Impacts of unit-level nurse practice environment, workload and burnout on nurse-reported outcomes in psychiatric hospitals: A multilevel modelling approach

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Abstract

Aim

To investigate impacts of practice environment factors, nurse perceptions of workload and self-reported burnout at the unit-level on job outcomes and nurse-assessed quality of care in psychiatric hospitals.

Background

Associations between practice environments and nurse and patient outcomes have been widely described in acute care hospitals in nursing research examining variables primarily at the respondent level. Research on this topic in psychiatric hospitals is sparse.

Design

A cross-sectional design with a survey.

Method

Samples of registered nurses, licenced practical nurses and non-registered caregivers from 32 clinical units in two psychiatric hospitals were surveyed. Validated instruments were used to measure work environment, workload, burnout, job outcomes and nurse-perceived quality of care. Unit-level associations were examined using multilevel modelling techniques.

Results

Multiple multilevel models identified depersonalization and nurse–physician relations as predictors of turnover intentions and quality of care of the interdisciplinary team. Ratings of nursing management at the unit level were predictors of all of the quality of care variables. Emotional exhaustion was predictive of quality of care at the unit level. While workload was correlated with burnout, it was not predictive of any of the outcomes examined in multiple multilevel models.

Conclusion

While relatively low levels of burnout and fairly favourable job and quality of care outcomes were reported by the mental health personnel surveyed, differences across units in ratings of practice environment factors such as nurse–physician relations and nurse management as well as levels of depersonalization were predictive of outcomes. While most findings are consistent with those from other studies of acute care settings, some (slight) differences were also identified.

Introduction

A large and growing literature describes associations of a variety of factors in nurses’ work environments with a range of objective and nurse-reported outcomes in hospital practice from job satisfaction to patient outcomes such as mortality and morbidity (Friese et al., 2008, Laschinger et al., 2003, Schubert et al., 2009). These findings appear to be consistent across countries and across a variety of methods for framing workplace context and across different dependent variables, including turnover intentions. More recent studies using responses aggregated to the nursing unit and hospital levels has suggested that the shared (consensus or group) experience of the psychosocial work environment by nurses as well as the personal experience of work are associated with nurse outcomes such as reports of burnout, job satisfaction and turnover intensions as well as nurse-reported quality of care studied in acute care facilities (Aiken et al., 2008, Rafferty et al., 2001, Vahey et al., 2004). An earlier study of these relationships with a sample of 546 acute care nurses from 42 units in four acute care hospitals using multilevel modelling technique found support for the majority of associations between unit-level nurse practice environment, burnout and job outcome and quality of care variables investigated at the unit level (Van Bogaert et al., 2010). Unit level analyses of nurse practice dimensions such as hospital and nurse management and nurse–physician relations were associated with emotional exhaustion, depersonalization and personal accomplishment. In addition, these nurse practice environment dimensions as well as some burnout dimensions (e.g. emotional exhaustion and depersonalization) were predictive of job satisfaction, intention to leave the nursing profession and nurse-reported quality of care variables.

Research examining nurses’ perceptions of their practice environment, and nurse outcomes such as burnout, job satisfaction, turnover intention and patients outcomes has been comparatively sparse in mental health care settings. A systematic review of 34 studies on the prevalence of nursing staff stress on psychiatric in-patient wards found relatively low levels of staff burnout and poor morale (Richards et al., 2006). However, the reviewed studies were mostly small, of poor quality and involved incomplete or non-standardized assessments of burnout. The authors of this review recommended more multi-site, prospective epidemiological studies using validated measures examined alongside personal and organizational variables.

A number of researchers have turned their attention to similarities and differences between psychiatric-mental health nursing and nursing in other specialties or in general hospital settings. Schulz et al., 2009 investigated the effects of effort-reward imbalance and burnout comparing nursing staff in medical-surgical and psychiatric hospitals. One in five mental health nurse respondents reported high imbalance between efforts and rewards. The authors suggested that contributing factors for mental health care nurses such as the more difficult client population, limited resources, particularly unbalanced and demanding interpersonal exchanges, and threats of violence and aggression were perhaps more common in psychiatric hospital settings. Nonetheless, nurses in medical departments in this study reported relatively higher levels of burnout than their colleagues in psychiatric departments. A number of studies corroborate claims of these lower levels of burnout among nursing staff working in mental health care (Kilfedder et al., 2001, Richards et al., 2006). In addition, it has also been suggested that more extensive communication among staff members, which may be more common in at least some psychiatric settings than in some medical-surgical care environments, plays a preventive role against staff disenchantment (Schulz et al., 2009). Nevertheless, hard evidence of this remains thin. A review of approximately 20 years of studies dealing with burnout in the mental health workforce found that this body of research failed to establish a causal link between burnout and staff turnover and identified a number of methodological problems in many of the papers in this area (Paris and Hoge, 2010). The authors suggested that human resource management and practice development in the mental health field must begin to focus on the organizational and system levels.

Despite limited setting-specific data, there is consensus that attention to work environment factors is critical to optimal staff and patient outcomes in mental health care. In a study investigating the impact of the six worklife factors (the extent of workload, control, community, fairness, rewards and shared values) in a sample of 2000 community mental health staff workers including psychiatrists, social workers, nurses and others, Laslavia et al., 2009 suggested that improving the workplace atmosphere may be the most important prevention strategy for staff burnout. A recent study of 12 general psychiatric in-patient wards in Sweden revealed that ward atmosphere characteristics such as patients’ personal problem orientation (patients’ capacity for expressing feelings and personal problems) and program clarity (stable and clear treatment structures, rules and behavioural expectations on the ward) were associated with a psychosocial work environment characterized by empowering leadership, perceived role clarity and positive organizational climate (Tuvesson et al., 2011). The authors recommended continued attention to psychosocial work environment factors at the ward level.

Therefore the aim of the present study was to investigate impacts of practice environment factors, nurse perceptions of workload and self-reported burnout at the unit level on job outcomes and nurse-assessed quality of care in psychiatric inpatient settings. The present study applies methods that have been used extensively by this and other teams to investigations in acute care settings.

Section snippets

Method

The cross-sectional study was conducted in two psychiatric public hospitals with 359 and 409 beds in different areas of Flanders, the Dutch-speaking region of Belgium. The ethics committees of the two hospitals approved the study.

Surveys were voluntarily completed by a convenience sample of 357 staff members from 34 acute and chronic care nursing units over a 5-month period between December 2010 and April 2011. Two of the 34 units were dedicated units for child and adolescent care. All staff

Descriptive and correlation analysis and analysis of variances

The present sample (357 staff on 32 units) shows unit-level means for age, experience in nursing and experience on the present unit of 36.0, 12.3 and 6.2 years, respectively. The majority were female (78%), worked more than 50% of a full-time position (86.5%) and an average of one out of four held baccalaureate degrees in nursing.

Table 1 presents the major study variables (independent and dependent) aggregated to the unit level. Two nurse practice environment dimensions, nurse–physician

Discussion

In the present study of 357 staff members from 32 inpatient mental health units, we investigated the impact of practice environment factors, nurse perceptions of workload and burnout at the unit level on job outcomes and nurse-assessed quality of care in psychiatric inpatient settings. Results from multilevel modelling were paralleled to those obtained in an earlier study of acute care staff nurses using very similar methods (Van Bogaert et al., 2010). The results here provide insights

Conclusion

A study approach developed in general medical and surgical acute care facilities to investigate impacts of unit-level nurse practice environment and burnout on nurse-reported outcomes was replicated in psychiatric inpatient settings using multilevel modelling. The results were grossly similar across the two studies, although certain differences were identified. Results here provide additional confirmation that peer and interdisciplinary teamwork are critical to fostering high performance and

Conflict of interest

None declared.

Funding

None declared.

Ethical approval

The study was approved by the ethics committees of the two hospitals.

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