Occupational burnout, retention and health outcomes in nephrology nurses.
Abstract: Occupational burnout can have serious implications on productivity, nurses health, service usage, and health care costs. This study examined the effect of burnout on nurses mental and physical health outcomes and job retention. Randomly selected Canadian nephrology nurses completed surveys consisting of the Maslach Burnout Inventory and the Pressure Management Indicator. The nurses also completed questions related to job retention. After controlling for age and years of nephrology nursing experience, the multivariate results demonstrated that almost 40% of mental health symptoms experienced by nephrology nurses could be explained by burnout and 27.5% of physical symptoms could be explained by burnout. Twenty-three per cent of the sample had plans to leave their current position and retention was significantly associated with burnout, mental, and physical symptoms. Organizational strategies aimed at reducing perceptions of burnout are important, as a means to keep nurses healthy and working to their fullest potential.

Keywords: nurse health outcomes, burnout, work environments, job retention, nephrology nursing
Article Type: Report
Subject: Burn out (Psychology) (Research)
Medical care, Cost of (Research)
Kidney diseases (Risk factors)
Kidney diseases (Care and treatment)
Kidney diseases (Research)
Nurses (Practice)
Authors: Harwood, Lori
Ridley, Jane
Wilson, Barbara
Laschinger, Heather K.
Pub Date: 10/01/2010
Publication: Name: CANNT Journal Publisher: Canadian Association of Nephrology Nurses & Technologists Audience: Trade Format: Magazine/Journal Subject: Health care industry Copyright: COPYRIGHT 2010 Canadian Association of Nephrology Nurses & Technologists ISSN: 1498-5136
Issue: Date: Oct-Dec, 2010 Source Volume: 20 Source Issue: 4
Topic: Event Code: 310 Science & research; 200 Management dynamics
Product: Product Code: 8043100 Nurses NAICS Code: 621399 Offices of All Other Miscellaneous Health Practitioners
Geographic: Geographic Scope: United Kingdom Geographic Code: 4EUUK United Kingdom
Accession Number: 244162788
Full Text: Introduction

Recent studies report that burnout is a significant issue for both American and Canadian nephrology nurses (Flynn, Thomas-Hawkins, & Clarke, 2009; Ridley, Wilson, Harwood, & Laschinger, 2009). Burnout among nephrology nurses has been reported to be as high as 41% (Ridley et al., 2009) and, as the global burden of kidney disease increases (Just et al, 2008), so too are demands being placed on the individuals who provide care to this patient population. The consequences of occupational burnout can be costly, affecting patient care and nurses' health, as well as costs to the health care system.

Burnout is a syndrome composed of three key features: emotional exhaustion, cynicism and reduced professional efficacy (Maslach, Jackson, & Leiter, 1997). It is representative of problems within the workplace, not the individual. Emotional exhaustion is considered the core measurement of burnout (Maslach, 2003), whereby the individual experiences overwhelming work stress, which ultimately erodes emotional and physical resources (Maslach, 2003). Numerous factors can contribute to burnout. Regardless of the source, consequences of burnout can be serious including decreased quality of patient care provided, poor morale, increased job turnover and absenteeism, as well as self-reported indices of physical exhaustion, insomnia, marital and family problems and alcohol and drug use (Maslach et al., 1997). Given these reported high burnout rates, further examination of the effects of burnout on nephrology nurses' physical and mental health outcomes is important.

Literature review

Factors associated with burnout

Many factors are documented in the literature as having a negative impact on burnout. Incongruent work status (Burke, 2004), younger age (Ilhan, Durukan, Tanner, Maral, & Bumin, 2008), new graduates (Cho, Laschinger & Wong, 2006; Ilhan et al., 2008), greater than 40 hours worked per week (Ilhan et al., 2008; Kanai-Pak, Aiken, Sloane, & Poghosyan, 2008), nurse staffing, and resource adequacy are significant predictors of burnout (Poghosyan, 2008). Workplace issues such as not working the night shift, fewer workplace changes and increased voluntary choice of workplace may decrease burnout (Arikan, Koksal, & Gokce, 2007).

Numerous studies have examined job satisfaction and work environments and their effect on contribution to burnout. Sadovich (2005) identified inverse correlations between work excitement and emotional exhaustion and work excitement and depersonalization. Several researchers have noted that job satisfaction and work environments have a direct negative effect on burnout (Kalliath & Morris, 2002; Shamian, Kerr, Laschinger, & Thomson, 2002). A common concern among nurses is requiring more time and/or resources to accomplish their work (Kanai-Pak et al., 2008). Hemodialysis nurses in a U.S. sample who reported higher workloads were five times more likely to experience burnout. Furthermore, respondents who reported leaving three or more necessary patient care activities undone during their shift were more than twice as likely to report burnout. For those nurses who reported burnout, they were three times more likely to leave their current position (Flynn et al., 2009).

Research has demonstrated that empowering work environments can have an effect on nurse burnout. Workload, community, control, rewards, fairness, and values can promote either burnout or engagement in staff (Laschinger & Finegan, 2005). New graduates who perceived their work environment to be inclusive of structural empowerment were noted to experience less burnout, specifically emotional exhaustion (Cho et al., 2006). This phenomenon is not restricted to novice nurses. Researchers have found that the degree of staff nurses' empowerment corresponded to the amount of job strain (Laschinger, Finegan, Shamian, & Wilk, 2001). Also important are empowering behaviours by leaders. Supervisor incivility and cynicism can have a negative effect on nurses' job satisfaction (Greco, Laschinger, & Wong, 2006; Laschinger, Leiter, Day, & Gillin, 2009), while a lack of workplace empowerment, emotional intelligence, organizational commitment (Young-Ritchie, Laschinger, & Wong, 2009) and organizational support have also been shown to affect nurse dissatisfaction and burnout (Aiken, Clarke, & Sloane, 2002).

Consequences of burnout

Nurse retention. Many studies have shown an association between burnout and intention to leave the job. Nurses who experience burnout are less committed to their organization (Cho et al., 2006; Laschinger, Leiter, Day, & Gilin, 2009) and are more likely to leave their position (Leiter, Harvie, & Frizzell, 1998). In Laschinger et al.'s (2009) study, emotional exhaustion, cynicism, and supervisor incivility most predicted staff turnover intentions. Congruent work status (e.g., part-time or full-time employment status per nurses' preferences) increased job retention and satisfaction and decreased absenteeism (Burke, 2004).

Nurse health outcomes. Occupational climate refers to employees' perceptions of organizational features such as how decisions are made in the workplace and frequency of injury. Occupational climate is independently associated with nurse injuries and measures of burnout (Stone, Du, & Gershon, 2007). A systematic review on the effect of occupational climate on nurse health outcomes provided support for an association between occupational climate and nurse health. However, data was limited, relationships were weak, and additional studies are required (Gershon et al., 2007). Other factors impacting nurses' health have also been studied. Congruent work status contributes to fewer psychosomatic symptoms and fewer physical health problems for nurses (Burke, 2004). Nurses who rated their workplace(s) positively using the Nursing Work Index-Revised reported better health status, as measured by the SF-36 (Budge, Carryer, & Woods, 2003). Supervisory support has also been studied. Nurses who consider their supervisor(s) to be supportive also perceive less occupational stress and report improved health outcomes such as fewer somatic complaints, headaches, fatigue, and backaches (Hall, 2007). A relationship between access to empowerment structures and occupational mental health has been identified. Perceived access was strongly associated with positive occupational mental health (Laschinger & Havens, 1997), whereas lack of access resulted in job stress and its associated sequelae, including absenteeism and a negative impact on mental health (Laschinger, Wong, McMahon, & Kaufmann, 1999).

Patient care. Patients' perceptions of quality of care are heavily influenced by the care they receive by nurses (Carey & Siebert, 1993). When registered nurses identified their work as satisfying and meaningful, patients reported being satisfied with the care they received (Leiter, Harvie, & Frizzell, 1998; Vahey, Aiken, Sloane, Clark, & Vargas, 2004). Research has supported the hypothesis that the relationship between workplace factors and adverse events is impacted by burnout (Laschinger & Leiter, 2006). Burnout has been documented to be associated with nurses' perceptions of lower patient safety (Halbesleben, Wakefield, Wakefield, & Cooper, 2008) and decreased quality of care (Kanai-Pak, Aiken, Sloane, & Poghosyan, 2008). A high level of burnout in nephrology nurses and physicians was also reported to be associated with poor patient and client satisfaction (Argentero, Dell'Olivo, & Ferretti, 2008).

Burnout and nephrology nurses. Like nurses in different areas of practice, nephrology nurses who perceive their work environment as negative were more likely to leave their job(s) (Gardner, Fogg, Thomas-Hawkins, & Latham, 2007). Workload, nurse-patient ratios (Flynn et al., 2009; Lewis, Bonner, Campbell, Cooper, & Willard, 1994) and hours worked (Klersy et al., 2007) were associated with burnout, as were personal aspects such as a low sense of team coherence, lack of support, and increased personal stress (Lewis et al., 1994). Older hemodialysis staff and more experienced staff in London, U.K., had higher levels of burnout, psychological distress, and job dissatisfaction (Ross, Jones, Callagnah, Eales, & Ashman, 2009). Forty-two per cent of the hemodialysis staff in this sample were non-nurses. In a Turkish sample, hemodialysis nurses reported higher emotional exhaustion scores for nurses who considered leaving the profession, did not find the profession suitable, and who worked in units where there were no precautions against infectious diseases (Kapucu, Akkus, Akdemir, & Karacan, 2009). Like other areas of practice, burnout also appears to have a negative effect on nephrology patients' perceptions of their care (Argentero et al., 2008).

In a descriptive study, Ridley et al. (2009) explored conditions of work effectiveness, magnet hospital traits, burnout, and physical and mental reaction to stress and empowerment. The results highlighted some concerns and areas of occupational stress for Canadian nephrology nurses. In a secondary data analysis of this sample (Harwood, Ridley, Wilson, & Laschinger, 2010) empowerment, specifically access to resources, was a predictor of burnout for nephrology nurses. Overall, the working environment was favourable with high standards of care and good relationships with peers. However, Ridley et al. (2009) concluded that some nurses appeared to be struggling with burnout, and mental and physical health symptoms and further examination was warranted.

Summary

Common contributors to burnout are job dissatisfaction, work environments that are not empowering and have inadequate supervisory support, difficult working conditions, nurse experience, workload, intrapersonal stress and lack of coping, and high nurse-patient ratios. The literature on nephrology nurses and burnout is growing, but remains limited. However, it would appear that contributing factors to burnout, such as work environment characteristics and workload, are similar to other practice areas. Nephrology nurses, like other nurses who experience burnout are more likely to leave their jobs. Nephrology patients are also impacted by nurse burnout with reported associations between burnout and the negative effect on patients' satisfaction with care. In summary, burnout appears to be a problem for nephrology nurses and from one descriptive study (Ridley et al., 2009), there is some rationale to hypothesize that burnout is contributing to mental and physical health symptoms for this group of nurses. However, further research is needed in this area.

Purpose

This study was a secondary data analysis of data derived from Ridley et al.'s (2009) study investigating nephrology nursing work environments in Canada. Specifically, the purpose of this secondary data analysis was to examine the influence of burnout among Canadian nephrology nurses on mental and physical health, as well as job retention. We hypothesized that burnout for nephrology nurses is similar to burnout experienced by nurses working in other practice areas and, as such, will have a negative impact on nurses' mental and physical health outcomes.

Research questions

The research questions that guided this analysis were as follows:

1. What is the relationship between nephrology nurses' perceptions of occupational burnout and their intention to leave their jobs?

2. What components of burnout are predictors of mental health symptoms in nephrology nurses?

3. What components of burnout are predictors of physical health symptoms in nephrology nurses?

Methodology

Sample

The sample consisted of randomly selected nurses from the Canadian Association of Nephrology Nurses and Technologists (CANNT) who consented to be on a mailing list for research information previously reported by Ridley et al. (2009). After ethical approval was obtained, surveys were mailed to 300 nurses. The surveys were distributed by mail with a second survey three months after the initial mail-out.

Instrumentation

The Maslach Burnout Inventory General Survey (MBI) was used in this study. The MBI is a self-administered survey that was developed to measure burnout in occupations providing human services. This is a 16-item, seven-point Likert scale (0 to 6) instrument with three subscales; emotional exhaustion, cynicism, and professional efficacy. Burnout is demonstrated with high levels of emotional exhaustion and cynicism and low levels of professional efficacy. It is the most widely used instrument to measure burnout (Maslach et al., 1997). An average rating on the zero to six frequency rating for each question in the subscale is calculated. Reliability for the MBI is well established with Cronbach alpha scores ranging from .71 to .91 (Maslach et al., 1997).

The Pressure Management Index (PMI) is a two-part questionnaire designed to assess health outcomes and burnout (Williams & Cooper, 1998). Two subscales of the PMI were used for this study. The frequencies of physical symptoms were measured in part one on a Likert scale ranging from one to six with high scores indicating greater frequency of symptom experience. Part two was a mini-mental health assessment asking questions regarding feeling nervous or down in the dumps, happy, downhearted, and blue. These items were rated on a Likert scale with scores ranging from zero to six. Questions related to feeling calm and happy were reverse-coded whereby a low score indicated the nurse experienced the symptom all of the time and a high score indicated none of the time. The internal consistency scores are reported at .82 to .85 across diverse populations. Predictive validity has been established with other mental health measures (Williams & Cooper, 1998).

Data analysis

SPSS was used for the statistical analysis and the significance level was set at 0.05. Hierarchical multiple linear regression was used to examine the predictors of burnout on mental and physical health symptoms. Bivariate analysis of retention and burnout was conducted using Pearson's correlation.

Results

The original response rate was 48% for return of the surveys (Ridley et al., 2009). The sample size for this study was 121, which is adequate for multiple regression (Tabachnick & Fidell, 2007). The demographic results of the sample are summarized in Table 1.

Burnout and retention

Nearly 42% of the sample reported experiencing severe emotional exhaustion while 23% reported severe cynicism (see Table 2). Combined, this suggests high levels of burnout among the respondents. Two of the three burnout subscales, emotional exhaustion and cynicism, were significantly associated with the nurses' intention to leave their jobs, as well as mental and physical health symptoms (see Table 3). Professional efficacy was not significantly associated with an intention to leave their job.

Mental health symptoms

Almost 40% ([R.sup.2] .394, P<.0001) of mental health symptoms experienced by nephrology nurses could be explained by burnout, specifically emotional exhaustion and cynicism, when controlling for age and years of nephrology nursing (see Table 4). For every standardized unit increase in emotional exhaustion and cynicism, mental health symptom scores decreased (worsened) by (-.353) and (-.333) respectively. Of the two measures of burnout examined, it was emotional exhaustion that had the greater impact on mental health symptoms. As the nurses experienced mental health symptoms such as feeling nervous, down in the dumps, not calm, down-hearted and blue, and not happy, scores decreased. Age and years of nephrology experience had an effect on mental health symptoms such that, as age and nephrology experience increased, mental health symptoms increased. However, this result was not significant.

Physical health symptoms

Almost 28% ([R.sup.2] .275, P<.001) of the physical symptoms that the nephrology nurses experienced could be explained by burnout, specifically emotional exhaustion and cynicism when controlling for age and years of nephrology nursing experience (see Table 5). However, for physical health symptoms (feeling tired or exhausted, short of breath, muscles trembling, pickling sensation), only emotional exhaustion had a significant impact. For every increase in emotional exhaustion unit scores, physical symptoms increased by .410. Cynicism also had a direct influence on physical health, but this was not significant.

Discussion

This cross-sectional study examined the variance of physical and mental health symptoms explained by burnout among nephrology nurses across Canada. Emotional exhaustion and cynicism increased mental health symptoms while only emotional exhaustion had an effect on physical health symptoms. Job retention was negatively associated with burnout.

It was previously reported that nephrology nurses who experience burnout were three times more likely to leave their jobs (Flynn et al., 2009). Our study provides additional evidence that burnout significantly contributes to nephrology nurses' intention to leave their jobs. Nephrology nurses are a highly skilled group of individuals requiring lengthy orientation programs to learn the technical aspects of the role, medication regimens, and dialysis access management, as well as the holistic impact of renal failure on individual patients and their families. Given the costs involved in orientation programs and the shortage of registered nurses available who may choose to work in the area, our research supports that retention should be a focus for nephrology leadership.

Mental and physical symptoms due to occupational burnout are very concerning. To our knowledge this is the first study to examine the effects of burnout on health outcomes for nephrology nurses. Although this study cannot conclude a causal relationship between burnout and mental and physical health, the results do suggest that a portion of the mental and physical health ailments nurses are experiencing may be associated with occupational burnout, particularly mental health and emotional exhaustion. Our results are consistent with previous studies, which have demonstrated associations between the work environment, burnout, and nurses' health (Bourbonnais, Comeau, Vezina, & Dion, 1998; Budge et al., 2003; Burke, 2004; Woodward et al., 1999) in non-nephrolo-gy settings. Application of the results of this study through the promotion of positive, empowering work environments may decrease burnout and, ultimately, improve retention and health outcomes. To do this, Kanter (1977) maintains that work environments that provide access to support, information, resources, and opportunities within the job are needed and will lead to empowered, active, and productive employees. Access to resources has been shown to be an important contributor to burnout for nephrology nurses (Harwood et al., 2010).

While difficult to consider in our economic climate, there are opportunities for nursing leaders to improve nurses' work environments through opportunities for shared decision-making (e.g., through unit level task teams), formal recognition of work well done, providing information to staff in a timely manner, and supporting the project work of employees on hospital-wide committees. Additionally, there are opportunities for nursing leadership to further their own knowledge through published literature on work environment characteristics that promote positive working conditions for their staff (e.g., magnet hospital traits). The key for nursing leaders is to be creative and involve their staff, both individually and collectively, in developing strategies to enhance nurses' learning and work-related goals.

Nursing leadership must also consider that increased absenteeism/sick days amongst their staff may be a sign of burnout. Nursing leaders have opportunities to identify resources within their organizations (e.g., employee assistance programs), and utilize them, as needed, to assist employees with managing their physical and mental health ailments. Once again, organizational strategies aimed at reducing perceptions of burnout would be an important consideration, as a means to keeping nurses healthy and working to their fullest potential.

It is also important for those in nephrology nursing to consider the impact of burnout on our patients. The nature of chronic renal failure dictates that nephrology nurses have long-term relationships with patients such that patients become familiar with their nurses and may become aware of subtle changes in nurses' behaviour and demeanour that may be associated with burnout. Patients who perceive their nurse to be 'burned out' may perceive less quality in the care they receive. For units that monitor patient satisfaction as a quality indicator, decreased patient satisfaction may be an indication of burnout among the staff.

Limitations

As previously stated (Harwood et al., 2010) the sample from this study was obtained from a volunteer professional association with the mandate for professional development and the influence of this on the results is unknown.

Conclusion

In summary, burnout is an important area of study, as its ramifications are far-reaching: decreased retention further worsening the nursing shortage, a reduction in the quality and quantity of service delivery, and increased costs associated with retraining. The results of this study demonstrate that occupational burnout for nephrology nurses extends beyond nurses' work life and impacts on their physical and mental health.

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By Lori Harwood, RN(EC), MSc, CNeph(C), Jane Ridley, RN(EC), MScN, CNeph(C), Barbara Wilson, RN, MScN, CNeph(C), and Heather K. Laschinger, PhD, RN, FCAHS, FAAN

Copyright [C] 2010 Canadian Association of Nephrology Nurses and Technologists

Lori Harwood, RN(EC), MSc, CNeph(C), Nurse Practitioner/Advanced Practice Nurse, London Health Sciences Centre, Victoria Hospital, London, ON.

Jane Ridley, RN(EC), MScN, CNeph(C), Nurse Practitioner/Advanced Practice Nurse, London Health Sciences Centre, University Hospital, London, ON.

Barbara Wilson, RN, MScN, CNeph(C), Advanced Practice Nurse, London Health Sciences Centre, Victoria Hospital, London, ON.

Heather K. Laschinger, PhD, RN, FCAHS, FAAN, Distinguished University Professor, Associate Director of Nursing Research, Arthur Labatt Family School of Nursing, University of Western Ontario, London, ON.

Address correspondence to: Lori Harwood, RN(EC), MSc, CNeph(C), Nurse Practitioner/Advanced Practice Nurse, London Health Sciences Centre, Victoria Hospital, Room A2-335, 800 Commissioner's Road East, Box 5010, London, ON N6A 5W9. Email: Lori.Harwood@lhsc.on.ca

Submitted for publication: July 8, 2010.

Accepted for publication in revised form: September 22, 2010.
Table 1. Demographic characteristics

Characteristics                     Mean (SD)

Years of Age (mean)                 46.2 (7.87)
Years in Nursing (mean)             23.2 (8.9)
Years in Nephrology Nursing (mean)  12.6 (8.12)
Gender                              Percent
Male                                3
Female                              97
n=121


Table 2. Burnout severity scores on Maslach Burnout Inventory

Severity         Cynicism  Emotional Exhaustion

Low (score <3)   76.6%     58.1%
High (score >3)  23.4%     41.9%

Table 3. Correlation between nurse retention and burnout and nurses'
health outcomes

Variable                Cynicism  Emotional   Professional
                                  Exhaustion  Efficacy

Intention to leave job  .488 *    .461 *      -.304

Variable                Mental Health  Physical Health
                        Symptoms       Symptoms

Intention to leave job  -.373 ^        .485 *

* p<0.0001, ^p<.001


Table 4. Hierarchical multiple regression of predictor values
explaining mental health symptoms

Variable              B      Standardized Beta  [beta]

Age                   -.002  -.017              -.216
Years in Nephrology   -.007  -.071              -.882
Emotional Exhaustion  -.195  -.353 *            -3.57
Cynicism              -.179  -.333 *            -3.38

[R.sup.2] = .394, adjusted [R.sup.2] = .373, df = 116, p <.0001,
* p<.001


Table 5. Hierarchal multiple regression of predictor values explaining
physical health symptoms

Variable              B      Standardized Beta  [beta]

Age                   -.017  -.135              -1.52
Years in Nephrology   .002   .019               .211
Emotional Exhaustion  .279   .410*              3.79
Cynicism              .077   .117               1.08

[R.sup.2] = .275, adjusted [R.sup.2] = .250, df = 116, p<.0001,
* p<.0001
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