A self-referral preventive intervention for burnout among Norwegian nurses: One-year follow-up study

Patient Education and Counseling 78 (2010) 191–197

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Burnout

A self-referral preventive intervention for burnout among Norwegian nurses: One-year follow-up study Karin E. Isaksson Rø a,b,*, Tore Gude a,b, Reidar Tyssen b, Olaf G. Aasland c,d a

Modum Bad, NO-3370 Vikersund, Norway Department of Behavioural Sciences in Medicine, Institute of Basic Medical Sciences, Faculty of Medicine, University of Oslo, Norway c The Research Institute, Norwegian Medical Association, Oslo, Norway d Institute of Health Management and Health Economics, University of Oslo, Norway b

A R T I C L E I N F O

A B S T R A C T

Article history: Received 2 February 2009 Received in revised form 10 June 2009 Accepted 3 July 2009

Objective: Burnout among nurses is an issue of concern, and preventive interventions are important to implement and evaluate. This study investigated levels and predictors of change in burnout dimensions after an intervention for help-seeking nurses. Methods: Nurses participating in a self-referral, counseling intervention, from 2004 to 2006 in Norway, were followed with self-reporting assessments. One-year follow-up was completed by 160/172 (93%, 155 women and 5 men). Results: Mean level of emotional exhaustion (one dimension of burnout, scale 1–5) was significantly reduced from 2.87 (SD 0.79) to 2.52 (SD 0.8), t = 5.3, p < 0.001, to the level found in a representative sample of Norwegian nurses. The proportion of nurses seeking psychotherapy increased after the intervention, from 17.0% (25/147) to 34% (50/147), p < 0.001. Less reduction in emotional exhaustion was independently predicted by reporting a work-related conflict (b 0.53 (SE 0.13), p < 0.001) or by getting a period of sick leave (b 0.28 (SE 0.12), p < 0.05) after the intervention. Conclusions: A short-term preventive intervention could contribute to reduction of emotional exhaustion in nurses. Work-related conflict and sick leave after the intervention were negatively associated with this reduction. Practice implications: Preventive interventions to reduce burnout for nurses should be considered, as well as programs for preventing or handling conflicts at work. ß 2009 Elsevier Ireland Ltd. All rights reserved.

Keywords: Nurses Burnout Preventive interventions

1. Introduction Burnout among nurses has over the last years been a cause of concern since it may lead to reduced function among this group of important health care workers. This applies to involvement with patient care and teamwork, as well as the suffering of individual nurses [1–5]. Preventive interventions have therefore been advocated [1,6,7]. Reduction in burnout after a self-referral, short-term intervention for burnout among Norwegian physicians [8] warrants the study of nurses seeking a similar intervention. Nurses constitute the largest proportion of health care workers. Their performance has a direct impact on patient care and communication with patients. A high degree of emotional exhaustion (one dimension of burnout) has been shown to predict lower both self- and supervisor-rated nurse performances, as well

* Corresponding author at: Modum Bad, NO-3370 Vikersund, Norway. Tel.: +47 32749700/32749863; fax: +47 32749868. E-mail address: [email protected] (K.E. Isaksson Rø). 0738-3991/$ – see front matter ß 2009 Elsevier Ireland Ltd. All rights reserved. doi:10.1016/j.pec.2009.07.008

as predicting intention to quit work [9]. High levels of emotional exhaustion were reported by 15–43% in a big international study [1]. The relative nurse shortage [1], coupled with a reported high intention to quit work (30% in a study from England/Scotland [1] and 55% in a Swedish study [4]) is worrying due to the association found between high nurse–patient ratios and emotional exhaustion [3]. Health promotion schemes for nurses, to prevent or reduce burnout, are thus important to maintain performance and to counteract turnover, which could ensure patient care. Role ambiguity (lack of role clarity, role conflict), workload (also quantitative demands), age, hardiness, active coping and social support are factors that have been shown to correlate strongly with burnout [10,11]. Role ambiguity and lack of role clarity lead to an increase in role conflicts [12]. Nurses have reported feeling bullied by having to attend responsibilities they do not define as part of the nursing role [13]. Frustration is described when having to implement morally or ethically ambivalent decisions taken by others [14,15], and intra- as well as inter-professional conflicts are reported as more or less pertaining to role ambiguity/role conflict [16,17]. A change is

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seen in the expectations to the nursing role from the student perspective to the confrontation with the working situation as a graduated nurse also in Norway [18]. Workload and time pressure have been found to explain 25– 50% of the variance in burnout-emotional exhaustion [19]. The lower number of work hours and workload reported among nurses than among physicians in some studies [5,20] might to a certain degree balance increased quantitative demands [3], as well as work–home interface stress [21]. This could be a protective factor against risk for burnout. The relationship between work-related sick leave and burnout is important, not least economically. Among Norwegian nurses changes in burnout scores have been found to explain only a small part of the changes observed in work-related sick leave, in contrast to other groups, like physicians, where they explained a substantial share of the changes in sickness absence [22]. Further exploration of these relationships is needed. Nine preventive interventions targeting burnout, five nursespecific and four offered to health personnel including nurses, from 1977 to 2005, were identified in four review papers [23–26]. Moderate or limited effects on reduction of burnout were found in individually oriented, cognitive-behavioural programs and multimodal interventions (combining cognitive-behavioural with relaxational programs). There was one study with a relaxational program only (mindfulness) and one which investigated a change in work organization. Follow-up periods were mostly short (1–3 months) or lacking (one study using a retrospective design). Psychotherapy as an intervention to prevent burnout in palliative care nurses has been described, but not evaluated [27]. Most of the referred interventions targeted nurses working at a particular ward or hospital and have not been specific for nurses feeling stressed or in need of help. In Norway a self-referral, preventive program for nurses was instituted in 2000. The program is described in Section 2. A study of the first 45 participants showed reduction in depression and anxiety among the 26/45 who completed 6 months follow-up [28,29]. Burnout was not investigated. On this background we wanted to study the course of burnout over a year in a larger cohort of nurses who had sought help in the preventive program, investigating the following questions: 1. What reasons do nurses report for coming to a self-referral, preventive intervention? 2. Are levels of burnout reduced from baseline to one-year followup? 3. Is reduction in burnout (a) predicted by age, gender, personality? (b) associated with number of life events, seeking treatment, conflict at work, taking sick leave, or reducing number of work hours/week during the year after the intervention? 2. Methods 2.1. Study design Nurses, coming to a preventive intervention at the Resource Centre, Villa Sana, Norway, from August 2004 through July 2006, were consecutively included in the study, signing an informed, written consent. Self-reporting assessments were completed 0–4 weeks before or during the first days of the course (baseline). Fiftyseven weeks (SD 6.1, range 43–73) after this intervention, followup questionnaires were completed (two reminders given) from August 2005 to July 2007.

Table 1 Demographic baseline variables for nurses coming to the Resource Centre, Villa Sana. Gender: women, number/total answered (%) Age, years (SD, range), n = 172 Marital status, proportion married or co-habitant, number/total answered (%) Children under 16, number/total answered (%) Consider themselves to have a leadership responsibility, number/total answered (%) In a present conflict at work, number/total answered (%)

82/170 (48.2) 76/169 (45.0) 31/161 (19.3)

up was completed by 160 (93%), 155 women and 5 men. Three lacked postal addresses and 9 gave no response. The number of male nurses is low in this sample, and the results are not significantly altered when omitting the men from the analyses. Results are thus primarily relevant for women nurses. The nurses were on average 47 years (SD 9.3, range 26–66). For other demographic data, see Table 1. A total of 41/172 (23.8%) worked as leaders and 81/172 (47.1%) had posts as specialist nurses. A total of 51/172 (29.7%) worked shifts. Some nurses had combined posts, and 21 nurses reported posts outside these categories (Table 2). The nurses came from both hospital and municipality employment. 2.3. Intervention The intervention consisted of a course at the Resource Centre for Health Personnel, Villa Sana, in Norway. The aims of the program are to enhance health and life quality, strengthen the professional identity and to prevent burnout. The course model is founded on cognitive theory, and concentrates on the potentials for change. Mindfulness and other relaxation exercises were taught, and physical activity was part of the program. Daily lectures introduced themes like ‘‘resources and courage for life’’, ‘‘the balance between work, cohabitation and family’’, ‘‘to have authority’’, ‘‘to approach and accept disease and personal limitations’’ as well as ‘‘prevention of burnout’’. The participants were invited to share personal experiences with the other members of the group and used fantasy exercises through visualization and registration of own experiences in a workbook. Participants were offered one individual counseling session during the week. The courses were led by two experienced clinical

Table 2 Type of employment for nurses coming to the Resource Centre, Villa Sana. Employee position Position as leader, n = 41

n

Position as specialist nurse, n = 81 Shift work, n = 51

2.2. Sample Of 189 eligible nurses 172 (91%) gave their informed, written consent to participate in the study, 167 women and 5 men. Follow-

167/172 (97.1) 47.0 (9.3, 26–66) 128/171 (74.9)

Total

Full-time leader Combined position as leader and specialist nurse Full-time specialist nurse. Specialist nurse working shifts. Shift work Non-specialist nurses only dayor night-time Other administrative/ educational posts, working in other professions or non-defined

% 29 12

16.9 7.0

59

34.3

10

5.8

41 6

23.8 3.5

15

8.7

172

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specialists in psychiatric nursing. Eight nurses/group stayed at Villa Sana for the 5-day course, ate meals together, had a cultural program and time for informal gatherings and discussions. The ‘‘non-medical’’ setting, without medical records, and with absolute confidentiality, was emphasized. The Norwegian Nurses’ Association took financial responsibility. The model has been described in detail elsewhere [29,30]. 2.4. Background data Gender, age, marital status, having children less than 16 years of age, experiencing leader responsibility. 2.5. Self-reported measures Reason(s) for help-seeking are defined as one or more of the following areas [31]: health and life quality, exhaustion/burnout, professional identity (meaning identification with the professional role) [32], work-related conditions, private relations and ‘‘other reasons’’ with an option for free text. Reasons are scored on a fivepoint scale (0—not decisive for help-seeking to 4—decisive for help-seeking). The scale is dichotomized into >2 as ‘‘weighty reason.’’ Burnout: Maslach’s Burnout Inventory (MBI), with three subscales—emotional exhaustion (10 items), depersonalization/ cynicism (8 items), and reduced personal accomplishment (7 items)—was used [33]. The original frequency scale has been criticized for having categories that are not mutually exclusive [34], and a five-point scale (1—does not fit and 5—fits very well) has therefore been used in previous Norwegian studies [35]. For comparability this scale was chosen in the present study, with reference to the last 2 weeks of work. The three factors have explained respectively 22%, 13% and 11% respectively of the total variance in the instrument, in a study of Norwegian physicians. Personal accomplishment was presented with a reverse scale, so that high values meant low levels of accomplishment. Due to different working conditions one or more items in MBI can be non-applicable to the present situation. A mean score of remaining items is then used. Emotional exhaustion was dichotomized in high and low, with cut-off >3 called case [8]. Life events during the last 12 months: these were measured according to 13 dichotomized items (0,1) and added together as a sum score [36]. Examples of life events are: serious disease/ accident/hospital admission in oneself or a family member/close friend, divorce/separation/broken relationship, death of a family member/close friend, problems with your partner. Sick leave: number of weeks on full-time/part-time sick leave/ rehabilitation/disability during the preceding year and registration of present status. Sick leave after the intervention is presented as a dichotomized variable: 1—a period of sick leave after the intervention (not including those who already were on sick leave at baseline) and 0—no sick leave or continued sick leave after the intervention. Conflict: baseline question: are you in a present work-related conflict? At follow-up: have you been in a work-related conflict during the follow-up period? Both scored 1—yes and 0—no. Treatment: in general practice and/or psychotherapy with a psychiatrist or a psychologist. Treatment with anti-depressants: 1—yes and 0—no. Number of work hours: sum of hours per week used in direct patient contact, meetings, paper work, on the telephone etc, research, and ‘‘other work activities’’. Reduction of work hours: work hours per week at baseline minus work hours per week at follow-up. Reduction is reported as a continuous variable and dichotomized (reduction of work

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hours = 1 and no change or increase in work hours = 0 after baseline). 2.6. Representativity No significant differences were found in age, gender or levels of burnout (Maslach) at baseline between those who completed and those who did not complete follow-up assessment among the nurses. 2.7. Statistics Differences in mean scores for continuous, normally distributed variables were analyzed with t-tests (for independent and paired samples) and for not normally distributed variables with Wilcoxon’s rank test. Proportions are presented in numbers and in % with 95% CI. Differences in proportions were investigated with McNemar’s test (for dependent measures). Prediction of reduction in MBI-emotional exhaustion was tested with linear regression. Bivariate associations were examined. In a multivariate model the significant bivariate associations were examined controlled for MBI at baseline, gender, age and personality dimensions. Results are reported as unstandardized and standardized b-values. A p-value <0.05 was considered statistically significant. SPSS version 16.0 was used as statistical software. 2.8. Ethics The study has been approved by the Data Inspectorate through the Norwegian Social Science Data Services. The Regional Ethical Research Committee in the South of Norway did not find special consent necessary for this study. 3. Results Eighty-three percent of the nurses (83%) reported issues concerning health- and life quality and 75% reported tiredness/ burnout as weighty reasons for seeking help at the Resource Centre. Fifty-seven percent saw job-related factors as important for coming, while 31% reported private relations as weighty reasons for coming. Problems with professional identity were a weighty reason for coming among 42% (Table 3). There was a significant reduction in level of emotional exhaustion (burnout) from 2.87 (SD 0.79) at baseline to 2.52 (SD 0.78) at follow-up (Table 4). Correspondingly the proportion of ‘‘cases’’ above cut-off with emotional exhaustion (MBI) was reduced from 40% (95% CI 33–48) at baseline to 26% (95% CI 19–33) at follow-up. There was a significant increase in

Table 3 Reasons for seeking help. Proportions of nurses presenting each of the following reasons as a weighty reason for coming to the Resource Centre, Villa Sana (each nurse can present one or more reasons). Weighty reasons for help seeking (%) (>2 on a scale from 0 to 4) (95% CI) (number/total answered) Came because professional Came because Came because Came because Came because Came because

of problems with identity of health and life quality of tiredness/burnout of private relations of job-related factors of other factors

41.9 (34.3–49.5) (72/162) 83.2 (77.5–88.9) (139/167) 74.9 (68.3–81.5) (125/167) 31.3 (24.2–38.4) (50/162) 56.7 (49.1–64.3) (93/164) 6.0 (2.4–9.6) (10/167)

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Table 4 Change from baseline to follow-up in burnout, use of antidepressants, work hours, sick leave and use of therapy among nurses seeking a preventive intervention at the Resource Centre, Villa Sana.

MBI-emotional exhaustion (1–5), n = 153 MBI EE-case (>3), n = 153 MBI-depersonalization (1–5), n = 153 MBI-reduced personal accomplishment (1–5), n = 153 Anti-depressants, n = 151 Therapy, n = 147 Work hours, n = 142 Proportion on full-time sick leave, n = 153 Number of weeks on full-time sick leave the preceding year, n = 135

Baseline, mean (SD) or number/total (%, 95% CI)

Follow-up, mean (SD) or number/total (%, 95% CI)

Change, mean (SD) or % (95% CI)

Significance t- or z-values with p-value or McNemar’s p

2.87 (0.79)

2.52 (0.78)

0.35 (0.82)

t = 5.31, p < 0.001

62/153 (40.5, 32.6–48.2) 1.77 (0.59)

40/153 (26.0, 19.0–33.0) 1.63 (0.51)

14.5 (8.9–20.1) 0.14 (0.49)

p = 0.001 t = 3.48, p = 0.001

2.29 (0.40)

2.35 (0.43)

0.06 (0.48)

t = 1.69, p = 0.09

13/151 (8.6, 4.1–13.1) 25/147 (17.0, 10.9–23.1) 32.72 (8.78) 20/153 (13.1, 7.8–18.4)

8/151 (6.3, 2.4–10.2) 50/147 (34.0, 26.3–41.7) 31.74 (8.31) 22/153 (14.4, 8.8–20.0)

2.3 ( 0.1 to 4.7) 17 (10.9–23.1) 0.98 (7.66) 1.3 ( 0.5 to 3.1)

p = 0.23 p < 0.001 z = 0.23, p = 0.82 p = 0.87

6.53 (12.0)

6.60 (11.97)

0.07 (16.56)

t=

0.05, p = 0.96

Table 5 Bivariate and multivariate associations to change in MBI-emotional exhaustion, n = 129.

MBI-emotional exhaustion at baseline Age Gender Neuroticism Introversion/Extroversion Conflict at work during the year Taking sick leave after the intervention Reduction of work hours after the intervention

Unadjusted associations (bivariate)

Adjusted associations (multivariate)

Unstandardized b (SE)

Standardized b

Unstandardized b (SE)

Standardized b

Explained variance %

0.55 (0.08) .004 (0.007) 0.59 (0.41) 0.07 (0.04) 0.06 (0.04) 0.46 (0.16) 0.38 (0.14) 0.34 (0.16)

0.53*** 0.04 0.12 0.12 0.13 0.24** 0.22** 0.18*

0.62 (0.08) 0.008 (0.007) 0.47 (0.39) 0.08 (0.04) 0.04 (0.03) 0.53 (0.13) 0.28 (0.12) 0.10 (0.14)

0.60*** 0.09 0.09 0.16* 0.10 0.28*** 0.16* 0.05

28.4

1.8 8.2 2.2

*

p < 0.05. p < 0.01. *** p < 0.001. **

proportion of nurses in therapy from baseline to follow-up, from 17% (95% CI 11–23) to 34% (95% CI 26–42). No changes were found in proportion of nurses on full-time sick leave (Table 4). The proportions on part-time sick leave (6%) and on rehabilitation/disability benefits (1–2%) were not significantly different from baseline to follow-up, and neither was number of weeks during the preceding year on the different benefits. The proportion of nurses taking anti-depressants and the number of work hours/week did not differ significantly from baseline to follow-up (Table 4). Of 160 nurses responding at follow-up 27 (17%) reported to be in conflict at work at baseline and 43 (21%) to have been in conflict at work during the follow-up year. The difference is not statistically significant (McNemar’s test, p = 0.33). Bivariate associations were examined between reduction in emotional exhaustion and emotional exhaustion at baseline, gender, age, personality, marital status, ‘‘having children below 16 years of age’’, being in a work-related conflict at baseline, ‘‘being in psychotherapy at baseline’’, ‘‘being on sick leave at baseline’’, ‘‘average number of life events the last 12 months at baseline and at follow-up’’, ‘‘starting psychotherapy’’, ‘‘taking sick leave’’, ‘‘reducing working hours’’, ‘‘being in a work-related conflict measured at baseline and through follow-up’’. There was a negative association between getting sick leave after the intervention and reduction in emotional exhaustion (b 0.38 (SE 0.14), p < 0.01), as well as between conflict at work during the follow-up year and reduction in exhaustion (b 0.46 (SE 0.16), p < 0.01), and a positive association between reduction

of work hours after the intervention and reduction in emotional exhaustion (b 0.34 (SE 0.16), p < 0.05) (Table 5). Multivariately, independent significant effects were from neuroticism (b 0.08 (SE 0.04), p < 0.05), conflict at work during the year (b 0.53 (SE 0.13), p < 0.001) and getting sick leave after the intervention (b 0.28 (SE 0.12), p < 0.05) (Table 5). Results do not vary significantly when analyzing only women nurses. The results concerning ongoing conflict at work and getting a sick leave after the intervention warranted further investigation. Neither the group with ongoing conflict nor the group getting sick leave after the intervention had significantly higher levels of emotional exhaustion at baseline than the rest of the group. Within the group reporting conflict (n = 34) there was no reduction in emotional exhaustion from baseline 3.02 (SD 0.64) to follow-up 3.01 (SD 0.62), t = 0.07, ns, whereas in those not reporting conflict (n = 110) emotional exhaustion was reduced from 2.81 (SD 0.82) to 2.34 (SD 0.74), t = 5.81, p < 0.001. The group who got sick leave after the intervention had a higher average number of life events during the follow-up year (1.55 (SD 1.14) vs 1.11 (SD 1.17) Mann– Whitney U-test, z = 2.46, p = 0.01). 4. Discussion and conclusion 4.1. Discussion One main finding in this study was that burnout was reduced among nurses a year after a preventive intervention. Compared

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with a representative sample of Norwegian nurses in 2003 [37], the Villa Sana sample had a higher level of emotional exhaustion at baseline, but approximately the same level as in the representative sample at follow-up. There was a corresponding reduction in number of ‘‘cases’’ with emotional exhaustion. Studies have shown that the combination of cognitive and mindfulness-based interventions seem to have an impact on burnout among nurses [25,26], which is consonant with the results from the present study among nurses who had actively sought a preventive intervention. Another important finding was that conflict was negatively associated with reduction in emotional exhaustion; the group of nurses reporting an ongoing conflict showing no reduction in emotional exhaustion. As described in the literature referred to above, different types of work conflicts can be inherent in the nursing role [12–16,38] and can influence work climate and risk of exhaustion. Empowerment of nurses to address conflict should therefore be more directly targeted in the preventive program. Nurses have little possibility to control or restrict their interactive arenas at work, and this additionally emphasizes the importance of monitoring these arenas in a constructive way [5,39]. Burnout is related to the working situation and can only be resolved in the interface between the individual and the working place [40,41]. The present results emphasize the importance of increasing the self-assertiveness in nurses, as well as handling or preventing conflicts in the workplace. It is an important leader responsibility to focus on these aspects [42]. A burnout-preventive, workplace based intervention for health personnel recently documented increased self confidence as well as behavioural change at work [43], which can reflect empowerment in handling situations, including conflicts, in a more constructive way. The association between lack of reduction in emotional exhaustion and conflict could also be interpreted as being due to negative affectivity [44], nurses with continuous high levels of emotional exhaustion could be more likely to define themselves as being in a conflict at work. However, even after controlling for neuroticism, which can influence the perception of distress variables towards reporting negatively, conflict during follow-up was a highly significant predictor for lack of change in emotional exhaustion. The relatively low proportion of nurses on sick leave at baseline (compared with women physicians coming to Villa Sana [8]) could partly be explained by somewhat lower average levels of burnout among nurses at baseline. The relatively frequent occurrence of part-time work among nurses [5] could also explain a reduced need for sick leave as a reaction to work-related exhaustion. The higher prevalence of life events during follow-up, among nurses who took sick leave after the intervention, could indicate that this sick leave was not primarily work-related (life events mainly describe circumstances outside of work, although there is an overlap). It is reasonable to believe that serious life events in combination with work-related exhaustion would induce more severe distress than the presence of exhaustion alone, and could thus explain the lack of reduction in emotional exhaustion found in the group that got sick leave after the intervention. These findings are in line with the results in a recent Norwegian study that has shown a relatively low correlation between changes in workrelated sick leave and changes in burnout among nurses [22]. A comparison would require measurement of work-related sick leave instead of total sick leave (which was measured in the present study). The personality dimension neuroticism was found to modify the decrease in emotional exhaustion to a limited extent. Studies have shown that a trait like self-criticism, which is closely related to neuroticism, both can increase the risk for stress, as described among nursing students [6], but also can enhance the ability for empathy [45]. With this trait, there is a need for individual recognition of the importance of balancing between functioning

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well as a nurse and the risk for exhaustion that it constitutes. Group psychotherapy for nurses in palliative care to help them cope with these dual aspects has been described [27], but results are not yet published. In the present study we documented a significant increase in proportion of nurses seeking psychotherapy after the intervention. One aspect of therapy could be to work with the balance between vulnerability for stress and capacity for empathy. This can be an important supplement to workplacerelated changes necessary to reduce or prevent burnout. The study shows reduction in self-reported emotional exhaustion, and an increase in the proportion of nurses seeking psychotherapy after the intervention, but cannot document changes in sick leave, use of anti-depressants or proportion of nurses in conflict. This could indicate a subjective reporting according to ‘‘social acceptability’’ or out of gratitude for attending the program. The association between sustained levels of emotional exhaustion in nurses with conflict at work and for nurses who have taken sick leave after the intervention, however, renders this conclusion unlikely. On the contrary, the lack of increase in sick leave and use of anti-depressants in this group of nurses, with initially elevated levels of emotional exhaustion, could indicate that the intervention contributed to prevent further development of burnout. Although there was no total reduction in number of work hours/week in the sample as a whole, we somewhat unexpectedly found that the nurses who had reduced work hours showed more reduction of emotional exhaustion (bivariate association). Since the relationship disappeared in multivariate analysis we cannot conclude that reduction in work hours could be an important initiative to reduce emotional exhaustion. As expected most of the nurses seeking help at Villa Sana presented health issues, exhaustion/burnout and work-related issues as weighty reasons for coming, in line with the aims for the centre. Issues of professional identity were important for coming, indicating that lack of role clarity (role ambiguity) as well as role conflicts can enhance the risk for burnout among nurses, as shown previously [10,11,46]. A recent study of Norwegian nurses also shows that many nurses during their first working years reported having ‘‘planned’’ a different career than the one they are in at present, which can increase the risk for dissatisfaction and role ambiguity [18]. It is important to pursue research into effects from working with role clarity and professional identity on prevention and reduction of burnout. Concerning private relations as a reason for coming, a recent study has shown that conflict in the work-family interaction increases burnout and vice versa, as well as the two aspects enhancing each other [21]. These relationships should also be investigated more thoroughly in a preventive perspective. 4.2. Strengths and limitations The longitudinal design with one-year follow-up and the comparison with a representative sample of Norwegian nurses are strengths in this study. The high proportion of participants completing follow-up (93%) strengthens the internal reliability of the results. The validity of the self-reported findings is strengthened by having controlled for neuroticism, which can influence the perception of distress variables towards reporting negatively (so-called negative affectivity) [44]. The study has limitations, principally the opportunistic design, that impedes the possibility to distinguish between effects having a causal relation to the intervention, being due to a spontaneous regression towards the mean, or being associated with factors not assessed in this study. However, the lack of reduction in emotional exhaustion in the group of nurses reporting conflict makes an overall regression of values to the mean less likely. Further studies,

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including a control group, are needed to attribute measured changes to the intervention. The reduction in emotional exhaustion is statistically significant, but the clinical significance of the reduction can be questioned. Measuring reduction in number of ‘‘cases’’ of emotional exhaustion is one way to approximate a clinically meaningful description, as we have done in this study. The issue of recall bias, especially concerning sick leave and work hours during the preceding year, is present, and objective measures could have given more accurate estimates. 4.3. Conclusion Our findings indicate that seeking and engaging in a preventive intervention could be conducive to reduction in burnout among nurses, as has previously been shown for doctors. Work-related conflict and sick leave after the intervention were negatively associated with this reduction. Further studies, with control group design, are needed to verify effects of the intervention. A qualitative approach could complement and extend the understanding of important processes in prevention of burnout. 4.4. Practice implications Preventive interventions to reduce burnout for nurses should be considered, as well as programs for preventing or handling conflicts at work. Further research to confirm the indications found in this study is important. Psychotherapy to prevent or treat burnout, as a complement to more directly work-related measures, should be further investigated. I confirm that all personal identifiers have been removed or disguised so the persons described are not identifiable and cannot be identified through the details of the story. Competing interests KR is employed at the Resource centre, Villa Sana. KR and TG work at the Research Institute, Modum Bad. There are no other competing interests. Authors’ contributions KR and TG conceptualized and designed the study, developed the construction of the questionnaire, analyzed and interpreted data and drafted the paper. RT has contributed to drafting the paper. OA has taken part in conceptualizing the study and has participated in construction of the questionnaire. He has contributed to drafting the paper. All authors have participated in revising the manuscript critically for important intellectual content and have approved of the final manuscript. Acknowledgements We thank The Norwegian Women’s Public Health Association and Modum Bad for financial support. We thank the participating nurses for their time and engagement in registering data. References [1] Aiken LH, Clarke SP, Sloane DM, Sochalski JA, Busse R, Clarke H, Giovannetti P, Hunt J, Rafferty AM, Shamian J. Nurses’ reports on hospital care in five countries. Health Aff 2001;20:43–53. [2] Hannan S, Norman IJ, Redfern SJ. Care work and quality of care for older people: a review of the research literature. Rev Clin Gerontol 2001;11:189–203.

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