CAP Draft Instructions

Students submit two drafts of their CAP paper during the term. The student’s clinical instructor reviews the drafts and provides feedback. Each draft earns a maximum of 5 points. Consult the “CAP Instructions and Rubric” document for guidance on content.

1st draft contains:

· Introduction

· Literature review of the topic/issue

The first draft includes proper APA-styled citations for the articles referenced. It does NOT need to include an APA-styled title page; however, this is a requirement for the final paper.

2nd draft contains:

· Literature review of the solution/interventions

· Implementation/intervention

The second draft includes proper APA-styled citations for the articles referenced.

Instructor Feedback

· These drafts are an opportunity for the instructor to tell the student if they are on the right track for content, writing, and formatting.

· The drafts are not an opportunity to receive detailed corrections on content and APA style.

Students are encouraged to seek writing/APA assistance from the APA Publication Manual, ResU’s lib guides, the Online Writing Lab (OWL) at Purdue, or through the TutorMe resource

Grading criteria

CAP drafts will be assessed using the following criteria. Late submissions will lose up to 10% for every day submitted past the due date.

4-5 points: very good/good

Draft follows all instructions; includes the required content contained in the CAP rubric. Writing is cohesive. Draft may have one or two deficiencies in completeness, content, writing mechanics, or APA format.

3 points: average

Draft follows most instructions; includes most of the required content contained in the CAP rubric. Writing may need improvement. Draft has three or four deficiencies in content, writing mechanics, or APA format.

1-2 points: deficient

Assignment is submitted but does not follow directions, lacks content, and/or is incomplete.

0 points: Nothing submitted

CAPInstructions and Rubric

Description
:  The Clinical Application Project (CAP) is an opportunity for the BSN student to identify an issue, topic, or challenge that is relevant to their Role Transition clinical placement. The student will examine the research related to their topic and investigate the literature regarding a potential solution for, or intervention to improve, the issue. The student then creates a final project, intervention, or solution to their identified topic. They will present their work in a professional paper and electronic poster which will be presented via video.

Step-by-step directions
: 

1. Identify a problem, issue, concern, or area for improvement relevant to your clinical setting. Consult with your RN preceptor and ResU clinical faculty regarding your topic. Your clinical faculty must approve the topic before work is initiated.

2. Educate yourself about the importance of your topic to nursing and your particular clinical placement. Whenever possible, you will want to include facts, statistics etc. relevant to your

3. Critically analyze the literature related to the area of concern.

4. Identify possible solutions to the selected area of concern, based on the evidence in the literature.

5. Review each for its strengths, weaknesses, and feasibility.

6. Select one solution.

7. Engage in the necessary work for this quality improvement project (e.g., develop a new form and identify approvals required for its use). Although students may not have enough time to actually implement their entire project or quality improvement activity, the final work product should clearly outline the plan for implementation, including a timeline. Students will provide evidence of their work by submitting the product of their (e.g., educational program outline, instructional pamphlet, nursing form, pocket resource, new policy, patient or family focused education, etc.)

The student will create an electronic poster which visually represents the clinical application project. The e-poster displays similar components as the paper, but in a very concise and visually pleasing design. Further guidelines and instructions for the e-poster are included in the document entitled “e-Poster Creation”.

The final paper and electronic poster are graded according to the specifics contained in the following grading rubric. Due to the pandemic, e-poster presentations will not take place on campus. Instead, students will present via video and upload to Brightspace.

CAP Instructions and Rubric

Points

Comments

/7

/6

/10

Grading criteria for PAPER		Points		Comments
Introduction · Introduces topic and provides overview of the issue (2 pts.) · Discusses why this issue is pertinent to the particular unit/organization and what led student to choose the topic (2 pts.) · Identifies unit, manager, etc. support for the project (1 pt.) · Identifies how the project will specifically benefit the unit/organization (2 pts.)		/7
Literature review: topic/issue · Includes two recent articles (less than 5-7 years) from professional nursing or health sciences journals (2 pts.) · For each article: provides brief summary and discusses how the article is pertinent and relevant to the topic/issue (4 pts./each article=8 total)		/10
Literature review: solution/intervention · Includes two recent (less than 5-7 years) articles from professional nursing or health sciences journals (2 pts.) · For each article: provides brief summary and discusses how the article is pertinent and relevant to the solution or interventions (4 pts./each article=8 total) · Articles support the student’s chosen solution or intervention (2 pts.)	/12
Implementation/intervention · Clearly describes final project or intervention (2 pts.) · Outlines specific steps to implement final project/solution, including timeline for how the project could be “rolled out” (4 pts.) · Discusses how the project will address/improve the clinical issue (2 pts.) · Discusses future follow-up, evaluation, and/or measurement of the impact of the project (3 pts.)	/11
Paper mechanics · Incorporates required content in a 4-5-page paper (not including title page and reference page) (2 pts.) · Follows correct APA: · Proper title page (1 pt.) · Appropriate text spacing, font size, headings, and in-text citations (2 pts.) · Formatted reference page (2 pts.) · Writes clearly; uses correct grammar, spelling, and punctuation; avoids first person voice (3 pts.)	/10
Grading criteria for e-POSTER
Topic/issue · Clearly displays the topic or issue (2 pts.) · Includes general information about the topic or issue (2 pts.) * · Communicates specifics about why it is pertinent to the particular unit or organization (2 pts.) * · States institutional support (1 pt.) *If applicable, poster uses appropriate graphic or visual which conveys national or local data, trends, organization or unit statistics, etc.
Literature review of the topic/issue · Includes literature support of the topic or issue (1 pt.) · Summarizes most important point(s) of each article (4 pts.) · Clearly connects authors with literature points (1 pt.)		/6
Solution/intervention · Clearly outlines solution and presents as feasible (3 pts.) · Includes literature support of chosen solution (2 pt.) · Clearly connects authors with solution literature (1 pt.)
Implementation · Identifies and explains final project and attaches a copy of “work product” (in-service handouts, pamphlet, form, pocket card, for example) (4 pts.) · Specifically describes how the final project would be implemented, including timeline for “roll-out” (2 pts.) · Describes how the impact of the project could be measured or evaluated (2) · Addresses the future implications of the project for the unit and/or nursing in general (2 pts.)
e-Poster mechanics · Professional looking: follows elements of e-poster construction; organized and clear layout that flows well (2 pts.) · Visually appealing: words and graphics are easy to see; appropriate use of color (2 pts.) · Student’s name, Resurrection University and project site are clearly identified (1 pt.) · Reference page is complete, in proper APA format, and submitted with the e-poster (1 pt.)	/6

TOTAL /85

Batalha EMSS, Melleiro MM, Borges EMN. Burnout and its interface with patient…

J Nurs UFPE on line. 2019;13:e239641

https://doi.org/10.5205/1981-8963.2019.239641

BURNOUT AND ITS INTERFACE WITH PATIENT SAFETY
BURNOUT E SUA INTERFACE COM A SEGURANÇA DO PACIENTE

BURNOUT Y SU INTERFAZ CON LA SEGURIDAD DEL PACIENTE
Edenise Maria Santos da Silva Batalha1, Marta Maria Melleiro2, Elisabete Maria das Neves Borges3

ABSTRACT

Objective: it was sought to analyze scientific articles of the last ten years that address the relationship of Burnout in
nursing workers with patient safety. Method: this is a descriptive bibliographical study, an integrative literature review
developed in the EBSCOhost and in the Virtual Health Library from November to December, 2018. A critical analysis of
the articles was performed and the results were presented in the form of figures. Results: ten articles were included
in the review. It was noted that higher levels of Burnout were associated with lower levels of patient safety and with
adverse events. Burnout was also associated with lapses in adherence to infection control and mediated the association
between depressive symptoms and perception of patient safety. Strong Burnout was negatively associated with time-
pressure at work and patient safety. Conclusion: there was a negative association between Burnout in nursing and
patient safety. Emphasis should be placed on organizational and personal measures to prevent and minimize Burnout.
Descriptors: Professional Burnout; Patient Safety; Nursing; Health; Occupational Health; Quality of Health Care.

RESUMO

Objetivo: buscou-se analisar artigos científicos dos últimos dez anos que contemplassem a relação do Burnout em
trabalhadores de enfermagem com a segurança do paciente. Método: trata-se de estudo bibliográfico, descritivo, do
tipo revisão integrativa da literatura, desenvolvido na EBSCOhost e na Biblioteca Virtual em Saúde, no período de
novembro a dezembro de 2018. Realizou-se a análise crítica dos artigos e os resultados foram apresentados em forma
de figuras. Resultados: incluíram-se na revisão dez artigos. Notou-se que níveis mais altos de Burnout estiveram
associados a níveis mais baixos de segurança do paciente e a eventos adversos. O Burnout esteve associado também a
lapsos na adesão do controle de infecções e mediou a associação entre os sintomas depressivos e a percepção de
segurança do paciente. Associou-se negativamente o alto Burnout com a pressão de tempo no trabalho e a segurança
do paciente. Conclusão: evidenciou-se associação negativa entre Burnout na enfermagem e segurança dos pacientes.
Devem-se enfatizar medidas no âmbito organizacional e pessoal a fim de prevenir e minimizar o Burnout. Descritores:
Esgotamento Profissional; Segurança do Paciente; Enfermagem; Saúde; Saúde do Trabalhador; Qualidade da Assistência
à Saúde.

RESUMEN

Objetivo: se intentó analizar artículos científicos de los últimos diez años que abarcasen la relación del Burnout en
trabajadores de enfermería con la seguridad del paciente. Método: se trata de un estudio bibliográfico, descriptivo,
del tipo revisión integradora de la literatura, desarrollado en la EBSCOhost y en la Biblioteca Virtual en Salud, en el
período de noviembre a diciembre de 2018. Se realizó el análisis crítico de los artículos y los resultados se presentaron
en forma de figuras. Resultados: se incluyeron diez artículos en la revisión. Se notó que niveles más altos de Burnout
estuvieron asociados a niveles más bajos de seguridad del paciente y a efectos adversos. El Burnout estuvo asociado
también a lapsos en la adhesión del control de infecciones e intermedió la asociación entre los síntomas depresivos y la
percepción de seguridad del paciente. Se asoció negativamente el alto Burnout con la presión de tiempo en el trabajo y
la seguridad del paciente. Conclusión: se evidenció una asociación negativa entre Burnout en la enfermería y seguridad
de los pacientes. Se deben subrayar medidas en el ámbito organizacional y personal con miras a prevenir y mitigar el
Burnout. Descriptores: Agotamiento Profesional; Seguridad del Paciente; Enfermería; Salud; Salud Laboral; Calidad de
la Atención de Salud.
1University of the State of Bahia, Department of Life Sciences/UNEB. Bahia (BA), Brazil. ORCID : http://orcid.org/0000-0003-0014-9529 Email:

edenisemaria@gmail.com 2University of São Paulo, School of Nursing/USP. São Paulo (SP), Brazil. ORCID : http://orcid.org/0000-0002-8835-406X

Email: melleiro@usp.br 3Higher School of Nursing of Porto/ESEP. Porto, Portugal. ORCID : http://orcid.org/0000-0002-6478-1008 Email:

elisabete@esenf.pt

How to cite this article
Batalha EMSS, Melleiro MM, Borges EMN. J Nurs UFPE on line. Rev enferm UFPE on line. 2019;13:e239641 DOI:
https://doi.org/10.5205/1981-8963.2019.239641

INTEGRATIVE LITERATURE REVIEW ARTICLE

https://doi.org/10.5205/1981-8963.2019.239641

https://support.orcid.org/hc/en-us

http://orcid.org/0000-0003-0014-9529

mailto:edenisemaria@gmail.com

https://support.orcid.org/hc/en-us

http://orcid.org/0000-0002-8835-406X

mailto:melleiro@usp.br

https://support.orcid.org/hc/en-us

http://orcid.org/0000-0002-6478-1008

mailto:elisabete@esenf.pt

https://doi.org/10.5205/1981-8963.2019.239641

Batalha EMSS, Melleiro MM, Borges EMN. Burnout and its interface with patient…

J Nurs UFPE on line. 2019;13:e239641
https://doi.org/10.5205/1981-8963.2019.239641

Patient safety in health services is currently

discussed and encouraged because it is one of the

main components of quality care. Efforts and

management and care strategies for

implementation of patient safety are growing. In

this context, health workers are the main actors

responsible for implementing in their professional

practice the policies, procedures, standards, and

routines to assist patients with safety and quality.

Nursing workers stand out among this group

because they are in great numbers within the

institutions and often provide direct and

continuous care to patients. It is noted that for

these workers to act safely they must be in

physical and psychological balance. However,

physical and emotional stress related to the work

process may lead these workers to experience

situations of suffering, which may hamper or even

prevent their safe performance in the care

provided.1

Burnout syndrome is among the problems that

can emerge in the work context of these

professionals. It is characterized as a psychological

syndrome that implies a prolonged response to

chronic interpersonal stressors in the work

composed of three dimensions: emotional

exhaustion; depersonalization; and personal

accomplishment.2

The dimensions are defined as follows: 1 –

Emotional exhaustion represents the component

related to the basic individual stress of Burnout,

the feeling of overload, and lack of emotional and

physical resources. The workers feel weakened

and without any source of replacement of energy;

2 – Depersonalization is related to the component

of the interpersonal context of Burnout, being a

negative response that makes the worker

insensitive and excessively apathetic to various

aspects of work; 3 – Reduction of personal

accomplishment at work represents the self-

assessment component of Burnout. It refers to

feelings of incompetence and lack of achievement

and productivity at work; the worker questions his

choice of career and has doubts about the

professional he has become, even developing

negative ideas about himself and other

colleagues.2

Burnout is associated with feelings of

hopelessness and difficulty in dealing with work or

doing the work effectively. Such negative feelings

usually have a gradual onset, and may cause the

feeling that the person’s efforts make no

difference. It is a combination of chronic

exhaustion and negative attitudes towards work,

with harmful consequences for the worker’s health

and productivity, being an important moderator of

daily performance.3 Furthermore, Burnout is

associated with work overload, an non-supportive

and low-resource working environment.1,4

The prevalence of Burnout has been estimated

in some studies in Brazil, with results ranging from

5.9% in nursing technicians in the hospital area,5

17% in intensive care nursing teams,6 7.1%7and

54.2%8 in primary care nursing teams, reaching

values of 82.7% among urgency and emergency

nurses.9 It is demonstrated, therefore, that

although Burnout happens in a heterogeneous way,

it is a reality in nursing and requires attention in

order to preserve the health of the workers and

guarantee the quality of care.

The impact of this syndrome on the physical

and mental health of workers does not pass

unnoticed; Burnout is associated with unhealthy

behaviors such as increased consumption of fast

food, infrequent exercise, increased alcohol

consumption, and more frequent use of

analgesics.10 Furthermore, the prevalence of this

syndrome is positively associated with headache

and dizziness.11

In view of the physical and emotional changes

deriving from Burnout and its consequences for

the quality of care, it is imperative to analyze its

relationship with patient safety. This research is

relevant to the understanding of the phenomenon

and to subsidize intervention proposals and

improvements in workers’ health and quality of

care.

● To analyze scientific articles of the last ten

years addressing the relationship of Burnout in

nursing workers with patient safety.

This is a descriptive, bibliographical study of

the integrative review type.12-3 The following six

steps were adopted: 1-Delimitation of the theme

and formulation of the research question; 2 –

Sampling or search in the literature, selection of

studies; 3 – Categorization of studies through a

previously repared instrument; 4 -Critical analysis

of the included studies; 5 – Interpretation of

results; and 6 – Presentation of the synthesis of

the review, showing the main results.13

The following research question was

established: What is the relationship between

Burnout in nursing workers and patient safety?

Data were collected from November to

December 2018 through all the databases of

EBSCOhost and the Virtual Health Library (VHL)

with access to the Latin American and the

Caribbean Literature in Health Sciences (LILACS)

and the Scientific Eletronic Library Online (SCIELO)

and other databases inserted in the VHL/BIREME

that presented articles meeting the inclusion

criteria of this review.

The following descriptors were used: “patient

safety”, “burnout” and “nursing” combined with the

Boolean operator AND. In order to expand the

INTRODUCTION

OBJECTIVE

METHOD

https://doi.org/10.5205/1981-8963.2019.239641

Batalha EMSS, Melleiro MM, Borges EMN. Burnout and its interface with patient…
J Nurs UFPE on line. 2019;13:e239641
https://doi.org/10.5205/1981-8963.2019.239641

search, the terms referring to the dimensions of

Burnout were also used: “emotional

exhaustion”,”Depersonalization”,”personal

accomplishment”, also combined with “patient

safety” and “nursing” through the Boolean operator

AND.

The selection criteria for inclusion of articles

were: original articles, available in full length,

published in English, Portuguese and Spanish from

2008 to 2018, meeting the objective of this

review. The exclusion criteria were: review

articles, editorials, articles of reflection, and

theoretical studies.

The intersection of descriptors using the filters

language, study period, and availability for

download resulted in 227 articles in EBSCOhost

and 134 articles in the VHL, totaling 361 articles.

A careful reading of titles, abstracts and keywords

was done. Articles repeated in both databases and

not meeting the objective of this research were

excluded. Thus, a total of 351 articles were

excluded. Therefore, 10 articles were included in

the integrative review. The flowchart of the

stages of the integrative review is shown in Figure

1.

Figure 1. Flowchart of identification, selection, eligibility, and inclusion of studies in the integrative review. Porto,

Portugal, 2018.

An instrument was created Microsoft Excel by

the authors for collection of information as a

method to organize and tabulate the data, and

later critical analysis. The instrument had the

following items: title; year of publication; journal

of publication; place of publication; goals;

methodology (the methodological trajectory was

evaluated through analysis of rigor of the

methods, interventions, and procedures adopted

for data collection and analysis, and level of

scientific evidence); main results; and conclusions.

The articles were analyzed critically and the

results were summarized, highlighting the

relationship between Burnout in nursing workers

and patient safety in health care. The results were

presented by means of figures.

The studies included in this review are

presented in the Figure 2 according to the title;

year; place; journal; and language of publication.

RESULTS

Items identified through searches in the
databases (n = 361)

Items after elimination of duplicate studies (n =
345)

Excluded studies
(n = 329)

Studies selected for
reading in full length

(n = 16)

Complete studies
evaluated for

eligibility (n = 16)

Full length
studies excluded

(n = 6)

ID
E
N

T
IF

IC
A

T
IO

N

Studies included in
the qualitative

synthesis (n = 10)

E
L
IG

IB
IL

IT
Y

S
E
L
E
C

T
IO
N

IN
C

L
U

S
IO

N

Studies included in
quantitative

synthesis (n = 0)

Items identified through surveys in other data
sources (n = 0)

https://doi.org/10.5205/1981-8963.2019.239641

Batalha EMSS, Melleiro MM, Borges EMN. Burnout and its interface with patient…
J Nurs UFPE on line. 2019;13:e239641
https://doi.org/10.5205/1981-8963.2019.239641

It was noted that most of the studies were published in English and in the year 2017.

Title/Year Local/Newspaper/Language

1 – Nurse burnout and patient safety outcomes nurse safety
perception versus reporting behavior/2008.14

Canada/
Western Journal of Nursing

Research/English
2 – Interactive effects of nurse-experienced time pressure and
burnout on patient safety: A cross-sectional survey/2010.15

Taiwan/
International Journal of Nursing

Studies/English

3 – Work environment and patient safety: comparison of data
between the studies SENECA and RN4CAST/2013.16

Spain
Clinical Nursing/Spanish

4 – Nursing unit teams matter: Impact of unit-level nurse
practice environment, nurse work characteristics, and burnout
on nurse reported job outcomes, and quality of care, and
patient adverse events—A cross-sectional survey/2014.17

International Journal of Nursing
Studies/English

5 – Safety climate, emotional exhaustion and job satisfaction
among Brazilian paediatric professional nurses/2016.18

Brazil/International Nursing
Review/English

6 – The association between patient safety culture and burnout
and sense of coherence: A cross-sectional study in restructured
and not restructured intensive care units/2016.19

Norway/Intensive and Critical Care
Nursing/English

7 – Job burnout reduces hand hygiene compliance
among nursing staff/2017.20

Greece/Journal Patient Safety/English

8 – Burnout mediates the association between symptoms of
depression and patient safety perceptions: A cross-sectional
study in hospital nurses /2017.21

United Kingdom/Journal of Advanced
Nursing/English

9-Effect of effort-reward

imbalance and burnout

on infection control among Ecuadorian nurses/2017.22

Ecuador/
International Nursing Review/English

10 – Hospital nursing organizational factors, nursing care left
undone, and nurse burnout as predictors of patient safety: A
structural equation modeling analysis/2018.23

China/
International Journal of Nursing

Studies/English

Figure 2. Description of articles included in the review according to title; year; place; journal; and language
of publication. Porto, Portugal, 2018.

The articles included in this review are

described in Figure 3 according to the objectives;

type of study; main results; and conclusions.

Main objective/Type of study Main Results and Conclusions

1 – To explore the relationship between
Burnout and perceptions about patient
safety, adverse events, and near-miss
notification behaviors.
Cross-sectional study.14

The dimensions of Burnout were negatively associated with the
degree of patient safety, suggesting that the highest Burnout
level was associated with a low degree of patient safety.
Burnout was negatively associated with near-miss notification
frequency; however, no Burnout component was associated with
the number of events reported in the previous 12 months.

2 – To investigate how time-pressure and
its interaction with burnout affect patient
safety.
Cross-sectional study.15

Patient safety was negatively related to time-pressure in the
group presenting high burnout. It was evidenced that nurses
under strong time-pressure and high level of Burnout are
probably affected in relation their performance with respect to
patient safety.

3 – To analyze the relationship between

the work environment, Burnout of nurses,
and the quality of care related to patient
safety in hospitals of the Unified Health
System of Spain, included in the SENECA
and RN4CAST studies.
Descriptive study with secondary analysis
of data obtained in the SENECA and
RN4CAST studies.16

The perception of safety of care by professionals was related to
Burnout syndrome in the dimensions of emotional exhaustion and
depersonalization. It is emphasized that organizations that
promote a more supportive work environment will have patients
who feel safer and the proper management of resources can
reduce the occurrence of adverse events.

4 – To investigate the impact of the work
environment, characteristics of the
nursing work and Burnout on nursing
outcomes, quality of care, and adverse
events for patients.
Cross-sectional study.17

Perceptions about quality of care in the hospital unit in the last
shift and in the last year were related to the three dimensions of
Burnout. Nosocomial infections were associated with the three
dimensions of Burnout, with falls and medication errors being
associated with the dimensions of emotional exhaustion and

depersonalization.

5 – To evaluate the correlation and
predictive effect of emotional exhaustion
and job satisfaction on safety climate and
quality of care.
Cross-sectional study.18

It was found that the lower the level of emotional exhaustion,
the more positive was the perception of safety climate and the
greater was the job satisfaction. The effects that professional
exhaustion can have on patient safety were demonstrated, and
higher levels of emotional exhaustion of professionals lead to
worse patient safety.

6 – To investigate associations between
perceptions of safety culture in Intensive
Care Units and Burnout and sense of
coherence.
Cross-sectional study.19

Positive safety culture was correlated with low Burnout scores
and a strong sense of coherence.

https://doi.org/10.5205/1981-8963.2019.239641

Batalha EMSS, Melleiro MM, Borges EMN. Burnout and its interface with patient…
J Nurs UFPE on line. 2019;13:e239641
https://doi.org/10.5205/1981-8963.2019.239641

7 – To analyze whether Burnout reduces
adherence to handwashing among nursing
staff.
Daily study conducted with a mixed
method approach (questionnaires and
observation).20

Burnout was negatively associated with adherence to hand
hygiene; nurses who reported high levels of Burnout were less
likely to comply with hand hygiene opportunities.

8 – To investigate the relations between
depressive symptoms, Burnout , and
perceptions of patient safety.
Cross-sectional study.21

The dimensions of emotional exhaustion and depersonalization
were associated with perceptions of patient safety. It was also
evidenced that Burnout mediated the association between
depressive symptoms and perception of patient safety both
individually and at the level of work area/unit.

9 – To examine the association between
effort-reward imbalance, Burnout , and
adherence to infection control measures.
Correlational, cross-sectional study.22

The study found that

Burnout was associated with lapses in

adherence to infection control measures, which may result in
increased infections, threatening the health of both the
workforce and the populations they assist.

10 – To explore the impact of the work
environment, workload, non-realized care
measures, and Burnout on patient safety.
Cross-sectional study.23

A better working environment was associated with lower
Burnout, which was subsequently related to a higher level of
patient safety and fewer adverse events.

Figure 3. Description of the articles according to objectives; type of study; main results; and conclusions.
Porto, Portugal, 2018.

A summary of relevant points of the articles

included in this review is presented in Figure 4,

showing the relationship between Burnout and

aspects of patient safety (PS) in health

institutions.

Figure 4. Relational Interface between Burnout in Nursing workers and Patient Safety (PS). Porto,

Portugal, 2018.

The relationship between Burnout and patient

safety was clearly demonstrated in the studies.

Highest Burnout levels were associated with a low

degree of patient safety14 and in contrast, a

positive patient safety culture was correlated with

low scores of patient safet.19 Yet, the lowest

levels of emotional exhaustion were related to the

perception of the most positive patient safety

climate18 and perceptions about the quality of

care were associated with the three dimensions of

Burnout.17

These findings can be seen in two ways; first,

because of aspects of Burnout, nursing workers

could be more prone to lower compliance with

quality standards, consequently generating more

errors and adverse events, and therefore leading

to the provision of care with lower patient safety.

Secondarily, the results may suggest the other way

around, that because nursing workers are in a

working environment with low patient safety, they

present higher levels of Burnout. In this regard,

the relationship can be cyclical and interventions

must be implemented in order to guarantee the

elimination or lower levels of burnout, and higher

levels of safety.

A better working environment was associated

with lower Burnout, which was subsequently

related to a higher level of patient safety and

fewer adverse events. Emphasis should therefore

be given to the importance of improving the work

environment so as to help to reduce Burnout and

promote patient safety.23

It was demonstrated that Burnout may be the

most important variable for patient safety, since it

completely mediated the association between

depressive symptoms and perception of patient

safety. Not only was Burnout associated with

depressive symptoms and perceptions of patient

DISCUSSION

Burnout

Patient safety

– High Burnout level was associated with lower PS levels and lower frequency of near miss reports;
– Low level of Burnout was related to a positive culture of PS; the lower the level of emotional
exhaustion the more positive was the perception of PS climate;
– The dimensions of Burnout were associated with falls, nosocomial infections, and medication errors;
– Burnout was associated with lapses in adherence to infection control measures and lower probability
to comply with hand hygiene opportunities;
– Burnout mediated the association between depressive symptoms and perception of PS;
– In high Burnout, time-pressure at work was negatively related to PS;
– A better work environment was directly associated with lower Burnout, which was subsequently

related to higher levels of PS and fewer adverse events.

https://doi.org/10.5205/1981-8963.2019.239641

Batalha EMSS, Melleiro MM, Borges EMN. Burnout and its interface with patient…
J Nurs UFPE on line. 2019;13:e239641
https://doi.org/10.5205/1981-8963.2019.239641

safety, but the best statistical fitness was found

when depressive symptoms were considered as a

result of Burnout rather than a predictor of this

condition.21 These results lead to the notion that

Burnout can further increase the risk of depressive

symptoms in nursing workers and that it is a major

mediator of erception of patient safety, both at

the level of individual and unit work. Therefore,

interventions aimed at Burnout are likely most

appropriate for improving patient safety.21

The relationship between Burnout and

depression has been confirmed in other studies,24-

5 pointing to the need to understand which

dimensions of Burnout can influence depression,

and in which manner. It is necessary, from this

understanding, to evaluate which interventions

would be most effective at the level of both

individual and organizational factors.

It was seen that time-pressure at work

adversely affected patient safety in the case of

nurses with a high level of Burnout, but not in

nurses with low levels of the syndrome.15

Time-pressure is recognized as a phenomenon

widely experienced in nursing work that has

substantially negative implications for quality and

safe care. It is imperative to establish a better

support for nurses by investing in staff

development and resource optimization. This

would reduce the circumstances in which nursing

workers are challenged to provide good care under

time-pressure.26

It turns out that nurses experiencing Burnout

showed to have little resources to adhere to their

demands in the workplace, creating a gap

between the necessary and real efforts in patient

care. It was also observed that these nurses had a

greater inability to adapt to time-pressure,

enhancing the probability of errors that negatively

interfere with patient safety.15

Workers with higher levels of Burnout were

associated with fewer near miss reports.14 This

result is worrisome because the prevention of

adverse events is linked to the identification of

near miss events.

The Near-Miss Nursing Model presents an

explanation of how a defective system and human

factors can result in harm to patients if not

intercepted. Three potential sources of error are

included in the model: technical, organizational,

and human failure. Any one of these failures,

isolated or combined, can result in a sequence of

events that, if left uninterrupted, may result in

adverse events. It is now well recognized that

technical and organizational failures are

responsible for a large number of errors.

Nevertheless, the importance of appreciating

human behaviors stands out because they play a

role in generating errors and also in their

vigilance, recovery and prevention.27

It was found that workers with Burnout tend to

report less near misses,14 proving that this human

factor may be fragile in relation to the

recognition, prevention and mitigation of errors,

thus hindering organizational learning and

improvement processes.

It was also found that the dimensions

exhaustion and depersonalization were associated

with falls and medication errors.17

The third worldwide challenge of patient safety

“No-harm Medication” by the World Health

Organization (WHO) was launched in 2017

motivated by the extent and magnitude of errors

related to use of medicines. The goal of this global

challenge was to improve drug safety based on the

fact that medication errors cause preventable

injuries and damages to health systems,

generating an estimated annual cost of $ 42

billion.28

A survey carried out with the participation of

nurses in 2018 revealed that all had witnessed or

experienced errors in the administration of

medication. Most of these events did not cause

harm to the patients, but three nurses reported

that death was the final outcome and pointed out

lack of attention as the main cause of the error.29

The important relation of Burnout with possible

medication errors is noteworthy. Burnout reduces

the effectiveness of workers due to physical and

emotional symptoms, including memory lapses.

A total of 27,339 falls were reported in Brazil

between March 2014 and September 2018.30 Falls

are among the most prevalent incidents in health

services, and can lead to damages to patients that

increase morbidity and mortality.

It was found that lower incidence of falls

resulted from the implementation of preventive

measures, suggesting that the prevention

protocol, the use of a risk assessment scale, the

systematic raising of awareness and guidance to

patients, family members and the nursing staff

may have impacted the occurrence of the event in

the institution.31

It should be emphasized that all measures to

prevent medication errors and falls are relevant.

However, what this review adds is that due to the

association of these types of incidents with the

dimensions of Burnout, it is also necessary to

improve the health of the workers, especially in

relation to emotional exhaustion and

depersonalization.
Burnout was associated with lapses in

adherence to infection control protocols22 and

with lower likelihood to comply with hand hygiene

opportunities.20 It is clear that Burnout interferes

with adherence to prevention measures, thus

becoming a contributing factor to unsafe acts that

lead to risks of infection in both patients and

workers. There is a close relationship between

patient safety and infection control. Many health

care measures to prevent infections focus on

adherence to hand hygiene through an interactive

process of information, training, observation,

https://doi.org/10.5205/1981-8963.2019.239641

Batalha EMSS, Melleiro MM, Borges EMN. Burnout and its interface with patient…
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https://doi.org/10.5205/1981-8963.2019.239641

feedback32, as well as on the education and

awareness of professionals, monitoring compliance

with protocols, and using technologies.33 However,

besides these preventive measures, another need

that deserves attention is care for the worker’s

health. Workers experience situations of suffering

and this can prevent them from following

standardizations, leading to more healthcare-

related infections. This has already been

demonstrated; nosocomial infections have been

proved to be related to the three dimensions of

Burnout.17

It is essential to promote the prevention and

minimization of Burnout. Preventive measures

must take into account how this syndrome

develops and which points are essential for its

mitigation.

It is understood that six areas are fundamental

to foment strategies regarding Burnout: 1.

Workload: an amount of demands than are beyond

the worker’s ability to manage, generating or

aggravating Burnout; 2. Control: it refers to the

worker’s participation in decisions that affect his

work; 3. Reward: recognition for the contributions

of the worker, which influences the vulnerability

to Burnout; 4. Community: the quality of

relationships with others at the workplace, which

plays a central role; 5. Equity: A sense of justice

makes workers to get involved with their

workplaces, while the experience of injustice

exhausts and discourages them, causing them to

set a emotional and physical distance from the

workplace; and finally, 6. Values: when the

worker has a team with which he shares values,

making him feel more energized and motivated.2

Personal measures should be combined with

organizational measures in the plan to relief and

prevent Burnout. Such measures must focus on the

workplace and try to change the conditions that

are actually causing stress when taking into

account work-oriented proposals. This model

includes redesigning tasks, increasing the

acknowledgement of workers, and developing

more fair and equitable policies. The goal is to

change work patterns, such as working less, taking

more breaks, avoiding extra work, balancing work

with the rest of life, and measures related to the

personal level. It also includes the development of

coping skills for conflict resolution and time

management; obtaining social support; using

relaxation strategies; promoting good health and

gymnastics; and developing self-knowledge.2

It should be noted that improvements in

relation to Burnout go through an intense

organizational commitment and personal

involvement of the worker. The need for

knowledge about the syndrome and its prevention

is something that must be highlighted. Poor

knowledge about this topic has been pointed out

by nursing workers.34-5Sometimes, Burnout is

understood only as occupational stress.35 This

information ratifies the need to discuss this

phenomenon in continuing education activities in

health services, seeking to engage the workers and

give them support to deal with Burnout.

The development of Burnout syndrome is

multifactorial and dependent on personal and

organizational aspects. The literature describes,

however, factors such as excessive working hours

and professional dissatisfaction as the main

predictors of this syndrome in nurses. 36 Therefore,

measures are needed to improve these factors and

to promote a better quality of life for workers

and, consequently, greater patient safety.

It was found that Burnout is negatively

associated with patient safety, and research has

revealed critical points that can be affected by

Burnout, including general adverse events,

especially falls, medication errors, and

healthcare-related infections. It was shown that

Burnout can mediate depressive symptoms and

interfere with the relationship of time-pressure at

work, thereby demeaning patient safety.

The association between burnout and the

patient safety culture and climate was evident in

the present study. This calls for the need to

strengthen this relationship and put Burnout

prevention at the center of the intervention

proposals. The health of nursing workers should be

prioritized when patient safety policies are

implemented.

Emphasis is placed on measures at the

organizational level to prevent and minimize

Burnout, particularly on workload and stressful

situations at work. It is also pointed out that

workers should pay attention to this syndrome and

seek measures to prevent and relief the problem

at individual and group level, especially within the

scope of work team.

A low number of articles addressing the theme

of the present study was observed, this fact leads

to believe that although there is a significant

number of studies in the area of Burnout and

patient safety, the relationship between these two

large areas in nursing is still recent and little

explored, thus constituting as a possibility for

further research. Particularly important is the

establishment of causal relations between these

two areas and proposing effective interventions to

improve care, working conditions, and worker’s

health.

As limitations of the study, there was the fact

that the articles included had a cross-sectional

design, which means that given portion of the

moment was studied, and implying that the

phenomenon was not followed-up over time in the

researched scenarios. The studies are therefore

limited to expressing the relationship between

Burnout and patient safety only in this temporal

CONCLUSION

https://doi.org/10.5205/1981-8963.2019.239641

Batalha EMSS, Melleiro MM, Borges EMN. Burnout and its interface with patient…
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https://doi.org/10.5205/1981-8963.2019.239641

interval. In addition, the studies were carried out

in specific contexts and samples, and therefore,

the generalization of the results should be done

with caution.

This work was held with the support of the

Coordination for the Improvement of Higher

Education Personnel – Brazil (CAPES) – Financing

Code 88881.190017/2018-01.

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Batalha EMSS, Melleiro MM, Borges EMN. Burnout and its interface with patient…
J Nurs UFPE on line. 2019;13:e239641
https://doi.org/10.5205/1981-8963.2019.239641

Submission: 2019/01/30
Accepted: 2019/06/03
Publishing: 2019/06/22

Corresponding Address

Edenise Maria Santos da Silva Batalha

Email: edenisemaria@gmail.com

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SEPTEMBER/OCTOBER 201938

By Suzanne Waddill-Goad

Managing
Stress, Fatigue,
and Burnout in

Nursing

It’s been nearly four decades since I was a nursing student.
Still, I remember long days filled with activities: commuting to
campus and clinical rotations, hours in class and study groups,
as well as working a part-time job. When I transitioned to the
workforce, my life seemed just as busy—working long shifts
and overtime when necessary, and then moving into nursing
leadership roles which seemed to require endless hours.

While nursing is a rewarding profession, the work can be
stressful. Competing priorities, pressures from both inter-
nal and external sources, unpredictability, and unintended
consequences add a layer of risk most other professions do not
experience. These stressors can be felt by nurses and nursing
students alike.

The concept of stress was first identified in the 1930s by Dr.
Hans Seyle. He dedicated his life’s work to study the body’s
ability to adapt to stressful conditions. Unfortunately, most of
the stress that people feel today is related to workplace condi-
tions, and has progressively escalated in the last few decades
(The American Institute of Stress, 2018).

In 2017, the Centers for Disease Control and Prevention cited
more than $3.3 trillion was spent on healthcare in the United
States (U.S.). And, the cost of stress to U.S. businesses was es-
timated to be well over $300 billion for injuries and untoward
health consequences (Smith, 2016).

Consequences of Stress, Fatigue, and Burnout
Regrettably, nurses are prone to experience more work-related
stress than the wider working population, and it often goes
unnoticed (Nursing.org, 2019). Stress can be insidious; it has
the potential to cause a host of health problems and negatively
affect one’s well-being. Everyone knows what fatigue feels
like, especially when you are a student. But too much stress
can potentiate fatigue and result in burnout. According to
The American Institute of Stress (2018), the severity of stress
perceived depends on the magnitude of the demands and an
individual’s sense of control.

The term burnout was first coined in the 1970s by the psy-
chologist Dr. Herbert Freudenberger to describe changes that
he saw in mood, attitude, motivation, and personality (Michel,
2016). Today, it is commonly referred to as a problem in the
social environment where people work, with both personal
and organizational precursors.

Burnout has been studied for nearly 50 years and encompasses
more than 100 symptoms. The most commonly used defini-
tion is from Maslach and Jackson (1981) who defined burnout
as “a syndrome of emotional exhaustion, depersonalization,
and reduced personal accomplishment.” More contemporary
definitions include loss of engagement.

NSNA IMPRINT® y www.nsna.org 39

Nurse researcher Nuria O’Mahoney (2011) summarized
decades of research and the costly significance of nurses’
burnout in the journal, Emergency Nurse. Her summary
highlighted a plethora of undesirable consequences such
as low morale; increased absenteeism; adverse health
conditions; decreased job performance, productivity and
effectiveness; and high turnover.

The effects of unrecognized and unmanaged stress can
clearly be detrimental. In the last four decades, I have ob-
served that one factor remains the same: most nursing and
healthcare environments are filled with stressors and have
the potential to lead to fatigue and burnout.

Self-Care Takeaways
When I decided to become a nurse, I knew I would have
to be at my best. Caring for others can take a toll on your
physical body, mental capacity, and emotional stability.
Stress is a highly personal phenomenon (The American
Institute of Stress, 2018) and only you can assess how you
feel.

My first takeaway for you is about mindset. It is simply
defined as a set of attitudes or a lens in which one views
the world (Dictonary.com, 2019). Mindset has the ability
to affect achievement, relationships and success. To illus-
trate it, I’ll share a personal story about reorganization and
sudden job loss. While losing the job was not completely
unexpected, it was still a shock. I had just purchased a
new home, was moving the following week, and had not
yet sold my previous home. I knew I had to quickly pull
myself together and assess my options.

Self-care takeaway number two is to build resilience skills.
Within nine weeks, I found the courage to start my own
business as a consultant in operational improvement and
leadership development. Resilience is defined as the ability
to recover or adjust to misfortune or change (Merriam-
Webster.com, 2019). It’s like being elastic—adversity can
be overcome with resilience.

Self-care takeaway number three is to create space, slow
down, and take time to think. With the amount of life
stressors I faced at that time, I knew I needed to process
it all. Taking a break is time well spent; it is so easy to get
caught up in “just doing” and not “just being.” Nurses are
excellent at adapting to changing conditions and continu-
ing to move forward. However, taking time for reflection
was insightful and provided clarity.

Self-care takeaway number four is to build a strong
network of supporters. This includes classmates, peers,
mentors, neighbors, family, and friends. The people in
each of these groups will add differing perspectives. In my
story, I knew I couldn’t change the circumstances; it forced
me to reframe my thinking and turn a negative event into
a positive outcome.

Harnessing Stress for Health
From a contrarian’s point of view, some think stress may
be good for us. Dr. Kelly McGonigal, a psychologist who
lectures on organizational behavior at Stanford University’s
Graduate School of Business, asserted so in her book titled,
The Upside of Stress (2015). She described how a modifica-
tion in mindset may change everything. And, in a 2013
TED talk, she explained how to make stress your friend.
Her talk can be found at this link: https://www.ted.com/
talks/kelly_mcgonigal_how_to_make_stress_your_
friend.

When I started my business, I noticed that most of my
clients looked extremely tired. I also was suffering ill effects
after leaving an executive role. These observations further
spurred my entrepreneurial interest and drove me to ponder
the true emotional cost of being a nurse.

Then in 2010, I began a doctor of nursing practice (DNP)
program. During the first week, I proudly wrote that my re-
search was going to be about Leadership Fatigue™. I defined
it as mental, physical, and emotional fatigue resulting from
prolonged stress due to uncontrollable forces in the work
environment secondary to a leadership role, causing insidi-
ous consequences to one’s performance, overall health, and
life balance. My journey of study about stress has come full
circle over the last decade as I continue to learn about the
best ways to harness it for optimal well-being.

Unfortunately, for most people it takes a catastrophic event
to change from unhealthy to healthy ways. Take time as you
begin your nursing journey to think about what’s important
to your own health and well-being. The American Nurses
Association’s Healthy Nurse, Healthy Nation™ Grand Chal-
lenge (2017) website provides a number of resources focus-
ing on five key areas for health: physical activity, nutrition,
rest, quality of life, and safety. Consider the following two
questions to design your career plan:

1. Do you know what you need to do your best work?
2. What self-care tactics will you adopt to make health a
priority?

Recognizing and addressing the potentially negative impact
of stress and the signs of overwork are imperative to avoid
fatigue and burnout (Waddill-Goad, 2016). A more calcu-
lated approach to nursing work in relation to the thoughtful
design of systems, forming efficient work processes, attaining
reasonable workloads, working effectively in high-perform-
ing teams, and establishing boundaries for work-life balance
are key attributes for success.

Mindfulness and Intuition in Nursing Practice
Research has shown how practicing mindfulness, engaging
in meditation, as well as being present and aware can relieve
anxiety, exhaustion, and depressive symptoms related to

SEPTEMBER/OCTOBER 201940

References
American Nurses Association. (2017). Healthy Nurse, Healthy Nation™ Grand
Challenge. Retrieved from http://www.healthynursehealthynation.org/

Centers for Disease Control and Prevention (CDC). (2017). National center for
health statistics: Health expenditures. Retrieved from: https://www.cdc.
gov/nchs/fastats/health-expenditures.htm/.

Dictionary.com. (2019). Definition: mindset. Retrieved from: https://www.
dictionary.com/browse/mindset/.

Lyndon, A. (2016). Burnout among health professionals and its effect on
patient safety. Patient Safety Network: Agency for Healthcare Research and
Quality (AHRQ). Retrieved from: https://psnet.ahrq.gov/perspectives/
perspective/190/burnout-among-health-professionals-and-its-
effect-on-patient-safety/.

McGonigal, Kelly. (2015). The Upside of Stress: Why Stress Is Good for You, and
How to Get Good at It. Avery: New York, NY.

Merriam-Webster.com. (2019). Definition: intuition. Retrieved from: https://
www.merriam-webster.com/dictionary/intuition/.

Merriam-Webster.com. (2019). Definition: resilience. Retrieved from: https://
www.merriam-webster.com/dictionary/resilience.

Michel, Alexandra. (2016, January 29). Burnout and the Brain. Association for
Psychological Science. Retrieved from: https://www.psychologicalscience.
org/observer/burnout-and-the-brain

Nursing.org. (2019). Nurse burnout. Retrieved from: https://www.nursing.
org/resources/nurse-burnout/.

Maslach C., Jackson. S. E. (1981) The Measurement of Experienced Burnout. J
Organ Behav. 2(2):99 – 113.

O’Mahoney, N. (2011). Nurse burnout and the working environment. Emerg
Nurse, 19 (5): 30-7.

Perkins, S. (2019, March 11). Why every nurse should practice mindfulness. The
Atlanta Journal Constitution. Retrieved from: https://www.ajc.com/life-
styles/meditation/why-every-nurse-should-practice-mindfulness-
and-how/zku6oVAn9zFBtJHDIw8JRK/.

Smith, J. (2016, June 6). Here’s why workplace stress is costing employers $300
billion a year. Business Insider. Retrieved from: https://www.businessin-
sider.com/how-stress-at-work-is-costing-employers-300-billion-a-
year-2016-6/.

The American Institute of Stress. (2018). Workplace stress. Retrieved from:
https://www.stress.org/workplace-stress/.

Waddill-Goad, S. (2016). Nurse Burnout: Overcoming Stress in Nursing. India-
napolis, IN: Sigma Theta Tau International.

Suzanne Waddill-Goad, MBA, BSN, RN, DNP, CEN,
is President and Principal Consultant of Suzanne M.
Waddill-Goad & Company, Inc., a consulting practice
specializing in operational improvement, interim
leadership and leadership development.

work stressors (Perkins, 2019). Perkins (2019) quoted
Susan Bauer-Wu, PhD, former Emory professor
and mindfulness advocate, who pointed out that
nurses can become so busy and preoccupied that they
disconnect from their own body’s experience. Mind-
fulness and meditation may provide a barrier to stress
by potentiating improved sleep patterns, interper-
sonal relationships, and lessen stress hormones. On a
personal note, mindfulness and meditation have been
very helpful for me in managing stress and are my
next self-care takeaway; consider learning about them
both.

In Perspectives on Safety, Lyndon (2016) proposed a
linkage between burnout in healthcare professionals
and safety. She described how emotional exhaus-
tion, cynical detachment, and physical fatigue affect
caregivers’ ability to feel, potentiating a threat to
healthcare quality and patient safety. Other studies
have cited up to one-half of all healthcare providers
are feeling the effects of burnout.

Lyndon (2016) also posited that burnout can impair
cognitive functions, placing patients at risk for harm.
We know care providers never intend to harm a
patient, but a lack of attention may result in an inad-
vertent mistake. Limiting distractions, interruptions,
detachment, stress, fatigue, and burnout are essential
to provide mindful as well as, safe care.

The last self-care takeaway is about intuition. As a
nurse, you must learn to develop it and then listen
to it. Intuition is defined as the ability to understand
something immediately without the need for rational
thought or inference (Merriam-Webster.com, 2019).
Every time I haven’t listened to my own intuition,
things didn’t work out as well as they could have.

Conclusion
Understanding stress and the associated consequences
is crucial to learning how to think differently about it.
Optimal well-being is a delicate balance between the
external and internal environment and how a person
responds to perceived stress.

To begin your healthful nursing journey, check your
score on the Perceived Stress Scale (Cohen, 1994)
which can be accessed here: https://www.mindgar-
den.com/documents/PerceivedStressScale G