Patient Risk Related to Healthcare Burnout

Introduction

The phenomenon known as burnout has been talked about more than almost any other problem in the workplace over the last 40 years.  This condition was identified in 1974 by both Sigmund Ginsburg and Herbert Freudenberger, and has since been the focus of several hundred scientific studies on how it affects people.  Over the past decade, this topic has become an ever-increasing interest for scientists and practitioners to study as it affects the workforce (Heinemann & Heinemann, 2017).  People are exhibiting signs that they are experiencing an ever-increasing pressure in their daily lives.  A high percentage of this pressure has been found to come from the workplace.  This has resulted in employees from a variety of professions who suffer from a condition referred to as burnout.  Burnout has been studied in a variety of occupations and even the studies that are considered to be conservative estimate that the prevalence of this condition is above 10% (Kant, Bultmann, Schroer, Beurskens, & Van Amelsvoort, 2003).  This indicates that burnout has become a very serious problem in today’s workforce.

Burnout is a reaction to chronic occupational stressors without having a sufficient amount of time to recover.   The results of nursing burnout are the exact opposite of providing great nursing care.  According to Heinemann & Heinemann (2017) this condition is “characterized by physical symptoms such as exhaustion, fatigue, frequent headaches and gastrointestinal disorders, sleeplessness, and shortness of breath.  Behavioral signs include frustration, anger, a suspicious attitude, a feeling of omnipotence or overconfidence, excessive use of tranquilizers and barbiturates, cynicism, and signs of depression.”  Many of these symptoms can affect the care patient’s receive from the nurse.

Some recent studies of new graduates disturbingly show that 66% of them were experiencing severe burnout and that burnout was associated with negative workplace conditions (Cho, Laschinger, & Wong, 2006).  Another study conducted by Bowles and Candela (2005) showed an actual first-year turnover rate of 30% with a 57% turnover rate after two years.  These numbers are alarming and suggest that burnout is a major problem in the nursing workforce.

Recent  studies  of  new  graduates

a r e  particularly  disturbing.  Cho,

L a s c h i n g e r,  and  Wong  (2006)

found that 66% of new graduates

w e r e experiencing severe burn o u t

One of the issues on the floor that I work on is that they have had to deal with nurse burnout.  The Nurse Educator on the floor, Kimberly Small stated that new grad burnout is a real issue and that we have experienced a good amount of it on our floor. The floor that I work on is comprised of mostly new nurses with over 70% of them having less than one year of experience as a nurse and more than 80% have less than two years of experience.  The few experienced nurses that have been around longer may also be suffering the effects of burnout as they may have had to pick up the slack of the inexperienced nurses.

Problem Statement

Patients should be able to come to a hospital and get the best care available to treat the illness that they have.  They should feel safe and secure knowing that the doctors, nurses, and aides are well rested, well trained, and are ready to take the best care of them.  However, it is known that many nurses experience a phenomenon known as burnout.  This can often happen to new grads or experienced nurses who have been overworked.   Burnout can cause physical, mental, and emotional exhaustion which can lead to disengagement, cynicism, and inattentiveness to detail while at work (Maslach & Leiter, 2009).

Without an engaged workforce, important details in the patient’s care can be missed, leading to medication errors.  Cynicism can lead to nurses ignoring the needs of their patient’s and putting them in harm’s way.  I want to know if having newer nurses on my floor has led to an increase in errors.  The question I will be asking and the focus of the paper will be this; does burnout among healthcare workers increase errors and add to patient risk?  By finding the answer to this question I anticipate being able to identify how nurse burnout may be affecting the patient experience on my floor.  Hopefully, I will be able to present ideas to my floor that are grounded in evidence based practice.

Literature Review

Measurment

Since Ginsburg and Freudenberger first described the symptoms of burnout in 1974, there have been many studies conducted and many papers written on the topic.  This idea of burnout is based on the person exhibiting three components according to Maslach & Leiter (2009): emotional exhaustion, cynicism and detachment, and the tendency to evaluate oneself negatively or feeling a lack of achievement at work.  One of the many people who has studied burnout exhaustively has been Christina Maslach.   Maslach, along with the help of Susan Jackson, were pioneers in burnout research and continued to outline and explain the expression of burnout with the development of The Maslach Burnout Inventory (MBI). The MBI is a tool developed to help measure the extent a person may be experiencing burnout (Maslach, & Jackson, 1981).  The MBI is a very important piece in determining burnout as it has proven to be a very reliable and valid approach to identify it (Laschinger & Leiter, 2006).  It has also been widely used, especially in conjunction with other studies, including many described here in this paper, to determine the degree to which the participants may be experiencing signs of burnout. 

But burnout is still a hot topic and depending on whom you talk to it may not be accepted as a real condition.  Along with this uncertainty, or maybe because of it, continual discussions on burnout in the work setting have attempted to pinpoint exactly what burnout is, how it can be diagnosed, and what can be done about it (Heinemann & Heinemann, 2017).  Instead of this proliferation of study clearing up the intricacies of burnout, they have shown an inability to explain and comprehend exactly what the definition of burnout should be.  According to Heinemann & Heinemann (2017), the explosion of studying has “contribute[d] to the vagueness of the concept, thereby triggering new research.”   In fact, Korczak, Huber, and Kister (2010, p. 3) have said that “no consistent valid definition exists.  Burnout seems to be more or less an ill-defined set of many definitions.  In the literature, a multitude of burnout symptoms and theories and explanatory models can be found.  This muddling of what burnout is makes it difficult to solve the problem and is a problem in itself that needs to be fixed.

Studies

There was a study performed by Duffield et al. (2010) that examined nurse workload, staff skill mix, work environment, and patient outcomes in Australia.  The group wanted to know what the relationships were between these many components of nurse life.  For the purposes of this study, a balanced workload and staff would be defined as a score of 100.  The average score was a lot higher at 124, demonstrating an imbalanced workload.  On average each nurse took care of between 6.13 to 9.9 patients during the study.  Rates of abuse were reported at 14.3% for physical abuse, 20.8% for threats of assault, and 38.7% for emotional abuse.  According to the results, approximately 18.4% of patients endured a medication error or fall (Duffield et al., 2010).  Unsurprisingly, the study found the quality of care was reduced when the workload was increased and especially when nurses felt threatened by abuse.  Having too low of staff for the units needs, high patient turnover, and a wide range of acuity led to more negative patient outcomes(Duffield et al., 2011). 

Laschinger & Leiter created a model connecting work environment to professional burnout called the Nursing Worklife Model (2006).  This model recognized five elements at work that can big a big contribution to burnout.  The five factors are having effective nurse leadership, staff participation in organizational affairs, adequate staffing, support for a nursing model type, and effective relationships between the nurse and physician. These five factors were believed to interact with each other in a way that can affect nurse and patient outcomes with regards to the burnout.  In order to test their Nursing Worklife Model, Laschinger & Leiter surveyed 8,597 nurses in Canada using both the MBI and the Nursing Work Index (NWI).  The outcome was that nursing leadership was one of the most influential factors in the Nursing Worklife Model.  Leadership influenced many of the other factors for good and affected nurse engagement and burnout.  A second study by Laschinger & Leiter was performed to connect work conditions to burnout and then went a step further to see if they were connected to patient outcomes (2006).  The MBI and NWI were used again and negative events were measured by nurses reporting how many times they occurred over the last year.  These negative events included patient falls, hospital-acquired infections, medication errors, and patient complaints.  Through this research high correlations were found between negative events and two of three key factors of burnout, emotional exhaustion, and depersonalization.  Laschinger & Leiter reported a direct link between inadequate staffing and negative events and also showed patient safety outcomes are correlated with the quality of the work environment (2006).

Karga, Kiekkas, Aretha, & Lemonidou (2011) performed a study on medication errors in the workplace.  They believed that distractions, heavy workloads, ineffective communication, and lack of supervision can be influences causing errors. Many of these components are indicative of also having burnout.  During this study, just over 500 nurses from hospitals in Greece were surveyed about emotional responses to errors, coping, senior staff responses to errors, and changes in nursing practice as a result of errors.  The apparent causes of what caused these errors were also evaluated.  The number one cause of errors (78.2%) from the study was the high workload that the nurses had to endure (Karga, et al., 2011).  When nurses made a medication error the way it was handled afterward was found to make a difference.  Karga et al. concluded that when the nurse made positive changes in their practice after an error it was linked to positive senior staff response, accepting responsibility, seeking social support, emotional self-control, and internal emotional responses (2011). 

Another study performed by Fogarty & Mckeon (2006) looked at intentional and unintentional medication errors and if they were linked to organizational climate, morale, quality of working life, and individual stress.  According to the study results, organizational and individual factors can and do influence the number of errors that take place (Fogarty & McKeon, 2009).  Stress and morale are two of these individual factors that correlate with an increase in errors.  If a nurse is overly stressed or suffering from low morale, mistakes can more easily occur, especially if there is a poor organizational climate.  A positive and supportive environment at work should lead to better morale, less stress and therefore less chance for nurses to make errors (Fogarty & McKeon, 2009).  This study lines up with what Karga et al. (2011) found on the importance of the social environment in reducing burnout and errors.

Another study using MBI and the Agency for Healthcare Research & Quality (AHRQ) done by Halbesleben, Wakefield, Wakefield, & Cooper (2008) observed a possible link between nurse burnout and patient safety outcomes.  Specifically, they were looking at things such as nurses’ safety perception and how that related to reporting behaviors.  The results of the study indicated that exhaustion and depersonalization were linked with lower patient safety scores and that the nurses involved believed they worked in an unsafe environment more often when their burnout score was higher (Halbesleben et al. 2008).   Interestingly the results revealed that nurses who are experiencing burnout identify the environment as unsafe but are less likely to join in reporting these issues.  “This study suggests that although burnout may not be associated with increased event reporting, it still plays a role in the investment of resources at work” (Halbesleben et al., 2008).  This study corroborates the study by Laschinger & Leiter (2006) mentioned earlier who also reported a link between burnout and the frequency of negative events reported.

Recommendations from Findings

This paper was written to find any research that can relate high burnout to errors and poor patient outcome.  The literature that was found points out that burnout and errors are closely related.  Most of these articles lead one to believe the work environment plays a role in both burnout and errors and poor patient outcome (Duffield et al., 2011; Fogarty & McKeon, 2006; Halbesleben et al. 2008; Karga, et al., 2011; Laschinger & Leiter, 2006).  Despite the similar contributory factors, there was no literature found to confirm a direct relationship between burnout and errors.  Part of this may be that “burnout seems to be more or less a fuzzy set of many definitions” (Korczak, Huber, and Kister, 2010, p. 3) and is hard to pinpoint.  Because there is no agreed upon definition, causes, or symptoms this may make it harder to link to other issues, like errors and patient outcomes.  This also raises the concern that all the studies that have previously identified causes of burnout or have measured the prevalence rates are not actually investigating the same thing.  In order to identify the causes of a disease or mental disorder and to determine the prevalence of it, there needs to be a common understanding of the illness (Schaufeli & Enzmann, 1998).  One of the first things that need happen is for this phenomenon to be a little more concrete in what it is and how to identify it.

Burnout will continue to increase whether we can adequately define it or not.  As it increases, it may inhibit nurses from fully considering the root of the problems, which may create an increase in errors.  Efforts are needed to address the root causes of these circumstances at work so that errors are less likely to happen repeatedly (Tucker & Edmondson, 2002).  Many possible interventions have been suggested to reduce burnout, but research has been inadequate because of the many proposed causes (Halbesleben & Buckley, 2004).

The work environment is an easy target to try to reduce burnout and errors.  Eliminating or lessening either of these could improve patient outcome.  Some of the things that could be addressed to improve work conditions would be to reduce nurse to patient workload (Duffield et al., 2010), increase positive support (Fogarty & McKeon, 2009), improve communication with the physicians, and have better supervision (Karga, et al., 2011).  These improvements to long-standing issues will not be easy to make but will be well worth it in the end if the patient does not have to endure challenges related to nursing errors.

Because burnout is thought to be a response to stress, any condition that could cause stress could encourage burnout.  It is suggested by Halbesleben, Osburn, and Mumford (2006) that getting groups to dissect the causes of burnout within their own specific work environment may be the best approach.  They would have a better idea at what local problems cause the most stress and could collectively develop solutions to fit their distinctive requirements.

Theory or Framework

I chose to associate my paper with Virginia Henderson’s Need Theory.  Her theory comprises of 14 components she believes people need in order to be well.  These 14 needs that make up her theory are as follows; breathe normally, eat and drink adequately, eliminate body wastes, move and maintain desirable postures, sleep and rest, select suitable clothes—dress and undress, maintain body temperature within normal range by adjusting clothing and modifying the environment, keep the body clean and well-groomed and protect the integument, avoid dangers in the environment and avoid injuring others, communicate with others in expressing emotions, needs, fears, or opinions, worship according to one’s faith, work in such a way that there is a sense of accomplishment, play or participate in various forms of recreation, and learn, discover, or satisfy the curiosity that leads to normal development and health and use the available health facilities.

This theory is usually applied specifically to the patient but I believe they apply very well to a nurse and their needs.  I believe that when these needs are not met a nurse becomes vulnerable to burnout.  Some of these like eat and drink and eliminate body wastes are simply things you may not think would be an issue but many nurses rarely find time to sit and eat during their shift.  Another issue could be getting enough sleep and rest.  By definition, burnout is a problem with exhaustion and fatigue to (Heinemann & Heinemann, 2017).  If a nurse is not getting this required need they will be more susceptible to burnout.  Another cause of burnout and increased errors that was noted was poor communication (Karga, et al., 2011).  If this basic need was met the chance of a nurse experiencing burnout and causing errors may be less.

References

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• Fogarty, G.J. & McKeon, C.M. (2006). Patient safety during medication administration: The influence of organizational and individual variables on unsafe work practices and medication errors. Ergonomics, 49, 5-6, 444-456. doi: 10.1080/00140130600568410
• Halbesleben, J. R. B., & Buckley, M. R. (2004). Burnout in organizational life. Journal of Management, 30, 859-879.
• Halbesleben, J. R. B., Osburn, H. K., & Mumford, M. D. (2006). Action research as a burnout intervention: Reducing burnout in the Federal Fire Service. Journal of Applied Behavioral Science, 42, 244-266.
• Halbesleben, J. R. B., Wakefield, B. J., Wakefield, D.S., & Cooper, L.B. (2008). Nurse burnout and patient safety outcomes: Nurse safety perception versus reporting behavior. Western Journal of Nursing Research, 30, 560-577.
• Heinemann, L., & Heinemann, T. (2017). Burnout Research. SAGE Open, 7, 1-12. doi:10.1177/2158244017697154
• Kant, I., Bultmann, U., Schroer, K., Beurskens, A., & Van Amelsvoort, L. (2003). An epidemiological approach to study fatigue in the working population: The Maastricht Cohort Study. Occupational and Environmental Medicine, 60(1), 32i-39i. doi:10.1136/oem.60.suppl_1.i32
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