Commentary on Kowalski C, Ommen O, Driller E, Ernstmann N, Wirtz M, Köhler T & Pfaff H (2010) Burnout in nurses – the relationship between social capital in hospitals and emotional exhaustion. Journal of Clinical Nursing 19, 1654–1663

Scientific research on burnout has existed for almost 30 years examining different aspects of the phenomenon across occupational groups and progressively enriching our insights into the impact of the organisational context of work on workers. Maslach and Leiter (2008) described burnout as a mismatch between person and job in six areas of work life; work overload, lack of control, lack of rewards, lack of community, lack of fairness and value conflict. Studies confirm that these areas are often influenced by organisational and managerial decisions and policies. Burnout has a negative impact on the individual worker and reduces productivity and adversely affects quality of service (Schaufeli & Buunk 2003). Burnout is the opposite of engagement in work and appears to reflect a failure in the organisation to create a professional practice environment (Van Bogaert et al. 2009). Therefore, attention to sources of chronic organisational stress is recommended to ensure productive health care organisations accomplish desired outcomes. Kowalski et al.’s (2010) paper examines the association between social capital and emotional exhaustion in a nurse population of 959 respondents from four hospitals in Germany. They define social capital as the existence of collective values and convictions and mutual trust between the members of an organisation. The authors conceptualise social capital as a resource available to both individuals and organisations, and supports coping with stress and that social relationships are promote general well-being and protect against physical harm. Kowalski et al. (2010) argue that little is known about the impact of social capital as an organisational characteristic on emotional exhaustion. Because of their associations with emotional exhaustion, perceived workload and decision latitude were selected as additional independent variables alongside job characteristics and working experience. Decision latitude was measured as a job characteristic concerning opportunities to make decisions, to be creative and to use and to develop professional and personal skills. Emotional exhaustion, the primary of three burnout dimensions, represents the strain experienced by nurses. It refers to feelings of being overextended and depleted of one’s emotional and physical resources (Maslach & Leiter 2008). Studies have confirmed associations between reciprocity imbalance – between ‘give’ and ‘take’ and feelings of burnout. Specifically, emotional exhaustion is theorised to develop when nurses perceive an unbalanced relationship with colleagues and the organisation in addition to their potential charged and unbalanced relationships with patients (Schaufeli & Buunk 2003, Schaufeli 2006). Other researchers have shown that emotional exhaustion is associated with a high work load and qualitative job demands (e.g. interpersonal demands) in combination with low job resources, for example, autonomy, social support, supervision relationship and performance feedback (Bakker et al. 2005). Although emotional exhaustion was strongly associated with nurses’ perceived workload, social capital and decision latitude were also linked with emotional exhaustion in the logistic regression tested models. Therefore, social capital and decision latitude sustained by participatory organisational culture could be protective factors against emotional exhaustion and risks of the associated outcomes such as nurse turnover and medical errors. In addition, Kowalski et al. (2010) mention that regular team meetings and supervision sessions may enhance the social climate in hospitals and improve communication. Another way to frame potential management intervention is to view nursing unit teams as the multidisciplinary core of a clinical microsystem. Clinical microsystems are the interface where patient and families and health care teams meet. They are the sharp end of health care delivery where both medical miracles happen and tragic mistakes are made (Nelson et al. 2007). Several studies suggest an association between care environments and patient outcome measures such as 30-day mortality and failure to rescue (Aiken et al. 2008, Friese et al. 2008). An international study confirmed the negative impact of burnout on nurse-rated quality of care (Poghosyan et al. 2010). In addition, variations across a nursing unit practice environment and burnout levels were predictive of job outcome and nurse-rated quality of care in another study (Van Bogaert et al. 2010). Taken together, these studies suggest that nursing teams with high levels of team work, structural support and empowered by physicians, unit managers and hospital leaders are more able to cope with the complexity in patient care and generate better outcomes. Kowalski et al. (2010) also mention that an individual burnout intervention programme can have an effect on emotional exhaustion training where health care professionals use particular coping skills based on cognitive restructuring and relaxation techniques. However, effective organisational and workplace interventions require the more active involvement of health care workers encouraged by nurse and hospital leaders (Le Blanc et al. 2007). Leiter and Maslach (2010) recommend a focus on all the six areas of work life as early predictors for burnout – engagement intervention. Moreover, rather than developing a generic ‘one size fits all’ change programme, efforts should differ and depend on the target groups and the potential risk factors. However, because of current socio-economic conditions, the support for interventions focusing, for example, on the potential imbalance of demands for resources is a problem. Nevertheless, health and health care is of great public interest and a universal right; therefore, external evaluation strategies and financial incentives for proper patient and workforce outcomes will sustain hospital management policies in choosing the right goals and strategies. Kowalski et al. (2010) have made a clear contribution on the impact of social capital on emotional exhaustion and the nurse working environment and its impact on feelings of burnout. Future research should concentrate on interventions that increase social capital in hospitals as an additional support for nursing teams and other health care professionals.