Causes of burnout syndrome and coping strategies among high dependency unit nurses of an institution in the greater Accra region of Ghana

Abstract Aim The aim of this study was to determine the causes of burnout syndrome and identify strategies to cope with them among nurses at high dependency unit if a regional Hospital in Ghana. Design A descriptive convenient and purposive cross‐sectional study design was used for this study. Methods The study involved 40 nurses in the high dependency unit of the Hospital. A Maslach Burnout Inventory (MBI) was adopted to measure burnout experienced by these nurses concentrating on feelings of being emotionally exhausted and lack of energy, depersonalization, feelings of impersonal response towards patients and personal achievement. Results 62.5% of the respondents were in the high emotional exhaustion, 55% scored high in the depersonalization section and 52.5% scored high in the personal achievement (competence) on the Maslach Burnout Inventory (MBI).


| BACKG ROU N D
Social changes over the last decades have led to changes at the workplace. This has led to physical and emotional exhaustion among workers resulting in excessive accumulation of workload and high burnout levels (Paiva et al., 2016). High burnout directly affects the physiological stability of individuals pre-disposing them to cardiovascular diseases, psychiatric disorders and gastrointestinal disorders (Paiva et al., 2016). The term "burnout" was coined by Freudenberger in 1974 to describe workers' reactions to the chronic stress commonly found in occupations involving numerous interpersonal interactions (Doulougeri et al., 2016). The document added that burnout is a psychological syndrome that involves a prolonged response to chronic emotional and interpersonal stressors. In addition, burnout syndrome refers to a situation in which workers appear disconnected from their job and everything seems to be senseless (Lorenz et al., 2010). Literally, this implies that the worker loses the sense of relationship to work.
Burnout is a syndrome comprises of three dimensions; the first of which is emotional exhaustion, which is when someone is "emotionally overextended and exhausted by work." The second is depersonalization, which is categorised by "unfeeling and impersonal response towards recipients of one's care or service" and lastly low personal achievement, which is when people have "feelings is a common problem among healthcare professionals, especially those at the frontline of healthcare delivery. Burnout affects nearly half of all nurses and physicians in developed countries, and it is associated with poor outcomes such as worse patient safety (Dolan et al., 2015).
In healthcare, burnout contributes to poor outcomes, including worse patient safety and lower patient satisfaction (Cimiotti et al., 2012). Burned-out employees are more probably to leave their jobs, take sick leave and suffer from depression and relationship problems. In addition, burnout can result in work-related consequences such as dissatisfaction with the work, reduction in the quality of care, unjustified absenteeism, intention of giving up their job and abandonment (Dyrbye et al., 2011).
Burnout is a complex phenomenon because it is not manifested in one single form and is influenced by broad social, cultural and professional factors. Different burnout measurement tools such as Professional Quality of Life Scale, Copenhagen Burnout Inventory and Maslach Burnout Inventory is used to measure occupational burnout. However, the Maslach Burnout Inventory (MBI) is the most commonly used measure of burnout. The MBI describes burnout according to three components (emotional exhaustion, depersonalization and reduced personal accomplishment) and provides the opportunity to assign a classification of burnout into low, medium or high burnout (Doulougeri et al., 2016).
Identifying and characterizing burnout is important as it can have a negative impact on providers and patient care. To help prevent burnout among health professionals and promote patient safety, there is a need to explore the causes and strategies to cope with burnout among nurses.

| AIM
The aim of this study was to determine the causes of burnout syndrome and identify strategies to cope with them among nurses at high dependency unit if a regional Hospital in Ghana.

| ME THODS AND MATERIAL S
A descriptive cross-sectional study was used to determine the causes of burnout syndrome and identify strategies to cope with them among nurses at a Regional Hospital over a study period of 3 months. The study was conducted among high dependency unit nurses in one of the Regional Hospitals in Ghana. The hospital has an ultra-modern facility of about 620 beds, with the full complement of specialist services that would adequately meet the growing demand for quality secondary and tertiary level healthcare services in Ghana (Laryea, 2017). It has seven (7) major departments namely Accident and Emergency Department, Surgery Department, Medical Department, Paediatrics Department,

Obstetrics and Gynaecology Department, Theater and Allied
Health Department. Each department has units and subunits.
The hospital has HDU, and all nurses in the units were enlisted to take part in the study. The dependency unit consists of intensive care unit (ICU), recovery ward and emergency unit of the Hospital (Egungwu, 2015).

| Population
The study was conducted among the high dependency unit nurses working at intensive care unit (ICU), recovery ward and emergency unit of the Hospital. Inclusion criteria was all permanent nurses working at the Hospital's DHU and those who are ready to participate in the study. The exclusion criteria are the other recognised staff such as doctors, pharmacists, anaesthetists and other paramedics.

| Sample size and sampling procedure
Nurses who qualify for this study were 45; a convenient and purposive sampling technique was used for the study. This nonprobability sampling was decided because the number of nurses in these units was 45, and so researchers decided to use all for the sake of precision.

| Data collection
Structured questionnaires based on research objectives were developed for the purpose of data collection after reviewing relevant literature. Data were collected by the principal investigator. The questionnaires used solicited information on socio-demographic data, the proportion of nurses with burnout syndrome, causes of burnout syndrome and strategies of coping with burnout syndrome. A Maslach Burnout Inventory (MBI) was adopted to measure burnout experienced by these nurses. The MBI is the most widely used inventory to assess burnout, and it consists of 22 questions across three dimensions: emotional exhaustion (first nine questions); feelings of being emotionally exhausted and lack of energy, depersonalization (next five questions); feelings of impersonal response towards recipients of the service and personal achievement (last eight questions); feeling of competence. Each question is scored on a scale from 0 (never) to 6 (everyday). The points from each dimension are added to provide a total score for that dimension. The score for each dimension can be categorized as low, moderate or high: emotional exhaustion (low ≤13; moderate 14-26; high ≥27); depersonalization (low ≤5; moderate 6-9; high ≥10); and personal achievement (high ≤33; moderate 34-39; low ≥40). Higher scores on emotional exhaustion and depersonalization and a lower score on personal achievement are associated with higher burnout (Doulougeri et al., 2016).

| Validity and reliability of questionnaire
To ensure validity and reliability, questionnaire was developed and structured guided by objectives of the study and information from the reviewed literature. The questionnaire was given to a supervisor who had a lot of experience in the area of study for input and the necessary corrections made. A pre-test was carried out using 15 nurses at 37 military hospitals to check for consistency, relevance and applicability of the questionnaire. These 15 questionnaires were entered into the SPSS Version 25.0. Cronbach's alpha was ran for the 22 items on the Maslach Burnout Inventory (MBI) on a Likert scale, and the reliability coefficient was 0.712.

| Data collection procedure
The establishment of good rapport with the nurses before the actual data collection at the study institution was ensured. Data were collected through one-on-one administration of questionnaires and retrieved in 1-2 weeks after administering them. Prior to the data collection, permission to carry out the research was obtained from the hospital. Study participants were not forced into the study rather through written and verbal informed consent. Respondents' confidentiality was assured through the use of numbers to identify the questionnaires.

An introductory letter from the School of Perioperative and Critical
Care Nursing was obtained and sent to the Research and Development unit of the Regional hospital where the study was conducted before the commencement of the study. Permission was also sought from the nurse manager at the hospital concerning the participation of her nurses. Respondents were informed that participation is voluntary, and any information given would be confidential. They were told not to write their names on the questionnaire to ensure anonymity.

| Data analysis procedure
Collected data were managed in Microsoft Excel and analysed using SPSS version 25. Features of the data gathered were explored to get a general description of responses given by respondents. Descriptive statistics were used to present data on the population by using percentages in tables. A Pearson chi-square test was done to determine factors associated with burnout syndrome at a confidence interval of p-value <.05 a considered statistically significant level.

| RE SULTS
Study samples were described in terms of their socio-demographic characteristics and the proportion of nurses with burnout syndrome.
Then, causes of burnout syndrome and strategies of coping with burnout syndrome are analysed. Table 1 is the percentage distribution of the socio-demographic characteristics of population used for the study. Forty-five questionnaires were sent out, but only 40 came back creating an 89% return rate. Majority (67.9%) of the respondents were females with age range of 29-58 years. Half (50%) of the nurses had Bachelor's degree, 30% had Diploma certificate and the rest (7.5%) had master's degree and were critical care nurses (45%), Registered Nurses (35%) and 20% were Emergency Nurses. Most (47.5%) of the respondents had worked for a minimum of 6 years, 22.5% had worked for 3-5 years, 17.5% had worked for more than 10 years and 12.5% had less than 3 years working experience as nurses. Table 2 shows the distribution of nurses by dimensions of the MBI according to the categories of low, moderate and high. More than half (62.5%) of the respondents were in the high emotional exhaustion (EE) range with a mean of 28.4, 55% scored high in the depersonalization (DP) section with a mean of 9.7 and 52.5% scored high in the personal achievement (PA) section with a mean of 33 on the scale. Thus, more than half of the respondents felt emotionally exhausted and lack of energy from their job, over half of them had TA B L E 1 Socio-demographic characteristics of respondents impersonal response towards recipients of the service and a little above half of them were found to be highly competent in their job.  Table 4 depicts coping strategies that best helped to relieve burnout.

| Strategies of coping with burnout syndrome
Majority (42.5%) of the respondents indicated that problem-focused coping strategy, emotional support from family/friends' strategy (22.5%), using humour as a coping strategy (15%), listening to music (12.5%) and emotion-focused strategy (7.5%) best relieve burnout.

| D ISCUSS I ON
For many years, conventional wisdom held that employees work primarily for money and could be motivated through financial reward and fear, a realization that performance at work place is much more complex (Banks, 1997). Higher scores on emotional exhaustion and depersonalization and a lower score on personal achievements are associated with higher burnout (Doulougeri et al., 2016). This study revealed that more than half of the respondents felt emotionally exhausted and a lack of energy from their job and characteristic, some had impersonal response towards recipients of the service (depersonalization) and a few were found competent in their job (personal achievement). This implies that despite this, more than half of them were remained competent towards their job. These findings are similar to previous studies that revealed that more than half of respondents had high levels of emotional exhaustion and high levels of distrust (da Silva et al., 2014;Kathriarachchi & Rowntree, 2016).
In addition, this study is also contrary to other studies that revealed that most respondents had reduced competence or personal accomplishments even though they had high levels of emotional exhaustion and depersonalization (Lasebikan and Oyetunde, 2012). The study agrees with study from Raftopoulos et al. (2012) portrayed that nurses find their job stressful.
Another study has also found out that intense and unsatisfactory work environment associated with long working hours and the suffering of work experiences in the intensive care unit were associated with burnout syndrome (Doulougeri et al., 2016).

| Strategies of coping with burnout syndrome
Coping is a pattern of constructed behaviour towards situations deemed stressful, with the aim of avoiding its negative effects  (Deklava et al., 2014). The outcome of this study is similar to a study that recommended strategies such as problem-focused coping strategy, emotion-focused strategy, avoidant coping strategy and humour for coping with burnout syndrome (Kathriarachchi & Rowntree, 2016). The document further added that some studies have also revealed that most popular coping strategies practised in stressful situations were listening to music, obtaining emotional support from family/friends and seeking comfort in religion.

| Strengths and weaknesses of the study
• The study might not be the first of its kind in Ghana but vividly spell out how HDU nurses feel about their work.
• It also showed that even though there were some existing coping strategies, some are not feasible, but respondents need to hold on to their job.
• The weakness was in the number of samples used-it was too small so generalization will not be possible.

| Implication for nursing
The study set out to investigate among HDU nurses in a regional hospital what caused occupational burnout and how they cope with the stress. It was designed overtly with the intent of advocating for motivation of nurses for their hard work.

ACK N OWLED G EM ENTS
We thank hospital that granted permission to conduct this research, and the HDU nurses who agreed to spend time to answer the questionnaire.

CO N FLI C T O F I NTE R E S T
The authors declare that they have no competing interests.

AUTH O R CO NTR I B UTI O N S
YAB conceived the study, was the principal investigator and made most extensive contribution to the research. SO was involved in the conception of the research, guided the development of the proposal and supervised the study. IKA and AAD revised the research and developed a manuscript for its intellectual and professional content.

E TH I C A L A PPROVA L
The study took an introductory letter from the school of Peri Operative, Korle-Bu, Accra and a gatekeeper letter from research unit of the hospital. Voluntary participation was accorded with oral, written and signed consent.

DATA AVA I L A B I L I T Y S TAT E M E N T
Data for this study will be available to any researcher upon reasonable request.