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Nursing Home Managers’ High Risk of Burnout

Published:November 14, 2021DOI:https://doi.org/10.1016/j.jamda.2021.08.045
      The tragic deaths of residents and staff during the COVID-19 pandemic called attention to the longstanding need for transformational change and redesign in nursing homes.
      • Grabowski D.C.
      • Mor V.
      Nursing home care in crisis in the wake of COVID-19.
      ,
      • Estabrooks C.
      • Straus S.
      • Fllod C.M.
      • et al.
      Restoring trust: COVID-19 and the future of long-term care.
      Stressors on the nursing home staff from increased workloads, to staffing shortages, and emotional strain were amplified.
      • White E.M.
      • Wetle T.F.
      • Reddy A.
      • Baier R.R.
      Front-line nursing home staff experiences during the COVID-19 pandemic.
      Nursing home managers’ retention is a known challenge. Factors influencing their intention to stay include work overload, inability to ensure high quality of care, insufficient resources, and a lack of perceived empowerment and recognition.
      • Hewko S.J.
      • Brown P.
      • Fraser K.D.
      • Wong C.A.
      • Cummings G.G.
      Factors influencing nurse managers' intent to stay or leave: A quantitative analysis.
      To tailor interventions to improve nursing home manager’s quality of work life, we need a thorough understanding of the characteristics of this group. Our objective here is to describe manager characteristics in the Western Canadian nursing homes immediately prepandemic.

      Methods

      We completed a cross-sectional analysis of managers’ questionnaire data collected between September 3, 2019, and February 28, 2020. Managers were from a random sample of 91 urban nursing homes in the 3 provinces of Alberta, Manitoba, and British Columbia. Ethics and operational approvals were obtained from participating organizations. Eligible managers (n=302) worked on 1 nursing home care unit for at least 50% of the time and for a minimum of 3 months. Means, standard deviations, frequencies, and percentages were used to describe the characteristics of the managers. Subgroup analyses were performed based on managers’ role within their organization. Analyses were completed using SPSS.

      Results

      Of the 302 eligible nursing home managers in 91 nursing homes, 199 managers (65.9%) participated fully in the study (Table 1). Managers were predominantly female (90.4%), well educated (16.5% graduate/professional degree), and nurses (81.2%). Half (51.3%) reported being a unit manager and half identified as either a director of care or a facility administrator. Generally, a director of care or facility administrator has responsibility for the entire facility and a manager for 1 or more resident care units with the facility; sometimes managers have facility level responsibilities; occasionally a director of care covers both facility and units. A total of 19.6% of nursing home managers were ≥60 years of age. Managers worked an average of 72.79 hours in a 2-week period, with 16.6% working more than 80 hours. Facility administrators and directors of care worked significantly more hours than unit managers. Unit managers, however, compared to directors of care have reported completion of more specialized courses (P = .031).
      Table 1Characteristics of Nursing Home Managers in Canada
      VariablesUnit Manager, n (%)

      (n = 102)
      Director of Care, n (%)

      (n = 44)
      Facility Administrator, n (%)

      (n = 53)
      Total Managers, n (%)

      (N = 199)
      ANOVA/χ2Post Hoc
      Post hoc test for significance were examined using the Bonferroni correction. UM, DC, FA denote the multiple comparison between nurse managers (UM = unit manager, DC = director of care, FA = facility administrator). Significant differences are provided between the nurse managers (eg, FA-UM implies a significant difference between facility administrators and unit managers). NA: not applicable/no significance found.
      Age, yP = .48NA
       <304 (3.9)02 (3.8)6 (3.0)
       30-3920 (19.6)9 (20.5)10 (18.9)39 (19.6)
       40-4921 (20.6)11 (25.0)13 (24.5)45 (22.6)
       50-5939 (38.2)18 (40.9)13 (24.5)70 (35.2)
       ≥6018 (17.7)6 (13.6)15 (28.3)39 (19.6)
      Female93 (92.1)42 (95.5)44 (83.0)179 (90.4)P = .08NA
      Nurse profession87 (85.3)41 (97.6)32 (60.4)160 (81.2)P < .0001
      P < .05, χ2 test used for categorical variables and 1-way ANOVA for continuous variables.
      UM-FA, UM-DC
      Education
       Diploma/certificate72 (82.8)34 (81.0)38 (82.6)144 (82.3)P = .97NA
       Bachelor’s degree61 (66.3)28 (66.7)30 (62.5)119 (65.4)P = .89NA
       Master’s degree10 (13.5)5 (13.2)9 (22.5)24 (15.8)P = .40NA
       PhD/PharmD degree1 (1.5)001 (0.7)P = .58NA
      Specialized courses completed (eg, Advanced Diploma in Gerontology)33 (35.9)26 (59.1)24 (49.0)83 (44.9)P = .031
      P < .05, χ2 test used for categorical variables and 1-way ANOVA for continuous variables.
      UM-DC
      Time worked in current role, mean (SD), y7.07 (6.42)5.75 (4.46)6.02 (6.18)6.50 (5.98)P = .38NA
       <330 (29.4)10 (22.7)19 (35.8)59 (29.7)
       3-943 (42.1)27 (61.4)22 (41.5)92 (46.2)
       10-1922 (21.6)6 (13.6)11 (20.8)39 (19.6)
       ≥207 (6.9)1 (2.3)1 (1.9)9 (4.5)
      Time worked on unit, mean (SD), y6.27 (6.4)7.80 (7.5)7.45 (7.64)6.92 (7.01)P = .40NA
       <226 (25.5)9 (20.5)8 (15.1)43 (21.6)
       2-535 (34.3)9 (20.5)21 (39.6)65 (32.7)
       6-919 (18.6)12 (27.2)12 (22.6)43 (21.6)
       ≥1022 (21.6)14 (31.8)12 (22.6)48 (24.1)
      Hours worked in 2 wk, mean (SD)68.49 (18.20)73.32 (20.80)78.72 (16.72)72.79 (18.75)P = .014
      P < .05, χ2 test used for categorical variables and 1-way ANOVA for continuous variables.
      FA-UM
       ≤4018 (17.7)6 (13.6)2 (3.8)26 (13.1)
       41-609 (8.8)3 (6.8)6 (11.3)18 (9.0)
       61-8066 (64.7)27 (61.4)29 (54.7)122 (61.3)
       >809 (8.8)8 (18.2)16 (30.2)33 (16.6)
      Job satisfaction, mean (SD)
      The score range for job satisfaction is 1 (strongly disagree) to 5 (strongly agree), with a higher score indicating a higher level of job satisfaction.
      4.43 (0.58)4.47 (0.54)4.50 (0.53)4.46 (0.55)P = .75NA
       Burnout risk
      A high risk for burnout is indicated by 1 or more of the following cutoffs: emotional exhaustion score greater than 3.00, cynicism score greater than 2.33, and efficacy score less than 3.30. A low risk for burnout is indicated by 1 or more of the following: emotional exhaustion score less than 1.67, cynicism score less than 1.00, and efficacy score greater than 4.00. The score range for emotional exhaustion, cynicism, and efficacy is 0 (never) to 6 (daily). In contrast to emotional exhaustion and cynicism, the efficacy scale was reverse-scored, so that higher scores indicate higher levels on all 3 scales.
      Emotional exhaustion, mean (SD)1.68 (1.31)1.63 (1.31)1.33 (1.03)1.57 (1.24)P = .25NA
       High15 (14.9)4 (9.1)2 (3.8)21 (10.6)
       Moderate27 (26.7)16 (36.4)16 (30.2)59 (29.8)
       Low59 (58.4)24 (54.5)35 (66.0)118 (59.6)
      Cynicism, mean (SD)1.51 (1.27)1.43 (1.24)1.18 (1.01)1.41 (1.20)P = .26NA
       High19 (18.8)8 (18.2)6 (11.3)33 (16.7)
       Moderate44 (43.6)21 (47.7)23 (43.4)88 (44.4)
       Low38 (37.6)15 (34.1)24 (45.3)77 (38.9)
      Efficacy, mean (SD)4.67 (0.99)4.82 (0.92)5.07 (0.81)4.81 (0.94)P = .040
      P < .05, χ2 test used for categorical variables and 1-way ANOVA for continuous variables.
      FA-UM
       High71 (71.0)34 (77.3)46 (86.8)151 (76.7)
       Moderate19 (19.0)7 (15.9)5 (9.4)31 (15.7)
       Low10 (10.0)3 (6.8)2 (3.8)15 (7.6)
      ANOVA, analysis of variance; SD, standard deviation.
      P < .05, χ2 test used for categorical variables and 1-way ANOVA for continuous variables.
      Post hoc test for significance were examined using the Bonferroni correction. UM, DC, FA denote the multiple comparison between nurse managers (UM = unit manager, DC = director of care, FA = facility administrator). Significant differences are provided between the nurse managers (eg, FA-UM implies a significant difference between facility administrators and unit managers). NA: not applicable/no significance found.
      The score range for job satisfaction is 1 (strongly disagree) to 5 (strongly agree), with a higher score indicating a higher level of job satisfaction.
      § A high risk for burnout is indicated by 1 or more of the following cutoffs: emotional exhaustion score greater than 3.00, cynicism score greater than 2.33, and efficacy score less than 3.30. A low risk for burnout is indicated by 1 or more of the following: emotional exhaustion score less than 1.67, cynicism score less than 1.00, and efficacy score greater than 4.00. The score range for emotional exhaustion, cynicism, and efficacy is 0 (never) to 6 (daily). In contrast to emotional exhaustion and cynicism, the efficacy scale was reverse-scored, so that higher scores indicate higher levels on all 3 scales.
      Nursing home managers’ job satisfaction was high—4.46 (0.55) with a range of 1-5. A total of 10.6% of managers reported high levels of emotional exhaustion and 16.7% high levels of cynicism. Conversely, a total of 76.7% reported high levels of professional efficacy. Facility administrators reported significantly greater efficacy compared with unit managers (P = .040).

      Discussion

      In this study, we found that most nursing home managers were female, middle-aged nurses who work full time. The fact that 16.6% of managers reported working overtime and approximately half reported moderate to high levels of emotional exhaustion and cynicism, yet high in their efficacy, indicates that managers are at significant risk for burnout. Emotional exhaustion—described as one’s feelings of being emotionally overextended by one’s work—among nursing home managers worldwide has been known to be high since the 1990s.
      • Membrive-Jiménez M.J.
      • Pradas-Hernández L.
      • Suleiman-Martos N.
      • et al.
      Burnout in nursing managers: A systematic review and meta-analysis of related factors, levels and prevalence.
      Given our results and the potential contributors—work overload, lack of time and support, and the need to manage staff conflicts—which were likely exacerbated by the pandemic, we anticipate burnout to be much higher post pandemic.
      Nursing home managers critically influence work environments, staff outcomes, and quality of care for residents. Their workload and well-being can significantly impact their ability to oversee and support resident care,
      • Membrive-Jiménez M.J.
      • Pradas-Hernández L.
      • Suleiman-Martos N.
      • et al.
      Burnout in nursing managers: A systematic review and meta-analysis of related factors, levels and prevalence.
      yet they are often overlooked as vital care team members. Therefore, it is urgent that nursing home managers be recognized and their work be thoroughly examined and supported. Creating a culture of recognition and positive work environments for nurse managers in nursing homes through engagement, recognition, administrative support, and access to external health and social services warrants further exploration.
      • Membrive-Jiménez M.J.
      • Pradas-Hernández L.
      • Suleiman-Martos N.
      • et al.
      Burnout in nursing managers: A systematic review and meta-analysis of related factors, levels and prevalence.
      ,
      • Mackoff B.L.
      • Triolo P.K.
      Why do nurse managers stay? Building a model of engagement: Part 2, Cultures of engagement.
      Limitations of this study are that survey responses are subject to self-report biases, and generalizations beyond the settings represented should be made with caution.

      Acknowledgment

      The authors acknowledge the Translating Research in Elder Care (TREC) 2.0 team for its contributions to this study.

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