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Mattering

How Organizations, Patients, and Peers Can Affect Nurse Burnout and Engagement

Haizlip, Julie MD, MAPP; McCluney, Courtney PhD; Hernandez, Morela PhD; Quatrara, Beth DNP, RN, CMSRN, ACNS-BC; Brashers, Valentina MD

Author Information
JONA: The Journal of Nursing Administration: May 2020 - Volume 50 - Issue 5 - p 267-273
doi: 10.1097/NNA.0000000000000882
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Abstract

It is no secret that the prevalence of nurse burnout is high. It has been almost 2 decades since a 1999 study of more than 10 000 inpatient RNs demonstrated that 43% of those surveyed reported a high degree of emotional exhaustion.1 More recently, researchers have reported that roughly half of direct care and charge nurses in oncology and critical care are experiencing burnout and secondary traumatic stress.2 Other studies have demonstrated that this emotional exhaustion not only is limited to the inpatient setting but also occurs in nurses in other practice settings.3 It has been further demonstrated that emotional exhaustion and associated cynicism predict a nurse's desire to leave his or her current job or, perhaps, the profession4 and that nurse turnover is an important issue that has a significant financial impact (5.2-8.1 million dollars) on the average hospital.5 What is less obvious, perhaps, is what those who lead healthcare organizations can do to practically address this problem.

The National Academy of Medicine has convened an Action Collaborative on Clinician Well-Being and Resilience and issued a call to explore and address burnout as an underrecognized threat to safe and high-quality care.6 This collaborative, which includes national nursing leaders from the American Nurses Association, the American Association of Critical Care Nurses, the National League for Nursing, and the American Association of Colleges of Nursing among others, seeks to understand the elements of organizations and practices that contribute to distress. However, the findings of their studies will not be immediate, and the issues of burnout, dissatisfaction, and turnover are pressing. Furthermore, several of the systems issues that have been proposed to contribute to burnout such as heavy patient loads, low levels of perceived organizational and social support, and implementation of electronic health records will not have easy fixes.1,7 Some authors have proposed that helping nurses reconnect to the meaning of their work may reduce burnout.8 However, others report that having meaningful professions or conducting work that is personally significant and that has a positive meaning for others does not reduce the felt experience of burnout.9 So the question becomes, what can be done in the short term to ameliorate the stresses of working in healthcare?

In other professions, it has been suggested that a sense of mattering can enhance an individual's ability to cope with various work-related stresses.10-12Mattering is a psychosocial construct that describes an individual's perception that he or she makes a difference in the lives of others and is significant in the world.13,14 As it was initially defined in the literature, mattering is composed of 4 domains: awareness, reliance, importance, and ego extension. Awareness encompasses the simple idea that others are aware of your presence and, moreover, your absence would be noticed. Reliance suggests that others depend on you or that you affect the lives of those around you. Importantly, however, reliance is something that must be perceived by the individual. It is not enough to cognitively know others depend on you (e.g., if I am not there, the unit will be short staffed), but rather, you must feel as though others need and desire your specific contribution. Feeling important to others is the result of their genuine expressed care and concern. Finally, ego extension represents the notion that others feel a sense of pride in your successes or disappointment in your failures, as though your performance reflects not only on yourself but also on them.

It is not difficult to envision how the concept of mattering can apply to one's professional life. Each of us wants to believe that we contribute to our work environment in a meaningful way. As investigators have begun to consider what it means to matter at work,15 2 new dimensions have been proposed—interpersonal and societal mattering. Interpersonal mattering describes an individual's perception of feeling recognized, valued, and appreciated by the people with whom they work. Societal mattering represents the belief that one's work contributes to society or meets a societal need. Mattering at work may be particularly important for healthcare professionals, because this desire to positively influence others' lives is at the heart of our professional identity. For many healthcare providers, “helping others” is how they identify the meaning of their work. Receiving feedback from patients, colleagues, or the organization that suggests that one's efforts are indeed making a positive impact could heighten one's sense of mattering. Such external feedback is distinct from the intrinsic benefits and meaning that healthcare professionals often derive from helping others; rather, we propose that a sense of mattering is derived from the cues provided by their interpersonal and social contexts.

We postulate that this enhanced sense of mattering may buffer the daily stressors and potentially diminish the incidence of burnout. This study is designed to answer the research questions: “Is there a relationship between a sense of mattering and burnout in nurses” and “Are the current definitions of mattering relevant to nursing practice?”. It also begins to investigate the relationships between mattering in nurses and objective measures of meaning, perceived support, and engagement.

Methods

We used a cross-sectional survey design to collect data from nurses and nurse practitioners in the United States working across specialties. The survey consisted of several previously validated scales and 2 open-ended questions. We recruited participants through TurkPrime, a research platform that improves the quality of crowdsourcing data collection processes,16 to survey nurses across geographic regions and healthcare settings, which increases the ecological validity of our findings. We restricted our sample to nurses and nurse practitioners working full or part-time in the United States.

Measures

Demographic Questionnaire

Demographic data collected included age, gender, income, race/ethnicity, profession, primary specialty, highest level of education, and job characteristics.

Mattering at Work Scale

Mattering was measured using the 10-item Mattering at Work scale (α = .93) on a 6-point Likert scale anchored by 1 (disagree very much) and 6 (agree very much) that measures the dimensions of interpersonal and societal mattering.15 Example items include “I am connected to society through my work” and “I feel like I matter to my colleagues/coworkers.” Higher scores indicate higher perceptions of mattering at work.

Work and Meaning Inventory

Meaning of work was measured using the 10-item Work and Meaning Inventory (α = .93) on a 5-point Likert scale anchored by 1 (absolutely untrue) and 5 (absolutely true) that measures the meaning an individual derives from their work.17 Example items include “I have found a meaningful career” and “My work helps me better understand myself.” Higher scores indicate higher perceived meaning of work.

Social Support

Social support was measured using an adapted 15-item Eisenberger Social Support Scale (α = .93) on a 5-point Likert scale anchored by 1 (strongly disagree) and 5 (strongly agree).18 We captured respondents' perception of social support from their organization, supervisor, peers or nurses at their same level, and subordinates. Example items include “Help is available from my organization when I have a problem” and “My supervisor shows a lot of concern for me.” Higher scores indicated higher perceived social support.

Burnout

Burnout was measured using the 10-item subscale for Burnout in the Professional Quality of Life scale (α = .75) on a 5-point Likert scale anchored by 1 (never) and 5 (very often).19 Example items include “I feel worn out because of my work as a nurse” and “I feel bogged down by the system.” Five items were reverse-coded so that higher scores indicated higher experiences of burnout.

Engagement

Engagement was measured using the 18-item measure of Job Engagement (α = .95) on a 5-point Likert scale anchored by 1 (strongly disagree) and 5 (strongly agree).20 Example items include “I devote a lot of energy to my job” and “I work with intensity on my job.” Higher scores indicated higher perceived engagement at work.

Open-ended Questions

Participants were asked to respond to the following questions: “Please tell us what is meaningful to you about your work,” and “Please tell us about a time when you felt like you mattered at work.”

Procedure

After approval by the University of Virginia's Social and Behavioral Science Institutional Review Board, our online survey created through Qualtrics® was launched through TurkPrime. Informed consent was obtained from participants before beginning the survey. Identifying information was not collected; anonymity was maintained. Participants were given 1 hour to complete the survey; on average, the survey required approximately 20 minutes to complete. It took approximately 10 days to collect an appropriate sample size for our analysis.

Data Analysis

Descriptive statistics were used to describe sample characteristics. Survey data were uploaded to SPSS (version 24; Armonk, New York) for analysis. We used Pearson r statistic to report correlations between mattering, meaning, social support, burnout, and engagement. In addition to statistical analyses, we conducted a content analysis of the open-ended responses to capture participants' descriptions of mattering at work. Two researchers (J.H. and C.M.) analyzed the themes identified in the content analysis and achieved consensus with strong agreement.

Results

Three-hundred twenty-four RNs completed our survey, from a possible total of 362. We excluded respondents who provide incomplete responses to our survey items or did not finish the survey. Demographic characteristics are presented in Table 1. A majority of participants were female and white, had earned a BSN, and were, on average, 39 years old. Most of our respondents' primary specialty was adult medical, and a majority worked full-time and worked in private inpatient settings. On average, participants had worked in their current position for slightly more than 12 years. There were no significant correlations found between the demographic data reported in Table 1 on the variables we measured in this study.

Table 1
Table 1:
Demographic Information

The nurses in this sample tended to experience high levels of engagement at work (mean [SD], 4.38 [0.60]). Respondents also reported moderately high levels of mattering at work (mean [SD], 4.93 [0.74]), meaning of work (mean [SD], 4.33 [0.69]), and social support from peers (mean [SD], 3.86 [0.84]) and subordinates (mean [SD], 3.84 [0.84]). Moderate levels of social support from their organization (mean [SD], 3.50 [1.06]) and supervisor (mean [SD], 3.42 [0.92]) were reported. Finally, the sample indicated relatively low levels of burnout (mean [SD], 2.18 [0.61]). Correlational analyses indicates that mattering is positively associated with meaning, social support, and engagement. In contrast, mattering demonstrates a strong negative correlation with burnout. Cronbach's α measure of internal consistency, means, standard deviations, and correlations for our variables are presented in Table 2.

Table 2
Table 2:
Descriptive Statistics, α Reliability, and Correlations Among Survey Items

In response to the open-ended question about the meaning of their work, 82% of participants replied that helping others or serving patients was their primary motivation. Eight percent noted their professional expertise, and 4% discussed relationships with peers or their organization in response to the question about meaning. When asked about an experience of mattering, respondents provided descriptions of positive encounters and relationships with patients (52%). Additional themes also emerged in the stories that resulted in a sense of mattering. These themes included demonstration of their professional expertise (25%), interactions with colleagues and/or the organization (42%), feeling appreciated (34%), being cared for as a person (4%), and knowing one has gone the extra mile for a patient or colleague (10%). Themes, examples from respondents, the component of mattering, and the frequency of these topics are presented in Table 3.

Table 3
Table 3:
Content Analysis of Open-ended Responses to Mattering Question

Discussion

The results of this cross-sectional survey study support our hypothesis that a sense of mattering may be an important factor to consider in the professional satisfaction and psychological health of nurses. The quantitative data demonstrate a positive association between a sense of professional mattering and a number of other metrics related to work satisfaction and engagement. Significant positive relationships were found between mattering, meaning of work, perceived social support at work, organizational commitment, and organizational engagement. Of particular interest was the finding that mattering was more highly correlated with perceived social support from peers and subordinates than with perceived social support from one's supervisor. The nursing literature has often focused on the relationship between nurses and their unit managers as being critical to the experience of the individual nurse.21 Although our data do endorse that perceived social support from one's supervisor is associated with professional mattering, they also suggest that the relationship with peers may be even more important. This finding supports the assertion that nurse-to-nurse peer relationships have important effects on the work environment22 and certainly deserves further investigation.

The survey data also demonstrated a significant negative correlation between professional mattering and burnout as measured by the ProQoL.19 These data only demonstrate that there is a negative relationship—that those with higher scores on professional mattering scales have lower indicators of burnout—and we cannot make assumptions about causality. However, these findings are consistent with our hypothesis that a greater sense of professional mattering may be protective against burnout.

Written responses to the questions “Please tell us what is meaningful to you about your work” and “Please tell us about a time when you mattered at work” provide depth to our quantitative statistical analysis. The answers about meaning were fairly general and often succinct. However, the responses to the question about mattering were often narratives about an experience with a specific patient or colleague. Responses to the mattering question demonstrated the impact a small gesture or appreciative comment can have. Although we provided no context or education about the psychosocial construct of mattering, respondents detailed experiences that demonstrated each of the 4 initially described components of mattering (awareness, reliance, importance, and ego extension), as well as both of the professional domains of mattering (interpersonal and societal). We therefore believe that the current definitions of mattering and mattering at work reflect the experience of nurses.

The narratives about mattering that demonstrated relationships with or dedication to patients were not surprising. The primacy of a nurse's responsibility to respect, serve, and advocate for patients is core to the professional identity and ethics of nursing.23 These stories illustrate how the interactions with patients can validate one's professional role and can instill a sense of mattering. Recognitions such as the DAISY Award for Extraordinary Nurses highlight specific descriptions of a nurse's caring and compassion and provide a tangible reminder of how nurses matter in the lives of patients and their families.24,25

Gratitude from a patient or family member is clearly meaningful, and yet, for some nurses, simply knowing for themselves that they had provided skilled and compassionate care was enough. However, nurses have limited control over how their patients will respond to them. Even when optimal care is delivered, a patient who is scared or in pain may not respond appreciatively.

For this reason, perhaps, the most notable finding from the qualitative data about experiencing mattering was the importance of interactions with interprofessional colleagues. Relationships with coworkers and the organization were brought up 10-fold more often when discussing mattering (42%) as compared with meaning (4%). Responses to the question about mattering demonstrate how even small, seemingly inconsequential interactions with colleagues can contribute significantly to an individual's sense of mattering. Nurses also expressed that knowing that their peers or organizations depend on them provided a sense of mattering. Specifically, daily interactions and small acts of gratitude, recognition, and caring between colleagues were noticed and remembered by nurses, and those interactions contributed to their sense of mattering.

One disturbing finding in the data is that there are individual nurses who can clearly articulate the meaning of their work who, when asked about mattering, responded with a statement such as “I cannot remember the last time I mattered” (n = 7). It is not surprising to find that these individuals had higher burnout scores compared with the larger sample (mean, 2.79 vs 2.18). It is unlikely that the efforts of these nurses are not appreciated by someone. However, it is clear that these nurses are not getting or not recognizing positive, external feedback that their contributions are noticed and valued. This suggests that there are opportunities for peers or organizations to intervene and create an environment that promotes a sense of mattering.

Implications for Leaders

This study demonstrates that, in a broad sample of nurses, a higher perception of mattering is correlated with self-reported lower levels of burnout and higher scores on meaning in work, engagement, and institutional commitment surveys. It further shows that nurses derive a sense of mattering from their patients, from their professional expertise, and from feeling appreciated and supported by their patients, colleagues, and organization. These findings may serve to help nurse leaders address issues of nursing burnout, turnover, and attrition.

There are a number of dissatisfiers in nursing practice that are challenging to address such as understaffing, diminishing reimbursement, and implementation of new technologies such as the electronic health record. As solutions for these challenges are being sought and trialed, it is within the power of an institution to create and encourage strong relationships and positive feedback processes among those who work there. An organization can create a forum for demonstrations of genuine gratitude for and among nurses. Although many organizations already recognize examples of professional excellence and organizational appreciation of extraordinary effort, taking notice of the day-to-day efforts of those who consistently demonstrate commitment to their patients and colleagues may be equally important. The DAISY Award provides recognition for patient-focused efforts.24,25 Might we find similar ways to celebrate efforts that enhance the work lives of our colleagues? According to the data from this study, these seemingly simple interventions have a notable effect on individual nurses and promote a sense of mattering.

In conclusion, we propose that nurse leaders may foster a greater sense of mattering in their staff by generating a culture that encourages strong relationships and explicit cues of appreciation among nurses as well as other interprofessional colleagues. This feeling of mattering could in turn lead to higher levels of resilience and engagement.

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