Critical Review of the Literature
Critical Review of the Literature
Student name: Jennie Kelliher
Student Number: 1027 0663
School of Nursing and Midwifery, Edith Cowan University
Unit code and title: MNP6101.3 Evidence based practice and research design
Lecturer: Hugh Davies
Due Date: 12 September 2022
Part A Words: 814
Part B Words: 1898Project Title
What are the causes and incidence of burnout among Registered Nurses in healthcare
Project Summary
COVID 19, the global pandemic posted many challenges in endoscopy practices with its lively shut downs resulting in sudden delays of medical diagnostics and endoscopic procedures (He et al., 2020). These shut downs, delayed the ability to diagnose and treat gastrointestinal disease and diagnostic cancer screening procedures (He et al., 2020).
As the world moves forward, medical practices are struggling with the challenges of providing high quality care to the large number of patients that are coming through with reduced staff retention following the after mass of the initial stages of COVID 19 (He et al., 2020). Staff became burnt out, as nurses retired, left for COVID vaccination clinics and the shortage of overseas recruits meant less workforce, yet more demand on nurses as they were sent to wards to look after the sick (Leo et al., 2021).
This research proposal therefore will focus on the effects that COVID 19 had on an aging nurse population as the country re-opens and moves on. In addition it will examine the staffing issues due to burn out and the repercussions this has had on both the individual and the health system in Australia. A systemic review will be carried out of the current literature to identify and critically evaluate the research relating to the question at hand. This will determine any gaps in the knowledge and build a framework for recommendations in the future.
Statement of the problem
In recent times the world has just experienced a global health crisis in the face of the COVID 19 pandemic (Leo et al., 2021). A significant strain has been put on the health services around the world. In fact, the World Health Organisation [WHO] (2022) reported as of the 15 August 2022 there was overall reported 587,396,589 confirmed cases globally and 6,428,661 deaths relating to COVID 19.
As a result of the pandemic, cut backs, and cessation of routine services, deployment of nurses to unfamiliar clinical environments, Personal Protective Equipment (PPE) shortages and medical resources reaching there maximum capacity due to the heightened demand has caused a serious impact within the health service (Denning et al., 2021).
These additional pressures have caused nurses to be physically and mentally exhausted. A study covering 3,537 nurses from the United Kingdom, Poland and Singapore in 2020 showed results in favour of this problem. 67% were burnt out, 20% suffering with anxiety and 11% were suffering with depression as a result of the pandemic (Denning et al., 2021).
The pandemic itself has highlighted gaps in healthcare systems (Parasa et al., 2020). It is estimated by the end of 2022 that more than 80,000 people in Victoria alone, will be awaiting elective surgery, but the suspension of diagnostic tests and services has lead to even longer waiting times (Schneider et al., 2022).
In endoscopy, activity fell substantially during the pandemic. Statistics show that in May 2020 endoscopy numbers were as much as 80 per cent lower than the year preceding, and although we are now seeing an increase in endoscopy procedures we are still way below the pre-covid levels (Parasa et al., 2020).
One concern with this fall in activity is the impact on delayed cancer diagnosis and treatment, as this can impact significantly on the treatment and outcome of the case (Schneider et al., 2022; He et al., 2020). Secondly and largely linked to the problem at hand is the number of patients on the waitlists and the demand on the already depleted, reduced, and tired nursing staff within these clinical environments (Sikaras et al., 2021).
Aim and objective of the project
Kraus et al., (2020) stress the importance of conducting an exhaustive and in-depth review of the existing literature prior to beginning a research project. Bramer et al., (2018), state that a thorough literature study will provide accurate assessment of the quality of the research, including its validity and importance to the research question, taking into account, both its strengths and weaknesses,
This research proposal is intended to give an overview of the continuing challenges faced by nurses as the country re-opens following COVID 19. It aims to highlight the potential long-term impacts on the nursing population, and find gaps in the evidence through reviewing the literature, enabling recommendations to be taken to retain and strengthen the nursing workforce.
Formulation of the research Question
Formulation of the research question is key prior to beginning any form of research (Eriksen & Frandsen, 2018). It aims to find an area of concern that instigates further investigation. Using the Population, Intervention, Comparison and Outcome model (PICO) to formulate the research question (Eriksen & Frandsen, 2018), the literature has identified scope to review the impact that COVID 19 has had on nurses as the country begins to re-open.
Critical Review of the Literature
Many studies identify a relationship between workplace variables, such as patient safety, quality of care, staff absences and turnover, as well as job dissatisfaction with burnout (Dall'Ora et al., 2016; DallOra et al., 2020; Laschinger et al., 2015). Burnout is a widespread phenomenon among nursing with growing evidence suggesting the relevance of occupational health, particularly following the recent Covid 19 pandemic (Ed-Valsania et al., 2022).
Health care professionals are at risk of burnout, given the physical and mental stresses of providing care to sick or dying patients (Maslach & Leiter, 2016). The prevalence of burnout in healthcare workers has been seen as high as Thirty Five to fifty four percent with data continuing to reveal the rates of burnout to be on the increase; proven by statistics showing seventeen precent of nurses in 2008, compared to thirty-one percent of nurses in 2017-2018, leaving their positions, due to burnout (Shah et al., 2021). Despite this evidence, little has changed in advancement of preventing workplace burnout among nurses, which has been further complicated during the COVID-19 pandemic because of understaffing and increased patient loads, not to mention pandemic-related anxiety (Shah et al., 2021).
Most studies throughout the literature commonly used the Maslach Burnout Inventory (MBI) Scale that comprises of three subheadings that define the theoretical model. They are emotional exhaustion, depersonalisation, and reduced Personal Accomplishment. This is then split into a further six domains of work life, comprising of workload, control, reward, community, fairness, and values (Maslach & Leiter, 2016). Other studies used the Copenhagen Burnout Inventory (CBI) that consists of personal, work-related, and client-related subheadings for burnout (Creedy et al., 2017). In addition to the two, were Malach-Pines Scale and the Professional Quality of Life Measure (ProQoL5) scale, both maintain burnout to be an element of fatigue (Hunsaker et al, 2015).
The majority of the studies found the relationship of burnout more prominent against the MBI scale, generally supporting the theory that these areas are predictors of burnout (Dall'Ora et al., 2016; DallOra et al., 2020; Laschinger et al., 2015).
Emotional Exhaustion
Most clinical areas for nurses present job-related stresses, such as, unwelcome experiences caused by managing unwell or dying patients, conflicts with team members and the lack of support from nurses managers. This makes the nursing profession, extremely high risk of burnout; know as emotional exhaustion (Costella, et al, 2021). A cross sectional study by Poku et al. (2020) was carried out to assess the rate of emotional exhaustion in a healthcare setting in Ghana. The results spoke for themselves, with ninety-one percent of nurses experiencing high rates of burnout (Poku et al., 2020). Similar studies are also aligned with these findings and nurses are self-reporting emotional exhaustion due to the workplace environment, workplace conflicts and also lack of social support (Poku et al., 2020; Diehl et al., 2021).
This argument was supported further by a recent study in 2021, that applied a cross sectional survey also investigating the relationship between workload and burnout in nurses (Diehl et al., 2021). The results of the study showed there was a higher level of burnout associated with a higher demand of work given to the nurses (Diehl et al., 2021). However, interestingly, this study indicated that the relationship between workload and burnout was lessened when nurses felt part of a good team, received recognition from a clinical nurse leader and had greater commitment to the workplace (Diehl et al., 2016). Also reflected by another study in Germany among specialist nurses, where the intensity of burnout was lowered in the presence of a good working team and workplace commitment (Diehl et al., 2020). A published review by Velando-Soriano et al. (2020) explained support by co-workers and clinical nurse leaders as a great foundation in preventing burnout among staff.
Conflicting evidence was found for burnout between its relationships to night shifts, compared to hours worked per week. The results favoured the association with long shifts and burnout. The link to night shift and the association with burnout and emotional exhaustion was presented, yet was not significant in two of the studies. Further conflicted, as permanent night shift did not correlate to burnout at all, however, nurses on a rotating roster and working irregular shifts did (Bagheri Hosseinabadi et al., 2017; Hunsaker et al., 2015). The hours worked per week was also not significant, whereas, working overtime was associated with emotional exhaustion and depersonalisation (Hunsaker et al., 2015). Shifts longer than twelve hours were highlighted against all MBI subheadings and with Emotional Exhaustion (Zhou et al., 2015) whilst a study that used the ProQoL5 burnout scale highlighted that shorter shifts showed staff to be more protected from burnout (Hunsaker et al., 2015).
Depersonalisation
It is well known that stress can be attributed to feeling unsupported at work leading to the lowered satisfaction in the workplace and increased rates of staff turnover, both affecting the quality of care given to patients (Koy et al., 2017). In support, a study by Diehl et al., (2021), found that higher levels of workload reduced the effect of burnout when workplace commitment from the staff was increased, which is evident by nurses commenting that their commitment to work gave them a feeling of security and stability, which gave them a feeling of belonging in the health care environment. A Serbian study echoed this, through evaluation of workplace commitment among nurses and medical staff, finding significant correlations between work demands, social support, stress reactions and work related burnout to exist (Ili et al., 2017). However, due to the high coping mechanisms for stress that nurses and doctors endure, staff overlooked these work stressors, as a normal part of their job, failing to see the severe consequences on their general and mental health (Ili et al., 2017). This could be an indication that more investigation is warranted between the connection of staffs awareness of their commitment to work and what is expected of them.
Reduced Personal accomplishment
Emotional exhaustion increases among nurses when it is perceived that there is no leadership or support from the nurse manager (Laschinger et al., 2015). These feelings towards the nurse managers ability, leadership and support correlates with frustration among staff, as the nurse manager should be a respected and valued member of the team that supports and leads by example (Tarcon et al., 2017). When leaders fail to influence daily practice, emotional stress is almost always noted among the nurses (Tarcon et al., 2017). This highlights a need for nursing managers to lead effective approaches to continue the development and retention of nursing staff, hence, implementing mechanisms to reduce emotional exhaustion among nurses.
There are numerous causes related to the shortages of nursing and is of great concern among the literature. Staffing levels relating to burnout reported nurses caring for higher number of patients than normal and reporting staffing shortages, especially following the Covid 19 pandemic. A key finding among literature in relation to staffing was the aging population, career and family progression and burnout in general.
Many studies showed evidence of the importance of worklife balance, time spent with family, support and self-care. This could indicate that in a workforce that is primarily females, balancing work with home and family life, could cause greater amounts of stress (Kemp et al., 2022).
Zborowska and collegues (2021) presented in their study that significant burnout among nurses was seen in the Personal advancement domain. This was echoed by a Asiedu et al. (2018) in a study that saw high numbers of burnout among nurses, specifically younger nurses that were having or raising families. This would add to the factors that lead to burnout even more. The study also highlighted, the frustration of lowered personal accomplishment due to the inability to advance in their career, whilst raising their family.
Age related burnout, appears to be conflicted among literature with Zhu et al., (2016) finding age to increase occupational burnout among nursing staff, yet, in contrast, in two additional studies of nurses, age did not affect occupational burnout at all (Zborowska et al., 2021; Tarcan et al, 2017). Age related concerns were noted as alarming with reference to the increasing age of nurses throughout the literature, especially in one study that found the mean age of nurses to be forty-nine years, which confirms that the nursing profession is aging at a rapid rate (Zborowska et al., 2021). This reinforces the decline of interest in the nursing profession between both men and woman, and agrees that this is placing more strain on the workforce.This shortage is at a critical low point globally for health care services around the world (Mar et al., 2019).
The importance of ongoing education and training to support the nursing role is well recognised (Dall'Ora et al., 2016). Opportunities for personal development can reduce burnout, a study suggesting that personal development as an intervention to prevent burnout was acknowledged as beneficial to the cause (Zborowska et al., 2021). One study concentrated on the limited opportunities among nursing staff but it did not acknowledge this presentation to low Personal Achievement or as a precursor to burnout (Bartosiewicz et al., 2020). Literature on the lack of experinced nurses to mentor the younger generation is limited, and given the lack of interest in new nurses coming into the profession, it is a worry for healthcare going forward.
In reflection of this, a study shared results that report newly qualified nurse that self report staffing issues in the workplace be at high risk of emotional exhaustion following there first year in work (Boamah et al., 2017). This again links the connection of poor staffing and the association with Emotional Exhaustion, Depersonalisation, and Personal Accomplishment.
In summary, evidence shows the correlation of a high workload with emotional exhaustion, and inadequate staffing with burnout.
Gaps and Limitations
The literature was over powered by cross-sectional studies, which is troublesome because the relationship between the evidence cannot be fully established. Most study was unable to control the variables, causing a lot of subjective data to be collected. As a result, the literature appears bias, and it is hard to identify the definite causation of burnout, making it challenging to utilise the evidence to recommend interventions to combat it. However, despite the variability, evidence clearly supports interventions aimed at the workplace environment in order to reduce burnout among nurses.
To help address this, recommendations to study nurses over longer periods of time to understand which factors contribute to burnout is needed, and should also include observation of employee behaviours such as staff turnover and sick calls from objective data as opposed to self reported data to reduce bias and subjective overlapping information.
Conclusion
The research suggests that work conditions and workplace variables and leadership are significant factors for nurse burnout. The results highlight the importance of leadership to create a positive work environment by enhancing personal achievement opportunities enabling staff to perform at a high level and providing autonomy. It found that the relationships between Maslachs theories were observed in several studies, concluding that the theory remains relevant.
These findings are useful for nursing leaders, as it can be utilised to increase awareness of burnout among staff and to achieve a healthier work environment.
Additional research is needed to expand the existing literature in this area. Evidence-based workplace interventions may better focus research to assist nurses to manage their job stress, increase positive and enhance work performance.
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