NE W G R A D U AT E S FA C E M A N Y

Heather K. Spence Laschinger Joan Finegan Piotr Wilk N ew Graduate Burn o u t : The Impa c t Of Professional Pra c t i c e E nv i ro n m e n t, Wo rkplace Civility, And Empowe rm e n t EX E C U T I V E SU M M A RY The future of professional nu r s i n g depends on finding ways to create high-quality wo rk env i r o n- ments that retain newcomers to the profe s s i o n. The purpose of this study was to examine the combined effect of s u p p o rt i ve professional pra c t i c e e nv i r o n m e n t s, civil wo rking relat i o n s h i p s, and empowe rment on n ew gra d u a t e s ex p e riences of bu rnout at wo rk. The results support previous ev i- dence of the importance of wo rking environments that enable new graduates to practice according to professional standards learn e d in their educational progra m s. F u rt h e r, the results provide a more comprehensive understanding of the impact of wo rk p l a c e conditions on new gra d u a t e bu rnout by demonstrating the a d d i t i ve value of wo rking in collegial wo rk settings in which nu r s e s respected others and refrain from incivility behaviors in their day to d ay wo rk. G i ven the current nursing shorta g e, eve ry effo rt must be made to ensure that new graduates are exposed to high-quality wo rk e nvironments that engage them with their wo rk. NE W G R A D U AT E S FA C E M A N Y challenges as they begin their nursing care e r s ( B e e c roft, Dore y, & We n t e n, 2008; Duchscher, 2001; Jasper, 1996). Transitioning from student status to the full professional ro l e re q u i res gaining clinical expert i s e and self-efficacy for practice within a work environment that supp o rts both professional practice and individual development. Nurses who are empowered to p rovide care according to pro f e s- sional nursing standards experience greater satisfaction with their work (Havens & Aiken, 1999; Sabiston & Laschinger, 1995), and a re less likely to leave their jobs (Nedd, 2006). Work enviro n m e n t s that support professional nursing practice also result in more positive outcomes for patients (Aiken, Smith, & Lake, 1994; To u r a n g e a u, Gioavannetti, Tu, & Wood, 2002). H o w e v e r, current nursing work e n v i ronments with their heavy workloads are stressful for even the most seasoned nurses who are re p o rting high levels of burn o u t and absenteeism (Greco, Laschinger, & Wong, 2006; Laschinger, Almost, Purd y, & Kim, 2004). Recent studies of new graduates a re particularly disturbing. Cho, L a s c h i n g e r, and Wong (2006) found that 66% of new graduates w e re experiencing severe burn o u t and that burnout was associated with negative workplace conditions. Beecroft et al. (2008) found that 30% of new graduates in their study had high turnover intentions, predominantly related to disempowering work enviro n- ments. Bowles and Candela (2005) re p o rted an actual turnover rate of 30% in the first year and 57% after 2 years. These results are a l a rming since the future of professional nursing depends on finding ways to create high-quality work environments that re t a i n newcomers to the pro f e s s i o n. New Graduate Work Experience Several factors are import a n t for new graduates job satisfaction, H E ATHER K. SPENCE LASCHINGER, PhD, RN, is Distinguished University Professor and Associate Director Nursing Research, Arthur Labatt Family School of Nursing, The University of We s t e rn Ontario, London, Ontario, Canada. JOAN FINEGAN, PhD, is Chair and Executive Officer, Undergraduate Affairs; Associate Dean, Social Science; and Associate Pro f e s s o r, The University of We s t e rn Ontario, London, Ontario, Canada. PIOTR WILK, PhD, is a Casual Associate P ro f e s s o r, School of Nursing, The University of Western Ontario, London, Ontario, Canada; and Scientist, Health R e s e a rc h e r, Middlesex-London Health Unit, London, Ontario, Canada. 377

work stress, and turnover intentions. Supportive supervisors and positive relationships with coworkers in the early stages of employment are part i c u l a r l y i m p o rtant (Casey, Fink, Kru g m a n, & Propst, 2004; Halfer & Graf, 2006; Oermman & Moff i t t - Wo l f, 1997; Roberts, Jones, & Ly n n, 2004). Cho et al. (2006) found that new graduates who felt their work e n v i ronment provided a stro n g sense of community were less likely to experience burnout, further supporting the importance of positive relationships among coworkers. I n s u fficient re s o u rces to provide high-quality care and heavy workloads are other sources of s t ress for new graduates (Gre e n e, 2005; Halfer & Graf, 2006; O e rmman & Moff i t t - Wolf, 1997). These factors were important predictors of burnout in Cho et al. s (2006) study of new graduates. They found that a lack of fit between new graduates personal s t a n d a rds for professional practice and those in their work settings was associated with higher levels of burnout. Opportunities for professional development were an i m p o rtant retention factor for new graduates in two recent studies ( G reene, 2005; Roberts et al., 2004). Ferguson and Day (2004) also found that new graduates valued opportunities to increase their knowledge and skills, which resulted in greater feelings of accomplishment and greater acceptance by experienced nurses in their work settings. Hayes et al. (2006) also highlighted the importance of working relationships for new graduates sense of belonging. T h e re are numerous anecdotal re p o rts of uncivil behaviors t o w a rd new graduates by senior nurses (Duchscher, 2001), although t h e re have been few published empirical studies in the literature. It is, however, reasonable to expect work environments that do not support professional practice in combination with workplace incivility among nurses are precursors to burnout in new graduates. There f o re, it is important to understand factors that can make a diff e rence in new graduates health and well-being. The literature suggests that when new graduates work in settings that empower them for professional nursing practice and are characterized by civil interpersonal relationships among their coworkers, they are less likely to experience work stress or burn o u t. H o w e v e r, we could find no study that examined these factors in a single study of new graduate nurses. There f o re, the purpose of this study was to examine the combined effect of supportive pro f e s- sional practice enviro n m e n t s, civil working relationships, and e m p o w e rment on new graduates experiences of burnout at work. Supportive Professional Practice Environments T h e re is considerable evidence that hospitals known to attract and retain nurses (Magnet hospitals) are characterized by feat u res that support pro f e s s i o n a l nursing practice (Aiken et al., 1994; Kazanjian, Green, Wong, & Reid, 2005; Kramer & Schmallenberg, 1988). Lake (2002) describes five elements of supportive pro f e s s i o n- al practice environments: adequate staffing, strong nursing leadership, staff decisional involvement, a nursing model of care (vs. medical model), and eff e c t i v e nurse-physician collaboration. These characteristics were re l a t e d to a variety of nursing and patient outcomes in numerous studies. Tourangeau et al. (2002) linked Magnet hospital characteristics to patient mort a l i t y, as did Aiken et al. (1994). Laschinger and Leiter (2006) demonstrated how these factors interacted to predict nurseassessed adverse events. Other re s e a rch has linked these characteristics to important nurse re t e n- tion factors, such as, job satisfaction (Aiken, Clarke, Sloane, Sochalski, & Silber, 2002; Hall & Doran, 2007; Laschinger, Almost et al., 2004), burnout (Laschinger & Leiter, 2006; Leiter & Laschinger, 2006), and workplace e m p o w e r- ment (Laschinger, Almost, & Tu e r- Hodes, 2003; Manojlovich & L a s c h i n g e r, 2007). Workplace Incivility Workplace incivility has received increasing attention in the general management and work s t ress literature (Cortina, Magley, Williams, & Laughout, 2001; Pearson, Anderson, & We g n e r, 2001). There were numerous anecdotal re p o rts of uncivil behavior in nursing and health care settings although few empirical studies exist in the literature. Wo r k p l a c e incivility is defined as low-intensity deviant behavior with ambiguous intent to harm the target, in violation of workplace n o rms for mutual respect. Uncivil behaviours are characteristically rude, discourteous, displaying a lack of respect for others (Andersson & Pearson, 1999, p. 457). Cortina et al. (2001) linked workplace incivility to decre a s e d job perf o rmance and job dissatisfaction. Lim, Cortina, and Magley (2008) found relationships between incivility and employee health and well-being, as well as t u rnover intentions. Dion (2006) found the staff nurses perc e p t i o n s of workplace incivility were significantly related to feeling supp o rted by their supervisor and positively related to feelings of occupational stress and turn o v e r intentions. Intere s t i n g l y, nurses in this sample did not re p o rt high levels of incivility in their workplaces, contrary to anecdotal re p o rt s. Burnout/Engagement B u rnout is defined as a psychological syndrome of exhaust i o n, cynicism and ineff i c a c y which is experienced in re s p o n s e to chronic job stressors (Maslach, 2004, p. 93). Leiter and Maslach (2004) argue that burnout is characterized by emotional exhaustion, cynicism, and pro f e s s i o n a l 378

i n e ff i c a c y. Emotional exhaustion is considered the core element of b u rnout, resulting in cynicism t o w a rd one s work and colleagues and low efficacy levels (Leiter, H a rvie, & Frizzel, 1998; Leiter & Maslach, 2004; Maslach & Leiter, 1997). Burnout has been studied extensively in nursing and health c a re in general. Aiken et al. (2002) linked high levels of emotional exhaustion to lower levels of staff nurse perceptions of autonomy, c o n t rol over practice, and nurse/physician collaboration o rganizational characteristics associated with Magnet hospitals. The combination of positive pro f e s- sional practice environments and low burnout is related to gre a t e r job satisfaction and better patient outcomes (Va h e y, Aiken, Sloane, Clark, & Va rgas, 2004). B u rnout among new graduates is alarmingly high. Cho et al. (2006) found that 66% of new graduates re p o rted severe levels of emotional exhaustion. Given the link between burnout and t u rnover in the general nursing population, high burnout of new graduates is particularly alarm i n g in light of the severe nursing s h o rt a g e. Model Tested in the Study We tested a model derived f rom a review of the literature integrating theory and re s e a rc h relating to supportive practice e n v i ronments, workplace incivilit y, empowerment, and burn o u t. We hypothesized that new graduates who feel their work enviro n- ments are supportive of pro f e s- sional nursing practice will also rate the level of civility among coworkers and their feelings of e m p o w e rment highly, which in t u rn, will result in lower levels of b u rnout (emotional exhaustion). To our knowledge this is the first study to examine these re l a t i o n- ships within the new graduate population. University ethical a p p roval was obtained for this s t u d y. Methods Setting and sample. We conducted an analysis of a subset of c ross-sectional data collected fro m s t a ff nurses in 2006 in a larg e Ontario provincial study (n= 3,180) designed to examine the impact of workplace empowerment on unit and individual nursing outcomes. For this analysis, we selected nurses who had been in the pro f e s s i o n for less than 2 years to create a sample of new graduate nurses (n=247). In the larger study, all re g- i s t e red staff nurses on 271 inpatient units received a questionnaire t h rough the hospital mail following ethical approval. The Dillman Total Design Methodology (Dillman, 2000) was used to i n c rease re t u rn rates (larger study re t u rn rate was 40%). A re m i n d e r letter was sent 3 weeks following the initial survey package, and a second survey package was sent 1 month after the reminder letter. Nurses were assured of the confidentiality of their responses. Table 1. Demographics Mean Standard Deviation Age 28.4 6.46 Years Nursing Experience 1.54 6.67 Years in Current Setting 1.38 0.71 Highest Education N % Diploma 85 34.8 University 159 65.2 Work Status Full-time 159 65.2 Part-time 85 34.8 Specialty Area Medical-surgical 136 58.6 Critical care 49 21.1 Maternal child 31 13.4 Mental health 14 6.0 Rehabilitation 2 0.9 On average, new graduate nurses in this analysis were 28 years of age (71% <30), had 1.5 years of nursing experience, and 1.3 years in their current nursing position (see Table 1). Most were female (94%), worked full-time (65%), were baccalaureate prep a red (65%), and worked on medi c a l - s u rgical units (59%) or critical c a re (21%). I n s t ru m e n t a t i o n. The Practice E n v i ronment Scale of the Nursing Work Index (NWI-PES) (Lake, 2002) consists of 31 items rated on a 4-point Likert scale, ranging fro m 1 (strongly agree) to 4 (strongly disa g ree). Items are reverse scored to c reate high scores signifying a high level of Magnet hospital characteristics in the work setting. Five subscales reflecting Lake s (2002) 5- factor professional practice environment characteristic were cre a t- ed by summing and averaging a p p ropriate items. Previous studies established acceptable C ronbach alpha reliability ranging f rom 0.65 to 0.84 (Arm s t rong & 379

Table 2. Observed Means and Standard Deviations for Instrument Scales and Subscales Instrument Mean Standard Deviation Cronbach Alpha Total NWI-PES (total Magnet hospital characteristics)* 2.63 0.43 0.88 Subscales Nursing participation* 2.41 0.52 0.83 Nursing foundation for care* 2.72 0.43 0.72 Management ability* 2.62 0.65 0.85 Adequate staff* 2.29 0.64 0.81 Collaborative relationships* 2.85 0.68 0.81 Global Empowerment** 3.40 0.96 0.89 Workplace Civility** 3.67 0.88 0.78 Emotional Exhaustion*** 3.43 1.38 0.91 Degree of Conflict among Unit Nurses** 2.39 1.09 N/A Score Range: *1-4, **1-5, ***0-6 n = 247 NWI-PES = The Practice Environment Scale of the Nursing Work Index L a s c h i n g e r, 2006; Lake, 2002; Laschinger & Leiter, 2006). In this s t u d y, Cronbach alpha re l i a b i l i t i e s ranged from 0.72 to 0.85 and 0.92 for the total NWI-PES (see Table 2). C o n s t ruct validity for the NWI-PES was demonstrated by a confirm a- t o ry factor analysis by Leiter and Laschinger (2006). New graduates perceptions of the quality of the re l a t i o n s h i p s among nurses on their units (workplace civility) were measured by 4- items from Shortell, Rousseau, Gillies, Devers, and Simons (1991) ICU Nurse-Physician Questionn a i re. Sample items included: nurses on this unit seem to have a low opinion of other nurses, and nurses do not receive the cooperation they need from each other. Items are rated on a 5-point scale, then summed and averaged to create an index of workplace civility (higher scores reflected low workplace incivility on their units). In this study, the Cronbach alpha c o e fficient was 0.82. A 1-item m e a s u re of nurses perceptions of the amount of conflict on their unit also was included as a constru c t validity measure (not included in the civility score ). Overall perceptions of emp o w e rment were measured by the 2-item Global Empowerment Scale ( L a s c h i n g e r, Finegan, Shamian, & Wilk, 2001). Items measure the extent to which respondents feel they are empowered to work eff e c- tively in their current work setting. Items are rated on a 5-point Likert scale ranging from strongly disagre e to strongly agree. This measure has been used in nursing populations and has acceptable internal consistency reliability (r=0.90) (Laschinger et al., 2001). It is strongly related to a well-established measure of s t ructural empowerment (Laschinger, F i n e n g a n, Shamian, & Wilk, 2004). Alpha reliability for this scale in this study was 0.92. F i n a l l y, the Emotional Exhaustion (EE) subscale of the Maslach Burnout Inventory - G e n e r a l S u rvey (Schaufeli, Leiter, Maslach, & Jackson, 1996) was used to measu re new graduate burnout. Items a re rated on a 7-point Likert scale ranging from 0 (never) to 6 (every day). Leiter and Maslach (2004) a rgue that a high score on this scale (>3) is indicative of burn o u t. C ronbach alpha coefficients for the EE scale range from 0.65 to 0.91 ( L a s c h i n g e r, Finegan, Shamian, & Wilk, 2003). In this study, the C ronbach alpha reliability coeff i- cient for EE was 0.91. Data analysis. The Statistical Package for Social Sciences 16.0 was used to conduct descriptive and inferential statistical analyses. We treated the scores on all measu res of major study variables as continuous data to permit the use of more powerful statistical analyses. According to Nunnally (1978) and Labovitz (1972), the negative consequences of this approach in behavioral re s e a rch are minimal and the use of more sensitive statistical pro c e d u res with known sampling error enhances the interp retability of the results (Pedhazur & Pedhazur Schmelkin, 1991). H i e r a rchical multiple re g re s s i o n analysis was used to test the model. R e s u l t s Descriptive re s u l t s. Table 2 contains the means and standard deviations for major study variables. New graduates perc e i v e d their work environment to have moderate levels of overall Magnet hospital characteristics (M=2.60, SD=0.44), somewhat similar to L a k e s (2002) results for non-magnet hospitals (M=2.65, SD=0.37), b u t 380

lower than those of Magnet hospitals (M=2.95, SD=0.40). Nursing as a foundation for care (vs. medical model) (M=2.99, SD=0.48) and nurse-physician re l a t i o n s h i p s (M=2.84, SD=0.68) were the highest Magnet hospital characteristics, while adequate staffing (M=2.24, S D = 0. 64 ) was the lowest. This patt e rn is similar to those in Lake s (2002) study, although the ratings of staffing adequacy were considerably lower in the current study. These findings are slightly lower than those in previous studies of Ontario nurses (Arm s t rong & L a s c h i n g e r, 2006; Laschinger et al., 2003 ). New graduates felt that their work environments were only somewhat empowering (M=3.30, SD=0.77), slightly higher than other studies of nurses generally ( A rm s t rong & Laschinger, 2005; L a s c h i n g e r, Finegan et al., 2004), but similar to new graduates in Cho et al. s 2006 study (X = 3.42, SD=0.95). I n t e re s t i n g l y, new graduates re p o rted somewhat positive ratings of workplace civility in their work setting (M=3.66, SD=7.88). They also re p o rted low levels of conflict among nurses on their units (M=2.23, SD=1.08), although t h e re was wide variation on these s c o res (only 16.5% agreed or s t rongly agreed with the statement that there was a lot of conflict among nurses on their units). This finding is encouraging although c o n t r a ry to many anecdotal re p o rt s in the literature about co-worker incivility in nursing settings. F i n a l l y, new graduates in this study re p o rted high levels of emotional exhaustion (62% scored >3, the cut point for severe burn o u t, a c c o rding to Maslach, Jackson, and Leiter [1996]). These results are similar to those of Cho et al. (2006), who found the 66% of new graduates studied were in the s e v e re burnout category. P redictors of new graduate b u rn o u t. H i e r a rch ical multiple re g ression analysis was conducted to examine the impact of workplace factors on new graduate s b u rnout level (emotional exhaustion). New graduates perc e p t i o n s of support for professional nursing practice in their work settings ( L a k e s 5 Magnet hospital characteristics) were significant independent predictors of emotional exhaustion (β= -0.221, p=0.004), as w e re workplace civility (β= -0.18, p=0.003) and empowerm e n t (β= -0.245, p=0.001); that is, a combination of a supportive practice e n v i ronment, civil working re l a- tions among nursing colleagues, and an overall sense of empowerment in the workplace contributed to lower levels of emotional exhaustion among new graduates, explaining 28% of the variance in b u rn o u t. D i s c u s s i o n The analysis provided support for the hypothesized model. A s u p p o rtive professional practice e n v i ronment, low levels of incivili t y, and an overall sense of workplace empowerment explained variance of new graduates experience of burnout at work. These results support previous evidence of the importance of working environments that enable new graduates to practice according to professional standards learned in their educational programs. Our results provide a more compre h e n- sive understanding of the impact of workplace conditions on new graduate burnout by demonstrating the additive value of working in collegial work settings in which nurses respected others and refrained from incivility behaviors in their day to day work. A subanalysis revealed that g reater EE was associated with s t a ffing inadequacy and the prim a ry focus on a medical model of c a re on their units. However, EE was significantly related to all aspects of Magnet hospital characteristics. Intere s t i n g l y, RN/MD collaboration was least and stro n g l y related to EE. On the other hand, p r i m a ry use of a nursing model of c a re (vs. medical) was negatively related to new graduates perc e p- tions of workplace incivility; that is, they experienced less incivility with their colleagues when there was strong nursing foundation of c a re. New graduates would have higher expectations for this a p p roach having recently completed their nursing education programs. This expectation may diff e r f rom those of the seasoned nurses in these settings and potentially lead to conflicts among the staff. The significant impact of these working conditions on new graduates experiences of burnout suggests that managerial strategies that empower nurses for pro f e s- sional practice are needed to e n s u re nurses health and wellbeing. Research has shown that nursing leadership is central to ensuring that components of supp o rtive professional practice environments are in place. When work e n v i ronments are stru c t u red in this way, nurses experience lower levels of burnout, which, in turn, result in greater job satisfaction and fewer adverse patient events (Laschinger & Leiter, 2006; Leiter & L a s c h i n g e r, 2006; Manojlovich & L a s c h i n g e r, 2007). In our study, new graduates perceptions of their manager s ability was an i m p o rtant factor relating to emotional exhaustion. This highlights the importance of unit manager leadership practices in pre v e n t i n g b u rnout, thereby ensuring higher quality of patient care and lower t u rnover intentions. Given evidence linking burnout of nurses to poor mental and physical health, turnover and other important outcomes strategies to prevent burnout are important for nurses, organizations, and patients. Leiter et al. (1998) and Vahey et al. (2004) found that patients on units with high nurse b u rnout were significantly less satisfied with their care than those on units with lower levels of burn o u t. These studies highlight the importance of creating positive work e n v i ronments for nursing practice for both nurses and patients. 381

Maslach and Leiter (1997) emphasize the need to create org a n i z a- tional interventions to pre v e n t b u rnout and promote engagement at work (in contrast to focusing exclusively on enhancing coping skills). Nurse leaders play a key role in supporting the implementation of these interventions in their work settings. Nurses in this study did not re p o rt high levels of workplace incivility or conflict on their units, c o n t r a ry to anecdotal re p o rts in the l i t e r a t u re. It is possible that the m e a s u re of incivility used in this study was not sensitive to the full range of the phenomena. However, the measure did tap nurses perceptions of the nature of working relationships among nurses on the unit, a key aspect of workplace incivility according to Pearson et al. (2001) and Cortina et al. (2001). Nurses perception of workplace incivility was significantly re l a t e d to both the extent to which they felt their work environment was s u p p o rtive of professional practice and their overall feelings of e m p o w e rment, both of which were independent significant pre d i c t o r s of burnout. This finding re i n f o rc e s the importance and inter- re l a t e d- ness of aspects of the pro f e s s i o n a l practice environment in new graduates relationships with their work. Given nursing leadership s role in creating environments that s u p p o rt professional practice, these results further suggest that s t rong leadership is a critical component for new graduate retention. L i m i t a t i o n s The cross-sectional nature of the original study precludes stro n g claims of causal effects. The study should be replicated using a sample that includes more experienced nurses to examine generational diff e rences and the impact of nursing experience on the b u rnout experience. However, s u p p o rt for a hypothesized model derived from theory and re s e a rc h in a re p resentative provincial sample is encouraging and suggests that further re s e a rch is warr a n t e d. A longitudinal study of changes over time would also be valuable. Replication of this study using a m o re precise measure of workplace incivility is also re c o m- m e n d e d. C o n c l u s i o n Our results provide support for a link between supportive professional practice enviro n m e n t s, workplace civility, empowerm e n t, and new graduates experience of b u rnout, a previously unstudied relationship. The results suggest that working in environments that p e rmit new graduates to practice a c c o rding to professional stand a rds and in alignment with their l e a rnings in their educational programs and that are free of uncivil behaviors among colleagues, matter to them and may protect them f rom burning out. 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