Nurses' professional values and its Relation to their Burnout in Minia university hospitals

Discussion:

Nurses are affected both mentally and physically at work, and they are particularly vulnerable to job burnout. Nurse burnout can be further differentiated based on clinical duties or specialty. Burnout, commonly defined as a work-related syndrome characterized by emotional exhaustion, depersonalization, and a sense of reduced accomplishment, negatively affects healthcare team health and productivity, and patient care (Agarwal et al., 2020).

The application of professional values by nurses in their practice is associated with better quality of patient care. They positively impact nurses' judgment and choices in their care for patients and their decisions and actions, complying with standards (Al Shammari et al., 2017; Stainton and Hughson 2017).

In other words, the professional aspect of nursing, including its philosophies, values and ideologies, can be combined with the occupational aspect, and the values derived from this combination should promote the professional satisfaction of individual nurses and the public’s recognition of nurses' values. One’s professional role in nursing is inseparable from one’s ethical values (Shahriari, et al., 2013).

Professional values affect the nurse’s quality of life because they determine the motives of someone who is attempting to deal with an ethical dilemma. Professional values are directly related to whether nurse’s efforts will result in feeling satisfied and rewarded and play a significant role in the burnout that nurses experience (Kohlen& McCarthy, 2020).

Nurses with positive professional values tend to be more competent with their employment and achieve greater results than other nurses because of their engagement with, and intense commitment to, the organization. Therefore, nursing values can be understood as a main concept in problem-solving strategies used by the profession to solve current problems (Scoot, 2017). However, investigations that have examined the relationship between nurses’ professional values and their burnout level are not rich and there is a need for more studies and researches.

Concerning the distribution of the staff nurses according to their personal data, it was noted from the current study results that there were more than three quarters of staff nurse's aged between 18 - < 28 with mean age 26.5 ± 6.1 years; more than half of staff nurses married, and lives in the urban area. Regarding educational qualification and current position; there were more than half of them had a nursing technician, as well as their current position is a nurse.

Also, the current study revealed that majority of staff nurses had from 1 - < 6 years with mean experience 5.6 ± 6.3 years in the nursing field. In addition there were less than half of the staff nurses work in emergency hospital, while lowest percentage work in nephrology and urology hospital and cardio thoracic surgery hospital.

Concerning the distribution of the staff nurses according to their professional values subscales; it was noted from the current study results that the staff nurses had moderate level for all subscales of professional values as; for Human dignity, Privacy, Safeguard client, Responsibility and accountability, Competence, Informed judgment, Contributes to knowledge, Improve standards, Conditions of employment, Maintain integrity, and for Collaborate.

These results may be as result of nurses' awareness and knowledge about their nursing profession ethics; the study subjects are from different categories of nurses and qualification in which there are high bachelor degree, technical degree, and diploma degree that provide nurses with huge information regarding professional ethics, beliefs and values.

Also, the study subjects are from different culture and different setting in which enrich them with ethical values and beliefs. They learn from their culture to protect their community setting from unsafe health product and practices as well as their environment may articulated them with values and goals of the nursing profession  

This justification come in line with Tehranineshat, et al., (2020)   who agreed that the professional values are rooted in personal values that are shaped by an individual’s culture, family, environment, religion, and ethnicity. The acquisition of these values is a gradual and evolutionary process and extends throughout one’s life. Also, nurses’ observance of professional values will not only improve the quality of nursing care, but increase nurses’ job satisfaction, professional survival, and organizational commitment (Lin, et al., 2010).

However; these results are not congruent with Allari, et al., (2017) who had a study on 150 Saudi female nurses living in Riyadh and their results show that Saudi female nurses have a high perception of professional values relating to confidentiality, privacy, moral and legal rights, health and safety, and the work environment.

Also, it was noted from the current study results that the subscales which had high level from staff nurses point of view were: Conditions of employment; Human dignity; Responsibility, and accountability; informed judgment; Competence; and Collaborate. While the subscales which had low level from staff nurses point of view were: Contributes to knowledge and Safeguard client.

These results may be due to the nurses recognize their patient right to choose treatment plan; they commitment to follow a written guidelines for practice and care providing; they refuse to participate in care which is ethical opposition to their own professional value; also, they act as a patient advocator. As well as the staff nurses use patient assessment data to develop a nursing care plan; they provide care without judgment to patients lifestyles or values. 

This finding in the same line with Bleda et al., (2020) determined whether nursing students attach increasing importance to professional values during the course of their academic degree, concluded that students’ scores were higher in the ethics dimension. The two highest scores were for Maintain patient confidentiality for years 1 and 2 (4.77 and 4.68, respectively) and Safeguard patients’ right to privacy for years 3 and 4 (4.95 and 4.98, respectively). Lower scores were observed in the professional expertise dimension across all years, and corresponded to a single item participate in peer review (3.51, 3.38, 3.98, and 3.26, respectively).

Concerning total score of professional values; current study results concluded that there were more than three quarter of the staff nurses had moderate score level of total professional value, less than one quarter of them had high score level degree, and there are only (0.90%) of them had low score level degree. 

These results are in the same context with the results of Monroe (2017) who had a study to measure the professional values of practicing registered nurses (RNs) in the state of Washington (WA) and revealed from results that nurses have level from moderate to high level mean score of professional values and its subscales as maintain competency in area of practice; accept responsibility and accountability for own practice; and act as a patient advocate

Also, Akbarilakeh et al. (2019) mentioned that near to two-thirds (58.1%) of the studied sample had moderate professional vale level and more than one third (36.5%) of them had high level of professional value.

But Allari (2018) described the perception of professional values and hospital ethical climate among nurses and the correlation between nurses' professional values and hospital ethical climate, revealed that nurses in Jordan have high professional values.

Also, these results are not in line with Sands, (2021) who had a study on 171 Midwestern United States participants from the payor industry and displayed that nurses placed high importance on professional values. 

Concerning the distribution of the staff nurses according to burnout subscales score level; current study results presented that there were less than two thirds of staff nurses had a high level to emotional exhaustion subscale; and low percentage of them had low score level. Regarding the depersonalization subscale, near to one thirds of staff nurses had a high level, and near to half as the highest percentage of them had low level score. Speaking about personal achievement, there were less than half of them had a low level of personal achievement and less than one third of them had high level.

These results may be due to staff nurses had job dissatisfaction than head nurses and loss of appreciation due to they were well trained, had high skills which make them over qualified than tasks assigned to them, they work hard and they didn’t have the credit for their work, they feel isolated, and they don’t had the career progress that as they wanted.

Moreover, this is understandable because nurses deal with deaths daily, go through emotional challenges of losing patients regularly, are constantly faced with consoling grieving relatives of patients, and sometimes have to go on relatively long shifts, thereby causing emotional exhaustion or burnouts

These results are consistent with Stafford and Judd (2010) who investigated the prevalence of psychiatric morbidity and occupational Burnout among Australian gynecologic oncologists in a survey study in Turkey where 42% had high emotional exhaustion scores, and 20% had high scores of depersonalizations, and 35.6% had low scores of personal accomplishment.

Also, this was consistent with Abdo et al. (2015) found that more than half (52.8%) of the studied nurses had a high level of emotional exhaustion, nearlyhalf (48.2%) of them had low depersonalization, and most (96.5%) of them had reduced in personal accomplishment.

Moreover, Anwar and Elareed (2017) revealed that 54.6% of nurses had average levels of emotional exhaustion, 48% scored high on depersonalization, and the majority (77.5%) had high levels of reduced personal accomplishment.

Also, Sillero and Zabalegui (2018) determined the influence of organizational factors of the perioperative nurse's work environment on the three burnout dimensions: emotional exhaustion, depersonalization, and personal accomplishment in a perioperative care unit at a university hospital in Barcelona, Spain, showed emotional exhaustion in 43% of nurses, depersonalization in 21%, and reduced personal accomplishment in 53%

In addition these finding are in the same line with Soltan et al. (2020), nearly one third (30.0%) of the studied nurses had high emotional exhaustion, depersonalization and nearly half (45.0%) of them reduced personal capacity.And Jalili et al. (2021), showed that more than one third and more than half of nurses experienced moderate and high levels in the emotional exhaustion axis, respectively,

Almodibeg & Smith (2021) detected the level of burnout and its most significant causes among perioperative nurses in a regional hospital in Saudi Arabia, showed that a high level of emotional exhaustion was detected in 87.2%. Similarly, a high level of depersonalization was detected in 56.4%, while 15.4% of nurses showed a low sense of personal accomplishment. 

Concerning total score of nurses burnout; current study results concluded that there were less than two third of staff nurses had high total score levels of Maslach’s burnout inventory; more than one third of them have moderate score level; and no one of them had low burnout level score.

These results may be due to the staff nurses have low satisfaction level because of their poor work environment that affect the quality of work life which is still need for more improvement; as they mentioned that rotating schedules negatively affect their work and life. Also, they reported that the workload is too heavy, and they need more support from administrative authority's personnel

Also, these results confirmed that nurses had the highest vulnerability in experiencing burnouts. This can be attributed to the studied nurses feeling used up at the end of the workday, fatigued when they get up in the morning, facing another day on the job, and job burnout.

These results confirmedwith Sillero and Zabalegui (2018) who determined the influence of organizational factors of the perioperative nurse's work environment on the three burnout dimensions: emotional exhaustion, depersonalization, and personal accomplishment in a perioperative care unit at a university hospital in Barcelona, Spain, reported that 41% of perioperative nurses in Spain had a moderate or high risk of burnout.

Also, Soltan et al. (2020) studied the prevalence of burnout levels and worked stress among medical oncologists working at multi-centers in Egypt (Cairo, Menoufia, Fayoum, and Assiut university hospitals). Out of 100 participants, 32% were overall burnout positive as they met the burnout subscales criteria.

As well as, Jalili et al. (2021) described the prevalence of burnout among healthcare professionals and the associated factors in the capital city of Tehran, Iran, mentioned that more than half (53.0%) of the studied health care workers experienced high levels of burnout.

González -Pando et al., (2021) analyzed the relationship between professional values, perceived stress, and professional quality of life among nurses during the COVID-19 crisis, mentioned that the majority of the studied sample had high level of burnout.

Concerning the correlations between staff nurses professional values and burnout level; the current study show that there were negative associations between emotional exhaustion of the nurse's staff with the subscales of professional values which are (privacy, competence, improve standards, Conditions of employment, and collaborate). Regarding correlation between depersonalization with subscales of professional values; there were negative correlations for all subscales of professional values except (informed judgment, and conditions of employment).

Also, there were positive associations between personal achievement with all subscales of professional values except the subscale (improved standards). In addition, there were negative associations between total professional values with emotional exhaustion subscale and with depersonalization subscale; while there is positive association between total professional values with personal achievement subscale. Also, it was noted from the table that, there is a negative correlational between total professional values of staff nurses and their score of burnout.

This may be because professional values consist of beliefs, attitudes, and feelings that guide nurses' decisions and actions. And the nurses who had high professional value become more responsible, safeguard patient, improve the standard of care and maintain competence in their area of practice and this add stressors for nurses and may lead to burnout.

These correlations are confirmed with Akbarilakeh et al., (2019) shown that there was a significant reverse relationship between professional value score and burnout score.

Also, these  findings are in the same line with a study done by Zhou et al. (2020), explored the mediating effect of emotional labor between professional values and job burnout among ICU nurses in Nanchang mentioned that professional values of ICU nurses had a direct predictive impact on job burnout.

However, these results are not in line with Abdalla et al. (2016) results who aimed to find out the relationship between professional values and burnout among nurses in Assuit University hospital in general and specialized medical, surgical and intensive care units, concluded that there was a positive correlation between nurses' professional values and burnout.

Conclusion:

It can be concluded from the current study that staff nurses had moderate level for all subscale of professional values as; for Human dignity, Privacy, Safeguard client, Responsibility and accountability, Competence, Informed judgment, Contributes to knowledge, Improve standards, Conditions of employment, Maintain integrity, and for Collaborate. Also, current study results concluded that there were more than three quarter of the staff nurses had moderate score level of total professional value, less than one quarter of them had high score level degree.

In addition there were less than two thirds of staff nurses had a high level to emotional exhaustion subscale; and low percentage of them had low score level. Regarding the depersonalization subscale, near to one thirds of staff nurses had a high level, as well there were less than half of them had a low level of personal achievement. Also, there were less than two third of staff nurses had high total score levels of Maslach’s burnout inventory; more than one third of them have moderate score level; and no one of them had low burnout level score. Also, it was noted that, there was a negative correlational between total professional values of staff nurses and their score of burnout.

Recommendations

Based on current study results these recommendations are introduced:

• Design a continuously training program for staff nurses to improve their professional values perception and decrease their burnout level should be done by head nurses. 
• Remove all organizational factors that hinder decision making process or generate conflict and create a healthy work environment and culture by the hospitals administrators.
• Participate the nurses in the development of hospital policy must be done by administrators to increase nurses creativity and production to reduce their burnout level.
• Create an empowering work environment with a mutual trust and respect for all parts should be done by top level managers.
• Improve nursing work conditions using the different strategies as; reduce nurse workload through appropriate staffing, distribute resources fairly, provide professional development opportunities, and provide effective leadership should be done by the nurse managers.