| Abstract|| |
Stress is a well known and identified problem within the nursing profession. Dialysis nurses are exposed to high level of stress. Increasing workload can aggravate stress and cause burnout and exhaustion. Stress and burnout are capable of having a detrimental impact on organizational productivity and pose serious health and safety hazards on the job. We aimed in this study to determine the type and level of stress and the amount of burnout among our dialysis nurses, and to evaluate the managing skills and the impact of stress on their work performance. There were 93 nurses (19 national and 74 expatriate nurses) who answered modified questionnaires to the aims of our prospective and descriptive correlational study. Our results show that most nurses involved in the study (national and expatriate) experienced a mild level of stress (79% and 68%, respectively) and moderate level of burnout (42% and 38%, respectively). The most common stressor among the national nurses was technical breakdowns of machines (15.9%) and that among expatriates was job insecurity (16.9%). The majority of the national nurses (21%) coped with this by increased sick leaves, whereas the majority (25%) of the expatriates responded by becoming easily frustrated. The most utilized coping skill among both groups was the relaxation methods (20.8% versus 24.9%) and the least utilized was denial (3.9% versus 0.5%). In conclusion, our results suggest the exposure of dialysis nurses to different types of stress and demonstrate the different experienced coping skills. These results may have implications for nursing management and hospital administration.
|How to cite this article:|
Karkar A, Dammang ML, Bouhaha BM. Stress and burnout among hemodialysis nurses: A single-center, prospective survey study. Saudi J Kidney Dis Transpl 2015;26:12-8
|How to cite this URL:|
Karkar A, Dammang ML, Bouhaha BM. Stress and burnout among hemodialysis nurses: A single-center, prospective survey study. Saudi J Kidney Dis Transpl [serial online] 2015 [cited 2020 May 31];26:12-8. Available from: http://www.sjkdt.org/text.asp?2015/26/1/12/148712
| Introduction|| |
Stress is a well known and identified problem within the nursing profession, and is related to the intense work environment and the nature of the profession.,, Nursing staff are usually exposed to different types of stress, which include increasing demands of care for excess number of patients, sicker and older patients, work overload with extra responsibilities and shortage of staff, timing and duration of working hours, personality conflict and fear of losing the job. , Long-term exposure to occupational stress may not only physically and mentally exhaust nursing staff but can also lead to burnout ,,,, and varying degrees of depression.  Furthermore, there is an inverse relationship between stress and job satisfaction,  where excess and continuous exposure to stress may lead nurses to leave the profession and consequently may contribute to shortage of nursing staff.  Finally, stress and burnout may have a negative impact on the organizational productivity and may pose serious health and safety hazards at the work-place. ,,
Hemodialysis (HD) nurses are also exposed to stress and burnout,  but are prone to additional and more specific types of stress. These include intense activities during initiation and termination of dialysis sessions, urgent interventions when life-threatening complications arise and sudden confrontation with patients who may become verbally and/or physically abusive. ,, Furthermore, HD nurses have to deal with complex dialysis techniques, sophisticated modern HD machines, strict implementation of infection control policies and procedures, increased work demands due to the growing number of patients with end-stage renal disease in need of dialysis treatment, continuous shortage of professional dialysis nursing staff and chronic relationships with patients and their families, ,, all of which can be a major source of stress and burnout. 
Different studies have been conducted on stress and burnout among nurses in the general profession, but fewer were conducted among dialysis nurses. ,,
We aimed in this study to determine the type and level of stress among the HD nurses, the amount of burnout, the impact of stress on their work performance and the coping skills that were utilized to overcome the stressors.
| Methods|| |
The Nursing Theorist Callista Roy's Adaptation Model was used to guide this research study.  This is based on its explicit assumption that a person is a bio-psycho-social being and that a person is in constant interaction and adaptation with a changing environment. The study was conducted using modified stress and burnout questionnaires, ,,,, which were answered by the participants who were working in the day and night shifts.
A descriptive correlational design of the questionnaires was used to determine whether there was a relationship between stress and burnout. For the stress scale, we listed 20 work-related stress causing factors wherein the participants were asked to rate their level of stress on each one from 0 to 5, where "0" meant rarely or never stressed and "5" reflected great deal of stress. For the burnout scale, a total of 25 questions, which provided an insight into the participants' susceptibility to burnout, were asked. The scale that was used indicated that 1 = never, 2 = rarely, 3 = sometimes, 4 = often and 5 = always. The negative effects of burn-out were evaluated by listing six outcome conditions and the participants were asked to encircle all those applicable. There were nine coping skills listed, and the participants were asked to encircle all those applicable.
Among 200 of our dialysis nurses who were approached to be included in this research, 93 female dialysis nurses participated in this prospective study. There were 20% nationals and 80% expatriate nurses, who included Filipinos, Indians, Indonesians and Pakistanis. Their years of employment and practice varied between 1 and 26 years in the same HD unit. The purpose of the study was indicated in the questionnaire and the respondents were guaranteed confidentiality; they were not asked to write their names to protect their identity.
| Statistical Analysis|| |
Results were analyzed by percentage and scoring. Data were treated with frequency distribution and percentages as shown in [Table 1], [Table 2], [Table 3] and [Table 4]. Pearson's product-moment correlation was applied to test the correlation between stress and burnout. 
|Table 1: Grouped frequency distribution of the levels of stress among the national HD nurses in our study.|
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|Table 2: Grouped frequency distribution of the levels of burnout among the national HD nurses in our study.|
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|Table 3: Grouped frequency distribution of the levels of stress among the expatriate HD nurses in our study.|
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|Table 4: Grouped frequency distribution of the levels of burnout among the expatriate HD nurses in our study.|
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| Results|| |
Among the 19 national dialysis nurses who participated in the study, 79% had a mild level of stress, 16% showed moderate level and only 5% did not experience stress in the workplace [Table 1]. In addition, 42% of the national nurses showed a moderate level of burnout, 32% showed a high level of burnout and 26% showed a low level of burnout [Table 2]. Among the 74 expatriate dialysis nurses who participated in the study, 68% showed a mild level of stress, 17% showed no stress, 14% showed a moderate level of stress and 1% showed severe stress in the workplace [Table 3]. In addition, 38% showed a moderate level of burnout, 36% showed a low level of burn-out, 21% showed no burnout and 5% showed a high level of burnout [Table 4].
The most common cause of stress among the national nurses was defective machines (technical breakdown), which accounted for 15.9%, followed by exposure to needle stick injury (14.6%), demanding and manipulative patients (11%), having to work for long hours (11%) and less job compensation (11%). In comparison, the most common cause of stress among the expatriate nurses was job insecurity (16.9%), followed by demanding and manipulative patients (11.1%) and defective machines (10%) [Table 5]. There was no correlation between stress/burnout and duration of employment.
|Table 5: Top ten stress-causing factors among the national and the expatriate HD nurses in our study.|
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The national and expatriate nurses reacted differently in responding to stress. The majority of national nurses (21%) increased their absence from work place by reporting sick leaves, followed by easy frustration (17.9%), decreased ability to work with colleagues, supervisors and physicians (17.9%), increased errors in decision making and/or performing role task (17.7%) and decreased patient care (16.1%). In comparison, the majority of the expatriate nurses responded by becoming easily frustrated (25%), followed by decreased ability to work with colleagues, supervisors and physicians (21%), increased errors in decision making and/or performing role task (17.7%) and decreased patient care (15.3%) [Table 6]. Coping with stress was similar among the national and the expatriate nurses. The most commonly used method was relaxation methods, which was used by 20.8% of the national nurses and 24.9% of the expatriate nurses. This was followed by dealing with the problem (18.2% and 24.3%) and learning new skills to deal with the problem (15.6% and 22.2%, respectively) [Table 7].
|Table 6: Outcome of stress among the national and the expatriate HD nurses in our study.|
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|Table 7: Stress reducing skills utilized by the national and the expatriate HD nurses in our study.|
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| Discussion|| |
General nursing is a profession that requires working in a variety of timings and situations with continuous and regular delivery of physical and emotional care.  It is also a situation where the nursing staff can be under continuous exposure to a wide range of occupational stressors. French et al  identified conflict with physicians, problems with peers and supervisors, workload, uncertainty concerning treatment, dealing with death and dying patients and dealing with patients and their families as being potential stressors for nurses in general practice. Nurses who work in HD units have to deal with chronic HD patients who can become verbally or physically abusive, or both.  Over half of the nurses in a study conducted by Perrin  encountered some forms of violence in their nephrology unit. This is because dialysis patients can become frustrated in many areas, which could possibly lead them to become potentially violent or aggressive.  These areas include having renal failure, delays in treatment, arriving late for dialysis, waiting for nurses or machines, machine faults, not being seen often enough by a regular physician, feeling that no one is really listening to them, lack of information and lack of control, all of which can expose HD nurses to continuous stress. Ross et al  have also shown a positive association between increased stress and burn-out among dialysis nurses and some other factors such as age and years of experience.
Our results showed that a significant percentage of our national and expatriate dialysis nurses experienced mild level of stress with an outcome of moderate level of burnout. These results are similar to earlier reported studies. , Correlation of our nurses' level of stress and burnout yielded a moderate correlation (r = 0.62) in the national nurses and a high positive correlation (r = 0.84) in the expatriate nurses. Our findings confirm that nurses working anywhere and of different backgrounds are confronted by stress that may lead to burnout, and that dialysis nurses are not immune to stress and its impact.
A high rate of stress and/or continuous exposure to stress can not only affect the individual nurse but also the healthcare field.  The exposure of our nursing staff to the different types of stressors resulted in negative outcomes such as frustration, decreased ability to work with colleagues, supervisors and physicians, increased errors in decision making and performing role task, decreased patient care and aggressive behavior toward staff and patients. Other studies had similar findings. ,
Therefore, it is important that nurses recognize the problem, confront stressors and learn to change the environment to reduce stressful situations in a productive and positive way.  It has been shown that the most common way nurses adapt to stressors is through the use of effective coping mechanisms.  The use of effective coping skills could also be very helpful to dialysis nurses to be able to manage job related stress.  Interestingly, both the national and the expatriate nurses in our study adapted similar skills to combat stress such as the relaxation methods. Rosenthal  recommended the elimination of stress by means of relaxation and desensitization techniques and biofeedback. Earlier studies , suggested the use of relaxation techniques along with a regimen for proper sleep, exercise, nutrition, meditation and socializing with family and friends.  The other coping skills used by the nurses in our study included dealing or learning new skills to deal with the problem, seeing humor in a situation and managing hostile feeling, whereas denial was the least-utilized coping skill.
Our study has implications for the nursing and hospital administration and education personnel,  such as assessing the structural and managerial aspects of nursing, properly addressing nurse's stress and burnout in order to prevent major crises and providing continuous support and effective guidelines to enable the nursing staff to deal with abusive patients in the dialysis unit as well as possible abuses by nurse managers. , These findings may also further support the development of a working group from both management and nursing staff to explore issues such as shift patterns and the time constraints.  In addition, theoretical education, practical training, continuous orientation program for new staff nurses and clinical supervision with proper protocols and guidelines that assess individual performance are necessary to ensure achievement of adequate skills and knowledge to independently manage patients on dialysis. ,,,
In conclusion, our results suggest the exposure of dialysis nurses to different types of stress and demonstrate the different experienced coping skills. These results may have implications for nursing management and hospital administration.
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PhD, FRCP, FASN Ayman Karkar
Kanoo Kidney Center, Dammam Medical Complex, P. O. Box 11825, Dammam 31463
Kingdom of Saudi Arabia
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6], [Table 7]