APPENDICIES
3.9. The Prevalence of Burnout and Job Strain in Primary Health Care Nursing
3.9.5. The Job Strain Model
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sector, there is very little chance for an individual to have autonomy in their working environment. Various studies have reported that nurses feel “left out” and not consulted enough” when asked about how empowered they feel in their environment. Accordingly, this study suggests that various types of job strain may contribute to burnout, the focal point being to assess the role job strain plays with regards to nurses’ levels of experienced wellbeing, burnout and job satisfaction.
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The model developed by Karasek postulates that strain, be it mental or physical, is a result of the combined effects of the demands of the work environment and the range of decision-making freedoms the worker has in facing those demands and not from one single aspect of the work environment (1979). His dissatisfaction with earlier work and health models that purely focused on job demands, led him to develop his own model that included a psychosocial dimension, which included the level of perceived control an employee has over their work situation (Karasek & Theorell, 1990).
Among the influences that led Karasek to develop his job strain model included that of Seligman’s theory of learned helplessness, theories of active and passive coping, and Sundbom’s studies of psychological strain in challenging occupations. Together, they contributed to Karasek’s idea of control and the importance of being able to make decisions at work (Theorell & Karasek, 1996). Karasek’s proposition was that job strain was a result of the combination of high psychological demands such as having to work hard and fast with little freedom to make decision which affect a person’s work such as the schedule they follow (Theorell & Karasek, 1996). This combination of high demands and low control increases the risk of disease. In contrast, when high demands are combined with high level of decision latitude, the stress can be positive and thus Karasek “proposed that the dimensions of demand and control might reflect different mechanisms of physiological activation” (Theorell &
Karasek, 1996, p. 14).
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Figure 3.2. Karasek Job Strain Model. Adapted from Schnall, Landsbergis and Baker, (1994, p. 382).
Figure 3.2 is a physical representation of the job strain model as developed by Robert Karasek. According to the model “the combination of high demands and low decision latitude will lead to negative physical health outcomes such as hypertension and cardiovascular disease” (Schnall, Landsbergis & Baker, 1994). The model makes two predictions, Diagonal line A represents when job demands are high and decision latitude is low, the person will experience strain (Schnall et al., 1994)). Diagonal line B represents when job demands are high and job decision latitude is also high, the job is defined as “active” and it is hypothesised that it leads to development of new behaviour patterns. Karasek further states that working in either the active job category or the high strain job has the potential to modify an individual’s psychological wellbeing as well as their coping styles (Karasek & Theorell, 1990).
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In order for the change processes of both the proposed NHI scheme and the Re- Engineering of PHC not to add to the strain of nurses, research is needed to assess the current levels of strain that nurses face in terms of the level of job demands, decision latitude and skills discretion. Such research will lead to practical recommendations being made towards altering the process so that it can have a positive rather than negative effect on the overall wellbeing of nurses. A stimulating environment can create a positive feedback loop which in turn helps a person to learn and to cope in times of overload, in contrast to a high strain job, which can create a negative feed-back loop that not only arouses feelings of inadequacy and lack of control, but also further inhibits learning and impairs confidence and self-esteem (Karasek & Theorell, 1990).
Nursing is a highly demanding profession in South Africa, where PHC nurses simply perform tasks as outlined in the guidelines and protocols received from the DoH. On the surface, it is logical to assume that nurses have more job control/decision latitude over their work as they lead PHC facilities. However, as Karasek (1979) has shown, job control is understood in terms of when individuals have control over the tasks they are asked to perform and their behaviour during the workday. It also includes the ability of the individual to
participate in and possess the authority to make decisions regarding how these skills are used, as well as the resources and time to complete their work (Petersen et al., 2015).
Irrespective of the fact that nurses may lead PHC facilities in South Africa, the
decisions that they make on a daily basis and how they do their work are mandated/guided by National Guidelines, Protocols and Treatment Guidelines. Additionally, nursing is a
compassionate profession and nurses are tasked with displaying the appropriate emotions
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while consulting with a patient, even though they may not feel that way. Therefore, the current levels of decision latitude that nurses are experiencing as a result of them leading PHC facilities, are not at the desired depths as envisioned by Karasek in terms of his job strain module. The nursing profession is one where job demands are high and decision latitude is fairly low given that nurses are hesitant to make any decision regarding patient treatment plans without first consulting their guidelines or a doctor. This often results in mental strain which ultimately leads to depression and burnout (Karasek, 1979). In an environment beset with tension and stress, it is now more important than ever before to identify and develop positive emotions in the workplace.