
of burnout including heavy workloads, lack of adequate consequences of burnout and psychological distress
resources to work with, lack of respect from doctors and among nurses and professionals in the health sector and
little input into unit decision making and psychological also help to add to the health promotion campaign of
distress as well as job dissatisfaction 14. the government.

Aiken et al. 15 have reported negative attitudes and low Method

psychological and physical wellbeing among nurses Study Design: It was a cross sectional descriptive study
with many of them expressing strong feelings to leave carried out between February and March 2013.
the profession. Burke et al.14 argued that there are
indications that nursing as a profession is becoming Study Setting: The study was carried out at the University
less attractive for young women and men than it was of Nigeria Teaching Hospital (UNTH) Ituku Ozalla,
in the past, that some countries even report shortage in Enugu State of Nigeria. Enugu State is a mainland
of nurses and this is even compounded by the fact that state in South East Nigeria. It has very large deposits
richer nations are luring nurses away from poorer ones. of coal, hence it is also known as the coal city state.

238 African Health sciences Vol 14 No. 1 March 2014

It occupies an area of about 7,161 square kilometres. deal very effectively with the problems of my patients).
The state has a population of about 5,590,513. The The respondents rated each item on a seven- point
University of Nigeria Teaching Hospital is a federal likert type scale for how frequently they experienced the
tertiary health institution and a center of excellence in feeling (0 = never, 6 = every day). The scale was scored
healthcare delivery in south eastern region of Nigeria. It by calculating subscale means5. Maslach and Jackson4
serves virtually all the south eastern states and beyond. reported reliability coefficients of 0.90 for EE; 0.79 for
The hospital has 500 bed capacity and 21 clinical DP and 0.71 for PA with test-retest reliabilities ranging
departments. It covers an area of 200 acres of land. from 0.50 to 0.82 for the three subscales. Both the
convergent and discriminant validity of the MBI have
Study Subjects: Subjects for the study were nurses working been established5.
at the various clinical departments of the hospital. The
total number of nurses in the clinical department was The MBI have been sighted in over 500 studies since it
1573. Study participants were selected from this sample was developed more than 20 years ago and this made
frame through convenience sampling method. The it to be regarded as the most viable instrument for the
purpose and procedures of the study was fully explained assessment of burnout2. Furthermore in Nigeria the
to them. They were also assured that their responses MBI has been validated and used in many studies on
will be treated confidentially and no respondent will burnout among different population groups including
be identified in person, and that participation was nurses, doctors, psychologists and teachers3,9,22,23. This
voluntary. All the respondents agreed to participate and wide usage of the MBI for various researches in Nigeria
signed the consent form. 10 nurses were sampled from therefore justifies its usage in the present study. Part
each clinical department making a total of 210 nurses three is the General Health Questionnaire (GHQ-
that took part in the study. 12). The GHQ-1224 is an instrument used to screen
Ethical approval for this study was obtained from for psychiatric morbidity. Although it does not yield a
the University of Nigeria Teaching Hospital Ethical diagnosis, positive scores are indicative of psychological
Committee. distress. Each item is rated 0 or 1 on the basis of the
frequency with which the subject had experienced the
Data collection and Instruments: Data was collected by the symptom in the recent past, yielding a maximum score
authors with the help of two psychology interns. The of 12. In the GHQ-12 subjects are asked to indicate,
subjects were given a self-administered instrument that for instance, how recently they have been able to
was made up of three parts. Part one contains basic concentrate on whatever they have been doing. The
demographic information such as age, gender, marital response options include; better than usual, same as
status, education, religion, rank and number of years usual, less than usual and much less than usual. A score
practiced as a nurse in the hospital. of 1 or above is suggestive of psychological distress.
Part two was the Maslach Burnout Inventory (MBI), The GHQ has been used for studies in Nigeria 8.
which is a 22 item questionnaire that relates to the three
dimensions of burnout: Emotional exhaustion (EE, 9 Data Analysis: The data for this study was analysed using
items), which captures the experience of having ones SPSS version 15.0. Frequency tables and percentages
emotional resources depleted and having no source of were used to compare certain demographic variables
replenishment. EE subscale items describe feelings of such as age, gender, marital status, educational level
being emotionally overextended and exhausted by ones and hierarchy, while Chi square was used to test for
work (e.g. I feel like I am at the end of the rope). (b) significant relationships between variables. Binary
Depersonalisation (DP, 5 items) describes the experience logistic regression was done to predict the probability
of becoming cold and indifferent to the need of others. of a nurse developing burnout and psychological
DP subscale items capture negative and cynical feelings distress. The level of significance chosen for this study
about ones patients or colleagues ( e.g. I dont really care was p0.05 and Confidence Interval was 95%.
to what happens to some patients) (C) Reduced personal
accomplishment (PA, 8 items) is a sense of inadequacy Study limitation: The most important limitation of this
about ones ability to relate to patients which may result study is that recent events may have a disproportionate
in a self imposed verdict of failure. PA subscale items influence on respondents mood at the time the test was
assess how one perceives his or her competence (e.g. I taken.

African Health sciences Vol 14 No. 1 March 2014 239

Study Strength: The data collecting tools [Maslach Results
Burnout Inventory and General Health Questionnaire A total of 210 nurses participated in the study and
(GHQ-12)] are validated and have been extensively used properly completed the survey instruments given a
in previous studies. proper response rate of 100%. Table 1 shows the
demographic characteristics of the respondents.

Table 1 Socio-demographic characteristics of the respondents

Variable Frequency (N = 210) Percent
Age (years)
35 117 55.7
> 35 93 44.3
Gender
Male 40 19.0
Female 170 81.0
Marital Status
Single 59 28.1
Married 151 71.9
Educational Level
Nursing certificate 181 86.2
Nursing degree 29 13.8
Religion
Christianity 197 93.8
Others 13 6.2
Years of Service
5 13 6.2
>5 197 93.8
Rank
Nursing Officer 71 33.8
Senior nursing officer 139 66.2
and above
Age range = 25 50 years; mean = 35.5; SD = 8.34
Years of service: range = 5 23 years; mean = 5.6; SD = 2.60

They were 210 in all. 81.0% were females, 71.0% were indicating presence of psychological distress.
married. The age range of the respondents was 25 to 50 Prevalence of Burnout: A high level of burnout was
years. The mean age was 35.58.34 years. 57.7% were identified in 42.9% of the respondents in the area
less than 35 years of age. 86.2% had nursing certificates of emotional exhaustion (EE), 47.6% in the area
and majority of the nurses were Christians (93.8%). of depersonalization (DP) and 53.8% in the area of
Furthermore 93.8% had worked for more than 5 years. reduced personal accomplishment (RPA). This was
In terms of rank 66.2% were the ranks of senior nursing significant, 2 =7.1, df = (1), p=0.01 (Table 2)
officer and above. 44.1% scored positive in the GHQ

240 African Health sciences Vol 14 No. 1 March 2014

 Table 2 Prevalence of Burnout
Burnout measurements

Emotional Exhaustion Depersonalization Reduced Personal

Accomplishment
Yes No Yes No Yes No
(%) (%) (%) (%) (%) (%)
90 120 100 110 113 97
(42.9) (57.1) (47.6) (52.4) (53.8) (46.2)

Variables Predicting Burnout: All the demographic nurses aged less than 35 years, females, those not
variables measured that is age, gender, marital status, married and those with nursing certificates as compared
educational level, and years of service and rank were to those with nursing degrees and those working as
found to significantly affect burnout measurements, nursing officers, (Table 3).
(p<0.01), see Table 3. Burnout occurred more in the
Table 3 Socio-demographic variables and burnout measurements
Variable Emotional Exhaus- Depersonalization Reduced Personal
tion (Yes) (Yes) N = 100 Accomplishment (Yes)
N = 90 N = 113
Frequency 2
(P F r e q u e n c y Value Fr e q u e n c y P Value
(%) Value) (%) (%)
Age (years)
35 90 (100.0) 125.19 100 (100.0) <0.01 113 (100.0) <0.01
> 35 0 (0.0) (<0.01) 0 (0.0) 0 (0.0)
Gender
Male 40 (44.4) 6 5 . 8 8 40 (40.0) <0.01 40 (35.4) <0.01
Female 50 (55.6) (<0.01) 60 (60.0) 73 (64.6)
Marital Status
Single 59 (65.6) 109.40 59 (59.0) <0.01 59 (52.2) <0.01
Married 31 (34.4) (<0.01) 41 (41.0) 54 (47.8)
Educational Level
Nursing 61 (67.8) 4 4 . 8 6 71 (71.0) <0.01 84 (74.3) <0.01
certificate (<0.01) 29 (25.7)
Nursing degree 29 (32.2) 29 (29.0)
Religion
Christianity 77 (85.6) 1 8 . 4 8 87 (87.0) <0.01 100 (88.5) <0.01
Others 13 (14.4) (<0.01) 13 (13.0) 13 (11.5)
Years of Service
5 13(14.4) 162.11 13 (13.0) <0.01 13 (11.5) <0.01
>5 77(85.6) (<0.01) 87 (87.0) 100 (88.5)
Rank
Nursing 19 (21.1) 143.02 29 (29.0) <0.01 42 (37.2) <0.01
Officer (<0.01)
Senior nursing 71 (78.9) 71 (71.0) 71 (68.8)
officer and
above

African Health sciences Vol 14 No. 1 March 2014 241

Similar observations were also noticed in psychological distress evaluation, (Table 4).

Table 4 Socio-demographic variables and psychological distress

Variable Psychological Distress measured using
GHQ-12
Positive Negative P Value
N = 87 (%) N = 123
Age (years) < 0.01*
35 87 (100.0) 30
> 35 0 (0.0) 93
Gender < 0.01*
Male 40 0 (0.0)
Female 47 123 (100.0)
Marital Status < 0.01*
Single 59 0 (0.0)
Married 28 123 (100.0)
Educational Level < 0.01*
Nursing certificate 58 123 (100.0)
Nursing degree 29 0 (0.0)
Religion < 0.01*
Christianity 74 (85.1) 123 100.0)
Others 13 (14.9) 0 (0.0)
Years of Service < 0.01*
5 13 0 (0.0)
>5 74 123 (100.0)
Rank < 0.01*
Nursing Officer 16 0
Senior nursing 71 123
officer and above
*Significant

Binary logistic regression was then done to predict psychological distress when the demographic variables
the probability of a nurse developing burnout and are known (Table 5).
Table 5 Binary Logistic Regression analysis of variables contributing to Burnout and Psychological distress

Variables Coefficient of Regression (B)

Burnout measurements Psychological
Distress
Emotional Depersonalization Reduce Personal
Exhaustion Accomplishment
Age of 3.310 3.546 6.034 3.137
respondent
gender -16.082 -18.395 -15.084 -16.943
Marital status -7.785 -8.647 -45.644 -7.311
Educational 19.799 22.196 18.934 20.673
level
religion 20.689 23.537 24.984 21.229
Year of service 16.998 19.391 15.985 17.882
rank .726 -20.430 -15.510 .735
Constant -178.796 -173.235 -199.631 -177.791

242 African Health sciences Vol 14 No. 1 March 2014

Discussion: nurses than those who are married. Unmarried nurses
The health status of health workers is of great may experience higher levels of burnout than the married
importance if healthcare delivery is to be achieved. ones apparently due to the fact that they are younger
As part of occupational health the work environment and may be assigned more work than their elderly and
should be such that it does not endanger the health senior counterparts. Moreover married female nurses
of those who work. Incidentally work stress has been usually take maternity leave which will give them
observed to impact greatly on the health of workers opportunity to rest in their homes and recover from
especially in some professions like teaching, nursing the stress associated with the working environment.
and other health workers like doctors and psychologists. Furthermore Adekola 22 had argued that family life
This study has revealed that burnout was highly tends to strengthen ones emotional wellbeing, human
prevalent among the nurses who took part in the study. contacts and interpersonal skills. He further argued that
It also showed that the nurses have high prevalence of married women whose husbands help in housework
psychological distress. The authors noticed significant and family responsibilities and support their carrier
difference in the prevalence of burnout across the three development are less prone to burnout than women
dimensions of emotional exhaustion, depersonalization who do not have such assistance. This may explain why
and reduced personal accomplishment. Furthermore unmarried women have higher levels of burnout than
all the demographic variables measured were found to the married ones in this study.
significantly affect burnout levels. Similar observations
were also noticed in the area of psychological distress Those in the rank of senior nursing officer and above
evaluation. experienced higher burnout levels than those in the
rank of nursing officer. This may be attributed to the
Female nurses recorded high levels of burnout than males practice whereby senior nursing officers are constantly
in the area of emotional exhaustion, depersonalization under pressure to ensure patients satisfaction as they
and reduced personal accomplishment. This finding usually play supervisory roles over the junior officers to
was in line with an earlier report by Kalimo et al 25 ensure compliance to the globally accepted standards
who reported that both sexes differ significantly in in the nursing profession with regards to care. This
the ways they cope with stress. This higher levels of may make them to overlabour themselves and then be
burnout experienced by females may be attributed to predisposed to higher stress with the associated burnout
the present economic situation in the country where and psychological distress.
most women especially the married ones play a dual
role of homemaker where they do full household work The high prevalence of burnout and psychological
including child caring and also work full time in their distress noticed among our subjects of study had clearly
various offices and professions as career ladies. This demonstrated that burnout is a negative response to
dual role may likely predispose them to experiencing chronic job related stress, which arises when people give
many job related stress which eventually will affect their
too much of their time, energy and effort on their job
burnout than their male counterparts who may usually over a long time without having much time to recover
after coming back from work may decide to visit a physically or emotionally 2, 3. This study in general also
nearby drinking house to ease off the days tension. corroborates that of Aiken et al 15 who reported negative
attitudes and low psychological wellbeing among nurses.
Our study also revealed that nurses aged less than 35 The high levels of burnout and psychological distress
years of age experienced significantly higher levels of observed among these nurses invariably can affect
burnout in the three dimensions than the elderly nurses their job satisfaction, organizational commitment and
aged more than 35 years of age. This pattern of finding intention to quit26, as well as their work to family and
was equally reported by Edwards et al 18. This may be family to work conflict 27. This may also manifest in both
because the younger nurses might not have acquainted physical and behavioural symptoms of stress such as
themselves with the vagaries of the nursing profession depression, anxiety, irritability, headache and insomnia
and might not have developed enough psychological as had been reported by many authors in Nigeria and
resilience to cope with the many challenges associated other parts of the world7, 9,28,29,30.
with their job, unlike the older nurses.
Conclusion
We equally noticed high burnout levels among unmarried This study has revealed high prevalence of burnout and

African Health sciences Vol 14 No. 1 March 2014 243

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