An exploration of burnout in nurses working in intensive care in Saudi Arabia: An explanatory sequential mixed methods study

Abstract

Nurses working in highly demanding and challenging environments, such as intensive care units, are prone to experiencing burnout compared to those in less demanding environments. In Saudi Arabia, the large number of nurses from other countries who work in intensive care contributes to the complexity of caring for critically ill people. Cultural complexity, high workloads and low morale may contribute to burnout in nurses, however how these factors affect nurse working in intensive care in Saudi Arabia is not well understood. Understanding these challenges, therefore, can help to mitigate burnout among nurses working in intensive care, improve patient outcomes, and assist recruitment and retention. This study aimed to investigate burnout among nurses working in the intensive care setting and to establish the factors which lead to burnout and which promote well-being and resilience among those nurses in Saudi Arabia. An explanatory sequential mixed methods design was used, and the data collection occurred across two phases. The first phase of the study sought to understand factors that contribute to nurses experiencing burnout. Paper-based questionnaires were distributed to nurses working in intensive care units across four tertiary hospitals in Riyadh, the capital of Saudia Arabia. The questionnaire contained two sections included the Maslach Burnout Inventory-Human Services Survey for Medical Personnel (MBI-HSS (MP)) scale used to explore the prevalence of burnout and the factors which contributed to the perception of burnout with the addition of participants’ demographic data and responses to the work characteristics questions. Data from the questionnaires were analysed using SPSS statistical software version 29. In Phase One, a total of 804 (80.4% response rate) nurses completed the questionnaire, with results indicating that more than half of the nurses experienced high levels of emotional exhaustion and depersonalisation, while more than half of those surveyed experienced moderate to low levels of personal accomplishment within the workplace. The analysis of demographic and work characteristic data, along with the MBI-HSS (MP) subscales, indicated that several factors may lead to burnout in nurses working within the intensive care setting. The demographic factors that contributed were gender, age, marital status, living arrangements, number of children, and nationality, while the work characteristics that contributed were work experience, type of intensive care, daily working hours, number of night shifts per month and number of patients per shift, attempts to maintain personal well-being, feeling stressed going to work, access to emotional support, feeling valued at work, salary satisfaction, and intention to leave. The findings from Phase One informed Phase Two, which used semi-structured interviews to delve deeper into and comprehend factors which led to nurses’ feelings of burnout and to identify their personal resilience against burnout. The interviews with consenting participants were undertaken online via Zoom or Microsoft Teams and analysed using a thematic analysis framework. In Phase Two, 20 semi-structured interviews were conducted with nurses who had completed the questionnaire and work in the intensive care setting. Three themes were identified from the thematic analysis: (i) “Being an intensive care nurse is challenging”; (ii) “The impact of the work upon me”; and (iii) “How I cope”. The first theme presented the nature of the work in intensive care settings in Saudi Arabia, highlighting the organisational challenges that participants encountered. The second theme reveals the physical, mental, psychosocial and professional impacts of working in intensive care in Saudi Arabia. The last theme captured the techniques participants used to cope with the challenges in the work environment. A pragmatic approach was used during data integration which influenced how this research was undertaken, presentation of the results and the structure of this thesis. Further, pragmatism helped explain the multiple realities that nurses encountered in their working environment in the intensive care setting in the cultural context of Saudi Arabia. The significant findings in this study are related to the unique cultural environment that exists in the nursing profession in Saudi Arabia and the interplay between the factors that contribute to and are protective against burnout. The contributing factors were the cultural and language challenges, which relied on nurses’ professional experience and adjustments to an altered scope of practice, and the protective factors, which included nurses’ capacity to build resilience, and how support systems created a complex dynamic that affected the participants’ performance and well-being. Whether nurses adapt or the environment adapts will be crucial in determining whether these nurses experience burnout or even leave the profession. Several recommendations stemming from this study are proposed to healthcare organisations, including policymakers, hospital leaders and nurse managers to improve work conditions in intensive care settings, which could potentially increase the adaptation to the work environment and, therefore, reduce burnout levels among nurses. In addition, it is crucial that stakeholders and hospital management understand the challenges that intensive care nurses encounter every day which impact their well-being as well as the quality of care. Policies and systems in hospitals, therefore, should be changed to help improve work conditions, which could potentially increase nurse retention and improve the quality of patient care.