CROSS-CULTURAL STUDY OF NURSE BURNOUT AND PATIENT SAFETY 1

Critical Appraisal: Cross-cultural Di erences in Nurse Burnout and the

Relationship with Patient Safety

Kimberly Stewart

West Chester University

College of Health Sciences | Department of Nursing

NSG313 Nursing Research

Dr. Noreen Pulliam

September 18, 2022

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PICOT Question(s)

(1) How do levels of burnout compare across nurses working in Australia and China?

(2) What is the amount of variance explained by burnout in patient safety cross-

culturally? (3) Do the burnout dimensions predict patient safety in similar or dissimilar

ways cross-culturally?

Overview of Study

Workforce burnout has a ected all aspects of the labor market, and the nursing

eld is no exception. The Fish et al. (2022) study sought to compare levels of nurse

burnout across eastern and western cultures, speci cally China and Australia. The

study also looked at the e ect of burnout on patient safety. Fish et al. (2022) aimed to

ll gaps in the literature, stating, "very little is known about di erences in nurse burnout

across eastern and western cultures, nor the in uence of burnout on patient safety

cross-culturally." And, "very few cross-national studies have been conducted to

directly compare burnout among nurses across countries and cultures." The present

study aimed to extend previous research by recruiting larger samples in Australia and

China to determine whether nurse burnout truly varies across these two cultures, and

to explore the consequences of burnout for patient care.

The resulting knowledge of the comparative cross-sectional study would inform

strategies to allay the detrimental sequelae of burnout on nurses themselves, patients,

healthcare organizations, and global healthcare delivery.

An ethics review was reported and the study approval was granted by two

universities in Australia and China. The potential participants were informed that
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participation was voluntary, anonymous, and con dential. All participants supplied

informed consent for the study.

General description of the Study

Fish et al. (2022) recruited convenience samples of Australian and Chinese

nurses. In the Chinese samples, head nurses distributed, collected, and returned the

surveys to the researchers. Eligible respondents were hospital-employed, registered

nurses, who gave informed consent to participate. The Australian participants were

recruited across public and private healthcare services and eligible respondents were

adult nurses working in South Australia.

Survey data were collected from Australian nurses for three months, between

August and October 2017 (n = 730), and for seven months, between April and October

2019 in China (n = 1107). Variables included burnout measures: emotional exhaustion,

depersonalization, personal accomplishment, as well as, nurse leadership and support,

sta ng and resource adequacy, and perceived patient safety.

The survey consisted of 71 items; a mixture of validated instruments and items

developed for the survey. The Australian survey was administered online using the

SurveyMonkey cloud-based software for three months, between August and October

2017. In China, a printed survey was translated into Mandarin for data collection and

translated back into English for the dataset. Printed surveys were completed in China

for seven months, between April and October 2019.

Research Question(s)

The two objectives of this study were to investigate and compare (1) levels of

nurse burnout and (2) the in uence of nurse burnout on patient safety across eastern
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and western countries. The research questions were: (1) How do levels of burnout

compare across nurses working in Australia and China? (2) What is the amount of

variance explained by burnout in patient safety cross-culturally? (3) Do the burnout

dimensions predict patient safety in similar or dissimilar ways cross-culturally?

Sampling

Non-probability, convenience samples of Australian and Chinese nurses were

recruited for this study. In the Chinese samples, head nurses distributed, collected, and

returned the surveys to the researchers. Eligible respondents were hospital employees,

registered nurses, who gave informed consent to participate. The Australian

participants were recruited across public and private healthcare services and eligible

respondents were adult nurses working in South Australia. Non-probability sampling

reduces the generalizability of results to the wider population. However, because the

Australian participants were recruited from various public and private health sectors,

the external validity and the overall strength of the results were improved.

The study had 730 Australian respondents and 1130 Chinese respondents.

Chinese study participants were signi cantly younger, χ2 (5) = 639.79, p < .001, and

were more likely to identify as female, χ2 (1) = 20.99, p < .001, compared with

Australian participants. About 70% of the Chinese respondents were between 25-34

and ~97% were females. 30% of the Australian respondents were 45-54 with ~20%

within each decade between 25 and 64 and ~92% female.

Major Variables

The study's respondents/characteristics were independent variables as were the

results of the Maslach Burnout Inventory for Human Services (MBI), and the perception
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measures of leadership support and adequate sta ng. Fish et al. (2022) reported that

the MBI is reliable and valid measure across diverse countries and that, in their study,

internal consistency was high on emotional exhaustion (Australia α = .92; China α =

.89), depersonalization (Australia α = .76; China α = .75) and personal accomplishment

(Australia α = .76; China α = .87) for both samples.

As independent variables, this study assessed three dimensions of burnout:

emotional exhaustion, depersonalization, and personal accomplishment. The emotional

exhaustion items measured feelings of exhaustion and being emotionally overextended

by work. Depersonalization items measured an impersonal response to patients, while

personal accomplishment items assessed feelings of competence and successful

performance in working with patients. “Burnout was de ned as high levels of emotional

exhaustion and depersonalization, and a low level of personal accomplishment.” (Fish

et al., 2022) The Maslach Burnout Inventory for Human Services was used to assess

occupational burnout in this study.

Other independent variables, leadership support, and sta ng adequacy were

measured and included, and analyzed as potential confounding variables to enable a

more appropriate estimate of the relationship between burnout and patient safety.

Survey items included measurement of perceptions of leadership support, recognition

of good work, safe sta ng levels, and adequate time to discuss patient care with other

nurses were included. Scale reliability was high on nurse manager ability, leadership,

support of nurses (Australia α = .87; China α = .79), and sta ng and resource

adequacy (Australia α = .80; China α = .80) for both samples.

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Patient safety was the dependent variable in this study and was measured using the

single-item overall patient safety grade from the Hospital Survey on Patient Safety

Culture and respondents graded their wards on a 1-5 scale.

Fish et al. (2022) reported appropriate and extensive data analytics that were

employed across and among all data sets separately. The relationships between

burnout indicators and patient safety were tested while controlling for support

resources (as possible confounding variables).

There was an unexplained recurring dropout of Australian participants over the

length of the survey. Of the 1511 Australian nurses who participated in the study,

approximately 40% were missing data across the study variables and the missing data

were not missing at random. In contrast, missing data were minimal for Chinese

participants (n = 1169), with less than 3% of study variables missing data. The

unexplained, high level of non-random missing data needs to be studied further.

Emotional exhaustion and depersonalization scores were signi cantly higher in

the Australian sample compared with the Chinese sample. Australian participants

reported signi cantly lower patient safety ratings than Chinese participants. The

Australian subjects were less likely to agree that support resources were present in

their current job. Data analysis indicated that patient safety was signi cantly

associated with poor sta ng and resource adequacy, poor nurse leadership and

support, and depersonalization among Australian participants. Poor sta ng and

resource adequacy, poor nurse leadership and support, low personal accomplishment,

and emotional exhaustion predicted patient safety for Chinese participants.

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Conclusion

Fish et al. (2022) determined that:

Australian nurses are at greater risk of burnout than Chinese nurses.

Burnout dimensions are di erentially associated with patient safety

across cultures. Culturally relevant interventions may be more optimal than universal

approaches for improving burnout and patient safety in nursing.

The Fish et al. (2022) study sought to compare levels of nurse burnout across

eastern and western cultures, speci cally China and Australia. The study also looked at

the e ect of burnout on patient safety and aimed to ll gaps in the literature, stating,

"very little is known about di erences in nurse burnout across eastern and western

cultures, nor the in uence of burnout on patient safety cross-culturally." And, "very few

cross-national studies have been conducted to directly compare burnout among

nurses across countries and cultures." Fish et al. (2022) aimed to extend previous

research by recruiting larger samples in Australia and China to determine whether

nurse burnout truly varies across these cultures, and to explore the consequences of

burnout for patient care. Research comparing eastern and western cultures is not

proli c but may provide valuable knowledge about cultural and health system factors

that may in uence burnout, how burnout is experienced, as well as the consequences

of burnout. The resulting knowledge would inform strategies to allay the detrimental

sequelae of burnout on nurses themselves, patients, healthcare organizations, and

global healthcare delivery.

The Fish et al. (2022) results contrasted with previous international comparative

research across western and eastern countries. Although Fish et al. (2022) used a
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di erent patient care outcome measure, the disparate results imply that culturally

relevant interventions may be more appropriate than universal approaches for

addressing the relationship between burnout and patient care.

Patient safety and healthcare employee well-being are of paramount importance

in the healthcare sector. Fish et al. (2022) astutely reported that:

Australian nurses were at greater risk of burnout than Chinese nurses and

burnout dimensions di erentially in uenced patient safety across eastern

and western cultures. This suggests that cultural factors are implicated in

nurse burnout and culturally relevant burnout interventions are warranted,

especially in Australia. However, burnout as conceptualized by Maslach

et al., (2021) was not an optimal model for explaining patient safety

among Australian nor Chinese nurses. Future interventions addressing

patient safety may more usefully address organizational resources (e.g.,

sta ng adequacy and supportive leadership), which were the strongest

predictors of patient safety across sub-groups. Longitudinal research is

required to increase the strength of this evidence and to inform

intervention design.
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REFERENCES

Fish, J. A., Sharplin, G., Wang, L., An, Y., Fan, X., & Eckert, M. (2022). Cross-cultural

di erences in nurse burnout and the relationship with patient safety: An East-West

comparative study. Journal of Advanced Nursing, 78, 1001– 1011. https://doi.org/

10.1111/jan.15024
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