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J Nurs Care Qual Vol. 30, No. 2, pp. 144–152 c 2015 Wolters Kluwer Health, Inc. All rights reserved. Copyright
Relationship of Adverse Events and Support to RN Burnout Erica J. Lewis, PhD, RN; Marianne B. Baernholdt, PhD, RN; Guofen Yan, PhD; Thomas G. Guterbock, PhD Registered nurse (RN) “second victims” are RNs who are harmed from their involvement in medical errors. This study used the conceptual model nurse experience of medical errors and found a relationship between RN involvement in preventable adverse events and 2 domains of burnout: emotional exhaustion (P = .009) and depersonalization (P = .030). Support to RNs involved in preventable adverse events was inversely related to RN emotional exhaustion (P < .001) and depersonalization (P = .003) and positively related to personal accomplishment (P = .002). Key words: adverse event, disclosure, medical error, nurse burnout, preventable adverse events, registered nurse, second victim
D
ESPITE efforts to decrease the incidence of medical errors since the 1999 Institute of Medicine1 report underscored the magnitude of the problem, medical errors remain too common.2,3 Preventable adverse events, medical errors resulting in harm to the patient,4 are particularly concerning, given that patient wellness has been altered by the occurrence. Although harm to the patient is of first importance, harm to health care providers involved in the preventable adverse event is also significant. Embracing
Author Affiliations: Department of Nursing, James Madison University, Harrisonburg, Virginia (Dr Lewis); School of Nursing, Virginia Commonwealth University, Richmond (Dr Baernholdt); Department of Public Health Sciences (Dr Yan), and Center for Survey Research (Dr Guterbock), University of Virginia, Charlottesville. The authors declare no conflict of interest. Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal’s Web site (www.jncqjournal.com). Correspondence: Erica J. Lewis, PhD, RN, Department of Nursing, James Madison University, 800 S. Main St, Harrisonburg, VA 22807 ([email protected]). Accepted for publication: July 3, 2014 Published online before print: August 21, 2014 DOI: 10.1097/NCQ.0000000000000084
a system approach to medical error, Wu and Steckelberg5 argued that well-intended providers who suffer after being involved in a preventable adverse event are termed second victims. Two literature reviews6,7 have indicated that second victims experience emotional and moral symptoms. These symptoms may alter the relationship between the second victim and the patient.8 The second victim response is thus relevant to both provider wellbeing and health care quality through a disruption in the provider-patient relationship. Regardless of the importance and high prevalence of second victims in health care organizations,6 few health care organizations have developed procedures for assisting second victims.9 The lack of procedures may exist primarily because of sparse evidence to inform how to care for second victims.9 Although interventions have been proposed to decrease second victim suffering,10 vague conceptualization of second victim outcomes prevents subsequent study of the effectiveness of these interventions. Second victim outcomes have been generally described as falling within the emotional or moral domain,6 but these descriptions lack specificity. One report7 of registered nurse (RN) second victims proposed that the emotional response to involvement in preventable adverse events could be understood as burnout, yet this idea
144
Copyright © 2015 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
LWW/JNCQ
JNCQ-D-14-00039
January 31, 2015
17:42
Relationship of Adverse Events and Support to RN Burnout has not been empirically tested. Burnout of RNs is a problem of significant consequence. Burnout has been linked to RN health complaints and intention to leave the profession of nursing.11 Moreover, patient satisfaction has been found to be lower in institutions with RNs experiencing burnout.12 Given the importance of burnout and the lack of research about whether this is indeed an outcome for second victims, this study examined whether RN second victims experience burnout. The aim of this study was to examine RN involvement in preventable adverse events and how burnout is associated with RN and system characteristics and interventions aimed at patients and RNs. THEORETICAL BACKGROUND This study was guided by the conceptual model of nurse experience of medical error, which was developed from an integrative literature review.7 In this study, the model depicts factors that influence burnout in nurses who have been involved in a preventable adverse event (see Supplemental Digital Content, Figure, available at: http:// links.lww.com/JNCQ/A117).7 Nurse burnout is associated with interventions for RNs and patients, RN characteristics, and system characteristics.13 The 2 interventions are support to RNs following a preventable adverse event and disclosure of preventable adverse events to patients. Support to RNs following a preventable adverse event is known to be important and theorized to be important specifically to RN burnout in situations of preventable adverse events.7,10 Disclosure of preventable adverse events to patients is also hypothesized to be important to RNs.7 The 2 interventions affect burnout through either RN or system characteristics and are conceptualized as being related to burnout regardless of whether the RN personally experienced a preventable adverse event. RN characteristics include years of nursing practice, and system characteristics include the work environment. Both years of nursing practice and work environ-
145
ment have previously been directly related to RN burnout.14,15 In the current study, RN burnout is represented by the following 3 distinct elements: high emotional exhaustion, high depersonalization, and low personal accomplishment.16 Emotional exhaustion is defined as decreased emotional resources, depersonalization as callousness or cynicism toward patients, and reduced personal accomplishment as a negative view of one’s professional self.16 METHODS Design The study used a cross-sectional survey design. Following institutional review board approval, each hospital’s nursing governance organization along with the chief nursing officer at 2 hospitals in the southeastern United States, an academic medical center and a community hospital, were approached regarding participation in the study. In June 2011, RNs from 28 units were notified about the study in unit meetings and by e-mail. The 28 units comprised all inpatient, procedural, and acute care units from the community hospital along with RNs from a representative sample of these same types of units from the academic medical center. Paper surveys were distributed to all RNs (n = 1155) on the 28 units. As suggested by Dillman et al,17 follow-up e-mails were sent at 2 and 4 weeks after survey distribution. Measurements Demographic questions from the Hospital Survey on Patient Safety Culture (Hospital SOPS)18 questionnaire were used to gather information about gender and education. RN involvement in preventable adverse events was measured using an individual item asking participants to indicate how many preventable adverse events they had been involved in during the past 12 months using 6 categories (categories: 0, 1-2, 3-5, 6-10, 1120, and ≥21). This item was modified from a question in Hospital SOPS.18 Hospital SOPS asks RNs the number of events for which they
Copyright © 2015 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
LWW/JNCQ
146
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have submitted reports.18 Since nurses are involved in more preventable adverse events than they submit reports for,19 this study asked about the number of preventable adverse events the RN was involved in regardless of whether an event report was submitted. Furthermore, Hospital SOPS defines events regardless of whether or not they resulted in patient harm.18 Since prior work7 suggests that it is important for RNs to distinguish between events causing harm and those that do not cause harm, this study defined a preventable adverse event as any type of error, mistake, incident, accident, or deviation that resulted in patient harm. The variable, RN involvement in preventable adverse events, was skewed, with a few RNs experiencing many adverse events and therefore coded as involvement in preventable adverse versus no involvement. The interventions of disclosure of preventable adverse events to patient and support to RNs were measured using 4 questions developed for this study. For disclosure to patient, the participants were asked how often preventable adverse events were disclosed to patients. For support to RNs, 3 support questions asked about the support of unit management, nurse peers, and physician colleagues. Support was defined for participants as actions of others that sustain or maintain well-being. For example, participants were asked how often RNs felt supported by unit management during preventable adverse events. For all 4 questions, the participants responded on a Likert-type scale ranging from 1 (never) to 5 (always). The individual support questions were highly intercorrelated and demonstrated multicollinearity when used as predictors. Thus, the 3 support questions were collapsed into a summary support index representing overall level of support (1 = never feel supported to 5 = always feel supported). In the analysis, either one of the individual support questions was used at a time or the summary support index was used. The system variable work environment was conceptualized as the work unit, which was the nursing unit where the RN worked most often. The work unit was used as a proxy
measure for unmeasured elements of a unit’s work environment. Since many RNs were cross trained among similar types of units in their hospital and therefore connected to more than 1 unit, work unit could not be measured as the specific nursing unit in which an RN worked. Instead, work units were grouped into type of nursing unit: general, operating room and procedure, obstetrics and pediatrics, emergency departments, and intensive care units. General units included medical surgical floors and specialty units such as telemetry. Procedures and operating room units included the operating room, ambulatory surgery, recovery rooms, and procedural areas. Obstetrics units were combined with newborn nursery and pediatric units since there was cross training of RNs among these units. The intensive care unit category included general and specialty intensive care units. Finally, the emergency department included only that unit type. The RN characteristic, years of RN practice, was measured in a question asking participants to indicate how long they had worked as an RN by selecting from the following: less than 1 year, 1 to 5 years, 6 to 10 years, 11 to 15 years, 16 to 20 years, and 21 years or more. RNs were considered to be novice if they had less than 1 year of experience, mid-career 1 to 15 years, and late career if they had more than 15 years of experience. The nurse outcome, RN burnout, was measured using the Maslach Burnout Inventory– Human Service Scale, which is a 22-item instrument assessing the following 3 domains of burnout: emotional exhaustion (9 items), depersonalization (5 items), and personal accomplishment (8 items).16 For health and human service providers, emotional exhaustion is defined as decreased emotional resources, depersonalization as callousness or cynicism toward patients, and reduced personal accomplishment as a negative professional self-image.16 Items about related feelings to each domain are rated on a 7-point frequency scale ranging from never to every day (score: 0-6). Each of the 3 domains of burnout is calculated separately by summing
Copyright © 2015 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
LWW/JNCQ
JNCQ-D-14-00039
January 31, 2015
17:42
Relationship of Adverse Events and Support to RN Burnout items from that domain. Potential score ranges are as follows: emotional exhaustion, 0 to 54; depersonalization, 0 to 30; and personal accomplishment, 0 to 48. Burnout is characterized by high emotional exhaustion and depersonalization along with reduced personal accomplishment. Emotional exhaustion and depersonalization are considered to be in the high range if the score is in the upper third, which is a score of 27 or higher for emotional exhaustion and 13 or higher for depersonalization. Personal accomplishment is considered to be in the low range if the score is 31 or less.16 Instrument reliability and validity along with norms for the nurse population are well established.20,21 Statistical analysis Data were analyzed using SPSS 20 (IBM Corp, Armonk, New York). Variable skewness, outliers, missing data, and collinearity were evaluated. Univariate regression was first used to determine the relationship of each of the variables: preventable adverse event, disclosure, support index (as well as each of the 3 support variables), years of RN practice, work unit type, and the nurse demographic variables (gender, education, and hospital) with each of the 3 domains of burnout (emotional exhaustion, depersonalization, personal accomplishment). For each burnout measure, multivariate analysis was performed that included involvement in preventable adverse events, disclosure, support index, years of RN practice, hospital, and unit type. RESULTS Sample characteristics Two hundred eighty-nine RNs (25% response rate) completed the survey, but only 218 completed the full survey (Table 1). For the 218 RNs who had complete data, 55% were from one hospital and 45% from the other. The majority of RNs worked on general units (36%) and intensive care units (22%), were female (94%), had a bachelor’s degree (50%), and were mid-career (50.5%). Fiftyseven (26%) reported being involved in 1 or
147
Table 1. Summary of Participants (N = 218) and Outcomes Mean (SD)
n (%)
Situation Preventable adverse events No adverse events 161 (73.9) Yes adverse events 57 (26.1) Interventions Disclosure 3.24 (0.97) Support Unit management 3.40 (1.15) support Nurse peer support 3.77 (0.85) Physician support 2.98 (1.00) Support index 3.38 (0.82) RN characteristic Experience level Early career 14 (6.4) Mid-career 110 (50.5) Late career 94 (43.1) System General unit 79 (36.2) OR and procedure 29 (13.3) OB and pediatrics 36 (16.5) ED 26 (11.9) ICU 48 (22.0) Outcome Burnout Emotional 22.97 (11.48) exhaustion Depersonalization 7.47 (5.69) Personal 37.64 (6.52) accomplishment Abbreviations: OB, obstetrics; ED, emergency department; ICU, intensive care unit; OR, operating room; RN, registered nurse.
more preventable adverse event during the past 12 months. Mean support of RN peers was 3.77 (SD = 0.85), unit management support was 3.40 (SD = 1.15), and support of physician colleagues was 2.98 (SD = 1.00), with an index support mean of 3.38 (SD = 0.82). Mean disclosure was 3.24 (SD = 0.97). The 3 domains of burnout had mean scores as follows: emotional exhaustion, 22.97 (SD = 11.48); depersonalization, 7.47 (SD = 5.69); and personal accomplishment, 37.64 (SD = 6.52). Cronbach αs were 0.92 for emotional exhaustion, 0.77 for depersonalization, and 0.79 for personal accomplishment. Both t and Mann-Whitney U tests were used to compare characteristics between the 218 participants with complete data and the 71
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excluded because of missing data. With one exception, there were no statistically significant differences in the measures between these 2 groups. For one intervention, disclosure to patient, scores were significantly lower (P = .003) in participants with no missing data (3.24) than among those with missing data (3.71).
preventable adverse event (P = .009 and P = .030) and lower RN support scores (P < .001 and P = .003) (Table 2). Being in late career (vs mid-career) was associated with better depersonalization scores (P = .011). Finally, better personal accomplishment was associated with higher RN support scores (P = .002). DISCUSSION
Relationships to RN burnout The univariate analyses for each emotional exhaustion and depersonalization revealed that involvement in preventable adverse events was associated with worsening scores (P = .001 and P = .012, respectively) whereas higher ratings on disclosure (P = .030 and P = .037) and support index (P < .001 and P < .001) were each associated with better scores. Being in late career (vs mid-career) (P = .003) was associated with less depersonalization. The third burnout measure, better personal accomplishment (a positive concept), was associated individually with higher ratings on disclosure (P = .019) and the support index (P < .001), and being in early career (.044) (see Supplemental Digital Content, Table, available at: http://links.lww.com/JNCQ/A116). In multivariate models, worse levels of emotional exhaustion and depersonalization were each associated with being involved in a
The Institute for Healthcare Improvement advocates for communication and swift action to mitigate harm to both first and second victims after an adverse event.22 We suggest several actions may alleviate harm to second victims so that they do not develop burnout. Support to RN second victims This study is the first report of the relationship between nurse managers’, peers’, and physicians’ support to RNs involved in preventable adverse events and burnout. These findings build on knowledge from several other qualitative and descriptive studies, which have suggested the importance of unit manager and peer support for RN second victims.23-25 Likewise, others have described that RNs talk to physicians after a preventable adverse event.23 However, none has specifically included physician colleague support as
Table 2. Relationships Among Model Variables and Domains of Burnouta
Situation Preventable adverse events (yes) Intervention Disclosure Support index RN characteristic Experience level Early career (vs mid-career) Late career (vs mid-career)
Emotional Exhaustion
Depersonalization
Regression Coefficient (SE)
Regression Coefficient (SE)
P
Personal Accomplishment
P
Regression Coefficient (SE)
P
4.25 (1.62)
.009
1.85 (0.85)
.030
− 1.33 (0.99)
.182
− 0.70 (0.77) − 5.22 (0.91)
.364
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J Nurs Care Qual Vol. 30, No. 2, pp. 144–152 c 2015 Wolters Kluwer Health, Inc. All rights reserved. Copyright
Relationship of Adverse Events and Support to RN Burnout Erica J. Lewis, PhD, RN; Marianne B. Baernholdt, PhD, RN; Guofen Yan, PhD; Thomas G. Guterbock, PhD Registered nurse (RN) “second victims” are RNs who are harmed from their involvement in medical errors. This study used the conceptual model nurse experience of medical errors and found a relationship between RN involvement in preventable adverse events and 2 domains of burnout: emotional exhaustion (P = .009) and depersonalization (P = .030). Support to RNs involved in preventable adverse events was inversely related to RN emotional exhaustion (P < .001) and depersonalization (P = .003) and positively related to personal accomplishment (P = .002). Key words: adverse event, disclosure, medical error, nurse burnout, preventable adverse events, registered nurse, second victim
D
ESPITE efforts to decrease the incidence of medical errors since the 1999 Institute of Medicine1 report underscored the magnitude of the problem, medical errors remain too common.2,3 Preventable adverse events, medical errors resulting in harm to the patient,4 are particularly concerning, given that patient wellness has been altered by the occurrence. Although harm to the patient is of first importance, harm to health care providers involved in the preventable adverse event is also significant. Embracing
Author Affiliations: Department of Nursing, James Madison University, Harrisonburg, Virginia (Dr Lewis); School of Nursing, Virginia Commonwealth University, Richmond (Dr Baernholdt); Department of Public Health Sciences (Dr Yan), and Center for Survey Research (Dr Guterbock), University of Virginia, Charlottesville. The authors declare no conflict of interest. Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal’s Web site (www.jncqjournal.com). Correspondence: Erica J. Lewis, PhD, RN, Department of Nursing, James Madison University, 800 S. Main St, Harrisonburg, VA 22807 ([email protected]). Accepted for publication: July 3, 2014 Published online before print: August 21, 2014 DOI: 10.1097/NCQ.0000000000000084
a system approach to medical error, Wu and Steckelberg5 argued that well-intended providers who suffer after being involved in a preventable adverse event are termed second victims. Two literature reviews6,7 have indicated that second victims experience emotional and moral symptoms. These symptoms may alter the relationship between the second victim and the patient.8 The second victim response is thus relevant to both provider wellbeing and health care quality through a disruption in the provider-patient relationship. Regardless of the importance and high prevalence of second victims in health care organizations,6 few health care organizations have developed procedures for assisting second victims.9 The lack of procedures may exist primarily because of sparse evidence to inform how to care for second victims.9 Although interventions have been proposed to decrease second victim suffering,10 vague conceptualization of second victim outcomes prevents subsequent study of the effectiveness of these interventions. Second victim outcomes have been generally described as falling within the emotional or moral domain,6 but these descriptions lack specificity. One report7 of registered nurse (RN) second victims proposed that the emotional response to involvement in preventable adverse events could be understood as burnout, yet this idea
144
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LWW/JNCQ
JNCQ-D-14-00039
January 31, 2015
17:42
Relationship of Adverse Events and Support to RN Burnout has not been empirically tested. Burnout of RNs is a problem of significant consequence. Burnout has been linked to RN health complaints and intention to leave the profession of nursing.11 Moreover, patient satisfaction has been found to be lower in institutions with RNs experiencing burnout.12 Given the importance of burnout and the lack of research about whether this is indeed an outcome for second victims, this study examined whether RN second victims experience burnout. The aim of this study was to examine RN involvement in preventable adverse events and how burnout is associated with RN and system characteristics and interventions aimed at patients and RNs. THEORETICAL BACKGROUND This study was guided by the conceptual model of nurse experience of medical error, which was developed from an integrative literature review.7 In this study, the model depicts factors that influence burnout in nurses who have been involved in a preventable adverse event (see Supplemental Digital Content, Figure, available at: http:// links.lww.com/JNCQ/A117).7 Nurse burnout is associated with interventions for RNs and patients, RN characteristics, and system characteristics.13 The 2 interventions are support to RNs following a preventable adverse event and disclosure of preventable adverse events to patients. Support to RNs following a preventable adverse event is known to be important and theorized to be important specifically to RN burnout in situations of preventable adverse events.7,10 Disclosure of preventable adverse events to patients is also hypothesized to be important to RNs.7 The 2 interventions affect burnout through either RN or system characteristics and are conceptualized as being related to burnout regardless of whether the RN personally experienced a preventable adverse event. RN characteristics include years of nursing practice, and system characteristics include the work environment. Both years of nursing practice and work environ-
145
ment have previously been directly related to RN burnout.14,15 In the current study, RN burnout is represented by the following 3 distinct elements: high emotional exhaustion, high depersonalization, and low personal accomplishment.16 Emotional exhaustion is defined as decreased emotional resources, depersonalization as callousness or cynicism toward patients, and reduced personal accomplishment as a negative view of one’s professional self.16 METHODS Design The study used a cross-sectional survey design. Following institutional review board approval, each hospital’s nursing governance organization along with the chief nursing officer at 2 hospitals in the southeastern United States, an academic medical center and a community hospital, were approached regarding participation in the study. In June 2011, RNs from 28 units were notified about the study in unit meetings and by e-mail. The 28 units comprised all inpatient, procedural, and acute care units from the community hospital along with RNs from a representative sample of these same types of units from the academic medical center. Paper surveys were distributed to all RNs (n = 1155) on the 28 units. As suggested by Dillman et al,17 follow-up e-mails were sent at 2 and 4 weeks after survey distribution. Measurements Demographic questions from the Hospital Survey on Patient Safety Culture (Hospital SOPS)18 questionnaire were used to gather information about gender and education. RN involvement in preventable adverse events was measured using an individual item asking participants to indicate how many preventable adverse events they had been involved in during the past 12 months using 6 categories (categories: 0, 1-2, 3-5, 6-10, 1120, and ≥21). This item was modified from a question in Hospital SOPS.18 Hospital SOPS asks RNs the number of events for which they
Copyright © 2015 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
LWW/JNCQ
146
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January 31, 2015
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JOURNAL OF NURSING CARE QUALITY/APRIL–JUNE 2015
have submitted reports.18 Since nurses are involved in more preventable adverse events than they submit reports for,19 this study asked about the number of preventable adverse events the RN was involved in regardless of whether an event report was submitted. Furthermore, Hospital SOPS defines events regardless of whether or not they resulted in patient harm.18 Since prior work7 suggests that it is important for RNs to distinguish between events causing harm and those that do not cause harm, this study defined a preventable adverse event as any type of error, mistake, incident, accident, or deviation that resulted in patient harm. The variable, RN involvement in preventable adverse events, was skewed, with a few RNs experiencing many adverse events and therefore coded as involvement in preventable adverse versus no involvement. The interventions of disclosure of preventable adverse events to patient and support to RNs were measured using 4 questions developed for this study. For disclosure to patient, the participants were asked how often preventable adverse events were disclosed to patients. For support to RNs, 3 support questions asked about the support of unit management, nurse peers, and physician colleagues. Support was defined for participants as actions of others that sustain or maintain well-being. For example, participants were asked how often RNs felt supported by unit management during preventable adverse events. For all 4 questions, the participants responded on a Likert-type scale ranging from 1 (never) to 5 (always). The individual support questions were highly intercorrelated and demonstrated multicollinearity when used as predictors. Thus, the 3 support questions were collapsed into a summary support index representing overall level of support (1 = never feel supported to 5 = always feel supported). In the analysis, either one of the individual support questions was used at a time or the summary support index was used. The system variable work environment was conceptualized as the work unit, which was the nursing unit where the RN worked most often. The work unit was used as a proxy
measure for unmeasured elements of a unit’s work environment. Since many RNs were cross trained among similar types of units in their hospital and therefore connected to more than 1 unit, work unit could not be measured as the specific nursing unit in which an RN worked. Instead, work units were grouped into type of nursing unit: general, operating room and procedure, obstetrics and pediatrics, emergency departments, and intensive care units. General units included medical surgical floors and specialty units such as telemetry. Procedures and operating room units included the operating room, ambulatory surgery, recovery rooms, and procedural areas. Obstetrics units were combined with newborn nursery and pediatric units since there was cross training of RNs among these units. The intensive care unit category included general and specialty intensive care units. Finally, the emergency department included only that unit type. The RN characteristic, years of RN practice, was measured in a question asking participants to indicate how long they had worked as an RN by selecting from the following: less than 1 year, 1 to 5 years, 6 to 10 years, 11 to 15 years, 16 to 20 years, and 21 years or more. RNs were considered to be novice if they had less than 1 year of experience, mid-career 1 to 15 years, and late career if they had more than 15 years of experience. The nurse outcome, RN burnout, was measured using the Maslach Burnout Inventory– Human Service Scale, which is a 22-item instrument assessing the following 3 domains of burnout: emotional exhaustion (9 items), depersonalization (5 items), and personal accomplishment (8 items).16 For health and human service providers, emotional exhaustion is defined as decreased emotional resources, depersonalization as callousness or cynicism toward patients, and reduced personal accomplishment as a negative professional self-image.16 Items about related feelings to each domain are rated on a 7-point frequency scale ranging from never to every day (score: 0-6). Each of the 3 domains of burnout is calculated separately by summing
Copyright © 2015 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
LWW/JNCQ
JNCQ-D-14-00039
January 31, 2015
17:42
Relationship of Adverse Events and Support to RN Burnout items from that domain. Potential score ranges are as follows: emotional exhaustion, 0 to 54; depersonalization, 0 to 30; and personal accomplishment, 0 to 48. Burnout is characterized by high emotional exhaustion and depersonalization along with reduced personal accomplishment. Emotional exhaustion and depersonalization are considered to be in the high range if the score is in the upper third, which is a score of 27 or higher for emotional exhaustion and 13 or higher for depersonalization. Personal accomplishment is considered to be in the low range if the score is 31 or less.16 Instrument reliability and validity along with norms for the nurse population are well established.20,21 Statistical analysis Data were analyzed using SPSS 20 (IBM Corp, Armonk, New York). Variable skewness, outliers, missing data, and collinearity were evaluated. Univariate regression was first used to determine the relationship of each of the variables: preventable adverse event, disclosure, support index (as well as each of the 3 support variables), years of RN practice, work unit type, and the nurse demographic variables (gender, education, and hospital) with each of the 3 domains of burnout (emotional exhaustion, depersonalization, personal accomplishment). For each burnout measure, multivariate analysis was performed that included involvement in preventable adverse events, disclosure, support index, years of RN practice, hospital, and unit type. RESULTS Sample characteristics Two hundred eighty-nine RNs (25% response rate) completed the survey, but only 218 completed the full survey (Table 1). For the 218 RNs who had complete data, 55% were from one hospital and 45% from the other. The majority of RNs worked on general units (36%) and intensive care units (22%), were female (94%), had a bachelor’s degree (50%), and were mid-career (50.5%). Fiftyseven (26%) reported being involved in 1 or
147
Table 1. Summary of Participants (N = 218) and Outcomes Mean (SD)
n (%)
Situation Preventable adverse events No adverse events 161 (73.9) Yes adverse events 57 (26.1) Interventions Disclosure 3.24 (0.97) Support Unit management 3.40 (1.15) support Nurse peer support 3.77 (0.85) Physician support 2.98 (1.00) Support index 3.38 (0.82) RN characteristic Experience level Early career 14 (6.4) Mid-career 110 (50.5) Late career 94 (43.1) System General unit 79 (36.2) OR and procedure 29 (13.3) OB and pediatrics 36 (16.5) ED 26 (11.9) ICU 48 (22.0) Outcome Burnout Emotional 22.97 (11.48) exhaustion Depersonalization 7.47 (5.69) Personal 37.64 (6.52) accomplishment Abbreviations: OB, obstetrics; ED, emergency department; ICU, intensive care unit; OR, operating room; RN, registered nurse.
more preventable adverse event during the past 12 months. Mean support of RN peers was 3.77 (SD = 0.85), unit management support was 3.40 (SD = 1.15), and support of physician colleagues was 2.98 (SD = 1.00), with an index support mean of 3.38 (SD = 0.82). Mean disclosure was 3.24 (SD = 0.97). The 3 domains of burnout had mean scores as follows: emotional exhaustion, 22.97 (SD = 11.48); depersonalization, 7.47 (SD = 5.69); and personal accomplishment, 37.64 (SD = 6.52). Cronbach αs were 0.92 for emotional exhaustion, 0.77 for depersonalization, and 0.79 for personal accomplishment. Both t and Mann-Whitney U tests were used to compare characteristics between the 218 participants with complete data and the 71
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excluded because of missing data. With one exception, there were no statistically significant differences in the measures between these 2 groups. For one intervention, disclosure to patient, scores were significantly lower (P = .003) in participants with no missing data (3.24) than among those with missing data (3.71).
preventable adverse event (P = .009 and P = .030) and lower RN support scores (P < .001 and P = .003) (Table 2). Being in late career (vs mid-career) was associated with better depersonalization scores (P = .011). Finally, better personal accomplishment was associated with higher RN support scores (P = .002). DISCUSSION
Relationships to RN burnout The univariate analyses for each emotional exhaustion and depersonalization revealed that involvement in preventable adverse events was associated with worsening scores (P = .001 and P = .012, respectively) whereas higher ratings on disclosure (P = .030 and P = .037) and support index (P < .001 and P < .001) were each associated with better scores. Being in late career (vs mid-career) (P = .003) was associated with less depersonalization. The third burnout measure, better personal accomplishment (a positive concept), was associated individually with higher ratings on disclosure (P = .019) and the support index (P < .001), and being in early career (.044) (see Supplemental Digital Content, Table, available at: http://links.lww.com/JNCQ/A116). In multivariate models, worse levels of emotional exhaustion and depersonalization were each associated with being involved in a
The Institute for Healthcare Improvement advocates for communication and swift action to mitigate harm to both first and second victims after an adverse event.22 We suggest several actions may alleviate harm to second victims so that they do not develop burnout. Support to RN second victims This study is the first report of the relationship between nurse managers’, peers’, and physicians’ support to RNs involved in preventable adverse events and burnout. These findings build on knowledge from several other qualitative and descriptive studies, which have suggested the importance of unit manager and peer support for RN second victims.23-25 Likewise, others have described that RNs talk to physicians after a preventable adverse event.23 However, none has specifically included physician colleague support as
Table 2. Relationships Among Model Variables and Domains of Burnouta
Situation Preventable adverse events (yes) Intervention Disclosure Support index RN characteristic Experience level Early career (vs mid-career) Late career (vs mid-career)
Emotional Exhaustion
Depersonalization
Regression Coefficient (SE)
Regression Coefficient (SE)
P
Personal Accomplishment
P
Regression Coefficient (SE)
P
4.25 (1.62)
.009
1.85 (0.85)
.030
− 1.33 (0.99)
.182
− 0.70 (0.77) − 5.22 (0.91)
.364
