Professional burnout, stress and job satisfaction of nursing staff at a university hospital1

OBJECTIVES: to describe the social and work characteristics of the nursing staff at a tertiary hospital in the Public Health Service of Andalucía, to assess the degree of professional professional burnout and job satisfaction of those professionals and to study the possible relation between the professional burnout variables and the stress and job satisfaction levels on the one hand and social and employment variables on the other. METHOD: descriptive and cross-sectional study in a sample of 258 baccalaureate and auxiliary nurses. As research instruments, an original and specific questionnaire was used to collect social and employment variables, the Maslach Burnout Inventory, the Nursing Stress Scale and the Font-Roja questionnaire. Descriptive, inferential statistics and multivariate analysis were applied. RESULTS: average scores were found for professional stress and satisfaction, corresponding to 44,23 and 65,46 points, respectively. As regards professional burnout, an average score was found on the emotional exhaustion subscale; a high score for depersonalization and a low score for professional accomplishment. Studies are needed to identify the scores on these subscales in health organizations and to produce knowledge on their interrelations.


Introduction
As a consequences of the changes in the organizations and of the current globalization processes, the exposure to psychosocial factors in the professional sphere has been more frequent and intense (1) . When these are adverse to the development of the professional activity and the individual's quality of life, they turn into a higher level of stress for the professional (2) .
In the last two decades, there has been a growing concern with the effects of stress on the nursing professionals (3) , which represent the most numerous group of health professionals who deliver care to patients 24 hours per day (4) . According to the Occupational Health and Safety Survey of the American Nurses Association (ANA), the main concern for the nursing staff with regard to health and safety in the work environment is the acute or chronic effect of stress (5) . The work conditions in nursing imply the exposure to pain and death, interpersonal conflicts (6) , lack of autonomy and authority for decision making and the lack of definition of the professional role, which produce a state of chronic stress (7) . The individual response to these situations can be psychological, including symptoms like anxiety, irritation and depression, or psychosomatic, involving headaches, nausea and sleep problems, with possible negative impacts for patient safety and for the quality of care (8) .
The prolonged exposure to professional stress is associated with the professional burnout syndrome (9) , characterized by high levels of emotional exhaustion, which refers to the decrease or loss of emotional resources, the depersonalization or development of negative attitudes towards patients and, finally, the lack of personal accomplishments, which provokes trends to assess one's work negatively (10) . The consequences of professional burnout include mental fatigue, lack of motivation (11) , increased risk of cardiovascular diseases, musculoskeletal problems (12) , low output levels, low productivity and absenteeism (13) .
Current evidence reveals job satisfaction as a predictor of the length of stay in a job, motivation and job productivity. The level of job satisfaction among nursing staff is dropping all over the world though (14) .
The main sources of nursing dissatisfaction include lack of staff, high care pressure and lack of professional acknowledgement (15) .
The objectives in this study were to describe the social and employment characteristics of the nursing staff at a tertiary hospital in the Public Health System of Andalucía, to assess these professional's degree of work-related stress, professional burnout and job satisfaction and to study the possible relation between the professional burnout dimensions and the workrelated stress and job satisfaction levels with social and employment variables.

Methods
An observational, descriptive and cross-sectional study was undertaken at a tertiary hospital in the Public Health System of Andalucía. The data were collected between February and June 2014. The study subjects were nurses or auxiliary nurses who worked at the hospital, who had worked at the service where they were active in care for more than one year and who were active at the time of the data collection. Accepting an alpha risk of 0.05, for an absolute precision level of 5% in a bilateral contrast and an estimated prevalence of professional burnout corresponding to 25% (16) , a sample of 258 subjects was determined, assuming a population of 2242 subjects. The sample size was calculated in the software Epidat version 4.0, departing from the least advantageous prevalence. The researchers received data on the total resources allocated to the nursing staff from the nursing head of the hospital. The following exclusion criteria were adopted: being a nursing student/auxiliary nurse or being a professional in specialized educational training.
The professionals were selected through random cluster sampling. The clusters corresponded to the services where the professionals worked. The hospital consists of 45 services. Using tables with random figures, eight services were selected in function of the sample size and the total number of nurses and auxiliary nurses working at the service. To foresee possible losses, two additional services were selected. All nursing professionals and auxiliary nurses from each of the selected services were considered for the study.
The study received approval from the hospital's Institutional Review Board (protocol 227, reference 2491). A dossier was designed to collect information, including an information letter in which the voluntary and anonymous nature was highlighted, an explicit request for cooperation which the professionals signed and data to agree to participate in the study, an original and specific form that collected social and employment variables, the Nursing Stress Scale (NSS) (17) , the Maslach Burnout Inventory (MBI) (18) and the Font-Roja questionnaire (19) . The researchers personally gave the problems with other nursing team members (5 items), work burden (6 items) and uncertainty in treatment (4 items). The total score is equivalent to the simple sum of the items in each subscale divided by the number of items. Any mean score higher than 1 was considered as a nursing stress factor. The global work-related stress was obtained by adding up the scores of the 34 items, so that the global score ranges between 34 and 102 points (16) . In this study, the internal consistency in the organization and performance of the function, 2 items), and job monotony (extent to which the job routine affects the subject, 2 items). The total score corresponds to the simple sum of the items, divided by the number of items. Score 3 was considered as the median satisfaction level. The global or total job satisfaction was calculated by adding up the scores for the 24 items, ranging between 24 and 120 points (18)  if the variance inflation factor was lower or equal to 10.
To diagnose extreme cases, the analysis of studentized residuals was used. The adjusted determination coefficient R 2 was used to assess the goodness of fit.
P-values inferior to 0.05 were considered significant in all statistical tests.
For the statistical analysis, the software G-Stat version 2 was used.

Results
In total, 258 properly completed dossiers were received. In the study sample, 77.52% of the professionals were women. with first-degree relatives obtained a mean score significantly higher by 9.83 points than professionals who lived with second-degree relatives. In the population, with a 95% confidence level, this score ranged between 3.92 and 15.74 points ( Table 2).
As regards the global job satisfaction, a positive and significant relation was found with the professionals' age: for each additional year of age, the job satisfaction increases by 0.22 points (Table 3).

Discussion
In this study, the sample was predominantly female. The mean age was 49.21 years. In addition, 69.38% were married. These results were similar to other studies in Spain (20)(21) and abroad (6) .
The mean scores on the professional burnout dimensions situated the sample at a medium level on the emotional exhaustion subscale; a high level for depersonalization and a low level for personal accomplishment. The comparison of the mean scores for the professional burnout dimensions with other studies (22)(23) proves that the mean scores in this study are similar for the emotional exhaustion and depersonalization dimensions. As regards personal accomplishment, the mean score was slightly higher in this study.
A significant and positive relation was found between the professionals' global stress level and their emotional exhaustion and depersonalization. This result is in line with the findings of another study (11) .
Nevertheless, no significant relation was found between the global stress level and personal accomplishment.
In the adjusted analysis, the association between emotional exhaustion and the global mean satisfaction derives from the nursing professionals' feeling of emotional impact of their work and the work relations established at the heart of the organization, reducing their job satisfaction (23) .
The mean score for depersonalization was significantly higher among single and married than among separated or divorced professionals. The relation between professional burnout dimensions and the marital status is a frequent source of discussion. While some researchers describe that marriage hampers the presence of the syndrome in health professionals (taking the form of a less cold attitude towards the patients) (21) , others consider that marriage is not a variable that significantly affects the professional burnout dimensions, considering that the social support received from the partner causes this influence (20) .
As regards the personal accomplishment dimension and adjusted by the other variables, professionals who lived with second-degree professionals showed a 25-percent lower score for personal accomplishment when compared to professionals who lived alone. The professionals may not perceive sufficient support from their relatives, which influences the professional's good performance.
The study limitations basically derive from the cross-sectional design, which only permits the analysis of associations between the variables, without the possibility of establishing causal relationships. In addition, the veracity factor in the professionals' answers should be mentioned, considering that the use of questionnaires tends to underestimate the degree of work-related stress, professional burnout and job dissatisfaction.
An action plan should be implemented in the hospital management to control the levels of stress, professional burnout and job satisfaction, enhancing the participation and communication between the professionals and the management.

Conclusions
The considered very important to strengthen optimism and self-esteem.