System-Level Improvements in Work Environments Lead to Lower Nurse Burnout and Higher Patient Satisfaction

Meta-Analysis of Factors Associated with Occupational Therapist Burnout

Burnout, a reaction to chronic emotional stress, affects health and reduces the quality of service. Reportedly, healthcare professionals are especially vulnerable to burnout. This meta-analysis is aimed at examining the factors associated with occupational therapists' burnout. The results of 2,430 occupational therapists, across 17 peer-reviewed English articles, the most recent published in 2020, were analysed. Results revealed significant associations between related variables and burnout. Marital status, work field, and work hours, job challenges, patient age, position, turnover intention, working type, and work addiction showed significant positive correlation effect sizes in relation to burnout, whereas age, education, engagement, job satisfaction, personal identity, professional identity, rewards, and feeling valued showed significant negative correlation effect sizes. The results of this meta-analysis suggest that strategies to reduce occupational therapists' burnout need to consider organizational as well as psychological aspects.

Mindful self-compassion for nurses: a systematic review

This article details a systematic review that aimed to synthesise and analyse the published research on the effects of mindful self-compassion interventions on stress in nurses. Five studies were identified that met the inclusion criteria and were analysed in terms of sample characteristics, intervention, measurement of self-compassion, additional psychosocial outcome measures, intervention duration and adherence, intervention outcomes and effect size and follow-up. The review found that mindful self-compassion interventions had medium-to-large effect sizes for self-compassion, traumatic stress, burnout, stress and compassion satisfaction. There was also high intervention adherence (mean=86%) in the included studies. Since these interventions can improve self-compassion and compassion in nurses, they have the potential to enhance the quality of compassionate care provided by nurses who undergo training in mindful self-compassion.

Relationships Between Nurses' Work System, Safety-Related Performance, and Outcomes: A Structural Equation Model

OBJECTIVES

We examined relationships between nurses' work system, safety-related performance, and outcomes based on a modified Systems Engineering Initiative for Patient Safety model.

METHODS

A cross-sectional survey was conducted with 408 nurses from 2 general hospitals. Data on work system factors (person, organization, environment, tools, and task), processes (safety-related performance), and outcomes (staff and clinical outcomes) were collected. Structural equation modeling was used to determine the relationships between nurses' work system factors, safety-related processes, and outcomes.

RESULTS

Structural equation modeling yielded a comparative fit index of 0.918, standardized root mean square residual of 0.055, and root mean square error of approximation of 0.054, indicating an acceptable model fit. The person factor had a significant positive direct effect on nurses' safety-related performance, and significant negative direct and indirect effects on the clinical outcome. The organization factor had significant positive direct effects on nurses' safety-related performance and staff outcome, and a negative indirect effect on the clinical outcome. The task factor had a significant positive direct effect on staff outcome. However, the environment and tools factors had no significant effects on safety-related performance or outcomes.

CONCLUSIONS

The findings demonstrated the usefulness of the Systems Engineering Initiative on Patient Safety model to explain safety-related performance and outcomes, indicating differential effects of work system factors. Although the person factor significantly affected safety performance and clinical outcomes, the organization factor was the most influential component for promoting safety-related performance and staff and clinical outcomes. These results can be used to prioritize activities for patient safety.

Effect of Practice Environment on Nurse Reported Quality and Patient Safety: The Mediation Role of Person-Centeredness

This study aims to explore the potential mediation role of person-centeredness between the effects of the work environment and nurse reported quality and patient safety. A quantitative cross-sectional survey collected data from 1055 nurses, working in medical and surgical units, in twelve Malaysian private hospitals. The data collection used structured questionnaires. The Hayes macro explored the mediation effect of person-centeredness between the associations of work environment dimensions and care outcomes, controlling nurses’ demographics and practice characteristics. A total of 652 nurses responded completely to the survey (61.8% response rate). About 47.7% of nurses worked 7-h shifts, and 37.0% were assigned more than 15 patients. Higher workload was associated with unfavorable outcomes. Nurses working in 12-h shifts reported a lower work environment rating (3.46 ± 0.41, p < 0.01) and person-centered care (3.55 ± 0.35, p < 0.01). Nurses assigned to more than 15 patients were less likely to report a favorable practice environment (3.53 ± 0.41, p < 0.05), perceived lower person-centered care (3.61 ± 0.36, p < 0.01), and rated lower patient safety (3.54 ± 0.62, p < 0.05). Person-centeredness mediates the effect of nurse work environment dimensions on quality and patient safety. Medical and surgical nurses, working in a healthy environment, had a high level of person-centeredness, which, in turn, positively affected the reported outcomes. The function of person-centeredness was to complement the effects of the nurse work environment on care outcomes. Improving the nurse work environment (task-oriented) with a high level of person-centeredness (patient-oriented) was a mechanism through which future initiatives could improve nursing care and prevent patient harm.

Interprofessional collaboration as a mediator in the relationship between nurse work environment, patient safety outcomes and job satisfaction among nurses

BACKGROUND

As an important organisational feature, the nurse work environment has been associated with increased work effectiveness, reduced patient safety issues and improved care quality. However, the mechanism underlying this association remains unexplored.

AIM

This study aims to assess the mediating role of interprofessional collaboration in the relationships between nurse work environment, select patient safety outcomes and job satisfaction.

METHODS

This cross-sectional, descriptive study used five standardized scales and included 881 clinical nurses employed in select teaching hospitals in Oman.

RESULTS

Nurses who worked in teaching hospitals in Oman perceived their work environment as highly favourable. Nurse work environment was directly and indirectly associated with nurse-assessed quality of care, adverse patient events and job satisfaction, through interprofessional collaborations.

CONCLUSION

Findings of the study suggest that enhancing nurse work environments can be a potential strategy to foster interprofessional collaboration and improve job satisfaction and patient safety outcomes.

IMPLICATIONS FOR NURSING MANAGEMENT

Organisational strategies to improve patient safety outcomes and job satisfaction in nurses can be facilitated by improving nurses' work conditions and enhancing interprofessional collaboration through supportive leadership, theory-driven approaches, obtaining hospital accreditation/certification and relevant workplace policies.

The Science of Health Care Worker Burnout: Assessing and Improving Health Care Worker Well-Being

CONTEXT.—

Problems with health care worker (HCW) well-being have become a leading concern in medicine given their severity and robust links to outcomes like medical error, mortality, and turnover.

OBJECTIVE.—

To describe the state of the science regarding HCW well-being, including how it is measured, what outcomes it predicts, and what institutional and individual interventions appear to reduce it.

DATA SOURCES.—

Peer review articles as well as multiple large data sets collected within our own research team are used to describe the nature of burnout, associations with institutional resources, and individual tools to improve well-being.

CONCLUSIONS.—

Rates of HCW burnout are alarmingly high, placing the health and safety of patients and HCWs at risk. To help address the urgent need to help HCWs, we summarize some of the most promising early interventions, and point toward future research that uses standardized metrics to evaluate interventions (with a focus on low-cost institutional and personal interventions).

The impact of perceived nurses' work environment, teamness, and staffing levels on nurse-reported adverse patient events in Oman

BACKGROUND

Fostering a healthy work environment becomes a necessity in health care institutions that value quality care and patient safety. However, limited studies investigated the impact of work environment characteristics including staffing and teamness among healthcare teams on adverse patient events in Oman.

AIMS

To examine the (1) impact of work environment, interprofessional teamness, staffing levels on adverse patient events and (2) predicting factors of perceptions of work environment among nurses in the Sultanate of Oman.

METHOD

A cross-sectional descriptive design was utilized to collect data from 2113 nurses. Participants completed a self-report questionnaire that included a set of instruments.

RESULTS

The results showed a strong positive relationship between work environment and teamness (r = 0.59, p < 0.001). Nurses working in a favorable environment that has positive teamwork reported a reduction in adverse events including patient and family complaints, patient and family verbal abuse, patient falls, nosocomial infections, and medication errors (p < 0.001). There was a nonsignificant correlation between staffing and adverse patient events.

CONCLUSION

Fostering a healthy and supportive work environment continue to be crucial for ensuring patient safety. Nurse administrators should strive to improve work environment through creating a culture that values interprofessional teamwork and collaborative relationships.

Evidence-Based Practice Culture and Mentorship Predict EBP Implementation, Nurse Job Satisfaction, and Intent to Stay: Support for the ARCC© Model

BACKGROUND

The Advancing Research and Clinical practice through close Collaboration (ARCC^© ) Model is a system-wide framework for implementing and sustaining evidence-based practice (EBP) in hospitals and healthcare systems. The model involves assessing organizational culture and readiness for EBP in addition to the development of a critical mass of EBP mentors who work with point-of-care clinicians to facilitate the implementation of evidence-based care. Determining how the various components of the ARCC^© Model relate to one another is important for understanding how EBP culture and mentorship impact EBP implementation, nurses' job satisfaction, and intent to stay.

AIMS

The current study aimed to test a model that could explain the relationships and direct pathways among eight key variables in the ARCC^© Model: (1) EBP culture, (2) mentorship, (3) knowledge, (4) beliefs, (5) competency, (6) implementation, (7) nurses' job satisfaction, and (8) intent to stay.

METHODS

Structural equation modeling was used to test relationships among the variables in the ARCC^© Model with data obtained from an earlier cross-sectional descriptive study with 2,344 nurses from 19 hospitals and healthcare systems across the United States.

RESULTS

The final structural equation model found that EBP culture and mentorship were key variables that positively impacted EBP knowledge, beliefs, competency, implementation, job satisfaction, and intent to stay among nurses.

LINKING EVIDENCE TO ACTION

As described in the ARCC^© Model, establishing a strong sustainable EBP culture along with a critical mass of EBP mentors is crucial for the development of EBP competency and consistent implementation of evidence-based care by nurses. A strong EBP culture along with EBP mentorship also can result in higher job satisfaction and intent to stay. Implementation of the ARCC^© Model is a key strategy in assisting systems to reach health care's Quadruple Aim.

Hospital nurse staffing and patient outcomes in Chile: a multilevel cross-sectional study

BACKGROUND

Unrest in Chile over inequalities has underscored the need to improve public hospitals. Nursing has been overlooked as a solution to quality and access concerns, and nurse staffing is poor by international standards. Using Chile's new diagnosis-related groups system and surveys of nurses and patients, we provide information to policy makers on feasibility, net costs, and estimated improved outcomes associated with increasing nursing resources in public hospitals.

METHODS

For this multilevel cross-sectional study, we used data from surveys of hospital nurses to measure staffing and work environments in public and private Chilean adult high-complexity hospitals, which were linked with patient satisfaction survey and discharge data from the national diagnosis-related groups database for inpatients. All adult patients on medical and surgical units whose conditions permitted and who had been hospitalised for more than 48 h were invited to participate in the patient experience survey until 50 responses were obtained in each hospital. We estimated associations between nurse staffing and work environment quality with inpatient 30-day mortality, 30-day readmission, length of stay (LOS), patient experience, and care quality using multilevel random-effects logistic regression models and zero-truncated negative binomial regression models, with clustering of patients within hospitals.

FINDINGS

We collected and analysed surveys of 1652 hospital nurses from 40 hospitals (34 public and six private), satisfaction surveys of 2013 patients, and discharge data for 761 948 inpatients. Nurse staffing was significantly related to all outcomes, including mortality, after adjusting for patient characteristics, and the work environment was related to patient experience and nurses' quality assessments. Each patient added to nurses' workloads increased mortality (odds ratio 1·04, 95% CI 1·01-1·07, p<0·01), readmissions (1·02, 1·01-1·03, p<0·01), and LOS (incident rate ratio 1·04, 95% CI 1·01-1·06, p<0·05). Nurse workloads across hospitals varied from six to 24 patients per nurse. Patients in hospitals with 18 patients per nurse, compared with those in hospitals with eight patients per nurse, had 41% higher odds of dying, 20% higher odds of being readmitted, 41% higher odds of staying longer, and 68% lower odds of rating their hospital highly. We estimated that savings from reduced readmissions and shorter stays would exceed the costs of adding nurses by US$1·2 million and $5·4 million if the additional nurses resulted in average workloads of 12 or ten patients per nurse, respectively.

INTERPRETATION

Improved hospital nurse staffing in Chile was associated with lower inpatient mortality, higher patient satisfaction, fewer readmissions, and shorter hospital stays, suggesting that greater investments in nurses could return higher quality of care and greater value.

FUNDING

Sigma Theta Tau International, University of Pennsylvania Global Engagement Fund, University of Pennsylvania School of Nursing's Center for Health Outcomes, and Policy Research and Population Research Center.

TRANSLATION

For the Spanish translation of the abstract see Supplementary Materials section.

Key Elements of the Critical Care Work Environment Associated With Burnout and Compassion Satisfaction

BACKGROUND

As the role of a health care system's influence on nurse burnout becomes better understood, an under-standing of the impact of a nurses' work environment on burnout and well-being is also imperative.

OBJECTIVE

To identify the key elements of a healthy work environment associated with burnout, secondary trauma, and compassion satisfaction, as well as the effect of burnout and the work environment on nurse turnover.

METHODS

A total of 779 nurses in 24 critical care units at 13 hospitals completed a survey measuring burnout and quality of the work environment. Actual unit-level data for nurse turnover during a 5-month period were queried and compared with the survey results.

RESULTS

Among nurses in the sample, 61% experience moderate burnout. In models controlling for key nurse characteristics including age, level of education, and professional recognition, 3 key elements of the work environment emerged as significant predictors of burnout: staffing, meaningful recognition, and effective decision-making. The latter 2 elements also predicted more compassion satisfaction among critical care nurses. In line with previous research, these findings affirm that younger age is associated with more burnout and less compassion satisfaction.

CONCLUSIONS

Efforts are recommended on these 3 elements of the work environment (staffing, meaningful recognition, effective decision-making) as part of a holistic, systems-based approach to addressing burnout and well-being. Such efforts, in addition to supporting personal resilience-building activities, should be undertaken especially with younger members of the workforce in order to begin to address the crisis of burnout in health care.

Prevalence of and Factors Associated With Nurse Burnout in the US

IMPORTANCE

Clinician burnout is a major risk to the health of the US. Nurses make up most of the health care workforce, and estimating nursing burnout and associated factors is vital for addressing the causes of burnout.

OBJECTIVE

To measure rates of nurse burnout and examine factors associated with leaving or considering leaving employment owing to burnout.

DESIGN, SETTING, AND PARTICIPANTS

This secondary analysis used cross-sectional survey data collected from April 30 to October 12, 2018, in the National Sample Survey of Registered Nurses in the US. All nurses who responded were included (N = 50 273). Data were analyzed from June 5 to October 1, 2020.

EXPOSURES

Age, sex, race and ethnicity categorized by self-reported survey question, household income, and geographic region. Data were stratified by workplace setting, hours worked, and dominant function (direct patient care, other function, no dominant function) at work.

MAIN OUTCOMES AND MEASURES

The primary outcomes were the likelihood of leaving employment in the last year owing to burnout or considering leaving employment owing to burnout.

RESULTS

The weighted sample of 50 273 respondents (representing 3 957 661 nurses nationally) was predominantly female (90.4%) and White (80.7%); the mean (SD) age was 48.7 (0.04) years. Among nurses who reported leaving their job in 2017 (n = 418 769), 31.5% reported burnout as a reason, with lower proportions of nurses reporting burnout in the West (16.6%) and higher proportions in the Southeast (30.0%). Compared with working less than 20 h/wk, nurses who worked more than 40 h/wk had a higher likelihood identifying burnout as a reason they left their job (odds ratio, 3.28; 95% CI, 1.61-6.67). Respondents who reported leaving or considering leaving their job owing to burnout reported a stressful work environment (68.6% and 59.5%, respectively) and inadequate staffing (63.0% and 60.9%, respectively).

CONCLUSIONS AND RELEVANCE

These findings suggest that burnout is a significant problem among US nurses who leave their job or consider leaving their job. Health systems should focus on implementing known strategies to alleviate burnout, including adequate nurse staffing and limiting the number of hours worked per shift.

Leveraging the Work Environment to Minimize the Negative Impact of Nurse Burnout on Patient Outcomes

BACKGROUND

Burnout remains a persistent issue affecting nurses across the US health system. Limited evidence exists about the direct impact of nurse burnout on patient outcomes. This study explores the relationship between nurse burnout and mortality, failure to rescue, and length of stay, while also considering the effect of a good work environment.

METHODS

Cross sectional data from nurses and hospitals were used in conjunction with patient claims data. Multivariate logistic regression was used to study the relationship between nurse burnout, patient outcomes, the work environment, and Magnet status.

RESULTS

Higher odds of patient mortality, failure to rescue, and prolonged length of stay were found in hospitals that had, on average, higher nurse burnout scores. Good work environments were found to attenuate the relationship between nurse burnout and mortality, failure to rescue, and length of stay. Magnet status, another indicator of a good work environment, was found to attenuate the relationship between nurse burnout and mortality and failure to rescue.

CONCLUSIONS

Improving the work environment remains a solution for hospitals looking to concurrently improve nurse burnout and patient outcomes. Administrators may look to the Magnet recognition program as a blueprint to better support nurses in providing safe, high quality care.

Burnout, job dissatisfaction and missed care among maternity nurses

AIM

This study examined the prevalence of job dissatisfaction and burnout among maternity nurses and the association of job dissatisfaction and burnout with missed care.

BACKGROUND

Nurse burnout and job dissatisfaction affect the quality and safety of care and are amenable to intervention. Little is known about job dissatisfaction and burnout among maternity nurses or how these factors are associated with missed care in maternity units.

METHODS

This was a cross-sectional secondary analysis of the 2015 RN4CAST survey data and the American Hospital Association's 2015 Annual Survey. Robust logistic regression models at the nurse level examined the association of job dissatisfaction and burnout with missed care.

RESULTS

One-quarter of nurses screened positive for burnout, and almost one-fifth reported job dissatisfaction. While 56.4% of nurses in the total sample reported any missed care, 72.6% of nurses with job dissatisfaction and 84.5% of nurses with burnout reported any missed care (p < .001).

CONCLUSIONS

The association of job dissatisfaction and burnout, which are modifiable states, with increased rates of missed maternity care suggests that addressing job dissatisfaction and burnout may improve care quality.

IMPLICATIONS FOR NURSING MANAGEMENT

Job dissatisfaction, burnout and missed care may decrease with an improved work environment.