personality hardiness, occupational stress, and burnout in critical care nurses

Research in Nursing & Health, 1989, 12, 1 79- 186

Personality Hardiness, Occupational Stress, and Burnout in Critical Care

Nurses Margaret Topf

Personality hardiness, occupational stress, and burnout were investigated in 100 critical care nurses. Hardiness was predictive of occupational stress and burnout. Hierarchical multiple regressions revealed that one of the three dimensions of hardiness, commitment to work, wos the only variable to account for significant amounts of variance (up to 24%) across three of four measures of burnout. The study did not provide support for the stress buffering effect of hardiness. That is, an interaction term, hardiness x occupational stress, was not convincingly predictive of burnout in nurses. The findings are discussed in terms of other research on burnout in critical care nurses and recent issues on the conceptualization of hardiness.

For some time, the focus of stress and illness research has been on resistance resources (An- tonovsky , 1979, 1987) that potentially prevent the psychological tension of everyday life from be- coming debilitating stress. Some of these resistance resources include one’s physiological adaptability, social support, cultural context, and personality (Antonovsky, 1979).

Following the logic of this line of research, Kobasa (1979) developed the concept of personality hardiness. Hardiness comprises three dimensions: commitment, challenge, and control. Hardy individuals have a higher sense of commitment or purpose (e.g., to work, to self, etc.) as opposed to a sense of alienation. These individuals tend to perceive life changes as challenges rather than threatening to their security. Finally, hardiness involves a sense of control over one’s life, as these individuals intervene in their own behalf when needed.

Hardiness has been theorized to affect stress and health in two ways. Greater hardiness has been conceived of as being associated with less psychological stress and consequently greater health because hardy individuals alter their perception of stress (e.g., to be a challenge). Secondly, both hardy and nonhardy individuals may undergo high

levels of stress due to life events. However, hardy individuals are more likely to use effective coping strategies and social resources to reduce stress and prevent illness. This tendency has been called the stress buffering effect of hardiness (Kobasa, 1982a; Kobasa & Puccetti, 1983). Kobasa and her colleagues have reported numerous studies on the relationships between hardiness, life event stress, and illness among executives, lawyers, and company managers (Kobasa, Maddi, & Comngton, 1981; Kobasa, Maddi, & Kahn, 1982; Kobasa, Maddi, & Zola, 1983; Kobasa & Puccetti, 1983).

The present study was part of a larger inves- tigation in which different hypotheses were tested. The present contention is that burnout is a negative health outcome of occupational stress and that hardiness affects occupational stress and burnout much as it affects life event stress and illness (e.g., Kobasa, 1979). These relationships are de- picted in Figure 1. The plan was to evaluate several of the relationships shown in Figure 1 with a sample of critical care nurses.

Most conceptualizations of stress (Lazarus, 1966; Mechanic, 1978; Selye, 1975) imply that it is the psychological discomfort that occurs when environmental stressors are perceived as too de- manding or as exceeding one’s coping abilities.

Margaret Topf, PhD, RN, has a research appointment in the School of Nursing, University

This article was received on February 8, 1988, wos revised, and accepted for publication

Requests for reprints can be addressed to Dr. Margaret Topf, School of Nursing, Factor

of California, Los Angeles.

September 8, 1988.

Building 3-659, UCLA, Los Angeles, CA 90024-1 702.

0 1989 John Wiley & Sons, Inc. 0160-6891/89/030179-08 $04.00

180 RESEARCH IN NURSING & HEALTH

Demands from

EYent. Occupational

+

Peraon.lity occup.tionF.1 Burnout Hardiness ____) Streaa

I I - Coping snd

S o c i a l R E O O Y I C e 6

FIGURE 1. Relationships between hardiness, stress, and burnout. Pluses and minuses indicate positive and negative relationships between variables. Adapted from Kobasa (1982a).

In Figure 1, the environmental demands stem from occupational events. Burnout has been defined as a syndrome of emotional exhaustion, depersonalization, and reduced personal accomplishment resulting from stress linked with occupational events in health careers (Cartwright, 1980; Maslach & Jackson, 1982). In Figure 1, greater demands from occupational events are linked with greater stress and consequently greater burnout, Studies have identified sources of occupational stress linked with burnout in critical care nurses. These have included interpersonal conflicts, ethical problems, dealing with administration, dealing with death and dying, inadequate knowledge and skill, work load, frustrated ideals, and more recently, critical care unit noise (Claus & Bailey, 1980; Duxbury, Armstrong, Drew, & Henly, 1984; Gray-Toft & Anderson, 1981; Kelly & Cross, 1985; Topf & Dillion, 1988).

In Figure 1, greater hardiness is shown as leading to less stress. Less stress, in turn, results in less burnout. Keane, Ducette, and Adler (1985) surveyed 96 nurses in surgical and medical units including intensive care units. A stepwise multiple regression indicated that two dimensions of hardiness (commitment to work and control) accounted for variance in burnout as measured by Jones' (1980a) Staff Burnout Scale for Health Profes- sionals. Although these authors did not present the percentage of variance accounted for by the separate dimensions of hardiness, the combined variance was significant. McCranie, Lambert, and Lambert (1987) measured burnout with the Tedium Scale (Pines & Aronson, 1981). Hardiness accounted for 11 % of the variance in burnout. Job

stress, independent of hardiness, accounted for 17% of the variance in burnout. These investigators did not identlfy the separate dimensions of hardiness linked with stress and burnout. Rich and Rich (1987) in a survey of 100 staff nurses showed that less hardiness and younger age accounted for 25% and 16% of the variance in burnout, respectively. A second multiple regression omitting the challenge dimension of hardiness showed that 57% of the variance in burnout scores was accounted for by the commitment and control dimensions (42%) as well as younger age (15%).

Drawing on the foregoing theory and research, four hypotheses were generated. These hypotheses were that greater hardiness would be predictive of less occupational stress and less burnout, and that greater occupational stress would be predictive of greater burnout. An interaction term, hardiness x occupational stress, was hypothesized to be predictive of less burnout. That is, greater stress/ greater hardiness nurses were expected to manifest less burnout than greater stress/less hardiness nurses. The latter procedure was recommended by Hull, Van Treuren, and Virnelli (1987) to test the stress buffering effect of hardiness.

Several investigators (Cronin-Stubbs & Rooks, 1985; MacNeil & Weisz, 1987) have agreed that specification of factors contributing to burnout in critical care nurses is pertinent to promoting optimal patient care. Conceptual models (Gray-Toft & Anderson, 1985; Moos & Schaefer, 1987; Sher- idan, Vredenburgh, & Abelson, 1984) and research (Cronin-Stubbs & Rooks, 1985; Eaton & Gottselig, 1980; Gray-Toft & Anderson, 1981; Jaco, 1979; Kelly & Cross, 1985; Lambert & Lambert, 1987; Norbeck, 1985; Topf & Dillon, 1988) have spec- ified links between work and nonwork variables influencing nursing staff performance and morale and patient outcomes. Recent studies have begun to give attention to personality factors such as hardiness that may insulate nurses against burnout. Although this research has provided some support for a relationship between hardiness and burnout, it was reasoned that replication of these results and attention to the stress buffering effect of hardiness in relation to burnout were needed before any definite conclusions could be made.

METHOD

Subjects

A convenience sample of 100 volunteer nurses (9 1 % female) from two large university-affiliated hospitals on the west coast was surveyed. Partic- ipants were from cardiac (25%), medical-surgical

PERSONALITY HARDINESS / TOPF 181

(55%), urology (4%), neonatal (2%), and pediatric (14%) critical care units. The average age of the subjects was 35.5 (ranging from 23 to 59) with a mean length of experience in critical care of 6 years. Ninety-three percent of the nurses were full time, 3% part time, and 4% per diem. The majority of the nurses were White (47%), while 29% were Filipino, 10% Black, 9% Asian, 4% Hispanic, and 1% American Indian. Most (44%) of the nurses were married, 39% were single, 9% were divorced, and 5% were cohabiting. Education varied, with 48% of the nurses having bachelor’s degrees, 36% associate degrees, 6% master’s degrees; and 8% having diplomas in nursing. Nurses were employed on day (36%), evening (46%), night (3%), and rotating (15%) shifts.

Instruments

Occupational stress. Gray-Toft and Ander- son’s (1981) Nursing Stress Scale was used to measure occupational stress. The scale consisted of 34 items comprising six subscales: death and dying, conflict with physicians, inadequate prep- aration, lack of support,.conflict with other nurses, work load, and uncertainty concerning treatment. Responses ranged from never (0) to very frequently (3). Nurses were instructed to check how often on their present unit they found the situations to be stressful. A total score was the sum of the 34 item scores. Higher scores indicated greater occupational stress.

Measures of reliability for the original Nursing Stress Scale were obtained from a sample of 31 nurses including test-retest after 2 weeks (.81), Spearman Brown (.79), Guttman split-half (.79), and an alpha of .89. Nursing Stress Scale scores significantly correlated with state (.35) and trait (.39) anxiety in a sample of 122 nurses ( p s < .Ol), indicating support for the criterion-related validity of the scale. The scale scores distinguished between nursing units with higher and lower job turnover. The investigators did not test the latter finding for significance, however (Gray-Toft & Anderson, 1981). The scale has been found to be a predictor of bumout in critical care nurses (Cronin-Stubbs & Rooks, 1985). Cronbach’s alpha for the present sample was .92.

Hardiness. Considerable research has been done on hardiness. Consequently, it was measured here with instruments currently used in this work. The dimensions of hardiness (commitment, control, challenge) were each measured separately. On all measures, lower scores were equal to greater hardiness. These scores were used to devise a

composite score for hardiness. Commitment was measured by the 12-item Alienation from Work Scale of the Alienation Test (Maddi, Kobasa, & Hoover, 1979). Across a number of adult samples, the average alpha coefficient for this scale was .79 (Maddi et al., 1979). The present sample yielded an alpha of . 8 1.

Commitment also was measured by 12 items from the Alienation from Social Institutions Scale of the Alienation Test. Coefficient alphas for several types of alienation ranged from .75 to .95 with a mean of .84. A specific alpha for the Alienation from Social Institutions Scale is not reported (Maddi et a]., 1979). The present sample yielded an alpha of .83.

Control was measured by 20 items from the Locus of Control Scale (e.g., Rotter, Seeman, & Liverant, 1962). There is considerable evidence that this scale is a reliable and valid measure of locus of control (Phares, 1976). Lower scores indicate an internal and higher scores an external locus of control. The present sample yielded an alpha of .72 for the scale items.

Challenge was measured by scores from the 15-item Security Scale of the California Life Goals Evaluation Schedules (Hahn, 1966). The reliability and validity of the scale have been widely doc- umented (Hahn, 1966). The present sample yielded an alpha of .67.

In keeping with recent research (Kobasa & h c - cetti, 1983; Wiebe & McCallum, 1986) a composite score for hardiness was obtained for each subject. Each subject’s z scores for the four measures were summed. Because control and challenge were measured by one scale, Kobasa’s (1982b) procedure for doubling these z scores was followed before summing for the composite.

Burnout. The Maslach Burnout Inventory (MBI) consists of 22 items assessing three com- ponents of burnout: emotional exhaustion, which contains 9 items; depersonalization, which contains 5 items; and personal accomplishment, containing 8 (Maslach & Jackson, 1981). This study used the frequency scale of the MBI since this was in keeping with current research (Firth, McIntee, McKeown, & Britton, 1985) and since a second scale on “how strong” has been criticized (Mitchell, 1985) as a poor fit for some items such as “I can easily understand how my patients feel about things.” A greater degree of burnout is reflected in high scores for emotional exhaustion and depersonalization and low scores for personal accomplishment. Cronbach alphas for the present sample were .88, .77, and .84 for the emotional exhaustion, depersonalization, and personal accomplishment subscales, respectively.


A second measure of burnout, 20 items from Jones’ (1980b) Staff Burnout Scale for Health Professionals (SBS-HP), was used because several items describe behavioral manifestations of burnout. The’MBI is limited to cognitive and emotional aspects of burnout. Hence it was reasoned that including the SBS-HP would lead to a more com- prehensive operationalization of burnout. Two items of the SBS-HP were deleted because these assessed physical iUness, which was not in keeping with the present conceptualization of burnout. Cronbach’s alpha was .84 for the present sample.

Procedure

Alternate forms of a questionnaire containing the self-report measures of the study variables were administered to nurses in the research hospitals. In Hospital A, 83 nurses were recruited to be in the study by a critical care clinical nurse specialist. In Hospital B, 50 nurses were recruited to be in the study by the clinical nurse specialists for 10 critical care units. Nurses were instructed to fill out the questionnaire at home and to return it within 3 days. Questionnaire return rates were 92% and 48% in Hospitals A and B, respectively. The overall return rate was thus 70%.

RESULTS

Descriptive statistics for the study variables are presented in Table 1. The correlation coefficients for the assessment of a relationship between hardiness and stress in nurses are shown in Table 2. Partial support was found for the prediction that greater hardiness would be linked with less occupational stress. Hardiness (lack of) composite scores were associated with greater occupational stress scores. Greater scores for the control dimension of hardiness (external locus of control)

were significantly linked with greater occupational stress. That is, nurses with an external locus of control reported greater occupational stress.

Partial support for the hypothesis that greater hardiness would be associated with less burnout is provided in Table 2. These results were man- ifested in correlations between hardiness (lack of) composite and MBI personal accomplishment scores; hardiness composite and SBS-HP scores; alienation from work and MBI emotional exhaustion, alienation from work and MBI personal accomplishment, and alienation from work and SBS-HP scores; as well as alienation from social institutions and SBS-HP scores. A lack of support is shown for the hypothesis that greater occupational stress would be associated with greater burnout (Table 2). Scores for demographic variables largely led to nonsignificant relationships with study variables with the exception that nurses who rotated shifts tended to have more emotional exhaustion, F (5, 93) = 2.70, p < .05.

Significant correlations between the study variables were analyzed further with separate hierarchical multiple regressions using SBS-HP and MBI emotional exhaustion and personal accomplishment scores as dependent variables. This allowed assessment of how much independent variance in burnout was accounted for by stress and hardiness in nurses. This also allowed variance in burnout due to interactions between hardiness and stress (e.g., occupational stress x hardiness composite, occupational stress x external locus of control) to be accounted for in an effort to assess whether a stress buffering effect was associated with bumout. Since type of shift yielded a significant relationship with MBI emotional exhaustion, it was entered into this multiple regression (Cohen & Cohen, 1975).

Together, three variables, occupational stress, the hardiness composite, and an interaction between

Table 1 , Descriptive Statistics for Study Variables

Voria ble n Mean SD

Nursing Stress Scale 99 Hardiness (lack of) composite 96 Alienation from work 100 Alienation from social institutions 100 External locus of control 9 9 Secu r i t y 96 Burnout

Emotional exhaustion 99

Persona I accompl is hmen t 98 Staff Burnout Scale 99

Depersonal izotion 9 9

43.03 0.00

229.92 289.97

7.34 48.44

20.88 6.16

33.68 56.32

12.96 1 .oo

189.13 20 1.67

3.66 7.22

9.77 5.24 9.01

17.48


Table 2. Correlations between Study Variables

Nursing Staff

Variable Scale Ex ha ust ion Depersona I iza tion Accom pl i s h men t Sca le

Nursing Stress Scale - -.079 - .059 -.089 -.115 Hardiness (lack of)

Stress Emotional Personal Burnout

com posite .2 10" ,185 ,121 -.281** .262** Alienation from work -.080 ,346"" * .164 -.253** .499*** Alienation from social

institutions ,013 ,185 ,125 -.139 .296** External locus of

control .344*** -.007 ,078 -.120 ,048 Security ,046 ,052 -.018 -.158 .008

Note: Lower scores are equal to greater hardiness on a l l measures. Greater burnout i s reflected in greater scores for staff burnout, emotional exhaustion, depersonalization, and lower scores for personal occornplishment.

* p < .05. ** p < .01. * * * p < ,001.

these, yielded a significant multiple correlation of R = .319, F (3, 92) = 3.46, p < .05, thus accounting for about 10% of the total variance in SBS-HP scores. However, the hardiness composite was the only variable accounting for a significant ( p < .01) amount of independent variance (9%) in SBS-HP scores. A subsequent multiple regression was undertaken to identify the specific dimensions of hardiness responsible for variance in SBS-HP scores. Together, four variables (occupational stress, alienation from work, alienation from social institutions, and an interaction term, external locus of control x occupational stress), led to a significant multiple correlation of R = .513, F (4, 93) = 8.33, p < .001, accounting for about 26% of the total variance in SBS-HP scores. Alienation from work accounted for most (24%) of this variance. Once the significant ( p < .001) variance in burnout accounted for by alienation from work was removed, alienation from social institutions accounted for no (0%) variance. The interaction term, external locus of control x occupational stress, also accounted for a nonsignificant degree ( 1 %) of variance in SBS-HP scores.

When the hardiness composite, occupational stress, shift, and interaction terms between these were independent variables and MBI emotional exhaustion the dependent variable, a nonsignificant multiple correlation (R = .253, F [6, 911 = 1.03, p > .05) was obtained. The hardiness composite, however, accounted for a significant ( p < .05) amount (4%) of independent variance in emotional exhaustion. The subsequent assessment of the specific dimensions of hardiness showed that alienation from work was the only variable accounting for a significant (12% p < .001) amount

of variance in emotional exhaustion. An interaction term, external locus of control x occupational stress, led to nonsignificant results.

When MBI personal accomplishment scores were the dependent variable, occupational stress x hardiness led to a significant multiple correlation of R = .349, F (2, 93) = 4.23, p <: .01. The hardiness composite and occupational stress x hardiness accounted for significant amounts (7%, p < .01; 3%, p < .05) of variance in personal accomplishment. When the dimensions of hardiness and the interaction term, external locus of control x occupational stress, were evaluated, alienation from work was the only variable to account for a significant (7%, p < .01) amount of variance in MBI personal accomplishment.

DISCUSS10 N

The findings of this study provided partial support for the hypotheses that greater hardiness in nurses would be associated with less stress and less burnout. Support was not found for the hypothesis that greater stress would be linked with greater burnout in nurses. Although there was a marginally significant relationship between the interaction term occupational stress x hardiness and burnout (e.g., personal accomplishment), this relationship did not hold up under closer scrutiny involving the one dimension of hardiness (external locus of control) significantly linked with occupational stress. Thus the present study did not provide convincing evidence of the stress buffering effect of hardiness. This result provides support for Funk and Houston's (1987) contention that so


few studies have shown the stress buffering effect of hardiness that the validity of this hypothesis should be questioned.

Although the hardiness composite yielded results in the expected direction, only one of three dimensions comprising the composite showed a similar pattern when these were analyzed separately with multiple regression. Alienation from work was independently linked with burnout on three of the four measures of this variable. This result provides support for Hull et al.’s (1987) claim that commitment has been the most consistent dimension to have its predicted effect. This occurred in five studies while control has had its predicted effect in four and challenge in one. Authors (Funk & Houston, 1987; Hull et al., 1987) have suggested that different processes may be involved in each dimension and that future research should em- phasize these processes rather than hardiness composite scores.

The fact that less commitment to work was convincingly linked with greater bumout is worthy of discussion. Commitment has been defined as the capacity to commit one’s self “to an objective or a relationship and to persevere, despite obstacles, to attain the goal” (Masterson, 1985, p. 27). In- terventions for the enhancement of this attribute may need to attend to commitment in nurses and to the nursing situation (e.g., Mischel, 1968). A good match between the ideology taught nurses and the approach to practice, such as primary nursing, may remove obstacles to commitment in some nurses. Cherniss and Krantz (1983) noted that identification with a formal ideology can lessen the ambiguity of human service work, provide a rationale for difficult decisions, and develop esteem for carrying out aversive tasks. Other interventions might attend to situational features (e.g., relatively lower economic incentives) in the nursing profes- sion that may decrease the likelihood of long- term commitment.

Other multiple regression studies have indicated that the total proportion of variance in burnout accounted for by life event stress in nurses was as high as 4% (Norbeck, 1985), by the stress of critical care situations as high as 18% (Norbeck, 1985; Stone, Jebsen, Walk, & Belshom, 1984), and by noise-induced stress up to 14% (Topf & Dillon, 1988). When social support was considered along with total stress, up to 35% of the variance in burnout was accounted for (Cronin-Stubbs & Rooks, 1985). The relative contribution of hardiness found here (up to 24% for commitment to work) should be evaluated within this context. When the explained variance in burnout is added across the latter studies it can be seen that ap-

proximately 75% of the independent variance in burnout may be identified. Investigators might assess whether these results can be replicated within single studies.

The present study involved correlational data analysis. Thus the study as designed could not assess causality. Several rival interpretations might explain the present results. Some might argue that greater stress causes less hardiness rather than greater hardiness causing less stress. Others (Moos & Schaefer, 1987) have suggested a reciprocal influence process between stressors in the work environment and negative outcomes in health care professionals. These possibilities also exist for the relationships found here between hardiness and burnout. The present findings thus provide support for future studies on the causal links and relative strength of influence of stress, hardiness, and burnout in nurses. For example, these variables might be assessed in new critical care nurses over time (e.g., path analysis) compared to new nurses working in a less stressful area of the hospital.

The present results should be evaluated with a possible measurement problem in mind. Funk and Houston (1987) noted that the use of negative and indirect indicators of hardiness (e.g., high challenge measured by low security) calls for assumptions that may be inaccurate. For example, a low score on security may not represent challenge but neutral feelings or may be unrelated to challenge. This type of logic also underlies measures of the commitment dimension. Early attempts to measure hardiness used positive and direct measures including leadership, dominance, endurance, and achievement. Until more empirical evidence on the validity of negative measures is available, investigators might include these as well as positive indices of commitment, challenge, and control. The recent availability of an abbreviated hardiness scale (S. Maddi, personal communication, 1988) should help to reduce the cumbersomeness of this approach.

The present study led to a number of unexpected findings. Occupational stress largely was not linked with burnout in nurses. These results are incon- sistent with some studies (Bartz & Maloney, 1986; Cronin-Stubbs & Rooks, 1985; Spoth & Konewko, 1987; Stone et al., 1984) and consistent with others (Albrecht, 1982; Baldwin, 1983; Hagemaster, 1983). The present study yielded moderate MBI subscale scores compared to normative samples provided by Maslach and Jackson (1981). How- ever, the SBS-HP mean score (56.32) was greater than the means (52.9 for N = 36 and 52.1 for N = 96) for two heterogeneous samples of nurses reported by Jones (1980a) and Keane and col-


leagues (1986), respectively. Despite these unexpected outcomes, sufficient support was found to substantiate future research on hardiness, stress, and burnout in nurses.

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