Changes in nurses’ working conditions in recent years have shown to influence the working environment and may impact on areas such as job satisfaction, burnout, perceived quality of care, and patient well-being [1, 2]. In Spain, current healthcare budget cuts have made the workplace environment more challenging for nurses in general and also for nurses working in the perioperative area because the workload has increased and surgical waiting lists have grown. As a result, stress levels have risen considerably and may be a factor of burnout among perioperative nurses [3].Perioperative nurses take care of the patient throughout the perioperative process, which covers admission, surgical intervention, and recovery in the post-anaesthesia care unit [4]. The roles of perioperative nurse ensure the quality of perioperative care and surgical patient safety [5]. However, certain stress factors limit nurses’ ability to work to provide best patient care. Several studies have shown that in the perioperative work environment, job stress and burnout are related to factors such as workload, time pressure, patient safety, inadequate communication among team members, feelings of unpreparedness for procedures, and demands for continuous learning [6-9].

Burnout is a syndrome defined by emotional exhaustion that results in depersonalization and decreases in personal work accomplishments [10].The consequences can be negative for the efficiency of the organization, decreasing productivity and the quality of care [11]. Burnout is thus associated with negative outcomes for nurses, inhibiting the development of professional nursing whose aims are to achieve the best results for patients [1].There is no doubt that burnout is a serious issue facing our profession [12, 13].

International studies have documented an association between nurses’ working environment and health outcomes [14, 15]. Research and measurement of the work environment has been recommended as an effective strategy to improve the workplace environment and reduce nurse burnout [16]. This research, which started in the US at Magnet hospitals, has shown that care excellence provides good nursing practices that are associated with positive results for both patients and nurses [17]. Magnet hospitals demonstrate the capacity to attract and retain professionals as they promote quality patient care, safety, interdisciplinary collaboration, positive communication, professional models of care practice, more opportunities for professional development and better practice environments than other hospitals [18]. In contrast, nurses working in environments with negative features are dissatisfied with their job [19], express greater intention of leaving their jobs [20], and are at higher risk of burnout [2]. These feelings have negative consequences on nurses’ mental health and general health and on quality of care for patients [21]. Various instruments have been developed to analyse care environments but that most widely used is the Nursing Work Index (NWI). This tool, which was first developed from research in Magnet hospitals, can measure, assess and compare the nursing practice environment [22]. Two decades after its implementation (2012), within the RN4-Cast (Nursing Care Research Project), several research lines forming part of the study of nurses’ working conditions in relation to patient health outcomes showed deficits in quality of care, job satisfaction and burnout among nurses in intensive care and medical-surgical environments [14].

Spain, along with Greece, is one of the countries with the worst practice environments for nursing care. In addition, it has the lowest nurse/patient ratio and the highest level of burnout [23]. The nurse/patient ratio is 5.4 per 1,000 inhabitants, while in the Organization for Economic Cooperation and Development (OECD) countries the average is 9 [24]. A number of Spanish studies about the working environment have observed high levels of burnout among nurses [25, 26]. However, in a review of the literature review, we found very few data concerning burnout and working environments in nursing practice in the perioperative setting [5, 8]. No studies have been conducted to date regarding perioperative nurses and the characteristics of their working environments in Spain. For this reason, we posed the following three research questions: What are the burnout levels in perioperative nurses? What is the practice environment in the perioperative unit? And which organizational factors explained the burnout dimensions of perioperatives nurses?

The aim of the study was to determine the influence of organizational factors on the perioperative nurses’ working environment on the three burnout dimensions: Emotional exhaustion, depersonalization and personal accomplishment.

Table 1 shows the participants’ socio-demographic and professional characteristics. A total of 130 surveys were included (95.6%), representing a high degree of participation. The nurses’ mean age was 43.5 years (SD = 11.9) and 91.5% (119) were women. The average number of years of nursing experience was 21 (SD = 12.13) and the average number of years of experience in the area was 14 (SD=11.14). Seventy-four percent of participants worked in the operating room area and 58.5% worked the morning shift. Most (83.1%) had permanent work contracts. A total of 98.5% of those surveyed had specialized training (Master or Postgraduate courses) (Table 1).

In this study we measured the organizational factors of the work environment and their association with the three dimensions of burnout in nurses in the perioperative area. Our study findings revealed Emotional Exhaustion (EE) in 43% of nurses, Depersonalization (D) in 21%, and Personal Accomplishment (PA) in 53%. The degree of general burnout was moderate. Nearly half of the nurses reported moderate-high burnout in emotional exhaustion, less than one-third had moderate to high burnout in despersonalization, and more than half showed low burnout in personal accomplishment. Some Spanish studies show a similar or even higher burnout [26, 29, 32], reflecting a high incidence of burnout among nurses in general in Spain. These results are consistent with many international studies with similar conditions of staff shortages and poor practice environments [14, 20]. In some of these studies, such as several from Turkey and Greece, burnout was even higher than in Spain. Several studies have shown how budget cuts have direct negative effects on staffing and practice environments of health professionals [33, 34].

In relation to the perception of the perioperative nurses’ environment work in our study, most nurses perceived their work environment as unfavourable for four of the five organizational factors: “Participation in hospital affairs”, “Nurse Managers’ ability, leadership and support of the nurses”, “Nurse - physician relation”, and “Staffing and resources adequacy”. Only one factor, “Nursing foundation quality of care”, was favourable. These results support findings from other studies conductued in hospitals with low staffing levels in areas where nurses care for critically ill patients who have complex conditions and needs [35, 36]. The most important finding in our study was that three organizational factors were associated with the dimensions of burnout: “Nurse manager ability, leadership, and support of nurses”; “Staffing and resources adequacy”; and “Nursing foundations of quality care”. The factor leadership and support for nurses were related to emotional exhaustion and depersonalization. Low leadership support for nurses has previously been shown to have a strong effect on nursing dissatisfaction and burnout [37]. Lack of recognition and unfair treatment is emotionally exhausting, possibly leading to a deep sense of cynicism about the work and increasing professional’s vulnerability to burnout [21]. The role of perioperative nurse leaders in the development of developing nurses’ burnout, should therefore be addressed [38]. These relationships are consistent with those of other studies which found that good nurse leadership can prevent emotional exhaustion among nurses [39, 40].

Shortages of staff and resources are a major concern of nurses as they are unable to meet all the demands of their work. Fewer nurses obviously increases the workload and has been clearly related to a greater risk of burnout [14, 41]. Shortages are likely of particular note in operating rooms and recovery rooms - in some places in our setting there are now only two nurses where there had previously been three nurses - as complexity has increased considerably in recent years due to advances in technology and greater numbers of aged patients with complex comorbidity [27].We did not find any evidence regarding standardized measures of nurse staffing for the surgical area and each hospital has its own staffing criteria to schedule the number of professionals needed for each intervention [42]. The RN4Cast focused on medical-surgical units and intensive care units, but to our knowledge, no studies have been performed to determine the number of surgical nurses needed in perioperative areas. Besides, there are no guidelines in Europe from any organization such as NICE (National Institute for Health and Care Excellence) or EORNA (European Operating Room Nurses Association) that have developed recommendations in this topic.

As concerns personal accomplishment, in our study this factor was related to “Nursing foundations and quality of care”. Despite the level of burnout among perioperative nurses and the unfavourable work environment, the nurses reported that their standard of care and clinical competence were high. This findings supports the observation of Lashinger & Leiter that nurses may compensate for the negative aspects of their work environment with their professional competency [43].

Analysis of the association between the presence of burnout and demographic and professional characteristics such as age, type of contract, job type and years in current job showed burnout was higher in older nurses who worked in postoperative services and had a permanent contract. In the multivariate analysis, however, these differences were not statistically significant. These results are consistent with observations in the literature that the burnout is primarily related to the nurse working environment and organizational factors, and that personal factors and demographic factors are secondary causes [44, 45].

Finally, several studies highlight the importance of considering job satisfaction and work engagement as environmental variables within health organizations so as to prevent burnout and job-related distress and to promote wellbeing of workers [46-48]. In the workplace included in the present study it is necessary to consider the impact that dimensions and indicators of organizational health have on the quality of work and on the perception of well-being of workers, such as the openness to the external environment and technological and cultural innovation [49].

Our results indicate that adequate staffing, leadership, and support for nurses and nursing foundations for quality care are paramount to avoid burnout in perioperative nurses.

Determining factors leading to burnout in perioperative nurses is essential to implement strategies to improve the care of surgical patients and promote psychosocial well-being and health of nurses in the perioperative setting.