The Exploration of Emotional Exhaustion in Developing Patient Safety Culture in a Tertiary Hospital in China

In recent years, safety culture has become a major issue faced by medical service systems globally. According to the annual report of the World Health Organization, 1 in 10 hospitalized patients experience medication-related harm due to adverse events and avoidable medication errors [1]. Similarly, the data of the National Health Commission of the People’s Republic of China (NHC) stated that the number of medical disputes in 2013 reached about 70,000 cases. In 2014, 115,000 cases of medical disputes were issued, and the safety situation of the patients remained severe [2]. The reports of the 19th CPC National Congress on health care clearly stated that it is critically important to develop a comprehensive patient safety in China.

In the medical industry, errors, failures, and malpractice during health care can pose threats to patient safety and prove extremely costly for medical organizations. Studies have illustrated that significant numbers of patients are harmed during a medical procedure, either resulting in patient failures, urinary tract infections or even death [3,4]. The development of patient safety culture is considered to be an important bridge to promote patient safety [5].

The instrument that has been widely used to evaluate the patient safety culture for healthcare organizations in practice from medical staff’s viewpoints is the safety attitudes questionnaire (SAQ) [6,7]. The SAQ was developed by Sexton et al. [8] in the United States and has a six-factor of patient safety culture, namely, teamwork climate, safety climate, perceptions of management, job satisfaction, stress recognition, and working conditions. However, the previous versions of SAQ have not explicitly discussed the emotional state of the medical staff during medial encounters. In fact, studies have confirmed that a high level of burnout affects medical staff’s well-being and work-life balance, which in turn causes adverse events and medication errors [9,10]. In 2014, the Joint Commission of Taiwan (JCT) modified the SAQ and integrated emotional exhaustion (EE) and work-life balance (WB) to form the newest Chinese version of SAQ [9,11]. Although studies have supported the importance of SAQ in improving medical services in China, little knowledge has clearly identified the role of emotional exhaustion plays in establishing patient safety culture. To better measure medical staff’s awareness of patient safety and forge patient-oriented services, it is therefore essential important to further explore the impact of emotional exhaustion on the establishment of patient safety culture in healthcare organizations.

This study aims to examine the role of emotional exhaustion plays in establishing patient safety culture, using the Chinese version of SAQ developed by the JCT [10]. As presented in Table 1, the contents of the questionnaire mainly include eight dimensions and 46 items. The eight variables are teamwork climate, safety climate, job satisfaction, stress recognition, perceptions of management, working conditions, emotional exhaustion, and work-life balance. Teamwork climate implies the atmosphere of cooperation among colleagues, safety climate represents the situation of a hospital’s security commitment, job satisfaction is one’s positive view of the enthusiasm for work, stress recognition represents one’s feelings of work stress, perceptions of management imply feelings about the management style of one’s manager, and working conditions describe one’s feelings about working conditions and resources. Emotional exhaustion describes a loss of passion for work, emotional exhaustion, and feelings of depersonalization. Worklife balance refers to balancing both work and other aspects of life [5,12].

Table 1: The Chinese version of safety attitude survey.

*Indicates the question item is worded negatively.

A total of 256 valid questionnaires were collected from medical staff from a tertiary hospital in Hubei province in 2018. Five-point Likert scales anchored by 1 (strongly disagree) and 5 (strongly agree) were used throughout the questionnaire except for the measures of work-life balance since its scales were four-point frequency ratings. After data screening, regression analysis was used to measure the impact of emotional exhaustion on the rest of six patient safety culture dimensions.

Table 2: Regression analysis.

Dependent variable: Emotional exhaustion.

The results of current study demonstrated that the Cronbach’s α coefficient of all dimensions of patient safety culture was within the range of 0.719 to 0.919. This suggests that the survey has a certain degree of internal consistency. Based on regression analysis shown in Table 2, emotional exhaustion was selected as the dependent variable in the step of regression analysis. In terms of the influence of each dimension on emotional exhaustion, stress recognition (β=0.448, p<0.01) was the most significant factor, followed by job satisfaction (β=-0.445, p<0.01).

By investigating the essential dimensions of patient safety culture from the perceptions of medical staff, the current study makes the following suggestions.

Enhancing job satisfaction

This study shows that job satisfaction has a negative significant effect on emotional exhaustion. That is, the more the medical staff is satisfied with the job, the less the emotional exhaustion is perceived to be. Studies have stated that job dissatisfaction could lead to negative outcomes (e.g. emotional tension, anger or fatigue), which in turn cause medical mistakes or medical malpractice [13,14]. enable satisfaction can be incentivized by establishing a systemic incentive mechanism in the hospital. For example, appropriate key performance indicators enable medical staff to achieve work tasks more effective. It has also been shown that high workload and low salaries are related to absenteeism among medical staff [15], which might influence not only medical staff’s work performance but also their emotional empathy. Therefore, we suggest implementing rational salary system with performance-based bonuses and standard handoff systems, to enhance the level of job satisfaction.

Relieving workplace stress

It is noted that a positive relationship between stress recognition and emotional exhaustion is found in the current study. Medical staff with high pressure in the workplace is shown to cause higher emotional exhaustion. Indeed, medical staff faces higher stress and challenges which result from multi-task working conditions in the hospital [5]. Thus, several stress management implementations are suggested to help medical staff relieving stress in the workplace, such as organizing stress reduction courses, music concerts, and sports parties, and outdoor activities.

The current study aims to identify the impact of emotional exhaustion on the patient safety culture dimensions. In summary, we suggest that hospital managers should pay more attention to job satisfaction, stress recognition, and emotional exhaustion. The investments of these implications can greatly reduce the occurrence of preventable medical accidents and ensure the safety of patients.

This study was supported by Law & Business College of Hubei University of Economics with the grant number of 2019K08.

1. World Health Organization (WHO) (2017) Patient safety: making health care safer. World Health Organization, Geneva, Switzerland.
2. National Health and Family Planning Commission of the People's Republic of China (NHC). Health planning reformation and development, China.
3. Gonzalez JZ, Wolf G, Dudjak L, Jordan B (2015) Impact of magnet culture in maintaining quality outcomes during periods of organizational transition. J Nurs Care Qual 30(4): 323-330.
4. Makary MA, Daniel M (2016) Medical error-the third leading cause of death in the US. BMJ 353: i2139.
5. Huang CH, Wu HH, Lee YC (2018) The perceptions of patient safety culture: A difference between physicians and nurses in Taiwan. Appl Nurs Res 40: 39-44.
6. Patel S, Wu AW (2016) Safety culture in Indian hospitals: A cultural adaptation of the safety attitudes questionnaire. J Patient Saf 12(2): 75-81.
7. Lee YC, Huang CH, Wu CF, Hsueh HW (2019) A longitudinal study of identifying critical variables influencing patient safety culture from nurses’ viewpoints in Taiwan. Journal of Testing Evaluation 47(5): 3387-3398.
8. Sexton JB, Helmreich RL, Neilands TB, Rowan KV, Boyden K, et al. (2006) The safety attitudes questionnaire: Psychometric properties, benchmarking data, and emerging research. BMC Health Serv Res 6: 44.
9. Huang CH, Wu HH, Chou CYH, Dai HY, Lee YC (2018) The perceptions of physicians and nurses regarding the establishment of patient safety in a regional teaching hospital in Taiwan. Iran J Public Health 47(6): 852-860.
10. Chi CY, Huang CH, Lee YC, Wu HH (2019) Critical demographic variables on affecting patient safety culture from medical staffs’ viewpoints. Engineering Letter 27(2): 328-335.
11. Lee YC, Shieh JI, Huang CH, Wang CY, Wu HH (2017) Analyzing patient safety culture from viewpoints of physicians and nurses-a case of a regional teaching hospital in Taiwan. J Healthc Qual 39(5): 294-306.
12. Lee YC, Weng SJ, Huang CH, Hsieh WL, Hsieh LP, et al. (2017) A longitudinal study of identifying critical factors of patient safety culture in Taiwan. Journal of Testing and Evaluation 45(3): 1029-1044.
13. Garrett C (2008) The effect of nurse staffing patterns on medical errors and nurse burnout. AORN Journal 87(6): 1191-1204.
14. Bagheri HM, Ebrahimi MH, Khanjani N, Biganeh J, Mohammadi S, et al. (2019) The effects of amplitude and stability of circadian rhythm and occupational stress on burnout syndrome and job dissatisfaction among irregular shift working nurses. Journal of Clinical Nursing 28(9-10): 1868-1878.
15. Alves DS, Guirardello EB (2016) Safety climate, emotional exhaustion and job satisfaction among Brazilian pediatric professional nurses. Int Nurs Rev 63(3): 328-335.