BurnoutResearch3(2016)76–87
ContentslistsavailableatScienceDirect
Burnout
Research
j ou rn a l h o m e pa g e :w w w . e l s e v i e r . c o m / l o c a t e / b u r n
Burnout
in
the
nursing
home
health
care
aide:
A
systematic
review
Sarah
L.
Cooper,
Heather
L.
Carleton,
Stephanie
A.
Chamberlain,
Greta
G.
Cummings
∗,
William
Bambrick,
Carole
A.
Estabrooks
FacultyofNursing,UniversityofAlberta,Level5,EdmontonClinicHealthAcademy,Edmonton,AB,Canada
a
r
t
i
c
l
e
i
n
f
o
Articlehistory: Received4April2016
Receivedinrevisedform21June2016 Accepted28June2016
Keywords: Burnout Careaides Longtermcare Systematicreview Nursinghome
a
b
s
t
r
a
c
t
Objective:Tosystematicallyreviewtheevidenceonfactorsthatinfluenceburnoutinhealthcareaides
workinginnursinghomes.
Design:Systematicliteraturereview.
Datasources:Twosearchengines(GoogleandEBSCODiscoveryService)andfivedatabases(MEDLINE,
Scopus,CINAHL,PsycINFOandProquestDissertations&Theses)throughtoAugust2013.Keywords:
nursinghome,healthcareaideandburnout(allsynonymswereincluded).
Methods:Twoauthorsindependentlyassessedmethodologicalquality,dataextraction,analysisand
syn-thesisonthe10includedpublications.100%reliabilitywasfoundbetweenthefirstandsecondauthors.
Dataextractedincludedprecipitatingandbufferingfactorsrelatedtoburnout,interventionsand
demo-graphicinformationforthehealthcareaidepopulation.Dataweresynthesizedaccordingtoindividual
andorganizationalfactors.
Results:Oursearchandscreeningyielded2787titlesandabstractsresultingin83manuscriptsforfull
manuscriptreviewand10includedpublications.Methodologicalqualityassessmentsrevealed3(30%)
ratedaslowquality,7(70%)ratedasmediumquality.Independentvariableswerecategorizedaseither
individualororganizationalfactors.Methodologicalproblemsandheterogeneityinindependentand
dependantvariablesyieldedfewsignificantresults.Onlypersonallife(attributesofprovider)wasfound
tosignificantlybufferburnout(depersonalization,emotionalexhaustionandpersonalaccomplishment).
Equivocalevidencewasfoundformanyoftheorganizationalfactors(workenvironment,workloadand
facility)supportingtheneedforfurtherrobuststudiesinthisfield.Ofthetwointerventionstudies,only
dementiacaremapping,andtraininginorganizationalrespectbufferedburnout.
Conclusion:Factorsassociatedwithburnoutinhealthcareaidesaresimilartothosereportedamong
nurses,althoughthelevelofevidenceandlowmethodologicalrigorofthesestudiessuggestmorerobust
studydesignsarewarranted.Ourfindingssuggestresearchfocusedonthisimportantbutlargelyinvisible
groupofcareproviderscouldyieldimportantadvancesinunderstandingburnoutinthisgroupandyield
potentialinterventionstobufferburnoutanditsconsequences.Withoutmitigatingtheeffectsofburnout
onnursinghomehealthcareaides,vulnerableolderadultsinresidentialcareareatrisk.
©2016TheAuthors.PublishedbyElsevierGmbH.ThisisanopenaccessarticleundertheCC
BY-NC-NDlicense(http://creativecommons.org/licenses/by-nc-nd/4.0/).
Contents
1. Introduction...77
1.1. Scopingreviewofburnoutliterature...77
2. Methods...78
2.1. Inclusioncriteria...78
2.2. Dataextraction...78
2.3. Qualityassessment...78
2.4. Datasynthesis...78
∗ Correspondingauthorat:Level5,EdmontonClinicHealthAcademy,1140587Avenue,Edmonton,AB,T6G1C9,Canada. E-mailaddress:gretac@ualberta.ca(G.G.Cummings).
http://dx.doi.org/10.1016/j.burn.2016.06.003
2213-0586/©2016TheAuthors.PublishedbyElsevierGmbH.ThisisanopenaccessarticleundertheCCBY-NC-NDlicense(http://creativecommons.org/licenses/by-nc-nd/ 4.0/).
S.L.Cooperetal./BurnoutResearch3(2016)76–87 77
3. Results ... 78
3.1. Studyselectionandscreening...78
4. Studycharacteristics...78
4.1. Demographics...78
4.2. Characteristicsofpublications...82
4.3. Methodologicalqualityofpublications...82
5. Findings...83 5.1. Individualbuffers ... 83 5.2. Organizationalbuffers ... 84 5.3. Individualprecipitators...84 5.4. Organizationalprecipitators...84 5.5. Interventions...84 6. Discussion...84 6.1. Limitations...84 6.2. Implications...84 7. Conclusion...84 Conflictofinterest...86 Acknowledgements ... 86 References...86 1. Introduction
Healthcareaides(HCAs),themajorityofwhich are unregu-lated,entry-levelstaff,aretheprimarycareprovidersforresidents in nursing home (NH) facilities (Estabrooks, Squires, Carleton, Cummings, & Norton, 2015; Hewko et al., 2015). HCAs (also described as personal support workers, continuing care assis-tants,residentialcareworkers)accountfor70–90%ofstaffinNHs andareresponsibleforupto90%ofthedirectcareprovidedto theseresidents(Bowers,Esmond,&Jacobson,2003;Instituteof Medicine,1996).Studieshaveconsistentlyshownthathigher staff-to-residentratiosarerelatedtohigherqualityofcare(Castle,2008; Harringtonetal.,2012;Katz,2011):staffinglevelsinNHsareoften reportedasinadequateforthisvulnerableolderadultpopulation (Grabowski,Aschbrenner,Rome,&Bartels,2010;Harringtonetal., 2012).Thedependencyandmedicalcomplexityofthisincreasing populationofoldandveryoldadults inNHsis mounting. Resi-dentsinNHscommonlyrequireassistancewithoneormoreof thefollowing:bathing,dressing,eating,transferring,toiletingand walking(Sahyoun,Pratt, Lentzner,Dey, &Robinson,2001).The medicalcomplexityoftheseresidentsisexacerbatedbyfrequent alterationsinhealthincludingpressureulcers(White-Chu,Flock, Struck,&Aronson,2011),depression(Thakur&Blazer,2008), infec-tion(Highetal.,2009),falls(Wallis&Campbell,2011)andfailure tothrive(Robertson&Montagnini,2004).Coupledwiththis,isthe increasingnumberofresidentswithdementia,reportsofupto57% inCanadianNHs(CanadianInstituteofHealthInformation,2009) and48.5%inUnitedStatesNHs(Harris-Kojetin,Sengupta,Park-Lee, &Valverde,2013),furtherstrainingtheHCAworkforceandquality ofcareprovided.
Organizationalfactorsthatprecipitateburnoutinalliedhealth professionsandhealthcareaidesinclude;characteristicsofhigh workload,highacuityofresidentsorpatients,littletimetoperform tasks,andlackofcongruencebetweenemployeeandemployer val-ues(Josefsson,Sonde,Winblad,&Wahlin,2007;Leiter&Maslach, 2009;Stevens,2008).Inthisreviewweusedtheterm“precipitate” toindicatethecauseofaneventorsituationthatisundesirable. Burnoutisan individualresponseassociated withworkrelated stressoveraprolongedperiodoftimewhichcanaffectjob satis-faction,productivity,performance,turnoverandwellbeingofboth theprofessionalandrecipientofwork(Maslach&Jackson,1981; Maslach,Jackson,&Leiter,1996).Burnoutiscomposedof emo-tionalexhaustion:anindividual’slossofemotionalresourcesand emotional/copingenergy(Maslach&Jackson,1981;Maslachetal., 1996);depersonalization:anindividual’sdetachment(including
emotionaldetachment)fromthepatientorresident,includes nega-tiveattitudestowardandlackofcompassionforpatientorresident (Maslach&Jackson,1981;Maslachetal.,1996);anddecreased per-sonalaccomplishment:anindividual’snegativefeelingstowards theirownworkandperceptionofcompetence(Maslach&Jackson, 1981;Maslachetal.,1996).Coupledwithadecreaseinsupport andresourcesandanincreaseindemandforcare,HCAsarebeing placedathigherriskforburnoutthantheirnursingcounterparts (Gerhard,2000).ConsideringtheimportanceoftheHCAsrolein NHcareitwouldseemparamounttoinvestigatethestateofthe scienceonburnoutinNH-HCAs.
1.1. Scopingreviewofburnoutliterature
Todeterminetheneedforasystematicreviewofburnoutof HCAsinNHsettingsandtodevelopoperationaldefinitions,a pre-liminaryscopingreviewwasconductedusingSCOPUSandEBSCO databases. Englishstudies throughAugust 2013 wereretrieved resultingin14,955titlespertainingtoburnoutinallhealthcare professions.Thesearchstrategyforthispreliminaryscopingreview isnotreportedinthismanuscript.Ofthese,11reviewswerekept forinclusion.Fiveweresystematicandsixwerenarrativereviews ofwhich,threeincludedmentalhealthnursesandstaff(Dickinson &Wright,2008;Edwards,Burnard,Coyle,Fothergill,&Hannigan, 2000;Leiter&Harvie,1996),threeincludednursingstaffin unspec-ifiedsettings(Duquette,Kerouac,Sandhu,&Beaudet,1994;Edward &Hercelinskyj,2007;Khamisa,Peltzer,&Oldenburg,2013),and oneeachofnursesinpalliativecaresettings(Pereira,Fonseca,& Carvalho,2011),oncologysettings(Toh,Ang,&Devi,2012),critical caresettings(Epp,2012),allhealthcareprofessionalsinallsettings (Bria,B˘aaban,&Dumitras¸cu,2012)andoneofdirectcareworkers employedwithintellectuallydisabledadults(Skirrow&Hatton, 2007).NoreviewsretrievedfocusedonHCAsorNHsettings.
Thereviewsreportedtwomainthemesinthestudyofburnout –factorsthatprecipitated,andfactorsthatbufferedburnout.In eachofthesethemes,wedevelopedsubcategoriesthatprovided the structure for oursystematic review’s data extractiontable, individual factors(Briaet al., 2012;Dickinson &Wright,2008; Duquetteetal.,1994;Edward&Hercelinskyj,2007;Edwardsetal., 2000;Epp,2012;Khamisaetal.,2013;Leiterand Harvie,1996; Pereiraetal.,2011;Skirrow&Hatton,2007;Tohetal.,2012)and organizationalfactors(Dickinson&Wright,2008;Duquetteetal., 1994;Edward&Hercelinskyj,2007;Edwardsetal.,2000;Leiter& Harvie,1996;Pereiraetal.,2011).Organizationalinfluenceswere themostcommonlycitedprecipitatorsandbuffersofburnout.
Pre-78 S.L.Cooperetal./BurnoutResearch3(2016)76–87 cipitatorsincludedworkload,time pressure,employeevalues of
safety,supervisionandenoughtimeforpersonalstudy(Briaetal., 2012;Dickinson&Wright,2008;Duquetteetal.,1994;Edward &Hercelinskyj,2007;Edwardsetal.,2000;Epp,2012;Khamisa etal.,2013;Leiter&Harvie,1996;Pereiraetal.,2011).Buffering factorsincludedeffectivecommunication,extratime,teamwork andsupport(Dickinson&Wright,2008;Edward&Hercelinskyj, 2007; Edwardset al., 2000; Epp,2012; Leiter, &Harvie, 1996; Pereiraetal.,2011).Threesystematicreviewsindicatedthatstress playsasignificantrole inthedevelopmentofburnout andmay predictburnout(Briaetal.,2012;Khamisaetal.,2013;Skirrow& Hatton,2007).Jobstrainandburdenofworkwerealsoattributedto burnoutinnursingstaff(Dickinson&Wright,2008;Edwardsetal., 2000;Khamisaetal.,2013;Tohetal.,2012).Onereviewproposed amodelillustratingtherelationshipbetweencontributingfactors suchasstressors,workstressandburnouthoweverpoorquality andalimitednumberofstudiesmeantcausalityanddirectionof therelationshipscouldnotbeestablished(Khamisaetal.,2013). Giventheavailableevidence,oursystematicreviewonburnoutin HCAsincluded;domainsofburnout(emotionalexhaustion, deper-sonalization,decreased personalaccomplishment)asdependant variablesandextractedbothindividualandorganizationalfactors associatedwitheitherprecipitatingorbufferingburnout.
Thepurposeofthisstudywastosystematicallyreviewexisting literaturetodeterminewhatisknownaboutHCAburnoutinthe NHsetting.
2. Methods
Usingtheresultsofthescopingreviewwedevelopedastudy protocolbasedontheCentreforReviewsandDissemination guide-line(CentreforReviewsandDissemination,2009)andstructured thissystematicreviewonthePRISMA(Moher,Liberati,Tetzlaff,& Altman,2009)guidelinesforsystematicreviews.Weusedtwo elec-tronicsearchengines,GoogleandEBSCODiscoveryServiceandfive electronicdatabases,MEDLINE,Scopus, CINAHL,PsychINFO and ProquestDissertations&Theses.Weidentifiedthreebroad cate-goriesofsearchterms:nursinghome,healthcareaideandburnout. Norestrictionswereplacedonlocationoryearofpublication.
2.1. Inclusioncriteria
Publicationswereincludediftheymetallofthefollowing cri-teria:1)researchstudies,2)reportedHCAsinNHsdefinedinthe protocol(inclusiveofassistedliving,LTCandallotherresidential carefacilitiesrequiringtheservicesofparaprofessionalstaff),3) writteninEnglish,and4)measuredtheconstructofburnoutor oneofitssubconceptsasthedependantvariable(inclusiveof syn-onymoustermslistedinthedefinitionsprovidedintheprotocol).
2.2. Dataextraction
The first author performed data extraction on all included publications. A second author confirmed dataextraction onall includedpublications. Differences were resolvedby consensus. Thefollowing dataelementswereextracted:samplesize, sam-plepopulation,geographiclocationofthestudyaswellastime period of data collection,setting (example,LTCversus demen-tia care), study design, quality assessment tool/score, research question/purpose/hypothesis, independent variables, dependent variablesandmeasurementscales,analysisused,interventionsand significant/non-significantresults.
2.3. Qualityassessment
Thequalityofeachstudywasassessedusingthe“Quality Assess-mentandValidityToolforCorrelationalStudies”andthe“Quality Assessment Pre-\Post Intervention Design” tools adapted from Cummingsetal.(2008).Qualityassessmentswereconductedon thefinalsampleofarticlesthatmettheinclusioncriteria.Strength ofthestudieswasdeterminedbyassigningascoreforitemsposed intherespectiveassessmenttoolandassignedtoweak(1–4score), moderate(5–9score)andstrong(10–14score)categories. Qual-ityassessmentswereusedtodescribetherelativestrengthofthe availableresearchfindings.Toconfirminter-raterreliability,a sec-ondreviewerwasaskedtoindependentlyscorethe10included publicationsandconsensuswasachieved.
2.4. Datasynthesis
Narrativesynthesisofthedataviacontentanalysiswasused (Grimshawetal.,2003;Moheretal.,2009).Dataweresynthesized accordingtoindividualandorganizationalfactorsthateitherbuffer orprecipitateburnout.Dataweretabulatedtodetermine statisti-callysignificantresultsrelatedtotheoutcomesspecifiedinthe tables.Votecountingwasusedduetotheheterogeneityofstudy factorsandmethods,theauthorsacknowledgethisintroducesa commonbiastowardssignificantresults.Quantitative synthesis wasachieved;factorsassessedinfewerthanfourpublicationswere codedasinconsistentindicatinginsufficientevidencetoreacha conclusion(Grimshawetal.,2003).Factorswerecodedas equiv-ocal if 40–60%of publications showed a significant association (Grimshawetal.,2003).Weconsiderafactorasequivocalifthe resultsareinconclusiveonthestrengthordirectionofthe associ-ation.Forexample,ifbetween40and60%ofpublicationsshowa significantassociationitisnotclearifmorethanhalforlessreport asignificantrelationship.
3. Results
3.1. Studyselectionandscreening
Thesearchyielded2787articles.Afterremovingduplicatesand screeningtitles,83publicationsremainedforfull-textretrieval.The inclusiontoolwastestedforinter-raterreliabilitywithasecond authoron10percent(n=8)ofthearticles.Theagreementratewas 100%.Afterapplyingtheinclusiontool,10manuscriptsremained inourdataset(seeFig.1).
4. Studycharacteristics 4.1. Demographics
ThemajorityofstudieswereconductedintheUnitedStates (n=4) (Gerhard, 2000; Ramarajan, Barsade, & Burack, 2008; Trainor,1994;Yeatts,Cready,Swan,&Shen,2010).Twooriginal studies(Chappell&Novak,1992;Goodridge,Johnston,&Thomson, 1996) resulting in five publications (Chappell & Novak, 1992; Goodridgeetal.,1996;Martone,1993;Novak&Chappell,1994, 1996)wereconductedinCanadaandonestudywasconductedin Australia(Jeonetal.,2012).Ofthe5Canadianpaperstwo indepen-dentdatasetswereused(ChappellandNovak,1992;Goodridge etal.,1996),althoughthesestudiesusedthesamedataset,they eachfocusedondifferentvariables.Theproportionoffemale par-ticipantsrangedfrom63%-100%,inthemajorityofstudiesfemales accountedfor90–100%ofthetotalparticipants.Participants’ages rangedfrom19to65years.Halfofthestudyparticipantswere mar-riedtheremainderwereeitherdivorced,singleorwidowed(inrank
S.L. Cooper et al. / Burnout Research 3 (2016) 76–87 79 Table1
CharacteristicsofIncludedStudies. Author,Journal,
Country,Year
Sample&Setting StudyDesign Purpose Independent variables
Dependent Variables
Analysisused QualityScore(0−1) QualityRating(Low,Med,High)
Chappell&Novak, Gerontologist, CANADA,1992
245NAs,26LTC Crosssectional descriptivesurvey
Testthebuffering hypothesisthat socialsupport mediatesthe relationship betweenstressors andthereactionor outcomeof burnout Stressorfactors– Workload& Rewardsand Motivations Burnout,Maslach BurnoutInventory (MBI)(␣=0.81) Multiple Regression 0.64 Med SupportFactors– Internaland external Demographic Variables FacilityVariables Gerhard,Dissertation, USA,2000
70NAs,1NH Crosssectional descriptivesurvey Determineif optimismisa bufferingfactorin LTCHCA’s Demographic questionnaire-41 itemsusinglikert scale Burnout MBI–emotional exhaustion, depersonalization andpersonal accomplishment. (␣=0.71–0.9) Multiple Regression 0.43 Med Revisedlife orientationtest-for optimism(r=0.78) Goodridgeetal,Jof
ElderAbuse&Neglect, CANADA,1996
126NAs,1LTCFacility Crosssectional descriptivesurvey Effectofconflicton burnout Adaptedscaleto measure assistant-resident conflict Burnout StaffBurnoutScale forHealth Professionals
Frequencies& correlations
0.14 Low
Jeonetal.,Int’lJ NursingStudies, AUSTRALIA,2012
124(43.5%NAsofNAs, RNs,TherapyStaff, OtherandEnrolled Nurses),15Residential AgedCaresites
Randomized ControlTrial
Testtheimpactof personcentered care,dementiacare mappingversus usualcareonstaff burnout,general well-being& attitudes. PersonCentered CareModel Burnout MBI–emotional exhaustion, depersonalization andpersonal accomplishment. (␣=0.46–0.9)
ANOVA NA HighRiskofBias
DementiaCare Mapping UsualCare Martone,Dissertation,
CANADA,1993a
227NAs,25LTCs Secondarydata analysisofaCross sectional descriptivesurvey Examinethe femalenursing assistants’ experienceof burnout
Paid/UnpaidWork Burnout MBI−frequency andintensityof emotional exhaustion, depersonalization andpersonal accomplishment (␣=0.64–0.90) Multiple Regression 0.64 Med Paid/unpaid workinterference scale(␣=0.67) Economic Dimensions
80 S.L. Cooper et al. / Burnout Research 3 (2016) 76–87 Table1(Continued) Author,Journal, Country,Year
Sample&Setting StudyDesign Purpose Independent variables
Dependent Variables
Analysisused QualityScore(0−1) QualityRating(Low,Med,High) Economic Rewardsand Motivations (␣=0.78) UnpaidWork PaidWork Dimension WorkloadScale, shift Participationin DecisionMaking SupportFactors– Internaland external(␣=0.67) Novak&Chapell,Int’lJ
Aging&Human Development, CANADA,1994a
245NAs,25LTC Crosssectional descriptivesurvey
Examinetheeffects ofcaringfor cognitively impairedpatients onarandom sampleofnursing assistants
StressorFactors Burnout,MBI– emotional exhaustion (␣=0.90), depersonalization (␣=0.74)and personal accomplishment. (␣=0.78) Multiple Regression 0.64 Med Memoryand BehaviorProblems checklist (MBPC)-occurrenceof variouspotentially disturbing behaviors(␣=0.92) AppraisalofCare Novak&Chappell,Int’l
JAging&Human Development, CANADA,1996a 140NAs,25LTC Facilities Crosssectional descriptivesurvey Determinethe effectsofworking conditionson nursingassistant stress Demographic Variables–shift worked
WorkStress,MBI domains-Personal accomplishment& Depersonalization (␣=0.74&0.77) MANOVA 0.57 Med LevelofCognitive Impairmentin patientLoad Ramarajanetal.,Jof PositivePsychology, USA,2008
108CNA,1LTCFacility Pre-test,post-test quasi-experimental Determinethe effectof organizational respecton emotional exhaustion Organizational respect=5domain likertscalesurvey (␣=0.81) Burnout,MBI– Emotional exhaustion (␣=0.76) Hierarchical Regression 0.56 Low
S.L. Cooper et al. / Burnout Research 3 (2016) 76–87 81 Trainor,Dissertation, USA,Trainor, Dissertation,USA,1994
150NAs,5LTCs Crosssectional descriptivesurvey Explorethe relationship between employee/job characteristicsand jobstrainamong womenemployed asnursing assistantsin long-termcare facilities Employee/job characteristics
Jobstrain,MBI– Emotional Exhaustion (␣=0.90) Correlations 0.57 Med DecisionLatitude Scale(␣=0.80) Inventoryof SociallySupportive Behaviors(ISSB) Attitudetowards OldPeopleScale Yeattsetal., Gerontologyand GeriatricsEducation, USA,2010 359NAs,11NH Facilities Crosssectional descriptivesurvey Determinethe effectofperceived trainingavailability onburnout Perceptionof Training availability Burnout,MBI– Emotional Exhaustion (␣=0.80), Depersonalization (␣=0.58)& Personal Accomplishment (␣=0.71) ANCOVA, MANCOVA 0.43 Med
Note:Onlyinformationpertainingtotheoutcomesofburnoutanditsassociatedtermsareextractedfromeachstudy. NA–nursingassistant.
NH–nursinghome. LTC–longtermcare.
CNA–certifiednursingassistant.
82 S.L.Cooperetal./BurnoutResearch3(2016)76–87 Scopus n=117 CINAHL n=507 PsycINFO n=581 ProQuest n=70 MEDLINE n=1512
Amalgamated search total n=2787
Aer duplicates removed n=2082
For Full manuscript review n=83
Duplicates removed n=705
Removed aer screening tle and abstract
n=1999
Total included
n=10 arcles
Removed aer full manuscript review n=67
n=5 not English
n=37 not long term care health care aides
n=5 insufficient informaon n=21 not on burnout
n=5 not primary or secondary research
Fig.1.SearchStrategy.
order).ThesettingwithinNH(e.g.,differentiationbetween demen-tiacare,lockedunitsandgeneralunits)wasnotreadilyidentifiable inthemajorityofstudies(seeTable1).
4.2. Characteristicsofpublications
Ofthe10quantitativestudies(Chappell&Novak,1992;Gerhard, 2000;Goodridgeet al.,1996; Jeonet al.,2012; Martone,1993; Novak&Chappell, 1994,1996;Ramarajan etal., 2008;Trainor, 1994;Yeattsetal.,2010),8werecrosssectional(Chappell&Novak, 1992;Gerhard,2000;Goodridgeetal.,1996;Martone,1993;Novak &Chappell, 1994,1996; Trainor,1994; Yeatts etal., 2010)one wasapretest-posttestinterventionstudy(Ramarajanetal.,2008) andonearandomizedcontrolledtrial(Jeonetal.,2012).Ofthe eightcross-sectionalstudies,fourwereanalyzedusingregression (Chappell&Novak,1992;Gerhard,2000;Martone,1993;Novak& Chappell,1994),twousedanalysisofvariance(Novak&Chappell, 1996;Yeattsetal.,2010),andtwousedcorrelationstatisticsonly (Goodridgeetal.,1996;Trainor,1994).Thepretest-posttest inter-ventionstudywasanalyzedusingdescriptivestatistics.
Sixstudiesfocusedonburnoutasthedependentvariableusing two differentmeasurements; all three domainsof the Maslach BurnoutInventory(Chappell&Novak,1992;Gerhard,2000;Jeon etal.,2012;Martone,1993;Yeattsetal.,2010),andStaffBurnout ScaleforHealthProfessionals(Goodridgeetal.,1996).The remain-ingstudiesaddressedemotionalexhaustion,depersonalizationand personalaccomplishmentusingoneormultipleMaslachBurnout Inventorydomains.Lessthanhalfofthestudieshadtheoretical framing.OnestudyreportsusingtheCognitiveAppraisalmodelof Stressframework,yetmadenomentionofhowitappliedtothe
study(Novak&Chappell,1994).Table1depictscharacteristicsof eachstudy.
4.3. Methodologicalqualityofpublications
Table2andTable3summarizethequalityassessmentresults ofincludedpublications.Twostudies(20%)ratedaslowquality (Goodridgeetal.,1996;Ramarajanetal.,2008),and7(70%)ratedas mediumquality(Chappell&Novak,1992;Gerhard,2000;Martone, 1993;Novak&Chappell,1994,1996;Trainor,1994;Yeattsetal., 2010),andnopublicationswereratedasstrong.Ofthe8 cross-sectionalstudiesfourusedprobabilitysampling(Chappell&Novak, 1992;Martone,1993;Novak &Chappell, 1994,1996)and none justifiedsamplesize.Ninereportedreliabilityinformation regard-ingtheirmeasureofburnout(Chappell&Novak,1992;Gerhard, 2000;Jeonetal.,2012;Martone,1993;Novak&Chappell,1994, 1996;Ramarajanetal.,2008;Trainor,1994;Yeattsetal.,2010) andeightreportedvalidityinformationpertainingtotheir mea-sureofburnout(Chappell&Novak,1992;Gerhard,2000;Jeonetal., 2012;Martone,1993;Novak&Chappell,1994,1996;Ramarajan etal.,2008;Trainor,1994).Allofthecross-sectionalstudiesused self-reportedmeasures of burnout. Fourstudies reportedusing atheoreticalframework(Gerhard,2000;Goodridgeetal.,1996; Novak&Chappell,1996;Trainor,1994);onlyoneaddressed man-agementofstatisticaloutliers(Yeattsetal.,2010).Theorieswere usedtointerpretthestudyresults(Trainor,1994)andlinkfindings toexistingtheory.Or,theoreticalframeworksweredescribedasa componentofacomprehensiveliteraturereview(Gerhard,2000). Inallofthestudiesweexaminedthatreportedusingatheoretical frameworkitisunclearhowthetheoreticalframeworkimpacted thedatacollectionoranalysis.
S.L.Cooperetal./BurnoutResearch3(2016)76–87 83 Table2
Summaryofincludedcorrelationalstudiesqualityassessment(n=8).
Criteria Numberofstudies(n)
Yes No
Design
1.Wasthestudyprospective? 0 8
2.Wasprobabilitysamplingused? 4 4
Sample
1.Wassamplesizejustified? 0 8
2.Wassampledrawnfrommorethan1site? 6 2
3.Wasanonymityprotected? 3 5
4.Wasresponserate>60% 5 3
1.Measurement
1.ArefactorsusedtomeasureBurnoutreliable? 7 1
2.ArefactorsusedtomeasureBurnoutmeasuredusingavalidinstrument? 5 3 3.Istheburnoutmeasure
a)observed(score2)or a)0 a)8
b)self-reported(score1) b)8 b)0
4.Ifscalewasusedmeasuringeffectsisinternalconsistency≥0.70? 6 2
5.Wasatheoreticalmodel/frameworkused? 4 4
Statisticalanalysis
1.Arecorrelationsanalyzedifmultipleeffectsstudied? 7 1
2.Areoutliersmanaged? 1 7
Note:adaptedfromCummingsetal.(2008).
Table3
Summaryofpre-postinterventionstudyqualityassessment(n=2).
Criteria:Pre-/PostInterventionStudyDesign Studies(N)
Yes No N/A
Sampling
1.Wasprobabilitysamplingused? 0 2
2.Wassamplesizejustifiedtoobtainappropriatepower? 1 1
Design
1.Onepre-testorbaselineandseveralpost-testmeasures? 1 1
2.Simplebefore-and-afterstudy? 1 1
Controlofconfounders
1.Doesthestudyemployacomparisonstrategy:Anattempttocreateorassessequivalenceofthegroupsatbaselineby:
a)matchingor 1 1
b)statisticalor 0 2
c)noneor 1 1
d)thegroupcomparisonswerethesameforalloccasions(free,baselineandpostevaluations) 2 Datacollectionandoutcomemeasurement
1.Wasthedependentvariabledirectlymeasuredbyanassessor? 0 2
2.Weredependentvariableseither:
a)directlymeasured 0 2
b)self-reported 1 0
3.Werethedependentvariablesmeasuredreliably(withreliabilityindicespreviouslyorforthisstudy)? 1 1 4.Weredependentvariablesmeasuredvalidly(withvalidityassessmentspreviouslyorforthestudy)? 1 1 Statisticalanalysisandconclusions
1.Was(were)thestatisticaltest(s)usedappropriateforthemainoutcomeandatleastthe80%ofothers? 2 0
2.Werekeyvaluesandconfidenceintervalsreportedproperly? 2 0
3.Ifmultipleoutcomeswerestudied,werecorrelationsanalyzed? 2 0
4.Weremissingdatamanagedappropriately? 0 2
Dropouts
Isattritionrate<30% 1 1
Note:adaptedfromCummingsetal.(2008).
5. Findings
Wenotedsignificantvariabilityinboth theindependentand
dependentvariables across studies.For potentialbuffering
fac-torsalone,morethan40independentvariableswerelisted.The
dependentvariable(burnout)wasassessedwith2different
mea-suresacrossthestudies.Weclassifiedtheindependentvariables
intoindividual(socio-demographic, personallifeandeducation)
ororganizationalfactors(facility,workenvironment,employment
characteristics,workloadandworkrelatededucation).These
clas-sificationsweredevelopedtogroupconceptuallysimilarvariables
andwerederivedfromourunderstandingoftheliterature
pertain-ingtoburnout.
5.1. Individualbuffers
Individual buffers predominately focused on subjective
appraisal ofthesurroundingeventsand environment(Chappell
& Novak, 1992; Gerhard,2000; Novak & Chappell, 1994). Sub-jectiveappraisalconsistedofjobenjoyment,reactiontopatient behaviour,optimism,pleasantnessoftasksandfeelingsofidentity. Positiveappraisalofthejob,patientsandtasksservedtoreduce feelingsofemotionalexhaustion(Novak&Chappell,1994).
whileincreasingfeelings ofaccomplishment(Gerhard,2000; Novak & Chappell, 1994). However, optimism as manifested throughpositiveoutlook,didnotsignificantlyaffect depersonaliza-tionoremotionalexhaustionbutdidservetoincreasefeelingsof accomplishment(Gerhard,2000).Feelingsofethnicidentityserved
84 S.L.Cooperetal./BurnoutResearch3(2016)76–87 to reduce the amalgamated overall burnout score (Chappell &
Novak,1992).‘Values’encompassedHCA’sperceptionofinfluence onresidents’wellbeingandthedesiretosharepositiveexperiences andchanges(Gerhard,2000). Thesevaluessignificantlyaffected emotionalexhaustion,depersonalizationandpersonal accomplish-ment.
Individualdemographicfactorshadasignificantinfluenceon depersonalizationonly(Gerhard,2000;Novak&Chappell,1994). Beingmarried,olderandholdingmoreyearsofeducationservedto reduceoverallfeelingsofdepersonalization(Gerhard,2000;Novak &Chappell,1994).Neithermaritalstatusnorgenderhada signif-icanteffectonemotionalexhaustionorpersonalaccomplishment (Gerhard,2000).Sexdidnotsignificantlyinfluence depersonaliza-tion(Gerhard,2000).However,thiscouldbeamaskedeffectdueto thelackofmaleparticipantsinstudies.Overall,authorsreported onmoreindividualbufferingfactorsthanorganizationalones. Pos-itivesubjectiveappraisalofthesurroundingenvironmentwasthe mostcommonlycitedindividualbufferingfactor,ahighdegreeof heterogeneityexistedacrossindividualbufferingfactors.
5.2. Organizationalbuffers
Fourstudiesinvestigatedorganizationalbufferingfactors’ influ-enceonburnout(Gerhard,2000;Jeonetal.,2012;Martone,1993; Novak&Chappell,1994).Theyfoundthatareductioninworkstrain accountedforimprovedemotionalexhaustion(Jeonetal.,2012), depersonalization(Jeonetal.,2012)andpersonalaccomplishment (Jeonetal.,2012)scores.Onestudyfoundtheperceptionof avail-ablejobtrainingbufferedallthreedomainsofburnout(Yeattsetal., 2010).Manyoftheattributesoftheworkenvironment (pleasant-nessoftasks,value/meaningofwork,emotionalreward,makinga difference)significantlybufferedemotionalexhaustionand deper-sonalizationmeasuresofburnout(Jeonetal.,2012).Suchas,the moretimeaproviderspendsonphysicalcareofapatienttheless depersonalizationexperienced(Jeonetal.,2012)(Table4). 5.3. Individualprecipitators
Individualfactorsassociatedwithprecipitatingburnoutwere few.Theindividualattributeofprioreducationoryears of edu-cationhad nosignificanteffect onburnout measures(Chappell &Novak,1992;Novak&Chappell,1996).Nostudiesexamineda balancednumberofpotentialbuffersorprecipitatorsfromeither individualororganizationalfactors.
5.4. Organizationalprecipitators
Onestudyfoundworkloadtosignificantlyprecipitateburnout through depersonalizationand emotional exhaustion (Martone, 1993).Theorganizationalstressorofpaid/unpaidwork interfer-encewasreportedtoprecipitateemotionalexhaustion,yetbuffer personalaccomplishmentmeasuresofburnout(Martone,1993). Martone(1993)labeledtheeffectthatpaidworkforemployment hasontheunpaidworkoffamilyandhomelifeincludingchildcare as‘paid/unpaidworkinterference’.
5.5. Interventions
Twointerventionstudiesareincludedinthissystematicreview. One of them focused on educationalinterventions (Jeon et al., 2012)whiletheotherstudiedorganizationalchangeandrespect (Ramarajanetal.,2008).Aneducationinterventionondementia caremappingsignificantly bufferedemotional exhaustion(Jeon et al., 2012). Ramarajan et al. (2008) examined organizational respectduringorganizationalchangewhichwasfoundto
signif-icantlybuffertheemotionalexhaustionmeasureofburnout(Jeon etal.,2012;Ramarajanetal.,2008).
6. Discussion
Researchershavestudiedabroadanddiversenumberoffactors thateitherprecipitateorbufferburnout.However,relativelyweak studydesignslimitconfidenceintheevidenceforthesevarious factorsandbothweakdesignandthesmallnumberofintervention studiesmakesitimpossibletorecommendeffectivestrategiesto reduceburnoutinthispopulation,inthissetting.
Notably,themajorityoffactorsthatprecipitateburnoutcanbe attributedtomodifiableorganizationalcharacteristics,eventsor obstaclesthatincreasethetimerequiredtocompletethetask(s)at hand.WiththerisingdemandsonresidentialLTCandincreasingly complexandheavyworkloadsoftheresidentpopulation,HCAs’ riskfordevelopingburnoutisalsolikelytorise.ArecentCanadian studyfoundHCAsatmoderateriskforburnout(higherthanthe nursingcounterpartsreportedintheirlargerstudy)butreported anunusuallyhighscorefor‘jobefficacy’(comparabletotheearlier MBImeasureofpersonalaccomplishment)(Estabrooksetal.,2015). Thismayaccountfortheconflictingresultsreportedinthestudy thatamalgamatedtheMBIsubscalesandonlyreported“burnout” (Chappell &Novak, 1992). High intrinsic rewards foundin the HCAworkforce(Estabrooksetal.,2015;Morgan,Dill,&Kalleberg, 2013)coupledwiththehypothesis thatorganizationalvariables thatincreasepersonalaccomplishmentscoresmaybufferburnout providesdirectionfor potentialinterventions.Theinterventions identifiedinthis reviewprimarilyconsistedof educational pro-gramswhichwereoflimitedutility.Theseinterventionsmayhave beenmoresuccessfulifdesignedincollaborationwithmanagers andHCAstodeterminewhattoolsorinformationtheyneeded. 6.1. Limitations
Limitationsofthisreviewincludetheexclusionofstudiesnot written in English, heterogeneity of included studies, and bias towardssignificantresultsinherentwithvotecountingprocedure. 6.2. Implications
Studies are needed that investigate the causal relationship between individual and organizational factors that influence burnout. Replication of studies investigating the relationship betweenorganizationalfactorssuchasworkloadandwork envi-ronment would strengthen or refute thefindings here. Results indicatingtheimportanceofpersonalattributesasbuffersshould betakenintoconsiderationduringworkforceplanningand recruit-ment of HCA staff. Although, our study found no significance betweenworkplacesupportandburnout,furtherstudies investi-gatingtherelationshipbetweenthebufferingcapacityofworkplace supportandburnoutarewarrantedasthestudiesinvestigatingthis wereoflowandmoderatequality.
7. Conclusion
Burnoutpresentsathreattoworkersownhealthandtoresident qualityofcare.Althoughithasbeenthefocusofmuchresearchfor over35years,littleresearchhasbeenundertakenwiththislarge workforcewhoprovidethemajorityofdirectcaretomedicallyand sociallycomplexandvulnerableolderadultsinresidentialLTC set-tings.Existingresearchonburnoutinthispopulationsuffersfrom seriousmethodologicalchallenges.Futureresearchshouldfocus effortsonpinpointingtheenvironmentalcharacteristicsthatcause increasedworkload anditssubsequenteffectonburnout.
Theo-S.L. Cooper et al. / Burnout Research 3 (2016) 76–87 85 Table4
ConclusionSummaryforBurnoutSub-Scales(Depersonalization,EmotionalExhaustion,PersonalAccomplishment).
DepersonalisationFactors EmotionalExhaustion PersonalAccomplishment
Factor Total#Studies* S** NS*** Conclusion Total#Studies* S** NS*** Conclusion Total#Studies* S** NS*** Conclusion Individualfactors
Sociodemographic
Age 2 2 0 Inconsistent 2 0 2 Inconsistent 2 0 2 Inconsistent
Gender 1 0 1 Inconsistent 1 0 1 Inconsistent 1 0 1 Inconsistent
MaritalStatus 3 0 3 Inconsistent 3 0 3 Inconsistent 3 0 3 Inconsistent
Collapsed 6 2 4(67%) NotSignificant 6 0 6 NotSignificant 6 0 6 NotSignificant
Personallifefactors
Attributes 5 3(60%) 2 Significant 5 3(60%) 2 Significant 5 3(60%) 2 Significant
Stressors 11 0 11(100%) NotSignificant 11 1 10(91%) NotSignificant 11 1 10(91%) NotSignificant
Support 2 0 2 Inconsistent 2 0 2 Inconsistent 2 0 2 Inconsistent
Collapsed 18 3 15(83%) NotSignificant 18 4 14(78%) NotSignificant 18 4 14(78%) NotSignificant
Education
Pre-employment 2 0 2 Inconsistent 2 0 2 Inconsistent 2 0 2 Inconsistent
Organizationalfactors Facility
Collapsed 4 0 4(100%) NotSignificant 4 2 2 Equivocal 4 0 4(100%) NotSignificant
WorkEnvironment
Attribute 15 7(47%) 8(53%) Equivocal 15 4 11(73%) NotSignificant 15 3 12(80%) NotSignificant
Stressors 2 0 2 Inconsistent 2 0 2 Inconsistent 2 1 2 Inconsistent
Support 10 2 8(80%) NotSignificant 10 4 6(60%) NotSignificant 10 1 9(90%) NotSignificant
Collapsed 27 9 18(67%) NotSignificant 27 8 19(70%) NotSignificant 27 5 22(81%) NotSignificant
EmploymentCharacteristics
Collapsed 11 1 10(91%) NotSignificant 11 0 11(100%) NotSignificant 11 0 11(100%) NotSignificant
Workload
Collapsed 7 3 4(57%) Equivocal 7 3 4(57%) Equivocal 7 0 7(100%) NotSignificant
WorkEducation
Varietyofvariables 3 1 2 Inconsistent 3 1 2 Inconsistent 3 1 2 Inconsistent
1.Toconcludewhetherornotafactorwasassociatedwithburnout,ithadtobeassessedaminimumof4times.Factorsassessedfewerthan4timeswerecodedasinconsistent(i.e.,insufficientevidencetoreachaconclusion). 2.Factorsassessed4ormoretimeswerecodedassignificantornotsignificantifatleast60%ofreportsshowedasignificantornotsignificantassociationwithburnoutrespectively.Factorswerecodedasequivocalif40–60%of reportsshowedasignificantassociation.
Total#ofStudies*=totalnumberofstudiesthatassessedthisfactor. S**=totalnumberofstudieswherethisfactorwassignificant. NS***=totalnumberofstudieswherethisfactorwasnotsignificant
86 S.L.Cooperetal./BurnoutResearch3(2016)76–87
reticalframinghasbeenlackingacrossstudiesandisneededto
developrobust interventionsand ensurerobustinterpretations.
Bothinterventionandlongitudinalstudiesareimportantto
suc-cessfulresearchandresearchtoactionactivityinthisarea.
Conflictofinterest
None.
Acknowledgements
Dr.CummingsisProfessor,FacultyofNursingandholdsa
Cen-tennialProfessor (2013–2020)at theUniversity of Alberta.She
headstheConnectingLeadership,Education&Research(CLEAR)
OutcomesResearchProgram.Dr.EstabrooksissupportedbyaTier
1CIHRCanadaResearchChairinKnowledgeTranslation.Ms.
Cham-berlainissupportedasadoctoralfellowbytheAlzheimerSociety
ofCanada.Nofundingagencylistedabovehadaroleinthestudy
design,datacollection,dataanalysis,orinterpretationofthedata.
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