Original Article

Burnout in hospital nurses: a comparison of

internal, surgery, psychiatry and burns wards
A. Sahraian1 MD, A. Fazelzadeh2 MD, A.R. Mehdizadeh3 MD, PhD &
S.H. Toobaee4 MD
1 Psychiatrist, 2 Research Assistant, 4 Associate Professor, Psychiatry Research Center, Hafez Hospital, Shiraz University of
Medical Sciences, Shiraz, 3 Researcher, Cancer Research Center, Omid Hospital, Mashad University of Medical Sciences,
Mashad, Iran

Fazelzadeh A., Mehdizadeh A. & Sahraeeian A. (2008) Burnout in hospital nurses: a comparison of internal,
surgery, psychiatry and burns wards. International Nursing Review 55, 62–67

Introduction: Burnout is a phenomenon in which the cumulative effects of a stressful work environment
gradually overwhelm the defenses of staff members, forcing them to withdraw psychologically. This study
compared the levels of burnout among nurses in different nursing specialties.
Materials and methods: The sample of the study consisted of all the nurses working in all public hospitals in
Shiraz, Iran who were graduates of either technological educational institutions or universities and had
experienced clinical nursing practice for at least 1 year. Using Maslach Burnout Inventory and General Health
Questionnaire (28-item version), we identified the psychiatric morbidity and burnout among nurses.
Results: Study results indicated that nurses of psychiatry wards showed significantly higher levels of
emotional exhaustion and depersonalization in comparison with nurses working in other wards, and burn
wards nurses showed significantly higher levels of personal accomplishment. Also, nurses who were single were
more emotionally exhausted.
Conclusion: Different clinical working environments appear to have an impact on the development of nurses’
burnout.

Keywords: Burnout, Clinical Wards, Environment, Iran, Nurse

Introduction and reduced feelings of personal accomplishment (PA), with any

Burnout is a phenomenon in which the cumulative effects of
a stressful work environment gradually overwhelm the defences
of staff members, forcing them to withdraw psychologically
(Maslach 1982).
Burnout is a syndrome common in occupations where time is
spent supporting other people (Maslach et al. 1996), and has been
studied extensively among medical practitioners. Burnout has
been associated with self-reported reduced levels of patient care
(Shanafelt et al. 2002). Maslach’s model of burnout describes a
syndrome of emotional exhaustion (EE), depersonalization (DP)
Correspondence address: Afsoon Fazelzadeh, Psychiatry Research Center, Hafez
Hospital, Shiraz University of Medical Sciences, Abiverdi Street, Shiraz, Iran.
Tel: 98-915-5103108; Fax: 98-511-8517505; E-mail: fazelzadeh23@yahoo.com.
combination of these features in a given individual. The opposite
of burnout (correlating with low burnout scores) is said to be
indicative of engagement with work (Tyssen et al. 2001).
Nurses are particularly susceptible to the development of burn-
out, mainly because of the natureand the emotional demands of
their profession (Foxall et al. 1990; Lindsey & Attridge 1989).
Burnout develops as a response to chronic emotional strain,
resulting from a deterioration of relationships between the nurse
and the patients, the co-workers, the family, and the social envi-
ronment (Adali & Priami 2002). Additionally, burnout has been
closely related to both the absenteeism of nurses from work
(Jenkins & Elliott 2004) and abandoning nursing (Schaufeli &
Janczur 1994). Finally, nursing burnout results in poor patient
care (Cronin-Stubbs & Brophy 1985; Montoro-Rodriquez &
Small 2006).

© 2008 The Authors. Journal compilation © 2008 International Council of Nurses 62

Burnout in hospital nurses
There are differences in the degree of burnout experienced by
nurses working in different fields. Comparisons among different
hospital units (operation theatres, paediatric, gynecological and
surgery wards) confirm the significance of the interpersonal
environment (Leiter 1988).
In this article, we report the current levels of burnout experi-
enced by nurses working in public Hospitals in Shiraz, Iran, and
particularly in internal medicine, surgery, psychiatry and burn
wards and the identification of factors that contribute to its
development.
Materials and methods
We performed a descriptive, cross-sectional study among nurses
in public hospitals using standard questionnaires.
The sample consisted of all the nurses working in all public
hospitals in Shiraz (five hospitals). In particular, we recorded the
views of nursing personals working in the following wards:
seven internal medicine, four surgery, three psychiatry and one
burn ward.
The nurses, who participated in the study, were all graduates of
either technological educational institutions, or universities and
they had experienced clinical nursing practice for at least 1 year.
After excluding those who did not match our criteria, 180 nurses
were invited to participate in the study.
Following approval from Shiraz University Research Commit-
tee and Ethical Clearance, informed consent was obtained
verbally from all participants included in this study. All the
questionnaires were anonymous and they were returned to the
investigator after 7 days.
Participants were invited to provide demographic details,
including age, gender, relationship status, education, type of
work shift, second job, any organic disease and drug usage. The
standardized and validated Maslach Burnout Inventory (MBI)
(Maslach et al. 1996) and General Health Questionnaire (GHQ
28-item version, Hare et al. 1988) were administered to partici-
pants. Control data for the GHQ were derived from the National
Survey of Health and Well-being (Landsbergis 1988) and a
United Kingdom medical student cohort study (Goldberg 1978).
Normative data reported by the authors of the MBI were used
for burnout measures.
Instruments
The GHQ (Hare et al. 1988) is a self-administered screening tool
that detects common non-psychotic psychiatric morbidity in the
community, including anxiety and depression. The question-
naire refers to symptoms experienced in the last few weeks, and
is therefore an indication of state rather than trait characteristics
at a point in time. The GHQ cannot be used to diagnose specific
psychiatric disorders, but identifies potential psychiatric
morbidity.
© 2008 The Authors. Journal compilation © 2008 International Council of Nurses
63
We used the 28-item version of the GHQ. Four subscales assess
somatic symptoms, anxiety and insomnia, social dysfunction
and depression. The generally recommended case identification
(cut-off) score for the 28-item version is a score greater than 4,
which allows for a highly sensitive identification of potential
psychiatric morbidity. However, the actual cut-off score chosen
depends on the purpose and context of each study, and relates to
the relative importance of sensitivity and specificity (Andrews
et al. 1999; Firth 1986).
Some authors have used higher cut-off scores for case identi-
fication (Andrews et al. 1999; Winefield et al. 1989), so we analy-
sed the prevalence of ‘caseness’ according to a range of cut-off
scores. Binary scoring (0011) of the GHQ was used for case
identification and for determining the total mean GHQ scores.
Subscale scores were obtained using a Likert (0123) method as
per accepted convention.
The MBI is considered the gold-standard measure for burnout
(Maslach et al. 1996), and consists of three independently scaled
measures. The EE scale assesses feelings of being emotionally
overextended and exhausted by one’s work. The DP scale assesses
the presence of an unfeeling and impersonal response towards
recipients of one’s efforts. The PA scale assesses feelings of com-
petence and successful achievement related to one’s work. High
scores in the EE or DP scales, or low scores in the PA scale,
indicate high levels of burnout. The MBI has been widely vali-
dated and recognizes the different burnout patterns of individu-
als who may share common stressors. Each subscale score can be
categorized as low, average or high burnout as defined by nor-
mative data. Our study adopted a definition of burnout used in
a recent survey of hospital resident staff in the United States
(EE > 26 and/or DP > 9,Shanafelt et al. 2002).
We did not include the subscale scores for PA in the criteria for
burnout because previous research has suggested that this sub-
scale measures a somewhat distinct dimension (Maslach et al.
1996).
Statistical analysis
The possible association of burnout with the different indepen-
dent variables (sex, age, marital state, work shift, second job,
educational level, organic disease, drug usage and the work
environment subscales) was evaluated by using t-test.
High scores of burnout reflect high scores of EE and DP and
low scores of PA. The assessment of the factors that are associated
with high scores of EE and DP will provide the evidences as to
which factor contributes to the development of burnout.
The selection of the predictor variables was performed with
the level of significance P < 0.05.
All analyses were conducted with spss version 13.0 software.
64 A. Sahraian et al.

Table 1 Demographic characteristics of the 180 participants (sample description)

Variables Burn Psychiatry Surgery Internal Total

n (%) n (%) n (%) n (%) n (%)

Sex
Male 3 (6.7) 22 (48.9) 23 (50) 20 (45.5) 68 (37.8)
Female 42 (93.2) 23 (51.1) 23 (50) 24 (54.5) 112 (62.2)
Work shift
Night (fixed) 0 0 1 (2.2) 0 1 (6)
Morning/night 17 (37.8) 9 (20) 12 (26.1) 9 (20.5) 47 (26.1)
Rotation 28 (62.2) 36 (80) 33 (71.7) 35 (79.5) 132 (73.2)
Second job 3 (6.6) 15 (33.3) 5 (11.1) 5 (11.1) 28 (15.5)
Marital state
Single 17 (37.8) 8 (17.8) 10 (21.7) 8 (18.2) 41 (22.8)
Married 29 (64.4) 36 (80) 35 (76.1) 35 (79.5) 133 (73.9)
Divorced 1 (2.2) 1 (2.2) 1 (2.2) 1 (2.3) 4 (2.2)
Widow/widower 2 (4.4) 0 0 0 2 (1.1)
Educational level
Technological educational 30 (67) 33 (73) 26 (57) 12 (27) 101 (56)
institutions graduates
University degree 15 (33) 12 (27) 20 (43) 32 (73) 79 (44)
Organic disease 16 (35.6) 8 (17.8) 4 (8.7) 4 (9.1) 32 (17.8)
Reported drug usage 12 (26.7) 5 (11.1) 3 (6.5) 3 (6.8) 23 (12.8)

Table 2 Maslach Burnout Inventory subclass scores for 180 participating nurses

Variables Burn Psychiatry Surgery Internal Total P-value

Emotional exhaustion 0.023

Number 45 45 46 44 180
Mean 26.11 26.93 19.3 16.60 25.8
Standard error 1.80 4.75 4.74 1.41 0.87
Depersonalization 0.001
Number 45 45 46 44 180
Mean 5.14 6.869 5.35 6.262 5.90
Standard error 1.3 0.664 0.633 0.651 0.34
Personal accomplishment 0.000
Number 45 45 46 44 180
Mean 36.199 30.36 26.159 26.726 29.56
Standard error 2.31 1.18 1.12 1.58 1.07

Results Of the 180 participants who completed the GHQ, 77 (70%)

The response rate of our participants was 100%. The majority of
nurses were females (62.2%). The mean age was 34.8 ⫾ 8.3 years.
Most nurses were married (73.9%) with 0–6 children
(2.05 ⫾ 1.38) and they had a work experience of up to 10 years
(2.8 ⫾ 1.41).
The educational level of nurses had a University degree (44%),
whereas the majority of nurses (56%) were graduates of Tech-
nological Educational Institutions.
Some of the features of our sample are presented in Table 1.
met criteria for psychiatric morbidity (using a conventional case
identification score of >4). The mean total GHQ score was
3.1 ⫾ 4.6.
Table 2 presents the burnout experienced by nurses, in
the total sample and in the different hospital wards.
There was a statistically significant correlation between
burnout and of the study ward of the hospital. In particular,
nurses who work in psychiatry wards reported a higher degree
of burnout.

© 2008 The Authors. Journal compilation © 2008 International Council of Nurses

Burnout in hospital nurses 65

Table 3 Prevalence of burnout and its subscales over different wards

High burnout criteria Burn (%) Psychiatry (%) Surgery (%) Internal (%) Total (%)

EE score >26 26.7 40 17.4 6.8 22.8

DP score >9 4.4 13.3 0 2.2 5
Burnout 28.9 46.7 17.4 7.0 25
PA score >34 48.9 28.9 2.2 2.3 20.6

DP, depersonalization; EE, emotional exhaustion; PA, personal accomplishment.

Table 4 Burnout subscale predictors in different wards

Ward subscale Burn Psychiatry Internal Surgery

Variable P-value Variable P-value Variable P-value Variable P-value

EE Night shift 0.003 Night shift 0.000 Night shift 0.000 Night shift 0.006
Psychiatric morbidity 0.001 Psychiatric morbidity 0.001 Psychiatric morbidity 0.004 Marital state 0.037
Marital state 0.029
DP Sex 0.004 Sex 0.001 Sex 0.031 Sex 0.032
Night shift 0.000 Night shift 0.003 Night shift 0.001 Night shift 0.000
Organic disease 0.000 Education 0.031
PA Education 0.014 Marital state 0.031 Education 0.043 Marital state 0.042
Age 0.041 Night shift 0.003

DP, depersonalization; EE, emotional exhaustion; PA, personal accomplishment.

In total, 25% of participants met study criteria for burnout
[a high DP score (>9) and/or high EE score (>26)], with 22.8%
in the high EE range and 5% in the high DP range and 20.6%
in the high PA score (>34)(Table 3).
In burn wards, the predictors for EE were night shift and
psychiatric morbidity whereas male gender and history of
organic disease and night shift were associated with high levels
of DP (Table 4).
In psychiatry wards, single nurses and those who had more
night shift hours or high levels of psychiatric morbidity were
more emotionally exhausted. Older nurses and those who were
married had more PA (Table 4).
In surgery wards, high levels of psychiatric morbidity and
night shift were predictors for EE. Male nurses and those who
had more hours of night shift were more depersonalized. PA was
higher in older and night worker nurses (Table 4). In internal
wards, singles and night workers were more emotionally
exhausted. Male nurses, night workers and those who had lower
educational degree were more depersonalized. Married nurses
showed significantly higher levels of PA (Table 4).
The MBI scores in different wards showed that PA score
was significantly more in burn wards. (36.19 ⫾ 2.31,
P-value = 0.001), and DP was significantly higher in psychiatry
wards (6.87 ⫾ 0.7, P-value = 0.002).
Male nurses were significantly more depersonalized than
female nurses [mean DP score (SD) for males 4.86 (5.71), for
females 3.02 (3.64), P-value = 0.001]. Participants who were
single were significantly more emotionally exhausted than those
who reported being in a relationship [mean EE score (SD), 19.5
(7.4) vs. 15.9 (7.6); mean difference 3.6; 95% CI, 0.4–6.8]. This
was the only significant difference based on partnership status
noted for any of the items measured.
Nurses with more night hour’s work during the week were
significantly more emotionally exhausted and more depersonal-
ized (P-value = 0.000). When the sample was analysed in terms
of risk of psychiatric morbidity (with a GHQ case-identification
score of >7 to increase the specificity of the instrument), EE was
strongly associated with risk of psychiatric morbidity.
Participants meeting criteria for psychiatric morbidity had
significantly higher mean EE scores. (P-value = 0.001). A similar
profile was observed when the conventional but specific case
identification score of >4 was used. No significant association
between risk of psychiatric morbidity and DP or PA was
observed.

© 2008 The Authors. Journal compilation © 2008 International Council of Nurses

66 A. Sahraian et al.
Discussion
The majority of nurses of the sample were female, with a mean
age below 40. These data are in accordance with international
data (Bartz & Maloney 1986; Brown 1989; Hasselhorn et al.
2006) and suggest that nurses tend to withdraw easy from the
clinical sector possibly because of early retirement, or change of
work area. Probably, the working conditions in the hospitals
studied do not really favour the long-term stay of nurses (Takase
et al. 2006).
The total degree of reported burnout in the sample of our
study is thought to be moderate, compared with reported Ameri-
can levels (Vachon 1978). Yet, this study confirms that levels
of psychological distress remain high among nurses despite
initiatives to improve the work environment in recent years.
If standard case identification criteria are used, the prevalence
of psychiatric morbidity is 26%, which is higher than for the
general population (Vachon 1978).
In particular, nurses working in psychiatry wards reported a
statistically higher degree of burnout, compared with nurses in
other wards. DP and EE were also higher in psychiatry wards, but
only DP had a statistically significant degree compared with
other wards. Among the reasons contributing to the develop-
ment of burnout, contact and conflict with patients have a poor
prognosis (Cronin-Stubbs & Brophy 1985) and have increased
emotional demands (Hare et al. 1988). This may be the reason of
more burnout, seen in psychiatry ward nurses.
One study that examined job-related stress and work burnout
found that intensive care unit (ICU) workers reported higher
levels of burnout than those working in other wards (Kelly &
Cross 1985). But in our study, even though the job stress for
psychiatry nurses was much lower than Internal or surgery
wards, we saw more burnout among psychiatry ward nurses.
Another study carried out with 296 nurses of four different
nursing specialties (ICUs, internal medicine wards, surgery and
psychiatry departments) supported our results and showed that
although the tension of occupational stress was much greater for
workers in ICUs, it was not sufficient to constitute a forecasting
factor for burnout (De Martino & Misko 2004).
However, most nurses in the psychiatry wards report ranges of
normal to high levels of PA. A possible explanation of this
finding seems to be that the work is not the single source of
satisfaction for them, given that 80% of nurses in psychiatry
wards were married.
The personality characteristics of the individuals are also very
important for the development of burnout, with their motiva-
tions for choosing a humanistic profession (Vachon 1978);
expectations from him/herself and others (Wessells 1989);
values, self-esteem and ability to express feelings; the control
exerted over events and others; and personal style. In previous
© 2008 The Authors. Journal compilation © 2008 International Council of Nurses
studies, we have found that histrionic and narcissistic nurses
reported the highest levels of DP and PA, respectively. So, differ-
ent personalities may be related to most of the differences. Many
nurses report that on entering nursing they had altruistic ideas,
fantasies of helping patients and heroic images of themselves
(Vachon 1978). After some years, the ability to achieve these
ideals may be seriously threatened, resulting in psychological
distress and the process of burnout. This may be the reason that
psychiatric nurses who are not usually involved in lifesaving and
heroic procedures become more burnt out.
The low degree of involvement of nurses in their job and the
inefficient control on behalf of the supervisor are closely associ-
ated with the development of impersonal behaviour. On the
other hand, nurses who are focused on the duties and are under
intensive control from the administrator have a strong feeling
of PA.
Study limitations
The limitations of our study are due mainly to the limited geo-
graphical distribution of the sample, which can influence the
prevalence of burnout because of climate and cultural differ-
ences. We also compared only four types of wards.
Conclusion
The results suggest that further investigation of the problem of
burnout among Iranian nurses using a more representative
sample, with more variables and in a wider geographical area,
might be productive.
Acknowledgements
This study was supported by a grant from the Shiraz University.
We thank Professor Hassan Haghshenas for his advice at the
onset of this study, the nurses and the clinical training units of
the participating hospitals in Shiraz, and Mrs Ghaem for her
data management skills.
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