The Open Psychology Journal




ISSN: 1874-3501 ― Volume 12, 2019
RESEARCH ARTICLE

The Impact of Workaholism on Nurses’ Burnout and Disillusion



Marcello Nonnis1, *, Davide Massidda1, Stefania Cuccu1, Claudio G. Cortese2
1 Department of Education, Psychology and Philosophy, University of Cagliari, Cagliari, Italy
2 Department of Psychology, University of Turin, Turin, Italy

Abstract

Background:

The literature has shown that workaholism acts at the root of burnout, but research regarding these constructs in the nursing profession is scant. Similarly, little attention has been paid to the impact of workaholism on disillusion, which is a dimension of burnout linked to professional vocation.

Objectives:

Contribute to the ongoing research on the relationship between workaholism and burnout among nurses. Moreover, this study considers disillusion as a dimension to be considered when investigating the relationship between workaholism and burnout, since nursing entails professional vocation.

Method:

The study followed a cross-sectional design. 614 nurses of six hospitals in South Italy have compiled two Self-report questionnaires: the Dutch Utrecht WorkAholism Scale (workaholism - Italian version) and the Link Burnout Questionnaire (burnout). Part of the group of subjects was diagnosed with both syndromes or considered at risk of developing them. The impact of workaholism on burnout was examined using Structural Equation Models for each variable.

Results:

More than 26% of the nurses are affected by burnout whereas 21% are workaholics. Working excessively proved to be a good predictor of both psychophysical exhaustion and disillusion.

Conclusions:

Nurses are at risk of workaholism and burnout. The study shows that workaholism is a predictor of nurses’ burnout, in particular working excessively (a dimension of workaholism) affects their psychophysical well-being and professional vocation.

Keywords: Burnout, Workaholism, Disillusion, Nursing, Professional vocation, Emotional labour.


Article Information


Identifiers and Pagination:

Year: 2018
Volume: 11
First Page: 77
Last Page: 88
Publisher Id: TOPSYJ-11-77
DOI: 10.2174/1874350101811010077

Article History:

Received Date: 19/2/2018
Revision Received Date: 14/3/2018
Acceptance Date: 16/4/2018
Electronic publication date: 25/5/2018
Collection year: 2018

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© 2018 Nonnis et al.

open-access license: This is an open access article distributed under the terms of the Creative Commons Attribution 4.0 International Public License (CC-BY 4.0), a copy of which is available at: (https://creativecommons.org/licenses/by/4.0/legalcode). This license permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.


* Address correspondence to this author at the Department of Education, Psychology and Philosophy, University of Cagliari, via Is Mirrionis 1, 09123- Cagliari, Italy; Tel: +39 070 6757516; Mobile: +39 328 2483183; Fax: +39 070 6757291; E-mail: marcello.nonnis@unica.it




1. INTRODUCTION

1.1. The Burnout Syndrome

Burnout is one of the most studied work-related types of stress in the recent decades, particularly within healthcare. Its preliminary definitions focused on the relational aspects, especially within the so-called ‘helping professions’. According to Edelwich and Brodsky [1Edelwich J, Brodsky A. Burnout: Stages of disillusionment in the helping professions 1981.] and Pines, Aronson, and Kafry [2Pines A, Aronson E, Kafry D. Burnout: From tedium to personal growth 1981.], burnout is a process that leads workers to lose energy, vocational drive and work engagement. Consequently, they start to develop low self-esteem, resulting in poorer work satisfaction and performance.

Maslach [3Maslach C. Burnout: The cost of caring 1982.] describes burnout as a three-dimensional construct characterised by exhaustion (i.e. the depletion or draining of mental resources), cynicism (i.e. indifference or a distant attitude towards one’s job), and lack of professional efficacy. Burnout is seen as a response to the chronic emotional effort that working excessively requires, especially when dealing with people in need.

Over the last decade, some research has concentrated on burnout as a syndrome that particularly affects service providers [4Maslach C, Leiter MP. The truth about burnout how organizations cause personal stress and what to do about it 2008.]. Lately, this syndrome was considered as part of the Job Demands-Resources (JD-R) model that measures work-related stress [5Bakker AB, Demerouti E. The job demands-resources model: State of the art. J Manag Psychol 2007; 22(3): 309-28.[http://dx.doi.org/10.1108/02683940710733115] -7Taris TW, Schaufeli WB. The job demand-resources model.The Wiley Blackwell handbook of the psychology of occupational safety and workplace health 2016; 157-80.]. According to this model, organizations are characterised by work demands (e.g. time pressure, inadequate work environment, workload) and job resources (e.g. control over people’s work, engagement, organizational support). Burnout stems from excessive job-related demands (which lead to exhaustion) and inadequate job resources (which lead to work disengagement) [8Demerouti E, Bakker AB, Nachreiner F, Schaufeli WB. The job demands-resources model of burnout. J Appl Psychol 2001; 86(3): 499-512.[http://dx.doi.org/10.1037/0021-9010.86.3.499] [PMID: 11419809] , 9Schaufeli WB, Dijkstra P, Borgogni L. Engagement: la passione nel lavoro 2012.].

Some recent research has reconsidered the importance of the relationships between help and burnout. People in need are often subject to discomfort and suffering; these factors are likely to affect their service provider and lead him or her to emotional exhaustion. The situation complicates further and can lead to burnout when service providers work excessively and struggle to cater to their patients’ needs [3Maslach C. Burnout: The cost of caring 1982., 10Pedditzi ML. Work-family interface, work relations and burnout in school teachers: A study on a group of subjects from Italian primary schools.Handbook on Burnout and Sleep Deprivation: Risk Factors, Management Strategies and Impact on Performance and Behavior 2011; 147-61.-12Pedditzi ML, Nonnis M. Psycho-social sources of stress and burnout in schools: Research on a sample of Italian teachers. Med Lav 2014; 105(1): 48-62.[PMID: 24552094] ]. Moreover, Santinello and Negrisolo [13Santinello M, Negrisolo A. Quando ogni passione è spenta La sindrome del burnout nelle professioni sanitarie 2009.] proposed reconsidering the importance of the vocational factor in relation to burnout. They revised the three dimensions of burnout proposed by Maslach [3Maslach C. Burnout: The cost of caring 1982., 14Maslach C, Jackson SE, Leiter MP. Maslach Burnout Inventory Manual 3rd ed. 3rd ed.1996.] and added the construct of disillusion. This dimension had already been included in the models designed by Edelwich et al. [1Edelwich J, Brodsky A. Burnout: Stages of disillusionment in the helping professions 1981.] and Pines et al. [2Pines A, Aronson E, Kafry D. Burnout: From tedium to personal growth 1981.]. All these scholars have pointed out that disillusion linked to burnout means developing a sense of weariness that leads to the complete destruction of any ideals relating to professional vocation.

1.2. Burnout and Nursing

Nursing is a profession particularly at risk of burnout. Some scholars have demonstrated that nurses’ burnout can be found in many different healthcare environments; others have focused on those factors that can help predict this syndrome [15Adriaenssens J, De Gucht V, Maes S. Determinants and prevalence of burnout in emergency nurses: A systematic review of 25 years of research. Int J Nurs Stud 2015; 52(2): 649-61.[http://dx.doi.org/10.1016/j.ijnurstu.2014.11.004] [PMID: 25468279] -19Tarcan M, Hikmet N, Schooley B, Top M, Tarcan GY. An analysis of the relationship between burnout, socio-demographic and workplace factors and job satisfaction among emergency department health professionals. Appl Nurs Res 2017; 34: 40-7.[http://dx.doi.org/10.1016/j.apnr.2017.02.011] [PMID: 28342622] ].

One of the most important factors that puts nurses at risk of burnout is the patient-caregiver relationship. This relationship entails emotional involvement, which caregivers must be able to handle in order to tackle various possible situations, including their patients’ suffering, fears, aggressiveness or lack of respect for their work [20Chou HY, Hecker R, Martin A. Predicting nurses’ well-being from job demands and resources: A cross-sectional study of emotional labour. J Nurs Manag 2012; 20(4): 502-11.[http://dx.doi.org/10.1111/j.1365-2834.2011.01305.x] [PMID: 22591152] , 21Campana KL, Hammoud S. Incivility from patients and their families: Can organisational justice protect nurses from burnout? J Nurs Manag 2015; 23(6): 716-25.[http://dx.doi.org/10.1111/jonm.12201] [PMID: 24372824] ]. Some recent research has highlighted the impact that job demands (e.g. treatments, patient care) have on burnout [20Chou HY, Hecker R, Martin A. Predicting nurses’ well-being from job demands and resources: A cross-sectional study of emotional labour. J Nurs Manag 2012; 20(4): 502-11.[http://dx.doi.org/10.1111/j.1365-2834.2011.01305.x] [PMID: 22591152] , 22Delgado C, Upton D, Ranse K, Furness T, Foster K. Nurses’ resilience and the emotional labour of nursing work: An integrative review of empirical literature. Int J Nurs Stud 2017; 70: 71-88.[http://dx.doi.org/10.1016/j.ijnurstu.2017.02.008] [PMID: 28235694] , 23Duarte J, Pinto-Gouveia J. Empathy and feelings of guilt experienced by nurses: A cross-sectional study of their role in burnout and compassion fatigue symptoms. Appl Nurs Res 2017; 35: 42-7.[http://dx.doi.org/10.1016/j.apnr.2017.02.006] [PMID: 28532725] ].

In the past, several scholars have underlined the importance of aspects such as professional vocation and expectations in relation to the possible development or contrast of this syndrome. Some of the most commonly shared vocational drivers among nurses that can be found in the literature are: being able to help others, contributing to improving society, empathy towards other people’s suffering, having the chance to do job that is useful for others, having other nurses in their family or other people they look to as an example [24While A, Blackman C. Reflections on nursing as a career choice. J Nurs Manag 1998; 6(4): 231-7.[http://dx.doi.org/10.1046/j.1365-2834.1998.00077.x] [PMID: 9832728] -26Newton JM, Kelly CM, Kremser AK, Jolly B, Billett S. The motivations to nurse: an exploration of factors amongst undergraduate students, registered nurses and nurse managers. J Nurs Manag 2009; 17(3): 392-400.[http://dx.doi.org/10.1111/j.1365-2834.2008.00945.x] [PMID: 21456319] ]. Yet, the literature regarding disillusion in the healthcare professions is scant (but see Bellieni et al. [27Bellieni CV, Righetti P, Ciampa R, Iacoponi F, Coviello C, Buonocore G. Assessing burnout among neonatologists. J Matern Fetal Neonatal Med 2012; 25(10): 2130-4.[http://dx.doi.org/10.3109/14767058.2012.666590] [PMID: 22571319] ] and Ruggieri et al. [28Ruggieri V, Zeppegno P, Gramaglia C, Gili S, Deantonio L, Krengli M. A survey of Italian radiation oncologists: Job satisfaction and burnout. Tumori 2014; 100(3): 307-14.[http://dx.doi.org/10.1177/1578.17212] [PMID: 25076243] ]) and almost non-existent as far as nursing is concerned [29Neveu JP. Burnout: exploratory research in hospital environment. Trav Hum 1996; 59: 173-86.].

1.3. Workaholism

In the last few decades, the literature related to work addiction has increased significantly [30Clark MA, Michel JS, Zhdanova L, Pui SY, Baltes BB. All work and no play? A meta-analytic examination of the correlates and outcomes of workaholism. J Manage 2016; 42(7): 1836-73.[http://dx.doi.org/10.1177/0149206314522301] , 31Van Beek I, Hu Q, Schaufeli WB, Taris TW, Schreurs BHJ. For fun, love, or money: What drives workaholic, engaged, and burned-out employees at work? J Appl Psychol 2012; 61(1): 30-55.[http://dx.doi.org/10.1111/j.1464-0597.2011.00454.x] ]. Workaholism as a term was first introduced by Oates in the 1970s to describe a constant need to work. The most common traits that are most frequently linked to workaholism are: neuroticism, conscientiousness, narcissism and perfectionism [32Andreassen CS. Workaholism: An overview and current status of the research. J Behav Addict 2014; 3(1): 1-11.[http://dx.doi.org/10.1556/JBA.2.2013.017] [PMID: 25215209] , 33Taris TW, van Beek I, Schaufeli WB. Why do perfectionists have a higher burnout risk than others? The mediational effect of workaholism. Rom J Appl Psychol 2010; 12(1): 1-7.]. Workaholism is closely intertwined with the social, cultural and economic changes developed in the last few decades, which affect several aspects of people’s work, such as temporary and flexible contracts, workload and working hours, the degree of control over one’s work, social status and feeling professionally underestimated, having to meet direct superiors’ requests and expectations [34Lo Presti A, Nonnis M, Briscoe JP. The protean and boundaryless career in Italy: Game on?Boundaryless Careers and Occupational Wellbeing 2011; 7-16.]. Several definitions of work addiction exist along with models to describe it [32Andreassen CS. Workaholism: An overview and current status of the research. J Behav Addict 2014; 3(1): 1-11.[http://dx.doi.org/10.1556/JBA.2.2013.017] [PMID: 25215209] ]. Recently, some researchers have attempted to integrate different approaches to the study of workaholism and to identify its main features [30Clark MA, Michel JS, Zhdanova L, Pui SY, Baltes BB. All work and no play? A meta-analytic examination of the correlates and outcomes of workaholism. J Manage 2016; 42(7): 1836-73.[http://dx.doi.org/10.1177/0149206314522301] ]. Schaufeli, et al. [35Schaufeli WB, Taris TW, Bakker AB. It takes two to tango: Workaholism is working excessively and working compulsively.The long work hours culture: Causes, consequences and choices 2008; 203-25.] define workaholism as the tendency to work excessively and compulsively. This definition clearly describes the central features of workaholism, including working excessively hard (which relates to the individual’s behaviour) and working compulsively (which relates to the individual’s cognitive sphere). Workaholism is diagnosed when both traits can be significantly detected in a person [36Schaufeli WB, Shimazu A, Taris T. Being driven to work excessively hard: The evaluation of a two-factor measure of workaholism in the Netherlands and Japan. Cross-Cultural Res 2009; 43(4): 320-48.[http://dx.doi.org/10.1177/1069397109337239] ].

1.4. Workaholism and Nursing

Some relevant literature reports that nursing is one among the professions at risk of work addiction [37Quinones C, Griffiths MD. Addiction to work: A critical review of the workaholism construct and recommendations for assessment. J Psychosoc Nurs Ment Health Serv 2015; 53(10): 48-59.[http://dx.doi.org/10.3928/02793695-20150923-04] [PMID: 26489104] ]. A research conducted by Burke et al. [38Burke RJ, Matthiesen SB, Pallesen S. Workaholism, organizational life and well-being of Norwegian nursing staff. Career Dev Int 2006; 11(5): 463-77.[http://dx.doi.org/10.1108/13620430610683070] ] used an ad hoc measuring scale to study workaholism in a sample of 496 Norwegian nurses. They demonstrated that workaholism may affect well-being at work, when associated with specific personality traits and certain work features. They also showed that a strong drive to work can lead to a lower level of work satisfaction.

Kubota et al. [39Kubota K, Shimazu A, Kawakami N, Takahashi M, Nakata A, Schaufeli WB. Association between workaholism and sleep problems among hospital nurses. Ind Health 2010; 48(6): 864-71.[http://dx.doi.org/10.2486/indhealth.MS1139] [PMID: 20616459] ] carried out a study on 312 Japanese hospital nurses; they focused on the relationship between workaholism and a series of sleep disorders reported on a checklist. They found that nurses with the highest scores for workaholism tended to work excessively and compulsively, and reported having trouble sleeping, feeling tired at work, and having difficulties to wake up, as well as showing signs of fatigue in the morning.

Van Beek et al. [31Van Beek I, Hu Q, Schaufeli WB, Taris TW, Schreurs BHJ. For fun, love, or money: What drives workaholic, engaged, and burned-out employees at work? J Appl Psychol 2012; 61(1): 30-55.[http://dx.doi.org/10.1111/j.1464-0597.2011.00454.x] ] conducted a study on a sample of Chinese healthcare professionals, which mainly comprised nurses (n = 544). They sought to better understand the relationship between the motivational factors postulated by Deci and Ryan’s Self-Determination Theory [40Ryan RM, Deci EL. Self-determination theory and the facilitation of intrinsic motivation, social development, and well-being. Am Psychol 2000; 55(1): 68-78.[http://dx.doi.org/10.1037/0003-066X.55.1.68] [PMID: 11392867] ] and the outcomes of their research in terms of well-being/unease at work, including workaholism. Deci and Ryan proposed a major distinction between intrinsic and extrinsic motivation. Van Beek et al. [31Van Beek I, Hu Q, Schaufeli WB, Taris TW, Schreurs BHJ. For fun, love, or money: What drives workaholic, engaged, and burned-out employees at work? J Appl Psychol 2012; 61(1): 30-55.[http://dx.doi.org/10.1111/j.1464-0597.2011.00454.x] ] demonstrated that workaholism is positively associated with high levels of introjected regulation (a dimension of extrinsic motivation), which implies the adoption of external standards of self-esteem and social acceptance without necessarily identifying with such standards. Moreover, workaholism is negatively affected by intrinsic motivation. Nonnis et al. [41Nonnis M, Cuccu S, Cortese CG, Massidda D. The Italian version of the Dutch Workaholism Scale (DUWAS): A study on a group of nurses. Applied Psychology Bulletin 2017; 278(1): 47-57.] recently conducted a study on 485 Italian nurses to find that 18% of them were workaholics and almost 30% were at risk of becoming work addicts.

1.5. Workaholism and Burnout

The last few decades have witnessed a swift increase in research on workaholism and burnout, which has also focused on different aspects of their relationship. The relationship between these two dimensions is complex and multifaceted. For instance, Andreassen et al. [42Andreassen CS, Ursin H, Eriksen HR. The relationship between strong motivation to work, “workaholism”, and health. Psychol Health 2007; 22(5): 615-29.[http://dx.doi.org/10.1080/14768320600941814] ] carried out a study on a sample of Norwegian bankers (n = 235) and found an existing correlation between the dimensions of workaholism and burnout. The same results were gathered by Schaufeli et al. [36Schaufeli WB, Shimazu A, Taris T. Being driven to work excessively hard: The evaluation of a two-factor measure of workaholism in the Netherlands and Japan. Cross-Cultural Res 2009; 43(4): 320-48.[http://dx.doi.org/10.1177/1069397109337239] ] who completed a cross-cultural research project using a sample of Japanese and Dutch workers (respectively n = 3.311 and n = 7.594). Guglielmi et al. [43Guglielmi D, Simbula S, Schaufeli WB, Depolo M. Self-efficacy and workaholism as initiators of the job demands-resources model. Career Dev Int 2012; 17(4): 375-89.[http://dx.doi.org/10.1108/13620431211255842] ], in a study conducted on a sample of Italian public school headmasters (n = 224) found that some of the job demands they are subject to (work-family conflict and inequity) contribute to mediating between workaholism and burnout.

Some other studies have also focused on other aspects of this relationship, including the dimensions that both constructs share. For instance, Schaufeli, Bakker, van der Heijden and Prins’s study of a sample of Dutch junior doctors (n = 2.115), demonstrated that role conflict mediated between workaholism, burnout and well-being [44Schaufeli WB, Bakker AA, van der Heijden FMMA, Prins JT. Workaholism, burnout and well-being among junior doctors: The mediating role of role conflict. Work Stress 2009; 23(2): 155-72.[http://dx.doi.org/10.1080/02678370902834021] ]. Taris et al. [33Taris TW, van Beek I, Schaufeli WB. Why do perfectionists have a higher burnout risk than others? The mediational effect of workaholism. Rom J Appl Psychol 2010; 12(1): 1-7.] conducted a study on a sample of Dutch managers (n = 199) revealing that workaholism contributes to amplify perfectionism, which can increase the risk of burnout.

In addition, Nie and Sun [45Nie Y, Sun H. Why do workaholics experience depression? A study with Chinese University teachers. J Health Psychol 2016; 21(10): 2339-46.[http://dx.doi.org/10.1177/1359105315576350] [PMID: 25836332] ] have demonstrated how burnout can mediate the relationship between workaholism and depression in a sample of Chinese university teachers (n = 412).

Some other studies have demonstrated that workaholism can be a strong predictor of burnout. For instance, in Clark et al.’s review of the existing literature on this phenomenon [30Clark MA, Michel JS, Zhdanova L, Pui SY, Baltes BB. All work and no play? A meta-analytic examination of the correlates and outcomes of workaholism. J Manage 2016; 42(7): 1836-73.[http://dx.doi.org/10.1177/0149206314522301] ], they confirmed the relationship between these two dimensions. For their part, Hamidizadeh et al. [46Hamidizadeh A, Koolivand H, Hajkarimi F. Is workaholism antecedent of Burn out? European Journal of Academic Essays 2014; 1(8): 1-9.] examined a sample of Iranian university lecturers (n = 77) and found that workaholism can be successfully used to predict all three of Maslach’s dimensions of burnout [3Maslach C. Burnout: The cost of caring 1982.]. Also, Molino et al. [47Molino M, Bakker AB, Ghislieri C. The role of workaholism in the job demands-resources model. Anxiety Stress Coping 2016; 29(4): 400-14.[http://dx.doi.org/10.1080/10615806.2015.1070833] [PMID: 26168061] ] examined a sample of Italian workers (n = 617) and found that workaholism is a good predictor of exhaustion, which is one of the three dimensions of burnout. Finally, Innanen et al. [48Innanen H, Tolvanen A, Salmela-Aro K. Burnout, work engagement and workaholism among highly educated employees: Profiles, antecedents and outcomes. Burn Res 2014; 1(1): 38-49.[http://dx.doi.org/10.1016/j.burn.2014.04.001] ] completed a longitudinal analysis of a sample of highly educated Finnish employees (n = 292) and found that some of these employees displayed a profile that links cynicism and exhaustion (burnout dimensions) to workaholism.

1.6. The Impact of Workaholism on Nurses’ Burnout

Workaholism may act as a root cause of burnout. Nonetheless, the relationship between workaholism and burnout in nursing was only briefly discussed. Moreover, other aspects such as the patient-caregiver relationship [20Chou HY, Hecker R, Martin A. Predicting nurses’ well-being from job demands and resources: A cross-sectional study of emotional labour. J Nurs Manag 2012; 20(4): 502-11.[http://dx.doi.org/10.1111/j.1365-2834.2011.01305.x] [PMID: 22591152] , 21Campana KL, Hammoud S. Incivility from patients and their families: Can organisational justice protect nurses from burnout? J Nurs Manag 2015; 23(6): 716-25.[http://dx.doi.org/10.1111/jonm.12201] [PMID: 24372824] ] and the vocational dimension that this profession entails [24While A, Blackman C. Reflections on nursing as a career choice. J Nurs Manag 1998; 6(4): 231-7.[http://dx.doi.org/10.1046/j.1365-2834.1998.00077.x] [PMID: 9832728] -26Newton JM, Kelly CM, Kremser AK, Jolly B, Billett S. The motivations to nurse: an exploration of factors amongst undergraduate students, registered nurses and nurse managers. J Nurs Manag 2009; 17(3): 392-400.[http://dx.doi.org/10.1111/j.1365-2834.2008.00945.x] [PMID: 21456319] ] deserve attention. Therefore, we suggest that the two dimensions of workaholism (Working Excessively and Working Compulsively [35Schaufeli WB, Taris TW, Bakker AB. It takes two to tango: Workaholism is working excessively and working compulsively.The long work hours culture: Causes, consequences and choices 2008; 203-25., 36Schaufeli WB, Shimazu A, Taris T. Being driven to work excessively hard: The evaluation of a two-factor measure of workaholism in the Netherlands and Japan. Cross-Cultural Res 2009; 43(4): 320-48.[http://dx.doi.org/10.1177/1069397109337239] ]) have an impact on all the dimensions that pertain to burnout, that is complaints of psychophysical exhaustion, relational deterioration, professional inefficacy, and disillusion [13Santinello M, Negrisolo A. Quando ogni passione è spenta La sindrome del burnout nelle professioni sanitarie 2009., 49Santinello M. LBQ Link Burnout Questionnaire 2007.].

2. THE PRESENT STUDY

2.1. Aims and Hipotheses

The objective of this study is twofold. On the one hand, it seeks to provide an exhaustive picture of well-being and unease in relation to burnout and workaholism among the nurses under scrutiny.

On the other hand, and most importantly, it aims to verify to what extent workaholism may be responsible for nurses’ burnout.

In particular, we would to verify the following hypotheses:

  • Hypothesis 1 – according to Schaufeli et al.’s model [35Schaufeli WB, Taris TW, Bakker AB. It takes two to tango: Workaholism is working excessively and working compulsively.The long work hours culture: Causes, consequences and choices 2008; 203-25., 36Schaufeli WB, Shimazu A, Taris T. Being driven to work excessively hard: The evaluation of a two-factor measure of workaholism in the Netherlands and Japan. Cross-Cultural Res 2009; 43(4): 320-48.[http://dx.doi.org/10.1177/1069397109337239] ], Working Compulsively is a dimension of workaholism that can directly and positively affect burnout and its dimensions, which are Psychophysical Exhaustion, Relational Deterioration, Professional Inefficacy, Disillusion (cf. the model to determine these dimensions proposed in Santinello et al. [13Santinello M, Negrisolo A. Quando ogni passione è spenta La sindrome del burnout nelle professioni sanitarie 2009., 49Santinello M. LBQ Link Burnout Questionnaire 2007.]);
  • Hypothesis 2 - Working Excessively is a dimension of workaholism that can directly and positively affect all the dimensions of burnout mentioned above.

Despite often being referred to in the literature (as mentioned earlier; but cf. also Edelwich et al. [1Edelwich J, Brodsky A. Burnout: Stages of disillusionment in the helping professions 1981.], and Pines et al. [2Pines A, Aronson E, Kafry D. Burnout: From tedium to personal growth 1981.]), empirical research is currently scant on Disillusion. Hence, this study concentrates particularly on this dimension of burnout.

2.2. Study Design

This is a cross-sectional and correlational study. Data collection was carried out via self-reporting procedures using one research protocol that was administered on paper consisting of two questionnaires and a form to elicit socio-biographical details. The data were collected by the researchers while the nurses were on duty. All participants were asked to fill in the two questionnaires and socio-biographic form in a single compilation session. All protocols were collected from April to September 2017. Some participants completed the questionnaire in the researcher’s presence. In other cases, the researcher explained to the nurses how to complete the questionnaires and collected them at a later stage. All participants were ensured anonymity and privacy (under the Italian Personal Data Protection Code). A total of 643 questionnaires were distributed and 614 were returned (redemption 95.48%).

2.3. Participants

This research was carried out on a group of 614 Italian nurses, working in 6 hospitals in Sardinia (Southern Italy). The group of subjects represents a convenience sample of nurses based on their availability (consequently, this group of subjects cannot be considered as representative of all nursing professionals); they all took part in this study on a voluntary basis. 174 nurses were men (28.3%) while 440 were women (71.7%). 155 nurses (25.2%) had work experience that ranged from 0-10 years, 219 (35.7%) from 11 to 20 years, while the remaining 240 (39.1%) had 21 years of experience or more. The nurses of this group of subjects work in a wide range of wards but most of them are employed in the following wards: Paediatrics (115, 18.7%), Oncology (93, 15.1%), General Medicine (89, 14.4%), Psychiatrics (51, 8.3%), Obstetrics (34, 5.5%), Neurology (33, 5.3%), Emergency (32, 5.2%) and Radiotherapy (28, 4.5%).

2.4. Instruments

The Italian version of the Dutch Workaholism Scale (DUWAS, Balducci et al. [50Balducci C, Avanzi L, Consiglio C, Fraccaroli F, Schaufeli WB. A cross-national study on the psychometric quality of the Italian version of the Dutch Work Addiction Scale (DUWAS). European Journal of Personnel Assessment 2017; 33(6): 422-8.[http://dx.doi.org/10.1027/1015-5759/a000300] ]; Nonnis et al. [41Nonnis M, Cuccu S, Cortese CG, Massidda D. The Italian version of the Dutch Workaholism Scale (DUWAS): A study on a group of nurses. Applied Psychology Bulletin 2017; 278(1): 47-57.]) was used to measure workaholism. It comprises 10 items on a 4-point scale ranging from 1 = (Almost) never to 4 = (Almost) always; the questionnaire is divided into two 5-item scales: Working Excessively (WE, α = .82; e.g. “I spend more time working than on socializing with friends, on hobbies, or on leisure activities”) and Working Compulsively (WC, α = .82; e.g. “I feel guilty when I take time off work”).

Individuals scoring high on both WE and WC are considered workaholics. Conversely, a combination of high WE and low WC identifies hard workers whereas a combination of low WE and high WC characterizes compulsive workers. Finally, individuals who are low on both WE and WC are relaxed workers [35Schaufeli WB, Taris TW, Bakker AB. It takes two to tango: Workaholism is working excessively and working compulsively.The long work hours culture: Causes, consequences and choices 2008; 203-25., 36Schaufeli WB, Shimazu A, Taris T. Being driven to work excessively hard: The evaluation of a two-factor measure of workaholism in the Netherlands and Japan. Cross-Cultural Res 2009; 43(4): 320-48.[http://dx.doi.org/10.1177/1069397109337239] , 41Nonnis M, Cuccu S, Cortese CG, Massidda D. The Italian version of the Dutch Workaholism Scale (DUWAS): A study on a group of nurses. Applied Psychology Bulletin 2017; 278(1): 47-57.].

Burnout was assessed with the Link Burnout Questionnaire (LBQ, Santinello [49Santinello M. LBQ Link Burnout Questionnaire 2007.]). It includes 24 items (in italian language) divided into 4 subscales (6 items for each dimension): Psychophysical Exhaustion (α = .77, e.g. “I feel physically drained because of my work”); Relational Deterioration (α = .79, e.g. “I have the feeling that most of my patients do not follow my instructions”); Professional Inefficacy (α = .78, e.g. “I feel that my skills are not sufficiently adequate to deal with unexpected circumstances”; Disillusion (α = .85, e.g. “I think that if I could do it all over again, I’d choose another job”). All items were placed on a 6-point frequency scale ranging from 1 = never to 6 = always.

2.5. Data Analysis

Each participant’s scores for the DUWAS scales were calculated considering the total average of the answers to all items. The participants were grouped together into two groups (with low and high scores) in relation to the baseline score that was set at 2.5 workers [35Schaufeli WB, Taris TW, Bakker AB. It takes two to tango: Workaholism is working excessively and working compulsively.The long work hours culture: Causes, consequences and choices 2008; 203-25., 36Schaufeli WB, Shimazu A, Taris T. Being driven to work excessively hard: The evaluation of a two-factor measure of workaholism in the Netherlands and Japan. Cross-Cultural Res 2009; 43(4): 320-48.[http://dx.doi.org/10.1177/1069397109337239] , 41Nonnis M, Cuccu S, Cortese CG, Massidda D. The Italian version of the Dutch Workaholism Scale (DUWAS): A study on a group of nurses. Applied Psychology Bulletin 2017; 278(1): 47-57.]. As for the LBQ scales, each participant’s final score was calculated by adding the scores of all items. Values equal or over 4.5 were considered as good indicators that the participant was at risk of burnout [49Santinello M. LBQ Link Burnout Questionnaire 2007.].

In order to assess the relationship between the DUWAS and LBQ scales, we fitted a structural equation model for observed variables. At first, we considered a full-fledged model that included both the DUWAS dimensions as predictors of the LBQ dimensions. Subsequently, we deleted those parameters that did not prove to be strong predictors of the LBQ dimensions. Moreover, we discarded all those relations between the DUWAS and the LBQ scales that could lead to drop in the Bayesian Information Criterion (BIC; see Burnham et al. [51Burnham KP, Anderson DR. Multimodel inference: Understanding AIC and BIC in model selection. Sociol Methods Res 2004; 33: 261-304.[http://dx.doi.org/10.1177/0049124104268644] , 52Burnham KP, Anderson DR, Huyvaert KP. AIC model selection and multimodel inference in behavioral ecology: Some background, observations, and comparisons. Behav Ecol Sociobiol 2011; 65: 23-35.[http://dx.doi.org/10.1007/s00265-010-1029-6] ], and Vrieze [53Vrieze SI. Model selection and psychological theory: A discussion of the differences between the Akaike information criterion (AIC) and the Bayesian information criterion (BIC). Psychol Methods 2012; 17(2): 228-43.[http://dx.doi.org/10.1037/a0027127] [PMID: 22309957] ] for further details). Put more simply, one relation was deleted, and its parameter assigned a null value. This procedure continued until deleting all those values led to an increase in the BIC, which reflected a worsening trend in the variables analysed.

The BIC can only be interpreted in terms of comparison between two alternative models. We therefore reported a ΔBIC for each comparison, which was obtained once the BIC of the model under scrutiny was subtracted from the BIC of the reference model. ΔBIC values < 0 show that the data can better fit the model used here.

Once the model was deemed adequate, we examined the most influential cases. Those participants that displayed a high generalised Cook’s distance in comparison to others were removed and the model was revised once again. This allowed for the further application of the model to a sub-group comprising participants who scored high in both workaholism (rough value > 2.5 on all DUWAS scales) and burnout (rough value > 4.5 in all LBQ scales).

The analysis was carried out using version 3.2.2 of the R software [54R Core Team R. A language and environment for statistical computing Vienna, R Found Stat Computing 2015 Retrieved from: https://www.R-project.org/, 2017.], along with version 0.5-22 of lavaan [55Rosseel Y. An R Package for structural equation modeling J Stat Software 2012; 48(2): 1-36. http://www.jstatsoft.org/v48/i02/] that helped to revise the model and influence.SEM [56Pastore M, Altoè G. influence.SEM. Case Influence in Structural Equation Models R package version 15 Retrieved from: https://cran.rproject.org/web/packages/influence.SEM/influence.SEM.pdf2017.], which was used to examine the most significant cases using Cook’s distance [57Cook RD. Detection of influential observations in linear regression. Technometrics 1977; 19: 15-8. [http://dx.doi.org/10.2307/1268249]., 58Cook RD. Assessment of local influence. J Royal Stat Soc 1986; 48(Series B Methodological): 133-69.]. Cook’s distance is a measure of influence for a data point, allowing single observations to be identified that have a significant influence on the results of a model. After identifying the model, we calculated Cook’s distance for each participant by using the generalized version of the index for the multivariate case [59Pek J, MacCallum RC. Sensitivity analysis in structural equation models: Cases and their influence. Multivariate Behav Res 2011; 46(2): 202-28.[http://dx.doi.org/10.1080/00273171.2011.561068] [PMID: 26741328] ]. For each subject, we calculated Cook’s measure and observed the distribution of the values, looking for potentially significant cases.

2.6. Ethical Issues

Consent to carry out this survey was granted by the hospital board of directors. The project did not focus on any sensitive topics and was carried out via self-evaluation procedures for adults. Moreover, it ensured all participants anonymity and privacy and the data were examined as aggregated information. Therefore, the hospital board of directors deemed it was not necessary to ask for further permission from their Ethics Committee.

3. RESULTS

3.1. Workhaolism and Burnout Among Nurses

Results show that 26.55% of the nurses in the group of subjects are at severe risk of burnout or already clearly suffering from it. More than 21% are workaholics while 50% display general well-being. The remainder (approximately 30%) is at risk of becoming a workaholic since they score high on one of the two dimensions of this syndrome (Table 1).

Table 1
Participants’ distribution according to the DUWAS scales. The values below 2.5 are considered to be low scores while values over 2.5 are considered high [29Neveu JP. Burnout: exploratory research in hospital environment. Trav Hum 1996; 59: 173-86., 30Clark MA, Michel JS, Zhdanova L, Pui SY, Baltes BB. All work and no play? A meta-analytic examination of the correlates and outcomes of workaholism. J Manage 2016; 42(7): 1836-73.[http://dx.doi.org/10.1177/0149206314522301] ].


The t test shows that the score for both the LBQ and DUWAS scales are not gender-related or connected to work experience (p > 0.05). The polyserial correlation between work experience and the scores retrieved for both the LQB and DUWAS scales are very low, ranging from -0.07 and 0.10.

Table 2 shows the Pearson’s correlations indexes along with the variance-covariance matrix regarding the four LBQ scales and the two DUWAS scales.

Table 2
Correlation matrix (upper part of the diagonal) and variance-covariance matrix among the variables used to build the model. Mean and standard deviations of each variable are reported at the bottom of the table.


3.2. The Impact of Workaholism on Burnout Among Nurses

We fitted a structural equation model to help us to predict all four burnout dimensions in relation to the two dimensions of workhaolism. This led us to remove the following relations from our analysis: WC and Psychophysical Exhaustion (ΔBIC = -6.29), WC and Relational deterioration (ΔBIC = -4.91) and WC and Professional Inefficacy (ΔBIC = -5.22). Interestingly, removing other relations leads to an increase in the BIC (Table 3). Therefore, we decided to keep them. This resulted in a model that could only have the WC and Disillusion relation along with the WE dimension and all four LBQ scales.

Table 3
Difference between the standard BIC model and the its versions minus the ΔBIC parameter. Score values for the adapted model are in percentiles.


We calculated Cook’s distance for each participant. Six subjects present a value outside the 99° percentile (Cook’s distance = 0.27). Three of these participants displayed extreme values (two scored 0.63 while one scored 1.38). After removing these participants, the model was again revised (Fig. 1). Interestingly, removing these potentially influential cases did not lead to significant changes in the dataset.

Fig. (1)
Path diagram of the model used for the whole group of subjects (n = 614), including estimated parameters for standardised solution.


The amount of explained variance is small, with R2 values of 0.09 for Psychophysical Exhaustion, 0.04 for Relational deterioration, 0.03 for Professional Inefficacy and 0.04 for Disillusion. Moreover, the WE dimension can effectively predict all four dimensions of burnout. Conversely, the WC dimension can only predict Disillusion.

The correlation between WE and Relational Deterioration (r = 0.20) and Professional Inefficacy (r = 0.15) and the correlation between WC and Disillusion (r = 0.02) are significantly low (Table 2). Therefore, it could be suggested that such correlations do exist, but they have a weak impact. It could also be that they appeared by chance. As for the relationship between WC and Disillusion, despite being significantly low, it is negative (Table 1 above), thus, contrary to our expectations. However, this result is consistent with the idea that those who work compulsively are also likely to have high expectations (and may have “illusions”) regarding the importance of their work, its results and related awards. Therefore, we used bootstrapping to further investigate these relations.

The model was refitted resampling the subjects with replacement for 1000 times (for a valuable introduction about resampling methods in psychology, see Wright et al. [60Wright DB, London K, Field AP. Using bootstrap estimation and the plug-in principle for clinical psychology data. J Exp Psychopathol 2011; 2(2): 252-70.[http://dx.doi.org/10.5127/jep.013611] ]). At the end of 1000 cycles, in order to identify the 95% range of estimations, for each parameter the percentiles 2.5th and 97.5th were calculated (Table 3).

Our analysis revealed that the limit of the parameter relating to the relation between WC and Disillusion is below -0.03, which is therefore very close to zero. Similarly, all the parameters regarding the relations between WE and Relational deterioration and Professional Inefficacy are quite low, but the variance range is less dramatic as its values are above 0.20. It can be therefore concluded that WE is not a strong predictor of burnout, thus making previous assumptions in this sense debatable. In contrast, all the other correlations appear to be more stable.

Therefore, we revised the model by considering only those participants that showed high levels of workaholism and burnout (n = 46). This demonstrated that the model could fit better if we removed the relations between WE and Relational deterioration, WE and Professional Inefficacy and WC and Disillusion (respectively, ΔBIC = -0.28, ΔBIC = -3.80, ΔBIC = -3.72). Progressively removing such relations meant that we retained only WE and Psychophysical Exhaustion and WE and Disillusion (Fig. 2), whose standardised parameters are respectively 0.36 and 0.38, with R2 values equal to 0.13 for Psychophysical Exhaustion and 0.15 for Disillusion.

Considering only the participants that scored high in both constructs demonstrated that the WE dimension of workaholism may mainly influence the Psychophysical Exhaustion and Disillusion dimensions of burnout.

4. DISCUSSION

4.1. Workaholism and Burnout Within the Group of Subjects

This study confirms previous research on the existence of workaholism and burnout among nurses. As for our group of subjects, 21% of the participants suffer from severe workaholism while 26% display a high risk of burnout. Moreover, 7.5% show a tendency toward a lack of well-being. These are alarming data if we consider the fact that all these professionals provide highly organised, technical and specific services, which also include creating a positive patient-caregiver relationship within healthcare organizations. It was fully demonstrated that ensuring nurses’ well-being at work is essential to ensure high quality healthcare services [20Chou HY, Hecker R, Martin A. Predicting nurses’ well-being from job demands and resources: A cross-sectional study of emotional labour. J Nurs Manag 2012; 20(4): 502-11.[http://dx.doi.org/10.1111/j.1365-2834.2011.01305.x] [PMID: 22591152] , 22Delgado C, Upton D, Ranse K, Furness T, Foster K. Nurses’ resilience and the emotional labour of nursing work: An integrative review of empirical literature. Int J Nurs Stud 2017; 70: 71-88.[http://dx.doi.org/10.1016/j.ijnurstu.2017.02.008] [PMID: 28235694] , 38Burke RJ, Matthiesen SB, Pallesen S. Workaholism, organizational life and well-being of Norwegian nursing staff. Career Dev Int 2006; 11(5): 463-77.[http://dx.doi.org/10.1108/13620430610683070] ].

Fig. (2)
Path diagram of the model used for those participants scoring high in workaholism and burnout (n = 46), including estimated parameters for standardised solution.


4.2. The Impact of Workaholism on Burnout Among Nurses

As for the correlations among the constructs investigated here, it seems that workaholism can only partly predict nurses’ burnout. Hypothesis 1, according to which working compulsively has an impact on all four dimensions of burnout, was not confirmed. Only the working excessively dimension of workaholism can effectively predict burnout, thus at least partially confirming Hypothesis 2. This is even more evident among those nurses that suffer from both syndromes, especially as far as Psychophysical Exhaustion and Disillusion are concerned.

Research on the lack of impact of Working Compulsively on the dimensions of burnout is sparse (with the exception of the weak and negative relationship with the Disillusion discussed above). Consequently, only explanatory reflections can be offered here. Working Compulsively is a cognitive dimension that obsessively and compulsively leads people to spend an excessive amount of time thinking about work [30Clark MA, Michel JS, Zhdanova L, Pui SY, Baltes BB. All work and no play? A meta-analytic examination of the correlates and outcomes of workaholism. J Manage 2016; 42(7): 1836-73.[http://dx.doi.org/10.1177/0149206314522301] , 32Andreassen CS. Workaholism: An overview and current status of the research. J Behav Addict 2014; 3(1): 1-11.[http://dx.doi.org/10.1556/JBA.2.2013.017] [PMID: 25215209] , 35Schaufeli WB, Taris TW, Bakker AB. It takes two to tango: Workaholism is working excessively and working compulsively.The long work hours culture: Causes, consequences and choices 2008; 203-25.]. However, it is not a behavioural pattern that makes people work hard and therefore feel physically or mentally exhausted. Conversely, burnout is a syndrome that affects those who choose to work excessively and continuously to the extent that they become increasingly stressed by it [8Demerouti E, Bakker AB, Nachreiner F, Schaufeli WB. The job demands-resources model of burnout. J Appl Psychol 2001; 86(3): 499-512.[http://dx.doi.org/10.1037/0021-9010.86.3.499] [PMID: 11419809] , 11Borgogni L, Consiglio C, Alessandri G, Schaufeli WB. “Don’t throw the baby out with the bathwater!” Interpersonal strain at work and burnout. Eur J Work Organ Psychol 2012; 21(6): 875-98.[http://dx.doi.org/10.1080/1359432X.2011.598653] ]. This important conceptual difference that sets apart Working Compulsively from burnout and its dimensions may explain why all these phenomena do not relate. That said, further research is certainly needed to confirm this claim.

As for the impact of Working Excessively on Psychophysical Exhaustion, our findings appear to generally match the results obtained from previous studies [42Andreassen CS, Ursin H, Eriksen HR. The relationship between strong motivation to work, “workaholism”, and health. Psychol Health 2007; 22(5): 615-29.[http://dx.doi.org/10.1080/14768320600941814] ], including those carried out in Italy [10Pedditzi ML. Work-family interface, work relations and burnout in school teachers: A study on a group of subjects from Italian primary schools.Handbook on Burnout and Sleep Deprivation: Risk Factors, Management Strategies and Impact on Performance and Behavior 2011; 147-61., 47Molino M, Bakker AB, Ghislieri C. The role of workaholism in the job demands-resources model. Anxiety Stress Coping 2016; 29(4): 400-14.[http://dx.doi.org/10.1080/10615806.2015.1070833] [PMID: 26168061] ]. This is unsurprising since is plausible to maintain that if a person works excessively, they are more than likely to eventually suffer from psychophysical exhaustion.

Finally, as far as the impact of Working Excessively on Disillusion is concerned, a sound comparison with previous empirical studies is not possible since they are extremely infrequent. Nonetheless, it seems safe to suggest that working excessively forces nurses to focus on the most contingent, urgent and practical issues connected with their work, preventing them from considering those that may have initially driven their vocation, e.g. helping people in need, doing a job that is useful for others, contributing to improve the society [24While A, Blackman C. Reflections on nursing as a career choice. J Nurs Manag 1998; 6(4): 231-7.[http://dx.doi.org/10.1046/j.1365-2834.1998.00077.x] [PMID: 9832728] -26Newton JM, Kelly CM, Kremser AK, Jolly B, Billett S. The motivations to nurse: an exploration of factors amongst undergraduate students, registered nurses and nurse managers. J Nurs Manag 2009; 17(3): 392-400.[http://dx.doi.org/10.1111/j.1365-2834.2008.00945.x] [PMID: 21456319] ].

This study has some limitations. Firstly, the group of subjects was selected ad hoc, depending on the voluntary participation of a number of nurses, and was not based on systematic sampling. Therefore, this group of subjects cannot be considered representative of all nursing professionals. Secondly, study a group of nurses allowed us to have a firm control over possible professional, social and demographic factors. However, these factors do not allow the formulation of more general hypotheses by a broader working population. Also, the application of a cross-sectional and self-report methodology to collect the data may have affected the measurement quality of the dimensions underlying workaholism and burnout.

Future research may be based on larger and more representative samples of the nursing population working in hospitals. Researchers could focus on vocation and motivation as a driver for becoming nurses (and their relationship with Disillusion). It may be also worth investigating what psychophysical aspects (relating to Psychophysical Exhaustion) might be mostly affected and depleted by working excessively.

CONCLUSION

This study confirms that workaholism and burnout cause a great deal of work-related unease among nurses. Moreover, our research corroborates the results of previous studies showing that an excessive workload can deplete nurses’ psychological and physical resources [47Molino M, Bakker AB, Ghislieri C. The role of workaholism in the job demands-resources model. Anxiety Stress Coping 2016; 29(4): 400-14.[http://dx.doi.org/10.1080/10615806.2015.1070833] [PMID: 26168061] ]. More interestingly, the correlation between excessive workload and Disillusion is a new finding. Working excessively seems to make nurses feel disappointed and frustrated about the social value of their work and their role within society, thus destroying their vocational attitude to work [24While A, Blackman C. Reflections on nursing as a career choice. J Nurs Manag 1998; 6(4): 231-7.[http://dx.doi.org/10.1046/j.1365-2834.1998.00077.x] [PMID: 9832728] , 25Rognstad M-K, Aasland O. Change in career aspirations and job values from study time to working life. J Nurs Manag 2007; 15(4): 424-32.[http://dx.doi.org/10.1111/j.1365-2834.2007.00655.x] [PMID: 17456171] ]. This aspect certainly deserves further research, since the literature in this sense is extremely limited.

In terms of application, this study contributes to stressing the importance that nurses be guaranteed an adequate and balanced workload. By doing so, it may be possible to prevent depleting their psychophysical energy, avoid exhaustion (or even the destruction) of their vocational drive, which initially made them choose such an important profession within the health system.

In conclusion, this study enhanced our understanding of the effects of workaholism on nurses’ burnout. What is more, it helped to comprehend the effect of Working Excessively on Disillusion, especially considering that empirical research on the role that the latter plays in inducing burnout is currently extremely limited.

SOURCES OF FUNDING

This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.

ETHICS APPROVAL AND CONSENT TO PARTICIPATE

Not applicable.

HUMAN AND ANIMAL RIGHTS

No animals/humans were used for studies that are the basis of this review.

CONSENT FOR PUBLICATION

Not applicable.

CONFLICT OF INTEREST

The authors declare no conflict of interest, financial or otherwise.

ACKNOWLEDGEMENTS

We would like to thank Tiziana Brundu (nurse in Department of Cardiology, Nuoro), Irene Angelini (Nursing Officer of the Cardiology clinic and UTIC AOU, Cagliari), and Barbara Masala (nurse in Medicine Oncology at the Armando Businco Hospital, Cagliari), who helped us to network with the hospitals and coordinate data collection.

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