NURSING PRACTICE AND HEALTH CARE

Thomas Shaw2
Richard C McKinnies1    2 Associate Professor, Southern Illinois University Carbondale, United States
Sandra K. Collins3           3 Professor and Program Director, Southern Illinois University Carbondale, United States

This article seeks to examine the impact of personal accomplishment on burnout as experienced by registered nurses. This examination includes assessing the relationships between the factors of work-life and burnout, specifically the relationships apparent during a health care crisis, such as the pandemic of COVID-19.

Cultures of employee wellness became a focus of attention when the Institute for Healthcare Improvement evolved from the Triple Aim to the Quadruple Aim [1]. This shift elevated the need for health care systems to consider the health and wellness of their employees, specifically examining potential areas for positive growth [2]. Both the National Academy of Medicine (NAM) and the American Nurses Association (ANA) fostered the promotion of health care employee health and wellness [3]. In order to promote an environment where patient care is paramount, it is essential to develop and hone the workplace environment into a supportive atmosphere [4]. Employee burnout can be devastating to the development of a healthy work place environment, as well as extending impact to subpar patient care and outcomes; therefore exploring venues to decrease burnout is pertinent. 

Burnout is defined by Maslach and Leiter as a collection of three different feelings; emotional exhaustion, depersonalization, and low personal accomplishment [5]. As developers of the Maslach Burnout Inventory, Maslach, Jackson, Leiter, Schaufeli, and Schwab noted how burnout exists in a dynamic state, potentially fluctuating from low to moderate, and even high levels of the perceived feeling [6]. Since burnout fluctuates, it is crucial that health care providers consider ways to minimize the impact of these feelings as well as working within a health care delivery system that values interventions aimed at recognition and prevention of these feelings. Proactively developing a culture that seeks to prevent burnout positively impacts both absenteeism and abandonment of the health care profession [7].

Burnout can be experienced as a work-place phenomenon negatively impacting the health of the health care provider and subsequent delivery of care. Within physician circles, burnout has reached staggering numbers, noted to be experienced by 50% of physicians [8]. Minimizing this impact is crucial to the delivery of effective patient care, not to mention the health and wellness of the health care provider. When burnout is not addressed and minimized, the impact is felt not only from the health care provider, but also the patients receiving care from these individuals [9]. This subpar delivery of care results in decreased patient satisfaction, which in turn impacts the fiscal health of the institution [10]. As noted by the Centers for Medicare and Medicaid Services, Hospital Consumer Assessment of Healthcare Providers and Systems Survey (HCACPS) hospitals must submit the HCACPS data to receive full funding from the Inpatient Prospective Payment System (IPPS); essentially, lower patient satisfaction scores yields a lower Medicare reimbursement [11,12].

Identifying ways to enhance Personal Accomplishment is one way to minimize burnout. As nurses functioning as heath care professionals delivering care to individuals, families, communities, and populations, it is of interest to examine the relationship of Personal Accomplishment towards the impact of burnout. Personal Accomplishment is defined as the feeling of accomplishment an individual feels when, in this research opportunity, working with people/patients [13]. Because working with patients can be both rewarding and exhausting, it is necessary to examine this relationship through the lens of what can be done to facilitate the experience of Personal Accomplishment, as a personal responsibility as well as organizationally

To engage individuals in Personal Achievement responsibility, cognitive-behavioral techniques can be utilized to identify instances of achievement and maximize their impact [14]. As noted by Yeun and Kim, supervisor support is crucial to minimize the impact of emotional exhaustion by promoting a sense of personal accomplishment; in fact, this support is so important is poses immediate benefits towards increasing nurse retention [15]. Lessons learned from Yean and Kim provide a format for supervisor development that exceeds the traditional fiscal responsibilities, change agent, and management responsibilities. Simply stated, the more frequent an individual realizes a sense of Personal Accomplishment, the more it serves to minimize the experience of Burnout. Therefore, fostering individual responsibility and organizational culture towards recognizing Personal Accomplishment yields positive results for the patient, employee, and organization [14].

Study design

A quantitative methodology approach was utilized to examine the impact of personal accomplishment on burnout among registered nurses in the United States. Specifically, the Maslach Burnout Inventory for Medical Personnel (MBI-HSS) and the Areas of Work life Survey (AWS) were distributed via solicited email. Burnout was defined by Maslach et al. by assessing feelings of personal accomplishment, emotional exhaustion, and depersonalization [6]. The AWS explores workload, control, reward, community, fairness, and values as domains within the parameter of work life [16].

Utilizing emails obtained from a national data distribution firm allowed the participants to access the survey via SurveyMonkey hyperlink. Utilizing the data from registered nurses across the United States was preferred to limiting the sample to a specific geographical area with a smaller sample size. 

Sample and setting

During the Spring of 2020, emails soliciting study participation were sent to over 10,000 participants, with 11 responses being deleted due to incomplete survey data, and 93 responses complete and available for analysis. The survey participants were registered nurses, with retired nurses and nurses that no longer practice also completing the survey.

Data collection

The institution’s Human Subjects Committee approved the study prior to the mass email dispersal. Within the email, the participants received a cover letter of introduction with a statement indicating that participation was voluntary and consent was inferred by submission. Utilization of a password protected SurveyMonkey account allowed all responses to be anonymous. Once the anonymous data was received, it was confidentially distributed among all four researchers. Participants were identified via identification numbers, with no personal identification being obtained. 

Data analysis

Per Human Subject Committee approval, all data was retrieved from SurveyMonkey and entered into a Microsoft Excel spreadsheet. SPSs-Version 26 was utilized to obtain descriptive and inferential analysis results. Descriptive data was completed by one researcher, which developed the foundational view of the results. Correlational studies were completed by a second researcher, while manipulating several of the variables to identify correlation. Once appropriateness was determined, a third researcher utilized linear regression to explore the independent variable of the six areas of work-life upon the dependent variable of personal accomplishment. All statistical analysis was verified by the fourth researcher. 

Findings

Of the 93 participants in the study, 89% reported themselves as females, with age ranges in 10 year increments from 25 through 65, with an additional range indicating 65+; of the respondents, 50.63 years was the average age. 62.4% were employed in the nursing profession for 16 years or greater. For employment status, 15.1% of the respondents reported part time status, 74.2% reported full time status, and 10.8% reported they had retired or left the nursing profession. Respondents reported employment position with 72% considering themselves as front line staff, 3.2% reporting themselves as supervisors, and 13% in either first level, intermediate or senior level management roles. Regarding organization stability, 40.9% reported being at their current organization for 5 years or less, 13.5% for 6- 10 years, 16.1% for 11-15 years, 11.2% for 16-20 years, and 10.1% for 21+ years; 5.6% reported they had retired or left the nursing profession [1] (Table 1). 

Personal accomplishment

Although Burnout has three distinct feelings associated with it, for purposes of this research, the feeling of Personal Accomplishment (PA) was examined. Respondents reported experiencing feelings associated with Personal Accomplishment once to several times a week. The minimum frequency of 2.00 indicated feelings of Personal Accomplishment once a month or less, while the maximum frequency of 6.00 indicated those feelings every day. The average PA score was a 37.78, with a minimum of 16 and a maximum of 48. Per the MBI inventory, the lower the score, the greater the correlation to burnout [6] (Table 2).

Areas of work life

Consisting of six subsets, workload (5 questions), control (4 questions), reward (4 questions), community (5 questions), fairness (6 questions) and values (4 questions), the Areas of Work life Scale (AWS) can indicate congruence between an individuals and their associated work role [16]. Although the AWS does not offer one singular score associated with a positive or negative indicator of Burnout, the six subsets can be examined together, allowing the researcher extrapolate findings based on the results from each of the subsets [1].

A robust picture of the sample responses was determined after completion of descriptive statistics. Additionally, relationships were examined using correlational studies. Additionally, linear regression was explored. There was no significance noted between demographic variables and Personal Accomplishment. Within the sections of the AWS, control, community, fairness and values were noted to be statistically significant with Personal Accomplishment. When examining the relationship between Personal Accomplishment and Emotional Exhaustion, a negative correlation is noted, indicating that an increase in Personal Accomplishment is associated with a decrease in Emotional Exhaustion (Table 3).

Using Personal Accomplishment as the dependent variable, linear regression provided additional statistical analysis when assessing the six subsets within AWS as independent variables. This analysis was appropriate as all assumptions were met, but no statistical significance was identified to indicate the AWS subsets work to predict the relationship with Personal Accomplishment.

Upon reviewing the data results, the information clearly describes the relationship that exists between Personal Accomplishment and the Emotional Exhaustion. As decreased feelings of Personal Accomplishment are noted, feelings of Emotional Exhaustion, and thus Burnout are noted. Conversely, when the individual notes an increase in feelings associated with Personal Accomplishment, feelings of Burnout as noted by Emotional Exhaustion is decreased. When examining these areas related to the AWS, indicators such as control, community, fairness, and values are noted to be statistically significant to feelings of Personal Accomplishment. With these relationships in mind, it is paramount that individuals take ownership of their Personal Accomplishments. This can be fostered and expanded through organization guidance, specifically which is obtained through the relationship between the employee and supervisor. Fostering this acknowledgement in accomplishments positively impacts the employee, which in turn yields positive results with patient satisfaction and patient outcomes. Promoting individual responsibility of awareness of Personal Accomplishments can develop a culture that minimizes and stunts the development of Burnout.

Developing ways to recognize Personal Accomplishments can start with an appreciation of care rendered, as well as acknowledging instances where the individual effectively deals with stressors in the workplace. Assisting nurses to problem solve effectively while recognizing their ability to positively impact their patients’ experience allows for identification of accomplishments. Based on the questions in this subset, it is imperative that nurses can identify their positive influence on others, their ability to handle daily tasks and problems, as well as instances where they feel physically empowered by their decisions [6]. In addition to fostering individual responsibility of recognizing Personal Accomplishments, developing the ability of supervisors/managers to develop relationships where acknowledgement of performance is foundational is crucial. By emphasizing the instances where their nurses have performed consistently well, supervisors can serve as that positive reinforcement towards mindfulness.

As noted by developers of the MBI inventory, individuals have a personal responsibility to utilize stress management techniques in an effort to minimize burnout. Such techniques include cognitive behavioral exercises, including mindfulness [14,6]. Additionally, when combined with concerted efforts from administration, supervisors are uniquely positioned to enhance interventions effective in minimizing facets of burnout [6,15]. Understanding the nature of burnout as well as techniques proven effective for enhancing the nurse’s sense of health and wellness is worth the effort when examining the positive impact of employee health on employee retention and patient satisfaction and outcomes.

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