Investigating factors that reduce burnout among newly licensed registered nurses

2.1 Contributors to burnout

Maslach states that burnout has several contributors, which include employees’ workload and community [5, 11]. A heavy workload contributes to burnout by decreasing employees’ ability to complete their jobs [5]. A chronically high workload provides few opportunities to rest. In contrast, a sustainable and manageable workload (the definition of which is unique to each employee) offers chances to improve one’s skill set and increase effectiveness in new areas [5].

The term “community” refers to an employee’s continual relationships with their co-workers [5]. When employees perceive a lack of support, trust, and unresolved conflict, the risk of burnout increases [5]. However, job engagement increases for employees with high-quality working relationships, which involve high social support and a comprise a means to resolve conflicts [5, 12]. For example, prior studies reported that when high levels of incivility were addressed in a hospital for nurses, burnout and absenteeism rates decreased, engagement increased, and the nurses’ working relationships improved [5, 13]. When social support is lacking, burnout is more likely to occur [14].

Chronic workplace stressors also contribute to burnout [11, 16]. Extended shifts at work can also contribute to burnout, especially when employees lack control over when they work overtime [14]. Unclear job expectations also contribute to the gap between employees’ work expectations and actual work [14]. Moreover, inappropriate feedback about performance and inadequate supervisory coaching and teamwork (such as not receiving support from co-workers and supervisors not inspiring their employees) contribute to burnout [11, 17–19].

2.2 Measuring burnout

In their survey of newly licensed registered nurses, Kovner et al. used several questions from the Maslach Burnout Inventory to measure burnout, combining those questions with survey items from the Nursing Work Index to identify factors about the environment in which nurses worked [9]. One advantage of the scales used by Kovner et al. is that burnout symptoms and the work environment were measured. Kovner et al.’s scale has also proven to be reliable and valid [21]. Therefore, connections can be established between the work environment and burnout symptoms. However, Kovner et al. did not analyze the relationship between work environment and burnout factors, nor did they study the drivers of burnout symptoms.

2.3 Burnout in newly licensed registered nurses

There is a lack of studies measuring burnout and factors contributing to burnout in the literature among newly licensed registered nurses, specifically cohort studies. To fill this literature gap, from 2006 to 2015, Kovner et al. conducted a cohort study of registered nurses who received their licenses between 2004 and 2005 [9, 23]. Their original purpose was to study turnover rates and factors contributing to turnover [9, 23]. However, they conducted several studies with their cohort, examining other issues besides turnover. Several articles have been written by Kovner et al. as a result of their survey of newly licensed registered nurses. Still, none of those studies examined burnout and the factors that reduce nursing burnout [22–34]. Additionally, none of those studies include a factor analysis of the data to deduce which survey items are related. This study uses their survey results as secondary data to analyze whether relationships exist between burnout symptoms and factors that could alleviate burnout, identified via the literature review.

Based on the previously cited literature on the contributors to burnout, as well as Kovner et al.’s research, a question remains: Are nurses’ survey responses regarding their job duties meeting their job expectations, job satisfaction, employers inspiring the best in employees, heavy workload, irritability, anxiety, feeling on edge, having friendly co-workers, mood swings, and job interference with home-life related to one another?

3.1 Study design and setting

Secondary data from Kovner et al.’s survey were used in the present study. Kovner et al. conducted a 10-year cohort study of nurses who obtained their nursing licenses in 2004 and 2005 [21]. A cross-sectional design was used with a randomly selected sample of NLRNs throughout the United States in 51 metropolitan statistical areas and nine rural areas defined by the United States Census Bureau [21]. The survey was sent to NLRNs over three months, typically from January to March [21]. Returned surveys sent four months after the first survey were not used in Kovner et al.’s reported results [21].

3.2 Participants

The sample includes 1,706 NLRNs who work in health systems across the United States. They obtained their nursing licenses between September 1, 2004, and August 31, 2005. The latest survey is a national study of NLRNs focusing on their attitudes toward work and career transitions, funded by the Robert Wood Johnson Foundation [22]. The participants included nurses within the fourteen states that had the most updated and accurate lists of NLRNs (Alabama, Kentucky, Maryland, Michigan, Nevada, New Jersey, North Carolina, Oregon, Tennessee, Pennsylvania, South Carolina, Texas, and West Virginia). Nurses who had graduated from nursing programs in the United States after 2002 were included [22]. Furthermore, the survey excluded nurses who had practiced outside of the United States before obtaining their license, those who did not complete the surveys during prior iterations of the survey, those who passed away before the survey, those whose identities were not able to be verified, and those who did not want to participate [22].

3.3 Procedures

The survey was sent to the nurses via the United States Postal Service mail, in addition to an initial alert letter, a $5 incentive, a reminder, and thank-you note [22]. Non-responders were mailed the survey a maximum of five times [22].

3.4 Measures

Two cohorts consisting of nurses who were licensed between 2004 to 2005 and between 2010 to 2011 were measured in four domains of “personal characteristics, work attributes, perceived work environment, and job opportunities,” across 22 scales [22]. Each scale, which included three to eight items, had an adequate to excellent reliability score; each scale’s Cronbach’s alpha coefficient was more significant than 0.70 [22]. The wording for questions in the domain of personal characteristics was based on language in the 2004 National Sample Survey of Registered Nurses [22]. Prior to data collection, a national advisory group that included nursing and academic experts reviewed the survey [22]. Additionally, pilot testing for the survey was conducted with NLRNs who were not part of the 1,706 survey participants [22]. Based on the feedback from the experts and the pilot test, the survey was revised [22]. Final copies of the survey were then sent to the participants. More detailed information about the measures can be found in Brewer et al.’s article “New Nurses: Has the Recession Increased their Commitment to their Jobs?” published in March 2012.

3.5 Data analysis

R software was used to analyze the secondary data from the survey. First, the six data sets of each survey were loaded into R. Next, R’s psych package was used to conduct a factor analysis with a varimax rotation on the data from each cohort to create a complete model, which is shown in Fig. 1. The factor loadings, reliability, and validity of the results were also calculated. Finally, six individual factor analyses were conducted for each model for each year’s survey results.

OPEN IN VIEWER

Fig. 1

Factor Analysis – Overall loadings from 2006 to 2015.

7.1 Contribution to the literature

This research contributes to the literature in several ways. First, this study identifies specific factors that leaders can manage to mitigate nurse burnout. The link between social support, the gap between workers’ job expectations and their actual job, inspirational motivation, and burnout is well documented. Still, Kovner and Brewer did not use items to measure burnout in their survey, nor did they examine whether any of their survey items (e.g., job satisfaction) were related to the answers to burnout questions. Factor analysis based on Kovner and Brewer’s findings can be conducted to make data-driven decisions in organizations.

7.2 Contributions to the nursing industry

This research contributes to the nursing industry in several ways. First, it identifies the importance of nursing leaders supporting their staff (ensuring that nurses’ job expectations are met) and inspiring the best in their employees to influence burnout symptoms, such as feeling on edge, anxious, and irritable. Nurse leaders include unit supervisors and charge nurses, who are staff nurses leading the day-to-day operations of a unit for one shift, in addition to attending to patients and nurses who have worked in a unit for many years; nurses with less seniority aspire become nurse leaders. Thus, nurse leaders should exemplify positive behaviors that nurses with less seniority can mimic, which could mitigate burnout. For example, nurse leaders should inspire the best in other nurses, such as by encouraging them in their tasks and showing them how to complete specific tasks. By becoming transformational servant leaders, nurse managers can not only increase job satisfaction but also inspire the best performance in staff nurses.

Second, this research identifies symptoms of burnout that nurse leaders can identify in staff nurses. If staff nurses show signs of anxiety, tension, or irritation due to minor setbacks, nurse leaders can address these symptoms before burnout worsens. For example, since this analysis showed a relationship between anxiety and heavy workloads, nurse leaders can instruct other nurses to lessen the workload of colleagues showing signs of anxiety. In a display of servant leadership, nurse managers can also fulfill the role of staff nurses to lessen anxious nurses’ workload.

Third, this factor analysis shows that the match between nurses’ job expectations and their actual jobs is linked to job satisfaction. Since job satisfaction is related to burnout, nursing leaders should ensure that potential employees understand the actual job they will be performing and that current employees’ job expectations are met. During the interview process, nurse leaders should ask potential new hires if they understand what the job entails, repeating, in their own words, what they believe their job duties will be. Nurse leaders can then address discrepancies between expectations and the reality of the job, thereby increasing job satisfaction. Furthermore, nurse leaders should allow potential employees to shadow other nurses for several hours so that they can gain a better understanding of what the job entails. Nurse leaders should schedule one-on-one meetings with current nurses to identify whether staff nurses’ job expectations are being met and, if not, address the discrepancies.

Finally, the factor analysis identifies the importance of ensuring that staff nurses are friendly and supportive of other nurses. During the interview process, nurse leaders should ask several behavioral questions to assess how potential employees might behave during stressful situations and whether they would continue to act in a professional and friendly manner.

7.3 Final remarks

Factors that influence burnout are cultivated via leadership. If leaders do not demonstrate the behaviors that they would like to see in their employees, burnout symptoms will not be alleviated. Leaders can alleviate burnout symptoms by focusing on the factors outlined in this research article, namely, the match between expectations job expectations and reality, inspiring the best in employees, and lessening workloads. The less prevalent burnout becomes in the healthcare sector, the better care patients will receive, and the healthier employees and patients will be.