Analysis of the risk and protective roles of work-related and individual variables in burnout syndrome in nurses

Burnout syndrome is a phenomenon that is becoming ever more widespread, especially in workers who have heavy workloads and time pressures, such as nurses. Its progression has been shown to be related to both individual and work-related variables. The objective of this study was to examine the risk and protective roles played by work-related and personal variables, both sociodemographic and psychological, in the development of burnout in nurses. The sample was made up of 1236 nurses. Exploratory tests were performed to understand the relationships between burnout and the other variables, as well as a binary logistic regression to understand their roles in the incidence of this syndrome. Lastly, a regression tree was constructed. The results showed that the sociodemographic variables examined in the study were not related with levels of burnout in nurses. However, certain work-related variables were, such as spending more time with colleagues and patients, and reporting good quality relationships with colleagues, superiors, patients and their families, exhibiting a significant, negative relationship to the presence of burnout. Of the psychological variables, the stress factors conflict-social acceptance, and irritability-tension-fatigue, along with informative communication were found to be risk factors for the appearance of burnout in nurses, in contrast to the communication skills factor, empathy, and energy-joy, which exercised a protective function. The irritability-tension-fatigue factor was the best predictor for the appearance of burnout in nurses.

certain non-technical skills, such as communication, which are central to good job performance [25].
Communication skills in nurses help to protect from and reduce the effects of burnout [26]. The perception of appropriate, effective communication with the patient by healthcare professionals has been related to decreased exhaustion in them and better satisfaction in the patient [27]. In line with that, there is research which indicates that good communication and relationships between team members and their superiors is a protective variable against burnout [28].
In the area of social relationships, the role of emotional intelligence is also notable when responding to and dealing appropriately with overwhelming situations [29][30][31][32]. Healthcare professionals' ability to regulate and manage their feelings is a factor which influences the appearance of burnout [33], especially given the close contact nurses have with patients in intensely emotional situations [34]. An individual's capacity to manage their emotions, keep calm, and contain empathy and distress allows them to think more clearly, which leads to better patient care [35]. This is why promoting practices which empower nurses to face high-stress situations in an emotionally effective manner is a priority in areas which are especially affectively intense, such as pediatric oncology or palliative care [36][37][38].

Stress and burnout in nurses
Workplace stress is a key variable in the development of burnout, as it may appear as a result of a long period of stress on the job. This is why vulnerability to stress is a risk factor for developing burnout [39][40].

Participants
The sample was made up of 1236 nurses aged between 21 and 57, with a mean age of 31. 50 (SD=6.18).
The majority of the sample (84.5%, n=1044) were women with a mean age of 31.65 (SD=6.23). The remaining 15.5% (n=192) were men with a mean age of 30.71 (SD=6.17).
At the time of the study, 69.3% (n=857) worked on short-term or temporary contracts and 30.7% (n=379) were employed on permanent contracts.

Instruments
We used an ad hoc questionnaire to collect sociodemographic data. It also included questions about jobrelated variables such as the type of contract, the amount of time spent each day interacting with colleagues, superiors, patients and families, and the quality of those relationships.
The Brief Burnout Questionnaire (CBB) [44] was used to evaluate this syndrome in the nurses. The instrument consists of 21 items in three blocks corresponding to the precursors, elements and consequences of burnout. Despite the objective of the questionnaire being the overall evaluation of the process of professional exhaustion, it addresses the factors proposed in the model from Maslach & Jackson [45] and the components that precede burnout and go along with it. The reliability of the instrument in the sample in our study was 0.87.
Self-efficacy was evaluated via the General Self-efficacy Scale [46]. This scale evaluates the feeling of personal competency to deal with stressful situations via 10 items with 4-point Likert-type scale responses.
Cronbach's alpha for the instrument in our study was 0.90.
The Self-esteem Scale [47] evaluates an individual's satisfaction with themselves. It has 10 items, with responses from 1 ("strongly agree") to 4 ("strongly disagree") in a Likert-type scale. The reliability of the scale in our study was 0.82.
We evaluated social support using the Perceived Social Support Questionnaire (CASPE) [48] This is made up of nine items which determine whether the subject has a partner and the quality of the relationship, social contact and interaction, family relationships and participation in social groups. The first seven items are Likerttype scales with four response options, the eighth item has 5 response options and the final item is answered yes or no. Cronbach's alpha for this instrument was 0.81.
For the evaluation of emotional skills in the sample, we used the Brief Emotional Intelligence Inventory

Procedure
The study was approved by the University of Almería Bioethics Committee. Participation in the study was voluntary, and the participants were informed of the study aims, and assured of the anonymity and confidentiality of their responses.
The questionnaires were self-administered and included control questions to check for participants answering randomly. The questionnaires were completed online which took 20-25 minutes. At the beginning of each questionnaire, respondents were given information about how to answer the questionnaire and the type of response in each test.

Data analysis
First, we present the data on burnout syndrome looking at sociodemographic and work-related variables through frequency analysis. In order to explore the relationship between the variables, we carried out a correlational analysis for the continuous quantitative variables, and the Student t test and ANOVA for the categorical variables.
Following that, we performed a binary logistic regression using the introduction method. To that end, the dependent variable (burnout) was dichotomized, the cutoff point was chosen as 25 points based on our assessment of the diagnosis of burnout syndrome. A person scoring over 25 points would be considered to be suffering from the syndrome [44]. The following predictor variables were used: general self-efficacy, overall self-esteem, emotional intelligence (intrapersonal, interpersonal, stress management, adaptability, mood), communication skills (empathy, informative communication, respect, social skills), perceived stress (conflict social acceptance, overburden, irritability-tension-fatigue, energy-joy, fear-anxiety, self-realization-satisfaction), and perceived social support. Lastly, we constructed a regression and classification tree using the CHAID (Chi-Square Automatic Interaction Detector) method.
Treatment and analysis of data was done using the SPSS statistical package version .23 for Windows.

Burnout, sociodemographic variables and workplace characteristics
Through the frequency analysis, looking at the presence or absence of burnout syndrome we see that 17.7% (n=219) of the nurses scored 25 or higher, as opposed to the 82.3% (n=1017) who scored lower. Of those who were affected by burnout, 19.6% (n=43) were men and 80.4% (n=176) were women. When we examined the dependent burnout variable without dichotomizing it, we did not find statistically significant differences in the mean scores (t=1.03; p=.30) between men (M= 20.56; SD= 5.27) and women (M= 20.17; SD= 4.75). No differences were seen in burnout related to civil status (F=.36; p=.77).
We performed correlational analysis in order to examine the relationship between burnout scores and the continuous quantitative variables. We did not find any significant relationship between burnout and age (r= .01; p=.57) or number of children (r=.00; p=.99).
With regard to work-related variables, such as the percentage of the workday spent with colleagues, superiors, patients or patients' families, we found negative correlations between burnout score and the amount of the work-day spent with colleagues (r=-.05; p<.05) and patients (r=-.08; p<.01). We found negative correlations between burnout and all cases of evaluation of the quality of relationships in the workplace: the quality of relationships with colleagues (r=-.19; p<.001), superiors (r=-.22; p<.001), patients (r=-.20; p<.001), and patients' families (r=-.23; p<.001).
Another work-related variable is the pattern of shifts worked (rotation, 24 hours, nights, mornings/evenings). On applying the ANOVA test, we found no statistically significant difference between the groups (F= 2.00; p= .11). However, we did find differences according to the type of contract. Nurses with permanent contracts (M=21.26; SD=5.04) had a higher mean score in burnout (t= -5.00; p<.001) than those on discontinuous contracts (M=19.78; SD=4.68).

Logistic regression model for the presence of burnout: Risk and protective factors
We performed the logistic regression analysis with burnout syndrome as a dependent variable. This had previously been dichotomized producing two categories: those affected by burnout syndrome, 17.7% (n=219), and those unaffected by it, 82.3% (n=1017).
The following predictor variables were added to the equation: general self-efficacy, overall self-esteem, emotional intelligence (intrapersonal, interpersonal, stress management, adaptability, mood), communication skills (empathy, informative communication, respect, social skills), perceived stress (conflict social acceptance, overburden, irritability-tension-fatigue, energy-joy, fear-anxiety, self-realization-satisfaction), and perceived social support. Table 3 presents these variables, regression coefficients, standard error of estimation, the Wald statistic with degrees of freedom and associated probability, the partial correlation coefficient and the odds ratio. The odds ratios for each variable indicate that: a) From the perceived stress dimensions, conflict-social acceptance and irritability-tension-fatigue act as risk factors with respect to the likelihood of suffering burnout. Nurses with higher mean scores in these dimensions would have a higher risk of developing the syndrome. Energy-joy exercises a protective function against burnout.
b) The elements of communication skills which are significantly involved are empathy (a protective factor) and informative communication (a risk factor).

INSERT TABLE 3 HERE
In terms of the fit of the model, we see an overall fit (χ 2 = 295.40; df= 18; p<.001) confirmed by the Hosmer-Lemeshow test (χ 2 = 5.86; df= 8; p= .66). Nagelkerke's R 2 indicates that 35% of the variability in the response variable is explained by the logistic regression model. In addition, from the table of classification of cases we estimate the probability that the logistic function is accurate at 85.4%, with a false positive rate of .03 and a false negative rate of . 34.

Multiple linear regression model of burnout, according to employment situation
We found differences in burnout between nurses on permanent contracts and those who worked under short-term, discontinuous contracts. In order to determine the explanatory value of the psychological variables (analyzed in the overall sample above), we constructed models for each of the groups depending on their employment situation via stepwise multiple linear regression analysis, using the employment situation as the selection variable (discontinuous/permanent).

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The regression analyses of the nurses with permanent contracts (30.7%; n=379) produced six models. The decision tree (Figure 1) shows that irritability-tension-fatigue is the best predictor of burnout.
Subjects with a high level (>23) of irritability-tension-fatigue exhibited the highest risk of burnout (57.9%). The lowest levels of burnout (96.8%) was found in in subject with very low levels (<14) of irritability-tension-fatigue.
Finally the goodness of fit of the model can be seen in its correct classification of 83.7% of the participants.

Discussion
Our results show that sociodemographic variables such as age, sex, civil status and number of children are not related to levels of burnout in nurses. This is in agreement with other studies in which these individual variables have not exhibited associations with the presence of burnout in these healthcare professionals [7][8].
We did find significant relationships between certain work-related variables and burnout. Spending more time with colleagues and patients, and reporting good quality relationships with colleagues, superiors, patients and their families was found to be negatively related to levels of burnout in nurses. This is in line with the literature, as indicated in research by Lee & Ji [28], having good relationships with members of the team reduces levels of exhaustion. Conversely, negative relationships and conflict are associated with higher levels of burnout [43]. Similarly, the lowest levels of burnout being in nurses who spent more of their work day with colleagues and patients may be due to less time pressure. Those nurses who can spend more time with their patents and colleagues may have less urgency in their daily tasks, which has been associated with lower levels of burnout, as it allows brief periods of physical and emotional recovery [15][16].
In terms of psychological variables, our results show a negative association of burnout with various factors of emotional intelligence [33], self-efficacy, social support [18], communication skills [26] and self-esteem [21]. However, in perceived stress, we found a positive relationship between high levels of burnout and factors associated with conflict, irritability, fatigue, overburden, fear and anxiety [39]. Conversely, energy-joy demonstrated a negative relationship with the presence of burnout, and was highest in those nurses who did not exhibit burnout.
Only some of the psychological variables were found to be protective or risk factors for the development of burnout. Irritability-tension-fatigue in the perceived stress scale, together with informative communication were shown to be risk factors in the appearance of burnout in nurses whereas the empathy factor in communication