Discussion The conclusion of the study indicates that emotional exhaustion decreases after the intervention and increases again in the 6 months. However, no significant difference was noted between groups and group ¥ time interaction. There was no change in depersonalization and personal accomplishment dimensions of burnout after the intervention. The fact that emotional exhaustion scores decrease with respect to time after the intervention is an important conclusion. The literature indicates that emotional
exhaustion is the dimension that specifies the character and also makes up the focus of burnout. According to the burnout model of Taris et al. (2005), the emotional exhaustion of an individual leads to depersonalization, and increase in depersonalization causes reduction in personal accomplishment. Emotional exhaustion also directly causes a reduction in personal accomplishment. Therefore, emotional exhaustion is the core dimension and is the first stage of burnout. A reduction especially in emotional exhaustion may decrease depersonalization, and it will be able to increase personal accomplishment. Although emotional exhaustion scores decrease with respect to time, the reason no significant difference was found between the groups may be sample losses. Because the intention-to-treat approach was based on the analyses, it was an anticipated result that the effect of the intervention was lower(Gross&Fogg2004). In the study conducted by Marine et al. (2006), it was reported that one of the biggest problems in studies on work stress was losses in samples. Because the sample losses encountered in this study posed an important problem, a qualitative study was con- ducted to clarify these losses (Günüs¸en & Üstün 2009). Nurses described burnout as resulting from work-related issues, and their attendance was impeded by working conditions and lack of support. Although we had support for our programme from the senior nursing administration, this did not always translate into support at the unit level, where nurse managers did not consistently develop schedules that allowed attendance. Most participants stated that they need work-directed rather than person- directed interventions to reduce stress and burnout. Therefore, their belief that person-directed interventions would be useless had a negative impact on the level of participation. This suggests that intervention programmes are more likely to be effective if they include person-directed as well as work-directed approaches (Günüs¸en & Üstün 2009). It is recommended to the researchers who wish to conduct this type of studies that they should take measures to minimize sample losses. Emotional exhaustion scores increased in 6 months. The reason for this might be that the effect of the intervention is not long lasting. It is seen that the follow-up periods for studies conducted on burnout were generally short (Marine et al. 2006). Burnout values presented just before and after the intervention can highlight the effectiveness of the intervention. Also, in this study, it could be said that the intervention had been very effective in reducing burnout if the scores for the 6 months following had not existed;that is why the increase observed in the 6 months is an important finding. Rowe (1999), who followed burnout scores for 2 years, supports this idea. Burnout levels of those who were given one-time coping training were observed to reduce in the short term but increased after the 6 months. In the light of these results, it can be considered that person-directed interventions cannot maintain their effectiveness in the long term, thus, they have to be repeated regularly. In Rowe’s study, it was found that the burnout scores of the group that had received refreshing coping training kept being sufficiently low during the course of 2 years of following. Another possible reason that the burnout scores increased in the 6 months was the changes that took place in the hospital. Data collection period for the 6 months coincided with the hospital’s preparation period for the receipt of quality certification. Nurses reported that they worked very hard in this period, that they underwent inspections and that this situation increased the work load and the pressure they felt. Additional stressors in nurses’ work life might cause them to feel more burned out. In this study, burnout has been integrated with the concepts of NSM. Burnout levels of the nurses were attempted to be reduced by means of strengthened psychological and sociocultural dimensions in the LOR through coping and social support groups. The fact that emotional exhaustion scores of the nurses decrease when the lines of resistance are strengthened validates Neuman’s hypothesis, which proposes that core response can be reduced by secondary prevention. In addition, burnout levels reduced in the short term but started to rise in 6 months. When one considers the fact that LOR is a type of coping method learned in time, it is difficult to expect the training programmes to come into effect right away. Therefore, if the training programmes are repeated regularly, then it will be possible for an individual to use what he/she learns. Another reason burnout increases again may be that the intervention was directed only to the psychological and socio- cultural dimensions. When one considers the fact that line of defence responds to stressor via the interaction of five pre- defined person dimensions, then another dimension that can be related to burnout is the spiritual dimension. According to Malach-Pines (2000), burnout stems from the sense of failure to find a meaning in life via working. The reason burnout increases after a while in this study may be the lack of a spiritual dimension in the interventions. Therefore, it is important for researchers who plan to proceed with similar interventions that they use the spiritual dimension as well in their studies. Burnout is a multidimensional problem, and for this reason, interventions have to be multidimensional.
Discussion The conclusion of the study indicates that emotional exhaustion decreases after the intervention and increases again in the 6 months. However, no significant difference was noted between groups and group ¥ time interaction. There was no change in depersonalization and personal accomplishment dimensions of burnout after the intervention. The fact that emotional exhaustion scores decrease with respect to time after the intervention is an important conclusion. The literature indicates that emotional
exhaustion is the dimension that specifies the character and also makes up the focus of burnout. According to the burnout model of Taris et al. (2005), the emotional exhaustion of an individual leads to depersonalization, and increase in depersonalization causes reduction in personal accomplishment. Emotional exhaustion also directly causes a reduction in personal accomplishment. Therefore, emotional exhaustion is the core dimension and is the first stage of burnout. A reduction especially in emotional exhaustion may decrease depersonalization, and it will be able to increase personal accomplishment. Although emotional exhaustion scores decrease with respect to time, the reason no significant difference was found between the groups may be sample losses. Because the intention-to-treat approach was based on the analyses, it was an anticipated result that the effect of the intervention was lower(Gross&Fogg2004). In the study conducted by Marine et al. (2006), it was reported that one of the biggest problems in studies on work stress was losses in samples. Because the sample losses encountered in this study posed an important problem, a qualitative study was con- ducted to clarify these losses (Günüs¸en & Üstün 2009). Nurses described burnout as resulting from work-related issues, and their attendance was impeded by working conditions and lack of support. Although we had support for our programme from the senior nursing administration, this did not always translate into support at the unit level, where nurse managers did not consistently develop schedules that allowed attendance. Most participants stated that they need work-directed rather than person- directed interventions to reduce stress and burnout. Therefore, their belief that person-directed interventions would be useless had a negative impact on the level of participation. This suggests that intervention programmes are more likely to be effective if they include person-directed as well as work-directed approaches (Günüs¸en & Üstün 2009). It is recommended to the researchers who wish to conduct this type of studies that they should take measures to minimize sample losses. Emotional exhaustion scores increased in 6 months. The reason for this might be that the effect of the intervention is not long lasting. It is seen that the follow-up periods for studies conducted on burnout were generally short (Marine et al. 2006). Burnout values presented just before and after the intervention can highlight the effectiveness of the intervention. Also, in this study, it could be said that the intervention had been very effective in reducing burnout if the scores for the 6 months following had not existed;that is why the increase observed in the 6 months is an important finding. Rowe (1999), who followed burnout scores for 2 years, supports this idea. Burnout levels of those who were given one-time coping training were observed to reduce in the short term but increased after the 6 months. In the light of these results, it can be considered that person-directed interventions cannot maintain their effectiveness in the long term, thus, they have to be repeated regularly. In Rowe’s study, it was found that the burnout scores of the group that had received refreshing coping training kept being sufficiently low during the course of 2 years of following. Another possible reason that the burnout scores increased in the 6 months was the changes that took place in the hospital. Data collection period for the 6 months coincided with the hospital’s preparation period for the receipt of quality certification. Nurses reported that they worked very hard in this period, that they underwent inspections and that this situation increased the work load and the pressure they felt. Additional stressors in nurses’ work life might cause them to feel more burned out. In this study, burnout has been integrated with the concepts of NSM. Burnout levels of the nurses were attempted to be reduced by means of strengthened psychological and sociocultural dimensions in the LOR through coping and social support groups. The fact that emotional exhaustion scores of the nurses decrease when the lines of resistance are strengthened validates Neuman’s hypothesis, which proposes that core response can be reduced by secondary prevention. In addition, burnout levels reduced in the short term but started to rise in 6 months. When one considers the fact that LOR is a type of coping method learned in time, it is difficult to expect the training programmes to come into effect right away. Therefore, if the training programmes are repeated regularly, then it will be possible for an individual to use what he/she learns. Another reason burnout increases again may be that the intervention was directed only to the psychological and socio- cultural dimensions. When one considers the fact that line of defence responds to stressor via the interaction of five pre- defined person dimensions, then another dimension that can be related to burnout is the spiritual dimension. According to Malach-Pines (2000), burnout stems from the sense of failure to find a meaning in life via working. The reason burnout increases after a while in this study may be the lack of a spiritual dimension in the interventions. Therefore, it is important for researchers who plan to proceed with similar interventions that they use the spiritual dimension as well in their studies. Burnout is a multidimensional problem, and for this reason, interventions have to be multidimensional.
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