Role of Work-Related Stress Assignment | Professional Writing Services

The Effect of Role-Related Stressors On Nurses’ Burnout Syndrome: The Mediating Role ofWork-Related Stress

Abstract

Purpose:This study aimed to investigate the role conflict, role ambiguity, and workload effect on burnout syndrome of clinical nurses working in university hospitals and the role of work-related stress mediation in this effect.

Design and Methods:Cross-sectional, questionnaire-based survey was conducted.Data from 386 nurses were evaluated. The research variables were analyzed using statistical methods such as factor analysis, correlation analysis, regression analysis, Sobel testsandbootstrapping method.

Findings: It was determined that role conflict, role ambiguity, workload, and work-related stressaffected nurses’ burnout significantly and work-related stress has a mediator role between burning out and the independent variables.

Practice Implications: Role ambiguity, role conflict, workload, and work-related stress are important factors for hospital management to control burnout syndrome in nurses.

Keywords:Role Conflict, Role Ambiguity, Workload, Work-Related Stress, Burnout

Introduction

Hospitals are high-tech institutions providing high-level services, specialized in terms of service type and quality, providing specialized health services.Although the technologies used in hospitals are advanced, employees are still the most important factor in the success of the institution. Working life has a different meaning for each individual. For some, economic gain is a necessity, for others, it is a pleasure and social status (Turan,Gülhan, & Yılmaz,2018). It is a known fact that individuals who love and enjoy their work are more successful in their work. World Health Organization (WHO) (2010)defines a healthy workplace as a work environment in which health, safety and improvement processes in the work environment are provided in collaboration with employees and managers to protect and improve the health, safety, and welfare of employees and the sustainability of the workplace (Burton, 2010). Workplace policy-makers recognize that being at work and having good working conditions are vital for health and well-being. Poor quality work characterized by severe working conditions (eg. long working hours) can be harmful to health (Thomas,Hertzman, &  Power,2009).

Work-related stress is defined as the perception of inconsistency between environmental demands (stressors) and individual capacities to fulfill these demands. Work-related stress is considered a structural problem that has an individual impact on each employee (American Institute of Stress, 2013)and affects the overall performance of an organization.The issue of work-related stress assessment is currently being evaluated in the legislation of many European countries (Giorgi,Arcangeli, Ariza-Montes, Rapisard, &Mucci,2019).In recent years, international organizations have created awareness of psychosocial risks and work-related stress. European stakeholders acted on these issues by producing important documents such as position papers and government regulations (Zoni &Lucchini,2012; Arun& Yildirim, 2017). Exposure to emotionally challenging situations for a long time and not coping with prolonged stress causes burnout (Maslach,Schaufeli& Leiter,2001). Especially burnout syndrome is frequently seen among nurses (Dwyer,Hunter, Sethares,& Ayotte,2019; Salam et al., 2019;Tsiga,Panagopoulou,& Montgomery, 2017).In this context, it is important to understand and analyze the concept of burnout in depth.

Role-related stressors in the workplace are those that relate to the role requirements of that work (Lambert,Hogan, Cheeseman,& Barton-Bellessa, 2013). Role stress is a reaction model that occurs when employees are presented with job demands that do not match their knowledge and skills that challenge their ability to cope (Kubicek,Bhanugopan,& O’Neill, 2019). Workplace role-related stressors are often conceptualized under role ambiguity, role conflict concepts, and work overload because employees experience them continuously (chronic)(Kahn, 1987; Onyemah, 2008; LePine Podsakoff,& Lepine,2005; Liu,& Li, 2018).All three role-stressors significantly affect anxiety in terms of effective commitment to task performance. It has been suggested that work stresses lead to a psychological (emotional) reaction affecting beliefs such as organizational outcomes and job attitudes

between work role stress factors, work-related stress, and burnout experienced by the nature of the nursing profession and the mediating effect of workload in these relationships.The main purpose of this study is to test the theoretical relationships between variables on the model (Fig.1). In the model that put forward the precursors of burnout syndrome, (1) to identify the elements of work stress (role conflict, role ambiguity, workload, work-related stress) and to examine the effects on nurses (2) to examine the relationship between the variables (3) to analyze the mediator effect of work-related stress.

Role-Related Stressors

The role ambiguity is to perceive the uncertainty as being deprived of the information required by the employee to do the work required of him/her and that this perception makes the employee feel helpless.It is a state of uncertainty in terms of employees. (Settles, Sellers, & Damas, 2002; Onyemah, 2008). Role ambiguity is broadly considered to include uncertainties about role definition, expectations, responsibilities, tasks, and behaviors involved in one or more facets of the task environment (Schmidt, Roesler,  Kusserow, & Rau, 2014). Role ambiguity is one of the sources of stress in the workplace (Kahn,Wolfe, Quinn, & Snoek,1964).The role ambiguity in the nursing profession can be defined as unclear situations about what to do for a particular patient due to conflicting messages given to them by different authorities. When nurses experience role ambiguity about the patient, they are not clear about what behaviors are expected of them to conduct their work. These conditions are suitable for producing negative results for patients (Brunetto,Wharton, Shacklock,& Robson, 2012).

Nurses serving in hospital service are often exposed to conflicting demands from managers and patients.It also requires the simultaneous realization of multiple roles in managerial tasks entrusted to them(Kirchhoff & Karlsson, 2018; Bolton, 2003). Requesting more than one social role from nurses causes one of the expected roles to be given more weight than others. This situation brings out the role ofconflict (Kahn et al., 1964). Role conflict is related to business content and tasks and is a typical source of stress that hinders nurses. Employers with low work efficacy have been reported empirically to have more role conflicts than those with high work efficiency (Liu & Li, 2018).The workload is defined as finishing a certain amount of work in the given time (Jex, 1998). The workload is one of the most important internal stress sources of employees (Schaufeli & Peeters, 2000). The workload of nurses can be defined as all the procedures carried out in the patient care process and the whole time given for these procedures (Campos,Oliveira, & Perroca,2018). Nurses have a heavy workload as they are interested in a large number of patients and take responsibility for these patients. The overload of nurses prevents the tasks from being performed properly (Jin,Chen, Munechika, Sano, & Kajihara,2018; Rosenberg, 2019; Kim,Parameshwara, Guo, & Pasupathy,2019; Daughtry & Engelke, 2018).

Work-Related Stress:

Stress is the adaptive behavior shown by individual differences and psychological processes, and any external and internal movement, situation, or event that causes extreme psychological and physical pressures on the person is the result of the organism (Gibson,Ivancevich, Donnelly, & Konopaske,2002). Work-related stress is perceived to have more work than the employee can handle, and from this situation, the worker is affected psychologically and physiologically (Eskildsen et al., 2017).Working in a hospital environment increases work stress (Ojekou & Dorothy, 2015; Puteri &Syaebani, 2018). Among health workers, nursing is considered one of the high-risk professions for physical and mental diseases (Menzel, 2007).The nursing profession is inherently stressful (long and intensive work hours). Stress affects the quality of life and health of nurses, the burden of workload, and their relationships with patients (Jafarizadeh,Zhiyani, Aghakhani, & Moradi,2017).

Burnout:

One of the forms of job strain is burnout.Burnout is a syndrome of emotional exhaustion and cynicism frequently seen in working individualsand incompetence lack of success and productivity at work. Burnout consists of three sub-dimensions: emotional exhaustion, depersonalization, and low personal accomplishment (Grant & Sonnentag, 2010; Maslach, Schaufeli, & Leiter, 2001). Emotional exhaustion is one of the subdimensions of burnout syndrome. Employees feel that their psychological and emotional resources are exhausted. Also, it is a feeling that is manifested by physical fatigue (Laurence,Fried, & Slowik,2013). Since their emotional resources are exhausted, employees may feel inefficient at the psychological level. Low personal accomplishment is the tendency of the employee to assess themselves negatively. The employee is not satisfied with the success of his / her work. The depersonalization is the attitude and behaviors of the employee who lack emotion in the workplace (Maslach & Jackson, 1981).

Recently employees gain experience and become better equipped to workplace stressors as they progress in their careers and have more resources to combat strains such as burnout (Beehr,King, & King, 1990). WHO (Burn-out, 2019) officially defined the burnout syndrome as professional deformation. WHO also listed burnout syndrome for version 11 of the International Classification of Diseases (ICD-11), the WHO’s handbook that guides medical providers in diagnosing diseases.

Role-Related Stressors and Work-Related Stress as Predictors of Burnout:Theoretical Background, Proposed Model, and Hypotheses:

Conservation of Resources (COR) Theory (Grandey & Cropanzano, 1999) and The Affective Events Theory (AET)  (Weiss & Cropanzano, 1996) provided the theoretical framework for this study. The fundamental principle of Conservation of Resources (COR) theory is that individuals strive to protect, build, and retain the resources they value, from the threat of potential or actual loss. The well-being of the individual depends on the acquisition and protection of these resources. There are four sources of resources in the resource protection model. Individuals get their object sources (home, car …), personal characteristics (personal respect, etc.), condition resources (being married, living with someone who is providing financial support, etc.) and energy sources (time, money, information, etc.). to work and to protect. When individuals faced with stress sources, they take the effort to minimize the loss of resources according to the theory. That individuals employ resources in the stress-coping process and that such employment often depletes these resources. Based on the COR’a theory, it is reasonable to assume that the organizational changes associated with the increase of work stress factors may exhaust the psychological resources of employees and consequently create a sense of burnout (Hobfoll, 1989). According to theory, the inter-role conflict between the individual and the job may lead to tension because the individual may lose resources for the sake of success in work and private life. The actual or potential loss of these resources can lead to a state negative state of being içeren, including dissatisfaction, depression, anxiety, or psychological tensions (Grandey &Cropanzano, 1999).

Organizational behavior variables are frequently explained in the literature with The Affective Events Theory (AET) (Weiss & Cropanzano, 1996).AET theory broadens our understanding of COR theory in the context of workplace stressors and strains.The AETexplains the positive and negative emotional responses that employees give to the effects of events and processes at work. The AET recommends that workplace stress sources, such as workload, role conflict, and role ambiguity, directly and indirectly, affect employees’ feelings for work (Luo & Chea, 2018). The AETexplains the positive and negative emotional responses that employees give to the effects of events and processes at work.

Stress and burnout are important risks for healthcare workers and are associated with a decline in health care quality, attrition, and reduced commitment to the practice(Kushnir,Cohen,& Kitai, 2000). When there is a conflict of value in the profession and therefore a gap between individual and organizational values, employees will find themselves in a balance between the work they have to do and the work they have to do, resulting in greater burnout (Selamu,Thornicroft, Fekadu,& Hanlon 2017).In a survey conducted on 314 nurses (243 nurses responded the questionnaire, response rate %73.4) in Turkey (city center of Kastamonu) in 2014, it was found that experienced nurses and surgical clinics nurses faced more role conflicts than unexperienced and other clinics nurses (Sivuk & Kıbrıs, 2016). In a study conducted in Turkey in Bitlis, 36.88% (52) of nurses reported that they take responsibility beyond their duties (Aydın & Argun, 2010).

In the light of these two theories, Figure 1 theoretical model has been developed in order to deeply understand the role conflict, role ambiguity, workload, work-related stress and burnout relationships.

Figure 1

Hypothesis 1: Perceived role ambiguity is significantly and positively related to nurses’ burnout levels.

Hypothesis 2: Perceived role conflict is significantly and positively related to nurses’ burnout levels.

Hypothesis 3: Employees perceived are significantly and positively related to nurses’ burnout levels.

Hypothesis 4: Perceived work-related stress is significantly and positively related to nurses’ burnout levels.

Hypothesis 5: Perceived role ambiguity is significantly and positively related to work-related stress.

Hypothesis 6: Perceived role conflict is significantly and positively related to work-related stress.

Hypothesis 7: Perceived workload is significantly and positively related to work-related stress.

Hypothesis 8: Perceived work-related stress has a mediator role between role ambiguity and burnout levels of nurses.

Hypothesis 9: Perceived work-related stress has a mediator role between role conflict and burnout levels of nurses.

Hypothesis 10: Perceived work-related stress has a mediator role between workload and burnout levels of nurses.

Methods

Research Design

Procedureand Data Analysis

Questionnaire-based survey was conducted. Data were obtained from full-time nurses of a public üniversity hospital in Eskişehir city in Turkey. The questionnaires used in this study were carried out by the researcher face to face with the participants. The demographic variables included education level, gender, marital status, age,and work experience. The survey contained a total of 48 five-point Likert scale items(role conflict, role ambiguity, workload and burnout)ranging from 1, being “strongly disagree”, to 5, being “strongly agree. Analyses the causal steps approach proposed by Baron and Kenny (1986) and bootstrapping method(Hayes & Scharkow, 2013) was tested using SPSS 21 software and PROCESS macro.

Data Collection Technique and Participants

Ethical approval was obtained from the Non-Interventional Clinical Research Ethics Committee of Eskişehir Osmangazi University (approval number: 254033353-050.99-E.1455668, date of approval:  10//12/2019).  In addition, permission of the institution where the study was conducted were obtained.Nurses voluntarily participated in this study and their oral consent was obtained.Due to the high workload, the selected study group consisted of nurses working in a university hospital (included all clinics) (n = 550) in Eskişehir. The sample size was determined as 226 people with 95% confidence (Sekaran, 1992: 253). A survey was sent to 500 nurses randomly selected by sampling method, and 403 questionnaires werereturned,9  questionnaires were excluded from the analysis because of missing data and 394 (%78.8) were found suitable for analysis (collected the data in December 2019). The data obtained were checked for outliers, skewness, normality, linearity, homoscedasticity and multiple connections, 8 data were extracted in the extreme value analysis (according to Trochim & Donnelly, 2006) and 386questionnaires were found suitable for evaluation. The demographic characteristics of participants can be seen in Table 1.

Table 1

As seen in Table 1 29,3% (n=113) of the sample is

Data Collection Tools

Information about the scales used in the research is given below. Cronbach alpha reliability coefficients of the scales were analyzed with the SPSS package program was analyzed.

Role ambiguity scale

Perceived role ambiguity levelsmeasured by a 6-item (i.e. “I feel certain about how much authority I have”)scale which was created by Rizzo, House and Lirtzman, (1970) then used by House, Schuler,and Levanoni (1983) and Schuler,Aldag,and Brief (1977). Cronbach’s alpha reliability coefficient of the scale was found 0.87 by Rizzo et al. (1970).In the scale, answers were obtained with a 5-point Likert scale (1 = Strongly disagree, 5 = Strongly agree).

Role conflict scale

To determine the levels of role conflict, an 8-item (i.e. “I have to do things that should be done differently”) scale created by Rizzo et al. (1970) was used. The scale also used by Schuler et al. (1977) and House et al. (1983). Cronbach’s alpha reliability coefficient of the scale was found 0.82 by Rizzo et al. (1970). In the scale, answers were obtained with a 5-point Likert scale (1 = Strongly disagree, 5 = Strongly agree).

Quantitative Workload Inventory

The 5-item(i.e. “I have not enough time to complete my work”) scale, which was developed by Spector and Jex (1998) and whose reliability coefficient was determined as 0.82, was used.He Turkish validation study was conducted by Keser (2006) and the reliability coefficient of the scale was 0.78. In the scale, answers were obtained with a 5-point Likert scale (1 = Strongly disagree, 5 = Strongly agree).

Work-related stress scale

The level of work-related stress was measured by 7 items (i.e. “I feel fidgety or nervous because of my job”)scale developed by House and Rizzo (1972). The scale was translated into Turkish by Efeoğlu (2006) and applied in the pharmaceutical sector. The Cronbach’s alpha reliability coefficients were reported to range between 0.71 and 0.89.In the scale, answers were obtained with a 5-point Likert scale (1 = Strongly disagree, 5 = Strongly agree).

Burnout scale

Maslach and Jackson (1981) developed by Maslach Burnout Inventory consisting of 22 items consisting of 3 subscales were used. The first subscale of the Maslach Burnout Inventory is the emotional exhaustion of 9 items (i.e. “I feel frusrated by my work”), the second is the depersonalization of 5 items (i.e. “I’ve become more callaus towardpeople since I took this jop”)and the third is the decrease in the low personal accomplishment of 8 items (i.e. “I feel very energetic”). Cronbach’s alpha reliability coefficients were 0.83, 0.65, and 0.72, respectively.In the scale, answers were obtained with a 5-point Likert scale (1 = Strongly disagree, 5 = Strongly agree).

Results

The data were analyzed with SPSS 21 and PROCESS macro. As shown in Table 2, sufficient evidence was obtained for the validity of the study scales. Mean, standard deviations, and correlations of study variables are presented in Table 2.

Table 2

As seen in Table 2, there are significant relationships between all dependent and independent variables. Therefore, significant effects can be predicted among the variables.

Collinearity was also examined to determine whether there is a multiple linear connection problem in the data set. Tolerance and VIF values gave results confirming that there was no multicollinearity between variables (Tolerance> .2, VIF <3).

The relationship between variables and mediation effect was analyzed with causal steps approach proposed by Baron and Kenny (1986).Findings of hierarchical regression analysis, Sobel tests, and mediation tests are presented in Tables 3, 4, and 5. For the mediation effect, four conditions are expected to occur.

• Independent variable must affect the dependent variable,
• Independent variable must affect the mediator variable,
• Mediator variable must affect the dependent variable,
• When the mediator variable included in the regression analysis with the independent variable, the effect of the independent variable on the dependent variable decreases, while the mediator variable should have a significant effect on the independent variable.

When the mediator variable is included in regression analysis, if the effect of the independent variable on the dependent variable is entirely through the mediator variable it refers to the full mediation, If there is a decrease in the relationship between the independent variable and the dependent variable, the partial mediating effect is mentioned.

As shown in Table 3 in Stage 1 of the mediation test, the relationship between the independent variable role ambiguity and burnout was examined.

Table 3

In Step 1 role ambiguity was found to have a significant effect on burnout (b= -.31, p<.001). In Step 2 role ambiguity was found to have a significant effect on work-related stress (b= -.12, p<.05). In Step 3 work-related stress was found to have a significant effect on burnout (b= .69, p<.001). In the last step of this stage role ambiguity and mediator work-related stress were analyzed together and their effects on burnout were examined.Results showed that the effect of role ambiguity on burnout continued and decreased (b= -.23, p<.001), while the effect of work-related stress on burnout continued (b= .66, p<.001). Following these steps, the Sobel test was performed to confirm the mediation effect and Sobel (z) was significant (z = -2.42, p <.05). This finding shows that work-related stress plays a partial mediating role in the effect of role ambiguity on burnout. As a result of this section analysis, it is seen that while H1 and H5 wererejected, H4 and mediation hypothesis H8 were supported.

As shown in Table 3, in Stage 2, sub-dimensions of burnout;emotional exhaustion, depersonalization,and low personal accomplishmentvariables and hypothesis variables were analyzed.

Hypothesis 1a: Perceived role ambiguity is significantly and positively related to nurses’ emotional exhaustion levels of nurses.

Hypothesis 4a: Perceived work-related stress is significantly and positively related to nurses’ emotional exhaustion levels.

Hypothesis 8a: Perceived work-related stress has a mediator role between role ambiguity and emotional exhaustion levels of nurses.

Hypothesis 1b: Perceived role ambiguity is significantly and positively related to nurses’ depersonalization levels of nurses.

Hypothesis 4b: Perceived work-related stress is significantly and positively related to nurses’ depersonalization levels.

Hypothesis 8b: Perceived work-related stress has a mediator role between role ambiguity and depersonalization levels of nurses.

Hypothesis 1c: Perceived role ambiguity is significantly and positively related to nurses’ low personal accomplishment levels of nurses.

Hypothesis 4c: Perceived work-related stress is significantly and positively related to nurses’ low personal accomplishment levels.

Hypothesis 8c: Perceived work-related stress has a mediator role between role ambiguity and low personal accomplishment levels of nurses.

In Step 1role ambiguity was found to have a significant effect on emotional exhaustion (b= -.24, p<.001).In Step 2 role ambiguity was found to have a significant effect on work-related stress (b= -.12, p<.05).In Step 3 work-related stress was found to have a significant effect on emotional exhaustion (b= .67, p<.001).In the last step of this stage role ambiguity and mediator work-related stress were analyzed together and their effects on emotional exhaustion were examined. Results showed that the effect of role ambiguity on emotional exhaustion continued and decreased(b= -.16, p<.001), while the effect of work-related stress on emotional exhaustion continued (b= .65, p<.001).Following these steps, the Sobel test was performed to confirm the mediation effect and Sobel (z) was significant (z=-2.41, p<.05). This finding shows that work-related stress plays a partial mediating role in the effect of role ambiguity on emotional exhaustion. . As a result of this section analysis, it is seen that while H1a was rejected, H4a and mediation hypothesis H8a were supported.

In Step 1role ambiguity was found to have a significant effect on depersonalization (b= -.19, p<.01).In Step 2 role ambiguity was found to have a significant effect on work-related stress (b= -.12, p<.05).In Step 3 work-related stress was found to have a significant effect on depersonalization (b= .60, p<.001).In the last step of this stage role ambiguity and mediator work-related stress were analyzed together and their effects on depersonalization were examined. Results showed that the effect of role ambiguity on depersonalization continued and decreased(b= -.12, p<.01), while the effect of work-related stress on depersonalization continued (b= .59, p<.001).Following these steps, the Sobel test was performed to confirm the mediation effect and Sobel (z) was significant (z=-2.40, p<.05). This finding shows that work-related stress plays a partial mediating role in the effect of role ambiguity on depersonalization. As a result of this section analysis, it is seen that while H1b was rejected, H4b and mediation hypothesis H8b were supported.

In Step 1role ambiguity was found to have a significant effect on low personal accomplishment(b= -.32, p<.001).In Step 2 role ambiguity was found to have a significant effect on work-related stress (b= -.12, p<.05).In Step 3 work-related stress was found to have a significant effect on low personal accomplishment (b= .20, p<.001).In the last step of this stage role ambiguity and mediator work-related stress were analyzed together and their effects on low personal accomplishment were examined. Results showed that the effect of role ambiguity on low personal accomplishment continued and decreased(b= -.30, p<.01), while the effect of work-related stress on low personal accomplishment continued (b= .16, p<.001).Following these steps, the Sobel test was performed to confirm the mediation effect and Sobel (z) was significant (z=-2.06, p<.05). This finding shows that work-related stress plays a partial mediating role in the effect of role ambiguity on low personal accomplishment. As a result of this section analysis, it is seen that while H1c was rejected, H4c and mediation hypothesis H8c were supported.

Table 4

As shown in Table 4 in Stage 1 of the mediation test, the relationship between the independent variable role conflict and burnout was examined.

In Step 1 role conflict was found to have a significant effect on burnout (b= .45, p<.001). In Step 2 role conflict was found to have a significant effect on work-related stress (b= .60, p<.001). In Step 3 work-related stress was found to have a significant effect on burnout (b= .69, p<.001). In the last step of this stage role conflict and mediator work-related stress were analyzed together and their effects on burnout were examined. As a result of this analysis, the effect of role conflict on burnout was eliminated (b= .06, p<.146), while the effect of work-related stress on burnout persisted (b= .65, p<.001). Following these steps, the Sobel test was performed to confirm the mediation effect and Sobel (z) was significant (z=12.04, p<.001). This finding shows that work-related stress plays a full mediation role in the effect of role conflict on burnout. As a result of this section analysis, it is seen that H2, H6 and mediation hypothesis H9 are supported.

As shown in Table 4, in Stage 2, sub-dimensions of burnout;emotional exhaustion, depersonalization,and low personal accomplishment variables and hypothesis variables were analyzed.

Hypothesis 2a: Perceived role conflict is significantly and positively related to nurses’ emotional exhaustion levels of nurses.

Hypothesis 9a: Perceived work-related stress has a mediator role between role conflict and emotional exhaustion levels of nurses.

Hypothesis 2b: Perceived role conflict is significantly and positively related to nurses’ depersonalization levels of nurses.

Hypothesis 9b: Perceived work-related stress has a mediator role between role conflict and depersonalization levels of nurses.

Hypothesis 2c: Perceived role conflict is significantly and positively related to nurses’ low personal accomplishment levels of nurses.

Hypothesis 9c: Perceived work-related stress has a mediator role between role conflict and low personal accomplishment levels of nurses.

In Step 1 role conflict was found to have a significant effect on emotional exhaustion (b= .42, p<.001). In Step 2 role conflict was found to have a significant effect on work-related stress (b= .60, p<.001). In Step 3 work-related stress was found to have a significant effect on emotional exhaustion (b= .67, p<.001). In the last step of this stage role conflict and mediator work-related stress were analyzed together and their effects on emotional exhaustion were examined. As a result of this analysis, the effect of role conflict on emotional exhaustion was eliminated (b= .03, p<.523),  while the effect of work-related stress on emotional exhaustion persisted (b= .65, p<.001). Following these steps, the Sobel test was performed to confirm the mediation effect and Sobel (z) was significant (z=11.70, p<.001). This finding shows that work-related stress plays a full mediation role in the effect of role conflict on emotional exhaustion. As a result of this section analysis, it is seen that H2a, and mediation hypothesis H9a are supported.

In Step 1 role conflict was found to have a significant effect on depersonalization (b= .43, p<.001). In Step 2 role conflict was found to have a significant effect on work-related stress (b= .60, p<.001). In Step 3 work-related stress was found to have a significant effect on depersonalization (b= .60, p<.001). In the last step of this stage role conflict and mediator work-related stress were analyzed together and their effects on depersonalization were examined. Results showed that the effect of role conflict on depersonalization continued and decreased(b= .12, p<.01), while the effect of work-related stress on depersonalization continued (b= .53, p<.001).Following these steps, the Sobel test was performed to confirm the mediation effect and Sobel (z) was significant (z=10.80, p<.05). This finding shows that work-related stress plays a partial mediating role in the effect of role ambiguity on depersonalization. As a result of this section analysis, it is seen that H2b and mediation hypothesis H9b are supported.

In Step 1 role conflict was found to have a significant effect on low personal accomplishment (b= .14, p<.001). In Step 2 role conflict was found to have a significant effect on work-related stress (b= .60, p<.001). In Step 3 work-related stress was found to have a significant effect on low personal accomplishment (b= .20, p<.001). In the last step of this stage role conflict and mediator work-related stress were analyzed together and their effects on low personal accomplishment were examined.As a result of this analysis, the effect of role conflict on low personal accomplishmentwas eliminated (b= .02, p<.707), while the effect of work-related stress on low personal accomplishmentpersisted (b= .19, p<.001).Following these steps, the Sobel test was performed to confirm the mediation effect and Sobel (z) was significant (z=3.79, p<.05). This finding shows that work-related stress plays a full mediating role in the effect of role ambiguity on low personal accomplishment.As a result of this section analysis, it is seen that H2c and mediation hypothesis H9c are supported.

As shown in Table 5 in Stage 1 of the mediation test, the relationship between the independent variable workload and burnout was examined.

Table 5

In Step 1 workload was found to have a significant effect on burnout (b= .49, p<.001). In Step 2 workload was found to have a significant effect on work-related stress (b= .66, p<.001). In Step 3 work-related stress was found to have a significant effect on burnout (b= .69, p<.001). In the last step of this stage workload and mediator work-related stress were analyzed together and their effects on burnout were examined. As a result of this analysis, the effect of workload on burnout was eliminated (b= .05, p<.295), while the effect of work-related stress on burnout persisted (b= .66, p<.001). Following these steps, the Sobel test was performed to confirm the mediation effect and Sobel (z) was significant (z=13.16, p<.001). This finding shows that work-related stress plays a full mediation role in the effect of workload on burnout. As a result of this section analysis, it is seen that H3, H7 and mediation hypothesis H10 are supported.

As shown in Table 5, in Stage 2,sub-dimensions of burnout;emotional exhaustion, depersonalization,and low personal accomplishment variables and hypothesis variables were analyzed.

Hypothesis 3a: Perceived workload is significantly and positively related to nurses’ emotional exhaustion levels of nurses.

Hypothesis 10a: Perceived work-related stress has a mediator role between workload and emotional exhaustion levels of nurses.

Hypothesis 3b: Perceived workload is significantly and positively related to nurses’ depersonalization levels of nurses.

Hypothesis 10b: Perceived work-related stress has a mediator role between workload and depersonalization levels of nurses.

Hypothesis 3c: Perceived workload is significantly and positively related to nurses’ low personal accomplishment levels of nurses.

Hypothesis 10c: Perceived work-related stress has a mediator role between role workload and low personal accomplishment levels of nurses.

In Step 1 workload was found to have a significant effect on emotional exhaustion (b= .44, p<.001). In Step 2 workload was found to have a significant effect on work-related stress (b= .66, p<.001). In Step 3 work-related stress was found to have a significant effect on emotional exhaustion (b= .67, p<.001). In the last step of this stage workload and mediator work-related stress were analyzed together and their effects on emotional exhaustion were examined. As a result of this analysis, the effect of workload on emotional exhaustion was eliminated (b= .003, p<.940),  while the effect of work-related stress on emotional exhaustion persisted (b= .67, p<.001). Following these steps, the Sobel test was performed to confirm the mediation effect and Sobel (z) was significant (z=12.72, p<.001). This finding shows that work-related stress plays a full mediation role in the effect of workload on emotional exhaustion. As a result of this section analysis, it is seen that H3a and mediation hypothesis H10a are supported.

In Step 1 workload was found to have a significant effect on depersonalization (b= .46, p<.001). In Step 2 workload was found to have a significant effect on work-related stress (b= .66, p<.001). In Step 3 work-related stress was found to have a significant effect on depersonalization (b= .60, p<.001). In the last step of this stage workload and mediator work-related stress were analyzed together and their effects on depersonalization were examined. Results showed that the effect of workload on depersonalization continued and decreased(b= .11, p<.01), while the effect of work-related stress on depersonalization continued (b= .53, p<.001).Following these steps, the Sobel test was performed to confirm the mediation effect and Sobel (z) was significant (z=11.59, p<.001). This finding shows that work-related stress plays a partial mediation role in the effect of workload on depersonalization. As a result of this section analysis, it is seen that H3b and mediation hypothesis H10b are supported.

In Step 1 workload was found to have a significant effect on low personal accomplishment (b= .16, p<.001). In Step 2 workload was found to have a significant effect on work-related stress (b= .66, p<.001). In Step 3 work-related stress was found to have a significant effect on low personal accomplishment (b= .20, p<.001). In the last step of this stage workload and mediator work-related stress were analyzed together and their effects on low personal accomplishment were examined. As a result of this analysis, the effect of workload on low personal accomplishment was eliminated (b= .05, p<.435),  while the effect of work-related stress on low personal accomplishment persisted (b= .16, p<.05).Following these steps, the Sobel test was performed to confirm the mediation effect and Sobel (z) was significant (z=3.82, p<.05). This finding shows that work-related stress plays a full mediation role in the effect of workload on low personal accomplishment. As a result of this section analysis, it is seen that H3c and mediation hypothesis H10c are supported

According to the results of the hierarchical regression analysis, it was determined that all independent variables affected the mediator variable and significantly increased burnout and subdimentions in work-related stress.

In this study, total, direct and indirect effects between the dependent variables and the independent variable were used with bootstrap method (Hayes & Scharkow, 2013) with 5000 resampling, 95% symmetric confidence interval and 95% confidence interval with deviation correction(Preacher & Hayes, 2008).The mediating role has been assumed as statistically significant when the lower limit (BootLLCI) and upper limit (BootULCI) of bootstrap results in %95 confidence interval are both below or above zero (Hayes, 2013). Findings obtained as a result of the analysis are shown in Tables 6,7 and 8.

Table 6

The magnitude of the mediation relationship of the work-related stress variable in the effect of role ambiguity on burnout. In the lower level confidence (95%) range – 1170 and in the upper level confidence (95%) range – 0074 (Preacher & Kelly, 2011: 93).

Table 7

The magnitude of the mediating relationship of the work-related stress variable in the effect of role conflict on burnout As shown in Table: Completely Standardized Indirect Effect line in Table 7; in the lower level confidence (95%) range, 3147 and in the upper level confidence (95%) range, 4874 (Preacher & Kelly, 2011: 93).

Table 8

The magnitude of the mediation relationship of the work-related stress variable in the effect of workload on burnout Table: As can be seen in the Completely Standardized Indirect Effect line in Table 8; in the lower level confidence (95%) range, 3519 and in the upper level confidence (95%) range, 5675 (Preacher & Kelly, 2011: 93).

Discussion and Conclusion

This study aims to reveal the relationship between role-related stressors and burnout levels of nurses working in Eskişehir University Training and Research Hospital, which is an intensive work tempo, and the mediator effect of work stress in this relationship.Consistent with previous studies (Olivares-Faúndez et. al., 2014; Papastylianou Kaila, 2009, Rhineberger-Dunn, & Mack, 2019) role ambiguity is a cognitive-attitudinal response and is a strong predictor of all three components of burnout syndrome.

Role conflict is a significant predictor of burnout (Piko, 2006; Jawahar et. al., 2007; Phillips, et. al., 2013). In this study, role conflict is associated with burnout and increases burnout and its sub-dimensions positively and significantly. Nurses who have role conflicts will lose their ability to determine the needs of the patients, to perform the necessary nursing process practices in line with their professional roles and responsibilities, and to provide more efficient health care services by having the ability to solve them effectively. In this way, nurses’ perceptions of their burnout may develop negatively.

Burnout syndrome is a common phenomenon that threatens employees’ well-being (Read, Colder, Merrill, Ouimette, White & Swartout, 2012). Burnout syndrome can be considered as a symptom of chronic workload and employee capacity imbalance (Lilly et. al., 2019). It was determined that the workload is associated with burnout and increases burnout and its sub-dimensions positively and significantly. Nurses play an important role in the quality of health care provided, patient safety, treatment process, and hospital performance indicators. However, due to the time constraints of nurses whose workload increases, they will not be able to perform these roles effectively, they will have to perform a large number of tasks in limited periods and this will lead to increased levels of burnout.

The prior studies result that work-related stress could significantly predict burnout (Hao, Hong, Xu,  Zhou, & Xie, 2015; Banovcinova,& Baskova, 2014). High levels of work stress are associated with high burnout syndrome (Smith et. al., 2018; Looseley et. al., 2019). It was determined that work-related stress was associated with burnout and increased burnout and its sub-dimensions positively and significantly. Work-related stress is one of the main sources of burnout. Therefore, work-related stress; the tendency of the employee to evaluate himself/herself negatively due to the negative or negative reaction of the employee’s emotional resources, such as lack of interest in other employees’ emotions and behaviors, neglect, alienation, hostile behavior or lack of responsiveness to the employees, and an increase in the feeling of inability to fulfill the job requirements.

It was determined that role ambiguity, role conflict, and workload were associated with work-related stress and increased work-related stress positively and significantly. It can be stated that the most important variables that increase the work-related stress of nurses are role ambiguity, role conflict, and workload.

It is thought that role ambiguity, role conflict, and workload have an effect on burnout and its sub-dimensions, and this effect may be reflected in output variables through some variables. From this point of view, the role of work-related stress in the effect of perceived role ambiguity, role conflict, and workload on burnout was investigated. The results showed that work-related stress has a partial mediating role in the effect of role ambiguity on burnout and its sub-dimensions, emotional exhaustion, depersonalization, low personal accomplishment. It was found that work-related stress plays a fully mediating role in the effect of role conflict on burnout. In the effect of role conflict on the dimensions of burnout, emotional exhaustion, depersonalization, low personal accomplishment; it was found that there was a full mediating role in the dimension of emotional burnout and a partial mediating role in depersonalization and decreased sense of personal accomplishment. It was found that work-related stress has a full mediating role in the effect of workload on burnout. The effects of work-related stress on the diminished dimensions of burnout, emotional exhaustion, depersonalization, low personal accomplishment; it was found that there was a full mediating role in the dimension of emotional exhaustion and a partial mediating role in depersonalization, low personal accomplishment. Health care professions, especially nursing, have outstanding and distinctive values as dynamic phenomena (Weis &Schank, 1991). They establish intense emotional relationships with their patients. The greatest obstacle for nurses to be able to commit themselves to their work and organization, to have increased motivation, to show their abilities such as creativity and problem solving, and to increase their self-confidence in their specialties is burnout. Work stress is a variable that has a significant effect on burnout  (Hao, et al, 2015; Banovcinova & Baskova, 2014).

The contributions of this study to the theory can be expressed as the finding that work-related stress can be increased by mediating role in the effect of role ambiguity, role conflict, and workload on burnout, which is an important output variable. Second, there was no study investigating the mediating effect of work-related stress in the relationship of these three independent variables with burnout. This finding on the positive effect of work-related stress on role ambiguity, role conflict, and increasing workload perceptions of burnout is important as the first evidence of scientific knowledge about the role of work-related stress. Thirdly, unlike the results of the other studies in the literature, the role ambiguity in Turkish culture reduces burnout levels. The contribution of the study to the application; In the nurses who have professional roles and responsibilities, there is an effect on the formation of the perception of burnout, role ambiguity, role conflict, workload, and work-related stress effect.

Nurses’ burnout levels have a negative and significant impact on the quality of health care provided, patient safety, treatment process, and hospital performance indicators. Therefore, when nurses perceive role conflict, workload, and work-related stress in management processes, it is considered that burnout levels may increase and face a very negative picture for the employee and the organization.

Limitations

In the research, questionnaire was used as a data collection tool. The data obtained is based on personal statement. The participants may not reflect what is actually happening by giving them the answers they think are ideal for the questions posed to them.

The data were collected in a certain period of time. The data collected for the research covers the nurses working at Eskişehir University Training and Research Hospital in December 2019. It should be taken into consideration that different findings can be obtained with the data collected in different periods and in a different geography.

Sample size is limited, and the proposed model contains multiple variables. It is necessary to collect evidence of validity of the proposed model by testing it on more samples.

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23-Apr-2020

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Reviewer(s)’ Commentsto Author:
Reviewer: 1

Commentstothe Author
I wanttothankyoufortheopportunitytoreviewthismanuscript. The time spentcreatingandshipping it is greatlyappreciated. IMHO, it offersinterestingresultsthat can benefitthescientificcommunityandTurkishbusinessleaders. However, currentlythemanuscriptpresentssomeproblemsthatmust be takenintoaccountandrepaired. Below I presentmyrecommendationsseparatedbysections. Hopefullytheywill be useful:

At a general level, thetextshouldsometimes be a deeprevision of theexpressionandthewording.

Summary
1. Line 30-32: indicatemoreconciselythepracticalimplications of yourstudy. Currentlythepracticalimplicationsoverlapwithwhat is stated in theresultsand do not providerelevantinformation.

Introduction:
2. Throughouttheintroduction, there is a lack of cohesionbetweenthedifferentstudiesincluded as studybackground. Checkthewordingandexpressionthroughoutthesection: repetitive, disconnectedandinconclusiveresult on manylines (forexample, line 40-42, line 44-45, line 51-56 …this is just a sample).
3. I suggestthatyoudividethecurrentresearchquestionintotwoquestions, as it is not understood. On theotherhand, it may be advisabletodeletetheresearchquestionandincludethestudyobjectiveinstead.
4. Forthefigure, it could be usefultousedashedlinesto mark theproposedmediationrouteanddifferentiate it fromthedirecteffects.

Method:
5. Indicatethereasonwhy 9 questionnaires of theexposedcollectionswererejected.
6. Alongwiththepercentages, add n tomake it easiertotrackyourdata. On theotherhand, nexttotheaverages, addthedeviation.
7. Intheinstrumentssection, indicateifthere is an ad hoc questionnaireforthecollection of sociodemographicinformationand, ifso, whatvariableswill be analyzed. Alsoindicate, foreachinstrumentused, theresponse format separately, as well as an itemtoexemplifythescales.
8. Itwould be appropriatetoincludethesubsections on procedureanddataanalysis.

Results:
9. Forthefollow-up of theproposedmodels, it is recommendedtoincludedifferentfiguresforeachindependentvariableanalyzed.
10. Ineachtable, it would be appropriatetoinclude a legend. Likewise, since Tables 4, 5 and 6 do not presentthesameresults, theyhavedifferenttitlesthatrefertotheirspecificcontent.

Discussion:
11. Theresultsfound in relationto role ambiguityarecontrarytoallpreviousliterature. Please be moreconciseandexhaustive in thepossibleexplanation of theseresults.
12. Missingconnectorsthatguidethereading of theconclusions. Pleasereviewthisaspect.
13. Itwould be appropriatetoincludethelimitations of thestudy.

References:
14. Review APA regulations in references. Somereferenceshave not beenorderedalphabetically.

Thanksforyourcontribution.

Reviewer: 2

Commentstothe Author
Why do theycarryout a CFA? Theyshoulduse SEM, whichworkswithobservableormeasurablevariablesandoneormorelatentorunobservedvariables, strengtheningthecorrelationsusedandmakingmorepreciseestimates of thestructuralcoefficients.
Themethodsectionsandthepresentation of resultsareconfusing.
Themanuscriptneeds an in-depthreview on methodologicalaspects. Forexample, they do not reportconfidenceintervals. Nor do theyspeakclearly of the total, directandindirecteffects of the model, …
Sample size is limited, andtheproposed model containsmultiplevariables