Nurses who co-create care with clients experience lower levels of burnout through the perception of fewer emotional demands: an observational study

Abstract

Background

Clients are especially satisfied about treatment of nurses providing person-centered care. Such care benefits from the co-creation of care, in which nurses and clients together shape the care process by investing in effective communication and supportive nurse-client relationships. Co-creation of care can especially benefit longitudinal collaboration between clients and their nurses in long-term care settings. However, it is unknown how nurses in these settings perceive the co-creation of care to affect their job demands, and ultimately, their levels of job burnout. We studied whether nurses’ perceptions of job demands (workload and emotional demands) mediated the association between the co-creation of care and job burnout in long-term care settings.

Methods

A web-based survey was completed by 256 nurses from two long-term care facilities in the Netherlands. Nurses were sent an email that included information about the study and a link to the web-based survey, consisting of items from validated questionnaires on the co-creation of care, job demands, and job burnout. Resulting data were analyzed using mediation analyses.

Results

The co-creation of care was associated with lower levels of burnout through the perception of fewer emotional demands (ß = –0.07; 95% percentile bootstrap confidence interval (PBCI) –0.12 to –0.02). Workload was also associated with lower burnout levels, but workload did not mediate the association between the co-creation of care and job burnout (ß = –0.01; 95% PBCI –0.07 to 0.05).

Conclusions

The co-creation of care supports nurses’ perception of their work in long-term care as less emotionally demanding, which helps them to experience less burnout. Thus, long-term care facilities could consider the promotion of the co-creation of care in efforts to reduce emotional demands and job burnout among nurses. Ultimately, investing in the co-creation of care can facilitate well-being of nurses as well as facilitate their person-centeredness in caring for their clients.

Background

Nursing care is highly valued by clients provided with person-centered treatment, which is tailored to their personal preferences and needs [1–3]. Such person-centered care also requires care decisions to be made in line with patient values, which can especially be facilitated when clients co-create care with their nurses [4]. Co-creation of care involves – based on the relational coordination theory – productive interactions between nurses and clients resulting from communication that is timely, accurate, and focused on problem solving [4, 5]. In turn, such communication promotes supportive nurse–client relationships, which are characterized by shared knowledge, shared goals, and mutual respect [5, 6]. This is highly relevant for clients in various health care settings, as well as in long-term care (LTC) settings in particular, as effective communication and supportive relationships can benefit the longitudinal collaboration between clients and their nurses in this setting [6, 7].

In LTC settings, nurses play a central role interacting daily with their clients to co-create care. Ultimately, the co-creation of care results in more positive client perceptions of care quality [7], better adherence to treatment recommendations, and better health outcomes [7, 8–10]. Furthermore, co-creation of care has shown to be positively associated with client well-being and may also contribute to better well-being of health providers themselves [5, 11]. Specifically, the co-creation of care has been associated with the physical and social well-being of community health nurses [6]; its association with the well-being of LTC nurses has not been studied yet. Nurses’ well-being has been studied widely through the examination of job burnout [12–15], a syndrome characterized by cynicism, reduced effectiveness, and emotional exhaustion at work [16]. A majority (51.6%) of nurses in LTC settings report emotional exhaustion, the core dimension of job burnout [12, 16].

Nurses in LTC experience more burnout when delivering care in work environments with stress-inducing job demands such as high workload and emotional demands [17, 18]. These job demands may be perceived as more or less stressful when health providers are engaged in the co-creation of care. Specifically, the co-creation of care has been associated with higher workload in specific settings (i.e., e-consultation in general practice) [19], but may also have the potential to reduce workload. Researchers have suggested, but not yet empirically demonstrated, that effective communication with clients facilitates efficient work processes, thereby reducing perceived workload among healthcare providers [5, 7]. Furthermore, healthcare providers who co-create care may face fewer emotional demands from clients due to the supportive relationships and effective communication [6, 11]. However, research has not yet provided insight into whether and how the co-creation of care in LTC settings is associated with nurses’ perceptions of job demands (i.e., workload and emotional demands).

Overall, the association between job demands and burnout has been demonstrated and explained widely by the evidence-based Job Demands-Resources (JD-R) model [18, 20, 21]. This model has outlined the health impairment process to clarify how burnout can develop in response to excessive job demands that increase stress and ultimately lead to exhaustion and poor well-being [22, 23]. On the other hand, the occupational well-being of healthcare providers may benefit from the co-creation of care [5, 6, 11]. However, research on co-creating care has not yet addressed burnout as a well-being indicator among LTC nurses [5, 6], and in this setting, it remains unknown whether the co-creation of care is related to job demands and burnout. Specifically, whether job demands may clarify (i.e., mediate) the potential association between the co-creation of care and burnout among LTC nurses is unclear. Thus, we studied whether LTC nurses’ perceptions of job demands (workload and emotional demands) mediate the association between the co-creation of care and burnout (Fig. 1).

Fig. 1.

Conceptual model of associations among co-creation of care, job demands, and job burnout among nurses in long-term care settings

Methods

Study design and setting

A cross-sectional web-based survey of LTC nurses was conducted. The results are reported according to the Strengthening the Reporting of Observational Studies in Epidemiology guidelines [24]. A convenience sample was recruited by inviting nurses from two facilities in the Netherlands that provided residential and home-based LTC to clients with somatic and psychogeriatric conditions to participate. They were sent an email that included information about the study and a link to the web-based survey. All LTC nurses were eligible to participate and were included, those with missing data on the study variables were excluded (see Results). Data were collected from March to May 2019 and were part of a larger research project [25]; the total survey consisted of 108 items on nurse demographics, job demands and resources, burnout, work engagement, empathy, individualized care and the co-creation of care. Below only measures relevant to the current study (consisting of 30 items in total) are reported.

Measures

Nurses’ co-creation of care with clients was measured using a modified version of the relational coordination instrument [5, 6, 26]; which has shown to meet psychometric validation standards in terms of interrater agreement and reliability, structural validity, content validity, and internal consistency [26–28]. This seven-item instrument addresses dimensions of communication (frequent, timely, and problem-solving) and relationships (shared knowledge, shared goals, and mutual respect) between healthcare providers and their clients. Responses were provided on a 5-point scale ranging from 1 (never) to 5 (always). Item responses were averaged to obtain total scores, with higher scores indicating more co-creation of care. The Cronbach’s alpha value for the scale was 0.85.

Nurses’ job demands were measured using the widely employed and validated Questionnaire on the Experience and Evaluation of Work [29], showing good reliability in different work and health care contexts [29–32]. We focused on workload (6 items) and emotional demands (5 items). Responses were given on a 4-point scale ranging from 1 (never) to 4 (always). They were recoded as needed and then averaged to obtain total subscale scores, with higher scores reflecting more demands. Cronbach’s alpha values for the workload and emotional demands subscales were 0.85 and 0.69, respectively.

The nurses’ job burnout was measured using the work-related (7 items) and patient-related (6 items) burnout subscales of the validated Copenhagen Burnout Inventory, with established reliability in different health care samples and settings [33–35]. These two subscales were considered to be relevant in reflecting job burnout, as work-related burnout involves exhaustion related to nurses’ work in general and patient-related burnout involves exhaustion related to caring for clients. Responses were provided on a 5-point scale ranging from 1 (never) to 5 (always). They were averaged to obtain total scores, with higher scores indicating more job burnout. The Cronbach’s alpha value for the scale was 0.90.

The survey also included questions about the nurses’ demographic characteristics [gender (female/male) and age], job position (nurse assistant/registered nurse), sector (residential/home care), and weekly work hours.

Data analyses

The data were analyzed using SPSS (version 28; IBM Corporation, Armonk, NY, USA). Descriptive statistics were used to characterize the sample and variables. Bivariate correlations were analyzed using Pearson and point-biserial correlation analyses. Using the PROCESS macro for SPSS [36], a mediation analysis was performed with the co-creation of care serving as the predictor, the job demands indicators (workload and emotional demands) serving as mediators, and job burnout serving as the outcome. Gender, job position, and weekly work hours were included as control variables, as they correlated significantly with one of the study variables. The mediation analysis was based on a series of linear multiple-regression and percentile bootstrapping analyses with 10,000 bootstrap samples. As it was performed with cross-sectional data, its results reflect atemporal mediation, i.e., correlational associations rather than causality [37].

Results

In total, 324 nurses initially responded to the survey, with 256 (79.0%) completing it. This final sample included 158 (61.7%) registered nurses and 98 (38.3%) nurse assistants. Most [n = 234 (91.4%)] participants were female, the mean age was 42.94 [standard deviation (SD), 13.13) years, and the average number of weekly work hours was 29.17 (SD, 7.40).

Descriptive statistics and correlations are shown in Table 1. The co-creation of care correlated significantly negatively with emotional demands and job burnout, but no significant correlation with workload was found. Workload and emotional demands both correlated significantly positively with job burnout.

Table 1.

Descriptive statistics and bivariate correlations between study variables and with control variables

Study variables	1	2	3	4	M (SD)
1. Co-creation of care					3.97 (0.57)
2. Workloads	− 0.01				2.32 (0.55)
3. Emotional demands	− 0.18**	0.35***			2.20 (0.36)
4. Job burnout	− 0.17**	0.23***	0.48***		2.18 (0.64)

* p < .05, ** p < .01, *** p < .001

The results of the mediation analysis are shown in Fig. 2. The co-creation of care had significant negative total and direct effects on job burnout, indicating that more co-creation of care was associated with less burnout, regardless of whether the mediators were taken into account. The co-creation of care also had a significant negative indirect effect on job burnout via emotional demands (ß = –0.07; 95% percentile bootstrap confidence interval (PBCI) –0.12 to –0.02), but not via workload (ß = –0.01; 95% PBCI –0.07 to 0.05). These results suggest that more co-creation of care is associated with less job burnout through the perception of fewer emotional demands.

Fig. 2.

Results of mediation analysis. Standardized coefficients (ß values) are reported. The coefficient in parentheses is for the total effect. Bold arrow paths indicate significant indirect effects. The paths for the control variables (gender, job position, and weekly work hours) have been omitted for figure clarity. *p < .05, **p < .01, ***p < .001

Discussion

Key findings

This observational study demonstrated that LTC nurses who co-created care perceived less job burnout, partly because they experienced fewer emotional demands at work. Their workload was not associated with the co-creation of care and did not mediate the association between the co-creation of care and job burnout.

Explanation of findings

Overall, our results align with the Job Demands-Resources (JD-R) model showing that job demands (emotional demands and workload) are associated with higher levels of burnout among healthcare providers [22]. Additionally, our study contributes to the body of knowledge on the JD-R model by showing that the co-creation of care can affect the way LTC nurses perceive their job demands – subsequently affecting their burnout levels. Our finding is in line with the previous finding that the co-creation of care is associated with better well-being among healthcare providers [7, 6], conflicts with the lack of association between the co-creation of care and burnout in one previous study among informal caregivers [38]. Apparently, the co-creation of care may have potential to reduce burnout in healthcare providers, but not in informal caregivers. The observation of the fostering of client satisfaction and empowerment may energize healthcare professionals in their work [7]; this aspect may explain the nurses’ perception of their work as less exhausting when co-creating care. Alternatively, the nurses’ exhaustion levels may have been lower because the co-creation of care is characterized by positive relationships with clients, which have intrinsic well-being benefits and/or reduce burnout [5, 6, 39]. Indeed, related research – in hospital-based settings – has shown positive patient relationships to foster physicians in feeling less burned-out [20], aligning with our finding that co-creating care is directly associated with lower levels of burnout.

Our study addressed the knowledge gap on how the association between co-creation of care and burnout among LTC nurses can be mediated by job demands, in particular showing the mediating role of emotional demands. Specifically, co-creation of care was indirectly associated with reduced burnout through the perception of fewer emotional demands. This may be related to the less emotionally demanding nature of clients who experience effective communication and supportive relationships with their nurses, with their needs and wishes adequately addressed through the co-creation of care. Nurses’ problem-solving communication during collaborative work on shared goals may reduce the likelihood that clients will disagree with their care-related decisions. This aspect may clarify the nurses’ reporting of less-difficult client interactions and a reduced burden of persuading their clients (as derived from the emotional demands subscale, see Measures). However, as this study is the first to demonstrate an association between the co-creation of care and emotional demands, the generalizability of this finding to diverse settings should be assessed.

Our finding that the nurses’ perceptions of workload were not affected by the co-creation of care does not align with discussions of the potential of the co-creation of care to improve the efficiency of work processes and thereby reduce healthcare providers’ perceived workloads in the literature [7]. It also does not align with a previous report that the co-creation of care (in the context of e-consultation in general practice) increases healthcare providers’ workloads [19]. The co-creation of care may increase providers’ workload by, for example, requiring the investment of more time in communicative and relational processes while decreasing workload by, for example, optimizing the efficiency of care, thereby neutralizing the association. A more-nuanced understanding of this association in the LTC setting, gained for example through additional qualitative analyses, is needed.

Limitations

This study demonstrated that our conceptual model applied to emotional demands, but not workload, among LTC nurses; only the former mediated the association between the co-creation of care and job burnout. The data for this study data were obtained from a convenience sample, and we could not calculate the response rate or assess the degree to which the scale scores were subject to self-selection bias. However, such bias may not have necessarily affected the directions or strength of associations between study concepts, which aligned with related findings [7] and the theoretical underpinnings of relational coordination theory and the Job Demands–Resources model [5, 40]. Previous findings on the JD-R model have been reported across different health care contexts and time periods [40]; our findings also show these associations in the LTC setting based on data from 2019. Both during and after this period, long term care has faced continuous pressures on job demands and nurse well-being, and our findings clarifying how these are affected by the co-creation of care, thus contribute to novel insights in addressing current workforce challenges in LTC. Moreover, our reported associations between job demands and nurse burnout have also been found in studies based on more recent data [7, 41, 42]; thereby showing that our findings fit into current trends in health care. Our findings should, nonetheless, be cautiously interpreted regarding causality; the study was cross-sectional, and we could not draw conclusions about the causal directions of the associations. Although longitudinal research has revealed causal associations of job demands with job burnout [21], the causality of associations of the co-creation of care with these factors is yet to be determined. Additionally, future research could focus on additional job demands or resources to help clarify the observed association between the co-creation of care and job burnout.

Implications of findings for practice

The facilitation of the co-creation of care could be considered in efforts to reduce nurses’ perceived emotional demands and job burnout through the implementation of initiatives at the client, healthcare provider, and service levels [7]. At the client level, health literacy and self-efficacy should be promoted to support clients’ ability to actively participate in the co-creation of care [43, 44]. Furthermore, at this level it may also be necessary to apply specific managerial methods, including healthcare user training, motivation and support building, to facilitate clients in the process of co-creating care [7]. At the provider level, resources (e.g., e-health tools or assistance with administrative tasks) should be made available to support providers dealing with the extra time requirements of the co-creation of care [7, 45]. Additionally, healthcare providers may be supported in the co-creation of care by managerial methods directed at staff training that help providers attaining new technical knowledge, motivational training or receiving managerial support in the co-creation of care [7]. Also managerial investment in continuing education interventions and an organizational culture characterized by patient-centeredness may support healthcare providers’ propensity to co-create care in efforts to optimize person-centered approaches [7, 44, 45]. At the service level, it is important that service reorganization be at an advanced stage; providers are less likely to co-create in organizations that face substantial reorganization needs [43]. Ultimately, the facilitation of the co-creation of care at these levels has the potential to support the reduction of emotional demands and job burnout among healthcare providers. Such support is important for not only healthcare providers’, but also clients’ well-being, which have been found to be associated with the co-creation of care [11, 46].

Conclusions

This study found the co-creation of care to support LTC nurses’ perception of their work as less emotionally demanding. Fewer emotional demands were associated with lower levels of job burnout, and thus with better well-being, among LTC nurses. The reduction of emotional demands and job burnout among nurses may be supported by promoting the co-creation of care, which ultimately facilitates LTC facilities to enable person-centered care in line with the preferences and needs of individual clients.

Author contributions

RS designed the paper, collected data, interpreted data analyses, drafted the manuscript, and approved the final manuscript. MV co-designed the paper, performed and reported data analyses, assisted in drafting the manuscript, and approved the final manuscript.

Funding

None.

Data availability

The datasets used and/or analysed during the current study are available from the corresponding author on reasonable request.

Declarations

Ethics approval and consent to participate

The Research Ethics Review Committee of the Erasmus School of Health Policy & Management waived the ethical approval requirement for this study (reference no. 21 − 016). The study was conducted according to the principles of the Declaration of Helsinki [37], and the participants were treated according to the ethical standards set forth by the American Psychological Association. All participants received information about the content and aim of study and were assured that participation is entirely voluntary and anonymous. Before starting the survey, participants digitally signed an informed consent form in which they confirmed that they understood the study aim and agreed to the terms of participation. Participants opening the survey link were again informed about the content and aim of the survey at the start of the survey, after which informed consent was implied when participants agreed to participate voluntarily.

Consent for publication

Not applicable.

Competing interests

The authors declare no competing interests.