Group-level impact of work environment dimensions on burnout experiences among nurses : a multivariate multilevel probit model

Background: Nurses' work environments are associated with burnout experiences among nurses. The RN4CAST project provides data on these constructs within a four-level structure (nurse, nursing unit, hospital, and country), implying more complicated multilevel analysis strategies than have been used in previous efforts studying this relationship. Objectives: First, to explore and investigate the effect of the nursing unit, hospital, and country level variability on the relationship between dimensions of nurses' work environment and dimensions of burnout. Second, to explore the significance of the nursing unit, hospital, and country level variability among the burnout dimensions. Design: Data from the RN4CAST project were available from a cross-sectional survey among 23,446 nurses in 2087 nursing units in 352 hospitals in 11 countries. Methods: Nurse-reported information on their work environment (managerial support for nursing, doctor-nurse collegial relations, and promotion of care quality) and burnout experiences (emotional exhaustion, depersonalization and personal accomplishment) were available. We specified ecological measures of the nurse work environment dimensions at the three organizational levels and combined these with individual-level outcomes within a series of multilevel statistical models. The final model was a multivariate multilevel probit model in which we modeled the work environment and burnout dimensions jointly. Results: Doctor-nurse collegial relations affected all burnout dimensions, but at the unit level only. For the dimension of promotion of care quality, the effect of the ecological exposure on burnout was pronounced at both the nursing unit and the hospital level for all three burnout dimensions. Findings for the dimensions of managerial support for nursing were ambiguous. Conclusion: Nurse work environment dynamics are related to nurses' burnout experiences at both the nursing unit and the hospital level. This implies that both hospital-wide and unit-specific interventions should be considered to achieve excellent work environments. The correlation structure among the three burnout outcomes varies across countries, but is stable between hospitals within countries and between nursing units within hospitals.