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Applied Nursing Research

journal homepage: www.elsevier.com/locate/apnr

Original article

Estimating the association between burnout and electronic health record- related stress among advanced practice registered nurses

Daniel A. Harris, MPHa,c, Jacqueline Haskell, MSc, Emily Cooper, MPHc,⁎, Nancy Crouse, CNSd, Rebekah Gardner, MDb,c

a Department of Epidemiology, Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada bWarren Alpert Medical School, Brown University, Providence, RI, United States of America cHealthcentric Advisors, Providence, RI, United States of America d Boston Medical Center, Boston, MA, United States of America

A R T I C L E I N F O

Keywords: APRN Burnout Electronic health record Health information technology

A B S T R A C T

Background: Health information technology (HIT), such as electronic health records (EHRs), is a growing part of the clinical landscape. Recent studies among physicians suggest that HIT is associated with a higher prevalence of burnout. Few studies have investigated the workflow and practice-level predictors of burnout among ad- vanced practice registered nurses (APRNs). Aim: Characterize HIT use and measure associations between EHR-related stress and burnout among APRNs. Methods: An electronic survey was administered to all APRNs licensed in Rhode Island, United States (N= 1197) in May–June 2017. The dependent variable was burnout, measured with the validated Mini z burnout survey. The main independent variables were three EHR-related stress measures: time spent on the EHR at home, daily frustration with the EHR, and time for documentation. Logistic regression was used to measure the association between EHR-related stress and burnout before and after adjusting for demographics, practice- level characteristics, and the other EHR-related stress measures. Results: Of the 371 participants, 73 (19.8%) reported at least one symptom of burnout. Among participants with an EHR (N=333), 165 (50.3%) agreed or strongly agreed that the EHR added to their daily frustration and 97 (32.8%) reported an insufficient amount of time for documentation. After adjustment, insufficient time for documentation (AOR=3.72 (1.78–7.80)) and the EHR adding to daily frustration (AOR=2.17 (1.02–4.65)) remained predictors of burnout. Conclusions: Results from the present study revealed several EHR-related environmental factors are associated with burnout among APRNs. Future studies may explore the impact of addressing these EHR-related factors to mitigate burnout among this population.

1. Introduction

Resulting from chronic job-related stress, burnout is characterized by emotional exhaustion, depersonalization, and decreased job sa- tisfaction (Maslach, Schaufeli, & Leiter, 2001). Given the high-stress nature of clinical environments, burnout among healthcare workers has been shown to exceed that of the general population (Shanafelt, Boone, Tan, et al., 2012). Among physicians, the first published report of “burnout” emerged in 1981 (Pines, 1981). A nationally representative survey of United States physicians revealed that nearly half (45.8%) experienced at least one symptom of burnout (Shanafelt et al., 2012; Shanafelt, Hasan, Dyrbye, et al., 2015). Moreover, results indicated that over 50% of physicians in “front line” specialties (e.g., emergency

medicine and general internal medicine) reported one or more symp- toms of burnout (Shanafelt et al., 2012). Several studies have identified associations between physician burnout and poorer quality of care (Melville, 1980; Yuguero, Marsal, Esquerda, & Soler-Gonzalez, 2017), reduced patient satisfaction (Haas et al., 2000), and increased risk of turnover (Williams, Konrad, Scheckler, et al., 2001). However, despite the breadth of literature investigating burnout among physicians, sig- nificantly fewer studies have explored burnout among advanced prac- tice registered nurses (APRNs) (Hoff, Carabetta, & Collinson, 2017).

In 2010, the Agency for Healthcare Research and Quality estimated that over 100,000 APRNs practice in the United States, with over half (52.0%) working in primary care (Agency for Research Health and Quality, 2012). As of 2017, the number of APRNs has grown to 234,000

https://doi.org/10.1016/j.apnr.2018.06.014 Received 4 March 2018; Received in revised form 19 June 2018; Accepted 23 June 2018

⁎ Corresponding author at: 235 Promenade Street, Suite 500, Providence, RI, United States of America. E-mail address: [email protected] (E. Cooper).

Applied Nursing Research 43 (2018) 36–41

0897-1897/ © 2018 Elsevier Inc. All rights reserved.

T

in the United States (American Association of Nurse Practitioners, 2017; Hoff et al., 2017). Similar growth of the APRN workforce has been observed in the Netherlands, Canada, Australia, Ireland and New Zealand from 2005 to 2015 (Maier, Barnes, Aiken, & Busse, 2016). APRNs comprise a large and crucial component of the clinical work- force especially as physician shortages in both primary and specialized care settings continue to increase (Hoff et al., 2017; Norful, Swords, Marichal, Cho, & Poghosyan, 2017). Despite the growth of the APRN workforce in the United States and internationally, few studies have investigated the work-related psychological outcomes experienced by this population. One study showed that compared to emergency nurses and nurse managers, APRNs tend to experience less burnout (Browning, Ryan, Thomas, Greenberg, & Rolniak, 2007). The authors suggested that lower burnout among APRNs may be because they enter the field to gain more autonomy (Whelan, 1997), a job characteristic that is typically associated with greater job satisfaction (Tri, 1991). A recent review of job satisfaction, burnout, and job turnover among APRNs and physician assistants revealed that although APRNs generally report high job satisfaction, considerable variation exists across studies (Hoff et al., 2017). The authors also noted that the literature examining burnout among APRNs has a number limitations: 1) many studies with sample sizes of less than<200, 2) a predominance of univariable and bivari- able analyses, as opposed to multivariable statistical methods, and 3) a limited consideration of work setting and organizational factors (Hoff et al., 2017).

In the United States, recent changes in the payment landscape (e.g., Meaningful Use and the Physician Quality Reporting System) and their connection to HIT have drawn investigators to explore potential asso- ciations between HIT and burnout among physicians (Shanafelt et al., 2012; Shanafelt, Dyrbye, Sinsky, et al., 2016). One recent survey of a nationally representative sample of United States physicians reported that overall satisfaction with electronic health records (EHRs) was ty- pically low and that physicians who used EHRs had higher odds of burnout (Shanafelt et al., 2016). Dissatisfaction with HIT has also been observed among physicians and nurses internationally (Griffon et al., 2017; Leslie & Paradis, 2018; Ologeanu-Taddei, Morquin, & Vitari, 2017). Similar to physicians, APRNs engage with HIT as part of their practice (Bowles, Dykes, & Demiris, 2015; Cooper, Baier, Morphis, Viner-Brown, & Gardner, 2014; Fund TC, 2017); however the re- lationship between HIT and burnout among this population remains unstudied. Therefore, the current study’s primary aim is to address several of the limitations in the literature by estimating the association between EHR-related stress and burnout among APRNs, while adjusting for demographic and organizational factors using multivariable methods. To further describe APRN engagement, attitudes and per- ceptions about HIT, our study’s secondary aim is to characterize other dimensions of HIT and EHR use (e.g., office communication). We hy- pothesize that EHR-related stress will be significantly associated with burnout.

2. Methods

Administered by the Rhode Island Department of Health, a state- wide electronic survey was sent to all 1197 APRNs licensed and in practice in Rhode Island. The survey period was from May 8th, 2017 to June 12th, 2017. As part of a legislative mandate (State of Rhode Island Plantations,

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