ArticlePDF Available

Abstract

This article examines the relationship between nurse burnout and patient safety indicators, including both safety perceptions and reporting behavior. Based on the Conservation of Resources model of stress and burnout, it is predicted that burnout will negatively affect both patient safety perceptions and perceived likelihood of reporting events. Nurses from a Veteran's Administration hospital completed the Maslach Burnout Inventory and safety outcomes subset of measures from the Agency for Healthcare Research and Quality Patient Safety Culture measure. After controlling for work-related demographics, multiple regression analysis supported the prediction that burnout was associated with the perception of lower patient safety. Burnout was not associated with event-reporting behavior but was negatively associated with reporting of mistakes that did not lead to adverse events. The findings extend previous research on the relationship between burnout and patient outcomes and offer avenues for future research on how nurse motivation resources are invested in light of their stressful work environment.
http://wjn.sagepub.com
Research
Western Journal of Nursing
DOI: 10.1177/0193945907311322
2008; 30; 560 originally published online Jan 9, 2008; West J Nurs Res
Lynn B. Cooper
Jonathon R. B. Halbesleben, Bonnie J. Wakefield, Douglas S. Wakefield and
Perception Versus Reporting Behavior
Nurse Burnout and Patient Safety Outcomes: Nurse Safety
http://wjn.sagepub.com/cgi/content/abstract/30/5/560
The online version of this article can be found at:
Published by:
http://www.sagepublications.com
On behalf of:
Midwest Nursing Research Society
at:
can be foundWestern Journal of Nursing Research Additional services and information for
http://wjn.sagepub.com/cgi/alerts Email Alerts:
http://wjn.sagepub.com/subscriptions Subscriptions:
http://www.sagepub.com/journalsReprints.navReprints:
http://www.sagepub.com/journalsPermissions.navPermissions:
http://wjn.sagepub.com/cgi/content/refs/30/5/560
SAGE Journals Online and HighWire Press platforms):
(this article cites 38 articles hosted on the Citations
distribution.
© 2008 SAGE Publications. All rights reserved. Not for commercial use or unauthorized
at University of Missouri-Columbia on August 19, 2008 http://wjn.sagepub.comDownloaded from
560
Nurse Burnout and Patient
Safety Outcomes
Nurse Safety Perception Versus
Reporting Behavior
Jonathon R. B. Halbesleben
University of Wisconsin–Eau Claire
Bonnie J. Wakefield
Harry S. Truman Memorial Veterans’Hospital and University of
Missouri–Columbia
Douglas S. Wakefield
University of Missouri–Columbia
Lynn B. Cooper
Harry S. Truman Memorial Veterans’Hospital
This article examines the relationship between nurse burnout and patient safety
indicators, including both safety perceptions and reporting behavior. Based on
the Conservation of Resources model of stress and burnout, it is predicted that
burnout will negatively affect both patient safety perceptions and perceived
likelihood of reporting events. Nurses from a Veteran’s Administration hospital
completed the Maslach Burnout Inventory and safety outcomes subset of measures
from the Agency for Healthcare Research and Quality Patient Safety Culture
measure. After controlling for work-related demographics, multiple regression
analysis supported the prediction that burnout was associated with the percep-
tion of lower patient safety. Burnout was not associated with event-reporting
behavior but was negatively associated with reporting of mistakes that did not
lead to adverse events. The findings extend previous research on the relationship
between burnout and patient outcomes and offer avenues for future research on
how nurse motivation resources are invested in light of their stressful work
environment.
Western Journal of
Nursing Research
Volume 30 Number 5
August 2008 560-577
© 2008 Sage Publications
10.1177/0193945907311322
http://wjn.sagepub.com
hosted at
http://online.sagepub.com
Authors’ Note:A previous version of this article was presented at the 2007 annual meeting of
the Academy of Management in Philadelphia, Pennsylvania, where it was named Best Theory-
to-Practice paper by the Health Care Management Division. This work was supported with
resources and the use of facilities at the Harry S. Truman Memorial Veterans’Hospital and the
University of Missouri Center for Health Care Quality. Please address correspondence to
Jonathon R. B. Halbesleben at halbesjr@uwec.edu.
distribution.
© 2008 SAGE Publications. All rights reserved. Not for commercial use or unauthorized
at University of Missouri-Columbia on August 19, 2008 http://wjn.sagepub.comDownloaded from
Halbesleben et al. / Nurse Burnout and Safety 561
Keywords: burnout; professional; medical error; safety; perceptions
T
he work environment and its effect on health care employees plays a
key role in patient outcomes (Institute of Medicine [IOM], 2004). One
aspect that has not been adequately addressed involves the consequences of
workforce burnout, particularly the effect of staff burnout on patient safety
perceptions and event-reporting behavior. Burnout is defined as a psycho-
logical response to work-related stress that consists of emotional exhaustion
(a depletion of work-related emotional resources), depersonalization (pulling
away from those associated with the job), and reduced perceptions of personal
accomplishment (a belief that one is not as good at the job as he or she once
was; Maslach, 1982). Burnout has become an important concern for health
care organizations because of its negative consequences in terms of workforce
turnover, job satisfaction, and performance (Aiken, Clarke, Sloane, Sochalski,
& Silber, 2002; Halbesleben & Buckley, 2004).
Although health care employees have been the most widely studied
occupational group in the burnout literature (Schaufeli & Enzmann,
1998), researchers have focused almost exclusively on the underlying
causes of burnout, without adequate attention given to the consequences
of burnout. It has become common to assume that burnout has significant
negative consequences, yet there is little empirical research testing this
assumption. Moreover, what research does exist on the consequences of
burnout generally finds very little shared variance between burnout and
its consequences (Schaufeli & Enzmann, 1998). Finally, for the most part,
burnout researchers have limited their investigations of burnout conse-
quences to outcomes associated with the individual experiencing burnout
(e.g., their performance, job satisfaction, or commitment; Aiken et al.,
2002; Halbesleben & Buckley, 2004) and have done little to explore the
manner in which an employee’s burnout influences other people. To truly
understand the impact of burnout on health care, we must understand
whether and how the burnout of the health care workforce results in
changes in patient care. For example, if burnout is associated with
reduced reporting of adverse events or near misses in hospitals, this sig-
nificantly undermines quality improvement initiatives in those hospitals.
Without such research, it is unknown whether burnout has any true nega-
tive impact for health care organizations or patients and, potentially,
reduces the need for interventions that are meant to address this issue.
The purpose of the present article is to explore the relationship between
distribution.
© 2008 SAGE Publications. All rights reserved. Not for commercial use or unauthorized
at University of Missouri-Columbia on August 19, 2008 http://wjn.sagepub.comDownloaded from
562 Western Journal of Nursing Research
staff nurse’s burnout and their perceptions of patient safety and adverse
event and near-miss reporting behaviors.
Description of the Problem
Burnout and Patient Safety Outcomes
Previous studies examining links between burnout and patient outcomes
have focused primarily on patient satisfaction. For example, Leiter, Harvie,
and Frizzell (1998) examined the relationship between unit-level nurse burnout
and patient satisfaction. Across 16 hospital units, they found a significant
relationship between higher levels of staff emotional exhaustion and deper-
sonalization and lower patient satisfaction. Vahey, Aiken, Sloane, Clark, and
Vargas (2004) echoed this finding, calling for changes in workforce factors
such as staffing, administrative staffing, and relationship development
between nurses and physicians that might help to reduce burnout and improve
patient satisfaction (see also Garman, Corrigan, & Morris, 2002).
In an attempt to expand the realm of outcomes associated with burnout,
Laschinger and Leiter (2006) recently found a significant relationship
between burnout and self-reported adverse events in a large sample of
Canadian nurses. They based their work on their Nursing Worklife Model
(Leiter & Laschinger, 2006), which suggests that certain variables within a
nurse’s work environment (e.g., leadership, staffing, etc.) predict burnout,
which leads to a higher likelihood of adverse events. However, although their
model predicts burnout in nurses by examining important environmental
features, their model is less clear in its prediction of nurses’ reactions to
burnout. Specifically, they found a significant relationship among percep-
tions of frequency with regard to adverse events but did not account for the
potential distinction between frequency of events and reporting of events.
Extending the Nursing Worklife Model by considering alternative models
of the burnout process may provide clarity in that relationship.
The Conservation of Resources model. The dominant theory to explain the
process of burnout has been Hobfoll’s (1988, 1989, 1998) Conservation of
Resources (COR) model. The COR model is based on psychological processes
associated with resources, defined as those psychological commodities that
we value (e.g., meaningful employment, time with family, satisfaction with
life and work, etc.). The model further proposes that stress results from one
of three processes: (a) loss of resources, (b) threat to current resources, or
(c) inadequate return on investments made to maximize resources (e.g., an
distribution.
© 2008 SAGE Publications. All rights reserved. Not for commercial use or unauthorized
at University of Missouri-Columbia on August 19, 2008 http://wjn.sagepub.comDownloaded from
Halbesleben et al. / Nurse Burnout and Safety 563
employee who engages in extra training to increase the likelihood of a pay raise
but does not receive the raise). Burnout is the result of repeated investment in
work resources without adequate return in that investment (Hobfoll & Freedy,
1993). Note that these processes are generally consistent with Leiter and
Laschinger’s (2006) Nursing Worklife Model; however, they are not specifi-
cally limited to nursing.
The COR model is valuable in that it further specifies the processes that
occur once an employee has become burned out. It suggests that once an
employee has reached the point of burnout, he or she becomes more careful
in how he or she invests future resources in work (Hobfoll, 2001; Hobfoll
& Shirom, 2000; Siegall & McDonald, 2004). This means, for example,
that when an employee experiences the emotional exhaustion symptom of
burnout, he or she may be more likely to pull away from those associated
with the job, including patients (Leiter, 1993). Moreover, employees may
demonstrate new resource investment strategies by directing their motiva-
tional resources in very specific aspects of the job (M. M. Baltes & Baltes,
1990; P. B. Baltes, 1997), for example, focusing only on the parts of the job
that they like or at which they believe they are good. Researchers have
demonstrated such an effect with regard to job performance, finding that
employees who are experiencing symptoms of burnout tend to focus their
motivation at work toward very specific aspects of the job (Halbesleben &
Bowler, 2007; Wright & Cropanzano, 1998).
Relationship With Patient Safety
When we apply the conservation of resources model to the relationship
between health care providers and patients, it suggests that as burnout increases,
providers will become careful in the future investment of their resources.
Given the noted negative reciprocity associated with the relationship with
patients (e.g., providers feel they invest more in the relationship than they
receive in return) and resulting negative attitudes toward patients (Bakker,
Schaufeli, Sixma, Bosveld, & van Direndonck, 2000), providers may be
hesitant to continue to invest extra motivational resources (beyond those
required for basic care of patients) in patient relationships. This conserva-
tion of motivational resources may lead to lower health care quality because
of a higher risk of medical errors. Burnout has been shown to be negatively
related to certain employee emotional states, particularly positive affect
(Thoresen, Kaplan, Barsky, Warren, & de Chermont, 2003). That is, employees
who are burned out are less likely to feel positive on the job. Positive affect
has been empirically linked to enhanced decision making (Fredrickson, 2001)
distribution.
© 2008 SAGE Publications. All rights reserved. Not for commercial use or unauthorized
at University of Missouri-Columbia on August 19, 2008 http://wjn.sagepub.comDownloaded from
564 Western Journal of Nursing Research
as well as problem solving and higher levels of patient-centeredness in
health care providers (Isen, 2001). It is likely that burned out employees are
less cognitively vigilant and less likely to put forth extra effort necessary
for the highest quality care delivery. Thus, we propose that burnout will be
associated with a higher perceived likelihood of medical errors, which will
lead nurses to perceive a less safe work environment.
Hypothesis 1: Burnout will be associated with perceptions of a less safe envi-
ronment for patients.
Medical Error Reporting
For hospital systems to truly understand the extent and impact of medical
errors, they frequently rely on voluntary adverse event/error reporting systems.
Such systems are dependent on the accurate reporting of errors by staff;
these systems rely on voluntary reporting by health care professionals who
have the ability to detect such errors. Error reporting involves “(1) error
recognition, (2) assessment of the need to report the error, (3) incident
report preparation, and (4) follow-up response by the party receiving the
report” (B. J. Wakefield, Uden-Holman, & Wakefield, 2005, p. 477).
However, because these programs are typically voluntary, members of the
health care workforce may be reluctant to report errors for a variety of rea-
sons, including time involved in documentation, lack of clarity regarding
whether the incident was actually an error, fear of retribution (legal or from
a supervisor), or confusion about the processes for reporting (cf. Uribe,
Schwikart, Pathak, & Marsh, 2002; D. S. Wakefield, Wakefield, Uden-
Holman, & Blegen, 1996). One reason that has not been studied is their
response to the demands of their work in terms of stress and burnout. Burnout
can influence any of the four steps cited by B. J. Wakefield et al. (2005).
First, burnout can influence error recognition. In situations where the
demands of the job are so great as to cause burnout, it may leave little
opportunity for health care workers to monitor their environment so that
they might notice medical errors occurring. For example, if required to
administer medications to a large number of patients in a limited amount of
time, a nurse may not double-check that the patient is receiving the appro-
priate dosage of medication.
Second, burnout can influence assessment of the need to report errors.
Given that the time it takes to report an error is a key barrier to reporting
(Uribe et al., 2002; D. S. Wakefield et al., 1996), burned out health care pro-
fessionals may be more likely to conclude that an error does not need to be
distribution.
© 2008 SAGE Publications. All rights reserved. Not for commercial use or unauthorized
at University of Missouri-Columbia on August 19, 2008 http://wjn.sagepub.comDownloaded from
reported because of other pressures on their time (e.g., time spent reporting
the error vs. providing follow-up care to the patient). Burned out individu-
als also have a tendency to focus on negative aspects of their work and thus
may feel that an error should be reported only if it has a significant nega-
tive effect on the patient. Similarly, one would expect that burned out health
care workers would be less likely to report “close calls” that did not result
in an error but could serve as a learning experience for the staff.
Third, burnout can influence incident report preparation. As with assessing
the need to report, if the incident report is seen as overly time-consuming to
the employee, then he or she may be hesitant to complete it. Given that paper-
work is a commonly cited source of stress and dissatisfaction among health
care professionals, and nurses in particular (Burnard, Edwards, Fothergill,
Hannigan, & Coyle, 2000; Lyons, Lapin, & Young, 2003), the added paperwork
of an incident report may seem too great a burden to a health care professional
who observes an error. As such, as a result of their burnout, they may be less
likely to complete a report for an observed error.
Finally, burnout can influence follow-up responses by the party receiving
the report. If the individual receiving the report is also experiencing burnout,
he or she may be hesitant to respond to the report in a timely manner, again
seeing it as an additional demand and as an event that has occurred in the past.
Because the incident report represents a past event, the employee receiving
the report may be hesitant to use it as a training opportunity because of extra
time it may take away from direct patient care. If the employee who completed
the report never receives follow-up, it can have two significant results. First,
it may actually increase that employee’s burnout because it represents an
investment in time resources without an associated reward (Hobfoll, 2001).
Moreover, it will decrease the likelihood of completing future reports because
the reports will be more likely to be seen as a waste of time without any
follow-up.
Taken together, to the extent that it represents an additional demand that
will not improve their working conditions, victims of burnout may be hesitant
to report medical errors (cf. D. S. Wakefield et al., 1999). As a result, although
we predict that burnout could lead to the perception of a less safe environment,
it is predicted that health care worker burnout will be associated with a lower
likelihood of actually reporting medical errors.
Hypothesis 2: Burnout will be associated with lower likelihood to report
errors and near misses.
Halbesleben et al. / Nurse Burnout and Safety 565
distribution.
© 2008 SAGE Publications. All rights reserved. Not for commercial use or unauthorized
at University of Missouri-Columbia on August 19, 2008 http://wjn.sagepub.comDownloaded from
Method
Participants
The present study used a cross-sectional survey design among nurses in
a hospital setting. The sample included 148 nurses from a Midwestern
Veteran’s Administration (VA) hospital. The participants represented all
areas of the hospital, with the greatest number coming from intensive care
units (n = 23), on-site clinics (n = 22), and medical/surgical units (n = 15).
The majority of the respondents were registered nurses (n = 90), although
licensed practical nurses (n = 17) and nurse practitioners (n = 10) also were
included in the sample. Ninety-five percent of the respondents indicated
that they worked 40 hours per week or more. Most of the participants were
either relatively new to the hospital (n = 50 had worked there 0-5 years) or
had been there more than 16 years (n = 56). Most of the participants (n =
86) had worked in their current work area less than 5 years; however, the
majority of participants (n = 95) had worked as a nurse for 16 years or
more. Ninety-one percent (n = 135) of the respondents indicated that they
had direct interaction or contact with patients; for all analyses, only those
respondents with direct contact with patients are included.
Measures
Burnout. Burnout was assessed using the exhaustion and depersonalization
subscales of the Maslach Burnout Inventory (MBI; Maslach, Jackson, &
Leiter, 1996). The MBI is the most commonly used burnout measure in
the literature. It is a 22-item measure including subscales for emotional
exhaustion (9 items), depersonalization (5 items), and personal accom-
plishment (8 items). A sample item includes, “I feel burned out from my
work.” Items are scored on a 5-point frequency scale ranging from never (1)
to always (5). Higher scores indicate higher levels of burnout. The personal
accomplishment subscale of burnout was not included in this study because
the recent burnout literature has questioned the validity of the measure and the
appropriateness of including personal accomplishment in the conceptual-
ization of burnout (cf. Demerouti, Bakker, Nachreiner, & Schaufeli, 2001;
Green, Walkey, & Taylor, 1991; Halbesleben & Bowler, 2007; Shirom,
2003). Previous research using the MBI among nurses suggests that it is
highly reliable (e.g., Laschinger & Leiter, 2006, reported Cronbach’s α levels
of .91 for emotional exhaustion and .80 for depersonalization).
566 Western Journal of Nursing Research
distribution.
© 2008 SAGE Publications. All rights reserved. Not for commercial use or unauthorized
at University of Missouri-Columbia on August 19, 2008 http://wjn.sagepub.comDownloaded from
Patient safety outcomes. The Agency for Healthcare Research and
Quality (AHRQ) Patient Safety Culture Survey (Sorra & Nieva, 2004) was
used to assess patient safety outcomes. The AHRQ measure assesses four
different outcomes, two of which assess patient safety perceptions (safety
grade and safety perceptions) and two of which assess reporting behaviors
(event reports and near-miss frequency reporting). Safety Grade asks each
participant to assign a grade (on the traditional A, B, C, D, and F scale) to
their unit on patient safety. It is a one-item measure scored from 4 (A) to 0
(F); a higher score indicates a higher grade. Safety Perceptions is a four-item
scale that includes statements such as, “Patient safety is never sacrificed to
get more work done” and “Our procedures and systems are good at preventing
errors from happening.” These items are scored on a 5-point, Likert-type
scale from strongly disagree (1) to strongly agree (5); a higher score indi-
cates a more safe environment. Event Reports are assessed with one item
that asks, “In the past 12 months, how many event reports have you filled
out and submitted?” Response categories included no event reports (0), 1 to
2 reports (1), 3 to 5 reports (2), 6 to 10 reports (3), 11 to 20 reports (4), and
21 or more reports (5). Near-Miss Reporting Frequency includes three
items that target reporting of mistakes that (a) are caught and corrected
before affecting the patient, (b) had no potential harm to the patient, and (c)
could harm the patient but did not. Participants were asked on a 5-point fre-
quency scale ranging from never (1) to always (5) how often such incidents
were reported.
Procedure
The study was approved by the University of Missouri–Columbia Health
Sciences Institutional Review Board and the Harry S. Truman Memorial
Veterans’Hospital Research and Development Board prior to administration
of the survey. The survey was distributed to all nurses at the facility through
the internal mail system, including a cover letter from the hospital’s chief
nursing executive and a postage-paid return envelope. The cover letter
described the participant’s rights as human subjects and indicated that their
consent to participate would be indicted by their return of the survey. Shortly
after the initial distribution, an e-mail was sent to nursing staff encouraging
participation. Two weeks after initial survey distribution, a second copy of
the survey was distributed to all nursing staff. The surveys were returned
directly to the first author via a postage-paid response envelope. The survey
was distributed to 295 individuals; 148 surveys were returned, representing
a response rate of 50%.
Halbesleben et al. / Nurse Burnout and Safety 567
distribution.
© 2008 SAGE Publications. All rights reserved. Not for commercial use or unauthorized
at University of Missouri-Columbia on August 19, 2008 http://wjn.sagepub.comDownloaded from
Results
Table 1 displays the means, standard deviations, scale reliability estimates
(Cronbach’s α, where appropriate), and correlations for study measures.
For scaled measures (exhaustion, depersonalization, safety perceptions, and
reporting frequency), Cronbach’s α indicated that the measures had high
levels of internal consistency (Nunnally, 1967). The mean values for
exhaustion and depersonalization were consistent with norms for nurses
taking the Maslach Burnout Inventory (Maslach et al., 1996). Exhaustion
and depersonalization were highly correlated; the level of correlation (r = .70)
is consistent with other studies of nursing burnout (e.g., Laschinger & Leiter,
2006, found a correlation of .71 between these variables using the same
scale). Unit and hours worked were not significantly correlated with either
burnout component; tenure within the hospital and within the profession were
negatively correlated with depersonalization (e.g., nursing staff with less
experience and fewer years at the hospital reported higher depersonalization).
The mean of 2.56 for patient safety grade suggests an average of a B–
grade given by the nurses. The safety perceptions average falls in the midpoint
of the Likert-type scale (M = 2.95). The data indicate that nurses reported
an average of one to two event reports in the 12 months prior to the survey.
Finally, the mean of 3.23 in near-miss reporting frequency translates to
preventive reports occurring between sometimes and most of the time in the
facility. A number of the demographic variables were significantly correlated
with safety outcome measures (see Table 1).
As a result of the significant correlations between hospital tenure, hours
worked, and the outcomes measures, we conducted individual multiple
regressions for each safety outcome measure with both burnout variables as
predictors and the tenure and hours variables as control variables. In addition
to their significant zero-order correlations with other variables in the study,
tenure and hours were included as control variables based on past research
suggesting that they may be associated with burnout and safety perceptions
and thus should be controlled in this type of study (cf. Halbesleben &
Buckley, 2004; Landrigan et al., 2004; Lundstrom, Pugliese, Bartley, Cox, &
Guither, 2002). These results are included in Table 2.
With regard to patient safety grade, after controlling for demographics,
both exhaustion and depersonalization were negatively associated with
nurses’perceived patient safety grades. This suggests that higher burnout was
associated with a lower patient safety grade. A similar finding emerged with
safety perceptions, again where higher burnout was associated with percep-
tions of a less safe environment. These findings supported the prediction of
568 Western Journal of Nursing Research
distribution.
© 2008 SAGE Publications. All rights reserved. Not for commercial use or unauthorized
at University of Missouri-Columbia on August 19, 2008 http://wjn.sagepub.comDownloaded from
569
Table 1
Study Means, Standard Deviations, Reliability Coefficients, and Variable Intercorrelations
MSD α 1 2 345 6 7 8
Control/demographic variables
1. Hospital tenure 3.64 1.66 NA
2. Hours per week 3.09 0.62 NA 0.06
Predictor variables
3. Exhaustion 2.72 0.88 0.94 –0.11 0.04
4. Depersonalization 2.02 0.87 0.87 –0.19* 0.08 0.70**
Outcome variables
5. Safety grade 2.56 0.89 NA 0.17 0.05 –0.41** –0.36**
6. Event reports 1.15 1.12 NA 0.06 0.07 –0.01 –0.03 0.02
7. Safety perceptions 2.95 0.94 0.81 0.09 0.00 –0.55** –0.18* 0.68** –0.21*
8. Near-miss reporting frequency 3.24 1.06 0.87 0.17* 0.02 –0.35** 0.41** 0.36** –0.11 0.28**
*p < .05. **p < .01.
distribution.
© 2008 SAGE Publications. All rights reserved. Not for commercial use or unauthorized
at University of Missouri-Columbia on August 19, 2008 http://wjn.sagepub.comDownloaded from
570 Western Journal of Nursing Research
Hypothesis 1 that burnout would be negatively associated with perceptions
of a safe environment.
When considering event reports, after controlling for demographics,
neither component of burnout was associated with number of events reported
in the previous 12 months. This finding was contrary to Hypothesis 2. However,
both burnout components were negatively associated with near-miss reporting
frequency after controlling for demographics, suggesting that higher burnout
was associated with lower frequency of preventive reporting. This finding
supported Hypothesis 2.
Discussion
This study found, after controlling for work-related demographic vari-
ables, that burnout was associated with perceptions of a less safe environment
and lower reporting of near misses. However, burnout was not associated
with the number of events reported in the previous year. The nonsignificant
relationship between burnout and event reports was unexpected. However,
two explanations may exist for the finding. First, there may have been a
floor effect with reports because many respondents fit into the no reports
and 1 to 2 reports categories. This may have restricted the range of possible
Table 2
Multiple Regression Results for Patient Safety Outcomes
Near-Miss
Safety Event Safety Reporting
Grade Reports Perceptions Frequency
β SE β SE β SE β SE
Control/demographic
variables
Hospital tenure .11** .04 –.04 .06 .13* .05 .09 .06
Hours per week .11 .12 .12 .16 .03 .11 .07 .13
Predictor variables
Exhaustion –.40** .12 –.02 .15 –.84*** .11 –.14* .13
Depersonalization –.16* .14 .01 .16 –.26* .12 –.36** .14
R
2
.22 .01 .36 .18
Note: All entries (except R
2
entries) are standardized beta coefficients.
*p < .05. **p < .01. ***p < .001.
distribution.
© 2008 SAGE Publications. All rights reserved. Not for commercial use or unauthorized
at University of Missouri-Columbia on August 19, 2008 http://wjn.sagepub.comDownloaded from
Halbesleben et al. / Nurse Burnout and Safety 571
responses for this variable, leading to a lower likelihood of statistical
significance.
Alternatively, respondents may have felt that although event reports
require effort, they are an important aspect of their work and/or a perceived
requirement for the job. As a result, they felt obligated to complete the
reports despite the added demands placed on them. In other words, the
event reports may not have been seen in terms of investment of resources
because they had no other choice. On the other hand, the reports of near
misses that may be seen as less essential (because they did not lead to an
adverse event) were significantly less likely as burnout was higher. This
suggests that although burnout may not be associated with event reports, it
still plays a role in the investment of resources at work.
Our findings are consistent with the recent work of Laschinger and
Leiter (2006), which reported a relationship between burnout components
and nurses’ reports of frequency of adverse events. Of importance, they
examined perceptions regarding how often events happened. The present
work extends their findings to shed light on the relationship between per-
ceived patient safety indicators and specific reporting behaviors in the face
of burnout.
Implications for Theory and Research
With regard to reports that are not perceived as essential, the findings
support the conservation of resources model in understanding how work
demands lead to reduced likelihood of reporting. This article extends
models of stress and burnout among health care professionals, most notably
Leiter and Laschinger’s (2006) Nursing Worklife Model. The conservation
of resources model may be helpful in understanding other outcomes of
work stress and burnout among health care professionals as well, including
such outcomes as providing additional assistance beyond what is expected
to both coworkers and patients. Research outside the domain of health care
(Halbesleben & Bowler, 2007) suggests that burned out health care profes-
sionals may be willing to invest their limited resources in extra-role behav-
iors that benefit coworkers or patients but may be unwilling to engage in
extra behaviors that would benefit the organization (e.g., offer to pick up
extra shifts). Although Halbesleben and Bowler’s research was not specifi-
cally conducted with nurses, further exploration of the conservation of
resources model may offer important avenues for additional research in
understanding behaviors of health care professionals.
Overall, this study has a number of implications for additional research
in the reporting of medical errors and near misses. A number of factors, in
distribution.
© 2008 SAGE Publications. All rights reserved. Not for commercial use or unauthorized
at University of Missouri-Columbia on August 19, 2008 http://wjn.sagepub.comDownloaded from
addition to burnout, may lead to lower reporting of errors, including disin-
centives to reporting (e.g., the perception that errors are punished, extra
effort, etc.), lack of agreement or understanding about what constitutes a
reportable error or near miss, and difficulty in accepting that errors occur
(Albert, 1993; Leape, 1994; Pepper, 1995; D. S. Wakefield et al., 1999;
Walters, 1992). Of interest, many of these factors also might be associated
with stress and burnout. For example, the cognitive dissonance associated
with thinking that errors should not occur and the realization that one has
may be quite stressful and that stress may further affect the reporting
process. Further research that affects how stress and burnout intersect with
other variables predicting error reporting behavior, particularly when incor-
porated into theoretical frameworks of stress and reporting behavior, would
be helpful in developing evidence-based solutions to reporting behavior.
Implications for Practice
The finding that higher burnout was associated with lower incidence of
near-miss reports is concerning. These reports are essential to organizations
because they can be markers of larger problems (e.g., work process problems,
other system-based problems in need of intervention). Roberto, Bohmer,
and Edmondson (2006) characterize mistakes that are caught or do not actu-
ally lead to harm as ambiguous threats—a signal of an operational problem
that may suggest future harm. They suggest that capturing and amplifying
these threats are important steps in the development of a culture of quality
because they allow organizations to address systemic problems rather than
focus on localized solutions that may perpetuate errors. However, recurring
discrepancies in whether a near miss is serious enough to merit reporting
may continue to hinder attempts to capture this information (O’Shea, 1999;
Wolf, 1989).
Along those lines, the work on burnout and investment of work resources
also may link to problem-solving behaviors at work. In their effort to con-
serve resources, nurses (and other professionals) may engage in simple
solutions to work process problems (sometimes called workarounds) to
complete their work with minimal disruption. However, as noted by Tucker
(2004; Tucker & Edmondson, 2003), these solutions often can lead to addi-
tional problems and do little to address critical operational failures that lead
to error. As burnout increases, it may be more likely to prevent nurses from
fully considering the causes underlying problems in work process and, as a
result, may create an increased threat of error. Efforts need to be undertaken to
address the underlying causes of unsafe conditions at work (e.g., specifically
572 Western Journal of Nursing Research
distribution.
© 2008 SAGE Publications. All rights reserved. Not for commercial use or unauthorized
at University of Missouri-Columbia on August 19, 2008 http://wjn.sagepub.comDownloaded from
Halbesleben et al. / Nurse Burnout and Safety 573
exploring faulty work processes that facilitate workarounds and errors) so
that errors are less likely to be repeated (Tucker & Edmondson, 2002). To
reach this goal, interventions that reduce burnout may be necessary.
The findings from this study suggest a need to address concerns of
burnout among nursing staff. Although a number of potential interventions
have been proposed for reducing burnout, research concerning the efficacy
of burnout intervention programs has been limited, primarily because of the
myriad potential causes of burnout in organizations (Halbesleben & Buckley,
2004). Because burnout is a response to work stress, any demand that causes
stress, if left unchecked, can lead to burnout. Given the localized nature of
burnout, Halbesleben, Osburn, and Mumford (2006) advocate a participatory
action research approach to reducing burnout, where work groups dissect the
causes of burnout within their specific work environment and collaboratively
develop solutions to fit their unique demands.
Limitations and Opportunities for Future Research
We acknowledge that this study has a number of limitations. The self-
report, cross-sectional nature of the findings limits our ability to assess causal
relationships between burnout and safety. Although the candid survey
responses about the lack of reporting of near misses appear to reduce these
concerns, examining these issues over time using other indicators of report-
ing behavior may strengthen the validity of the findings. The sample was
limited to one hospital, and the response rate for the survey was a bit low
compared to published surveys of nurses (50% vs. the 61% reported by
Asch, Jedrziewski, & Christakis, 1997); however, the sample was generally
representative of the population of nurses in the hospital. A higher repre-
sentation of different nursing specialties and various units may have allowed
for better assessment of burnout and safety outcomes by specialty, which
would be particularly valuable in developing interventions. Future research
that longitudinally replicates our study in a larger sample would be particularly
valuable.
Moreover, in most error reporting research there is an implicit assumption
that all nurses on a unit or within a facility would have an equal opportunity
to observe, and thus report, errors. This assumption may not hold true because
there may be individual differences (e.g., conscientiousness, propensity to
report) and work setting differences (e.g., working in a setting where there are
fewer or more opportunities for error) that affect whether errors are observed
and reported. This was supported in the present study by the floor effect in
error reports, where most nurses indicated that they had reported either zero
distribution.
© 2008 SAGE Publications. All rights reserved. Not for commercial use or unauthorized
at University of Missouri-Columbia on August 19, 2008 http://wjn.sagepub.comDownloaded from
or very few errors in the past year. As noted, this nonnormal distribution may
have affected the measured relationships with burnout and is a factor that
other researchers in this area will need to consider.
We recognize that the measure of error reports may not have been an
entirely accurate measure of errors or error reporting behavior. It was
dependent on memory throughout 12 months, and, moreover, the categorical
scale used in the AHRQ measure might limit the variability in responses
that might bias the statistical tests due to nonnormality of the data. Future
research that replicates the present study using observation of errors and
error reporting behavior may help to alleviate this concern.
Finally, as an initial examination of the links between burnout and safety
outcomes, there are other factors that predict perceptions of safety and
reporting behaviors. In addition, there may be intervening factors between
burnout dimensions and the dependent variables that were not accounted
for in our study or potential third-variable explanations for the reported
relationship between burnout and safety perceptions (e.g., negative affec-
tivity). These concerns suggest an underspecified model that can be
expanded through future research.
Conclusion
This article extended previous work on the links between burnout and
patient safety by testing theory-based hypotheses regarding the impact of
burnout on reporting behaviors and safety perceptions. The findings suggest
that burnout is associated with perceptions of an unsafe environment and a
lower likelihood of engaging in preventive reporting behavior that may be
critical to addressing safety concerns in the environment.
References
Aiken, L. H., Clarke, S. P., Sloane, S. P., Sochalski, J., & Silber, J. H. (2002). Hospital nurse
staffing and patient mortality, nurse burnout, and job dissatisfaction. JAMA, 288, 1987-1993.
Albert, V. L. (1993). Medication errors: A disciplinary approach to prevention for nurses.
Neonatal Pharmacology Quarterly, 2(2), 37-42.
Asch, D. A., Jedrziewski, M. K., & Christakis, N. A. (1997). Response rates to mail surveys
published in medical journals. Journal of Clinical Epidemiology, 50, 1129-1136.
Bakker, A. B., Schaufeli, W. B., Sixma, H. J., Bosveld, W., & van Direndonck, D. (2000).
Patient demands, lack of reciprocity, and burnout: A five-year longitudinal study among
general practitioners. Journal of Organizational Behavior, 21, 425-441.
574 Western Journal of Nursing Research
distribution.
© 2008 SAGE Publications. All rights reserved. Not for commercial use or unauthorized
at University of Missouri-Columbia on August 19, 2008 http://wjn.sagepub.comDownloaded from
Halbesleben et al. / Nurse Burnout and Safety 575
Baltes, M. M., & Baltes, P. B. (1990). Psychological perspectives on successful aging: The
model of selective optimization with compensation. In P. B. Baltes & M. M. Baltes (Eds.),
Successful aging: Perspectives from the behavioral sciences (pp. 1-34). New York:
Cambridge University Press.
Baltes, P. B. (1997). On the incomplete architecture of human ontogeny: Selection, optimiza-
tion, and compensation as foundation of development theory. American Psychologist,
52, 366-380.
Burnard, P., Edwards, D., Fothergill, A., Hannigan, B., & Coyle, D. (2000). Community
mental health nurses in Wales: Self-reported stressors and coping strategies. Journal of
Psychiatric and Mental Health Nursing, 7, 523-528.
Demerouti, E., Bakker, A. B., Nachreiner, F., & Schaufeli, W. B. (2001). The job demands-
resources model of burnout. Journal of Applied Psychology, 86, 499-512.
Fredrickson, B. L. (2001). Positive emotions in positive psychology: The broaden-and-build
theory of positive emotions. American Psychologist, 56, 218-226.
Garman, A. N., Corrigan, P. W., & Morris, S. (2002). Staff burnout and patient satisfaction:
Evidence of relationships at the care unit level. Journal of Occupational Health Psychology,
7, 235-241.
Green, D. E., Walkey, F. H., & Taylor, A. J. W. (1991). The three-factor structure of the
Maslach Burnout Inventory. Journal of Social Behavior and Personality, 6, 453-472.
Halbesleben, J. R. B., & Bowler, W. M. (2007). Emotional exhaustion and job performance:
The mediating role of motivation. Journal of Applied Psychology, 91, 93-106.
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.
Hobfoll, S. E. (1988). The ecology of stress. New York: Hemisphere.
Hobfoll, S. E. (1989). Conservation of resources: A new attempt at conceptualizing stress.
American Psychologist, 44, 513-524.
Hobfoll, S. E. (1998). Stress, culture, and community. New York: Plenum.
Hobfoll, S. E. (2001). The influence of culture, community, and the nested self in the stress
process:Advancing conservation of resources theory. Applied Psychology: An International
Review, 50, 337-370.
Hobfoll, S. E., & Freedy, J. (1993). Conservation of resources:A general stress theory applied
to burnout. In W. B. Schaufeli, C. Maslach, & T. Marek (Eds.), Professional burnout:
Recent developments in theory and research. Washington, DC: Taylor & Francis.
Hobfoll, S. E., & Shirom, A. (2000). Conservation of resources: Applications to stress and
management in the workplace. In R. T. Golembiewski (Ed.), Handbook of organizational
behavior (2nd ed., pp. 57-81). New York: Dekker.
Institute of Medicine. (IOM). (2004). Keeping patients safe: Transforming the work environ-
ment of nurses. Washington, DC: National Academy Press.
Isen, A. M. (2001). An influence of positive affect on decision making in complex situations:
Theoretical issues with practical implications. Journal of Consumer Psychology, 11, 75-85.
Landrigan, C. P., Rothschild, J. M., Cronin, J. W., Kaushal, R., Burdick, E., Katz, J. T., et al.
(2004). Effect of reducing interns’ work hours on serious medical errors in intensive care
units. New England Journal of Medicine, 351, 1838-1848.
Laschinger, H. K. S., & Leiter, M. P. (2006). The impact of nursing work environments on
patient safety outcomes: The mediating role of burnout. Journal of Nursing Administration,
36(5), 259-267.
distribution.
© 2008 SAGE Publications. All rights reserved. Not for commercial use or unauthorized
at University of Missouri-Columbia on August 19, 2008 http://wjn.sagepub.comDownloaded from
Leape, L. L. (1994). Error in medicine. JAMA, 272, 1851-1857.
Leiter, M. P. (1993). Burnout as a developmental process: Consideration of models. In
W. B. Schaufeli, C. Maslach, & T. Marek (Eds.), Professional burnout: Recent developments
in theory and research. Washington, DC: Taylor & Francis.
Leiter, M. P., Harvie, P., & Frizzell, C. (1998). The correspondence of patient satisfaction and
nurse burnout. Social Science and Medicine, 47, 1611-1617.
Leiter, M., & Laschinger, H.K.S. (2006). Relationships of work and practice environment to
professional burnout: Testing a causal model. Nursing Research, 55(2), 137-146.
Lundstrom, T., Pugliese, G., Bartley, J., Cox, J., & Guither, C. (2002). Organizational and
environmental factors that affect worker health and safety and patient outcomes. American
Journal of Infection Control, 30(2), 93-106.
Lyons, K. J., Lapin, J., & Young, B. (2003). A study of job satisfaction of nursing and allied
health graduates from a mid-Atlantic university. Journal of Allied Health, 32, 10-17.
Maslach, C. (1982). Burnout: The cost of caring. Englewood Cliffs, NJ: Prentice Hall.
Maslach, C., Jackson, S. E., & Leiter, M. P. (1996). Maslach Burnout Inventory. Palo Alto,
CA: Consulting Psychologists Press.
Nunnally, J. (1967). Psychometric theory. New York: McGraw-Hill.
O’Shea, E. (1999). Factors contributing to medication errors: A literature review. Journal of
Clinical Nursing, 8, 496-504.
Pepper, G. A. (1995). Errors in drug administration by nurses. American Journal of Health
System Pharmacy, 49, 1405-1412.
Roberto, M. A., Bohmer, R.M.J., & Edmondson, A. C. (2006). Facing ambiguous threats.
Harvard Business Review, 84(11), 106-113.
Schaufeli, W. B., & Enzmann, D. (1998). The burnout companion to study and practice.
London: Taylor & Francis.
Shirom, A. (2003). Job-related burnout: A review. In J. C. Quick & L. E. Tetrick (Eds.),
Handbook of occupational health psychology (pp. 245-264). Washington, DC: American
Psychological Association.
Siegall, M., & McDonald, T. (2004). Person-organization congruence, burnout, and diversion
of resources. Personnel Review, 33, 291-301.
Sorra, J. S., & Nieva, V. F. (2004). Hospital survey on patient safety culture (prepared by
Westat, under Contract No. 290-96-0004; AHRQ Publication No. 04-0041). Rockville,
MD: Agency for Healthcare Research and Quality.
Thoresen, C. J., Kaplan, S. A., Barsky, A. P., Warren, C. R., & de Chermont, K. (2003). The affec-
tive underpinnings of job perceptions and attitudes: A meta-analytic review and integration.
Psychological Bulletin, 129, 914-945.
Tucker, A. L. (2004). The impact of operational failures on hospital nurses and their patients.
Journal of Operations Management, 22, 151-169.
Tucker, A. L., & Edmondson, A. C. (2002). Managing routine exceptions: A model of nursing
problem solving behavior. Advances in Health Care Management, 3, 87-113.
Tucker,A. L., & Edmondson,A. C. (2003). Why hospitals don’t learn from failures: Organizational
and psychological dynamics that inhibit system change. California Management Review, 45,
55-72.
Uribe, C. L., Schwikart, S. B., Pathak, D. S., & Marsh, G. B. (2002). Perceived barriers to
medical-error reporting:An exploratory investigation. Journal of Healthcare Management,
47, 263-279.
Vahey, D. C., Aiken, L. H., Sloane, D. M., Clarke, S. P., & Vargas, D. (2004). Nurse burnout
and patient satisfaction. Medical Care, 24(2), 57-66.
576 Western Journal of Nursing Research
distribution.
© 2008 SAGE Publications. All rights reserved. Not for commercial use or unauthorized
at University of Missouri-Columbia on August 19, 2008 http://wjn.sagepub.comDownloaded from
Wakefield, B. J., Uden-Holman, T., & Wakefield, D. S. (2005). Development and validation of the
Medication Administration Error Reporting Survey. In K. Henriksen, J. B. Battles, E. Marks, &
D. I. Lewin (Eds.), Advances in patient safety: From research to implementation: Vol. 4.
Programs, tools, and products (AHRQ Publication No. 05-0021-4). Rockville, MD:Agency for
Healthcare Research and Quality.
Wakefield, D. S., Wakefield, B., Uden-Holman, T., & Blegen, M. A. (1996). Perceived barriers in
reporting medication administration errors. Best Practices and Benchmarking in Healthcare,
1(4), 191-197.
Wakefield, D. S., Wakefield, B. J., Uden-Holman,T., Borders, T., Blegen, M., & Vaughn, T. (1999).
Understanding why medication administration errors may not be reported. American Journal
of Medical Quality, 14, 81-88.
Walters, J. A. (1992). Nurses’ perceptions of reportable medication errors and factors that
contribute to their occurrence. Applied Nursing Research, 5, 86-88.
Wolf, Z. R. (1989). Medication errors and nursing responsibility. Holistic Nursing Practice, 4,
8-17.
Wright, T. A., & Cropanzano, R. (1998). Emotional exhaustion as a predictor of job performance
and voluntary turnover. Journal of Applied Psychology, 83, 486-493.
Halbesleben et al. / Nurse Burnout and Safety 577
distribution.
© 2008 SAGE Publications. All rights reserved. Not for commercial use or unauthorized
at University of Missouri-Columbia on August 19, 2008 http://wjn.sagepub.comDownloaded from
... 11 Of the very few studies exploring the relationship between nurse burnout and medication errors, the findings are not congruent. [12][13][14][15][16] Some researchers reported that all three subscales of the Maslach Burnout Inventory (MBI), which is the most commonly used instrument to measure burnout, that is, EE, depersonalization (DP), and low personal accomplishment (PA), were related to MAEs by nurses, 12,13 whereas other researchers reported that only EE and DP were associated with medication errors. 14,15 Furthermore, a study conducted to investigate the relationship between nurse burnout and patient safety among 148 nurses from a Midwestern Veteran's Administration (VA) hospital found no significant relationship between nurse burnout and adverse event reports, including MAEs. ...
... 14,15 Furthermore, a study conducted to investigate the relationship between nurse burnout and patient safety among 148 nurses from a Midwestern Veteran's Administration (VA) hospital found no significant relationship between nurse burnout and adverse event reports, including MAEs. 16 These different findings could be explained by the different study methods and definitions used. Some studies combined MAEs with all other adverse events and did not analyze them as a separate category of adverse events. ...
Article
Background: Every one out of 10 nurses reported suffering from high levels of burnout worldwide. It is unclear if burnout affects job performance, and in turn, impairs patient safety, including medication safety. The purpose of this study is to determine whether nurse burnout predicts self-reported medication administration errors (MAEs). Methods: A cross-sectional study using electronic surveys was conducted from July 2018 through January 2019, using the Copenhagen Burnout Inventory. Staff registered nurses (N 5 928) in acute care Alabama hospitals (N 5 42) were included in this study. Descriptive statistics, correlational, and multilevel mixed-modeling analyses were examined. Results: All burnout dimensions (Personal, Work-related, and Client-related Burnout) were significantly correlated with age (r 5 20.
... Burnout of nurses and physicians in the emergency setting was favored by the stress of emotionally-charged decision-making as well as heavy workloads and extended work hours [10]. On one hand, burnout can affect physical and mental health, causing sleep pattern alteration, fatigue, concentration deficit and irritability; on the other hand, it can produce impairment in quality of care and patients' health outcomes, besides increased absenteeism [11]. ...
... According to the ProQOL subscales, the mean score of the compassion satisfaction was 31.60±5.0, the burnout one was 14.89±4.92 and the compassion fatigue one was 10 In a logistic regression model (sensitivity=53.8% and specificity=95.6%.), considering the gender and education, besides MOODS-SR mood-depressive, energy-depressive, cognition-depressive and rhythmicity scores as independent variables, and the PTSD diagnosis as the dependent variables, the mood-depressive [b=0.256 ...
Article
Full-text available
Background PTSD and burnout are frequent conditions among emergency healthcare personnel because exposed to repeated traumatic working experiences. Increasing evidence suggests high comorbidity between PTSD and mood symptoms, particularly depression, although the real nature of this relationship still remains unclear. The purpose of this study was to investigate the relationship between PTSD, burnout and lifetime mood spectrum, assessed by a specific scale, among health-care professionals of a major University Hospital in Italy. Methods N=110 Emergency Unit workers of the Azienda Ospedaliero-Universitaria Pisana (Pisa, Italy) were assessed by the TALS-SR, MOODS-SR lifetime version and the ProQOL R-IV. Results Approximately 60% of participants met at least one PTSD symptom criterion (criterion B, 63.4%; criterion C, 40.2%; criterion D 29.3%; criterion E, 26.8%), according to DSM-5 diagnosis. Almost sixteen percent of the sample reported a full symptomatic DSM-5 PTSD (work-related) diagnosis, and these showed significantly higher scores in all MOODS-SR depressive domains, as well as in the rhythmicity domain, compared with workers without PTSD. Further, mood-depressive and cognition-depressive MOODS-SR domains resulted to be predictive for PTSD. Significant correlations emerged between either PTSD diagnosis and criteria or ProQOL subscales and all the MOOD-SR domains. Conclusion A significant association emerged among PTSD, burnout and lifetime MOOD Spectrum, particularly the depressive component, in emergency health care operators, suggesting this population should be considered at-risk and undergo regular screenings for depression and PTSD.
... Work-related consequences may include reduced empathy for patients and avoidance of particular patient groups (Adimando, 2018). At the organizational level, poor professional quality of life may also lead to increased employee turnover (Spence Laschinger et al., 2009) and decreased patient satisfaction and safety in the facility (Halbesleben et al., 2008;Welp et al., 2014). ...
... Considering the close relationships between meaning in life and vicarious traumatization as well as vicarious traumatization and secondary traumatic stress, a lower level of the professional quality of life of helping professionals who do death work may therefore be associated with a lower level of meaning in life. Poor professional quality of life may also initiate helping professionals' active search for meaning, so as to cope with the challenges encountered in death work (Frankl, 2008;Steger et al., 2008). ...
Article
We examined the moderating role of self-competence in death work, and the relationships of professional quality of life with personal well-being and self-competence in death work. Two hundred helping professionals (mean age = 40.43, 85.5% female) completed a questionnaire. Better professional quality of life (i.e., a higher level of compassion satisfaction and lower levels of burnout and secondary traumatic stress) was associated with better personal well-being and self-competence in death work. Self-competence in death work moderated the negative impact of a lower level of compassion satisfaction on depression. Implications on self-care of helping professionals doing death work are discussed.
... Five studies considered aspects of patient safety: burnout was correlated with negative patient safety climate [111]. Emotional Exhaustion and Depersonalisation were both associated with negative patient safety grades and safety perceptions [112], and burnout fully mediated the relationship between depression and individual-level safety perceptions and work area/unit level safety perceptions [108]. Emotional Exhaustion mediated the relationship between workload and patient safety [51], and a higher composite burnout score was associated with lower patient safety ratings [113]. ...
... Regarding adverse events, high DEP and low Personal Accomplishment predicted a higher rate of adverse events [85], but in another study, only Emotional Exhaustion predicted adverse events [51]. When nurses were experiencing high levels of Emotional Exhaustion, they were less likely to report near misses and adverse events, and when they were experiencing high levels of Depersonalisation, they were less likely to report near misses [112]. ...
Article
Full-text available
Background: Workforce studies often identify burnout as a nursing 'outcome'. Yet, burnout itself-what constitutes it, what factors contribute to its development, and what the wider consequences are for individuals, organisations, or their patients-is rarely made explicit. We aimed to provide a comprehensive summary of research that examines theorised relationships between burnout and other variables, in order to determine what is known (and not known) about the causes and consequences of burnout in nursing, and how this relates to theories of burnout. Methods: We searched MEDLINE, CINAHL, and PsycINFO. We included quantitative primary empirical studies (published in English) which examined associations between burnout and work-related factors in the nursing workforce. Results: Ninety-one papers were identified. The majority (n = 87) were cross-sectional studies; 39 studies used all three subscales of the Maslach Burnout Inventory (MBI) Scale to measure burnout. As hypothesised by Maslach, we identified high workload, value incongruence, low control over the job, low decision latitude, poor social climate/social support, and low rewards as predictors of burnout. Maslach suggested that turnover, sickness absence, and general health were effects of burnout; however, we identified relationships only with general health and sickness absence. Other factors that were classified as predictors of burnout in the nursing literature were low/inadequate nurse staffing levels, ≥ 12-h shifts, low schedule flexibility, time pressure, high job and psychological demands, low task variety, role conflict, low autonomy, negative nurse-physician relationship, poor supervisor/leader support, poor leadership, negative team relationship, and job insecurity. Among the outcomes of burnout, we found reduced job performance, poor quality of care, poor patient safety, adverse events, patient negative experience, medication errors, infections, patient falls, and intention to leave. Conclusions: The patterns identified by these studies consistently show that adverse job characteristics-high workload, low staffing levels, long shifts, and low control-are associated with burnout in nursing. The potential consequences for staff and patients are severe. The literature on burnout in nursing partly supports Maslach's theory, but some areas are insufficiently tested, in particular, the association between burnout and turnover, and relationships were found for some MBI dimensions only.
... Halbesleben et al. found that emotional exhaustion and depersonalization experienced by the nurses significantly affected their attitudes towards patient safety. 8 Aiken et al. found that the nurses suffered emotional exhaustion and depersonalization, which adversely affected the quality of care they provided for the patients and their attitudes and behaviours towards patient safety. 9 All these studies show that the emotional exhaustion and depersonalization that nurses experience negatively affect their attitudes and behaviours towards patient safety. ...
... Heather et al. stated that working conditions and job (workplace) stress experienced by nurses directly affected their attitudes towards patient safety. 8 The mean scores obtained from the Emotional Exhaustion and Depersonalization subscales were at the highest level in the 22---31 age group. Young nurses may have had high burnout scores because they mostly work in intensive care units in this hospital. ...
Article
Aim Burnout can affect nurses’ patient safety-related attitudes due to adverse conditions it creates in nurses and can lead to medical errors. The purpose of this research is to determine the relationship between the patient safety attitudes and pediatric nurses’ burnout. Method This study was designed as a descriptive and cross-sectional study. The study was carried out with 104 nurses working in pediatric clinics of a university hospital in Turkey. Data were collected using the Sociodemographic Characteristics Questionnaire, the Maslach Burnout Inventory and the Patient Safety Attitude Questionnaire. Results There was a negative significant correlation between the Patient Safety Attitudes score and Emotional Burnout score. A positive correlation was found between Patient Safety Attitude Questionnaire scores and Personal Accomplishment subscale scores. It was found that the Emotional Exhaustion score increased as the Patient Safety Attitude Questionnaire scores decreased. It was also found that Personal Accomplishment subscale scores increased, Patient Safety Attitudes scores increased. As the Emotional Exhaustion scores increased, Job Satisfaction subscale scores, Teamwork Climate subscale scores, Safety Climate subscale scores, Management Mentality subscale scores decreased. While Personal Accomplishment subscale scores increased Job Satisfaction subscale scores, Teamwork Climate subscale scores increased too. It was found that nurses who participated in the study had emotional exhaustion and this emotional exhaustion had a negative impact on the patient safety attitude. Conclusion Burnout prevention programs should be planned and regular psychological counseling and supportive services should be provided. The importance of nursing care on patient safety is known. Systems to improve patient safety should be developed in the institutions.
... e scenario. Figley (2002) identified compassion fatigue as a form of burnout. The phenomena of burnout and compassion fatigue are significant for health care organizations because of the verified relationships to health care client satisfaction, and client safety (Garmen, Corrigan, & Morris, 2002; Halbesleben, Wakefield, Wakefield, & Cooper, 2008).Halbesleben et al. (2008) suggested that, to view the repercussions of burnout on health care providers, one must understand how burnout of the health care employees results in changes in personal care. In an analysis conducted byLeiter, Harvie, and Frizzell (1998), an inverse connection was found between health care expert burnout and personal tests of the qual ...
... Nurses are one of the professional groups with very high risk of burnout [6,15]. Nurses who experience burnout feel negative emotions and attitudes toward patients [18] and fail to concentrate on work, causing patient safety-related problems [19,20]. In addition, physical and mental exhaustion due to burnout leads to a decrease in job-related achievement and satisfaction, causing nurses to consider turning over [15,21]. ...
Article
Full-text available
Nursing burnout is associated with reduced nursing performance outcomes. Positive psychological capital is known to play an important role in improving workers’ job performance. However, the association among the three variables has rarely been addressed. The purpose of this cross-sectional descriptive study was to explore the association between burnout and nursing performance outcomes among Korean nurses working at a tertiary hospital and the mediating role of psychological capital in this relationship. Recruited through convenience sampling, a total of 285 nurses provided data on their demographic characteristics and completed a structured questionnaire consisting of items from the Professional Quality of Life Scale (burnout), Nursing Performance Scale, and Psychology Capital Questionnaire. Descriptive statistics, student’s t-tests, one-way analysis of variance, Pearson’s correlation coefficients, and multiple linear regression analyses were used to analyze data. The significance of the mediation effect was obtained using a bootstrap approach with the PROCESS macro. The mean age of participants was 30.51 years, and most participants were females (94.0%) and unmarried (71.6%); more than half (57.5%) experienced a severe workload. The average (±standard deviation) scores of burnout, nursing performance outcomes, and positive psychological capital were 28.77 ± 4.93, 2.98 ± 0.32, and 3.19 ± 0.45, respectively. Burnout was associated with nursing performance among clinical nurses (β = −0.20, p < 0.001). Positive psychological capital mediated the association between burnout and nursing performance outcomes (β = 0.41, p < 0.001). These findings contribute to the understanding that burnout among nurses could be reduced by increased positive psychological capital, which results in improved performance outcomes. The findings also indicate that interventions to improve positive psychological capital should be developed and implemented for nurses’ burnout management and improvement in nursing performance outcomes.
... (5) As altas taxas de burnout entre os enfermeiros em geral estão associadas a muitos efeitos adversos no atendimento ao paciente, incluindo aumento das infecções associadas aos cuidados de saúde, diminuição no reconhecimento e notifi cação de erros, aumento na mortalidade de pacientes e diminuição da satisfação profi ssional. (6,7) Os hospitais cujos enfermeiros têm altas taxas de burnout são mais propensos a ter altas taxas de atraso e absenteísmo dos funcionários. (8) Ressalta-se a importância de uma assistência humanizada dentro dessa unidade, que é um ambiente complexo e um gerador de estresse não só para os bebês, mas também para os pais e para os profi ssionais. ...
... B urnout was first described in the literature in 1974 1 and is defined as a psychological syndrome that includes emotional exhaustion (EE), depersonalization of patients (DP), and decreased perception of personal accomplishment (PA). 2 Burnout has been identified in a variety of health care professionals, including physicians, 3,4 psychiatrists, 5 dentists, 6,7 paramedics, 8,9 nurses, 10,11 and psychologists. [12][13][14] In fact, among physicians, 4 a high level of EE was reported in 31%, a high level of DP in 25.3%, and a low level of PA in 12.3%; among nurses, 11 a high level of EE was reported in 36%, a high level of DP in 12%, and a low level of PA in 10%. ...
Article
Full-text available
Objective To identify the causes, effects, and prevalence of burnout in athletic trainers (ATs) identified in the literature. Data Sources EBSCO: SPORTDiscus and OneSearch were accessed, using the search terms athletic trainer AND burnout. Study Selection Studies selected for inclusion were peer reviewed, published in a journal, and written in English and investigated prevalence, causes, effects, or alleviation of AT burnout. Data Extraction The initial search yielded 558 articles. Articles that did not specifically involve ATs were excluded from further inspection. The remaining 83 full-text articles were reviewed. Of these 83 articles, 48 examined prevalence, causes, effects, or alleviation of AT burnout. An evaluation of the bibliographies of those 48 articles revealed 3 additional articles that were not initially identified but met the inclusion criteria. In total, 51 articles were included in data collection. Data Synthesis Articles were categorized based on investigation of prevalence, causes, effects, or alleviation of burnout. Articles were also categorized based on which subset of the athletic training population they observed (ie, athletic training students, certified graduate assistants, high school or collegiate staff members, academic faculty). Conclusions Burnout was observed in all studied subsets of the population (ie, students, graduate assistants, staff, faculty), and multiple causes of burnout were reported. Suggested causes of burnout in ATs included work-life conflict and organizational factors such as poor salaries, long hours, and difficulties dealing with the “politics and bureaucracy” of athletics. Effects of burnout in ATs included physical, emotional, and behavioral concerns (eg, intention to leave the job or profession).
... [12] Although compassion fatigue and burnout are recognized as contributing to lowered professional quality of life and other negative outcomes, these outcomes have not been examined in relation to death anxiety. [13,14] Multiple factors may affect nurses' attitudes towards death. Such attitudes are often formed early in life as a result of socialization, cultural values, religious beliefs, personal deathrelated experiences, and spirituality. ...
Article
Full-text available
Background/Objective: Clinical nurse educators globally have recognized the prominent necessity of evaluating for death anxiety in students, and adopting curriculum that provides education about death and dying. Reliable assessment tools are needed to evaluate death anxiety in the student population. The study evaluates the hierarchical factor structure of the Persian-translated Templer's Death Anxiety Scale (TDAS) in nursing students from Iran. Methods: A repeated measures standard psychometric analysis was conducted. In total 400 undergraduate and graduate nursing students from a major university campus in Sari, Iran finished the Persian translated 15-item TDAS. Construct validity was assessed. Reliability was tested using Cronbach's Alpha (α), Theta (θ), and McDonald's Omega (Ω) coefficients. Results: Exploratory factor analysis (N = 200) indicated the TDAS had two factors (Fear of loss of life; Fear to face death). Model fitness indicators confirmed two independent TDAS structure levels. The Cronbach's alpha, Theta, McDonald, and construct reliability were larger than .70. Conclusions: Study outcomes corroborated acceptable psychometric properties and factor structure for the TDAS in a sample of Iranian nursing students. Findings suggest that the scale can be utilized for reliable and valid educational evaluation of death anxiety in Iranian nursing students.
Article
In this article, the author describes a new theoretical perspective on positive emotions and situates this new perspective within the emerging field of positive psychology. The broaden-and-build theory posits that experiences of positive emotions broaden people's momentary thought-action repertoires, which in turn serves to build their enduring personal resources, ranging from physical and intellectual resources to social and psychological resources. Preliminary empirical evidence supporting the broaden-and-build theory is reviewed, and open empirical questions that remain to be tested are identified. The theory and findings suggest that the capacity to experience positive emotions may be a fundamental human strength central to the study of human flourishing.
Book
Burnout is a common metaphor for a state of extreme psychophysical exhaustion, usually work-related. This book provides an overview of the burnout syndrome from its earliest recorded occurrences to current empirical studies. It reviews perceptions that burnout is particularly prevalent among certain professional groups - police officers, social workers, teachers, financial traders - and introduces individual inter- personal, workload, occupational, organizational, social and cultural factors. Burnout deals with occurrence, measurement, assessment as well as intervention and treatment programmes.; This textbook should prove useful to occupational and organizational health and safety researchers and practitioners around the world. It should also be a valuable resource for human resources professional and related management professionals.
Article
This study among a sample of 207 general practitioners (GPs) uses a five-year longitudinal design to test a process model of burnout. On the basis of social exchange and equity theory, it is hypothesized and found that demanding patient contacts produce a lack of reciprocity in the GP-patient relationship, which, in turn, depletes GPs' emotional resources and initiates the burnout syndrome. More specifically, structural equation analyses confirmed that - both at T1 and T2 - lack of reciprocity mediates the impact of patient demands on emotional exhaustion. Emotional exhaustion, in turn, evokes negative attitudes toward patients (depersonalization), and toward oneself in relation to the job (reduced personal accomplishment). Moreover, this process model of burnout was confirmed at T2, even after controlling for T1-scores on each of the model components. Finally, T1 depersonalization predicted the intensity and frequency of T2 patient demands, after controlling for T1 patient demands. This major finding suggests that GPs who attempt to gain emotional distance from their patients as a way of coping with their exhaustion, evoke demanding and threatening patient behaviors themselves. The theoretical and practical implications of these findings are discussed. (aut.ref.)
Article
Despite a rapidly growing body of work on the nature of stress and burnout in organizations, relatively little research has been conducted to develop strategies for reducing burnout. In this article, we discuss collaborative action research as a mechanism for the reduction of burnout. The authors demonstrate the efficacy of this approach in the context of a federal fire department. Findings suggest that action research has potential as a mechanism for the reduction of burnout, particularly because it is a more holistic approach that can be tailored to fit the needs of an organization.
Article
The Maslach Burnout Inventory (MBI) is a widely used measure of three specific aspects of the burnout syndrome-namely; emotional exhaustion, depersonalization, and lack of personal accomplishment. It is rapidly becoming a valued tool in assessment of perceived burnout in human service professionals. Although its reliability and validity are well established, its factor structure is not. In previous studies different researchers have found very different factor solutions. In the present study this problem was solved by principal components analysis of previously published American data and New Zealand data, followed by three- and four-factor varimax rotations. The outcome produced a clear, replicable three-factor solution consistent with that of the MBI authors' descriptions. No replicable four-factor structure was found.