Nurse burnout and patient satisfaction

Burnout in residents of otolaryngology-head and neck surgery: a national inquiry into the health of residency training

PURPOSE

To characterize resident burnout on a national scale with a large sample size and to identify associated modifiable factors to minimize burnout and improve the quality of residency education.

METHOD

A survey was mailed to all 1,364 U.S. residents of otolaryngology-head and neck surgery in September 2005. The main outcome measures were the Maslach Burnout Inventory-Human Services Study, demographic information, and potential burnout predictors, including stressors, satisfaction, self-efficacy, and support systems.

RESULTS

The response rate was 50% (684/1,364). Current second-year through fifth-year residents were included for further analysis (514). Burnout was extremely common among otolaryngology residents. High burnout was seen in 10% of residents (51), moderate burnout in 76% (391), and low burnout in 14% (72). The strongest associated demographic factor was work hours (P < .001). Hours worked was predictive of emotional exhaustion, with exhaustion scores rising by 0.19 for each hour worked (P < .001). Furthermore, there was an 8% (41 resident) reported violation rate of the Accreditation Council for Graduate Medical Education (ACGME) 80-hour-workweek limitation. Satisfaction with the balance between personal and professional life, relationship stability, and satisfaction with career choice were negatively associated with burnout (all P < .001).

CONCLUSIONS

Burnout is widely prevalent among U.S. otolaryngology residents and is present at greater levels than those seen in chairs or faculty of the same specialty. Work hours predict emotional exhaustion, and adherence to the ACGME 80-hour workweek may help protect against burnout and its deleterious consequences in residents of all specialties.

US nurse labor market dynamics are key to global nurse sufficiency

OBJECTIVES

To review estimates of U.S. nurse supply and demand, document trends in nurse immigration to the United States and their impact on nursing shortage, and consider strategies for resolving the shortage of nurses in the United States without adversely affecting health care in lower-income countries.

PRINCIPAL FINDINGS

Production capacity of nursing schools is lagging current and estimated future needs, suggesting a worsening shortage and creating a demand for foreign-educated nurses. About 8 percent of U.S. registered nurses (RNs), numbering around 219,000, are estimated to be foreign educated. Eighty percent are from lower-income countries. The Philippines is the major source country, accounting for more than 30 percent of U.S. foreign-educated nurses. Nurse immigration to the United States has tripled since 1994, to close to 15,000 entrants annually. Foreign-educated nurses are located primarily in urban areas, most likely to be employed by hospitals, and somewhat more likely to have a baccalaureate degree than native-born nurses. There is little evidence that foreign-educated nurses locate in areas of medical need in any greater proportion than native-born nurses. Although foreign-educated nurses are ethnically more diverse than native-born nurses, relatively small proportions are black or Hispanic. Job growth for RNs in the United States is producing mounting pressure by commercial recruiters and employers to ease restrictions on nurse immigration at the same time that American nursing schools are turning away large numbers of native applicants because of capacity limitations.

CONCLUSIONS

Increased reliance on immigration may adversely affect health care in lower-income countries without solving the U.S. shortage. The current focus on facilitating nurse immigration detracts from the need for the United States to move toward greater self-sufficiency in its nurse workforce. Expanding nursing school capacity to accommodate qualified native applicants and implementing evidence-based initiatives to improve nurse retention and productivity could prevent future nurse shortages.

Extending work environment research into home health settings

Organizational attributes in work environments that support nursing practice are theoretically associated with superior nurse and patient outcomes, and lower frequencies of adverse events. This study explored associations between organizational support for nursing practice in home health care agencies and (a) the frequency of nurse-reported adverse events, (b) nurse-assessed quality of care, (c) nurse job satisfaction, and (d) nurses' intentions to leave their employing agency. Data were collected from a sample of 137 registered nurses employed as home health staff nurses in the United States and analyzed using descriptive techniques and bivariate correlation. As anticipated, organizational support for nursing was negatively associated with nurse-reported adverse patient events and intent to leave, and positively associated with nurse-assessed quality of care and job satisfaction. These findings may be helpful to nursing administrators who seek to create work environments in home health agencies that maximize patient outcomes and nurse satisfaction.

State Nursing Shortages and Patient Satisfaction

This study of 827,430 patients, 733 hospitals, and 25 states compares state performance in patient satisfaction with the supply of registered nurses. A significant, positive relationship exists between a state's supply of registered nurses and patients' evaluations of their care experiences. Hospitals in states with nursing shortages may be challenged by national comparisons of patient satisfaction and should take these results into account when devising their quality improvement strategy.

An Exploration of the Factor Structure of the Nursing Work Index

RATIONALE

The nurse shortage is increasing in the developed world. Organisational context is important in determining issues associated with nurse shortages, such as retention, recruitment, and job satisfaction. Recent research has utilised the Nursing Work Index-Revised (NWI-R) as a measure of organisational context traits. Within the NWI-R a four-factor model has been reported as being important in determining good organisational context, yet researchers have recently questioned the stability of the four-factor structure.

AIM

No known study has attempted to replicate the four-factor structure reported in the NWI-R. The aim of this research is to examine the factor structure of the 15 items that comprise the four factors of the NWI-R.

METHODS

The NWI-R is an instrument that is focused on capturing organisational attributes that characterise professional nursing environments. A random sample of 172 (50%) acute care hospital nurses completed the NWI-R as part of a larger research project. The sample was diverse concerning nursing grade and specialty. Data were analysed using SPSS.11.0 to extract factors' structures (principal component and maximum likelihood), measures of homogeneity and descriptive statistics were generated from the findings.

RESULTS

The four-factor structure of the NWI-R was not replicated in the data analysis. Instead a modified three-factor structure was identified accounting for 57% of the variance. Measures of internal consistency were acceptable.

DISCUSSION

Previous research utilised the four factors of the NWI-R as a method to identify supportive organisational context and practice. The three-factor model raises questions regarding the stability of the findings using the NWI-R. This research shows the synthesis of the two models in light of previous findings.

CONCLUSIONS/IMPLICATIONS

The findings might have far reaching implications for research that has utilised the NWI-R as a measure of organisational context. Further research is required to examine this study's findings and literature.

Nurse Practice Environments and Outcomes: Implications for Oncology Nursing

PURPOSE/OBJECTIVES

To examine practice environments and outcomes of nurses working in oncology units or Magnet hospitals and to understand the association between the two.

DESIGN

Secondary analysis of survey data collected in 1998.

SETTING

Medical and surgical units of 22 hospitals, of which 7 were recognized by the American Nurses Credentialing Center Magnet program.

SAMPLE

1,956 RNs, of whom 305 worked in oncology units.

METHODS

Chi-square tests compared nurse-reported outcomes by work setting, analysis of variance tested practice environment differences by setting, and logistic regression estimated the effects of practice environment, specialty, and Magnet status on outcomes.

MAIN RESEARCH VARIABLES

Practice environments, emotional exhaustion, job satisfaction, and quality of care.

FINDINGS

Oncology nurses had superior outcomes compared with nononcology nurses. Emotional exhaustion was significantly lower among oncology nurses working in Magnet hospitals. Scores on the Collegial Nurse-Physician Relations subscale were highest among oncology nurses. Outcomes were associated with Practice Environment Scale of the Nursing Work Index scores and Magnet status. Oncology nurses with favorable collegial nurse-physician relations were twice as likely to report high-quality care.

CONCLUSIONS

Oncology nurses benefit from working in American Nurses Credentialing Center Magnet hospitals. Adequate staffing and resources are necessary to achieve optimal outcomes. Collegial nurse-physician relations appear to be vital to optimal oncology practice settings.

IMPLICATIONS FOR NURSING

In addition to pursuing American Nurses Credentialing Center Magnet recognition, nurse managers should assess practice environments and target related interventions to improve job satisfaction and retention. High-priority areas for interventions include ensuring adequate staff and resources, promoting nurse-physician collaboration, and strengthening unit-based leadership.

Congruent satisfaction: is there geographic correlation between patient and physician satisfaction?

CONTEXT

Satisfaction among both physicians and patients is optimal for the delivery of high-quality healthcare. Although some links have been drawn between physician and patient satisfaction, little is known about the degree of satisfaction congruence among physicians and patients living and working in geographic proximity to each other.

OBJECTIVE

We sought to identify patients and physicians from similar geographic sites and to examine how closely patients' satisfaction with their overall healthcare correlates with physicians' overall career satisfaction in each selected site.

METHODS

We undertook a cross-sectional analysis of data from 3 rounds of the Community Tracking Study (CTS) Household and Physician Surveys (1996-1997, 1998-1999, 2000-2001), a nationally representative telephone survey of patients and physicians. We studied randomly selected participants in the 60 CTS communities for a total household population of 179,127 patients and a total physician population of 37,238. Both physicians and patients were asked a variety of questions pertaining to satisfaction.

RESULTS

Satisfaction varied by region but was closely correlated between physicians and patients living in the same CTS sites. Physician career satisfaction was more strongly correlated with patient overall healthcare satisfaction than any of the other aspects of the healthcare system (Spearman's rank correlation coefficient 0.628, P<0.001). Patient trust in the physician was also highly correlated with physician career satisfaction (0.566, P<0.001).

CONCLUSIONS

Despite geographic variation, there is a strong correlation between physician and patient satisfaction living in similar geographic locations. Further analysis of this congruence and examination of areas of incongruence between patient and physician satisfaction may aid in improving the healthcare system.

Emotional exhaustion and job performance: The mediating role of motivation

The literature concerning the relationship between emotional exhaustion and performance led researchers to raise questions about the extent to which the variables are related. In 2 time-lagged samples, the authors found that motivation mediates the emotional exhaustion-job performance relationship. Moreover, the authors found that participants appear to target their investment of resources in response to emotional exhaustion to develop social support through social exchange; specifically, emotional exhaustion was associated with communion striving resources that were manifest in the form of organizational citizenship behaviors targeted at individuals. Implications of this relationship for theories of burnout and for management practice are discussed.

Evaluation and development of potentially better practices to improve the discharge process in the neonatal intensive care unit

OBJECTIVE

Our goal was to identify potentially better practices that create a successful discharge planning process that spans the entire newborn intensive care stay to the next level of care by embedding the discharge planning into all aspects of patient care and communication.

METHODS

Potentially better practices were developed through recommendations from a content expert and a literature review. Internal benchmarking, self-assessment tools, monthly conference calls, the Neonatal Intensive Care Quality Improvement Collaborative 2002 listserv, parent feedback, and semiannual conferences were used to finalize recommendations and implement practices.

RESULTS

Potentially better practices included (1) create an easy-to-use/easy-to-access discharge planning tool kit, (2) restructure written and oral communication tools and processes to reflect plans for the day, the stay, and the way to discharge, (3) maximize the impact and use of caregiver educational tools, and update materials and delivery systems for caregiver education, (4) use continuous quality improvement tools and processes to ensure parent/caregiver and staff satisfaction, and (5) analyze and enhance transfers into and interactions with the community.

CONCLUSION

The potentially better practices are recommendations that are designed to integrate organizational, clinical, and operational processes to ensure optimal discharge planning from admission through follow-up in the community.

Implementation and case-study results of potentially better practices to improve the discharge process in the neonatal intensive care unit

OBJECTIVE

The objective of this study was to implement potentially better practices for discharge planning in the NICU.

METHODS

Each participating hospital completed a self-assessment tool on discharge planning and a staff satisfaction survey. Parent satisfaction data were obtained from an Internet-based survey. Many projects regarding discharge planning were completed at each participating center. A major emphasis was the development of transition points to span discharge planning over the entire hospitalization. Results of compliance with tasks or processes that were identified by the transition points and results of staff and parent satisfaction surveys were monitored over time.

RESULTS

The implementation of the transition points at each center demonstrated an improvement in the completion of discharge tasks within the recommended time frame. Combined results of all centers demonstrated a moderate improvement in compliance with transition points from baseline to final measurement in the following areas: unit orientation (56%-81%), identification of a parent feeding plan (74%-92%), completion of cardiopulmonary resuscitation training (55%-72%), and car seat education (42%-63%). Staff survey results showed improvement from baseline to final measurement in the following areas: staff satisfaction with the discharge process (32%-50%), clear documentation of the discharge plan (26%-40%), and clarity of team members' roles in the discharge process (24%-44%). A resource kit on discharge planning was developed for staff and included a section with parent education material. An Internet-based parent satisfaction survey was implemented successfully.

CONCLUSIONS

All centers that participated in the collaborative made significant strides in the discharge planning process. Overall, parent satisfaction with discharge planning was high, and improvements were noted in staff satisfaction and availability of resource material.

Outcomes of variation in hospital nurse staffing in English hospitals: cross-sectional analysis of survey data and discharge records

CONTEXT

Despite growing evidence in the US, little evidence has been available to evaluate whether internationally, hospitals in which nurses care for fewer patients have better outcomes in terms of patient survival and nurse retention.

OBJECTIVES

To examine the effects of hospital-wide nurse staffing levels (patient-to-nurse ratios) on patient mortality, failure to rescue (mortality risk for patients with complicated stays) and nurse job dissatisfaction, burnout and nurse-rated quality of care.

DESIGN AND SETTING

Cross-sectional analysis combining nurse survey data with discharge abstracts.

PARTICIPANTS

Nurses (N=3984) and general, orthopaedic, and vascular surgery patients (N=118752) in 30 English acute trusts.

RESULTS

Patients and nurses in the quartile of hospitals with the most favourable staffing levels (the lowest patient-to-nurse ratios) had consistently better outcomes than those in hospitals with less favourable staffing. Patients in the hospitals with the highest patient to nurse ratios had 26% higher mortality (95% CI: 12-49%); the nurses in those hospitals were approximately twice as likely to be dissatisfied with their jobs, to show high burnout levels, and to report low or deteriorating quality of care on their wards and hospitals.

CONCLUSIONS

Nurse staffing levels in NHS hospitals appear to have the same impact on patient outcomes and factors influencing nurse retention as have been found in the USA.

Counselor emotional exhaustion and turnover intention in therapeutic communities

Counselor turnover is a significant problem facing substance abuse treatment agencies. Understanding the role of organizational culture in predicting burnout and turnover intention may yield important information on how to address turnover in treatment organizations. Using data collected from 817 counselors employed in a national sample of 253 therapeutic communities (TCs), structural equation modeling was used to estimate the associations between emotional exhaustion, turnover intention, and three measures of organizational culture: centralized decision making, distributive justice, and procedural justice. The model controlled for counselor demographics, credentials, and earnings. Counselors' emotional exhaustion scores were higher in TCs with greater centralized decision making (p < .01) but lower in TCs where greater distributive justice (p < .05) and procedural justice (p < .001) were reported. Likewise, turnover intention was positively associated with centralized decision making (p < .05) and inversely associated with the workplace justice measures (p < .001). These data suggest that management practices in TCs and perhaps in other types of substance abuse treatment facilities likely play a substantial role in counselors' well-being and in their decisions to leave their jobs. Because these practices are not structural features of organizations, they may be targeted for intervention and change.

Caregiver stress and burnout in an oncology unit

Purpose:Caring for patients with cancer can be taxing for front-line health care providers. The growing intensity of treatment protocols, in conjunction with staff shortages, reduced hospital stays, and broader pressures on the health care system may exacerbate these challenges, leading to increased risk for burnout. This article reviews the research literature regarding the prevalence of burnout and psychosocial distress among oncology providers, examines multifactorial occupational and personal determinants of risk, and considers intervention strategies to enhance resilience.

Methods:Literature review of empirical peer-reviewed studies focusing on prevalence and correlates of burnout among oncology physicians and nurses.

Results:Findings from a number of studies using validated measures and large samples suggest that prevalence rates for burnout and psychosocial distress are high among oncology staff, though not necessarily higher than in non-cancer-practice settings. A growing database has examined occupational (e.g., workload) and demographic (e.g., gender) factors that may contribute to risk, but there is less information about personal (e.g., coping) or organizational (e.g., staffing, physician–nurse relations) determinants or multilevel interactions among these factors. Oncologist burnout may adversely affect anticipated staff turnover. Other important endpoints (biological stress markers, health status, patient satisfaction, quality-of-care indices) have yet to be examined in the oncology setting. Intervention research is at a more rudimentary phase of development.

Conclusions:Burnout and distress affect a significant proportion of oncology staff. There is a need for additional conceptually based, longitudinal, multivariate studies regarding burnout and its associated risk factors and consequences.

Improved nurse job satisfaction and job retention with the transition from a "mandatory consultation" model to a "semiclosed" surgical intensive care unit: a 1-year prospective evaluation

OBJECTIVE

The change from a "mandatory consultation" to a "semiclosed" surgical intensive care unit (SICU) model will impact nurses considerably. We hypothesize that nurse job satisfaction, job turnover rates, and hospital costs for temporary agency nurses will improve and these improvements will be more dramatic in SICU sections with greater involvement of a dedicated surgical critical care service (SCCS).

DESIGN

Prospective longitudinal survey.

SETTING

Tertiary-care university hospital.

SUBJECTS

SICU staff nurses.

INTERVENTIONS

Change from mandatory consultation to semiclosed SICU.

MEASUREMENTS AND MAIN RESULTS

We surveyed SICU nurses during the year-long transition to a semiclosed SICU service (five time points, 3-month intervals). The first four surveys included ten questions on nurse job satisfaction. The final survey included two additional questions. All questions were on a 5-point Likert scale (1 = strongly disagree to 5 = strongly agree). Nurse job turnover rates and money spent on agency nurses were compared over time; 503 of a possible 914 surveys were completed (55% overall return rate). Nurse job satisfaction scores significantly improved over time for all questions (p < .05). Hospital spending on agency nurses decreased significantly (p = .0098). The yearly nurse job turnover rate dropped from 25% to 16% (p = .15). The scores for both year-end statements ("I am more satisfied with my job now than 1 year ago" and "The SCCS management of all orders has improved my job satisfaction") were significantly higher in sections with greater SCCS involvement (p = .0070 and p < .0001).

CONCLUSIONS

Nurse job satisfaction improved significantly with the transition to a semiclosed SICU. This higher satisfaction was associated with a significant decrease in spending on temporary agency nurses and a trend toward increased staff nurse job retention. SICU sections with greater SCCS involvement had more dramatic improvements. This semiclosed SICU model may help retain SICU nurses in a competitive job market in which experienced nurses are in short supply.

The professional self-image of nurses in Belgian hospitals: A cross-sectional questionnaire survey

This paper reports data on the professional self-image of 9638 nurses employed in 22 Belgian general hospitals with the goal of identifying problems affecting recruitment and retention. Nurses reported having a positive self-image. Most were proud to be a nurse and considered themselves competent health professionals having great responsibility. Although they reported that an ideal practice requires effective teamwork, supportive management, societal recognition, and sufficient time to perform their duties, they also felt that these essential conditions were absent in daily practice.

Customer convergence: patients, physicians, and employees share in the experience and evaluation of healthcare quality

This article explores the interrelationships between three categories of service quality in healthcare delivery organizations: patient, employee, and physician satisfaction. Using the largest and most representative national databases available, the study compares the evaluations of hospital care by more than 2 million patients, 150,000 employees, and 40,000 physicians. The results confirm the relationship connecting employees' satisfaction and loyalty to their patients' satisfaction and loyalty. Patients' satisfaction and loyalty were also strongly associated with medical staff physicians' evaluations of overall satisfaction and loyalty to the hospital. Similarly, hospital employees' satisfaction and loyalty were related to the medical staff physicians' satisfaction with and loyalty to the hospital. Based upon the strength of the interrelationships, individual measures and subscales can serve as leverage points for improving linked outcomes. Patients, physicians, and employees, the three co-creators of health, agree on the evaluation of the quality of that service experience. The results demonstrate that promoting patient-centeredness, enhancing medical staff relations, and improving the satisfaction and loyalty of employees are not necessarily three separate activities in competition for hospital resources and marketing leadership attention.

Organizational dimensions of relationship-centered care. Theory, evidence, and practice

Four domains of relationship have been highlighted as the cornerstones of relationship-centered health care. Of these, clinician-patient relationships have been most thoroughly studied, with a rich empirical literature illuminating significant linkages between clinician-patient relationship quality and a wide range of outcomes. This paper explores the realm of clinician-colleague relationships, which we define to include the full array of relationships among clinicians, staff, and administrators in health care organizations. Building on a stream of relevant theories and empirical literature that have emerged over the past decade, we synthesize available evidence on the role of organizational culture and relationships in shaping outcomes, and posit a model of relationship-centered organizations. We conclude that turning attention to relationship-centered theory and practice in health care holds promise for advancing care to a new level, with breakthroughs in quality of care, quality of life for those who provide it, and organizational performance.

Is staff well-being and communication enhanced by multidisciplinary work shift evaluations?

OBJECTIVE

To study the implementation of multidisciplinary structured work shift evaluations at a pediatric intensive care unit (PICU) to enhance team communication.

DESIGN AND SETTING

Prospective, repeated measurements design, comparison of pre/post measurements and process measures in a Dutch tertiary care, university-affiliated PICU.

PARTICIPANTS

All 61 PICU staff members.

INTERVENTIONS

Implementing multidisciplinary structured work shift evaluations. Before the implementation phase the PICU team received feedback training and eight participants (four physicians, four nurses) were trained as "work shift evaluation leader."

MEASUREMENTS AND RESULTS

Outcome measures covered: (a) quality and process of the implementation through prestructured checklists during the 3 months of implementation, (b) a subjective evaluation of a feedback training on team communication as anticipated action and on the level of communication (about patients and with colleagues), and (c) emotional exhaustion complaints and work-related fatigue. The interdisciplinary structured work shift evaluations were implemented successfully as planned during the work shift; all staff were trained ahead, and the process was followed almost completely. Almost two-thirds (62%) of the staff felt a positive influence on team communication. Almost all staff members (92%) were satisfied regarding communication with their colleagues after the intervention, compared to 76% before. Emotional exhaustion in the PICU team decreased significantly after the implementation, but no differences in work-related fatigue levels were found.

CONCLUSIONS

As organizational change the implementation of a multidisciplinary structured work shift evaluation at a PICU was successful and team communication improved. Emotional exhaustion decreased during the study period.

Swedish dental hygienists' preferences for workplace improvement and continuing professional development

The present study examined factors for workplace improvement and continuing professional development (CPD) for Swedish dental hygienists. Seventy-one per cent of 577 randomly selected members of Sweden's Dental Hygienist Association responded to a questionnaire. The chi-square test, Spearman's rank correlation, and multiple stepwise logistic regression modelling were used in the statistical analysis. The results showed that dental hygienists having more than 10 sick days annually and with a strong commitment to their work increased the preference for workplace improvements, such as peer recognition of dental hygienists' professional qualifications, clinical process quality, and time for reading research articles and participating in projects. In addition, dental hygienists in the 41-52 age group were associated with workplace improvements. This is in contrast to the factors that decreased preferences for workplace improvements: clear work roles, a 1-year training programme, a male clinic manager, and working in the private sector. Practicing dental hygiene in the public sector and lifestyle factors were the most influential determinants for a strong interest in CPD.

CONCLUSION

Workplaces should observe people that are obviously committed to their work, those with many sick days, and those in a specific age group, as they indicate different preferences for workplace improvements. CPD seems to be a lower priority than workplace improvements for Swedish dental hygienists.

Organizational Attributes Valued by Hospital, Home Care, and District Nurses in the United States and New Zealand

PURPOSE

To determine whether hospital-based, home care, and district nurses identify a core set of organizational attributes in the nursing work environment that they value as important to the support of professional practice.

DESIGN

Survey data, collected in 2002-2003 from 403 home care nurses in the United States (US) and 320 district nurses in New Zealand (NZ), were pooled with an existing data set of 669 hospital-based nurses to conduct this descriptive, nonexperimental study.

METHODS

The importance of organizational attributes in the nursing work environment was measured using the Nursing Work Index-Revised (NWI-R). Frequency distributions and analysis of variance were used to analyze the data.

FINDINGS

At least 80% of hospital-based, home care, and district nurses either agreed or strongly agreed that 47 of the 49 items comprising the NWI-R represented organizational attributes they considered important to the support of their professional nursing practice. Mean importance scores among home care nurses, however, were significantly lower than were those of the other two groups.

CONCLUSIONS

Overall, hospital-based, home care, and district nurses had a high level of agreement regarding the importance of organizational traits to the support of their professional practice. The intensity of the attributes' importance was less among home care nurses. Further research is needed to determine whether this set of organizational traits, measured using the NWI-R, is associated with positive nurse and patient outcomes in home care and district nursing practice, as has been shown in acute care settings.