Complexity of Care is Tied to Environmental Stressors and Emotional Exhaustion

CNS studies factors that affect how nurses manage work

In May, Deborah Solomon, MSN, RN, ACNS-BC, a clinical nurse specialist at Cleveland Clinic, published findings of her latest research on complexity of nursing care in the journal Applied Nursing Research. It was the culmination of more than six years of work and two studies aimed at understanding the complexity of care patterns experienced by nurses working in clinical hospital environments.

Advertising Policy

Cleveland Clinic is a non-profit academic medical center. Advertising on our site helps support our mission. We do not endorse non-Cleveland Clinic products or services Policy

“I have been a nurse for more than 30 years and have always felt there’s a lot to this role that I just can’t put my finger on,” says Solomon. “There’s so much involved in nursing, and I wanted to get a better grasp of it.”

Examining Environmental Stressors


Deborah Solomon, MSN, RN, ACNS-BC

In 2010, Solomon and her co-investigators conducted a pilot study of 21 nurses on a medical-surgical unit at Cleveland Clinic to examine the impact of environmental stressors on complexity of care. They defined complexity of care as difficulties nurses experienced managing their work. “We looked at two different components of complexity of care – difficulties of the work itself (work complexity), and difficulties with mental work that underlies decisions (cognitive complexity),” says Solomon.

In the original pilot study, four environmental factors were experienced by more than 25 percent of nurses and were associated with work complexity of care:

Advertising Policy
  • Coordinating tasks to complete work on time
  • Multiple stimuli affecting concentration
  • Lack of space for work
  • Multiple interruptions

“We wanted to build on the original study findings to learn if environmental stressors were associated with the nursing role complexity in a larger, more diverse sample,” says Solomon. “We also wanted to learn if emotional exhaustion was associated with work and cognitive complexity.”

Adding in Emotional Exhaustion

The multicenter study, conducted in 2013, used a prospective, correlational, cross-sectional design and valid questionnaires to answer research questions. Solomon and her team recruited 281 nurses at six hospitals across the Cleveland Clinic health system. More than half had worked as a nurse for less than 10 years, and most had worked on the same unit for more than two years. Unit types varied and included intensive care, telemetry and medical-surgical units.

Nurses completed three questionnaires. The first was a 48-item investigator-developed scale, Exploring the Complexity of Nurses’ Role, which was designed to reflect work complexity in the three-hour period before completing the questionnaire. The second was a 9-item subscale of Maslach’s Burnout Inventory to assess emotional exhaustion. The final questionnaire was an investigator-developed 12-item tool to measure environmental stressors. In addition, Solomon collected data on nurse and work characteristics, such as age, gender, nursing degree and work setting.

Findings and Implications

One cognitive complexity factor – nurses using goals to guide care – was significant in predicting emotional exhaustion after controlling for nurse characteristics and environmental stressors. Every one unit increase in complexity related to care guided by goals was associated with a 3 percent increase in the odds of having a high emotional exhaustion score.

Advertising Policy

Further, three environmental stressors occurred with greater than 50 percent frequency in the three hours of work that nurses were asked to reflect on when responding to questions – multiple stimuli that affect concentration, coordinating tasks to complete work and multiple interruptions. “For every added stressor, there was a 34 percent increase in the odds of high emotional exhaustion,” says Solomon.

One important implication of the findings is the need for teamwork among nurses. “When nurses function as a team, they may lessen their cognitive load and reduce complexity of care,” says Solomon. “It will be important to conduct new research to learn if interventions that foster teamwork to reduce cognitive complexity and environmental stressors reduce emotional stress.”