Outline I (Your Name) Characteristic Focus Goal Perspective Coverage Organization Audience Categories Research outcomes Research methods Theories Practices or applications Integration (a) Generalization (b) Conflict resolution (c) Linguistic bridge-building Criticism Identification of central issues Neutral representation Espousal of position Exhaustive Exhaustive with selective citation Representative Central or pivotal Historical Conceptual Methodological Specialized scholars General scholars Practitioners or policymakers General public Similar to the trust a patient has in their physician, a healthcare organization's employees, patients and stakeholders must have trust in its' leadership. Healthcare leaders drive an organization's mission and manage an institution's resources. Therefore, a culture of trust must be a component of an organization for it to succeed both internally and externally. The purpose of this literature review will be to discuss the important variables a leader must cultivate in order to create a culture of trust. Based on the existing body of literature this will be a qualitative review. I. II. III. IV. Introduction Definition of a culture of trust. Focus of the review. a. Inclusion criteria. Methods and behaviors that create internal and external trust. b. Exclusion criteria. Events outside of healthcare (Politics and world events) that impact trust Identification of essential themes. V. VI. VII. Creation of the hypothesis[ CITATION Pix08 \\l 1033 ][ CITATION Ser09 \\l 1033 ][ CITATION Rog \\l 1033 ] Summary Conclusion Bibliography Ciancutti, A. R., & Steding, T. L. Built on Trust: Gaining Competitive Advantage in any Organization. Chicago, IL: Contemporary Books. Covey, S. M., & Covey, S. R. (2006). The Speed of Trust: the One Thing That Changes Everything. New York, NY: Simon & Schuster . Pixton, P. (2008). Creating a Culture of Trust. Accelinnova.com. Rogers, R., & Riddle, S. (n.d.). Trust in the Workplace. 2009: DDI Competitive Advantage Realized. Serrat, O. (2009, August). Building Trust in the Workplace. Knowledge Solutions. Shore, D. A. (2006). The Trust Crisis in Healthcare. New York, NY, USA: Oxford University Press. Shore, D. A. (2005). The Trust Prescription for Healthcare. Chicago, IL: Health Administration Press Literature Review Outline II (Your Name) Nursing Stress and Burnout Characteristic Categories Focus Research outcomes Research methods Theories Practices or applications Goal Integration (a) Generalization (b) Conflict resolution (c) Linguistic bridge-building Criticism Identification of central issues Perspective Neutral representation Espousal of position Coverage Exhaustive Exhaustive with selective citation Representative Central or pivotal Organization Historical Conceptual Methodological Audience Specialized scholars General scholars Practitioners or policymakers General public Introduction o The NIOSH report on the right is an excellent resource that cites the following: 40% of workers reported their job was very or extremely stressful; 25% view their jobs as the number one stressor in their lives; Three fourths of employees believe that workers have more on-the-job stress than a generation ago; 29% of workers felt quite a bit or extremely stressed at work; 26 percent of workers said they were "often or very often burned out or stressed by their work" Job stress is more strongly associated with health complaints than financial or family problem o Because of the widespread damage stress can cause, it's important to know your own limit. But just how much stress is \"too much\" differs from person to person. Some people roll with the punches, while others crumble at the slightest obstacle or frustration. Some people even seem to thrive on the excitement and challenge of a high-stress lifestyle. o Research has shown that there are three critical factors promoting negative stress in the work environment. The first deals with employees' lack of confidence in their ability to deal with work demands. The second concerns lack of personal control, for example, one can't exert influence over tasks during a normal working day (Karasek 1979). The third factor concerns social sup- port, for example, employees' feelings of exclusion from the group and their lack of confidence in coworkers. Another aspect of low support is that competence and experience are not noticed and respected, as shown through support and feedback from supervisors (Cohen & Wills 1985).Absence of response: a study of nurses experience of stress in the workplace o Stress and Burnout in Nurse Anesthesia You may be more prone to burnout if*: You identify so strongly with work that you lack a reasonable balance between work and your personal life. You try to be everything to everyone. Your job is monotonous The first 2 are characteristic of the typical alpha individual drawn to our profession. As the stressful routine becomes the norm, burnout becomes a likely consequence Of the CRNAs responding, 40% were male and 60% females. Associate members had a higher response rate for females, at 70% Of the individuals who were CRNAs, the educators were the most stressed, with an average daily stress score of 6.15 and 90% of that stress from their jobs. When asked about how they handle stress, 31% of the members and 27% of the associate members indicated they had sought professional help for their stress. Of the CRNAs, educators have a higher degree of stress than others, with most of their stress coming from their jobs. They are second only to the associate members (students), who likewise have a higher degree of stress coming from their learning environment. Staff CRNAs have the lowest degree of stress. o Define Stress and Symptoms Stress is a normal physical response to events that make you feel threatened or upset your balance in some way. When you sense danger - whether it's real or imagined - the body's defenses kick into high gear in a rapid, automatic process known as the \"fight-or-flight\" reaction, or the stress response. The stress response is the body's way of protecting you. When working properly, it helps you stay focused, energetic, and alert. In emergency situations, stress can save your life - giving you extra strength to defend yourself, for example, or spurring you to slam on the brakes to avoid an accident. The stress response also helps you rise to meet challenges. Stress is what keeps you on your toes during a presentation at work, sharpens your concentration when you're attempting the game-winning free throw, or drives you to study for an exam when you'd rather be watching TV. It has long been observed that nurses are at a high risk of burnout (Maslach 1982). To date, nursing burnout as been related to high workload, age, gender, education level, length of experience in nursing profession, and personal characteristics such as hardiness, coping strategies and social support (Maslach 1982, Cameron 19940) o Acute The most common symptoms of acute stress include the following; emotional distress, manifested as anger, irritability, or depression; muscular problems, including tension headache, hack pain, and jaw pain; stomach, gut, and bowel problems; and physical symptoms such as elevated blood pressure, rapid heartbeat, sweaty palms, heart palpitations, dizziness, migraine headaches, cold hands or feet, shortness of breath, and chest pain.'' o Chronic Long-term exposure to stress can lead to serious health problems. Chronic stress disrupts nearly every system in your body. It can raise blood pressure, suppress the immune system, increase the risk of heart attack and stroke, contribute to infertility, and speed up the aging process. Long-term stress can even rewire the brain, leaving you more vulnerable to anxiety and depression Method of Research o EBSCOhost CINAHLplus: Nursing and Allied Health Literature MEDLINE: (PubMed) o Search terms: Nurse, Stress, Burnout, and Manager - nine results o Search terms: Nurse, Stress, Burnout - 331 Identify Themes of Findings o o o o o Education Age Workload Support Control Education o Job stress, achievement motivation and occupational burnout among male nurse Wong et al. (2001) noted that nurses with tertiary education have more positive thinking skills, and self confidence and commitment, all of which would help them handle occupational stress better than nurses with a secondary education. o Understanding Nurses' psychosomatic complications The majority of the participants made reference to the dissonance between their initial image of nursing when entering the nursing profession and the actual reality they experienced in their daily nursing practice. The first one relates to the dissonance between nurses' role expectations at the commencement of their career and the organizational and cultural restrictions of their practice reality that inhibit the fulfillment of these initial role expectations. o When does nursing Burnout begin? The study indicates that a significant proportion of nursing graduates reach the end of their university training in a dangerously fatigued state. This then raises the question of how nursing graduates can reasonably be expected to recover from this state as they progress into the environment of even more demanding and enduring stress during the GNP year, immediately after the completion of the BN course Age o Relationship between assertiveness and burnout among nurse managers It has been demonstrated that nurses are more prone to burnout the lower their age (Suzuki et al., 2003; Washimi & Nagae, 1998; Williams, 1989) and the shorter their nursing experience (Suzuki et al., 2003; Tao & Kubo, 1996). Tao and Kubo (1996) reported a critical point in age and years of experience, and nurses are less likely to burnout when exceeding the critical point at age 40 or 11 years of experience, although this could be interpreted that only those who survived burnout were remaining o Burnout among hospital nurses in China Age, years of experience, working position and professional title were significantly positively related to Emotional Exhaustion and were negatively related to Personal Accomplishment. Nurses who were married, senior and had higher professional titles experienced significantly higher levels of Emotional Exhaustion. Nurses aged 31-35 had the highest scores in Emotional Exhaustion, which were significantly higher than age group 21-25 (P = 0.001). Single nurses' Emotional Exhaustion score was significantly lower than the marriedgroup (P = 0.014). The manager groups' Emotional Exhaustion score was significantly higher than the nurse group (P = 0.003). The results of this study showed that younger nurses with less work experience, lower professional titles and lower working positions experienced lower levels of Emotional Exhaustion. This finding was supported by Foster (2003). However, this finding differs from Maslach and Jacksons (1996), who found that older nurses in the United States experienced a lower level of burn- out in Emotional Exhaustion, Depersonalization and reduced Personal Accomplishment than younger nurses. The findings of this research showed that younger nurses experienced lower levels of Personal Accomplishment. Another possible reason why older nurses with a greater experience and a higher professional title in nursing experienced higher levels of personal accomplishment could be related to what they have achieved in their lives. They may have achieved a good position, a higher professional title as they gained experience, and they may have had a greater opportunity to start (or have started) a family. o Contrasting burnout, turnover intention,... Generation X nurses experience more symptoms of job burnout and are more inclined to change their jobs than their colleagues of the Baby Boomer generation. The Generation X nurses reported a clearly more negative evaluation of value congruence, control and personal knowledge sharing involvement. In conclusion, the research reported here demonstrated that Generation X nurses experience their work settings as less consistent with their personal values than do nurses from the Baby Boomer generation. They also display more indicators of job burnout and less inclination to participate in knowledge sharing. o When does nursing burnout begin? Several studies have noted younger nurses showing a greater tendency towards burnout (or maladaptive chronic fatigue states) than older nurses (Bartz & Maloney 1986, Beierholm et al. 1989, Lee & Wang 2002, Bernardi et al. 2005, Winwood et al. 2006b). The study indicates that a significant proportion of nursing graduates reach the end of their university training in a dangerously fatigued state. This then raises the question of how nursing graduates can reasonably be expected to recover from this state as they progress into the environment of even more demanding and enduring stress during the GNP year, immediately after the completion of the BN course. Relatively inexperienced, newly graduated, nurses also commonly experience significant anxieties about clinical competency and role ambiguity (Healy & McKay 2000, Chang & Hancock 2003) o Burnout and the Med-Surg Nurse One study (Erickson & Grove, 2008) found a higher number of nurses experiencing burnout while still under the age of 30. \"Registered nurses under age 30 reported experiencing significantly higher rates of the most intense levels of frustration, anger, and irritation...than those over 30\" (Erickson & Grove, 2008, p. 8). It could be posited that burnout is higher in this age group of nurses because they continue to retain the ideals and techniques developed in nursing school, although it can also be posited that more experienced nurses have developed emotion management techniques that help defray the frustration felt by the younger, lessexperienced nurse. o Work-related fatigue and recovery The youngest age group reported the highest fatigue and poorest recovery compared to the oldest group, who reported the best characteristics. However, this latter group may represent a particularly well adapted 'survivor cohort'. The relationship between age and fatigue was partly confounded by older, experienced, nurses with greater job responsibilities, working fewer multiple shifts including night duty. In general, increasing age was not associated with poorer recovery or higher maladaptive fatigue. We had expected that age would be correlated with increased fatigue and poorer recovery between shifts. Instead, we found that the oldest age group in the study sample (55 years) reported the least chronic fatigue and acute fatigue and best recovery. The better recovery and lower fatigue among the oldest age group may also be explained by them forming a 'survivor cohort' which is particularly well adapted to the nursing profession, and in addition manifesting 'healthy worker' attributes (Sterling & Weinkam 1985, Portela et al. 2004). By comparison, those in the youngest age group (18- 24 years) reported the highest chronic fatigue and acute fatigue scores and the lowest recovery. The poor results of this group are consistent with reports that nurses face significant challenges in the first years after graduation in adapting to the work demands of nursing whilst overcoming inexperience and developing practical nursing and life skills, including time management (McNeese-Smith & van Servellen 2000, McNeese-Smith 2000). Workload o Nursing specialty and burnout Nurse practitioners often enter the field because they desire greater autonomy Emergency nurses often deal with an overload of patients and nurse managers must often negotiate the concerns of staff and management, nurse practitioners may be able to concentrate more fully on patient care. Opportunities to spend additional time with patients may help reduce work- related stressors, increase control, and ultimately decrease burnout. o Working Conditions, psychosocial resources and works stress Tennant (2001) claims that work stress is of increasing importance due to continuing changes in the workplace, with both increasing job demands and job insecurity imposed on employees. Karasek and Theorell (1990) found psychosocial job demands along with time pressure and conflicts to be significant sources of risk for stress-related illness. Job demands reflect the determined aspects of work, such as deadlines, challenges and expected performance. Other components included are stresses arising from personal conflicts that may have been caused by role conflict and task pressure (Karasek & Theorell 1990). It was found in both the manager groups that those who reported high job demands had more than six times higher probability for high work stress than those who were not in this situation. This study revealed that nurse managers and clinical directors who were exposed to high job demands had a significantly higher probability of high level of work stress than those who were not in this situation. The result also indicated that those who were exposed to high job demands had an increased risk of high level of work stress irrespective of available support taken together inside and outside work. o Job stress, achievement motivation and occupational burnout among male nurse Our study showed that job loading was the main source of job stress. o Absence of response: a study of nurses experience of stress in the workplace The nurses described that it was difficult for them to suffice when several people (patients, relatives, assistant nurses) were simultaneously in need of their help. The informants reported in the interviews that high workloads and staff shortages were the reasons why they still thought about work at home, which led to tiredness and irritation. Not having enough time to care for patients, due to increased time spent on administrative work, was frustrating. The nurses experienced a feeling of emotional powerlessness when there was not sufficient time, which decreased their chances to take care of the patients in a way they saw fit. The nurses' understanding that they could not influence their work situation caused them to have a feeling of hopelessness Harmful stress arises when leadership places high demands that are not balanced by employees' influence over their work. In situations of imbalance, such as staff shortages and heavy workloads, employees feel worn out and tired, which can lead to reduced self-confidence. Absence of response from supervisors can cause imbalance in an entire workplace. o Burnout and the Med-Surg Nurse Burnout results from the inability to adequately manage work-related stress. This happens when workloads are too heavy, a sense of empowerment is missing, or ideals are greatly mismatched with reality. With such large patient loads, it becomes a challenge to pro- vide the needed care to all patients, adding to the sense of frustration and reduced personal accomplishment. o Stressors, burnout and social support Lack of adequate staffing was the main stressor reported by qualified staff, while dealing with physically threatening, difficult or demanding patients was the most stressful aspect for unqualified staff. Qualified nurses reported significantly higher workload stress than unqualified staff. Approximately half of all nursing staff showed signs of high burnout in terms of emotional exhaustion. A variety of stressors were positively correlated with emotional exhaustion and depersonalization. Higher levels of support from co-workers were related to lower levels of emotional exhaustion. Higher stressor scores were associated with higher levels of depersonalization for staff reporting high levels of social support, but not for those reporting low levels of support (a reverse buffering effect). The main stressor cited by qualified staff was a lack of adequate staffing, which is consistent with the findings of a number of previous studies of mental health nurses (Carson et al. 1995, Cushway et al. 1996). o Turkish nurses; perspectives on a program to reduce burnout Most of the nurses described work overload, insufficient staff, being undervalued and misunderstood by the administration as the causes of burnout. o Work-related fatigue and recovery Taken together, our results failed to demonstrate that full- time working nurses with domestic and dependent responsibilities are more 'at risk' of low recovery from acute work fatigue between shifts, and consequently developing mal- adaptive fatigue symptomology, compared with unpartnered nurses without dependents. All our analyses confirmed that working multiple shifts, which include night work, was associated with higher acute work- related fatigue, poorer intershift recovery and higher maladaptive chronic fatigue. These observations are consistent with many other reports of the relationship between shift- work and work strain (Tasto et al. 1978, Baker 1980, Kandolin 1993, Harrington 1994, Cruz et al. 2000, Akerstedt et al. 2002, Folkard & Tucker 2003 o When does nursing Burnout begin? Relatively inexperienced, newly graduated, nurses also commonly experience significant anxieties about clinical competency and role ambiguity (Healy & McKay 2000, Chang & Hancock 2003 In addition, they begin working the unpredictable internal shift rotation system (including night duty) which is traditional within nursing, and of which younger nurses are expected to do far more. (Learthart 2000, Winwood et al. 2006b). Support o Stress and burnout in forensic mental health nursing: a literature revision Burnout, however, is an elusive concept; moreover, in 1974 Freudenberger suggested that certain commonalities and themes pervaded the literature. Burnout is a psychological experience that manifests itself in the individual, particularity those involved in difficult person-to-person relationships as part of their working practice. In accord with Kirby and Pollock (1995) and Cacciacarne et al (1986), Chalder and Nolan (2000) conclude that staff should have easy and confidential access to support systems within the workplace and that managers should foster an open and honest culture wherein individuals can feel free to speak up for themselves and others about issues that are causing stress. o Working Conditions, psychosocial resources and works stress According to Johnson (1991) social support at work and job support might function as an important coping resource, which potentially may modify the impact of social environmental stress Nurse managers who reported low instrumental support more than doubled their probability of high level of work stress The results indicated that the job demands on nurse managers and clinical directors might have become too high to be buffered within ordinary supporting limits related to the work situation. Both nurse managers and clinical directors who were exposed to high job demands had significantly increased odds for high level of work stress regardless of the available psychosocial resources taken together in daily life (inside and outside work) One finding in this study was the nurse managers' experience of high level of work stress in relation to low instrumental support, which was not found in the group of clinical directors. Here, the nurse managers more than doubled their probability for high level of work stress. A possible explanation to this finding might be that the nurse managers, who historically just entered higher structural levels of chief management, by tradition and/ or organizational culture do not require essential instrumental support from other professional groups within the organization. o Work-related stress, education and work ability among hospital nurses In the last few years, there has been growing interest in the psychosocial work environment of healthcare workers. This is because they are at high risk of stress, burnout, role conflict and job dissatisfaction. o Job stress, achievement motivation and occupational burnout among male nurse Nurses who work in very stressful environments with minimal control and organizational interaction from colleagues may actually have a negative effect on patient safety (Berland et al. 2008). In addition, nurses with frequent job stress could experience numerous psychological and physical problems (Wong et al. 2001) o Burnout among hospital nurses in China Nurses who claimed to receive enough support from friends had a significantly lower level of Depersonalization, while nurses with support from coworkers and managers experienced significantly lower levels of Emotional Exhaustion o Contrasting burnout, turnover intention,... Individuals who assert a high self-rating for control believe they have the capacity, resources and cooperation from their employer that are necessary to shape their work environment. o Absence of response: a study of nurses experience of stress in the workplace The experience of not being acknowledged by one's immediate supervisor strengthens the feeling and experience of stress in the work situation. Not being seen is experienced as lack of emotional support. In one interview absence of both positive and negative response is expressed. o Hospital nurses; job satisfaction: literature review Human relationships between nurses and various communal factors are of major importance for nurses' job satisfaction, and several studies (Adams & Bond 2000, Newman & Maylor 2002, Dunn et al. 2005, McLennan 2005) have indicated them to be the best predictors of job satisfaction. According to Adams and Bond (2000), job satisfaction is most strongly predicted by social and professional relationships in the work- place. o Stressors, burnout and social support With regard to social support, we found evidence of both main effects and buffering. Main effects were confined to only one of the four sources of support measured, with higher levels of support from co-workers associated with lower levels of emotional exhaustion. The positive relationship between levels of support from fellow nurses and emotional exhaustion indicates that staff support groups have an influential role to play in alleviating some of the effects of occupational stress. o The Impact of Stress Management on Nurse Productivity & Retention Based on these results, nurses within a positive, supportive environment may experience reduced stress, fewer health-related problems, and greater adherence to self- care practices such as regular use of stress-reduction techniques. Fostering the building of relationships within the workplace can contribute to emotional. Instrumental, and informational support. Individuals given opportunities to relate vent about stressors, and commune with co-workers may feel emotionally affirmed and reassured. Instrumentally assisted through mutual problem solving, and potentially o The relationship between multidimensional leadership and burnout (leadership) Passive laissez-faire leadership of nurse manager seemed to expose especially temporary nursing staff to emotional exhaustion, whereas the effect on permanent staff was minor. Rewarding transformational leadership seems to protect especially temporary nursing staff from emotional exhaustion, whereas the effect on permanent staff was minor. Rewarding trans- formational leadership and active management-by- exception were statistically significant predictors in the regression model. They functioned as protecting factors from depersonalization. Working in a supervisory position and in irregular work (such as three- shift and night work) seems to reduce personal accomplishment of nursing staff Nurses in a supervisory position reported higher levels of personal accomplishment (mean 6.3) when they perceived their immediate supervisor as using passive laissez-faire leadership extremely seldom, while they perceived lower levels of personal accomplishment (mean 5.8) when their supervisor often used passive laissez-faire leadership. The results suggest that rewarding transformational leadership and active management-by-exception functioned as protecting factors, and passive laissez-faire leadership as an exposing factor in terms of burnout among nursing staff. Rewarding transformational leader- ship seems to protect from depersonalization and to increase personal accomplishment. Active management-by-exception seems to protect from emotional exhaustion and depersonalization as well as to increase personal accomplishment. Passive laissez-faire leadership seems to function as an exposing factor for emotional exhaustion and depersonalization, and also as a decreasing factor for personal accomplishment among nursing staff. Passive laissez-faire leadership of nurse manager seems to expose especially temporary nursing staff to emotional exhaustion and depersonalization. Correspondingly, rewarding transformational leadership seems to protect especially temporary staff from emotional exhaustion and depersonalization An active role of the nurse manager may create feelings of safety, especially among temporary nurses, a In addition, passive laissez-faire leadership decreased the feelings of personal accomplishment among respondents in supervisory position and a sense that the nurse manager is actively present, cares about her staff and respects their work Control o Stress and burnout in forensic mental health nursing: a literature revision Higher rates of burnout were reported by lower-ranking staff, who usually had more direct contact with the patients. The findings of the study suggest that power, decision-making, and control over the work environment are important factors in preventing burnout. o Nursing specialty and burnout Nurses are prone to burnout because they often enter their profession with high expectations of control over the workplace and patient outcomes (Muldary, 1983) Emergency nurses reported lower initial and current expectations and greater loss of control than nurse practitioners. Emergency nurses also reported lower current expectations, and greater loss of control than nurse managers The present research revealed that emergency nurses experienced greater loss of control, greater burnout, greater hostility and depressive symptoms, greater stress, and less mastery and optimism than nurse practitioners. Nurse managers were similar to nurse practitioners in terms of control. However, nurse managers reported greater depersonalization, less personal accomplishment, and more frequent work-related stressors than did nurse practitioners. Hostility consistently resulted in greater burnout among emergency nurses, complementing the control-related findings, as hostility is a natural response to low-control situations (Wortman & Brehm, 1975). Depressive symptoms, which mediated emotional exhaustion among emergency nurses versus nurse practitioners, is another emotional response to low control situations. In contrast, work-related stressors consistently mediated the tendency for nurse practitioners to exhibit lower burnout o Contrasting burnout, turnover intention,... Control includes the capacity to seek out the information and resources required of an effective employee. It also represents the influence employees have on decisions that affect their work (Leiter & Maslach 2004a,b). In a longitudinal study of nurses working in a hospital setting in the Nether- lands, Gelsema et al. (2006) found that giving nurses more control over their jobs increased their overall job satisfaction o Stress and Verbal Abuse in nursing Managers must attempt where possible to involve nursing in decisions regarding policies and procedures. Individuals are who involved and invested in these decisions are less likely to experience occupational burnout. Conclusion o Strengths of research o Weakness of research o Is anything missing in research? 1. Billeter-Koponen S, Freden L. Long-term stress, burnout and patient-nurse relations: Qualitative interview study about nurses' experiences. Scand J Caring Sci. 2005;19:20-27. 2. Burtson PL, Stichler JF. Nursing work environment and nurse caring: Relationship among motivational factors. J Adv Nurs. 2010;66:1819-1831. 3. Chipas A, McKenna D. Stress and burnout in nurse anesthesia. AANA J. 2011;79:122-128. 4. Cross W, Moore A, Ockerby S. 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