Prevalence of job burnout in Iranian nurses: A systematic review and meta-analysis

1 Introduction

Nowadays, the health sector is one of the most significant areas of sustainable development given its direct relationship with the human health. Achieving this goal requires healthy, vibrant, and highly motivated therapists. The cadre of hospital nurses is a group of therapists. We faced nurses in all hospital wards that have been activated and motivated before embarking on the nursing profession. They feel tired and are willing to resign after a while and facing lots of problems and job stress [1]. The nursing profession is covered by the Hard and Harmful Occupations Act and nurses suffer the most from the job among the people working in medical centers [2]. Exposure to job stress leads to job burnout; burnout is a psychological response to chronic work stress [3]. Jackson and Maslach described job burnout as a psychological syndrome of emotional exhaustion, depersonalization, and diminished personal performance that mostly occurs in occupations that requiring communications with people [4]. They also described emotional fatigue as mental stress, feeling pressured, and losing emotions. Depersonalization is a negative and pessimistic attitude towards others and clients. Decreased sense of self-value is a decrease in feeling competent and being able to successfully perform assigned tasks. It is also a negative attitude and evaluation towards oneself [5].

According to studies, the prevalence of job burnout in the UK is 36% [6]. Various studies have shown that this syndrome can cause a decline in quality of service delivery, and is a factor in quitting the job, absenteeism, or low mood. It is connected with the disorders such as physical fatigue, insomnia, alcohol and drug abuse, and family and marital problems. Although early researches on job burnout have focused on organizational performance, several types of researches have focused on negative effects of burnout on physical and mental health in recent years. Such studies on job burnout have shown that people do not suffer the burnout to the same extent under the same conditions. Burnout is affected by many factors, including individual, interpersonal, occupational, and personality traits [7, 8].

The complications of job burnout not only create physical and psychological symptoms in people but also increase the rate of absenteeism because of illness [9], job dissatisfaction, tendency to quit the job [10], and poor work outcomes [11, 12].

In the clinical field, burnout means losing the desire to provide clients with adequate and human care [11, 13]. Studies conducted in Iran have shown that the suicide rate because of burnout in nurses is significantly higher than the average rate in the society, and the life expectancy of nurses is only one year higher than mine workers [14]. Studies conducted in the country have shown that burnout is prevalent among the Iranian nurses in public health centers. Job burnout’s detrimental consequences for nurses, patients, and hospitals emphasize the recognition of key influential factors to prevent or minimize the consequences and to eliminate them in the Iranian nursing society [15]. Because of the importance of the issue, this study aimed to investigate the prevalence of job burnout among nurses in Iran through a systematic review and meta-analysis.

2 Research methodology

2.2 Data extraction

Based on the inclusion and exclusion criteria, the abstracts were studied by the researcher. Then, the unrelated papers were removed, and research-related ones were identified to receive full texts and data extraction. The quality of the selected papers was investigated and verified using the researcher-designed checklist (Fig. 1). A framework was prepared to extract the data, which included the number of samples, type of study, age, geographical area, place of the study, and the prevalence of total job burnout, job burnout based on gender, author’s name, and the year of publication.

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Fig. 1

Flowchart of study selection process.

2.3 Data analysis

The variance of each study was calculated based on the binomial distribution, and the studies were combined according to the number of samples and variances. The point estimation and 95% confidence interval of the prevalence of burnout for each study were calculated separately based on gender and different geographical areas. The stochastic effects model was used to combine the studies based on the heterogeneity of the studies and the significance of the heterogeneity index [I2]. The Cochran’s Q test and I2 index were used to evaluate any non-uniformity in the studies (I2 index less than 25% are low heterogeneity, between 25% to 75% is a moderate heterogeneity, and more than 75% are high heterogeneity). The Forest chart was used to investigate the heterogeneity between the studies (p < 0.1 significant). The Egger test and funnel plot were used to evaluate the heterogeneity of the studies. The Meta-regression analysis was used to investigate the relationship among the prevalence of burnout, the year of the studies publication and the size of samples. The level of prevalence along with confidence interval-based geographical area was presented in the Forest chart. All the analyzes were performed using version 2.0 of the Comprehensive Meta-Analysis (CMA) software.

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Fig. 2

The prevalence of job burnout of nurses in each segment shows the length of the confidence interval, and the rhombus sign indicates the combination of studies with a 95% confidence interval.

Fourteen eligible studies from 2002 through 2020 with a total sample size of 2271 entered the review process. Table 1 shows the general characteristics and data of each of the mentioned samples. The Maslach questionnaire was used to determine the rate of job burnout in all papers.

The results showed that the overall prevalence of job burnout was 44% in males and 66% in females. Fars province, with 89.2 %, had the highest, and Zanjan province, with 25.9 %, had the lowest prevalence of job burnout. The highest rate of burnout was in the east regions of the country. According to the meta-regression diagram of the frequency of job burnout, the frequency of burnout increases as the year (Fig. 3) and the sample size of the study increase (Fig. 4).

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Fig. 3

Meta-regression diagram of the frequency of job burnout based on the year of study.

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Fig. 4

Meta-regression diagram of the frequency of job burnout based on the sample size of the studies.

Job burnout in nurses was investigated through a systematic review and meta-analysis. For this purpose, fourteen studies were reviewed. Different levels of prevalence were reported based on the provinces studied and the gender of the nurses. Accordingly, the highest prevalence of job burnout in nurses was reported in Fars Province (89.2%), and the lowest one was in Zanjan province (25.9 %).

Since the nurses in metropolitan hospitals are under high pressure in terms of workload because of the lack of access to health facilities and specialized physicians to provide specialized health services, many patients from remote and small neighboring cities come to big cities and provinces. Therefore, it is not far-fetched to see more burnout in metropolitans.

The prevalence rates reported by other provinces also showed a high prevalence of job burnout in the nursing profession in Iran and nurses experience higher levels of job burnout because of the high levels of job stress compared to other members of the health team. In a systematic study conducted by Rezaei et al. on the job burnout of Iranian nurses, the prevalence of burnout was 36% [17]. The high prevalence of burnout in nurses is not limited to Iran and it is high in many parts of the world [18].

About 15 to 45% of working nurses in the western countries and 50% of working nurses in China suffered from burnout [19]. The socio-cultural context of Iranian society and the variables affecting it have exacerbated these problems and made it more difficult for nurses to tolerate. Many studies have reported high levels of job stress in nurses [20–22]. This issue causes 30 to 50% of job burnout in this profession [23–25]. According to Rezaei et al., a reason for the difference in the prevalence of burnout in different countries can be attributed to factors such as gender and age of nurses, different working conditions, use of various measuring tools, and different sample sizes [17].

One of the objectives of this study was to investigate the prevalence of job burnout among nurses based on gender. The prevalence of burnout in female nurses was about 20% higher than in male ones (66% vs. 44%). Given that women are more emotionally vulnerable than men, this finding seems reasonable. Workplace pressures and especially the conflicts between job and family make women more vulnerable to stress than men.

The role of women as mothers, working at home, and intimate relationships with husband and children increase their psychological sensitivity, limit their power directly and indirectly, and increase their sensitivity in the workplace and the prevalence of job burnout in this group. Therefore, the prevalence of burnout in women is higher, as a significant relationship has been reported between the gender and emotional aspect in other studies [26–28].

Different studies have reported different reasons for the nurse job burnout, including low salaries and benefits, lack of social support, lack of support in managers at different levels, job insecurity, and long working hours [29]. According to Greenglass et al., there was a significant and direct relationship between high workload and job burnout of nurses [30]. Job burnout is a symptom that is caused by the interaction among various individuals, interpersonal, and organizational factors [31].

Burnout is associated with symptoms such as mental fatigue, physical fatigue, and reduced ability to work. It causes more irritability because of reduced concentration and energy depending on the type of work that a person carries out. Nurses, who experience job burnout, are usually physically, emotionally, and mentally exhausted and this has a considerable impact on the quality of patient care. Compared to other jobs, nursing is known as one of the high-risk occupations in terms of job burnout [32]. Therefore, it is important to pay more attention to nurses as the important members of the medical staff.

5 Conclusion

Based on the results of the study, the prevalence of job burnout is high in some areas of Iran. The relevant authorities’ special attention is required to solve the problem because of the considerable role of nurses in the healthcare system and the improvement of public health. It is recommended to implement plans to reduce job burnout and to improve mental health in nurses including reducing the working hours; giving an opportunity to nurses to express their level of salary and benefits, and creating better working conditions.

Moreover, the awareness about the level of nursing job burnout can provide significant information with healthcare officials and managers to introduce management plans, reduce the turn-over and relinquish the nursing profession, increase job productivity and enhance the client satisfaction.