CHAPTER 1

INTRODUCTION

1.1 Background of the study

The purpose of this study is to determine the relationship between workload and burnout
among nurses. Nursing is one of ten jobs with the highest levels of occupational injury or
illness. However, nursing remains as one of the fastest growing workforces in the U.S. Between
2003 and 2011, there was an increment of 10.1 percent in the number of employed registered
nurses. The number of employed registered nurses increased from 2,449,000 to 2,724,570 (U.S.
Department of Labor, 2003). In addition, The U.S. Department of Labor (DOL) also predicts that
employment of registered nurses will grow 26 percent from 2010 to 2020 faster than the average
for all occupations. While there has been a reprieve in the nursing shortage, there is expected to
be a shortage of nurses by 2020. There is still a great shortage longing to be filled. As of
February 2012, the Bureau of Labor Statistics predicted that employment in nursing would reach
3.4 million by the year 2020 (Tuten, 2012). One U.S. study found that 49 percent of nurses under
the age of 30 and 40 percent of nurses over 30 experienced high levels of burnout (Grove, 2006).

Many nurses complain that current workloads are causing burnout. Burnout can be
described by a number of symptoms, including chronic fatigue, irritability, insomnia, headaches,
back pain, weight gain, depression, and high blood pressure (Malugani, 2009). According to a
study in the Journal of the American Medical Association, each additional patient per nurse
carries a 23 percent risk of increased burnout and a 15 percent decrease in job satisfaction
(Aiken, Clarke, Sloane, Sochalski, & Silber, 2002). While referring to a study by Aiken et al.,
(2010), the study found that for each additional patient over four in a nurse workload, the risk of
death for hospital patients increases by seven percent. Patients in hospitals with eight patients per
nurse have a 31 percent higher risk of dying than those in hospitals with four patients per nurse

1
(Aiken, Clarke, Sloane, Sochalski, & Silber, 2002). From the above researches, the result
indicated that increase in workload effect in burnout among nurses.
Malaysia with a nursing workforce of close to 39, 000 and average of 1.69 nurses per
1000 populations in the year 2000, has been placed in the low density cluster in the world
(Soilek, 2006). This indicated that Malaysia has the lowest nurse density in the region or cluster
and is believed to be suffering from excessive nurse migration, low job satisfaction, poor
retention and high turnover (Casey, Fink, Krugman, & Propst, 2004). The shortage of nurses has
always been the major symptoms of high turnover in the health care industry (Global Health
Workforce Alliance, 2008). Turnover rate is one of the indicators of burnout among nurses.
Nursing profession is one of the stressful job as it required nurses to perform and jungle with
many jobs at many places in the hospital or medical centers. Moreover, it is becoming more
stressful in the current situation as nurses facing more workload due to increasing number of
patient and amount of workload. Henceforth, it is important for this study, to determine the
association of workload and burnout among nurses.

1.2 Problem statement

Currently, with the increase number of patient, the workload of nurses also increases as
nurses are caring for more patients. Nurses not only responsible in general health care of the
patients but also required in competing paperwork related to each patients. Henceforth, increases
in number of patient, increases nurses’ workload. Worldwide, the number of burnout among
nurses is increasing. There are many factors or types of stressor that effect in nurses’ burnout.
However, till today there is a lack of research linking the relationship between workload and
burnout. Therefore, it is important for this study to evaluate the relationship between workload
and burnout so that proactive steps could be taken if workload is affecting burnout.

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1.3 Objectives of the study

1.3.1 General objective

This research is carried out to determine the relationship between workload and burnout among
nurses.

1.3.2 Specific objectives

1) To identify the level of workload among nurses

2) To identify the level of burnout among nurses

3) To determine the relationship between workload and burnout

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1.4 Operation Defination

i. Burnout - defined as emotional and physical exhaustion resulting from a combination of

exposure to environmental and internal stressors and inadequate coping and adaptive skills. In
addition to signs of exhaustion, the person with burnout exhibits an increasingly negative attitude
toward his or her job, low self-esteem, and personal devaluation.

ii. Workload – an amount of work to be performed within a specific time period.

iii. Stressor – an activity, event, or other stimulus that causes stress.

iv. Turnover – the rate at which employees leave a workforce and are replaced.

v. Emotional exhaustion – feelings of being emotionally overextended and exhausted by one’s

work.

vi. Depersonalization – an unfeeling and impersonal response toward recipients of one’s service,
care treatment, or instruction.

vii. Personal achievement – feelings of competence and stressful achievement in one’s work.

viii. Mental demand – the amount of cognitive process required to perform the task.

ix. Physical demand – the amount and intensity of physical activity required to complete the task.

x. Temporal demand – the amount of time pressure involved in completing the task.

xi. Effort – how hard the participants have to work to maintain their level of performance.

xii. Performance – the level of success in completing the task.

xiii. Frustration level – how insecure, discouraged, or secure or content the participant felt during
the task.

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1.5 Conceptual Framework

Personal
Accomplishment

Emotional
Workload Burnout
Exhaustion

Depersonalizatio
n

Figure 1: Conceptual Framework

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1.6 Significant of the study

Since the number of burnout among nurses is increasing, the quality of nursing care are in
jeopardized as well as burnout increase the number of turnover rate among nurses. Henceforth,
there is shortage of nurses caring for increases number of patients. Therefore it is important to do
study in workload and burnout, so that the relationship between workload and burnout could be
identified and appropriate measure can be addressed to overcome burnout. This study gave
description of how workload affecting burnout

At the same time, the findings of from this study will increase awareness regarding the
relationship between workload and burnout, how workload affecting burnout. Henceforth, it is
essential for this study so that one of the factors causing burnout could be addressed and
overcome. Moreover, this study could educate and increase awareness among society that
workload could negatively impact nurses in terms of burnout.

1.6.1 Significant to the patient

Nurses are the first line of defense when it comes to identifying problems that a patient
may be experiencing. Nurses pick up on small indicators that patients may be in trouble. High
patient loads and long shifts can only endanger the patient as mistakes are more likely once
people have worked beyond a certain number of hours (Tuten, 2012). Nurses are the core of
patient care. It's through their dedicated work and observations that patients are helped, not hurt.
Workload not only affects burnout among nurses but also the health of the patient. Henceforth it
is important for this study to identify relationship between workload and burnout among nurses
so that effective measure could be taken in ensuring effective care of patients.

1.6.2 Significant to organization

Researchers have found that reduction in the burnout of nurses would reduce hospital
losses dramatically. According to Dr. Steven Hunt (2009), the financial cost of losing a single
nurse has been calculated to equal about twice the nurse's annual salary. For every 1 percent
increase of annual nurse turnover, hospitals lose$300,000 (Tuten, 2012). Henceforth, it is
important for the organization to be aware of relationship between workload and burnout so that

6
effective measure could be taken in ensuring reduces among of burnout and turnover rate among
nurses.

1.6.3 Significant to nursing profession

As relationship between workload and burnout among nurses is identified, it would help
the nurses to do their job effectively. When workload is identified as one of the factors affecting
burnout, proactive measurement can be implemented toward more effective and efficient
workload management among nurses.

1.7 Research Question

i. What are the relationship between workload and burnout among nurses in medical and surgical
ward?

ii. Why important to assess the relationship between workload and burnout?

iii. What are the levels of workload among nurses in medical and surgical ward?

iv. What are the levels of burnout among nurses in medical and surgical ward?

1. 8 Limitation of the study

One of the limitations of this study is small sample size. This might affect the accuracy of
the results, therefore a future study should consider a bigger sample size by conducting research
on the other relevant setting, which involves more institution or others organization.

Other limitation of this study is time constrain. It difficult to identified all the barriers in
implementing effective wound care management within short limit of time. Limited staff (small
group of nurses in the medical and surgical unit) and financial are another limitations in this
research.

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 CHAPTER 2

LITERATURE REVIEW

2.1 Workload among Nurses

Attempting to juggle life and family commitments with regular work patterns is difficult
enough. When needed to work overtime to meet the demand of higher workload, the nurses
would be more pressured and stressed. The current result in research often highlighted that there
may be a cost for extra work commitment if workers feel pressured to engage in overtime work
that is unexplained and unexpected (Patrick & Lavery, 2007).

The workload is a construct intrinsically complex and multifaceted usually defined as the
portion of resource spent to performing a particular activity, for example, the maximum capacity
of performance (Barker, 2009). Nurses are experiencing higher workload due to increased
demand for nurses, inadequate supply of nurses, reduced staffing and increased overtime, and
reduction in patient length of stay.

Various studies have attempted to find and classify the main stressors that affect nursing
staff in general which could be related to burnout (Garrosa et al., 2006). Garcia-Izquierdo &
Rios-Risquez (2002), found that one of the fundamental stressor present among nursing staff is
excessive workload. Stordeur et al., (2001), listed stressors in order of severity of their possible
effect on workers. Excessive workload was at the top of the list followed by conflicts with
doctors, conflicts with colleagues and lack of clarity in tasks and objectives.

This research study is important as it will bring positive impact to nursing industry. The
research would provide a comprehensive examination of the relationship between workload and
burnout among nurses. This study would help to identified workload as factor that affect burnout
among nurses and effective measure could be taken to manage workload in order to prevent
higher burnout rate among nurses. The identified relation between workload and burnout would

8
enable higher management to become more aware and understand the situation better, and
therefore evolve preventive strategies to manage burnout problems.

2.2 Burnout among Nurses

Currently the total number of people missing from work due to burnout is increasing. The
increase of turnover rate due to burnout has become a mass phenomenon receiving constant
attention. The term burnout was coined in the 1970s by the American psychologist Herbert
Freudenberger. He used it to describe the consequences of severe stress and high ideals
experienced by people working in “helping” professions. For examples, doctors and nurses, who
sacrifice themselves for others, would often end up being “burned out” – exhausted, listless, and
unable to cope (PubMed Health, 2013). Burnout is a psychological term that refers to long-term
exhaustion and diminished interest in work. Burnout has been assumed to result from chronic
occupational stress such as work overload (Alarcon, Eschleman, & Bowling, 2009).

Three main areas of symptoms are considered to be signs of burnout syndrome included
emotional exhaustion, alienation and reduced performance. Emotional exhaustion causes people
affected to feel drained and exhausted, overloaded, tired and low, and do not have enough
energy. Physical symptoms include pain or problems with the stomach or bowel. Alienation
affected people by causing them feeling that their jobs increasingly negative and frustrating.
They may develop a cynical attitude towards their work environment and their colleagues. They
may, at the same time, increasingly distance themselves emotionally, and disengage themselves
from their work. Reduced performance mainly affects everyday tasks at work, at home or when
caring for family members. People with burnout regard their activities very negatively, find it
hard to concentrate, are listless and experience a lack of creativity.

Burnout is one such stress-related outcome, has been conceptualized as a

multidimensional construct consisting of emotional exhaustion, depersonalization and reduced
personal accomplishment (Patrick & Lavery, 2006). Emotional exhaustion can be understood as
a dysphoric feeling of being down. Depersonalization refers to assuming an impersonal attitude
toward the people with whom one works. While reduced accomplishment indicates a reduction
9
in the feeling of being competent (Maslach, 1993). Many factors in the work environment
contributed to burnout. Shortage of nurses is one of those factors that makes hospital short-
staffed and increases nurses’ workload. Heavy workload adversely affects nurses by threatening
physical safety, lowering job satisfaction and causing burnout (Clarke, Sloane, & Aiken, 2002;
Hart, 2003).

2.3 The Maslach Burnout Inventory

Burnout is a global nursing workforce challenge that undermines nurse retention.

Investigations of nurse burnout are highly relevant given the global shortage of nurses and the
need to retain qualified nurses in clinical care roles (Aiken, Buchan, Sochalski, Nichols, &
Powell, 2004). Social psychologists Christina Maslach and Susan Jackson developed what is the
most widely used instrument for assessing burnout, namely, the Maslach Burnout Inventory. The
Maslach Burnout Inventory (MBI) has been recognized for more than a decade as the leading
measure of burnout, incorporating the extensive research that has been conducted in the more
than 25 years (Maslach, Jackson, Leiter & Schaufeli, 1996). This burnout assessment addressed
three components which are emotional exhaustion, depersonalization and personal
accomplishment. Emotional exhaustion measures feelings of being emotionally overextended
and exhausted by one’s work, depersonalization measures an unfeeling and impersonal response
toward recipients of one’s service, care treatment, or instruction and personal accomplishment
measures feelings of competence and successful achievement in one’s work (Maslach, Jackson,
Leiter & Schaufeli, 1996). The Maslach Burnout Inventory incorporated a 22-item survey which
uses a 7-point scale for responses. An answer can range from “Never” to Every day.”

A review of 34 burnout studies by Hwang & colleagues (2003) concluded that even

though all three factors of the Maslach Burnout Inventory have not been replicated exactly across
studies, there was considerable evidence that the Maslach Burnout Inventory is a useful tool
across a wide range of occupations, languages, and countries. The studies reviewed were
conducted by many different researchers using differing research protocols and study designs.
The unique advantage of this study is that it explores the factorial structure and performance of

10
the Maslach Burnout Inventory using a common investigator and instrument in eight countries,
thus adding new knowledge regarding burnout measurement cross-nationally. Other researchers
have added to the evidence confirming the MBI as a useful tool for research (Greenglass, Burke,
& Fiksenbaum, 2001; Hastings, Horne, & Mitchell, 2004), and supporting the three
dimensionality of the MBI (Evans & Fischer, 1993).

2.4 The NASA Task Load Index

The NASA Task Load Index is a subjective, multidimensional assessment tool that rates
perceived workload. It was developed by the Human Performance Group at NASA’s Ames
Research Center over a three year development cycle that included more than 40 laboratory
simulations (Hart & Staveland, 1988). It is a multi-dimensional rating procedure that derives an
overall workload score based on a weighted average of ratings on six subscales. The subscales
include Mental Demands, Physical Demands, Temporal Demands, Performance, Effort and
Frustration. The participants self-rate on a scale of 1 (low) to 20 (high).

Advantages of this assessment tool are that it provides a quick and simple estimate of
operator mental workload and the generic subscales allow the technique to be used across
multiple domains. The instrument’s sensitivity has been demonstrated using a great variety of
tasks. The NASA Task Load Index has been applied successfully in different multitask contexts
(Rubio, Diaz, Martin, & Puente, 2004).

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 CHAPTER 3
METHODOLOGY

3.1 Research Methodology

The purpose of this study is to determine the relationship between workload and burnout
among nurses in Medical unit and Surgical unit, Penang General Hospital. Therefore researcher
choose a quantitative research method approach which collects data that can be summarize
numerically, the methodology describe the design of the study, population, setting and sample,
data collection procedure and data analysis.
For this study, quantitative descriptive design is most appropriate because researcher plan
to evaluate the relationship between nurses’ workload and nurses’ burnout. It’s involved a self
administration questionnaire, whereby researcher can get information from the population
regarding a particular issue (workload and burnout). The researcher will be describing the
characteristics of the respondents in one or more variables (age, gender, marital status and etc),
the respondent will be asking a number of questions pertaining workload and burnout.

3.2 Research Design

The target population for this research is the staff nurses from surgical ward and medical
ward. This population will represent the entire population to generalize the result s of this
research. The target is 20 nurses.
The study will be conducted at Penang General Hospital. The study will be conducted in
four wards under two units which include surgical unit and medical unit.
For this study, a probability sampling technique will be used. In this study researcher use
simple random sampling, as there is no bias and everyone have an equal chance of being selected
12
to represent the population. The sample includes all nurses working in medical ward and surgical
ward based on :
Inclusion Criteria:
I. Staff nurses who is working in shift and divided duty under four wards in two
units (medical and surgical)
II. Staff nurses who is working in medical ward and surgical ward regardless of year
of services and age.
III. Staff nurses who volunteer to participate in the study and have to sign the consent
form.

Exclusion Criteria:
I. Staff nurses who is involves in pilot project of the study.
II. Staff nurses who is on maternity leave and taking post basic course.
III. Staff nurses who are not volunteer to participate in this study

3.3 Research Informant

Informed consent asking permission to be involved in this study will be given to the staff
nurses. The informed consent informs on how the test will be done and how the result and data
obtained will be keep confidential. The form will fill by the staff nurses who are willing to be
involved in this study.

3.4 Instrumentation of the study

Researcher will use self administered survey questionnaire to collect data from all the
staff nurses working in medical ward and surgical ward without intervening. The content of the
questionnaire will be divided into three sections: section A on demographic data of staff nurses,
section B determine the level of workload experience by the nurses, and section C determine the
level of burnout experience by the nurses.

13
 Section A demographic data questionnaire consisted of 9 items to assess the participants
demographic data including age, gender, marital status, basic education, current areas of practice,
length of service and participants’ perception about their workload.
Section B level of nurses’ workload questionnaire was design to assess the level of
nurses’ workload based on the six subscales of The NASA Task Load Index. The NASA Task
Load Index (Hart & Staveland, 1988) is multi-dimensional rating procedure that provides an
overall workload score based on a weighted average rating on six subscales: mental demands,
physical demands, temporal demands, performance, effort and frustration. The total scored
ranged from 1-20 and it was then converted into percentage. The higher scores indicated the
higher level of workload.
Section C level of nurses’ burnout questionnaire which consisted of 22 items was
developed based on The Maslach Burnout Inventory (MBI). The Maslach Burnout Inventory
(MBI) is the most commonly used tool to self-assess whether you might be at risk of burnout. To
determine the risk of burnout, the MBI explores three components: exhaustion, depersonalization
and personal achievement. The participants were asked to rate the risk of burnout ranged from 0
to 6; 6 = everyday, 5 = a few times per week, 4 = once a week, 3 = a few times per month, 2 =
once a month, 1 = a few times per year, and 0 = never. Items 1 to 7 are components of
exhaustion, items 8 to 14 are components of depersonalization and items 15 to 22 are
components of personal achievement. Total scores of each components of burnout were
categorized into three levels. A high score in component 1 and 2 and low score in component 3
many indicate burnout. The categorizations of scores of each level were as followed:

Component 1: Exhaustion
 Total 17 or less: Low-level burnout
 Total between 18 and 29 inclusive: Moderate burnout
 Total over 30: High-level burnout
Component 2: Depersonalization
 Total 5 or less: Low-level burnout
 Total between 6 and 11 inclusive: Moderate burnout
 Total of 12 and greater: High-level burnout
Component 3: Personal Achievement
14
 Total 33 or less: High-level burnout
 Total between 34 and 39 inclusive: Moderate burnout
 Total greater than 40: Low-level burnout

3.5 Validity and Reliability of Instrumentation

Validity
The questionnaire will be check for content validity by expert in this area. The Head of
Department from both medical unit and surgical unit, sister and senior staff nurses in medical
unit and surgical unit who have a vast experience in workload and burnout ( who not Include in
the study) will be ask to validate the instrument.

Reliability
Internal consistency and reliability of the nurses’ workload and burnout were examined
through a pilot study. Several studies carried out by Iwanicki & Schwab (1981) and Gold (1984)
support reliability such as the three factor structure and internal reliability. Cronbach’s alpha
ratings of 0.90 for emotional exhaustion, 0.76 for depersonalization and 0.76 for personal
accomplishment were reported by Schwab; very similar ratings were reported by Gold.

Pilot Study
A pilot study will be carry out by researcher on 5 respondent from medical ward and 5 from
surgical ward.

3.6 Data Collection

Data will be collected using self-administered questionnaire. Researcher will recruit a
total number of 20 respondents from staff nurses working in medical ward and surgical ward. A
written consent will enclose in questionnaire for every respondent to obtain consent prior to
participate in this research. Once approval was obtained, researcher will explain the purpose of
the study to the nursing sister in medical ward, and surgical ward by producing a permission

15
letter .Then the questionnaires were place in nursing counter with the name list of staff attached,
to ensure all staff are taking part by sign in their name after completed the questionnaire. Nursing
Sister will help the researcher to distribute them to respondent who eligible for participate in the
study.

3.7 Data Analysis

Data were analyzed using descriptive and inferential statistics. Descriptive statistics were
used for presenting demographics characteristics. Workload and burnout level were described in
terms of frequency and percentage.

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 CHAPTER 4
RESULT AND DISCUSSION

4.1 Description of Demographic Data

The nurses are mainly between age 25-30 years old (40.0 %, n=8), followed equally by
25 years old or less (30.0%, n=6) and age 31-40 years old (30.0%, n=6). While age 41-50 years
old and more than 50 years old equally 0.0% (n=0). Pie chart 1 represented the nurses’ age.

Pie chart 1: Nurses’ age

17
 The majority of the nurses participated in this study are female (85.0%, n=17) and the
remaining are male (15.0%, n=3). Pie chart 2 represented the nurses’ gender.

Pie chart 2: Nurses’ gender

18
 Marital status of the nurses participated in this study are mostly single (65.0%, n=13),
while marital status of married (35.0%, n=7) and divorced/widowed (0.0%, n=). Pie chart 3
represented the nurses’ marital status.

Pie chart 3: Nurses’ marital status

19
 Educational level of nurses are mainly in Diploma in Nursing (70.0%, n=14), followed
by Diploma in Nursing with Post Basic (15.0%, n=3), Bachelor in Nursing (10.0%, n=2) and
Bachelor in Nursing with Post Basic (5.0%, n=1). Pie chart 4 represented the nurses’ educational
level.

Pie chart 4: Nurses’ educational level

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 The nurses’ length of service are mainly between 2-5 years and 5-10 years, each
respectively 30.0% (n=6), followed by less than 2 years service (25.0%, n=5) and more than 10
years service (15.0%, n=3). Pie chart 5 represented the nurses’ length of service.

Pie chart 5: Nurses’ length of service

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 Most of the nurses (80.0%, n=16) work in surgical ward while (20.0%, n=4) work in
medical ward. Pie chart 6 represented the nurses’ current place of service.

Pie chart 6: Nurses’ current place of service

22
 All the nurses participated in this study reported that there has been increment in their
workload (100.0%, n=20). Pie chart 7 represented the nurses’ answer to question whether there
has been an increase in the workload.

Pie chart 7: Nurses’ answer to question whether there has been an increase in the workload

23
 In addition, most nurses answer ‘yes’ to the question if they ever go to work early or stay
late of their regular or normal working hours in order to keep up with their workload. Pie chart 8
represented the nurses’ answer to question if they ever go to work early or stay late of their
regular or normal working hours in order to keep up with their workload.

Pie chart 8: Nurses’ answer to question they ever go to work early or stay late of their regular or
normal working hours in order to keep up with their workload

24
 Most of the nurses feel pressured when they need to work overtime to keep up with their
workload (65.0%, n=13), while the rest of the nurses (35.0%, n=7) feel voluntary to work
overtime. Pie chart 9 represented what the nurses’ feel when need to work overtime to keep up
with workload.

Pie chart 9: Nurses’ feeling when need to work overtime to keep up with workload

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 Summarizations of demographic data of participants were tabulated in Table 1.

Background Variables Number Percent (%)

Age

<25 6 30.0%

25-30 8 40.0%

31-40 6 30.0%

41-50 0 0.0%

>50 0 0.0%

Gender

Female 17 85.0%

Male 3 15.0%

Marital Status

Single 13 65.0%

Married 7 35.0%

Divorced/widowed 0 0.0%

Educational Level

Diploma in Nursing 14 70.0%

Diploma in Nursing with Post Basic 3 15.0%

Bachelor of Nursing 2 10.0%

Bachelor of Nursing with Post Basic 1 5.0%

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Length of Service

< 2 years 5 25.0%

2-5 years 6 30.0%

5-10 years 6 30.0%

> 10 years 3 15.0%

Current Department of Practice

Surgical 16 80.0%

Medical 4 20.0%

Has there been an increase in your workload?

Yes 20 100.0%

No 0 0.0%

Did you ever go to work early or stay late of your regular or normal
working hours in order to keep up with your workload?

Yes 20 100.0%

No 0 0.0%

How do you feel when you need to work overtime to keep up with
your workload?

Voluntary 7 35.0%

Pressured 13 65.0%

Table 1: Demographic Data of Participants

27
4.2 Description of Nurses’ Workload

The nurses’ workload questionnaire was based from The NASA task load index (NASA
TLX). The NASA task load index is a tool for measuring and conducting a workload assessment.
It rates performance across six dimensions to determine an overall workload rating. The six
dimensions are mental demand, physical demand, temporal demand, effort, performance and
frustration level. The mean of each six dimensions are mental demand (x̅ = 0.62), physical
demand (x̅ = 0.68) , temporal demand (x̅ = 0.67), effort (x̅ = 0.68), performance (x̅ = 0.59), and
frustration level (x̅ = 0.63) as shown in table 2.

Dimension of NASA task load index mean Percent%

Mental Demand 0.62 62.0%

Physical Demand 0.68 68.0%
Temporal Demand 0.67 66.5%
Effort 0.68 67.75%
Performance 0.59 58.75%
Frustration 0.63 63.0%
Table 2: Mean in each Dimension of Workload

Range of score of nurses’ level in workload was between 0-100. Nurses’ level of workload was
divided into three levels (low:0-30, moderate:31-70 and high:71-100). Dimension of mental demand
deals with how much thinking, deciding or calculating was required to perform the task. Higher level of
mental demand illustrated large amount of thinking required to perform the task and in parallel higher
workload level. In mental demand workload dimension, most nurses scored moderate level of workload
(65.0%, n=13), followed by high level of workload (30.0%, n=63) and low level of workload (5.0%, n=1).
Table 3 shows the number and frequency of nurses in mental demand dimension of workload level. Bar
chart 1 represented level of workload in mental demand dimension.

28
Dimension 1: Mental Demand n=20 %

Low-level workload 1 5.0%

Moderate workload 13 65.0%

High-level workload 6 30.0%

Table 3: The frequency of nurses’ level of workload in mental demand

Bar chart 1: Level of workload in mental demand dimension

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 Dimension of physical demand deals with the amount and intensity of physical activity
required to complete the task. Higher level of physical demand illustrated large amount of
physical activity required to complete the task and in parallel higher workload level. In physical
demand workload dimension, most nurses scored moderate level of workload (64.0%, n=13),
followed by high level of workload (35.0%, n=7) and low level of workload (0.0%, n=0). Table
4 shows the number and frequency of nurses in physical demand dimension of workload level.
Bar chart 2 represented level of workload in physical demand dimension.

Dimension 2: Physical Demand n=20 %

Low-level workload 0 0.0%

Moderate workload 13 65.0%

High-level workload 7 35.0%

Table 4: The frequency of nurses’ level of workload in physical demand.

Bar chart 2: Level of workload in physical demand dimension

30
 Dimension of temporal demand deals with the amount of time pressure involved in
completing the task. Higher level of temporal demand illustrated large amount of time pressure
involved in completing the task and in parallel higher workload level. In temporal demand
workload dimension, most nurses scored moderate level of workload (55.0%, n=11), followed by
high level of workload (40.0%, n=8) and low level of workload (5.0% n=1). Table 5 shows the
number and frequency of nurses in temporal demand dimension of workload level. Bar chart 3
represented level of workload in temporal demand dimension.

Dimension 3: Temporal Demand n=20 %

Low-level workload 1 5.0%

Moderate workload 11 55.0%

High-level workload 8 40.0%

Table 5: The frequency of nurses’ level of workload in temporal demand

Bar chart 3: Level of workload in temporal demand dimension

31
 Dimension of effort deals with how hard does the participant have to work to maintain
their level of performance. Higher level of effort illustrated large amount of work involved to
maintain their performance and in parallel higher workload level. In effort workload dimension,
most nurses scored moderate level of workload (70.0%, n=14), followed by high level of
workload (30.0%, n=6) and low level of workload (0.0%, n=0). Table 6 shows the number and
frequency of nurses in effort dimension of workload level. Bar chart 4 represented level of
workload in effort dimension.

Dimension 4: Effort n=20 %

Low-level workload 0 0.0%

Moderate workload 14 70.0%

High-level workload 6 30.0%

Table 6: The frequency of nurses’ level of workload in effort

Bar chart 4: Level of workload in effort dimension

32
 Dimension of performance deals with the level of success in completing the task. Higher
level of workload illustrated large amount of effort in accomplishing the task and in parallel
failure in performance. In performance workload dimension, most nurses scored moderate level
of workload (60.0%, n=12), followed by high level of workload (30.0%, n=6) and low level of
workload (10.0%, n=2). Table 7 shows the number and frequency of nurses in performance
dimension of workload level. Bar chart 5 represented level of workload in performance
dimension.

Dimension 5: Performance n=20 %

Low-level workload 2 10.0%

Moderate workload 12 60.0%

High-level workload 6 30.0%

Table 7: The frequency of nurses’ level of workload in performance

Bar chart 5: Level of workload in performance dimension

33
 Dimension of frustration deals with the amount of how insecure, discouraged, or secure
or content the participant felt during the task. Higher level of frustration illustrated large amount
of insecure and discouraged in completing the task and in parallel higher workload level. In
frustration workload dimension, most nurses scored moderate level of workload (65.0%, n=13),
followed by high level of workload (25.0%, n=5) and low level of workload (10.0% n=2). Table
8 shows the number and frequency of nurses in frustration dimension of workload level. Bar
chart 6 represented level of workload in frustration dimension.

Dimension 6: Frustration n=20 %

Low-level workload 2 10.0%

Moderate workload 13 65.0%

High-level workload 5 25.0%

Table 8: The frequency of nurses’ level of workload in frustration

Bar chart 6: Level of workload in frustration dimension

34
4.3 Description of Nurses’ Burnout

The nurses’ burnout questionnaire was based from The Maslach Burnout Inventory
(MBI). The Maslach Burnout Inventory (MBI) is a tool for self-assessment of burnout risk. To
determine the risk of burnout, the MBI explores three components which are exhaustion,
depersonalization and personal achievement. The participants were asked to rate the risk of
burnout ranged from 0 to 6; 6 = everyday, 5 = a few times per week, 4 = once a week, 3 = a few
times per month, 2 = once a month, 1 = a few times per year, and 0 = never. Items 1 to 7 are
components of exhaustion, items 8 to 14 are components of depersonalization and items 15 to 22
are components of personal achievement. Total scores of each components of burnout were
categorized into three levels which are high-level, moderate and low-level. Overall nurses’ level
of burnout of each component was at a moderate and high level. Table 9 shows the percentage
and level of nurses’ burnout in each component of burnout. Data indicated that 50.0% of nurses
possessed moderate level of burnout in exhaustion. Data indicated that 85.0% of nurses
possessed high level of burnout in depersonalization while 75.0% of nurses scored high level of
burnout in personal achievement.

Burnout components Level of Burnout Percent%

Exhaustion Moderate 50.0%

Depersonalization High 85.0%
Personal Achievement High 75.0%
Table 9: Percentage and level of nurses’ burnout in each component of burnout

35
 In Exhaustion of Burnout, nurses indicated moderate level of burnout. Exhaustion
measures feelings of being emotionally overextended and exhausted by one's work. In
component of exhaustion, majority of nurses indicated moderate level of exhaustion burnout
(50.0%, n=10). Followed by low-level of exhaustion burnout (40.0%, n=8) and high-level of
exhaustion burnout (10.0%, n=2). Pie chart 10 represented nurses’ level of exhaustion and table
10 shows the percentage in each level of exhaustion component of burnout.

Pie chart 10: Nurses’ level of exhaustion of burnout

Component 1: Exhaustion n=20 %

Low-level burnout 8 40.0%

Moderate burnout 10 50.0%

High-level burnout 2 10.0%

Table 10: Percentage in each level of exhaustion component of burnout

36
 In Depersonalization of Burnout nurses indicated high-level of burnout.
Depersonalization measures an unfeeling and impersonal response toward recipients of one's
service, care treatment, or instruction. In component of depersonalization, majority of nurses
indicated high-level of depersonalization burnout (85.0%, n=17). Followed by moderate level of
depersonalization burnout (10.0%, n=2) and low-level of depersonalization burnout (5.0%, n=1).
Pie chart 11 represented nurses’ level of depersonalization and table 11 shows the percentage in
each level of depersonalization component of burnout.

Pie chart 11: Nurses’ level of depersonalization of burnout

Component 2: Depersonalization n=20 %

Low-level burnout 1 5.0%

Moderate burnout 2 10.0%

High-level burnout 17 85.0%

Table 11: Percentage in each level of depersonalization component of burnout

37
 In Personal Achievement of Burnout nurses indicated high-level of burnout. Personal
Achievement measures feelings of competence and successful achievement in one's work. In
component of personal achievement, majority of nurses indicated high-level of personal
achievement burnout (75.0%, n=15). Followed by low-level of personal achievement burnout
(15.0%, n=3) and moderate level of personal achievement burnout (10.0%, n=2). Pie chart 12
represented nurses’ level of personal achievement and table 12 shows the percentage in each
level of personal achievement component of burnout.

Pie chart 12: Nurses’ level of personal achievement of burnout

Component 3: Personal Achievement n=20 %

Low-level burnout 3 15.0%

Moderate burnout 2 10.0%

High-level burnout 15 75.0%

Table 12: Percentage in each level of personal achievement component of burnout

38
 CHAPTER 5

FINDING AND DISCUSSION

5.1 Findings and Discussion

The study aimed at exploring the level of nurses’ workload and nurses’ burnout and
hence determining the relationship between workload and burnout among nurses. The findings
revealed that nurses had a moderate level of workload. All six dimensions of workload which are
mental demand, physical demand, temporal demand, effort, performance and frustration level
indicated moderate level of workload. The mean of workload in physical demand and effort are
the highest. This indicated that the nurses experienced most workload from physical demand and
effort dimension of workload. Dimension of physical demand deals with the amount and
intensity of physical activity required to complete the task. While effort deals with how hard
does the participant have to work to maintain their level of performance. Higher level of effort
illustrated large amount of work involved to maintain their performance. The findings showed
that the nurses experienced high demand on physical activity from their work and high amount
of effort required in performing their tasks. Furthermore, from the questionnaire, all the nurses
participated in this study reported that there has been increment in their workload (100.0%,
n=20). Apart from that, all nurses reported that they have to go to work early or stay late of their
regular or normal working hours in order to keep up with their workload (100.0%, n=20). Most
of the nurses feel pressured when they need to work overtime to keep up with their workload
(65.0%, n=13). Henceforth, the data collected from this study indicated that the nurses
experienced workload from their work.

The Maslach Burnout Inventory (MBI) tool for self-assessment of burnout is used to
measure level of burnout among nurses. This burnout inventory explores three components
which are exhaustion, depersonalization and personal achievement. The findings revealed that
nurses had moderate to high level of workload in those three components. In Exhaustion
component, nurses indicated moderate level of burnout. Majority of nurses indicated moderate
39
level of exhaustion burnout (50.0%, n=10). While in Depersonalization component, nurses
indicated high-level of burnout. Majority of nurses indicated high-level of depersonalization
burnout (85.0%, n=17). In Personal Achievement component, nurses indicated high-level of
burnout. Majority of nurses indicated high-level of personal achievement burnout (75.0%, n=15).
Majority of nurses indicated that they are experiencing moderate to high burnout. Emotional
exhaustion causes people affected to feel drained and exhausted, overloaded, tired and low, and
do not have enough energy. Physical symptoms include pain or problems with the stomach or
bowel. Alienation affected people by causing them feeling that their jobs increasingly negative
and frustrating. They may develop a cynical attitude towards their work environment and their
colleagues. They may, at the same time, increasingly distance themselves emotionally, and
disengage themselves from their work. High level of burnout in personal achievement is due to
reduced accomplishment, which indicates a reduction in the feeling of being competent
(Maslach, 1993). Reduced performance mainly affects everyday tasks at work, at home or when
caring for family members. People with burnout regard their activities very negatively, find it
hard to concentrate, are listless and experience a lack of creativity.

Burnout has been assumed to result from chronic occupational stress such as work
overload (Alarcon, Eschleman, & Bowling, 2009). Various studies conducted have found that
one of the fundamental stressor present among nursing staff is excessive workload. The result
from this study is parallel from previous conducted studies. The increase in level of workload,
increase the level of burnout as well. The nurses reported moderate to high level of burnout as
they going through increases in their workload. Studies have repeatedly shown that nurses
experiencing burnout have undergone long periods of work-related stress. This stress is often
linked to workload. Burnout is characterized by emotional exhaustion, depersonalization and
reduced personal accomplishment (Maslach, Schaufeli & Leiter, 2001). The degree of job
burnout a person experience is based on the degree of match or mismatch with the work
environment. Six area of mismatch include workload, control, reward, community, fairness and
values (Maslach & Leiter, 1997). These six areas are influenced by staffing, job demands, work
environment, supervisor support, nurse-physician relationship and coping skills.

40
 There are some limitations to this study. The main limitation was using self-report
questionnaire to examine level of nurses’ workload and burnout. The participants might not
reflect actual level of workload and burnout. This study was conducted in Medical unit and
Surgical unit, Penang Hospital. Henceforth, this finding may not be generalized to other hospital
or department. Future studies should also evaluate methods of reducing burnout such as peer-
support group, social support, group-based therapies, recreational music-making protocol and s
on that would help to improve nurses’ perceived health, burnout and work conditions.

This research study is important as it will bring positive impact to nursing industry. This
study would help to identified workload as factor that affect burnout among nurses and effective
measure could be taken to manage workload in order to prevent higher burnout rate among
nurses. The identified relation between workload and burnout would enable higher management
to become more aware and understand the situation better, and therefore evolve preventive
strategies to manage burnout problems.

As a conclusion from the overall findings, it is found that the level of workload among
nurses in Medical unit and Surgical unit was at moderate level. The level of burnout among
nurses in Medical unit and Surgical unit was at moderate to high level. There is a relationship
between workload and burnout among nurses. Increase in level of workload in parallel increase
level of burnout among nurses in Medical unit and Surgical unit, Penang General Hospital.

41
REFERENCES

1. Aiken, L. H., Buchan, J., Sochalski, J., Nichols, B., & Powell, M. (2004). Trends In
International Nurse Migration.Health Affairs. 23(3):69–77. 

2. Alarcon, G., Eschleman, K. J., & Bowling, N. A. (2009). Relationships between personality
variables and burnout: A meta-analysis. Work & Stress, 23(3), 244-263.

3. Barker, L.M. (2009). Measuring and Modeling the Effects of Fatigue on Performance:
Specific Application to the Nursing Profession. PhD Disertation. University of Virginia, United
State.

4. Hart, P. D. (2003). Patient –to-nurse Staffing Ratios: Perspectives from Hospital Nurses.
Retrieved August 06, 2014 from http://www.aft.org/health-care/pubs-reports/index.htm

5. Hernandez-Arellano, J.L., Mejia, G. I., Serratos-Perez, J. N.,Garcia-Alcaraz, J. L., & Brunette,

M.J. (2012). Construction of a Survey to Assess Workload and Fatigue among AMT Operators
in Mexico. Retrieved August 05, 2014 from http://www.ncbi.nlm.nih.gov/pubmed/22316973

6. Hoonakker, P., Carayon, P., Gurses, A., Brown, R., McGuire, K., Khunlertkit, A., & Walker,
J. M. (2011). Measuring workload of ICU nurses with a questionnaire survey: the NASA task
load index (tlx). IIIE Trans Healthc Syst Eng, 1(2), 131–143.
Doi:10.1080/19488300.2011.609524.

7. Hwang, C. E., Scherer, R. F., & Ainina, M. F. (2003). Utilizing the Maslach Burnout
Inventory in cross-cultural research. International Journal of Management. 20(1), 3–10.

8. Jennings, B. M. (n.d.). Chapter 26: Work Stress and Burnout Among Nurses: Role of the
Work Environment and Working Conditions. Patient Safety and Quality: An Evidence-Based
Handbook for Nurses. Retrieved July 30, 2014 from http://www.ahrq.gov/professionals/
clinicians-providers/resources/nursing/resources/nurseshdbk/JenningsB_WEWCN.pdf

9. Maslach, C. & Jackson, S. E. (1981). The Measurement of Experienced Burnout. Journal of

Occupational Behavior, 2, 99-113.

42
10. Maslach, C. & Jackson, S. E. (1986). The Malach Burnout Inventory Manual (2nd e.d.). Palo
Alto, CA: Consulting Psychologist Press.

11. Maslach, C., Jackson, S. E., Leiter, P. M., & Schaufeli, W.B. (1996). Maslach Burnout
Inventory (MBI). Retrieved August 05, 2014 from http://www.statisticssolutions.com/maslach-
burnout-inventory-mbi/

12. Maslach, C., & Leiter, M. P. (1997). The truth about burnout. San Francisco, CA: Jossey-
Bass.

13. Maslach, C., Schaufeli, W. B., & Leiter, M. P. (2001). Job Burnout. Annual Review of
Psychology, 52, 397-422.

14. Poghosyan, L., Aiken, L. H., & Sloane, D. M. (2009). Factor structure of the Maslach
Burnout Inventory: An analysis of data from large scale cross-sectional surveys of nurses from
eight countries. doi: 10.1016/j.ijnurstu.2009.03.004. Retrieved August 06, 2014 from
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2700194/

15. The Department for Professional Employees. (2013). Nursing: A Profile of The Profession.
Retrieved July 30, 2014 from http://dpeaflcio.org/wp-content/uploads/nursing-2013.pdf

16. Tuten, T. (2012). Reducing Nurse Burnout: A Win-Win situation. Retrieved August 05, 2014
from http://www.huffingtonpost.com/tera-tuten/reducing-nurse-burnout_b_1916350.html

43
APPENDIX 1

Letter to Hospital Director

SITI HAJAR BINTI SHUIB

JURURAWAT TERLATIH U29,

UNIT ENDOSCOPY JABATAN PEMBEDAHAN AM,

HOSPITAL PULAU PINANG,

10400 JALAN RESIDENSI, P.PINANG

---------------------------------------------------------------------------------------------------------------------

PENGARAH HOSPITAL PULAU PINANG,

PEJABAT PENGARAH,

HOSPITAL PULAU PINANG,

10400 JALAN RESIDENSI, P.PINANG 07 DECEMBER 2013

PUAN,

MEMOHON KEBENARAN UNTUK MELAKUKAN KAJIAN DI WAD PERUBATAN DAN

WAD PEMBEDAHAN HOSPITAL PULAU PINANG.

Merujuk kepada perkara di atas.

1. Saya seperti nama di atas adalah pelajar berdaftar dengan ‘Open University Malaysia’,
ingin memohon kebenaran untuk melakukan kajian penyelidikan di wad perubatan dan wad
pembedahan, Hospital Pulau Pinang. Tajuk kajian saya ialah ‘Workload and Burnout among
Nurses’.

44
2. Disertakan lampirkan surat sokongan dari pihak Open University Malaysia untuk rujukan
puan.

Saya berharap pihak puan dapat memberikan pertimbangan yang sewajarnya terhadap
permohonan ini.

Sekian , Terima Kasih.

Yang Benar,

(SITI HAJAR BINTI SHUIB)

45
APPENDIX 2

Consent for Participant

You are being invited to take part in a research study. Before you decide to participate in this
study, it is important that you read the following information.

Tittle of study: Barriers to the implementation of practice in wound care at Plastic Surgery
Department, Penang General Hospital.

Confidentiality:

All your information will be keep confidential. However , this information may be used in
publications or presentation.

Risks:

There are no known or anticipated risks to your participation in this study.

Person to contact:

Should you have any question about the research or any related matters, please contact the
researcher @( 013-4618010 or [email protected]).

Voluntary Participant:

Your participation in this study is voluntary. It is up to you to decide whether or not to take part
in this study. If you do decide to take part in this study, you will be asked to sign a consent form.
You can refuse to complete this questionnaire if you want to do so, however it will be highly
appreciated if you can give me your cooperation.

Consent

I hereby agree to take part in the clinical research (questionnaire study). I have read and
understand this consent form.

Signature ________________ Date _____________

46
Dear Participant,

The purpose of this study is to complete the assignment for my Bachelor of Nursing Science.
ALL INFORMATION COLLECTED WILL BE KEPT CONFIDENTIAL.

I would like to ensure you that this study has been received ethics clearance through the Hospital
Director and Head of Department from Medical ward and Surgical ward.

Thank You,

------------------------------------

(SITI HAJAR BINTI SHUIB)

47
 APPENDIX 3

Gantt Chart

Title/Month aug sep oct nov dec jan feb mac apr may jun july aug

Choose a research
topic

Read literature
review

Research proposal
writing

Distribution
questionaire

Submit proposal

Collection of data

Analysis of data

Report writing

Conclusions and
recommendations

Submit of research

48
APPENDIX 4

Budget

LIST OF BUDGET FOR RESEARCH

A4 PAPER RM100

PRINTER RM300

PRINTER INK RM100

BINDING RM50

PEN RM10

PENCIL RM10

TOTAL RM370

49
APPENDIX 5

Questionnaire

This questionnaire contains three sections (section A, Section B and section C). You are not
advised to write your name. Kindly complete the questionnaire by placing (/) or filling in the
spaces provided:

Section A: Demographic Data

Instructions: Answer questions as they relate to you. Fill in the blanks with a tick ( / ).

1. Age
25 or less
25-30
31-40
41-50
50 or more

2. Gender
Female
Male

3. Marital Status
Single
Married
Divorced/widowed

4. Educational Level
Diploma in Nursing
Diploma in Nursing with Post Basic
Bachelor of Nursing
Bachelor of Nursing with Post Basic

5. Length of Service
Less than 2 years
2-5 years
5-10 years
More than 10 years

6. Current Place of Service

Surgical Ward
50
 Medical Ward

7. Has there been an increase in your workload?

Yes
No

8. Did you ever go to work early or stay late of your regular or normal
working hours in order to keep up with your workload?
Yes
No

9. How do you feel when you need to work overtime to keep up with your
workload?
Voluntary
Pressured

51
Section B: Nurses’ Workload

Instructions: Please read each statement carefully and fill the box with tick ( / ) for statement
that most closely reflects your answer to the following questions.

Mental Demand How mentally demanding was the task?

Very Low Very High

Physical Demand How physically demanding was the task?

Very Low Very High

Temporal Demand How hurried or rushed was the pace of the task?

Very Low Very High

Performance How successful were you in accomplishing what you were asked
to do?

Perfect Failure
52
Effort How hard did you have to work to accomplish your level of
performance?

Very Low Very High

Frustration How insecure, discouraged, irritated, stressed, and annoyed were

you?

Very Low Very High

53
Section C: Nurses’ Burnout

Instructions: Please read each statement carefully and fill the box with tick ( / ) for statement that most
closely reflects your answer to the following questions.

Questions Never A few Once A few Once A few Every

times a times a times day

per year month per week per

month week
Component 1 0 1 2 3 4 5 6
I feel emotionally drained by my
work.
Working with people all day long
requires a great deal of effort.
I feel like my work is breaking me
down.
I feel frustrated by my work.

I feel I work too hard at my job.

It stresses me too much to work in

direct contact with people.
I  feel  like  I’m  at  the  end  of  my  rope.

Total score – COMPONENT 1

Questions Never A few Once A few Once A few Every

times a times a times day

per month per week per

year month week
Component 2 0 1 2 3 4 5 6
I feel I look after certain patients/clients
impersonally, as if they are objects.
I feel tired when I get up in the
morning and have to face another day

I have the impression that my

patients/clients make me responsible

I am at the end of my patience at the

end of my work day.
I  really  don’t  care  about  what  happens  

I have become more insensitive to

I’m  afraid  that this job is making me

uncaring.
54
Total score – Component 2

Questions Never A few Once a A few Once A few Every

times month times a times day
per per week per
year month week
Component 3 0 1 2 3 4 5 6
I accomplish many worthwhile things
in this job.
I feel full of energy.

I am easily able to understand what

my patients/clients feel.
I  look  after  my  patients’/clients’  

In my work, I handle emotional

problems very calmly.
Through my work, I feel that I have a
positive influence on people.
I am easily able to create a relaxed
atmosphere with my patients/clients.
I feel refreshed when I have been
close to my patients/clients at work.
Total score – Component 3

55