Introduction Nelleke Bak



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Understanding stress/ burnout

‘Burnout’ is defined in existing literature as emotional exhaustion, and the inability to give at a psychological level is a common component of such definitions (Bennett et al, 1994). The term ‘burnout’ was introduced by Freudenberger in the seventies, with many subsequent definitions being offered (Shirom, 1989).


Maslach and Jackson (1981) have put forward one of the most widely-used definitions of burnout. This definition has formed the basis for the development of the Maslach Burnout Inventory (MBI) which is a commonly-accepted valid instrument in caregiver burnout studies.
Burnout is defined as a combination of three components:


  1. emotional exhaustion: individuals feel exhausted and emotionally overextended by their work (Bennett et al, 1994),

  2. depersonalization: individuals feel emotionally detached and adopt an impersonal response to patient/clients (Bennett et al, 1994), and

  3. lack of personal accomplishment: individuals tend to evaluate themselves negatively, in relation to work and are dissatisfied with their accomplishment at work (Bennett et al, 1994).

Maslach (1982) proposes that burnout is a result of an interaction between individuals and their environment. Thus to understand burnout more comprehensively, one has to look at the context in which it occurs. Factors such as a perceived lack of control, as well as poor relations with superiors, contribute to levels of burnout of staff (Maslach, 1982). Burnout thus interferes with and disrupts the relationship between the caregiver and the patient as a result of excessive demands and exhaustion.



Caregiver burnout and sources of stress for caregivers of people with HIV/AIDS

Researchers note high caregiver turnover rates and reports of burnout in organisations providing care for HIV/AIDS (Bennett, Michie and Kippax, 1991; Bennett, Kelhar and Ross, 1994).


Barbour (1994) investigated studies that looked at the impact of working with people with HIV/AIDS. She notes that determinants of burnout were related to the youth of the patients, neurological conditions presenting as a result of AIDS-related illnesses, and the issue of bereavement overload. She also notes that because of the slow course of the disease, many caregivers have more intimate contact with patients, which can present further difficulties for caregivers. Stresses involved in AIDS work specifically are seen as a consequence of the diversity of the client population, and the difficulty of dealing specifically with neurophysiological aspects of the illness, particularly in view of many caregivers having limited previous experience of psychiatric care. Barbour (1994) also raises a discussion about the impact of caregiver characteristics influencing their vulnerability to psychological distress. Specifically training, previous experience, age, personality and sexual identity are noted as influencing the caregivers’ adaptation to the demands of AIDS-related work.
Bennett et al (1991) examined burnout and its associated factors in the nursing care of AIDS patients. They noted that when compared to burnout among oncology nurses, AIDS nurses showed a greater intensity of burnout. Length of time working with AIDS patients was identified as increasing the likelihood of burnout, while age was inversely related to burnout. Bennett et al (1991) also notes higher levels of patient dependency with AIDS patients, as the patients require greater amounts of care. This then is suggested as influencing the intensity of emotional exhaustion measured in the caregivers. They also note that the stigma associated with AIDS care and the age of the patients may be further contributing factors to the intensity of emotional exhaustion.
Catalan et al (1996) looked at the psychological impact and levels of occupational burnout experienced by staff involved in AIDS care and oncology using the MBI. Reports of significant measures of work-related burnout were found in a fifth of the sample. Aids workers reported significantly lower levels of personal accomplishment, both in terms of frequency and intensity. The researchers noted that staff used informal support groups to cope with difficulties experienced and would be likely to respond to interventions aimed at improving their ability to cope with their work-related stresses.
Horsman and Sheeran (1995) note that HIV/AIDS care raises issues of fear of infection, attitudes towards sexuality, fear of social stigmatisation and concerns about caregivers having a right to refuse care for people with AIDS. Particularly within the hospital environment, economic pressures and employment difficulties can mean that healthcare workers feel obliged to provide such care. In addition to this, health care workers face the high levels of patient mortality and increased work demands, as the care requirements of people with AIDS are estimated as being 40% greater than those of patients who are terminally ill with cancer (Horsman and Sheerman, 1995).
Berkowitz and Nutall (1996) looked at the attitudes of pediatric nurses facing HIV risk. They noted that greater occupational experience of caring for people with AIDS resulted in more positive attitudes towards care. While a majority of the nurses expressed a willingness and responsibility towards such care, they noted that their families and friends were concerned about their occupational risk (Berkowitz and Nutall, 1996).
Klonoff and Ewers (1990) investigated the sources of stress associated with the care of AIDS patients. They note that nurses identified three sources of stress associated with AIDS care. Firstly, nurses were concerned about the transmission of the virus and because of this they needed thorough training regarding specific methods of care. Secondly, they experienced anxiety concerning the use of invasive interventions and, thirdly, they felt stress related to family and friends’ attitudes and concerns about their work.

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