Role of Spirituality and Psychological Capital in the Prediction of Occupational Burnout in Nurses in Khorramabad, Iran during 2016

Introduction are providers, such as emergency personnel, firefighters, nurses, doctors, and other community service providers are among the primary victims of occupational stress and its complications due to their constant exposure to stressful circumstances. Hospitals are among the most stressful organizations and employment in such an environment puts nurses in difficult and stressful conditions (1). The nursing profession is inherently stressful due to the nature of its tasks. In addition, their special working conditions, such as rotating shifts, separate them from society. Low wage is another one of the stressful issues facing nurses. Continuation of such conditions can lead to their occupational burnout (2). Occupational burnout is a psychological syndrome that has complications, such as chronic fatigue, development of negative and C Please Cite This Article As: Abdi Zarrin S, Veyskarami M. Role of Spirituality and Psychological Capital in the Prediction of Occupational Burnout in Nurses in Khorramabad, Iran during 2016. Health Spiritual Med Ethics. 2020;7(4):16-24. Abstract


Introduction
are providers, such as emergency personnel, firefighters, nurses, doctors, and other community service providers are among the primary victims of occupational stress and its complications due to their constant exposure to stressful circumstances. Hospitals are among the most stressful organizations and employment in such an environment puts nurses in difficult and stressful conditions (1).
The nursing profession is inherently stressful due to the nature of its tasks. In addition, their special working conditions, such as rotating shifts, separate them from society. Low wage is another one of the stressful issues facing nurses. Continuation of such conditions can lead to their occupational burnout (2).
Occupational burnout is a psychological syndrome that has complications, such as chronic fatigue, development of negative and C pessimistic tendencies towards colleagues and clients, decreased productivity, and resignation. Occupational burnout consists of three aspects, namely emotional exhaustion, depersonalization, and feelings of lack of personal accomplishment (3). Emotional exhaustion is a direct result of stress and loss of one's emotional resources. Depersonalization refers to cruel and negative responses to clients which is indicative of negative and repulsive perceptions of clients. Finally, a decrease or lack of personal accomplishment consists of a decreased sense of competence in the performance of tasks and a negative selfevaluation (4).
According to previous studies, nurses and hospital staff face more psychological and physical pressures and are more prone to burnout due to continuous and direct evaluation of their performance by colleagues, doctors, and even patients; frequent and direct exposure to death, pain, and injury; long working hours; high physical activity; short vacations; short time for socialization with their friends and families; inadequacy and sometimes lack of a social support network; and increased expectations of people. In general, occupational burnout depends on various organizational, interpersonal, and intrapersonal factors and has detrimental effects on the staff health, productivity, and quality of patient care (5).
Negative and harmful effects of occupational burnout have led to the shortage of nurses in developed countries which is a major problem for their health care systems and is one of the concerns of their health officials (6). Based on the results of a meta-analytic study about the prevalence of occupational burnout in nurses from 2000 to the end of 2017 which was conducted on 32 studies, the prevalence of burnout in nurses in Iranian hospitals is 25% (7).
Psychological capital is one of the indicators of positive psychology which is defined by characteristics, such as patience, persistence, perseverance, belief in one's abilities to achieve success, creation of positive attributions about oneself, and endurance of problems (8). Psychological capital enables people to better cope with problems and stressful situations, be less stressed, be more capable in the face of such situations, to have a clear understanding of themselves, and be less affected by daily stressful situations (9).
Psychological capital is the product of the combination and synergy of four components, namely a) self-efficacy, which means selfconfidence, commitment, and attempt to succeed in challenging tasks; b) optimism, which refers to positive attributions about one's present and future successes; c) hope, which means perseverance towards goals and if necessary redirection of the path to achieve the goal and success; d) resilience, which refers to stability and persistence in the face of adversity, attempt to maintain and recover, and even growth and progress in the face of adversity (10).
With the development of psychology and the complex nature of modern societies, more attention has been paid to human spiritual needs along with material needs and desires. Accordingly, the World Health Organization (WHO) has considered the spiritual aspect in its definition of the aspects of human existence, in addition to physical, psychological, and social aspects (11). Spirituality is derived from spiritias which is a Latin word and means the soul of life or a way of being and experiencing which is the result of awareness of an immaterial dimension (12). According to WHO, spirituality includes transcendence, connection to the universe, the establishment of goals and values, such as faith, generosity, a sense of belonging, and love, that are the same in individuals with different ethnic, cultural, and religious backgrounds (13).
Prevalence of occupational burnout in nurses is high which can lead to a decrease in their occupational performance and sometimes resignation from work. Many studies have been conducted about this issue which have introduced several variables in this regard. Therefore, it appears that focusing on positive aspects can be more effective. In other words, it seems to be more fruitful to focus on the positive antecedents that mitigate and prevent burnout instead of the negative antecedents that predict the increase of burnout. In this regard, the present study aimed to find out whether spirituality and psychological capital have the ability to predict burnout in nurses in Khorramabad, Iran.

Research design
The present study was applied in terms of purpose and correlational in terms of method; accordingly, the purpose of this research was to describe and analyze the relationships between variables in the study population. The independent variables or predictors of this study were spirituality and psychological capital while the dependent variable or criterion was occupational burnout.

Sample size and sampling methods
The statistical population of the present study consisted of all nurses with more than five years of work experience who were employed by Lorestan University of Medical Sciences since 2016. The sample size was calculated at 150 subjects based on Cochran's formula and the samples were selected using the multistage cluster sampling method. Inclusion criteria consisted of employment and five years of work experience as a nurse, while the exclusion criteria were being unwilling to participate and undergoing psychological treatment.
The samples were selected from three hospitals that were affiliated to Lorestan University of Medical Sciences and Medical Services, namely Shohada-ye Ashayer, Shahid Rahimi, and Ayatollah Madani hospitals. From Shohada-ye Ashayer Hospital, the emergency, orthopedic, ICU, and male surgical wards, from Shahid Rahimi Hospital, male emergency, chemotherapy, pediatric, and internal medicine wards, and from Shahid Madani Hospital, heart, neonatal, angiography, and general wards were randomly selected. Accordingly, four wards were randomly selected from each hospital, and from each ward, 13-14 nurses were randomly selected for the study. The researchers attended the wards after making the necessary arrangements and provided the nurses with a brief explanation about the purpose of the research and how to complete the questionnaires. In total, 167 questionnaires were distributed; however, some of which were removed from the study due to being unfinished; finally, 150 questionnaires were analyzed.
Regarding the ethical considerations, the samples were free to participate in the study according to their will; moreover, their information was kept confidential and only used for the objectives of the research. The sample size was calculated based on a formula developed by Tabachnick and Fidell which was m8 + 50 N> (m=number of predictor variables). The used Cochran formula was as follows:

Research tools Maslach and Jackson Burnout Inventory
The occupational burnout was measured using Maslach and Jackson (1981) Burnout Inventory. This questionnaire has 22 items that are scored based on a six-point Likert scale ranging from never to very much. Reliability of this questionnaire was verified for the first time in Iran by Filian (14) and its overall reliability coefficient was calculated at 0.78 by Cronbach's alpha. In the present study, the reliability of the Maslach Burnout Inventory was calculated at 0.91 using Cronbach's alpha.

Spirituality Questionnaire
Spirituality was measured using a spirituality questionnaire developed by Parsian and Dunning (2009). This scale is a self-report tool including 29 items which is scored based on a four-point Likert scale ranging from strongly disagree to strongly agree. This questionnaire consists of four subscales, namely selfawareness (10 items), the importance of spiritual beliefs in life (4 items), spiritual activities (5 items), and spiritual needs (9 items). The overall alpha coefficient of the test has been reported to be 0.94. This questionnaire was standardized by Asghari Ebrahimabad et al. (15) and its overall reliability was calculated at 0.90 by Cronbach's alpha. Moreover, its reliability in this study was calculated at 0.94.

Psychological Capital Questionnaire
Psychological Capital Questionnaire by Luthans (2007) was used to evaluate the psychological capital in subjects. This questionnaire includes 24 items that are scored based on a six-point Likert scale. It includes four subscales, namely hope, resilience, optimism, and self-efficacy. The reliability of this questionnaire in Iran was calculated at 0.85 by Bahadori Khosroshahi et al. (16) using Cronbach's alpha. In the present study, the reliability of this questionnaire was calculated at 0.86 by Cronbach's alpha method.
The collected data were analyzed in SPSS software (version 23) using the multiple regression analysis to predict the dependent variable and Pearson correlation coefficient to determine the correlation of the variables.
It should be noted that ethical considerations were respected in all stages of the research, including the principle of voluntary participation and confidentiality of information which referred to the fact that the collected data was used only for research purposes. The research proposal was reviewed and approved before its implementation by the Research Committee of Qom University.

Result
This section provides the demographic characteristics of the subjects which are followed by the analytical results of the research, including the results of correlation and regression analyses. Table 1 summarizes the demographic characteristics of the research subjects.
Pearson correlation coefficient was used to examine the relationship of occupational burnout with spirituality and psychological capital variables in nurses of Khorramabad hospitals and the results are shown in Table 2.
As shown in Table 2, the correlation coefficient between occupational burnout and spirituality was -0.672 (P≤0.05) while the correlation coefficient between occupational burnout and psychological capital was calculated at -0.516 (P≤0.05). In other words, occupational burnout has a significant negative relationship with the two variables of spirituality and psychological capital. Moreover, the correlation coefficient between spirituality and psychological capital was calculated at 0.542 (P≤0.05). Therefore, it can be said that there was a significant direct relationship between spirituality and psychological capital.
In order to present a regression model for the prediction of the rate of occupational burnout in nurses, two variables of spirituality and psychological capital were entered into the   Figure 1). According to Table 3 and based on the calculated value of F and its level of significance (P=0.001), it can be concluded that the model is significant. Therefore, it can be said that predictor variables can predict the criterion variable. As shown in Table 4, the two variables of spirituality and psychological capital as predictor variables were able to significantly predict 43.5% of changes in the occupational burnout of nurses. In order to determine the share of each of the predictor variables, the β and B values are also calculated and summarized in Table 5.
According to Table 5 and standardized and unstandardized coefficients of predictor variables in the prediction of the criterion variable, it can be said that the influence coefficients (β) of spirituality and psychological capital variables in the prediction of burnout were 0.509 and 0.233, respectively. Since the level of significance of both is less than 0.05, both variables are able to predict occupational burnout. In the next step, the components of spirituality and psychological capital were added to the regression model.
To determine the contribution of each of the four components of spirituality to the prediction of occupational burnout, the β is  given in Table 6. According to Table 6, it can be said that among the four components of spirituality, the components of "selfawareness" and "importance of spiritual beliefs in life" were able to predict occupational burnout. The relative contributions of each of these components to the prediction of occupational burnout were 0.329 and 0.308, respectively. According to Table 7, it can be said that out of the four components of psychological capital, only the components of "hope" and "resilience" were able to predict occupational burnout and their relative shares in the prediction were 0.411 and 0.238, respectively. In addition, the two components of "selfefficacy" and "optimism" cannot predict occupational burnout.

Discussion
According to the results, spirituality and psychological capital were able to predict the occupational burnout of nurses. Moreover, it was found that occupational burnout had a negative relationship with spirituality and psychological capital while spirituality had a direct relationship with psychological capital. In addition, the findings revealed that among the components of spirituality, "self-awareness" and "importance of spiritual beliefs in life", and among the four components of psychological capital, only "resilience" and "hope" could significantly predict occupational burnout. Ding et al. (17) in their study found that psychological capital can predict occupational burnout which is in line with the results of the present study. Furthermore, the results of a research conducted by Nezami and Givarian (18) indicated that psychological capital was correlated with occupational burnout, and among its components, "hope" had a major share in the prediction of burnout. The results of another study performed by Sadoughi and Zarjini (19) revealed that psychological capital can predict occupational burnout. Moreover, according to the results of a study performed by Shakerinia et al. (20), one of the predictors of occupational burnout in nurses was their level of resilience. Asgharpour Hajieabadi et al. (21) in their study found that spirituality had a negative relationship with occupational burnout. Similarly, the results of a study carried out by Kordtamini,Nikmanesh,and Ghanbarpoor (22) indicated that higher levels of spirituality result in lower levels of occupational burnout in nurses.
Given the obtained results, it can be said that psychological capital can predict the motivational behaviors of employees and is an important factor for the improvement of work performance and employee motivation (23). Characteristics, such as hope and resilience lead to an increase in effort, creativity, and the individual's ability to adapt to stressors which, in turn, reduce physical, psychological, and emotional complications at work (24). Occupational burnout is a type of psychological complication that is a direct product of work-related stress. Therefore, positive states, such as spirituality, and the inherent capabilities of psychological capital increase the resistance to tension and occupational stress, and thereby reduce occupational burnout (25).
According to previous studies, transcendence and the sense of connection with God and the universe protect one against stress and environmental pressures (26). Furthermore, it can be said that people who have higher levels of spirituality and inner faith are less influenced by the negative and destructive effects of occupational burnout. It has been found that such people use stress as an opportunity to develop spirituality. Therefore, spirituality has been introduced as an effective method for the formation of positive psychological traits (27).
Regarding the correlation between spirituality and psychological capital for the prediction of occupational burnout in nurses, the results of previous research have indicated that spiritual connection predicts psychological capital while psychological capital and spiritual connection predict spiritual well-being. The results of structural equation modeling and mediation analysis indicated that psychological capital is a partial mediator variable. This means that spiritual connection can enhance the spiritual well-being of nurses both indirectly (through reinforcement of psychological capital) and directly (28).
In this regard, the results of another study revealed that psychological well-being had a positive significant relationship with psychological capital and spirituality at work while psychological capital and spirituality at work explained 70% of the variance of psychological well-being in nurses (29). Moreover, the findings of another study indicated that the adaptive performance of nurses had a significant positive relationship with psychological capital and spiritual intelligence. In the above-mentioned study, it was also found that among the components of psychological capital, resilience and selfefficacy, and among the components of spiritual intelligence, transcendent selfawareness, patience, and spiritual experiences could predict adaptive performance in nurses in that order (30). Occupational burnout reduces mental, physical, and psychological well-being in nurses (31); therefore, it is very important to identify, prevent, and treat occupational burnout in them.

Conclusion
Based on the results, psychological capital and spirituality have a negative relationship with occupational burnout and can also predict it. In addition, it was found that among the components of spirituality, "self-awareness" and "importance of spiritual beliefs", and among the components of psychological capital, the components of "hope" and "resilience" were able to predict occupational burnout in nurses. Therefore, it is suggested to examine the mentioned capabilities while selecting and hiring nurses. Moreover, it is recommended to strengthen the psychological preparedness of nurses according to positive psychology, such as psychological capital and spirituality.
One of the limitations of the present study was that the data were collected from the hospitals of only one city. Therefore, caution should be exercised in the generalization of the results to other communities. Another limitation of this research was the mere usage of the questionnaire for data collection. Due to the limitations of this tool, it is recommended to use qualitative tools, such as interview and observation, in future research. nurses of hospitals in Khorramabad who cooperated in this research and helped the researchers to achieve their goals with their accurate answers. It is worth mentioning that this research was not funded by any department or organization.