The association of job satisfaction and burnout with individualized care perceptions in nurses

Introduction

Healthcare ethics, clinical ethics, and nursing ethics underscore the importance and value of every patient as individuals. ¹ International Council of Nurses (ICN) stated that the fundamental responsibility of a nurse is to preserve life, alleviate pain and suffering, and promote health and that respect for people, human rights, and appreciation of people are inherent to nursing. ² Good clinical practice requires nurses to have adequate knowledge regarding ethical issues such as informed consent, autonomy, truthfulness, honor, patient rights, and individuality. ³ The right to be respected as an individual is among the cornerstones of nursing ethics. ³ Accordingly individualized care, which is about fulfilling ethical responsibilities in health services, has a strong foundation in the philosophy of nursing. ¹ Nurses can plan the best and most effective care for every patient by supporting the patient’s individuality. ⁴ They can also protect the honor and uniqueness of every patient. ^3,5 It is of utmost importance that nurses provide individualized care focused on specific patient problems and needs in accordance with the profession’s ethical responsibilities. ³

Individualized care, which is shaped according to multiple factors including culture, religion, and life experiences of an individual, stresses that individuals have different personal values and beliefs which should be respected. ⁶ Individualized care takes into account that each individual is in a dynamic interaction with the environment he or she lives in Amaral et al. ⁷ Individualized care focuses on the individual and his or her health problem. ⁵ According to individualized care, each individual is unique and different applications need to be performed in order to meet their needs. ^8,9

Individualized care encompasses care applications emerging during the interaction between the nurse and the patient. ¹⁰ It is the application of nursing care according to the emotions, thoughts, experiences, and perceptions of the individual. ^1,4,5,8 Suhonen et al. ^1,4 have defined individualized care as

how nursing care is adapted for the specific health condition of the individual, his/her characteristics, needs, and preferences, as well as being a form of nursing care applied according to the views of the patient on how the patient perceives the reflection of the individuality of the patient in the applications of nurses.

Individualized care was found to increase patient satisfaction, ^12,13 strengthen the ability of individuals to manage their own care at home after discharge, ¹³ and increase quality of life. ^14,15 At the same time, it has been underscored that developing an individual centered approach and attitude was closely related to the worklife of nurses, increasing their job satisfaction and motivation. ^{14,16 –18}

Job satisfaction is a very important factor as it enables working happily, productively, and efficiently. ¹⁹ The job satisfaction of nurses can be affected by several factors including age, marital status, willingly choosing the profession, employment duration, the working environment and its conditions, relations to managers and colleagues, uncertainties regarding professional roles, and employment statuses. ¹⁹ In this context, many individual and organizational factors can decrease the job performance and efficiencies of nurses, causing them to experience burnout. ²⁰

Burnout in nurses can cause various problems in nurses including insomnia, fatigue, short temper, decreased self-esteem, anxiety, alienation to the institution, reduced work motivation, and communication problems with the health team members, patients, and their relatives. ^20,21 In worklife, burnout can lead to decreased productivity, difficulties in realizing professional responsibilities, and decreases in the efficiency of the institution and the quality of care. ^22,23 At the same time, burnout may negatively affect the ability of nurses to understand the individual they care for and his or her family, interpret verbal and non-verbal behavior, and meet their needs. ²⁴

Provision of high-quality healthcare is dependent upon nurses’ satisfaction with the institution and the workplace. Accordingly nurses with high job satisfaction and low burnout can provide individualized care at optimal levels. ²⁵ Previous studies indicated that little is known about the association of nurses’ individualized care perceptions with job satisfaction and burnout at healthcare settings. ^{26 –28} To our knowledge, this study is the first to examine the association of nurses’ individualized care perceptions with job satisfaction and burnout in Turkey. The current study will provide insights to the association of nurses’ individualized care perceptions with job satisfaction and burnout, which in turn can be used in developing appropriate strategies for increasing the quality of care provided to healthy/ill individuals.

Aim

This study was conducted in order to determine the association of job satisfaction and burnout with individualized care perceptions in nurses working at a university hospital located in the Central Black Sea region of northern Turkey.

This study aimed to answer the following questions:

At what level are the individualized care perceptions of the nurses?

Methods

Ethical considerations

The study protocol was approved by the Ondokuz Mayıs University Clinical Studies Board of Ethics (13.02.2017/ number; B.30.2.ODM.0.20.08/682-749). Permission to conduct the study was granted by the study hospital’s chief doctor (15374210-929-E.4423). Data were collected by the researchers. Nurses who met the inclusion criteria were invited by the researchers to participate in the study. Nurses who participated in the study were informed about the study, and their oral informed consent was taken. They were explained that the decision to participate in the study was completely theirs, their names will not be written on the questionnaires, and data collected for the study will be used for scientific purposes only. Nurses received a written instruction on how to complete the questionnaires. The descriptive information form and the scales were completed by the nurses during hours of less workload. Service head nurses provided a quiet room for the participants to fill out the questionnaires. Necessary permissions were obtained in order to administer the three scales used in this study.

Findings

A total of 419 nurses participated in the study. It was determined that 21.2% of the nurses were aged 17–26 years, 59.7% were aged 27–36 years, and 19.1% were aged 37–46 years. Among the nurses, 92.1% were female, 7.9% were male, 66.8%were married, 33.2% were single, 7% graduated from a vocational school of health, 5.7% had a pre-bachelor’s degree, 81.1% had a bachelor’s degree, 6.2% had a postgraduate degree, 39.1% worked at the internal medicine unit, 27.2% worked at the surgical units, 33.7% worked at the intensive care units, 76.1% were permanent staff, 23.9% were on contract, 15.5% worked only during daytime, 84.5% worked only in night shifts, 33.9% worked as a nurse for 6–10 years, 52.3% had 21 and more patients, 57.5% voluntarily chose the nursing profession, 58.2% loved their job, and 43% were satisfied with the service they worked at (Table 1).

OPEN IN VIEWER

Table 1.

The distribution of the socio-demographic and work-related characteristics of the nurses.

Characteristics	n	%
Age groups (31.6 ± 5.7)
17–26	89	21.2
27–36	250	59.7
37–46	80	19.1
Gender
Female	386	92.1
Male	33	7.9
Marital status
Married	280	66.8
Single	139	33.2
Education
Vocational school of health	29	7.0
Pre-bachelor’s degree	24	5.7
Bachelor’s degree	340	81.1
Postgraduate degree (master’s)	26	6.2
Service worked at
Internal Units	164	39.1
Surgical Units	114	27.2
Intensive Care	141	33.7
Employment status at hospital
Permanent	319	76.1
Contractual	100	23.9
Employment type at hospital
Day	65	15.5
Night	354	84.5
Employment duration
1–5 years	119	28.4
6–10 years	142	33.9
11–15 years	90	21.5
16–20 years	45	10.7
21 years and above	23	5.5
Number of patients cared for
1–5 patients	123	29.4
6–10 patients	6	1.4
11–15 patients	39	9.3
16–20 patients	32	7.6
21 patients and above	219	52.3
Voluntary choice of the profession
Yes	241	57.5
No	178	42.5
Loves the job
Loves	244	58.2
Doesn’t love	63	15.0
Indecisive	112	26.8
Pleased with the service worked at
Pleased	180	43.0
Not pleased	74	17.7
Partially Pleased	165	39.3

The mean total ICSA-Nurse score was found to be 3.9 ± 0.7 with a median of 3.9. The median scores of the Clinical Condition, Personal Life Condition, and Decision Making Control sub-dimensions of the ICSA-Nurse were found to be 4.0, 3.5, and 4.0, respectively. The mean total ICSB-Nurse score was found to be 4.1 ± 0.6 with a median of 4.0. The median scores of the Clinical Condition, Personal Life Condition, and Decision Making Control sub-dimensions of the ICSB-Nurse were found to be, respectively, 4.3, 4.0, and 4.2. The mean General Satisfaction, Internal Satisfaction, and External Satisfaction sub-dimension scores of the Minnesota Job Satisfaction Scale were found to be respectively 56.9 ± 12.3, 37.8 ± 7.1, and 19.1 ± 6.5. The mean Emotional Burnout, Desensitization, and Personal Achievement sub-dimension scores of the Maslach Burnout Inventory were found to be 23.2 ± 6.7, 7.2 ± 4.3, and 11.0 ± 4.6, respectively (Table 2).

OPEN IN VIEWER

Table 2.

The Individualized Care Scale, Minnesota Job Satisfaction Scale, and Maslach Burnout Inventory scores of the nurses.

	Item number	x ¯ ± S.S.	Median	Min-Max
ICSA-nurse sub-dimensions
Clinical Condition	7	4.0 ± 0.7	4.0	1–5
Personal Life Condition	4	3.5 ± 0.9	3.5	1–5
Decision Making Control	6	4.0 ± 0.7	4.0	1–5
Total	17	3.9 ± 0.7	3.9	1–5
ICSB-Nurse sub-dimensions
Clinical Condition	7	4.3 ± 0.7	4.3	1–5
Personal Life Condition	4	3.9 ± 0.9	4.0	1–5
Decision Making Control	6	4.1 ± 0.7	4.2	1–5
Total	17	4.1 ± 0.6	4.0	1–5
Minnesota Job Satisfaction Scale sub-dimensions
General Satisfaction	20	56.9 ± 12.3	57	20–100
Internal Satisfaction	12	37.8 ± 7.1	38	12–60
External Satisfaction	8	19.1 ± 6.5	19	8–40
Maslach Burnout Inventory sub–dimensions
Emotional Burnout	9	23.2 ± 6.7	24.0	1–36
Desensitization	5	7.2 ± 4.3	7.0	0–20
Personal Achievement	8	11.0 ± 4.6	11.0	0–28

ICS-A: individualized care scale-A; ICS-B: individualized care scale-b; x ¯ : arithmetic mean; S.S.: standard deviation; Min: minimum; Max: maximum.

The total ICSA-Nurse score had weak but significant positive relationships with the Internal Satisfaction (r = 0.183, p < 0.01) and General Satisfaction (r = 0.121, p < 0.05) sub-dimension scores of the Minnesota Job Satisfaction Scale. Also, the total ICSA-Nurse score had weak but significant correlations with the Desensitization (r = –0.115, p < 0.05) and Personal Achievement (r = –0.256, p < 0.01) sub-dimension scores of the Maslach Burnout Inventory (Table 3).

OPEN IN VIEWER

Table 3.

The relationship between the ICSA and ICSB Nurse versions, the Minnesota Job Satisfaction Scale and the Maslach Burnout Inventory.

ICSA-Nurse	Clinical Condition	Personal Life Condition	Decision Making Control	Total
Minnesota Job Satisfaction Scale
Internal Satisfaction	r = 0.209*	r = 0.010	r = 0.266*	r = 0.183*
External Satisfaction	r = 0.116**	r =–0.176*	r = 0.146**	r = 0.032
General Satisfaction	r = 0.183*	r =–0.097**	r = 0.233*	r = 0.121**
Maslach Burnout Inventory
Desensitization	r = –0.135**	r = –0.039	r = –0.145**	r = –0.115**
Personal Achievement	r = –0.213*	r = –0.179*	r = –0.277*	r = –0.256*
Emotional Burnout	r = –0.084	r = 0.103**	r = –0.130**	r = –0.039
ICSB-Nurse	Clinical Condition	Personal Life Condition	Decision Making Control	Total
Minnesota Job Satisfaction Scale
Internal Satisfaction	r = 0.172*	r =–0.002	r = 0.157*	r = 0.125**
External Satisfaction	r =–0.064	r =–0.212*	r =–0.023	r = –0.108**
General Satisfaction	r = 0.061	r =–0.125**	r = 0.077	r = 0.009
Maslach Burnout Inventory
Desensitization	r = –0.167*	r = –0.044	r = –0.146*	r = –0.143*
Personal Achievement	r = –0.142**	r = –0.103**	r = –0.215*	r = –0.182*
Emotional Burnout	r = 0.003	r = 0.101**	r = –0.062	r = 0.007

r: spearman correlation coefficient.

*p < 0.01 level significance, **p < 0.05 level significance.

A weak but significant positive relationship was found between the total ICSB-Nurse score and the Internal Satisfaction (r = 0.125, p < 0.05) sub-dimension score of the Minnesota Job Satisfaction Scale, while a weak but significant negative relationship was found between the total ICSB-Nurse score and the External Satisfaction (r =–0.108, p < 0.05) sub-dimension score of the Minnesota Job Satisfaction Scale. The total ICSB-Nurse score had weak but significant negative relationships with the Desensitization (r = –0.143, p < 0.01) and Personal Achievement (r = –0.182, p < 0.01) sub-dimension scores of the Maslach Burnout Inventory (Table 3).

Discussion

In this study, the mean total ICSA-Nurse score, which evaluates how much the nurses support the individuality of the patients they care for, was found to be 3.9 ± 0.7, while the mean total ICSB-Nurse score, which evaluates the perceptions of nurses regarding the individualization of patient care, was found to be 4.1 ± 0.6. In a study performed by Suhonen et al. ¹¹ which compared individualized care perceptions of nurses from different countries, the mean total ICSA-Nurse score of Turkish nurses was found to be 3.96 ± 0.48, while their mean total ICSB-Nurse score was found to be 3.93 ± 0.52. ¹¹ In another study, the mean total ICSA-Nurse score was reported to be 3.80 ± 0.72. ²⁹ In the current study, the ICSA-Nurse and ICSB-Nurse scores of the nurses, which implied that they supported patient individuality, were in line with previous study findings.

The mean total ICSA-Nurse and ICSB-Nurse scores were found to be higher in nurses who had bachelor’s and postgraduate degrees, worked during the day, were employed in surgical units, loved the job, were pleased with the service worked at, were female, and had an employment duration of 21 years or more. In parallel to our findings, Idvall et al. ³⁰ found that nurses with postgraduate degrees supported individualized care. Despite the findings of our study, other studies reported that individualized care scores did not vary according to gender, ^3,30 educational level, and employment type. ²⁹

In the current study, it was determined that nurses with higher levels of education prioritized patients’ uniqueness during the provision of healthcare. Nurses are obliged to be sensitive toward patients’ physical and emotional needs and provide care accordingly. In this aspect, ethical sensitivity and responsibility are important for nurses who provide care based on their own moral values. ⁴² Ethical codes guide professionals in dealing with problems related to proper applications or acts. Moreover, nursing ethics compel nurses to act in a certain way during the provision of high-quality healthcare. ⁴³

According to the findings of this study, the total ICSB-Nurse score was found to be higher in nurses who had an employment duration of 21 years or more. The higher individualized care perception in nurses with greater employment duration can be related to the improvement inexperienced nurses’ knowledge, skills, and attitudes in patient care as well as their problem-solving skills. Appreciation of one’s occupation is also strongly associated with the quality of the care provided. Effective provision of care requirements for the individual depends on nurses’ willingness to do their job. Nurses who chose their job willingly since they found the skills and abilities required by the job appropriate for themselves can adapt to their work environment easier, and thus experience increases in their dedication to their job and institution as well as their job satisfaction.

In the current study, nurses who worked as permanent staff had higher ICSA-Nurse and ICSB-Nurse scores compared to nurses who worked on contract. These findings may stem from the fact that contracted nurses experience stress and anxiety related to possible job loss, while nurses on permanent staff think they have job security in the future. ⁴⁴

It is known that working in shifts may cause negative effects in terms of physical and psychological health and negatively affect the quality of the care provided by nurses. ⁴⁵ Working in night shifts in particular may cause fatigue, attention and perception deficits, difficulties in decision-making, stress, burnout, reduced job satisfaction, loss of motivation, insufficiencies in patient care and monitoring, and communication problems with health team members in nurses. ^20,45 The socio-demographic and work life–related characteristics of nurses associated with ICSA-Nurse and ICSB-Nurse scores vary according to the study settings, the working environment, working conditions, and care load of nurses.

In the current study, it was found that the nurses had moderate levels of job satisfaction and that ICSA-Nurse scores increased as the General satisfaction sub-dimension score of the Minnesota Job satisfaction Scale increased. Nurses regarding the internal (success, recognition, responsibilities, etc.) and the external characteristics of the job (institutional policy, relationships to colleagues and employees, working conditions, etc.) and nurses with high job satisfaction were found to support the individuality of the patients at very high rates. In a study by Edvardsson et al., ⁴⁶ which was conducted with nurses who worked at retirement homes, it was reported that there was a significant relationship between the level of individualized care provision and job satisfaction.

It was determined that the nurses had high levels of emotional burnout and that the Desensitization and Personal Achievement sub-dimension scores of the Maslach Burnout Inventory decreased as ICSA-Nurse and ICSB-Nurse scores increased. Accordingly, nurses with high personal achievement and low desensitization were highly supportive of individualize care. Previous studies are in line with these findings as they indicated that factors including job satisfaction affected the care provided by nurses and set the ground for ethical problems. ^{47 –49}

A variety of factors such as long working hours, heavy workload, working in shifts, dissatisfaction with the work environment, negative interactions between team members, role conflict, and role ambiguity can lead to burnout in nurses. Having a negative working environment in particular can precipitate moral distress. Jameton, ⁵⁰ Hamric, ⁵¹ and Wilkinson ⁵² indicated that moral distress derives from limitations in units, the healthcare system, and the environment and people working at an ethically enhanced work environment experience significantly less moral distress. In this context, it is of paramount importance that managers pay attention to factors related to employee burnout and device a working environment which increases job satisfaction and motivation.

Although the individualized working environment forms the basis of individualized care, ⁵³ the individualized care applications of nurses are highly related to a positive working environment and job satisfaction. ^17,26,27 Indeed, it has been reported that the quality of the care provided in healthcare environments and positive perceptions regarding the work environment increase job satisfaction, ⁵⁴ with nurses providing high-quality care being more satisfied with their job. ⁵⁵ In this aspect, individualized care is an indicator of care quality. ⁵⁶ Also, the quality of care is closely linked to job satisfaction and burnout. Although it is possible to mention an indirect relationship between job satisfaction, burnout, and individualized care, ^{16,26,27,54,55,57} it is important to examine this relation and develop appropriate strategies on the subject.

Strengths and limitations

This is the first study to examine the association of job satisfaction and burnout with individualized care perceptions in nurses working at a university hospital located in the Central Black Sea region of northern Turkey. One of the strengths of the study include revelation of factors, such as the work environment and conditions arranged by managers, associated with the provision of individualized care. A limitation of the study is that observations and evaluations regarding the effects of nurses’ job satisfaction and burnout on individualized care practices could not be undertaken. Future studies can employ qualitative research methods as well and conduct focus groups regarding the effects of nurses’ job satisfaction and burnout on individualized care perceptions.

Clinical and research impact of study

Work-related factors associated with nurses’ individualized care perceptions, job satisfaction, and burnout should be determined, and necessary precautions should be taken accordingly. Also, the number of patients nurses care for should be taken into consideration and human resources planning at healthcare institutions should be done properly. In order to increase nurses’ job satisfaction and motivation, their individual choices regarding the clinics they wish to work in should be considered. Training programs and seminars should be arranged for reinforcing care behaviors supportive of patient individuality. In addition, managers should use motivators that may affect nurses’ job satisfaction and provide routine feedback on nurses’ achievements. It is recommended to cross-cultural studies on the topic by examining different samples from different countries.

Conclusion

There was a weak but significant positive correlation between the total ICSA-Nurse score and the General Satisfaction sub-dimension score of the Minnesota Job Satisfaction Scale. It was determined that the total ICSA-Nurse score increased as the General Satisfaction sub-dimension score of the Minnesota Job Satisfaction Scale increased. The total ICSA-Nurse and the ICSB-Nurse scores were weakly but significantly and positively associated with the Desensitization and Personal Achievement sub-dimension scores of the Maslach Burnout Inventory. It was determined that the total ICSA-Nurse and the ICSB-Nurse scores increased as the Desensitization and Personal Achievement sub-dimension scores of the Maslach Burnout Inventory decreased. Accordingly, nurses with high job satisfaction and low burnout levels had higher individualized care perceptions, which is affected by various factors including culture, religion, and life experiences.