Relationships Among Structural Empowerment, Psychological Empowerment, And Burnout in Registered Staff Nurses Working in Outpatient Dialysis Centers

Janice L. OBrien

Continuing Nursing Education

urse burnout has typically been associated with hospitalbased nurses. Recent research, however, has found that burnout is a problem in nephrology settings as well. Flynn, ThomasHawkins, and Clarke (2009) found that 1 in 3 nurses working in dialysis settings experienced burnout. This is a serious problem because the consequences of nurse burnout have been associated with high rates of nurse absenteeism, interference with processes of care, low patient satisfaction, and intent of nurses to leave their job (Flynn et al., 2009; Vahey, Aiken, Sloane, Clarke, & Vargas, 2004). Reports by the U.S. Government Accounting Office (2001a, b) indicate that negative factors in the work environment, those that are antecedent to burnout, have contributed to the current nursing shortage in the U.S. Nephrology nurses working in outpatient dialysis centers provide essential care to approximately 598,772 patients (U.S. Renal Data System [USRDS], 2010). According to the USRDS (2010), the number of patients with end stage renal disease (ESRD) requiring treatment increases by approximately 50,000 per year. The current nursing shortage and the rise in patients requiring dialysis accentuate the need to understand nurse burnout in this setting to retain experienced nurses in chronic dialysis settings.

Copyright 2011 American Nephrology Nurses Association OBrien, J.L. (2011). Relationships among structural empowerment, psychological empowerment, and burnout in registered staff nurses working in outpatient dialysis centers. Nephrology Nursing Journal, 38(6), 475-481. This study explored relationships among structural empowerment, psychological empowerment, and burnout in registered staff nurses working in outpatient hemodialysis settings. The sample consisted of 233 registered staff nurses. The Emotional Exhaustion Subscale of the Maslach Burnout Inventory, the Conditions for Work Effectiveness II Questionnaire, and Psychological Empowerment Instrument were used to measure variables. Findings indicate that in this population of nurses, there is a significant inverse relationship between structured empowerment and burnout.
Key Words: Nephrology nurses, structural empowerment, psychological empowerment, burnout.

Goal

To provide an overview of relationships among structural empowerment, psychological empowerment, and burnout in registered staff nurses working in outpatient hemodialysis settings.
Objectives

1. 2. 3.

Define burnout. Explain how high levels over burnout may affect nephrology nurses and patient care in the dialysis setting. Discuss the relationship between structural empowerment and psychological empowerment, and their role as mechanisms to help overcome burnout.

Burnout is defined as a psychological process characterized by feelings of emotional exhaustion, detachment, and lack of personal accomplishment (Maslach, 2003; Maslach & Leiter, 1997; Maslach, Schaufeli, & Leiter, 2001). Burnout has been attributed to

constant exposure to chronic stressors in the work environment (Cherniss, 1980; Cox, Kuk & Leiter, 1992; Maslach, 2003). Some work environment stressors antecedent to burnout include lack of autonomy, lack of organizational support, poor manage-

This offering for 1.3 contact hours and 80 pharmacology minutes is provided by the American Nephrology Nurses Association (ANNA).
Janice L. OBrien, PhD, RN, AHN-BC, is an Assistant Professor, Saint Peters College, School of Nursing, Englewood Cliffs, NJ. She may be contacted via e-mail at Jobrien5@SPC.edu Statement of Disclosure: The author reported no actual or potential conflict of interest in relation to this continuing nursing education article.

ANNA is accredited as a provider of continuing nursing education (CNE) by the American Nurses Credentialing Centers Commission on Accreditation. ANNA is a provider approved by the California Board of Registered Nursing, provider number CEP 00910. Accreditation status does not imply endorsement by ANNA or ANCC of any commercial product. This CNE article meets the Nephrology Nursing Certification Commissions (NNCCs) continuing nursing education requirements for certification and recertification.

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Relationships Among Structural Empowerment, Psychological Empowerment, and Burnout in Registered Staff Nurses Working in Outpatient Dialysis Centers

ment, lack of resources, and high workload (Cherniss, 1980; Cox et al., 1993; Maslach, 2003). High levels of burnout have been associated with health problems in nurses, work-related injuries, anxiety and depression, relationship problems with family and friends, decrease in work performance, and lowered job satisfaction (Clarke, Sloane, & Aiken, 2002; Glasberg, Eriksson, & Nordberg, 2007; Maslach, 2003; Maslach et al., 2001; Wright & Bonnet, 1997; Zapf, Seifert, Schmutte, Mertini, & Holtz, 2001). Organizations reporting high nurse burnout may have high attrition rates, low patient satisfaction scores, and safety issues that affect both patient and nurse (Clarke et al., 2002; Halbesleben, Wakefield, Wakefield, & Cooper, 2008; Vahey et al., 2004). Recent studies indicate that nurse burnout in dialysis settings is a significant problem (Argerntero, DellOlivo, & Ferretti, 2008; Dermody & Bennet, 2008; Flynn et al., 2009; Klersy et al., 2007). Studies indicate that nurses working in outpatient hemodialysis facilities perceive their work environments as unsupportive, deficient in opportunity and resources, and overly demanding, making it difficult to provide quality care (Gardner & Walton, 2011; Thomas-Hawkins, Currier, Denno, & Wick, 2003). Additionally, nurses negative ratings of the dialysis work environment significantly predict staff nurse burnout in outpatient dialysis settings (Flynn et al., 2009). These findings underscore an important need to further examine factors that contribute to nurse burnout in outpatient dialysis settings. Research exploring burnout in hospital-based registered nurses (RNs) indicates that a work environment perceived by nurses as supportive of professional nursing practice is an important factor that contributes to reduced levels of nurse burnout (Aiken, Clarke, Sloane, Sochalski, & Silber, 2002; Hochwalder, 2007; Leiter & Laschinger, 2006). Laschinger and Havens (1996) noted that hospitalbased nurses perceived supportive work environments as those struc-

tured to empower nurses. Using Kanters (1993) theory of structural empowerment in organizations, Laschinger and Havens (1996) found that hospitals providing structures designed to empower nurses experienced lower nurse burnout rates. According to Kanter (1993), empowering structures are those that provide workers with access to information, resources, opportunity, and support. Empowering work environments enable nurses to provide safe and effective care (Leiter & Laschinger, 2006; Manojlovich, 2005). Moreover, nurses must not only perceive the work environment as empowering, the nurse must feel an inner sense of empowerment. In other words, the nurse must feel psychologically empowered (Carless, 2004; Wallach & Mueller, 2006). Psychological empowerment is important because it influences attitudes and behavior (Thomas & Velthouse, 1990). Psychological empowerment is characterized by an indivudals perception that the job has meaning and that he or she is competent and able to influence outcomes and perceives a sense of autonomy (Conger & Kanungo, 1988; Menon, 2001; Spreitzer, 1995a, b; Thomas & Velthouse, 1990; Zimmerman, 1995). This inner perception of empowerment improves the individuals attitude and behavior, and thus creates a more positive outcome for workers by lowering burnout levels (Hochwalder, 2007). Psychological empowerment is proposed to be an underlying mechanism that mediates the relationship between structural empowerment and worker outcomes, such as burnout (Spreitzer, 1995a). The basic proposition is that when individuals view their work environment as providing opportunities for rather than constraints on individual behavior and positive worker outcomes, they feel personally (psychologically) empowered. In turn, psychological empowerment leads to positive worker outcomes, such as low levels of burnout. No studies were found, however, that explored structural empowerment and psychological empowerment in relation to burnout in nurses

working in outpatient dialysis centers. Therefore, the purpose of this study was to examine those relationships among structural empowerment, psychological empowerment, and burnout in staff RNs working in outpatient dialysis settings. The following hypotheses were explored in this study: There is an inverse relationship between structural empowerment and burnout. There is an inverse relationship between psychological empowerment and burnout. There is a positive relationship between structural empowerment and psychological empowerment. Psychological empowerment mediates the relationship between structural empowerment and burnout.

Method
A descriptive, correlational research design was used to investigate the relationships among structural empowerment and psychological empowerment and burnout in nurses working in outpatient dialysis centers. The study was approved by the universitys Institutional Review Board prior to data collection to protect study participants. A cover letter included in the survey packet sent to participants explained that return of the survey served as consent. A selfreported paper and pencil survey in accordance with the Dillman (2010) survey method was used. Surveys were mailed to the participants homes, and reminder postcards were mailed at the recommended intervals. A power analysis was conducted for correlation and regression analysis. Based on previous literature (Hatcher & Laschinger, 1996; Hockwalder & Brucefors, 2005; Sarmiento, Laschinger, & Iwasiw, 2004) using a moderate effect size (r = 0.30), a minimum of 119 subjects was needed for a power of 0.80 at a 0.05 level of significance (Cohen, 1988).

Sample
A list of 1400 registered nurses who identified themselves as staff

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nurses working in outpatient hemodialysis centers in the U.S. was obtained from a nephrology nurse organization. A systematic sampling method, drawing every third name from the list, was used to select 500 nurses.

Measures
Nurse burnout was measured using the Emotional Exhaustion Subscale (EES) of the Maslach Burnout Inventory (Maslach & Jackson, 1981). This subscale is the most frequently used to measure burnout (Schaufeli, Bakker, Hoogduin, Schaap, & Kladler, 2001). The EES consists of nine items rated on a scale from 0 to 6. The scores on the EES range from 0 to 54, with high scores indicative of high levels of emotional exhaustion and burnout (Maslach & Jackson, 1981). According to Maslach and Jackson (1981), a score of 27 or more indicates a state of burnout. The internal consistency coefficient for this study was 0.91, indicating an acceptable reliability in this sample of nurses. Structural empowerment was measured using the Conditions of Work Effectiveness Questionnaire (CWEQ-II). Reliability and validity of this instrument for use in samples of nurses has been established (Laschinger, Finnegan, Shamain, & Wilk, 2001). The CWQE-II consists of 19 items over 6 subscales that measure the respondents perception of structural empowerment in the work environment consistent with Kanters theory (such as access to information, support, resources, opportunity, formal power, and informal power) (Laschinger & Havens, 1996). The 19 items are rated on a scale ranging from 1 to 5. Scores range from 6 to 30, with the high score indicating a high perception of structural empowerment (Laschinger et al., 2001). The internal consistency coefficient of 0.92 in this sample of nurses indicates acceptable reliability for this study. Psychological empowerment was measured using Spreitzers (1995a) Psychological Empowerment Instrument (PEI). This scale has been wide-

ly used to measure the concept of psychological empowerment. Reliability and validity have been established in samples of nurses (Hochwalder & Brucefors, 2005; Laschinger et al., 2001). The PEI consists of 12 items divided into four subscales using a Likert scale ranging from 0 to 6. Each subscale measures one of the four dimensions of psychological empowerment (meaning, competence, selfdetermination, and impact) congruent with the theory (Spreitzer, 1995a; Thomas & Velthouse, 1990). Scores for each subscale are summed, averaged, and then totaled for a score. High score for the PEI indicates high levels of perception of psychological empowerment. The internal consistency coefficient for this study sample was 0.91 indicating acceptable reliability in this study.

present to establish mediation. First, the independent variable must be significantly related to the mediating variable. This was tested by regressing burnout on structural empowerment. Second, the independent variable must be significantly related to the dependent variable. This was tested by regressing psychological empowerment on structural empowerment. Third, the mediating variable must be significantly related to the dependent variable. This was tested in a third regression entering structural empowerment, psychological empowerment, and burnout into the equation simultaneously. Mediation occurs if the effect of the mediating variable is more significant than the independent variable on the dependent variable (Baron & Kenny, 1986).

Results Data Analysis

Data were analyzed using the Statistical Package for the Social Sciences (SPSS) version 16.0 for Windows. Scores for the EES were summed. Scores for the CWQE-II and PEI were summed and averaged by the number of subscales to obtain a total score. Correlational analysis was conducted to determine if demographic variables were associated with the study variables to determine the necessity to control for these in the multivariate analysis. No associations between demographic and study variables were found. Hypothesis 1, 2, and 3 were tested using correlational analysis. Baron and Kennys (1986) method for testing a mediation model was used to test hypothesis 4. According to Baron and Kenny (1986), a mediating variable is an intervening or underlying mechanism that explains the relationship of the independent variable to the dependent variable. The mediating variable is useful in explaining how or why a relationship exists between the independent variable and the dependent variable (Baron & Kenny, 1986). Using Baron and Kennys (1986) method, three conditions must be A return of 310 surveys yielded a response rate of 62%. Of the 310 respondents, 233 met the criteria of staff nurses currently working in outpatient hemodialysis centers and were thus the sample for this study. The demographic characteristics of the sample are displayed in Table 1. In this study, 33.0% of nurses reported high levels of burnout indicated by scores above 27 on the EES. In addition, 27.5% of the respondents reported a moderate level of burnout (scores ranging between 17 and 26). Nurses perceived moderate levels of psychological empowerment, with scores ranging from 0- to 8 (M = 13.6, SD = 2.61). Of the nurses who responded, 67.8% perceived a moderate level of structural empowerment in their organization, 10.7% perceived low levels, and only 18.5% felt their workplace provided high level of structural empowerment. Subscale scores for structural empowerment (see Table 2) indicate the nurses perceived their work environment as deficient in resources (M = 2.73, SD = 0.849), information (M = 3.17, SD = 1.04), support (M = 3.23, SD = 0.962), and a lack of formal power (M = 2.90, SD = 0.905). Additional examinations of

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the relationship between structural empowerment and burnout were conducted to further understand the impact of the dimensions of structural empowerment on burnout. Correlational analysis was conducted between all dimensions of structural empowerment (support, resources, information, opportunity, informal power, and formal power) and burnout (see Table 3). Findings revealed that all dimensions were significantly related to burnout. In addition, regression analysis was conducted to determine which dimensions significantly predicted burnout. The six dimensions of structural empowerment were entered simultaneously into the regression as independent variables. Collinearity statistics, including the variance inflation factor (VIF) and tolerance, indicated no multicollinearity between the predictors. Findings revealed that resources ( = -0.241, p = 0.002) and formal power ( = -0.341, p = 0.000) were the dimensions of structural empowerment that significantly predicted burnout. Correlation analysis (see Table 4) was conducted to test the hypothesized relationships for hypothesis 1, 2, and 3. Findings indicated that a) structural empowerment was inversely related to burnout (r = -0.445, p = 0.000), thus supporting hypothesis 1; b) psychological empowerment was inversely related to burnout (r = 0.349, p = 0.000), supporting hypothesis 2; and c) structural empowerment was positively related to psychological empowerment (r = 0.0592, p = 0.000), thus supporting hypothesis 3. To test the mediation model, a series of three regressions were performed as specified by Baron and Kenny (1986). In the first regression, the dependent variable (burnout) was regressed on the independent variable (structural empowerment) and indicated that structural empowerment was a significant predictor of burnout ( = -0.445, p = 0.000). For the second regression, the mediating variable (psychological empowerment) was entered as the dependent variable and regressed on the inde-

Table 1 Demographic Characteristics of Subjects (N = 233)

Variable Gender Female Male Race Caucasian African-American Asian Filipino Alaskan/Native American Mixed Educational Background Diploma Associates degree Bachelors degree Masters degree Type of Dialysis Center Hospital-owned Independently owned Work Status Full-time Part-time Per diem Range Age Years in current position Years as a nurse Hours worked per week 24 to 68 Less than 1 to 40 years 2 to 46 2 to 70 173 50 9 Mean 49.6 9.6 22.5 37 Median 50.0 7.0 23.0 40.0 74.6 21.4 3.90 SD 8.6 7.9 10.1 7.8 106 127 45.5 54.5 42 80 106 4 18.0 34.3 44.5 1.70 163 19 21 17 1 2 70.0 8.0 9.0 7.3 0.4 0.9 217 16 93.0 6.9

Percentage

Table 2 CWEQ-II Subscale Scores (N = 233)

N
Opportunity Support Information Resources Formal power Informal power Total score Valid N (listwise) 231 232 233 233 230 232 226 226 Mean 3.7431 3.2356 3.1702 2.7382 2.9072 3.5129 19.3149 Standard Deviation 0.75336 0.96252 1.04959 0.84963 0.90558 0.79115 4.10952 Variance 0.568 0.926 1.102 0.722 0.820 0.626 16.888

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Table 3 Correlation Matrix of Dimensions of Structural Empowerment and Burnout

Variable Burnout Opportunity Support Information Resources Formal power Informal power -0.157* -0.317** -0.301** -0.444** -0.449** -0.310** 0.507** 0.387** 0.291** 0.422** 0.513** 0.641** 0.526** 0.565** 0.566** 0.475** 0.542** 0.481** 0.598** 0.453** 0.607** 1 2 3 4 5 6

Table 4 Correlational Matrix of Variables for Testing Hypotheses 1, 2, and 3

Variable Burnout SE PE -.0445** -.0349** 0.592** 1 2

** Indicate p 0.05 (2-tailed).

* Correlation is significant at the p 0.05 level (2- tailed). ** Correlation is significant at the p 0.01 level (1-tailed).

pendent variable (structural empowerment). Findings indicated that structural empowerment was a significant predictor of psychological empowerment ( = -0.592, p = 0.000). In the third regression, the independent variable (structural empowerment) and the mediating variable (psychological empowerment) were entered simultaneously. The finding from this analysis revealed that structural empowerment remained a significant predictor of burnout ( = -0.364, p = 0.000) with the mediator psychological empowerment in the model. Findings indicate that in this population of nurses, there is a significant inverse relationship between structured empowerment and burnout. Psychological empowerment was not a significant independent predictor of burnout and did not mediate the relationship between structural empowerment and burnout.

Discussion
Findings in this study indicate that one in three nurses in chronic outpatient hemodialysis centers experience a high level of burnout. In addition, another 27% reported a moderate level of burnout, indicating risk for burnout. These findings are consistent with those from hospital-based nurses and similar studies in hemodialysis settings, indicating burnout is a significant problem for staff nurses working

in outpatient hemodialysis centers (Flynn et al., 2009; Klersey et al., 2007). This is an alarming proportion of nurses experiencing burnout in this setting and may potentiate the negative consequences associated with burnout to patient safety and quality of care, the health of the nurse, and the impact on the organization. A significant inverse relationship was found between the nurses perceptions of a structurally empowering work environment and burnout. This is consistent with findings of studies conducted with hospital-based nurses and reinforces findings from previous studies that relate burnout to insufficiencies in the registered nurse work environment (Hatcher & Laschinger, 1996; Leiter & Laschinger, 2006). Findings from this study indicate that similar to hospital-based settings, empowerment structures in the hemodialysis work environment are important as well. This further underscores the need for managers and administrators in the hemodialysis setting to be proactive in creating positively structured work environments that empower nurses. Nurse perceptions of empowering work environments (structural empowerment) were directly and positively correlated to the nurses perceptions of psychological empowerment in this study. These findings are consistent with similar studies of nurses in hospital work environments.

Furthermore, this is consistent with the theoretical perspective, suggesting that to actualize empowerment, one must have the perception or the feeling of empowerment. A significant inverse relationship was also found between psychological empowerment and burnout, and is consistent with similar findings in hospital-based nurses. Psychological empowerment, however, was not found to be a significant independent predictor of burnout; nor was it a mediator in the relationship between structural empowerment and burnout in this population, and is not congruent with findings from similar studies of hospital-based nurses. Several factors may explain this. First, the sample consisted only of nurses who belonged to a professional organization; therefore, psychological empowerment may be a characteristic of nurses who belong to such an organization, and thus, is a study limitation. Second, nurses in this study were in their current positions for an average of nine years. The experience level of nurses in the sample indicated they were seasoned hemodialysis nurses, and because of the years of experience, had an inner sense of competence and confidence increasing their perception of psychological empowerment. Third, methodological issues, such as common method variance and correlational methodology, may also be a study limitation.

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Congruent with recent studies on burnout in hemodialysis settings, these findings suggest that negative factors in the work environment are antecedent to nurse burnout. Hemodialysis centers providing work environments that offer empowerment, such as resources, information, support, and opportunity, may help reduce burnout and improve retention of staff nurses in this setting. In addition, by reducing burnout, nurse job performance, patient satisfaction, and quality of care should improve.

Reducing nurse burnout is not only important to retaining this specialized work force of nurses, but it is necessary to ensuring that patients receiving dialysis center services receive the quality of care essential to their needs. Organizations attentive to creating positive work environments, those that empower nurses, create a healthy nurse work force that is more capable of providing safe and effective care. References
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Summary
Perceived structural empowerment and psychological empowerment were significantly related to burnout; however, structural empowerment was the only significant predictor of burnout in this population of registered nurses. These findings emphasize the importance of structuring positive work environments to reduce chronically occurring stressors that contribute to nurse burnout. More importantly, negative consequences associated with nurse burnout have a ripple effect. As the nurse experiences physical, psychological, and emotional problems, the patient may experience a reduction in the quality of care. Moreover, as a result, the organization may experience low levels of patient satisfaction and high attrition rates in staffing. Administrators and managers should be alert for the signs of nurse burnout and offer interventions for staff to prevent or reduce the process. While there is a beginning body of research in the outpatient hemodialysis setting, there is much to explore. Future studies should include quantifying patient outcomes with nurse burnout in hemodialysis settings. Research into interventions that reduce or reverse nurse burnout would be valuable. In addition, replication of this study, including nurses who are both members and nonmembers of a professional nephrology nurse organization, might improve the understanding of the relationships explored in this study.

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Nephrology Nursing Journal Editorial Board Statements of Disclosure

In accordance with ANCC-COA governing rules Nephrology Nursing Journal Editorial Board statements of disclosure are published with each CNE offering. The statements of disclosure for this offering are published below. Paula Dutka, MSN, RN, CNN, disclosed that she is a consultant and research coordinator, is on the speakers bureau, and has sat on the advisory board for Genentech. Patricia B. McCarley, MSN, RN, NP, disclosed that she is on the Consultant Presenter Bureau for Amgen, Genzyme, and OrthoBiotech. She is also on the Advisory Board for Amgen, Genzyme, and Roche and is the recipient of unrestricted educational grants from OrthoBiotech and Roche.

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Spreitzer, G. (1995a). Psychological empowerment in the workplace: Dimensions, measurement, and validation. Academy of Management Journal, 38(3), 1442-1464. Spreitzer, G. (1995b). An empirical test of a comprehensive model of intrapersonal empowerment in the workplace. American Journal of Community Psychology, 23(5), 601-629. Thomas, K., & Velthouse, B. (1990). Cognitive elements of empowerment: An interpretive model of intrinsic task motivation. Academy of Management Review, 15(4), 666-681. Thomas-Hawkins, C., Currier, H., Denno, M., & Wick, G. (2003). Staff nurses perceptions of the work environment in freestanding hemodialysis facilities. Nephrology Nursing Journal, 30(4), 377-485. U.S. Government Accounting Office. (2001a). Emerging nurse shortage due to multiple factors (GAO-01-944). Washington, DC: Author. U.S. Government Accounting Office. (2001b). Multiple factors create nurse recruitment and retention problems (GAO-01-912T). Washington, DC: Author.

U.S. Renal Data System (USRDS). (2010). URSDS annual data report: ESRD incidence and prevalence. Retrieved from http://www.usrds.org/qtr/default. html Vahey, D.C., Aiken, L.H., Sloane, D.M., Clarke, S.P., & Vargas, D. (2004). Nurse burnout and patient satisfaction. Medical Care, 42, II-57-66. doi: 10.1097/01.mlr.0000109126.50398.5a Wallach, V., & Mueller, C. (2006). Job characteristics and organizational predictors of psychological empowerment among paraprofessionals within human service organizations. Administrations in Social Work, 30(1), 95-113. Wright, T., & Bonnet, D. (1997). The contribution of burnout to work performance. Journal of Organizational Behavior, 18, 491-499. Zapf, D., Seifert, C., Schmutte, B., Mertini, H., & Holtz, M. (2001). Emotion work and job stressors and their effects on burnout. Psychology and Health, 16, 527-545. Zimmerman, M.A. (1995). Psychological empowerment: Issues and illustrations. Journal of Community Psychology, 23(5), 581-599.

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1. What would be different in your practice if you applied what you have learned from this activity? (Response Required) ____________________________________________________________ ____________________________________________________________ ____________________________________________________________ ____________________________________________________________ ____________________________________________________________

To provide an overview of relationships among structural empowerment, psychological empowerment, and burnout in registered staff nurses working in outpatient hemodialysis settings.
Please note that this continuing nursing education activity does not contain multiple-choice questions. This activity substitutes the multiple-choice questions with an open-ended question. Simply answer the open-ended question(s) directly above the evaluation portion of the Answer/Evaluation Form and return the form, with payment, to the National Office as usual.

Evaluation 2. By completing this offering, I was able to meet the stated objectives a. Define burnout. b. Explain how high levels over burnout may affect nephrology nurses and patient care in the dialysis setting. c. Discuss the relationship between structural empowerment and psychological empowerment, and their role as mechanisms to help overcome burnout. 3. The content was current and relevant. 4. This was an effective method to learn this content. 5. Time required to complete reading assignment: _________ minutes. 6. I am more confident in my abilities since completing this material.

Strongly disagree 1 1 1 1 1 1 2 2 2 2 2 2 3 3 3 3 3 3 4 4 4 4 4 4

Strongly agree 5 5 5 5 5 5

I verify that I have completed this activity ________________________________________________________________________________ (Signature)

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Nephrology Nursing Journal

November-December 2011

Vol. 38, No. 6

Copyright of Nephrology Nursing Journal is the property of American Nephrology Nurses' Association and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.