Practice Environment, Work Characteristics and Levels of Burnout as Predictors of Nurse Reported Job Outcomes, Quality of Care and Patient Adverse Events: A Study across Residential Aged Care Services

Peter Van Bogaert, Tinne Dilles, Kristien Wouters, Bart Van Rompaey

Departement of Nursing and Midwifery Sciences, Centre for Research and Innovation in Care (CRIC), Faculty of Medicine and Health Sciences, University of Antwerp, Antwerp, Belgium.
Department of Scientific Coordination, University Hospital Antwerp, Antwerp, Belgium.

DOI: 10.4236/ojn.2014.45040                

Abstract

To understand how to create a stabile workforce achieving excellent quality of care and patient safety, associations between practice environments and nurse and patient outcomes have been widely studied in acute and psychiatric care hospitals. Knowing residential aged care services are challenged to tackle complex patients’ needs within certain working conditions, to what extent do nurses perceive their practice environment in geriatric care? In a cross-sectional survey, a sample of 709 registered nurses, licensed practical nurses and nurse aides employed in 25 residential aged care services completed a structured questionnaire composed of various validated instruments measuring nurse practice environment factors, nurse work characteristics, burnout, nurse reported job outcomes, quality and patient adverse events. Associations between variables across residential aged care services were examined using multilevel modelling techniques. Associations were identified between practice environment factors, work characteristics, burnout dimensions, and reported outcome variables across residential aged care services. Multiple multilevel models showed independent variables (nursing management at the unit level, workload, decision latitude, social capital, emotional exhaustion and depersonalization) as important predictors of nurse reported outcome (job satisfaction, turnover intensions), quality of care (at the unit, the last shift, and in the service within the last year) and patient adverse events (patient and family complaints, patient falls, pulmonary and urinary tract infections, and medications errors). Results suggested the importance of nurse practice environment factors, nurse work characteristics and perception of burnout on nurse and patient outcomes across their nurse practice environment. Challenging the complex care of a vulnerable and frail population executives, physicians, nursing leaders as well as nurses in their nurse practice environment shared responsibility to create working conditions achieving excellent quality and patient safety.

Keywords

Burnout, Job Satisfaction, Nurse Practice Environment, Quality of Care, Residential Aged Care, Multilevel Modelling

Conflicts of Interest

The authors declare no conflicts of interest.

References

[1]	Choi, J., Bakken, S., Larson, E., Du, Y. and Stone, P. (2004) Perceived Nursing Work Environment of Critical Care Nurses. Nursing Research, 53, 370-378. http://dx.doi.org/10.1097/00006199-200411000-00005
[2]	Estabrooks, C., Tourangeau, A., Humphrey, C., Hesketh, K., Gioviannetti, P., Thomson, D., Wong, J., Acorn, S., Clarke, H. and Shamian, J. (2002) Measuring the Hospital Practice Environment: A Canadian Context. Research in Nursing & Health, 25, 256-268. http://dx.doi.org/10.1002/nur.10043
[3]	Gunnarsdóttir, S., Clark, S., Rafferty, A.M. and Nutbeam, D. (2007) Front-Line Management, Staffing and Nurse-Doctor Relationship as Predictors of Nurse Outcome and Patient Outcome. A Survey of Icelandic Hospital Nurses. International Journal of Nursing Studies, 46, 920-927.
[4]	Li, Y., Lake, E., Sales, A., Sharp, D., Greiner, G., Low, E., Liu, C., Mitchell, P. and Sochalski, J. (2007) Measuring Nurses’ Practice Environments with the Revised Nursing Work Index: Evidence form Registered Nurses in the Veterans Health Administration. Research in Nursing and Health, 30, 31-44. http://dx.doi.org/10.1002/nur.20172
[5]	Schubert, M., Clarke, S., Glass, T., Schaffert-Witfield, B. and De Geest, S. (2009) Identifying Thresholds for Relationships between Impacts of Rationing of Nursing Care and Nurse- and Patient-Reported Outcomes in Swiss Hospitals: A Correlational Study. International Journal of Nursing Studies, 46, 884-893. http://dx.doi.org/10.1016/j.ijnurstu.2008.10.008
[6]	Rafferty, A.M, Ball, J. and Aiken, L. (2001) Are Teamwork and Professional Autonomy Compatible and Do They Result in Improved Hospital Care? Quality in Health Care, 10, ii32-ii37.
[7]	Vahey, D.C., Aiken, L.H., Sloane, D.M., Clarke, S.P. and Vargas, D. (2004) Nurse Burnout and Patient Satisfaction. Medical Care, 42, 57-66. http://dx.doi.org/10.1097/01.mlr.0000109126.50398.5a
[8]	Kowalski, C., Ommen, O., Driller, E., Ernstmann, N., Wirtz, A.M., Köhler, T. and Pfaff, H. (2010) Burnout in Nurses—The Relationship between Social Capital in Hospitals and Emotional Exhaustion. Journal of Clinical, 19, 1654-1663.
[9]	Leiter, P. and Maslach, C. (2009) Nurse Turnover: The Mediating Role of Burnout. Journal of Nursing Management, 17, 331-339. http://dx.doi.org/10.1111/j.1365-2834.2009.01004.x
[10]	Aiken, L., Clarke, S., Sloane, D., Lake, E. and Cheney, T. (2008) Effects of Hospital Care Environment on Patient Mortality and Nurse Outcome. Journal of Nursing Administration, 38, 223-229. http://dx.doi.org/10.1097/01.NNA.0000312773.42352.d7
[11]	Friese C., Lake, E., Aiken, L., Silber, J. and Sochalski, J. (2008) Hospital Nurse Practice Environment and Outcomes for Surgical Oncology Patients. Health Service Research, 43, 1145-1163. http://dx.doi.org/10.1111/j.1475-6773.2007.00825.x
[12]	Laschinger, H. and Leiter, M. (2006) The Impact of Nursing Work Environments on Patients Safety Outcomes. The Mediating Role of Burnout/Engagement. Journal of Nursing Administration, 36, 259-267. http://dx.doi.org/10.1097/00005110-200605000-00019
[13]	Tourangeau, A., Coghlan, A., Shamian, J. and Evans, S. (2005) Registered Nurse and Registered Practical Nurse Evaluations of Their Hospital Practice Environments and Their Response of These Environment. Nursing Research, 18, 54-69.
[14]	Roche, M. and Duffieldj, C. (2009) A Comparison of the Nursing Practice Environment in Mental Health and Medical-Surgical Settings. Journal of Nursing Scholarship, 42, 195-206. http://dx.doi.org/10.1111/j.1547-5069.2010.01348.x
[15]	Hanrahan, N., Aiken, L., McClaine, L. and Hanlon, L. (2010) Relationship between Psychiatric Nurse Work Environment and Nurse Burnout in Acute Care General Hospitals. Issues in Mental Health Nursing, 31, 198-207. http://dx.doi.org/10.3109/01612840903200068
[16]	Hanrahan, N., Kumar, A. and Aiken, L. (2010) Adverse Events Associated with Organizational Factors of General Hospital Inpatient Psychiatric Care Environment. Psychiatric Services, 61, 569-574. http://dx.doi.org/10.1176/appi.ps.61.6.569
[17]	Van Bogaert, P., Clarke, S., Wouters, K, Franck, E., Willems, R. and Mondelaers, M. (2013) Impacts of Unit-Level Nurse Practice Environment, Workload and Burnout on Nurse-Reported Outcomes in Psychiatric Hospitals: A Multilevel Modelling Approach. International Journal of Nursing Studies, 50, 357-365. http://dx.doi.org/10.1016/j.ijnurstu.2012.05.006
[18]	Van Bogaert, P., Clarke, S., Willems, R. and Mondelaers, M. (2013) Nurse Practice Environment, Workload, Burnout, Job Outcomes and Quality of Care in Psychiatric Hospitals: A Structural Equation Model Approach. Journal of Advanced Nursing, 69, 1515-1524. http://dx.doi.org/10.1111/jan.12010
[19]	Dwyer, D. (2011) Experiences of Registered Nurses as Managers and Leaders in Residential Aged Care Facilities: A Systematic Review. International Journal of Evidence Based Healthcare, 9, 388-402. http://dx.doi.org/10.1111/j.1744-1609.2011.00239.x
[20]	Barba, B.E., Hu, J. and Efird, J. (2012) Quality Geriatric Care as Perceived by Nurses in Long-Term and Acute Care Settings. Journal of Clinical Nursing, 21, 833-840. http://dx.doi.org/10.1111/j.1365-2702.2011.03781.x
[21]	Secrest, J., Iorio, D.H. and Martz, W. (2005) The Meaning of Work for Nursing Assistants Who Stay in Long-Term Care. Journal of Clinical Nursing, 14, 90-97. http://dx.doi.org/10.1111/j.1365-2702.2005.01282.x
[22]	Kuo, H.T., Yin, T.J. and Li, I.C. (2008) Relationship between Organizational Empowerment and Job Satisfaction Perceived by Nursing Assistants at Long-Term Care Facilities. Journal of Clinical Nursing, 17, 3059-3066. http://dx.doi.org/10.1111/j.1365-2702.2007.02072.x
[23]	Li, I.C., Chen, Y.C. and Kuo, H.T. (2008) The Relationship between Work Empowerment and Work Stress Perceived by Nurses at Long-Term Care Facilities in Taipei City. Journal Clinical Nursing, 17, 3050-3058. http://dx.doi.org/10.1111/j.1365-2702.2008.02435.x
[24]	Sung, H.C., Chang, S.M. and Tsai, C.S. (2005) Working in Long-Term Care Settings for Older People with Dementia: Nurses’ Aides. Journal of Clinical Nursing, 14, 587-593. http://dx.doi.org/10.1111/j.1365-2702.2004.01111.x
[25]	Tellis-Nayak, V.A. (2007) Person-Centered Workplace: The Foundation for Person-Centered Caregiving in Long-Term Care. Journal of American Medical Directors Association, 8, 46-54.
[26]	Pekkarinen, L., Elovainio, M., Sinervo, T., Finne-Soveri, H. and Noro, A. (2006) Nursing Working Conditions in Relation to Restraint Practices in Long-Term Care Units. Medical Care, 44, 1114-1120. http://dx.doi.org/10.1097/01.mlr.0000237198.90970.64
[27]	Morgan, D.G., Stewart, N.J., D’Arcy, C., Forbes, D. and Lawson, J. (2005) Work Stress and Physical Assault of Nursing Aides in Rural Nursing Homes with and without Dementia Special Care Units. Journal of Psychiatric Mental Health Nursing, 12, 347-358. http://dx.doi.org/10.1111/j.1365-2850.2005.00846.x
[28]	Shinan-Altman, S. and Cohen, M. (2009) Nursing Aides’ Attitudes to Elder Abuse in Nursing Homes: The Effect of Work Stressors and Burnout. Gerontologist, 49, 674-684. http://dx.doi.org/10.1093/geront/gnp093
[29]	de Rooij, A.H., Luijkx, K.G., Declercq, A.G., Emmerink, P.M. and Schols, J.M. (2012) Professional Caregivers’ Mental Health Problems and Burnout in Small-Scale and Traditional Long Term Care Settings for Elderly People with Dementia in the Netherlands and Belgium. Journal American Medical Director Association, 13, 486.e7-e11.
[30]	Van Bogaert, P., Meulemans, H., Clarke, S., Vermeyen, K. and Van de Heyning, P. (2009) Hospital Nurse Practice Environments, Burnout, Job Outcomes and Quality of Care: Test of a Structural Equation Model. Journal of Advanced Nursing, 65, 2175-2185. http://dx.doi.org/10.1111/j.1365-2648.2009.05082.x
[31]	Van Bogaert, P., Kowalski, C., Weeks, S.M., Van heusden, D. and Clarke, S.P. (2013) The Relationship between Nurse Practice Environment, Nurse Work Characteristics, Burnout and Job Outcome and Quality of Nursing Care: A Cross-Sectional Survey. International Journal Nursing Studies, 50, 1667-1677. http://dx.doi.org/10.1016/j.ijnurstu.2013.05.010
[32]	Van Bogaert, P., Roelant, E., Clarke, S., Meulemans, H. and Van de Heyning, P. (2010) Impacts of Unit-Level Nurse Practice Environment and Burnout on Nurse-Reported Outcomes: A Multilevel Modeling Approach. Journal of Clinical Nursing, 19, 1664-1674. http://dx.doi.org/10.1111/j.1365-2702.2009.03128.x
[33]	Van Bogaert, P., Timmermans, O., Weeks, S.M., Van heusden, D., Wouters, K. and Franck, E. (2013) Nursing Unit Teams Matter: Impact of Unit-level Nurse Practice Environment, Nurse Work Characteristics, and Burnout on Nurse Reported Job Outcomes, and Quality of Care, and Patient Adverse Events? International Journal of Nursing Studies. (Epub ahead of print) http://dx.doi.org/10.1016/j.ijnurstu.2013.12.009
[34]	Aiken, L. and Patrician, P. (2000) Measuring Organizational Traits of Hospitals: The Revised Nursing Working Index. Nursing Research, 49, 146-153. http://dx.doi.org/10.1097/00006199-200005000-00006
[35]	Lake, E. (2002) Development of Practice Environment Scale of the Nursing Work Index. Research in Nursing & Health, 25, 176-188. http://dx.doi.org/10.1002/nur.10032
[36]	Van Bogaert, P., Clarke, S., Vermeyen, K., Meulemans, H. and Van de Heyning, P. (2009) Practice Environments and their Associations with Nurse-Reported Outcomes in Belgian Hospitals: Development and Preliminary Validation of a Dutch Adaptation of the Revised Nursing Work Index. International Journal of Nursing Studies, 46, 54-64. http://dx.doi.org/10.1016/j.ijnurstu.2008.07.009
[37]	Richter, P., Hemmann, E., Merboth, H., Fritz, S., Hansgen, C. and Rudolf, M. (2000) Das Erleben von Arbeitsintensität und Tätigkeitsspielraum-Entwicklung und ValidierungeinesFragebogenszurorientierenden Analyse (FIT). Zeitschriftfür Arbeitsund Organisationspsychologie, 44, 129-139.
[38]	Pfaff, H., Lutticke, J., Badura, B., Piekarski, C. and Richter, P. (2004) Weiche’ Kennzahlen fur das strategische Krankenhausmanagement. Stakeholderinteressen zielgerichtet erkennen und einbeziehen. Hans Huber, Bern.
[39]	Ernstmann, N., Ommen, O., Driller, E., Kowalski, C., Bartholomeyczik, S. and Pfaff, H. (2009) Social Capital and Risk Management in Nursing. Journal of Nursing Care Quality, 24, 340-347. http://dx.doi.org/10.1097/NCQ.0b013e3181b14ba5
[40]	Maslach, C., Jackson, S. and Leiter, P. (1996) Maslach Burnout Inventory Manual. 3rd Edition, Mountain View, California.
[41]	Schaufeli, W. and Van Dierendonck, D. (2000) Handleiding van de Utrechtse Burnout Schaal (UBOS) (Manual Utrecht Burnout Scale). Swets Test Services, Lisse.
[42]	Aiken, L., Sermeus, W., Van den Heede, K., Sloane, D., Busse, R., McKee, M., Bruyneel, L., Griffiths, P., Moreno-Casbas, M., Tichelman, C., Scott, A., Brzokstel, T., Kinnunen, L., Schwendimann, R., Heinen, M., Zikos, D., Sjetne, I., Smith, H. and Kutney-Lee, A. (2012) Patient Safety, Satisfaction, and Quality of Hospital Care: Cross Sectional Surveys of Nurses and Patients in 12 Countries in Europe and the United States. British Medical Journal, 344, e1717, http://dx.doi.org/10.1136/bmj.e1717
[43]	Fitzmaurice, G., Laird, N. and Ware, J. (2004) Applied Longitudinal Analysis. John Wiley & Sons, Hoboken.
[44]	Kreft, I. and De Leeuw, J. (1998) Introduction to Multilevel Modelling. Sage Publications, London.
[45]	McGilton, K.S., Tourangeau, A., Kavcic, C. and Wodchis, W.P. (2013) Determinants of Regulated Nurses’ Intention to Stay in Long-Term Care Homes. Journal Nursing Management, 21, 771-781. http://dx.doi.org/10.1111/jonm.12130
[46]	Tourangeau, A., Cranley, L., Spence Laschinger, H.K. and Pachis, J. (2010) Relationships among Leadership Practices, Work Environments, Staff Communication and Outcomes in Long-Term Care. Journal Nursing Management, 18, 1060-1072. http://dx.doi.org/10.1111/j.1365-2834.2010.01125.x
[47]	Li, I.C., Kuo, H.T., Huang, H.C., Lo, H.L. and Wang, H.C. (2013) The Mediating Effects of Structural Empowerment on Job Satisfaction for Nurses in Long-Term Care Facilities. Journal Nursing Management, 21, 440-448. http://dx.doi.org/10.1111/j.1365-2834.2012.01396.x
[48]	Stuckless, T. and Power, M. (2012) Newfoundland and Labrador: 80/20 Staffing Model Pilot in a Long-Term Care Facility. Nursing Leadership (Toronto Ontario), Spec No. 2012, 45-50.
[49]	O’Brien, J., Ringland, M. and Wilson, S. (2010) Advancing Nursing Leadership in Long-Term Care. Nursing Leadership (Toronto Ontario), Spec No. 2010, 75-89.