Nurses who co-create care with clients experience lower levels of burnout through the perception of fewer emotional demands: an observational study

This observational study demonstrated that LTC nurses who co-created care perceived less job burnout, partly because they experienced fewer emotional demands at work. Their workload was not associated with the co-creation of care and did not mediate the association between the co-creation of care and job burnout.

Overall, our results align with the Job Demands-Resources (JD-R) model showing that job demands (emotional demands and workload) are associated with higher levels of burnout among healthcare providers [22]. Additionally, our study contributes to the body of knowledge on the JD-R model by showing that the co-creation of care can affect the way LTC nurses perceive their job demands – subsequently affecting their burnout levels. Our finding is in line with the previous finding that the co-creation of care is associated with better well-being among healthcare providers [7, 6], conflicts with the lack of association between the co-creation of care and burnout in one previous study among informal caregivers [38]. Apparently, the co-creation of care may have potential to reduce burnout in healthcare providers, but not in informal caregivers. The observation of the fostering of client satisfaction and empowerment may energize healthcare professionals in their work [7]; this aspect may explain the nurses’ perception of their work as less exhausting when co-creating care. Alternatively, the nurses’ exhaustion levels may have been lower because the co-creation of care is characterized by positive relationships with clients, which have intrinsic well-being benefits and/or reduce burnout [5, 6, 39]. Indeed, related research – in hospital-based settings – has shown positive patient relationships to foster physicians in feeling less burned-out [20], aligning with our finding that co-creating care is directly associated with lower levels of burnout.

Our study addressed the knowledge gap on how the association between co-creation of care and burnout among LTC nurses can be mediated by job demands, in particular showing the mediating role of emotional demands. Specifically, co-creation of care was indirectly associated with reduced burnout through the perception of fewer emotional demands. This may be related to the less emotionally demanding nature of clients who experience effective communication and supportive relationships with their nurses, with their needs and wishes adequately addressed through the co-creation of care. Nurses’ problem-solving communication during collaborative work on shared goals may reduce the likelihood that clients will disagree with their care-related decisions. This aspect may clarify the nurses’ reporting of less-difficult client interactions and a reduced burden of persuading their clients (as derived from the emotional demands subscale, see Measures). However, as this study is the first to demonstrate an association between the co-creation of care and emotional demands, the generalizability of this finding to diverse settings should be assessed.

Our finding that the nurses’ perceptions of workload were not affected by the co-creation of care does not align with discussions of the potential of the co-creation of care to improve the efficiency of work processes and thereby reduce healthcare providers’ perceived workloads in the literature [7]. It also does not align with a previous report that the co-creation of care (in the context of e-consultation in general practice) increases healthcare providers’ workloads [19]. The co-creation of care may increase providers’ workload by, for example, requiring the investment of more time in communicative and relational processes while decreasing workload by, for example, optimizing the efficiency of care, thereby neutralizing the association. A more-nuanced understanding of this association in the LTC setting, gained for example through additional qualitative analyses, is needed.

This study demonstrated that our conceptual model applied to emotional demands, but not workload, among LTC nurses; only the former mediated the association between the co-creation of care and job burnout. The data for this study data were obtained from a convenience sample, and we could not calculate the response rate or assess the degree to which the scale scores were subject to self-selection bias. However, such bias may not have necessarily affected the directions or strength of associations between study concepts, which aligned with related findings [7] and the theoretical underpinnings of relational coordination theory and the Job Demands–Resources model [5, 40]. Previous findings on the JD-R model have been reported across different health care contexts and time periods [40]; our findings also show these associations in the LTC setting based on data from 2019. Both during and after this period, long term care has faced continuous pressures on job demands and nurse well-being, and our findings clarifying how these are affected by the co-creation of care, thus contribute to novel insights in addressing current workforce challenges in LTC. Moreover, our reported associations between job demands and nurse burnout have also been found in studies based on more recent data [7, 41, 42]; thereby showing that our findings fit into current trends in health care. Our findings should, nonetheless, be cautiously interpreted regarding causality; the study was cross-sectional, and we could not draw conclusions about the causal directions of the associations. Although longitudinal research has revealed causal associations of job demands with job burnout [21], the causality of associations of the co-creation of care with these factors is yet to be determined. Additionally, future research could focus on additional job demands or resources to help clarify the observed association between the co-creation of care and job burnout.

The facilitation of the co-creation of care could be considered in efforts to reduce nurses’ perceived emotional demands and job burnout through the implementation of initiatives at the client, healthcare provider, and service levels [7]. At the client level, health literacy and self-efficacy should be promoted to support clients’ ability to actively participate in the co-creation of care [43, 44]. Furthermore, at this level it may also be necessary to apply specific managerial methods, including healthcare user training, motivation and support building, to facilitate clients in the process of co-creating care [7]. At the provider level, resources (e.g., e-health tools or assistance with administrative tasks) should be made available to support providers dealing with the extra time requirements of the co-creation of care [7, 45]. Additionally, healthcare providers may be supported in the co-creation of care by managerial methods directed at staff training that help providers attaining new technical knowledge, motivational training or receiving managerial support in the co-creation of care [7]. Also managerial investment in continuing education interventions and an organizational culture characterized by patient-centeredness may support healthcare providers’ propensity to co-create care in efforts to optimize person-centered approaches [7, 44, 45]. At the service level, it is important that service reorganization be at an advanced stage; providers are less likely to co-create in organizations that face substantial reorganization needs [43]. Ultimately, the facilitation of the co-creation of care at these levels has the potential to support the reduction of emotional demands and job burnout among healthcare providers. Such support is important for not only healthcare providers’, but also clients’ well-being, which have been found to be associated with the co-creation of care [11, 46].