|Year : 2017 | Volume
| Issue : 3 | Page : 80-86
Cross-Sectional study of the overall emotional functioning of health-care providers in Saudi
Abbas Al Mutair1, Fadillah Al Obaidan2, Mohammed Al-Muhaini3, Khulud Al Salman4, Samer Al Mosajen5
1 Inaya Medical College, Riyadh, Saudi Arabia, Wollongong University, Australia
2 Nursing Department, Al Qatif Hospital, Ministry of Health, Al Hassa, Saudi Arabia
3 King Saud Ben Abdulaziz University for Health Sciences, Al Hassa, Saudi Arabia
4 Patient Safety, Al Jaber Hospital, Al Hassa, Ministry of Health, Saudi Arabia
5 Mohammed Al Mana College for Health Sciences, Dammam, Saudi Arabia
|Date of Web Publication||16-Feb-2018|
Abbas Al Mutair
Inaya Medical College, Riyadh, Saudi Arabia, Wollongong University, Australia
Source of Support: None, Conflict of Interest: None
Background: Health-care professionals work long hours, handle demanding patient loads, and make important decisions under conditions of uncertainty. These uncertain conditions have been shown to be associated with negative emotional and psychological outcomes for health-care professionals. In addition, they have been shown to lead to anxiety, depression, and other psychological and interpersonal strains, ultimately compromising the quality of patient care. Purpose: The purpose of this study is to evaluate the mental health issues of health-care providers including anxiety, depression, behavioral control, positive effect, and general distress. Methods: This is a cross-sectional study using a self-administered questionnaire. The questionnaire was distributed to health-care providers working at governmental and private health sectors in Saudi Arabia from January to April 2016. The questionnaire included a demographic survey and the Mental Health Inventory. Forty-five (45%) staff members completed the questionnaire. Results: Health-care professionals scored higher within the psychological distress, anxiety, depression, and loss of behavioral emotional control domains, indicating greater psychological distress. Females scored more on the depression domain than male participants. Further, physicians scored higher on the general positive effect domain than other health-care providers. Non-Saudi health-care providers scored higher on psychological distress scale than Saudi participants. Multiple regression analysis indicated that general positive effect, emotional ties, and life satisfaction were predictors of psychological well-being; on the other hand, anxiety, depression, and loss of behavioral/emotional control were predictors of psychological distress. Conclusion: High psychological distress may result from stressors associated with high work demands, workload, staff shortage, fear of infection, licensing board, fear of losing job, fear of reaction from leadership, peer, and patients and their families. Implication for Nursing Policy: Organizational supportive programs should be developed to enhance the psychological well-being of health-care professionals. These programs may decrease staff stress, anxiety, and depression and contribute to improve psychological well-being.
Keywords: Anxiety, depression, emotional ties, health-care providers, life satisfaction, loss of behavioral/emotional control general positive effect, mental health, psychological distress, psychological well-being
|How to cite this article:|
Al Mutair A, Al Obaidan F, Al-Muhaini M, Al Salman K, Al Mosajen S. Cross-Sectional study of the overall emotional functioning of health-care providers in Saudi. Saudi Crit Care J 2017;1:80-6
|How to cite this URL:|
Al Mutair A, Al Obaidan F, Al-Muhaini M, Al Salman K, Al Mosajen S. Cross-Sectional study of the overall emotional functioning of health-care providers in Saudi. Saudi Crit Care J [serial online] 2017 [cited 2021 Jan 28];1:80-6. Available from: https://www.sccj-sa.org/text.asp?2017/1/3/80/225729
| Introduction|| |
Psychological distress is a state of emotional suffering characterized by moderate-to-severe depressive and anxiety symptoms (Drapeau et al. 2010). A health professional is an individual who provides preventive, curative, promotional, or rehabilitative health-care services in a systematic manner to people, families, or communities. A health professional may operate within medicine, surgery, midwifery, dentistry, nursing, pharmacy, psychology, or allied health professions. A health professional may also be a public/community health expert working for the common good of the society (Ruotsalainen et al. 2016).
Health-care providers are exposed to high levels of workplace-related stress. Growing evidence suggests that health-care providers may experience mental health issues. Health-care professionals provide care for patients suffering from life-threatening trauma or facing death and dying. Working in such situations is stressful and may result in psychonxious among health-care providers., Stress often results from care delivery and may be coupled with depression and anxiety., High rates of anxiety, stress, and depression might be because of high patient flow rates, clinical shift working, and risk of getting infections.,,
Occupational stress and occupational burnout are highly prevalent among health-care professionals. Some studies suggest that workplace stress is pervasive in the health-care industry because of staff shortage, long working hours, exposure to infectious diseases and hazardous substances leading to illness or death, and in some countries, the threat of malpractice litigation., Other stressors include the emotional labor of caring for ill people and high patient loads. The consequences of this stress can include substance abuse, suicide, major depressive disorder, and anxiety, all of which occur at higher rates among health-care professionals than the general working population.,,, Elevated levels of stress are also linked to high rates of burnout, absenteeism, and diagnostic errors, as well to reduced rates of patient satisfaction.,
High workload, staff shortage, and limited resources threaten health-care providers' emotional well-being and lead to mounting stress, psychological distress, emotional exhaustion, and burnout., Furthermore, these factors contribute to job and life dissatisfaction among health-care providers. In their recent research, Jordan et al. found that 90% participating midwives reported feeling worn out, 86% were emotionally exhausted, 85% had high levels of frustration at work, and of the total sample, only 9.3% reported feeling energetic. Furthermore, health-care professionals are also likely to experience sleep deprivation due to their jobs. Many health-care professionals are on a shift work schedule, and therefore, experience misalignment of their work schedule and their circadian rhythm. In 2007, 32% of health-care workers reported getting fewer than 6 h of sleep a night. Sleep deprivation also predisposes health-care professionals to make mistakes that may potentially endanger a patient.
In a mental health survey of 560 UK ambulance workers, nearly 10% of the participating ambulance workers reported clinical levels of depression and 22% registered clinical levels of anxiety. Other studies have also shown high levels of psychological distress among health-care professionals. It has been reported that a quarter to half of the studied staff reported distress (Gross, 1998; Graham et al. 1996).,,,,,,,, Increased psychological distress noted in previous studies were associated with heavy workload, work pressure, risk of violence, inadequate resources, insufficient training, low job satisfaction, poor management style, and low involvement in decision-making.
It has been suggested that individual variables such as age, health-care professionals' position, and years of experience may influence health outcome. In study by Jordan et al., participants aged 35 years or younger and with <10 years of midwifery experience were seen to score the highest on personal and work-related domains. The study also showed that participants over 35 years scored the highest within the client-related domain. Furthermore, midwives at junior positions scored the highest for work-related and client-related burnout; midwives at senior positions scored the highest for personal burnout. Female health-care workers may face specific types of workplace-related health conditions and stress.
Based on the foregoing evidence, it is clear that stress among health-care providers may have a negative impact on their mental health. Therefore, it is essential to identify the mental health status of health-care professionals to help them to deal with it effectively and be more productive in their professions. The finding of this research will help to identify the most vulnerable health professions. It will further open a means for health professionals to seek help before the stress leads to depression, decreased job satisfaction, and psychological distress.
Aim of the study
This study aims to evaluate the mental health issues of health-care providers including anxiety, depression, behavioral control, positive effect, and general distress.
| Methods|| |
A cross-sectional multicenter survey study was performed. Data were collected using a questionnaire aimed at answering the research question. The questionnaire used in the study was Mental Health Inventory (MHI) to evaluate the mental health issues of health-care providers.
The study was conducted at multiple public and private hospitals located in different geographical areas in Saudi Arabia. The study used a probability convenience sample to recruit health-care providers employed in both critical and noncritical areas in the study. A sample size of 500 participants was chosen to allow estimation of effects of moderate size at 5% significance level with 80% power. However, the actual sample size in the present study was a total of 614 participants.
A link to the anonymous survey was distributed through various communication channels among health-care providers in Saudi Arabia. The survey was open for completion from January to April 2016 to provide adequate time for health-care providers in Saudi Arabia to participate.
Ethical approvals to conduct the research including the methodology used to collect the data were received from the General Administration of Medical Research in the Saudi Arabian Ministry of Health (No 826811). The MOH is the principal governing body of health-care services in Saudi Arabia. Participants were informed that participation is voluntary and consent is inferred by submission of the completed surveys.
Data collection instrument
The MHI was used to measure the overall emotional functioning of health-care providers. The MHI includes 38 items, in which the respondent uses a six-point Likert-style response and can generally be completed without help. The tool was developed as part of the National Health Insurance Study  and has been extensively studied in a variety of populations. It provides an assessment of several domains of mental health including anxiety, depression, behavioral control, positive effect, and general distress. The full-length version of the MHI has a Cronbach's alpha of 0.93. The MHI has been studied extensively in large populations and has considerable evidence regarding its validity. Another part was added to the tool concerning the demographic characteristics of the participants including, age, gender, marital status, qualifications, health-care profession, nationality, and type of health-care facilities.
Demographic data and responses to scale items were downloaded and analyzed. Data were collated through descriptive and inferential statistics using IBM-SPSS Version 22 (IBM Corp., Armonk, 2011, New York, USA). Inferential statistics including frequency distributions and parametric and nonparametric methods were computed, as appropriate.
| Results|| |
The overall response rate across multiple health-care facilities was 45%, representing 614 health-care providers. As illustrated in [Table 1], more than two-thirds of the participants were married with a median age of 32 years, and the median age range was 18–63 years. Of the 614 participants, 509 (83.7%) were female health-care providers. Almost half (284) of the participants had a diploma (46.3%), 239 (39.2%) had a bachelor degree, and the rest had a postgraduate degree including Master's and PhD. Participants were mainly nurses 450 (74.5%), physicians 76 (12.6%), pharmacists 23 (3.8%), lab technologists 17 (2.8%), and other health-care professionals 38 (6.3%). Approximately 409 (73.2%) participants were Saudi and 150 (24.4%) are non-Saudi health-care providers. In general, most participants worked in public health-care facilities (565 [92%]) and only 37 (6.1%) worked in private health-care facilities.
The Psychological Distress and Psychological Well-being global scales represent complementary summary scales with psychological distress indicating negative states of mental health and psychological well-being indicating positive states. Of the total 38 items, 24 were used for psychological distress and 14 for psychological well-being with no item overlap. The participants scored a total mean of 91.02 (18.03) indicating greater psychological distress, they also scored a total of 48.07 (11.68) indicating moderate psychological well-being [Table 2].
As reported in [Table 3], participants scored higher on anxiety, depression, and loss of behavioral/emotional control domains as 35.00 (8.61), 15.44 (3.71), and 33.29 (5.36), respectively. Higher scores on these three subscales (anxiety, depression, and loss of behavioral/emotional control) indicate negative states of mental health among the participating health-care providers. In addition, general positive effect, emotional ties, and life satisfaction subscales scored an average mean of 34.47 (8.67), 5.96 (2.46), and 3.30 (1.09), respectively.
An independent t-test was conducted to compare the results of MHI domains among male and female. There were no statistically significant differences between males and females and scores of psychological distress, psychological well-being, anxiety, loss of behavioral emotional control, emotional ties, and life satisfaction scales (P > 0.05). There was a statistically significant difference between gender and depression scale, (t(561) = −0.91, P = 0.01), as illustrated in [Table 4]. Females scored higher than male participants. There were also slightly statistically significant differences between participants' gender and general positive effect scale, (t (547) = 0.52, P = 0.01). Males had more a positive effect behavior than female participants.
An independent t-test was conducted to compare the MHI domains and participants' marital status. There were no statistically significant differences between single and married health-care providers and scores of psychological distress, psychological well-being, anxiety, loss of behavioral emotional control, emotional ties, and life satisfaction scales (P > 0.05) [Table 5].
Analysis of variance test was performed to compare the MHI domains and health-care providers' qualifications. The test showed a statistically significant difference between participants' psychological distress and their qualifications (P = 0.008). Bachelor degree holders had more psychological distress (mean = 95.45 ± 15.61) compared to diploma holders (mean = 88.57 ± 18.70) and postgraduate degree holders (mean = 88.66 ± 24.67). Physicians scored higher on the general positive effect scale (mean = 37.47 ± 6.88, P = 0.01) than nurses (mean = 33.82 ± 8.95), pharmacists (mean = 36.70 ± 8.51), and lab technologist (mean = 35.45 ± 7.91). Moreover, statistically significant differences were detected between nationality and psychological distress (t(259) =3.84, P = 0.0001). Non-Saudi health-care providers (mean = 96.74 ± 13.90) scored higher on psychological distress scale than Saudi participants (mean = 88.44 ± 18.90).
In addition, statistically significant differences were found between nationality and anxiety scale (t(280) = 4.68, P = 0.003). The test showed that Non-Saudi health-care providers scored higher on anxiety domain (mean = 38.16 ± 6.83) than Saudi participants (mean = 33.50 ± 8.87).
Collinearity statistics showed that age was interfering too much with participants' emotional functioning. There was a statistically significant relationship between participants' age and psychological distress domain (F = 2.68, P = 0.03). Older participants scored higher on psychological distress. A statistically significant relationship was also detected between older health-care providers and anxiety (F = 4.57, P = 0.001) and depression (F = 5.25, P = 0.0001). In addition, a statistically significant difference relationship was computed between age and loss of behavioral emotional control. Older health-care providers scored higher on the loss of behavioral emotional control scale.
Predictors of psychological well-being
Multiple regression analysis was performed using mean psychological well-being as the dependent variable and general positive effect, emotional ties, and life satisfaction as predictors. The model accounted for 98% of the variance regarding psychological well-being [Table 4]. Significant predictors included frequency of general positive effect, emotional ties, and life satisfaction. In this sample, being life satisfied, having general positive effect and strong emotional ties predicted good psychological well-being.
Predictors of psychological distress
Multiple regression analysis was performed with mean psychological distress as the dependent variable and anxiety, depression and loss of behavioral/emotional control as predictors. The model accounted for 99% of the variance in psychological distress [Table 4]. Significant predictors were frequency of anxiety, depression, and loss of behavioral/emotional control as predictors. Being depressed and having anxiety and loss of behavioral/emotional control predicted psychological distress in our sample.
| Discussion|| |
This study aimed to evaluate the mental health issues of health-care providers including anxiety, depression, behavioral control, positive effect, and general distress. Various studies including the current study have shown high amounts of psychological distress in doctors, nurses, and other health-care providers working in different health-care facilities. At present, the largest proportion of practicing health-care providers are Saudi female married nurses in their 20–30 s, and mainly working in public health-care facilities, which reflects the health-care workforce in Saudi Arabia.
In contrast with the previous studies,, age was associated with participants' psychological distress. Elderly individuals scored higher on psychological distress including anxiety, depression, and loss of behavioral/emotional control revealing that when age increases, stress increases making one prone to psychological distress. An explanation for the distribution of psychological distress by age is that elderly individuals are commonly perceived to have less control over their mental health than adults. This lack of perceived control has adverse effects on how they cope with stressful situations, which may result in psychological distress including anxiety and depression.
These results are consistent with previous studies conducted among health-care professionals (Aasland et al. 1998),,, where participants reported high psychological distress. Participants in the current study scored a total mean of 91.02 (18.03), indicating greater psychological distress, they also scored a total of 48.07 (11.68), indicating moderate psychological well-being. Health-care professionals at the workplace are exposed to high levels of work-related stress because of patient care delivery, as indicated by Jordan et al. and Mollart et al. High psychological distress might be due to high patient flow rates, work shifts, and risk of getting infections.,, The same was also reported by Jordan et al. who reported that 90% of the midwives felt worn out, 86% were emotionally exhausted, and 85% had high levels of frustration at work.
Although the present study must be interpreted in light of its limitations, it is interesting that Bennett et al. and the present study reported high levels of depression and anxiety among health-care providers. The findings of a recent study indicated negative state of mental health among participating health-care providers who scored higher on anxiety, depression, and loss of behavioral/emotional control, 35.00 (8.61), 15.44 (3.71), and 33.29 (5.36), respectively. Medication errors and absence of patient and medication safety culture might be the reasons for high anxiety and depression among health-care professionals. In Saudi Arabia, high medication errors are reported every day. Various fears may cause psychological distress among health-care professionals, including fear of punishment, lack of a “just culture of safety,” fear of press or media, licensing board, fear of losing job, fear of reaction from leadership, peer, patients and their families, fear from being considered as troublemakers.
Depression levels among women were found to be higher than men health-care providers (P = 0.01). The demographic association with depression is consistent with those reported in previous studies. The differences in depression between men and women could be accounted by high work demands experienced and a lack of role clarity among health-care providers in Saudi Arabia. In previous studies, women were twice as likely to experience depression than men. They were also likely to suffer up to three times more from anxiety. They are several reasons of these gender differences such as hormonal differences or women tend to be more involved in personal relationships.
Furthermore, qualifications, profession, and health-care nationality were all significantly related to psychological distress, anxiety, and general positive effect, which is consistent with other studies (Olaf et al. 1997). High levels of psychological distress, depression, and anxiety in the work-related and personal domains are more likely to be the result of a health-care industry that is becoming increasingly busy, chaotic, and risk adverse. The results reveal that bachelor-degree holders and non-Saudi health-care providers had more psychological distress and anxiety and physicians scored higher on general positive effect scale. Although more studies are required, there is evidence that having children and a life outside of work reduces levels of anxiety and work-related stress and is a positive strategy for coping with psychological distress., Non-Saudi female health-care providers mainly live in Saudi Arabia alone without their children. This work–life imbalance may result in high anxiety and psychological distress scores.
The results of the multiple regression analyses indicated that general positive effect, emotional ties, and life satisfaction were all significantly related to psychological well-being. Moreover, anxiety, depression, and loss of behavioral/emotional control were all significantly related to psychological distress. The general picture is, however, the same. In the present study, levels of anxiety, depression, and loss of behavioral/emotional control were dependent on the levels of psychological distress (as measured by the MHI). In turn, levels of general positive effect, emotional ties, and life satisfaction were dependent of the levels of psychological well-being. These findings provide some evidence of the more anecdotal suggestions that high level of anxiety, depression, or loss of emotional control experienced by health-care providers are largely accounted for by higher levels of psychological distress. The work demands in health-care services predict additional psychological distress, which is evident from the fact that the two global mental health domains, psychological well-being, and distress, are in an inverse relationship. Greater clarification of these concepts is needed before general models of the psychological distress can be of use.
The results, however, need to be understood within the limitations of the study. The principle limitation of the current study was that the number of health-care professionals other than nurses was very small compared to nurses because of the low response rate in these groups. The mental health issues were only measured at one time point, and hence, the findings cannot be generalized. The present study used the MHI self-administered questionnaire to measure the mental health issues of health-care providers. It is important to keep in mind that the MHI cannot be used to generate a formal psychiatric diagnosis. Therefore, in-depth assessment methods to assess and diagnose mental health issues must be used in the future to validate the study results. Although further work is indicated and despite the limitations of this study, the results add to the growing body of evidence around the emotional well-being of the health-care professional workforce.
| Conclusion and Clinical Implications|| |
It is possible that the health-care professionals who participated in the study had higher psychological distress because of the stressors associated with high work demands. This study was conducted in 24 different geographical areas in Saudi Arabia. The results are representative of the study participants. The study results demonstrate that interventions should be introduced to improve the emotional well-being of health-care professionals. Organizational supportive programs must be developed to improve the psychological well-being of health-care professionals. These strategies may decrease stress, anxiety, and depression, and contribute to improved psychological well-being. The study may inform the development of subsequent research and future wellness programs for health-care providers in Saudi Arabia or other Arab countries.
The authors would like to send their sincere thanks to all health-care workers in Saudi Arabia who volunteered to participate in this research.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Drapeau A, Beaulieu-Prévost D, Marchand A, Boyer R, Préville M, Kairouz S, et al.
Alife-course and time perspective on the construct validity of psychological distress in women and men. Measurement invariance of the K6 across gender. BMC Med Res Methodol 2010;10:68.
Ruotsalainen JH, Verbeek JH, Mariné A, Serra C. Preventing occupational stress in healthcare workers. Sao Paulo Medical Journal 2016;134:92.
Courtney JA, Francis AJ, Paxton SJ. Caring for the country: Fatigue, sleep and mental health in Australian rural paramedic shiftworkers. J Community Health 2013;38:178-86.
Rice V, Glass N, Ogle K, Parsian N. Exploring physical health perceptions, fatigue and stress among health care professionals. J Multidiscip Healthc 2014;7:155-61.
Lim J, Bogossian F, Ahern K. Stress and coping in Australian nurses: A systematic review. Int Nurs Rev 2010;57:22-31.
Alexander DA, Klein S. First responders after disasters: A review of stress reactions, at-risk, vulnerability, and resilience factors. Prehosp Disaster Med 2009;24:87-94.
Jordan K, Fenwick J, Slavin V, Sidebotham M, Gamble J. Level of burnout in a small population of Australian midwives. Women Birth 2013;26:125-32.
Mollart L, Skinner VM, Newing C, Foureur M. Factors that may influence midwives work-related stress and burnout. Women Birth 2013;26:26-32.
Courtney JA, Francis AJ, Paxton SJ. Caring for the carers: Fatigue, sleep, and mental health in Australian paramedic shiftworkers. Aust N
Z J Organ Psychol 2010;3:32-41.
Bentley MA, Crawford JM, Wilkins JR, Fernandez AR, Studnek JR. An assessment of depression, anxiety, and stress among nationally certified EMS professionals. Prehosp Emerg Care 2013;17:330-8.
Zhu JL, Hjollund NH, Andersen AM, Olsen J. Shift work, job stress, and late fetal loss: The National Birth Cohort in Denmark. J Occup Environ Med 2004;46:1144-9.
Zeller JM, Levin PF. Mindfulness interventions to reduce stress among nursing personnel: An occupational health perspective. Workplace Health Saf 2013;61:85-9.
Singh C, Sharma S, Sharma RK. Level of stress and coping strategies used by nursing interns. Nurs Midwifery Res J 2011;7:152, 160.
Swanson N, Tisdale-Pardi J, MacDonald L, Tiesman HM. “Women's Health at Work”. National Institute for Occupational Safety and Health; 2013. [Last retrieved on 2015 Jan 21].
Hartley D, Ridenour M. Free On-line Violence Prevention Training for Nurses. National Institute for Occupational Safety and Health. NIOSH Science Blog; 2013.
Pijl-Zieber EM, Hagen B, Armstrong-Esther C, Hall B, Akins L, Stingl M. Moral distress: an emerging problem for nurses in long-term care?. Quality in Ageing and Older Adults 2008;9:39-48.
Görgens-Ekermans G, Brand T. Emotional intelligence as a moderator in the stress-burnout relationship: A questionnaire study on nurses. J Clin Nurs 2012;21:2275-85.
Hartley D, Ridenour M. Workplace Violence in the Health Care Setting. National Institute for Occupational Safety and Health; 2011. Available from: http://www.medscape.com/viewarticle/749441
. [Last accessed on 2017 Dec 12].
Bennett P, Williams Y, Page N, Hood K, Woollard M. Levels of mental health problems among UK emergency ambulance workers. Emerg Med J 2004;21:235-6.
Weinberg A, Creed F. Stress and psychiatric disorder in healthcare professionals and hospital staff. Lancet 2000;355:533-7.
Jex SM, Hughes P, Storr C, Baldwin DC Jr., Conard S, Sheehan DV, et al.
Behavioral consequences of job-related stress among resident physicians: The mediating role of psychological strain. Psychol Rep 1991;69:339-49.
Richardsen AM, Burke RJ. Occupational stress and work satisfaction among Canadian women physicians. Psychol Rep 1993;72:811-21.
Gross EB. Gender differences in physician stress: Why the discrepant findings? Women Health 1997;26:1-14.
Tholdy Doncevic S, Romelsjö A, Theorell T. Comparison of stress, job satisfaction, perception of control, and health among district nurses in Stockholm and prewar Zagreb. Scand J Soc Med 1998;26:106-14.
van Wijk C. Factors influencing burnout and job stress among military nurses. Mil Med 1997;162:707-10.
Aasland OG, Olff M, Falkum E, Schweder T, Ursin H. Health complaints and job stress in Norwegian physicians: The use of an overlapping questionnaire design. Soc Sci Med 1997;45:1615-29.
Graham J, Ramirez AJ, Cull A, Finlay I, Hoy A, Richards MA, et al.
Job stress and satisfaction among palliative physicians. Palliat Med 1996;10:185-94.
Hardy GE, Shapiro DA, Borrill CS. Fatigue in the workforce of National Health Service trusts: Levels of symptomatology and links with minor psychiatric disorder, demographic, occupational and work role factors. J Psychosom Res 1997;43:83-92.
Veit CT, Ware JE Jr. The structure of psychological distress and well-being in general populations. J Consult Clin Psychol 1983;51:730-42.
Kowalski C, Ommen O, Driller E, Ernstmann N, Wirtz MA, Köhler T, et al.
Burnout in nurses – The relationship between social capital in hospitals and emotional exhaustion. J Clin Nurs 2010;19:1654-63.
Aboshaiqah AE. Barriers in reporting medication administration errors as perceived by nurses in Saudi Arabia. Middle East J Sci Res 2013;17:130-6.
Nolen-Hoeksema S. Gender differences in depression. Curr Dir Psychol Sci 2001;10:173-6.
Korunka C, Tement S, Zdrehus C, Borza A. Burnout: Definition, recognition and prevention approaches. Boit; 2010.
Schluter PJ, Turner C, Huntington AD, Bain CJ, McClure RJ. Work/life balance and health: The nurses and midwives e-cohort study. Int Nurs Rev 2011;58:28-36.
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5]