Running head: PROBLEM-BASED RESEARCH 1

Problem-Based Research

Charlene Dover

Delaware Technical and Community College

NUR 340 Nursing Research

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PICOT question: in nurses, does providing additional days off (mental health days),

reduce nurse burnout and decrease call outs? Nurses work very demanding jobs, typically up to

12 hours a day, in a frenzied environment, every other or third weekend, every other holiday,

each second of everyday is different. Some days, at the end of a shift, a nurse leaves saying to

themselves “did I react fast enough? did I do enough? did I miss something? I’m starving, did I

eat lunch, when was the last time I used the bathroom?” As the nurse is attempting to leave for

the day, looking forward to having the day off, they get a message from their supervisor “can

you work tomorrow, overtime offered, we are super short”

“Burnout can be defined as a long-lasting, work related mental condition, which is

characterized by exhaustion, dissatisfaction and low capacity” (Billeter-Koponen & Freden,

2005). High nurse-to-patient ratios, feeling unsupported, chronic overwhelm leads to high stress

and leads nurses to feel unsupported and stressed, afraid to not provide the best care, or afraid to

make a mistake nurses have to call out to “get a break”.

How can nurse burnout be reduced and can providing more days off reduce the call out

time? Signs and symptoms of burnout can be depersonalization, exhaustion, overwhelming

anxiety, dread, and lack of accomplishment (Billeter-Koponen & Freden, 2005). When nurses

feel these signs/symptoms arising and can take time off to offset the signs so that they can

recuperate. This will also mean not having to call out of work multiple days or go to work and

give subpar care to their patients.

The qualitative study, quantitative study, guideline/standard of care and articles reviewed

all address burnout, and how nurse burnout effects patient care/satisfaction. “Prevalence of

burnout syndrome in clinical nurses at a hospital of excellence” was a 2012 cross-sectional,

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quantitative study that sampled 188 surgical nurses in a private hospital in Sao Paulo, Brazil.

The Maslach Burnout Inventory (MBI) was the tool utilized that used three dimensions:

emotional exhaustion, depersonalization and professional underachievement to assess nurse

burnout. A socio-demographic questionnaire, The MBI, the most widely used instrument to

assess burnout syndrome was established in 1986 and the internal consistency of the three

dimensions of the inventory is satisfactory (Ribeiro, et al., 2014). The MBI questionnaire,

distributed after signed consent and approved by the Ethical Committee in Research,

consisted of close-ended, multiple choice, and open-ended questions, covering different

spheres of life of the subject: identification (sex, marital status, age, children), training, time

at work, work characteristics (employment status, time at work, other jobs, number of

working hours per day, shift, weekly rest, work impressions, pleasant and unpleasant work

attributes), personal circumstances (work related health problems, non-work related activities,

dedication to family, on weekends, symptoms, and a stress self-assessment.

The study showed the prevalence of burnout was 10.1% and 55.4% of the subjects studied had

a propensity to develop burnout. Results indicated the frequency of emotional and health

(mostly musculoskeletal pain) complaints was, as expected, higher in individuals affected

with the syndrome. According to Ribeiro et al, 2014 the findings were consistent with the

high rates of sick leave associated with burnout.

“Long-term stress, burnout and patient–nurse relations: qualitative interview study

about nurses’ experiences”. The Nordic School study utilized open interviews that were

analyzed by the Grounded Theory Methodology to help achieve a better understanding of how

nurses experience long lasting stress and burnout. In 2003 over 5,000 of 77,000 nurses in

Sweden were long-term (over 30 days) sick-listed and about 40% of these have the diagnosis
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burnout (exhaustion depression); this number has grown by more than 20% during the previous

year (Billeter-Koponen & Freden, 2005). The material for the qualitative study, based on the

Grounded Theory, was gathered through 1-hour semi-structured recorded interviews based on

themes: burnout experience, effects on work, working situation, and support. The transcribed

text received from the interviews was then coded, where code numbers matched direct quotes but

still ensured the nurse participants’ confidentiality. The study showed feelings of inadequacy

across the board. Most nurses blamed themselves for feelings of burnout and felt it could not be

avoided. The nurses were found to have high emotional exhaustion and increased job

dissatisfaction. “Nurses are working with individuals who experience a special situation as

patients. That is why professionals who can support these human beings on their way to getting

as healthy as possible are needed. It must be considered important to create a working

environment that promotes the health of professionals, so that they can do good work (Billeter-

Koponen & Freden, 2005).

The National Institute for Health Care and Excellence (NICE) in the UK, has a policy,

NICE guideline SG1, which has guidelines for nursing staff requirements for the safety of the

patients as well as the safety of the nursing staff. The SG1 policy is a recommendation on

how to provide safe staffing in acute adult hospitals. The SG1 policy guidelines are hoping to

achieve safe nurse to patient ratios by making everyone in the organization accountable.

Some of the recommendations are education and staff training to ensure that the nurses have

the appropriate skills to handle fluctuating ratios and demands to maximize their

effectiveness. The policy also addresses management and their role in ensuring adequate

staffing. Some of the recommendations for management is to be sure there are procedures and

contingency plans to support flexibility and adapting shifts for nurses. The outcome the policy
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is trying to achieve is to ensure hospitals wards have enough nursing staff, so patients always

get the appropriate care. The population addressed in the policy is inpatient wards for patients

18 and older that are in acute hospitals. The evidence for the policy followed commissioned

reports, expert papers, and reports of field testing.

“Outcomes of variation in hospital nurse staffing in English hospitals: Cross-sectional

analysis of survey data and discharge records” is a cross sectional study that was combined with

nursing survey data. The purpose of the study was to examine nurse-to-patient ratios and

compare them to patient mortality, nurse burnout and the quality of nursing care. Participants

were nurses and general patients. The nurses were full-time nurses as well as a few select nurses

from other inpatient specialties. The nurse’s questions were on basic demographic factors

(education, age, duration in job, qualifications), nurse’s workloads, nurse’s evaluations of the

quality of their work environment, the quality of care, their job satisfaction and their

occupational health (Rafferty et al, 2006). The patients in this study were between the ages 20-

85 (mean age 54.5), were general or orthopedic patients form one of the thirty hospitals in the

study. Out of the 3,984 nurses in the study 36% stated they felt high burnout and were not

satisfied with their job. 118,572 patients were a part of the study in which, 2.3% died and 35.9%

experienced extended lengths of stay and had complicated hospital stays. The results showed

that the hospitals with lower nurse-to-patient ratios had better outcomes. Patients in the

hospitals with the higher patient to nurse ratios had 26% higher mortality; and nurses in those

hospitals had higher burnout levels.

“Nurse burnout and quality of care: Cross-national investigation in six countries”, a

secondary analysis, conducted in the US, UK, Canada, Germany, New Zealand and Japan. Data

for the study was conducted in the International Hospital Outcomes Study (IHOS) where the
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relationship between nurse burnout and quality of care was evaluated. The study mailed

questionnaires to 53,486 nurses and utilized the Maslach Burnout Inventory and found that

reducing nurse burnout would be an effective strategy for nurse-rated quality of care in hospitals

(Poghosyan et al, 2010).

The literature provided supports the ideas that nurse burnout is a real-life issue that

affects nurses every day. Triggers for nurse burnout need to be recognized and changes to

policies need to be made to protect the nurses and the patients that the nurses care for.

According to Gaines, 2019, a resilient work environment is only possible when nurses can

discuss concerns to their administrators and for them to listen, acknowledge and act on the

nurse’s concerns.
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References

Billeter-Koponen, S., & Freden, L. (2005). Long-term stress, burnout and patient-nurse relations:

Qualitative interview study about nurses’ experiences. Scandinavian Journal of Caring

Sciences, 19(1), 20–27. http://dx.doi.org/10.1111/j.1471-6712.2005.00318.x

Gaines, K. (n.d.). Joint Commission Tackles Nurse Burnout in New Report. Retrieved from

https://nurse.org/articles/joint-commission-tackles-nurse-burnout/.

Langford, R., & Young, A. (2013). Making a difference with nursing research. Boston, MA:

Pearson.

Making sure there are enough nursing staff in adult wards. (n.d.). Retrieved from

https://www.nice.org.uk/guidance/sg1/resources/safe-staffing-for-nursing-in-adult-

inpatient-wards-in-acute-hospitals-pdf-15432266437

Poghosyan, L., Clarke, S. P., Finlayson, M., & Aiken, L. H. (2010). Nurse burnout and quality of

care: Cross-national investigation in six countries. Research in Nursing & Health, 33(4),

288–298. http://dx.doi.org/10.1002/nur.20383

Rafferty, A. M., Clarke, S. P., Coles, J., Ball, J., James, P., McKee, M., & Aiken, L. H. (2007).

Outcomes of variation in hospital nurse staffing in English hospitals: Cross-sectional

analysis of survey data and discharge records. International Journal of Nursing Studies,

44(2), 175–182. http://dx.doi.org/10.1016/j.ijnurstu.2006.08.003

Ribeiro, V. F., Filho, C. F., Valenti, V. E., Ferreira, M., de Abreu, L. C., de Carvalho, T. D., …

Ferreira, C. (2014). Prevalence of burnout syndrome in clinical nurses at a hospital of

excellence. International Archives of Medicine, 7(22) http://dx.doi.org/10.1186/1755-

7682-7-22