Introduction

Nursing as a profession has long been plagued with professional or occupational burnout for as long as people have been working. The prevalence of professional or occupational burnout is not lost on the nursing as a profession. The prevalence of burnout among nursing professionals is high and the following indicators have been studied: Gender, age, marital status, level of healthcare, shift work, work shift and healthcare service areas predicted at least one of the dimensions of the syndrome. Burnout is a combination of chronic exhaustion and negative attitudes toward work with damaging consequences for employee health and productivity. Chronic burnout is considered as an important moderator of daily employee functioning. Bakker & Costac, [1] state “Chronic burnout strengthens the loss cycle of daily job demands, daily exhaustion, and daily self-undermining and the burned-out worker needs help in structurally changing their working conditions and health status” [1].

The medical model has recognized the propensity for medical students and physicians alike, to progress into burnout with studies focusing on burnout in the various practice areas. Physician surveys have been conducted within each of the specialty focus areas that physicians practice with alarming high rates of physician occupational burnout being recognized. Many additional studies have been conducted for emergency department physicians, which identify a higher burnout rate within that setting, specifically noting 60% physician burnout rates. There is limited research on advanced practice nurse’s external or work locus of control and the impact of professional or occupational burnout. The concept of professional or occupational burnout and the impact on the Nurse Practitioner’s (NP’s) role is of primary focus. The role of the Nurse Practitioner (NP) and risk of burnout may be equivalent to physicians, in the primary care provider role or general Internal Medicine - is of interest. In addition, understanding or recognizing the relationship of occupational burnout amongst primary healthcare providers to patient safety outcomes is of concern for the following risks: medical errors, and lower patient satisfaction [2] or inability of patients to reach desired outcomes. There are several effects of physician burnout, as reported on many longitudinal surveys being conducted within the medical community, but few surveys identified are pertaining specifically to NP’s.

Purpose

The purpose was to explore the literature for incidence, themes and factors associated with occupational burnout amongst Nurse Practitioner’s [Family (FNP), Adult (ANP), Adult-Geriatric (AGNP), Gerontological (GNP)] actively employed in clinical practice as a Primary Care Provider (PCP) or Advanced Practice Provider (APP).

Definitions

Nurse Practitioner: Nurse Practitioners who are licensed to practice (diagnose, prescribe and treat) medicine and may do so independently [3].

Burnout: Burnout is considered a chronic response to prolonged, job-related, negative stressors [4]. “A negative state of physical, emotional, and mental exhaustion that is the result of a gradual process of disillusionment” [5].

Burnout Syndrome: Freudenberger [6] was the first clinician to coin the term “Burnout Syndrome” to describe a state of physical and emotional depletion experienced most frequently in human service professions, such as health care, mental health, and social services, ones involving caregiving relationships to service recipients.

Burnout Theory: “All persons belonging to the phases of frustrated strivings, success depression, strenuous noncommitment, general depression, circumscribed frustration and work alienation, irrespective of their etiological pattern” qualifies as experiencing burnout and is a theoretical approach grouped on a hierarchy of levels: loss of autonomy, environmental factors and personality dispositions, individual case studies and individual action episodes or disturbed action episodes [5].

Background

The medical profession has evaluated burnout within the various focus areas of physician practice. According to the Medscape Family Physician Lifestyle Report (2017), studies reveal 55-60% burnout, particularly amongst Emergency Room, Internal Medicine and Family Practice focus areas [7]. Their findings identify significant increases within the longitudinal studies for occupational burnout in the recent 10-years. The comparison from prior studies conducted in 2011, reflected an increase in burn-out by 10% in all physician specialties (Medscape, 2015, 2016). Influencing factors ranking amongst the culprits of burnout included: work-life balance, organizational coherence, electronic health record burdens, paperwork, volume of patients seen and other administrative burdens were highest on the impact of burnout. Women physicians had a higher burnout risk as did younger physicians than older physicians who had more experience in practice or had more years in practice [8]. Maslach & Leiter [9] identified three interrelated dimensions to burnout continuum: exhaustion-energy, cynicism-involvement, and inefficacy-efficacy and found there is a strong robust relationship between them. Lack of recognition as cited by Cordes & Dougherty [10], from service recipients, colleagues, managers, and external stakeholders devalues both the work and the workers and is closely associated with feelings of inefficacy as cited by Maslach [9]. Research based on these theoretical frameworks of Bakker, et al. [11]; Schaufeli, et al. [12], has found that a lack of reciprocity, or imbalanced social exchange processes, is predictive of burnout while control over the workplace hazards increases employees’ energy and health at work.

Methods

Design: Systematic Research Review

Data Sources: CINHAHL Complete [1993 - 2017]. Cochrane Library [1990 - 2017]. CQEW Nursing [1993 - 2017]. Health Source: Nursing Academic Ed. [1981 - 2017]. Medline [1992 - 2017]. Medscape [1993 - 2017]. PubMed [1990 - 2017]. PsychINFO [1981 - 2017]. See the data source matrix within (Figure 1).

Database Selection: Electronic database selection, the number of potential articles and those articles reviewed. CINHAHL Complete, MEDLINE, Health and Psyche Instruments, Health Source: Nursing/Academic Edition, Academic Search Complete, Professional Development Collection, Psychology and Behavioral Sciences, Health Reference Center Academic (192). See the database listing within (Table 1) and the literature review listing within (Table 2).

Exclusion Criteria: Duplicates were removed. Focus areas for Critical Care, Certified Registered Nurse Anesthetist (CRNA), Clinical Nurse Specialist (CNS), Neonatal, Pediatrics, oncology, Psych/Mental Health, Midwife, general surgery, obstetrics, women’s health, Palliative Care/Hospice, Long-term Care, Nursing Management, and acute care specialty services as well as other health care staff roles or non-relevant focus area topics were excluded.

Inclusion Criteria: Published peer reviewed observational, cross-sectional, longitudinal and prospective studies focusing on burnout in the role of a direct health care provider as an Advanced Practice Nurse, Nurse Practitioner (certified in Family, Adult, Adult-Geriatrics and Gerontological), Advanced Practice Provider, Physician Assistants (PAs), physician’s in comparison to NP and PA roles within primary care, Internal Medicine, or as a generalist medical provider role with a predominant focus in areas related to NP practice environments for primary care and Internal Medicine type practices were included. English language was required and there were no restrictions on year of publication.

Literature Review

Burnout

Leiter & Maslach [30] reveal there are five profiles that have emerged from the burnout analysis: Burnout (high on all three dimensions), Engagement (low on all three), Overextended (high on exhaustion only), Disengaged (high on cynicism only), and Ineffective (high on inefficacy only). Each of these profiles showed a different pattern of correlates with organizational variables. The Disengaged profile was more negative than Overextended, and closer to the Burnout profile, which argues against the use of exhaustion alone as a proxy for burnout. Canadas-De la Fuente, et al. [18] identified that neuroticism, agreeability, extraversion and conscientiousness are personality traits that predict at least two of the dimensions of burnout syndrome in nurses. Historically, studies investigated the physical and psychological symptoms, complaints or effects of burnout on the individual within various service professions or occupations. Burnout may be interpreted negatively as avoidance of professional responsibilities [31] or loss of job interest [32] in a way that often leaves the person feeling unsupported. Risk factors for burnout include a lack of observable clinical effectiveness, isolation, ambivalence about competency and working with resistive, confrontational, violent or aggressive clients [33].

Work Locus of Control

Perceptions of lack of job control are antecedent to burnout, which, in turn, precedes depressive affect. McKnight, & Glass [15] wrote greater burnout is associated with less personal control. The article identified a perceived lack of control led to burnout and then to a depressive affect. The results of a 2-year longitudinal study of nurses reflected on the initial assessment and follow-up, whereby the burned-out nurses displayed accurate perceptions of job uncontrollability. A national survey conducted in 2012, within the Academic General Internal Medicine (GIM) division [25] reported: short visits, insufficient support staff, documentation time pressure, and undervaluing education as key themes. Other factors for work condition identified included: very busy or chaotic work environments and too much time spent on Electronic Medical (EMR) with additional EMR challenges as impacting factors for stress and burnout, particularly in the ambulatory or out-patient locations versus the inpatient or hospital areas. The Linzer study, conducted in 2012, revealed burnout was associated with high stress, low work control and low values alignment with leaders [25]. A survey was conducted amongst 465 physician generalists (general internal medicine, primary care internal medicine, preventive medicine, or hospital internal medicine) in one major hospital. The group generalist group represented various roles general practice, research and academia demonstrated more time spent in meaningful work resulted greater satisfaction and less burnout. Women represented 23% of those surveyed. The results of the overall study revealed 34% of faculty members were burned out. Generalists were more likely to be burned out than subspecialists (42.3%), women (43%) and physicians younger than 55 years (37.3%) were recognized as burned out. Burnout was observed without regard for relationship status or if there were children 18 years or younger living at home [16].

The study conducted reported by Jiang & Probst [14] evaluated individual-level job insecurity and burnout. The Conservation of Resources (COR) theory was used in the study. The basic tenant of COR theory is that people are driven to maintain, foster, and protect resources (i.e., objects, conditions, personal characteristics, energies) and that income inequality at the country-level and statelevel threatens one’s obtainment of object resources, which in turn would result in an exacerbation of personal stress response and burnout. The findings contribute to the literature on psychological health disparities for income-inequality and the results support the exacerbating role of higher-level income inequality on the jobinsecurity-burnout relationship. There was a positive relationship to the emotional exhaustion, cynicism for burnout and was stronger in context with greater income inequality. Wang Q, et al. [22] evaluated work locus of control and distinguishes between individuals who have an internal locus of control (i.e., those who believe that they can control their own lives) and individuals who have an external locus of control (i.e., those who believe that their lives are controlled by outside influences, such as other people or fate) within the work environment. Their hypothesis stated: “Work locus of control will yield stronger relationships with work-related criteria than general locus of control” and yielded a stronger relationship with work-related criteria (e.g., job satisfaction, affective commitment, and burnout) than general locus of control. The study demonstrated three conclusions: 1) many of the effects of locus of control may occur via perceptual processes, 2) locus of control may influence job performance and career success via effects on motivational processes, and 3), locus of control may influence interpersonal relationships at work via effects on one’s behavior in social situations.

Alacron [28] conducted a meta-analysis was conducted on job demands, resources, and attitudes and their relationship with burnout associated to the COR theory. The hypotheses in the study predicted that demands, resources, and organizational attitudes would be related to each dimension of burnout, several relations are worth noting. First, all three demands had significant relations with burnout. Specifically, demands had the strongest relation with exhaustion. Organizational attitudes had moderate to strong relations with burnout. Reduced personal accomplishment had moderate correlations with job attitudes. Resources had seemingly consistent relations with exhaustion and cynicism, but a stronger relation with reduced personal accomplishment.

Work-Life Balance and Engagement

Small to medium Sized Enterprise Owner-Managers (SMEs) are vulnerable to burnout and Fernet, et al. [19], discovered complex pathways toward burnout and job stressors associated with the contextual factors of entrepreneurial orientation (occupational loneliness) with low versus high entrepreneurial orientation.

Innanena, et al. [20] conducted a longitudinal study to identify different profiles of subject wellbeing at work (i.e. burnout, work engagement and workaholism) among highly educated employees. It is noted that work engaged employees experienced detachment and relaxation, life satisfaction and rewards. The study found two latent classes: Engaged and Exhausted-Workaholic. The results revealed that employees with the Engaged profile experienced high levels of energy and dedication, whereas employees with the Exhausted-Workaholic profile experienced exhaustion, cynicism and workaholism. Social pessimism was further identified as the transition from high education to work predicted poor subjective well-being at work. Organizational climate may be a barrier for nurse practitioners within primary care. The work conducted by Poghosyan, et al. [17] investigated this issue and found the following themes: poor communication and lack of support for NPs, prevent NPs in primary care settings from fully utilizing their skills and knowledge to provide high-quality patient care. Even though NPs are providing care to millions of patients, little is known about outcome affects regarding organizational climate, the workforce, and the direct care impact. Linzer, et al. [25] conducted an email survey of physicians, nurse practitioners, and physician assistants in 15 General Internal Medicine (GIM) divisions. The survey participants were recruited from Veterans Affairs (VA) divisions form around the United States where a ten-item survey queried stress, burnout, and work conditions such as electronic medical record (EMR) challenges for the VA and civilian clinicians. The survey items were categorized into burnout, high stress, chaos, good teamwork, high values alignment documentation pressures and excessive EMR use. Key themes from the qualitative analysis included: short visits, insufficient support staff, a Relative Value Unit mentality, documentation time pressure, and undervaluing education. The survey response rate was 47% with 579 responses from 1235 clinicians sampled. The high stress was present in 67 %, with 38 % burned out (burnout range 10-56 % by division). Half of respondents had low work control, 60 % reported high documentation time pressure, half described too much home EMR time, and most reported very busy or chaotic workplaces.

Well-Being, Burnout and Patient Safety

Michie & Williams [29] found an association between work factors and psychological ill health among health care staff. These factors are likely to lead to problems for patients in that both the quantity and quality of patient care may be diminished and thus a systematic examination of selected databases was conducted. The results revealed the following themes: doctors found an association between work control and social support and psychological distress; there was a lack of co-worker support among nurses; job influence, organizational climate and role ambiguity were associated with psychological distress. In addition, sickness absence was associated with work pressures and lack of training, unsupportive management style, role ambiguity, tolerance of absenteeism, and low pay. Hall, et al. [24] conducted a systematic research review to determine whether there is an association between healthcare professionals’ wellbeing, burnout with patient safety. Forty-six studies were identified and most of the studies reviewed identified that poor wellbeing and moderate to high levels of burnout were associated. The patient safety outcomes: medical errors-lacked ability to determine causality. There was a correlation between poor wellbeing and worse patient safety in 16 of 27 studies and there was a significant association between burnout and patient safety in 21 of 30 studies, with four additional studies finding an association between one or more (but not all) subscales of the burnout measures employed and patient safety.

A Dutch study was conducted to examine work engagement as a positive antipode and the differentiation of personality and temperament for neuroticism and low extraversion. The study conducted by Langelaan, et al. [26] hypothesized that employees who score high on burnout are characterized by high levels of neuroticism and low levels of extraversion and that there would be a plausible positive relationship with extraversion and a negative relationship with neuroticism. The results indicted a high neuroticism as a core characteristic of burnout and work engagement is characterized by low neuroticism in combination with high extraversion and high levels of mobility. Personality and temperament were shown to make a difference in work engagement and burnout. Dunkley, et al. [27] found an association between Self-Criticism (SC) and neuroticism with self-report depressive symptoms, interviewer-rated major depression, and global domains of psychosocial functional impairment. Their research found a relationship between SC and depressive symptoms is explained by the tendency of these individuals to experience higher levels of daily stress and to negatively appraise the availability of social resources. In addition, their research found negative social interactions were indirectly related to the depression/ global impairment composite through lower perceived social support, but that negative social interactions were not directly related to the depression/global impairment over time. They conferred a possibility that negative social interactions might not be a unique prospective predictor of maladjustment outcomes over time.

Discussion

Many psychological and behavioral theories and tools have been used to study and evaluate burnout. Maslach has a burnout theory (1981a, 1982a, 1982c, 1986) as well as an inventory tool (1981, 1982a, 1982c, 1984), Maslach & Jackson inventory tool manual [34] which has been a standard for conducting research focusing on occupational burnout. However, there are very few studies conducted specific to advanced practice nurses or nurse practitioners specifically. The healthcare landscape has once again altered toward another paradigm shift - including advanced practice providers amongst the provider variables. The synthesis review identified the five profiles that emerged from burnout research analysis: Burnout (high on all three dimensions), Engagement (low on all three), Overextended (high on exhaustion only), Disengaged (high on cynicism only), and Ineffective (high on inefficacy only) conducted by Leiter & Maslach [9]. Each of the profiles showed a different pattern of correlates with organizational variables and the disengaged profile was more negative than Overextended profile, and closer to the Burnout profile, which argues against the use of exhaustion alone as a proxy for burnout. The Canadas-De la Fuente, et al. [18], found variable statistically significant differences in burnout levels associated with the following variables: age, gender, marital status, having children, level of healthcare, type of work shift, healthcare service areas and conducting administrative tasks. In addition, their research also demonstrated that burnout was associated with personality-related variables.

Dunkley, et al. [27] found an association between SelfCriticism (SC) and neuroticism with self-report depressive symptoms, interviewer-rated major depression, and global domains of psychosocial functional impairment. Their research found a relationship between SC and depressive symptoms is explained by the tendency of these individuals to experience higher levels of daily stress and to negatively appraise the availability of social resources. In addition, their research found negative social interactions were indirectly related to the depression/ global impairment composite through lower perceived social support, but that negative social interactions were not directly related to the depression/global impairment over time. Houkes, et al. [21] found evidence for gender differences between men and women in the etiological process of burnout or causal order of the three burnout dimensions. This research identified that women seem to develop more emotional exhaustion over time, even when working fewer hours than male GPs. In addition, men scored - on average - higher on depersonalization scores. Women who are exhausted and depersonalizing their patients, also felt guilty and less certain about their work and the quality of care provided.

The evidence discussed in Poghosyan, et al. [17] supports improvement of organizational climate for NP practice and identified the following organizational climate barriers within primary care settings: such as poor communication and lack of support for NPs; preventing NPs in those settings from fully utilizing their skills and knowledge to provide high-quality patient care; have ethical challenges; low levels of empowerment; and greater dissatisfaction within intra-practice partnerships and NPs were least satisfied with intra-practice partnership/ collegiality, professional growth, and benefits. The research showed that when entrepreneurial orientation is low, the conditional indirect effect of loneliness was stronger and significant, but weaker and not significant when entrepreneurial orientation is high. Jiang and Probst [14] drew upon the basic tenant of conservation of resource theory is that people are driven to maintain, foster, and protect resources (i.e., objects, conditions, personal characteristics, energies) in their research and confirmed the following: job insecurity is positively related to burnout (i.e., exhaustion alone; emotional exhaustion and cynicism, Income inequality, at the country level and at the state level, moderates the positive relation between job insecurity and burnout such that this relationship is stronger within the context of greater income inequality.

Literature review research results by Innanena, et al. [20] revealed the following: that employees with the Engaged profile experienced high levels of energy and dedication, whereas employees with the Exhausted-Workaholic profile experienced exhaustion, cynicism and workaholism; social pessimism in the transition from high education to work predicted poor subjective well-being at work; workaholism decreased during the career among members of the Exhausted-workaholic profile; and that engaged employees experienced detachment and relaxation, life satisfaction and rewards. In addition, the results by Langelaan, et al. [26] identified that high neuroticism is the core characteristic of burnout, whereas work engagement is characterized by high extraversion and high levels of mobility in combination with low neuroticism. Thus, personality and temperament makes a difference in burnout and work engagement. Hall, et al. [24] identified a significant correlation between poor wellbeing and worse patient safety in 16 or 27 studies that measured wellbeing and found a significant association between burnout and patient safety in 21 of 30 studies that measured burnout. Their results provided support for the hypotheses about early predictors of burnout and also found a correlation for the three dimensions of burnout and the six areas of work-life. Women (43%) and physicians younger than 55 years (37.3%) had higher rates of burnout in the study conducted by Shanafelt, et al. [16]. Their study identified that those spending less than 20% of their time (approximately 1 day/week) on the most meaningful activity had higher rates of burnout (53.8%) and the time spent on the most meaningful activity was the largest predictor of burnout. Michie, et al. [29] identified that doctors found an association between work control, social support and psychological distress. Among nurses, lack of co-worker support, job influence, and organizational climate and role ambiguity were associated with psychological distress.

Linzer, et al. [25] found high stress was present in 67% of General Internal Medicine physicians with 38% burned out on average. However, the ranges of burnout were 10-56 % by division within the Veterans Affairs (VA) and civilian work environments. Half of respondents had low work control, 60% reported high documentation time pressure, half described too much home EMR time, and most reported very busy or chaotic workplaces. Key themes from the qualitative analysis were short visits, insufficient support staff, a Relative Value Unit mentality (productivity measures), documentation time pressure, and undervaluing education. Two-thirds felt aligned with departmental leaders’ values, and three-quarters were satisfied with teamwork. Burnout was associated with high stress, low work control, and low values alignment with leaders. Langelaan [26] identified their results suggested higher demands, lower resources, and lower adaptive organizational attitudes are associated with burnout. The following hypotheses were correlational: Demands are positively related to emotional exhaustion, cynicism, and reduced personal accomplishment. Perceived control and autonomy at work are negatively related to emotional exhaustion, cynicism, and reduced personal accomplishment. Job satisfaction and organizational commitment are negatively related to emotional exhaustion, cynicism, and reduced personal accomplishment; in contrast turnover intentions are positively related to the three dimensions of burnout.

Barriers

The exploration of the constructs of professional burnout, specific to nurse practitioners has been a daunting task. The obstacles of identifying active and current search terms has been challenging and more difficult and frustrating than one might think. The search terms used for a literature review or a literature search seem to be ever-evolving as nursing trends shift. These terminology trends seem contribute as a process barrier for the literature review. The search terms become difficult to pinpoint and if you are unaware of the current “Lingo” your search may be incomplete. The barrier in exploration of knowledge is evident as nursing “Lingo” trends shifting of terminology continues to demonstrate a metamorphosis within paradigm shifts. The search terms become difficult to pinpoint and if you are unaware of the current “Lingo” your search may be incomplete. The concepts, ideas, recent research conducted may be housed within an assortment of databases and not readily evident under a larger umbrella of search terms. See the Cause & Effect Flow Chart in (Figure 2). The identified search terms may be within nooks and crannies of a body of work, but certainly not easily accessible when hidden or unavailable for general search terms. A novice exploring literature review searches for a simple topic discovery may not appear, unless specified terms are refined for a detailed or narrow focused subject. Methods and search barriers are restrictive to learning, knowing and to recognizing the available nursing research, thus Nursing Informatics may need to develop the field of library science to facilitate the ease of discovery over the next decade. Expanded search terms and formatting for process discovery may impart the nursing science into the nursing community and the public.

Conclusion

The literature results suggest that higher demands, lower resources, and lower adaptive organizational attitudes are associated with burnout. Based on the research, the following hypotheses were correlational: Demands are positively related to emotional exhaustion, cynicism, and reduced personal accomplishment. Perceived control and autonomy at work are negatively related to emotional exhaustion, cynicism, and reduced personal accomplishment. Job satisfaction and organizational commitment are negatively related to emotional exhaustion, cynicism, and reduced personal accomplishment; in contrast turnover intentions are positively related to the three dimensions of burnout. The literature review research results supported the moderation effect of job control on the relationship between workload and exhaustion. Results also found support for the sequential link from exhaustion to cynicism and that workload is positively related to exhaustion; job control is negatively related to exhaustion; job control moderates the relationship between workload and exhaustion; exhaustion is positively related to cynicism; and thus, exhaustion mediates the relationship between workload and cynicism. It appears that burnout realism is distinct from depressive realism and nurses demonstrated accurate perceptions of the criterion of control and the research suggests that burnout realism is situationally determined. Thus, supporting the view that excessive exposure to demanding and nonchallenging environments is associated with burnout.

Acknowledgements

This paper would like to acknowledge Danita Alfred, Ph.D., R.N., mentor and Professor at the University of Texas at Tyler and Dr. Kate O’Neill, DNP, R.N., Sr. Advisor Practice, Education and Innovation.

Figure 1: Matrix of Literature Review Search.

Figure 2: Burnout_Cause & Effect.

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