ORIGINAL ARTICLE

Burnout, Empathy and Sense of Coherence among Swedish District Nurses before and after Systematic Clinical Supervision Maj-Britt Palsson, RNT, LMSc, Doct. stud.a, ', lngalill R, Hallberg, RNT, DMSc", Astrid Norberg, RN, PhDa, and Hjordis Bjorvell, RN, DMScd

From the aDepartmemt of Advanced Nursing, Umea University, Umea, "The Baltic International School of Public Health, Karlskrona, =Care Research and Development Unit, University of Lund and Kristianstad College for Health Professions, Kristianstad, and %entre of Caring Sciences, Karolinska Hospital, Stockholm, Sweden

Scand J Caring Sci 1996; 10: 19-26

The relationships between, on the one hand, burnout, empathy and sense of coherence (SOC) and, on the other, personality traits were investigated, together with the effects of systematic clinical supervision on these phenomena among Swedish district nurses. The results in the supervisory group (n = 21) were compared with those of a comparison group (n = 12) in a quasi-experimental design. Personality traits were assessed by means of the Karolinska Scales of Personality. The results indicated some correlations between personality traits and burnout, empathy, and SOC, as well as correlations between the latter three phenomena. There were no significant effects of clinical supervision on burnout, empathy, or SOC. More research is needed regarding the effects of clinical nursing supervision.

Key wordr: systematic clinical supervision, burnout, empathy, sense of coherence, the Karolinska scales of personality, district nurses, cancer care.

Submitted 5 October 1994 Accepted 13 September 1995

INTRODUCTION

Cancer patients represent a heavy workload for dis- trict nurses. Care may encompass ethically and aes- thetically difficult situations, such as the daily dressing of ulcerous and malodorous cancer wounds, getting too close to the patient, dealing with the patient's trust in alternative medicine, and having to 'play the game' with the patient who represses or denies his/her situation (Pilsson et al. 1995). Facing the suffering and the patient's impending death can cause anxiety, which may lead to the nurse setting up defences (Homer 1984, cf. Menzies 1970). It is reasonable to expect that these difficulties create job-related stress and feelings of strain among district nurses, which may result in a negative impact on the quality of care.

Several studies have shown that lack of psychologi- cal support for oncology nurses correlates with high burnout scores (Bram & Katz 1989, Jenkins & Ostchega 1986, Yasko 1983). In that context, system- atic clinical supervision may function as a psychologi-

0 Scandinavian University Press, 1996. ISSN 0283-9318

cal support system. In an empirical study, supervision has been proved to decrease mental exhaustion and increase job satisfaction (Hallberg 1994), as well as to decrease burnout and increase creativity among nurses (Berg et al. 1994). In other studies, nurses report experiences of satisfaction with supervision and nurs- ing care (Jansson et al. 1993), increased co-operation in the work group (Hallberg et al. 1994), professional development (Pilsson et al. 1994), reduced strain in the care of demented patients (Hallberg & Norberg 1993), as well as improvement of the quality of care (Paunonen 1991). Research into the effects of supervi- sion should be extended by the use of methods which measure other factors than those mentioned above, and should cover not only hospital nurses but also other nursing professionals.

In the present study, clinical group supervision of district nurses, focused on narrating and reflecting upon care situations, was expected to reduce the degree of burnout and improve empathetic under-

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20 M.-B. Pdlsson ei ul.

standing and coping ability. The possibility to reflect on demanding situations was assumed to have a posi- tive impact on empathy. Furthermore, discussions with colleagues about the problems and emotions evoked in patient care should reduce experiences of stress, and foster new ideas about problem solving.

Nurses’ coping strategies are of importance for decreasing anxiety and preventing burnout. Successful coping may be dependent on a strong sense of coher- ence (SOC). This represents a feeling of comprehensi- bility that the stimuli one confronts in life are structured, predictable and explicable; that one has the resources to meet the demands created by these stimuli; and that these demands are challenges worth becoming involved in (Antonovsky 1987).

Experiencing burnout should correlate with a lower SOC, and consequently with a diminished ability to act empathetically in the relationship with the patient. Astrom and coworkers (1990, 1991) found that high burnout correlated with low empathy and less positive attitudes towards demented patients among nursing personnel in geriatric and psychogeriatric care. No study seems to have been performed concerning the relations between burnout, empathy and SOC, and personality traits.

It has been shown that the degree of burnout is sensitive to interventions (Berg et al. 1994, Hallberg 1994). However, it is not known whether empathy and SOC will change as a result of clinical supervision, or whether these variables are related to presumably stable personality traits. The effects of systematic clin- ical supervision on burnout, empathy and SOC among district nurses (DNs) have not previously been evaluated.

AIM

The aim of the present study was to explore the possible relationships between burnout, empathy and SOC, and the extent to which these phenomena correlate with personality traits. A further aim was to investigate the degree of burnout, empathy, and SOC in DNs before and after systematic clinical su- pervision as compared with a similar comparison group.

METHOD

Sample

Thirty-nine DNs (out of a possible 62) from ten primary health care districts in a county council area in the southeast of Sweden participated in a training programme. Because of the work load at the time of the study, a further 23 DNs were unable to partici- pate. Only the DNs who joined the training pro- gramme are described in this article.

Twenty-four out of the 39 DNs were offered sys- tematic clinical supervision after the training. These DNs, working in five of the ten health care districts, were arbitrarily assigned by the first author to a supervisory group, and the remaining 15 DNs were assigned to a comparison group. The following crite- ria for assignment to the groups were used: a) all the DNs in each health care district formed either a supervisory or a comparison group to avoid partici- pants and non-participants influencing each other; b) country as well as urban areas should be represented in both groups. Thus, in this quasi-experimental study, the DNs were not randomly assigned to the groups. Before the supervision began, there was a drop-out of one DN for personal reasons in the supervisory group. Only those DNs (n = 21) in the supervisory group and those in the comparison group (n = 12), 85% in all, who completed instruments at both the first and the second assessment, were in- cluded in this analysis. The reasons why 5 DNs did not answer were: educational leave, parental leave, and job transfer. The characteristics of the subjects (n = 33), all women, are shown in Table I.

The mean age of the non-responders was 46.4 (SD 1 l.9), the mean number of years in nursing care was 23.6 (SD 10.3), and as a DN 12.0 (SD 8.2). There were no significant differences between the responders and the non-responders in these respects.

Intervention

Background. The present study is part of a larger investigation, aimed at improving the nursing care of women with newly diagnosed breast cancer (Pilsson & Norberg 1995).

Prior to the clinical supervision, DNs took part in the 40 h training programme which covered medical care and treatment for breast cancer patients, psycho-

Table I. Characteristics of the respondents (baseline). Differ- ences between the groups were tested by ihe Mann- Whiiney U-test

Supervisory Comparison group group

DN (n=21) DN (n=12)

Mean age in yrs (SD*) 49.0 (7 .1) 46.3 (8.3) Mean number of yrs (SD)

In nursing care 24.0 (8.2) 21.8 (6.9) As district nurse 16.1 (6.5) 14.0 (7.3)

Full-time 14 61% 8 67% Part-time 7 33yQ 4 33%

Permanent staff 19 90% 10 83% Temporary substitute 2 10% 2 17%

Employment

Position

*SD = Standard Deviation.

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Burnout, empathy and sense of coherence among Swedish district nurses 21

Table 11. Groups, participants and sessions in systematic clini- cal suDervision fn = 23)

Group

1 2" 3 DN DN DN ( n = 9 ) (n = 8) (n = 6)

Number of Sessions 15 19 16 Hours 26 34 24

Mean (range)b 7 (4-9) 5 (4-8) 5 (4-6) Attendance

~

"Three DNs left group 2 after eight months, as all the personnel ( DNs and enrolled nurses) in their district were to receive supervision from a psychologist. After that, group 2 consisted of DNs from one workplace. bThe absence from individual sessions was explained by heavy work-load in regular work, illness or holidays.

logical reactions, coping strategies, and crisis interven- tion. There were also discussions about the organ- ization of the nursing care of women with breast cancer and the problems they had to deal with in their work (Pglsson et al. 1994).

Systematic clinical supervision. After the training, the majority of the DNs were offered systematic clini- cal supervision during a period, which coincided ap- proximately with the implementation of the nursing care to facilitate breast cancer patients' adjustment to everyday life (February 1991 -April 1992)

The clinical supervision was conducted by the first author and a research assistant. Both supervisors are registered nurses and qualified teachers with several years of experience of training nurses in clinical work. They had theoretical training in supervision and sup- port from the second author, who is a trained psy- chotherapist and experienced nursing supervisor. The supervisors had no formal attachment to those super- vised or to primary health care during the period in question.

The DNs were supervised in three different groups. Group 1 included DNs from only one work place, while those in group 2 and 3 came from two different health service centres. The supervision was provided at intervals of 2 to 4 weeks, and each session lasted between 1.5 and 2 h. The number of supervision ses- sions, hours and attendance at sessions are illustrated in Table 11.

The overall purpose of the systematic clinical super- vision was to support the DNs emotionally, and to make them aware of the emotions evoked in them in the provision of care (cf. Hallberg 1994). Real situa- tions with patients or problems in their daily work were focused on. Each session started with a DN presenting a situation, what was perceived as the problem in the care, how she had handled it, and what feelings the

contact with that particular patient had evoked. Then the others in the group gave their reflections, either in relation to the patient in question, or by talking about a comparable patient. The discussion focused on reflec- tions and interpretations of the narratives, and formed the base for possible solutions. The supervisors inte- grated theoretical nursing into the discussions and made the group members go more deeply into their accounts by asking questions about their experiences. The session ended with a summary of the discussion, and the designation of the participant who would present a care situation at the next session.

During the period of clinical supervision and the changes in the nursing care (Pilsson & Norberg 1995), the first author visited the participants of a comparison group four times in order to show interest in that group, and to reduce misunderstandings re- lated to the nursing care of women with breast cancer.

Instruments A questionnaire including the background variables gender, age, education, and time spent as a hospital nurse and a DN was used together with the following scales.

The Karolinska Scales of Personality (KSP) (Schalling et al. 1983) is a Swedish personality scale with 135 items grouped into three main categories; Anxiety proneness scales, Extraversion-related scales and Aggression-hostility scales (described in detail by Bjorvell et al. 1985). The KSP has been assumed to measure relatively stable personality traits. The self- report responses are given on a four-point Likert scale. The items explicitly refer to habitual behaviour or feelings. The higher the score, the more of the phenomena measured.

The Burnout Measure (Schaufeli & Enzmann 1993) consists of 21 items with response alternatives from 1 to 7. The total burnout score is the mean of the scores for all the items. Scores of 3.0 or more indicate a risk of burnout (Pines & Aronson 1988). The burnout measure has been used in previous Swedish studies among staff working in geriatric care (Berg et al. 1994, Astrom et al. 1987, 1990, 1991), and in child psychiatric care (Hallberg 1994).

The Empathy Construct Rating Scale (ECRS), de- veloped by La Monica (1981). contains 84 items. It measures aspects of how a person feels about or reacts to another person. The responses are given on a six-point scale. The lowest score (84 points) is inter- preted as 'lack of empathy' and the top score ( 5 0 4 points) as 'well-developed empathy'. Scores around 400 indicate a moderate grade of empathy in accor- dance with previous Swedish studies (Kuremyr et al. 1994, Astrom et al. 1990, 1991).

The Sense oJ Coherence ( S O C ) Scale (Antonovsky 1987) comprises 29 items covering three components

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22 M.-B. Pdsson el al.

assumed to be of importance for coping: comprehensi- bility, manageability, and meaningfulness. The re- sponse alternatives are scored from 1 to 7. Possible scores range from 29 to 203; the higher the score, the stronger the SOC. The SOC scale has been used with nurses and a healthy, randomized Swedish population (Langius & Bjorvell 1993, Langius et al. 1992). The SOC-scale is described in detail by Langius and coworkers (1992).

The reliability as measured by means of Cronbach’s alpha (Cronbach 1951) was found to be 0.78 for the burnout measure; 0.96 for the empathy scale and 0.89 for the SOC scale.

Procedure

All the 33 DNs answered the KSP questionnaire before the training. The other questionnaires were completed both before the training, i.e., at baseline, and after the systematic clinical supervision (27-28 months later). The instruments were administered in connection with the information about the interven- tion (at baseline), and later in connection with inter- views performed to find out about the DNs’ experiences of the supervision (PBlsson et al. 1994). The DNs used a personal code at both data collec- tions. DNs who failed to return the questionnaires were sent a reminder at their place of work. The instruments required about one hour to complete on each occasion.

The study was approved by the Medical Ethical Research Committee of the University of Lund, and by the Computer Inspection Board.

The statistical analyses were made by non-paramet- ric methods, since data were based on ordinal scales,

and since the groups were small. Spearman’s rank correlation coefficient was used to examine baseline correlation between burnout, empathy, and SOC, and personality traits. Differences in burnout, empathy, and SOC over time within the groups were tested by the Willcoxon signed rank test, and differences be- tween the groups with regard to these phenomena and personality traits (KSP) by means of the Mann-Whit- ney U-test.

RESULTS

No significant differences were found at baseline be- tween the supervisory group (n=21) and the com- parison group (n = 12) concerning demographic details (Table I) or personality traits, measured with the KSP scores, except on two of the KSP sub- scales-detachment and inhibition of aggression- which showed significantly lower scores in the comparison group (Table 111).

Correlations between the KSP and burnout, empathy and sense of coherence

Significant correlations between burnout, empathy, SOC, and some of the three anxiety proneness mea- sures were found. The highest correlation was found between the empathy score and the somatic anxiety variable (Table IV). The lower the scores on the empathy and SOC scales and the higher the scores on burnout, the higher the scores of somatic and psychic anxiety. Significant negative correlations were found between the empathy scores on the one hand, and detachment and psychastenia on the other (Table IV). All the KSP subscales showed the same pattern of

Table 111. Medians and quartiles for the personality variables of the KSP questionnaire for DNs (n = 21) in the supervisory group, and DNs (n = 12) in the comparison group at baseline. Differences between the groups were tested by the Mann- Whitney U-test

Variable

Supervisory group Comparison group

Median Ql-Q3 Median Q1-43 P-value

Anxiety Proneness Somatic anxiety Psychic anxiety Muscular tension Psychasthenia

Impulsiveness Monotony avoidance Detachment Socialization

Aggression Aggression Hostility Inhibition of aggression

Extraversion

16.5 21.5 15 22.5

23 21 20.5 69

34 21 25.5

12- 19.5 18.5-22.5 11-16 19-25

20-25 19-24

65-73

32.5-36.5 18.5-23 23-27

17.5-22.5

13.5 19.5 15.5 20.5

22 22 17 68.5

31.5 19 22

12-16.5 14.5 - 23 13-17.5 16-22

20.5-22.5 19.3-23.8 14.5-18 67-71.5

28-34 18-21.5 19-23.5 *

*

*p < 0.05.

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Burnout, empathy and sense of coherence among Swedish district nurses 23

Table IV. Spearman rank correlation coeficient (r) between burnout, empathy, SOC and KSP measures before intervention in the total group (n = 33)

scores ( r = 0.76, p < 0.001): the higher the empathy score, the higher the SOC score.

Burnout Empathy SOC r r r

Anxiety Proneness Somatic anxiety 0.55** -0.60*** -0.44* Psychic anxiety 0.29 -0.48** -0.34 Muscular tension 0.27 -0.30 -0.20

Impulsiveness 0.33 -0.24 -0.40' Extraversion

Monotony avoidance 0.37' -0.27 -0.42*

Detachment 0.38' -0.66*** -0.44* Socialization -0.54** 0.42* 0.50**

Aggression 0.45* -0.14 -0.20 Aggression

Hostility 0.43* -0.33 -0.37* Psychasthenia 0.61*** -0.61*** -0.40. Inhibition

of aggression 0.42* -0.54** -0.33

*p < 0.05, **p < 0.01, ***p < 0.001.

negativelpositive correlations with empathy, SOC and burnout scores except for socialization, which showed an opposite pattern (Table IV). Thus, the higher the SOC and empathy scores and the lower the burnout scores, the higher the socialization scores.

Correlations between burnout, empathy and sense of coherence

There was a negative correlation between the burnout and empathy scores (r = -0.64, p < 0.001): the lower the burnout score, the higher the empathy score. Burnout also showed a significant correlation with the SOC score (r = -0.69, p < 0.001). Thus, the lower the burnout score, the stronger the SOC score. Further- more, the empathy scores correlated with the SOC

Burnout, empathy and sense of coherence before and after supervision

Description data related to the degree of burnout, empathy, and SOC are shown in Table V. There were no significant differences found with regard to these phenomena over time within the groups, nor between the groups at baseline or after the intervention (27 to 28 months later).

The number of respondents in the supervisory group (n = 21) with burnout scores >3.0, which, ac- cording to Pines and Aronson (1988), indicates a risk of developing burnout, were 7 before and 4 after the intervention (ns). In the comparison group (n = 12), the corresponding figures were 1 and 3 respectively (ns).

DISCUSSION

The aim of this study was to explore possible relation- ships between burnout, empathy and SOC, and their relationships with personality traits. A further aim was to evaluate the effects of systematic clinical super- vision on these phenomena in DNs.

In this quasi-experimental study, the DNs were not randomly assigned to the groups, which implies a number of threats to the internal validity of the conclusions, for instance, selection biases and the loss of subjects during the course of the intervention (Polit & Hungler 1989, pp. 135-137). There were, however, no significant differences between DNs who re- sponded to the scales and the non-responders with regard to age and years in the profession. The groups were carefully selected to ensure that they were as similar as possible. There were no significant differ-

Table V. Scores for burnout, empathy and sense of coherence in the supervisory group (n = 21) and in the comparison group (n = 12) before and ajier the systematic clinical supervision. Differences wirhin the groups tested by the Wilcoxon signed rank test and between the groups at baseline or after the intervention bv the Mann- Whitnev U-test

Baseline After 27-28 months

Mean SD Range Mean SD Range

Supervisory P U P

Burnout 2.7 0.6 1.7-3.9 2.5 0.7 1.5-4.2 Empathy* 419 31 369-483 427 30 380-479 SOC 148 17.5 123-178 151 16.6 119-175

Comparison group

Burnout 2.3 0.7 1.3-3.3 2.3 0.8 1.1-3.6 Empathy 435 35 389 - 492 432 30.1 391 -478

134-188 SOC 154 13.6 135-183 153 17.3

*One DN in the supervisory group was excluded from the description of empathy because there were several missing values on the empathy scale.

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24 M.-B. PBIsson el al.

ences between the groups at baseline with regard to demographic characteristics, or to burnout, empathy and SOC. However, there were significant differences concerning detachment and inhibition of aggression (Table 111). These differences between the groups may be interpreted as if the comparison group had had a somewhat better starting-point than the supervisory group. However, since there were no differences be- tween the groups in the other 9 subscales (KSP), reasonably, the two groups did not differ at baseline. The activities were expected to be similar in the differ- ent health care districts during the clinical supervision. Furthermore, the staff drop-out was limited to one DN during the period, and was thus no threat to the validity.

The results of an intervention study are threatened by things that happen within and outside the supervi- sory and comparison groups, causing various sources of error.

Personal sources of support in the DNs’ social network and personal problems in their private lives were not examined. However, these social and individ- ual factors are likely to be evenly distributed between the DNs in the groups. During the year of supervi- sion, there was a large organizational change in pri- mary health care in Sweden, which affected DNs (Alaby 1992). However, this change concerned both groups, so it seems unlikely that it influenced the results differentially. Another source of bias might be the Hawthorne effect (Merton 1968, pp. 120-121). As the comparison group also received training and was visited four times and given feedback during the study, the bias was probably equal for both groups. On the other hand, these regular contacts may have decreased the possibility of evaluating the effects of clinical supervision, and implies an increased threat to the validity.

All the correlations between the KSP and the burnout, empathy, and SOC scores were in a logically concordant direction (Table IV). Thus, DNs with high somatic anxiety had low empathy and SOC scores; high psychic anxiety correlated with low empa- thy; high socialization correlated with high empathy and SOC scores; and high psychasthenia and inhibi- tion of aggression correlated with low empathy and SOC, but high burnout scores. These correlations indicate that there is an association between personal- ity traits and these variables. The relationships be- tween the SOC scores and personality traits (KSP) are in agreement with findings by Langius and coworkers ( 1992), who showed significant correlations between the SOC and the somatic/psychic anxiety scores. These findings indicate that there is a negative rela- tionship between self-rated pathogenic anxiety and self-rated salutogenic sense of coherence (Antonovsky 1987). However, as both samples are small, more

research is needed to achieve a greater understanding of the relationship. The DNs showed lower scores on most of the KSP variables when compared to a group of severely obese patients (Bjorvell et al. 1985), and a group of depressed patients (Perris et al. 1983), which seems logical, as the DNs must be seen as a normal population sample.

The fact that empathy and SOC scores correlated significantly and positively indicated that people with a high SOC score experience themselves as more empathetic in their relationships with other people than do those with a low SOC score. A high general comprehensibility might produce a deeper under- standing of other individuals’ problems. Emotional involvement with seriously ill cancer patients is de- manding (PBlsson et al. 1995), but if nurses have the resources to meet these demands (high SOC scores), it may lead to satisfaction and feelings of meaningful- ness. The significant negative correlation between the SOC and the burnout scores makes it reasonable to assume that the individual does not experience emo- tional exhaustion when the SOC remains high.

This study failed to show any significant improve- ment in burnout, empathy, or SOC due to clinical supervision, although interview data indicated that the supervision had generated deeper knowledge, in- creased self-confidence, confirmation and relief of thoughts and feelings (PBlsson et al. 1994). The fact that interview data produced different results does not mean that either or both kinds of data are invalid. More likely, it may be a result of measuring different aspects. The results can be explained by the well- known difficulty of obtaining significant differences when the scores at baseline are already high (empa- thy, SOC), or low (burnout).

There may have been shortcomings in the way the clinical supervision was carried out. For instance, a more intensive and extensive intervention period than the one used may be needed to influence such phe- nomena as burnout, empathy, and SOC. In a similar quasi-experimental intervention study, a significant decrease was found in nurses’ experiences of strain (Hallberg & Norberg 1993) and burnout, as well as increased creativity (Berg et al. 1994). No changes occurred in the control group. The clinical supervision in this study was, however, combined with supervised implementation of individualized nursing care, and was thus more extensive. It was also provided to a homogeneous group of nurses who shared patients and working conditions. The divergent results of the study mentioned above and the present study indi- cated the need for further research.

Eight of the DNs (24%) at the first and seven DNs (21%) at the second measure had burnout scores above the critical level 3.0, which, according to Pines & Aronson (1988), indicates a risk of developing

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Burnout, empathy and sense of coherence among Swedish district nurses 25

burnout. This proportion is comparable to the 27% reported by Astrom and coworkers (1991) among Swedish nursing staff working in geriatric care. The reason a considerable number of the nurses ran the risk of developing burnout could be a long-term and close involvement with the patients, and/or the high work-load imposed on the nurses by cancer patients (Cohen & Sarter 1992).

The mean SOC scores are comparable to data from Langius and coworkers (1992) in their investigation of three Swedish samples of registered nurses participat- ing in an in-house training programme (means 143 and 152), and in a selective research training course (mean 160).

The mean scores of empathic ability are comparable to results from previous investigations of Swedish health care workers in geriatric care (mean 422) (Astrom et al. 1990), anong Swedish staff caring for demented patients (mean 423) (Kuremyr et al. 1994).

The empathy and SOC scores indicate that the DNs have the prerequisites for empathic understanding for their clients (La Monica 1981), and successful coping (Antonovsky 1987).

CONCLUSION

The findings showed that there are strong relation- ships between some of the personality traits measured and burnout, empathy and SOC. There were also inter-relationships between burnout, empathy and SOC. There was no significant change found in burnout, empathy, and SOC over time within or between the groups, which implies that the interven- tion had no effects on these phenomena. More re- search is needed to investigate the effects of clinical supervision to find out if the results of this study are supported. There is also a need for larger samples and perhaps a more intensive and extensive intervention period. As Swedish district nurses often work alone in patients’ homes and have to rely on their own re- sources in handling demanding care situations, it seems important to give them opportunities to verbal- ize and reflect on problems with colleagues.

ACKNOWLEDGEMENTS

This study was supported by the Swedish Work Environ- ment Fund (No. 91-1293). the Regional Council for Health Care Research, Faculty of Medicine, University of Lund and the Baltic International School of Public Health, Karlskrona. We are grateful to the district nurses for their cooperation, and we thank Mr. Olof PHlsson, MA, and Ms. Pat Shrimp- ton, foreign lecturer, Umei University, Sweden, for revising the English.

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