Predictors of burnout, work engagement and nurse reported job outcomes and quality of care: a mixed method study

Abstract

Background: High levels of work-related stress, burnout, job dissatisfaction, and poor health are common within the nursing profession. A comprehensive understanding of nurses' psychosocial work environment is necessary to respond to complex patients' needs. The aims of this study were threefold: (1) To retest and confirm two structural equation models exploring associations between practice environment and work characteristics as predictors of burnout (model 1) and engagement (model 2) as well as nurse-reported job outcome and quality of care; (2) To study staff nurses' and nurse managers' perceptions and experiences of staff nurses' workload; (3) To explain and interpret the two models by using the qualitative study findings.

Method: This mixed method study is based on an explanatory sequential study design. We first performed a cross-sectional survey design in two large acute care university hospitals. Secondly, we conducted individual semi-structured interviews with staff nurses and nurse managers assigned to medical or surgical units in one of the study hospitals. Study data was collected between September 2014 and June 2015. Finally, qualitative study results assisted in explaining and interpreting the findings of the two models.

Results: The two models with burnout and engagement as mediating outcome variables fitted sufficiently to the data. Nurse-reported job outcomes and quality of care explained variances between 52 and 62%. Nurse management at the unit level and workload had a direct impact on outcome variables with explained variances between 23 and 36% and between 12 and 17%, respectively. Personal accomplishment and depersonalization had an explained variance on job outcomes of 23% and vigor of 20%. Burnout and engagement had a less relevant direct impact on quality of care (≤5%). The qualitative study revealed various themes such as organisation of daily practice and work conditions; interdisciplinary collaboration, communication and teamwork; staff nurse personal characteristics and competencies; patient centeredness, quality and patient safety. Respondents' statements corresponded closely to the models' associations.

Conclusion: A deep understanding of various associations and impacts on studied outcome variables such as risk factors and protective factors was gained through the retested models and the interviews with the study participants. Besides the softer work characteristics - such as decision latitude, social capital and team cohesion - more insight and knowledge of the hard work characteristic workload is essential.

Keywords: Burnout; Job satisfaction; Quality of care; Sensitizing concepts; Structural equation model; Turnover intentions; Work engagement.

Fig. 1

Model 1 - burnout as mediating outcome variable - retested model. Legend: All variables, with the exception of workload, emotional exhaustion and depersonalization were coded for analysis whereby higher scores indicated a stronger agreement or more favourable ratings. On the latter measures, higher scores are suggestive of unfavourable perceptions or conditions. All pathways were significant (p < .05). The independent variables of nurse practice environment predict the mediating variables of burnout dimensions, as well as job outcomes and nurse-assessed quality of care (dependent variables). In addition, workload, decision latitude, and social capital have a mediating position between the nurse practice environment and burnout dimensions. Nurse–physician relations and hospital management – organizational support impact nurse management at the unit level. Nurse management at the unit level has a strong direct impact on job outcomes and nurse-assessed quality of care as well as on decision latitude and social capital. Hospital management – organizational support has a direct impact on personal accomplishment and an indirect impact on the outcome variables through workload and burnout dimensions. Nurse–physician relations shows an indirect impact on the outcome variables through decision latitude. Social capital has an inverse impact on feelings of emotional exhaustion, and decision latitude supports feelings of personal accomplishments. Personal accomplishment, impacts indirectly by emotional exhaustion and directly by depersonalization, has a direct impact on job outcomes and nurse-assessed quality of care. The variances in job outcomes and nurse-assessed quality of care explained by this model were 63 and 53%, respectively. Nurse management at the unit level has a strong direct impact on outcome variables with explained variances of 25 and 36%, respectively

Fig. 2

Model 2 – work engagement as mediating outcome variable – retested model. Legend: All variables, with the exception of workload, were coded for analysis whereby higher scores indicated a stronger agreement or more favourable ratings. On the latter measure, higher scores are suggestive of unfavourable perceptions or conditions. All pathways were significant (p < .05) except between absorption and nurse assessed quality of care (p = .076). The independent variables of nurse practice environment predict the mediating variables of work engagement dimensions, as well as job outcomes and nurse-assessed quality of care (dependent variables). In addition, workload, decision latitude, and social capital have a mediating position between the nurse practice environment and work engagement dimensions. Nurse–physician relations and hospital management – organizational support impact nurse management at the unit level. Nurse management at the unit level has a strong direct impact on job outcomes and nurse-assessed quality of care as well as on decision latitude and social capital. Hospital management – organizational support has an indirect impact on the outcome variables through workload and work engagement dimensions. Nurse–physician relations shows an indirect impact on the outcome variables through decision latitude. Social capital impacts feelings of vigor, and decision latitude supports feelings of dedication. Absorption, impacts indirectly by vigor and directly by dedication, has a direct impact on nurse-assessed quality of care. The variances in job outcomes and nurse-assessed quality of care explained by this model were 59 and 53%, respectively. Nurse management at the unit level has a strong direct impact on outcome variables with explained variances of 23 and 37%, respectively