The Social Ecology of Burnout: A framework for research on nurse practitioner burnout.

BACKGROUND: The U.S. health system is burdened by rising costs, workforce shortages, and unremitting burnout. Well-being interventions have emerged in response, yet data suggest that the work environment is the problem. Nurse practitioner (NP) burnout is associated with structural and relational factors in the work environment, practice autonomy, and hierarchical leadership. PURPOSE: We explore the unique social, cultural, and political environment in which NPs work through the lens of social ecology and present the Social Ecology of Burnout (SEB) framework. METHODS: We review current burnout frameworks in the context of the NP practice environment and discuss the SEB, specifically exploring psychological safety and its influence on burnout. FINDINGS: Psychological safety, work environment, and policy are presented within the SEB and solutions which empower NPs are considered. DISCUSSION: Our framework can serve as a guide for future nursing research, practice, and policy.

The Use of Antifactor Xa Assays in a Comprehensive Pediatric Extracorporeal Membrane Oxygenation Anticoagulation Protocol is Associated with Increased Survival and Significant Blood Product Cost-Savings.

We augmented our standard extracorporeal membrane oxygenation laboratory protocol to include antifactor Xa assays, thromboelastography, and antithrombin measurements. We performed a retrospective chart review to determine outcomes for patients placed on extracorporeal membrane oxygenation (ECMO) prior to and after the initiation of our anticoagulation laboratory protocol. A total of 663 consecutive ECMO runs were evaluated from January 1, 2007 to June 30, 2018. Of these patients, 252 were on ECMO prior to initiation of the anticoagulation laboratory protocol on September 1, 2011, and 411 patients were on ECMO after initiation of the protocol. There were no major changes to our extracorporeal membrane oxygenation circuit or changes to our transfusion threshold during this continuous study period. Transfusion utilization data revealed statistically significant decreases in almost all blood components, and a savings in blood component inflation-adjusted acquisition costs of 31% bringing total blood product cost-savings to $309,905 per year. In addition, there was an increase in survival to hospital discharge from 45 to 56% associated with the initiation of the protocol ( p = 0.004). Our data indicate that implementation of a standardized ECMO anticoagulation protocol, which titrates unfractionated heparin infusions based on antifactor Xa assays, is associated with reduced blood product utilization, significant blood product cost savings, and increased patient survival. Future prospective evaluation is needed to establish an antifactor Xa assay-driven ECMO anticoagulation strategy as both clinically superior and cost-effective.

Adverse Events and Burnout: The Moderating Effects of Workgroup Identification and Safety Climate.

BACKGROUND: Prior research has found that adverse events have significant negative consequences for the patients (first victim) and caregivers (second victim) involved such as burnout. However, research has yet to examine the consequences of adverse events on members of caregiving units. We also lack research on the effects of the personal and job resources that shape the context of how adverse events are experienced. OBJECTIVES: We test the relationship between job demands (the number of adverse events on a hospital nursing unit) and nurses' experience of burnout. We further explore the ways in which personal (workgroup identification) and job (safety climate) resources amplify or dampen this relationship. Specifically, we examine whether, and the conditions under which, adverse events affect nurse burnout. RESEARCH DESIGN: Cross-sectional analyses of survey data on nurse burnout linked to hospital incident reporting system data on adverse event rates for the year before survey administration and survey data on workgroup identification and safety climate. SUBJECTS: Six hundred three registered nurses from 30 nursing units in a large, urban hospital in the Midwest completed questionnaires. RESULTS: Multilevel regression analysis indicated that adverse events were positively associated with nurse burnout. The effects of adverse events on nurse burnout were amplified when nurses exhibited high levels of workgroup identification and attenuated when safety climate perceptions were higher. CONCLUSIONS: Adverse events have broader negative consequences than previously thought, widely affecting nurse burnout on caregiving units, especially when nurses strongly identify with their workgroup. These effects are mitigated when leaders cultivate safety climate.

The Relationship Between Nurse-Reported Safety Culture and the Patient Experience.

OBJECTIVE: The purpose of this study was to better understand the relationship between nurse-reported safety culture and the patient experience in a multistate sample of nurses and patients, matched by hospital unit/service line and timeframe of care delivery. BACKGROUND: Nurses play a key role in the patient experience and patient safety. A strong safety culture may produce positive spillover effects throughout the nurse caregiving experience, resulting in patient perception of a high-quality experience. METHODS: Multivariate mixed-effects regression models were specified using data from a multistate sample of hospital units that administered both the Agency for Healthcare Research and Quality (AHRQ) staff safety culture survey and the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) patient satisfaction survey over a 12-month period. Survey response variables are measured at the unit (service line) and hospital level. RESULTS: Key variables in the HCAHPS and AHRQ surveys were significantly correlated. Findings highlight the relationship between 3 safety culture domains: teamwork, adequate staffing, and organizational learning on the achievement of a positive patient experience. CONCLUSION: Modifiable aspects of hospital culture can influence the likelihood of achieving high HCAHPS top box percentages in the nursing and global domains, which directly impact hospital reimbursement.

Co-worker characteristics and nurses' safety-climate perceptions.

PURPOSE: Previous research indicates that nurses' safety-climate perceptions are influenced by individual nurse characteristics, leadership, staffing levels and workplace structure. No literature was identified that explored the relationship between nurses' safety climate perceptions and staffing composition in a particular hospital unit. This paper aims to fill some of the gaps in the research in this area. DESIGN/METHODOLOGY/APPROACH: Data supplied by 430 registered nurses working in two Midwestern US hospitals were analyzed to co-worker characteristics such as education, licensure, experience and full- or part-time status. FINDINGS: Registered nurses working in hospitals with proportionally more-experienced nurses perceived their workplaces to be significantly safer for patients. Surprisingly, co-worker licensure, education and full- or part-time status did not significantly influence nurses' safety climate perceptions. PRACTICAL IMPLICATIONS: Findings indicate that safety-climate perceptions vary significantly between hospital units and experienced nurses may act as a resource that promotes a positive safety climate. Hospitals retaining experienced nurses may potentially reduce errors. ORIGINALITY/VALUE: The paper illustrates that the results highlight the importance of providing nurses with an environment that encourages retention and creates a workplace where experienced nurses' skills are best utilized.

The relational antecedents of voice targeted at different leaders.

We investigated how employees can, simultaneously, speak up to leaders at different levels of the organizational hierarchy. In particular, we examined 2 targets of employees' upward voice on work-related issues: the direct leader (i.e., the supervisor) and the skip-level leader (i.e., supervisor's boss). Drawing on emerging research on the socially embedded nature of leader-member exchanges and using data from 237 employees and their direct and skip-level leaders, we found that the choice of a particular leader as a target was affected by the quality of the dyadic relationship between that leader and the employee. Further, the association between voice to the direct leader and the quality of the employee's relationship with the direct leader was more positive when the relationship between the direct leader and the skip-level leader was stronger. By contrast, the association between voice to the skip-level leader and the quality of the employee's relationship with the skip-level leader was more positive when the relationship between the direct leader and the skip-level leader was weaker. The implications of these findings are discussed.

A relational leadership perspective on unit-level safety climate.

OBJECTIVE: This study compared nursing staff perceptions of safety climate in clinical units characterized by high and low ratings of leader-member exchange (LMX) and explored characteristics that might account for differences. BACKGROUND: Frontline nursing leaders' actions are critical to ensure patient safety. Specific leadership behaviors to achieve this goal are underexamined. The LMX perspective has shown promise in nonhealthcare settings as a means to explain safety climate perceptions. METHODS: Cross-sectional survey of staff (n = 711) and unit directors from 34 inpatient units in an academic medical center was conducted. RESULTS: Significant differences were found between high and low LMX scoring units on supervisor safety expectations, organizational learning-continuous improvement, total communication, feedback and communication about errors, and nonpunitive response to errors. CONCLUSION: The LMX perspective can be used to identify differences in perceptions of safety climate among nursing staff. Future studies are needed to identify strategies to improve staff safety attitudes and behaviors.

Reporting trends in a regional medication error data-sharing system.

Inter-organizational systems for sharing data about medication errors have emerged as an important strategy for improving patient safety and are expected to encourage not only voluntary error reporting but also learning from errors. Yet, few studies have examined the hypothesized benefits of inter-organizational data sharing. The current study examined the developmental trends in information reported by hospitals participating in a regional reporting system for medication errors. A coalition of hospitals in southwestern Pennsylvania, under the auspices of the Pittsburgh Regional Healthcare Initiative (PRHI), implemented a voluntary system for quarterly sharing of information about medication errors. Over a 12-month period, 25 hospitals shared information about 17,000 medication errors. Using latent growth curve analysis, we examined longitudinal trends in the quarterly number of errors and associated corrective actions reported by each hospital. Controlling for size, teaching status, and JCAHO accreditation score, for the hospitals as a group, error reporting increased at a statistically significant rate over the four quarters. Moreover, despite significant baseline differences among hospitals, error reporting increased at similar rates across hospitals over subsequent quarters. In contrast, the reporting of corrective actions remained unchanged. However, the baseline levels of corrective actions reporting were significantly different across hospitals. Although data sharing systems promote error reporting, it is unclear whether they encourage corrective actions. If data sharing is intended to promote not just error reporting but also root-cause-analysis and process improvement, then the design of the reporting system should emphasize data about these processes as well as errors.

Medical trainees' formal and informal incident reporting across a five-hospital academic medical center.

BACKGROUND: Despite the importance of incident reporting for promoting patient safety, the extent to which residents and fellows (trainees) in graduate medical education (GME) programs report incidents is not well understood. A study was conducted to determine the prevalence of and variations in incident reporting across hospitals in an academic medical center. METHODS: Trainees enrolled in GME programs sponsored by the Indiana University School of Medicine (IUSM) completed (1) the Behavior Index Survey (BIS), which asked respondents if they knew how to locate incident forms and if they ever submitted an incident form, and (2) the Safety Culture Survey (SCS), which asked about the frequencies of their formal and informal incident reporting behaviors. RESULTS: Some 443 of 992 invited trainees (45% response rate) participated in the study. Of the 305 BIS respondents who rotated through all five hospitals, varying proportions knew how to locate an incident form (22.3%-31.5%) and had completed an incident form (6.2%-20%) in each hospital. Incident report completion rates were higher (20.1%-81.3%) among trainees who knew how to locate an incident form. Higher proportions of the 443 SCS respondents had informally discussed an incident with other trainees (90%), faculty physicians (70%), and at resident meetings and conferences (73%). DISCUSSION: The study confirms that GME trainees formally report incidents rarely. The flow of communication to and from trainees about patient safety and incidents is low, despite an organizational focus on safety and quality. Discussion of safety issues among trainees occurs more informally among colleagues and peers than with faculty or through formal reporting mechanisms. The data suggest a number of strategies to increase the culture of safety among GME trainees.

The effect of provider- and workflow-focused strategies for guideline implementation on provider acceptance.

BACKGROUND: The effective implementation of clinical practice guidelines (CPGs) depends critically on the extent to which the strategies that are deployed for implementing the guidelines promote provider acceptance of CPGs. Such implementation strategies can be classified into two types based on whether they primarily target providers (e.g., academic detailing, grand rounds presentations) or the work context (e.g., computer reminders, modifications to forms). This study investigated the independent and joint effects of these two types of implementation strategies on provider acceptance of CPGs. METHODS: Surveys were mailed to a national sample of providers (primary care physicians, physician assistants, nurses, and nurse practitioners) and quality managers selected from Veterans Affairs Medical Centers (VAMCs). A total of 2,438 providers and 242 quality managers from 123 VAMCs participated. Survey items measured implementation strategies and provider acceptance (e.g., guideline-related knowledge, attitudes, and adherence) for three sets of CPGs--chronic obstructive pulmonary disease, chronic heart failure, and major depressive disorder. The relationships between implementation strategy types and provider acceptance were tested using multi-level analytic models. RESULTS: For all three CPGs, provider acceptance increased with the number of implementation strategies of either type. Moreover, the number of workflow-focused strategies compensated (contributing more strongly to provider acceptance) when few provider-focused strategies were used. CONCLUSION: Provider acceptance of CPGs depends on the type of implementation strategies used. Implementation effectiveness can be improved by using both workflow-focused as well as provider-focused strategies.

Influence of workplace demands on nurses' perception of patient safety.

Patient safety is an ongoing challenge in the design and delivery of health-care services. As registered nurses play an integral role in patient safety, further examination of the link between nursing work and patient safety is warranted. The present study examines the relationship between nurses' perceptions of job demands and nurses' perceptions of patient safety. Structural equation modeling is used to analyze the data collected from a survey of 430 registered nurses at two community hospitals in the USA. As hypothesized, nurses' perception of patient safety decreases as the job demands increase. The level of personal control over practice directly affects nurses' perception of the ability to assure patient well-being. Nurses who work full-time and are highly educated have a decreased perception of patient safety, as well. The significant relationship between job demands and patient safety confirms that nurses make a connection between their working conditions and the ability to deliver safe care.

Development and validation of measures to assess prevention and control of AMR in hospitals.

BACKGROUND: The rapid spread of antimicrobial resistance (AMR) in the US hospitals poses serious quality and safety problems. Expert panels, identifying strategies for optimizing antibiotic use and preventing AMR spread, have recommended hospitals undertake efforts to implement specific evidence-based practices. OBJECTIVE: To develop and validate a measurement scale for assessing hospitals' efforts to implement recommended AMR prevention and control measures. STUDY DESIGN: Surveys were mailed to infection control professionals in a national sample of 670 US hospitals stratified by geographic region, bedsize, teaching status, and VA affiliation. SUBJECTS: : Four hundred forty-eight infection control professionals participated (67% response rate). METHODS: Survey items measured implementation of guideline recommendations, practices for AMR monitoring and feedback, AMR-related outcomes (methicillin-resistant Staphylococcus aureus prevalence and outbreaks [MRSA]), and organizational features. "Derivation" and "validation" samples were randomly selected. Exploratory factor analysis was performed to identify factors underlying AMR prevention and control efforts. Multiple methods were used for validation. RESULTS: We identified 4 empirically distinct factors in AMR prevention and control: (1) practices for antimicrobial prescription/use, (2) information/resources for AMR control, (3) practices for isolating infected patients, and (4) organizational support for infection control policies. The Prevention and Control of Antimicrobial Resistance scale was reliable and had content and construct validity. MRSA prevalence was significantly lower in hospitals with higher resource/information availability and broader organizational support. CONCLUSIONS: The Prevention and Control of Antimicrobial Resistance scale offers a simple yet discriminating assessment of AMR prevention and control efforts. Use should complement assessment methods based exclusively on AMR outcomes.

In the shadow of the boss's boss: effects of supervisors' upward exchange relationships on employees.

Dyadic relationships in an organizational hierarchy are often nested within one another. For instance, the relationship between a supervisor and an employee is nested within the relationship between that supervisor and his or her boss. In that context, the authors propose that the supervisor's relationship with his or her boss (leader-leader exchange) moderates the effects of the supervisor's relationship with the employee (leader-member exchange). Specifically, the authors argue that leader-member exchange has a stronger positive effect on employees' attitudes toward the organization and its customers when leader-leader exchange is higher. Cross-level analysis of data from 581 frontline nurses and 29 supervisors in a midwestern hospital supports this contention. Implications for research and practice are discussed.

The need for organizational change in patient safety initiatives.

OBJECTIVES: This study describes a computer simulation model that has been developed to explore organizational changes required to improve patient safety based on a medication error reporting system. METHODS: Model parameters for the simulation model were estimated from data submitted to the MEDMARX medication error reporting system from 570 healthcare facilities in the U.S. The model's results were validated with data from the Pittsburgh Regional Healthcare Initiative consisting of 44 hospitals in Pennsylvania that have adopted the MEDMARX medication error reporting system. The model was used to examine the effects of organizational changes in response to the error reporting system. Four interventions were simulated involving the implementation of computerized physician order entry, decision support systems and a clinical pharmacist on hospital rounds. CONCLUSIONS: Results of the analysis indicate that improved patient safety requires more than clinical initiatives and voluntary reporting of errors. Organizational change is essential for significant improvements in patient safety. In order to be successful, these initiatives must be designed and implemented through organizational support structures and institutionalized through enhanced education, training, and implementation of information technology that improves work flow capabilities.