Citation
The burnout maze

Material Information

Title:
The burnout maze an exploration of the interrelationships of burnout, hardiness, depression, response mode to burnout, and demographic variables
Creator:
Clarke, Betty Matthews
Place of Publication:
Denver, CO
Publisher:
University of Colorado Denver
Publication Date:
Language:
English
Physical Description:
xiv, 252 leaves : forms ; 29 cm.

Thesis/Dissertation Information

Degree:
Doctorate ( Doctor of Philosophy)
Degree Grantor:
University of Colorado Denver
Degree Divisions:
School of Public Affairs, CU Denver
Degree Disciplines:
Public affairs

Subjects

Subjects / Keywords:
Burn out (Psychology) ( lcsh )
Human services personnel -- Job stress ( lcsh )
Burn out (Psychology) ( fast )
Human services personnel -- Job stress ( fast )
Genre:
bibliography ( marcgt )
theses ( marcgt )
non-fiction ( marcgt )

Notes

Thesis:
Thesis (Ph. D.)--University of Colorado at Denver, 1991. Public affairs
Bibliography:
Includes bibliographical references.
General Note:
Submitted in partial fulfillment of the requirements for the degree, Doctor of Philosophy, Graduate School of Public Affairs.
General Note:
School of Public Affairs
Statement of Responsibility:
by Betty Matthews Clarke.

Record Information

Source Institution:
University of Colorado Denver
Holding Location:
|Auraria Library
Rights Management:
All applicable rights reserved by the source institution and holding location.
Resource Identifier:
25695861 ( OCLC )
ocm25695861

Downloads

This item has the following downloads:


Full Text
THE BURNOUT MAZE: AN EXPLORATION OF THE INTERRELATIONSHIPS OF BURNOUT, HARDINESS, DEPRESSION, RESPONSE MODE TO BURNOUT, AND DEMOGRAPHIC VARIABLES
!' by
Betty Matthews Clarke
i
B.S., Colorado Women's College, 1975 M.s.N., Medical College of Georgia, 1978
j A thesis submitted to the
I
Faculty of the Graduate School of the
j
University of Colorado in partial fulfillment of the requirements for the degree of
J Doctor of Philosophy
!
i i
, Graduate School of Public Affairs
1991

4



\
I
Clarke, Betty Matthews (Ph.D., Public Administration)
The Burnout Maze: An Exploration of the
Interrelationships of Burnout, Hardiness,
Depression, Response Mode to Burnout, and Demographic Variables
Thesis directed by Associate Professor Mark Emmert
i
The type of stress known as burnout pervades a wide variety of jwork settings. The many negative outcomes of burnout, siich as high absenteeism and turnover, have stimulated ja great deal of research and conjecture about this entity. However, the knowledge needed to prevent or effectively treat burnout is still incomplete.
The questions that this study addressed relate to the role of) depression in burnout, the possible buffering effects between stress and burnout of selected personality^ characteristics, and the issue of a possible
i
j
response mode to burnout. This research study was
I
. I , ,
designed to examine the relationships between burnout
i
(using the Maslach Burnout Inventory), the personality
construct hardiness (using the 50-item Personal Views
. j
Survey), depression (using the Beck Depression
i
Inventory),,and response mode to burnout (using the
i


I
i
t
involvement, autonomy, and task orientation subscales of
the Work Environment Scale).
[
Relationships between and among these variables were
t
examined looking not only at composite or total scores, but also at the subscales of burnout, hardiness, and response mode. Subjects included staff nurses (response rate of 67%? n=157) working full-time in two large,
k
{
metropolitan, full-service hospitals in the Rocky
j
Mountain region.
The findings of this study can be briefly summarized as follows:) (1) Individuals higher in hardiness will
experience less burnout and less depression. (2)
i.
Subjects experiencing burnout are more likely to also
experience depression. (3) Burnout victims with an
!
active resppnse mode to burnout have lower levels of burnout, higher levels of hardiness, and are less likely to experience depression. (4) Depression and the passive response moJie to burnout appear to be closely related.
I
(5) The hardiness dimension of commitment has the most explanatory value for burnout and depression. (6) Questions raised by other researchers about the viability of the challenge dimension of hardiness were supported in
this study. (7) Overall, demographic variables were not
>
related to the other study variables.
v


A self-efficacy model of burnout is suggested as a
possible integrative theoretical umbrella to encompass
!
the constructs of burnout, hardiness, depression, and
I
response mode to burnout. Suggestions are made for future research utilizing both longitudinal and qualitative designs.
The form and content of this abstract are approved. I
recommend its publication.
s S iqned _____________________________
Mark Emmert
vi


THE BURNOUT MAZE: AN EXPLORATION OF THE INTERRELATIONSHIPS OF BURNOUT, HARDINESS, DEPRESSION, RESPONSE) MODE TO BURNOUT, AND DEMOGRAPHIC VARIABLES
by
I
Betty Matthews Clarke B.S., Colorado Women's College, 1975 M.S.N., Medical College of Georgia, 1978
j A thesis submitted to the Faculty of the Graduate School of the University of Colorado in partial fulfillment of the requirements for the degree of
1 Doctor of Philosophy
i
Graduate School of Public Affairs
1991


1991 by Betty M. Clarke All rights reserved.


This thesis for the Doctor of Philosophy
f
degree by
Betty Matthews Clarke
has been approved for the
Graduate School of
Public Affairs
by

i
I
D


1
f
Clarke, Betty Matthews (Ph.D., Public Administration)
The Burnout Maze: An Exploration of the
Interrelationships of Burnout, Hardiness,
Depression, Response Mode to Burnout, and
i
Demographic Variables
k
Thesis directed by Associate Professor Mark Emmert
i
i
The type of stress known as burnout pervades a wide
variety of (work settings. The many negative outcomes of
1
burnout, such as high absenteeism and turnover, have stimulated ja great deal of research and conjecture about this entity. However, the knowledge needed to prevent or
i
effectively' treat burnout is still incomplete.
The questions that this study addressed relate to
the role of' depression in burnout, the possible buffering
)
effects between stress and burnout of selected
|
personality, characteristics, and the issue of a possible
j.
response mode to burnout. This research study was
i
designed to^ examine the relationships between burnout
I
(using the Maslach Burnout Inventory), the personality
j
construct hardiness (using the 50-item Personal Views
i
Survey), depression (using the Beck Depression
I
Inventory),(and response mode to burnout (using the
!


!
!
involvement, autonomy, and task orientation subscales of the Work Environment Scale).
Relationships between and among these variables were examined looking not only at composite or total scores,
S
(
but also at the subscales of burnout, hardiness, and response mode. Subjects included staff nurses (response rate of 67%; n=157) working full-time in two large, metropolitan, full-service hospitals in the Rocky Mountain region.
The findings of this study can be briefly summarized as follows:! (1) Individuals higher in hardiness will experience (less burnout and less depression. (2)
Subjects experiencing burnout are more likely to also
experience ^depression. (3) Burnout victims with an
I
active response mode to burnout have lower levels of
i
burnout, higher levels of hardiness, and are less likely
. !
to experience depression. (4) Depression and the passive
!
response mode to burnout appear to be closely related.
1
(5) The hardiness dimension of commitment has the most
explanatory^ value for burnout and depression. (6)
1
Questions raised by other researchers about the viability
of the challenge dimension of hardiness were supported in
i
this study.; (7) Overall, demographic variables were not related to the other study variables.
v
i


)
A self-efficacy model of burnout is suggested as a
possible integrative theoretical umbrella to encompass
I
I
the constructs of burnout, hardiness, depression, and response mode to burnout. Suggestions are made for future research utilizing both longitudinal and qualitative designs.
The form arid content of this abstract are approved. I
recommend i!ts publication.
i
Signed
i Mark Emmert
\ j
i
|
f
>
\
)
i
f
vi


f
!
f
i
i
This dissertation is dedicated to my husband, Steve, whose support, encouragement, strength, and love made the
completion 'of this dissertation possible. And, to my
| daughters, Ashley and Taylor, whose arrivals during the
j
course of this project helped me to keep my perspective
r ['
and to remember what is truly important in life.
!
!
\
\
1
i
I
i


I
CONTENTS
Figures
Tables
. Xll
xiii
CHAPTER
1.
2.
INTRODUCTION ..............................
J,
Purpose of the Study ... ..................
\
Significance of the Study .................
i
i
Implications of the Study .................
Definition of Terms .......................
I
Burnout .............................
Hardiness ............................
i
A. Brief Overview of the Study.............
General Limitations of the Study .
Organization of Chapters ..................
LITERATURE REVIEW .........................
1
8
9
11
14
14
17
20
21
23
25
The Burnout Syndrome Versus
General Work Stress........................26
Sources of Burnout ............ ..... 27
I The Person-Environment Fit Model . 28
i
! Personal Sources & Moderators of
Burnout...............................31
Environmental Characteristics ... 43
Outcomes...................................51
6


( Physical Outcomes..................... .
| Psychological Outcomes ................
Effects of Burnout on Others .
Phases of Burnout .......................
j Eight Phase Model of Burnout .
j
Active & Passive Response Models to Burnout ..............................
i
i
}
Summary .................................
Research Questions ......................
3. RESEARCH METHODOLOGY .....................
Overview ................................
\
I
Population and Sample ...................
Characteristics of the Sample .
I
Measures ................................
i Maslach Burnout Inventory . Beck Depression Inventory .
; Hardiness Instrument ..................
(
Work Environment Scale .............
J
Method of Analysis ......................
4. FINDINGS OF THE STUDY ....................
Overview ................................
i
Section One ........................
I
\ Data Comparisons Between
Hospital A and Hospital B .
i Hospital A versus Hospital B
I
Hospital A versus Hospital B:
; Non-critical Care Nurses Only
52
52
53
56
57
59
61
67
70
70
71
73
76
76
78
81
83
85
87
87
91
91
92
93
ix


Hospital A versus Hospital B: Critical Care Nurses Only ... 94
Section Two.........................96
Support for Hypothesis One . . 96
Support for Hypothesis Two . . 99
Support for Hypothesis Three 100 Support for Hypothesis Four . . 100
Support for Hypothesis Five . . 102
Support for Hypothesis Six . . 104
Support for Hypothesis Seven 106
Section Three ...................... Ill
Regression Analysis with
Total Burnout as the
Dependent Variable ............ 112
Regression Analysis with
Emotional Exhaustion as
the Dependent Variable .... 115
Regression Analysis with
Depersonalization as
the Dependent Variable .... 116
Regression Analysis with
Personal Accomplishment as
the Dependent Variable .... 118
Regression Analysis with
Depression as the
Dependent Variable ............ 119
Summary...............................121
5. CONCLUSIONS OF THE STUDY...................124
j
Summary and Discussion of Findings 124
Burnout and Hardiness ............... 125
Commitment: The Key Variable 129
x


Response Mode to Burnout...........132
Demographic Variables ............... 136
l
Challenge: The Problematic
Variable .............................137
A Self-efficiency Model of Burnout . 139
Person-Environment Fit versus Reciprocal Determinism .............. 150
The Self-efficiency Model of Burnout and the Profession of Nursing . . . 151
Summary.................................163
Implications ............................. 164
Future Research .......................... 166
Closing Comments ......................... 169
APPENDIX
A. QUESTIONNAIRES AND COVER LETTER ........... 172
B. DEMOGRAPHIC DATA COMPARISONS BETWEEN THIS STUDY AND DATA FROM THE COLORADO STATE BOARD OF NURSING AND THE
COLORADO NURSES ASSOCIATION .............. 185
i
C. T-TEST & CHI-SQUARE RESULTS ............... 186
D. PEARSON CORRELATION COEFFICIENTS . . . .191
E. DEPRESSION AND LEARNED HELPLESSNESS . . . 192
|
Depression..............................192
Learned Helplessness ..................... 197
Learned Helplessness and Depression . . . 199
F. sbciAL LEARNING THEORY AND
SELF-EFFICACY ............................ 201
BIBLIOGRAPHY ........................................ 205
xi


FIGURES
Figure (
5.1 Interactive Effects of Perceived
Self-efficiency and Expected Environmental Outcomes ...................
5.2 Schematic Representation of Two Alternative Conceptions of Interaction .

. 143 151
xii


TABLES
Table
2.1 Eight|Phase Model of Burnout ............... 58
2.2 Personal and Environmental Variables and
Their|Relationships with Burnout ............... 66
2.3 Research Questions ............................. 68
3.1 Sample Characteristics ......................... 74
. j
4.1 Research Questions and Study Results ........... 90
4.2 T-test Results Between Hospital A
and Hospital B...................................92
4.3 T-test Results Hospital A versus Hospital B:
Critical Care Nurses Only........................95
4.4 Pearson Correlation Coefficients for Burnout
and Hardiness ...................................96
4.5 Internal Consistency of the 36-item Hardiness
Short Form Subscales.............................98
4.6 Internal Consistency of the Hardiness 50-item
Short Form Subscales.............................99
4.7 Pearson Correlation Coefficients for
Depression and Hardiness ....................... 99
4.8 Pearson Correlation Coefficients for Burnout
and Depression..................................100
4.9 Pearson Correlation Coefficients for Depression and Response Mode to Burnout and for Depression and Work Environment Scales .... 101
4.10 Pearson Correlation Coefficients for Hardiness and thje Active Response Mode to Burnout and for Hardiness and the Work Environment Subscales 104


4.11
Pearson Correlation Coefficients for Burnout and tlie Response Mode to Burnout and the Work Environment Scales ..............................
i . ,
4.12 T-test Results for Critical Care Versus Non-critical Care Nurses at Hospitals A and B .
! .
4.13 Regression Analysis with Total Burnout as the
Dependent Variable .............................
i
I
4.14 Forced Regression with Total Burnout as the Dependent Variable with Hospital A
Nurses Only ....................................
i
4.15 Forced Regression with Total Burnout as the Dependent Variable with Hospital B
Nurses Only.....................................
|
4.16 Regression Analysis with Emotional Exhaustion
as the Dependent Variable ......................
1, .
4.17 Regression Analysis with Depersonalization
as the Dependent Variable .... .................
k
4.18 Regression Analysis with Personal Accomplishment as the Dependent Variable .
' j
4.19 Regression Analysis with Depression
as the Dependent Variable ......................
r
!
I,
xiv
106
107
113
114
115 115 117
119
120
i


CHAPTER ONE
INTRODUCTION
An overstretched rubber band ... a rag doll with half the stuffing gone meeting a brick wall .
i
caught on a railroad track with a freight train bearing down ... a prisoner in a glass box feet and hands tied browning in dust bleeding to death slowly .1. an overloaded plane that can't get off the ground. These are some of the statements one group of workshop pJrticipants used to describe their feelings of
I'
burnout (Ryerson & Marks, 1981). These vivid burnout
!
images are itypical of the ways in which human service professionals characterize their experiences of burnout. These phrases give some sense of the acute pain and distress burnout victims experience.
Burnout is a type of job-related stress. The problem of job-related stress has been discussed for
decades, bujt indications are that occupational stress
1
continues tjo grow rather than decline. Stress on the job affects organizational effectiveness through absenteeism, turnover, decreased productivity, and increased medical
i
costs for employers. Legal costs have also risen as


employees file record numbers of stress-related workers'
i
compensation claims. In the United States the total
i,
cost of job-related stress has been estimated to be as high as ten percent of the gross national product (Ivancevich & Matteson, 1980).
Job stress also exacts a toll on affected employees. These human costs are less easy to quantify but are alarming, nonetheless.
The individual, organizational, and societal costs of job stress have stimulated considerable activity on the part of researchers who seek to identify the causes of job stress. The ultimate goal is to prevent the negative mental and physical effects of occupational
stress on the employee.
i
The term "burnout" was first applied to the issue of occupational stress in 1974 by Freudenberger. Freudenberger used the term "burnout" to describe the physical and psychological effects on individuals working in the free clinic movement.
The term "burnout" had considerable intuitive appeal and soon became the catchword of the 1970s and 1980s to describe a wide variety of stress-related entities. Of the many books and articles written about burnout, most are descriptive and anecdotal; and only a small percentage are based on empirical research. Savicki and
2


]
Cooley (1983) point out that only approximately 25 percent of'the articles in the burnout literature provide data to support their burnout conceptions.
This lack of scientific corroboration of the concept of burnout jhas led to criticisms from many corners. Typical of ;the criticisms are those of Eiseidel and Tuily
(1981) Tliey cite a lack of operational and conceptual definitions of burnout, the lack of replications and extensions jof previous research, and the over emphasis on the practical aspects of burnout to the detriment of the scientific lelements of burnout. In short, Eiseidel and Tuily describe the many individual and organizational components |of burnout as an "unwieldy universe."
i
A considerable amount has been written about nurses
being one group of professionals that includes many , . I
victims of burnout. This raises immediate and practical
I
concerns for a number of reasons.
The United States is currently facing a nursing
I
j, ...
shortage which is rapidly reaching crisis proportions. A
!'
1986 survey: (American Hospital Association, 1987) noted
!
that the vacancy rate for registered nurses in hospitals more than doubled between 1985 and 1986. Some estimates
5
predict that the shortage of baccalaureate prepared nurses willjbe about 390,000 by 1990 and about 578,000 by the year 2000 (American Nurses Association, 1988).
3


1
I
Although nursing shortages have occurred in the past in a cyclical fashion, the current shortage is different
and more serious. It involves all types of nurses in all
j
kinds of hpspitals and in all regions of the country (American Hospital Association, 1987).
r
This shortage occurs at a time when hospitals more
|
than ever need skilled and highly-educated nurses to
manage increasingly sophisticated technology, to make
i .
critical decisions, and to care for a higher proportion
of patients with greater acuity and complex needs. The
shortage al!so occurs at a time when the demand for health
care continues to rise because of an increase in the
elderly population, an increased availability of health
insurance, 'and rising incomes (Tregarthen, 1987).
ij , ,
There are a number of causes for the existing shortage of nurses. A 1988 report (American Nurses Association1) cites the major factors affecting the supply of nurses as follows: declining enrollments and graduations' at schools of nursing, increased options and opportunities for women outside of nursing, poor working conditions,; inadequate pay, lack of respect for nursing, and the poor image of nursing.
"The medical community can no longer afford to chew up its nurses and spit them out" (Gorman, 1988, p.78). Historically, nurses have been treated as a disposable


commodity. "The nursing profession has a supply-side
i
tradition of generating a high flow of highly motivated nurses and not worrying about retention" (Will, 1988, p.80). The current conditions of shortage demand that this practice must stop. Measures must be taken not only to make the profession of nursing more attractive to men
and women to boost nursing school enrollments, but
1
immediate measures must also be taken to stem the increasing itide of nurses leaving the profession.
Among ;the issues that must be faced if nursing
p
retention is to be substantially improved is the problem
i \
of burnout in the nursing profession. As one of the key people-helping professions, nursing has characteristics that make it a prime target for burnout. Most young nurses begin their nursing practice with a high degree of idealism and unrealistic expectations. This is often
l
based on their original ideas of helping others which . i. ,
motivated them to enter nursing in the first place. This interest in helping others as well as the perceptions of personal impact are reinforced during the socialization
t
process that occurs in nursing schools. Upon entering
!
employment,! new graduates are often faced with a reality quite different from their expectations. "The pain of the world is no longer an abstract philosophical idea but
5


I
}
knocks daily at one's door in concrete self-presentations of suffering individuals" (Pruyser, 1984, p, 357).
Nurses are often expected to, and frequently expect
themselves jto, be able to do the impossible in providing
(
care and comfort for their patients. Nurses perform
I
tasks that .'are frequently viewed as distasteful by others. Providing nursing care brings nurses into
intimate contact with the human body, a body that may be
i
diseased and/or deformed. Nurses are required to meet not only tlje physical needs of their patients but also their patients' emotional needs as well as those of the patients' families and friends. In the daily exercise of her/his duties, the nurse not only finds the physical demands of (providing nursing care but also the demands
I
for compassion, sympathy, and caring.
I
These myriad demands are placed on the nurse in an environment; which often provides few resources for the nurse to replenish her/his emotional and physical stores.
r
Support may not be available from colleagues because nurses sometimes stoically feel that as professionals, they should! be able to cope; and also they may expect their fellojw nurses to cope with individual problems
without aid from others. Also, disincentives to disclose feelings and concerns may exist because nursing is viewed by some as a profession that "spends far too much time
{
6


policing its members and too little energy supporting them" (Storlie, 1979, p. 2111).
This lack of mutual support is compounded by the absence of support from other sources. In one study of nurses the second most frequent reason stated for leaving nursing is jthe treatment nurses received from physicians and administrators (Sigardson, 1982). This incentive to leave the nursing profession precedes dissatisfaction with pay and benefits and is outranked only by concerns
i
with understaffing and working long hours.
The practice of nursing often takes place in institutions that may operate via bureaucratic rules and regulations which constrain the way nurses care for their patients. |Nurses often risk personal injury and physical illness (Hay & Oken, 1972). In addition, the problems of understaffing, long working hours, frequent (undesired) overtime, rotating shifts, lack of supplies, problems of getting needed cooperation from other departments, and the necessity of spending time on non-nursing functions
i,
are endemic to nursing.
Considering the list of issues facing nursing today, it is not surprising that nurses frequently complain of being burned out and that burnout studies using nurses as subjects show high levels of experienced burnout.
7


I
Purpose of the Study
It isjthe purpose of this investigation to help clarify some of the current theories about the role that personality characteristics and depression play in the development and progression of burnout and to further
examine two suggested response modes to burnout.
|
In looking at the role of personality characteristics, the study will examine the relationship between burnout and "hardiness," a term used to describe
i
a constellation of personality characteristics that have
i
been found jin some studies to serve as a moderator between stress and illness and stress and burnout.
I
There has been considerable speculation, although little validation through research, about the role depression J'plays in burnout. This study will specifically examine the degree to which depression correlates with the subscales of burnout, the subcomponents of hardiness, and the two response modes to burnout.
It is also the purpose of this study to determine
i
which, if any, demographic variables correlate
significantly with burnout.
\
The objectives of this study include not only an attempt to further the understanding of the burnout phenomena, but also to be able to suggest appropriate
8
1


interventions for victims of burnout, and to suggest
means of identifying those who might have a propensity
I
toward burnout.
Significance of the Study
The concept of the burnout syndrome has captured the
interest and imaginations of many researchers since it
I
was first introduced in the 1970's. As a result of the popular appeal of the term burnout, it became a "vague verbal tent" covering a number of phenomenal areas (Golembiewski & Munzenrider, 1988b, p. 8). Entities such as alienation, free-floating anxiety, and depression were put under the same conceptual tent leading to a confusion of constructs.
I
Various authors came up with shopping lists of sources and causes of burnout covering emotional, physical, and environmental spheres. Conspicuously absent from the literature were studies that could
legitimately establish causation and validate any of
!
these lists.
There jwere a plethora of studies and articles describing the burnout syndrome and offering prescriptions for its amelioration. Unfortunately, the treatments suggested were rarely supported by empirical
9


1
i
l
research and solid research conclusions (Savicki &
I
Cooley, 1983).
The research completed in this study will add to the body of knowledge about burnout in several ways. First,
i
I,
it will help identify the role that personality characteristics play in the propensity of some individuals to succumb to burnout. Second, it will help clarify the part that depression plays in burnout.
Third, it Will provide additional information about the
different ways in which individuals respond to burnout.
1
And, fourth, it will make a contribution toward ending the controyersy concerning the role demographic variables play in burnout.
t
Burnout pervades a wide variety of work settings.
\
The knowledge gained in this research may help
I
administrators in public, private, and non-profit
i
institutions make decisions in training, work assignment,
i
continuing ieducation, and employee counseling that might both help prevent and help ameliorate burnout.
At the individual level, this and other burnout research can have great significance for enhancing the career livejs of human service professionals. Prior
i
I
research hajs clearly shown a positive correlation between burnout andj a number of negative outcomes such as alcohol abuse, mential illness, marital conflict, suicide
10


(Maslach, 1976), physical symptoms, absenteeism, and low energy levels (Golembiewski, Munzenrider, & Stevenson,
i
1986). Knowledge gained through burnout research which helps prevent and treat burnout should also provide
I
relief from burnout related problems such as those
mentioned above.
I
i
; Implications of the Study
l
Knowledge gained in this study^has implications in
i
many areasj First are the implications for patient care.
I
A major concern about burnout is the indirect effects it can have on the recipients of services provided by
i
victims of(burnout (see Chapter Two). Decreasing the incidence of burnout in helping professionals can improve
the care that patients receive. For example, care givers
I
will be less likely to Withdraw from clients and treat them in depersonalized ways. Care givers who are not
i
suffering from emotional exhaustion will be able to give
i
j,
more to their clients, particularly at the psychological level. As care givers experience higher levels of personal accomplishment, they experience a renewed commitment Jto their work. The need for highly qualified nurses able to function at a high level has never been
J
greater tha!n it is now when issues of increasingly
!
11


sophisticated technology and higher patient acuity are faced on a daily basis.
Second, decreasing burnout also has implications for
health care costs that are increasing at an alarming
|
rate. Although the quality of patient care is not the only factor involved in the initiation of malpractice
suits, it probably can be assumed that an improvement in
I
patient care would have some positive effect on the rate at which m4lpractice suits are filed. A decrease in malpractice suits has implications for decreasing direct
i
costs for insurance to health care practitioners and health care institutions and should ultimately impact the overall cost of the provision of health care.
Victims of burnout have been found to have higher rates of absenteeism and turnover. The costs related to
j
both of these issues are well known to health care
j
administrators. Programs successful in decreasing absenteeism and turnover should have a direct positive effect on decreasing overall health care costs.
Third, decreasing burnout has implications for enhancing the lives of not only the victims of burnout but also thleir friends and families. Stress related to
burnout which is not resolved at work is often
\
resurrected at home.
!
12


Fourth, the prevention and treatment of burnout has implications for the practice of nursing. Issues of
i
retention and absenteeism have already been discussed.
In view of of nursing
the need for highly skilled nurses, the issue recruitment is of equal importance. Nursing school enrollments are down. If ways are not found to make nursing more attractive as a profession, the nursing shortage tliat is already being experienced nationwide
l..
will become even more alarming. This is a multi-faceted problem that will not be solved with easy remedies.
i
However, dealing with the issues of burnout in nursing would be a ;major step in the right direction.
v i '
Addressing issues of burnout in nursing also has
i
implications for nursing education. It would be fruitful to incorporate new knowledge about how to predict, identify, prevent and treat burnout in the education of new nurses and in the continuing education of nurses already practicing. Information obtained in this study
might also joffer help in counseling nurses regarding
<
areas of practice.
Although the focus of this study is on nurses, knowledge obtained has implications for any human service professional. This is of prime importance at a time when our reliance on human service professionals is growing, particularly in the public sector. In recent decades we
13
i


)
have increasingly turned to public agencies to provide many of the functions previously provided by one's
" f
j
family, church, and neighborhood. The hospitals, social
i . ...
welfare agencies, and mental health agencies providing
these services are staffed by human service professionals
|
at high risk for burnout (Cherniss, 1980c).
Information obtained from this study also has
!
implications for management theory. When given an
|
adequate body of knowledge, managers can play a key role in helping!to solve the problem of burnout in human service professionals. A more developed understanding of burnout can affect the way in which human service workers
might more!effectively be assigned, educated, supported,
i
and evaluated.
i
;
! Definition of Terms
i
i;
Burnout j
!
In the midst of competing models and definitional
i
ambiguity of the burnout concept, there is a core of
\'
j , #
researchers who approach the burnout construct with rigor
!
|
and empiricism. Among this central group of burnout
i
researchers, the concept proffered by Maslach and Jackson
(
i
is the one|most frequently adopted.
6 ,
As defined by Maslach and Jackson (1981b), burnout is a "syndrome of emotional exhaustion and cynicism that
i
14


i
recipient. Jackson is
occurs frequently among individuals who do 'people work'
|
of some kind" (p. 100). The stress of burnout results
from the social interaction between a helper and a
Burnout as conceptualized by Maslach and
made up of three elements: emotional
exhaustion, depersonalization, and reduced personal
accomplishment.
. 1 .
Emotional exhaustion refers to the depletion of an individual's emotional resources coupled with a feeling that one has nothing left to give. The helper gets over involved emotionally and feels overwhelmed by the demands placed on her/him by others. This condition of emotional exhaustionjwas described by one victim as "compassion fatigue" (Maslach, 1982a, p. 31). This has also been
f
described as "professional autism," a state in which "mandated actions are carried out, but the emotional investment|that transforms a task into an art form is missing" (Storlie, 1979, p. 2108).
i
The second aspect of the burnout syndrome is
1 i,
depersonalization which results in the helper putting
distance between her/himself and recipients.
. i
Depersonalization is characterized by a detached, callous, dehumanized response to recipients.
Depersonalization can be viewed as an extreme form of "detached concern," an attitude adopted by many
15


individuals in people helping professions which combines

a careful balance between empathy for a recipient and
I
enough separateness from the recipient to enable the helper to function most effectively (Leif & Fox, 1963). The balance between closeness and distance demanded by detached concern is very difficult to achieve. As the balance shifts to increased distance, depersonalization develops; and the helper increasingly views recipients
I
with a negative, callous perspective. This negative
i{
perspective can often lead helpers to begin to believe that the recipients of their help are somehow deserving of their problems, "blaming the victim" (Ryan, 1971). As helpers begin to "blame the victim," they tend to be less sympathetic, to feel less responsible for their clients, and ultimately to do less for their clients.
The third aspect of burnout is a feeling of reduced
personal accomplishment. Individuals who choose helping
1
professions as their life's work are freguently very dedicated and committed (Freudenberger, 1975a). As burnout develops and emotional exhaustion and depersonalization increase, helpers begin to feel less
i
and less positive about the work they are doing; and they
begin to feel guilty about the way they have treated
>
recipients. Helpers begin to feel like failures and self-esteem declines.
J
16


Hardiness
Kobasa and her colleagues at the University of Chicago formulated the concept of "hardiness" to describe
a constellation of personality characteristics which
: j
serve to moderate the effects of high levels of stress.
Drawing from existential personality theory (e.g., Kobasa i
& Maddi, 1977), the literature on coping and the literature on human development Kobasa (1977) conceptualized the three components of hardiness to be commitment, challenge, and control.
The personality characteristics of commitment, challenge land control influence an individual's perception of an event in such a way that the event is perceived to be less stressful by the individual possessing(hardiness. This cognitive appraisal of the event as .less threatening effects a more positive response of the individual to the event. This promotes activities that are more proactive and less avoidance oriented (Kobasa, Maddi, & Kahn, 1982).
The personality characteristic of commitment results
in an individual being significantly invested in her/
\
himself. It allows her/him to find meaning in all aspects of her/his life, and to resist giving up when
i
under pressure. The committed individual will confront
i Hi
: I
problems directly, involve her/himself deeply in whatever


s/he does, jand have a sense of purpose. "In short, committed persons' relationships to themselves and to the environment involve activeness and approach rather than passivity and avoidance" (Kobasa, Maddi & Kahn, 1982, p.
169) .
r
j
Work by other theorists supports the concept of commitment. Antonovsky (1974) wrote about what he considered to be the most essential stress-resistance resource, j'a sense of coherence," which also involves a sense of purpose. Moss (1973) theorized that alienation
i1
and a lack of commitment make one more susceptible to illness.
, I

The personality characteristic of control enables an to feel influential rather than helpless when facing life's events. Control allows her/him to perceive
r
events as a result of her/his own actions, so that they feel less strange and unexpected (Kobasa, Maddi, & Kahn,
individual
1982).
The concept of control is built primarily upon the research on locus of control (e.g., Phares, 1976). This research suggests that individuals differ in the degree to which they perceive that they can influence their environment. Persons with an internal locus of control have the perception that they can significantly affect their environment, thus they feel less helpless in the
18


face of adversity. Persons with an external locus of control perceive themselves to be more at the mercy of others, chance, and fate (Rotter, 1966).
r
Individuals with the personality characteristic of
challenge \jiew change as stimulating rather than
. i
threatening. They perceive change, rather than stability, to be a normal part of life. Change is exciting in that it provides an opportunity to learn and grow. Challenge also promotes flexibility and openness
(Kobasa, Maddi, & Kahn, 1982).
Jr
Csikszentmihalyi (1975) discussed challenge as it
1
I
relates to janxiety and boredom. When a person is faced with demands s/he is unable to meet, anxiety results.
When a person is faced with demands s/he has the ability
to meet, Mflow" results. "Flow" is the sensation that
!
results when an individual acts with total involvement.
; !.
"Whether orie is in flow or not depends entirely on one/s perception of what the challenges and skills involved are" (Csikszentmihalyi, 1975, p.50).
The concept of challenge is also supported by
research on the need for variety (Maddi, Propst, &
I
Feldinger, |l965) and on sensation seeking. Smith,
I ...
Johnson, and Sarason (1978) found that individuals who
score high Ion a measure of sensation seeking are more
tolerant of negative life changes, whereas individuals
19


scoring low on sensation seeking suffered psychological distress in the face of negative life changes.
Based on the above information, the hardy individual may be characterized as curious, intrinsically motivated
(Maddi & Kobasa, 1981), inclined to take vigorous control
f
of his life (Kobasa, 1979), and interested and satisfied with the activities of his life. The hardy person will also view change as a stimulating and natural part of life that provides opportunities to learn and develop
1 t ,
(Kobasa, Maddi, & Puccetti, 1982).
. }:
Individuals low in hardiness will perceive their environments as boring, threatening, and meaningless.
They will ie passive and pessimistic in their
interactions with their environments and will feel
:}
, i-
powerless in the face of adversity and change. Stability
i
in life is(preferable to the individual low in hardiness, is perceived as negative (Kobasa, Maddi, &
and change Puccetti, 1982).
A Brief Overview of the Study
I
I ...
This sjtudy was designed to investigate several areas
of inquiry
depression,
variables.
relating to burnout including hardiness, response mode to burnout, and demographic Staff nurses from two large metropolitan
hospitals comprised the subject group. Four previously
20


validated instruments were used to measure burnout, depression, hardiness, and response mode to burnout.
Each subject also completed a demographic data sheet.
Data were collected at one time period only.
Data obtained from these instruments were primarily
f
analyzed by computing Pearson Correlation Coefficients and t-tests and by using multiple regression analyses.
General Limitations of the Study
A number of issues may limit the generalizability of this study. One issue concerns the representativeness of the sample. A random sample was not used. Subjects participating in this study were registered nurses working full-time (defined as 40 hours per week) who were in staff positions with no administrative responsibilities. Although all nurses meeting these criteria were asked to participate in the study, some self-selection bias may have existed for those who chose to participate versus those who declined. This may be particularly pertinent in a study of burnout, since individuals suffering from high levels of burnout may be disproportionately represented in the non-participants.
Another potential threat to generalizability lies in the choice of the hospitals selected for the study. Both hospitals are large, private, non-profit institutions in
21


a large metropolitan area in the same geographical area.
\
The fact that previous burnout studies have failed to identify any consistent and robust association between demographic variables and burnout offers encouragement.
i
A methodological limitation to this study relates to
the use of the degree
a correlational design. Correlations indicate to which variables covary together.
Assumptions about causation are not justified based on these data alone. Although two variables may be highly correlated, it is not possible to tell whether there is a causal relationship, which direction any causal relationship would take, or whether the relationship
between the two variables is a result of some other
!
phenomena ,
the time sequence of events and situations is element in determining causation (Babbie, fact that this study collected data at only one time point also limits the degree to which assumptions about causation can be made.
Anothlr potential imitation of this stUdy ie the
Since a critical 1983), the
use of self-report measures that could not practically be verified through trained observation. However, one group
1 i
of researchers has completed studies that have demonstrated that self-report measures can be as good as
behavioral
measures and, in some instances, may be
22
i


superior (Howard, Scott, Wiener, Boynton, & Rooney, 1980).
Defining study participants as nurses working 40 hours per week created sampling difficulties. Both
hospitals in this study have flexible scheduling arrangements, allowing each nursing unit to decide what
schedule nurses will work. In both hospitals a high
!
i
proportion of the critical care units work 12-hour shifts
and define|a full-time nurse as one who works 36 hours per week. jThis created an under-sampling of critical
j
care nurses, particularly at Hospital A where no intensive care unit or coronary care unit nurses were able to participate in the study. However, most studies examining the differences in burnout levels between critical care and non-critical care nurses have found
l
j
that the type of unit in which a nurse works is not significantly related to burnout scores (see Chapter Two for details).
I
I
Organization of Chapters
Chapter Two reviews selected literature pertaining to burnout^ hardiness, depression, and response modes to
burnout, and proposes research questions of interest.
!
J
Chapter Three focuses on the methodology involved in
i
I
the research. The three sections of this chapter include
i
23


the following: research methods and objectives; the
i
'!
sources and characteristics of the sample; and methods of
t
. t
data analysis.
!
I
Chapter Four addresses each of the research questions examined in the study and presents the results of the statistical techniques used to analyze the data. Chapter Five provides a summary of the results of
'i
t ...
the study and discusses the implications of these
r:
findings and makes suggestions for future research.
I
l
!
\
i
l
i
!
I
I
\
f
1
!
i
\
r
i
24


CHAPTER TWO
LITERATURE REVIEW
i
This chapter presents a review of the literature on burnout. Based on this review, burnout will be conceptualized as one type of stress that affects human service professionals as a result of their interactions
with their environments.
I
Both personal and environmental sources of burnout will be reviewed. Possible personal sources of burnout
V
include demographic traits and personality characteristics such as idealism, assertiveness and self-actualization. Hardiness as a constellation of the
I
personality dimensions of commitment, challenge, and
I1
control will be discussed at length. Both support for hardiness and criticism of this construct will be
l
included. ,
i
Possible environmental sources of burnout reviewed in this chapter incite roie characteristics such as roie
( I
conflict, social support, leadership style, type of
i
organizational unit, and job qualities such as job
overload


I
The effect of burnout on somatic complaints, energy levels, absenteeism, turnover, alcohol and drug abuse, and idealism are also reviewed in this chapter. The
I
spillover effects of burnout on the family, friends, and clients of:burnout victims are also included.
A discussion of phase models of burnout and
j
response modes to burnout will complete this chapter.
The Burnout Syndrome Versus General Work Stress
As conceptualized by Maslach (1982a), burnout is
1
restricted to include only individuals in the human services professions. This conceptualization is supported by other researchers of burnout (Burke, Shearer, &
Deszca, 1984a). Maslach resists the efforts of others to include all types of work and the stresses involved in interacting with individuals in non-work settings (e.g., mothers interacting with their children). Maslach (1982a) argues that a broader concept of burnout will
make the term meaningless. "If burnout means everything,
1
i
it means nothing at all" (p. 34).
Maslach (1982b) also argues against extending the term burnout to include all types of work stress. She views burnout as one subcategory of work stress.
Research by other investigators supports this view. Two
!
studies (Numerof & Gillespie 1984; Numerof & Seltzer,
I 26
r


)
1986) demonstrate that burnout can be understood as a "segment on the continuum" of the much broader concept of stress. While the umbrella term of "stress" includes
t
I
both positive and negative experiences, both in and out
1
of the work environment, burnout includes only negative
experiences in the workplace. A study by Jayaratne and
]'
Chess (1984) also supports the delineation of burnout as separate from work stress and job satisfaction.
Tennis (1987) contends that the fact that extensive
i
1
reviews of\organizational stress by authors such as Beehr and Newman (1978) and Schuler (1980) do not refer at all
to the concept of burnout would suggest that these
I
authors also support the argument for a concept of
1
burnout as separate from work stress. Farber (1983)
argues that burnout is the result of unsuccessful
|
attempts to cope with stress. Brill (1984) agrees with
s'
Farber adding that burnout requires outside help or
|
environmental changes to bring about improvement.
i
f
Sources of Burnout
j
i .
Much disagreement exists among major burnout researchers about the primary causes and dynamics of burnout. Maslach (1982a) argues that rather than looking at "defective" people, attention should be focused more on the environment in which people work. Based on her
!
i
I
27


I
research she feels that burnout "is best understood in terms of situational sources of job-related, interpersonal stress" (p. 9). Cherniss (1980a) and
Freudenberger and Richelson (1980a) agree that it is
{
probably more reasonable to focus on the situation rather
\
than on the individual, in part because if one wants to
j
provide some type of intervention to decrease burnout, it
i
, , i t # , ,
is easier to change the situation than it is to change
i;
the individual.
i
The Person-Environment Fit Model
Meier|(1983) argues for a more interactionist view
. s
of burnouti He believes that the causes of burnout do
l
i
not reside|in either the individual or the environment
alone; rather, that burnout is a function of both
s;
I
influences: The development of burnout lies both within
I
the individual and the formal and informal physical and social environments that make up the workplace (Savicki & Cooley, 1983). Meier's (1983) view is more in keeping
i
i
with the person-environmental interaction perspective (Beehr & Newman, 1978). This perspective makes the assumption!that job stress results when there is a poor fit between a worker and the environment in which s/he
i
works. This person-environment (P-E) fit model argues that how a|person functions on the job is influenced by both the stresses encountered in the environment and the
28


personality type of the individual. Garden (1989) believes tllat the personality of an individual may influence not only how burnout is manifested but also one's predisposition to burnout. It is the "goodness of fit" between job demands and individual personal
characteristics that determines how much stress an
I
j
individualjwill experience (French & Caplan, 1972). The
r
P-E fit model corresponds to the "social ecological perspective." This perspective states that human behavior is a dynamic interaction between the individual and the social environments of which s/he is a part (Carrol, 1979; Cherniss, 1980a).
i
Both P-E fit theory and the social ecological
i
perspective indicate that personality characteristics or
!
environmental characteristics could function both as sources ofJstress or moderators of the stress reaction
t
(Tennis, 1987). They also explain why some individuals
(
i
experience:burnout while other individuals in the same environment do not. A review of burnout literature finds support for this theory. For example, although death and dying has been speculated to be a source of stress for nurses, Turnipseed (1987) found that burnout is not a
widespread; problem among hospice nurses. Other research
1:
has found that hospice nurses report organizational stress or staff support stress far more often than stress
29


1
concerningjpatients and their families (Yancik, 1984; Turnipseed,; 1987) In a related study, Yasko (1983) reports that hospital nurses' current level of direct contact wiih cancer patients was not associated with
i
greater degrees of burnout.
In discussing the P-E fit model French, Rodgers, and
j
Cobb (1974) argue that it is essential to consider two meanings of "environment." One must examine not only the
"objective',1 environment that exists independently of the
!
person's perception of it, but also the "subjective" environment as it is perceived and reported by the person. Ajkey theoretical concept of psychological stress is lhat of appraisal. Appraisal, discussed by Lazarus and Opton (1966), refers to the evaluation by the
individualjof the harmful significance of some event.
I
j ... ...
Threat occurs when a cue signifies to the individual that a harmful experience may be anticipated. "Thus, the same stimulus may be either a stressor or not, depending upon the nature!of the cognitive appraisal the person makes regarding the significance for him" (Speisman, Lazarus,
i.
Davison, &jMordkoff, 1964, p. 367). One person's treat
!
may be another person's poison. The appraisal of an
event can result in the conclusion that the situation is
[
!
harmful, disgusting, or challenging (Lazarus, 1971).
30


I
Assuming that the interaction between the individual and the environment is the most likely overall explanation of burnout, there are a number of causes/ moderators Iwhich deserve consideration. These factors
I . .
can most easily be divided into personal characteristics and environmental characteristics.
Personal Sources and Moderators of Burnout
i
Researchers have investigated a number of personal
ij-
characteristics that may influence burnout. These
I .
include personality characteristics and demographic traits such as gender, age, education, marital status, experience! and position in the organization. Although
I
studies scrutinizing possible relationships between
personality characteristics and burnout have been
!
fruitful, studies in the area of demographic variables
I
have been less successful. Numerous demographic
i
variables have been, and continue to be, the subject of study. The associations between burnout and demographics "provide no evidence of significant and sizable covariation" and do not seem "robust" (Golembiewski & Sccichitano, 1983, p. 446). Golembiewski and Munzenrider (1988b) call burnout an "affirmative action affliction" (p. 138). | Maslach and Jackson (1984) urge caution when interpreting differences in variables relating to sex,
i
marital status, and family status because of the
! 31
I
\


1
)
probability of confounding from sex role socialization,
|
differences in social support and different job expectations.
I
Gender. The findings regarding the influence of
I
gender on burnout are equivocal. Two studies have
identified'males to be more prone to burnout than females
j
(Daley, 1979; Thompson, 1980); and, in two studies, males experienced more depersonalization and less personal
s
accomplishment than females (Golembiewski, 1983; Olsen,
1985). Inja study by Maslach and Jackson (1981b),
]
females scored higher than males on emotional exhaustion;
[
and males scored higher on depersonalization than females. Other studies have found no gender differences in reported levels of burnout (von Baeyer & Krause, 1983-84; Etzion; 1984; Guyon, 1984; Igodan, 1985; McDermott, 1984; Maslach & Jackson, 1985; McCarthy, 1985; Numerof &
I..
Seltzer, 1986; Golembiewski & Munzenrider, 1988b).
Aae. |Research examining the relationship between age and burnout is more consistent than the findings on gender. Although four studies found no relationship between age and level of burnout (Cheatham & Stein, 1982; von Baeyer! & Krause, 1983-84; Harris, 1984; Numerof & Seltzer, 1986), the majority of studies found an inverse relationship between age and burnout (Pines & Kafry,
1978; Daley, 1979; Gann, 1979; Maslach & Jackson, 1979;
32


)
Gillespie, 1981; Maslach & Jackson, 1981b; Pines & Kafry, 1981c; Golembiewski & Sccichitano, 1983; Yasko, 1983;
Guyon, 1984; McDermott, 1984; Numerof & Gillespie, 1984;
!
McCarthy, 1985; Shea, 1985; Igodan, 1985; Olsen, 1985).
i
Experience. Studies also demonstrate an inverse relationship between burnout and years of experience
i'
(Streepy, 1981; Livingston & Livingston, 1984; Numerof &
i
Gillespie, 1984; Martof, 1985; Shea, 1985; Whitehead, 1985). One would expect, based on the findings relating
to age and|experience, that individuals at higher levels
i
in the organizational hierarchy would experience less burnout. This has proved to be true in some studies
I
(Kahn, 1978; Kimmel, 1982; Harris, 1984; Whitehead,
1985). Das (1981) found no relationship between job
level and turnout. Pines and Kafry (1978) report higher
i
burnout atfhigher positions. This contradictory finding
h'
might be explained by the fact that the Pines and Kafry
i
(1978) study was the only one which did not measure burnout by'using the Maslach Burnout Inventory.
Educational Preparation. Educational preparation is not usually identified as having an influence on
I
experienced burnout (Fong, 1985; Louis, 1985). However, Guyon (1984) found in one study that personal
. I
accomplishment decreases as educational level increases. Maslach and Jackson (1981b) found that higher levels of
i


education are associated with higher scores on emotional exhaustion^and lower scores on depersonalization.
Marital Status and Children. Results studying the
i
effect of marital status on burnout are equivocal. In three studies married subjects demonstrate less burnout than unmarried subjects (Numerof & Gillespie, 1984;
Maslach & Jackson, 1985; Numerof & Seltzer, 1986). In two
I
studies no relationship is found between marital status
I
and burnout (von Baeyer & Krause, 1983-84; McDermott,
1
1984). In I one study single or divorced subjects are found to be higher on emotional exhaustion (Maslach & Jackson, 1981b).
i
j,
Subjects with children show less burnout (Yasko, 1983; Maslach & Jackson, 1985) or no relationship between
burnout and having children (Guyon, 1984).
|
Idealism and Unrealistic Expectations. Personality characteristics have been viewed as playing a major role in burnoutJsince the first discussion of burnout by Freudenberger (1974). Freudenberger observes that individuals who are highly committed and dedicated are
f
more prone!to burnout. Individuals prone to burnout are also idealistic and tend to set standards for themselves that are unrealistically high (Freudenberger & Richelson,
i
1980a). Individuals with a high need to help others often choose a helping profession and find themselves


I
I
I
unable to readjust their unrealistic expectations to meet
the reality of the situation (Savicki & Cooley, 1983).
1
The role that unrealistic expectations plays in the
i
experience{Of burnout is supported by other researchers
i:
(Veninga, 1979; Fischer, 1983; Meier, 1983; Sakharov &

1
Farber, 1983). However, Jackson, Schwab, and Schuler (1986) find that unmet expectations about the job are not associated;with higher levels of burnout; and Seabold (1984) demonstrates that nurses with higher initial
expectations have significantly lower burnout than other
nurses.
Miscellaneous Personality Attributes. There are other personality attributes that have been hypothesized to influence the development of burnout which have
f
i,
received less attention than the notion of unrealistic
expectations. For example, individuals who are more self-actualized suffer less burnout than subjects who measure lower in self-actualization (Cheatham & Stein,
i
1982). The personality variables of achievement,
I;
abasement,jnurturance, and succorance are positively
I
related toiintensity of emotional exhaustion and
negatively!related to frequency of personal
i
accomplishment (Grutchfield, 1982). A study by Nagy (1985) shows that assertiveness did not influence the degree of experienced burnout.
/
35


, i
Hardiness. An area of extensive investigation relating to personality characteristics has been the work of Kobasa and her colleagues at the University of Chicago. In beginning her research, Kobasa (1977) was interested!in examining individuals who did not become ill when confronted with significant levels of stress. After evaluating data collected as part of the Chicago Stress Project, Kobasa formulated the concept of "hardiness'i' to describe a constellation of personality characteristics that serve to derate the ejects of
I
f
high levels of stress. Drawing from existential personality theory (e.g., Kobasa & Maddi, 1977), the literature on coping, and the literature on human development, Kobasa conceptualized the three components of hardiness to be commitment, challenge, and control.
The personality characteristics of commitment, challenge,t and control influence an individual's
I;
perception|of an event in such a way that the event is perceived to be less stressful by the individual possessing!hardiness. This cognitive appraisal of the
l
event as less threatening effects a more positive response of the individual to the event. This promotes
activitiesjwhich are more proactive and less avoidance
!
oriented (Kobasa, Maddi, & Kahn, 1982).
36


The personality characteristic of commitment results in an individual being significantly invested in her/himself. The hardiness dimension of control enables an individual to feel influential rather than helpless when facing life's events. Individuals with the personality characteristic of challenge view change as stimulating rather than threatening (Kobasa, Maddi, &
Kahn, 1982).
The Personal Views Survey (PVS) is the instrument developed by Kobasa (1979) to measure hardiness. The PVS consists of separate items to determine subscale scores for commitment, challenge, and control. A composite
hardiness score can also be determined.
[
All of the studies done in conjunction with the Chicago Stress Project have identified hardiness as a significant moderator of the relationship between stress
I
and illness (Kobasa, 1979; Kobasa, Maddi, & Courmgton, 1981; Kobasa, Maddi, & Puccetti, 1982; Kobasa, Maddi, &
Zola, 1983; Kobasa & Puccetti, 1983; Kobasa, Maddi,
: [
Puccetti, & Zola, 1985). Subsequent studies by other
- \
researchers also support the validity of the construct of
hardiness (Wendt, 1982; Rhodewalt & Agustsdottir, 1984;
.1'
Sagert, 1984; Bigbee, 1986; Howard, Cunningham, & Rechnitzerj 1986; Banks & Gannon, 1988; Allred & Smith, 1989; Nagy & Nix, 1989). Only a few studies fail to
37


identify any relationship between hardiness, stress, and illness (Seger, 1984; Bennett, 1986; Schmied & Lawler,
1986; Roth,; Wiebe, Fillingim & Shay, 1989) .
j.
Studies have also been done to examine the
i
I
relationship between hardiness and burnout. These
studies, many of which used nurses as their subjects
!
(D'Ambrosia, 1987; Jama, 1987), consistently identify hardiness as a buffer between stress and burnout (Berger, 1983; Nowack & Hanson, 1983; Keane, Ducette, & Adler, 1985; Nowack, 1985; D'Ambrosia, 1987; Holt, Fine, & Tollefson, 1987; Jama, 1987; Rich & Rich, 1987; Schoenig,
Klipple, &
1987). In[a related study Savage (1987) reports that
: j
subjects with high hardiness and social support have lower levels of negative psychological symptoms.
I
Two studies of hardiness have used subject groups with a specific disease entity, rheumatoid arthritis (RA) (Okun, Zautra, & Robinson, 1988; Lambert, Lambert, Mewshaw, 1989).
In the first study, the control dimension of hardiness was positively correlated with an objective measure of|positive immune response (circulating t-cells) (Okun et al., 1988). This led the investigators to conclude that hardiness is a useful construct for
i
understanding a patient's adaptation to rheumatoid arthritis. These researchers speculate that RA patients'
38


cognitive beliefs regarding their influence over their lives does jaffect their immune system functioning. In a later study of RA patients, researchers find that regardless jof severity of illness, satisfaction with social support and hardiness are significant predictors of psychological well-being (Lambert et al., 1989).
i
Although the findings of the earlier hardiness
research wdre fairly consistent with the theoretical
!'
framework outlined by Kobasa and her colleagues, more recently a ^ number of theoretical and empirical criticisms
i
have been directed at hardiness research and theory.
|
These criticisms relate to how hardiness is
operationalized, concerns about analysis and
l
interpretation of data from previous research, and doubts about hardiness as a unitary measure (Funk & Houston, 1987; Hull^ Van Treuren, & Virnelli, 1987; Rhodewalt &
I
Zone, 1989).
One ok the issues of measurement relates to the
i
evolution of the hardiness instrument and the
, : I,
inconsistent use of any one measure of hardiness by
i
various researchers. The hardiness instrument was
I
developed by Kobasa and her colleagues using subscales from other^ previously validated tools. For example, one of the measures of the control dimension was the Internal-External Locus of Control Instrument (Rotter,
39


Seeman, & Liverant, 1962; Lefcourt, 1973). As Kobasa^s research progressed, changes were made in the composition
. r
of the hardiness measure based on information obtained in
i
previous studies. This resulted in the use of a number
of different iterations of the hardiness tool by
!'
different investigators, which made study comparisons
, . I
difficult (Hull et al., 1987).
Another measurement criticism deals with the use of
I
negative wording in the hardiness instrument (e.g.,
. j
determine high challenge by measuring low security) which
calls for assumptions that may not be accurate (Funk &
I
Houston, 1987; Parkes & Rendall, 1988). Another concern
, j
is that the negative wording will tap maladjustment and,
I
in fact, that many of the subscales used to indicate hardiness are very similar to those found in measures of maladjustment (Funk & Houston, 1987).
The concern that the hardiness instrument may measure some form of maladjustment is supported by a
I
number of studies. Funk and Houston (1987), using the Beck Depression Inventory (BDI) as their measure of
. i
depression!; find that hardiness is more strongly related to depression than to physical illness, and that many of
I
the effects of hardiness are not found when they
I
statistically controlled for depression. Several other investigations of hardiness using the BDI as a measure
40


of depression also find an inverse relationship between hardiness and depression (Ganellen & Blaney, 1984; Watson & Clark, 1984; Rhodewalt & Zone, 1989). Using a different measure of depression Manning, Williams, and
l
Wolfe (1988) also identify a negative relationship
I
between hardiness and depression.
i
Allred and Smith (1989) argue that previous hardiness effects may actually reflect the operation of
the personality dimension of neuroticism. They speculate
I
that the relationship between hardiness and health reflects ajrelation between neuroticism and somatic complaints. The results of their study demonstrate that hardiness and neuroticism are clearly confounded. Parkes
and Rendall (1988) conducted a study that examined the
j
relationship between hardiness and extraversion and neuroticism. They find all components of hardiness to be
c
positively!related to extraversion and negatively related to neuroticism. Parkes and Rendall (1988) also provide evidence that neurotic introverts have particularly low
. i
hardiness scores, which is consistent with the
psychological vulnerability viewed as typical of this
I
group (Eysenck, 1978).
The maladjustment dimension, labeled neuroticism by Allred and! Smith (1989), has also been called general dysphoria |(Gotlib, 1984) or negative affectivity (Watson


!
i
i
I
& Clark, 1984). As stated earlier, Watson and Clark
i
(1984) utilized a widely-used measure of depression (the
i
Beck Depression Inventory) in their hardiness study.
They arguejthat the BDI not only measures depression but is also highly correlated with the more global construct of negative affectivity, the tendency to magnify and
I
dwell upon I negative events. Rhodewait and Zone (1989)
I
argue thatjlow hardy people manifest an "existential
t
malaise" which they postulate is the same as, or related
..!
to, negative affectivity. Rhodewalt and Zone (1989) conclude that nonhardiness is a correlate of negative
I
affectivity rather than hardiness providing a special resiliency! to stress.
The use of hardiness as a unitary measure is another major concern of critics (Hull, Van Treuren, & Virnelli, 1987; Carvfer, 1989). Their arguments are that combining measures and using a composite index results in a loss of information that might otherwise "embellish and flesh
I
out" the picture, or might prevent discovering "that the picture is> in fact, wrong" (Carver, 1989, pp. 580, 581). Two studies that support this argument are; (a) a study in which challenge and commitment correlated with social
support but control did not (Ganellen & Blaney, 1984),
|
and (b) a study in which the composite measure of
i


I
hardiness yielded no effects and the challenge subscale
I
yielded only one (Hull, Van Treuren, Propsom, 1988).
The argument against the use of a composite
i
hardiness xheasure at this stage of research is further
i
supported ^>y the inconsistent results obtained by many
researchers relating to the challenge subscale. In a
i ,
number of studies the subcomponent of challenge either
did not significantly correlate with outcome measures
(Kobasa, 1982a; Magnani, 1986; Schlosser, 1986; Rich &
Rich, 1987; Hull et al., 1987; Manning et al., 1988; Roth
et al., 1989; Toft, 1979), or it yielded an effect in the
i
opposite direction of commitment and control (Hull et
!
I
al., 1988)1
t
Environmental Characteristics
!
"The search for causes [of burnout] is better directed away from identifying the bad people and toward uncoveringj the characteristics of the bad situations where manyj good people function" (Maslach, 1978b, p.
114). This emphasis on the role of the environment in effecting burnout has stimulated the study of a wide-ranging list of environmental characteristics as antecedents of burnout.
Role Characteristics. Role characteristics have
I
received attention as possible antecedents of burnout.
Role theory as developed by Kahn (1974) shows that job
(
i
i


satisfaction decreases in the presence of role conflict and role aihbiguity. Cherniss (1980a) indicts role ambiguity and role overload as strong contributors to burnout among human services professionals.
Role conflict occurs when an individual is torn
i
between the conflicting demands of different groups that
\
are all important to the individual (Pines, 1981). Role conflict as an antecedent of burnout is supported by studies examining priests (Chiarmonte, 1983) and teachers (Jackson et al., 1986).
Role conflict has been a suspected source of stress
[
in women torn between the conflicting demands of home and
].
work outside of the home. In a study of professional women by Pines and Kafry (1981c), the hypothesis that conflicts exist between the demands of home and work was
l1
supported.j However, this study also shows that the number of roles in and of themselves did not promote
I'
burnout. On the contrary, the variety of roles added interest and stimulation and promoted satisfaction and happiness.! In this study variety is negatively correlatedj with burnout, which leads the authors to
speculate that "when a woman has different roles and many
|
different things to do, each one is experienced as less stressful,#| (Pines & Kafry, 1981c, p. 132) This might
help to explain the data stated earlier that individuals
I
i
i
44


1
who are married and have children tend to experience less burnout. 1
Role ambiguity, a lack of clarity about what is expected of an individual, has also been implicated in the development of burnout. However, studies investigating this dimension do not support this hypothesisj. Instead, they show that role ambiguity may have a positive quality. A study by Leiter and Meechan
i
(1986) suggests that although role ambiguity may cause
i [
some individuals difficulty in defining their roles, for
1
other individuals role ambiguity is perceived as an opportunity to define their roles in ways which are compatiblejwith their own interests. In fact, in this study, measures of personal accomplishment are higher in
l
individuals who experienced role ambiguity. A study by Jayaratne and Chess (1984) also finds that role ambiguity is not implicated in the development of burnout.
However, one study identifies task clarity as a significant contributor to emotional exhaustion in park and recreation professionals (Rosenthal, Teague, Retish, West, & Vejssell, 1983).
Job Qualities. There are a number of job qualities
l
that have been suspected as playing a role in the development of burnout. The job qualities that will be discussed here include job overload, the number of hours
45


an individual works, the amount of time spent in contact
!
with clients, the type of work unit in which the individual!works, social support, and leadership styles.
J
1
The issue of job overload has been investigated by a number of researchers. With one exception (Jayaratne &
Chess, 1984), work overload correlates significantly and
!
positivelyj with burnout (Gentry, Foster, & Froehling, 1972; Maslach & Pines, 1977; Pines & Maslach, 1978; Fong, 1985). I
The number of hours worked by an individual may affect burnout. The results in this area are less
definitivej than those on job overload, however. Although
j
two researchers are able to identify a direct positive
relationship between the number of hours worked and the
I
developmenjt of burnout (von Baeyer & Krause, 1983-84; Fong, 1985), other studies do not support these findings (Maslach & Pines, 1977; Das, 1981; McDermott, 1984;
Olsen, 198p) Tine away fron the job (e.g., vacations, time out) is shown to have an inverse relationship to
burnout (Pines & Maslach, 1978; Seiderman, 1978; Cooper,
!
1984). i
I
Contact Time with Clients. The amount of time spent in contact| with clients has also been implicated in the development of burnout. Several studies show that as the
i
amount of time in direct contact with clients increases,
i
46


burnout also increases (Maslach & Pines, 1977; Das, 1981;
Livingston & Livingston, 1984). However, the exact
|
opposite effect has been found in examining the amount of time supervisors spend in direct contact with their subordinates. In a study of nurses by Harris (1984),
managers who spend more time with subordinates experience
\
lower levels of burnout. Managers who spend less time with their subordinates experience higher levels of guilt
I
and a lower sense of personal effectiveness as a manager.
Type of Organizational Unit. Research examining burnout in! nurses has tried to identify different types of organizational units which might be implicated in the
i
development of burnout. Based on research that has examined psychological stresses experienced by critical care nurseb (Gentry et al., 1972), usually the hypothesis has been that critical care areas, such as emergency
g
rooms and intensive care units, will promote more burnout than areasj such as obstetrics and medical/surgical units. This assumption is not consistently born out, and most studies examining this variable find that there is no
f
difference; in burnout levels based on the type of unit in
j.
which one jworks (Das, 1981; Harris, 1984; Cronin-Stubbs &
i
Rooks, 1985; Keane et al., 1985). McCarthy (1985) shows that burnojut is not higher in nurses working with highly
disturbed psychotic patients. However, Cronin-Stubbs and
)
47


Brophy (1985) find that nurses working in psychiatric
units or in the operating room show higher levels of burnout than nurses working in intensive care units or in the trauma! unit.
I
Social Support. Social support has been proposed as a major resource which might reduce the development of burnout (Cobb, 1976; Cherniss, 1980b; Pines, Aronson, & Kafry, 1981). This hypothesis is confirmed by a number of studies^ examining the effects of support on burnout
i
(Pines & Kafry, 1981a; Rosenthal et al., 1983; Yasko, 1983; Yarne, 1984; Cronin-Stubbs & Brophy, 1985). Leiter
i-
and Meechan (1986) report that subjects experience less
r
emotional exhaustion when an individual's social support
. i
network isj not limited solely to the formal work
i
subgroup. [Pines and Kafry (1978) show that interpersonal relations With clients and colleagues are more important in preventing burnout than other work conditions, such as
the variety of job assignments. Jackson et al. (1986)
|
find that teachers experience higher levels of personal accomplishment in supportive environments, and that the
i
support ofi one's principal is particularly significant in
helping to
increase personal accomplishment. Lack of
support from one's principal is positively correlated to
depersonal of support
ization. Cherniss (1988) argues that the type from one's principal influences burnout rates
48


among teachers. In his study Cherniss observed specific behaviors in the principal with the staff with the lowest burnout levels. These behaviors include interacting less frequently|with staff members, spending less time observing staff in their classrooms, talking more and listening less, spending more time discussing work-related problems, and giving her staff more emotional support but spending less time in "small talk" with them.
j
Paredes (1983) also finds that supervisory support rather than co-worker support is more significant in preventing
i,
burnout for hospital nurses.
I
Some of the literature on support and burnout makes a distinction between support at home and support at work. Most of these studies find that both on-the-job
i.
I
and off- the-job social support are negatively associated with burnout (Pines, Aronson, & Kafry, 1981; Kafry & Pines, 1980; Cronin-Stubbs & Rooks, 1985). Several other
studies examine only work support. Dick (1985) reports that subjects with collegial support have decreased burnout. [Yasko (1983) finds that a decrease in work support leads to an increase in burnout scores, and Fong (1985) argues that the support of peers and the
chairperson lead to lower levels of burnout in nurse educators.
49



A stucly of Israeli managers and social service professionals by Etzion (1984) adds complexity to the distinction between different types of support. As predicted, life and work stress are positively related for men ank for women. Also, social support in life and
in work arle negatively related to burnout for both men
!
and women.j However, work stress for men is moderated by social support in the workplace, and work stress for women is moderated by social support outside of work (e.g., fainily and friends). Etzion (1984) speculates, based on these results, that the recommendation that individuals develop support groups at work as a means of alleviating burnout might be more appropriate for men than for women. She is concerned that this approach for women mighjt conflict with their investment in developing social relationships outside work and impair the source of support that is most beneficial for them. "Developing
i
and maintaining social relationships beyond one's need might provL a demand stressful in itself ..." (Etzion, 1984, p. 621).
I'
Leadership Style. Some researchers have investigated whether or not the leadership style of one's supervisor: plays any role in the development of burnout. Dick (1985) finds that nurses whose supervisors have a participative management style experience less burnout.
i
t
50


Consideration, adequacy of communication with the supervisor!, and amount of communication with supervisors
i
are all found to be inversely related to burnout by
j.
Numerof and Seltzer (1986). This study also found that
i ...
with high levels of supervisory consideration, burnout is
lowest under conditions of high or moderate structure.
I
This finding supports a previous study in which burnout
in neonatal intensive care nurses is found to be highest
|
under conditions of low consideration and high structure
1
(Duxbery, Armstrong, Drew, & Henly, 1984). However, these researchers speculate that it might be the environment that is causing the leader to burn out. Subsequently, the leader develops a leadership style characterized by high structure and low consideration since leadership style is, in part, a response to the work situation (Duxbery et al., 1984).
In summary, the role of personal and environmental
variables
clear.
in the development of burnout is far from
j Outcomes
I
!
The impact of burnout on the individual in terms of emotional jexhaustion, depersonalization, and a decreased sense of personal accomplishment have already been
mentioned.
There are a wide variety of other physical
51


and psychological consequences that are experienced by
burnout victims. There are also ways in which burnout
| .
affects the family, friends, and clients of the victims
u
of burnout1.
I
I
Physical Outcomes
Burnout has been associated with a wide range of somatic complaints including headaches, backaches, sleep problems, loss of appetite, nervousness, chronic colds, and generally poor physical health (Pines, 1981; Conner, 1983; Burke et al., 1984b; Golembiewski, 1987a). These
physical symptoms often lead to decreased energy level
; i.
and increased absenteeism and turnover (Pines, 1981; Cheatham &| Stein, 1982; Golembiewski, 1987a).
Psychological Outcomes
t i
| .
Alcoholism and drug abuse are other outcomes of
burnout asj victims attempt to cope with the negative
' j,
emotional and physical effects of burnout (Maslach, 1976;
i
Pines, 1981; Jackson & Maslach, 1982). Burnout is also associated]with mental illness and suicide (Maslach,
i
I
1976). Mitchell (1988) reports that in England, nursing has one of the highest rates of suicide in any professional group and tops the list of outpatient psychiatric referrals.
52
i
i


Often the victims of burnout, who started out with such idealism and high expectations, become disillusioned
with their low morale
professions, lose their idealism, suffer from and develop negative attitudes toward their work (Freudenberger, 1975a; Sackeroff, 1982;
Golembiewski, 1987a). Helpers may be overwhelmed by the "bottomless well of needs awaiting their response" (Lenrow, 1978b, p. 560).
Jonesj (1981a) identifies other disturbing possible effects of burnout. In a study of nurses, he reports that nurses with higher burnout scores are more likely to
score higher on a dishonesty test measuring attitudes
; |
toward theft and are more likely to steal drugs intended for patients.
Effects of
Burnout on Others
The effects of burnout reach far beyond the burnout
I
victim. Others "singed" (Maslach, 1982a) are the family,
the friendL, the recipients of the services provided by
; I
the victimj of burnout, the institution with which the
: ]
victim is associated, and society at large.
In a jstudy of police officers, Jackson and Maslach (1982) repjort that burnout can have direct and devastating effects on the families of burnout victims. Officers suffering from burnout spend more time away from their families, are less involved in family matters when
53


?
they are home, are more likely to have unsatisfactory marriages, and are more quick to anger.
The indirect effects burnout can have on the recipients;of services provided by burnout victims is a
l
r
major concern. Cherniss (1980a) is concerned that whole
!'
groups may]burn out affecting the climate of the
I.
unit/institution to such a degree that a therapeutic environment becomes impossible. An early study conducted
f;
by Schwartz and Will (1953) observes that the psychiatric patients cared for by burned out professionals on one
unit were neglected, causing them to regress and to
j< . .
become more depressed, violent, and suicidal. The
concerns of Cherniss (1980a) have been supported by
research. Rountree (1984) reports that there is a strong
tendency for people m a task group to have similar
levels of burnout. The studies of Golembiewski and
,
\ ...
Munzennder (1988b) also find that immediate work groups
have an affinity for extreme scorers, in the majority of
cases, and^ that mixed groups seem rare.
I,
The development of emotional exhaustion by victims of burnoutj has major implications for human service recipients!. As a consequence of emotional exhaustion, the professional often loses positive feelings toward clients, and develops instead a cynical and callous perspective about people. "A virtual hallmark of the
54


burnout syjidrome is a shift in the individual's view of other people a shift from positive and caring to negative and uncaring" (Maslach, 1982a, p. 17).
The development of depersonalization also has a major effect on the way clients are treated. As depersonalization develops, the person suffering from burnout will increasingly withdraw from her/his clients and begin to respond less to their clients as humans and
more as things (Maslach, 1982a). Dehumanization often
' I
develops, and clients may be perceived to be "subhuman,
bad human,
This makes "inhumane" There
or non-human" (Maslach & Pines, 1977, p. 102).
it possible to act in "antisocial" or ways (Maslach & Pines, 1977).
are a number of ways that distance from
i
clients can be obtained. The victim of burnout may use
r
i. .
verbal techniques to establish distance, such as
.-'X
referring to her/his clients as "my caseload" or the "broken hip in room 212." The burned out person may intellectualize about situations to make them more objective and less personal. S/he may also withdraw
physically or talking going into
iby doing such things as avoiding eye contact to the client from the doorway rather than the room (Maslach & Pines, 1977). In this technological age, it is also possible to provide a distance between the health care provider and .the patient
55


by focusing on laboratory reports and technological apparatus.
Compassion is translated into intellectual concern. Instead of looking at the patient, some helpers may examine with fascination the plates that come out of theirj visualization machines as well as the printouts of their computerized lab studies. (PrUyker, 1984, p. 363).
, I:
Another method of withdrawing from clients is to "go by the book" rather than examining the facts of a specific case and acting accordingly (Maslach, 1976).
Phases of Burnout
Beginning with the early writing about burnout, some
I.
authors have conceptualized the syndrome as a process occurring 'in phases. According to Freudenberger (1974), victims of burnout first exhibit anger, irritation, and frustration and have a difficulty holding in feelings. These symptoms are followed by suspicion and paranoia which may lead to a sense of omnipotence and over-confidencfej, This may be exhibited in risk-taking behavior and/or self-treatment with drugs and alcohol.
The burned out individual also becomes rigid, inflexible, and resistant to change.
Edelwjich and Brodsky (1980) describe four developmental stages of burnout based on their interviews with peoplje working in human service capacities. The first stage, enthusiasm, is characterized by high hopes,
56


unrealistic expectations, and over identification with clients, jin the second stage of burnout, stagnation, the emphasis turns from devoting all of one's energies to the
job to meeting one's own personal needs. The third stage
\
of burnoutj is characterized by frustration, the
1
realization that it is difficult, if not impossible, to
1;
do what one set out to do. The fourth stage of burnout,
' |
apathy, ocburs as a defense against frustration. The
i; . . .
victim of burnout begins to do only what is minimally
required and avoids challenges.
I
. i !
Eight Phase Model of Burnout
The primary work to empirically validate a phase model of burnout has been done by Golembiewski and his colleaguesj (Golembiewski & Munzenrider, 1988b). This phase model seeks to extend Maslach's work on the three componentsj of the burnout syndrome, emotional exhaustion, depersonalization, and personal accomplishment (Maslach,
1982a).
I
The phase model makes assumptions about the relative potencies jbf the subscales of the Maslach Burnout Inventory.] Depersonalization is seen as the usual and least potent entry into burnout (Golembiewski & Munzenrider, 1988b). Personal accomplishment is seen as
intermediate, and emotional exhaustion is considered the
i
57


most virulent of the subscales and the one most
.1
characteristic of advanced phases of burnout.
the MBI the phase model developed by iki and Munzenrider (1988b) distinguishes subjects as high or low on each of the MBI subscales
f
(Table 2.1).
Using
Golembiews
Table 2.1.1 The Eight Phase Model of Burnout.
Progressive Phases of Burnout
Depersonalization
I II III IV V VI VII VIII
Lo Hi LO Hi LO Hi Lo Hi
Lo Lo Hi Hi LO Lo Hi Hi
Lo Lo LO Lo Hi Hi Hi Hi
ment (reversed)
NOTE: From Phases of Burnout (p.28) by R. T.
Golembiewski and R. F. Munzenrider, 1988, New York: Praeger. (Copyright 1988 by R. T. Golembiewski and R. F. Munzenrider. Reprinted by permission.
The phase model suggests that each of the phases is increasingly virulent but does not require that individualL suffering from burnout progress through each phase in succession. Two advantages of the phase model is that it;provides a way to classify individuals in
if
terms of the virulence of their particular cases and permits the more accurate targeting of ameliorative interventions (Golembiewski & Munzenrider, 1988b).
58


I
A series of studies by Golembiewski and his colleagues;provides increasing evidence that an eight phase model of burnout is valid and reliable (Golembiewski & Munzenrider, 1981; Golembiewski, Munzenrider, & Carter, 1983? Golembiewski & Munzenrider, 1984b; Golembiewski, Hilles, & Daly, 1986; Golembiewski &
I
Munzenrider, 1988b). Data from these studies also suggest that advanced burnout is widespread, and that burnout sefems to last for a long period of time (Golembiewski, 1986b). As for the chronicity of burnout,
; t
Golembiewski and Munzenrider (1988b) suggest that if anyone is hoping that a "tincture of time" will cure
burnout, t
Active anil
lat one should not count on it.
Passive Response Modes to Burnout
Prior1clinical observations about burnout (Freudenberger & Richelson, 1980a) have indicated that there may be two response modes to burnout, identified by Golembiewski (1984a) as active and passive. Golembiewski and Munzenrider (1988b) comment that the distinction between thL two response modes to burnout suggests
analogs to "hardiness
such personal features as "helplessness" and If such modes exist, they are of both theoretical! and practical concern.
An active response mode refers to behavior that is characterized by a frenetic burst of energy wherein
59


individuals work harder and longer, but not smarter (e.g., Freudenberger & Richelson, 1980b; Cherniss,
1980a). Freudenberger (1977b) has also described this type of burnout victim to be on a treadmill in "an unending cycle of accelerating effort and decelerating reward" (pj. 27). The behavior of other burnout victims may be characterized by a state of resignation, described by Golembipwski (1984a) as the passive response mode to burnout, j
Research by Golembiewski and his colleagues (see Golembiewski & Munzennder, 1988b) on the phases of burnout has also included some work on response modes.
studies have found is that the response modes seem to characterize all phases of burnout, and that about one-Lifth of those in advanced phases of burnout seem to bej in the active response mode, while approximately four-fifths are in the passive response mode. BasLd on limited evidence, it appears that passivity (increases more or less directly, phase by phase (Golembiewski & Munzenrider, 1988b).
' j,
It has been speculated that the passive response mode to burnout may be clinical depression (Levinson, 1986; Golembiewski, 1987b). Freudenberger (1974) identifies; depression as a symptom of burnout. Weiskopf
What these
60


(1980) views depression as the end state of burnout, and Ficklin (1983) uses burnout as a synonym of depression.
Other
authors theorizing on a possible relationship
between burnout and depression have questioned whether
I
burnout may be a new name for an old idea. In a study of university faculty, Meier (1984) finds not only strong support for the convergent validity of burnout, but also
. 1 i
a high correlation between burnout and depression,
j
weakening the argument for burnout's discriminant
validity. liResults of a study by Schucker (1985) in which
i'
psychiatric nurses were subjects support the hypothesis that depression will rise as job stress rises. Using the
Beck Depression Inventory to measure depression another
. |
study shows a high correlation between depression and emotional exhaustion, one of the subscales of burnout as measured by the Maslach Burnout Inventory (Firth,
McKeown, Mclntee, & Britton, 1987).
Summary
Based on this literature review, in this study
burnout will be viewed as a type of stress affecting
i
human service professionals. The three components of burnout arL emotional exhaustion, depersonalization, and personal accomplishment.
i
61


Burnout is best understood as resulting from interactions between individuals and their environments. Stress resulting in burnout can originate from both personal and environmental sources.
Demographic traits, idealism, assertiveness, self-actualization, ad the personality construct hardiness are the primary personal characteristics discussed in
this review. Although age and experience level primarily
j
show an inverse relationship with burnout, relationships between other demographic traits, such as gender, marital
I
status, position in the organization, and educational
|
preparation, are equivocal. In the two studies examining
i
the effectj of having children on burnout, one study reports less burnout in individuals with children and the
other study reports no relationship between having
,1
children and developing burnout.
\ .
According to this review, assertiveness does not
: j ...
influence degree of burnout, but individuals who are more self-actualized experience lower levels of burnout. The
. . i' ...
majority of studies reviewed found that individuals who are idealijstic and have unrealistic expectations are more prone to burnout.
The pjersonality construct hardiness is comprised of three dimensions, commitment, challenge, and control.
. I . ...
The primary body of hardiness research has identified
62


hardiness as a significant moderator between stress and illness, and stress and burnout. Criticisms of hardiness
i; j
include issues of how it is operationalized, concerns about dataj analysis and interpretation in the Kobasa studies, doubts about hardiness as a unitary measure, and the evolution of the hardiness instrument.
it . . .
Questions remain about the relationships between hardiness and burnout and the following entities: neuroticiSm, introversion, dysphoria, negative
affectivity, depression, and existential malaise.
t.
Among the environmental factors included in this review, social support and time away from the job result in lower burnout. Role conflict, time in direct contact with patients, and job overload result in higher levels
i! i
of burnout!; Studies examining the effect of role clarity
or ambiguity as well as the type of organizational unit
! !
in which one works with the development of burnout have equivocal:results. Leaders with participative management
styles, or
high supervisory consideration and high or
moderate structure, have subordinates with lower levels of burnout!
. li .
This!review outlines a number of negative outcomes
:: 1
resulting from burnout. Victims of burnout experience higher levels of emotional exhaustion and
:i:
depersonalization, and lower levels of personal
63


accomplishment. Burnout victims have an increased incidence of somatic complaints, a generally lower level
j
j
of wellness, and often lower energy levels. Higher levels of absenteeism, turnover, disillusionment, and low morale arej also found among individuals suffering from
burnout. Burnout is also associated with a higher
i
incidence of alcohol and drug abuse, mental illness, and suicide. j
. I'
Indirect effects of burnout include negative interactions between the victim of burnout and her/his family and!friends. Burnout also has a negative effect on the delivery of services to clients and on patient care. |
L
Phasejmodels of burnout have been proposed with the . . i . .
most significant work resulting in an eight phase model
I
i
that extends the work of Maslach. Research associated
i.
with the phase model suggests that emotional exhaustion is the most virulent component of burnout, and that advanced burnout is widespread and chronic. One of the values of a phase model is that it allows more accurate targeting of ameliorative interventions.
The final subject of this review is response mode to
burnout. There are indications for both active and
i
. |
passive response modes to burnout. In the active response mode, victims of burnout work harder and longer
i
64


but not necessarily smarter. The passive response mode
"
is characterized by resignation and appears to be associated with the clinical state of depression.
For ah overview of the variables included in this
review and 2.2.
their relationships with burnout, see Table
I
i
I
I
65


Table 2.2. Personal and Environmental Variables and Their Relationships with Burnout.
Variable Relationship with Burnout
Positive Inverse None Equivocal
Gender , +
Age Primarily
Education Level +
Marital Status I +
! 1 Experiencje Primarily
Position Organizat . LI Lc i jn +
Children +* +*
Idealism Primarily
f Selfactual: zationj +*
Achievemen 1 s : +*
Abasement]; +*
1; Nurturance +*
|,' Succorance i +*
Assertive ness _ +*
Hardiness +
!
f
I-
II I'
66


Relationship with Burnout
Variable
_______L
: Positive Inverse None Equivocal
Role Conflict +
Role Ambiguit Clarity +
Job Over-j load i !i +
# of Hours Worked J +
Time in Contact with Clients S +
i Time Away* from Job) j. +
Type of | Work Unitj +
Social Support ; +
Leadership Style j +**
* Represent only one study
** Leadership style includes supervisors with either participative management styles or with high supervisory consideration and high or moderate structure
\,
' Research Questions
This study will examine possible relationships between burnout and the personality construct of
i'
hardiness,jdepression, demographic variables, and
i
r
67


response modes to burnout. Thus, this research will test the hypotheses stated in Table 2.3. Chapter Three outlines the research methodology used to test these hypotheses!.
Table 2.3. Research Questions: Hypotheses Regarding the Relationships Between Burnout, Hardiness, Depression, Demographic Variables,and Response Mode to Burnout.
HI: Hardiness scores will vary depending on degree of
burnout.

Hla: Subjects scoring higher on hardiness will have lower burnout scores.
Hlb: Subjects scoring lower on hardiness will have higher burnout scores.
H2: Hardiness scores will vary depending on level of depression.
H2a: Subjects scoring higher in hardiness will have lower depression scores.
H2b: (Subjects scoring lower in hardiness will have higher depression scores.
H3: Burnojut scores will vary depending on level of depression.
H3a: Subjects scoring higher in burnout will have higher depression scores.
H3b: Subjects scoring lower in burnout will have lower depression scores.
H4: Depression scores will vary depending on the subject's response mode to burnout.
H4a: Subjects with a passive response mode to
burnout will have higher depression scores.
H4b: Subjects with an active response mode to
burnout will have lower depression scores.
1


1
H5: Hardiness scores will vary in accordance with a subject's response mode to burnout.
I
H5a: Hardiness scores will be higher for subjects with an active response mode to burnout.
H5b: Hardiness scores will be lower for subjects with a passive response mode to burnout.
|
H6: Burnopt scores will vary in accordance with a
subject's response mode to burnout.
i .
H6a: Burnout scores will be higher for subjects with a passive response mode to burnout.
i
H6b: Burnout scores will be lower for subjects with an active response mode to burnout.
H7: Demographic data will not contribute to the
explained variance in burnout scores, hardiness scores, or response modes to burnout.
I
I
r.
\
(
i
69
l


CHAPTER THREE
RESEARCH METHODOLOGY
Overview
This study tested hypothesized relationships among
. i'
burnout, depression, selected personality characteristics, demographic variables, and two response
t
modes to burnout. The data were collected exclusively
1
for this sjtudy. The survey questionnaire utilized all, or part, of four standardized instruments (Maslach Burnout Inyentory, Beck Depression Inventory, Work Environment Scale, and the Personal Views Survey) and included aj number of questions about demographic factors. (See Appendix A for samples of these instruments.)
Since] this study is exploratory and descriptive in nature, the method of observation used was survey research; j cross-sectional data were collected. Survey research was also chosen because of its economy and
efficiency. In order to achieve the specific goals of
(
this study!, quantitative techniques were employed. In the intere'st of time, qualitative techniques were not
j
used to supplement the quantitative data. The selection and characteristics of the population, data collection
i


I
procedures; instrumentation, and data analysis are
I
\
described below.
Population and Sample
i
!
The sample used for this research consisted of 158 registered! nurses from two private, non-profit hospitals
s
in a largfe metropolitan area in the Rocky Mountain
I
Region. Both hospitals provide a full range of emergency and non-emjergency services. Both hospitals are large;
i
Hospital Al employs 1800 people, and Hospital B has a total of 2032 employees.
The data were collected from registered nurses
I
i #
working full-time (defined as 40 hours per week) who were in staff positions with no administrative
responsibilities. The subject group was defined in this
!
way for two reasons. First, since it is probable that working part-time decreases ones chances of experiencing
i
burnout, only nurses working a full work week were included in this study. Unfortunately this created sampling problems, since it was discovered during the
i
process ofj' data collection that both hospitals consider 36 hours per week to be a full-time work schedule. This was particularly a problem regarding critical care
f
nurses, since most inpatient critical care nurses only I 71
i


worked a 36-hour work week. These sampling issues will be discussed in greater length in Chapters Four and Five.
The second reason the subject group was defined in this way relates to the staff nurse issue. It was decided that only staff nurses with no administrative responsibilities would be included in the study, since it is reasonable to expect that nurses with only clinical duties might experience different types of stress than nurses with clinical and/or administrative duties. Any individuals defined as staff nurses who had any degree of administrative responsibility beyond being charge nurses (e.g.f assistant head nurses) were eliminated from the study.
The sample included nurses working in both inpatient and outpatient settings in a wide variety of specialty areas. With the permission of nursing administration at each hospital, nurses who met the study criteria were contacted in person while on duty. The purpose of the study was explained, and it was also explained that participants in the study would receive the results of their scores and an overview of the outcome of the study if they wished. Return rates were 69 percent at Hospital A and 65 percent at Hospital B, yielding an overall return rate of 67 percent.
72


Characteristics of the Sample
Table 3.1 presents selected characteristics of the sample. Analysis of the respondents' characteristics reveals that the average age was 39 years; 94 percent were Caucasian; 2 percent were black; 2 percent were Asian; and 2 percent were Hispanic or Native American. Forty-five percent of the respondents were married; and 42 percent had at least one child currently living at home. Thirty-two percent of the subjects had completed an associate degree in nursing; 32 percent had received a diploma in nursing; 33 percent had a bachelor's degree in nursing; and 2 percent had received master's degrees in nursing. The average length of experience in nursing was 14 years; and the average length of time employed at their current hospital was 8 years.
73


Table 3.1. Sample Characteristics.
Average Age 39.05
(S.D. = 9 .94)
Gender 94% female
Married 45%
Number of Children Living at Home
None 55%
One or more 42% Type of Nursing Unit OB/GYN
Educational Level Labor & Delivery
Associate Degree 32% Nursery
Diploma 32% Neonatal ICU
Bachelor's Degree 33% Recovery Room
Master's Degree 2% Operating Room
or higher Emergency Room Pediatrics
Years of Nursing Experience ICU/ecu
(frequency) Medical/Surgical
One Year or Less 7 Outpatient Clinic
2 to 5 Years 26 Telemetry
6 to 10 Years 24 Neurology/
11 to 15 Years 26 Neurosurgery
16 to 20 Years 18 Float
21 to 25 Years 17
26 Years or More 16 Shift (frequency) 7-3
Tenure in Organization 3-11
(frequency) 11-7
One Year or Less 27 7am-7pm
2 to 5 Years 31 7pm-7am
6 to 10 Years 36 Rotating
11 to 15 Years 22 Other
16 to 20 Years 9
21 Years or More 8
Race (frequency)
Caucasian 149
Black 3
Asian 3
Hispanic/Native 2
American
3
12
2
4
7
19
14
4
5
54
7
13
6
8
45
17
14
12
12
21
14


Some data are available to make comparisons between this group of nurses and other nurses in Colorado.
Survey data gathered by the Colorado State Board of Nursing (1991) and the Colorado Nurses Association (1988) relating to gender, race, and education level show figures comparable to those found in this study (see Appendix B for details). Since these figures relate to nurses working in all types of settings, these data lend some support for the generalizability of these findings to nurses working outside of hospital settings.
These findings are supported by the observations of this researcher, based on 23 years of experience as a nurse or as a consultant to nursing groups in hospital settings. Areas of experience include both inpatient and outpatient settings; both critical care and non-critical care nursing units; both staff nurse and administrative positions; in public and private for-profit and nonprofit hospitals, in four different states. Based on this experience, I would argue that the subjects in this study do not differ significantly from other hospital-based nurses in the United States. Therefore, regarding these factors, I believe that it is reasonable to generalize the findings of this study from the sample studied here to the general population of hospital-based nurses.
75


Measures
The questionnaire used in this study consisted of four standardized instruments and a demographic data sheet. The demographic questions sought to determine respondent age, sex, marital status, type of nursing education, race, number of children currently living at home, length of experience as a nurse, length of time employed in her/his current hospital, the nursing unit on which s/he worked, and the shift primarily worked. Following is a description of the four standardized instruments used in this study.
Maslach Burnout Inventory
Although a number of instruments have been developed for the purpose of measuring burnout, a survey of the literature clearly indicates that the tool used most consistently in burnout research is the Maslach Burnout Inventory (MBI) developed by Maslach and Jackson (1981a). Based on their extensive exploratory research examining the burnout syndrome, Maslach and Jackson postulate that burnout is comprised of three dimensions: emotional exhaustion, depersonalization, and personal accomplishment. The MBI is designed to measure these three dimensions, each of which is measured by a separate subscale using a total of 22 questions. Questions are
76


written in the form of statements about personal feelings or attitudes (e.g., I feel emotionally drained from my work; I feel very energetic). Respondents rate each statement on a scale of 0-6 depending on how often they feel that way (e.g.f 0 = never; 6 = every day).
As conceptualized by Maslach and Jackson (1981a) burnout is a continuous variable that ranges from low to high degrees of experienced feeling. Higher scores for emotional exhaustion and depersonalization indicate more negative burnout effects. Lower scores for personal accomplishment indicate more negative burnout effects.
For this study scores were computed for the three burnout subscales and a total burnout score was determined by summing the subscale scores with personal accomplishment reversed.
Maslach and Jackson (1981b) have reported considerable evidence supporting the reliability and validity o'f the MBI. Using Cronbach's alpha (n=1316) the three subscales of the MBI have demonstrated a high level of internal consistency with each other. The reliability coefficients were .90 for emotional exhaustion, .79 for depersonalization, and .71 for personal accomplishment (Maslach & Jackson, 1981a). Test-retest reliabilities for these scales ranged from
77


0.60 to 0.80 for one sample (n=53) and from 0.54 to 0.60 for a second sample (n=248) (Maslach & Jackson, 1981a).
Convergent validity for the MBI was demonstrated by correlating scores with behavioral ratings, by correlating scores with the presence of certain job characteristics suspected to contribute to burnout (e.g., heavy caseload), and by correlating scores with outcomes hypothesized to be related to burnout (e.g., desire to leave job) (Maslach & Jackson, 1981a). Discriminant validity of the MBI was obtained by distinguishing it from other psychological constructs that might be confounded with burnout (e.g., dissatisfaction with one's job) (Maslach & Jackson, 1981a). Maslach and Jackson (1981a) also provide evidence that the inventory is not subject to social desirability response set distortion.
A number of studies have supported the claims made for the MBI by its designers (Golemhiewski &
Munzendrider, 1981; Iwanicki & Schwab, 1981; Belcastro, Gold, & Hays, 1983; Golembiewski, Munzenrider, & Carter, 1983; Stout & Williams, 1983; Meier, 1984; Rafferty, Lemkau, Purdy, & Rudisill, 1986; Green & Walkey, 1988; Lahoz & Mason, 1989).
Beck Depression Inventory
Developed in 1961, the Beck Depression Inventory (BDI) has become one of the most widely accepted
78


instruments in clinical psychology and psychiatry for assessing depression in both psychiatric patients and in normal populations (Steer, Beck, & Garrison, 1985). The Center for Cognitive Therapy (CCT) of the University of Pennsylvania Medical School, which serves as the clearinghouse for the dissemination of the BDI, reports that the BDI has been used in more than 500 research
I
studies and has been translated into a variety of languages (Steer et al., 1985). The BDI has been called the "touchstone against which to compare assessments derived from other measures" (Steer et al., 1985).
The BDI consists of 21 clinically-derived questions designed to assess the severity of depression in adolescents and adults. The questions on the inventory were selected to represent depressive symptoms (Beck, 1972) with each question consisting of four statements listed in order of severity (e.g., I don't feel disappointed in myself ... I hate myself).
The BDI may be used in an interviewer-assisted manner or self-administered. The self-administered version used in this study has been in use since 1978 and has been found to have psychometric properties comparable to the original BDI (Beck & Steer, 1984). The
psychometric properties of the BDI have been tested
. (
extensively by the CCT. These studies have demonstrated
79


high reliability and validity in both clinical and nonclinical populations. Recent studies of the internal consistency of the EDI using Cronbach's alpha report mean coefficient alphas of 0.85 for the first group of studies and 0.86 for the second group (Beck & Steer,
1984).
Internal consistency has also been evaluated using split-half reliability. The Pearson correlation between the odd and even categories yielded a reliability coefficient of 0.86 (Beck & Beamesderfer, 1974).
The BDI has been shown to have high inter-rater reliability and concurrent validity. The BDI has also been found to correlate with other measures of depression with correlations between scales ranging from 0.69 to 0.75 (Beck & Beasmesderfer, 1974). The construct validity of the BDI has been supported by a number of studies in which the BDI has been used as the criterion measure (Beck & Beamesderfer, 1974).
The BDI has demonstrated a high discriminant validity with a correlation of 0.72 between the BDI and clinical Ratings of depression and a correlation of 0.14 between the BDI and clinical ratings of anxiety (Beck, 1967).
Other studies with samples of both psychiatrically diagnosed populations and normal populations have
80


reviewed the psychometric properties of the BDI and have supported its claims for reliability and validity (Bumberry, Oliver, & McClure, 1978; Glazer, Clarkin, & Hunt, 1981; Edwards et al., 1984; Lips & Ng, 1985; Steer, Beck, Riskind, & Brown, 1986).
Hardiness Instrument
The personality construct of hardiness was measured using the Personal Views Survey (PVS). Originally developed by Kobasa in 1977, the PVS has gone through a number of modifications. The first form of the PVS employed six scales from existing instruments to measure hardiness. The questions measuring commitment were taken from the Alienation from Work and Alienation from Self scales of the Alienation Test (Maddi, Kobasa, & Hoover, 1979). Control was measured using the External Locus of Control scale (Rotter, Seeman, & Liverant, 1962) and the Powerlessness Scale (Maddi, Kobasa, & Hoover, 1979). Challenge was measured using the Security Scale of the California Life Goals Evaluation Schedules (Hahn, 1966) and the Cognitive Structure Scale of the Personality Research Form (Jackson, 1974). Each of these scales has known and adequate reliability and validity (Kobasa & Maddi, 1982).
Kobasa and Maddi (1982) report that in their samples to date, the distribution of hardiness composite
81


scores has been somewhat skewed to the right. For the original versions of the PVS, estimates of internal consistency have been in the 80's and an estimate of stability over a five-year period was .61 (Kobasa &
Maddi, 1982).
More recently hardiness has been measured using a 36-item revised version of the PVS. The revised PVS consists of a subset of the original scale items and has been found to correlate with the full scales at 0.89 (Kobasa, as quoted in Allred & Smith, 1989). Kobasa also reported to Allred and Smith (1989) that all major findings of previous hardiness studies were replicated when the revised PVS was substituted for the full scale in her earlier samples. In a study of the psychometric properties of the PVS, a correlation of 0.76 between the original long form and the 36-item revised PVS was reported (Hull, Van Treuren, & Virnelli, 1987). Adequate reliability and validity for the 36-item PVS has also been reported by Lambert, Lambert, Klipple, and Mewshaw (1989).
The most recent form of the PVS, consisting of 50 questions, was used in this study. As mentioned in Chapter Two, one of the criticisms of hardiness research was the use of negative wording in the hardiness tool.
The third generation form of the PVS used in this study
82


Full Text

PAGE 1

... I I I THE BURNOUT MAZE: AN EXPLORATION OF THE INTERRELATIONSHIPS OF BURNOUT, HARDINESS, DEPRESSION, RESPONSE MODE TO BURNOUT, AND DEMOGRAPHIC VARIABLES 1 .. I I _by Betty Matthews Clarke J I .B.S., Colorado Women's College, 1975 I -M.;S.N., Medical College of Georgia, 1978 I I A thesis submitted to the I university of the Graduate School of the of Colorado in partial fulfillment 9f the requirements for the degree of I I I I I Doctor of Philosophy Graduate School of Public Affairs 1991 f. ,_ F ,..:;, .... 4:_...,.._..,,:,..,."J

PAGE 2

' Clarke, Betty Matthews (Ph.D., Public Administration) I The Burnout Maze: An Exploration of the of Burnout, Hardiness, Response Mode to Burnout, and I I Var1ables Thesis by Associate Professor Mark Emmert l The of stress known as burnout pervades a wide variety of 1work settings. The many negative outcomes of burnout, sU:ch as high absenteeism and turnover, have stimulated ja great deal of research and conjecture about this However, the knowledge needed to prevent or effectively!: treat burnout is still incomplete. The qu;estions that this study addressed relate to the role o'f) depression in burnout, the possible buffering effects betkeen stress and burnout of selected personalityl characteristics, and the issue of a possible I response mode to burnout. This research study was I designed to1 examine the relationships between burnout I (using the Maslach Burnout Inventory), the personality I construct (using the so-item Personal Views I l Survey), depression (using the Beck Depression I Inventory),,and response mode to burnout (using the I

PAGE 3

I involvement, autonomy, and task orientation subscales of the Work EAvironment Scale) I Relationships between and among these variables were I examined looking not only at composite or total scores, but also at the subscales of burnout, hardiness, and I response mode. Subjects included staff nurses (response rate of 6.7%: n=157) working full-time in two large, l full-service hospitals in the Rocky 1 Mountain region. ) The findings of.this study can be briefly summarized as follows:i (1) Individuals higher in hardiness will experience 1ess burnout and less depression. (2) I Subjects experiencing burnout are more likely to also experience .depression. l (3) Burnout victims with an active resppnse mode to burnout have lower levels of burnout, higher levels of hardiness, and are less likely to experienbe depression. (4) Depression and the passive I response to burnout appear to be closely related. (5) The hardiness dimension of commitment has the most explanatory value for burnout and depression. (6) Questions raised by other researchers about the viability ' of the dimension of hardiness were supported in this study. (7) Overall, demographic variables were not ) related to the other study variables. v

PAGE 4

A model of burnout is suggested as a possible theoretical umbrella to encompass I the constructs of burnout, hardiness, depression, and response to burnout. Suggestions are made for future utilizing both longitudinal and qualitative designs. The form and content of this abstract are approved. I recommend fts publication. Mark Emmert vi

PAGE 5

BURNOUT MAZE: AN EXPLORATION OF THE I OF BURNOUT, HARDINESS, DEPRESSION, RESPONSE.1 MODE TO BURNOUT, AND DEMOGRAPHIC VARIABLES by Betty Matthews Clarke B.S., Colorado Women's College, 1975 I M.S.N., Medical College of Georgia, 1978 A thesis submitted to the Faculty of the Graduate School of the University of Colorado in partial fulfillment of the requirements for the degree of Doctor of Philosophy I Graduate School of Public Affairs 1991

PAGE 6

. i991 by Betty M. Clarke All rights reserved. '

PAGE 7

I This thesis for the Doctor of Philosophy I I degree by Betty Matthews Clarke has been approved for the Graduate School of Public Affairs by .' Mark A. Emmert c. Buechner -8"-q I Date

PAGE 8

Clarke, Betty Matthews (Ph.D., Public Administration) The Maze: An Exploration of the of Burnout, Hardiness, Response Mode to Burnout, and I Variables I Thesis directed by Associate Professor Mark Emmert The of stress known as burnout pervades a wide variety of jwork settings. The many negative outcomes of : burnout, as high absenteeism and turnover, have stimulated Ia great deal of research and conjecture about this However, the knowledge needed to prevent or effectivelyj treat burnout is still incomplete. The that this study addressed relate to the role depression in burnout, the possible buffering l effects between stress and burnout of selected personality! characteristics, and the issue of a possible l response moae to burnout. This research study was i designed to! examine the relationships between burnout I (using the Maslach Burnout Inventory), the personality l construct (using the 50-item Personal Views I Survey), depression (using the Beck Depression l Inventory),1and response mode to burnout (using the

PAGE 9

I involvement, autonomy, and task orientation subscales of I the Work Environment Scale). I I Relationships between and among these variables were I I examined looking not only at composite or total scores, I but also at the subscales of burnout, hardiness, and response mqde. Subjects included staff nurses (response rate of 67%; n=157) working full-time in two large, I full-service hospitals in the Rocky Mountain The of this study can be briefly summarized as follows:! (1) Individuals higher in hardiness will experience iless burnout and less depression. (2) Subjects eJperiencing burnout are more likely to also I I exper1ence :depress1on. (3) Burnout victims with an I active response mode to burnout have lower levels of I burnout, hfgher levels of hardiness, and are less likely : I to exper1ence depression. (4) Depression and the passive I response mode to burnout appear to be closely related. I (5) The hardiness dimension of commitment has the most ,I explanatory; value I Questions raised for burnout and depression. (6) by other researchers about the viability of the dimension of hardiness were supported in this study.; (7) Overall, demographic variables were not related to the other study variables. I v

PAGE 10

I I I I A self-eff1cacy model of burnout is suggested as a I possible integrative theoretical umbrella to encompass I the constructs of burnout, hardiness, depression, and I response mode to burnout. Suggestions are made for I future research utilizing both longitudinal and I qualitative designs. I The form arld content of this abstract are approved. I I recommend publication. i Signed ___ MarkEmmert vi

PAGE 11

This is dedicated to my husband, Steve, '" whose support, encouragement, strength, and love made the j this dissertation possible. And, to my I daughters, Ashley and Taylor, whose arrivals during the \ course I t of proJect helped me to keep my perspec 1ve and to remember what is truly important in life.

PAGE 12

CONTENTS I F1gures xii xiii CHAPTER 1. INTRODUCTION 1 .. Purpose of the Study 8 ., Significance of the Study 9 2. I Implications of the Study Definition of Terms Burnout Hardiness A Brief Overview of the Study General Limitations of the Study Organization of Chapters LITERATURE REVIEW The Burnout Syndrome Versus Work Stress Sources of Burnout 11 14 14 17 20 21 23 25 26 27 The Person-Environment Fit Model 28 Personal Sources & Moderators of Burnout 31 Environmental Characteristics 43 outcomes 51

PAGE 13

3. 4. Physical Outcomes Psychological Outcomes Effects of Burnout on Others I Phases of Burnout I I Eight Phase Model of Burnout I Active & Passive Response Models to Burnout I I $ummary Research Questions I' METHODOLOGY Overview ; Ropulat1on and Sample Characteristics of the Sample I Measures Maslach Burnout Inventory Beck Depression Inventory Hardiness Instrument Work Environment Scale I Method of Analysis I FINDINGS OF THE STUDY I l gverview Section One Data Comparisons Between Hospital A and Hospital B 52 52 53 56 57 59 61 67 70 70 71 73 76 76 78 81 83 . 85 87 87 91 91 Hospital A versus Hospital B 92 Hospital A versus Hospital B: Non-critical Care Nurses Only 93 ix

PAGE 14

5. J Hospital A versus Hospital B: Critical Care Nurses Only Section Two . . . . Support for Hypothesis One Support for Hypothesis Two Support for Hypothesis Three Support for Hypothesis Four Support for Hypothesis Five Support for Hypothesis Six Support for Hypothesis Seven Section Three . . . . Regression Analysis with Total Burnout as the . . 94 96 96 99 100 100 102 104 106 111 Dependent Variable 112 Regression Analysis with Emotional Exhaustion as the Dependent Variable 115 Regression Analysis with Depersonalization as the Dependent Variable 116 Regression Analysis with Personal Accomplishment as the Dependent Variable . 118 Regression Analysis with Depression as the Dependent Variable Summary 119 121 CONCLUSIONS OF THE STUDY i 124 Summary and Discussion of Findings 124 Burnout and Hardiness 125 Commitment: The Key Variable 129 X

PAGE 15

APPENDIX Response Mode to Burnout 132 Demographic Variables 136 Challenge: The Problematic Variable . . . . . 137 A Self-efficiency Model of Burnout 139 Person-Environment Fit versus Reciprocal Determinism 150 The Self-efficiency Model of Burnout and the Profession of Nursing 151 Summary 163 Implications . . . . . 164 Future Research 166 Closing Comments 169 A. QUESTIONNAIRES AND COVER LETTER . 172 B. DEMOGRAPHIC DATA COMPARISONS BETWEEN THIS STUDY AND DATA FROM THE COLORADO STATE BOARD OF NURSING AND THE COLORADO NURSES ASSOCIATION 185 I c. T-TEST & CHI-SQUARE RESULTS 186 D. PEARSON CORRELATION COEFFICIENTS 191 E. DEPRESSION AND LEARNED HELPLESSNESS 192 Depression 192 Dearned Helplessness 197 Learned Helplessness and Depression . 199 F. LEARNING THEORY AND SELF-EFFICACY xi 201 205

PAGE 16

FIGURES Figure 5.1 Interactive Effects of Perceived Self-efficiency and Expected Envirdnmental Outcomes 143 I 5.2 Schematic Representation of Two Conceptions of Interaction 151 l xii

PAGE 17

TABLES Table 2.1 Eight!Phase Model of Burnout 58 2.2 2.3 3.1 4.1 4.2 4.3 4.4 4.5 4.6 4.7 4.8 4.9 4.10 Personal and Environmental Variables and Their with Burnout Research Questions l Characteristics j Reseaich Questions and Study Results T-test Results Between Hospital A and Hdspital B T-test. Results Hospital A versus Hospital B: Critical Care Nurses Only I Pearson Correlat1on Coeff1c1ents for Burnout and Internal Consistency of the 36-item Hardiness Short Form Subscales Consistency of the Hardiness 50-item Short Form Subscales Pearsdn Correlation Coefficients for Depres:sion and Hardiness Correlation Coefficients for Burnout 66 68 74 90 92 95 96 98 99 99 and Depression 100 l . . Pearson Correlat1on Coeff1c1ents for Depress1on and Rfisponse Mode to Burnout and for Depres!sion and Work Environment Scales 101 Pearson Correlation Coefficients for Hardiness and thk Active Response Mode to Burnout and for Hardiness and the Work Environment Subscales 104

PAGE 18

4o11 4o12 4o13 4o14 4o15 4o16 I I Pearsbn Correlation Coefficients and tfie Response Mode to Burnout Envir9nment Scales o o o o o o o I for Burnout. and the Work 0 106 T-test Results for Critical Care Versus Non Care Nurses at Hospitals A and B o o 107 Analysis with Total Burnout as the Depen4ent Variable o o o o o o o o o o o o o o 113 I Forced Regression with Total Burnout as the Depenqent Variable with Hospital A Nurses Only o o o o o o o o o o o o o o o o o 114 I : Forceq Regression with Total Burnout as the Depenqent Variable with Hospital B Nursee;; Only o o o o o o o o o o o o o o o o o 115 RegreJsion Analysis with Emotional Exhaustion as Dependent Variable o o o o o o o o 115 4 o17 RegreJ'sion Analysis with Depersonalization as Dependent Variable o o o o o o o o o o 117 4o18 Analysis with Personal Accomplishment as the Dependent Variable o o o 119 I 4o19 Analysis with Depression as Dependent Variable o o o o o o o o o o 120 xiv

PAGE 19

t CHAPTER ONE INTRODUCTION l An overstretched rubber band a rag doll with ) I half the gone meeting a brick wall I caught on a railroad track with a freight train bearing down f a prisoner in a glass box feet and hands tied ldrowning in dust bleeding to death slowly ) an overloaded plane that can't get off the ground. workshop These are some of t' 0 t d par 1c1pan s use I' the statements one group of to describe their feelings of burnout (RY!erson & Marks, 1981). These vivid burnout I images are !typical of the ways in which human service I professionct:ls characterize their experiences of burnout. These give some sense of the acute pain .and distress victims experience. Burnoul is a type of job-related The problem of JOb-related stress has been d1scussed for I decades, indications are that occupational stress I continues to grow rather than decline. Stress on the job affects orglnizational effectiveness through absenteeism, turnover, productivity, and increased medical costs for erployers. Legal costs have also risen as

PAGE 20

employees file record numbers of stress-related workers' compensation claims. In the United States the total i. cost of job-related stress has been estimated to be as high as ten percent of the gross national product I (Ivancevich & Matteson, 1980). Job stress also exacts a toll on affected employees. These human costs are less easy to quantify but are alarming, The individual, organizational, and societal costs l of job stress have stimulated considerable activity on the part researchers whoseek to identify the causes of job The ultimate goal is to prevent the negative mental and physical effects of occupational stress on the employee. The term "burnout" was first applied to the issue of occupational stress in 1974 by Freudenberger. Freudenberger used the term "burnout" to describe the physical and psychological effects on individuals working in the free clinic movement. The term "burnout" had considerable intuitive appeal and soon became the catchword of the 1970s and 1980s to describe a wide variety of stress-related entities. Of the many books and articles written about burnout, most are descriptive and anecdotal; and only a small percentage are based on empirical research. Savicki and 2

PAGE 21

I Cooley (1983) point out that only approximately 25 l percent oflthe articles in the burnout literature provide data to support their burnout conceptions. I I This lack of scientific corroboration of the concept I of burnoutjhas led to criticisms from many corners. I Typical of1the criticisms are those of Eiseidel and Tully I (1981). They cite a lack of operational and conceptual I of burnout, the lack of replications and extensions lof previous research, and the over emphasis on the practidal aspects of burnout to the detriment of the scientific lelements of burnout. In short, Eiseidel and I Tully desc:r!-ibe the many individual and organizational !of burnout as an "unwieldy universe." I A consliderable amount has been written about nurses I being one of professionals that includes many I victims of This raises immediate and practical I concerns a number of reasons. The States is currently facing a nursing j shortage is rapidly reaching crisis proportions. A l 1986 surveyj (American Hospital Association, 1987) noted that the vacancy rate for registered nurses in hospitals I I I more than doubled between 1985 and 1986. Some estimates I I predict thaf the shortage of baccalaureate prepared nurses willlbe about 390,000 by 1990 and about 578,000 by I the year 2000 (American Nurses Association, 1988). I 3

PAGE 22

I Although nursing shortages have occurred in the past I I in a cycli6al fashion, the current shortage is different and more serious. It involves all types of nurses in all kinds of hJspitals and in all regions of the country (American Hospital Association, 1987). This t shortage occurs at a time when hospitals more I than ever rieed skilled and highly-educated nurses to manage sophisticated technology, to make critical dJcisions, and to care for a higher proportion \ of patients with greater acuity and complex needs. The shortage aiso occurs at a time when the demand for health care contirtues to rise because of an increase in the i elderly an increased availability of health ' I 1.nsurance, and rising incomes (Tregarthen, 1987). II There jare a number of causes for the existing shortage of nurses. A 1988 report (American Nurses Associationi) cites the major factors affecting the supply ; of nurses ars follows: declining enrollments and graduations' at schools of nursing, increased options and opportunitibs for women outside of nursing, poor working I conditions,! inadequate pay, lack of respect for nursing, and the poor image of nursing. "The medical community can no longer afford to chew up its nurses and spit them out" (Gorman, 1988, p.78). nurses have been treated as a disposable 4

PAGE 23

commodity. "The nursing profession has a supply-side I tradition of generating a high flow of highly motivated nurses and ,1 not worrying about retention" (Will, 1988, p.80). ThJ current conditions of shortage demand that this must stop. Measures must be taken not only to make the profession of nursing more attractive to men and women to boost nursing school enrollments, but I immediate measures must also be taken to stem the increasing !tide of nurses leaving the profession. Among;the issues that must be faced if nursing retention to be substantially improved is the problem \ of burnout in the nursing profession. As one of the key I people-helping professions, nursing has characteristics that make a prime target for burnout. Most young nurses begi1n their nursing practice with a high degree of idealism and unrealistic expectations. This is often based on their original ideas of helping others which I, mot1vated them to enter nursing in the first place. This interest in:helping others as well as the perceptions of personal impact are reinforced during the socialization process occurs in nursing schools. Upon entering l employment,! new graduates are often faced with a reality quite from their expectations. "The pain of the world no longer an abstract philosophical idea but 5 .

PAGE 24

knocks daily at one's door in concrete self-presentations of sufferiJg individuals" (Pruyser, 1984, p. 357). are often expected to, and frequently expect themselvesjto, be able to do the impossible in providing I care and comfort for their patients. Nurses perform I . tasks that;are frequently v1.ewed as dl.stasteful by others. Providing nursing care brings nurses into intimate contact with the human body, a body that may be l ,. diseased arid/or deformed. Nurses are required to meet not only physical needs of their patients but also their patients' emotional needs as well as those of the patients' families and friends. In the daily exercise of herjhis duties, the nurse not only finds the physical demands of !providing nursing care but also the demands I for compasE!ion, sympathy, and caring. I These 'myriad demands are placed on the nurse in an which often provides few resources for the nurse to herjhis emotional and physical stores. I Support may not be available from colleagues because nurses stoically feel that as professionals, they should be able to cope; and also they may expect their fellqw nurses to cope with individual problems without aiJ from others. Also, disincentives to disclose feelings concerns may exist because nursing is viewed by some as !a profession that "spends far too much time 6

PAGE 25

policing its members and too little energy supporting them" (Storlie, 1979, p. 2111). This lack of mutual support is compounded by the absence of;support from other sources. In one study of nurses the second most frequent reason stated for leaving nursing treatment nurses received from physicians and administrators (Sigardson, 1982). This incentive to leave the nursing profession precedes dissatisfaction with pay and benefits and is outranked only by concerns I with understaffing and working long hours. The practice of nursing often takes place in institutions that may operate via bureaucratic rules and regulations which constrain the way nurses care for their patients. 1Nurses often risk personal injury and physical illness (Hay & Oken, 1972). In addition, the problems of understaffing, long working hours, frequent (undesired) I overtime, rotating shifts, lack of supplies, problems of getting needed cooperation from other departments, and the necessity of spending time on non-nursing functions \ are endemic to nursing. Considering the list of issues facing nursing today, it is not surprising that nurses frequently complain of being burne'd out and that burnout studies using nurses as subjects high levels of experienced burnout. 7

PAGE 26

Purpose of the Study It islthe purpose of this investigation to help clarify of the current theories about the role that personalitt characteristics and depression play in the development and progression of burnout and to further I examine two suggested response modes to burnout. In loJking at the role of personality i the study will examine the relationship I between and "hardiness," a term used to describe I I a constellation of personality characteristics that have i been found!in some studies to serve as a moderator between stDess and illness and stress and burnout. I There has been considerable speculation, although little through research, about the role depression lplays in burnout. This study will specifically examine the degree to which depression I correlates :'with the subscales of burnout, the of hardiness, and the two response modes to burnout. I I I It is 'also the purpose of this study to determine which, if Jny, demographic variables correlate significantily with burnout. The objectives of this study include not only an attempt to !further the understanding of the burnout I phenomena,. but also to be able to suggest appropriate 8

PAGE 27

for victims of burnout, and to suggest means of identifying those who might have a propensity toward bur:Qout. Significance of the Study i The of the burnout syndrome has captured the interest and imaginations of many researchers since it I was first introduced in the 1970's. As a result of the popular appeal of the term burnout, it became a "vague verbal tent." covering a number of phenomenal areas (Golembiewski & Munzenrider, 1988b, p. 8). Entities such as alienation, free-floating anxiety, and depression were put under the same conceptual tent leading to a confusion of constructs. I Various authors came up with shopping lists of sources an4 causes of burnout covering emotional, physical, and environmental spheres. Conspicuously absent from the literature were studies that could legitimately establish causation and validate any of these lists. There ;were a plethora of studies and articles describing the burnout syndrome and offering prescriptions for its amelioration. Unfortunately, the treatments suggested were rarely supported by empirical 9

PAGE 28

I research solid research conclusions (Savicki & I i Cooley, 1983). The research completed in this study will add to the I body of it will J kndwledge about burnout in several ways. I I. I I I help 1dent1fy the role that personal1ty characteristics play in the propensity of some First, individual, to succumb to burnout. Second, it will help clarify part that depression plays in burnout. Third, it will provide additional information about the different Jays in which individuals respond to burnout. And, fourth, it will make a contribution toward ending the concerning the role demographic variables play in buJnout. I Burnout pervades a wide variety of work settings. The knowledge gained in this research may help l administrat,ors in public, private, and non-profit I institutioris make decisions in training, work assignment, I continuing ieducation, and employee counseling that might I. both help prevent and help amel1orate burnout. I I At individual level, this and other burnout I research can have great significance for enhancing the career of human service professionals. Prior I I research has clearly shown a positive correlation between 1 burnout and a number of negative outcomes such as alcohol I abuse, illness, marital conflict, suicide 10

PAGE 29

(Maslach, i976), physical symptoms, absenteeism, and low energy levlls (Golembiewski, Munzenrider, & Stevenson, 1986). gained through burnout research which i helps prevent and treat burnout should also provide I relief from burnout related problems such as those mentioned Implications of the study gained in this study,has implications in I many areas.! First are the implications for patient care. I A major concern about burnout is the indirect effects it can have on the recipients of services provided by I victims of!burnout (see Chapter Two). Decreasing the incidence of burnout in helping professionals can improve the care that patients receive. For example, care givers I will be likely to withdraw from clients and treat them in depersonalized ways. Care givers who are not I suffering (rom emotional exhaustion will be able to give I more to thJir clients, particularly at the psychological J level. As ,care givers experience higher levels of personal a9complishment, they experience a renewed commitment ito their work. The need for highly qualified nurses to function at a high level has never been greater th,p it is now when issues of increasingly 11

PAGE 30

sophisticated technology and higher patient acuity are faced on a !:daily basis. decreasing burnout also has implications for health costs that are increasing at an alarming rate. the quality of patient care is not the only factor involved in the initiation of malpractice suits, it probably can be assumed that an improvement in I patient ca*e would have some positive effect on the rate at which suits are filed. A decrease in malpracticJ suits has implications for decreasing direct costs for insurance to health care practitioners and health care institutions and should ultimately impact the I overall cost of the provision of health care. Victims of burnout have been found to have higher rates of absenteeism and turnover. The costs related to I both of issues are well known to health care Programs successful in decreasing and turnover should have a direct positive I effect on decreasing overall health care costs. Third,, decreasing burnout has implications for enhancing. lives of not only the victims of burnout I but also their friends and families. Stress related to burnout whi'ch is not resolved at work is often I I resurrected at home. I I 12

PAGE 31

I I I Fourth, the prevention and treatment of burnout has for the practice of nursing. Issues of l retention and absenteeism have already been discussed. In view of l.the need for highly skilled nurses, the issue of nursing!recruitment is of equal importance. Nursing school enrollments are down. If ways are not found to make more attractive as a profession, the nursing shortage t6at is already being experienced nationwide l .. will become even more alarming. This is a multi-faceted problem will not be solved with easy remedies. I However, with the issues of burnout in nursing would be a .;major step in the right direction. ,.: issues of burnout in nursing also has I implications for nursing education. It would be fruitful to incorpoiate new knowledge about how to predict, I. identify, and treat burnout in the education of new nurses ;:and in the continuing education of nurses already Information obtained in this study might also!offer help in counseling nurses regarding I areas of I Although the focus of this study is on knowledge Jbtained has implications for any nurses, human service professional. This is of prime importance at a time when 1 i our re 1.ance on human service professionals is growing, in the public sector. In recent decades we I 13

PAGE 32

' have turned to public agencies to provide many of thl functions previously provided by one's I family, chJrch, and neighborhood. The hospitals, social welfare and mental health agencies providing I these services are staffed by human service professionals I I I at h1gh r1sk for burnout (Cherniss, 1980c). I obtained from this study also has I I for management theory. When given an l adequate b9dy of knowledge, managers can play a key role in solve the problem of burnout in human service pr6fessionals. A more developed understanding of burnout can affect the way in which human service workers l might moreleffectively be assigned, educated, supported, i and evaluated. l I Burnout i Definition of Terms In the midst of competing models and definitional j ambiguity of the burnout concept, there is a core Qf I I who approach the burnout construct with rigor and Among this central group of burnout I researchers, the concept proffered by Maslach and Jackson I I is the onelmost frequently adopted. I I As def1ned by Maslach and Jackson (1981b), burnout is a of emotional exhaustion and cynicism that I 14

PAGE 33

l I I l occurs frequently among individuals who do 'people work' of some kind" (p. 100). The stress of burnout results from the interaction between a helper and a I recipient. Burnout as conceptualized by Maslach and Jackson made up of three elements: emotional exhaustion; depersonalization, and reduced personal I accomplishment. I exhaustion refers to the depletion of an I: individualfs emotional resources coupled with a feeling f that one has nothing left to .give. The helper gets over involved and feels overwhelmed by the demands placed by others. This condition of emotional : I exhaustionjwas described by one victim as "compassion fatigue" 1982a, p. 31). This has also been described.Is "professional autism," a state in which "mandated .. ictions are carried out, but the emotional investment:that transforms a task into an art form is missing" (Storlie, 1979, p. 2108). i The sTcond aspect of the burnout syndrome is I. depersonalization which results in the helper putting distance b+tween her/himself and recipients. I j is characterized by a detached, : r callous, response to recipients. D I 1 t b d t f epersona 1za 1on can e v1ewe as an ex reme orm I I of "detached concern," an attitude adopted by many l I l 15 I l

PAGE 34

d' 'd ll 1.'n 1 h 1 f h' h mb' 1.n l.Vl. ua s peop e e p1.ng pro ess1.ons w l.C co 1.nes a careful balance between empathy for a recipient and enough separateness from the recipient to enable the I I helper to most effectively (Leif & Fox, 1963). i The balance between closeness and distance demanded by detached concern is very difficult to achieve. As the balance shifts to increased distance, depersonalization I develops; and the helper increasingly views recipients i I with a negative, callous perspective. This negative I perspective can often lead helpers to begin to believe \. i that the recipients of their help are somehow deserving of their problems, "blaming the victim" (Ryan, 1971). As helpers to "blame the victim," they tend to be less to feel less responsible for their clients, and ultimately to do less for their clients. i The aspect of burnout is a feeling of reduced personal Individuals who choose helping I as their life's work are frequently very dedicated committed (Freudenberger, 1975a). As burnout deyelops and emotional exhaustion and depersonalization increase, helpers begin to feel less I I ' and less pos1.t1.ve about the work they are doing; and they I i begin to feel guilty about the way they have treated Helpers begin to feel like failures and self-esteem declines. J I I 16

PAGE 35

I l Hardiness l: Kobasa and her colleagues at the University of Chicago folulated the concept of "hardiness" to describe a constelljtion of personality characteristics which I 'I I serve to the effects of high levels of stress. Drawing fr4m existential personality theory (e.g., Kobasa & Maddi, the literature on coping and the literature .on human development Kobasa (1977) conceptualized the three components of hardiness to be commitment.J challenge, and control. h I, l't h t t' f 't t T e pjrsona 1 y c arac er1s 1cs o comm1 men challenge;and control influence an individual's :J l.'of an event in such a way that the event is perce1ved be less stressful by the individual possessing ''hardiness. This cognitive appraisal of the I l event as threatening effects a more positive response of the individual to the event. This promotes r activities l:that are more proactive and less avoidance ; I or1ented (Kobasa, Maddi, & Kahn, 1982). The plrsonality characteristic of commitment results in an indlJidual being significantly invested in her; himself . ; lt allows her/him to find meaning in all aspects of .her/his life, and to resist giving up when I under The committed individual will confront l problems involve her/himself deeply in whatever 17 l i I I

PAGE 36

l I sjhe does, j'and have a sense of purpose. 11 In short, committed.persons' relationships to themselves and to the environmenJ involve activeness and approach rather than passivity avoidance" (Kobasa, Maddi & Kahn, 1982, p. I I 169). .. I Work by other theorists supports the concept of commitmentJ Antonovsky (1974) wrote about what he considered l:to be the most essential stress-resistance ) resource, ;, 'fa sense of coherence, 11 which also involves a sense of purpose. Moss (1973) theorized that alienation and a commitment make one more susceptible to illness. I l : I The personality characteristic of control enables an 'to feel influential rather than helpless when I facing life's events. Control allows her/him to perceive I events as ; : result of herjhis own actions, so that they I feel less,strange and unexpected (Kobasa, Maddi, & Kahn, I 1982). The of control is built primarily upon the research on locus of control (e.g., Phares, 1976). This I research suggests that individuals differ in the degree I l: to which they perceive that they can influence their 0 ,l 0 h 0 1 t Persons Wl.t an 1.nterna locus of con rol have the that they can significantly affect th 0 :I e1.r env1.ronment, thus they feel less helpless in the I I 18 I

PAGE 37

I face of a,ersity. Persons with an external locus of control themselves to be more at the mercy of j others, chance, and fate (Rotter, 1966). I. Individuals with the personality characteristic of change as stimulating rather than threateninJ. They perceive change, rather than I stability, l:to be a normal part of life. Change is exciting irl' that it provides an opportunity to learn and grow. Chc:Jlenge also promotes flexibility and openness I '. (Kobasa, Maddi, & Kahn, 1982) .. CsiksJentmihalyi (1975) discussed challenge as it I I relates to;anxiety and boredom. When a person is faced , I' with dema11-qs sjhe is unable to meet, anxiety results I. When a perJon is faced with demands sjhe has the ability I I to meet, results. "Flow" is the sensation that results whJn an individual acts with total involvement. !. "Whether on:e is in flow or not depends entirely on one's l: perceptionlof what the challenges and skills involved are" (Csikszentmihalyi, 1975, p.50). I. The concept of challenge 1s also supported by ol' research the need for variety (Maddi, Propst, & Feldinger,,, j:1965) and on sensation seeking. Smith, Johnson, arld Sarason (1978) found that individuals who score high 1on a measure of sensation seeking are more .. ' i tolerant negative life changes, whereas individuals i I. I I I 19

PAGE 38

scoring low on sensation seeking suffered psychological d't .lth f f t' l'f h 1s ress 1n e ace o nega 1ve 1 e c anges. Based on the above information, the hardy individual may be characterized as curious, intrinsically motivated (Maddi & 1981), inclined to take vigorous control of his lifJ (Kobasa, 1979), and interested and satisfied with the :aJtivities of his life. The hardy person will also view:Jhange as a stimulating and natural part of life that1Jrovides opportunities to learn and develop I l .. (Kobasa, Jilddi, & Puccetti, 1982). Individuals low in hardiness will perceive their environmenJ' s as boring, threatening, and meaningless. q: They will : tile passive and pessimistic in their interacticiJs with their environments and will feel : I ;. powerless:in the face of adversity and change. Stability I in life islpreferable to the individual low in hardiness, and ;is perceived as negative (Kobasa, Maddi, & Puccetti, .1!982). I I l A Brief Overview of the Study I I This.study was designed to investigate several areas of inquiry relating to burnout including hardiness, depression, response mode to burnout, and demographic b f var1a les. I Staff nurses from two large metropol1tan h 't 1 :I. d th b. 1 osp1 a s crompr1se e su Ject group. Four prev1ous y I I i I l' 20

PAGE 39

validated instruments were used to measure burnout, depression, hardiness, and response mode to burnout. Each subject also completed a demographic data sheet. Data were collected at one time period only. Data 9btained from these instruments were primarily analyzed by computing Pearson Correlation Coefficients and t-tests and by using multiple regression analyses. General Limitations of the Study A number of issues may limit the generalizability of this study. One issue concerns the representativeness of the A random sample was not used. Subjects participating in this study were registered nurses working full-time (defined as 40 hours per week) who were in staff positions with no administrative I responsibilities. Although all nurses meeting these criteria were asked to participate in the study, some self-selection bias may have existed for those who chose to participate versus those who declined. This may be particularly pertinent in a study of burnout, since individuals suffering from high levels of burnout may be disproportionately represented in the non-participants. Another potential threat to generalizability lies in the choice of the hospitals selected for the study. Both hospitals are large, private, non-profit institutions in 21

PAGE 40

a large metropolltan area in the same geographical area. The fact tJat previous burnout studies have failed to identify consistent and robust association between r demograph{G variables and burnout offers encouragement. A limitation to this study relates to the use of .'a correlational design. Correlations indicate the degree1to which variables covary together. Assumptionl about causation are notjustified based on these data alone. Although two variables may be highly it is not possible to tell whether there is a l. causal reltionship, which direction any causal .J relationship would take, or whether the relationship between two variables is a result of some other I phenomena 1 Since.the time sequence of events and situations is a critical,element in determining causation (Babbie, I 1983), the :fact that this study collected data at only one time peint also limits the degree to which assumption! about causation can be made. Anothlr potential limitation of this study is the 1: use of measures that could not practically be I verified trained observation. However, one group I i of researchers has completed studies that have r -demonstrated that self-report measures can be as good as I behavioral :measures and, in some instances, may be I l 22 I I

PAGE 41

L superior (Howard, Scott, Wiener, Boynton, & Rooney, l 1980). Defining study participants as nurses working 40 hours per:Jeek created sampling difficulties. Both I hospitals in this study have flexible scheduling I arrangements, allowing each I schedule will work. I proportion of the critical !. nursing unit to decide what In both hospitals a high care units work 12-hour shifts and define ja full-time nurse as one who works 36 hours per week. ;This created an under-sampling of critical care nurse$, particularly at Hospital A where no intensive eare unit or coronary care unit nurses were I able to patticipate in the study. However, most studies examining the differences in burnout levels between critical care and non-critical care nurses have found I l that the type of unit in which a nurse works is not significantly related to burnout scores (see Chapter Two I' for I to I I Organization of Chapters I Chapter Two reviews selected literature pertaining r burnout; hardiness, depression, and response modes to burnout, arid proposes research questions of interest. I I Three focuses on the methodology involved in I I the research. The three sections of this chapter include 23

PAGE 42

I I I i the following: research methods and objectives; the 1 I sources and characteristics of the sample; and methods of ; data analysis. Chapter Four addresses each of the research questions lxamined in the study and presents the results of the statistical techniques used to analyze the data. r Chapter Five provides a summary of the results of I the study discusses the implications of these findings makes suggestions for future research. i t i I 24

PAGE 43

CHAPTER TWO LITERATURE REVIEW This ehapter presents a review of the literature on I . burnout. Based on th1s rev1ew, burnout w1ll be conceptualized as one type of stress that affects human I service professionals as a result of their interactions I with their,' environments. j Bothpersonal and environmental sources of burnout will be reviewed. Possible personal sources of burnout ,. include demographic traits and personality I such as idealism, assertiveness and self-actualization. Hardiness as a constellation of the l personality dimensions of commitment, challenge, and 1: control will be discussed at length. Both support for hardiness . and criticism of this construct will be 1 , included. I Possible environmental sources of burnout reviewed in this include role characteristics such as role I conflict, social support, leadership style, type of I I organizatipnal unit, and job qualities such as job I I overload.

PAGE 44

' I The ef.fect of burnout on somat1c compla1nts, energy l levels, absenteeism, turnover, alcohol and drug abuse, and idealism are also reviewed in this chapter. The I spillover effects of burnout on the family, friends, and clients oflburnout victims are also included. A dis6ussion of phase models of burnout and I i response mGdes to burnout will complete this chapter. I The Burnout Syndrome Versus General Work Stress I As by Maslach (1982a), burnout is 1 include only individuals in the human services professions. This conceptualization is supported I by other researchers of burnout (Burke, Shearer, & I I Deszca, 1984a). Maslach resists the efforts of others to include all types of work and the stresses involved in with individuals in non-work settings (e.g., I ,. mothers interacting with their children). Maslach I (1982a) argues that a broader concept of burnout will I. make the term meaningless. "If burnout means everything, I it means nbthing at all" (p. 34). I term I Maslach burnout (1982b) also argues against extending the to include all types of work stress. She views burnout as one subcategory of work stress. I Research other investigators supports this view. Two I studies (Numerof & Gillespie; Numerof & Seltzer, 26

PAGE 45

' 1986) demoAstrate that burnout can be understood as a r "segment on the continuum" of the much broader concept of I stress. While the umbrella term of "stress" includes I both posittve and negative experiences, both in and out of the wor* environment, burnout includes only negative in the workplace. A study by Jayaratne and I I' Chess (1984) also supports the delineation of burnout as separate ffom work stress and job satisfaction. Tennis (1987) contends that the fact that extensive I reviews of!organizational stress by authors such as Beehr l and Newman (1978) and Schuler (1980) do not refer at all to the concept of burnout would suggest that these \ I authors also support the argument for a concept of 1 burnout as'separate from work stress. Farber (1983) I argues that burnout is the result of unsuccessful l attempts t0 cope with stress. Brill (1984) agrees with Farber adding that burnout requires outside help or r environmental changes to bring about improvement. i ( Sources of Burnout I. I Much d1sagreement exists among major burnout I researchers about the primary causes and dynamics of burnout. Maslach (1982a) argues that rather than looking I at people, attention should be focused more I on the environment in which people work. Based on her 27

PAGE 46

research I I she j' feels that burnout 11is best understood in terms of situational sources of job-related, t i. 1 t II ( 9) h ( 980 ) d 1n erpersona s ress p. c ern1ss 1 a an l I Freudenberger and Richelson (1980a) agree that it is probably m9re reasonable to focus on the situation rather I than on individual, in part because if one wants to I provide type of intervention to decrease burnout, it ; I is easier change the situation than it is to change I the individual. i I I The PersonlEnvironment Fit Model I I Me1eri (1983) argues for a more interactionist view l of burnouti He believes that the causes of burnout do I 1 not residelin either the individual or the environment I alone; that burnout is a function of both \' The development of burnout lies both within I the and the formal and informal physical and I social environments that make up the workplace (Savicki & i I Cooley, Meier's (1983) view is more in keeping I I with the person-environmental interaction perspective I. (Beehr & Nfwman, 1978). This perspective makes the I I I assumpt1onthat JOb stress results when there 1s a poor 1 t fit a worker and the environment in which sjhe I works. This person-environment (P-E) fit model argues that how alperson functions on the job is influenced by both the stresses encountered in the environment and the I 1 28 l

PAGE 47

l i type of the individual. Garden (1989) I believes that the personality of an individual may I 1nfluence not only how burnout is manifested but also I one's predisposition to burnout. It is the goodness of fit11 betweJn job demands and individual personal I characteristics that determines how much stress an I J individual!will experience (French & Caplan, 1972). The I' P-E fit corresponds to the 11social ecological I perspective.11 This perspective states that human J. behavior is a dynamic interaction between the individual and the social environments of which sjhe is a part i (Carrol, Cherniss, 1980a). I I Both p-E f1t theory and the social ecological indicate that personality characteristics or environmental characteristics could function both as I sources of,. stress or moderators of the stress reaction I (Tennis, 1987). They also explain why some individuals I I experience I: burnout while other individuals in the same environment do not. A review of burnout literature finds support for this theory. I dying has .. feen speculated For example, although death and to be a source of stress for nurses, (1987) found that burnout is not a , widespread;problem among hospice nurses. Other research l: has found that hospice nurses report organizational l stress or staff support stress far more often than stress 29

PAGE 48

I I concerningjpatients and their families (Yancik, 1984: Turnipseed;, 1987). In a related study, Yasko (1983) reports contact greater hospital nurses' current level of direct cancer patients was not associated with degrees of burnout. In discussing the P-E fit model French, Rodgers, and J Cobb (1974j argue that it is essential to consider two meanings "environment." One must examine not only the environment that exists independently of the person's ptrception of it, but also the "subjective" environment as it is perceived and reported by the person. A:key theoretical concept of psychological stress is of appraisal. Appraisal, discussed by Lazarus Opton (1966), refers to the evaluation by the individualjof the harmful significance of some event. I Threat when a cue signifies to the individual that a harmful experience may be anticipated. "Thus, the same ( stimulus be either a stressor or not, depending upon I the naturelof the cognitive appraisal the person makes regarding the significance for him" (Speisman, Lazarus, I I. Davison, &jMordkoff, 1964, p. 367). One person's treat l may be another person's poison. The appraisal of an I event can result in the conclusion that the situation is I harmful, disgusting, or challenging (Lazarus, 1971). i 30

PAGE 49

! I Assuming that the interaction between the individual I and the environment is the most likely overall explanation of burnout, there are a number of causes/ I moderatorslwhich deserve consideration. These factors can most eJsily be divided into personal characteristics and environmental characteristics. I l Personal S0urces and Moderators of Burnout I Researchers have investigated a number of personal \ that may influence burnout. These include petsonality characteristics and demographic traits such as gender, age, education, marital status, experience! and position in the organization. Although I studies sctutinizing possible relationships between I personality characteristics and burnout have been I fruitful, in the area of demographic variables I have been less successful. Numerous demographic variables have been, and continue to be, the subject of I study. associations between burnout and demographics I "provide no evidence of significant and sizable ' covariatioh" and do not seem "robust" (Golembiewski & Sccichitanl, 1983, p. 446). Golembiewski and Munzenrider I (1988b) call burnout an "affirmative action affliction" I (p. 138). IMaslach and Jackson (1984) urge caution when interpretihg differences in variables relating to sex, j marital status, and family status because of the I 1 31

PAGE 50

of confounding from sex role socialization, I in social support and different job expectations. I Gender. The findings regarding the influence of I gender on burnout are equivocal. Two studies have identified!males to be more prone to burnout than females I I , (Daley, 1979; Thompson, 1980); and, 1n two stud1es, males I \ experienced more depersonalization and less personal accomplish,ent than females (Golembiewski, 1983; Olsen, 1985). rn!a study by Maslach and Jackson (1981b), 1 females scored higher than males on emotional exhaustion; I I and males higher on depersonalization than : I females. 0ther studies have found no gender differences in levels of burnout (von Baeyer & Krause, 1983I t I 84; E 1984; Guyon, 1984; Igodan, 1985; McDermott, ,. 1984; Maslach & Jackson, 1985; McCarthy, 1985; Numerof & Seltzer, 1986; Golembiewski & Munzenrider, 1988b). i Age. I. Research examining the relationship between I age and is more consistent than the findings on gender. four studies found no relationship between and level of burnout (Cheatham & Stein, 1982; von Baeyeri. & Krause, 1983-84; Harris, 1984; Numerof & Seltzer, 1986), the majority of studies found an inverse I r. relationship between age and burnout (Pines & Kafry, I I 1978; Daley, 1979; Gann, 1979; Maslach & Jackson, 1979; I l 32

PAGE 51

I Gillespie, 1.1981; Maslach & Jackson, 1981b; Pines & Kafry, 1981c; Golembiewski & Sccichitano, 1983; Yasko, 1983; Guyon, 1984; McDermott, 1984; Numerof & Gillespie, 1984; I McCarthy, +985; Shea, 1985; Igodan, 1985; Olsen, 1985). I EXPerience. Studies also demonstrate an inverse relationsh+p between burnout and years of experience l (Streepy, 1981; Livingston & Livingston, 1984; Numerof & I Gillespie, ,.1984; Martof, 1985; Shea, 1985; Whitehead, I 1985). One would expect, based on the findings relating I to age and.! experience, that individuals at higher levels i I in the hierarchy would experience less I burnout. this has proved to be true in some studies I . (Kahn, 1978; K1mmel, 1982; Harr1s, 1984; Wh1tehead, 1985). (1981) found no relationship between job I level and burnout. i Pines and Kafry (1978) report higher burnout at1higher positions. This contradictory finding i might be by the fact that the Pines and Kafry I (1978) study was the only one which did not measure I burnout the Maslach Burnout Inventory. Educational Preparation. Educational preparation is not identified as having an influence on I exper1enced burnout (Fang, 1985; Louis, 1985). However, Guyon (1984) found in one study that personal decreases as educational level increases. I Maslach and Jackson (1981b) found that higher levels of 33

PAGE 52

' education dre associated with higher scores on emotional exhaustionland lower scores on depersonalization. Status and Children. Results studying the I effect of .. marital status on burnout are equivocal. In three studies married subjects demonstrate less burnout than unmarried subjects (Numerof & Gillespie, 1984; I Maslach & 1985; Numerof & Seltzer, 1986). In two I studies no relationship is found between marital status I and burnout (von Baeyer & Krause, 1983-84; McDermott, I I 1984). In:one study single or divorced subjects are found to higher on emotional exhaustion (Maslach & Jackson, 1$81b). I Subje6ts with children show less burnout (Yasko, 1983; Maslach & Jackson, 1985) or no relationship between I burnout and having children (Guyon, 1984). I L and Unrealistic Expectations. Personality characteristics have been viewed as playing a major role in burnoutlsince the first discussion of burnout by (1974). Freudenberger observes that individuals who are highly committed and dedicated are I' more prone!to burnout. Individuals prone to burnout are I also idealistic and tend to set standards for themselves that are unrealistically high (Freudenberger & Richelson, l 1980a). with a high need to help others often choose a helping profession and find themselves 34

PAGE 53

unable to their unrealistic expectations to meet the of the situation (Savicki & Cooley, 1983). I The rqle that unrealistic expectations plays in the i experience,of burnout is supported by other researchers L (Veninga, 1979; Fischer, 1983; Meier, 1983; Sakharov & ,. ,. I Farber, 1983). However, Jackson, Schwab, and Schuler I (1986) find that unmet expectations about the job are not I, associated(with higher levels of burnout; and Seabold I' (1984) demonstrates that nurses with higher initial I expectations have significantly lower burnout than other I !, nurses. Miscellaneous Personality Attributes. There are other perstnality attributes that have been hypothesized to the development of burnout which have 1 l. received l.ess attention than the notion of unrealistic I expectations. For example, individuals who are more I ,t self-actualized suffer less burnout than subjects who I measure in self-actualization (Cheatham & Stein, I I 1982). personality variables of achievement, I. abasement,lnurturance, and succorance are positively I related to:intensity of emotional exhaustion and negatively!related to frequency of personal l I accompl1shment (Grutchfield, 1982). A study by Nagy I. I (1985) shows that assertiveness did not influence the l I degree of Txperienced burnout. 35

PAGE 54

i Hardi.Jess. An area of extensive investigation relating"tl personality characteristics has been the of Kobasa and her colleagues at the University of I work . Ch1cago. ..In beg1nn1ng her research, Kobasa (1977) was interestedlin examining individuals who did not become ill when cqnfronted with significant levels of stress. I After evalttating data collected as part of the Chicago l Stress Pro]ect, Kobasa formulated the concept of to describe a constellation of personality that serve to moderate the effects of I i high levels of stress. Drawing from existential personality theory (e.g., Kobasa & Maddi, 1977), the F coping, and the literature on human development, Kobasa conceptualized the three components j of hard1ness to be comm1tment, challenge, and control. The pkrsonality characteristics of commitment, challenge,t.and control influence an individual's I perceptioRiof an event in such a way that the event is ,. perceived be less stressful by the individual hardiness. I This cognitive appraisal of the !. event as threatening effects a more positive I' response of the individual to the event. This promotes activitiesjwhich are more proactive and less avoidance I oriented (Kobasa, Madd1, & Kahn, 1982). 36

PAGE 55

I The .PJrsonality characteristic of commitment results in an indiJidual being significantly invested in The hardiness dimension of control enables I. an to feel influential rather than helpless I :. I when facing life's events. Individuals with the personaliiJ. characteristic of challenge view change as stimulatinJ rather than threatening (Kobasa, Maddi, & r Kahn, 1982).. The Plrsonal Views Survey (PVS) is the instrument developed:Ty Kobasa (1979) to measure hardiness. The PVS consists of separate items to determine subscale scores :I for commitjent, challenge, and control. A composite hardiness:score can also be determined. I' I' I All of the studies done in conjunction with the Chicago stbess Project have identified hardiness as a I significant moderator of the relationship between stress "' and (Kobasa, 1979; Kobasa, Maddi, & Courington, 1981; Kobata, Maddi, .& Puccetti, 1982; Kobasa, Maddi, & Zola, 1983 ;: Kobasa & Puccetti, 1983; Kobasa, Maddi, l Puccetti, & Zola, 1985). Subsequent studies by other I I also support the validity of the of hardl.ness (Wendt, 1982; Rhodewalt & Agustsdottl.r, 1984; l' Sagert, 1984; Bigbee, 1986; Howard, Cunningham, & Rechnitzerl 1986; Banks & Gannon, 1988; Allred & Smith, 1989; Nagyl& Nix, 1989). Only a few studies fail to l.. .l.. I l. 37

PAGE 56

! identify any relationship between hardiness, stress, and I' illness (Seger, 1984; Bennett, 1986; Schmied & Lawler, 1986; Roth; Wiebe, Fillingim & Shay, 1989). J i Studies have also been done to examine the I l relationship between hardiness and burnout. These studies, many of which used nurses as their subjects I 1987; Jama, 1987), consistently identify hardiness as a buffer between stress and burnout (Berger, 1 1983; & Hanson, 1983; Keane, Ducette, & Adler, ;, .11 . 1985; 1985; D'Ambros1a, 1987; Holt, F1ne, & ) Tollefson, 1987; Jama, 1987; Rich & Rich, 1987; Schoenig, I 1987). related study savage (1987) reports that subjects with high hardiness and social support have lower of negative psychological symptoms. I Two studies of hardiness have used subject groups a disease entity, rheumatoid arthritis (RA) with (Okun, Zautra, & Robinson, 1988; Lambert, Lambert, Klipple, &j:Mewshaw, 1989). In the first study, the control dimension of hardiness ras positively correlated with an objective measure oflpositive immune response (circulating t-cells) I (Okun 1988). This led the investigators to .. conclude that hardiness is a useful construct for I r understanding a patient's adaptation to rheumatoid I arthritis. These researchers speculate that RA patients' 38

PAGE 57

i cognitive beliefs I I 11ves doeslaffect later study of RA regarding their influence over their their immune system functioning. In a patients, researchers find that regardless l.of severity of illness, satisfaction with social support and hardiness are significant predictors of psycholJgical well-being (Lambert et al., 1989). i the findings of the earlier hardiness I research W$re fairly consistent with the theoretical !' framework outlined by Kobasa and her colleagues, more recently alnumber of theoretical and empirical criticisms I have been directed at hardiness research and theory. I These relate to how hardiness is I operationalized, concerns about analysis and l interpretation of data from previous research, and doubts l about hardiness as a unitary measure (Funk & Houston, I 1987; Van Treuren, & Virnelli, 1987; Rhodewalt & I Zone, 1989) I One of the issues of measurement relates to the I evolution of the hardiness instrument and the I . t" l f f h d' b 1ncons1s use o any one measure o ar 1ness y I various researchers. The hardiness instrument was I developed Kobasa and her colleagues using subscales from previously validated tools. For example, one I of the of the control dimension was the Internal-External Locus of Control Instrument (Rotter, 39

PAGE 58

i l L Seeman, & 1962; Lefcourt, 1973). As Kobasa's 1 research progressed, changes were made in the composition I I I' ,, of the har4iness measure based on information obtained in \ \ previous This resulted in the use of a number of different iterations of the hardiness tool by I" I different investigators, which made study comparisons l. difficult (Hull et al., 1987). Another measurement criticism deals with the use of !:negative w9rding in the hardiness instrument (e.g., determine challenge by measuring low security) which calls for that may not be accurate (Funk & I Houston, Parkes & Rendall, 1988). Another concern :. is that the negative wording will tap maladjustment and, I in fact, t?at many of the subscales used to indicate hardiness are very similar to those found in measures of !' I maladjustment (Funk & Houston, 1987). I The c9ncern that the hardiness instrument may measure form of maladjustment is supported by a I I number of studies. Funk and Houston (1987), using the Beck Deprebsion Inventory (BDI) as their measure of I depress1onl.r f1nd that hard1ness is more strongly related to depression than to physical illness, and that many of I the effects of hardiness are not found when they controlled for depression. Several other of hardiness using the BDI as a measure I 40

PAGE 59

of depression also find an inverse relationship between I hardiness and depression (Ganellen & Blaney, 1984; Watson 1 I & Clark, 1984; Rhodewalt & Zone, 1989). Using a different measure of depression Manning, Williams, and I Wolfe (1988) also identify a negative relationship i between hardiness and depression. l Allred and Sm1th (1989) argue that previous hardiness Tffects may actually reflect the operation of the personality dimension of neuroticism. They speculate I that the between hardiness and health reflects ajrelation between neuroticism and somatic The results of their study demonstrate that hardiness and neuroticism are clearly confounded. Parkes and Rendall (1988) conducted a study that examined the j relationship between hardiness and extraversion and l neuroticism. They find all components of hardiness to be I positively! related to extraversion and negatively related to neurotipism. Parkes and Rendall (1988) also provide I evidence that neurotic introverts have particularly low hardiness which is consistent with the psychologipal vulnerability viewed as typical of this I group (Eysenck, 1978). i The maladjustment dimension, labeled neuroticism by Allred and! Smith (1989), has also been called general dysphoria i(Gotlib, 1984) or negative affectivity (Watson 41

PAGE 60

& Clark, As stated earlier, Watson and Clark I (1984) a widely-used measure of depression (the Beck Inventory) in their hardiness study. They arguelthat the BDI not only measures depression but is also highly correlated with the more global construct of affectivity, the tendency to magnify and l dwell uponlnegative events. Rhodewalt and Zone (1989) argue that i low hardy people manifest an "existential I malaise" which they postulate is the same as, or related to, affectivity. Rhodewalt and Zone (1989) conclude nonhardiness is a correlate of negative I I affectivity rather than hardiness providing a special resiliency!to stress. The of hardiness as a unitary measure is another 1 major concern of critics (Hull, Van Treuren, & Virnelli, 1987; 1989). Their arguments are that combining measures using a composite index results in a loss of information that might otherwise "embellish and flesh I l I out" the picture, or might prevent discovering "that the i picture is!, in fact, wrong" (Carver, 1989, pp. 580, 581) I Two studies that support this argument are: (a) a study J in which challenge and commitment correlated with social r support but control did not (Ganellen & Blaney, 1984), I I. and (b) a in which the composite measure of 42

PAGE 61

I hardiness yielded no effects and the challenge subscale 0 l y1elded only one (Hull, Van Treuren, Propsom, 1988). I The against the use of a composite hardiness at this stage of research is further i supported 6y the inconsistent results obtained by many researchers relating to the challenge subscale. In a number of the subcomponent of challenge either did not significantly correlate with outcome measures (Kobasa, 1982a; Magnani, 1986; Schlosser, 1986; Rich & I I Rich, 1987; Hull et al., 1987; Manning et al., 1988; Roth et al., Toft, 1979), or it yielded an effect in the I opposite direction of commitment and control (Hull et I I al., 1988) Environmental Characteristics I "The search for causes [of burnout] is better I directed away from identifying the bad people and toward uncoveringlthe characteristics of the bad situations where manyl good people function" (Maslach, 1978b, p. 114). Thip emphasis on the role of the environment in I effecting burnout has stimulated the study of a wide-. I ranging list of environmental characteristics as I antecedents of burnout. I Role Characteristics. Role characteristics have 0 d tl to 0 rece1ve a, ten 1on as poss1ble antecedents of burnout. Role theory as developed by Kahn {1974) shows that job ( 43

PAGE 62

.I i satisfaction decreases in the presence of role conflict I and role Cherniss (1980a) indicts role ambiguity 4nd role overload as strong contributors to I burnout am0ng human services professionals Role conflict occurs when an individual is torn I between conflicting demands of different groups that I are all important to the individual (Pines, 1981). Role i conflict as an antecedent of burnout is supported by I studies priests (Chiarmonte, 1983) and teachers al., 1986). Role conflict has been a suspected source of stress I 1 in women torn between the conflicting demands of home and j. work outside of the home. In a study of professional women by and Kafry (1981c), the hypothesis that j conflicts exist between the demands of home and work was r supported.: However, this study also shows that the I I number of in and of themselves did not promote burnout. oh the contrary, the variety of roles added I interest ahd stimulation and promoted satisfaction and happiness .1' In this study variety is negatively I correlated, with burnout, which leads the authors to speculate fhat "when a woman has different roles and many I. d1fferent to do, each one is experienced as less stressful"! (Pines & Kafry, 1981c, p. 132). This might help to explain the data stated earlier that individuals 44

PAGE 63

1: d marr1e l and have children tend to experience less who are burnout. Role a lack of clarity about what is I . . . expected of an 1nd1v1dual, has also been 1mpl1cated 1n the of burnout. However, studies investigating this dimension do not support this l hypothesisr Instead, they show that role ambiguity may have a quality. A study by Leiter and Meechan i (1986) suggests that although role ambiguity may cause some difficulty in defining their roles, for l 1 other individuals role ambiguity is perceived as an to define their roles in ways which are f compatible! with their own interests. In fact, in this study, measures of personal accomplishment are higher in I I individuals who experienced role ambiguity. A study by Jayaratne knd Chess (1984) also finds that role ambiguity ' is not implicated in the development of burnout. j: However, one study identifies task clarity as a significanL contributor to emotional exhaustion in park and recreation professionals (Rosenthal, Teague, Retish, West, & 1983). Job QOalities. There are a number of job qualities that have been d 1 : L f eve opmenr 0 discussed here .. suspected as playing a role in the burnout. The job qualities that will be include job overload, the number of hours 45

PAGE 64

I an individbal works, the amount of time spent in contact I with clients, the type of work unit in which the ' individual:works, social support, and leadership styles. i I The of job overload has been investigated by a I number of researchers. With one exception (Jayaratne & Chess, 1984), work overload correlates significantly and i I positivelylwith burnout (Gentry, Foster, & Freehling, 1972: Maslach & Pines, 1977: Pines & Maslach, 1978: Fong, 1985). I I' The of hours worked by an individual may affect burnout. The results in this area are less definitivefthan those on job overload, however. Although two are able to identify a direct positive I l between the number of hours worked and the I developmenf of burnout (von Baeyer & Krause, 1983-84: Fong, other studies do not support these findings (Maslach & Pines, 1977: Das, 1981: McDermott, 1984: i . Olsen, 1985). T1me away from the job (e.g., vacat1ons, I time out) is shown to have an inverse relationship to burnout & Maslach, 1978: Seiderman, 1978: Cooper, I 1984). I I Contact Time with Clients. The amount of time spent in contactj with clients has also been implicated in the of burnout. Several studies show that as the amount of time in direct contact with clients increases, 46

PAGE 65

j burnout also increases (Maslach & Pines, 1977; Das, 1981; l Livingston: & Livingston, 1984). However, the exact opposite etfect has been found in examining the amount of J time supervisors spend in direct contact with their In a study of nurses by Harris (1984), managers who spend more time with subordinates experience I I lower of burnout. Managers who spend less time with their subordinates experience higher levels of guilt I and a sense of personal effectiveness as a manager. I Type of Organizational Unit. Research examining I burnout inlnurses has tried to identify different types of organizational units which might be implicated in the I i development of burnout. Based on research that has examined psychological stresses experienced by critical I care nurses (Gentry et al., 1972), usually the hypothesis has been th.at critical care areas, such as emergency I rooms and intensive care units, will promote more burnout than areasj such I assumpt1.on as obstetrics and medical/surgical units. This is not consistently born out, and most I studies examining this variable find that there is no I difference: in burnout levels based on the type of unit in I which one. (Das, 1981; Harris, 1984; Cronin-Stubbs & I Rooks, 198 '5; Keane et al., 1985). McCarthy (1985) shows l that burnopt is not higher in nurses working with highly disturbed psychotic patients. However, Cronin-stubbs and I 47

PAGE 66

I Brophy (1985) find that nurses working in psychiatric I i units or in the operating room show higher levels of burnout thin nurses working in intensive care units or in the trauma!unit. I Social Support. Social support has been proposed as a major which might reduce the development of I l burnout (Cobb, 1976; 1980b; Aronson, & Kafry, 198L. This hypothesis is confirmed by a number I of studies!: examining the effects of support on burnout I (Pines & Kafry, 1981a; Rosenthal et al., 1983; Yasko, j I 1983; Yarne, 1984; Cronin-Stubbs & Brophy, 1985). Leiter ,1 and Meechan (1986) report that subjects experience less I emotional when an individual's social support I network not limited solely to the formal work 'i subgroup. and Kafry (1978) show that interpersonal I relations clients and colleagues are more important in burnout than other work conditions, such as j.: the variet of job assignments. Jackson et al. (1986) find that experience higher levels of personal accomplishkent in supportive environments, and that the support one's principal is particularly significant in helping to: increase personal accomplishment. Lack of support from one's principal is positively correlated to Cherniss (1988) argues that the type of supporJ: from one's principal influences burnout rates I, I I. I I 1: 48 .!

PAGE 67

I I among teachers. In his study Cherniss observed specific l behaviors the principal with the staff with the lowest I burnout levels. These behaviors include interacting less frequently!with staff members, spending less time I observing staff in their classrooms, talking more and listening less, spending more time discussing workJ. related and giving her staff more emotional support spending less time in "small talk" with them. i Paredes (1983) also finds that supervisory support rather than support is more significant in preventing burnout hospital nurses. I Some of the literature on support and burnout makes I a distinct1on between support at home and support at work. Most of these studies find that both on-the-job I, I and off-the-job social support are negatively associated r with burnopt (Pines, Aronson, & Kafry, 1981; Kafry & I P1nes, 1980; Cron1n-stubbs & Rooks, 1985). Several other studies only work support. Dick (1985) reports that subjebts with collegial support have decreased burnout. (1983) finds that a decrease in work I support leads to an increase in burnout scores, and Fong 'l (1985) argues that the support of peers and the I chairperson lead to lower levels of burnout in nurse r educators' I. I I 49 I

PAGE 68

i A study of Israeli managers and social service : l by Etzion (1984) adds complexity to the distinctiop between different types of support. As predicted, I life and work stress are positively related for men and for women. Also, social support in life and in work arb negatively related to burnout for both men I I and women.! However, work stress for men is moderated by social support in the workplace, and work stress for women is mbderated by social support outside of work (e.g., and friends). Etzion (1984) speculates, ,I based on these results, that the recommendation that I develop support groups at work as a means of alleviatink burnout might be more appropriate for men than for women. She is concerned that this approach for I I women mighf conflict with their investment in developing social outside work and impair the source of that is most beneficial for them. "Developing I and mainta!ining social relationships beyond one 1 s need might provk a demand stressful in itself 11 (Etzion, 1984, p. 6'21). I. I. Leadersh1p style. Some researchers have investigat,kd whether or not the leadership style of one 1 s supervisor): plays any role in the development of burnout. Dick (1985) finds that nurses whose supervisors have a participat.a. ve management style experience less burnout. 50

PAGE 69

. I I Consideration, adequacy of communication with the l supervisor!, and amount of communication with supervisors are all fohnd to be inversely related to burnout by I j. Numerof and Seltzer (1986). This study also found that I with high of supervisory consideration, burnout is I lowest under conditions of high or moderate structure . I This findihg supports a previous study in which burnout I. in neonatai intensive care nurses is found to be highest J under of low consideration and high structure I. (Duxbery, Armstrong, Drew, & Henly, 1984). However, I these speculatethat it might be the environmehh that is causing the leader to burn out. 1: Subsequently, the leader develops a leadership style ... I by high structure and low consideration since leadbrship style is, in part, a response to the I work situaFion (Duxbery et al., 1984) l In the role of personal and environmental variables in the development of burnout is far from clear. i l outcomes ,. I The impact of burnout on the individual I in terms of emotional' bxhaustion, depersonalization, and a decreased sense of plrsonal accomplishment have already been mentioned . : There are a wide variety of other physical 51 I I I

PAGE 70

' and psychoJ..ogical consequences that are experienced by burnout vi&tims. There are also ways in which burnout : I affects family, friends, and clients of the victims l of burnouti. I Physical bhtcomes Burnoht has been associated with a wide range of somatic colplaints including headaches, backaches, sleep l problems# loss of appetite, nervousness, chronic colds, i' and generally poor physical health (Pines, 1981; Conner, I . 1983; Burke et al., 1984b; Golemb1ewsk1, 1987a). These t phys1cal symptoms often lead to decreased energy level I I and increased absenteeism and turnover (Pines, 1981; l I Cheatham & Stein, 1982; Golembiewski, 1987a). Psychological Outcomes L I Alcohblism and drug abuse are other outcomes of I burnout aslvictims attempt to cope with the negative l J: emot1onal and phys1cal effects of burnout (Maslach, 1976; l I Pines, Jackson & Maslach, 1982). Burnout is also associatedlwith mental illness and suicide (Maslach, .. I 1976). Mitchell (1988) reports that in England, nursing I has one of the highest rates of suicide in any 1: profess1onal group and tops the list of outpatient .I referrals. I ' I' l I I I 52 I

PAGE 71

Often.the victims of burnout, who started out with such ideaiism and high expectations, become disillusioned with their.professions, lose their idealism, suffer from low moral.a, and develop negative attitudes toward their l work (Freudenberger, 1975a; Sackeroff, 1982; I. 1: Golembiewski, 1987a). Helpers may be overwhelmed by the : "bottomless well of needs awaiting their response" 1,. (Lenrow, 1978b, p. 560). Jonesl. (1981a) identifies other disturbing possible effects In a of he reports that with higher burnout scores are more likely to score highbr on a dishonesty test measuring attitudes : l toward and are more likely to steal drugs intended i for patienbs. Effects of;Burnout on Others l The effects of burnout reach far beyond the burnout victim. Others "singed" (Maslach, 1982a) are the family, the friendL, the recipients of the services provided by I the victimJ of burnout, the institution with which the victim is and society at large. 1. In a study of police officers, Jackson and Maslach I (1982) repbrt that burnout can have direct and effects on the families of burnout victims. Officers from burnout spend more time away from their famH .. ies, are less involved in family matters when l I l 53 I I

PAGE 72

r I I I I they are hqme, are more likely to have unsatisfactory marriages, ;and are more quick to anger. The indirect effects burnout can have on the !' recipients;of services provided by burnout victims is a I I major Cherniss (1980a) is concerned that whole I groups mayiburn out affecting the climate of the I unit/institution to such a degree that a therapeutic I l:, environmenr becomes impossible. An early study conducted j: by and Will (1953) observes that the psychiatric patients for by burned out professionals on one unit were neglected, causing them to regress and to become depressed, violent, and suicidal. The concerns Cherniss (1980a) have been supported by research. I Rountree (1984) reports that there is a strong I : tendency for people in a task group to have similar I levels of burnout. The studies of Golembiewski and Munzenridet (198Bb) also find that immediate work groups 1: have an af1inity for extreme scorers, in the majority of cases, and I, that mixed groups seem rare. I I The development of emotional exhaustion by victims of burnoutl has major implications for human service recipients!. As a consequence of emotional exhaustion, I the often loses positive feelings toward clients, abd develops instead a cynical and callous perspectiv:e about people. "A virtual hallmark of the I 54 I

PAGE 73

I l: i 1: burnout syndrome is a. shift in the individual's view of : I: other people -a shift from positive and caring to I! negative and uncaring" (Maslach, 1982a, p. 17). 1: The drvelopment of also has a maJor effect on the way cl1ents are treated. As develops, the person suffering from l: burnout wiil increasingly withdraw from her/his clients and begin respond less to their clients as humans and more as (Maslach, 1982a). Dehumanization often I f develops, clients may be perceived to be "subhuman, bad human,:or non-human" (Maslach & Pines, 1977; p. 102). This makes.it possible to act in "antisocial" or "inhumane" ways (Maslach & Pines, 1977). There .. are a number of ways that distance from I clients can be obtained. The victim of burnout may use I' l. verbal techniques to establish such as r referrin<;J ro her/his clients as "my caseload" or the "broken hip in room 212 i The burned out person may about situations to make them more objective Lnd less personal. S/he may also withdraw doing such things as avoiding eye contact '' or talking:; to the client from the doorway rather than going intb:the room (Maslach & Pines, 1977). In this ., technologipal age, it is also possible to provide a distance the health care provider and,the patient 55 I.:

PAGE 74

'' l by focusing on laboratory reports and technological apparatus: I Compassion is translated into intellectual concern. of looking at the patient, some helpers may examihe with fascination the plates that come out of thetrlvisualization machines as well as the prin-pputs of their computerized lab studies. (Pruyser, 1984, p. 363). 1: Another method of withdrawing from clients is to "go I by the boqk" rather than examining the facts of a specific and acting accordingly (Maslach, 1976). I Phases of Burnout : l: . . Beg1nn1ng w1th the early wr1t1ng about burnout, some I authors haYe conceptualized the syndrome as a process occurring lin phases. According to Freudenberger ( 197 4) victims of:burnout first exhibit anger, irritation, and and have a difficulty holding in I . These sympfoms are followed by susp1c1on and which mayllead to a sense of omnipotence and feelings. paranoia over-confidence:. This may be exhibited in risk-taking behavior and/or self-treatment with drugs and alcohol. The burnedlout individual also becomes rigid, inflexible, r and to change. ,, L and Brodsky (1980) descr1be four stages of burnout based on their interviews with peo:p:lj working in human service capacities. The first enthusiasm, is characterized by high hopes, t 56 I

PAGE 75

:) 1.' l expectations, and over identification with clients., .[n the second stage of burnout, stagnation, the I 'I emphasis thrns from devoting all of one's energies to the p job to one's own personal needs. The third stage of burnoutlis characterized by frustration, the realizatior that it is difficult, if not impossible, to . do what set out to do. The fourth stage of burnout, l apathy, ocburs as a defense against frustration. The I. r victim of .burnout begins to do only what is minimally I '. \ required and avoids challenges 'I l I Eight Phase Model of Burnout !: The primary work to empirically validate a phase model of bhrnout has been done by Golembiewski .. colleagues (Golembiewski & Munzenrider, 1988b). This '' phase seeks to extend Maslach's work on the three of the burnout syndrome, emotional exhaustion, depersonai;ization, and personal accomplishment (Maslach, I 1982a). l j Thephase model makes assumptions about the relative potencies the subscales of the Maslach Burnout Inventory'.l Depersonalization is seen as the usual and 'l least potent entry into burnout (Golembiewski & r Munzenrider, 1988b). Personal accomplishment is seen as I and emotional exhaustion is considered the I 1 j: '' :1 r i\ ,j I 57

PAGE 76

most virulent of the subscales and the one most J 0 character1st1c of advanced phases of burnout. Using.the MBI the phase model developed by Golembiewski and subjects high I i (Table 2. ;IJ) ' .. Munzenrider (1988b) distinguishes or low on each of the MBI subscales Table 2. 1 . The Eight Phase Model of Burnout. I 1 l. Progressive Phases of Burnout I II III IV V VI VII VIII Lo Hi Lo Hi Lo Hi Lo Hi Personal Lo Lo Hi Hi Lo Lo Hi Hi ment (revrsed) Emotional1 Exhaustion Lo Lo Lo Lo Hi Hi Hi Hi 'J: h t NOTE: Frppt P as.es of Burnou (p. 28) by R. T. and R. F. Munzenrider, 1988, New York: Praeger ... popyright 1988 by R. T. Golembiewski and R. F. Reprinted by permission .. l 'f The phase model suggests that each of the phases is 0 0 I. 0 0 v1rulent but does not requ1re that i l individuais suffering from burnout progress through each I' l: :: : phase Two advantages of the phase model is that it:. provides a way to classify individuals in I i terms of the virulence of their particular cases and I permits thb more accurate targeting of ameliorative (Golembiewski & Munzenrider, 1988b). 58

PAGE 77

I l. A series of studies by Golembiewski and his colleagues:provides increasing evidence that an eight phase mode!L of burnout is valid and reliable & Munzenrider, 1981; Golembiewski, : l Munzenrider, & Carter, 1983; Golembiewski & Munzenrider, 1984b; GotLmbiewski, Hilles, & Daly, 1986; Golembiewski & Munzenrid$k, 1988b). Data from these studies also suggest thLt advanced burnout is widespread, and that burnout sebms to last for a long period of time I: 1986b). As for the chronicity of burnout, ; I and Munzenrider (1988b) suggest that if : j: anyone is,foping that a "tincture_of time" will cure burnout, that one should not count on it. ' Active and:Passive Response Modes to Burnout clinical observations about burnout ,j: (Freudenberger & Richelson, 1980a) have indicated that r I there may be two response modes to burnout, identified by I Golembiewsfi (1984a) as active and passive. Golembiewski l and Munzenrider (1988b) comment that the distinction : I. between tpe two response modes to burnout suggests analogs to.such personal features as "helplessness" and If such modes exist, they are of both and practical concern. An acfive response mode refers to behavior that is by a frenetic burst of energy wherein 59

PAGE 78

work harder and longer, but not smarter (e.g., & Richelson,' 1980b; Cherniss, ; r 1980a). Freudenberger (1977b) has also described this type of victim to be on a treadmill in "an unending of accelerating effort and decelerating reward" (pl. 27). The behavior of other burnout victims l may be characterized by a state of resignation, described b 1 mb .. I. k c > th d t y Go e 1ews 1 1984a as e pass1ve response mo e o I burnout . 1 j; by and his colleagues (see l Golembiewski & Munzenrider, 1988b) on the phases of I burnout has also included some work on response modes. What these studies have found is that the response modes seem to characterize all phases of burnout, .and that !' l about of those in advanced phases of burnout seem to the active response mode, while four-fifths are in the passive response mode. on limited evidence, it appears that passivity: !increases more or less directly, phase by phase (GolembiewLki & Munzenrider, 1988b). It been speculated that the passive response ,!" mode to burnout may be clinical depression (Levinson, . 1.' 1986; 1987b). Freudenberger (1974) identifies:' depression as a symptom of burnout. Weiskopf 60

PAGE 79

(1980) viets depression as the end state of burnout, and . I F1ckl1n (1983) uses burnout as a synonym of depress1on. Other.authors theorizing on a possible relationship ,. between and depression have questioned whether l' burnout be a new name for an old idea. In a study of uni versi tyl; faculty, Meier ( 1984) finds not only strong support fot the convergent validity of burnout, but also ; I a high between burnout and depression, I I weakening the argument for burnout's discriminant l validity. LResults of a study by Schucker (1985) in which \ psychiatrib nurses were subjects support the hypothesis that deprebsion will rise as job stress rises. Using the Beck Inventory to measure depression another l study a high correlation between depression and I emotional; .kxhaustion, one of the subscales of burnout as I measured by the Maslach Burnout Inventory (Firth, : I. McKeown, Mcintee, & Britton, 1987). r I I summary 1. on this literature review, in this study burnout be viewed as a type of stress affecting ,, human serVkce professionals. The three components of burnout arL emotional exhaustion, depersonalization, and i personal accomplishment. !. I J 61

PAGE 80

' I is best understood as resulting from interactiohs between individuals and their environments. stress resllting in burnout can originate from both j personal ahd environmental sources . I h' t t d 1 t lf Demograp 1c ra1 s, 1 ea 1sm, asser 1veness, se I actualization, and the personality construct hardiness l are the primary personal characteristics discussed in this reviek. Although age and experience level primarily show an inyerse relationship with burnout, relationships between other demographic traits, such as gender, marital I status, position in the organization, and educational t l 1 th t t d' .. prepara 1on, are equ1voca In e wo s u 1es exam1n1ng I I the of having children on burnout, one study reports leks burnout in individuals with children and the other reports no relationship between having .I children ahd developing burnout. I Accorhing to this review, assertiveness does not I : l influence degree of burnout, but individuals who are more r . self-actuaa1zed exper1ence lower levels of burnout. The I majority of studies reviewed found that individuals who are idealibtic and have unrealistic expectations are more I l prone to burnout. The pLrsonality construct hardiness is comprised of th d . j t t h 11 d t 1 ree 1meps1ons, comm1 men c a enge, an con ro I. The pr1mar body of hard1ness research has 1dent1f1ed I I I I I I I 62

PAGE 81

hardiness:as a significant moderator between illness, stress and burnout. Criticisms include of how it is operationalized, I stress and of hardiness concerns about data analysis and interpretation in the Kobasa studies, dpubts about hardiness as a unitary measure, and the of the hardiness instrument. :r remain about the relationships between hardiness i: knd burnout and the following entities: II t . . neurot1c1sm, 1ntrovers1on, dysphor1a, negat1ve depression, and existential malaise. [1. li Amon?. the environmental factors included in this review, social support and time away from the job result in lower Role conflict, time in direct contact with and job overload result in higher levels of Studies examining the effect of role clarity [;! or ambiguity as well as the type of organizational unit l. I I ! 1n wh1ch one works with the develop.ment of burnout have l'.'l I equivocal: iesul ts. Leaders with participative management I styles, or,high supervisory consideration and high or j moderate have subordinates with lower levels of burnoutt outlines a number of negative outcomes resulting;; from burnout. Victims of burnout experience higher of emotional exhaustion and I l' II. depersonalization, and lower levels of personal 1: I I .l J 63

PAGE 82

accomplisnLent. Burnout victims have an increased somatic complaints, a generally lower level of wellnesb, and often lower energy levels. Higher levels of kbsenteeism, turnover, disillusionment, and low morale also found among individuals suffering from burnout. Burnout is also associated with a higher j. incidence bf alcohol and drug abuse, mental illness, and I suicide. I .. I . Ind1rect effects of burnout 1nclude negat1ve interactiols between the victim of burnout and her/his I family friends. Burnout also has a negative effect I on the delivery of services to clients and on patient I care. I Phase!models of burnout have been proposed with the most work resulting in an eight phase model l 1 that extends the work of Maslach. Research associated I with the phase model suggests that emotional exhaustion I I 1s the most v1rulent component of burnout, and that advanced.blrnout is widespread and chronic. One of the values phase model is that it allows more accurate targetingbf ameliorative interventions. I Thefinal subject of this review is response mode to I burnout. There are indications for both active and I l passive rerponse modes to burnout. In the active response m0de, victims of burnout work harder and longer !" 64

PAGE 83

but not necessarily smarter. The passive response mode I is character1zed by resignation and appears to be the clinical state of depression. For an overview of the variables included in this l review andl.their relationships with burnout, see Table 2.2. 1. i t I I I l l I ; l: l i I I t I I l l I l i I 65

PAGE 84

Table 2.2. Personal and Environmental Variables and Their Relafionships with Burnout. Variable!: Relationship with Burnout i: Positive Inverse None Equivocal Gender I + I. Age I Primarily I Education + Level Marital I Status: + I I. ExperJ.encr Primarily P 't' I. OSJ. l.On a.n Organizataon + : j! Children, I +* +* Idealism l Primarily .T Selfactl:la!l.i-+* II I I zatiop1 I' I Achievement +* :. I I I .: +* +* I succorancb +* I +* ness : ,. Hardines!;' + l : l f I I 66 I I

PAGE 85

'i ; ( j. Relationship with Burnout I Positive Inverse None Equivocal Role ' Conflict + Role j Ambiguity Clarity + Job load + # of I'' Hour.s Worked [ + Time in I + Contact : with I Clients L I Time Awayr + from Job1 J. 'ii Type of 1. Work Unitj + Social Support I + \ style I +** !: Represent only one study ** style includes supervisors with either management styles or with high supervisory consideration and high or moderate structure I I j 1: This study l. between barnout :1. l Research Questions will examine possible relationships and the personality construct of hardiness,jdepression, demographic variables, and 67

PAGE 86

l l response modes to burnout. Thus, this research will test l. the hypotheses stated in Table 2.3. Chapter Three I, outl1nes the research methodology used to test these l hypothesesj. I Table 2. 3 .1. Research Questions: Hypotheses Regarding the Relationships Between Burnout, Hardiness, Depression, Demographif Variables,and Response Mode to Burnout. Hl: H2: H3: H4: l Hardihess scores will vary depending on degree of burnout. I Hla: Subjects scoring higher on hardiness will have tl.ower burnout scores. l I ' Hlb: SubJects scor1ng lower on hardiness will have higher burnout scores. Hardibess scores will vary depending on level of depression. H2a:. bubjects scoring higher in hardiness will have aower depression scores. I H2b: scoring lower in hardiness will have higher depression scores. I will vary depending on level of depress1on. I H3a:. scoring higher in burnout will have higher depression scores. H3b: scoring lower in burnout will have [ower depression scores. scores will vary depending on the subject's response mode to burnout. I . . H4a:. w1th a pass1ve response mode to burnout will have higher depression scores. I . . H4b: w1th an act1ve response mode to burnout will have lower depression scores. I l 68

PAGE 87

H5: H6: H7: I l I Hardiness scores will vary in accordance with a subjebt's response mode to burnout. H5a: scores will be higher for subjects with an active response mode to burnout. H5b: Hardiness scores will be lower for subjects a passive response mode to burnout. I Burno4t scores will vary in accordance with a subjebt's response mode to burnout. I H6a:.hurnout scores will be higher for subjects with t a pass1ve response mode to burnout. I i H6b: Burnout scores will be lower for subjects with active response mode to burnout. data will not contribute to the explained variance in burnout scores, hardiness scores, or response modes to burnout. I .. I 69

PAGE 88

CHAPTER THREE RESEARCH METHODOLOGY overview I This tested hypothesized relationships among r . burnout, dfpress1on, selected personal1ty demographic variables, and two response I I modes to burnout. The data were collected exclusively I I I for this srudy. The survey questionnaire utilized all, or part, of four standardized instruments (Maslach I Burnout Inrentory, Beck Depression Inventory, Work Environment Scale, and the Personal Views survey) and included alnumber of questions about demographic factors. (See Appehaix A for samples of these instruments.) Sincel'this study is exploratory and descriptive in I. nature, method of observation used was survey research; J cross-sectional data were collected. Survey j: research was also chosen because of its economy and In order to achieve the specific goals of this quantitative techniques were employed. In the of time, qualitative techniques were not used to sukplement the quantitative data. The selection : 1: . and characfer1st1cs of the population, data collection

PAGE 89

Procedures I, instrumentation, and data analysis are i described below. Population and Sample The sample used for this research consisted of 158 registered;nurses from two private, non-profit hospitals in a metropolitan area in the Rocky Mountain I I Region. Both hospitals provide a full range of emergency and services. Both hospitals are large; I Hospital A! employs 1800 people, and Hospital B has a total of 2.032 employees. The data were collected from registered nurses I j working (defined as 40 hours per week) who were in staff positions with no administrative responsibHI.ities. The subject group was defined in this I way for twp reasons. First, since it is probable that working part-time decreases ones chances of experiencing I burnout, nurses working a full work week were included in this study. Unfortunately this created sampling p'l:'oblems, since it was discovered during the I process ofj data collection that both hospitals consider 36 hours per week to be a full-time work schedule. This ', was particplarly a problem regarding critical care I nurses, sihce most inpatient critical care nurses only I 71

PAGE 90

worked a work week. These sampling issues will be discussed in greater length in Chapters Four and Five. The second reason the subject group was defined in this way relates to the staff nurse issue. It was decided that only staff nurses with no administrative responsibilities would be included in the study, since it is reasonable to expect that nurses with only clinical duties might experience different types of stress than nurses with clinical andjor administrative Any individuals defined as staff nurses who had any degree of administrative responsibility beyond being charge nurses (e.g., ass.istant head nurses) were eliminated from the study. The sample included nurses working in both inpatient and outpatient settings in a wide variety of specialty areas. With the permission of nursing administration at each hospital, nurses who met the study criteria were contacted in person while on duty. The purpose of the study was explained, and it was also explained that participants in the study would receive the results of their scores and an overview of the outcome of the study if they wished. Return rates were 69 percent at Hospital A and 65 percent at Hospital B, yielding an overall return rate of 67 percent. 72

PAGE 91

Characteristics of the Sample Table 3.1 presents selected characteristics of the sample. Analysis of the respondents' characteristics reveals that the average age was 39 years; 94 percent were caucasian; 2 percent were black; 2 percent were Asian; and 2 percent were Hispanic or Native American. Forty-five percent of the respondents were married; and 42 percent had at least one child currently living at home. Thirty-two percent of the subjects had completed an degree in nursing; 32 percent had received a diploma ih nursing; 33 percent had a bachelor's degree in nursing; and 2 percent had received master's degrees in nursing. The average length of experience in nursing was 14 years; and the average length of time employed at their hospital was a years. 73

PAGE 92

Table 3.1. Sample Characteristics. Average Age 39.05 (S.D. = 9.94) Gender 94% female Married 45% Number of Children Living at Home None 55% One or more 42% Educational Level Associate Degree 32% Diploma 32% Bachelor's Degree 33% Degree 2% or' higher Years of Nursing Experience (frequency) One Year or Less 7 2 to 5. Years 26 6 to 10 Years 24 11 to 15 Years 26 16 to 20 Years 18 21 to Years 17 26 Years or More 16 Tenure in Organization (freqUency) One Year or Less 27 2 to 5 Years 31 6 to 10 Years 36 11 to 15 Years 22 16 to 20 Years 9 21 Years or More 8 Race (frequency) 149 Black 3 Asian 3 Hispanic/Native 2 American Type 74 of Nursing Unit OB/GYN Labor & Delivery Nursery Neonatal ICU Recovery Room Operating Room Emergency Room Pediatrics ICU/CCU Medical/Surgical Outpatient Clinic Telemetry Neurology/ Neurosurgery Float Shift (frequency) 7-3 3-11 11-7 7am-7pm 7pm-7am Rotating Other 3 12 2 4 7 19 14 4 5 54 7 13 6 8 45 17 14 12 12 21 14

PAGE 93

Some data are available to make comparisons between this group of nurses and other nurses in Colorado. Survey data gathered by the Colorado State Board of Nursing (1991) and the Colorado Nurses Association (1988) relating to gender, race, and education level show figures comparable to those found in this study (see Appendix B for details). since these figures relate to nurses working in all types of settings, these data lend some support for the generalizability of these findings to nurses:working outside of hospital settings. These findings are supported by the observations of this researcher, based on 23 years of experience as a nurse or as a consultant to nursing groups in hospital settings. Areas of experience include both inpatient and outpatient settings; both critical care and non-critical care nurslng units; both staff nurse and administrative positions; in public and private for-profit and nonprofit hospitals, in four different states. Based on this experience, I would argue that the subjects in this study do not differ significantly from other hospitalbased nurses in the United States. Therefore, regarding these factors, I believe that it is reasonable to generalize the findings of this study from the sample studied here to the general population of hospital-based nurses. 75

PAGE 94

Measures The questionnaire used in this study consisted of four standardized instruments and a demographic data sheet. The demographic questions sought to determine respondent age, sex, marital status, type of nursing education, race, number of children currently living at home, length of experience as a nurse, length of time employed in herjhis current hospital, the nursing unit on which worked, and the shift primarily worked. Following is a description of the four standardized instruments used in this study. Maslach Burnout Inventory Although a number of instruments have been developed for the purpose of measuring burnout, a survey of the literature clearly indicates that the tool used most consistently in burnout research is the Maslach Burnout Inventory (MBI) developed by Maslach and Jackson (198la). Based on their extensive exploratory research examining the burnout syndrome, Maslach and Jackson postulate that burnout is comprised of three dimensions: emotional exhaustion, depersonalization, and personal accomplishment. The MBI is designed to measure these three dimensions, each of which is measured by a separate subscale using a total of 22 questions. Questions are 76

PAGE 95

written in the form of statements about personal feelings or attitudes (e.g., I feel emotionally drained from my work; I feel very energetic). Respondents rate each statement on a scale of 0-6 depending on how often they feel that way (e.g., 0 =never; 6 =every day). As conceptualized by Maslach and Jackson (1981a) burnout is, a continuous variable that ranges from low to high degrees of experienced feeling. Higher scores for emotional exhaustion and depersonalization indicate more negative burnout effects. Lower scores for personal accomplishment indicate more negative burnout effects. For this study scores were computed for the three burnout supscales and a total burnout score was determined. by summing the subscale scores with personal accomplishment reversed. Maslach and Jackson (1981b) have reported considerap:le evidence supporting the reliability and validity the MBI. Using Cronbach's alpha (n=l316), the three subscales of the MBI have demonstrated a high level of internal consistency with each other. The reliability coefficients were .90 for emotional exhaustion, .79 for depersonalization, and .71 for personal accomplishment (Maslach & Jackson, 1981a). Test-retes't reliabilities for these scales ranged from I, '. 77

PAGE 96

0.60 to 0.80 for one sample (n=53) and from 0.54 to 0.60 for a second sample (n=248) (Maslach & Jackson, 1981a). Convergent validity for the MBI was demonstrated by correlating scores with behavioral ratings, by correlating scores with the presence of certain job characteristics suspected to contribute to burnout (e.g., heavy caseload), and by correlating scores with outcomes hypothesized to be related to burnout (e.g., desire to leave job) (Maslach & Jackson, 198la). Discriminant validity of the MBI was obtained by distinguishing it from other psychological constructs that might be confounded with burnout (e.g., dissatisfaction with one's job) (Maslach & Jackson, 1981a). Maslach and Jackson (1981a) also provide evidence that the inventory is not subject to social desirability response set distortion. A number of studies have supported the claims made for the MBI by its designers (Golembiewski & Munzendrider, 1981; Iwanicki & Schwab, 1981; Belcastro, Gold, & Hays, 1983; Golembiewski, Munzenrider, & Carter, 1983; Stout & Williams, 1983; Meier, 1984; Rafferty, Lemkau, Purdy, & Rudisill, 1986; Green & Walkey, 1988; Lahoz & Mason, 1989). Beck Depression Inventory Developed in 1961, the Beck Depression Inventory (BDI) has become one of the most widely accepted 78

PAGE 97

instruments in clinical psychology and psychiatry for i ; assessing.depression in both psychiatric patients and in normal pop*lations (Steer, Beck, & Garrison, 1985). The Center for' Cognitive Therapy (CCT) of the University of Pennsylvania Medical School, which serves as the clearinghouse for the dissemination of the BDI, reports that the BPI has been used in more than 500 research studies has been translated into a variety of languages, ('Steer et al., 1985). The BDI has been called I the "touchstone against which to compare assessments derived from other measures" (Steer et al., 1985). The BDI consists of 21 clinically-derived questions designed to assess the severity of depression in adolescents and adults. The questions on the inventory were seleqt,ed to represent depressive symptoms (Beck, 1972) witl'i each question consisting of four statements listed in order of severity (e.g., I don't feel disappointed in myself .. I hate myself). The'BDI may be used in an interviewer-assisted ' manner or self-administered. The self-administered version used in this study has been in use since 1978 and has been to have psychometric properties comparable to the original BDI (Beck & Steer, 1984). The psychometric properties of the BDI have been tested I extensively by the CCT. These studies have demonstrated 79 '

PAGE 98

high reliability and validity in both clinic.al and nonclinical populations. Recent studies of the internal consistency of the BDI using Cronbach's alpha report mean coefficient alphas of 0.85 for the first group of studies and 0.86 for the second group (Beck & Steer, 1984). Internal consistency has also been evaluated using split-half reliability. The Pearson correlation between the odd and even categories yielded a reliability coefficient of 0.86 (Beck & Beamesderfer, 1974). The BDI has been shown to have high inter-rater reliability and concurrent validity. The BDI has also been found'to correlate with other measures of depression with correlations between scales ranging from 0.69 to 0.75 (Beck & Beasmesderfer, 1974). The construct validity of the BDI has been supported by a number of studies in which the BDI has been used as the criterion measure (Beck & Beamesderfer, 1974). The BDI has demonstrated a high discriminant validity with a correlation of 0.72 between the BDI and clinical of depression and a correlation of 0.14 between the BDI and clinical ratings of anxiety (Beck, 1967). Other studies with samples of both psychiatrically diagnosed populations and normal populations have 80

PAGE 99

reviewed the psychometric properties of the BDI and have supported its claims for reliability and validity (Bumberry, Oliver, & McClure, 1978; Glazer, Clarkin, & Hunt, 1981; Edwards et al., 1984; Lips & Ng, 1985; Steer, Beck, Riskind, & Brown, 1986). Hardiness Instrument The personality construct of hardiness was measured using the Personal Views Survey (PVS). Originally developed by Kobasa in 1977, the PVS has gone through a number of modifications. The first form of the PVS employed six scales from existing instruments to measure hardiness. The questions measuring commitment were taken from the Alienation from Work and Alienation from Self scales of the Alienation Test (Maddi, Kobasa, & Hoover, 1979). control was measured using the External Locus of Control scale (Rotter, Seeman, & Liverant, 1962) and the Powerlessness Scale (Maddi, Kobasa, & Hoover, 1979). Challenge was measured using the Security Scale of the California Life Goals Evaluation Schedules (Hahn, 1966) and the Cognitive structure Scale of the Personality Research Form (Jackson, 1974). Each of these scales has known and adequate reliability and validity (Kobasa & Maddi, 1982). Kobasa and Maddi (1982) report that in their samples to date, the distribution of hardiness composite 81

PAGE 100

scores has been somewhat skewed to the right. For the original versions of the PVS, estimates of internal consistency have been in the SO's and an estimate of stability over a five-year period was .61 (Kobasa & Maddi, 1982). More recently hardiness has been measured using a 36-item revised version of the PVS. The revised PVS consists of a subset of the original scale items and has been found to correlate with the full scales at 0.89 (Kobasa, as quoted in Allred & Smith, 1989). Kobasa also reported to Allred and Smith (1989) that all major findings of previous hardiness studies were replicated when the revised PVS was substituted for the full scale in her earlier samples. In a study of the psychometric properties of the PVS, a correlation of 0.76 between the original long form and the 36-item revised PVS was reported (Hull, Van Treuren, & Virnelli, 1987). Adequate reliability and validity for the 36-item PVS has also been reported by Lambert, Lambert, Klipple, and Mewshaw (1989). The recent form of the PVS, consisting of 50 questions, was used in this study. As mentioned in Chapter Two, one of the criticisms of hardiness research was the use of negative wording in the hardiness tool. The third generation form of the PVS used in this study 82

PAGE 101

responds to that criticism by using a mixture of positively worded and negatively worded questions. The PVS asks respondents to rate each question from 0 (not at all true) to 3 (completely true) (e.g., I like a lot of variety in my work; I really look forward to my work). The so-item form of the PVS has not yet been widely used and information concerning the reliability and validity of this version is not yet available. An examination of the internal reliability of the so-item PVS used in this study yielded Cronbach's alpha values as follows: commitment .78, control .63, and challenge .59. Work Scale Golembiewski and his colleagues are the only researchers at this time reporting studies on response mode to burnout. Early in this work, they used the Job Involvement (JI) scale to measure response mode (Golembiewski & Munzenrider, 1984a). More recently three subscales (.involvement, autonomy, and task orientation) from the Work Environment Scale (Moos, 1986) have been used to make distinctions between active and passive response modes to burnout (Golembiewski, Hilles, & Daly, 1987). The subscale, involvement, measures the extent to which are concerned about and committed to their jobs. Autonomy measures the extent to which employees are encouraged to be self-sufficient and to 83

PAGE 102

make their own decisions. Task orientation measures the degree of emphasis on good planning, efficiency, and getting the job done (Moos, 1986). These three subscales serve as a'surrogate measure of response mode and focus on the respondent's milieu rather than on the respondent. Using interviews and observations, the researchers assessed the validity of using these three subscales as a measure of response mode (Golembiewski et al., 1987). They found that the perceived work site requirements and subject responses were "overWhelmingly congruent" (p. 299). Mean standard scores greater than 50 for each scale indicates an active response mode to burnout, based on national norms for "health care work settings" (Moos, 1986, pp. 43-44). Studies of the WES show good reliability and validity ('see Moos, 1986). Measures of internal consistency for the three subscales used in this study are all in .the acceptable range with Cronbach's alphas of .84 for involvement, .73 for autonomy, and .76 for task orientation (Moos, 1986). Test-retest reliabilities for these thre.e subscales are also in the acceptable range with correlations .83 for involvement, .77 for autonomy, and .73 for task orientation (Moos, 1986). 84

PAGE 103

Method of Analysis The primary focus of this study was an investigation of the relationships among burnout (as represented by results of the Human Services Survey), the personality construct hardiness (as represented by results of the Personal Views Survey), depression (as represented by results of the Beck Depression Inventory), and response mode to burnout (as represented by three subscales of the Work Scale). All analyses were performed using the SPSS-X program. As a first step in the data analysis, Pearson's Correlations Coefficients were computed between burnout, hardiness, depression, and response mode, examining not only total or composite scores, but also scores for all subscales. T-tests and chi-squares were run to identify any statistically significant differences for any of the study variables between nurses from Hospital A and nurses from Hospital B, and between critical care and noncritical ca:re nurses. To further elaborate the relationships between the study variables, stepwise multiple regression analyses were computed with total burnout, emotional exhaustion, depersonalization, personal accomplishment, and depression' :as dependent variables. In one instance forced regression analyses were run to elaborate the 85

PAGE 104

differences between Hospital A and Hospital B regarding total burnout. To examine the internal reliability of the Personal Views survey used to measure hardiness and the subscales of hardiness, Cronbach's alphas were calculated. For hypothesis testing, the level of significance was set at <.05. The results and overall findings of the study are presented in Chapter Four. 86

PAGE 105

CHAPTER FOUR FINDINGS OF THE STUDY This chapter discusses the findings of the study. The intent of the study was to explore interrelationships between burnout, hardiness, response mode to burnout, depression, and selected demographic variables. The first segment of this chapter, Overview, presents a brief synopsis of the results of the tests of I hypotheses.. Section One outlines the results of t-tests run to identify any statistically significant differences between data from the two hospitals involved in this study. Two provides results of the Pearson Correlations which were computed to examine the relationships among burnout, hardiness, response mode to burnout, depression, and demographic variables. Section Three provides the results of the stepwise multiple regression analyses run to further examine these relationships. Overview The purpose of this study was to shed additional light on the type of occupational stress known as

PAGE 106

burnout. Initially the relationship between burnout and a constellation of personality characteristics known as "hardiness'' were explored. It was hypothesized that individuals high in hardiness would have a higher resistance to job stress and would have lower levels of experienced burnout. Both a composite hardiness score and scores for the subscales of hardiness (commitment, control, .and challenge) were computed. The role that depression plays in burnout was a second of investigation for this study. It was hypothesized that depression is an important component of burnout. Specifically, it was hypothesized that burnout victims with a passive response mode to burnout will experience.higher levels of depression. Related to this hypothesis, it was also the purpose of this study to further elaborate upon the relationship between the passive response mode to purnout and depression (e.g., could they be the same thing?). In addition, it was hypothesized that individuals high in hardiness and individuals with an active response mode to burnout will experience less depression. The ro,le of certain demographic variables in the development of burnout was also explored in this study. It was hypo:thesized that there would be no significant 88

PAGE 107

relationships between demographic variables and burnout, hardiness, depression, and response mode to burnout. Overall, an analysis of the data supported the hypotheses:of the study. An overview of these findings (significance p< .05) follows: There is an inverse relationship between hardiness and burnout. There is an inverse relationship between depression and hardiness. There is a positive relationship between ,depression and total burnout, emotional exhaustion and depersonalization. There is an 'inverse relationship between depression and personal accomplishment. There is an inverse relationship between .depression and the active response mode to burnout. There is a positive relationship between hardiness and the active response mode to burnout. There is an inverse relationship between total burnout, emotional exhaustion, and depersonalization and the active response mode burnout. There is a positive relationship between_personal accomplishment and the active response mode to burnout. With a few exceptions, there are no significant relationships between demographic variables and :burnout, hardiness, depression, and response .mode to burnout. Regression analyses showed that the hardiness dimension "commitment" had the greatest explanatory power in predict:fng burnout (r squared = 377), depression (r squared= .319), emotional exhaustion (r squared= .237), 89

PAGE 108

and personal accomplishment (r squared= .220). Table '' 4.1 presents an overview of the study hypotheses and the results. Table 4.i. Research Questions and Study Results: Hypotheses'Regarding the Relationships Between Burnout, Hardiness, Depression, Demographic Variables, and Response Mode to Burnout. ' Hl: Hardiness scores will vary depending on degree of burnout. Hla: .subjects scoring higher on hardiness will have lower burnout scores. SUPPORTED Hlb: Subjects scoring lower on hardiness will have higher burnout scores. SUPPORTED H2: scores will vary depending on level of H2a: Subjects scoring higher in hardiness will have lower depression scores. SUPPORTED H2b: !Subjects scoring lower in hardiness will have 'higher depression scores. SUPPORTED HJ: Burnout scores will vary depending on level of depression. HJa:. 'S'!lbjects scoring higher in burnout will have higher depression scores. SUPPORTED HJb: Subjects scoring lower in burnout will have lower depression scores. SUPPORTED H4: scores will vary depending on the subject's response mode to burnout. H4a: Subjects with a passive response mode to burnout will have higher depression scores. SUPPORTED H4b: Subjects with an active response mode to burnout will have lower depression scores. SUPPORTED 90

PAGE 109

H5: Hardiness scores will vary in accordance with a subject's response mode to burnout. H5a: Hardiness scores will be higher for subjects with an active response mode to burnout. SUPPORTED H5b: Hardiness scores will be lower for subjects with a passive response mode to burnout. SUPPORTED HG: Burnout scores will vary in accordance with a subjeCt's response mode to burnout. H6a: Burnout scores will be higher for subjects with a passive response mode to burnout. SUPPORTED H6b: Burnout scores will be lower for subjects with an active response mode to burnout. SUPPORTED H7: Demographic data will not contribute to the explained variance in burnout scores, hardiness or response modes to burnout. PARTIALLY SUPPORTED Section One Data Between Hospital A and Hospital B To maximize the generalizability of the data from this study to other groups of nurses, it was important to determine whether there were any statistically significant differences between the two hospitals in either demographic data or other study variables. Chi-square values were computed for nominal level data and t-tests were run for interval level data. Three sets of t-tests were run to identify differences between groups as follows: (1) Hospital A versus Hospital B; (2) Hospital A 91

PAGE 110

versus B (non-critical care nurses only); (3) ., Hospital A.: versus Hospital B (critical care nurses only) In only instance were statistically significant findings identified for any of the demographic variables. These relating to the type of nursing unit on which a subject worked, will be discussed later in this chapter. Following is a description of the significant findings to other study variables. (See Appendix C for a of all chi-square and t-test data.) Hospital Aversus Hospital B When:t-tests were run between the subject pool of critical care and non-critical care nurses at both hospitals, significant differences were '' found in total burnout, depersonalization, and depression scores 4.2). Hospital B:had higher scores for all three variables. Table 4. 2. ; T-test Results (Pooled Variance Estimates) Between A and Hospital B. Total Burno:ut T = 2.56 p = .011 F = 1.17 p = .505 tion T = 2.06 p = .041 F = 1.66 p = .032 .. T = 2.62 p = .010 F = 1.48 p = .085 92

PAGE 111

Hospital A .versus Hospital B: Non-critical Care Nurses Only In the test scores for each unit at both hospitals*t became apparent that the critical care units tended to have higher burnout and depression scores, particulatfy at Hospital B. For this part of the data analysis, subjects from both hospitals were divided into critical care or non-critical care practice areas. Nursing UJ!l:i.ts included in the critical care practice coronary care unit (subjects only from Hospital B), neonatal intensive care unit (subjects only from B), emergency rooms, post-anesthesia care units (recovery room}, telemetry, and the intermediate neuro units (which had many patients on ventilators or requiring levels of skilled nursing care). I units included in the non-critical care practice category were: pediatrics (only at Hospital B), obstetrics'and gynecology units, labor and delivery units, well-baby nursery (only at Hospital A), medical-surgical units (including general surgery, orthopedics, oncology, urology and general medicine), operating rooms, and outpatient units (other than the emergency rooms). Five float nurses who only worked in non-critical care areas were,included in this analysis. Three float nurses who workedin both critical care and non-crit'ical care areas were dropped from this analysis. 93

PAGE 112

the t-tests were re-run omitting all of the I subjects working in critical care units, no statistically significant differences remained. Hospital A:versus Hospital B: Critical Care Nurses Only Since:.Hospital B appeared to have more high-scoring critical nurses than Hospital A, t-tests were run to determinewhether there were any statistically significant. differences between the critical care nurses at the hospitals. Statistically significant I were found in the following scores: total burnout, personal accomplishment, commitment, composite (Table 4.3). Hospital B had higher total burnout and depression scores and lower scores personal accomplishment, commitment, and There were three units at Hospital B which had particularly high burnout and depression scores. These were the coronary care unit (n=5), the neonatal intensive care unit (n=4), and the telemetry I unit 94

PAGE 113

Table 4.3 . T-test Results (Pooled Variance Estimates) Hospital Aversus Hospital B: Critical care Nurses Only. Total Burnc;mt T = 3.02 p = .004 F = 1.12 p = .791 Personal Accomplishment T = -3.25 p = .002 F = 1.24 p = .621 Composite Hardiness T = -2.17 p = .036 F = 1.15 p = .752 Commitment T = -2.53 p = .015 F = 1.21 p = .659 Depression T = 3.25 p = .002 F = 2.14 p = .076 Based on informal observations made and from information collected from both of these hospitals, there is no reas9n to suspect that the critical care units at Hospital B would be different from those at Hospital A in any significant way. Cauti0n should be used in drawing conclusions from these data,for the following reasons: (1) there were sampling problems involving the critical care units (see Chapter Three); (2) the sample sizes in the three highscoring units are very small. However, these data have implications for the generalizability of the findings of this study. The assumption was made at the beginning of this study that Hospitals A and B were comparable and that demographic data from each hospital would not significantly vary. The findings relating to the critical carejnon-critical care weaken arguments for the generalizability of these findings to the general population of nurses. 95

PAGE 114

Section Two support for Hypothesis One The first hypothesis regarding the relationship between burnout and hardiness was initially investigated through the use of Pearson Correlation Coefficients. (See Appendix D for a complete correlation matrix.) Correlations were run between total burnout and the three subscales of burnout (emotional exhaustion, depersonalization, personal accomplishment) and the composite hardiness score and the three subscales of hardiness (challenge, commitment, control). These correlations may be seen in Table 4.4. Table 4.4. Pearson Correlation Coefficients for Burnout and Hardiness (Total Scores and Subscores). Total Burnout & Composite Hardiness Total Burnout & Challenge Total Burnout & Commitment Total Burnout & Control Emotional Exhaustion & Composite Hardiness Emotional Exhaustion & Challenge Emotional Exhaustion & Commitment Emotional Exhaustion & Control Depersonalization & Composite Hardiness & Challenge Depersonalization & Commitment Depersonalization & Control Personal Accomplishment & -.5717 -.1569 -.6142 -.4557 -.4866 -.1795 -.4876 -.4513 -.3235 -.0242 -.3734 -.2437 +.4238 Composite Hardiness Personal Personal Personal Accomplishment & Challenge +.1378 & Commitment +.4700 & Control +.2975 96 p = <.001 p = .034 p = <.001 p = <.001 p = <.001 p = .018 p = <.001 p = <.001 p = <.001 p = .389 p = <.001 p = 001 p = <.001 p = .055 p = <.01 p = <.001

PAGE 115

Overall, these correlations support the hypothesis that there.would be an inverse relationship between hardiness and burnout. There are statistically I significant inverse relationships between total burnout and composite hardiness, challenge, commitment, and control; between emotional exhaustion and composite hardiness,:challenge, commitment, and control; and between depersonalization and composite hardiness, and control. Thus, as hardiness, commitment, challenge, and control decrease, burnout, emotional '' exhaustionr and depersonalization (except for the challenge subscale) increase. are statistically significant positive relationsJ::lips between personal accomplishment and compositelhardiness and the hardiness subscales. As I hardiness:and the subscales of challenge, commitment, and I control inrease, personal accomplishment, the positive component 9f burnout, increases. A statistically significant correlation was not found for and challenge. Even though the between challenge and total burnout, emotional exhaustion and personal accomplishment are statistically significant, these correlations are of much less magnitude than is found between the other total scores and subscores. These findings relating to the 97

PAGE 116

challengedimension of hardiness support other findings outlined in Chapter Two which raised questions about the legitimac)'.Of challenge as a viable part of hardiness. One has examined the psychometric properties of a hardiness short form similar, but not identical, to the Views Survey (PVS) used in this research project Van Treuren, & Virnelli, 1987). This analysis of the PVS short form revealed problems with the I ; In a factor analysis, challenge was the thirdfactor to be extracted. In addition, examinatien of the internal reliability of the short form revealed low alpha coefficients for the challenge dimensio:r:t (Table 4. 5) Table 4.5 . Internal Consistency of the 36-item Hardiness Short Formsubscales (Hull, Van Treuren, & Virnelli, 1987) Subscale Cronbach's alpha Cronbach's alpha Sample A Sample B Commitment .73 .72 Control .71 .72 Challenge .41 .44 An examination of the internal reliability of the 50-item hardiness scale used in this study by this researcher revealed a similar picture. Once again, the challenge subscale has the lowest alpha value (Table 4. 6) 98

PAGE 117

Table Internal Consistency of the Hardiness SO-item Short Form Subscales. Subscale Commitment Control Challenge Cronbach's alpha .78 .63 .59 Support for Hypothesis Two Pearson Correlation Coefficients examining the relationship between hardiness and depression provide support for hypothesis two (Table 4.5). As hypothesized, there is a statistically significant inverse relationship between the hardiness composite score and depression. There are also statistically significant inverse relationships between depression and the subscales of composite hardiness, commitment, challenge, and control. Thus, as hardiness, challenge, commitment, or control decrease, depression increases. Table 4.7. Pearson Correlation Coefficients for Depression and Hardiness. Depression.& Composite Hardiness Depression & Commitment Depression & Challenge Depression & Control 99 -.5657 p -.5654 p -.3632 p -.5347 p = <.001 = <.001 = <.001 = <.001

PAGE 118

Support for Hypothesis Three Pearson Correlation Coefficients support hypothesis three that'predicted a positive relationship between total burnout, emotional exhaustion, and depersonalization, and depression. As predicted there is also an inverse relationship between personal accomplishment and depression (Table 4.8). As total burnout and the negative components of burnout (emotional exhaustion and depersonalization) increase, depression increases. As depression increases, personal accomplishment decreases. Table 4.8. Pearson Correlation Coefficients for Burnout and Depression. Depression & Total Burnout +.4431 p = <.001 Depression & Emotional +.4481 p = <.001 Exhaustion Depression & Depersonalization +.2453 p = .001 Depression & Personal -.2545 p = .001 Accomplishment support for Hypothesis Four Hypothesis four predicted that depression and the passive response mode to burnout would be closely related. Pearson Correlation Coefficients showing an inverse relationship between depression and the active response mode support this hypothesis {Table 4.9). Response mode to burnout was measured using three 100

PAGE 119

I subscales of the Work Environment Scale (Moos, 1986). It was that these three subscales, involvement, autonomy, and task orientation, would be inversely related t9 depression. This hypothesis was supported for I 'I the subscales of involvement and task orientation, but the subscale autonomy did not reach statistical ' ' significance. Based on this analysis, depression .I negatively; affects the degree to which an individual is I \, committedlto her/his job (involvement) and the degree to I,, which is an emphasis on getting the job done (task ,I orientati9ri). However, in this study, the data indicate that does not affect the degree to which an individual: feels encouraged to be self-sufficient and to I make her/his own decisions. This finding is contrary to ., the literature on depression. Table Pearson Correlation Coefficients for Depressio:t;t;and Response Mode to Burnout and for Depressionand Work Environment Scales Depression & Active Response -.3744 p Mode I I , Depression:'' & Involvement -.2623 p Depression: & Autonomy -.1159 p & Task -.2596 p Orientation = <.001 = <.001 = .073 = <.001 Accoraing to the literature on depression (Beck, ,i 1967), decreased motivation is the "symptom par excellence'" of depression (p. 263). A major component of 101 : 0

PAGE 120

this decreased motivation is an increase in dependency commonly found in depressives. Depressed individuals have dependency needs for several reasons: (1) The person views her/himself in negative terms; (2) sjhe tends to owerestimate the complexity and difficulty of what to be accomplished; and (3) the depressed person expects everything to turn out badly (Beck, 1967). Given these issues, many depressives want someone to take care of and to help them with their problems. Since the findings of this study are contrary to the depression literature, the relationship between autonomy and depression needs to be further explored. Support !br Hypothesis Five five predicted that there would be a positive relationship between hardiness and the active response Pearson Correlation Coefficients between the active response mode and composite hardiness and the hardiness of challenge, commitment, and control support this hypothesis (Table 4.10). There are also statistically significant correlations between composite hardiness.and the Work Environment Subscales of autonomy, and task orientation that were used to measure response mode to burnout. Based on these data, hardy individuals are less likely to respond to burnout with depression and are more likely to feel 102

PAGE 121

to be committed to their work, and to have an emphasis on getting the job done. These findings are further supported by the correlati9ns between the individual subscales of hardiness and the subscales of the Work Environment Scale. The only exceptions to this support involve correlations with the challenge subscale of hardiness. It should be noted that all of the correlations between the challepge dimension and the subscales of the Work Scale are of less magnitude than all other correlations in this data set; and autonomy is the only subscale to reach statistical significance (although only marginally so). Once again the question of the strength of the challenge dimension is raised. 103

PAGE 122

Table 4. 10.;. Pearson Correlation Coefficients for Hardiness :(.and hardiness subscales) and the Active Response Mode to Burnout and for Hardiness (and the hardiness and the Work Environment Subscales. Active Response Mode & Composite Hardiness Active Response Mode & Active Response Mode & commitment Active Response Mode & Control Composite .Hardiness & Involvement 1 I '. 1 Compos1te1Hard1ness & AutonomY: Composite1Hardiness & Task Orientation Challenge 1 Involvement Challenge:& Autonomy Challenge.&. Task Orientation Commitment & Involvement Commi & Autonomy Commitment, & Task Orientation Control & :Involvement Control &.Autonomy Control & fask Orientation Support for Hypothesis Six +.4134 +.1834 +.3772 +.3995 +.3536 +.2954 +.2651 +.1073 +.1366 +.0096 +.4022 +.2492 +.3284 +.3159 +.2490 +.1728 p = <.001 p = 014 p = <.001 p = <.001 p = <.001 p = <.001 p = .001 p = .099 p = .051 p = .117 p = <.001 p = 001 p = p = p = p = <.001 <.001 .001 .015 It was hypothesized that there would be an inverse between total burnout, emotional exhaustion, and depersonalization and the active response mode to I burnout. It was also hypothesized that there would be a positive between personal accomplishment and the active:response mode to burnout. Pearson Correlation Coefficients support these hypotheses (Table 4.11). Thus, data indicate that as individuals experience 104

PAGE 123

increased 'ievels of burnout, emotional exhaustion, and depersonalization, they are more likely to have a passive response mode to burnout. Conversely, individuals with higher levels of personal accomplishment are more likely to have an active response mode to burnout. An analysis of total burnout and the three subscales of the Work Environment Scale shows an inverse relationship between these variables. Thus, as burnout increases, involvement, autonomy, and task orientation decrease. This inverse relationship between burnout and the subscales of the Work Environment Scale is further supported by correlations between the subscales of burnout and the subscales of the Work Environment Scale. The only exception to this support is the correlation between depersonalization and autonomy which does not reach statistical significance. Burnout victims will be less committed to their jobs, will experience less autonomy, and will have less emphasis on getting the job done. 105

PAGE 124

Table 4 .11;.. Pearson Correlation Coefficients for Burnout and the Response Mode to Burnout and the Work Environment Scales. Active Mode & Total Burnout Active Response Mode & Emotional Exhaustion Active Response Mode & Depersonalization Active Response Mode & Personal Accomplishment Total Burnout & Involvement Total Burnout & Autonomy Total Burnout & Task EmotionaliExhaustion & Emotional Exhaustion & Autonomy Emotional Exhaustion & Task Orientation & Involvement Depersonalization & Autonomy Depersonalization & Task Orientation Personal & Involvement Personal Accomplishment & Autonomy Personal & Task Orientation Support for Hypothesis Seven -.3179 -.3467 -.1544 +.1806 -.3687 -.2664 -.2308 -.3808 -.2920 -.1799 -.2060 -.1230 -.1345 .2137 .1417 .1919 p = <.001 p = <.001 p = .031 p = .015 p = <.001 p = .001 p = .003 p = <.001 p = <.001 p = .014 p = .006 p = .069 p = .052 p = .005 p = .045 p = .010 seven predicted that there would be no significant relationships between demographic variables and burnout, hardiness, depression, or the response mode to burnout. overall, this hypothesis was supported. The 106

PAGE 125

only in which hypothesis seven was not supported involved the critical care/non-critical care dichotomy. After' dividing the subjects into critical care and non-critical care areas as described earlier in this chapter, statistically significant differences (using the t-test) were found between the two groups on three variables: total burnout, depersonalization, and task orientatibh (Table 4.12). Critical care nurses in this study have higher total burnout scores, higher scores, and lower task orientation scores than their non-critical care counterparts. Table 4 .12. T-test Results (Pooled Variance Estimates) for Critical Care Versus Non-critical Care Nurses at Hospitals:A and B. Total Burnout T = -2.98 p = .003 F = 1.04 p = .917 tion T = -3.60 p = <.001 F = 1.61 p = .052 Task T = 2.46 p = .015 F = 1.13 p = .590 critical care Nursing and Burnout. Although much has been written about the stressful nature of critical care units, a great deal of the literature is anecdotal, lacking confirmatory research studies. Research studies examining critical care versus non-critical stress have been inconclusive. Although one study that critical care nurses experience more psychologiCal stress than non-critical care nurses 107

PAGE 126

' (Gentry, ;Foster, & Freehling, 1972), the majority of studies hawe not supported the hypothesis that critical care will experience more stress (Das, 1981: Stehle, 1981; Mohl, Denny, Mote, & Coldwater, 1982; Harris, 19.84; Cronin-Stubbs & Rooks, 1985). Maloney (1980) higher stress and anxiety in non-critical care nurstas. Critti.cal Care Nursing and Depersonalization. To find depersonalization scores in critical care nurses surprising, although there are no research studies addressing this issue to confirm or refute the I finding ih this study. Both: inpatient and outpatient (e.g., emergency room) critical nurses often have less contact with their patients less opportunity to get to know them as ., people. As soon as the condition of the patient improves, :sjhe is transferred to a non-critical care nursing unit. Patients in critical care areas are often or so ill that they are unable to interact ., with the caring for them. A patient's condition ' may be so, that the nurse must devote herjhis full attention to the technical component of the .. r patient's .. bare (e.g., administering medications, making to sophisticated equipment, monitoring vital 108

PAGE 127

signs) little or no time to interact with the patient oh a personal level. The patient's obtunded condition;,: the equipment attached to her/him, dressings, and wounds may combine to make critical care patients ' look "nonh:uman" {Hay & Oken, 1972). Given these circumstances, nurses may find it more difficult relate to the patient as a person. Indeed, in focusing on the technical component of the patient's care, may forget that there is a human being I attached t.o all of the medical paraphernalia. This view of the patient can promote on the part of the nurse. Care Nursing and Task Orientation. At first glance, the finding that critical care nurses have lower task' orientation scores than non-critical care nurses counter-intuitive. This finding indicates that critical care nurses have a lower degree of emphasis on good planning, efficiency, and getting the job done. However, g:iven further thought, possible explanations for ' the planning and efficiency components of task orientatiop arise. Due to the emergent nature of critical care areas, it is not possible for critical care nurses to plan in the same that nurses in non-critical care areas plan. A patient''s condition can change at a moment's notice, 109

PAGE 128

and new P?tients in critical condition can arrive with little or no prior warning. This can make planning in the traditional sense impossible. Critical care nurses must be able to respond immediately to any situation with actions dr'iven by rapid observation, experience, and instinct. In one sense critical care nurses appear to be the ultimate in efficiency, acting quickly with little wasted motion. abwever, in another sense, efficiency can be I lost in critical situations. For example, it is efficient to use only the minimum number of supplies required fpr any given procedure, eliminating waste and unnecessary cost. However, observation in any critical care unit will find that waste and cost are often issues given little consideration in a crisis. For example, a nurse mayi go through a number of intravenous catheters, an expensiye item, starting an intravenous line. The crisis not allow the critical care nurse to carefully prepare to insert the line in an unhurried and deliberate; manner. The critical care nurse faces a situation .where sjhe is surrounded by other people, where it is often difficult to maintain a sterile field long enough to insert the line, where patients are often combative or confused, or where the physical condition of the patient makes insertion difficult. Rather than 110

PAGE 129

efficient in a traditional sense, the behavior of the critical care nurse might better be characterized as purposeful but disorganized. In spite of the intuitive appeal of these findings relating to higher burnout and depersonalization and, to a lesser degree, lower task orientation in critical care nurses, these data must be viewed with caution. When considering any findings in this study relating to critical care or hospital A, it is important to remember that these variables are problematic. As mentioned in Chapter Three, there were sampling problems involving the critical care units. Nurses from these units were undersampl,ed because many of them worked only 36 hours per week. There were no coronary care or neonatal intensive dare unit nurses in the sample from Hospital A. In addition, the coronary care, neonatal intensive care unit, and telemetry unit nurses from Hospital B tended to have burnout and depression scores than the other critical care nurses at Hospital B. Because of these issues caution should be used in drawing any conclusions from these data. Section Three Since this study was exploratory in nature and lacked a clear theoretical model, multiple linear 111

PAGE 130

regression', analysis was selected as a method of statistical inquiry in the second phase of data analysis. Specificaliy, a stepwise regression analysis was chosen, since this procedure is particularly helpful in an exploratory study. Multi-collinearity was an issue of concern in this study for: .several reasons. There are problems inherent in measuring psychological constructs since they lack clear It is difficult to know whether the I I instruments used to measure these constructs are ' specifically measuring what the researcher intends or whether instrument is tapping into some other entity. In the high degree of correlation between the independent variables demanded that the issue of multi-collinearity be considered. I': analysis offers help in this evaluation. ' If multicollinearity is a problem, will issue a warning on: the regression printout. It is encouraging that no were issued during the course of the completion. of the regression analyses discussed below. I Regression Analysis with Total Burnout as the Dependent Variable The f'irst regression was run with total burnout as I the dependent variable. In this regression, commitment, I a subscale of hardiness, alone explained almost 38 112

PAGE 131

percent of. total burnout (Table 4.13). Other variables entering the equation were involvement (a subscale of the Work Environment Scale), critical care, and Hospital A. Table 4 .13.. Regression Analysis With Total Burnout as the Dependent Variable. Step Variable B Beta r squared 1 Col1Uilitment -10.283 -.5297 .37725 2 Involvement .024 -.1542 .39492 3 critical Care + 1. 043 .2232 .4468 4 A .665 -.1528 .4689 ,, Based.on these data, individuals who are high in commitment: will have less burnout. Individuals high in commitment' (as a subscale of hardiness) will be significantly invested in her/himself, will resist giving up under pressure, will confront problems directly, will involve her/himself deeply in whatever sjhe does, and will have a sense of purpose (Kobasa, Maddi,& Kahn, 1982). reasonable that these attributes of the person high in commitment would help defend against the of burnout. It is' not surprising that involvement was the second variable entering the equation since it is closely related to: commitment. According to the developer of the Work Environment Scale, the subscale involvement was intended t.o measure "the extent to which employees are 113

PAGE 132

concerned about and committed to their jobs" (Moos, 1986, p. 2) The findings of this regression analysis support the earlier correlation which found that critical care nurses are more likely to experience burnout than non-critical care nurses. Given the Hospital A results, forced regression analyses were done in order to further elaborate the between the two hospitals. Forced regressions were run, ,first using only nurses from Hospital A (Table 4.14) and next using only nurses from Hospital B (Table 4.15). These data show that nurses from Hospital B (which had. the coronary care, neonatal intensive care unit, and telemetry unit nurses with high burnout and scores) are more likely to have higher burnout scores than nurses from Hospital A. Table 4.14. Forced Regression with Total Burnout as the Dependent'yariable with Hospital A Nurses Only. Step 1 2 3 variable Commitment Involvement critical care B -11.2106 .0111 + .9437 114 Beta -.5586 -.0819 .2135 r squared .3215 .3322 .3752

PAGE 133

Table 4.15. Forced Regression with Total Burnout as the Dependent:Variable with Hospital B Nurses Only. Step 1 2 3 variable Commitment Involvement Critical Care B -9.8540 .0396 +1.1780 Beta -.5318 -.2129 .2499 r squared .4053 .4586 .5188 Regression Analysis with Emotional Exhaustion as the Dependent. Variable In a regression analysis with emotional exhaustion as the dependent variable, the hardiness subscale, commitment, again had the most explanatory power (Table 4.16). Thus, individuals high in commitment will experience' less emotional exhaustion. In addition, individuals high in control and involvement will also experience less emotional exhaustion, although these variables explain only an additional 7 percent of the variation. Subjects higher in emotional exhaustion will experience more depression. Table 4.16. Regression Analysis with Emotional Exhaustion as the Dependent Variable. Step Variable B Beta r 1 Commitment -17.0288 -.1949 .2377 2 Control -16.5803 -.1608 .2738 3 Involvement .1436 -.1992 .3080 4 Depression + .3038 .1996 .3329 115

PAGE 134

It is: reasonable that commitment would serve the same role of protecting against emotional exhaustion as it did for total burnout since emotional exhaustion is a subscale of burnout. This holds true for involvement as a concept to commitment which also helped explain total burnout in an earlier regression analysis. Control, a dimension of hardiness, enables an individual to feel influential rather than helpless when facing events. Burnout victims who are high in exhaustion feel overwhelmed by the demands placed on :her/him by others. The person who is high in control and feeling influential is less likely to the feelings of depletion and helplessness of the person experiencing emotional exhaustion. The [I.J terature states that depression is characterized by feelings of worthlessness, helplessness, hopelessness, and apathy. Thus, it is not surprising that victims of emotional exhaustion may also experience depression. Regression Analysis with Depersonalization as the Dependent' Variabie The analysis with depersonalization as the variable revealed a different picture from the regres.sions discussed previously. Although 116

PAGE 135

commitment was again the first variable to enter the regression, for the first time challenge also entered. On the third step composite hardiness entered the regression and commitment dropped out of the regression on step four. On steps five and six control and critical care enter. This leaves a regression with the variables challenge, composite hardiness, control and critical care in the equation (Table 4.17). Table Regression Analysis with Depersonalization as the Variable. Step Va:r;-iable B Beta r squared 1 Challenge 25.906 .5419 .1613 2 Cc;>mposite -.6167 -1.016 .2018 Hardiness 3 Control 19.297 .3756 .2391 4 Critical Care 2.5253 .2378 .2939 Part of the explanation for the results of this regression probably lies in the high correlation between composite pardiness and the commitment subscale of hardiness (.8719, p = <.001). Commitment, which is the variable with the highest explanatory value in the previous r,egressions, drops out of the regression probably because of interactive effects with composite hardiness. These data indicate the individuals higher in hardiness are less likely to experience depersonalization 117

PAGE 136

and that individuals higher in challenge and control and/or in a critical care unit are more likely to depersonalization. With the exception of the critical care piece which supports discussed earlier in this chapter, the findings in this regression analysis are contradictory of each other and contrary to earlier findings reported in this study:. As subscales of hardiness, it is difficult to why challenge and control would be higher in individuals suffering from depersonalization when composite hardiness is lower. Although one might expect subjects in hardiness to experience more depersonaiization, there is no reason to expect that subjects h:igher in challenge and control would experience more depersonalization. The findings relating to challenge and control in this are inconsistent with other data in this study and. with other studies. These findings appear to be the result of a statistical anomaly and will be disregarded. Regression .Analysis with Personal Accomplishment as the Dependent: Variable In a regression analysis with personal accomplisp;ment as the dependent variable, commitment was the only independent variable to enter (Table 4.18). 118

PAGE 137

Thus, individuals with higher levels of commitment will ,, experience' higher levels of personal accomplishment. Table 4 .18 . Regression Analysis with Personal Accomplishment as the Dependent Variable. Variable Commitment B +26.8927 Beta .4699 r squared .2209 It is. clear that personal accomplishment and commitment are closely related to one another when the characteristics of each are examined. Victims of burnout experience lower personal accomplishment; they feel like failures; and they feel less positive about the work they are doing. The person high in commitment feels significantly invested in her/himself, feels deeply involved the work sjhe is doing, has a sense of purpose, is less likely to give up, and is able to find meaning in all aspects of herjhis life. Thus, the person high in commitment has many characteristics that could protect against lower personal accomplishment. Regression Analysis with Depression as the Dependent Variable A regression analysis with depression as the dependent variable had six variables enter the regression equation, explaining a total of almost 46 percent of depression (Table 4.19). Commitment was again the first 119

PAGE 138

variable tp enter, indicating that individuals high in commitment:. are less likely to become depressed. Control, entering second, was also negatively related to depression:. Hospital A (the hospital at which there were no high burnout and depression neonatal, or coronary care unit sub]eots) was also inversely related to depression. Thus, high in commitment andjor control and/or challenge: working at Hospital A who are childless are I less to experience depression. Conversely, subjects p:igh in emotional exhaustion andjor working in a critical care unit are more likely to experience depression. Table 4. Regression Analysis with Depression as the Dependent; variable. Step Variable B Beta r squared I 1 Coinmitment -14.9020 -.2597 .3197 2 -15.9468 -.2354 .3749 3 Emptional .1099 .1673 .3973 Exhaustion 4 A -1.6166 -.1257 .4103 5 Cpallenge -10.0936 -.1623 .4236 6 Cr!i.tical 1. 7100 .1237 .4370 7 Childless 1. 5297 -.1180 .4502 The !findings that subjects with higher commitment are less likely to experience depression and that emotional :exhaustion is higher in victims of depression 120

PAGE 139

support earlier correlation data and have been discussed earlier in this chapter. The finding that subjects higher in control will experience less depression is consistent with the literature on depression and learned helplessness. The concept of' control is central to the development of learned helplessness (Seligman & Maier, 1967) and is a common theme in the discussion of depression (Beck, 1967). Locus of control, like helplessness, concerns the beliefs that individuals hold regarding the relationships between actions and outcomes (Lefcourt, 1980b). Persons with an external locus of control believe that events occur for reasons that are irrelevant to a person's actions, and thus they are unable to control these events (Lefcourt, 1980a). Lefcourt (1980b) views external locus of control as equivalent to the state of learned helplessness. The variables critical care and Hospital A and their relationsh.ip with depression have been discussed earlier in this ch.apter and will be discussed again in Chapter Five. Summary Overall, the findings of this study, as reviewed above, support the hypotheses of this research. These 121

PAGE 140

l findings be briefly summarized as follows: (1) Individua;t.s higher in hardiness will experience less burnout and less depression. (2) Individuals ,, ', experiencipg burnout are more likely to also experience depression. (3) Burnout victims with an active response mode to burnout have lower burnout scores, higher I hardiness, scores, and are less likely to experience depression:. ( 4) Depression and the passive response '' mode to bhrnout appear to be closely related. (5) The correlations of the hardiness dimension of challenge with ''. I other variables were less consistent and of less magnitude, .than those of the commitment and control dimensions. This finding adds support to the data of researchers who question challenge as a legitimate dimension! .of hardiness. ( 6) The hardiness dimension of commitment: had the most explanatory value for total .,, burnout, exhaustion, personal accomplishment, and depres'sion. Individuals high in commitment are less likely to .experience burnout, emotional exhaustion, and depression and are more likely to experience a sense of I .. personal accomplishment. (7) Depression is also explained' by the hardiness dimensions of control and challenge .and by emotional exhaustion. Individuals with higher le:v .. els of control and challenge will experience less depre'ssion, and subjects with higher levels of 122

PAGE 141

emotional exhaustion will experience greater depression. (8) In this study critical care nurses experienced higher levels of burnout, depersonalization, and depression and experienced lower levels of task orientation. These findings are problematic, however, because of the sampling problems involving the critical care nurses. A small number of neonatal, telemetry, and coronary care unit nurses at Hospital B had high burnout and depression scores. These scores skew these data to a degree that makes it difficult to generalize the findings relating to the critical care/non-critical care dichotomy beyond the hospitals involved in the study. The sample sizes in the coronary care, neonatal, and telemetry units are too small to draw any conclusions as to whether or not these types of units foster higher burnout and/or depression levels in nurses working in these specialized units. Chapter Five contains a more detailed discussion of these resu.lts, outlines conclusions which can be drawn from these. findings, discusses the implications of these findings, pnd offers suggestions for further research. 123

PAGE 142

CHAPTER FIVE CONCLUSIONS OF THE STUDY The. purpose of this study was to examine the relationships among burnout, hardiness, depression, response mode to burnout, and selected demographic variables:.! This chapter discusses the findings of the study, draws conclusions about these findings, discusses the of these findings, and provides for future research in this area. In ,, addition, a self-efficacy model of burnout is discussed as a possiple integrative theoretical framework to encompass: the constructs of burnout, depression, I hardiness:,: and response mode to burnout. 1 summary and Discussion of Findings I discussing the findings of the study in depth a few comments about this research project follow: '(,1) With only a few exceptions the I relationsp1ips among the variables examined in this study are in the direction predicted and are statistically significapt. (2) The results of this study strengthen the predictivevalidity of hardiness and its role in

PAGE 143

buffering not only burnout, but also depression. This is particularly true for the hardiness dimension commitment. (3) This study also provides data implicating depression as a major component of the burnout syndrome and offers evidence of a close relationship between the passive respon$e mode to burnout and depression. (4) These data also question the role of challenge as a viable dimension of thehardiness construct. Burnout and Hardiness This study clearly demonstrates an inverse relationship between hardiness and burnout. This relationship is true not only for composite hardiness and total burnout, but also for all of the subscales of both of these constructs. The only instance in which these relationships are not inverse is for the personal accomplishment subscale of burnout in which a positive relationship exists. Since persqnal accomplishment is the one positive component of burnout, it was predicted that its relationship with hardiness would be in this direction. The only instance in which statistical significance was not reached was in the correlation between depersonalization and challenge. It was also noted that all correlations involving challenge were of less 125

PAGE 144

magnitude.than those involving other variables. The issue of challenge as a viable component of hardiness will be discussed later in this chapter. These correlation data are further supported by the results of regression analyses in which the three dimensions of hardiness contribute significantly to the regression equation explaining total burnout and the burnout subscales of emotional exhaustion, depersonalization, and personal accomplishment. Although the hardiness dimensions control and challenge make a contribution to explaining burnout, the largest and most consistent contribution is made by commitment. The singularly important protective role that commitment plays against burnout will be discussed later in this chapter. This study provides evidence that persons who have higher levels of hardiness are more resistant to the debilitating effects of burnout. Individuals with lower levels of hardiness, commitment, and control will experience higher levels of burnout. Specifically, these burnout v:fctims will have higher levels of emotional exhaustion and depersonalization and lower levels of personal accomplishment. The data from this study demonstrate an inverse relationship between depression and hardiness. This is 126

PAGE 145

true for both composite hardiness and for all three subscales .of hardiness. Individuals with lower hardiness scores experienced higher levels of depression. The relationship between depression and burnout is opposite to that between hardiness and burnout. Burnout victims with higher levels of emotional exhaustion and depersonalization and lower levels of personal accomplishment experience more depression. These relationships between hardiness and depression and burnout and depression are further supported by regression analysis with the subscales commitment, control, emotional exhaustion, and challenge explaining approximat.ely 40 per cent of the regression equation. i Once agaip the data show that persons higher in commitment, control, and challenge will experience less depression, and burnout victims higher in emotional exhaustion will experience more depression. It is not surprising that emotional exhaustion has the explanatory power for depression of the three burnout subscales. Emotional exhaustion refers to the depletion of an individual's emotional resources coupled with a feeling that one has nothing left to give (Maslach & Jackson, 1985). The emotional and motivational depletion found in emotional exhaustion is also found in depression. 127

PAGE 146

The role that depression plays in both burnout and hardiness is one of the most interesting and potentially valuable findings of this study. The literature on burnout hardiness discusses depression to some degree, but it is also filled with other terms which are found on closer examination to be either directly or indirectly related to depression. Neuroticism, dysphoria, negative affectivity, existential malaise, and negative attributional style are some of the more common terms and, concepts found to be related to depression and hardiness andjor burnout. The literature on depression, as it relates to hardiness and burnout, seems sparse at first. However, when it is viewed in combination with all of the above terms, the references to depression in the burnout and hardiness literature are more plentiful. The f'indings of this study and an examination of the depression literature would indicate that learned helplessness might well be a precursor to the depression found in burnout (see Appendix E for a discussion of depression and learned helplessness). The reformulated learned hypothesis claims that depression is the result of learning that outcomes are uncontrollable (Abramson, Seligman, & Teasdale, 1978). Thus, the concept o'f control central to hardiness is also central to learned helplessness and depression. This 128

PAGE 147

relationship will be discussed later in this chapter as part of a self-efficacy model of burnout. Commitment: The Key Variable Although other variables in this study are helpful in understanding both burnout and depression, it is the commitment dimension of hardiness that makes the largest contribution. Commitment has strong correlations with the burnout and depression variables {a mean correlation value of .50). Commitment is the first variable to enter regressions with total burnout {r.squared = .3772), emotional exhaustion {r squared= .2377), and depression {r squared = .3197) as the dependent variables. Commitment is the only variable to enter a regression equation with personal accomplishment as the dependent variable {r squared= .2209). These data support commitment' as a variable key to the understanding of burnout depression. Characteristics of the Committed Individual. As conceptualized by Kobasa (1979), individuals high in commitment. will have a clear sense of their values, goals, apd capabilities and a belief in their importance. Committed individuals have a generalized sense of purpose that allows them to identify and find meaning in the events, things, and persons in their environments. By viewing events and people in a meaningful context, 129

PAGE 148

committed .individuals are more likely to cope in a manner characterized by activeness and approach rather than passivity and avoidance (Maddi & Kobasa, 1984). Commi-,:.ted persons view stress as a part of life, not always as a negative entity. For those high in commitment, events are viewed as meaningful and interesting despite their stressfulness; stress is kept in perspective (Kobasa, Maddi, Puccetti, & Zola, 1985). Committed individuals are invested enough in themselves and their relationships with their environments that they cannot easily give up under pressure (Kobasa, Maddi, & Kahn, 1982). Commitment and Positive Cognitive Appraisal. It is the positive cognitive appraisal of stressful events characteristic of individuals high in commitment that is \ the key to' viewing these events as meaningful and interesting. One study found a strong correlation between and a positive attributional style (Hull, Van Treuren, & Propsom, 1988). It is a negative attributional style, or negative affectivity, which is characteri.stic of depressed individuals (Rhodewalt & Zone, 1989). In view of the importance of a positive cognitive appraisal in individuals high in commitment, it is easy tounderstand the strong explanatory power that the dimension commitment has for depression. 130

PAGE 149

Commitment and Existential Personality Theory. In order to further understand the importance of the role commitment plays in protecting individuals against burnout and depression, it is helpful to turn to existential personality theory, which forms an essential part of the theoretical background for the hardiness concept. Existential psychology views the primary task of an individual to be the search for and establishment of meaning (Kobasa & Maddi, 1977). It argues that a person can take hold of her/his own life and shape it through an. active process of decision making. It holds the view that life is by its nature chaotic and threatening, and those persons live best who are able to recognize the challenges of life and respond to them forthrightly (Kobasa & Maddi, 1977). Victor Frankl (1963) shifted to existentialism in his attempts to understand his experiences as a prisoner in a World War II concentration camp. It is his belief that it is the ability to create one's own individual meaning in life which enables individuals to survive even the most severe stressful experiences. In summary, it would appear that individuals high in commitment have a positive cognitive appraisal style which enables them to view the events, situations, and people in their lives in a positive light and are able to 131

PAGE 150

create meaning in their lives even under considerable stress. on our understanding of burnout and it seems clear that these attributes would provide a significant protective force in defending individuals high in commitment from both burnout and ,, depression. Response Mode to Burnout One o.f the goals of this study was to examine further concept of response mode to burnout, building on the work of Golembiewski and his colleagues (see Golembiewski & Munzenrider, 1988b, for a review). This study pred:icted that the active response mode to burnout would be' positively related to hardiness, that the active response mpde to burnout would be negatively related to burnout, a,nd that there would be a strong correlation between the passive response mode to burnout and depressioh. overall, these predictions were supported by the data. Following the more recent work of Golembiewski and Munzenrider (1988b), response mode to burnout was determineq using a surrogate measure developed by employing.three subscales of the Work Environment Scale (Moos, 19.86). Scores for these subscales (involvement, autonomy, and task orientation) and a composite score for the acti v:e 'response mode to burnout had strong positive 132

PAGE 151

'I 1', '' correlatipns with hardiness and the hardiness subscales. ' Thus, hardy individuals are more likely to have an active I response to burnout. Based on the subscale correlations, hardy individuals are also more likely to I f feel autonomous, to be committed to their work, and to have an emphasis on getting the job done. '' Out of the sixteen correlations as described above, only the cbrrelations between challenge and task orientation and challenge and involvement failed to reach ',. statisticki It should be noted that the '' ' correlation between challenge and autonomy was of less I magnitude: other correlations in this data set and I that this' correlation was only marginally statistically This again raises the issue of the strength of the c:ha:ilenge dimension. I Correlation data supported the predicted inverse I relationship between burnout and the active response mode to burnout. Victims of burnout will be less committed to their jobs., will experience less autonomy, and will have less on getting the job done. Individuals with higher le;v1els of emotional exhaustion and and with lower levels of personal are less likely to have an active response mode to burnout. 133

PAGE 152

Based on prior research and descriptions of victims of burnout'with a passive response mode, a close relationship between the passive response mode to burnout and was suspected. This study lends support to that notion. There is an inverse relationship between the active response mode to burnout and depression. Burnout victims with a passive response mode will have higher levels of depression. There is also a statistically significant inverse relationship between depressioh'-' and involvement and depression and task orientation. Depression negatively affects the degree to which an individual is committed to hisjher job and the degree to which there is an emphasis on getting the job done. The literature states that depression is '., ' characterized by feelings of worthlessness, helplessness, hopelessness, and apathy (Yager, 1989). Given these symptoms, :it is reasonable to find that victims of depression place less emphasis on getting the job done (task orientation) and are less committed to their work ( invol The correlation between autonomy and depression did not reach statistical significance. This finding indicates. '.that for the subjects in this study, depression does not affect the degree to which an individual feels 134

PAGE 153

to be self-sufficient and to make herjhis own decisions. As discussed in Chapter Four, this finding appears to be contrary to the literature on depression. Further study is needed to determine whether this finding is anomalous or whether some depressed individuals are able to maintain their self-sufficiency. This study supports the importance of the concept of control as central to hardiness and depression. Given the of control, a model of depression developediby Wortman and Brehm (1975) offers further explanations for the active and passive response modes to burnout. This model maintains that the nature and intensity of an individual's response to an uncontrollable outcome depends on both an expectation of control over the outcome and the outcome's importance. I', Their proposes an invigoration-depression sequence of events: in which individuals who expect to be able to influence, ,an important outcome will exhibit angry and aggressive behaviors in the face of loss of control. As they continue to experience unsuccessful attempts to alter the: outcome, expectations of control will diminish. When they' no longer make attempts, passivity and depression will occur. Individuals who never expected to be able to influence the outcome will become depressed in the face o'f lack of control without an initial period of 135

PAGE 154

"invigoration." Wortman and Brehm (1975) argue that the greater the expectation of control a person has, the more controlling behavior that person will show prior to giving up, and the greater will be the subsequent depression:. Variables This study predicted that there would be no relationships among demographic variables and burnout,, hardiness, depression, or the response mode to burnout. The only instance in which this hypothesis was not involved the critical carejnon-critical care dichotomy. As described in Chapter Four, when subjects were divided into critical care and non-critical care it was found that the critical care nurses in this study' have higher total burnout scores, higher depersonalization scores, and lower task orientation scores their non-critical care counterparts These data must be viewed with caution. As discussed in Chapters Three and Four, there were sampling problems with the critical care nurses. These sampling problems resulted in uneven sampling of the critical care nurses both hospitals. Also, the high burnout and depression;:scores for the coronary care, telemetry, and neonatal intensive care unit nurses from Hospital B may have the data. Additional research needs to be 136

PAGE 155

done to further exqmine these variables before any conclusiops can be drawn. Challenge:: The Problematic Variable In tpis study all variables consistently and strongly correlated with each other in the direction expectedwith few exceptions. The exceptions to this trend primarily to the challenge subscale of hardiness.: Specifically, the correlations between challenge, and depersonalization, challenge and task orientatic;;,n, and challenge and involvement did not reach I statistica:l In the regression analyses, challenge entered regression equations only twice. I I Although ft was the first variable to enter the equation when the variable was depersonalization, it provided :only slight explanatory value (r squared = .1613). depression as the dependent variable, I challenge was the fifth variable to enter, making only a slight contribution to the regression equation (r squared ' change of: only 04) Also the correlations involving challenge :which did reach statistical significance were i :! consistently of less magnitude than the other variable I I' correlati!dns. I Altho,ugh these findings are not provocatively damning, iin light of recent criticisms of the challenge dimension.in the literature, they deserve note. 137 0

PAGE 156

Specifically, in a number of studies, the challenge subscale either did not significantly correlate with outcome measures (Rich & Rich, 1987; Schlosser, 1986; Magnani, 1986; Manning, Williams, & Wolfe, 1988; Roth, Wiebe, Fillingim, & Shay, 1989), or it yielded an effect in the opposite direction of commitment and control (Hull, Van. Treuren, & Propsom, 1988). Another criticism of the hardiness construct discussed in Chapter Two addresses the variety of instruments used to measure hardiness. Besides making it difficult to compare the findings of different studies, these changes in the instrument make it difficult to utilize the reliability and validity findings of other researchers. Challenge: A Part of Commitment? As conceptualized by Kobasa, (1979), the idea of challenge is key to the hardiness construct. However, it may be that rather than being a separate dimension, it may be more appropriate to view challenge as a part of the commitment dimension. Kobasa (1979) agrees that the components of hardiness are "inextricably intertwined" aspects that bear a resemblance to one another. The P!=>sitive cognitive appraisal style of committed individuals is congruent with the ability of individuals high in challenge to view change in a positive light and 138

PAGE 157

as an opp9rtunity for learning and growth. In this respect it would appear that the characteristics of challenge, as conceptualized by Kobasa (1979), are a component of commitment. Thus, the concept of challenge I is an important piece of the commitment dimension of hardiness. Based on this and other studies, it would seem that the status of the challenge dimension is equivocal. However, there. is not evidence available to fully '' support refute criticisms of the challenge dimension. It remains to be determined if it is simply a matter of whether the measurement of this dimension is inadequate, or whether' challenge is more appropriately viewed as a part of commitment, or whether challenge as a dimension of hardiness is theoretically invalid. A Self-efficacy Model of Burnout The of this study highlight the interrelationships of the concepts of burnout, hardiness, depression and response mode to burnout. This study also supports the importance of commitment and control to burnout, depression, and response mode to burnout. Given these connections, a search was begun for a model that might serve as a theoretical umbrella for all of these concepts and thus serve as an integrative 139

PAGE 158

theoretical framework for burnout. Self-efficacy appears to have significant utility in this respect. Self-efficacy is a central component of Bandura's (1977) social learning theory (see Appendix F for a more detailed discussion of self-efficacy and social learning theory). Self-efficacy refers to people's beliefs about what they'can achieve. The degree of self-efficacy one has is determined by the individual's confidence in the level of task difficulty she/he can attain, the degree to which this. confidence can be generalized across situations, and the strength of conviction she/he has about mastery. Self-efficacy perceptions are influenced by information obtained through repeated performance accomplishments, vicarious experience, verbal persuasion, and one's physiological state (Bandura, 1982). The concept of locus of control is central to self-efficacy but is not the same thing as self-efficacy (Gist, 1987). In comments on learned helplessness and depression earlier in: this chapter, it was argued that a perceived inability to influence those things which significantly affect onels life (external locus of control) will lead to undesirable outcomes. Self-efficacy theory argues that these outcomes are futility and despondency and identifies two judgmental sources of futility (Bandura, 1982). People may give up because they doubt their 140

PAGE 159

and do not believe they can accomplish what needs to be done. Or, they may give up even if they believe that they have the required capabilities because they "expect their efforts to produce no results due to the unresponsiveness, negative bias, or punitiveness of the environment" (Bandura, 1982, p. 140). Bandura (1982) argues that behavior may be predicted by considering both self-efficacy and outcome beliefs. In his model individuals with high self-efficacy operating in a responsive environment will have assured, active responsiveness. Individuals with high self-efficacy operating in an unresponsive environment will intensify their efforts to achieve their goals and may try to change the environment through protest, activism, and collective efforts. If change is not possible, people will leave their current environments given reasonable alternatives. Individuals with low self-efficacy in an unresponsive environment will give up readily and become apathetic and resigned. Individuals with low self-efficacy in a responsive environment (i.e., they see similar others succeeding) will become self-disparaging and depressed. Based on the reformulated theory of helplessness, the expectancy of inability to control stress is a sufficient condition for learned helplessness and 141

PAGE 160

depression; to develop. Thus, experience with uncontrollable stress does not always result in helplessness and depression. This also explains "why the same uncontrollable stressor may result in depression in some individuals and not in others the expectancy of a future lack of control over stress is presumed to be the causal agent" (Garber, Miller, & Seaman, 1979, p. 352). Bandura's (1982) self-efficacy model has utility for I I expla1n1ng the development of burnout and the role of depression in burnout. Figure 5.1 depicts the interactive effects of perceived self-efficacy and outcome expectations of the environment on behavior and affective reactions. 142

PAGE 161

Figure Interactive Effects of Perceived Self efficacy and Expected Environmental Outcomes. outcome expectations of the environment perceived self-efficacy + social activism protest milieu change resignation apathy depression/ burnout + assured, opportune action self-devaluation despondency depression/ burnout NOTE: "Self-efficacy mechanism in human agency" by A. Bandura, 1982, American Psychologist, 37(2), p. 140. Copyright' l982 by the American Psychological Association, Inc. Adapted by permission. This model of burnout is similar to Meier's (1983) conceptualization of burnout. Meier believes that burnout develops when individuals expect little reward and considerable punishment from work because of a lack of valued reinforcement, controllable outcomes, or personal competence. Based on the self-efficacy burnout model outlined above, the person with moderate to high self-efficacy functioning in an environment in which one expects positive outcome expectations will have psychological well-being and performance success (Bandura, 1982). The competent person with moderate to high selfefficacy functioning in an environment in which she/he 143

PAGE 162

expects negative outcomes will persevere in their efforts and will make attempts to change the environment (Bandura, 1982). If no environmental changes occur, it is likely that the person will leave in favor of a situation :'!'-'hich provides a better chance of positive outcomes (a possible explanation for the high turnover rates frequently found in nursing). I I The competent person with moderate to high self-efficacy in a negative environment might choose not to leave but rather to continue to exert efforts toward environmental change. The stronger a person's belief is in effectiveness, the greater and more persistent her/his efforts will be. Strong perseverance may pay off in performance accomplishments (Wood & Bandura, 1989). According the theory of learned helplessness, if perseverance does not effect more positive outcomes, the person will eventually develop an expectation that outcomes are uncontrollable and become inactive and depressed (Abramson, Seligman, & Teasdale, 1978). The with low self-efficacy operating in an environment with expected positive outcomes (i.e., they see similar others achieving success) is most likely to be self-critical and become depressed (Bandura, 1982). It may be that the similar others are objectively achieving .success, or it may be that the low-efficacy :I 144

PAGE 163

person is.only perceiving higher success levels for others. lt is possible that the person entering a new environment is already depressed and will have the negative attributional style and stringent selfcriteria characteristic of depressives (Rehm, 1977). may require greater quantitative or qualitativ.e excellence for self-approval, may set higher goals for themselves, and may overgeneralize failure in one area to failure in an entire class of behavior (Beck, 1967). Depressives are characterized by relatively low rates of and high rates of self-punishment (Rehm, 1977). Victims of depression also tend to underestimate the amount of positive reinforcement they receive (Garber, Miller, & Abramson, 1980). A person with low operating in an environment with expected negative outcomes will give up fairly readily and become apathetic and depressed (Bandura, 1982). and the Active and Passive Response Modes to Burnout. Golembiewiski's concept of active and passive response modes to burnout is congruent with this model of The state of resignation described.by Golembiewski (1984a) as indicative of the passive response mode is one of the affective reactions of the low self-efficacy individual to an unresponsive or 145

PAGE 164

punitive environment (Bandura, 1982). The high activity levels exhibited by the high to moderate self-efficacy person in the negative environment is comparable to behavior observed in some burnout victims (Freudenberger, 1977a; Freudenberger & Richelson, 1980b; Cherniss, 1980c). These high activity levels are also exhibited by burnout victims in an active response mode (Golembiewski, 1984a). As discussed earlier, the high self-efficacy person may develop low self-efficacy and depression in the face bf continued efforts which do not effect environmental change. Thus, it may be that the high activity levels of the person with high to moderate of self-efficacy are a precursor and warning of the development of low self-efficacy and the debilitating outcomes of apathy and depression. This sequence of high activity levels followed by low activity levels is consistent with the invigoration-depression model of W:ortman and Brehm (1975) discussed earlier in this chapter. A period of frenetic activity followed by resignation has been observed clinically (Freudenberger & Richelson,, 1980b) and has been speculated upon based on a phase model of burnout (Golembiewski & Munzenrider, 1988b). and the Maslach and Jackson Theory of Burnout. This self-efficacy model of burnout does not 146

PAGE 165

conflict with the theory of burnout proposed by Maslach and Jackson (198la). The somatic symptoms experienced by victims of: depression, such as decreased energy level, headaches, and loss of appetite, are often found in victims of burnout. The dimensions of emotional exhaustion, depersonalization, and decreased personal accomplishment can be understood in terms of low self-' efficacy and depression. : In alstudy by Jackson and Maslach.(1982) the feelings of lack of control characteristic of low self-efficacy and depression were also found linked to feelings of emotional exhaustion. Workers suffering from emotional, exhaustion find that their resources are depleted to the point that they no longer can give of '. themselves at a psychological level (Maslach & Jackson, : : 1986). This description of depleted resources could also be used to'describe workers suffering from depression. as described by Maslach and Jackson o .. 981a), has also been cited as being associated with depression (Hamilton, 1989) and anxiety (Yager, 1989). Maslach and Jackson (1981a) describe decreased personal as "the tendency to evaluate oneself negatively, particularly with regard to one's work with' plients. Workers may feel unhappy about 147

PAGE 166

themselves and dissatisfied with their accomplishments on the job" (p. 1). As discussed earlier, the tendency to evaluate opeself negatively is typical of the negative attributional style (Sweeney, Anderson, & Bailey, 1986), overgeneralizations of failure (Beck, 1967), and stringent self-evaluative criteria (Rehm, 1977) found in depressives. Depression. and Hardiness. For a number of reasons, it appears that depression low hardiness are closely related; and there is some argument that they may be the same thing. First, the findings of this study. show a strong, statistically significant, inverse between hardiness and depression. Second, as. outlined in Chapter Two, there is analytical support for the concern that the hardiness instrument may be measuring depression or a similar form of maladjustment. Third, a major component of both depression and hardiness is the concept of control. Fourth, depression and low hardiness share a negative attributional style (Hull, Van Treuren, & Propsom, 1988). Fifth, there are similarities between characteristics of an individual with low commitment and the loss of interest (anhedonia) found in depressives (Kaplan & Sadock, 1989). 148

PAGE 167

; Not only do hardiness and low self-efficacy have much in common, but it may be that what the hardiness instrument: is actually measuring is self-efficacy. First, there is once again the common central theme of control in, both self-efficacy and hardiness. Second, the descriptions of the varied early environment needed to develop commitment and control (Maddi & Kobasa, 1984) bear a very close resemblance to the environment needed for the development of self-efficacy (Bandura, 1981). I In summary, the self-efficacy model of burnout is consistent: with the Maslach and Jackson theory of burnout and with Golembiewski's conception of response modes to burnout. within the self-efficacy model of burnout locus of learned helplessness and depression find another home. In this model of burnout, the concepts of hardiness and those of self-efficacy are so intertwined that boundaries are unclear; and it is difficult determine where one ends and another begins. This raises the question of whether or not hardiness and self-efficacy are one and the same thing. The self, efficacy model of burnout accounts for why some in the same environment will experience depression and burnout and others will not. This model of burnout' .. also explains, at least in part, why nursing turnover rates are often very high. Given the potential 149

PAGE 168

i. that the self-efficacy model of burnout has for incorporating the many issues enumerated above under one umbrella, it deserves serious consideration for further empirical exploration. Person-Environment Fit versus Reciprocal Determinism In chapter Two the person-environment (P-E) fit theory was suggested as a model which might best provide an explanation of burnout. However, social learning theory argues against the dyadic interaction of the P-E fit theory in favor of a triadic reciprocal interacti9n (Bandura, 1978c). This triadic interaction, or reciprocal determinism, takes into account the fact that one's.environment is partly of one's own making. Behavior,' internal personal factors, and environmental influencesall operate as "interlocking determinants" of each other: (see Figure 5.2) (Bandura, 1977). For example, individuals effect different environmental I I reactions based not only on their behavior, but also on factors such as physical appearance (e.g., sex, race, attractiveness), and social attributes, roles, and status (Bandura,.1.978c). In this theory, different sources of influences may have different strengths, and reciprocal not occur simultaneously. Because influences are bi-directional, people are both producers and products of their environment (Wood & Bandura, 1989). 150

PAGE 169

In light of a self-efficacy model of burnout, the theory I', of reciprppal determinism would appear to be more germane than that of P-E fit. ,. Figure Schematic Representation of Two Alternative Conceptions of Interaction. (B signifies behavior, P the cognitive:and other internal events that can effect perceptions and actions, and E the external environment.) : P-E Fit (Partially Bi-directional) B = f (P ( ) E) RECIPROCAL p B E NOTE: "The self system in reciprocal determinism" by A. Bandura, 1978, American Psychologist, 33(4), p. 345. Copyright 1978 by American Psychological Associati9n, Inc. Reprinted by permission. The Self-e;fficacy Model of Burnout and the Profession of Nursing Like Maslach and Jackson (1981a) model of burnout, the self-efficacy model of burnout is germane to all helping professionals. Using one of these professional groups, nurses, it will be argued that many of the facing nursing today can be understood in I terms of the self-efficacy burnout model. Nursing will be discussed in the context of two key factors in the self-efficacy model, control and environmental feedback. 151

PAGE 170

Nursing and Control. There are a number of issues relating tq lack of control that have a significant effect on nurses. Some of the issues that have been found to be among the major causes of job dissatisfaction among nurses are problems dealing with physicians and administrators, bureaucratic interference in nursing practice, conflicting demands, role ambiguity, little influence :in changing working conditions, and overload (Pines & Kanner, 1982: Buerhaus, 1987; Sigardson, 1982: Bishop, 1983). In spite of the many contributions of Florence Nightingale to nursing, it was she who set the stage for the control of physicians over nursing in the Crimean War (Kalish Kalish, 1978). In order to obtain the permission of physicians to let her nurses care for the wounded, she agreed that the nurses would do only that which the physician deemed necessary. Thus, all nursing work origh'iated from the doctor's orders and nursing became a part of the physician's work rather than an independent entity (Freidson, 1972). over 100 years later, nur$es continue to have only partial autonomy, having only "secondhand" power which is limited by the "dominant profession" of medicine (Hiestand, 1966). In a way unparalleled in any other profession, medicine has been able to achieve a "singular degree of economic power 152

PAGE 171

and cultural authority" (Starr, 1982, p. 29). In contrast to physicians, nurses are handicapped by a "resource deficiency arising from . the apolitical tradition inherent in the political socialization of nurses and women" (Kalish & Kalish, 1982, p. 58). A major dilemma for the nurse 11is that while she may expect to with professional independence of judgment in certain areas of work, many doctors will expect her to behave only as an obedient extension of their own professional judgment" (Kramer, 1974, p. 21). Unlike physicians, nurses have been unable to achieve unqualified recognition as professionals. While nurses think of themselves as professionals, sociologists continueto refer to nursing as a semi-profession (Levi, 1980). This ambiguity over professional status has i implications for the control nurses have over nursing practice in the areas of autonomy, evaluation of their work by persons outside of the profession, prestige, and political power (Freidson, 1972). Nursing is predominantly a woman's profession and, as such, is affected by and reflects the position of women in our society today. Many issues of major concern to women in general are directly related to those concerns confronting the nursing profession. The struggles of nurses for greater autonomy and power are 153

PAGE 172

influenced1 by the fact that most institutions, including those providing health care, are controlled by men. One ot the problems concerning nurses which plays a role in struggle for professional recognition is nursing'spublic image. This has had an influence on both professional status and economic issues. Judge (1974) argQes that health care consumer groups have not brought pressure in support of higher salaries and more I, professional status for nurses because of the image of I" hospitals! as charity institutions and nurses as service I workers. about autonomy and professional status I has contri:puted to another major stressor for nurses, role ambiguity. The traditional distinction between the medical and nursing professions asserts that the roles of physician:and nurse are clearly defined and separated, with phys.i:pians functioning to cure patients and nurses functionihg to give care. However, observations of nurses at: !work suggest that such a clear distinction between roles is more theoretical than real. Nurses are often fouhd giving medical advice to physicians, albeit in subtle ways (Stein, 1967), and carrying out procedures that are supposed to be the exclusive domain of the '' physician JMaslach & Jackson, 1982). A study by Jacobson (1978) found that physicians sometimes encroach on what 154

PAGE 173

nurses perbeive to be their jurisdiction (e.g., a r physician telling a patient that breast feeding her I premature infant was too much trouble after nurses had spent considerable time supporting the mother's desire to and making arrangements for her to do so). Conversely,, physicians often shift their responsibilities onto the nurse (e.g., leaving nurses to tell parents that their baby: had died, or leaving the nurse to decide whether or. not life support should be continued 1978]). Nurses often feel unable to exercise control, either over the of the physicians with whom they are closely interdependent or over the decision of the administrators who determine the hours and conditions of their work' (Maslach & Jackson, 1982). Following is a sample of of the situations about which nurses complain:physicians who fail to show up for physicians who schedule surgery without informing' the nurses, physicians who disappear without leaving word of where they can be reached in an emergency (Maslach & Jackson, 1982), the use of outside agency nurses who do not have intensive care experience in intensive care units, the reluctance of some physicians to transfer patients out of intensive care when that level of care is no longer indicated, being required to 155

PAGE 174

care for patients with no hope of recovery, : and the lack of involvement in discussions concerning the treatment .of patients (Bishop, 1983). There are many aspects of caring for patients that are out of: the control of the nurse which may cause considerable distress among nurses who have not come to understand: the limitations imposed upon all health care Modern medicine is not sufficiently advanced to the medical problems of all patients, or treatment. can be offered only to a level short of what is needed. These inadequacies can cause considerable turmoil for nurses. I' Even' the means for treating a patient are I known, "the success of the treatment may be sabotaged by an patient who refuses to follow prescribed I treatment!3" (Maslach & Jackson, 1982, p. 236). Lenrow i t (1978a) uses the term the "dilemma of interdependence" to ',' describe the situation in which the effectiveness of the health provider in terms of how sjhe can benefit a patient is dependent on something the health care provider eannot control, namely, the relationship between the and the recipient I The process of decision making can sometimes be a major of stress for health professionals who want to make based on adequate data, who are forced 156

PAGE 175

' I I to make "rapid, complex, and critical" decisions based only on inadequate data (Patterson, craven, Schwartz, Nardell, & Noble, 1985). Conflicts about death can also be a source of stress. "Because death is usually viewed as an adversary to be fought and overcome, ., adying becomes a visible sign of the failure and powerlessness" (Maslach & Jackson, l982, p. Feedback and the Nurse. In addition '' : I to feedback from the environment is another major factor in the self-efficacy model of burnout. In a I study by Maslach and Jackson (1982), they found that not '. only is about one's performance very important to nurses; :it was especially important for the maintenance of a positive self-evaluation. Nurses who I feedback were higher in emotional exhaustion,: and depersonalization and lower in personal That there is often a lack of positive feedback ftom nursing administrators and nursing ' discussed in Chapter One. There are also a number of reasons why nurses frequently do not receive positive fe.edback from patients andjor their families. First, individuals are injured or ill, they and their fam:i,.lies and friends are often experiencing considerable stress. This may result in nurses hearing 157

PAGE 176

only compiaints and criticisms about the job they are '" doing; and in some instances, they may even be "the targets of:hostile remarks or even threatening actions" (Maslach & Jackson, 1982, p. 242). Second, nurses often receive a lack of feedback by virtue of the kind of work they do. 'That is, once patients no longer need their care, they.are gone. This may be particularly true for nurses and intensive care nurses, since patients have been unconscious or so ill that they have no memory of the care they received from nurses in these areas. Third, some patients cannot give feedback to the nurses caring for them because of their condition. Nurses often care for comatose or similarly disabled patients for extended lengths of time with no response from the patients. Fourth, the current shortage of nurses can result in understaffing and unreasonably large case loads. Patients who are recipients of the rushed care that may be all the nurses can provide may not be "eager to shower the nurses with appreciation and affection" (Pines & 1982, p. 30). Fifth, the work of helping is often taken for granted, so that many individuals think there is only a need to provide feedback there are problems (Maslach, 1981). This response compounded by the fact that the standards set 158

PAGE 177

,'I ,. by society for helping professionals are so high that they may l;>e impossible to attain. The Nurse and High Expectations. According to the self-efficacy theory of burnout, futility will lead to burnout when there is a discrepancy between a person believes sjhe can accomplish and i ', the perceived outcomes of her/his behavior. Storlie (1979) views burnout as a problem primarily related to '. resignation, and powerlessness in which the realitfes of one's job are in conflict with one's personal l:;>eliefs and ideals. She argues that "burnout is '. resignati9n to a lack of power -the perception that no i matter what you do or how hard you try, you cannot make a differenc! . 11 (Storlie, 1979, p. 2109). I In particularly among less experienced I nurses, 1s often a wide gap between the one has about what sjhe will be able to accomplish and what one is actually able to achieve. It has been that idealistic and dedicated young professionals are particularly susceptible to burnout ,, (Freudenberger & Richelson, 1980a; Storlie, 1979; Edelwich &arodsky, 1980). I In a1extensive study, Kramer (1974) described the new graduate nurses to their first work situation. She used the term "reality shock" to describe 159

PAGE 178

the widespread reaction of novice nurses to the realization that they are unprepared for their new jobs, and that many of the professional ideals and values that I were stress.ed during their nursing education are not operationai and go unrewarded in the "real" world. i It is role deprivation that is central to the concept of:. "reality shock." Corwin (1960) defines role deprivation as the disparity between idealized role that which is found operable and sanctioned'in the work situation. Choosing a helping profession often indicates a high need for helping others. sqme of these idealistic helpers will be unable I to readjust their expectations and will develop burnout (Savicki & Cooley, 1983). Kramer (1974) found that in some instances the reaction to the discovery of the disparity between "school-bred" values and "work-world" values was so strong that nurses were unable to continue in their j,obs. Kramer (1974) argues that it is the confusion, frustration, sense of failure, and despair that results from "reality shock" that is a major contributor to job-hopping and the exodus of nurses from practice. It is .not only inexperienced nurses who struggle with failed expectations (Brief, Aldag, Van Sell, & Melone, 1919). More experienced nurses may be 160

PAGE 179

disappointed in new jobs in specialized nursing units (e.g., a dialysis unit) that they thought would be challenging and exciting, which soon became monotonous and boring (Pines & Kanner, 1982; Bishop, 1983). With the rapid changes in health care in recent years, there have been concurrent changes in the type of nursing care required for many patients. Experienced nurses whose expectations were formed in the 1960s and 1970s may find that their expectations are no longer germane to nursing in the 1980s and 1990s (Paine, 1981). Many experienced nurses who are able to cope with the 'physical and "emotional" stresses of their jobs are still unable to come to terms with the "frustrated hopes and aspirations that originally had been the reason for their choice of nursing as a career" (Pines & Kanner, 1982, p. 33) The socialization process that occurs in nursing education not only promotes unrealistic expectations, it also raises issues of competency for new graduates (Kramer, 1974). Kramer (1974) quotes one director of nursing who has observed in new graduates an "amazing lack of self-confidence a fear of her own inadequacy . limited self-assurance" (p. 29). There:are a number of ways in which inexperienced nurses have their confidence shaken. First, Kramer 161

PAGE 180

.' (1974) fotirid a major difference between the method of organizing:the work as taught in school (what she called ., the professional model) and as it is practiced in the work she called the bureaucratic model). Second, the new nurse often has skills primarily in the areas of instruction and counseling and the planning arid coordination of patient care, and a lack of technical ;knowledge and skill, qualities highly valued in the work (Martof, 1985; Brief, Aldag, Van Sell, & Melone, 1979; Kramer, 1974). Third, experienced nurses : I sometimes contribute to the neophyte's lack of confidence by expressing a lack of understanding and patience when asked to assist a new graduate Fourth, many helping ... have a tendency to deny or avoid revealing any thougtit:.s that might be considered "unprofessional" by ' their and to behave as if one were in control I .. of one's job (Maslach, 1981). This tendency results in I':. "pluralistic ignorance which leads to the belief that I I, one's reaqtions and insecurities are unique and not shared by qthers. Pluralistic ignorance makes it difficult others to offer help and for the nurse to : ask for which precludes many opportunities for I '[ learning increased competence. 162

PAGE 181

Summary relates to peoples's beliefs in their abilities 'to mobilize the resources needed to exercise control over events in their lives and arises from the acquisition of skills through experience (Bandura, 1977). A perceived inability to influence those things which significantly affect one's life (external locus of control) dan lead to undesirable outcomes such as learned helplessness, depression, and burnout. The high activity levels exhibited by the high to moderate self-efficacy person in a negative environment are to the activity levels seen in burnout victims with an active response mode, and in the invigoration phase of the Wortman and Brehm (1975) depression, model. The three dimensions of burnout as conceptualized by Maslach and. Jackson (1981a) are consistent with the affective behaviors of individuals with low self-efficacy and The dimensions of commitment and control central to the concept of hardiness are also central to the concept of self-efficacy. There is great similarity between low hardy and low self-efficacy individuals and between high hardy and high self-efficacy individuals. 163

PAGE 182

Many of the issues facing nursing today can be understood using a self-efficacy model of burnout, addressing issues of control and feedback. Implications The findings of this study confirm that individuals high in hardiness will experience less burnout and depression,that depression is an important component of burnout, that there is a relationship between the passive response m0de to burnout and depression, and that demographic-variables offer little value in the prediction of burnout. These findings have significant implications for managers in terms of screening for burnout, hardiness, and depression, planning interventions designed to decrease burnout, developing assistance for workers suffering from depression, and in exploring programs in the workplace that can help employees develop hardiness. Based on the significant relationship between burnout and.hardiness, it would seem that the measurement of hardiness in the workplace has merit. To facilitate I this process, these data indicate that it might be possible to use the commitment dimension of hardiness as an effective, fast-screening device. 164

PAGE 183

According to Kobasa (as quoted in Wood, 1987), it is possible to stimulate hardiness in adults who do not display it. A group counseling approach used by Maddi (as reported by Kobasa in Wood, 1987) can be used to carry hardiness into the organizational setting. Kobasa (as quoted to Wood, 1987) believes that systems interactions for encouraging the expression of hardiness can be developed. She believes that organizations can be changed in such a way as to foster greater hardiness among its members. The significant role that depression plays in low hardiness and burnout has been underestimated in,the past and deserves more consideration than it has been given previously. The debilitating effects of depression are well known. The effects that depression can have are of concern not only in terms of the individual, but the impact of depression also raises serious concerns at the organizational level. It is not possible for victims of depression to be totally functioning organizational members. In. nursing, the disabling effects of depression have serious implications for patient care. The apparent high incidence of depression also has implications for burnout interventions. Many of the interventions aimed at decreasing burnout currently in use are inappropriate for victims of depression. These 165

PAGE 184

interventions require a level of participation difficult, if not impossible, for an individual suffering from depression. Not only will these interventions be but they also have the potential to be harmful when they are directed at workers suffering from depression. It would be prudent to screen for depression prior to beginning such an endeavor. For workers suffering from depression, less demanding interventions need to be planned. Future Research This study has answered some questions about burnout and its relationships with hardiness, depression, and response modes. However, many questions remain unanswered; and new questions have been raised. Following are some of the areas for further research suggested by this study. 1. There is a great need for longitudinal studies of burnout. Such studies would provide a clearer picture of the onset and progression of burnout and would enable us to establish causation. It would be possible to answer questions such as whether individuals first experience burnout and subsequently develop depression, or whether 166

PAGE 185

individuals experience burnout because they are depressed, or both. 2. There is a need for triangulation in the study of burnout. The collection of quantitative data in conjunction with confirmatory case studies would be very helpful in shedding additional light on this subject. This study could be used as a framework to observe nurses in the workplace. An ethnographic method of research, such as participant observation, has potential for adding depth and richness to the current research on burnout. 3. The response mode to burnout deserves further study. It would be helpful to know if the active response mode is' a precursor to the passive response mode and might, as such, act as an indicator that some type of intervention is needed to prevent high levels of burnout from developing. It is important to make more explicit the relationship between the passive response mode to burnout and depression. An evaluation of the instrument used to measure response mode to burnout is needed before further research is conducted. Although the Work Environment Scale has been found to be highly and valid, the three subscales of this instrument used to measure response mode have not 167

PAGE 186

been adequately examined in terms of their use as a surrogate measure for response mode. 4. There is a need for both conceptual and methodological refinements of the hardiness instrument. The instrument used to measure hardiness needs to be standardized, and studies of its validity and reliability need to be performed. TQe challenge dimension of hardiness clearly requires further study to determine whether it is a valid dimension of hardiness, whether it is a component of the commitment dimension, or whether it needs to be eliminated from the hardiness construct. 5. In this study there was not a statistically significant relationship between autonomy and depression. Based on the literature on depression, one would expect to find autonomy inversely related to depression. This surprising finding deserves further study. 6. There is considerable need for studies to tease out the relationships among depression, burnout, low hardiness, attributional style, external locus of controi, and helplessness. We need to determine where these entities overlap and where they differ. An examination of the instruments used to measure these conceptions is needed to determine 168

PAGE 187

whether these instruments are, in fact, measuring separate concepts (e.g., depression, burnout, low hardiness) or whether they are measuring some general type of maladjustment. 7. A self':""efficacy model of burnout merits evaluation. It is rich in heuristic value and has the potential for being able to integrate many of the concepts discussed in this study. Closing Comments It is clear that the concepts of hardiness, selfefficacy, burnout, response mode to burnout, and depression are complexly interwoven. Rather than disentangling them, the central question might be how to find a way to amalgamate them. It is possible that the salient issues present in these entities might find a source of explanation in existential personality theory. It may be that the individual high in hardiness and selfefficacy is the authentic person described in existential personality theory. As described by Kobasa and Maddi (1977), the authentic person is well integrated and demonstrates originality and change. The authentic person has a basic orientation toward the future, and its associated uncertainty, and accepts anxiety as a necessary part of 169

PAGE 188

vigorous living. The primary task of man according to existential personality theory is the search for, and establishment of, meaning in herjhis life. The concept of the authentic individual provides an explanation for why some individuals become depressed and burned out in certain settings while others do not. For example, the fact that few oncology nurses experience depression burnout may be a result of the oncology nurse's ability to find meaning in herjhis work that is different from the more frequent goal of the nurse (to help individuals toward wellness). That is, the oncology nurse may find meaning in helping her/his patients to find comfort (both physical and psychological) and peace in dying. Extending this thinking one step further, it may be that depression, burnout, low hardiness, and low selfefficacy are a type of existential depression, existential neurosis, or existential malaise. If this is true, clear prescriptions for treatment are available. Existential psychotherapy which has been primarily used at the individual level can also be adapted for use at the group or organizational level. On the road to authenticity, individuals learn that they need not be victims, that the disappointments and limitations in life do not need to spawn resignation and 170

PAGE 189

passivity. As they travel this road, they also learn that one can accept inevitabilities and can sharpen one's perceptions of what can be accomplished through commitment and personal effort. They learn that the authentic person can be proactive and can effectively influence her/his environment. They realize that they can be influential rather than hopeless when facing the varied contingencies and stresses inherent in today's modern, industrialized world. Perhaps it is the development of authenticity that will ultimately provide the hope, courage, and self-confidence that will guard against the development of burnout and depression. 171

PAGE 190

APPENDIX A QUESTIONNAIRES AND COVER LETTER 172

PAGE 191

Dear I NEED YOUR HELP! 345 Franklin Street Denver, Colorado 80218 November 22, 1988 I am a nurse of 21 years currently working on my Ph.D. in public administratiori at the University of Colorado at Denver. As part of the research related to my dissertation I will be collecting information from staff nurses at two hospitals in the Denver Metropolitan Area. The hospital where you currently work is one of the study sites selected, and you are among the nurses randomly selected to participate in my study if you chose to do so. WHAT IS THE STUDY ABOUT? I am studying issues related to job stress in the profession of nursing. I cannot be more specific than that without possibly influencing some of your responses to the study questions. WHAT IS INVOLVED? Enclosed in this packet you will find a variety of questionnaires which need to be filled out. Nurses who have pre-tested these questionnaires have found that it takes approximately 30 minutes to complete them all. WHAT IS IN IT FOR ME? Nurses willing to participate in the questionnaire results from me, including the scores for each instrument mean. inservices at the participating hospitals at study to review the findings and conclusions study can obtain their an of what I also plan to do the c6nclusian of my of this project. WHAT ABOUT CONFIDENTIALITY? Each set of q4estionnaires has been assigned a number code. I will be the only person who will know the identity of the individual completing the questionnaire. INDIVIDUAL DATA OBTAINED FROM THE QUESTIONNAIRES WILL NOT BE SHARED WITH ANYONE AT YOUR PLACE OF WORK OR ANYWHERE ELSE.

PAGE 192

WHAT DO I DO TO PARTICIPATE? 1. Fully complete the enclosed questionnaires and demographic data sheet. 2. If you want me to send you a copy of your questionnaire results, complete the enclosed "Follow-up lnformation Sheet" providing me with your address and phone number. I do not have access to this information from the hospital, so I will need this order to get in touch with you. 3. Place all materials in the self-addressed stamped envelope provided in this packet and mail it to me. It is probably a good idea to include a return address on the envelope in case the packet gets misplaced in the holiday mail. WHEN CAN I EXPECT TO HEAR FROM YOU? Due to the time it will take to complete data collection and data analysis and reach conclusions about the findings, it will probably be early spring before you will hear from me. I hope this delay is not a problem. HOW SOON DO I NEED TO DO THIS? My goal is to.have questionnaires returned to me NO LATER THAN DECEMBER 15, 1988. The closer it gets to the holidays the more difficult it will be to find time to do this, so I hope you will be able to find 30 minutes to complete the enclosed materials SOON. The success of this project to a very large extent depends on the level of participation I get from the nurses randomly selected to be a part of this study. Your participation in this project will not only help me meet my research goals, it can also provide you with interesting and helpful information about yourself, and hopefully it will also provide information to help nurses deal with the stresses related to the practice of their profession. OTHER QUESTIONS? Call Betty Clarke at 722-9920. Sincerely, Betty M. Clarke, RN, MSN

PAGE 193

DEMOGRAPHIC DATA SHEET Your sex: <1> male <2> female Your age: years Are you : ( 1 ) Asian, Asian American ( 2) Blac:k ( 3) Latino, Hispanic:, Mexican American ( 4) Native American, American Indian ( 5) White, Caucasian ( 6) Other single <4> wid.owed <2> married <5> other divorced If you have children, how many of them are now living with you? children live with me I have no children What is achieved? the highest level OF NURSING EDUCATION that you have Associate Degree Diploma Bac:calareate Degree Master's Degree Ph.D.

PAGE 194

On what type of unit do you work PRIMARILY? OB/GYN ___ Labor S. Delivery ___ Nursery Neonatal ICU Recovery Room Operating Room Emergency Room Pediatrics ICU/CCU Medical &/or Surgical Ward Out-patient clinic Psychiatry Other ___________________ How many years have you actively practiced nursing? ______ How long have you been emploYed by this institution? What shift do you work PRIMARILY? 7-3 3-11 11-7 7am-7pm 7pm-7am Rotating shifts . Other
PAGE 195

Date: Name:----'---------------Marital Status: _____ Age: ____ Sex: __ ________________ Education: _______________ This questionnaire consists of 21 groups of statements. After reading each group of statements care: circle the number (0, 1, 2 or 3) next to the one statement in each group which best describes the have been feeling the past week, includiDg today. If several statements within a group seem to apply eq well, circle each one. Be sure to read all the statements in each group before mekjng ;your choice. ___ Subtotal Page 1 t\TI\ THE PSYCHOLOGICAL CORPORATION \&/HARCOURT BRACE jOVANOVICH, INC. Copyright 1978 by Aaron T. Beck. All rights reserved. Printed in the U.S.A. NOTICE: II is against the law to photocopy or otherwise reproduce this questionnaire without the publisher's wrinen permission. CONTINUED ON I

PAGE 196

14 0 I don't feelllook any worse than I used to. 18 0 I haven't lost much weight, if any, lately. I am worried that I am looking old or I have lost more than 5 pounds unattractive. 2 lhavelostmorethan 10pounds. 2 I feel that there are permanent changes I have lost more than 15 pounds. in my appearance that make me look 3 unattractive. 3 I believe that I look ugly. I am purposely trying to lose weight by eating less. Yes ___ No ___ 16 0 I can work about as well as before. 20 It takes an extra effort to get started at 0 I am no more worried about my health doing something. than usual. 2 I have to push myself very hard to do I am .worried about physical problems such as aches and pains; or upset anything. stomach; or constipation. 3 I can't do any work at all. I am very worried about physical 2 problems and it's hard to think of much else. 18 u I can sleep as well as usual. 3 I am so worried about my physical problems that I cannot think about I don't sleep as well as I used to. anything else. 2 I wake up 1 hours earlier than usual and find it hard to get back to sleep. 3 I wake up several hours earlier than I 21 used to and cannot get back to sleep. ll I have not noticed any recent change in my interest in sex. I am less interested in sex than I used to be. 17 (l I don't get more tired than usual. 2 I am much less interested in sex now. I get tired more easily than I used to. a I have lost interest in sex completely. I get tired from doing almost anything. 3 I am too tired to do anything. 18 u My appetite is no worse than usual. My appetite is not as good as it used to be. 2 My appetite is much worse now. 3 I have no appetite at all anymore. ___ Subtotal Page 2 ___ Subtotal Page 1 ___ Total Score TPC 0528-000 17111D1112ADC

PAGE 197

Christina Maslach Susan E. Jackson Human Services Survey The purpose of this survey is to discover how various persons in the human services or helping professions view their jobs and the people with whom they work closely. Because persons in a wide variety of occupations will answer this survey, it uses the term recipients to refer to the people for whom you provide your service, care, treatment, or instruction. When answering this survey please think of these people as recipients of the service you provide, even though you may use another term in your work. On the following page there are 22 statements of job-related feelings. Please read each statement carefully and decide if you ever feel this way about your job. If you have never had this feeling, write a "0" (zero) before the statement. If you have had this feeling, indicate how often you feel it by writing the number (from 1 to 6) that best describes how frequently you feel that way. An example is shown below. Example: HOW OFTEN: 0 1 2 3 4 5 .6 Never Afewtimes Once a A few Once A few Every a year month times a a times day or less or less month week a week t:IQW QEIE;t:J 0-6 Statement: I feel depressed at work. If you never feel depressed at work, you would write the number "0" (zero) under the heading "HOW OFTEN." If you rarely feel depressed at work (a few times a year or less), you would write the number "1." If your feelings of depression are fairly frequent (a few times a week, but not daily) you would write a "5." Consulting Psychologists Press, Inc. 577 College A venue Palo Alto, CA 94306 Copyright e 1986 Consulting Psychologists Pmss, Inc. All rights msei'VBd. No portion of this material may be reproduced by any means without wrinen PflmiiSSion of the Publisher. Printed In the U.S.A. 3463

PAGE 198

Human Services Survey HOW OFTEN: HOW OFTEN 0-6 1. __ 2. __ 3. __ 4. __ 5. __ 6. __ 7. __ B. __ 9. __ 10. __ 11. __ 12. __ 13. __ 14. __ 15. __ 16. __ 17. __ 18. __ 19. __ 20. __ 21. __ 22. __ (Administrative use only) 0 1 Never A few times a year or less Statements: 2 Once a month or less 3 A few times a month I feel emotionally drained from my work. I feel used up at the end of the workday. 4 Once a week 5 A few times a week Every day I feel fatigued when I get up in the morning and have to face another day on the job. I can easily understand how my recipients feel about things. I feel I treat some recipients as if they were impersonal objects. Working with people all day is really a strain for me. I deal very effectively with the problems of my recipients. I feel burned out from my work. I feel I'm positively influencing other people's lives through my work. I've become more callous toward people since I took this job. I worry that this job is hardening me emotionally. I feel very energetic. I feel frustrated by my job. I feel I'm working too hard on my job. I don't really care what happens to some recipients. Working with people directly puts too much stress on me. I can easily create a relaxed atmosphere with my recipients. I feel exhilarated after working closely with my recipients. I have accomplished many worthwhile things in this job. I feel like I'm at the end of my rope. In my work, I deal with emotional problems very calmly. I feel recipients blame me for some of their problems. cat. cat. EE: ---DP: __ PA: ---cat.

PAGE 199

T T T T T T T T T T y T T T WORK ENVIRONMENT SCALE INSTRUCTIONS: Then: arr 27 in this survey. Thry an: statements about the placr in which you woriL. The Stalrments are intended to apply to alJ.work enYironments. HoweYer, some words may not be quite sui.table for yout work. enYinmmenL For example, the term supemsor is meam to refer to the boss, manager, depanmenr head, or the person or persons to whom an employee reporu. You are to decide which statements are rrue of your worlt. en \'ironment and which are falu!. If you think the statements is TRUE or mostly TRUE of your work enYironment please circle the"T" in the column to the left of the question. If you think the is FAL'iE or mostly FAL'iE of your worlr. enYironment please circle the "F" in the column to the left of the question. Please be sure to answer rYery statemcnL F l. The work is really challenging. T F 15. Getting a lot of work done is F 2. Few employees have any imponant important to people. responsibilities. T F 16. Few people ever volunteer. F 3. People pay a lot of attention to T F 17. Employees generally do not try to getting work done. be unique and differenL F 4. There's not much group spirit T F 18. There's an emphasis on work before pial F 5. Employees have a great deal of freedom T F 19. It is quite a lively place to do as they like T F 20. Employees are encouraged to learn t F 6. There's a lot of rime wasted because even if they are not directly related of inefficiencies to the job. F 7. A lot of people seem to be just putting in time. T F 21. Employees work very hard. T F 22. It's hard to get people to do any F 8 Employees are encouraged to make extra work their own decisions. T F 23. Employees function fairly independ F 9. Things rarely get "put off'' ently of supervisors. until tomorrow. T F 24 People seem to be quite inefficient F 10. People seem to take pride in the organization. T F 25. The work is usually very interesting F II. People can use their own initiative T F 26. Supervisors meet with employees rq to do things to discuss their future work goals. F 12 This.is a highly efficient, work T F 27. There's a tendency for people to oriented place. come to work late. F 13 People put quite a lot of effon into what they do. F 14. Supernsors encourage employees to rely on themselves when a problem arises Reproduced by special permission of the Publisher, Consulting Psychologists Press, Inc., Palo Alto, CA 9olS06, from the Worlr. Environment by Rudolf Moos. 1974 Further n:production is prohibited without the Publishrr's consent.

PAGE 200

PERSONAL VIEWS SURVEY Below are some items that you may agree or disagree with. Please indicate how you feel about each one by circling a number from 0 to 3 in the space provided. A zero indicates that you feel the item is not at all true; circling a three means that you feel the item is completely true. As you will see, many of the items are worded very strongly. This is to help you decide the extent to which you agree or disagree. Please read all the items carefully. Be sure to answer all on the basis of the way you feel now. Don't spend too much time on any one item. 0 =Not at all true 1 = A litde true 2 = Q.uite a bit true 3 = Completely true I. 1 often wake up eager to take up my life where it left off the day before ......................... 0 2. I like a lot of variety in my work ............... : ........................................... 0 3. Most of the time, my bosses or superiors will listen to what I have to say ........................ 0 4. Planning ahead can help avoid most future problems ....................................... 0 5. I usually feel that I can change what might happen tomorrow, by what I do today .............. 0 6. I feel uncomfortable if I have to make any changes in my everyday schedule ................... 0 7. No matter how hard I try, my efforts will accomplish nothing. .............................. 0 8. I find it difficult to imagine getting excited about working ................................... 0 9. No matter what you do, the "tried and true" ways are always the best ......................... 0 10. I feel that it's almost impossible to change my spouse's mind about something ................. 0 11. Most people who work for a living are just manipulated by their bosses ....................... 0 12. New laws shouldn't be made if they hun a person's income .................................. 0 13. When you marry and have children you have lost your freedom of choice ..................... 0 14. No matter how hard you work, you never really seem to reach your goals ...................... 0 15 .. A person whose mind seldom change$ can usually be depended on to have reliable judgment .................................................................... 0 16. I believe most of what happens in life is just meant to happen ................................ 0 17. It doesn't matter if you work hard at your job, since only the bosses profit by it anyway . ...... ........ .......................... 0 18. I don't like conversations when others are confused about what they mean to say ............... 0 19. Most of the time it just doesn't pay to try hard, since things never tum out right anyway .......................................................... 0 20. The most exciting thing for me is my own fantasies ....................................... 0 21. 1 won't answer a person's questions until! am very clear as to what he is asking ............... 0 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 3 3 3 3 3 3 l 3 3 3 3 3 3 3 3 3: 3 3 3'-3 3.

PAGE 201

0 = Not at all aue 1 = A little aue 2 = Q.uite a bit aue !I = Completely aue 22. When I make plans I'm certain I can make them work ..................................... o 23. I really look foJWlU'd to my work .............................................. 0 24. It doesn't bother me to step aside for a while from something I'm involved in, if I'm asked to do something else ................................... ............. 0 25. When I am at work performing a difficult task I know when I need to ask for help ............ 0 26. It's exciting for me to learn something about myseU ..................................... 0 27. I enjoy being with people who are unpredicable ......................................... 0 28. I find it's usually very hard to change a friend's mind about something ...................... 0 29. Think.ing ofyour5elf as a free person just makes you feel frustrated and unhappy ............ 0 !10. It bothers me when something unexpected interrupts my daily routine ...................... 0 31. When I make a mistake, there's very little I can do to make things right again ................. 0 !12. I feel no need to try my best at work, since it makes no difference anyway ; .................. 0 33. I respect rules because they guide me ................................ .................. 0 34. One of the best ways to handle most problems is just not to think about them ............... o 35. I believe that most athletes are just born good atsporu .. .. .. .. . .. . .. .. .. .. .. .. .. 0 36. I don't like things to be uncenain or unpredictable.. . . .. .. .. .. .. . .. . . .. . .. .. .. 0 3 7. People who do their best should get full financial suppon from society . . . . . . . . . . o 38. Most of my life get! wasted doing things that don't mean anything ......................... o 39. Lots of times I don't really know my own mind .......................................... 0 40. I have no use for theories that are not closely tied to the faru . . . . . . . . . . . . . . . 0 41. Ordinary work is just too boring to be wonh doing. . . . .. . . . .. . . . . . . . . 0 42. When other people get angry at me, it's usually for no good reason . . . . . . . . . . . 0 43. Changes in routine. bother me. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 0 44. 1 find it hard to believe people who tell me that the work they do is of value to society .......................................... . . . . . . . . . 0 45. I feel that if someone tries to hun me, there's usually not much I can do to try and stop him . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 0 46. Most days, life just isn't very exciting for me . . . . . . . . . . . . . . . . . . 0 4 7. I think people believe in individuality only to impress others. . . . . . . . . . . . . . . 0 48. When I'm reprimanded at work, it usually seems to be unjustified . . . . . . . . . . . 0 49. I want to be sure sOmeone will take care of me when 1 get old. . . . .. . . . . .. . . .. . 0 50. Politicians run our lives . . . . . . . . . . . . . . . . . . . . . . . . . . . 0 Copyrighr (c) 1985. The Hardiness lnslirure, Inc. Released for R!Seal'Ch use only. 1 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 !I

PAGE 202

Colorado Nurses Assoc. Gender Race: Caucasian Black Hispanic Other Education Level: APPENDIX B DEMOGRAPHIC DATA COMPARISONS BETWEEN THIS STUDY AND DATA FROM THE COLORADO STATE BOARD OF NURSING AND THE COLORADO NURSES ASSOCIATION This Study 94% female 97% 2% 1% 2% Colorado Nurses Colo. State Association* Board of Nursing** 97% female 96% female 95% 2% 1% 1% Diploma 32% 41% 25% 34% AD 32% BSN 33% MS 2% Source: Colorado Nurses Association (1991). Pnpublished raw data. ** source: Department of Regulatory Agencies, Colorado State Board of Nursing. (1990). Annual Report. Denver, co: Author. 184

PAGE 203

APPENDIX C T-TEST & CHI-SQUARE RESULTS Table C.l. T-test Results (Pooled Variance Estimates) Between Hospital A and Hospital B. Depression T = 2.62 p = .010 F = 1.48 p = .085 Emotional Exhaustion T = 1.87 p = .063 F = 1.15 p = .551 Depersonaliza-tion T = 2.06 p = .041 F = 1.66 p = .032 Personal Accomplishment T =-1.48 p = .141 F = 1.19 p = .471 Involvement T = 1.55 p = .124 F = 1.60 p = .038 Autonomy T = .95 p = .341 F = 1.30 p = .242 Task Orientation T = .52 p = .604 F = 1.44 p = .110 Active Response Mode T = .87 p = .388 F = 1.07 p = .772 Challenge T = .48 p = .631 F = 1. 33 p = .232 Commitment T =-1. 64 p = .104 F = 1.38 p = .179 Control T =-1.11 p = .269 F = 1.24 p = .347 Composite Hardiness T =-1.15 p = .250 F = 1.48 p = .106 Total Burnout T = 2.56 p = .011 F = 1.17 p = .505

PAGE 204

Table C.2. T-test Results (Pooled Variance Estimates) Between Hospital A versus Hospital B: Non-critical care nurses only. Depression T = 1.00 p = .320 F = 1.02 p = .954 Emotional Exhaustion T = 1.32 p = .190 F = 1.32 p = .338 Depersonaliza-tion T = 1. 65 p = .101 F = 2.10 p = .012 Personal Accomplishment T = .11 p = .915 F = 1.42 p = .226 Involvement T = 1. 60 p = .112 F = 1.56 p = .111 Autonomy T = .50 p = .618 F = 1.16 p = .584 Task orientation T = 1.03 p = .306 F = 2.19 p = .005 Active Response Mode T = .75 p = .456 F = 1.08 p = .770 Challenge T = .76 p = .451 F = 1. 32 p = .338 Commitment T =-0.46 p = .648 F = 1.44 p = .205 Control T =-0.64 p = .526 F = 1.35 p = .286 Composite Hardiness T =-0.32 p = .749 F = 1.53 p = .146 Total Burnout T = 1.23 p = .221 F = 1.10 p = .740 186

PAGE 205

Table C.3. T-test Results (Pooled Variance Estimates) Between Hospital A versus Hospital B: Critical care nurses only. Depression T = 3.25 p = .002 F = 2.14 p = .076 Emotional Exhaustion T = 1.42 p = .162 F = 1.22 p = .628 tion T = 1.14 p = .259 F = 1. 32 p = .522 Personal Accomplishment T =-3.25 p = .002 F = 1.24 p = .621 Involvement T = .43 p = .668 F = 1.76 p = .172 Autonomy T = .77 p = .443 F = 1.76 p = .175 Task Orientation T =-0.18 p = .855 F = 1.27 p = .573 Active Response Mode T = .38 p = .706 F = 1.03 p = .941 Challenge T =-1.01 p = .320 F = 1.16 p = .742 Commitment T =-2.53 p = .015 F = 1.21 p = .659 Control T =-1. 30 p = .199 F = 1.03 p = .929 Composite Hardiness T =-2.17 p = .036 F = 1.15 p = .752 Total Burnout T = 3.02 p = .004 F = 1.12 p = .791 187

PAGE 206

Table C.4. 'T-test Results (Pooled Variance Estimates) Between Hospital A versus Hospital B: Critical care nurses versus non-critical care nurses. Depression T =-1.67 p = .097 F = 1.73 p = .021 Emotional Exhaustion T =-1.15 p = .252 F = 1.41 p = .195 Depersonaliza-tion T =-3.60 p = .000 F = 1. 61 p = .052 Personal Accomplishment T = 1.42 p = .158 F = 1.03 p = .933 Involvement T = 1.12 p = .264 F = 1.16 p = .567 Autonomy T =-0.17 p = .864 F = 1.13 p = .633 Task Orientation T = 2.46 p = .015 F = 1.13 p = .590 Active Response Mode T = .96 p = .340 F = 1.08 p = .743 Challenge T =-1. 29 p = .201 F = 1.35 p = .277 Commitment T = .10 p = .922 F = 1.29 p = .295 Control T = .72 p = .471 F = 1.38 p = .214 Composite Hardiness T = .17 p = .869 F = 1.13 p = .625 Total Burnout T =-2.98 p = .003 F = 1.04 p = .917 188

PAGE 207

Table C.5. T-test Results (Pooled Variance Estimates) Comparing Tptal Burnout Scores by Demographic Variables. Sex T = .66 p = .511 F = 1.37 p = .420 Marital Status T = -.70 p = .487 F = 1.06 p = .787 Children T = -.64 p = .524 F = 1.02 p = .912 Type of Nursing Education T = .07 p = .942 F = 1.21 p = .476 Table C.6. Chi-Square Results for Demographic Variables: Hospital A versus Hospital B. Race Sex Marital Status Education Chi-Square 6.65871 0.20353 1. 67282 4.78036 D. F. 5 1 4 3 189 Significance 0.2473 0.6519 0. 79,56 0.1886 New E.F. 0.481 4.810 1.924 1.433

PAGE 208

APPENDIX D l PEARSON CORRELATION COEFFICIENTS Per;.. comEmoposite Task Active tional Deper-Accom-Total Chal-Commit-Hard-Involv-Auto-orient-Response Depres-Exhaus-sonalileQge_ ment control .iness ment. nomy at-ion Mode sion tion zation ment Total 1.0000 -.1569 -.6142 -.4557 -.5717 -.3687 -.2664 -.2308 -.3179 .4431 .8002 .7893 -.5817 Bumout P=. P=.034 P=.OOO P=.OOO P=.OOO P=.OOO P=.001 P=.003 P=.OOO P=.OOO P=.OOO P=.OOO pz.ooo Challenge .1569 1.0000 .4235 .4079 .7313 .1073 .1366 .0996 .1834 -.3632 -.1795 -.0242 .1378 P=.034 P=. P=.OOO P=.ooo P=.OOO P=.099 P==.051 P=.117 P=.014 P.:.OOO P==.OOO P==.389 P...055 Commitment -.6142 .4235 1.0000 .6196 .8719 .4022 .2492 .3284 .3772 -.5654 -.4876 -.3734 .4700 P=.OOO P=.ooo P=. P==.OOO P=.ooo P=.OOO P==.001 P==.ooo P=.OOO P=.OOO P==.ooo P=.OOO P=.OOO Control -.4557 .4079 .6196 1.0000 .8085 .3159 .2490 .1728 .3995 -.5347 -.4513 -.2437 .2975 P=.ooo P=.ooo P=.OOO P=. P=.OOO P=.;OOO P==.001 P==.015 P=.OOO pz.ooo P==.ooo P=.001 P=.OOO Composite -.5717 .7313 .8719 .8085 1.0000 3536 .2954 .2651 .4134 -.5657 -.4866 -.3235 .4238 \0 Hardiness P=.ooo P=.ooo P=.OOO P=.OOO P=. P=.OOO P==.OOO P=.001 P=.OOO P.:.OOO P=.OOO P==.006 P...OOO 0 Involvement -.5687 .1073 .4022 .3159 .3536 1.0000 .5418 .5851 .6786 -.2623 -.3808 -.2060 .2137 P=.ooo P=.099 P=.OOO P=.OOO P=.ooo P=. P==.OOO P==.OOO P=.OOO pz.ooo P==.OOO P=.006 P=.005 Autonomy -.2664 .1666 .2492 .2490 .2954 .5418 1.0000 .3216 .6744 -.1159 -.2920 -.1230 .1417 P=.001 P=.051 P=.001 P=.001 P=.OOO P=.OOO P=. P==.ooo P=.OOO P=.073 P=.ooo P=.069 P=.045 Task -.2308 .0996 .3284 .1728 .2651 .5851 .3216 1.0000 .4958 -.2596 -.1799 -.1345 .1919 tion P=.003 P=.l17 P=.OOO P=.015 P=.OOO P=.OOO P==. P=.OOO P=.OOO P=.014 P==.052 P=.010 Active -.5179 .1834 .3772 .3995 .4134 .6786 .6744 .4958 1.0000 -.3744 -.3467 -.1544 .1806 Response P=.OOO P=.014 P=.OOO P=.OOO P=.OOO P:.:.OOO P=.OOO P=.OOO P=. pz.oooP=.ooo P=.031 P=.015 Mode .4431 . 3632 -.5654 -.5347 -.5657 -. -.1159 -.2596 -.3744 1.0000 .4481 .2453 -.2545 Depression P=.ooo P=.ooo P=.ooo P=.OOO P=.OOO P:.:.OOO P=.073 P=.ooo P=.OOO P=. P=.OOO P=.001 P...001 Emotional .8002 -.1795 -.4876 -.4513 -.4866 -.3808 -.2920 -.1799 -.3467 .4481 1.0000 .5910 -.1445 Exhaustion P=.ooo P=.013 .P=. 000 P=.OOO P=.OOO P:.:.OOO P=.OOO P=.014 P=.OOO P=.OOO P=. P=.OOO P...041 Depersonal.7893 -.0242 -.3734 -.2437 -.3235 -.2060 -.1230 -.1345 -.1544 .2453 .5910 1.0000 -.1224 ization P=.ooo P=.389 P=.OOO P=.OOl P=.OOO P=.006 P=.069 P=.052 P=.031 P=.001 P=.OOO P=. P...071 Personal -.5817 .1378 .4700 .2975 .4238 .2137 .1417 .1919 .1806 -.2545 -.1445 -.1224 1.0000 Accomplish-P=.ooo P=.os5 P=.OOO P=.OOO P=.OOO P= .. oos P=.045 P=.010 P=.015 P=.001 P=.041 P=.071 -P=. ment

PAGE 209

,.''1 APPENDIX E DEPRESSION AND LEARNED HELPLESSNESS Depression It is not surprising that depression is intertwined with stress-related issues, such as burnout and low hardiness. Depression is ubiquitous and universal, accounting for perhaps seventy-fie percent of all psychiatric hospital admission, and seriously affecting some twelve percent of the population at some time during their lives (Glazer, Clarkin, & Hunt, 1981). Even these statistics downplay the impact of depression on society, since they do not take into account those individuals suffering from milder forms of depression who do not seek therapy. "Mild depression is an enormously widespread and significant problem; its cost in misery and loss of productivity is untold" (Seligman, 1978, p.177). Despite the prevalence of depression and the extensive attention it has received by a number of disciplines, depression still lacks a clarity of definition and has many unresolved issues. Depression can be viewed on a continuum ranging from nonpathological experiences of depressed state to severe pathological

PAGE 210

conditions. The term depression has been used to describe an. emotional state, a syndrome, and a group of specific disorders (Yager, 1989). Depression may appear as a symptom in any mental disorder and is also a symptom in many organic diseases and toxic conditions (Hamilton, 1989). Beck (1967) defines depression in terms of the following attributes: a specific alteration in mood, a negative self-concept, regressive and self-punitive wishes, vegetative changes stich as anorexia and insomnia, and change in activity level. However, an individual may be depressed without exhibiting all of the symptoms of depression. One of the advantages of the learned helplessness model of depression, which will be discussed later, is that it can account for cases of depression that do not incorporate all of the symptoms listed above (Garber, Miller, & Abramson, 1980). A feature that helps distinguish abnormal from normal depressed mood is the disturbance in judgement (negative attributional style) so often found in more serious depressions. There are three primary attributional dimensions: Internal-external; stableunstable; global-specific (Abramson, Garber, & Seligman, ). The internal-external dimension refers to locus of control. The stable-unstable dimension identifies 192

PAGE 211

whether an attribution is long-lived and recurrent or short-lived or intermittent. The global-specific dimension identifies whether or not the attribution affects a wide variety of situations. A number of studies have demonstrated that victims of depression make internal, stable, and global attributions for negative events, and external, unstable, and specific attributions for positive events (Sweeney, Anderson, & Bailey, 1986). Beck (1967) describes a triad of negative judgments typically found in victims of depression: negative interpretations of experience; negative evaluations of the self; and negative expectations of the future. "Patients not only are occupied with the gloomy side of things, but they also feel that everything is valueless and futile. The future is hopeless, and the past was useless" (Hamilton, 1989, p.896). "Depressed individuals believe themselves to be even more ineffective than they actually are: small obstacles to success are seen as impossible barriers, difficulty in dealing with a problem is seen as complete failure, and even outright success is often misconstrued as failure" (Seligman, 1975, p.85). This negative cognitive set has been viewed by Beck (1967) as the "universal hallmark" of depression. The heterogeneous nature of depression and the lack of a clear definition of depression have thwarted efforts 193

PAGE 212

to design a classification system that is universally accepted. One of the more common topologies of depression is the endogenous-reactive dichotomy (Depue & Monroe, 1978). Endogenous depressions are those for which symptoms are the result of biological factors. In reactive depressions, symptoms are related to precipitating environmental stresses, there are no psychotic features, and anxiety and associated symptoms play a role (Hamilton, 1989). Another area in which considerable ambiguity still exists is the distinction between depression and anxiety. Historically, anxiety and depression have been viewed as separate entities. The boundaries are not nearly so distinct, however. Some theorists have argued that the two disorders cannot be distinguished because they share so many common symptoms (Garber, Miller, & Abramson, 1980). In general, anxious individuals have lowered activity and a decreased initiation of voluntary responses. Despite the behavioral differences, there is considerable overlap between the two syndromes, and it is difficult to distinguish between them in individuals suffering both syndromes simultaneously (Garber, Miller, & Abramson, 1980: Gotlib, 1984). Wolpe (1971) emphasizes the role of anxiety as a critical etiological factor in depression. 194

PAGE 213

Lazarus and Opton (1966) argue that anxiety and depression share a belief in uncontrollability, but that the distinction between the two comes from a difference in the perceived probability of outcome. Whereas helplessness may be a component of both states, it is the uncertainty about the outcome that produces anxiety. Thus, the major factor distinguishing anxiety from depression is the perceived probability of obtaining a desired outcome (the degree of hopelessness). They conclude that it seems logically possible for an individual to simultaneously experience anxiety and depression. Clinical evidence from both normal populations and clinical populations supports this assumption .(Garber, Miller, & Abramson, 1980). Based on both clinical and laboratory studies, it would appear that anxiety and depression are highly interrelated emotional states (see Gotlib, 1984, for a review). However, the possibility cannot be ruled out that it may be inadequacies in measuring depression and anxiety that contribute to the lack of distinction between these two states. Gotlib (1984) reports various studies in which it was difficult to separate depression and anxiety in psychiatric patients. It would appear from these studies that measures of anxiety and depression do not measure separate entities but 195

PAGE 214

rather appear to tap a more general state of maladjustment. Leff (1978) found that psychiatrists tend to make more clear-cut distinctions among depression, anxiety, arid irritability, whereas patients conceive of these emotions as having considerable overlap. Learned Helplessness The concept of learned helplessness was first articulated by Seligman and Maier in 1967 to describe deficits in escape avoidance behavior in dogs exposed to uncontrollable shocks in laboratory settings. Central to the learned helplessness model was an apparent need to control the environment. This need for control is so important that uncontrollability (real or perceived) is sufficient for the occurrence of the symptoms of helplessness. Subsequent testing of the helplessness model with other animals confirmed the findings with dogs, but studies using human subjects produced inconsistent results Miller & Norman, 1979, for a review). To address these inconsistencies and other criticisms, a reformulated theory of helplessness was proposed (Abramson, Seligman, & Teasdale, 1978). The reformulated theory provides a framework for integrating data from both animal and human studies and argues that the type of 196

PAGE 215

helplessness effects one experiences depends on the attribution of causality that an individual makes when faced with an uncontrollable outcome. That is, helplessness effects may stem not from the uncontrollability of an aversive stimulus, but from the way in which the stimulus is interpreted by the subject. The new theory states that when people experience helplessness, they ask implicitly or explicitly why they are helpless. The kinds of attributions people make for lack of control influence whether helplessness will produce low self-esteem and whether their helplessness will generalize across situations and time (Garber, Miller, & Abramson, 1980). According to the reformulated theory of learned helplessness, there are three deficits that result from uncontrollability: motivational, cognitive, and emotional (Abramson, Seligman, & Teasdale, 1978). Motivational deficits are the result of feelings of futility and consist of the retarded initiation of voluntary responses. Learning that some outcomes are uncontrollable results in cognitive deficits, since such learning makes it difficult to recognize later on that outcomes can be controlled. This theory is also cognitive in that exposure to uncontrollability is not sufficient to develop helplessness; there must be an 197

PAGE 216

expectation that outcomes are uncontrollable in order for helplessness to occur. Emotional deficits result from learned helplessness in the form of depressed affect. Learned Helplessness and Depression Repeated experiences with uncontrollable outcomes alter a person's beliefs about her/himself and her/his ability to influence her/his environment. The formulated helplessness hypothesis claims that depression is the result of learning that outcomes are uncontrollable. However, depressed affect occurs only when individuals receive, or anticipate that they will receive, a bad outcome or will lose a highly desired outcome. Also, depression will be greater when individuals attribute their lack of control to internal, rather than external, factors (Abramson, Seligman, & Teasdale, 1978). In a meta-analysis of over 100 studies, Sweeney, Anderson, and Bailey (1986) examined the relation of attributional styles to depression. This analysis lends support to the attributional model of depression and calls Seligman's (1975) learned helplessness model "the most successful application of a non-clinically derived explanation of depression" (Sweeney, Anderson, & Bailey, 1986, p. 974). 198

PAGE 217

As previously discussed, the syndrome of depression is extremely complex with inadequate systems of classification. It is difficult to determine exactly what type of depression helplessness most closely models. Comparisons using symptoms, etiology, therapy, and prevention have proved inadequate (Abramson, Garber, & Seligman, 1980). Depue and Monroe (1978) place helplessness depression in the reactive category. Although he later changed his view, in 1975 Seligman speculated that the helplessness model would not fit exactly into any current classification of depression; but it would probably come most close to the reactive category in which environmental events are necessary causes. More recently Seligman suggests it is highly unlikely that learned helplessness serves as the primary etiologic factor in all forms of depression. It is more likely that there may exist a subclass of helplessness depression which cuts across traditional subtypes and is defined by the expectation that outcomes are independent of responding (Seligman, 1978). This helplessness depression would be "characterized by symptoms of passivity, negative cognitive set, and depressed affect, and may be treated with therapies that are designed to alter the expectation of controllability" (Abramson, Garber, & Seligman, 1980, p.27). I

PAGE 218

APPENDIX F SOCIAL LEARNING THEORY AND SELF-EFFICACY Social learning theory was originally developed by Rotter {1954) as an attempt to explain human behavior in relatively eomplex situations. The theory was particularly influenced by the work of Alfred Adler, J. R. Kantor, and Kurt Lewin {Rotter, Chance, & Phares, 1972). Self-efficacy has to do with people's beliefs in their abilities to mobilize the resources needed to exercise control over events in their lives and arises from the acquisition of skills through experience {Bandura, 1977). Individuals with low self-efficacy will tend to behave ineffectually, even though they know what to do {Bandura, 1982). Learned helplessness can be viewed as tpe negative of personal efficacy {Poser, 1978). Self-efficacy has three dimensions (Bandura, 1977). "Magnitude" refers to the level of task difficulty an individual believes she/he can attain. "Generality" refers to the degree to which an expectation may be generalized across situations. "Strength" refers to the

PAGE 219

level of conviction one has about mastery. Individuals with weak expectations are easily discouraged in the face of disconfirming feedback. "Those will low self-efficacy tend to engage in fewer coping efforts; they give up more easily under adversity and evidence less mastery, which in turn reinforces their low self-efficacy" (Gist, 1987, p.474). Individuals with strong self-efficacy have higher levels of motivation. The stronger their belief in their self-efficacy, the greater and more persistent their efforts will be (Wood & Bandura, 1989). According to social learning theory, perceptions of self-efficacy are based on four primary sources of information (Bandura, 1982). The most influential source is inactive mastery, defined as repeated performance accomplishments. While positive mastery experiences enhance self-efficacy, negative experiences (failures) tend to decrease self-efficacy. Slightly less influential than inactive mastery, vicarious experience (modeling) is another source of self-efficacy information. Seeing similar others perform successfully can raise efficacy expectations (Bandura, 1982), while seeing similar others fail despite high efforts can lower efficacy expectations (Brown & Inouye,, 1978). 201

PAGE 220

A third source of efficacy information is verbal persuasion, which is aimed at convincing a person of her/his capabilities concerning a task (Bandura, 1982). Although effective than inactive mastery or modeling, it is most effective if the heightened appraisal is within realistic bounds. The Pygmalion effect (enhanced learning or performance resulting from the positive expectations of others) may affect selfefficacy persuasive influence (Gist, 1987). Types of information which affect the success of persuasion are the following: "credibility and expertness of the sources, consensus among multiple sources, and familiarity of the source with task demands" (Bandura, 1984, as cited in Gist, 1987, p.477). Fourth, a person's judgment about her/his physiological state can influence perceptions of efficacy (Bandura, 1982). For example, if a person experiences physiological symptoms of anxiety, she/he may have lower expectations of success. Likewise, feelings of fatigue or aching muscles may create perceptions of lower physical efficacy in the athlete. The role of locus of control in hardiness, learned helplessness, and depression was discussed in Chapters Two and Five. Locus of control is also related to selfefficacy. Studies of addiction, such as the research by 202

PAGE 221

Chambliss and Murray (1979) on smoking reduction, demonstrate that internal locus of control combined with high self-efficacy leads to the greatest reduction in smoking. studies of phobics demonstrate that perceived self-efficacy operates as a cognitive mechanism by which controllability reduces fear arousal (Bandura, Adams, & Beyer, 1977). Gist (1987) states that individuals with an internal locus of control may respond more readily to modeling and may need fewer inactive mastery experiences to increase self-efficacy and performance. Conversely, individuals with external locus of control may view inactive mastery experiences as luck. 203

PAGE 222

BIBLIOGRAPHY Abbey, D. E., & Esposito, J.P. (1985). Social support and principal leadership style: A means to reduce teacher stress. Education, 105(3), 327-332. Abramson, L. Y., Garber, J., & Seligman, M. E. P. (1980). Learned helplessness in humans: An attributional analysis. In J. Garber & M. E. P. Seligman (Eds.), Human Relplessness (pp. 3-34). New York: Academic Press. Abramson, L. Y., Seligman, M. E. P., & Teasdale, J. D. (1978). Learned helplessness in humans: Critique and Journal of Abnormal Psychology, 87(1), 49-74. Abush, R., & Burkhead, E. J. (1984). Job stress in midlife working women: Relationships among personality type, job characteristics, and job tension. Journal of Counseling Psychology, 31(1), 36-44.' Adams, E. M. (1983). Examination of burnout in nurses. Dissertation Abstracts International, 44, 1634A-1635. Akiskal, H. s. (1979). A biobehavioral approach to depres.sion. In R A. Depue (Ed.), The psychobiology of the depressive disorders: Implications for the effects of stress (pp.409-437). New York: Academic Press. Albrecht, T. L. (1982). What job stress means for the staff nurse. Nursing Administration Quarterly, 2(1), 1-11. Alexander, c. J. (1980). Counteracting burnout. AORN Journal, 32(4), 597-604. Allred, K. Q., & Smith, T. w. (1989). The hardy personality: Cognitive and physiological responses to evaluative threat. Journal of Personality and Social.Psychology, 56(2), 257-266.

PAGE 223

American Association, (1987). u.s. hospitals facing severe shortage of nurses. Chicago: Author. American Nurses Association. (1988). A report on state nurses' associations: Activities related to the supply and demand of registered nurses. Kansas City: Author .. Antonovsky, A. (1974). Conceptual and methodological problems in the study of resistance resources and stressful life events. In B. Dohrenwend & B. Dohrenwend (Eds.), Stressful life events: Their nature and effects. New York: John Wiley and Sons. Applebaum, s. H. (1980). Management/organizational stress': Identification of factors and symptoms. Health care Management Review, 2(1), 7-16. Argyris, c., & Schon, D.A. (1974). Theory and practice: Increasing professional effectiveness. San Francisco: Jossey-Bass. Arsenault, A., & Dolan, s. (1983). The role of personality, occupation and organization in understanding the relationship between job stress, performance, and absenteeism. Journal of Occupational Psychology, 56(3), 227-240. Babbie, E. (1983). The practice of social research (3rd ed.). Belmont, CA: Wadsworth Publishing Company. Bandura, A. (1977). Self-efficacy: Toward a unifying theory of behavioral change. Psychological Review, 84(2), 191-215. Bandura, A. (1978a). Reflections on self-efficacy. Ins. Rachman (Ed.), Advances in behavior research and therapy (Vol. 1, pp. 237-269). Oxford: Pergamon Press. Bandura, A. (1978b). Self-efficacy: Toward a unifying theory of behavioral change. Ins. Rachman (Ed.), Advances in behavior research and therapy (Vol. 1, pp. 139-161). Oxford: Pergamon Press. Bandura, A. (1978c). The self system in reciprocal determinism. American Psychologist, 33(4), 344-358. 205

PAGE 224

Bandura, A. (1981). Self-referent thought: A developmental analysis of self-efficacy. In J. H. Flavell & L. Ross (Eds.), Social cognitive development: Frontiers and possible futures (pp. 200-239). Cambridge: Cambridge University Press. Bandura, A. (1982). Self-efficacy mechanism in human agency. American Psychologist, 37(2), 122-147. Bandura, A., & Adams, N. E. (1977). Analysis of a selfefficacy theory of behavior. Cognitive Therapy and Research, 287-308. Bandura, A., Adams, N. E., & Beyer, J. (1977). Cognitive processes mediating behavioral change. Journal of Personality and Social Psychology, 35(3), 125-139. Bandura, Adams, N. E., Hardy, A. B., & Howells, G. N. (1980). Tests of the generality of self-efficacy Cognitive Therapy and Research, 4(1), 39-66. Bandura, A., & Schunk, D. H. (1981). Cultivating competence, self-efficacy, and intrinsic interest proximal self-motivation. Journal of Personality and Social Psychology, 41(3), 586-598. Banks, J. K., & Gannon, L. R. (1988). The influence of hardiness on the relationship between stressors and psychosomatic symptomatology. American Journal of Commun'ity Psychology, 16(1), 25-37. Bartunek, J. N., & Reynolds, c. (1983). Boundary spanning and public accountant role stress. Journal of Social Psychology, 121, 65-72. Beck, A. T. (1967). Depression: Causes and treatment. Philadelphia: University of Pennsylvania Press. Beck, A. T., & Beamesderfer, A. (1974). Assessment of depression: The depression inventory. Modern of Pharmacopsychiatry, 7, 151-169. Beck, A. T., Laude, R., & Bohnert, M. (1974). Ideational components of anxiety neurosis. Archives of General Psychiatry, 31(3), 319-325. Beck, A. T., & Steer, R. A. (1984). Internal consistencies of the original and revised Beck Depression Inventory. Journal of Clinical Psychology, 40, 1365-1367. 206

PAGE 225

Beck, A. T., Ward, c. H., Mendelson, M., Mock, J., & Erbaugh, J. (1961). An inventory for measuring depression. Archives of General Psychiatry, 53-63. Beck, A. T., Weissman, A., Lester, D., & Trenxler, L. (1974). The measurement of pessimism: The hopeless scale . Journal of Consulting and Clinical Psychology, 42(6), 861-865. Beck, J. (1984). Nurses have needs, too. Part Three: Take time to care for yourselves. Nursing Times, 80(41), 31-32. Beehr, T. A., & Newman, J. E. (1978). Job stress, employee health, and organizational effectiveness: A facet analysis, model, and literature review. Personnel Psychology, 31(4), 665-699. Belcastro, P. A., Gold, R. s., & Hays, L. c. (1983). Maslach Burnout Inventory: Factor analysis for samples of teachers. Psychological Reports, 53(2), 364-366. Bennett, a. L. (1986). A study of the impact of environmental stressors, stress coping resources, and psychological hardiness on job performance and health. Dissertation Abstracts International, 47, 357B. Benson, P. G., Kemery, E. R., Sauser, w. I., & Tankesley, K. E. (1985). Need for clarity as a moderator of the role ambiguity -job satisfaction relationship. Journal of Management, 11(3), 125-130. Berg, M. (1980). Tune in, turn on, drop out? A look at burnout. Imprint, 27(4), 11-13. Berger, H. (1983). An investigation of the relationship among burnout, hardiness, job and demographic characteristics, life event change and physical health.in school psychologists. Dissertation Abstracts International, 45, 655B. Bhagat, R. s. (1983). Effects of stressful life events on individual performance effectiveness and work adjustment processes within organizational settings: A model. Academy of Management Review. 8(4), 660-671. 207

PAGE 226

Bigbee, J. L. (1986). Rural-urban differences in hardiness, stress and illness among women. Dissertation Abstracts International, 47, 567B. Bishop, v. (1983). Stress in the intensive care unit. Occupational Health, 35(12), 537-543. Bissell, B. P., Feather, R. B., & Ryan, D. M. (1984). Helping students survive institutional patients and burnout in staff in chronic psychiatric care facilities. Perspectives in Psychiatric Care, 22(5), 108-114. Blau, G. (1981). An empirical investigation of job stress, social support, service length and job strain. Organizational Behavior and Human Performance, 27 (2), 279--302. Borkovec, T. D. (1978). Self-efficacy: Cause or reflection of behavioral change? In s. Rachman (Ed.), Advances in behavior research and therapy (Vol. 1, pp. 163-170). Oxford: Pergamon Press. Borland, J. J. (1981). Burnout among workers and administrators. Health and Social Work, 73-78. Bowers, D. G. (1983). What would make 11,500 people quit their jobs? organizational Dynamics, 11(3), 5-19. Boyle, G. J. (1985). Self-report measures of depression: Some psychometric considerations. British Journal of Clinical Psychology, 24, 45-59. Bramhall, & Ezell, s. (1981a). Part 1: How burned out. are you? Public Welfare, 39(1), 23-27. Bramhall, M., & Ezell, s. (1981b). Part 2: Working your way out of burnout. Public Welfare, 39(2), 32-39. Bramhall, M., & Ezell, s. ( 1981c) Part 3: How agencies can prevent burnout. Public Welfare, 39(3), 33-37. Brief, A. P., Aldag, R. J., Van Sell, M., & Melone, N. ( 1979) .. Anticipatory socialization and role stress among registered nurses. Journal of Health and Social Behavior, 20(2), 161-166. Brill, P. L'. ( 1984). The need for an operational definition of burnout. Family and Community Health, 6(4), 12-24. 208

PAGE 227

Brookings, J. B., Bolton, B., Brown, C. E., & McEvoy, A. (1985). Self-reported job burnout among female human service professionals. Journal of Occupational Behavior, 6(2), 143-150. Brown, D. L. (1983). Burnout or cop-out? American Journal of Nursing, 83(7), 1110. Brown, I., & Inouye, D. K. (1978). Learned helplessness through modeling: The role of perceived similarity in competence. Journal of Personality and Social Psychology, 36, 900-908. Buchwald, A.M., Coyne, J. c., & Cole, c. s. (1978). A critical evaluation of the learned helplessness model pf depression. Journal of Abnormal Psychology, 87 ( 1) 180-193. Buechler, K. (1985). Help for the burned out nurse? Support groups. Nursing Outlook, 11(4), 181-182. Buerhaus, p'r. (1987). Not just another nursing shortage. Nursing Economics, 5(6), 267-279. Bulman, R. J., & Wortman, c. B. (1977). Attributions of blame and coping in the "real world": Severe accident victims react to their lot. Journal of Personality and Social Psychology, 35(5), 351-363. Bumberry, Oliver, J. M., & McClure, J. N. (1978). Validation of the Beck Depression Inventory in a university population using psychiatric estimate as the criterion. Journal of Consulting and Clinical Psychology, 46(1), 150-155. Bundy, o. K. (1981). Everything you always wanted to know about professional burnout but were afraid to ask. Contemporary Education, 53(1), 9-11. Bunker, D. R., & Wijnberg, M. (1985). The supervisor as a mediator of organizational climate in public social service organizations. Administration in Social Work, 59-72. Burke, R. J. (1986). Career orientations and burnout among police officers. Journal of Health and Human Resources Administration, 56-77. 209

PAGE 228

Burke, R. J. (1989). Toward a phase model of burnout: Some conceptual and methodological concerns. Group and Organizational studies, 14(1), 23-32. Burke, R. J., Shearer, J., & Deszca, G. (1984a). Burnout among men and women in police work: An examination of Cherniss model. Journal of Health and Human Resources Administration, 7(2), 162-188. Burke, R. J., Shearer, J., Deszca, E. (1984b). Correlates of burnout phases among police officers. Group & Organization Studies, 9(4), 451-466. Cahoon, A. R., & Rowney, J. I. A. (1984). Managerial burnout: A comparison by sex and level of responsibility. Journal of Health and Human Resources Administration, 2(2), 249-263. Calhoun, G. L. (1980). Hospitals are high stress employers. Hospitals, 54(12), 171-172, 175. Caplan, G. (1974). Support systems and community mental health:: Lectures on concept development. New York: Behavioral Publications. Caplan, R. D., & Jones, K. W. (1975). Effects of workload, role ambiguity, and type A personality on anxiety, depression and heart rate. Journal of Applied Psychology, 60(6), 713-709. Cardinell, c. F. (1981). Burnout? Mid-life crisis? Let's understand ourselves. Contemporary Education, 52(2), 103-108. Carroll, J. F. (1979). Staff burnout as a form of ecological dysfunction. Contemporary Drug Problems, 207-225. Carver, c. s. (1989). How should multifaceted personality constructs be tested? Issues illustrated by selfmonitoring, attributional style, and hardiness. Journal of Personality and Social Psychology, 56(4), 577-585 . Castledine, G. (1985). When the pressure gets too much. Nursing Times, 81(18), 22. Ceslowitz, s. B. (1989). Burnout and coping strategies among hospital staff nurses. Journal of Advanced Nursing, 14(7), 553-558. 210

PAGE 229

Chambliss, c., & Murray, E. J. (1979). Cognitive procedures for smoking reduction: Symptom attribution versus efficacy attribution. Cognitive Therapy and Research, d, 91-95. Chance, P. (1981). That drained-out, used-up feeling. Psychology Today, 15(1), pp. 90, 94-95. Cheatham, J., & Stein, R. (1982). Relationship between self actualization scores in staff nurses and burnout syndrome symptoms. Nursing Leadership, 2(3), 2-13. Cherniss, c. (1979). Institutional barriers to social support among human service staff. In K. A. Reid, & R. A. Quinlan (Eds.), Burnout in the helping professions (pp. 4810-4811). Kalamazoo: Western university Press. Cherniss, c. (1980a). Professional burnout in human service organizations. New York: Praeger. Cherniss, c. (1980b). Social support networks. InK. A. Reid & R. A. Quinlan (Eds.), Burnout in the helping professions. Kalamazoo: Western University Press. Cherniss, c. (1980c). Staff burnout: Job stress in the human services. Beverly Hills: Sage Publications. Cherniss, c. (1988). Observed supervisory behavior and teacher burnout in special education. Exceptional Children, 54(5), 449-454. Cherniss, c., & Egnatios, E. (1978a). Is there job satisfaction in mental health? community Mental Health Journal, 14(4), 309318. Cherniss, c., & Egnatios, E. (1978b). Participation in decision-making by staff in community mental health programs. American Journal of Community Psychology, 6(2), 171-190. Cherniss, c., Egnatios, E., & Wacker s. (1976). Job stress.and career development in new public professionals. Professional Psychology, 2(4), 428-437. Chiarmonte, A. J. (1983). Psychological correlates of burnout in clergymen. Dissertation Abstracts International, 44, 433A. 211

PAGE 230

Chiriboga, D. A., Jenkins, G., & Bailey, J. (1983). Stress and coping among hospice nurses: Test of an analytic model. Nursing Research, 32(5), 294-298. Clark, c. c. (1980). Burnout: Assessment and intervention. Journal of Nursing Administration, 10(9), 39-43. Cleland, v. (1971). Sex discrimination: Nursing's most pervasive problem. American Journal of Nursing, 71(8) 1542-1547. Cobb, s. (1976). Social support as a moderator of life stress. Psychosomatic Medicine, 34, 300-314. Cohen, A. (1984). Care of care givers. Medical Journal of Australia, 141(8), 520-523. Conner, V. L. (1983). A comparative study of nursing burnout and somatic complaints in three occupational settings. Dissertation Abstracts International, 43, 1887A . Cooke, D. A. (1985). A study undertaken to examine the variance in stress sources between critical care and noncritical care nurses. Dissertation Abstracts International, 44, 2112B. Cooper, c. L. (1984). Alcoholism at work. Leadershio and Organization Development Journal, 2(5), 15-16. Cooper, c. & Marshal, J. (1976). Occupational sources of stress: A review of the literature relating to coronary heart disease and mental ill health. Journal of Occupational Psychology, 49, 11-28. Cooper, c. L., & Melhuish, A. (1980). Occupational stress and managers. Journal of Occupational Medicine, 22(9), 588-592. Corwin, R. (1960). Role conception and mobility aspiration: A study in the formation and transformation of bureaucratic, professional and humanitarian nursing identities. Dissertation Abstracts International, 21, 1280. Costello, c. G. (1978). A critical review of Seligman's laboratory experiments on learned helplessness and depression in humans. Journal of Abnormal Psychology, 87(1), 21-31. 212

PAGE 231

Cronin-StuQbs, D. (1982). Professional burnout, part I: The concept, sources, and methods of coping with job related stress. Journal of Enterostomal Therapv, 10-13. Cronin-stubbs, D. (1983a). Professional burnout, part II: A survey of enterostomal therapists. Journal of Enterostomal Therapy, 10(4), 123-127. Cronin-Stubps, D. (1983b). Professional impairment: Strategies for managing the troubled nurse. Nursing Administration Quarterly, 44-54. Cronin-stubbs, D. (1984). The relationships among occupational stress, life stress, social support and the burnout experienced by staff nurses working in diverse hospital-based specialty areas. Dissertation Abstracts International, 45, 127B. D., & Brophy, E. B. (1985). Burnout: Can social support save the psych nurse? Journal of Psychosocial Nursing, 23(7), 8-13. Cronin-Stubbs, D., & Rooks, c. A. (1985). The stress, social support, and burnout of critical care nurses: The results of research. Heart and Lung, 14(1), 39. Csikszentmihalyi, M. (1975). Beyond boredom and anxiety. san Francisco: Jessey-Bass Publishers. Cummings, o. w., & Nall, R. L. (1983). Relationships of leadership style and burnout to counselors' perceptions of their jobs, themselves, and their clients. Counselors Education and Supervision, 22 (3) 1 227-234 Curtin, L. L. (1980). Enough of reality shock, burnout and identity crisis! Supervisor Nurse, 11(10), 7. Dailey, A. :L. (1985). The burnout test. American Journal of Nursing, 85(3), 270-272. Daley, M. R. (1979). Preventing worker burnout in child welfare. Child Welfare, 48(7), 443-450. D'Ambrosia, s. J. (1987). A study to examine if there is a relationship between burnout and hardiness of nurses working with oncology patients. Dissertation Abstracts International, 48, 309A. 213

PAGE 232

Daones, K. A. (1983). Relationship of burnout to personality and demographic traits in nurses. Dissertation Abstracts International, 44, 1588B. D'Arcy, c., Syrotuik, J., & Siddique, c. M. (1984). Perceived job attributes, job satisfaction, and psychological distress: A comparison of working men and women. Human Relations, 37(8), 603-611. Das, E. B ... (1981). Contributory factors to burnout in the nursing environment. Dissertation Abstracts International, 42, 1393B. Davidson, M. J., & Cooper, c. L. (1984). Occupational stress in female managers: A comparative study. Journal of Management Studies, 21(2), 185-205. Dean, A., &'Lin, N. (1977). The stress buffering role of social support. The Journal of Nervous and Mental Disease, 145(6), 403-417. Deckard, G. J., Rountree, B. H., & Golembiewski, R. T. (1986). Worksite features and progressive burnout phases: Another replication cum extention. Journal of Health and Human Resources Administration, 38-55. De Leo, D., Magni, G., & Vallerini, A. (1982). Anxiety and depression in general and psychiatric nurses: A comparison. International Journal of Nursing Studies, 19(3), 173-175. Depue, R. A:., & Monroe, s. M. (1978). Learned helplessness in the perspective of the depressive disorders: Conceptual and definitional issues. Journal of Abnormal Psychology, 87(1), 3-20. Dick, M. J. (1985). Nurse faculty burnout: Relationships to collegial support, management behavior and workload in collegiate nursing programs. Dissertation Abstracts International, 45, 2100B. Douglas, s. (1985). Crisis in care: The most stressful specialty? Nursing Mirror, 161(18), 32-33. Drotar, D. (1976-77). Consultation in the intensive care nursery. International Journal of Psychiatry in Medicine, Z(1), 69-81. 214

PAGE 233

Duxbery, M.: L. ( 1984) Nurse burnout in high stress work settings. Surgical Rounds, 7(3), 113-115. Duxbery, M. L., Armstrong, G. D., Drew, D. J., & Henly, s. J. (1984). Head nurse leadership style with staff nurse burnout and job satisfaction in neonatal intensive care units. Nursing Research, 33(2), 97101. Edelwich, J., & Brodsky, A. (1980). Burn-out: Stages of disillusionment in the helping professions. New York: Human Sciences Press. Edwards, B. c., Lambert, M. J., Moran, P. w., McCully, T., Smith, K. c., & Ellingson, A. G. (1984). A metaanalytic comparison of the Beck Depression Inventory and the Hamilton Rating Scale for depression as measures of treatment outcome. British Journal of Clinical Psychology, 93-99. Eiseidel, L., & Tully, J. (1981). Methodological considerations in studying the burnout phenomenon. In J. Jones (Ed.), The burnout syndrome: Current research theory and interventions (pp. 89-106). Park Ridge, IL: London House. Eldridge, w., Blostein, s., & Richardson, v. (1983). A multi-dimensional model for assessing factors associated with burnout in human service organizations. Public Personnel Management, 12(3), 314-321. Etzion, D. (1984). Moderating effect of social support on the stress-burnout relationship. Journal of Applied Psychology, 69(4), 615-622. Eysenck, H. J. (1978). Expectations as causal elements in behavioral change. Ins. Rachman (Ed.), Advances in behavior research and therapy (Vol. 1, pp. 171-175). Oxford: Pergamon Press. Farabaugh, N. (1984). Do nurse educators promote burnout? International Nursing Review, 31(2), 47-48, 52. Farber, B. A. (1983). Stress and burnout in the human service professions. New York: Pergamon Press. 215

PAGE 234

Fawzy, F. I., Wellisch, D. K., Pasnau, R. o., & B. (1983). Preventing nursing burnout: A challenge for liaison psychiatry. General Hospital Psychiatry, 5(2), 141-149. Ficklin, T. N. (1983). Doing burnout. The Personnel & Guidance Journal, 2, 578-579. Firth, H., .& Britton, P. (1989). 'Burnout', absence and turnover amongst British nursing staff. Journal of Occupational Psychology, 62(1), 55-59. Firth, H., Mcintee, J., McKeown, P., & Britton, P. G. (1985). Maslach Burnout Inventory: Factor structure and norms for British nursing staff. Psychological Reports, 57(1), 147-150. Firth, H., McKeown, P., Mcintee, J., & Britton, P. Professional depression, 'burnout' and personality in longstay nursing. International Journal of Nursing Studies, 24(3), 227-239. Fischer, J. J. (1983). A psychoanalytic view of burnout. In B. A. Farber (Ed.), Stress and burnout in the human service professions (pp. 40-45). New York: Pergamon Press. Fong, c. M. (1985). A study of the relationships between role overload, social support and burnout among nursing educators. Dissertation Abstracts International, 45, 2868B. Ford, D. Murphy, c. J., & Edwards, K. J. (1983). Exploratory development and validation of a job burnout inventory: Comparison of corporate sector and human services professionals. Psychological Reports, 52(3), 995-1006. Ford, R. (1983). Reducing nursing-staff stress through scheduling, orientation, and continuing education. Nursing Clinics of North America, 18(3), 597-601. Frankl, v. E. (1984). Man's search for meaning. New York: Washington Square Press. Freeman, s. J. (1985). Predicting stress in intens_ive care nurses. Dissertation Abstracts International, 45, 8288. 216

PAGE 235

Freidson, E. (1972). Profession of medicine. New York: Dodd, Mead & Company. French, J. R. P., & Caplan, R. D. (1972). Organizational stress and individual strain. In A. J. Morrow (Ed.), The failure of success (pp. 30-66). New York: AMACOM. French, J. R. P., & Raven, B. (1959). The basis of social power. In D. Cartwright (Ed.), studies in social power. Ann Arbor: University of Michigan Press. French, J. R. P., Rodgers, w., & Cobb, B. (1974). Adjustment as person-environment fit. In G. V. Coelho, D. A. Humburg, & J. E. Adams (Eds.), Coping and adaptation (pp. 316-333). New York: Basic Books, Inc. Freudenberger, H. J. (1974). Staff burnout. Journal of Social Issues, 30 (11), 159-165. Freudenberger, H. J. (1975a). The staff burnout syndrome. Washington, DC: Drug Abuse Council. Freudenberger, H. J. (1975b). The staff burnout syndrome in alternative institutions. Psychotherapy: Therapy, Research and Practice, 12(1), 73-82. Freudenberger, H. J. (1977a). Burnout: Occupational hazard of the child care worker. Child Care Quarterly, .2.(2), 90-99. Freudenberger, H. J. (1977b). Burnout: The organizational menace. Training and Development Journal, 31(7), 26-27. Freudenberger, H. J. (1982). Coping with job burnout. Law and Order, 30(5), 64-66. H. J., & North, G. (1982). Situational anxiety: Coping with everyday anxious New York: Doubleday. H. J., & Richelson, G. (1980a). Burnout: How to'beat the cost of success. New York: Bantam/Doubleday. Freudenberger, H. J., & Richelson, G. (1980b). Burnout: The high cost of high achievement. Garden City, NY: Doubleday & Company, Inc. 217

PAGE 236

Freudenberger, H. J., & Robbins, A. (1979). The hazards of being a psychoanalyst. The Psychoanalytic Review, 66(2),. 275-296. Friel, M., & Tehan, c. (1980). Counteracting burn-out for the hospice caregiver. Cancer Nursing, 3(4), 285-293. Friend, K. :E (1982). Stress and performance: Effects of subjective work load and time urgency. Personnel Psychology, 35(3), 623-633. Frohm, K. (1988). Hardiness, the Type A pattern, and reactivity. Dissertation Abstracts International, 48, 3715B. Funk, s. D., & Houston, B. K. (1987). A critical analysis of the hardiness scale's validity and utility. Journal of Personality and Social Psychology, 53(3), 572-578. Gaines, J., & Jermier, J. M. (1983). Emotional exhaustion in a high stress organization. Academy of Management Journal, 26(4), 567-586. Ganellen, R. J., & Blaney, P. H. (1984). Hardiness and social support as moderators of the effects of life stress. Journal of Personality and Social Psychology, 47(1), 156-163. Gann, M. L. (1979). The role of personality factors and job characteristics in burnout: A study of social workers. Dissertation Abstracts International, 40, 3366B. Ganong, J. M. (1982). A correlational study of relationships among self-actualization, tolerance of ambiguity, job stress, and performance track record as perceived by nurse administrators. Dissertation Abstracts International, 42, 435JB. Garber, J., Miller, s. M., & Abramson, L. Y. (1980). On the distinction between anxiety and depression: Perceived control, certainty, and probability of goal attainment. In J. Garber & M. E. P. Seligman (Eds.), Human helplessness (pp. 131-169). New York: Academic Press. 218

PAGE 237

Garber, J.,.Miller, w. R., & Seaman, s. F. (1979). Learned helplessness, stress, and the depressive disorders. In R. A. Depue (Ed.), The psycholobioloqy of the depressive disorders: Implications for the effects of stress (pp. 335-363). New York: Academic Press. Garden, A. (1989). Burnout: The effect of psychological type on research findings. Journal of Occupational Psychology, 62(3), 223-234. Gaston, s. K. (1982). An analysis of the role conception, deprivation, strain and behavior in novice and experienced nurse educators. Dissertation Abstracts International, 42, 100A. Gatti, G. M. (1983). Person-environment fit and work relatetl stress indicators among nurses. Dissertation Abstracts International, 43, 3095A. Gentry, w. D., Foster, s. B., & Freehling, s. (1972). Psychological response to situational stress in intensive and nonintensive nursing. Heart and Lung, .!(6), 793-796. Gillespie, D. F. (1981). Correlates of active and passive types of burnout. Journal of Social Service Research, 1-16. Gillespie, D. F., & Cohen, s. E. (1984). causes of worker burnout. Children and Youth Services Review, 115-124. Gist, M. E. (1987). Self-efficacy: Implications for organizational behavior and human resource management. Academy of Management Review, 12(3), 472-485. Glazer, H. I., Clarkin, J. F., & Hunt, H. F. (1981). Assessment of depression. In J. F. Clarkin & H. I. (Eds.), Depression: Behavioral and directive intervention strategies (pp. 3-30). New York: Garland STPM Press. Godard, D. R., & Pleis, J. (1979). A case study perspeetive of staff burnout. Contemporary Drug Problems, 8(3), 427-434. 219

PAGE 238

Golembiewski, R. T. (1981, November). Organizational development interventions: Limiting burnout through change's in interaction, structure and policies. Paper presented at the First National Conference on Burnout, Philadelphia. Golembiewski, R. T. (1983). The distribution of burnout among.work groups. In D. D. Van Fleet (Ed.). Proceedings of the Academy of Management Annual Meeting, 158-163. Golembiewski, R. T. (1984a). An orientation to psychological burnout: Probably something old, definitely something new. Journal of Health and Human Resources Administration, 2(2), 153-161. Golembiewski, R. T. (1984b). Perspectives on burnout: Seven views of the construct, its character, and costs -a symposium. Journal of Health and Human Resources Administration, 7(2), 142-152. Golembiewski, R. T. (1986a). Recent developments in analysis and amelioration: An introduction to interacting challenges. Journal of Health and Human Resources Administration, 6-15. Golembiewski, R. T. (1986b). The epidemiology of progressive burnout: A primer. Journal of Health and Human Resources Administration, 16-37. Golembiewski, R. T. (1986c, Summer). Toward ameliorating burnout: A tough nut cracked, in part. Academy of Management OD Newsletter, p. 4-5. Golembiewski, R. T. (1987a, August). Diagnosis for providers and their systems: An entry design and its supporting theory. Paper presented at the of the Academy of Management, New Orleans, LA. Golembiewski, R. T. (1987b, Summer). More on ameliorating burnout. Academy of Management OD Newsletter, pp. 6, 9. Golembiewski, R. T. (1989). A note on Leiter's study: Highlighting two models of burnout. Grouo and Organizational Studies, 14(1), 5-13. 220

PAGE 239

Golembiewski, R. T., & Byong-Seob, K. (1989). Self-esteem and phases of burnout. Organization Development Journal, 2(1), 51-58. Golembiewski, R. T., Hilles, R., & Daly, R. (1986). Ameliorating advanced burnout: A design for the easier of two modes and some consequences. Journal of Health and Human Resources Administration, 9(1), 125-147. Golembiewski, R. T., Hilles, R., & Daly, R. (1987). Some effects of multiple OD interventions on burnout and worksite features. Journal of Applied Behavioral Science, 1d, 295-314. Golembiewski, R. T., & Munzenrider, R. (1981). Efficacy of three versions of one burn-out measure: The MBI as total score, sub-scale scores, or phases? Journal of Health and Human Resources Administration, 4(2), 228-246. Golembiewski, R. T., & Munzenrider, R. (1984a). Active and passive reactions to psychological burnout. Journal of Health and Human Resources Administration, 2(2), 264-289. GolembiewskL R. T., & Munzenrider, R. (1984b). Phases of psychological burn-out and organizational covariants: A replication using norms from a large population. Journal of Health and Human Resources Administration, Q(3), 290-323. Golembiewski, R. T., & Munzenrider, R. F. (1986). Profiling acute vs. chronic burnout, III: Phases and life events impacting on patterns of covariation. Journal of Health and Human Resources Administration, 9(2), 173-184. Golembiewski, R. T., & Munzenrider, R. F. (1988a). Burnout as an indicator of gamma change, I: Methodological perspectives on a crucial surrogacy. Journal of Health and Human Resources Administration, 11(2), 218-248. Golembiewski, R. T., & Munzenrider, R. F. (1988b). Phases of burnout: Developments in concepts and applications. New York: Praeger Publishers. 221

PAGE 240

Golembiewski, R. T., Munzenrider, R. F., & Carter, D. (1983). Phases of progressive burnout and their worksi'te covariants: Critical issues in OD research and praxis. The Journal of Applied Behavioral Science, 19(4), 461-481. Golembiewski, R. T., Munzenrider, R. F., & Stevenson, J. G. (19.85). Profiling acute vs. chronic burn-out, I: Theoretical issues, a surrogate, and elemental distributions. Journal of Health and Human Resources Administration, 8(2), 107-125. Golembiewsk.j., R. T., Munzenrider, R. F., & Stevenson, J. G. (1986). Stress in organizations: Toward a phase model of burnout. New York: Praeger. Golembiewski, R. T., & Sccichitano, M. (1983). Testing. for demographic covariants of psychological burn-out: Three sources.of data rejecting robust and regular associations. International Journal of Public Administration, 2(4), 435-447. Goodstadt, .B. E., & Hjelle, L. A. (1973). Power to the powerLess: Locus of control and the use of power. Journal of Personality and Social Psychology, 27(2), 190-19'6. Gorman, c. (1988, March 14). Fed up, fearful and frazzled. Time, pp. 77-78. Gotlib, I. H. (1984). Depression and general psychopathology in university students. Journal of Abnormal Psychology, 93(1), 19-30. Green, D. E., & Walkey, F. H. (1988). A confirmation of the three-factor structure of the Maslach Burnout Inventory. Educational and Psychological Measurement, 48(3), 579-585. Greer, J. G., & Wethered, c. E., (1984). Learned helplessness: A piece of the burnout puzzle. Exceptional Children, 50(6), 524-530. Gribbins, R.. E., & Marshall, R. E. (1982). Stress and copingin the NICU staff nurse: Practical implications for change. Critical Care Medicine, 10(12), 865-867. 222

PAGE 241

Grimm, R. B. (1987). The contribution of personality type and selected individual, role/task, and factors to the experience of burnout (Doctoral dissertation, University of Colorado, Boulder, 1986). Dissertation Abstracts International, 47, 4442A. : Grutchfield, L. E. (1982). Relationships between selected personality variables, demographic variables, and the eXperience of burnout among registered nurses. Dissertation Abstracts International, 42, 4723A. Guyon, LA. (1984). Herzberg's hygiene and motivation factors as related to burnout in prison employees. Dissertation Abstracts International, 44, 2894A. Haack, M. R., & Harford, T. c. (1984). Drinking patterns among student nurses. International Journal of the Addictions, 19(5), 577-583. Hach'e'-Faulkner, N., & MacKay, R. c. (1985). Stress in the workplace: Public health and hospital nurses. Canadian Nurse, 81(4), 40-43. Hackett, G . & Betz, N. E. (1981). A self-efficacy approach to the career development of women. Journal of Vocational Behavior, 18, 326-339. Hahn, M. E. (1966). California Life Goals Evaluation. Palo Alto: Western Psychological Services. Hall, D. T. (1975). Pressures from work, self and home in the life stages of married women. Journal of Vocational Behavior, 121-132. Hall, R., Gardner, E. R., Perl, M., Stickney, s., & Pfefferbaum, B. (1979) The professional burnout syndrome. Psychiatric Opinion, 16(4), 12-15. Hamilton, M. (1982). Symptoms and assessment of depression. In E. s. Paykel (Ed.), Handbook of Affective Disorders (pp. 3-11). New York: The Guilfo:rd Press. Hamilton, M. (1989). Mood disorders: Clinical features. In H. I. Kaplan & B. J. Sadock (Eds.), Comprehensive textbook of psychiatry/V (Vol. 1, pp. 892-913). Baltimore: Williams & Wilkins. 223

PAGE 242

Hammer, J. s., Jones, J. w., Lyons, J. s., Sixsmith, D., & Afficiando, E. (1985). Measurement of occupational stress in hospital settings: Two validity studies of a measure of self-reported stress in medical emergency rooms. General Hospital Psychiatry, 7(2), 156-162. Handy, J. A. (1988). Theoretical and methodological problems within occupational stress and burnout research. Human Relations, 41(5), 351-369. Hannah, T. E. (1988). Hardiness and health behavior: The role of health concern as a moderator variable. Behavioral Medicine, 14(2), 59-63. Hannah, T. E., & Morrissey, c. (1897). Correlates of psychological hardiness in Canadian adolescents. The Journal of Social Psychology, 1271(4), 339-344. Hare, J., & Pratt, c. c. (1988). Burnout between professional and paraprofessional nursing staff in acute care and long-term care health facilities. The Journal of Applied Gerontology, 7(1), 60-72. Harris, P. c. (1984). Burnout in nursing administration. Nursing Administration Quarterly, 1l,(3), 61-70. Harrison, w. D. (1980). Role strain and burnout in child protective service workers. Social Service Review, 54, 31':"'44. Hay, D., & Oken, D. (1972). The psychological stresses of intensive care unit nursing. Psychosomatic Medicine, 34, 109-118. Helrich, K. L. (1985). The use of hardiness and other stress-resistance resources to predict symptoms and performance in police academy trainees. Dissertation Abstracts International, 46, 2083 B. Hickey, J. v. (1982). Combating 'burn-out' by developing a theoretical framework. The American Association of Neurosurgical Nurses, 14(2), 103-107. Hiestand, D. L. (1966). Research into manpower for health Milbank Memorial Fund Quarterly, 44(4), 146-181. Hodgkinson, P. (1984). Nurses have needs too: Nursing stress, part 3. Nursing Times, 80(41), 35-36. 224

PAGE 243

Hollon, s .. D., & Garber, J. (1980). A cognitive expectancy theory of therapy for helplessness and depression. In J. Garber & M. E. P. Seligman (Eds.), Humanbelplessness (pp. 173-195). New York: Academic Press. Holt, P., Fine, M. J., & Tollefson, N. (1987), Mediating stress: Survival of the hardy. Psychology in the Schools, 24(1), 51-58. Horner, D. A. (1985). Burnout in psychiatric hospital staff: An attributional view. Dissertation Abstracts International, 45, 305GB. Howard, G. s., Scott, E. M., Wiener, R. L., Boynton, K. s., & Rooney, w. M. (1980). Is a behavioral measure the best estimate of behavioral parameters? Perhaps not. Applied Psychological Measurement, 293-311. Howard, J. H., Cunningham, D. A., Rechnitzer, P. A. (1986). Personality (hardiness) as a moderator of job stress and coronary risk in Type A individuals: A longitudinal study. Journal of Behavioral Medicine, 9(3), 229-244. Huesman, L. R. (1978). Cognitive processes and models of depression. Journal of Abnormal Psychology, 87(1), 194-198. Hull, J. G., Van Treuren, R. R., & Propsom, P.M. (1988). Attributional.style and the components of hardiness. Personality and Social Psychology Bulletin, 14(3), 505-513. Hull, J. G., Van Treuren, R. R., & Virnelli, s. (1987). Hardiness and health: A critique and alternative approach. Journal of'Personality and Social Psychology, 53(3), 518-530. Hunter, K., Jenkins, J. o., & Hampton,, L.A. (1982). Burnout among providers of emergency health care. Crisis'rnternational, 12(4), 141-152. Igodan, o. c. (1985). Factors associated with burnout among extension agents in the Ohio Cooperative Extension Service. Dissertation Abstracts International, 45, 2360A. 225

PAGE 244

Ivancevich, J. M., & Matteson, M. T. (1980). Stress and work: 'A managerial perspective. Glenview, IL: Scott, Foresman. Ivancevich, J. M., & Matteson, M. T. (1984). A type A-B environment interaction model for examining occupational stress and consequences. Human Relations, 37(7), 491-513. Ivancevich,, J. M., Matteson, M. T., & Preston, c. (1982). Occupational stress type A behavior, and physical well being. Academy of Management Journal, 25(2), 373-391. Ivancevich, J. M., & Smith, s. v. (1982). Job difficulty as interpreted by incumbents: A study of nurses and Human Relations, 35(5), 391-412. Iwanicki, E. F., & Schwab, R. L. (1981). A cross validation study of the Maslach Burnout Inventory. Educational and Psychological Measurement, 41(4), 1167-1174. Jackson, o. H. (1974). Personality Research Form Manual, Goshen, NY: Research Psychologists Press. Jackson, s. E. (1983). Participation in decision making as a strategy for reducing job-related strain. Journal of Applied Psychology, 68(1), 3-19. Jackson, s., & McGrath, H. (1983). Nurses under stress. New Yo'rk: John Wiley & Sons. Jackson, s. E., & Maslach, c. (1982). After-effects of job-related stress: Families as victims. Journal of Occupational Behaviour, 63-77. Jackson, S . E., Schwab, R. L., & Schuler, R. S. (1986). Toward an understanding of the burnout phenomenon. Journal of Applied Psychology, 71(4), 630-640. Jacobson, P. (1978). Stressful situations for neonatal intensive care nurses. American Journal of Maternal Child Nursing, 144-150. Jama, v. J. (1987). The relationship between hardiness and burnout of professional nurses in the specialty of Dissertation Abstracts International, 48, 13'!)2B. 226

PAGE 245

Jamal, M. (1984). Job stress and job performance contrqversy: An empirical assessment. Organizational Behavior and Human Performance, 33 (-1), 1-21. Janz, T., Dugan, s., & Ross, M.s. (1986). Organizational culture and burnout: Empirical findings at the individual and department levels. Journal of Health and Human Resources Administration, 78-92. Jayaratne, s., & Chess, w. A. (1984). The effects of emotional support on perceived job stress and strain. The Journal of Applied Behavioral Science, 20 (2), 141-153. Jeglin-Mendez, A.M. (1982). Burnout in nursing education. Journal of Nursing Education, 21(4), 29-34. Jenkins, G. J. (1981). Stress and coping of hospice nurses. Dissertation Abstracts International, 42, 2600B-2601B. Johnson, J. H., & Sarason, I. G. (1978). Life stress, depression and anxiety: Internal-external control as a moderator variable. Journal of Psychosomatic Research, 22, 205-208. Johnson, S .. H. (1982). Preventing group burnout. Nursing Management, 13(2), 34-38. Jones, J. w. (1981a). Dishonesty, burnout, and unauthorized work break extensions. Personality and Social'Psychology Bulletin, 7(3), 406-409. Jones, J. w. (Ed.). (1981b). The burnout syndrome: Current research, theory. interventions. Park Ridge, IL: London House Press. Judge, D. (1974). The new nurse: A sense of duty and destiny. Modern Healthcare, 21-27. Kafry, D., & Pines, A. (1980). The experience of tedium in life and work. Human Relations, 33(7), 477-503. Kahn, R. L. (1974). Conflict, ambiguity, and overload: Three in job stress. In A. McLean (Ed.), Occupational stress. Springfield, IL: C. c. Thomas. Kahn, R. L. (1978). Job burnout: Prevention and remedies. Public Welfare, 36(2), 61-63. 227

PAGE 246

Kalish, B., & Kalish, P. (1978). The advance of American nursing. Boston: Little, Brown and Company. Kalish, B., & Kalish, P. (1982). Politics of nursing. Philadelphia: J. B. Lippincott. Kanner, A. D., Kafry, D., & Pines, A. (1978). Conspicuous in its absence: The lack of positive conditions as a source of stress. Journal of Human Stress, 33-39. Kanungo, R . N. (1980). Affiliation and autonomy under stress. Psychological Reports, 46(3), 1340. Kaplan, B. ;H., Cassel, J. c., & Gore, s. (1977). Social support and health. Medical Care, 25, 47-58. Kaplan, H. I., & Sadock, B. J. (Eds.). (1989). Comprehensive textbook of psychiatry I V. Baltimore: Williams & Wilkins. Karger, H. J. (1981). Burnout as alienation. social Service Review, 55, 270-283. Kazdin, A. E. (1978). Conceptual and assessment issues raisedby self-efficacy theory. Ins. Rachman (Ed.), Advances in behavior research and therapy (Vol. 1, pp. 177-185). Oxford: Pergamon Press. Keane, A., Ducette, J., & Adler, D. c. (1985). Stress in ICU and non-ICU nurses. Nursing Research, 34(4), 231-236. Kimmel, M. R. (1982). Coping strategies, social support, and role related problems as predictors of burnout in nurses. Dissertation Abstracts International, 42, 4621B. Klein, K. J., & D'Aunno, T. A. (1986). Psychological sense of community in the workplace. Journal of Community Psychology, 14, 365-377. Kobasa, s. c. (1977). Stress, personality, and health: A study of an overlooked possibility. (Doctoral dissertation, University of Chicago, Chicago, 1977). Dissertation Abstracts International, 38, 2430B. Kobasa, s. c. (1979). Personality and resistance to illness. American Journal of Community Psychology, 1(4), 413-423. 228

PAGE 247

Kobasa, s. c. (1982a). Commitment and coping in stress resistance among lawyers. Journal of Personality and Sociaf Psychology, 42(4), 707-717. Kobasa, s. c. (1982b) The hardy personality: Toward a social psychology of stress and health. In G. s. Sanders & J. Suls (Eds.), The social psychology of health and illness (pp. 3-32). Hillsdale, NJ: Lawrence Erlbaum Associates, Publishers. Kobasa, s. c., Hilker, R. R., & Maddi, s. R. (1979). Who stays healthy under stress? Journal of Occupational Medicine, 21(9), 595-598. Kobasa, s. c., & Maddi, s. R. (1977). Existential personality theory. In R. J. Corsini (Ed.), Current personality theories (pp. 243-276). Itasca, IL: F. E. Peacock Publishers, Inc. Kobasa, s. c., & Maddi, s. R. (1982). [Hardiness measurement]. Private communication to author. Kobasa, s. c., Maddi, s. R., & Courington, s. (1981). Personality and constitution as mediators in the stress-illness relationship. Journal of Health and Social Behavior, 22(4), 368-378. Kobasa, s. c., Maddi, s. R., & Kahn, s. (1982). Hardiness and health: A prospective study. Journal of Personality and Social Psychology, 42(1), 168-177. Kobasa, s. c., Maddi, s. R., & Puccetti, M. c. (1982). Personality and exercise as buffers in the stressillness relationship. Journal of Behavioral Medicine, 2(4), 391-404. Kobasa, S.c., Maddi, s. R., & Puccetti, M. c. (1983). Personality and social resources in stress resistance. Journal of Personality and Social Psychology, 45(4), 839-850. Kobasa, s. C., Maddi, s. R., Puccetti, M. c., & Zola, M. z. (1985). Effectiveness of hardiness, exercise and social support as resources against illness. Journal of Psychosomatic Research, 29(5), 525-533. Kobasa, s. :C., Maddi, s. R., & Zola, M. z. (1983). Type A and hardiness. Journal of Behavioral Medicine, 6(1), 41-51. 229

PAGE 248

Kobasa, s. c., & Puccetti, M. c. (1983). Personality and social resources in stress resistance. Journal of Personality and Social Psychology, 45(4), 839-850. Kramer, M. (1969). Collegiate graduate nurses in medical center hospitals: Mutual challenge or duel. Nursing Research, 18(3), 196-210. Kramer, M. (1974). Reality shock: Why nurses leave nursing. st. Louis: The c. v. Mosby Company. Lacey, H. M. (1979). Control, perceived control, and the methodological role of cognitive constructs. In L. c. Perlmuter & R. A. Monty (Eds.), Choice and perceived control (pp. 5-15). Hillsdale, NJ: Lawrence Erlbaum Associates, Publishers. Lahoz, M. R., & Mason, H. L. (1989). Maslach Burnout Inventory: Factor structures and norms for USA pharmacists. Psychological Reports, 64(3), 1059-1063. Lamb, H.R. (1979). Staff burnout in work with long-term patients. Hospital and Community Psychiatry, 30(6), 396-398. Lambert, V.:A., Lambert, C. E., Klipple, G. L., & Mewshaw, E. A. Social support, hardiness and psychological well-being in women with arthritis. IMAGE: Journal of Nursing Scholarship, 21(3), 128-131. Lammert, M. {1981). A group experience to combat burnout and learn group process skills. Journal of Nursing Education, 20(6), 41-46. Lang, P. J. (1978). Self-efficacy theory: Thoughts on cognition and unification. Ins. Rachman (Ed.), Advances in behavior research and therapy (Vol. 1, pp. 187-192). Oxford: Pergamon Press. Lavandero, R. (1981). Nurse burnout: What can we learn? Journal of Nursing Administration, 11(11/12), 17-23. Lazarus, R. s. (1966). Psychological stress and the coping process. New York: McGraw Hill. Lazarus, R. s. (1971). The concepts of stress and disease. In L. Levi (Ed.), Society. stress, and disease (pp. 53-58). Oxford: Oxford Press. 230

PAGE 249

Lazarus, R. s. (1974). Psychological stress and coping in adaptation to illness. International Journal of Psychiatry in Medicine, .2(4), 321-332. Lazarus, R. s., & Opton, E. M. (1966). The study of psychological stress: A summary of theoretical formul-ations and experimental findings. In c. D. Spielberger (Ed.), Anxiety and behavior (Vol. 1, pp. 225-26"2). New York: Academic Press. Lee, H. J. (1983). Analysis of a concept: Hardiness. Oncology Nursing Forum, 10(4), 32-35. Lefcourt, H. M. (1973). The function of the illusions of control and freedom. American Psychologist, 28(5), 417-426. Lefcourt, H. M. (1980a). Locus of control and coping with life's events. In E. Straub (Ed.), Personality: Basic aspects and current research (pp. 200-235). Englewood Cliffs, NJ: Prentice-Hall, Inc. Lefcourt, H. M. (1980b). Personality and locus of control. In J. Garber & M. E. P. Seligman (Eds.), Human helplessness: Theory and applications (pp. 245-259). New York: Academic Press. Lefcourt, H. M. (1989). Locus of control and stressful life events. InT. w. Miller (Ed.), Stressful life events (pp. 157-166). Madison, CT: International Universities Press. Leff, J.P. (1978). Psychiatrists' versus patients' concepts of unpleasant emotions. British Journal of Psychiatry, 133, 306-313. Leif, H. I., & Fox, R. c. (1963). Training for "detached concern" in medical students. In H. I. Leif, V. F. Leif, N. R. Leif (Eds.), The psychological basis of medical practice (pp. 12-35). New York: Harper & Row. Leiter, M.P., & Meechan, K. A. (1986). Role structure and burnout in the field of human services. Journal of Applied Behavioral Science, 22(1), 57-52. Lenrow, P. B. (1978a). Dilemmas of professional helping: Continuities and discontinuities with folk helping roles. In L. Wispe (Ed.), Altruism .. sympathy and helping (pp. 263-290). New York: Academic Press. 231

PAGE 250

Lenrow, P. B. (1978b). The work of helping strangers. American Journal of Community Psychology, 555-571. Levi, M. (1980). Functional redundancy and the process of professionalization: The case of registered nurses in the us. Journal of Health. Politics. Policy. and Law, S'(2), 333-353. Levine, G. (1981). I quit: A guide to burnout professions. orange, CA: Indeco. Levinson, H. (1986, Winter). Letter to the editor. Academy of Management OD Newsletter, p. 8. Lewiston, N.J., Cooley, J., & Blessing-Moore, J. (1981). Measurement of hypothetical burnout in cystic fibrosis caregivers. Acta Paediatrica Scandinavica, 70, 935-939. Lipowski, z. L. (1975). Sensory and information inputs overload: Behavioral effects. Comprehensive Psychiatry, 16(3), 199-121. Lips, H. M., & Ng, M. (1985). Use of the Beck Depression Inventory with three non-clinical populations. Canadian Journal of Behavioral Science, 18(1), 62-73. Livingston, M., & Livingston, H. (1984). Emotional distress in nurses at work. British Journal of Medical Psychology, 57(j), 291-294. Lobb, M., & Reid, M. (1987). Cost-effectiveness at what price? An investigation of staff stress and burnout. Nursing Administration Quarterly, 12(1), 59-66. Locke, E. A., Frederick, E., Lee, c., & Babka, P. (1984). Effect of self-efficacy, goals, and task strategies on task performance. Journal of Applied Psychology, 69 (2) 1 241-251. Louis, D. R. (1985). The relationship between degrees of burnout and educational tracks among registered nurses in Texas. Dissertation Abstracts International, 45, 755A. Lowery, B. J. (1981). Misconceptions and limitations of locus of control and the Scale. Nursing Research, 30(5), 294-186. 232

PAGE 251

Maddi, s. R. (1967). The existential neurosis. Journal of Abnormal Psychology, 72(4), 311-325. Maddi, s. R., & Kobasa, s. c. (1981). Intrinsic motivation and health. In H. I. Day (Ed.), Advances in intrinsic motivation and aesthetics (pp. 299-32i1). New York: Plenum Press. Maddi, s. R., & Kobasa, s. C. (1984). The hardy executive: Health under stress. Homewood, IL: Dow Jones-Irwin. Maddi, s. R., Kobasa, s. c., & Hoover, M. (1979). An alienation test. Journal of Humanistic Psychology, 19(4), 73-76. Maddi, s. R., Propst, B. s., & Feldinger, I. (1965). Three expressions of the need for variety. Journal of Personality, 33, 82-98. Magill, K. A. (1982). Burning, burnout and the brightly burning. Nursing Management, 13(7), 17-21. Magnani, L. E. (1986). The relationship of hardiness and self-perceived health to activity in a group of independently functioning older adults. Dissertation Abstracts International, 46, 4184B. Maier, N. R. F. (1973). Problem solving behavior vs. frustration behavior: Psychology in industrial behavior. Boston: Houghton Mifflin. Maloney, J.P. (1980). Job stress and its consequences on a group of intensive care and non-intensive care nurses. Dissertation Abstracts International, 41(2), 521-5228. Maloney, M. J., & Ange, c. (1982). Group consultation with highly stressed medical personnel to avoid burnout. Journal of the American Academy of Child Psychiatry, 21(5), 481-485. Manning, M. R., Ismail, A. H., & Sherwood, J. J. (1981). Effects of role conflict on selected physiological, affective, and performance variables: A laboratory simulation. Multivariate Behavioral Research, 16(1), 125-141. 233

PAGE 252

Manning, M. R., Williams, R. F., & Wolfe, D. M. (1988). Hardiness and the relationship between stressors and outcomes. Work & stress, 205-216. (1980). Stress amongst nurses. In c. L. Cooper & J. Marshall (Eds.), White collar and professional stress (pp. 19-59). New York: John Wiley & Sons, Inc. Marshall, R. E., & Kasman, c. (1980). Burnout in the neonatal intensive care unit. Pediatrics, 65(6), 1161-1165. Martin, M. J. (1982). Burnout: Fact or fad. Psycho'somatics, ll(5), 461-461. Martof, M. :T. (1985). Stress in new graduate registered nurses in North Carolina. Dissertation Abstracts International, 45, 3207B. Maslach, c. (1976). Burned-out. Human Behavior, 2, 16-22. Maslach, c. (1978a). Job burnout: How people cope. Public Welfare, 36(2), 56-58. Maslach, c .. (197Bb). The client role in staff burnout. Journal of Social Issues, 34(4), 111-124. Maslach, c. (1979). The burnout syndrome and patient care. In c. A. Garfield (Ed.), Stress and survival: The emotional realities of life-threatening illness (pp. 111-120). St. Louis: Mosby. Maslach, c. (1981). A social psychological analysis. In J. w. Jones (Ed.), The burnout syndrome: Current research, theory, interventions (pp. 30-53). Ridge Park, IL: London House Press. Maslach, c. (1982a). Burnout: The cost of caring. Englewood Cliffs, NJ: Prentice-Hall, Inc. Maslach, c. (1982b). Understanding burnout: Definitional issues in analyzing a complex phenomenon. In W. s. Paine (Ed.), Job stress and burnout (pp. 29-40). Beverly Hills: Sage Publications. Maslach, c., & Jackson, s. E. (1979). Burned-out cops and their families. Psychology Today, 12(12), pp. 59-62. 234

PAGE 253

Maslach, & Jackson, S. E. (1981a). The Maslach burnout inventory. Palo Alto: Consulting Psychologists Press. Maslach, c., & Jackson, s. E. (1981b). The measurement of experienced burnout. Journal of Occupational Behavior, 1,(2), 99-113. Maslach, c., & Jackson, s. E. (1982). Burnout in health profes'sions: A social psychological analysis. In G. Sanders & J. Suls (Eds.), Social psychology of health and illness (pp. 227-251). Hillsdale, NJ: Lawrence Erlbaum. Maslach, c., & Jackson, s. E. (1984). Patterns of burnout among'a national sample of public contact workers. Journal of Health and Human Resources Administration, 1.(2), 189-i12. Maslach, c., & Jackson, s. E. (1985). The role of sex and family variables in burnout. Sex Roles, 12(7/8), 837-851. Maslach, c., & Pines, A. (1977). The burnout syndrome in the day care setting. Child Care Quarterly, 100-113. Maslach, c., & Pines, A. (1979). Burnout: The loss of human caring. In A. Pines & c. Maslach (Eds.), Experiencing social psychology. New York: Knopf. McCarthy, P. (1985). Burnout in psychiatric nursing. Journal of Advanced Nursing, 10(4), 305-310. McConnel, E. A. (1981). How close are you to burnout? RN, 44(5), 29-32. McCrane, E . w., Lambert, v. s., & Lambert, c. E. (1987). Work stress, hardiness, and burnout among hospital staff nurses. Nursing Research, 36(6), 374-378. McCranie, w., & Brandsma, J. M. (1988). Personality antecedents of burnout among middle-aged physicians. Behavioral Medicine, 14(1), 30-36. McDermott, D. (1984). Professional burnout and its relation to job characteristics, satisfaction and control. Journal of Human Stress, 10(2), 79-85. 235

PAGE 254

McNitt, P. C., & Thornton, D. W. (1978). Depression and perceived reinforcement: A reconsideration. Journal of Psychology, 87(1), 137-140. Mechanic, D. (1976). stress, illness, and illness behavior. Journal of Human Stress, 2-6 Meier, s. T. (1983). Toward a theory of burnout. Human 36(10), 899-910. Meier, s. T. (1984). The construct validity of burnout. Journal of Occupational Psychology, 57(3), 211-219. Miller, I. w., III, & Norman, w. H. (1979). Learned helple'ssness in humans: A review and attribution theory model. Psychological Bulletin, 86(1), 93-118. Miller, s. M. (1980). Why having control reduces stress: If I can stop the roller coaster, I don't want to get off. In J. Garber & M. E. P. Seligman (Eds.), Human helplessness: Theory and applications (pp. 71-95). New York: Academic Press. Mitchell, R. G. (1988). The emotional cost of nursing. Nursing, 1021-1025. Mohl, P. c., Denny, N. R., Mote, T. A., & Coldwater, c. (1982). Hospital unit stressors that affect nurses: Primary task vs. social factors. Psychosomatics, 23(4), 366-374. Monat, A'., Averill, J. R., & Lazarus, R. s. (1972). Anticipatory stress and coping reactions under various conditions of uncertainty. Journal of Personality and Social Psychology, 24(2), 237-253. Montowidlo ,. s. J., Packard, J. s., & Manning, M. R. (1986). Occupational stress: Its causes and for job performance. Journal of Applied Psychology, 71(4), 618-629. Moore, J. (1984). Part One: Caring for the carers. Nursing Times, 80(41), 28-30. Moos, R. H. (1986). Work Environment Scale (3rd ed.). Palo Alto: Consulting Psychologists Press. Morrow, L. (1981). The burnout of almost everyone. Time, 21, pp. 84. 236

PAGE 255

Moss, G . E. (1973). Illness. immunity, and social interaction. New York: John Wiley and Sons. Mossholder, K. w., Bedeian, A. G., & Armenakis, A. A. (1982)-. Group process-work outcome relationships: A note on the moderating impact of self-esteem. Academy of Management Journal, 25(3), 575-585. Mullane, M. (1976). Politics begins at work. RN, 39(7), 45-51 . Mullins, A. c., & Barstow, R. E. (1979). care for the caretakers. American Journal of Nursing, 79(8), 1425-1427. Nagy, s. (1985). Burnout and selected variables as components of occupational stress. Psychological Reports, 56(1), 195-200. Nagy, s., &. Nix, c. L. (1989). Relations between health behavior and hardiness. Psychological Reports, 65(1), 339-345. Niehouse, 0. I. (1984). Controlling burnout: A leadership guide for managers. Business Horizons, 27(4), 80-85. Norbeck, J. s. (1985). Types and sources of social support for managing job stress in critical care nursing. Nursing Research, 35(4), 255-230. Nowack, K. M. (1985). The relationship between stress, cognitive hardiness, and health coping behavior to psychoiJ.ogical well-being. Dissertation Abstracts International, 46, 1737B. Nowack, K. (1986). Type A, hardiness, and psychological distress. Journal of Behavioral Medicine, 537-548. Nowack, K. M. (1989). Coping style, cognitive hardiness, and health status. Journal of Behavioral Medicine, 12(2) 1 145-158. Nowack, K .. M., & Hanson, A. L. (1983). The relationship between stress, job performance, and burnout in college student resident assistants. Journal of College Student Personnel, 24(6), 545-550. 237

PAGE 256

Numerof, R. E., & Abrams, M. N. (1984). Sources of stress among nurses: An empirical investigation. Journal of Human Stress, 10(2), 88-100. Numerof, R. E., & Gillespie, D. F. (1984, August). Predicting burnout among health service providers. Paper presented at the 44th Annual Meeting of the Academy of Management, Boston, MA. Numerof, R. E., & Seltzer, J. (1986, August). The relationship between leadership factors. burnout, and stress symptoms among middle managers. Paper presented at the Academy of Management Health Care Administration Division, Chicago, IL. Oganowski, J. L. (1984). The relationship between burnout, somatic complaints and illnesses and levels of self actualization of registered nurses in Columbus, OH. Dissertation Abstracts International, 45, 75'6A. Ogle, M. E. (1983). Stages of burnout among oncology nurses in the hospital setting. Oncology Nurse Forum, 10(1), 31-34. Okun, M.A., Zautra, A. J., & Robinson, s. E. (1988). Hardiness and health among women with rheumatoid arthritis. Personality and Individual Differences, 101-107. Olsen, c. F. (1985). The relationship of selected variables and perceived burnout among principals. Dissertation Abstracts International, 45, 3257A. OrRico, M. J. (1982). Psychologial stress, emotional distress and personality characteristics of nurses. Dissertation Abstracts International, 42, 4586B. Paine, W. s. (1981). The burnout syndrome in context. In J. w. Jones (Ed.), The burnout syndrome: Current research. theory. intervention (pp. 1-29). Park Ridge, IL: London House Press. Paine, w. s. (1982). Job stress and burnout. Beverly Hills:sage Publications. Paine, W. s. (1984). Professional burnout: Some major costs. Family and Community Health, 6(4), 1-11. 238

PAGE 257

Parasueraman, s., & Alutto, J. A. (1981). An examination of the organizational antecedents of stressors at work. Academy of Management Journal, 24(1), 48-67. s., & Alutto, J. A. (1984). Sources and outcomes of stress in organizational settings: Toward the development of a structural model. Academy of Management Journal, 27(2), 330-350. Paredes, F. c. (1983). The relationship of psychological resources and social support to occupational stress and burnout in hospital nurses. Dissertation Abstracts International, 43, 881B. Parker, c. M. (1984). A study of occupational stress in selected specialties in the nursing profession. Dissertation Abstracts International, 44, 2052A. Parker, D. F., & DeCothiis, T. A. (1983). Organizational determinants of job stress. organizational Behavior and Human Performance, 32(2), 160-177. Parkes, K. R. (1982). Occupational stress among student nurses.: A natural experiment. Journal of Applied Psychology, 67(6), 784-796. Parkes, K. R., & Rendall, E. (1988). The hardy personality and its relationship to extraversion and neuroticism. Personality and Individual Differences, ,2(4), 785-790. Patrick, P. K. (1979). Burnout: Job hazard for health workers. Hospitals, 53(22), 87-88, 90. Patrick, P. K. (1984). Professional roles at risk for burnout. Family and Community Health, 25-31. Patterson, w. B., Craven, D. E., Schwartz, D. A., Nardell, E. A., Kasmer, J., & Noble, J. (1985). Occupational hazards to hospital personnel. Annals of Internal Medicine, 102(5), 658-680. Perlman, B., & Hartman, E. A. (1982). Burnout: summary and future research. Human Relations, 35(4), 283-305. 239

PAGE 258

Phares, E. J. (1972). A social learning theory approach to psychopathology. In J. B. Rotter, J. E. Chance, & E. J. Phares (Eds.), Applications of a social learning theory of personality (pp. 436-469). New York: Holt, Rinehart and Winston, Inc. Phares, E. J. (1976). Locus of control in personality. Morristown, NJ: General Learning Press. Pines, A. (1981). Burnout: A current problem in pediatrics. Current Problems in Pediatrics, 11(7), 1-32. Pines, A. (1982). Helper's motivation and the burnout syndrome. InT. A. Wills (Ed.), Basic processes in helping relationships. New York: Academic Press. Pines, A., & Aronson, E. (1983). Combatting burnout. Children and Youth Services Review, 5(3), 263-275. Pines, A., Aronson, E., & Kafry, D. (1981). Burnout: From tedium to personal growth. New York: The Free Press. Pines, A., Etzion, D., & Kafry, D. (1979). Job stress from a. cross cultural perspective. InK. Reid (Ed.), Burnout in the helping professions. Ann Arbor: Michigan University Press. Pines, A., & Kafry, D. (1978). Occupational tedium in social service professionals. Social Work, 499-507. Pines, A., & Kafry, D. (1981a). Coping with burnout. In J. Jon.es (Ed.), The burnout syndrome (pp. 139-150). Park Ridge, IL: London House Press. Pines, A., & Kafry, D. (1981b). Tedium in the life of professional women as compared with men. Sex Roles, .2(10), 963-977. Pines, A., & Kafry, D. (1981c). The experience of tedium in three generations of professional women. Sex Roles, 2(2), 117-134. Pines, A., & Kanner, A. D. (1982). Nurses' burnout: Lack of positive conditions and presence of negative conditions as two independent sources of stress. Journal of Psychosocial Nursing and Mental Health, 20(8), 30-5. 240

PAGE 259

Pines, A.,, & Maslach, c. (1978). Characteristics of staff burnout in mental health settings. Hospital and Community Psychiatry, 29(4), 233-237. Pines, A., & Solomon, T. (1977). Perception of self as a mediator in the dehumanization process. Personality and Social Psychology Bulletin, d(2), 219-223. Pollock, s. E. (1986). Human responses to chronic illness: Physiologic and psychosocial adaptation. NursiRg Research, 35(2), 90-95. Poser, E. G. (1978). The self-efficacy concept: Some theoretical, procedural and clinical implications. Ins. Rachman (Ed.), Advances in behavior research and therapy (Vol. 1; pp. 193-202). Oxford: Pergamon Press. Posner, I., Lester, D., & Leitner, L. (1983). Stress in lower
PAGE 260

Rehm, L. P. (1977}. A self-control model of depression. Behavior Therapy, 787-804. Reid, K. E. (Ed.}. (1979}. Burnout in the helping professions. Kalamazoo: Western Michigan University. Rhodewalt, F., & Aqustsdottir, s. (1984}. On the relationship of hardiness to the Type A behavior pattern: Perception of life events versus coping with life events. Journal of Research in Personality, 18(2), 211-223. Rhodewalt, F., & Zone, J. B. (1989}. Appraisal of life change, depression, and il.lness in hardy and nonhardy women. Journal of Personality and Social Psychology, 56(1}, 81-88. Rich, v. L . & Rich, A. R. (1987). Personality hardiness and burnout in female staff nurses. IMAGE: Journal of Nursing Scholarship, 19(2), 63-66. Ricotta, P. F. (1985). Perceived stress in nursing: Relationship to job satisfaction, locus of control, occupational prestige, achievement and capacity for status. Dissertation Abstracts International, 45, 3207B. Rizley, R ... (1978). Depression and distortion in the attribution of causality. Journal of Abnormal Psychology, 87(1), 32-48. Roelens, A. I. (1984). Job stress and burnout among staff nurses in acute care hospitals. Dissertation Abstracts International, 44, 457-458B. Rosenthal, E., Teague, M., Retish, P., West, J., & Vessell, R. (1983). The relationship between work environment attributes and burnout. Journal of Leisure Research, 15(2}, 125-135. Rosenthal, T. L. (1978). Bandura's self-efficacy theory: Thought is father to the deed. Ins. Rachman (Ed.), Advances in behavior research and therapy (Vol. 1, pp. 203-209). Oxford: Pergamon Press. Roth, D. L., Wiebe, D. J., Fillingim, R. B., & Shay, K. A. (1989). Life events, fitness, hardiness, and health:; A simultaneous analysis of proposed stressresistance effects. Journal of Personality and Social Psychology, 57(1), 136-142. 242

PAGE 261

Rotter, J. B. (1954). Social learning and clinical psychology. New York: Prentice Hall. Rotter, J. B. (1966). Generalized expectancies for internal v. external control of reinforcement. Psychological Monographs, 80(1, Whole No. 609). Rotter, J. B. (1972). Generalized expectancies for internal versus external control of reinforcement. In J. B. Rotter, J. E. Chance, & E. J. Phares (Eds.), Applications of a social learning theory of personality (pp. 260-306). New York: Holt, Rinehart and Winston, Inc. Rotter, J. B., Chance, J. E. & Phares, E. J. (1972). Applications of a social learning theory of personality. New York: Holt, Rinehart, & Winston. Rotter, J. B., Seeman, M., & Liverant, s. (1962). Internal v. external locus of control of reinforcement: A major variable in behavior therapy. InN. F. Washburne (Ed.), Decisions. values, and groups (pp. 473-516). London: Pergamon Press. Rountree, B. H. (1984). Psychological burnout in task groups: Examining the proposition that some task groups of workers have an affinity for burnout, while others do not. Journal of Health and Human Resources Administration, 2(2), 235-248. Rubovits, P. c., & Maehr, M., L. (1973). Pygmalion black and white. Journal of Personality and Social Psychology, 25(2), 210-218. Ryan, w. (1971). Blaming the victim. New York: Pantheon. Ryerson, D., & Marks, N. (1981). Career burnout in the human .services: strategies for intervention. In J. W. Jones (Ed.), The burnout syndrome (pp. 151-163). Park Ridge, IL: London House Press. Sabbe, J. (1981). Creative policies help end frustrations for "burned out" nurses. AORN Journal, ll(4), 363,638. Sackeroff, M. L. (1982). A critical study of burnout in the nurturing professions. Dissertation Abstracts International, 43, 3081-3082B. 243

PAGE 262

Sagert, J. M. (1984). The influence of attentional self regulation on personality based hardiness. Dissertation Abstracts International, 46, 1370-1371B. Sakharov, M., & Farber, B. A. (1983). Critical study of burnout in teachers. In B. A. Farber (Ed.), Stress and burnout in the human service professions (pp. 65-81,). New York: Pergamon Press. Sarata, B. P. v. (1977). Job characteristics, work satisfactions and task involvement as correlates of service delivery strategies. American Journal of Psychology, 2(1), 99-109. Sarata, B. P. V., & Jeppesen, J. c. (1977). Job design and staff satisfaction in human service settings. American Journal of Community Psychology, 5(2), 229-236. Savage, J. s. (1987). Social support and personality hardiness as mediators of stress in professional women. Dissertation Abstracts International, 48, 49A. Savicki, v., & Cooley, E. (1983). Theoretical and research considerations of burnout. Children and Youth Services Review, 5(3), 227-238. Scalzi, c. c. (1985). An exploratory study of the relationship between role conflict and ambiguity and depressive symptoms in top level nurse administrators. Dissertation Abstracts International, 45, 2872B. Schlosser, M. B. (1986). stress, coping, hardiness and health-protective behavior. Dissertation Abstracts International, 46, 4028B. Schmale, A. H., & Iker, H. (1971). Hopelessness as a predictor of cervical cancer. Social Science & Medicine, 5(1), 95-100. Schmied, L . A., & Lawler, K. A. (1986). Hardiness, Type A behavior, and the stress-illness relation in working women. Journal of Personality and Social Psychology, 51(6), 1218-1223. 244

PAGE 263

Schoenig, T. M. (1987). An investigation of the relationships among burnout, hardiness, stressful teaching events, job and personal characteristics in public school teachers, Dissertation Abstracts Interriational, 47, 4334-4335. Schucker, c. L. (1985). The cognitive appraisal of job stress in the hospital psychiatric nursing staff. Dissertation Abstracts International, 45, 3961B. Schuler, s. (1980). Definition and conceptualization of stress in organizations. organizational Behavior and Human Performance, 25, 184-215. Schwartz, M.s., & Will, G. T. (1953). Low morale and mutual withdrawal on a mental hospital ward. Psychiatry, 16(4), 337-353. Scully, R. (1980). Stress in the nurse. American Journal of Nursing, 80(5), 912-915. Scully, R. (1981). Staff support groups: Helping nurses to help themselves. Journal of Nursing Administration, 11(3), 48-51. Seabold, D. R. (1984). The development of a predictive model and measure of occupational burnout in the nursing profession. (Doctoral dissertation. University of Wisconsin, Madison, 1983). Dissertation Abstracts International, 45, 1595B. Seers, A., McGee, G. w., Serey, T. T., & Graen, G. B. (1983). The interaction of job stress and social support: A strong inference investigation. Academy of Management Journal, 26(2), 273-284. Seever, M. F. (1985). Burnout in nurses: The relationship of selected personality and interpersonal factors and demographic data to burnout. Dissertation Abstracts International, 46, 338-339B. Seger, K. A. (1984). The relationship between role and life event stress, mental and physical health, and hardiness dimensions. Dissertation Abstracts International, 46, 990B. Seiderman, s. (1978). Combatting staff burnout. Daycare and Early Education, .2(4), 6-9. 245

PAGE 264

Seligman, M. E. P. (1975). Helplessness: On depression. development and death. San Francisco: w. H. Freeman & co . Seligman, M. E. P. (1978). Comment and integration. Journa'l of Abnormal Psychology, 87(1), 165-179. Seligman, M. E. P., Abramson, L. Y., Semmel, A., & von Baeyer., c. (1979). Depressive attributional style. Journal of Abnormal Psychology, 88(3), 242-247. Seligman, M. E. P., & Maier, s. F. (1967). Failure to escape traumatic shock. Journal of Experimental Psychology, 74(1). 1-9. Seltzer, J . & Numerof, R. E. (1988). Supervisory leadership and subordinate burnout. Academy of Management Journal, 31(2), 439-446. Selye, H. (1978). The stress of life.-New York: McGraw Hill. Seuntjens, A. D. (1982). Burnout in nursing: What it is and how to prevent it. Nursing Administration 2(1), 12-19. Shea, c. A. (1985). An investigation of the emotional aspect of burnout and stressors in reso.urce LD teachers. Dissertation Abstracts International, 45, 3325A. Sheridan, J. E. (1985). A catastrophe model of employee withdrawal leading to low performance, high absenteeism, and job turnover during the first year of employment. Academy of Management Journal, 28(1), Sheridan, J. E., & Vredenburgh, D. J. (1978). Usefulness of leadership behavior and social power variables in predicting job tension, performance and turnover of nursing employees. Journal of Applied Psychology, 63(1), 89-95. Shinn, M. (1981). Caveat emptor: Potential problems in using information on burnout. In w. s. Reid (Ed.), Proceedings of the First National Conference on Burnout (pp. 161-194). Philadelphia: Mercy Catholic Medical Center. 246

PAGE 265

Shubin, s. (1978). Burnout: The professional hazard you face in nursing. Nursing. 78, !l,(7), 22-27. Shubin, s. (1979). RX for stress-your stress. Nursing. 79, 9(1), 52-55. Sigardson, K. M. (1982). Why nurses leave nursing: A survey of former nurses. Nursing Administration Quarterly, 2(1), 20-24. Silberner, J. (1988, April 25). The need for doctors and dentists won't go away, and getting into medical or dental school is easier now. u.s. News & World Report, pp. 74,76. Silver, R. L., & Wortman, c. B. (1980). Coping with undesirable life events. In J. Garber & M. E. P. Seligman (Eds.), Human helplessness: Theory and applications (pp. 279-135). New York: Academic Press. Simoni, P. A. s. (1988). Hardiness as a predictor of burnout in nursing. Dissertation Abstracts International, 49, 736A. Skinner, K. (1979). Bur.n-out: Is nursing dangerous to your Journal of Nursing Care, 12(11), 8-9, 30. Smith, R. Johnson, J. H., & Sarason, I. G. (1978). Life change, the sensation seeking motive, and psychological distress. Journal of Consulting and Clinical Psychology, 46, 348-349. Speisman, J. c., Lazarus, R. s., Davison, L. A., & Mordkoff, A.M. (1964). Experimental analysis of a film used as a threatening stimulus. Journal of Consulting Psychology, 28, 23-33. Starr, P. ('1982). The social transformation of American medicine. New York: Basic Books, Inc. Steer, R. A., Beck, A. T., & Garrison, B. (1985). Applications of the Beck Depression Inventory. In N. Sartorius & T. A. Ban (Eds.), Assessment of depression (pp. 123-135). New York: Springer-Verlag. 247

PAGE 266

Steer, R. A., Beck, A. T., Riskind, J. H., & Brown, G. (1986). Differentiation of depressive disorders from generalized anxiety by the Beck Depression Inventory. Journal of Clinical Psychology, 42(3), 475-477. Stehle, J . (1981). Critical care nursing stress: The findings revisited. Nursing Research, 30, 182-188. Stein, L. (1967). The doctor-nurse game. Archives of General Psychiatrv, 16(6), 699-703. Stewart, B. E., Yarkin, K.L., Meyerowitz, B. E., Harvey, J. H., & Jackson, L. E. (1982). Psychological stress associated with outpatient oncology nursing. Cancer Nursing, 2(5), Storlie, F. J. (1979). Burnout: The elaboration of a concept. American Journal of Nursing, 79(12), 21082111. Stout, J. & Williams, J. M. (1983). comparison of two measures of burnout. Psychological Reports, 53(1), 283-289. Stout, J. K., & Williams, J. M. (1985). The measurement of burnout. International Journal of Management, -40. Streepy, J.', (1981). Direct service providers and burnout. Social Casework, 62(6), 352-361. Sweeney, P . D., Anderson, K. A., & Bailey, s. (1986). Attributional style in depression: A meta-analytic Journal of Personality and Social Psychology, 50(5), 974-987. Sykes, I. & Eden, D. (1985). Transitional stress, social support and psychological strain. Journal of Occupational Behavior, 293-298. Teasdale, J.D. (1978). Self-efficacy: Toward a unifying theory of behavioral change? Ins. Rachman (Ed.), Adyances in behavior research and therapy (Vol. 1, pp. 211-215). Oxford: Pergamon Press. 248

PAGE 267

Tennis, c. N. (1987). An exploration of the relationship between job burnout and selected workplace process variables. (Doctoral dissertation, University of Colorado, Boulder, 1986). Dissertation Abstracts Inter.national, 47, 4136A. Thomas, N. R. (1984). A study of stress and its .consequences on the critical care nurse and the noncritical care nurse. Dissertation Abstracts International, 44, 1065B. w. (1980). Burnout in group home American Journal of Psychiatry, 137(6), 710-714. Tiedeman, D. v. (1979). Burning and copping out of counseling. Personnel and Guidance Journal, 57(6), 328-330. Tierney, G., & Strom L. M. (1980). Stress: Type A behavior in the nurse. American Journal of Nursing, 80(5), 917-918. Timmons, c. L. (1985). An analysis of stress in the nursing profession. Dissertation Abstracts International, 45, 3087B. Toft, P. G ... (1979). An analysis of stress experienced by nurses in a hospital setting and an evaluation of a counseling and consulting support program. Dissertation Abstracts International, 40, 3129-3'130B. Tregarthen, T. (1987, November 11). This nursing shortage is different. The Wall Street Journal, p. 26. Trygstad, Ih N. (1985). Stress and coping in psychiatric nursing. Dissertation Abstracts International, 45, 3775B. Turnipseed, D. L. (1987). Burnout among hospice nurses: An assessment. Hospice Journal, 105-119. Vachon, M. L., Lyall, W. A., & Freeman, s. J. ( 1978) Measurement and management of stress in health professionals working with advanced cancer patients. Death Education, 1(4), 365-375. 249

PAGE 268

Veninga, R. L. (1979). Administrator burnout: Causes and cures. Hospital Progress, 60(2), 45-52. Veninga, R. L., & Spradley, J.P. (1981). The work/stress connection: How to cope with job burnout. Boston: Little, Brown. Von Baeyer, c., & Krause, L. (1983-84). Effectiveness of stress management training for nurses working in a burn treatment unit. International Journal of Psychiatry in Medicine, 13(2), 113-125. Vredenburgh, D. J., & Trinkaus, R. J. (1983). An analysis of role stress among hospital nurses. Journal of Vocational Behavior, 23(1), 82-95. Watson, D.,. & Clark, L. A. (1984). Negative affectivity: The disposition to experience aversive emotional states. Psychological Bulletin, 96(3), 465-490. Weiner, M. "F., Caldwell, T., & Tyson, J. (1983). stresses and coping in ICU nursing: Why support groups fail. General Hospital Psychiatry, 179-183. Weinstein, s. P. (1979). The staff burnout phenomenon: An etiological model. Contemporary Drug Problems, 419-425. Weiskopf, P. E. (1980). Burnout among teachers of exceptional children. Exceptional Children, 47(1), 18-23. Weiss, H. M., Ilgen, D. R., & Sharbaugh, M. E. (1982). Effects of life and job stress on information search behav:i,.:ors of organizational members. Journal of Applied Psychology, 67(1), 60-66. Weiss, J. M. (1971). Effects of coping behavior in different warning signal conditions on stress pathology in rats. Journal of Comparative and Physiological Psychology, 77(1), 1-13. Wendt, B. (1982). The role of hardiness as a mediator stress and illness among adolescents. Dissertation Abstracts International, 43, 891B. Wessells, D. T., Kutscher, A. H., Seeland, I. B., Seider, F. E.,' Cherico, D. J., & Clark, E. J. (Eds.). Professional burnout in medicine and the helping professions. Loss, Grief. & care, d(l/2). 250

PAGE 269

West, D. S;, Horan, J. J., & Games, P. A. (1984). Comporent analysis of occupational stress inoculation applied to registered nurses in an acute care hospital setting. journal of Counseling Psychology, 31(2), 209-218. White, R. w. (1959). Motivation reconsidered: The concept of competence. Psychological Review, 66(5), 297-333. Whitehead,.J. T. (1985). Job burnout in probation and parole: Its extent and intervention implications. criminal Justice and Behavior, 12(1), 91-110. Will, G. G (1988, May 23). The dignity of nursing. p. 80. Williams, c. A. (1989). Empathy and burnout in male and female helping professionals. Research in Nursing & Health, 12(3), 169-178. Willis, M. :H., & Blaney, P. H. (1978). Three tests of the learned helplessness model of depression. Journal of Abnormal Psychology, 87(1), 131-136. Wilson, G. T. (1978). The importance of being A commentary on Bandura's "Self efficacy: Towards a unifying theory of behavioral change .. 11 In s. Rachman (Ed.), Advances in behavior research and therapy, (Vol. 1, pp. 217-230). Oxford: Pergamon Press. Wimbush, F. B. (1983). Nurse burnout: Its effect on care. Nursing Management, 14(1), 55-57. Wolman, B. :B. (Ed.). (1977). International encyclopedia of psychiatry, psychology, psychoanalysis. & neurology (Vol. 8). New York: Aesculapius Inc. Wolpe, J. (l971). Neurotic depression: Experimental analog, clinical syndromes, and treatment. American Journal of Psychotherapy, 25, 362-368. Wolpe, J. (;1.978). Self-efficacy theory and psychotherapeutic change: A square peg for a round hole. iin s. Rachman (Ed.), Advances in behavior research and therapy (Vol. 1, 231-236). oxford: Pergam:on Press. 251

PAGE 270

Wood, C. (1987). Buffer of hardiness: Ari.interview with Suzanne c. Ouellette Kobasa. Advances, 37-45. Wood, R., & Bandura, A. (1989). Social cognitive theory of management. Academy of Management Review, 14(3), 361-384. Wortman, c. B., & Brehm, J. w. (1975). Responses to outcomes: An integration of reactance theory and the learned helplessness model. In L. Berkowitz (Ed.), Advances in experimental psychology (pp. 277-336). New York: Academic Press. Wortman, c. B., & Dintzer, L. (1978). Is an attributional analysis of the learned helplessness phenomenon viable? A critique of the Abramson-Seligman-Teasdale reformulation. Journal of Abnormal Psychology, 87(1), 75-90. Yager, J. (1989). Clinical manifestations of psychiatric disorders. In H. I. Kaplan & B. J. Sadock (Eds.), Comprehensive Textbook of Psychiatry (Vol. 1, pp. 572-892). Baltimore: Williams & Wilkins. Yancik, R. (1984). Sources of work stress for hospice staff. Journal of Psychosocial Oncology, 21-31. Yarne, s. K. (1984). Burnout: The relationship of organizational climate, personal values, and their interactions to job-related attitudes. Dissertation Abstracts International, 44, 1270B-1271B. Yasko, J. M. (1983) . Variables which predict burnout experienced by oncology clinical nurse specialists. Cancer,Nursing, .2.(2), 109-116. Zaleznik, A., Kets de Vries, M. F. R., & Howard, J. (1977). Stress reactions in organizations: Syndromes, causes and consequences. Behavioral Science, 22(3), 151-162. Zung, W. W. K. (1974). The measurement of affects: Depression and anxiety. Modern Problems of the Pharmacopsychiatrist, 2, 170-188. 252