Iran Journal of Nursing

Introduction
Due to having multiple tasks in ensuring the health of patients, primary healthcare workers are under many stresses that may lead to job burnout. Exposure to long-term stress in the workplace is one of the serious risk factors of job burnout. Occupational stress in healthcare providers can affect the quality of services provided to patients and eventually lead to a decrease in the quality of care and in the health of people and society. Since primary healthcare workers are at the forefront of providing healthcare services in the country, their physical, mental, and social health is very important since they are exposed to various occupational and environmental stressors. Therefore, the present study aims to determine the relationship between occupational stress and job burnout in primary healthcare workers.

Method
This is a descriptive correlational study conducted in 2019. The study population consists of all primary healthcare workers covered by hospitals affiliated to Saveh University of Medical Sciences. Due to the small size of the study population, all primary healthcare workers (n=128) were selected by a census method for the study. The inclusion criteria were at least one year of work experience, age 20-60 years, being employed by the Health Center of Saveh and Zarandiyeh cities, being under work during the study, and not having stressful problems such as incurable diseases (in themselves or first-degree family members) in the last year, not using sedatives, no drug addiction, and consent to participate in the study. Data collection tools were a demographic form, the Maslach burnout inventory (MBI), and Spielberger’s job stress survey (JSS). The JSS has 30 items, each measuring a stressful event in the workplace, rated on a scale from 1 to 9 based on the severity of each event. The total score ranges from 30 to 270. The MBI contains 22 items that measure the intensity and frequency of three domains of burnout (emotional exhaustion, personal accomplishment, and depersonalization). The scoring is based on a seven-point Likert scale: 0=never, 1=very low (a few times a year), 2=low (once a month), 3=moderate (a few times a month), 4=moderate to high (once a week), 5=relatively high (a few times a week), 6=high (every day), and 7=very high. For the dimension of emotional exhaustion, which includes 9 items, the total frequency score is 54 and the total intensity score is 63; for the personal accomplishment with 8 questions, the total frequency score is 48 and the total intensity score is 56; and for depersonalization with 5 questions, the total frequency score is 30 and the total intensity score is 35. Obtaining a high score in emotional exhaustion and depersonalization and a low score in personal accomplishment indicates a higher degree of job burnout. Data were analyzed in SPSS software, version 18 using descriptive statistics (such as Mean±SD and frequency), Pearson correlation test (to assess the correlation between the scores of main variables), and independent t-test and analysis of variance (to assess the difference between the scores of main variables in terms of demographic variables).

Results
Most of participants (58.3%) were living in rural areas, married (87%), female (62.6%) with a high school diploma (56.5%). The mean age and work experience of the participants was 40.8±8 and 18.13±8.9 years, respectively. Most of participants (41.7%) had moderate occupational stress. Among the demographic variables, only income had a significant relationship with occupational stress, and Tukey’s test showed a significant difference between the group with a relatively sufficient income and the group with an insufficient income (P=0.002), where those with insufficient income had a higher stress score than those with relatively sufficient income. The mean score of JSS was 140.7±48.6, which was lower than the median score (150). The mean frequency score was 23.43±8.3 for the dimension of emotional exhaustion, 17±4.78 for depersonalization, and 14.43±6.74 for personal accomplishment. Also, the mean intensity score was 26.63±9.43 for emotional exhaustion, 18.35±4.84 for depersonalization, and 16.76±7.97 for personal accomplishment. Occupational stress had a positive and significant relationship with the frequency of emotional exhaustion (r=0.59, P<0.001) and depersonalization (r=0.22, P<0.001), and a negative and significant relationship with the frequency of personal accomplishment (r=-0.47, P<0.001). This indicates that with the increase of occupational stress, the frequency of emotional exhaustion and depersonalization increases, while the frequency of personal accomplishment decreases. Moreover, occupational stress had a postive and significant relationship with the intensity of emotional exhaustion (r=0.63, P<0.001) and  depersonalization (r=0.32, P<0.001), and a negative and significant relationship with the intensity of personal accomplishment (r=-0.50, P<0.001).

Conclusion
The primary healthcare workers in this study has a moderate occupational stress and a high level of job burnout in the areas of depersonalization and personal accomplishment. Considering the high level of job burnout and its relationship with occupational stress in these healthcare workers, and the fact that these factors can have a negative impact on the quality of healthcare services, it is necessary to carry out necessary interventions to reduce and manage occupational stress and job burnout of primary healthcare workers.

Ethical Considerations
Compliance with ethical guidelines
This study was approved by the Ethics Committee of Iran University of Medical Sciences (Code: IR.IUMS.REC.1398.240). All participants signed a written informed consent form.

Funding
The paper was extracted from the master’s thesis of Gholamreza Molaahmadi, approved by the Faculty of Nursing and Midwifery, Iran University of Medical Sciences and was funded by Iran University of Medical Sciences (Grant No.: 14976).

Authors' contributions
Conceptualization, methodology and supervision: Maryam Gharacheh and Gholamreza Molaahmadi; Data collection: Gholamreza Molaahmadi; Data analysis: Shima Haghani and Mahmood Karimi; Funding acquisition and resources: Maryam Gharacheh; Investigation, writing original draft, and review & editing: All authors.

Conflict of interest
The authors declared no conflict of interest.

Acknowledgments
The authors would like to thank all healthcare workers participated in this study for their cooperation.

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