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Stress of conscience and burnout in healthcare: the danger of deadening one's conscience
Umeå University, Faculty of Medicine, Omvårdnad.
2007 (English)Doctoral thesis, comprehensive summary (Other academic)
Abstract [en]

The overall purpose of this thesis is to investigate whether there is an association between “stress of conscience” — that is, stress related to a troubled conscience — and burnout, and to obtain an enhanced understanding of factors related to stress of conscience and burnout in healthcare. Of the four “studies” included, one uses qualitative research methods and the others use quantitative research methods. The data are based on cross-sectional questionnaire studies (I, II, and IV) and open-ended interviews (III).

We could find no existing suitable instrument for measuring troubled conscience in healthcare, and so we constructed and tested the “Stress of Conscience Questionnaire” (SCQ) (I), a nine-item instrument for assessing stressful situations and the degree to which they trouble the conscience. We included 164 participants in the pilot studies, an additional 444 in the main analysis, and 55 in the test-retest verification. Participants had various occupational backgrounds and were recruited from different parts of Sweden. Our findings suggest that the SCQ is a valid and reliable measurement for use in various healthcare contexts. Cronbach’s α for the overall scale was 0.83, ensuring internal consistency. Explorative factor analysis identified and labelled two factors: “internal demands” and “external demands and restrictions”.

To investigate factors related to stress of conscience and burnout (II, IV) we used a sample of 423 healthcare personnel from various specialities and with various occupations, from a district in northern Sweden. Multiple regression analysis showed that the factors related to stress of conscience (II) were: perceiving that conscience warns us against hurting others while at the same time not being able to follow one’s conscience at work, and having to deaden one’s conscience in order to keep working in healthcare; and also moral sensitivity items belonging to the factor “sense of moral burden”. In addition, deficient social support from superiors, low levels of resilience, and working in internal medicine wards were all associated with stress of conscience. The model explained 40% of the total variance.

Interviews were conducted with 30 healthcare managers, to illuminate their explanatory models of the sources contributing to burnout in healthcare settings (III). The data were analysed using qualitative content analysis. The findings indicate that continuous reorganisation and downsizing of health care has reduced resources, while at the same time demands and responsibilities have increased. These problems are compounded by high ideals and expectations, making staff question their own abilities and worth. All in all this throws healthcare employees into a spiralling sense of inadequacy and an emerging sense of pessimism and powerlessness.

Multiple regression analysis showed that having to deaden one’s conscience, stress of conscience from lacking the time to provide the necessary care, the work being so demanding that it influences one’s home life, not being able to live up to others’ expectations, low social support from co-workers, and low levels of resilience were all related to emotional exhaustion. Other factors that had an impact were being female, being a physician or being other healthcare professional and working in geriatric care or a primary healthcare centre. The full model explained 59% of the variance. Factors contributing to depersonalisation were: having to deaden one’s conscience, stress of conscience from not being able to live up to others’ expectations and from having to lower one’s aspirations to provide good care, deficient social support from co-workers, and being a physician; however, the percentage of variation explained was smaller (30%) (IV).

The findings indicate that burnout is related to being unable to live up to one’s moral convictions; thus, it is a consequence of healthcare employees’ feeling that they are not acting on their values and for the wellbeing of the patients.

Place, publisher, year, edition, pages
Umeå: Omvårdnad , 2007. , 91 p.
Series
Umeå University medical dissertations, ISSN 0346-6612 ; 1101
Keyword [en]
conscience, troubled conscience, stress, burnout, healthcare personnel
National Category
Nursing
Identifiers
URN: urn:nbn:se:umu:diva-1111ISBN: 978-91-7264-316-1 (print)OAI: oai:DiVA.org:umu-1111DiVA: diva2:140236
Public defence
2007-05-25, Aulan, Vårdvetarhuset, 901 87 Umeå, Umeå, 09:00 (English)
Opponent
Supervisors
Available from: 2007-05-04 Created: 2007-05-04 Last updated: 2009-05-19Bibliographically approved
List of papers
1. Development and initial validation of the Stress of Conscience Questionnaire
Open this publication in new window or tab >>Development and initial validation of the Stress of Conscience Questionnaire
Show others...
2006 (English)In: Nursing Ethics, ISSN 0969-7330, E-ISSN 1477-0989, Vol. 13, no 6, 633-648 p.Article in journal (Refereed) Published
Abstract [en]

Stress in health care is affected by moral factors. When people are prevented from doing 'good' they may feel that they have not done what they ought to or that they have erred, thus giving rise to a troubled conscience. Empirical studies show that health care personnel sometimes refer to conscience when talking about being in ethically difficult everyday care situations. This study aimed to construct and validate the Stress of Conscience Questionnaire (SCQ), a nine-item instrument for assessing stressful situations and the degree to which they trouble the conscience. The items were based on situations previously documented as causing negative stress for health care workers. Content and face validity were established by expert panels and pilot studies that selected relevant items and modified or excluded ambiguous ones. A convenience sample of 444 health care personnel indicated that the SCQ had acceptable validity and internal consistency (Cronbach's alpha exceeded 0.83 for the overall scale). Explorative factor analysis identified and labelled two factors: 'internal demands' and 'external demands and restrictions'. The findings suggest that the SCQ is a concise and practical instrument for use in various health care contexts.

Keyword
Adult, Aged, Conscience, Ethics; Professional, Factor Analysis; Statistical, Female, Health Personnel/ethics/*psychology, Humans, Male, Middle Aged, Questionnaires, Reproducibility of Results, Stress; Psychological/etiology/*psychology, Sweden
Identifiers
urn:nbn:se:umu:diva-6689 (URN)10.1177/0969733006069698 (DOI)17193804 (PubMedID)
Available from: 2008-01-16 Created: 2008-01-16 Last updated: 2017-12-14Bibliographically approved
2. Factors associated with 'stress of conscience' in healthcare.
Open this publication in new window or tab >>Factors associated with 'stress of conscience' in healthcare.
2008 (English)In: Scandinavian Journal of Caring Sciences, ISSN 0283-9318, E-ISSN 1471-6712, Vol. 22, no 2, 249-258 p.Article in journal (Refereed) Published
Abstract [en]

AIM: The main purpose of this study was to examine factors related to 'stress of conscience' i.e. stress related to a troubled conscience in healthcare. METHODS: A series of questionnaires was completed by 423 healthcare employees in northern Sweden as part of this cross-sectional study. The series of questionnaires comprised the 'Stress of Conscience Questionnaire', 'Perception of Conscience Questionnaire', 'Revised Moral Sensitivity Questionnaire', Social Interactions Scale, Resilience Scale and a Personal/Work Demographic form. RESULTS: Nonautomatic stepwise regression analysis with forward inclusion resulted in a model that explained approximately 39.6% of the total variation in stress of conscience. Individual items associated with stress of conscience were; perceiving that conscience warns us against hurting others while at the same time not being able to follow one's conscience at work and having to deaden one's conscience to keep working in healthcare. In addition moral sensitivity items belonging to the factor 'sense of moral burden' were; one's ability to sense patient's needs means that one is doing more than one has strength for, having difficulty to deal with feelings aroused when a patient is suffering and one's ability to sense patient's needs means feeling inadequate all added significantly to the model. In addition, deficient social support from superiors, low levels of resilience and working in internal medicine wards were all associated with stress of conscience. CONCLUSION: Healthcare employees seem to experience stress of conscience in their everyday practise. Particular contributing factors are not being able to follow one's conscience at work, and the 'negative' dimension of moral sensitivity - moral burden - which is an inability to deal with moral problems. Thus, in order for conscience and moral sensitivity to become an asset instead of a burden, healthcare employees need to be able to express their moral concerns.

Identifiers
urn:nbn:se:umu:diva-19053 (URN)10.1111/j.1471-6712.2007.00522.x (DOI)18489696 (PubMedID)
Available from: 2009-03-03 Created: 2009-03-03 Last updated: 2017-12-13
3. Sources of burnout among healthcare employees as perceived by managers.
Open this publication in new window or tab >>Sources of burnout among healthcare employees as perceived by managers.
2007 (English)In: Journal of Advanced Nursing, ISSN 0309-2402, E-ISSN 1365-2648, Vol. 60, no 1, 10-19 p.Article in journal (Refereed) Published
Keyword
burnout, empirical research report, healthcare professionals, interviews, managers, qualitative content analysis, research report
Identifiers
urn:nbn:se:umu:diva-6859 (URN)doi:10.1111/j.1365-2648.2007.04370.x (DOI)17824935 (PubMedID)
Available from: 2007-12-20 Created: 2007-12-20 Last updated: 2017-12-14Bibliographically approved
4. Burnout and 'stress of conscience' among healthcare personnel.
Open this publication in new window or tab >>Burnout and 'stress of conscience' among healthcare personnel.
2007 (English)In: Journal of Advanced Nursing, ISSN 0309-2402, E-ISSN 1365-2648, Vol. 57, no 4, 392-403 p.Article in journal (Refereed) Published
Keyword
Adult, Burnout; Professional/*psychology, Conscience, Cross-Sectional Studies, Female, Health Personnel/*psychology, Humans, Male, Middle Aged, Questionnaires, Regression Analysis, Sweden
Identifiers
urn:nbn:se:umu:diva-6858 (URN)doi:10.1111/j.1365-2648.2007.04111.x (DOI)17291203 (PubMedID)
Available from: 2008-01-16 Created: 2008-01-16 Last updated: 2017-12-14Bibliographically approved

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