3.2. Discussion
This study examined the relationships between work related stress, burnout, job satisfaction and general health of nurses. Of the five stressors contributing to work related stress, staff issues was found to be most associated with burnout as well as job satisfaction. Burnout explained the highest amount of variance in general health of nurses.
Existing literature confirms that staff issues including excessive administration, stock control and colleagues not doing their job influences the levels of stress experienced by nurses [
32,
40]. Staff issues have been reported as one of the most significant stressors among nurses [
28]. In one such study, professional, enrolled and auxiliary nurses reported severe stress due to staff issues [
32]. This can be explained by the overburdened South African health system where nurses may be unable to meet the demands of their job due to poor staff management which may negatively affect morale [
41], lack of resources which may negatively affect patient care [
29] and security issues owing to high levels of crime in the country [
42].
This study found that stress related to staff issues in particular was associated with all three dimensions of burnout explaining 16% variance in emotional exhaustion, 13% variance in depersonalization and 10% variance in personal accomplishment. In support of these findings, studies conducted in developed contexts have found staff issues such as poor staff management and resource inadequacy to be associated with emotional exhaustion, depersonalization and personal accomplishment [
43]. In this study, poor staff management as well as poor or inadequate equipment explained the highest amount of variance in burnout (16%). These issues have been reported in several news articles, including the New York Times [
44] and News24 [
45], however, empirical evidence for this association has been shortcoming, with minimal impact on nursing policies and practices.
Stress related to staff issues and job satisfaction with communication were also found to be associated. Although research has shown that staff issues such as poor staff management and resource inadequacy are associated with job satisfaction [
43], the findings of this study revealed that security risks in the workplace also play a role in influencing job satisfaction among nurses. Within the South African context, political violence is surpassed by high levels of violent crime. As such feelings of insecurity and fear become predominant. This can be understood from Maslow’s needs hierarchy, whereby in order to satisfy higher level needs, lower level needs such as safety must first be satisfied. In the event that an individual’s safety and security is in danger, patient care becomes less important [
46].
Security risks in the workplace, has also been found to affect general health of nurses [
47,
48]. The findings of this study show that security risks in the workplace as well as other staff issues including poor staff management and resource inadequacy explains 11% variance in social dysfunction. This means that nurses experiencing work related stress as a result of staff issues are more likely to feel incapable of enjoying activities and engaging in healthy social behavior. This prevents adaptational outcomes, such as psychological wellbeing and good somatic health [
49]. Furthermore, stress related to patient care is equally important in influencing mental health among nurses (explaining 11% variance). This is supported by research showing that poor communication with doctors, negative patient outcomes and mistakes when treating patients are all associated with mental health problems [
14]. Burnout (emotional exhaustion) and job satisfaction (with communication) demonstrate a negative relationship in this study. Limited research shows that opportunities for communication about stress provoking issues provides a buffer for emotional exhaustion, which results when coping resources become depleted [
3].
Based on the findings of this study, stress related to staff issues is associated with burnout, job satisfaction and general health of nurses. The major staff issues identified in this study include poor staff management, resource inadequacy and security risks in the work place. According to Fretwell, staff management is important given that the managers’ decisions influence the working environment [
50]. Poor staff management therefore diminishes the staff morale, which leads to feelings of depersonalization (burnout) as well as job dissatisfaction [
51]. Moreover, lack of resources invokes feelings of insecurity about obtaining and maintaining resources necessary for meeting job demands, thereby triggering stress, which manifests in burnout [
40]. Lack of essential resources, such as treatment equipment, medication and examination facilities, compromises patient care and negatively affects job satisfaction [
5]. In the context of South Africa, security risks in the workplace involve situations of violence and crime, whereby nurses are exposed to dangerous situations on their way to work and while at work [
52]. This prompts stressful responses, which eventually leads to burnout. As such nurses are restricted from working to their full potential, thereby negatively affecting their levels of job satisfaction [
5] and their health [
53].
In addition to stress related to staff issues, job satisfaction is also significantly associated with general health. However, both variables explain a smaller amount of variance in general health compared to burnout in this study. Although the association between burnout and poor physical, mental as well as social health outcomes has been confirmed in many studies [
54,
55,
56,
57,
58], this study shows that burnout is most strongly associated with anxiety/insomnia. With mental health problems reported among the top ten work related consequences, these findings can be understood as the depletion of mental energy (emotional exhaustion) and mental distancing (depersonalization), thereby compromising nurses’ ability to perform tasks and resulting in anxiety/insomnia [
48].
Stress prevention strategies are both person level as well as organization level. Stress management programs involving education and training on coping with stress is a person level strategy that provides support for nurses dealing with stress related outcomes. Organization centered approaches address work related stressors by reducing or eliminating them through better management of nurses and provision of adequate resources [
59]. These have been found to be successful in work settings, whereby stress in the workplace is not viewed as a weakness but rather a phenomenon that can be managed by creating a culture of openness and understanding [
53]. It is recommended that an integrated stress prevention strategy of both person centered and organizational centered approaches be used to address work related stress, burnout, job dissatisfaction and poor general health among nurses. This should involve input from nurses as well as management in order to ensure collective commitment towards improving nurse and patient related outcomes.
These findings provide some empirical evidence confirming the relationship between work related stress, burnout, job satisfaction and general health of nurses in a developing country context. Although issues related to security risks in the workplace may be more salient within the context of a developing country like South Africa, these study findings also confirm a number of the findings that have been previously identified from studies undertaken in more developed countries. Poor staff management and resource inadequacy are associated with burnout, job satisfaction and general health of nurses in both developing and developed contexts. It is very important to identify and delineate very clearly which factors are particularly salient and relevant to developing countries because it is very important to develop strategies and intervention programs, which can either prevent or at least ameliorate these. It is also equally important to recognize that the role of work related stress, burnout, job satisfaction and general health of nurses on poor patient outcomes, high turnover, low retention, poor job performance, absenteeism and increased healthcare costs are also evident within an international context.
Several studies have shown that intervention strategies such as additional training in identification and management of work related stress through assertiveness and relaxation have successfully improved job performance levels among nurses. Support groups as well as process consultation with nurse managers have also been effective in solving problems across interdisciplinary staff teams [
60]. The effect of such interventions on staff absenteeism and turnover is not well researched and should be explored in the context of South Africa.
Limitations include generalizability (based on one province) and study design (cross sectional). However, it is the intention of the authors to use this study as a foundation for further evaluation of the same sample at a later stage to determine causality. Given that this study included a sample of nurses from one province in South Africa, it would be useful to replicate this study among South African nurses across the other provinces to compare findings and improve generalizability. Future research should also examine reverse relationships between the variables. Personal stressors including family problems, financial status and difficult relationships should also be studied in relation to work related stress, burnout, job satisfaction and general health of nurses. Differences between nurses working in public vs. private hospitals should be explored in future studies.