Multi-level analysis of individual and work environment factors associated with nurses' perceived emotional exhaustion

Highlights

• Emotional exhaustion persists as concerning problem for over 80% of nurses

• Female and lower-educated nurses are at higher risk of emotional exhaustion

• High workload and emotional job demands expose nurses to increased risk of emotional exhaustion

• Followership’s satisfaction, group closeness, independence and meaning at work reduce the risk of emotional exhaustion

• Hospital ward type appears to be not associated with nurses’ levels of emotional exhaustion

Abstract

Background

Several factors at the individual- and work environment-level were suggested to correlate with emotional exhaustion development in nurses.

Aim

To explore nurses' perceived emotional exhaustion and associated factors by employing hierarchical modelling techniques.

Methods

1539 nurses completed the cross-sectional survey. Generalized Linear Mixed Model was performed to identify predictors of emotional exhaustion.

Results

At the individual level, female gender, high workload and emotional job demands increased the risk of emotional exhaustion; instead, higher education, satisfaction with the role of follower, perceiving nursing profession as meaningful, feeling independent at work, and group closeness were protective factors. At the work environment level, hospital ward type did not affect emotional exhaustion.

Conclusions

Emotional exhaustion is largely influenced by ward culture and organizational policies, and to a lower extent by socio-demographic variables. Moreover, it emerges as an intrinsic risk of the nursing profession rather than being associated with the clinical area profile.

Introduction

The past decades have seen a growing interest around how healthcare work environment impacts on nursing workforce well-being outcomes including mental health, in addition to work outcomes (e.g., job performance, commitment, career satisfaction, and intention to leave the profession), organizational outcomes (e.g., job turnover, absenteeism, and sick leave) and patient outcomes (e.g., quality of care, patient safety) (Cummings et al., 2018). Among nurses' mental health outcomes, burnout has been the subject of several investigations as suggested by a recent theoretical review that identified over 90 papers about the causes and consequences of burnout in nursing (Dall'Ora et al., 2020).

Burnout has been originally conceptualized as a work-based psychological syndrome consequent to intensive physical, affective and cognitive strain due to prolonged exposure to certain job demands (Maslach, 1998). According to Maslach's conceptualisation, burnout is constituted of three dimensions, including a) emotional exhaustion – feeling of being emotionally drained and lacking emotional resources; b) depersonalisation – negative and detached response to others and loss of idealism; and c) reduced personal accomplishment – feeling of reduced competence and performance at work (Maslach, 1998). Demerouti and colleagues have more recently proposed the Job Demands-Resources (JD-R) model which conceptualizes burnout as a process rather than a state (Demerouti et al., 2001). According to this model, burnout is based upon excessive job demands such as high workload and emotionally demanding tasks leading to exhaustion, and insufficient job resources (e.g., co-worker support, role clarity) leading to disengagement (Demerouti et al., 2001). Thus, emotional exhaustion has been suggested to be the first step in the nurses' burnout process that moves forward only in presence of dysfunctional coping (i.e., cynicism and disengagement) (Gustavsson et al., 2010).

Several factors at the individual- and work environment-level were suggested to correlate with emotional exhaustion development in nurses (Dall'Ora et al., 2020). Among individual factors, the relationship between socio-demographic (e.g., gender, civil status) (Cañadas-De la Fuente, Ortega, et al., 2018; Gómez-Urquiza, Vargas, et al., 2017), occupational (e.g., work experience, work shift, working hours) (Gómez-Urquiza, Vargas, et al., 2017; Vargas et al., 2014) and job variables (workload, work-team climate, leadership style) (Cummings et al., 2018) and the development of emotional exhaustion has been highlighted. Younger age, female gender, being single or divorced, and not having children appear related to higher level of emotional exhaustion (Cañadas-De la Fuente, Ortega, et al., 2018; Gómez-Urquiza, Vargas, et al., 2017); moreover, nurses often have to routinely cope with stressful job situations such as rotating shifts and work overload because of understaffing. Role conflict and emotional demanding tasks positively contribute to emotional exhaustion (Vandenbroeck et al., 2017). Instead, co-workers and supervisors support can modify perceived job demands by providing informational and emotional support beyond actual help to the working activities (Chen et al., 2020; Velando-Soriano et al., 2020). Relational leadership styles such as transformational leadership are associated with improved outcomes for nurses and their work environments; instead, task-focused leadership styles such as abusive or authoritarian leadership are associated with lower job satisfaction, lower empowerment at work, and higher nurses' intent to leave (Boamah et al., 2018; Cummings et al., 2018). This suggests the leader's influence in shaping the experience of employees, including their experience of demands and resources, and maintaining a work and team climate conducive to the achievement of workers and organizational goals (Cummings et al., 2018).

Similarly, several factors at the work environment level including hospital ward type, model of nursing care, and development opportunities contribute to emotional exhaustion (Dall'Ora et al., 2020). Emotional exhaustion was suggested to vary across hospital services in relation to nurses' daily workload and emotional demands (Vargas et al., 2014). Some hospital ward type such as emergency medicine, general internal medicine and oncology are at higher risk of emotional exhaustion likely due to specific demands of the setting. Nurses working in an emergency unit are exposed to hectic and unpredictable demands and have to cope with a broad range of diseases and injuries (Vandenbroeck et al., 2017); nurses working in internal medicine wards have to tackle with heavy workload with poor nurse-to-patient ratio that may increase the risk of missed nursing care (Gnerre et al., 2017); oncology nurses have to care for people who suffer from life-threatening diseases, and may be asked to communicate bad news, make ethically difficult decisions and cope with relatives' grieving processes (Cañadas-De la Fuente, Gómez-Urquiza, et al., 2018; Houlihan, 2015).

To date, the association between socio-demographic, occupational, job and work environment variables and the development of emotional exhaustion has been explored only at one level of aggregation, while evidence for associations at different aggregation level is lacking. Adopting hierarchical modelling techniques which allow one to analyse data including several aggregation levels can help to measure the relative contribution to and importance of individual- and work environment-level covariates in a way that represents a methodological improvement over standard regression model (Snijders & Bosker, 2011).

Therefore, the purpose of this study was to explore frontline nurses' perceived emotional exhaustion and associated factors that emerged during their clinical practice by employing a multilevel approach. The research question that guided this study was: “Which factors at the individual- and work environment-level affect frontline nurses' perceived emotional exhaustion?”