Elliot Shewchuk Hagglund Rybarczyk Harkins

8/3/2019 Elliot Shewchuk Hagglund Rybarczyk Harkins

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Occupational Burnout, Tolerance forStress, and Coping Among Nurses

in Rehabilitation UnitsTimothy R . ElliottRichard Shewchuk

University of Alabama at BirminghamKristofer HagglundUniversity o f Missouri-Columbia

Bruce RybarczykRush-Presbyterian-St. Luke's Medical Center Chicago, IL

Stephen HarkinsMedical College o f Virginia/Virginia Commonwealth University

ABST RAC T. The re la t ion of problem -solving confidence, perceived tolerance,and si tuation-specif ic coping effor ts to occupational burnout was examinedamong nurses in physical rehabil i ta t ion units . Consistent with predict ions,confidence in one 's abil i ty to handle problems and perceived tolerance weresignificantly predict ive of lower bu rno ut scores, regardless of t ime spent on thejob. Of the coping var iables, emo tion-focused coping was sig nif ica ntly associ-a ted with high er bu rno ut scores. P ost-hoc inspe ction of self- reported copingact ivi t ies generated in response to a thought- l i s t ing probe ind icated that somecoping efforts (e.g., taking t ime off from w o r k , confront ing a supervisor ) couldbe construed as symp toms of burnout , according to theoretical co nceptualizat ions.Imp l ica tions for contempo rary not ions of burnou t and psychosocial interven-t ions with rehabi l i ta t ion staff are discussed.

Occupa tional bu rnou t is considered en dem ic to the hu m an service profess ions,and the construct has achieved considerable albeit unc ri t ica l acceptancein the popular cul ture and contemporary workplace . People in the h u m a nservice professions are part icularly at r isk for b u r n o u t as their work isemot iona l ly involv ing , and work outcomes can be r e la tive ly indep enden tof theeffort exerted by the profession al (Maslach & Jackson, 1982; Pines & Aronson ,1989). Occupational burnout is associated w ith increased w ork experience

REHABILITATION PSYCHOLOGY Vol. 41, No. 4, 1996 1996 by the Division of Rehabilitation Psychology of the Am erican Psychological AssociationPublished by Springer Publishing Company, Inc. , 53 6 Broadway, New York, NY 10012267


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268 Elliott et al.(Sherwin et al., 1992), increased workload (Maslach & Florian, 1988), ab-sences and time missed from work (Firth & Britton, 1989), impaired empathyand cynical att i tudes toward clientele (Shinn, Rosario, Morch, & Chesnut,1984; Williams, 1989), and with thoughts about leaving and actual jo bt e rmina t ion (Jackson, Schwab & Schuler, 1986). Rehabili tation staff whoreport fewer personal resources appear to be more susceptible to burno u t thanthose w it h more resources, regardless of the t ime spent on the job (Clanton,Ru d e , & Taylor, 1992). The deleterious effects of burnout in rehabili tationhave been observed across disciplines in the rehabilitation setting (Stav &Florian, 1986; Ursprung, 1986).

Despite these f indings , research h as cast shadows on the ubiq uito us natureand theoretical parameters of the burn ou t construc t, sugge sting that under-standing of this phenomenon is incomplete. For example, burnout has dis-played considerable overlap with measures of depression (Glass, McKnight , &V aldim arsd ottir , 1993) and neuroticism (Hills & Norvell , 1991). Exper imenta lresearch indicates that rehab ili tation nurses with higher burno ut scores may bepreoccupied with se lf - re levant thoughts when confronted with chal lengingpatients, and may not necessarily denigrate these patients in the manneroriginally assumed (Marmarosh et al., 1994). Several studies indicate thatsocial-cognitive processes such as commitmen t to work (Taft, 1989), self-efficacy (Chwalisz , Al tmaier , & Russell, 1992), learned resourcefulness(Clanton et al., 1992), and hope (S herw in et al., 1992) mig ht insula te ind ivi du -a ls f rom burno ut .Social-cognitive processes are often embedded within theoretical frame-wo rks that offer directions for psychological in terven tions (Elliott & Marmarosh,1995). It is important, then, to identify characterist ics predictive of burnoutthat may be amenable to preventive and remedial strategies. Some character-istics m ay relate to global and relative ly stable chara cteristics of the ind iv idua l ;others may be more situation-specific. For example, the transactiona l modelofstress appraisal and coping (Lazarus, 1991) and contempo rary theories of workadjus tment (Dawis & Lofquist , 1984) emphasize that s i tuation-specific ap-praisals of the self and one 's options for coping are salient mechanisms inr esponding to job stress. T he Minnesota Theory of W ork Adjus tmen t ( M W A ;Dawis & Lofquis t , 1984) stipulates that work stress is a subjective psychologi-cal state that occurs when the correspondence between the person and thee n v i r o n m e n t b e c o m e s i m b a l a n c e d . T h e r e s u l t i n g s t a t e , t e r m e ddiscorrespondence, then mo tivates th e person to strive to regain some sense ofequ i l ib r ium. In this mod el, some people are able to tolerate stress before actingto reduce the discorrespondence. Thus, the perceived ability to tolerate stressis an important cognitive appraisal process that can potentially buffer thene ga tive effects of w ork-related stress. A recent test of this hyp othes is ve rifiedthat perceived tolerance is a strong predictor of em otion al distress associatedwith an occup ational stressor am ong school teachers and journalists , and thisrelationship is not mediated by trait levels of affectivity (Elliott, Chartrand, &H a rk i n s , 1994).


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Burnout Amo ng the Nurses 269Alternat ively , occupational burnout m ay stem from employee inabil i t ies to

cope effectively with recurrent jo b demands and stressors. T he social problem-solving model posits that persons with chronic depression and anxie ty have anegative problem orientat ion that inhibi ts and impairs problem-solving at-tempts (Nezu & D'Zurilla, 1989). A person w ith a negative or ienta t ion harborspessim istic atti tudes ab out the self and is una ble to deal effectiv ely wi th m i n o rprob lems so that they exacerbate over time. These ineffectual behaviors andunfor tunate cons equ ences reinforce the nega tive orien tation (Nezu, 1987). Incontrast , an employee with a positive orientation is l ikely to m a i n t a i n a senseof competency in daily tasks, and is capable of staving off prolonged periodsof negat ive mood, and may even experience a posi t ive emotional tone understressful conditions (Elliott , Sherwin , Hark ins , & Marmarosh, 1995; Study 2).An employee with a posi t ive or ientat ion would be more motivated to dispatchwith rout ine problems on the job, main ta in an optimal emotional tone, feelmore competent , and be less vulnerable to burnout. In contrast, a person witha negat ive o r ientat ion wil l l ikely be preoccupied with unresolved personal andvocational problems, and wil l then rely on em otion-focuse d coping s tra tegies(MacNair & Elliott , 1992). Em ployees w ith high er levels of b u r n o u t use morepalliative and less problem-focused coping strategies than colleagues w hohave lower burnou t scores ( Ch w a l i s z e t a l . , 1992; Ogus , 1992;Thorton, 1992).Despite the importance many theorists have placed on si tuat ion-specif icappraisals and coping efforts in the workplace (e.g., Lazarus, 1991), it isuncerta in if these behaviors contribute to the prediction of burnout oncedispositional factors are considered. Distressed people m ay simply havehabitual ways of coping, general ly (Coyne, A ldw in, & Lazarus, 1981; MacNair& Elliott , 1992). It is possible tha t situ atio n-s pe cific appraisals and coping addl i t t le toward the prediction of burnou t once a person 's general p rob lem -so lv ingorientation is taken into account.

These issues were explored in the present s tudy. Specif ical ly , a posi t iveproblem orientation w as expected to be associated w ith lower burn out amo ngnurses in chronic care units, after taking time on the job in to account . I t wasuncerta in , however , if situation-specific tolerance appraisals of job stresswould be associated w ith bur nou t after acco u n t in g for one ' s p rob lem-so lv ingorien tation . Sim ilarly, i t was unclear if coping w ould con tribu te to the predic-tion of burnout when added in the f inal step of the regression equ at io n.

M E T H O DParticipantsParticipants were 98 nurses (8 6 w o m e n , 12 men; average age = 38.33,SD = 10.4) recruited from three different sites. Twenty-three worked as nursesfor in-patient rehabilitation units at the Univers i ty of Alab am a-B i rm in g ham ,42 were with the rehabilitation service at Rush-Presbyter ian-St . L u k e ' s Medi-


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27 0 Elliott et al.cal Center in Chicago, and 33 were wi th the in -p a t i en t rehabi l i ta t ion p ro g ram sat the U n i v e r s i t y of M issouri H eal th Sciences C enter . Of the f inal n u m b e r (n= - 88) re ta ined for data analysis , 68 were registered nurses, 9 were licensedprofessional nurses , 6 were cer t i f ied nursing assis tants , and 5 were s tuden tnurses .

ProcedurePart ic ipants were informed of the purpose of the s tudy and those interested

were giv en a set of qu est ion naire s that included the measures em ploye d in thiss tudy . They were first asked to complete a measure of burnout (describedbelow ), and were then adminis tered a "stress qu est ion naire " that required themto lis t the stressors encountered at wo rk and the i r ab i l i ty to tolerate thisstressor. Pa rticip an ts were then asked to l is t their typical way s of coping withthis s t ressor . They subse que ntly completed a measure of problem solving andre turned th e packet to a contact person at each respec tive site. A response rateof 68% was observed across sites.

MeasuresThe ins t ruc t iona l set and phenomen ological fo rmat for the stress qu est ion -naire were taken from the transactional model of stress appraisal and coping(Folkman & Lazarus, 1986; 1988). Rather than provide a list of stressfuleve nts, partic ipan ts were asked to list the five most common stressors experi-enced at wo rk and from this l ist , identify the most stressful experience theyencou ntered at wo rk. Par t ic ipants referred to this s t ressor w hen respo nding to

the m easure of to lerance, and wh en l is t in g their typical way s of coping w ith thestressor. This procedure a t tempts to provide a more phenomenological analy-sis of the si tuat ion-specif ic re la t ions between appraisals of tolerance andcoping efforts. The device has been used in previous s tudies of occupationalstress (Elliott , Chartrand, & H ark in s , 1994). After participants completed thisques t ionna i re , they were asked to complete the measure of self-appraisedprob lem-so lv ing ab i l i ty .

Perceived Tolerance. A 150 m m visual analogue scale (VAS) was used tomeasure appraisals of to lerance. The measure of to lerance similar to theexperim ental scale provid ed by Da wis and L ofq uis t (1984; p . 216) requiredpar t ic ipants to respond to the fo l lowing sta tement , "How difficul t is it for youto tolerate this stressor?," re fe r r ing to the mo st stressful i tem iden tified earlierby each part ic ipa nt . At the extreme left the line wa s anchored w ith "not at all"in terms of difficul ty; the extreme r ight was anchored w ith "the most ima gin-able" in terms of difficul ty. Part ic ipants were required to indicate theirappraisal by plac ing an "X" between the anchors . Higher scores reflectperceptions of less toleran ce. A ltho ugh this measu re is si tuat ion-specif ic , it has


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Burnout Amo ng the Nurses 271nonetheless yielded a six-week test-retest coefficient of .61 (Harkins , E l l io t t,& W an , 1996). Evidence of validity has been observed in correlations inhypothesized directions w ith rating s of emotional distress on the job (Elliott ,Chartrand, & Harkins , 1994).Coping. Fol lowing th e tolerance item, participants were then given thefo l lowing ins t ruc t ions : "List the different ways you have coped wi th th isstressor, or wi th the circumstances or feel ings that accompany the stressor."The th ou gh t-lis ting approach w as used for several reasons. M an y of theinstruments used to assess coping make several a prior i assumptions aboutcoping options that respondents have at their disposal. Often coping instru-men ts are adminis tered in an incon sis ten t fashion; some studies require therespondent to endorse only those that ap ply to the si tuat ion, and others requirerespondents to denote their usual coping tendencies. T he thought - l i s t ingassessment of coping relied primarily on the phenomenological in terpreta t ionof coping as defined by the participant. Thought- l is t ing techniques are effi-cient measures of cognit ive responses , which represent the end product ofinformation-processing in reaction to a si tuat ion , object, or issue (Cacioppo,Hark ins , & Petty , 1981). The thou ght- l is t in g device provides a more ambigu-ous ins t ruc t iona l set than direct measures, and may t hu s be less susc eptible tosocial desirability effects as it el ic i ts more na tural ly occurr ing, spontan eous,and familiar responses from participants.

Ind iv idua ls unfami l i a r with the study rated each strategy according to theoperat ional defini t ion s for problem-focused and emotion-focused coping.Specif ical ly , em otion-focused c opin g was defined as any effort to ". . .changeei ther (a) the way the s tressful re la tionship w ith the enviro nm ent is a t tended to(as in vigi lance or avoidance) , or (b) the re la t ional meaning of w h a t ishappening , w hich mit igates the stress event thoug h the actual condit ions of there la t ionship have not changed" (Lazarus, 1993, p. 238). Items coded asproblem-focused coping efforts inclu ded any attempt to ".. .change the troubledperson-env ironment re la t ionsh ip by ac t ing on the en v i ro n m en t or on oneself(Lazarus, 1993, p. 238). Thus, emotion-focused efforts were construed aspalliative strategies, a nd prob lem -focus ed efforts were ins tru m en tal and activestrategies to alter th e person-env i ronment re la t ionsh ip (Auerbach , 1989). F orexample, "made light of the si tuat ion" wo uld be coded as a pall ia tive , em otion-focused strategy; "reorganized m y schedule to prepare for the meeting" wouldbe coded as an instru m enta l , problem-focused s tra tegy. Responses that couldnot be coded were categorized as "miscel laneous." Interra ter coeff ic ientsindicated adequate agreement between the two rat ings of emotion-focused(.90) and problem-focused coping (.92). To obtain a single index for eachcoping variable, the ratings from tw o separate judges on each coping variablewere summed and averaged. The average scores for each were used insubsequent analyses .Problem-Solving Orientation. The Problem Solv ing Inven tory - Form A(PSI; Heppner, 1988) w as used to measure self-appraised problem-solvingabi l i ty . The PSI conta ins 32 i tems w hich are rated on a 6-po int Likert scale (1


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27 2 Elliott etal= s t rongly agree to 6 = strongly disagree). T he PSI contains three factors:Problem-Solv ing Confidence (PSC), Approach-Avoidance (AA), and Per-sonal Control (PC; Heppner, 1988). A total score is derived by s u m m i n g thefactor scores. R eli ab ili t y estim ates reveal that these construc ts are in te rna l lyconsis ten t (a lpha coeff ic ien ts from .1 2 to .90) and stable over a 2-week period(test-retest correlations from .83 to .89; Heppner, 1988). Validity estimatesindicate th at the PSI total score and subscales a re sign ifican tly related inpredicted directions with a variety o f self-report and observational measures(Heppner , 1988). Low er scores ref lect m ore effec t ive problem -solv ing abi l i ty ,and high er scores deno te a more neg ative, inef fecti ve prob lem -solving reper-toire.

Recen t l y , Elliott and colleagues have asserted that the Problem-SolvingConfidence and Personal Control factors parallel the problem-solving orienta-tion component delineated in the social problem-solving model (Nezu &D 'Zu ril la , 1989). Effe ctiv e PS C scores, in particular , have been associatedw i t h a prosocia l demeano r and a procl iv i ty for posi t ive affects in everyday andstressful situatio ns (Elliott , H errick, MacNair, & H arkin s, 1994; E lliott et al . ,1995). In contras t , ineffec t ive PSC scores have been c onsistently predictive ofdepression (e.g., Priester & C lu m , 1993). Ineffective PSC scores were ex-pected to be sign ifica ntly predictive of greater bur no ut in the present stud y.Nei ther the PC nor the AA fac tor were inc luded fo r ana lyse s because theseassess aspects of the prob lem -solv ing process theore t ica lly u nre la ted to bu rn-out. Thus, they were excluded from the analyses.

Occupational Burnout.A 21 - i tem b urn ou t measure developed by Pines andAronson (1989) was used. This measure l is ts 21 possible symptoms of occu-pational b urn ou t, and a respo nde nt rates on a 1 (never) to 1 (alw ay s) scale thef requency of each expe rienced sym ptom du rin g the past week at w ork. Scoresare derived from an algorithm provided by the authors. The authors reportacceptable tes t-retest relia bilit ies over 1-month (.89), 2-month ( .76), and 4-m o n t h ( .66) inter vals . In tern al consistency coe fficients have averaged betw een.91 and .93. Considerable evidence for construc t va l id i ty is apparent inmean ing fu l correlations w ith measures o f w ork satisfaction, inte ntio ns to leavewo r k , job tu rnover , and phys ical health problem s (Pines & Aronson, 1989; pp .220-222). H igher scores indic ate a greater inten sity of bu rno ut.

Data AnalysisThe data were first inspected to ensure assumptions for regression proce-dures w ere met . M ult iva r ia te out l ie rs were ident i f ied in the data, based on the

pat tern of residuals across the self-report variables (n = 10). These outliersindicated tha t these par t ic ipants were responding e i ther in an extreme orrandom fashion. Consequently, these outliers appeared to exer t an u n u s u a lin f luence on the resu l ts and were thu s deleted. A n e x a m in a t i o n of the plottedres idual scores versus the predicted scores evidenced a pattern of greatdispersion of variances across predicted scores. C on seq ue ntly , an attem pt w as


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B u r no u t A mo ng th e Nurses 273made to correct th is heteroscedast ic i ty by em plo yin g a reciprocal t ransforma-tion of b u r n o u t scores as a varian ce-stab i l iz ing measure (Tabachnick & Fidell ,1989). The PSC and t ime variables were also skewed; th e pattern of PSC rawscores revealed a clear g rou pin g toward the lower range of the dis t r ibu t ion .This pattern indicated that the major i ty of participants in the present samplereported a greater confidenc e in their abi l i ty to solve problems. The lack of anormal dis tr ib ut ion violated basic assu mp tions necessary to conduc t param et-ric proced ures, g ene rally , and regression ana lyses, spe cific ally . Therefore, asquare root t ransfo rma tion was com puted to norm alize the dis tr ibut ions of thePSC and t ime variables (Tabachnick & Fidell, 1989). These procedures werenecessary to obtain the most norm al-appe aring dis tr ibut io n for these variables,based on inspection of the skewness and kurtosis for each distribution.

After these t ransform ations, time on the job, problem-solving confidence,perceived tolerance, and the emotion-focused and problem-focused copingscores were entered in successive steps in a regression equation to predictburnout. Following these parametric tests of these hypotheses, th e mostfrequently reported stressors and natu rally occu rring coping strategies listed inresponse to probes were tallied.

RESULTSRaw score mean s, standard devia tion s, and correlations for the predictor

and criterion variables are con ta ined in Table 1. Regression analysis revealedthat time on the job was n ot a signif icant prediction of b u rn o u t , ns. Consis tentwith expectat ions, PSC was s ign if icant ly predict ive of burn ou t a t the secondstep of the eq u a t io n , Fiac(l, 85) = 7.28,R2 nc = .08, p< .01.Greater conf idencein prob lem -solvin g ability was associated w ith less bur no ut regardless of timeon the job. Tolerance, entered at the second step, w as also s ign i f ican t lypred ictive of burnout , F ine (1,84) = 9.58, R2 ,nc = .09, p < .01. Inabil i ty to toleratestress w as associated with greater bu rno ut , consis tent wit h the theoret icalproperties of this appraisal a ctiv ity. F ina lly, the block of co pin g variab lesentered at the final step of the equation did not reach conventional levels ofs ignif icance in the prediction of b u r n o u t , F iiK (2, 82) = 2.47, /?2 = .05,p = .09.H ow ever , inspect ion of the corresponding beta w eights indicated that the lackof significance was due to the lack of effect fo r problem-focused coping (|3 =-.13, t = -1.09, ns). Emotion-focused coping, however , w as s ign i f ican t lyassociated with burnout , P = -.26, t - -2.22, p < .05. Consis tent with pr iorresearch, increased emotion-focused coping w as associated with high er levelsof bu rn ou t. Thus, the situation-s pecific appraisals of stress toleran ce andpall ia t ive coping effor ts con tr ibute d to the predict ion of burn ou t af ter takin gthe PSC into account. The f inal model accounted for 22% of the variance inburnou t .


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274 Elliott et al.Table 1. Means, Standard De viatio ns and Co rrelations of Predictor andCriterion Variables

1 . B u r n o u t2. PSC3. Tolerance4. Problem focused

1 2 3 4-.28* ---.34* .1 3

5 M SD2.85 1.0223.44 6.86

78.71 36.80coping .06 -.26* .05 - 1.37 1.18

5. Emotion focusedcoping -.21 .15 -.07 -.53* - 2.02 1.30

6. Time on the Job .03 - .12 .14 .09 -.26* 77.40 72.90Note. PSC = Problem So l v i n g Conf idence .* / ?< . 0 5 .

Post -Hoc AnalysesA n a l y s i s of the stress and cop ing measure a l lowed de tec t ion of i n t r i g u i n g

pa t te rn s in the types o f s t res so rs and cop ing m ech an ism s repor ted by par t i c i -pan ts . U s in g ca tegories i d en t i f i ed by G r ay - T o f t an d A n d e r s o n ( 1 9 8 1 ) in t h e i rs tudy of nurse s t ress , s i tuat ions f r equ en t l y en d o r s ed a s p r im a r y s t ressors in thepresen t s ample inc luded interpersonal conflicts on the unit ( n = 31) , workload(28), lack o f training and education (15) , issues concerning patient educationan d treatment (13) , and lack o f institutional support ( 1 1 ) . P a r t i c i p an t - g en e r -ated cop ing re sponses were receded to ref lect the actual ecology in w h i c h thecoping responses were m ad e . A nons tandardized s t ress appraisal and co p in gasses sment method wo uld po ten t ia l ly ob ta in a v a l i d in d i ca t i o n of nurse copingef for ts w itho u t en t rap p in g o r p r i m ing them in the a p r io r i l angu age o f suchi n s t r u m e n t s . Fur therm ore , p ar t i c ip an ts were ab le to generate m o r e than on eresponse to the cop ing measure ; the re fo re , the r esu l t ing ca tegories were no tm u t u a l l y ex c lu s iv e . A s depicted in Tab le 2, the mos t f r eq uen t ly l i s ted cop in geffor ts i n c lu d ed seeking advice (n = 31) , taking time o f f from work (27) ,confronting the supervisor (27), using humor (21) , rescheduling time at work(18) , prioritizing work activities (16) , confronting coworkers (14) , and main-taining an optimistic attitude (12) .Tak ing t ime o f f f rom w ork and increased con f ron ta t io n have been typ ica l lycons t rued as e lements of o ccu p a t i o n a l b u r n o u t , and m a n y of the p a r t i c i p an t scons t rued these as co p in g m ech an i s m s at their d isposal . A mul t ip le r esponsean aly sis (Noru sis , 1993) w as used to e x a m i n e the n o n m u tu a l l y ex c lu s iv erepor t ing of coping s t ra tegies ( i .e . , pa r t ic ip an ts could gen erate m o r e than on ecop ing s t r a tegy) . This enabled a cros s - tabu la t ion of the co p in g re sponsecategor ies w ith categor ies of nurses based on median spl i ts of the b u r n o u t ,to lerance, an d p r o b l em - s o lv in g co n f id en ce v a r i ab l e s . H o w ev e r , th e n o n m u t u -al ly exc lus ive na tu re o f the cop ing response ca tegor ies p rec luded s ta t i s t i ca ltests of the r e la t ive p ropor t ions in each cel l .


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Table 2. Nurse Coping Strategies by Level of Occupational BurnoutLow Burnout High Burnout Total

Nurses Nurses Listings( / ? = 3 8) (f l = 44)

Seek adviceNumber of nurses listin g strategy 18 13 31% of all nurses listing this strategy 58.1 41.9With in group % of responses* 24.7 13.0Take time off of workNumber of nurses listing strategy 11 16 27% of all nurses l isting thi s strateg y 40.7 59.3Within group % of responses 15.1 16.0Confronted supervisorNumber of nurses list ing strategy 9 18 27% of all nurs es lis tin g this strategy 33.3 66.7Within group % of responses 12.3 18.0

Used hum orNumber of nurses listing strategy 6 15 21% of all nurses l isting th is strategy 28.6 71.4Within group % of responses 8.2 15.0

Rescheduled time at workNumber of nurses listing strategy 6 12 18% of all nurs es lis tin g thi s strategy 33.3 66.7With in group % of responses 8.2 12.0Prioritized work activitiesNumber of nurses listing strategy 5 11 16% of all nurses listing this strategy 31.3 68.8Within group % of responses 6.8 11.0Confronted co-workerNumber of nurses li stin g strategy 9 5 14% of all nurse s lis tin g thi s strategy 64.3 35.7Within group % of responses 12.3 5.0

Maintain optimistic attitudeNumber of nurses listing strategy 6 6 12% of all nurses l istin g this strategy 50 50Within group % of responses 8.2 6.0U se relaxation strategyNumber o f nurses listing strategy 3 4 7% of all nurses listing thi s strategy 42.9 57.1Within group % of responses 4.1 4.0Total number of coping strategiesGenerated 73 100Note. Total number of Nurses = 82

* Within group percentages reflect th e proportion of strategies generated by nurseswithin the respective burnout group (e.g., the 18 responses for seeking adviceamong low burnout nurses represents 24.7% of all coping strategies listed by lowburnout nurses).


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276 Elliott et al.A s depicted in Table 2, nurs es tha t scored above the m ed i an on the b u r n o u t

measure generated more coping strategies than low burnout nurses, generally.H igh bu rno ut nurse s reported m ore s tra tegies inv olv ing the use of h u m o r on thejob (71.4 % vs . 28.6%), pr io r i t iz in g thei r work schedules (69%), con fron t ingthei r supervisors (67%), and taking t ime off f rom work (59%) than nursesscor ing below the m ed i an on the bu rno ut var iable . Nurses w i th greater bu rno utgenerated fewer s t ra tegies in wh ich they wou ld seek advice (42%) or con fron tthei r cow orkers (36%) than those wi th low er bu rno ut scores. Moreover , among161 nur ses wi th h igher burn ou t scores, (18 of the 44) l is ted coping s trategiesthat involved conf ron t ing a supervisor , 36% l isted ta kin g t ime off from work,and 34% listed the use of h u m o r . In contras t , 47% of the nurses wi th lowb u r n o u t (18 out of 38) l is ted coping s trategies categorized as advice seekingand 29% l is ted taking t ime off f rom work.Nurses w ho were in to leran t of wo rk stress (again def ined by a m edian sp l i t )generated more coping s t ra tegies that involved con fronta t ions w i th a supervi -sor (74 .1%) and reschedul ing thei r work (61.1%) than nurses repor t ing agreater sense of tolerance (see Table 3). Nurses w ho reported a greater senseof tolerance generated more s trategies that ref lected an opt imis t ic a t t i tude(67%), advice seeking (65%), and pr ior i t iz in g thei r work act iv i t ies (63%) thannurses repor t ing less to lerance. Moreover , among the low- tolerance nursesconf ron t ing a supervisor was the most f requent ly ;osted coping strategy , as wast ak ing t ime off from work and u s i n g h u m o r .O n l y one subs tant ive di f ference was apparent among par t ic ipants on theproblem -solving c onf iden ce var iable . Nu rses wi th a greater confidence in theirproblem-solving abi l i t ies l i s ted reschedul ing thei r work (72.2%) more thannurses wi th less conf idence.

DISCUSSION

These results provide an engag ing v iew of the theoretical and clinicaldynamics that character ize occupat ional burnout among nurses in rehabi l i ta-t ion set t ings . Cons is tent wi th cur rent models of problem solving, greaterconf idence in one's abi l i ty to hand le eve ryday problems wa s associated wi thless bu rno ut . M oreover , s i tuat ion-spe ci f ic appraisals of tolerance accountedfor a s ign i f i can t degree of var iance above and beyond problem -solving c onf i -dence. F ina l ly , emot ion- focused cop ing w as associated w i th higher bu rno utscores at the f inal step of the predict ive equat ion. These f ind in gs ind ica te tha ts i tuat ion-speci f ic appraisal and coping act iv i t ies accoun t for a uniqu e degreeof var iance in burnout af ter taking in to account an individual d i f ferencecons t ruct , as described in t ransact ional models of stress appraisal and copingin the workplace (Dawis & Lofquist, 1984; Lazarus, 1991).M a n y nurses in this s tudy reported a high degree of confidence in theirprob lem -solving abi l i ty , and a t ransfo rm at ion of the var iable was necessary inorder to achieve a norm al d is t r ibut io n for ana lys is . The issue of "overes t imat-


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Table 3. Nurse Coping Strategies by Level of Tolerance for StressLow Tolerance H igh Tolerance Total N

Nurses Nurses of(n = 40) (n = 42) NursesSeek advice

Num ber of nurses listi ng strategy 1 1 20 31% of all nurses listing this strategy 35.5 64.5Within group % of responses* 12.4 23.8

Take time off of workNumber of nurses listing strategy 12 15 27% of all nurses list ing this strategy 44.4 55.6Within group % of responses 13.5 17.9

Confronted supervisorNumber of nurses listing strategy 20 7 27% of all nurses listing this strategy 74.1 25.9Within gro up % of responses 22.5 8.3

Used humorNumber of nurses listing strategy 12 9 18% of all nurses listing this strategy 57.1 42.9With in group % of responses 13.5 10.7Rescheduled time at workNumber of nurses listing strategy 11 7 18% of all nurses listing th is strate gy 61.1 38.9Within group % of responses 12.4 8.3Prioritized wo rk activitiesNumber of nurses li sting strategy 6 10 16% of all nurses listin g this strategy 37.5 62.5Within group % of responses 6.7 11.9Confronted co-workerNumber of nurses listing strategy 8 6 14% of all nurses listin g this strategy 57.1 42.9With in grou p % of responses 9.0 7.1

Maintain optim istic attitudeNumber of nurses listing strategy 4 8 12% of all nurses listing th is stra tegy 33.3 66.7Within group % of responses 4.5 9.5U se relaxation strategyNumber o f nurses l istin g strategy 5 2 7% of all nurses listin g this strategy 71.4 28.6Within group % of responses 5.6 2.4Total number of coping strategiesGenerated 89 84

* Within group percentages reflect the proportion of strategies generated by nurseswithin th e respective tolerance groups, (e.g., th e 11 responses for the Seek Ad vicecoping category represents 12.4% of all coping strategies listed by low tolerancenurses).


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278 Elliott el al.ing" one ' s prob lem-so lv ing abil i ty has been observed in prior research (cf.Larson & Heppner , 1989). Some nurses m ay have "overreported" rather than"overestimated" the ir sense of efficacy in so lv ing problems. Once a normaldis t r ibu t ion w as achieved, the expected relation between problem-solvingconfidence and b u r n o u t w as observed. Nurses perform in an e n v i r o n m e n t inw h i ch a strong sense of conf idence may be expected , cu l t iva ted , and re in-forced, and for some th is could hav e translated into a pos it ive response bias onthe Problem So lv ing Inv en to ry . A pos itive response b ias m igh t be character-is t ic of the e n v i r o n m e n ta l d e m a nd s and expecta t ions of th is par t icu lar occupa-t ional group. Among some occupational groups, an air of conf idence may becrucia l to performance in day- to-day demands . These issues are not wel lunderstood in the problem-solving l i terature, and it may be necessary toexplore other possible corrective procedures fo r research and applied pur-poses.

Effect ive problem-solv ing conf idence has been l inked with a greater pro-cl iv i ty for pos i t ive mood and p leasant engagem ents w ith the env iron m ent inprevious studies (Elliott , Herrick et al., 1994; Elliott et al., 1995). Problem-so lv ing confidence m ight exer t a benef ic ia l in f luence by prom oting a buo yan tsense of self, a set of positive expectancies, a greater proclivity for posi t ivemood in r o u t in e and stressfu l s i tua t ions , and by in s u l a t i n g a person fromposs ib le negat ive connota t ions about the self while facing the grue l ing de-m a n d s of da i ly job performance . These behaviors are characteristic of ind i-v iduals who are able to main ta in a posi t ive set of beliefs that foster an optimallevel of emotional w ell- be ing in face of vocational (C hw alisz et al . , 1992;Sherwin et al., 1992) and life stress (Taylor & B r o wn , 1988).T he present stud y also revealed that ind iv id ua ls w ith higher bu rno ut scorescan be d is t ingu ished by the ir difficul t ies in tolerating stress on the job and theiruse of em otion-focused coping s t ra tegies. Burn ed-out employees are prone torely on pal l ia t iv e coping effor ts at wo rk, presum ably to deal with the emotionalconcomi tan ts of work-re la ted s t ress (Chwalisz et al., 1992; Ogus, 1992;Thorton, 1992). Nurses with greater burnout are more l ikely to focus onthemselves in s t ressfu l in terpersonal s i tua t ions at work (Marmarosh et al.,1995); th e present data reveal a s imilar tendency to be preoccupied withr e l i ev ing the negat ive emotional consequences of job stress. Occupationalb u r n o u t seems to increase an employee 's self-focus to the extent tha t theburned-out employee may have diff iculty appreciating or generating alterna-tive and perhaps more i n s t r u m e n ta l options for cop ing .Explora tory analyses of coping efforts revealed several nuances about theb u r n o u t - co p i n g rela tion . Prior research has found b u r n o u t to be associated withdays off f rom work and absenteeism (Firth & Bri t ton , 1989). Often absentee-ism has been considered a symptom of b u r n o u t and job stress (Ross &A l t m a i e r , 1994). Others have extolled "taking time off from work" as anadaptive coping strategy to gain distance from work stress and assist inarrangin g personal pr ior i t ies to prevent burn out (Pines & Aronson, 1988, pp.151-152). However, absenteeism of this sort could reduce motivation and


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Burnout A mo ng th e Nurses 279complicate ex isting problem s in the workplace (Ross & Altmaier , 1994). Thisphenomenologica l approach suggests that nurses with highe r bu rn ou tare moreincl ined th an other nurses to see t ime off from work as a reasonable and v iab leoption for coping with jo b stress. Absenteeism may not necessarily reflect a"symptom" per se; rather, i t may reflect a somewhat c ircumscribed copingrepertoire. I t may be more useful to reconsider the phenomenological , subjec-tive perspective of the employee in order to prescribe more mean ing fu l ,instrumental a l ternatives for coping with job demands .U n iq u e to the present study was the pronounced con t r ibu t ion of toleranceappraisals to the prediction of burno ut . Accord ing to the Minnesota Theory ofW o r k A d j u s t m e n t , i n d i v i d u a l s w h o h a v e d i f f i c u l t y t o l e r a t i n g t h ediscorrespondence betw een their expectations for work and the actual de-mands of the job wil l be more likely to fa t igue , be dissat isfied w ith their w ork,withdraw from others, take aggressive actions toward others and the envi ron-ment , and eventual ly leave th e posi t ion (Dawis & Lofquist, 1984, pp. 118-120). Results from post-hoc analysis of coping responses generated in re-sponse to the thoug ht- l is t ing probe par t ia l ly support th is posi t ion: Intolerantnurses were more likely to con front supervisors u nde r s tress . N urses w ith agreater tolerance for stress generated more strategies of advice seeking, beingoptimistic, and prior i t iz ing.Interestingly , nurse s with higher bur no ut scores reported a greater w il l ing-ness to use hu m o r as a coping device than nonb urne d-ou t nurses . A lthoughcross-sectional and experimental studies with undergraduate samples indicatethat hum or can potent ia l ly buffer one from the deleterious effects of life stress(Nezu, Nezu, & Blissett, 1988; Porterfield, 1987), field research has failed tofind a buf fer ing effect among nu rses (DesCamp & Thomas, 1993). H u m o r isoften recommended as an option for coping w ith bu rn ou t (e.g., Pines &Aronson, 1988), but the present data imply that the effects may be strictlypal l ia t ive . Jok ing and ma kin g l ight of s i tuat ions in the workplace m ay "dis-tance" oneself from th e stressful aspects of the job, or from others in theenvironment (Duncan, 1985; Kuhlman, 1988). A s such , humor may be anextension of the depersonalization process that can accompany occupationalb u r n o u t (Maslach & Jacks on, 1982). These issues wa rran t furth er study amo ngpersons in h igh-bu rnout s i tua t ions.Interpersonal confl ic t on the job was the most frequ ently reported stressoramo ng these par t ic ipan ts . In terpersonal difficul t ies are k n o w n to be a sourceof staff stress in rehab i l i ta t ion , but research to date has focused on strainedpatient-staff in teract ions (e.g. , Du nn , Umlauf , & Mermis , 1992). T he presentstudy clearly in dicates that conf lict betw een staff is a source of considerablestress in reha bilitatio n, and it m erits more atten tion from those inve sted in thepsychosocial aspects of rehabilitation. I t is possible that those with fewersocial cog nit ive resources for apprais ing stress and under duress m ay feel amore p ronounced lack of support and greater f rustra t ion in meeting jobdemands, and subsequently shift the emotional burden of their p l ight ontocolleagues. In the process, attempts to ameliorate work stress m ay inadver t -ently exacerbate it .


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280 Elliott etal.Interpersonal confrontat ions have been espoused as effective, direct waysto address th e inequ i t i es of work or the lack of collegial support (Pines &Aronson , 1989). Suppor t from relat ionships that potential ly offer guidanc e and

direction has been identified as a salient feature in the prediction of burnout(Ross, Altmaier , & Russell, 1989; Russell, Altmaier , & V an Velzen, 1987).Our data are l imited in that the relat ive eff icac y of these techn ique s could notbe determined, but it is noteworthy that these s trategies were spontaneouslyoffered as cop ing m echan isms by those with corresponding problems tolerat-ing stress and with higher levels of occupational burnout. Tolerant nurses andthose with lower levels of b u r n o u t , in contrast , were more apt to seek advicefrom their colleagues.

The resul ts of the present s tudy have several im plica tions for psychologicalin tervent ions w ith s taff . Effe ctive interv en tion s w ith rehabil i tat ion s taff shou ldaddress the appraisal of stressors on the job and offer alternative means ofcoping with interpersonal confl icts and workload issues, specifically. Clini-c ians can implement problem-solving s trategies and sel f -management tech-niques in training programs with nursing s taff to enhance the acquisi t ion ofspecific stress-reducing coping skills and to aid in emot ional regulat ion wh enproblem solving. Generally, problem-solving training has emphasized skill-bu i ld ing in f ive broad areas of problem solv ing : (a) prob lem -solving orienta-t ion, (b) problem def in i t ion and fo rmula t ion , (c) generat ion of alternatives andsolut ions , (d) decis ion making and evaluat ion of possible solutions, and (e)implementa t ion and verif icat ion of solutions (Nezu & D'Zur i l la , 1989). Theproblem -solving orientation component incorporates skills to ward off nega-t ive affect , maintain favorable opinions about one ' s abil i t ies , and enhancemot iva t ion for solving other problems that require more cognit ive-behav ioralskil ls and goal-directed efforts (Nezu & D'Zur i l la , 1989). Cl in ic ians canenhance a c l ient ' s prob lem-so lving or ientat ion by teaching ef fect ive ski l ls inregulating and m onito ring emo tional experiences when solving problems,generally, and wh en coping w ith certain s tressors and hassles at work, specif i-cally. In th is process , staff may be t augh t to inhibi t impuls ive, unplannedat tempts to solve problems on the job, and to va lue and engage in morethought fu l , planful , and goal-oriented efforts . These skil ls may reinforcefavorable opinions about th e self and stave off prolonged experiences ofnegat ive emot ions that might impair or inhibi t effective problem solving (Nezu& D'Zur i l l a , 1989).Tra in ing in the problem orientat ion stage can also include other techniquescommonly used in behavioral heal th in terven t ions . F or example, s taff may betaught the utility of emotion-focused strategies that aug m ent self-regulationunder s tressful circumstances (e.g., imag ery, relaxation exercises, etc.). Strat-egies that assist staff in regulat ing emotional experiences are par t i cu la r lyrecomm ended wh en a person is facing s i tuat ions and condi t io ns that are ofbr ief durat ion, and w h en the person has l i t t le actual con trol over the s i tua t ion(Auerbach, 1989). Addi t ional ly , evidence suggests that increased positiveaffect can h ave a ben ef ic ia l ef fect on cl in ical problem solving , increa s ing the


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Burnout Among th e Nurses 281f lexibil i ty in j u d g m e n t and the in teg ra t ion of in fo rmat ion am ong advancedme dical stude nts (Isen, Ro senzw eig, & Y ou ng, 1991). Such tec hn iq ue s canthen be employed in e f fec t ive conf l ic t ma nagem en t and assertion sk il ls train -i ng . Thus, combined t ra in ing in a posi t ive problem-solv ing or ien ta t ion and inactual problem-solving techniques may be mos t he lp fu l in promoting effec t ivecop ing and personal to lerance am ong reha bi l i ta t ion s taff .

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284 Elliott et al .Toft, M . (1989). Personality hardiness, occupational stress, and burnou t in critical

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Acknowledgment. This manuscr ip t is based in part on a paper presented at the a nnua lconvent ion of the American Associat ion of Spinal Cord Injury Psychologists andSocial Workers in 1995. The authors appreciate the cont r ibut ions of Julie Bullard,Laura Mizzel l , and Mary Kather ine Peacock at var ious stages of the s tudy.

Offprints. Requests for offpr ints should be directed to Timothy R. Elliott , Ph.D.,Depar tment of Rehabi l i ta t ion Medicine, Univers i ty of Alabama at B i rmi ngha m, 530Spain Rehabili tation Center, 1717 Sixth Aven ue South, Birm ingham , A L 35233-7330.Submi t ted : June 1995Revised: December 1995Accepted: March 1996

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