Influence Of Personal Functioning And Behaviour Type On Burnout Among Public Health Workers

Project and Seminar Material for Psychology

Influence Of Personal Functioning And Behaviour Type On Burnout Among Public Health Workers


The study investigated influence of Personal functioning and Behavior type on burnout among public health workers”. Two hundred and thirty-one (231) health workers comprising of Hundred and one (101) males (44.5%) and Hundred and twenty-six (126) females (55.5%) were selected from hospitals in Uyo metropolis. Participants were selected using convenient sampling technique. Their age ranged between 18 and 62 years with a mean age of 38 years. Maslach Burnout Inventory -General survey (MBI-GS) developed by Maslach and Jackson, (1986), Personal functioning Inventory (PFI) developed by John, Brien Wood, Pickering and Decicco (2003), and Behaviour type inventory developed by Peter Omoluabi (1997) Were the instruments used for the study.

The study was a survey that used a cross-sectional design. independent t-test, was used for data analysis. Result revealed that public health workers with high level of personal functioning did not report higher burnout (Mean=76.19) compared to public health workers with low level of personal functioning (Mean=76.58), p>0.05, t = -0.20. Result revealed that public health workers with Type A scored higher on burnout (Mean=79.48) as compared with public health workers with Type B behaviour (Mean=73.07) with p < 0.05 (t = 3.48). Result also revealed that older public health workers scored slightly higher on burnout (Mean=77.06) as compared with younger public health workers (Mean=75.67) with p > 0.05 (t = 0.74). It was concluded that high level of personal functioning and older health workers did not predict burnout, type A behavior type predicts burnout am public health workers in Uyo. Implications and recommendations were made on the basis of the findings in this study.

Chapter One:


1.1 Background to the Study

The term “burnout” was identified thirty years ago to describe a state of fatigue and frustration among health and service workers arising from excessive demands on their resources. According to Maslash & Leiter (2008) is a prolonged response to chronic emotional and interpersonal stressors on the job, and is defined by the three dimension of exhaustion, cynicism and inefficacy. Leiter & Maslash (2009) also saw it as a cumulative negative reaction to constant occupational stressors relating to the misfit between workers and their desired jobs. with this understanding it can be deciphered that burnout is a psychological syndrome response to chronic stressors in the work place that leads to, physical & emotional exhaustion, cynicism and detachment and feelings of ineffectiveness and lack of accomplishment. Exhaustion is mainly related to an individual’s experience of stress, which is in turn related to a decline in emotional and physical resources.

According to Leiter & Maslack (2003). “The experience of exhaustion reduces worker’s initiative while progressively limiting their capacity for demanding work” while cynicism refers to a detachment from work in reaction to the overload of exhaustion, and the burnout component perceived professional inefficacy refers to the feelings of ineffectiveness and lack of achievement productivity at work and also lack of confidence in one’s work. Most workers in the health sector have encountered occupational stressors in their working environment that often makes them care professionals such as the Doctors, Nurses, lab scientists, pharmacists, social workers and psychologists (Leiter & Malash 2009).

When an individual is psychologically burned out due to occupational stress and depression, frustration set in the working environment and this affects the individuals psychological, physical and mental wellbeing. The nation of wellbeing is examined in two aspects, those being subjective wellbeing and psychological well-being, subjective well-being corresponds to the hedonistic view predicting the individual’s elusion from pain and approach to pleasure, while psychological well-being corresponds to ensuring the individuals personal development and realizing one’s potentials, going beyond the search of pleasure which include psychological and spatial health (Shanhun, 2010).

In recent years increasing attention has been paid to the phenomenon of burnout particularly in human service professions, psychological burnout appears to be a response to interpersonal stressors on the job, in which an overload of contact with people result in changes in attitudes and behaviors towards them (Schaufeh, Leiter & Maslash 2008). Burnout can show up as poor job performance, impersonality with patients and lack of motivation. Health problems such as high blood pressure, insomnia, depression or addiction can also be sign of burnout and it’s as a result most people in the health care professions carry their job home with them; it’s good to really care about your patients. But if you don’t know how to distance yourself at times, it will be a problem “(Synder,2007).

Also burnout which is as a result of prolonged stress in the work place, is globally considered as a risk factor for worker’s health and safety. More specifically the health care, sector is a constantly changing environment, and the working conditions in the hospitals are increasingly becoming demanding and stressful .Several studies; studies focusing on the health sector have shown that health care professionals are exposed to a variety of severe occupational stressors, such as time pressure, low social support at work, a high work load, uncertainty concerning patient treatment and predisposition to emotional responses due to exposure to suffering, frustration, depression anxiety and anger, and in this case health care workers are at a high risk of experiencing severe distress, burnout and both mental and physical illness . (Peterson, Demerouts, Bergstom, Samielsson, Asbsg, & Nigren, 2008).

According to Demerouti, Bakker, Nachrainer & Schaufele (2001), the syndrome of burnout is more prevalent among human service providers. The two core dimensions of burnout can be distinguished as emotional exhaustion and depersonalization. Burnout is a syndrome characterized by emotional exhaustion that results in depersonalization and decreased personal accomplishment at work. The emotional exhaustion clinicians may develop a sense of cynical detachment from work and view people, especially patients as objects, such that clinicians no longer feel effective at work because they have lost sense of their ability to contribute meaningfully in the past few years, the growing prevalence of burnout syndrome among health care personal has gained attention as potential threat to health care quality and patient safety.

Burnout is common among health care workers and the characteristics of the health care environment contributing work processes, role conflict and poor relationship between groups and with leadership, when these are combined with leadership and personal disposing factors and the emotional intensity of clinical work, they put clinicians at risk. Burnout is viewed as a threat to patient’s safety because depersonalization is presumed to result in poorer interaction with patients, clinicians aremore likely to subjectively rate patient’s safety lower in their organization and to admit having mistaken or delivered standardized care at work.

Burnout complaints among nurses have not been consistently related to occupational species stressors such as confrontation with death and dying and interactions with difficult situations. More specifically, psychological burnout has three syndromes which are emotional, depolarization and a reduced sense of personal accomplishment that can occur among individuals who work with people in some capacity. As described above, burnout is studied in three different types, “emotional” this refers to over extended and drained by one’s contact with other people” depersonalization “this refers to an unfeeling and callous response towards people who are usually the recipients of one’s service or care and reduced personal accomplishment” this refers to a deadline in one’s feeling of competence and successful achievement in one’s work with people. These three aspect of syndrome have been the causes and outcomes.

Burnout individuals simultaneously experience high levels of chronic fatigue, and distance themselves emotionally and cognitively from their work activities employees with higher levels of burnout are more likely to experience a hold range of psychological and physical health problems including anxiety, depression, sleep disturbance, memory impairment (Peterson, Demerouts, Bergstom, Samielsson, Asbsg, & Nigren, 2008). Consequently, burnout employees are likely to display one or more withdrawal behaviours such as lateness, absence or turnover according to (Maslach, Schaufeli & Leiter 2001). Clinically, burnout employees may get justified absence leaves from work. However other burnout employees remain at work which leads to a form, existence more psychological and physical health problems, and this influences their behavior at work in a significant way.

(Picco, 2017) emphasizes on occupational burnout which is characterized by exhaustion, lack of enthusiasm and motivation, feeling of ineffectiveness which may also have the dimension of frustration or cynicism, and as a result reduces efficacy within the workplace. Bakker, Demerouti & Sanzvergel (2014), emphasizes on the antithesis of burnout engagement which is characterized by energy involvement and efficacy, (the opposite of exhaustion, cynicism and inefficacy). According to Bakker et al (2014), the causes of burnout are generally divided into two categories situational factors and individual factor situational factors include job demands and lack of job resources. Job demands are aspects of the job demands and lack of job resources. Job demands are aspects of the job that requires strenuous effort, (Demerouti et al, 2001). Therefore, job demands are associated with psychological and physical costs, such as an increased heart rate and fatigue such symptoms may set the ground for the experience of burnout, because job demands lead to employees to feel exhausted and to psychologically distance themselves from work (Bakker Schaufeli, Sixma, Bosvveld & Van Dierendonck, 2000).

Role ambiguity, role conflict, role stress, stressful events, workload and work pressure are among the most important job demands that cause burnout (Akercon, 2011). Individual factors which are concerned with both socio-economic status and personality variables have been analyzed as creating a predisposition to suffer from burnout symptoms.

Also (Leiter & Maslach, 2005) maintained that the sources of burnout at work are lack of control which entails that there is high job demands in combination with low control and that there is a disconnection between the workers care value and the care values of the organization, the next sources of burnout is insufficient reward which entails that the workers may feel being taken for granted not recognized and under compensated, this entails demanding employees to engage in more work activities, one employee can carry out the work in which three or more people are supposed to carry out and they are not properly rewarded for, this can lead to burnout, work overload is another source of burnout which entails that the workers workload is too much, too complex or too important to be ignored. Maslach, Schaufeli, & Leiter (2001), burnout can be caused by stressors in which a person is unable to cope with fully. Occupational burnout often develops slowly and may not recognized until it has become severe, when one’s expectation about a job and its reality differs burnout can begin, how pressure is dealt with, determine how much stress someone feels and how close they are to burnout. One individual can experience few stressors, but be unable to handle the pressure well and thus experience burnout. Another person however can experience a far greater number of stressors but affectively deal with them and avoid burnout. According to Sorenson & German (2013), the most recent Gallup survey on employee engagement entails that 50% of worker’s report being not engaged, while another 20% report being actively disengaged. Another source of burnout is unfairness which entails that employees are treated unfairly, that there is a culture of favoritism, assignment fashion and discussed behind closed doors.

Breakdown of community is a source of burnout which entails that workers have to work with patronizing colleagues, and that there is no mechanism or conflict resolution and that feed-back is non-existence (MC Pherson, Smith-Lovin & Brashears, 2006). The perception of an inequitable work environment might also lead to burnout, in addition to the work environment in the industries ,some personal characteristics or individual differences also, appear to predict burnout, these include both demographical and dispositional variables.

Alarcon, Eschleman, & Bowling (2009), found out that four of the big five factors of personality, which are emotional stability, extraversion, conscientiousness and agreeableness were consistently negatively related to each of the three dimensions of burnout. Further, individuals high in self-efficacy, optimism and self-esteem were better able to deal with job demands, most likely because they believe they have control over their work environment, and therefore are more likely to proactively solve problems and seek resources when facing job demands, one possible explanation for the negative link between burnout and performance is that exhausted employees lack the concentration needed to perform well, and therefore make more mistake. One problem that is evident from the literature and follows logically from observation is that burnout coincides with impaired job performance and that burnout predicts increased job demands overtime (Bakka et al, 2014). Several studies have been attributed to psychological burnout such as expectation, self-concept, self-esteem and self-actualization (Den, 2001).

This study considers variables such as personal functioning and behavior among health workers. Due to high rate of health workers encountering psychological burnout arising from occupational stress, anger, frustration, depression and sadness in the health sectors, the purpose of this study is focusing on how to cope and function maximally so that it would not lead to burnout. One of the variables of interest that can influence psychological burnout is personal functioning. It has to do with adaptive coping strategies and healthy way of dealing with stress. The subjective assessment of personal functioning is that some people believed that it is best not to think about a troublesome issue, thought, feelings as getting upset about it may only make the issue worse. In some instances, this will be true depending on how you react to situations, inability to deal with stress, anxiety, or troubling issues as it arises to feel a whole range of emotions about any given situations is healthy but it is what you do in reaction to this emotion however can be unhealthy.

According to Sarafino, (2012), stress is when an individual perceives a discrepancy between the physical or psychological demands of a situation and the resources of his or her psychological or social systems. There are many ways of coping with stress, their effectiveness depends on the type of stressors, the particular individual involved and the circumstances. There are two types of coping responses which are emotional focused and problem focused. Emotional focused coping involves trying to reduce the negative emotional responses associated with stress such as embarrassment, fear, anxiety, depression, and frustration.This may only be the only realistic option when the source of stress is outside the person’s control. Problem focused coping ,target the cause of stress in practical ways which tackles the problem or stressful situation that is causing stress, problem focused strategies aim at removing or reducing the causes of the stressors including problem solving, time management and obtaining instrumental social support.

Personal functioning and Psychological burnout

The ability of health workers to adapt and make use of coping skills is very beneficial to them , coping occurs in response to psychological stress which is usually triggered in an effect to maintain mental health and emotional well-being coping strategies are the behaviors, thoughts and emotions that can be used to adjust the environment by health workers. The inability of the health workers to employ the different coping skills that will help them to cope and adapt to the changes and the unwelcome situations that they encounter in their working environment may bring about burnout, but if health workers make use of different coping skills that will help them adapt to the changes they faced in their working environment, such may hinder the occurrence of burnout and may help them to function personally.

The coping strategies in which the health workers should adapt include self-control, sharing emotions with other co-workers when they face stressful situations and also when they are depressed. Self-control entails engaging in positive thinking, tolerance and forced acceptance, using positive thinking to overcome negative thoughts when health workers make use of this coping strategy, it may help them in reducing tension and stress. Other coping strategies health workers may use to reduce tension and stress include ignoring negative feelings, and thoughts. workers may use these to reduce tension and stress, an also ignoring negative feelings thought stopping and avoiding stressful situations. If the health workers can cope in other to bring about a positive personal functioning, it may be helpful because work stress depression, anxiety and fear are the major predictors that can make health workers to be psychological burnout. Research has shown that burnout is accompanied with diverse types of problems which can affect the health workers physical and psychological well-being as well as their health conditions. The ability of the health workers to cope with occupational stressors would hinder the occurrence of burnout but the inability of the health workers to cope with occupational stressors may trigger the occurrence of burnout.

Behavior type and Psychological Burnout

Unwelcome situations can make health workers not to be happy and prolong encountering of this unpleasant and frustrating situations in the work environment can trigger burnout which, affects the health workers well-being, psychologically and psychically. The inability of the health workers being faced with challenging situations in the work environment to regulate their emotions positively can lead to burnout thus behavior type goes a long way to determine whether burnout will occur among health workers if the environment does not correspond with their personality but when the health workers are able to use different coping strategies to cope with stress and unwelcome situations despite their behavior type, it can hinder the occurrence of burnout among health workers.

Thornton & Ryckman (2011), maintained that the ability of health workers to cope with day to day functioning in the worker place irrespective of their behavior type will hinder the occurrence of burnout in response to chronic emotion strain in daily interactions with clients. Human providers may feel emotionally over stretched and drained by the interactions with other people. A way of coping with this is emotionally distancing oneself from them. Decrease involvement and also by reducing empathy. This detached attitude or depersonalization may vary from nurses concerning their patients as impersonal objects. As a result, human service professionals are unable to perform adequately which in turn may result in a decline in the feelings of professional efficacy.

Since health workers with type A behavior are more competitive, aggressive, they always want to achieve a lot in a short period of time, and when they are not able to achieve what they thought of achieving in a short period of time they will be sad and long encountering of this would lead to burnout compared to those with type B behavior, but if the health workers despite their type of behavior employed the different coping skills, it would go a long way to hindering the occurrence of burnout.

1.2 Statement of Problem

The negative impact of psychological burnout on individuals has remained prevalent throughout history. Increasing demands of our time make job burnout a major factor that most employees have to contend with, the inability of the health workers, to cope, with stress and unwelcome situation in their working environment and their inability to function personally have become a major factor that triggers burnout, in our everyday life one requires motivation to carryout various degree of tasks. One of the most important factors that lead one to his or her goals is motivation drive. Thus to be motivated is a constant need when health workers are motivated in terms of paying them salary to match their desire and also lowering work overload like health workers carring out a job which is supposed to be carried out by two or five people, when all these is compromised for it would lower the experience of burnout, for every individual there is a driving force.

In fact, it’s not just a single factor, but a combination of factors that lead people to achieve and alien. Health workers working in health sector are properly motivated in terms of rewards such as paying them salary that match their desire, and also lower the rate of encountering workload because when an individual with type A behavior pattern do not accomplish what the desire to achieve in a speculated time they desire they would be depressed, sad, angry and long experience of these unpleasant and unwelcoming situations would leads to the experience of burnout and it can even make them develop hypertension and coronary heart disease.

1.3 Research Questions

  1. To what extent will personal functioning determine burnout among public health workers?
  2. To what extent will type A and B behavior determine burnout among public health workers?
  3. To what extent will personal functioning and behavior type lead to burnout among public health workers?

1.4 Purpose of Study

The general aim is to examine if personal functioning and behavior type will influence burnout among public health workers.

While the specific aim of the work is as follows:

  1. To examine, if personal functioning will lead to burnout among public health workers.
  2. To examine; if behavior type would lead to burnout among public health workers.
  3. To determine if personal functioning and behavior type can jointly lead to burnout.

1.5 Significance of the Study

Burnout is common among public health care workers. Characteristics of the health care environment, including time pressure, lack of control over work processes, role conflict, and poor relationships between groups and with leadership, combine with personal predisposing factors and the emotional intensity of clinical work to put clinicians at high risk, until recently estimates for the prevalence of burnout ranged from 10%-70% among nurses and 30% – 50% among physicians, nurse practitioners, and physician assistants. In late 2015, a study conducted by the Mayo Clinic, in partnership with the American Medical Association, found that more than half of American physicians now have at least one sign of burnout, a 9% increase from the group’s prior results in a study conducted 3 years earlier. Burnout is viewed as a threat to patients safety because depersonalization is presumed to result in poorer interactions with patients.

Clinicians with burnout are more likely to subjectively rate patient safety lower in their organizations and to admit to having made mistakes or delivered substandard care at work. Thus a number of influential organizations, including the American Medical Association and the Mayo Clinic, have highlighted burnout as a priority. This Annual perspective summarizes studies published in 2015, with a particular focus on the relationship between burnout and patient safety and interventions, and probable causes and victims burnout among clinicians. Specially the significance of this study will be as follows:

The findings of this study will be of importance to employees during selection and placement, so as to place and hire applicants whose behavior type are well matched to the available job in order to avoid job burnout; which in turn leads to low productivity and high worker turn over.

1.6. Definition of Terms

In the present study, the definitions of the following terms were applied:


The emotional and physical response everyone experiences when the person perceives an imbalance between demands placed on him and his resources (Welbourne et al, 2007).

Occupational Burnout:

The harmful physical and emotional reactions that happen when the needs of the job do not match the abilities, resources, or needs of the worker (Brunero et al, 2006).


A mental state of altered mood characterised by various aspects of cognition, behaviour, physiology and specific relevant symptoms, including loss of appetite, sleep disturbance, slow movement and diminished ability to concentrate (WHO, 2008).

Post-Traumatic Burnout:

A group of symptoms results as a delayed reaction to an acute stressful and life threatening event or situation, such as combat exposure in a war zone (Lavoie et al, 2011).


The cognitive and behavioural efforts that individuals make to manage conditions perceived as potentially harmful or stressful (McElfatrick et al, 2000).

Specialist Hospital:

A health facility disciplined in a particular area of illness, where patients receive treatment.

1.6 Limitations of the Study

Notwithstanding its strengths, the study has some limitations. The questionnaires relating to occupational burnout were only received by health workers who were in employment in the specialist hospital. A selection bias may have occurred because the investigator could not make contact with the health workers who were absent from work during data collection.

Despite very limited data were missing in the quantitative study, more participants did not respond to the questions in the qualitative questions. This has reduced the data that support the findings of quantitative study particularly about specific stressful events experienced by participants and the coping strategies used by them to deal with burnout.

Burnout measurements were based on self-report rather than by physiological biochemical assessments. One limitation of self-reported questionnaires about burnout is that they provide subjective measures, representing the perceptions of individuals. The investigator firmly believes that the above limitations have not defeated the purpose of the study.

Chapter Five

Discussion of Findings Recommendations and Conclusion

5.1 Discussion of Findings

The prevalence of psychological distress is 63%, depression is 59.7% and trauma is 69.4%.

The most frequent and severe occupational causes of burnouts are: „Workload‟ and „Death and dying‟.
Psychological distress is significantly associated with gender, age, experience, night shifts and extra-work.

Depression is significantly associated with gender, hospital type, age, night shifts, experience and marital status.
Severity of occupational causes of burnouts is significantly associated with age, night shifts, specialisation and qualifications.

Frequency of occupational causes of burnouts is significantly associated with hospital type, experience specialisation and night shifts.

Trauma is significantly associated with hospital type, experience and night shifts.

The predictors of psychological distress are: uncertainty about treatment (severity), experience and qualifications of health workers.

The predictors of depression are: lack of support (frequency and severity), uncertainty about treatment (frequency), workload (severity), and trauma.

The predictors of trauma cases are: depression, extra work, workload (severity), lack of support (severity), uncertainty about treatment and conflicts with physicians.

I will now go on to consider each of these in turn and place them into context starting with sample demographics.

5.2 Conclusion

The systematic approach used in this study examines the prevalence of burnout and related concepts and sources of burnout in health workers worldwide. However, there was limited quantitative literature in this area in Nigeria and other Africa countries which suggests that this area requires further exploration. This study has given an insight into work-related burnout among health workers in hospitals in Uyo, Uyo and explored the factors responsible for the same. Also, it has tried to create a ladder of concern, with which the causes of burnouts running in the health workers‟ life and work should be geared in burnout reduction programmes. This should provide an appropriate path and help in designing effective burnout management programmes to improve the burnout levels of health workers and thus enable them to provide better patient care.

The most important result of this study was that the frequency of the reported psychological distress among Palestinian hospital health workers was high enough to be considered serious. These findings support previous research which suggests that health workers are exposed to high level of burnout. The most common occupational causes of burnouts appeared to be „Workload‟ followed by „Emotional issues related to death and dying‟. The least common occupational burnoutor appeared to be „Conflict with other health workers‟.

The key predictors of psychological distresscases for participants in this study were uncertainty about treatment (severity), depression cases, years of experience and qualifications. The key predictors for SCL-D cases were: lack of support (frequency), uncertainty about treatment (frequency), workload (severity), lack of support (severity) and trauma cases. The key predictors for IES-R cases were: depression cases, extra work, workload (severity), lack of support (severity), uncertainty about treatment and conflicts with physicians. These findings are consistent with some of the literature.

Also, the findings of the qualitative study showed negative effects of burnout on nursing care as low standard of performance, errors in giving medications and errors in nursing notes.

From these results one can conclude that health workers in Uyo need more attention to deal with their psychological conditions. These conditions include distress, occupational burnout, depression and trauma. Nursing managers and other in charge personnel are in good position to support health workers, especially when health workers express different sources of burnout. health workers should be cared for their burnout as they are the backbone of Palestinian health care system and represent more than 60% of manpower in public hospitals in Uyo (Palestinian Nursing Society, 2007). There may also be some advantage in providing formal burnout management programme to health workers, particularly if this programme can be tested for its effectiveness. Any future research into health worker burnout, therefore, needs to focus primarily on interventions in order to manage burnout effectively. Being a Palestinian health worker is a stressful experience; the utility in any future research is finding out how best these health workers can be helped manage this burnout.

5.3 Recommendations

Based on the results of the study, some recommendations were made with specific indication to nursing research, education and practice:

The levels of burnout and related concepts were high among Uyo specialist hospital health workers, which indicated the need for future research that should be directed on effects of burnout management. Based on transactional theory, burnout can be tackled on primary (prevention), secondary (timely reaction) or tertiary (rehabilitation) levels (Cox et al, 2000). Primary interventions attempt to eliminate the sources of burnout in organisations by focusing on changing the physical or socio-political environment to match individual needs and granting them with more control over their work situation (Cooper et al, 2001). Although it is often impossible to remove some causes of burnouts, concessions can sometimes be made. Primary level interventions could be effective if communication processes are improved, jobs are redesigned or employees have been involved in the decision-making process (Jordan et al, 2003). One consideration regarding hospital health workers in Uyo could include a reduction in unnecessary workload. Another consideration could be the war and the siege against Uyo and if there was a peace health workers would be less burnouted. Secondary interventions will help health workers in managing burnout without trying to eliminate or modify workplace causes of burnouts through training programmes. These programmes help health workers to identify symptoms of burnout in themselves and others, and to improve their coping skills (Jordan et al, 2003). Tertiary prevention strategies aim to help health workers who are experiencing current problems originated either from the job environment or their job lives. These programmes seek to adapt health workers‟ behaviour and lifestyle without much reference to changing hospital practices (Jordan et al, 2003).

As getting health workers to participate in future complex intervention programme, an MRC approach (MRC, 2008) could be used. Findings of this study will help us to establish the most important variables to be tested as part of a Randomised Controlled Trial of a complex intervention. The complex framework has five phases. The first phase is theoretical phase: this may be formal theory of individual or organisational behaviour or it may be informal evidence regarding organisational constraints or types of patient‟‟ or health professional‟s beliefs that may promote or inhibit behavioural changes. The second phase is modelling: this involves delineating an intervention‟s components and how they inter-relate. The third phase is exploratory trial: to experiment with intervention and varying different components to see what effect each has on the intervention as a whole. The fourth phase is the main trial: to evaluate a complex intervention with a stated outcome. The fifth phase is long term surveillance: to establish the long-term and real-life of effectiveness of intervention (Medical Research Council, UK, 2000: 3-5).

Education and training programmes should be designed to recruit and develop health workers who are capable to react properly to the health care requirements of the people they care for. Education and training is needed to help health workers deal with the many identified causes of burnouts generated from the challenging and emotionally demanding work they engage in. Also, education and training should include a relevant, reality-based curriculum that is congruent with the situation in Uyo such as dealing with emergency triage and causalities more than normal.

Workload was found to be the first occupational causes of burnouts, so efforts should be taken to reduce the impact of causes of burnouts by organisational interventions. These interventions might include hiring more registered health workers which is an obvious potential solution for decreasing workload, increasing enrolled health worker auxiliaries to carry out tasks suitable for them such as bed linen change, taking temperature and blood pressure will allow the registered health workers to focus on their functions and hiring clerical staff to decrease non-nursing tasks. Employing new staff is not easy decision in the current financial condition but this depends on how the Palestinian Ministry of Health in Uyo is convinced to take this decision according to priority.

The findings of this study provide several implications and recommendations to nursing administration and nursing research. The nursing administrators in both hospitals should consider death/dying and workload as major causes of burnouts and find strategies to manage health worker‟s workload and facilitate the comfortable workplace for
health workers while dealing with patient‟s death/dying. The nursing administrators also need to encourage their staff health workers to utilise more problem-focused coping strategies than emotion-focused and dysfunctional coping.

Working conditions for health workers should be improved and support and counselling services after stressful events should be provided. Some of these actions are considered costly and some are not such as some management efforts. Managers can reduce burnout levels of health workers by developing systems for valuable two-way communication, illuminating role and performance expectations, practical resolution of conflicts, developing policies that reduce burnout from shift work, support group for nursing personnel, psychological counselling should be accessible and available for affected health workers, and increasing observational skills to detect increased burnout and burnout levels. The findings of Jonsson & Halabi (2006) burnout the need for health workers to support each other, for supervisors to support their staff and also for the management to encourage support.

One predictor of psychological distress among health workers was „Uncertainty concerning treatment‟ which concerns lack of autonomy, decision making and power to change. This shows the need for transition programmes to link the theoretical and clinical setting and to prepare health workers to use skills of critical thinking in managing severely ill patients to ensure health workers are confident to deal with the degree of autonomy they are required to demonstrate as a registered health worker (Halfer, 2007).

Prolonged burnout may lead to increased risk of health issues, both physical and psychological. Attention should be given to what aspects of the job causes of burnouts that could be changed, and what practical steps can be taken to identify vulnerable individuals and support them at an early stage. A rational strategy for the Ministry ofHealth would be to offer employment environments in which health workers can work effectively without negatively affecting their health.

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