DISCUSSION
Burnout prevalence and workplace factors that influence burnout were
measured among clinicians who provide pediatric care in a
hematology-oncology setting. Burnout levels were substantial across all
4 role-based cohorts in all 3 MBI dimensions, similar to previous
studies.10,11 To contextualize part of our results,
respondents from all 4 cohorts reported feeling emotionally exhausted or
experiencing reduced personal accomplishment from their work an average
of twice per month. Depersonalization (e.g., treating a patient as an
immaterial object) rates were substantially lower compared to emotional
exhaustion and reduced personal accomplishment, which is encouraging as
this construct represents a lack of presenteeism and may reflect a more
severe expression of burnout.26
Among workplace factors associated with burnout, the NASA-TLX dimension,
“frustration”, was the most significant contributor across all 4
cohorts and 3 MBI dimensions. Temporal demand was also associated with
burnout among MDs and nurses, but to much less a degree than
frustration. Similarly, PSE involvement was significantly associated
with burnout only among nurses.
Our post-hoc review of open-response comments elucidates the strong
associations we observed between burnout rates and frustration levels.
Comments addressing time constraints parallel our temporal demand
results, and perceptions of feeling rushed or having inadequate time to
complete tasks effectively are known predictors of
burnout.28-30 Respondents expressed perceptions of
insufficient administrator support in terms of feeling unable to garner
managerial assistance when experiencing confrontations with colleagues,
families, or patients. They also noted a general disconnect between the
leadership’s perspective and the realistic needs of front-line staff.
Insufficient institutional support for self-care reflected a desire for
time away from work after experiencing patient loss, including both an
immediate reprieve from clinical duties and paid time off to grieve and
recover. Finally, perceptions of inadequate staffing and frequent
turnover were identified. Inadequate staffing can result in increased
individual task demands (a commonly cited predictor of
burnout),31 and restrict employees’ ability to utilize
paid time off. Turnover, especially voluntary turnover, can affect unit
morale.32,33 When team members quit, remaining members
may face a paucity of expertise and need to mentor new colleagues.
Hence, inadequate staffing and turnover may create and perpetuate
burnout in those perceiving a lack of adequate resources as an increase
in individual demands is required to accomplish the necessary tasks.
PSE involvement can be detrimental to a clinician’s psychological
well-being decades after the event, and there are unfortunate examples
of clinician suicide after medical errors.34 Effects
can mirror post-traumatic stress disorder and include lingering negative
perceptions of professional self-efficacy.35 Our study
is one of the first to identify a connection between involvement in PSEs
and burnout among inpatient and ambulatory nurses in a pediatric
hematology-oncology setting. Given the known consequences of burnout
that include job performance deficits and potential turnover, our study
provides further evidence for the development and implementation of
resources to preserve the psychological well-being of staff involved in
medical errors and serious safety events.
One strength of our study was using RWA, which addresses concerns raised
when researchers use unique variance accounted for in regression models
to rank predictors by significance.36 The principal
challenge is that predictor variables are often intercorrelated, which
leads to flawed interpretations of traditional metrics to partition
unique predictor variance. We treated the 3 MBI dimensions as separate
outcomes and used RWA to determine unique contributions of 6 predictors
(NASA-TLX dimensions and PSE involvement).
As for limitations, St. Jude has a unique care model treating only a
specialized population of patients. Our results may not generalize well
to other pediatric hospitals caring for children with varied acute and
chronic issues or to smaller pediatric oncology settings.
Cross-sectional designs have many limitations, including causality,
directionality, and biases originating from the study sample (e.g.,
responder bias, recall bias, and selection bias). Lastly, the MBI is the
most widely used burnout survey instrument but does not include
clinically validated cutoff scores. Publishers of the MBI do not
advocate using results to determine burnout rates or support cutoff
scores for low, moderate, and high levels of MBI dimensions. Researchers
have developed their own MBI cutoff scores, but they vary
widely.37 Lack of standardized MBI cutoff scores
limits the ability to compare burnout rates across studies, which
hinders its capability in expanding knowledge on causes, effects, and
protective resources to reduce and prevent burnout.