Chapter 26. Work Stress and Burnout Among Nurses: 

Role of the Work Environment and Working Conditions 

Bonnie M. Jennings 

Background 

Stress has been categorized as an antecedent or stimulus, as a consequence or response, and 

as an interaction. It has been studied from many different frameworks (or perspectives?). For 

example, Selye1

 proposed a physiological assessment that supports considering the association 

between stress and illness. Conversely, Lazarus2 (p. 19) advocated a psychological view in which 

stress is “a particular relationship between the person and the environment that is appraised by 

the person as taxing or exceeding his or her resources and endangering his or her well-being.” 

Stress is not inherently deleterious, however. Each individual’s cognitive appraisal, their 

perceptions and interpretations, gives meaning to events and determines whether events are 

viewed as threatening or positive.2

 Personality traits also influence the stress equation because 

what may be overtaxing to one person may be exhilarating to another.3

Nevertheless, stress has been regarded as an occupational hazard since the mid-1950s.4 In 

fact, occupational stress has been cited as a significant health problem.5–7 Work stress in nursing 

was first assessed in 1960 when Menzies8 identified four sources of anxiety among nurses: 

patient care, decisionmaking, taking responsibility, and change. The nurse’s role has long been 

regarded as stress-filled based upon the physical labor, human suffering, work hours, staffing, 

and interpersonal relationships that are central to the work nurses do. Since the mid-1980s, 

however, nurses’ work stress may be escalating due to the increasing use of technology, 

continuing rises in health care costs,9 and turbulence within the work environment.10

In 1974, Freudenberger11 coined the term “burnout” to describe workers’ reactions to the 

chronic stress common in occupations involving numerous direct interactions with people. 

Burnout is typically conceptualized as a syndrome characterized by emotional exhaustion, 

depersonalization, and reduced personal accomplishment.12 Work life, however, is not 

independent from family life; these domains may even be in conflict.13, 14 Stress may result from 

the combined responsibilities of work, marriage, and children.15–17 The effects of both work and 

nonwork stress among nurses have been studied infrequently.18 And yet, nonwork stress may be 

particularly salient to nursing, a predominantly female profession. Women continue to juggle 

multiple roles, including those roles related to the home and family, for which the women may 

have sole or major responsibility. 

Nevertheless, work stress and burnout remain significant concerns in nursing, affecting both 

individuals and organizations. For the individual nurse, regardless of whether stress is perceived 

positively or negatively, the neuroendocrine response yields physiologic reactions that may 

ultimately contribute to illness.1 In the health care organization, work stress may contribute to 

absenteeism and turnover, both of which detract from the quality of care.9

 Hospitals in particular 

are facing a workforce crisis. The demand for acute care services is increasing concurrently with 

changing career expectations among potential health care workers and growing dissatisfaction 

among existing hospital staff.19 By turning toxic work environments into healthy workplaces, 

researchers and nurse leaders believe that improvements can be realized in recruitment and 

1 
Patient Safety and Quality: An Evidence-Based Handbook for Nurses

retention of nurses, job satisfaction for all health care staff, and patient outcomes—particularly 

those related patient safety.20 

Research Evidence 

Work stress continues to interest researchers, as illustrated by studies identified in this review 

that focused on occupations other than health care. For example, in a 3-year study of 14,337 

middle-aged men, there was no strong evidence that job demands or job strain were predictors of 

coronary heart disease (CHD).21 Findings did verify, however, that a supportive work 

environment helped reduce CHD. The importance of work support was corroborated in a study 

of 1,786 lower-ranking enlisted Army soldiers where support helped decrease psychological 

strain from job demands.22 A study of 472 Air Force personnel illustrated high levels of work 

stress in 26 percent of the respondents, with 15 percent claiming work-related emotional distress 

and 8 percent noting work stress negatively affected their emotional health.23 Finally, in a sample 

of 25,559 male and female German workers, the combined effects of exposure to work stress and 

downsizing contributed to more symptoms than either experience alone.24 

Stress in the Health Care Professions 

Numerous recent studies have explored work stress among health care personnel in many 

countries. Investigators have assessed work stress among medical technicians,25 radiation 

therapists,26 social workers,27 occupational therapists,28 physicians,29–33 and collections of health 

care staff across disciplines.34–38 Most of the studies focused on nurses, but the studies were not 

always clear regarding which types of nursing personnel participated. Registered nurses (RNs) 

were the dominant focus.39–83 Other investigations considered licensed practical nurses (LPNs) 

and nursing aides;84–86 licensed nurses (e.g., RNs and LPNs);87–90 RNs, aides, and clerical staff;91

and generic assessments of nursing staff.92–104

Only four of these investigations considered the effect of stress and burnout among nurses on 

patient outcomes.40, 56, 90, 99 These studies examined burnout in relation to increased mortality, 

failure to rescue,40, 56 and patient dissatisfaction.90, 99 Similarly, in an investigation of the 

relationship between personal stress and clinical care, 225 physicians reported 76 incidents in 

which they believed patient care was adversely affected by their stress.30 

Most of the investigations explored the effects of work stress and burnout on health care 

personnel in acute care settings. Staff working in long-term care (LTC)102 and nursing 

homes84, 85, 100 were the focus of four studies, however. Interestingly, two reports from nursing 

homes found that staff experienced more stress when caring for patients with dementia.84, 100 In 

addition, possible differences among types of nursing personnel were illustrated in a study of 

rural nursing homes where aides reported more job strain than RNs.100 

Findings are also emerging about differences in work stress based on shift length and 

generational cohort. Generational differences were explored in a single-site report of 413 RNs, in 

which baby boomers (43 percent) and Generation Xers (41 percent) had different perceptions of 

work stress.78 The investigators expanded their work to four hospitals in the Midwest (N = 694 

RNs).77 Baby boomers comprised 53 percent of the sample; their scores for stress and strain 

variables were significantly worse than nurses in the older and younger cohorts. The baby 

boomers also had significantly less social support. 

2
Work Stress & Burnout for Nurses

Shift length, 8-hour versus 12-hour, was explored in relation to both burnout95 and role 

stress.60 In a random sample of Michigan nurses, RNs working 12-hour shifts (n = 105) reported 

significantly higher levels of stress than RNs working 8-hour shifts (n = 99).60 However, when 

differences in experience were controlled, stress was similar in both groups. Conversely, a study 

from Poland illustrated that nurses working 12-hour shifts (n = 96) compared unfavorably in 

several aspects to nurses working 8-hour shifts (n = 30).95 Although the type of nursing 

personnel involved was unclear, the nurses on 12-hour shifts experienced significantly more 

chronic fatigue, cognitive anxiety, and emotional exhaustion. 

Gender and Family Obligations 

The complexity of work stress is further illustrated in two studies that considered gender 

effects. The prevalence of burnout was studied in a convenience sample of hospital-based 

neonatologists (n = 86) and office-based pediatricians (n = 97).32 Although the prevalence of 

burnout was comparable between the specialty groups, burnout was found more frequently in 

female physicians (79 percent) than male physicians (62 percent). In a study of female 

physicians, 51 working full-time and 47 working reduced hours, burnout was not related to 

number of hours worked per se.29 Rather, burnout was lower if female physicians worked the 

number of hours they preferred (r = -0.22, P = 0.03). These studies may have particular 

relevance for nursing because the profession is predominately female. 

Findings from studies that explored family-work conflict in relation to stress, burnout, and 

well-being indicated the importance of considering both work and family 

spheres.25, 29, 38, 44, 45, 86, 94 An investigation conducted using a diverse sample of 342 

nonprofessional employees (17 percent worked in health care; 70 percent were women) found 

family-work conflict was a predictor of well-being.86 A study of a diverse group of health care 

personnel compared 64 cases with 64 controls.38 Although the subjects in the case group were 

more likely to experience more objective stressful situations in and out of work, for both the case 

group and the control group, both work and nonwork stress contributed to anxiety and depressive 

disorders. 

Work interfering with family had a direct relationship with work exhaustion in a 4-year study 

of medical technologists, 80 percent of whom were female.25 Family interfering with work, 

however, was not studied. A study of 101 female nurses found that work interfered with family 

more than family interfered with work.94 The investigators noted, however, that most of the 

nurses, who were in their mid-40s, were between the demands of child care and elder care. This 

finding is consistent with findings from a study of 170 Australian nurses: the principal 

determinant of stress was workload; nurses were unlikely to bring personal stress to work.45 

Conversely, there was no difference between female physicians working full-time or reduced 

hours in regard to work interfering with family or family interfering with work.29 In addition, a 

study of family-work conflict identified personality as an important factor in whether individuals 

perceive situations as stressful.44 

Personal Characteristics and Work Relationships 

Personality was explored as an important variable in the burnout/work stress equation in a 

number of investigations.26, 37, 41, 49, 50, 81, 82, 92 Together, these studies support findings that 

perceptions of job stress and burnout are not just a product of work conditions because not all 

3 
Patient Safety and Quality: An Evidence-Based Handbook for Nurses

workers, exposed to the same conditions, develop burnout or perceive stress. However, the 

specific features of personality that affect the perception of stress or burnout remain unclear. 

Neuroticism has been associated with exhaustion.41, 92 External locus of control has 

demonstrated a positive relationship with burnout92 and stress.26 Findings are mixed for 

hardiness.37, 50, 81 Evaluations of anxiety reflect a link with stress and burnout.49, 82 Anxiety is 

viewed as having two components—state anxiety, the temporary component which manifests 

when an individual perceives threatening demands or dangers, and trait anxiety, the more stable 

component which may be regarded as a personality characteristic.105 In a study of intensive care 

unit nurses, the investigators concluded that individuals high on state-anxiety were not only at 

risk for burnout, but also for making medical errors.82 In another study, higher trait-anxiety 

predicted psychological distress.49 In addition, relationships with other staff—coworkers, 

physicians, head nurses, other departments—were also predictors of psychological distress.

Investigators have also examined the association between interpersonal relationships and 

burnout and stress. The exact linkages are not yet understood. Problematic relationships among 

team members were shown to increase burnout.93 Verbal abuse from physicians was noted to be 

stressful for staff nurses.71 In a study of 260 RNs, conflict with physicians was found to be more 

psychologically damaging than conflict within the nursing profession.59 However, a study 

exploring verbal abuse among 213 nursing personnel (95 percent RNs) found the most frequent 

source of abuse was other nurses (27 percent).88 Families were the second most frequent source 

of abuse (25 percent), while physicians ranked third (22 percent). 

Management Styles 

Relationships between staff nurses and nurse managers are particularly important when 

examining stress and burnout.49, 53, 65, 70, 89 Numeric ratings from a survey of 1,780 RNs indicated 

that supervisor support and quality of supervision were lowest for nurse managers.53 Handwritten 

comments from 509 (28.6 percent) of the RNs clarified these ratings by noting the following 

problems: (a) inadequate unit leadership and the frequent turnover of nurse mangers, (b) 

insufficient physical presence of the supervisor on the unit, (c) failure to address problems—too 

much sweeping them aside or not even being aware they exist, and (d) modest awareness of 

numerous staffing issues. 

These ideas were corroborated in a study of 537 RNs from Canada.65 Using structural 

equation modeling, the investigators substantiated the importance of manager behavior on 

employee experiences. Similarly, in a qualitative study of 50 nurses conducted in England, 

managers were identified as a direct cause of stress.89 Finally, responses from 611 RNs on 50 

inpatient nursing units in four southeastern U.S. hospitals showed that group cohesion was 

higher and job stress lower when nurse managers used a more participative management style.70 

In addition to illustrating a likely connection between nurse managers and staff nurse 

stressors, these studies also reflected the demanding role of today’s nurse managers who are 

often responsible for multiple patient care areas. However, only two studies were identified 

between 1995 and 2005 in which burnout was assessed in nurse managers and nurse 

administrators. One study was conducted in the United States69 and the other study in Canada.66

Investigators for the Canadian study examined burnout in a random sample of nurses in first-line 

(n = 202) and middle-management (n = 84) positions.66 Nurses in both groups reported high 

levels of emotional exhaustion and average job satisfaction. In the U.S. study, the investigators 

explored burnout among nurses (N = 78) from rural and urban hospitals in a southeastern State 

4
Work Stress & Burnout for Nurses

who held positions in middle-management and higher.69 Almost half the respondents (49%) 

reported high levels of emotional exhaustion. 

Lessening Stress 

Various studies were designed to evaluate ways to mitigate stress. Studies of social support 

and empowerment dominated these investigations. Although social support is a multifaceted 

construct, definitions and types of support were not typically found in these more recent 

investigations. However, the importance of coworker support was verified in one study.39 In 

another study, a general construct labeled “organizational support” exhibited the expected 

negative relationship with work exhaustion.25 Similarly, social support from supervisors or 

colleagues demonstrated a negative association with work stress.31, 72, 96 Stated differently, based 

on another study, as nurses felt more stress, they relied more on social support.87 A cluster 

analysis demonstrated that high social support was found only in the cluster with low burnout 

and low stress.59 No buffering effects were discerned in the studies, but there was a direct and 

beneficial effect of social support on workers’ psychological well-being and organizational 

productivity.36 Although these findings do not clarify the mechanism for social support, they do 

indicate that coworkers and supervisors at all levels would be wise to consider the importance of 

reciprocal interpersonal exchanges that enhance security, mutual respect, and positive feelings. 

All but two studies80, 96 of nurses and workplace empowerment were conducted by teams 

involving Laschinger.57, 62, 64–68 Work empowerment showed a strong, negative association with 

job tension and a strong positive relationship with perceived work effectiveness.62, 65 Similarly, 

in other reports, structural empowerment in the workplace (e.g., opportunity, information, 

support, resources, power) contributed to improved psychological empowerment (e.g., meaning, 

confidence, autonomy, impact).64, 67, 68 Psychological empowerment, in turn, had a strong 

positive effect on job satisfaction and a strong negative influence on job strain. Likewise, as 

perceptions of empowerment increased, staff nurses reported less emotional exhaustion and 

depersonalization along with a greater sense of personal accomplishment—the three components 

of burnout.57 Empowerment was negatively associated with work stressors in another study as 

well.96 

Because empowerment is often viewed as a characteristic of how work environments are 

structured, it has strong implications for nurse managers’ behaviors. However, one study 

revealed an interpretive side to empowerment that derives from nurses’ perceptions of their 

personal effectiveness and success.80 Additionally, there is beginning evidence that nurse 

managers experience empowerment in a way that mirrors staff nurse experiences. That is, nurse 

manager perceptions of structural empowerment influenced their sense of psychological 

empowerment, which, in turn, affected the extent to which they experienced burnout.66 

Evidence-Based Practice Implications 

Based on current empirical evidence on stress and burnout in nursing, there is difficulty in 

making recommendations regarding how to enhance patient safety. Although findings 

consistently indicated that nurse burnout was negatively related to job satisfaction, only two 

studies explored the relationship between nurse burnout and patient satisfaction.90, 99

Additionally, findings are inconsistent for two studies that examined the relationship between 

nurse burnout, 30-day mortality, and failure to rescue for surgical patients.40, 56 Data for one of 

5 
Patient Safety and Quality: An Evidence-Based Handbook for Nurses

these studies were collected from nurses and patients throughout Pennsylvania.40 Data for the 

other study were collected from nurses and patients at a single site.56 Some of the differences can 

be accounted for by numerous methodological variations between the two studies. Other 

differences might be attributed to the strong collective bargaining unit at the single-site study that 

had negotiated staffing based on nurse-patient ratios that were adjusted for patient acuity.56

Moreover, fewer nurses from the single-site study reported being either dissatisfied or very 

dissatisfied with their jobs, compared with the Pennsylvania study (8 percent versus 25 percent, 

respectively). 

Practice implications are also unclear regarding the effects of work stress on nursing staff. 

The lack of clarity derives, in part, from the complexities of the work stress concept. In one 

study, for example, nurses were grouped into one of four clusters based on their level of stress, 

affective and physical symptoms, burnout, and unit social support.59 In another, the nurse ratings 

of job strain placed them in four groups ranging from high to low strain.68 This heterogeneity 

suggests that many dynamics are operational in relation to stress and burnout. The effects of shift 

length on stress is one of the dynamics that is not yet understood.60, 95 Likewise, evidence about 

how verbal abuse88 and generational differences77 operate in the stress equation is just beginning 

to emerge. The role of personality, family-work conflict, and other features of stress require 

further study. 

Evidence is accruing about the utility of empowerment and social support in mitigating 

stress. Some caution is warranted in regard to empowerment, however, because the work of one 

investigator dominates the field.57, 62, 64–68 Findings related to social support indicated that 

interpersonal exchanges with coworkers and supervisors may enhance security, mutual respect, 

and positive feelings—which helped to reduce stress.31, 39, 72, 96 Overall, however, the assessments 

of social support were often founded on weak conceptualization and relied upon 

psychometrically weak instruments to measure the concept. Moreover, the analytical models did 

not always consider the direct, indirect, and interactive effects of social support. 

Although the evidence is sparse, the studies have practice implications for nurse managers. 

First, managerial behaviors were linked to stress and burnout. Managerial support38 and 

participative management70 helped to reduce stress. Similarly, burnout and work stress were 

reduced when administrators created work environments that provided staff with access to 

opportunity, information, resources, and support—the features of empowerment.64, 65 Second, 

and studied even more infrequently, nurses in supervisory positions may encounter stress69 and 

burnout66 themselves. There is no existing evidence, however, that empirically illustrates how 

managerial stress affects staff stress or the manager’s ability to behave in a way that reduces staff 

stress. Given the current emphasis on improving the work environment, there is an imperative to 

carefully investigate both aspects of the nurse administrator in relation to stress and burnout. 

Despite lacking absolute clarity, there is a body of research addressing work stress that spans 

more than 50 years in the nursing profession. Stress is pervasive in nursing and health care. 

Moreover, working conditions seem to be deteriorating at the same time that a severe and 

protracted nursing shortage is occurring. Leaders of health care organizations can no longer 

ignore these findings. Just as institutional leaders need to understand their financial standing, 

they also need to assess how environmental stress is affecting patients and staff and take action 

to alter unhealthy situations. 

6
Work Stress & Burnout for Nurses

Research Implications 

To derive a better understanding of stress and burnout in the workplace, solid 

conceptualizations are needed that bring together the various pieces of the stress puzzle. At 

present, research is often conducted absent a solid theoretical and conceptual base. A more 

comprehensive blueprint of nurse stress and burnout in the work place needs to be developed. 

Empirical studies could then be conducted to investigate these very complex relationships, 

prospectively, over time. Once work stress is examined from a more solid theoretical and 

conceptual basis, then intervention studies can be initiated to assess the most useful ways to 

mitigate work stress. 

Studies need to move beyond the tendency to use descriptive designs. There is sufficient 

evidence to believe that work stress is a factor among health care personnel. What is less well 

understood is the effect of stress on patient outcomes. Studies are needed to enhance the 

understanding of stress and burnout on patient safety. Studies are also needed to better 

understand stress beyond the acute care setting. 

In addition, because nurse administrators are responsible for creating the environment in 

which nursing is practiced and patient care is given,106 it is important to explore interventions 

that will reduce the stress and burnout experienced by nurse administrators. Findings from 

studies of this nature could have a threefold effect. By reducing the stressful nature of the nurse 

administrator’s work, nurse administrators could be more satisfied in their positions. This role 

satisfaction, in turn, could lead to enhancing those managerial behaviors that improve the work 

environment for staff nurses. Finally, improved working conditions for nurse administrators 

might make the role more appealing and help correct the serious dearth of individuals interested 

in pursuing administrative positions.

107 

Conclusion 

Stress and burnout are concepts that have sustained the interest of nurses and researchers for 

several decades. These concepts are highly relevant to the workforce in general and nursing in 

particular. Despite this interest and relevance, the effects of stress and burnout on patient 

outcomes, patient safety, and quality care are not well defined by evidence. In fact, the link 

between stress and burnout to patient outcomes has been explored in only four investigations. 

There is a great need for comprehensive studies that will examine these dynamics in a way that 

will yield more solid evidence on which to base practice. 

Acknowledgments 

Tremendous gratitude is expressed to the staff of the Armed Forces Medical Library for their 

considerable support of this work. They conducted the database searches and assisted in 

acquiring numerous papers considered in this review.

Author Affiliations 

Bonnie M. Jennings, D.N.Sc., R.N., F.A.A.N., colonel, U.S. Army (retired), health care 

consultant. E-mail: bmjennings@cox.net. 

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Patient Safety and Quality: An Evidence-Based Handbook for Nurses

Search Strategy 

Both MEDLINE® and CINAHL® databases were searched to locate literature for this review. 

A reference librarian conducted the searches after working with the author to specify search 

terms. The search terms for MEDLINE® were psychological stress, professional burnout, work 

stress, and occupational health. The search terms for CINAHL® were occupational stress, 

professional burnout, and nursing units. For both databases, the searches were limited to research 

articles published in the English language between 1995 and 2005. 

There were 1,145 articles identified in the CINAHL® search and 392 identified by the 

MEDLINE® search, with some duplication in the citations identified by the two databases. All 

1,537 abstracts were reviewed. Numerous abstracts were eliminated from further consideration. 

For example, articles about instrument development, stress in specific populations (e.g., children, 

adolescents, pregnant women, parents, caregivers) and occupations other than health care (e.g., 

the police force, fishermen, flight crews, farm workers) were omitted from this review. Likewise, 

dissertations, literature reviews, concept analyses, and physiologic and immunologic studies of 

stress in general were not included. 

Once the unrelated articles were eliminated, 138 articles remained as candidates for this 

review. A complete copy of each of these papers was acquired and read, following which an 

additional 53 articles were removed from further consideration. Dominant among the reasons for 

excluding these papers were that they were not research based or they were short reports that 

were lacking essential details. 

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Evidence Table 

Source Safety Issue 

Related to Clinical Practice

Design Type

Study Design, Study Outcome Measure(s)

Study Setting & Study Population 

Study Intervention 

K

Aiken 200240 Burnout Cross-sectional (4) Design: Level 4 

Patient outcomes: 30-day mortality, failure to rescue (Level 1) Nurse outcomes: burnout 

Pennsylvania; 10,134 RNs (survey data) linked with discharge data for 232,342 surgical patients from 168 hospitals. Nurses: 94% female; 40% BSN or higher; average of 14 years working as a nurse. Patients: 44% male, average age 59, general surgery (44%), orthopedic surgery (51%), vascular surgery (5%). 

Staffing A

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Halm 200556 Burnout Cross-sectional (4) Design: Level 5 

Patient outcomes: mortality and failure to rescue (Level 1) Nurse outcomes: emotional exhaustion 

Large Midwestern hospital; 140 RNs (survey data), discharge data for 2,709 surgical patients. Nurses: 96% female; 43% BSN or higher; average 17 years working as a nurse. Patients: 37% male, average age 56, general surgery (50%), orthopedic surgery (46%), and vascular surgery (4%). 

Staffing A

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13
14

Source Safety Issue 

Related to Clinical Practice

Design Type

Study Design, Study Outcome Measure(s)

Study Setting & Study Population 

Study Intervention 

K

Hillhouse 199759 Affective and 

physical symptoms 

Cross-sectional (4) Design: Level 5 

Nurse outcomes: affective symptoms, physical symptoms 

A large university hospital; 260 nurses: 97% female, average age 34, all college educated, in current positions an average of 5 years with an average of 11 years experience as a nurse. 

Data related to stress, burnout, physical and emotional symptoms were grouped using statistical techniques. 

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Hoffman 200360 Stress Cross-sectional (4) Design: Level 4 

Nurse outcomes: role stress 

Michigan; 208 RNs randomly selected from the Michigan Nurses Association. Nurses: 92% female, average age 43, 95 (46%) had diplomas or associate degrees, 88 (42%) had a BSN, average experience on their units = 9 years. 99 worked mostly 8-hour shifts (48%), 105 (51%) worked a combination of 8-, 10-, and 12-hour shifts 

Length of work shift 

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Source Safety Issue 

Related to Clinical Practice

Design Type

Study Design, Study Outcome Measure(s)

Study Setting & Study Population 

Study Intervention 

K

Laschinger 200163

Burnout Cross-sectional (4) Design: Level 5 

Staff outcomes: burnout, nurse perception of care quality 

Ontario, Canada; 3,016 medical surgical nurses from 135 hospitals. Nurses: average age of 44 years, average experience in nursing 19 years, 84% were diploma prepared, 69% were from small hospitals, 18% were from teaching hospitals, 13% were from community hospitals. 

Magnet Hospital characteristics 

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Laschinger, 200164

Job strain Cross-sectional (4) Design: Level 3 

Nurse outcomes: job strain 

Urban tertiary care hospitals in Ontario, Canada; 404 randomly selected staff nurses: 52% female; all worked in large urban teaching hospitals; on average, 40 years old (standard deviation [SD] = 8.07), 16 years nursing experience (SD = 8.5), 8 years experience in current workplace (SD = 5.8); 58% worked full time; 15% had baccalaureate degrees, 85% were diploma graduates. 

Empowerment—both structural and psychological 

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16

Source Safety Issue 

Related to Clinical Practice

Design Type

Study Design, Study Outcome Measure(s)

Study Setting & Study Population 

Study Intervention 

K

Laschinger 199965 Empowerment, job stress Cross-sectional (4) Design: Level 3 Nurse outcomes: 

empowerment, job tension, work effectiveness 

Two sites of a large, merged urban teaching hospital in Canada. Nurses: 537 staff nurses; 95% female; 84% diploma educated; 69% worked full time; on average 40 years old (SD = 6.5), 17 years nursing experience (SD = 6.9), 10 years experience in current specialty (SD = 5.5). 

Leader behavior A 

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Laschinger 200167

Job strain Cross-sectional (4) Design: Level 3 

Nurse outcomes: job strain, quality of work life 

Urban tertiary care hospitals in Ontario, Canada; 404 randomly selected staff nurses: 52% female; on average, 40 years old (SD = 8.07), 16 years nursing experience (SD = 8.5), 8 years experience in current workplace (SD = 5.8); 58% worked full time; 15% had baccalaureate degrees, 85% were diploma graduates. 

Quality of work life 

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17

Source Safety Issue 

Related to Clinical Practice

Design Type

Study Design, Study Outcome Measure(s)

Study Setting & Study Population 

Study Intervention 

K

Lee 199669 Burnout Cross-sectional (4) Design: Level 3 

Nurse outcomes: stress, commitment, social support 

Members of a State organization of nurse executives working at 134 rural and urban hospitals in the southeastern U.S. 78 nurse administrators: female (93%); ages 31–40 (35%); positions—chief nurse officers (CNOs) (45%), assistant CNOs (19%), division or department heads (30%), nurses with executive-level roles (6%); education—doctorate (3%), master’s (42%), baccalaureate (29%), associate degree (3%), diploma (26%); average administrative experience, 13 years (range 2–32), CNO tenure in current positions 2 years or less (51%). 

Commitment N

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18

Source Safety Issue 

Related to Clinical Practice

Design Type

Study Design, Study Outcome Measure(s)

Study Setting & Study Population 

Study Intervention 

K

Leiter 199899 Burnout Cross-sectional (4) Design: Level 3 

Patient outcomes: satisfaction (Level 3) 

16 inpatient units from 2 settings at an 800-bed tertiary care hospital in central Canada. Nurses: 711 with an average of 34 respondents from each inpatient unit (range 22–63), 97% female, 18% had worked for the hospital for > 20 years (2% for < 1 year); 83% RNs, 14% registered practical nurses. Patients: 605 with an average of 36 respondents from each inpatient unit (range 3–104); 55% female, most were between 66 and 75 years old (22%); length of stay was most often up to 3 days (35%). 

Patient satisfaction 

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19

Source Safety Issue 

Related to Clinical Practice

Design Type

Study Design, Study Outcome Measure(s)

Study Setting & Study Population 

Study Intervention 

K

Leveck 199670 Stress Cross-sectional (4) Design: Level 3 

Nurse outcomes: perceived quality of care, management style, group cohesion 

50 inpatient units from 4 acute care hospitals in the southeastern U.S. Nurses: 358 RNs. Patients: retrospective audits of 525 randomly selected charts. 

Management style, group cohesion 

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Rowe 200588 Stress and verbal 

abuse nurse-tonurse 

Cross-sectional (4) Design: Level 5 500-bed teaching 

hospital in Philadelphia. Nurses: 213 RNs and LPNs (69% response rate, 5% were LPNs); 96% female, most were diploma graduates (33%); 53% worked full time, 85% had > 5 years experience, 88% were staff nurses. 

None—descriptive 

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20

Source Safety Issue 

Related to Clinical Practice

Design Type

Study Design, Study Outcome Measure(s)

Study Setting & Study Population 

Study Intervention 

K

Santos 200377 Stress, strain, 

coping 

Cross-sectional (4) Design: Level 5 Four Midwestern 

hospitals. Nurses: 694 RNs representing 3 age cohorts—1909–1945, matures (8%); 1946–1964, baby boomers (53%); 1965–1979, Generation Xers (35%). 

None—descriptive 

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Simoni 200480 Stress Cross-sectional (4) Design: Level 3 

Nurse outcomes: empowerment 

Two hospitals in a mid-Atlantic State. Nurses (randomly selected, n = 142) RNs with an average age of 35 years (SD = 10.1), 48% had baccalaureate degrees, most had been working <5 years since becoming RNs (42%). 

Empowerment T

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21

Source Safety Issue 

Related to Clinical Practice

Design Type

Study Design, Study Outcome Measure(s)

Study Setting & Study Population 

Study Intervention 

K

Vahey 200490 Burnout Cross-sectional (4) Design: Level 3 

Patient outcomes: satisfaction (Level 3) 

2 units each in 20 urban hospitals across the U.S. using 1991 data. Nurses (n = 820—both RNs and LPNs): 93% male; on average, 35 years old (SD = 10), 10 years in nursing (SD = 9), 4 years on present unit (SD = 4). Patients (with AIDS) (n = 621): 88% male, average age 37 years (SD = 8). 

Patient satisfaction 

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22

Source Safety Issue 

Related to Clinical Practice

Design Type

Study Design, Study Outcome Measure(s)

Study Setting & Study Population 

Study Intervention 

K

Weinberg 200038

Stress Cross-sectional (4) Design: Level 3 

Staff outcomes: psychiatric disorders 

City-based hospital. Four groups of staff members (randomly selected): nurses, physicians, administrative, ancillary. Based on scores from survey responses, participants were identified who had minor psychiatric disorders (e.g., definite depressive or anxiety disorders). These 69 cases were matched to controls by occupational group, gender, and age (within 5 years). Each group had 23 nurses, 8 physicians, 23 administrative staff, and 10 ancillary staff. 52 of the 69 individuals in each group were females (75%). Mean age for cases and controls was 39 years (SD = 10). 

Psychiatric disorders (especially depression or anxiety) 

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