The impact of stress and its consequences has been at the center of many healthcare studies in the past . The constant interaction between professional standards, personal ego integrity and patient needs within the therapeutic relationship often leave the nurse vulnerable to stress, fatigue, and burnout.
For nursing, the topic of stress has received its’ greater attention in the form of exploring the effects of the “burnout syndrome” (BOS). Nurses are more susceptible to experiencing burnout than some of the other healthcare professions because of the implicit relationship of job stress to burnout. There have been many studies trying to verify the relationship between stress and burnout in various clinical settings [2–4] however; little light has been shed on specific associations and inter-relationships between the two concepts.
The burnout syndrome refers to a situation in which workers appear disconnected from their job and everything seems to be senseless and any effort or activity, meaningless. In 1974, Freudenberger coined the term “burnout” to describe workers’ reactions to the chronic stress commonly found in occupations involving numerous interpersonal interactions . Burnout is typically conceptualized as a syndrome characterized by emotional exhaustion, depersonalization, and reduced personal accomplishment . The term “burnout syndrome”, mainly applied to the caring professions, defines the breakdown of energy resources and adaptability as a reaction to chronic stress [6–8].
There has been much research on burnout in nurses, presumably because of the intense nature of their contact with patients/clients . However, studies undertaken in different groups of nurses show variations in the expressed levels of burnout. Variation exists also in terms of the consequences of burnout . Burnout can be manifested as psychological distress, somatic complaints, alcohol and drug abuse for healthcare workers [11, 12]. In this light Melchior et al.  assert that burnout has been related virtually to every symptom due to the ambiguity surrounding this concept. This can be attributed to the varying responses of people towards burnout.
In relation to the contributing factors to nurses’ burnout Schaufeli  and Duquette et al.  assert that based on the available evidence there are various levels of correlations. However, both researchers assert that there is sufficient evidence to show that age, work pressure, role confusion, less hardiness, passive coping style and limited social support can negatively influence burnout in nurses. Several studies have indicated that the presence of social resources can contribute to low levels of burnout [16, 17]. These contributing factors have also been identified earlier by Maslach et al. .
Burnout and fatigue are related but conceptually are different constructs. Therefore burnout is conceptualized as a work related condition and fatigue as a more general condition. An interesting theorization of fatigue comes from Valent  who asserts that fatigue occurs when one cannot rescue or save the individual from harm and results in guilt and distress. On the other hand, fatigue according to Shen et al.  refers to an overwhelming sense of tiredness, lack of energy, and a feeling of exhaustion associated with impaired physical and/or cognitive functioning.
In 1992 a related term to fatigue was introduced in the literature that of “compassion fatigue” . Yoder  asserts that the term referred to situations in which nurses had either turned off their own feelings or experienced helplessness and anger in response to the stress they feel watching patients go through devastating illnesses or trauma.
Studies in the wider working population have shown that fatigue can be associated with sickness absence and work disability [21, 23]. For the nursing population the studies have demonstrated that long working hours, rotating shifts and night shifts can lead nurses to fatigue. The effects of fatigue include but are not limited to poor performance, errors in clinical practice, and prolonged fatigue may lead to burnout. Existing evidence support that the healthcare workers’ performance on tasks requiring vigilance, attention to detail, or which are long in duration may be particularly susceptible to fatigue-related consequences [24, 25].
On a financial basis, for hospitals, burnout, stress and fatigue can be costly leading to increased employee tardiness, absenteeism, turnover, decreased performance, and difficulty in recruiting and retaining staff [26, 27]. Based on the preceding studies, it seems unlikely that healthcare organizations with high levels of burnout among health professionals could achieve the performance characteristics such as patient-centeredness as a strategy to improve quality of care [28, 29].
Healthcare context in Cyprus
Cyprus has a mixed health care system, which is in transition to a National Health Care System. Being a mixed system, it means that the public has the option to receive care either by a public or a private provider. However, there appear to be major discrepancies between public and private hospitals. Public hospitals are responsible for providing primary (primary care is the first point of contact a person has with the health system), secondary (provision of acute and specialist services, treating conditions which normally cannot be dealt with by primary care specialists or which are brought in as an emergency) and tertiary care (provision of specialized consultative care, usually on referral from primary or secondary medical care personnel), where as the private hospitals are confined to provide secondary care, and limited preventive services. The public hospitals are faced up with a challenge; how to meet the increasing demand for health care without an adequate increase of resources [30–32].
The private hospitals’ operation is contingent on market incentives. Because private hospitals are not subsidised and depend on income from clients/users, it can be argued that they are more inclined than public hospitals to provide quality services and to be concerned about client/user satisfaction . The majority of the population (95%) is entitled to either free medical care, or to publicly provided healthcare at reduced cost coverage. The remaining percentage of the population seeks health care services from the private establishments (i.e. private hospitals, clinics).
Nursing personnel comprise the largest group of healthcare workers employed both by public and private hospitals. The nursing education is Cyprus is provided on a bachelor’s level, requiring 4 years of education and training. Nursing education is nowadays provided solely by public and private universities. Previously, nurses were educated on a diploma basis requiring only 3 years of education. Registered nurses under the new act (released on 2012) are required to renew their practice license every four years based on specific criteria in relation to lifelong learning.
However, as a result of ongoing change, due to the introduction of a National Healthcare System, nurses face challenges requiring them to balance high-quality care with lower costs . The consequence of this on nurses has been considerable and far-reaching . With less nurses to care for patients, their workload significantly increased. Overall, stress levels also increased when more patients had to be processed in the same number of hours and patient turnover is faster than in the past [34, 35].
Taking the above into consideration and keeping in mind that the phenomenon of burnout has not been examined within the population of nurses in the Cypriot Healthcare context, a research study was undertaken to investigate the burnout syndrome within this population. Furthermore, there is a gap in the international literature in relation to the study of the prevalence of burnout and fatigue among nurses, demonstrating the need for further research in this field.
This study was designed to explore the factors associated with the burnout syndrome in Cypriot nurses who work in the private and public healthcare sectors.
The research questions posed by this study were the following:
What is the point prevalence of burnout syndrome in Cypriot nurses?
Which factors are associated with burnout syndrome in Cypriot nurses?
What is the difference in burnout syndrome between Cypriot nurses working in the private and the public sector?
Is there an association between fatigue and burnout?