Burnout in and Commission of Medical Errors by Secondary School Athletic Trainers

The commission of medical errors by health care professionals is a constant concern, as researchers¹ estimated that approximately 251 000 deaths per year in the United States are attributable to some form of medical error. Nonlethal medical errors are even more common, occurring at an estimated rate 10 to 20 times higher than lethal errors.² Medical errors also carry a heavy financial toll, as the cost of medical errors committed in 2008 in the United States was estimated at $17.1 billion.³

Many researchers^4–6 have examined the commission of medical errors by residents and physicians. Among a sample of physicians, 10.5% (n = 6586) reported a major medical error in the previous 3 months.⁴ Of those medical errors (n = 679), 39% involved an error in judgement; 20%, a wrong diagnosis; and 13%, a technical mistake during a procedure.⁴ In 2 prospective longitudinal cohort studies of medical residents conducted over several years, investigators found that 34%⁵ and 39%⁶ of the samples reported committing at least 1 major medical error. Researchers studying nurses found that 30% of the sample (n = 393) admitted to committing at least 1 medical error in the previous month.⁷ In the same study, 58% of errors involved a mistake in medication administration; 18%, a procedural error; and 12%, a charting mistake.⁷

Multiple causes of medical errors have been identified.⁸ These causes include extrinsic factors (eg, too many tasks to complete and complexity of the case) and intrinsic factors (eg, fatigue and lack of experience), although specific analyses to determine which causes led to which types of errors were not reported.⁸ Fatigue as an intrinsic factor that causes medical errors is of particular interest as emotional exhaustion is a component of burnout, which is commonly described in health care professionals.^9–11

Physicians,⁹ nurses,¹¹ and athletic trainers (ATs)¹² have been found to suffer from burnout. Burnout is a psychological syndrome that involves emotional exhaustion, depersonalization of patients, and a decreased sense of personal accomplishment.¹³ Causes of burnout include work-family conflict^9,14 and decreased job satisfaction.¹⁵ Among collegiate ATs, 38.9% of the sample (n = 783) reported high emotional exhaustion; 33.6%, high depersonalization; and 17.7%, low personal accomplishment.¹² The same researchers¹² also observed a direct association between work-family conflict and emotional exhaustion along with an inverse association between work-family conflict and personal accomplishment. In addition, an increased number of hours worked per week, lower salaries, and decreased social support have been associated with increases in burnout among ATs.¹² The Smith Cognitive-Affective Model of Athletic Burnout¹⁶ suggests that emotional exhaustion and decreased personal accomplishment in ATs are directly associated with various behaviors such as substance use¹² and intention to leave the profession of athletic training.¹⁷

Burnout and the commission of medical errors were directly associated in physicians.^4,18 For every 1-point increase in emotional exhaustion, the odds of committing a medical error increased 5%.⁴ Furthermore, a 5% increase in the odds of error commission occurred for every 1-point decrease in personal accomplishment.⁴ Other investigators¹⁸ found that a 7% increase in the odds of committing a medical error occurred for every 1-point increase in emotional exhaustion. However, to our knowledge, the commission of medical errors by ATs or the possibility of these errors being a behavioral outcome of burnout have not been addressed. Therefore, the purpose of our study was 2-fold: to examine the occurrence of medical error commission by secondary school ATs and to determine if commission of medical errors was associated with burnout. We hypothesized that burnout would be directly associated with the commission of medical errors in a statistically significant manner.

METHODS

Before data collection, approval was granted by the institutional review board. The participants were all certified ATs who primarily worked in the secondary school setting at the time of data collection. We chose to examine ATs in the secondary school setting because they represented approximately 26% of certified ATs in the National Athletic Trainers' Association (NATA) membership directory, more than any other work setting.¹⁹ We recruited participants from all regions of the country. All data were collected via a 1-time cross-sectional survey that was delivered (Qualtrics) to participants through social media first and then the NATA Research Survey Service. First, a recruitment message was shared along with a link to the survey on several social media pages that are dedicated to and populated by ATs. The recruitment message expressed the purpose of the study and indicated that it was intended only for ATs who practiced in the secondary school setting. When this recruitment method did not yield an adequate number of responses (n = 91), we then contacted the NATA Research Survey Service to have a recruitment email sent to 4000 NATA members who identified as practicing in the secondary school setting. Data collection through the NATA Research Survey Service lasted 4 weeks, and a reminder email was sent at every 1-week interval.

RESULTS

Demographics

Ninety-one surveys were received through the social media campaign and 480 (12% response rate) were received through the NATA Research Survey Service, resulting in 571 surveys. Because we were unable to calculate a response rate from the social media campaign, an overall response rate was also incalculable. Of the 571 survey responses, 565 individuals consented to participate. Twenty responses were removed because the participant acknowledged not currently practicing in the high school setting. Another 98 participants started the survey but did not complete it, and an additional 44 participants had other missing data. Therefore, a total of 168 participants were removed from the dataset, resulting in an analytic dataset of 403 participants. The average age of our sample was 35.7 ± 11.2 years, and the sample was mostly female (n = 265, 65.8%), White (n = 347. 86.1%), married (n = 205, 50.9%), and childless (n = 260, 64.5%). All NATA districts were represented in the sample, with District 4 (n = 76, 18.9%) and District 5 (n = 19, 4.7%) having the greatest and least representation, respectively. Participants in our sample had acquired 12.4 ± 10.2 years of experience as an AT. They worked a median of 45 (IQR = 15) hours per week in the fall and 40 (IQR = 14) hours per week in the spring. Approximately 47% (n = 188) of the sample earned between $40 000 and $60 000 annually, with 25.1% (n = 101) earning less and 28.3% (n = 114) earning more. Additional demographic information pertaining to our sample can be found in Table 1.

Table 1 Demographics of the Sample (N = 403)

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Data pertaining to medical errors in our sample are also available in Table 1. Approximately 18.4% reported a self-perceived medical error in the last 30 days. Among those who reported a medical error, the number of errors committed ranged from 1 to 7.

A summary of scores on each of the MBI subscales is presented in Table 2. Subscale scores were grouped as low, medium, or high burnout based on previous AT burnout research.²¹ Emotional exhaustion scores ≥27, depersonalization scores ≥10, and personal accomplishment scores ≤33 were labeled as high burnout. The scores of nearly 29% (n = 116) of our sample were categorized as high emotional exhaustion, 23.1% (n = 93) each as high depersonalization and low personal accomplishment.

Table 2 Participant Scores on Survey Scales (N = 403)

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Regression Analyses

A logistic regression model was performed to examine the association between emotional exhaustion, personal accomplishment, and commission of medical errors. In this model, medical error was a dichotomous variable (yes or no). This model suggested that emotional exhaustion (odds ratio [OR] = 1.02; 95% CI = 1.00, 1.05; P = .037) and decreased personal accomplishment (OR = 1.06; 95% CI = 1.02, 1.10; P = .003) were both directly associated with commission of medical errors (Table 3). Each 1-point increase in emotional exhaustion increased the odds of a self-reported medical error by 2%. Similarly, each 1-point decrease in personal accomplishment increased the odds of a self-reported medical error by 2%.

Table 3 Logistic Regression Model Examining the Association Between Personal Accomplishment, Emotional Exhaustion, and Having Made a Medical Error in the Past 30 Days (N = 403)

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We then created a Poisson regression model to examine the relationship between emotional exhaustion, personal accomplishment, and number of medical errors committed in the subgroup of participants who admitted to at least 1 medical error in the last 30 days (n = 74). Although emotional exhaustion (B = 0.02; 95% CI = 0.01, 0.03; P = .002) had a significant direct association with the number of errors committed, personal accomplishment (B = .005; 95% CI = −0.02, 0.03; P = .66) was not significantly associated (Table 4).

Table 4 Poisson Regression Model Examining the Association Between Personal Accomplishment, Emotional Exhaustion, and No. of Medical Errors in the Past 30 Days Among Those Who Made a Medical Error (N = 74)

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DISCUSSION

The purpose of our study was to examine the commission of medical errors in secondary school ATs and then determine if a relationship existed between medical errors and burnout. Approximately 18.4% of our sample admitted to committing at least 1 medical error in the last 30 days. This percentage was higher than that in a recent study⁴ of physicians, in which investigators found that 10.5% of their sample reported committing an error in the previous 3 months. However, this percentage was lower than in research⁷ on nurses, among whom 30% described committing an error in the previous month. Commission of medical errors in our sample also occurred at a lower rate than seen in several longitudinal cohorts of resident physicians: 34%⁵ and 39%⁶ of the samples committed at least 1 medical error during the course of the study. Note that those cohorts were followed for a much longer period and the statistics accounted for any participant who reported at least 1 medical error throughout the study, whereas we asked participants to only recall any errors committed in the last 30 days. In one of the physician studies,⁵ the authors noted 14.7% of participants described at least 1 medical error at each 3-month follow-up. These different time frames may explain the variance in the commission of errors. Moreover, participants in those samples were limited to resident physicians who were early in their careers; our sample was not limited based on years of experience. We did not find a correlation between the commission of errors and years of experience.

A direct relationship was present between emotional exhaustion and the likelihood of having committed a medical error in the last 30 days. The model also revealed a direct relationship between decreased personal accomplishment and the likelihood of having committed a medical error. Although previous researchers^12,23 observed correlations between burnout and variables that affect the wellbeing of ATs, this is one of the first published studies to directly address the correlation between burnout and quality of work in ATs. These results are in agreement with earlier literature on physicians⁴ and interns and residents,¹⁸ which also demonstrated a relationship between depersonalization and the commission of medical errors. However, the Smith Cognitive-Affective Model of Athletic Burnout¹⁶ would suggest that depersonalization and the commission of medical errors are both behavioral manifestations brought forth by cognitive appraisal (perceived personal accomplishment) and physiological response (emotional exhaustion). Therefore, we determined that an analysis of the relationship between these 2 variables in our sample was unnecessary.

A direct relationship was evident between emotional exhaustion and the number of medical errors committed by ATs who had committed at least 1 error in the last 30 days. In other words, as emotional exhaustion increased, the number of medical errors committed by an individual tended to increase as well. These findings agree with those in the existing literature.^24,25 Still, perhaps more interesting was that although personal accomplishment was significantly associated with the odds of committing a medical error in our sample, it was not significantly associated with the number of errors committed. Our results support the logic that a more exhausted individual is prone to more mistakes. Thus, decreasing emotional exhaustion in our health care workforce is a potentially valuable method of decreasing the number of medical errors committed.

Our findings endorse the notion that burnout negatively affects not only ATs but also the patients those professionals interact with on a daily basis. In a recent study of physicians,⁴ the investigators stated that interventions that reduce burnout and improve clinician wellbeing must be introduced to improve patient outcomes through the reduction of medical errors. We believe this approach should be adopted by ATs as well.

CONCLUSIONS

We found a direct association between burnout, commission of medical errors, and the number of errors committed in secondary school ATs. These results imply a correlation between burnout and the quality of health care delivered by ATs. In addition, these findings suggest that burnout affects not only ATs but also the patients they interact with on a daily basis. Because burnout may affect the wellbeing of both the clinician and patient, more efforts are needed to diminish burnout in ATs, both in the secondary school setting and elsewhere.