DR JUDITH JOHNSON (Orcid ID : 0000-0003-0431-013X)

Accepted Article
Received Date : 06-Jun-2016
Revised Date : 05-Dec-2016
Accepted Date : 13-Dec-2016
Article type : Original Research: Empirical research - quantitative

RUNNING HEAD: Burnout, depression and patient safety perceptions

Burnout mediates the association between depression and patient safety perceptions: A cross-

sectional study in hospital nurses

Judith JOHNSON, PhD, ClinPsyDacd* ,Gemma LOUCH, PhDce, Alice DUNNINGaf, Olivia

JOHNSONag, Angela GRANGE, PhD, RSCN, RGN ch, Caroline REYNOLDS, BScci, Louise

HALL, MScacj and Jane O’HARA, PhDbck

*Corresponding author.

a. School of Psychology, University of Leeds, Leeds, LS29JT, UK; Tel: +44 (0)113

3435724; Fax: +44 (0)113 3435749;

b. Leeds Institute of Medical Education, University of Leeds, Level 7, Worsley Building,

Clarendon Way, Leeds, LS2 9NL, Tel: +44 (0)113 343 7234

c. Bradford Institute of Health Research, Bradford Royal Infirmary, Bradford, BD9 6RJ, UK;

Tel: +44 (0)1274 38 34 18

d. [email protected] @DrJTJohnson; Lecturer

e. [email protected]; Research Fellow

f. [email protected]; Research and Implementation Assistant

g. [email protected]; Research and Implementation Assistant

h. [email protected]; Lead Nurse for Research

This article has been accepted for publication and undergone full peer review but has not
been through the copyediting, typesetting, pagination and proofreading process, which may
lead to differences between this version and the Version of Record. Please cite this article as
doi: 10.1111/jan.13251
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 i. [email protected]; Research Practitioner

j. [email protected]; PhD student

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k. Jane.O’[email protected]; Lecturer

Funding Statement:

This research received no specific grant from any funding agency in the public, commercial,

or not-for-profit sectors.

Conflict of interest:

No conflict of interest has been declared by the authors.

ABSTRACT

Background

There is growing interest in the relationships between depressive symptoms and

burnout in healthcare staff and the safety of patient care. Depressive symptoms are higher in

healthcare staff than the general population and overlap conceptually with burnout. However,

minimal research has investigated these variables in nurses. Given the conceptual overlap

between depressive symptoms and burnout, there is also a need for an explanatory model

outlining the relative contributions of these factors to patient safety.

Aims

To investigate the relationships between depressive symptoms, burnout and

perceptions of patient safety. A mediation model was proposed whereby the association

between symptoms of depression and patient safety perceptions was mediated by burnout.

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 Design

A cross-sectional questionnaire was distributed at three acute NHS Trusts.

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Method

Three-hundred and twenty-three hospital nursing staff completed measures of

depressive symptoms, burnout and patient safety perceptions (including measures at the level

of the individual and the work area/unit) between December 2015 - February 2016.

Results

When tested in separate analyses, depressive symptoms and burnout facets were each

associated with both patient safety measures. Furthermore, the proposed mediation model

was supported, with associations between depressive symptoms and patient safety

perceptions fully mediated by burnout.

Conclusion

These results suggest that symptoms of depression and burnout in hospital nurses may

have implications for patient safety. However, interventions to improve patient safety may be

best targeted at improving burnout in particular, with burnout interventions known to be most

effective when focused at both the individual and the organisational level.

Keywords: burnout, depression, healthcare, health services, nursing, patient safety,

workforce issues

SUMMARY STATEMENT

Why is this research needed?

• A small number of studies have found that burnout and depressive symptoms are

linked with patient safety outcomes in healthcare staff, but further research is needed

in nursing populations.

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 • There is a need to better understand how depressive symptoms and burnout relate to

each other and to patient safety in nursing staff.

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What are the key findings?

• When tested in separate analyses, burnout and depressive symptoms were each

directly associated with patient safety perceptions in nursing staff.

• A mediation model was tested and results indicated that burnout fully mediated the

association between depressive symptoms and patient safety perceptions.

How should the findings be used to influence policy/practice/research/education?

• These results highlight the importance of supporting nurse wellbeing to enhance the

quality and safety of patient care.

• In particular, these results suggest that burnout may be the more important staff

wellbeing factor for patient safety interventions to focus on.

• Burnout interventions should focus on both work-restructuring interventions in

addition to individual-level interventions such as mindfulness courses.

INTRODUCTION

With around 10% of hospital inpatient episodes affected by clinical errors (Baines et

al., 2013, Vincent et al., 2001) improving patient safety remains a priority in acute healthcare

settings. To develop interventions to reduce errors, a growing body of research has sought to

understand underlying causes and contributing factors. One area has focused on the role that

human factors such as staff burnout and depressive symptoms may play (Hall et al., 2016).

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 Background

The burnout concept originated in health services and describes a chronic stress
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response comprising three dimensions of emotional exhaustion, depersonalisation and low

accomplishment (Maslach and Jackson, 1981). Due concerns about the validity and relevance

of the personal accomplishment scale (Demerouti and Bakker, 2008, Demerouti et al., 2001),

much research has focused on the remaining two dimensions. Emotional exhaustion captures

feelings of emotional and physical resource depletion and depersonalisation captures

excessively detached attitudes towards patients (Maslach et al., 2001). A range of factors can

lead to burnout, including excessive workload, work conflicts and personality factors

(Garrosa et al., 2008). When it occurs, burnout may have wide-ranging consequences such as

lower staff empathy and poorer patient experience (Vahey et al., 2004, Leiter et al., 1998,

Passalacqua and Segrin, 2012). Several studies indicate that burnout may also be linked with

clinical errors (Hall et al., 2016), although the majority of this research has been amongst

doctors.

Depression is a broader concept which is statistically and conceptually distinct from

burnout (Iacovides et al., 2003, Thuynsma and de Beer, 2016). Rather than focusing on work-

related attitudes, the concept of depression encompasses a more holistic sense of low mood

and psychological distress (Henry and Crawford, 2005). Research suggests that depression is

not a discrete category, but one that exists on a continuum, ranging from low depression (or

fewer depressive symptoms), to high depression (or more depressive symptoms) (Wood et

al., 2010, Hankin et al., 2005). Similarly to burnout, depressive symptoms in healthcare staff

may have consequences for patient care such as a greater likelihood of cognitive failures and

medical errors (Allan et al., 2014, West et al., 2006). However, there has been less research

into the consequences of depressive symptoms than burnout and only two studies have

investigated depressive symptoms and patient safety amongst nursing staff (Tanaka et al.,

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 2012, Saleh et al., 2014).

Symptoms of mental health problems such as depression have long been known to be
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elevated amongst healthcare staff, particularly in nurses (Su et al., 2009, Letvak et al., 2012,

Wall et al., 1997) and recent reports suggest that burnout rates are increasing (Shanafelt et al.,

2015, Ives et al., 2015). As such, identifying associations between burnout, depressive

symptoms and patient safety could both highlight an area for patient safety interventions to

target and suggest that such interventions are of escalating importance.

Contribution of the research

There are two main areas that need addressing. First, most studies investigating

burnout or depressive symptoms and patient safety have focused on medical staff, so there is

a need for further research in nursing staff, as a considerable amount of patient care is centred

around the work of nurses (Hughes, 2008). To date, no research has investigated either

depressive symptoms or burnout and patient safety in UK hospital nurses. Of the studies

which have been conducted in nursing, results suggest that higher levels of burnout and

depressive symptoms are associated with lower perceptions of patient safety (Halbesleben et

al., 2008, Laschinger and Leiter, 2006) and higher rates of objectively measured errors (Saleh

et al., 2014), although these findings have not been replicated consistently (Holden et al.,

2011).

Second, there is a need to understand how burnout and depressive symptoms relate to

each other in their association with patient safety. The two concepts are overlapping but

distinct and interventions to reduce depressive symptoms differ from those aiming to reduce

burnout. In particular, while interventions addressing depressive symptoms may focus at the

level of the individual (e.g., mindfulness), interventions for burnout should also involve

organisational-level change, considering work-related changes such as work process

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 restructuring, shift readjustments and performance appraisals (Awa et al., 2010, West and

Dawson, 2012). A small number of studies have investigated both burnout and depressive
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symptoms (de Oliveira Jr et al., 2013, Dyrbye et al., 2013, Fahrenkopf et al., 2008, Garrouste-

Orgeas et al., 2015), but none have proposed an explanatory model of how these variables

contribute together to patient safety outcomes. Furthermore, each of these studies has been

amongst doctors and no research has investigated these variables together in nursing staff.

Based on evidence that i) depressive symptoms increase risk of burnout (Ahola et al., 2005),

ii) burnout is the more consistent predictor of subsequently reported errors (West et al., 2006,

West et al., 2009) and ii) healthcare staff attribute errors to work-related stressors, fatigue and

burnout (Shanafelt et al., 2010), we propose that the two variables relate to patient safety

outcomes via a mediating model (see Figure 1a). This model does not suggest that depressive

symptoms result in burnout, but rather that it is the proportion of depressive symptoms that

overlap with burnout that is associated with patient safety perceptions (see Figure 1b). If this

is the case, it may suggest that while staff-level interventions for depressive symptoms, such

as mindfulness, could have patient safety benefits, interventions to enhance patient safety

may be better targeted at addressing burnout.

Theoretical framework

This work was grounded in Hobfoll’s Conversation of Resources model (COR)

(Hobfoll, 2001). This model suggests that a person experiences psychological stress: (1)

when their resources are threatened with loss; (2) when their resources are actually lost; and

(3) when they fail to gain anticipated resources following significant resource investment.

The term ‘resource’ loosely refers to commodities related to individual values and can allude

to personal, social and economic assets. Once an individual is experiencing psychological

distress, the model proposes that they will be more cautious with investing future resources.

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 In the healthcare literature, research using the COR has focused on the concept of

burnout as psychological distress and has investigated the relationship between burnout and
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patient safety (Halbesleben et al., 2008, Welp et al., 2014). It has been suggested that once a

healthcare professional is experiencing burnout – a form of psychological stress – they may

be likely to ‘pull away’ from their patients and focus their efforts on specific aspects of their

job which they find enjoyable (Halbesleben et al., 2008). Halbesleben and colleagues (2008)

suggest burnout contributes to patient safety risks by diverting attention towards preferred

aspects of work and reducing extra behaviours that would benefit the organisation. The

current study tested the COR model in a sample of UK hospital nurses, investigating whether

the model’s predictions regarding an association between burnout and patient safety was

confirmed. Furthermore, we sought to extend this model by testing whether these findings

held when depressive symptoms were included as the form of psychological distress, rather

than burnout.

THE STUDY

Aims

The present study investigated the relationships between depressive symptoms,

burnout and patient safety in hospital nursing, taking a cross-sectional approach. In line with

previous research, the two burnout facets of Emotional Exhaustion and Depersonalisation

were included (Halbesleben et al., 2008). Safety perceptions were used to measure patient

safety, as previous research has suggested these are associated with objectively measured

patient safety outcomes (Hansen et al., 2011, Hofmann and Mark, 2006, Mardon et al., 2010)

and are useful for detecting variations in perceived safety between individual practitioners

(Halbesleben et al., 2008, Louch et al., 2016). There were two hypotheses:

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 Hypothesis 1: There will be a direct association between depressive symptoms and

patient safety perceptions.

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Hypothesis 2: The two facets of burnout (Emotional Exhaustion and

Depersonalisation) will mediate the association between depressive symptoms and

patient safety perceptions.

Design

A cross-sectional questionnaire design was used.

Participants

A convenience sample of UK hospital nurses, midwives and healthcare assistants

were recruited from three acute NHS Trusts from December 2015 - February 2016.

Data collection

The study was advertised through posters displayed in hospital staff rooms.

Questionnaires were distributed on wards and participants completed these in a location and

at a time of their choice. Participants were informed of the date when questionnaires would

be collected and could return these to the researchers directly, or leave them in sealed

envelopes in drop-boxes in secure, locked rooms. Participants could choose to be entered into

a prize draw for shopping vouchers (20 prizes with a total value of £900).

Measures

Demographic information

Information regarding age, length of time in post, gender, qualifications and typical

hours worked per week were recorded in a questionnaire proforma.

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 Depressive symptoms

Depressive symptoms were measured using the Depression subscale of the 21-item
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version of the Depression, Anxiety and Stress Scale (DASS-21) (Henry and Crawford, 2005).

This contains seven items including ‘I found it difficult to work up the initiative to do things’.

Participants rated the extent to which they experienced each item in the past week on a 4-

point scale from 0 (‘Did not apply to me at all’) - 3 (‘Applied to me very much, or most of the

time’). Possible scores ranged from 0-21.

Burnout

Burnout was measured using the Emotional Exhaustion and Depersonalisation

subscales of the Maslach Burnout Inventory (MBI) (Maslach and Jackson, 1981). The

Emotional Exhaustion subscale comprises nine items including ‘I feel emotionally drained

from my work’. The Depersonalisation subscale contains five items including ‘I feel I treat

some patients as if they were impersonal objects’. Items were rated on a 7-point scale from 0

(‘Never’) - 6 (‘Every day’). Possible scores ranged from 0-63 on the Emotional Exhaustion

subscale and 0 to 35 on the Depersonalisation subscale.

Patient safety perceptions

Perceptions were reported at both the individual level and the work area/unit level,

based on evidence that these measures provide useful and complementary information that

vary between nurses in response to stress and individual differences (Louch et al., 2016).

Individual safety perceptions. To assess perceptions of safety at the level of the

individual, participants completed the Safe Practitioner Measure (Louch et al., 2016), a one-

item statement (‘My practice is not as safe as it could be because of work related

factors/conditions’). The was rated from 1 (‘Strongly disagree’) - 5 (‘Strongly agree’) (Louch

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 et al., 2016). Responses were recoded such that higher scores indicated a more favourable

perception.
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Work area/unit safety perceptions. Perceptions of patient safety at the work area/unit

level were measured using a four-item measure from the Agency for Healthcare Research and

Quality (AHRQ) Hospital Survey on Patient Safety Culture (HSOPC) (Sorra and Nieva,

2004). Items included, ‘It is just by chance that mistakes don't happen around here’ and were

scored from 1 (‘Strongly disagree’) 5 (‘Strongly agree’). Possible scores ranged from 0-20.

Higher scores indicated more favourable perceptions.

Ethical considerations

Participants were given an information sheet about the study and asked to provide

written informed consent. On collection of the questionnaires, identifiable information was

separated from non-identifiable questionnaire data and stored securely. The research was

approved by the University of Leeds, School of Psychology Ethics Committee (15-0183).

Validity, reliability and rigour

Depressive symptoms

The DASS-21 depression subscale (Henry and Crawford, 2005) demonstrated good

internal consistency in the current study (α = 0.87). Previous research indicates that the

subscale has convergent validity with longer depression measures (Norton, 2005).

Burnout

The MBI subscales (Maslach and Jackson, 1981) demonstrated acceptable internal

consistency in the current study (α = 0.83 for Emotional Exhaustion, α = 0.70 for

Depersonalisation).

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 Patient safety perceptions

Individual safety perceptions. Previous research has found convergent reliability

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between this item and nurse-patient ratios and longer patient safety measures (Louch et al.,

2016).

Work area/unit safety perceptions. The AHRQ subscale (Sorra and Nieva, 2004)

demonstrated acceptable internal consistency in the current study (α = 0.74) and has

previously been established as an effective measure for gathering patient safety perceptions in

nursing staff (Halbesleben et al., 2008, Louch et al., 2016).

Data analysis

Preliminary data analysis was undertaken using SPSS version 22. Descriptive

statistics (means and standard deviations) and bivariate associations were conducted for study

variables and the demographic variables ‘length of time in current position’ and ‘typical

hours worked per week’. Spearman’s Rho correlations were performed, as the distributions of

most variables in the dataset did not conform to the assumptions of normality.

Missing data analyses were then undertaken for study variables. Rates of missing data

on individual measures ranged from 0% (safe practitioner measure) to 10.2% (Emotional

Exhaustion subscale). In total, 15.48% of cases were missing data for one or more measures.

Little’s chi-square statistic for testing whether values are missing completely at random

(MCAR) (Little, 1988) was not significant (x=30.06, df=31, p=0.51), indicating there was no

systematic pattern to the missing data. When data is not missing systematically and overall

rates of missing data are <20%, data imputation is preferred over case deletion, as this

preserves statistical power (Garson, 2015). Data imputation was conducted using regression

imputation in AMOS 22. This method first fits the proposed statistical model using maximum

likelihood and model parameters are set as equal to their maximum likelihood estimates.

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 Linear regression is then used to predict each missing value as a linear combination of the

observed values for that same case. Predicted values are imputed for missing values
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(Arbuckle, 2013).

To examine whether the associations between depressive symptoms and patient safety

perceptions were mediated by the two burnout subscales (Emotional Exhaustion and

Depersonalisation), Structural Equal Modelling (SEM) was undertaken using AMOS 22. This

approach has three main benefits over the ‘causal steps’ hierarchical regression approach

outlined by Baron and Kenny (1986). First, it has greater flexibility and enables the testing of

multiple mediators in one model (Preacher and Hayes, 2008). Second, measurement errors

can bias the parameter estimates for mediation resulting from the hierarchical regression

approach, but these can be controlled for in the SEM approach (Cheung and Lau, 2007).

Third, the AMOS 22 programme enables hypothesis tests to be conducted using the

bootstrapping method. Bootstrapping is a nonparametric resampling procedure which does

not require data distributions to conform to the assumptions of parametric tests (e.g.,

normality). Bootstrapping provides the most powerful method for obtaining confidence limits

for mediation effects (Preacher and Hayes, 2008) and Cheung and Lau (2007) suggest that a

sample size of 100 provides adequate power to detect a medium to large effect size.

We used the bootstrapping approach (5000 bootstrap samples; 95% confidence

interval) to test six models. All models controlled for age, gender and length of time in

current position. The first model tested the direct association between depressive symptoms

and safety perceptions at the individual level and the second model repeated this but instead

used patient safety perceptions at the work area/unit level. The second two models (one for

each outcome measure) then tested whether any direct association was mediated by the two

burnout facets (Emotional Exhaustion and Depersonalisation; Figure 1). For completeness,

the final two models then tested for the opposite mediation pattern, whereby depressive

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 symptoms mediated the association between the two burnout facets (Emotional Exhaustion

and Depersonalisation) and each patient safety outcome variable. In line with
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recommendations by Cheung and Lau (2007), bias-corrected bootstrap confidence intervals

were calculated and used to test hypotheses.

We also calculated fit statistics for each model. The use of model fit indices in studies

of mediation using SEM is much debated, as proposed cut-off values have often been based

on research using simulated models with a large number of degrees of freedom (df) (Kenny et

al., 2014). The commonly used RMSEA statistic is particularly unreliable in the context of

small df models, such as those used to test for mediation. In line with recommendations by

Kenny and colleagues (Kenny et al., 2014, Kenny, 2016), we reported the chi-squared

statistic (X2), the Comparative Fit Index (CFI), where values above 0.9 were considered

acceptable and the Akaike Information Criterion (AIC). There are no recommended cut-offs

for the AIC, but lower values represent better fit.

RESULTS

Participant characteristics

Three-hundred and twenty-three eligible participants completed the

questionnaires (M age=39.79, SD= 12.31, 92.3% female). Ninety-one percent of participants

were white, 1.9% were Afro-Carribean, 2.2% were Asian, 3.1% were of another ethnicity,

1.5% preferred not to state their ethnicity and data were missing for 0.3% of participants. For

education, 4% of participants reported a Masters degree as their highest qualification, 48.9%

reported a bachelors degree, 18.6% reported A-Levels or equivalent, 16.1% reported GCSEs

or equivalent, 7.4% had completed some secondary school and 4.6% reported ‘other’. Data

were missing for 0.3% participants. In terms of staff position in the hospital, 42.1% of

participants were staff nurses, 31.9% were healthcare assistants, 13.6% were ward

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 sisters/charge nurses, 4% were ward managers, 3.7% were midwives, 2.5% were agency staff

and 1.9% were student nurses.

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Descriptive statistics

Descriptive statistics for study variables are presented in Table 1. Spearman’s Rho

correlations indicated significant positive associations between both the Safe Practitioner

measure and the AHRQ with depressive symptoms (rs=-0.28, p<0.001 and rs=-0.34, p<0.001,

respectively), Emotional Exhaustion (rs=-0.41, p<0.001 and rs=-0.51, p<0.001, respectively)

and Depersonalisation (rs= -0.43, p<0.001 and rs=-0.45, p<0.001, respectively). There were

also significant positive associations between hours worked with Emotional Exhaustion

(rs=0.15*, p=0.01) and Depersonalisation (rs=0.16, p=0.005), but not depressive symptoms

(rs=0.05, p=0.42).

Structural Equation Models

We then constructed a series of six structural equation models to test our mediation

hypotheses. We used bootstrapping, a nonparametric resampling procedure which provides

the most powerful method of obtaining confidence limits for mediation effects.

Depressive symptoms and patient safety perceptions

When depressive symptoms were the only predictor variable in the models, there was

a direct association between these and individual level safety perceptions (c = -0.277, CI=-

0.364,-0.181, p =0.001; X2(3)=2.537, p=0.469, CFI=1, AIC=36.537; Figure 2) and work

area/unit level safety perceptions (c=-0.303, CI=-0.404,-0.193, p<0.001; X2(3)=9.304,

p=0.026, CFI=0.951, AIC=43.304; Figure 3).

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 Burnout as a mediator of the association between depressive symptoms and patient

safety perceptions
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When the burnout facets (Emotional Exhaustion and Depersonalisation) were

included in the model with individual safety perceptions as the outcome variable (Figure 2B),

the direct association between depressive symptoms and safety ceased to be significant

(c’=0.027, CI=-0.103, 0.163, p=0.730). The direct associations between depressive symptoms

and Emotional Exhaustion (a1=0.602, CI=0.495, 0.685, p=0.001) and Depersonalisation (a2=

0.492, CI=0.402, 0.576, p <0.001) were significant, as were the direct associations between

Emotional Exhaustion and Depersonalisation and individual safety (b1=-0.228, CI=-0.403, -

0.075, p=0.002 and b2=-0.356, CI=-0.465,-0.246, p <0.001, respectively). These results

indicated that the two facets of burnout fully mediated the association between depressive

symptoms and perceived patient safety. Model fit indices were X2(10)=58.643, p<0.001,

CFI=0.902, AIC=108.643.

Similar results were found when the model was tested with work area/unit level safety

perceptions as the outcome variable (Figure 3B). With Emotional Exhaustion and

Depersonalisation included as mediators, the direct association between depressive symptoms

and safety ceased to be significant (c’=0.065, CI=-0.074, 0.219, p=0.411). The direct

associations between depressive symptoms and Emotional Exhaustion (a1=0.598, CI=0.486,

0.679, p=0.001) and Depersonalisation (a2= 0.485, CI=0.393, 0.569, p<0.001) were

significant, as were the direct associations between Emotional Exhaustion and

Depersonalisation and work area/unit level safety perceptions (b1=-0.411, CI=-0.554, -0.294,

p=0.001 and b2=-0.267, CI=-0.387, -0.145, p<0.001, respectively). Again, these results

indicated that the two facets of burnout fully mediated the association between depressive

symptoms and perceived patient safety. Model fit indices were X2(10)=66.146, p<0.001,

CFI=0.893, AIC=116.146.

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 Testing depressive symptoms as a mediator of the association between burnout and

patient safety perceptions

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For completeness, we then repeated these two models but reversed the mediation

pattern, in effect testing whether the association between the burnout facets (Emotional

Exhaustion and Depersonalisation) and the patient safety outcome variables ceased to be

significant once depressive symptoms were included as a mediator in the models. Neither of

these found evidence for the reverse mediation pattern.

In the model testing individual patient safety perceptions as the outcome variable

(Figure 4A), Emotional Exhaustion and Depersonalisation were both significantly associated

with depressive symptoms (a1=0.482, CI=0.324, 0.623, p=0.001 and a2=0.206, CI=0.059,

0.355, p=0.006). Emotional Exhaustion and Depersonalisation were also both significantly

associated with patient safety perceptions (c’1=-0.224, CI=-0.390, -0.075, p=0.002 and c’2=-

0.348, CI=-0.455, -0.240, p<0.001). However, depressive symptoms were not directly

associated with patient safety perceptions, suggesting they were not a mediator (b=0.025, CI=

-0.105, 0.156, p=0.767).

In the model testing patient safety perceptions at the area/unit level safety as the

outcome (Figure 4B), Emotional Exhaustion and Depersonalisation were both significantly

associated with depressive symptoms (a1=0.480, CI=0.322, 0.620, p=0.001 and a2=0.209,

CI=0.062, 0.356, p=0.004). Emotional Exhaustion and Depersonalisation were also both

significantly associated with patient safety perceptions (c’1=-0.392, CI=-0.532, -0.281,

p=0.001 and c’2=-0.255, CI=-0.371, -0.135, p<0.001). However, depressive symptoms were

not directly associated with patient safety perceptions, suggesting they were not a mediating

variable (b=0.058, CI=-0.076, 0.205, p=0.449).

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 Interestingly, the fit indices for these models were better than the initial models

(X2(6)=5.605, p<0.469, CFI=1, AIC=63.605 for individual patient safety perceptions and
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X2(6)=18.679, p=0.005, CFI=0.975, AIC=76.679 for ward level perceptions).

DISCUSSION

This paper presents findings from a cross-sectional questionnaire survey in UK

hospital nurses from multiple clinical areas, across three acute NHS Trusts. The results

suggested that there was a direct association between depressive symptoms and safety

perceptions at both the individual and area level. However, this association was fully

mediated by two facets of burnout, Emotional Exhaustion and Depersonalisation.

Interestingly, the best overall model fit was found when burnout variables were modelled as

predictors in the models, with depressive symptoms modelled as an outcome of burnout.

However, no evidence was found for the reverse mediation pattern (where depressive

symptoms mediated the association between burnout and patient safety perceptions).These

findings add to the literature in three main ways.

First, these results support previous research indicating an association between

burnout and patient safety in medical staff (Fahrenkopf et al., 2008, West et al., 2006) and

extend this by finding the first evidence for this link amongst UK hospital nursing staff. Only

a small number of studies have investigated whether burnout is associated with patient safety

perceptions amongst nurses in any nation (Halbesleben et al., 2008, Laschinger and Leiter,

2006) and one previous study by Holden and colleagues reported no evidence for this link

(Holden et al., 2011). Holden et al.’s study measured patient safety perceptions using a single

item asking about perceived risk of medication error (Holden et al., 2011), whereas the

present study measured patient safety using the Safe Practitioner Scale (SPS) (Louch et al.,

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 2016) and the AHRQ Perceptions of Safety Subscale (AHRQ PSS) (Sorra and Nieva, 2004)

and found evidence of this association according to both measures. It is possible that the
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divergence in results between the present study and the one by Holden and colleagues (2011)

is owing to the measure of patient safety perceptions used, suggesting that the SPS and

AHRQ PSS may be more sensitive measures suitable for future research in this area.

Second, these results provide the first evidence of an association between depressive

symptoms and perceptions of patient safety in UK hospital nurses. Only a limited number of

studies have previously investigated this and have focused on number of perceived errors

(Tanaka et al., 2012, Saleh et al., 2014). The current study finds further support for a link

between depressive symptoms and safety perceptions in nurses, suggesting this is also present

in UK nurses. Furthermore, by measuring safety perceptions using the SPS and AHRQ PSS,

the current study suggests that this link generalises to both individual safety perceptions and

perceptions at the area level.

Third, this study proposed and tested the first explanatory model of the relationships

between burnout, depressive symptoms and patient safety perceptions and found evidence

that the association between depressive symptoms and safety is explained by the overlap

between depressive symptoms and burnout. Few studies have investigated both burnout and

symptoms of depression together (Fahrenkopf et al., 2008, Dyrbye et al., 2013, de Oliveira Jr

et al., 2013, Garrouste-Orgeas et al., 2015) and none have proposed mechanisms for how

these variables contribute together to patient safety perceptions. Furthermore, each of these

studies was amongst medical staff. Results from the present study support previous findings

that both variables are separately associated with patient safety perceptions and extend this to

suggest that this association is also present in nursing staff groups. Importantly, the current

study suggests that burnout may be the more important variable in relation to patient safety.

Not only was the association between depressive symptoms and patient safety perceptions

This article is protected by copyright. All rights reserved.

 entirely mediated by burnout, but the best statistical model fit was found when depressive

symptoms were considered an outcome of burnout, rather than a predictor of burnout and
Accepted Article
patient safety perceptions. However, it should be noted that as a cross-sectional study, it is

not possible to draw conclusions regarding cause and effect and the associations described

could be bi-directional.

Theoretical framework

The study was grounded in the Conversation of Resources model (COR) (Hobfoll,

2001), which suggests that once a person is experiencing psychological distress, they will

become cautious regarding resource investment. Theorists have proposed that burnout is a

form of psychological stress (Halbesleben et al., 2008, Welp et al., 2014) and have used the

model to explain the links between burnout and patient safety perceptions. In particular, it has

been suggested that once a healthcare staff member is experiencing burnout, they may stop

investing their personal resources by ‘pulling away’ from their patients, instead focusing their

efforts only on aspects of their job which they enjoy (Halbesleben et al., 2008). The current

study tested the predictions of this model in a UK nursing sample and found evidence that as

the model would suggest, both forms of psychological distress measured (depressive

symptoms and burnout) were linked with patient safety perceptions. The current study also

extends the model by finding evidence that work-related psychological distress (i.e., burnout)

may be the more important variable leading to inhibition of resource investment amongst

nurses, explaining the association between more general psychological distress (i.e.,

depressive symptoms) and safety perceptions.

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 Limitations

The study was limited by its cross-sectional design, which prevents the extent to
Accepted Article
which any causal interpretations can be made regarding the data. Previous longitudinal

research has indicated that the relationship between depressive symptoms, burnout and errors

may be cyclical, with depressive symptoms or burnout increasing risk for subsequent errors

and involvement in errors leading to increased risk of depressive symptoms or burnout (West

et al., 2006, West et al., 2009). In the current study we were interested in understanding

patient safety as the outcome variable, but it is possible that the relationships between each of

the variables studied may be bi-directional.

The study was also limited by reliance on self-report measures, which may have led to

bias in responses. However, each of the measures was carefully selected and had been

previously validated as suitable self-report tools. Furthermore, there are no objective rating

tools for burnout and collecting accurate objective patient safety outcome data for nurses at

the individual level is rarely possible, owing to the team-based nature of nursing work.

Previous research has suggested that safety perceptions are associated with objectively

measured patient safety outcomes (Mardon et al., 2010, Hofmann and Mark, 2006, Hansen et

al., 2011) and are useful for capturing individual-level variations in patient safety

(Halbesleben et al., 2008, Louch et al., 2016).

Finally, as questionnaires were not addressed to individual nurses, the study was

limited by a lack of response rate information. However, as questionnaires were distributed to

three acute NHS Trusts, our sample will only reflect a minority of eligible participants, which

may have led to a higher rate of extreme responders (e.g., participants particularly high or

low on measures of depressive symptoms/burnout). Whilst conclusions from inferential

statistics are likely to be robust to this bias, this limits the interpretation of overall

burnout/depressive symptoms reported.

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 Implications

There is an increasing recognition of the importance of healthcare staff wellbeing in

Accepted Article
contributing to patient outcomes (NHS, 2013, DoH, 2013). However, the concept of

wellbeing has been poorly defined and as such, it has been unclear where interventions to

support and promote staff wellbeing should be focused. Due to the limited sample size, the

current results must be interpreted with caution. However, they offer the tentative suggestion

staff burnout, rather than depressive symptoms, may be particularly important in relation to

patient safety and interventions focused on reducing burnout may be beneficial for patient

safety outcomes. Burnout interventions are thought to be most effective when they not only

address staff stress via individual-level interventions, for example staff counselling, but when

they also address aspects of the workplace (Awa et al., 2010). Such interventions might

consider restructuring work processes, adjusting shifts or implementing or changing

performance appraisals (Awa et al., 2010, West and Dawson, 2012). These types of

interventions require organisational involvement and can be challenging to deliver, however

the current research suggests they may be more beneficial for patient safety than those

targeted only at addressing personal staff stress levels.

Future research

Longitudinal research is necessary to understand the relationships between depressive

symptoms and burnout on patient safety outcomes over time. Previous research in doctors

suggests that the relationship may be cyclical (West et al., 2006, West et al., 2009), but

further research is needed to explore this in a nursing population. Research is also needed to

test whether interventions targeting staff burnout are effective for burnout reduction and lead

to concomitant improvements in staff safety perceptions. No studies have yet tested this in

either medical or nursing populations.

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 CONCLUSION

When tested in separate analyses, both depressive symptoms and burnout were
Accepted Article
associated with patient safety perceptions amongst UK hospital nurses. Furthermore, the

association between depressive symptoms and perceptions of patient safety was fully

mediated by burnout. These findings suggest that nurse wellbeing may have implications for

patient safety and that interventions focused on addressing burnout, rather than symptoms of

depression, may be most effective for patient safety improvements.

Author Contributions:

All authors have agreed on the final version and meet at least one of the following criteria

(recommended by the ICMJE*):

1) substantial contributions to conception and design, acquisition of data, or analysis and

interpretation of data;

2) drafting the article or revising it critically for important intellectual content.

* http://www.icmje.org/recommendations/

REFERENCES

AHOLA, K., HONKONEN, T., ISOMETSÄ, E., KALIMO, R., NYKYRI, E., AROMAA, A.

& LÖNNQVIST, J. 2005. The relationship between job-related burnout and

depressive disorders—results from the Finnish Health 2000 Study. Journal of

Affective Disorders, 88, 55-62.

ALLAN, J. L., FARQUHARSON, B., JOHNSTON, D. W., JONES, M. C., CHOUDHARY,

This article is protected by copyright. All rights reserved.

 C. J. & JOHNSTON, M. 2014. Stress in telephone helpline nurses is associated with

failures of concentration, attention and memory and with more conservative referral
Accepted Article
decisions. British Journal of Psychology, 105, 200-213.

ARBUCKLE, J. L. 2013. IBM® SPSS® Amos™ 22 User’s Guide, IBM Corp.

AWA, W. L., PLAUMANN, M. & WALTER, U. 2010. Burnout prevention: A review of

intervention programs. Patient Education and Counseling, 78, 184-190.

BAINES, R. J., LANGELAAN, M., DE BRUIJNE, M. C., ASSCHEMAN, H.,

SPREEUWENBERG, P., VAN DE STEEG, L., SIEMERINK, K. M., VAN ROSSE,

F., BROEKENS, M. & WAGNER, C. 2013. Changes in adverse event rates in

hospitals over time: a longitudinal retrospective patient record review study. BMJ

Quality & Safety, 22, 290-298.

BARON, R. M. & KENNY, D. A. 1986. The moderator–mediator variable distinction in

social psychological research: Conceptual, strategic and statistical considerations.

Journal of Personality and Social Psychology, 51, 1173.

CHEUNG, G. W. & LAU, R. S. 2007. Testing mediation and suppression effects of latent

variables: Bootstrapping with structural equation models. Organizational Research

Methods.

DE OLIVEIRA JR, G. S., CHANG, R., FITZGERALD, P. C., ALMEIDA, M. D., CASTRO-

ALVES, L. S., AHMAD, S. & MCCARTHY, R. J. 2013. The prevalence of burnout

and depression and their association with adherence to safety and practice standards: a

survey of United States anesthesiology trainees. Anesthesia & Analgesia, 117, 182-

193.

DEMEROUTI, E. & BAKKER, A. B. 2008. The Oldenburg Burnout Inventory: A good

alternative to measure burnout and engagement. In: HALBESLEBEN, J. R. B. (ed.)

Handbook of Stress and Burnout in Health Care. 0. Hauppauge, NY: Nova Science.

This article is protected by copyright. All rights reserved.

 DEMEROUTI, E., BAKKER, A. B., NACHREINER, F. & SCHAUFELI, W. B. 2001. The

job demands-resources model of burnout. Journal of Applied Psychology, 86, 499.

Accepted Article
DOH 2013. A promise to learn– a commitment to act: Improving the Safety of Patients in

England. In: HEALTH, D. O. (ed.).

DYRBYE, L. N., SATELE, D., SLOAN, J. & SHANAFELT, T. D. 2013. Utility of a brief

screening tool to identify physicians in distress. Journal of General Internal

Medicine, 28, 421-427.

FAHRENKOPF, A. M., SECTISH, T. C., BARGER, L. K., SHAREK, P. J., LEWIN, D.,

CHIANG, V. W., EDWARDS, S., WIEDERMANN, B. L. & LANDRIGAN, C. P.

2008. Rates of medication errors among depressed and burnt out residents:

prospective cohort study. British Medical Journal, 336, 488-491.

GARROSA, E., MORENO-JIMENEZ, B., LIANG, Y. & GONZÁLEZ, J. L. 2008. The

relationship between socio-demographic variables, job stressors, burnout and hardy

personality in nurses: An exploratory study. International journal of nursing studies,

45, 418-427.

GARROUSTE-ORGEAS, M., PERRIN, M., SOUFIR, L., VESIN, A., BLOT, F., MAXIME,

V., BEURET, P., TROCHÉ, G., KLOUCHE, K. & ARGAUD, L. 2015. The Iatroref

study: medical errors are associated with symptoms of depression in ICU staff but not

burnout or safety culture. Intensive Care Medicine, 41, 273-284.

GARSON, D. G. 2015. Missing Values Analysis and Data Imputation, Asheboro, USA,

Statistical Associates Publishing.

HALBESLEBEN, J. R., WAKEFIELD, B. J., WAKEFIELD, D. S. & COOPER, L. B. 2008.

Nurse burnout and patient safety outcomes: nurse safety perception versus reporting

behavior. Western Journal of Nursing Research, 30, 560-577.

HALL, L. H., JOHNSON, J., WATT, I., TSIPA, A. & O’CONNOR, D. B. 2016. Healthcare

This article is protected by copyright. All rights reserved.

 Staff Wellbeing, Burnout and Patient Safety: A Systematic Review. PloS One, 11,

e0159015.
Accepted Article
HANKIN, B. L., FRALEY, R. C., LAHEY, B. B. & WALDMAN, I. D. 2005. Is depression

best viewed as a continuum or discrete category? A taxometric analysis of childhood

and adolescent depression in a population-based sample. Journal of abnormal

psychology, 114, 96.

HANSEN, L. O., WILLIAMS, M. V. & SINGER, S. J. 2011. Perceptions of hospital safety

climate and incidence of readmission. Health Services Research, 46, 596-616.

HENRY, J. D. & CRAWFORD, J. R. 2005. The short-form version of the Depression

Anxiety Stress Scales (DASS-21): Construct validity and normative data in a large

non-clinical sample. British Journal of Clinical Psychology, 44, 227-239.

HOBFOLL, S. E. 2001. The influence of culture, community and the nested self in the

stress process: advancing conservation of resources theory. Applied Psychology, 50,

337-421.

HOFMANN, D. A. & MARK, B. 2006. An investigation of the relationship between safety

climate and medication errors as well as other nurse and patient outcomes. Personnel

Psychology, 59, 847-869.

HOLDEN, R. J., SCANLON, M. C., PATEL, N. R., KAUSHAL, R., ESCOTO, K. H.,

BROWN, R. L., ALPER, S. J., ARNOLD, J. M., SHALABY, T. M. &

MURKOWSKI, K. 2011. A human factors framework and study of the effect of

nursing workload on patient safety and employee quality of working life. BMJ

Quality & Safety, 20, 15-24.

HUGHES, G. 2008. Nurses at the ‘Sharp End’ of Patient Care. In: HUGHES, G. (ed.) Patient

Safety and Quality: An Evidence-Based Handbook for Nurses. Rockville (MD):

Agency for Healthcare Research and Quality (US).

This article is protected by copyright. All rights reserved.

 IACOVIDES, A., FOUNTOULAKIS, K., KAPRINIS, S. & KAPRINIS, G. 2003. The

relationship between job stress, burnout and clinical depression. Journal of Affective
Accepted Article
Disorders, 75, 209-221.

IVES, J., SHAER, D., SHERRING, S. & MARKS-MARAN, D. 2015. Increasing burnout

among nurses: How can nurse managers respond? British Journal of Mental Health

Nursing, 4, 288-293.

KENNY, D. A. 2016. Measuring model fit [Online]. Available:

http://davidakenny.net/cm/fit.htm [Accessed 20th September 2016.

KENNY, D. A., KANISKAN, B. & MCCOACH, D. B. 2014. The performance of RMSEA

in models with small degrees of freedom. Sociological Methods & Research,

0049124114543236.

LASCHINGER, H. K. S. & LEITER, M. P. 2006. The impact of nursing work environments

on patient safety outcomes: The mediating role of burnout engagement. Journal of

Nursing Administration, 36, 259-267.

LEITER, M. P., HARVIE, P. & FRIZZELL, C. 1998. The correspondence of patient

satisfaction and nurse burnout. Social Science & Medicine, 47, 1611-1617.

LETVAK, S., RUHM, C. J. & MCCOY, T. 2012. Depression in hospital-employed nurses.

Clinical Nurse Specialist, 26, 177-182.

LITTLE, R. J. 1988. A test of missing completely at random for multivariate data with

missing values. Journal of the American Statistical Association, 83, 1198-1202.

LOUCH, G., O’HARA, J., GARDNER, P. & O’CONNOR, D. B. 2016. The daily

relationships between staffing, safety perceptions and personality in hospital nursing:

A longitudinal on-line diary study. International Journal of Nursing Studies, 59, 27-

37.

MARDON, R. E., KHANNA, K., SORRA, J., DYER, N. & FAMOLARO, T. 2010.

This article is protected by copyright. All rights reserved.

 Exploring relationships between hospital patient safety culture and adverse events.

Journal of Patient Safety, 6, 226-232.

Accepted Article
MASLACH, C. & JACKSON, S. E. 1981. The measurement of experienced burnout. Journal

of Occupational Behavior, 2, 99-113.

MASLACH, C., SCHAUFELI, W. B. & LEITER, M. P. 2001. Job burnout. Annual review of

psychology, 52, 397-422.

NHS 2013. Report of the Mid Staffordshire NHS Foundation Trust Public Inquiry. London:

The Stationery Office.

NORTON, P. J. 2005. A psychometric analysis of the Intolerance of Uncertainty Scale

among four racial groups. Journal of Anxiety Disorders, 19, 699-707.

PASSALACQUA, S. A. & SEGRIN, C. 2012. The effect of resident physician stress, burnout

and empathy on patient-centered communication during the long-call shift. Health

Communication, 27, 449-456.

PREACHER, K. J. & HAYES, A. F. 2008. Asymptotic and resampling strategies for

assessing and comparing indirect effects in multiple mediator models. Behavior

Research Methods, 40, 879-891.

SALEH, A. M., AWADALLA, N. J., EL-MASRI, Y. M. & SLEEM, W. F. 2014. Impacts of

nurses’ circadian rhythm sleep disorders, fatigue and depression on medication

administration errors. Egyptian Journal of Chest Diseases and Tuberculosis, 63, 145-

153.

SHANAFELT, T. D., BALCH, C. M., BECHAMPS, G., RUSSELL, T., DYRBYE, L.,

SATELE, D., COLLICOTT, P., NOVOTNY, P. J., SLOAN, J. & FREISCHLAG, J.

2010. Burnout and medical errors among American surgeons. Annals of Surgery, 251,

995-1000.

SHANAFELT, T. D., HASAN, O., DYRBYE, L. N., SINSKY, C., SATELE, D., SLOAN, J.

This article is protected by copyright. All rights reserved.

 & WEST, C. P. Changes in burnout and satisfaction with work-life balance in

physicians and the general US working population between 2011 and 2014. Mayo
Accepted Article
Clinic Proceedings, 2015. Elsevier, 1600-1613.

SORRA, J. S. & NIEVA, V. F. 2004. Hospital survey on patient safety culture (prepared by

Westat, under Contract No. 290-96-0004; AHRQ Publication No. 04-0041),

Rockville, MD, Agency for Healthcare Research and Quality.

SU, J. A., WENG, H. H., TSANG, H. Y. & WU, J. L. 2009. Mental health and quality of life

among doctors, nurses and other hospital staff. Stress and Health, 25, 423-430.

TANAKA, M., TANAKA, K., TAKANO, T., KATO, N., WATANABE, M. & MIYAOKA,

H. 2012. Analysis of risk of medical errors using structural-equation modelling: a 6-

month prospective cohort study. BMJ Quality & Safety, 21, 784-790.

THUYNSMA, C. & DE BEER, L. T. 2016. Burnout, depressive symptoms, job demands and

satisfaction with life: discriminant validity and explained variance. South African

Journal of Psychology, 0081246316638564.

VAHEY, D. C., AIKEN, L. H., SLOANE, D. M., CLARKE, S. P. & VARGAS, D. 2004.

Nurse Burnout and Patient Satisfaction. Medical Care, 42, II57-II66.

VINCENT, C., NEALE, G. & WOLOSHYNOWYCH, M. 2001. Adverse events in British

hospitals: preliminary retrospective record review. British Medical Journal, 322, 517-

519.

WALL, T. D., BOLDEN, R., BORRILL, C., CARTER, A., GOLYA, D., HARDY, G.,

HAYNES, C., RICK, J., SHAPIRO, D. & WEST, M. 1997. Minor psychiatric

disorder in NHS trust staff: occupational and gender differences. The British Journal

of Psychiatry, 171, 519-523.

WELP, A., MEIER, L. L. & MANSER, T. 2014. Emotional exhaustion and workload predict

clinician-rated and objective patient safety. Frontiers in Psychology, 5.

This article is protected by copyright. All rights reserved.

 WEST, C. P., HUSCHKA, M. M., NOVOTNY, P. J., SLOAN, J. A., KOLARS, J. C.,

HABERMANN, T. M. & SHANAFELT, T. D. 2006. Association of perceived

Accepted Article
medical errors with resident distress and empathy: a prospective longitudinal study.

JAMA, 296, 1071-1078.

WEST, C. P., TAN, A. D., HABERMANN, T. M., SLOAN, J. A. & SHANAFELT, T. D.

2009. Association of resident fatigue and distress with perceived medical errors.

JAMA, 302, 1294-1300.

WEST, M. & DAWSON, J. 2012. Employee engagement and NHS performance. The King's

Fund.

WOOD, A. M., TAYLOR, P. J. & JOSEPH, S. 2010. Does the CES-D measure a continuum

from depression to happiness? Comparing substantive and artifactual models.

Psychiatry Research, 177, 120-123.

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 Table 1: Means, Standard deviations a and correlations for variables

Mean
2 3 4 5 6 7
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1.Length of time in 96.05 -.26*** -.02 -.14* .08 .02 -.06
current position 95.67
(months)

2.Typical hours per 35.39 .02 -.05 .05 .15* .16**

week 20.07

3. Individual-level 3.11 .48*** -.28*** -.41*** -.43***

safety (Safe 1.19
practitioner
measure)

4. Work area/unit 12.49 -.34*** -.51*** -.45***

level safety 3.73
(AHRQ subscale)

5.Depression 4.27 .67*** .52***

(DASS subscale) 4.30

6.MBI Emotional 26.08 .60***

Exhaustion 13.00

7. MBI 6.50
Depersonalisation 6.00
Note. *p<0.05, **p<.01, ***p<0.001. AHRQ = Agency for Healthcare Research and Quality;
DASS = Depression, Anxiety and Stress Scale; MBI = Maslach Burnout Inventory. aStandard
deviations appear in italics below the means.

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Accepted Article

Figure 1. Hypothesised mediation of two subfacets of burnout on the relationship

p between
depression and patient safety (A) a
and conceptual depiction of this (B).

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Accepted Article

Figure 2. Structural Equation Mode els for depression, burnout and patient safety assessed
a at
the individual level (Safe Practition
ner measure).

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Accepted Article

els for depression, burnout and patient safety assessed at

Figure 3. Structural Equation Mode
the work area/unit level (AHRQ).

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Accepted Article

Figure 4. Structural Equation mode els testing the opposite mediation pattern at bo
oth the
individual level (A) and the area/un
nit level (B).

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