August 2nd, 2012
By Jennifer Olin, BSN, RN
In past posts I have written about how infections take hold and the nurse’s responsibility in preventing them. I just recently posted a piece about methods for avoiding nurse burnout, a problem affecting thousands of nurses nationwide. Now it seems, researchers have found a correlation between the two—nursing burnout and higher patient infection rates.
A study recently published in the American Journal of Infection Control concludes that not only does nurse burnout lead to higher healthcare-associated infections (HAIs) but it ultimately cost hospitals millions of additional dollars annually.
Researchers from the Center for Health Outcomes and Policy Research at the University of Pennsylvania School of Nursing analyzed data from the Pennsylvania Health Care Cost Containment Council, the American Hospital Association Annual Survey, and a 2006 survey of more than 7,000 registered nurses from 161 hospitals in Pennsylvania. They were specifically looking to study the effect of nurse staffing and burnout on catheter-associated urinary tract infections (CAUTI) and surgical site infections (SSI), two of the most common HAIs.
To measure job-related burnout the research team used the nurse survey responses and the Maslach Burnout Inventory (MBI). The MBI has been recognized for more than a decade as the leading measure of burnout. It incorporates extensive research conducted over more than 25 years and addresses three general scales:
The MBI filters 22 items on job-related attitudes against the three scales, identifying emotional exhaustion as the key component to burnout syndrome. More than one-third of the survey respondents received an emotional exhaustion score of 27 or greater, the MBI definition for healthcare personnel burnout.
Comparing CAUTI rates with nurses' patient loads (5.7 patients on average), the researchers found that for each additional patient assigned to a nurse, there was roughly one additional infection per 1,000 patients (or 1,351 additional infections per year, calculated across the survey population). Additionally, each 10 percent increase in a hospital's high-burnout nurses corresponded with nearly one additional CAUTI and two additional SSIs per 1,000 patients annually.
This is all very scientific and having facts to back up assertions makes for a better argument. However, this research study is hardly news to the millions of nurses out there working with patients.
”I believe burnout, chronic understaffing, wasted resources, workplace violence, and workplace injuries, are inter-related phenomenon that impact all sentinel events,” said Beth Boynton, RN, MSN and author of "Confident Voices: The Nurses' Guide to Improving Communication & Creating Positive Workplaces." “We need work environments that support our work…enough staff, enough time, enough training are key as well as respectful communication at all levels. If you look at the sentinel event data re: root causes on TJC (The Joint Commission) website with a focus on human behavior you'll see profound links.”
So, research supports what we know as common sense. We all know, when you get tired, when you are angry or depressed, when you are physically exhausted or emotionally drained you may show up at the job but you often are just going through the motions.
Tired people make mistakes. Overworked people make mistakes. Unhappy people make mistakes. Cutting staff to save money ultimately seems to cost more money. When will our healthcare institutions learn?
It’s been about 10 years since California mandated minimum nurse-to-patient ratios and the outcomes have been controversial and continue to raise questions. However, we do know that nurse turnover rates and nurse burnout rates have declined while the number of qualified nurses willing to work has gone up, as has nursing morale according to the California Nurses Association.
Other advocates claim there is improved patient satisfaction and reduced medical errors, including medication mistakes and falls in high-traffic, high-intensity areas like emergency services.
Opponents of the mandated staffing legislation say it is very hard for the hospitals to meet all qualifiers of the legislation and to keep the staffing numbers consistent. They also say the mandated staffing actually slows down care in areas like emergency rooms where patients have longer wait times even getting to an exam room much less being seen due to the staffing issues.
Of course, staffing is only one part of the equation when it comes to burnout and quality of care, specifically higher infections rates. As reported in the Philadelphia Inquirer, “when there also is a lack of teamwork and support from the top, and an inability to act independently, 'stress builds up and builds up and builds up until the giver of care just detaches,' said lead author Jeannie P. Cimiotti, and ‘all of a sudden they are doing work, but they are not even cognizant of what they are doing, they are so stressed.’”
With that stress, the nurse may forget to wash her hands between patients, or may not clean the patient as thoroughly before inserting a Foley urinary catheter or prepping the patient for surgery. These actions do not happen with intent, nor is it the goal of the nurse (or other care providers for that matter) to make the patient sicker but when we are tired and overextended mistakes happen.
Researchers on this study determined that if nurse burnout rates could be reduced to 10 percent from an average of 30 percent, Pennsylvania hospitals could prevent an estimated 4,160 infections annually with an associated savings of $41 million. These findings were based on the average cost per-patient associated with CAUTIs ($749 to $832 each) and SSIs ($11,087 to $29,443 each).
"Health care facilities can improve nurse staffing and other elements of the care environment and alleviate job-related burnout in nurses at a much lower cost than those associated with health care-associated infections," Cimiotti and colleagues concluded. "By reducing nurse burnout, we can improve the well-being of nurses while improving the quality of patient care."
While the study uncovered an association between nursing staff burnout and infections among patients, it did not prove a cause-and-effect relationship. However, it sounds like plain, old-fashioned common sense—if the nursing staff is pushed beyond its limits because of an unpleasant work environment or low staffing ratios, more mistakes can happen and patient care and safety can be jeopardized. We just need our healthcare facility administrators to embrace the message and work toward better outcomes for both the staff and the clients.