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This course provides an overview of burnout, including the evolution of its definition, its causes, related symptoms, identification, and measurement. The effects of burnout are broad, with consequences not only for the individual personally and professionally but also for patient care and healthcare systems; these implications will be explored. Among the most significant implications is the nursing shortage and a subsequent decrease in the quality of patient care. A review of the literature provides insights into the primary sources of job dissatisfaction, stress, and burnout among healthcare professionals and nurses in particular. Knowledge of the most common risk factors for burnout can help individuals modify their personal and professional lifestyles more effectively. Suggestions are given for ways organizations and nursing leadership can create a healthy work environment in which priority is given to nurses' psychosocial well-being and to fostering supportive relationships. While these strategies are aimed at creating a better work environment for nurses, they also ultimately promote better care and safety of patients.
Education Category Management
Release Date 04/01/2012
Expiration Date 03/31/2015
This course is designed for nurses and nurse practitioners at all levels and in all settings, especially oncology, palliative care, mental health, and critical care.
NetCE is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center's Commission on Accreditation.
NetCE designates this continuing education activity for 5 ANCC contact hour(s). NetCE designates this continuing education activity for 6 hours for Alabama nurses. AACN Synergy CERP Category C.
In addition to states that accept ANCC, NetCE is approved as a provider of continuing education in nursing by: Alabama, Provider #ABNP0353, (valid through December 12, 2017); California, BRN Provider #CEP9784; California, LVN Provider #V10662; California, PT Provider #V10842; Florida, Provider #50-2405; Iowa, Provider #295; Kentucky, Provider #7-0054 through 12/31/2017.
Given the integral relationship between job dissatisfaction, stress, burnout, and patient care, properly addressing nursing burnout is essential. The purpose of this course is to allow nurses to identify burnout and to provide them with effective strategies to avoid it.
Upon completion of this course, you should be able to:
Lori L. Alexander, MTPW, ELS, is President of Editorial Rx, Inc., which provides medical writing and editing services on a wide variety of clinical topics and in a range of media. A medical writer and editor for nearly 30 years, Ms. Alexander has written for both professional and lay audiences, with a focus on continuing education materials, medical meeting coverage, peer-review articles and guidelines for healthcare professionals, and educational materials for patients. She is the Editor Emeritus of the American Medical Writers Association (AMWA) Journal, the peer-review journal representing the largest association of medical communicators in the United States. Ms. Alexander earned a Master’s degree in professional and technical writing, with a concentration in medical writing, at Northeastern University, Boston, has completed the AMWA core and advanced curriculum programs, and is certified by the Board of Editors in the Life Sciences.
Contributing faculty, Lori L. Alexander, MTPW, ELS, has disclosed no relevant financial relationship with any product manufacturer or service provider mentioned.
The division planner has disclosed no relevant financial relationship with any product manufacturer or service provider mentioned.
The purpose of NetCE is to provide challenging curricula to assist healthcare professionals to raise their levels of expertise while fulfilling their continuing education requirements, thereby improving the quality of healthcare.
Our contributing faculty members have taken care to ensure that the information and recommendations are accurate and compatible with the standards generally accepted at the time of publication. The publisher disclaims any liability, loss or damage incurred as a consequence, directly or indirectly, of the use and application of any of the contents. Participants are cautioned about the potential risk of using limited knowledge when integrating new techniques into practice.
It is the policy of NetCE not to accept commercial support. Furthermore, commercial interests are prohibited from distributing or providing access to this activity to learners.
Table of Contents
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Work is a significant source of stress in all occupations; a nationwide poll by the American Psychological Association (APA) showed that approximately 75% of Americans experienced substantial stress at work and nearly half noted that their work productivity decreased because of the stress . High costs are associated with work-related stress, in terms of absenteeism, decreased productivity, and employee turnover, as are a wide variety of physical conditions, from headaches and insomnia to cardiovascular and immune diseases . Work-related stress that is left unaddressed has the potential to develop into burnout over a long period of time. The costs of burnout are even higher than stress and affect not only the well-being of the individual but that of the individual's family, friends, and colleagues. Burnout has been more prevalent in the so-called helping professions, and high levels of burnout have been documented in the healthcare professions, especially nursing.
This course provides an overview of burnout, addressing development, identifying characteristics, and measurement. The characteristics of burnout unique to the healthcare professions are outlined, with a specific focus on burnout in nursing. Nurses are especially vulnerable to the syndrome, and this is of particular concern for several reasons . First, nurses represent the largest faction of healthcare professionals, with more than 2.6 million nurses in the United States, and they are the frontline for direct patient care in hospitals . Second, job dissatisfaction and subsequent burnout have been strongly linked to nursing turnover, which has led to the nursing shortage that began in the late 1990s . This shortage remains ongoing, and estimates for the shortage by the year 2020 range from 340,000 to 1 million . Third, and most important, the inadequate nursing staffing levels caused by excessive turnover have been significantly associated with nursing errors and poorer patient outcomes [7,8,9,10,11]. Thus, enhancing job satisfaction and avoiding burnout is crucial to maintaining an adequate population of nurses, and an adequate population of nurses is vital to maintaining high-quality patient care. After a discussion of the primary sources of work-related stress and burnout among nurses, several strategies for preventing burnout at the individual and organizational level are presented.
The term "burnout" originated in the 1940s as a word to describe the point at which a jet or rocket engine stops operating . The word was first applied to humans in the 1970s by the psychiatrist Herbert Freudenberger, who used the term to describe the status of overworked volunteers in free mental health clinics . He compared the loss of idealism in these volunteers to a building—once a vital structure—that had burned out, and he defined burnout as the "progressive loss of idealism, energy, and purpose experienced by people in the helping professions as a result of the condition of their work" .
The term burnout is used (perhaps overused) by many, and definitions have varied since the time the word was first applied to humans. The term has been used to describe a mild degree of unhappiness caused by stress, as well as any degree of distress, from fatigue to major depression . In the early 1980s, social psychologist Christina Maslach began to explore the loss of emotional feeling and concern for clients among human services professionals. Since then, she has researched burnout extensively, becoming the leading authority on the topic and the author of the gold-standard tool to assess burnout, the Maslach Burnout Inventory [15,16].
Maslach emphasizes that burnout is not a problem related to an individual . Instead, her research indicates that burnout is a problem of the social environment in which people work and is a function of how people within that environment interact with one another and perform their jobs . She notes that burnout is more likely when there is a "major mismatch between the nature of the job and the nature of the person who does the job" . These mismatches are at the core of the development of burnout. The term burnout is now usually limited to mean burnout as described by Maslach: a syndrome of emotional exhaustion, depersonalization, and reduced personal accomplishment .
Burnout can occur in any setting, and it has been studied most extensively in a wide range of occupations within the human services field, from healthcare professionals to teachers, police, and prison workers [3,18]. High levels of burnout among healthcare professionals have been well-documented.
In general, when an individual first enters a chosen career, he or she is motivated. If the work environment is not supportive of the individual's efforts and concerns, the reality of the job and the individual's expectations begin to diverge and frustration and disappointment arise [3,19]. These feelings can lead to job dissatisfaction, resulting in decreased productivity, loss of confidence and enthusiasm, and behavior changes . If the situation is not addressed, stress accumulates and causes typical stress-related symptoms. These physical symptoms, when coupled with emotional emptiness, signify the first stage of burnout: mental and physical exhaustion . Left untreated, burnout will continue through four more stages: indifference, feelings of failure as a professional, feelings of failure as a person, and feeling of emotional numbness (being "dead inside") (Figure 1) .
The specific stressors within the work environment that lead to stress and subsequent burnout vary among occupations and among individuals within a single occupation. The root of burnout is in the work environment, but because not all individuals working in a single environment will experience burnout, personal risk factors must have a role in making an individual vulnerable. These personal risk factors include demographic variables and personality traits (Table 1).
POTENTIAL RISK FACTORS FOR BURNOUT
Burnout is more likely when an individual's experience (actual or perceived) does not match one or more situational factors in a work environment . Among the mismatches that most commonly lead to burnout in any work environment are :
Work overload: Limitations in terms of staff, time, and other resources
Lack of control: Unable to perform job functions the way an individual believes is the "right" way
Insufficient reward: Absence of acknowledgment of an individual's contributions in the work environment and lack of opportunities to advance
Absence of community: Poor working relationships, absence of adequate supervisory or peer support, poor leadership style
Lack of fairness: Inequality in workload, salary, or other signs of professional respect
Conflict in values: Disagreement between job requirements and an individual's personal principles
Demographic variables have been studied in relation to burnout, and several have been found to influence the risk of burnout, alone or in combination, including :
Burnout is less prevalent among older individuals because they tend to be more stable and have a more balanced perspective on life . In addition, the increased rate of burnout among younger individuals is a function of a "survival of the fittest" concept. Burnout usually occurs early in one's career (in the first 1 to 5 years), and many young, burned out individuals leave the profession; as a result, the remaining individuals in an occupation are the "survivors" .
Comparing burnout across racial/ethnic groups is difficult, as most studies have not involved sufficient numbers of minority workers. What has been determined is that the rates of burnout among Asian workers have been similar to those among white workers, whereas the rates among black workers have been lower . Black workers also experience emotional exhaustion and depersonalization at lower levels of intensity. This difference may be related to a greater emphasis on family and social networks in the black community .
Family status also seems to play an important role in burnout; rates of burnout are higher among single workers and workers with no children than among married workers and those with children . The emotional resources provided by a family are thought to be the reason for this difference.
Educational status seems to have an effect, with higher levels of burnout among workers with higher levels of education . This difference could be the result of the expectations associated with advanced education and job choices .
Levels of burnout have been somewhat consistent among men and women; however, there are gender differences with respect to other demographic variables . For example, a survey of 3,424 employees indicated that a low educational level and low social status increased the risk of burnout for women, whereas marital status (single, divorced, or widowed) increased the risk for men .
Studies have also been done to explore relationships between personality traits and the risk of burnout. Maslach noted that characteristics such as low self-esteem or lack of confidence, failure to recognize personal limits, need for approval, drive to overachieve, need for autonomy, impatience, intolerance, and empathy increased susceptibility to burnout . Others have postulated that extreme conscientiousness, perfectionism, and self-giving (selflessness) also increase susceptibility, as does a type D personality (a joint tendency for negative emotions and social inhibition) [22,23,24]. Hardiness (resiliency) has also been studied as a risk factor for burnout. Although a lack of hardiness is usually (but not always) a predictor of burnout, greater hardiness does not prevent high stress levels from leading to high levels of burnout; coping style also influences the effect [25,26,27,28].
Many of the personal risk factors described here are common among healthcare professionals; in fact, several are essential for success in the healthcare field. This may explain, in part, the high levels of burnout in the healthcare setting.
Identifying the signs of stress and burnout is important to preserve the overall health and well-being of individuals. Burnout is associated with many signs and symptoms. For accurate identification, care should be taken to distinguish burnout from other conditions, such as stress, prolonged fatigue, compassion fatigue, and depression(Table 2).
DISTINCTION BETWEEN BURNOUT AND CLINICAL ENTITIES WITH SIMILAR PRESENTATION
|Other Clinical Entity||Burnout|
Result of prolonged stress
Associated with job-related factors
Related to specific factors in the work setting
Stress can cause many of the same physical, psychologic, and interpersonal/social symptoms as burnout. However, stress is distinct from burnout in that it is usually precipitated by isolated or situational instances, whereas burnout is the result of prolonged stress [3,29]. Prolonged fatigue is distinct from burnout-related fatigue, primarily because of the precipitating factor; fatigue is usually associated with health-related causes, whereas burnout is caused by job-related factors . Prolonged fatigue may occur simultaneously with burnout, and in general, overall health and psychologic distress are worse for individuals who have concurrent prolonged fatigue and burnout .
Compassion fatigue is another term used to describe the emotional exhaustion related to caregiving [31,32,33]. Compassion fatigue is usually a reaction to an immediate or specific situation, whereas burnout develops over a longer period of time . Also, an individual with compassion fatigue can still care and be involved; an individual with burnout becomes uncaring and distant [34,35].
Depression and burnout may have a similar clinical presentation, and signs of depression can be associated with burnout. However, depression is related to factors within every domain of an individual's life and is not limited to specific factors in the work setting [22,36,37]. Depression is more likely among individuals who have had a recent loss or a personal or family history of depression, but burnout is more likely if symptoms are worse in the work environment and if the individual works long hours and has no time for outside interests . Differences in symptoms can help distinguish depression from burnout (Table 3) [22,37].
SYMPTOMS DISTINGUISHING DEPRESSION FROM BURNOUT
|Inability to find pleasure in once pleasurable activities||Ability to enjoy nonwork activities|
|Anger directed internally||Anger directed externally|
|Unrealistic feelings of guilt||No (or realistic) guilt|
|Significantly ambivalent||Somewhat ambivalent|
|More dependent||More independent|
|Avoids conflicts||Interpersonal conflicts increase|
|Overeating, undereating||Appetite unaffected|
|Wake up early||Difficulty falling asleep|
The most important distinction between burnout and all of these entities is that only burnout is characterized by the collective features of emotional exhaustion, depersonalization, and lack of accomplishment, as measured on the Maslach Burnout Inventory.
The signs and symptoms associated with stress and burnout are multidimensional, with somatic, psychologic/psychiatric, and interpersonal/social manifestations [1,18]. As such, a multidisciplinary approach should be taken not only to confirm the presence of stress and/or burnout but also to rule out other illnesses or conditions. In addition to the traditional medical history and physical examination, a social and occupational history should be obtained in an effort to identify potential stress factors and possible social consequences . An evaluation of the type, course, and frequency of symptoms can help distinguish them as signs of stress or burnout, and a drug history can help to identify potential substance abuse problems. The signs and symptoms of burnout discussed here are similar across work settings. Burnout among healthcare workers is associated with these characteristics as well as some unique features, which will be described later.
Stress has been linked to many somatic conditions of varying degrees of severity. The APA has estimated that approximately 75% of the American population has experienced stress-related physical symptoms . Stress has been found to significantly contribute to several diseases and conditions, such as cardiovascular disease, hypertension, gastrointestinal disorders, musculoskeletal symptoms, respiratory illness, immune diseases, headache, insomnia, changes in appetite, and accidental injuries [1,2,3,18]. The most common stress-related physical symptom is fatigue; in a survey of burnout among 600 American workers, "exhaustion" was reported by 62% of those who said they felt stressed and burned out by work .
Studies have shown that job stress (specifically, high psychologic demands and low level of decision making) has a significant effect on ambulatory blood pressure and left ventricular mass index, which provides a partial explanation for the link between stress and heart disease . The findings of large-scale studies further support stress as a risk factor for cardiovascular disease. Evaluation of more than 10,000 civil servants in London demonstrated that work-related stress was an important contributor to coronary heart disease through direct effects on the neuroendocrine stress pathways and indirect effects on health behaviors [39,40]. In fact, researchers found that nearly one-third of the effect of work-related stress was attributable to health behaviors, especially a low level of physical activity, poor diet, and metabolic syndrome .
Stress and burnout are also associated with a range of psychologic symptoms. Anger and depression are the most common psychologic manifestations; among stressed and burned out workers, anger was reported by 62% and depression by approximately 33% . Individuals who say they are depressed warrant careful evaluation to ensure that the depression is part of the burnout syndrome and not a distinct clinical entity. Several other psychologic effects have also been associated with stress and burnout (Table 4) [1,2,3]. Substance abuse is of concern, as a study of 3,276 Finnish employees demonstrating increases in alcohol dependence of 51% in men and 80% in women for each 1-point increase in burnout score .
MANIFESTATIONS OF STRESS AND BURNOUT
Interpersonal and social relationships may also be compromised by burnout. Individuals experiencing burnout may have a difficult time communicating with others in the work environment as well as with friends and family and may create emotional distance . The cynicism that is characteristic of the syndrome may lead individuals to treat co-workers with suspicion and to have critical attitudes toward them . Other effects include marital conflict and divorce, neglect of family and social obligations, and questioning of previously held spiritual beliefs [3,42].
As noted, the most widely used instrument to measure burnout is the Maslach Burnout Inventory, a self-assessment tool first published in 1981 by Maslach and Jackson . The Maslach Burnout Inventory was originally developed for the human services industry, and since then, two additional versions have been developed—a general survey and an educator-specific survey . The tool has been shown to be reliable, valid, and easy to administer and has been translated into several languages for use around the world. The Maslach Burnout Inventory is often used in conjunction with other assessments to evaluate the relationship between burnout and organizational policies, productivity, and social support .
The Maslach Burnout Inventory addresses the three defining aspects of burnout syndrome with 22 statements in three subscales :
Emotional exhaustion: Nine statements to measure feelings of being emotionally overextended and exhausted by one's work
Depersonalization: Five statements to measure an unfeeling and impersonal response to the recipients of one's services, care treatment, or instruction
Personal accomplishment: Eight statements to measure feelings of competence and successful achievement in one's work
Each statement in the Maslach Burnout Inventory expresses a particular feeling or attitude; for example, one statement in the depersonalization subscale is "I've become more callous toward people since I took this job" . For each statement, the respondent indicates how frequently he or she experiences that feeling by using a fully anchored scale ranging from 0 (never) to 6 (every day). Higher scores on the emotional exhaustion and depersonalization subscales indicate higher degrees of burnout. A lower score on the personal accomplishment subscale corresponds to a lower degree of burnout. A separate score is determined for each subscale, and a scoring key provides threshold scores to indicate a low, average, or high degree of burnout on each subscale.
The use of psychologic assessment tools in conjunction with the Maslach Burnout Inventory can help professionals gain a better understanding of the sources of stress for individuals. The General Health Questionnaire, developed by Goldberg, is designed to measure common mental health problems (domains of depression, anxiety, somatic symptoms, and social withdrawal) and was developed as a measure to identify individuals who are likely to have or be at risk for the development of psychiatric disorders [43,44]. The General Health Questionnaire is frequently used in conjunction with the Maslach Burnout Inventory to evaluate psychologic morbidity and burnout, as the pathways to both are related .
The General Health Questionnaire has been translated into several languages and is available in a variety of versions, with a range of 12 to 60 items; the version with 28 items (GHQ-28) has been used most often in workplace settings . A score of 0 to 3 is assigned to four possible responses ("not at all," "no more than usual," "rather more than usual," and "much more than usual") to such questions as:
Have you found everything getting on top of you?
Have you been getting scared or panicky for no good reason?
Have you been getting edgy and bad tempered?
Another exercise, the Burnout Risk Survey, was developed by John Henry Pfifferling, the director of the Center for Professional Well-Being, who has extensively studied stress in healthcare professionals (Table 5) . This tool is designed to demonstrate the probability of mismatches between an individual and his or her work environment. A "yes" response to three or more of these items indicates a risk of burnout and a "yes" response to four or more items indicates high risk.
BURNOUT RISK SURVEY
Are your achievements your self-esteem?
Do you tend to withdraw from offers of support?
Will you ask for/accept help?
Do you often make excuses, like, "It's faster to do it myself than to show or tell someone?"
Do you always prefer to work alone?
Do you have a close confidant with whom you feel safe discussing problems?
Do you "externalize" blame? (Obsessively seek to place blame away from yourself)
Are your work relationships asymmetrical? Are you always giving?
Is your personal identity bound up with your work role or professional identity?
Do you value commitments to yourself to exercise/relax as much as you value those you make to others?
Do you often overload yourself—have a difficult time saying "no?"
Do you have few opportunities for positive and timely feedback outside of your work role?
Do you abide by the "laws:" "Don't talk, don't trust, don't feel?"
Do you easily feel frustrated, sad, or angry from your regular work tasks?
Is it hard for you to easily establish warmth with your peers and/or service (patients/clients) recipients?
Do you feel guilty when you "play" or rest?
Do you get almost all of your needs met by helping others?
Do you put other's needs before or above your own needs?
Do you often put aside your own needs when someone else needs help?
Healthcare professionals are trained to put the needs of others before themselves and spend each working day exposed to the emotional strain of dealing with people who are sick or dying and who have extreme physical and/or emotional needs. This emotional strain, coupled with other stress factors inherent in the healthcare work environment, renders healthcare professionals especially vulnerable to burnout .
Burnout has been studied in populations of all types of healthcare professionals around the world, including allied healthcare professionals, medical residents and fellows, and dentists [47,48,49,50,51,52,53]. The rates of burnout vary among these subgroups, but in general, the rates are higher among healthcare professionals than among individuals in nonhelping occupations. Burnout has been studied most extensively in physicians and nurses.
The reported prevalence of burnout among physicians has varied widely. In a review of several small studies, Chopra et al. found that 46% to 80% of physicians had moderate-to-high scores for emotional exhaustion on the Maslach Burnout Inventory, 22% to 93% had moderate-to-high scores for depersonalization, and 16% to 79% had low-to-moderate scores for personal achievement . The findings of studies published after that review have confirmed high levels of burnout among physicians [55,56,57]. Moderate-to-high levels of burnout have been documented across all physician specialties. The specialties at highest risk for burnout have been emergency medicine, critical care, and oncology [55,56,58,59,60,61,62,63].
The job-related factors contributing to burnout among physicians are similar to those in non-healthcare settings. Across studies, work overload, lack of work/life balance, and lack of control over one's work have been the most commonly reported causes of stress and burnout, leading to emotional exhaustion, sense of failure, depression, and lack of satisfaction with one's work. Physicians are also challenged by many stressors unique to the practice of medicine. In the U.S. Physician Worklife Study, which involved responses from 2,326 physicians, the predictors of stress included demands of solo practice, complex patients, long hours, lack of support from colleagues or family for work demands, pace of work, interruptions, and isolation . Similar results were found in a study of nearly 900 physicians of different specialties in the United Kingdom . In that study, the three primary sources of stress were work overload (and its effect on personal life), feeling poorly managed with limited resources, and dealing with patients' suffering . A Canadian study of more than 2,500 physicians found that both work demands and value conflicts contributed to job dissatisfaction and burnout .
Age and gender have been found to be factors in burnout among physicians. Burnout has been reported to be more prevalent among physicians younger than 55 years of age [60,61]. The U.S. Physician Worklife Study showed that female physicians were approximately 1.6 times more likely than male physicians to report burnout, and the odds for burnout increased with the amount of time worked .
The rates of stress and burnout among nurses have been found to be higher than the rates among other healthcare professionals, with approximately 40% of hospital nurses having burnout levels that are higher than the norm for healthcare workers . Many studies have indicated that the prevalence of burnout is higher among nurses who work in especially stressful settings, such as oncology, mental health, emergency medicine, and critical care [35,68,69,70,71,72]. However, an early study found no difference in burnout rates for nurses in acquired immunodeficiency syndrome (AIDS) units, oncology units, intensive care units, and general medical-surgical units .
Several factors unique to nurses' work environments add to their vulnerability for burnout. First, nurses spend an increasing number of hours each day involved in patient care, especially with the advent of extended shifts and overtime [3,74,75,76]. These long hours spent engaged in a high number of interpersonal relationships and subjected to high physical and emotional demands leave nurses fatigued, with insufficient energy to cope with stress effectively [77,78]. Second, changes in healthcare delivery have created feelings of disillusionment and uncertainty among nurses [3,79,80]. Third, nurses have made efforts to overcome the traditional domination of physicians, and nurse-physician relationships have been documented as a common source of stress for nurses [81,82,83,84].
Given that stress and burnout are direct consequences of job dissatisfaction, an understanding of the prevalence and causes of job dissatisfaction among nurses can help to define the sources of stress and burnout. According to the 2008 National Sample Survey of Registered Nurses, the rates of moderate or extreme job satisfaction were lowest for staff nurses (79%), patient coordinators (82%), and nursing managers/administrators (83%); the highest rates were found for certified nurse anesthetists (94%), midwives (93%), and clinical nurse specialists and educators (90%) . These rates of job satisfaction are much higher than those reported in earlier studies .
Studies have indicated that among nurses, factors within the work environment are greater predictors of job dissatisfaction than factors related directly to the care of patients [8,74,67,84]. In addition, work environment factors are more predictive of stress and burnout than demographic factors [8,67,85]. As Maslach indicated, age influences the risk of burnout, and studies have shown that burnout is usually more prevalent among nurses younger than 30 years of age [67,86]. However, more recent data indicate an increase in dissatisfaction among older nurses. In the 2008 survey of registered nurses, moderate dissatisfaction was high among nurses younger than 25, but the rate of moderate or extreme dissatisfaction was the highest for nurses 40 to 44 (12%) and 45 to 49 (13%). The highest rate of extreme dissatisfaction (only) was found for nurses 55 to 59 and 45 to 49 (approximately 3% each) .
Nurses' job dissatisfaction varies according to setting and position. The highest rates of job dissatisfaction have been reported among nurses in nursing homes (17%) and hospitals (12%) . The rate of job dissatisfaction among hospital nurses has been estimated to be four times greater than the average for all workers in the United States . Because the majority (62%) of nurses work in a hospital setting, most on a medical-surgical unit, that population is the focus of this course .
Numerous surveys and studies have indicated several primary sources of job dissatisfaction among nurses: staffing inadequacy and schedule, lack of involvement in decision making, lack of support from nursing leadership and administration, interpersonal conflict (interactions with physicians and peers), and inadequate pay. These sources of dissatisfactions can be correlated with four of the mismatches identified by Maslach, namely, work overload, lack of control, insufficient reward, and absence of community (Table 6) . An additional factor that should be considered is the emotional demands of nursing.
CORRELATION OF SOURCES OF DISSATISFACTION AND AREAS OF MISMATCH
|Area of Mismatch||Dissatisfaction||Specific Factors|
|Work overload||Inadequate staffing||
|Lack of control||Lack of involvement in decision making||
|Insufficient reward||Lack of recognition||
|Absence of community||
By far the most common source of stress and burnout among nurses is work overload brought on by inadequate staffing [67,84,87,88]. According to a 2008 survey of more than 10,000 nurses across the United States, 73% of respondents said that the staffing on their unit and shift was insufficient . Sixty percent of respondents said that they knew someone who had left direct-care nursing because of concerns about safe staffing, and 54% of respondents said that they themselves were considering leaving their current position; 43% of these latter respondents cited inadequate staffing as the reason . Work overload creates a stressful work environment, which has been noted to be a reason for leaving the nursing profession (along with burnout and poor management) by 41% of nurses younger than 50 and approximately 36% of nurses 50 and older . In studies in which the Maslach Burnout Inventory has been used to measure burnout, inadequate staffing has correlated with a high score on the emotional exhaustion subscale [8,81,94]. A study of 820 nurses from 20 urban hospitals demonstrated that a poor work environment (with insufficient staffing as one criterion) was associated with a two to three times greater likelihood of high scores on the emotional exhaustion and depersonalization subscales of the Maslach Burnout Inventory . In a much larger study (more than 10,000 nurses), the rate of burnout increased 23% for every additional patient per nurse .
Increased workload is related to other factors besides actual patient volume, including extended shifts, overtime (often mandatory), many consecutive days of work, rotating shifts, weekend work, and on-call requirements. The number of nurses who work 12-hour shifts and/or work overtime has increased; approximately 25% to 56% of nurses work 12 hours or more per day [75,76,89]. One-third of 2,273 nurses surveyed said they worked more than 40 hours per week, and more than one-third said they had worked 6 or more days in a row at least once in the preceding 6 months . Long hours and scheduling factors have serious consequences. For example, high levels of fatigue related to long hours have been associated with increased risk of errors [79,90,91].
Increased levels of patient acuity also contribute to workload, and advances in treatment have led to nursing care that is often demanding and challenging. This high level of care, coupled with shorter stays as a result of changes in the healthcare system and the nursing shortage, result in nursing workloads that are not balanced across various levels of care within the patient population [3,81].
A sense of control, or autonomy, is important to nurses, and job satisfaction is greater when nurses, especially younger ones, feel as if they have some control over how they perform their job [92,93]. However, this sense of control appears to be lacking for many nurses. In a large survey, 40% of nurses said they felt powerless to effect change necessary for safe, high-quality patient care, and in a study of more than 1,200 nurses in nursing home settings, one of the most stressful factors noted by nurses was nonhealth professionals determining how nurses' work should be done [86,88]. Perhaps the most telling evidence of the desire for more control is that more than one-third to one-half of nurses are dissatisfied with their level of decision making [94,95].
The risk of burnout is increased among nurses who perceive a lack of control in their work environment [3,72,88]. A sense of control varies across nursing specialties, which in part explains the range of burnout rates among specialties. For example, in a study of nurse managers, emergency department nurses, and nurse practitioners, the least amount of control was reported by emergency department nurses, who also had the highest rate of burnout; in contrast, nurse practitioners reported having the most control and the lowest rate of burnout . Greater job influence has a significant protective effect on the emotional exhaustion and enhanced personal accomplishment subscales of the Maslach Burnout Inventory .
Insufficient reward relates to several aspects, including lack of recognition of contributions, inadequate compensation (salary), and few opportunities for advancement. Being fairly rewarded and recognized for contributions is important to nurses, and those who perceive respect and recognition are more likely to be satisfied with their job and to have a lower likelihood of burnout [87,92,96,97]. However, the sense of feeling rewarded for contributions has been reported to be lower among nurses than among employees in other occupations . In a study by Aiken et al., 39% of nurses said that their contributions were publicly acknowledged . In addition, a survey indicated that 48% of nurses were very or somewhat dissatisfied with the level of recognition they receive .
Nurses' dissatisfaction with salary has varied widely, with a range of 18% to 60% [84,94,95,98]. Inadequate compensation was the deciding factor for 22% of nurses who left the profession in 2007–2008 . Despite this level of dissatisfaction with salary, nurses have fairly consistently ranked other work environment factors as being of more concern than money [94,98].
Career promotion and skill development opportunities have been associated with a decreased likelihood of burnout and greater staff morale among nurses in community health centers, yet more than two-thirds of nurses have reported that opportunities for advancement are not available to them in their job [67,96]. The lack of advancement opportunities has been implicated in high rates of burnout, and 13% of nurses leaving the profession in 2007–2008 gave this as their reason .
The nurse's community consists of peers, physicians, patients, and leadership. Positive, supportive relationships with all these constituencies have been related to job satisfaction and a decreased likelihood of stress and burnout [35,77,87]. In contrast, lack of peer cohesion, difficulties with nurse-physician interactions, and inadequate administrative and supervisor support have all been factors in high rates of burnout, especially on the emotional exhaustion and depersonalization subscales [29,80,81,99]. Ten percent of nurses who left the profession in 2007–2008 said they left because of a lack of collaboration/communication; this rate is about half the rate reported in 2004, which may indicate improvements in this area .
In a large survey of nurses, the highest level of satisfaction was given to relationships with other nurses . Still, the survey showed that one-third of nurses were dissatisfied with the interactions with their peers . Interpersonal conflict with other nurses is a stress factor in and of itself, but a lack of close working relationships deprives nurses of their colleagues as a source of support . This is important, as nurses have ranked their peers as providing the most support within the hospital community, and higher levels of support from co-workers have been related to lower levels of emotional exhaustion on the Maslach Burnout Inventory [69,100]. Although resolving conflicts can mitigate stress, the style of conflict resolution has also been a significant predictor of burnout. A study of three conflict resolution styles—avoidance, confrontational, and cooperative—showed that the avoidance and confrontational styles were associated with a higher rate of burnout, while the cooperative style was associated with a lower rate .
Nurse-physician relationships and their effect on nurses have an extensive history. Two surveys of more than 1,200 nurses, physicians, and hospital executives found that daily interactions between nurses and physicians strongly influenced nurses' morale [102,103]. Difficulties in nurse-physician relationships were perceived by most respondents in these surveys as having negative or worsening effects on stress, frustration, concentration, communication, collaboration, and information transfer between nurses and physicians [102,103]. A meta-analysis of 31 studies (14,567 nurses) demonstrated that job satisfaction correlated strongly with good nurse-physician collaboration . Conversely, 42% of nurses said they were dissatisfied with their interaction with physicians, and studies have indicated that difficulty with nurse-physician relationships is a factor in high levels of burnout [80,81,89].
Relationships with patients can also be stressful for many nurses, especially in settings that present unique challenges, such as oncology, critical care, emergency medicine, and mental health, which are also settings in which high levels of burnout have been found [35,68,69,70,71,72]. Conversations with patients about limited treatment options and end-of-life decisions can be particularly challenging for nurses, especially given that many patients and families in this setting are frustrated, sad, fearful, and/or angry [104,105]. In the mental health setting, the intensity of nurse-patient interactions and challenging patient behavior have been associated with high stress levels . Language and cultural barriers in communicating with patients are also sources of stress .
Support from nursing leaders and administration is essential for job satisfaction [87,94]. Studies have indicated, however, that most nurses do not have or perceive supportive leadership. Approximately 45% to 70% of nurses are dissatisfied with nursing management and administration because they do not listen to or address nurses' concerns or deal with nurses truthfully about decisions affecting their jobs [67,94,95,97]. Lack of administrator and supervisor support has been a factor in high rates of burnout, particularly on the subscales of emotional exhaustion and depersonalization [80,81,99].
The emotional demands of the nursing profession are well recognized. In 2002, the American Nurses Association (ANA) surveyed nurses with the question "How do you feel as you leave your job each day?" The most common responses were exhausted and discouraged (50%) and discouraged and saddened by what they could not provide for their patients (44%) . Despite these prevailing emotions, little is known about how emotional demands relate to burnout . A 2007 study represented a step forward in that area; the findings of that study indicated that how nurses handle their emotions influences the risk of burnout . Levels of emotional exhaustion on the Maslach Burnout Inventory were higher among nurses who masked their emotions or who pretended to feel "expected" emotions .
Emotional demands are greater in settings such as oncology, palliative care, and critical care, where grief and loss have been identified as a source for stress among healthcare professionals, including nurses [35,104]. The sense of loss extends beyond the loss of the relationship with the patient to identifying with the pain of the family, past unresolved loss and anticipated future loss, and loss of one's goals and expectations . Nurses in these settings may experience stress when they cannot provide adequate care at the end of life or help a patient die a "good death" [35,108]. Although death and dying were associated with high levels of emotional exhaustion among hospice nurses, the rate of burnout was low . This finding may be related to the fact that stressors within the work environment have a greater effect on the risk of burnout than the clinical status of patients or close relationships with patients' families .
The physical, psychologic, and interpersonal/social effects of stress and burnout among healthcare professionals can vary from those felt in the general workforce. Professional consequences of burnout among nurses have serious implications not only for the health and well-being of nurses but also for the health and safety of patients.
As discussed, burnout is related to the work environment, but its effects extend into the personal lives of healthcare professionals. In a survey of oncologists, 85% of respondents who reported being burned out said that the syndrome was affecting their personal and social life . In addition, the emotional demands and other stressors in the healthcare environment erode workers' emotional resources, potentially resulting in addictive behaviors (increased substance misuse), although the rates of substance misuse among healthcare professionals (and nurses specifically) are similar to the rates among the general population [109,110,111,112,113]. Increased work-related stress may precipitate substance misuse, however. The findings of an anonymous survey of 2,375 full-time nurses indicated that the recent use of drugs (for a nonmedical reason) was 1.5 times more likely among nurses with a high level of job stress than among those with a low level .
Prolonged stress-related anxiety, feelings of incompetency, and perceived lack of personal accomplishments can contribute to depression in healthcare professionals. A study of 368 nurses showed a weak but significant relationship between burnout and depression . In general, rates of depression are slightly higher among healthcare professionals than other subgroups. According to statistics from 2004–2006, healthcare practitioners had the fourth highest rate of depression (defined as a major depressive episode within the past year) among all occupational categories .
A variety of professional consequences are related to prolonged stress and burnout, and poor work performance is the ultimate result. Emotional exhaustion leads to absenteeism and decreased productivity, both of which affect work overload for other nurses and can compromise patient care. As a result, burned out individuals create distance between themselves and patients as well as colleagues (referred to as depersonalization), potentially decreasing the quality of care. Maslach described the detrimental change in a burned out individual's work performance :
Motivation is down, frustration is up, and an unsympathetic, don't-give-a damn attitude predominates. They don't take care in making their judgments, and they don't care as much about the outcome. They 'go by the book' and are stale rather than innovative and fresh. They give the bare minimum rather than giving their all, and sometimes they give nothing at all.
This decline in attitude and behavior has been associated with an increased incidence of errors in clinical care and has serious implications for the care and safety of patients .
The nursing shortage has reached crisis proportions. Demand for nurses has outstripped supply, and with the expected retirements among nurses of the baby boom generation, the nursing shortage will grow even greater in the coming years. Although the current downturn in the U.S. economy has resulted in an easing of the nursing shortage in the short term, the shortage is still projected to grow to more than 260,000 by 2025 (Figure 2) . The ongoing shortage is directly related to the high turnover among nurses as a result of burnout. The problems of burnout and the nursing shortage escalate in a cyclical manner: job dissatisfaction leads to burnout, nursing turnover, and inadequate staffing, which further increases job dissatisfaction (Figure 3). A 2008 poll of more than 10,000 nurses indicated that more than half of nurses are currently considering leaving their job. Of those considering leaving their position, nearly half stated that insufficient staffing was the reason . A study by Aiken et al. demonstrated similar findings, with 43% of surgical nurses with high levels of burnout saying that they planned to leave their job within the next 12 months; in contrast, 11% of nurses who were not burned out said that they planned to leave their jobs .
The shortage has left remaining nurses fearful of patient safety. Approximately 73% of nurses nationwide believe that staffing on their hospital unit is not sufficient to deliver high-quality care . In addition, 52% believe that the quality of care has declined over the past year, and 51% would not feel confident having someone close to them receive care in their facility . Several studies have shown that decreased staffing as a result of burnout poses a serious threat to patient safety and outcomes [8,80,116].
Two surveys of nurses found that errors in medication administration and treatments are, in many cases, perceived by nurses to be a result of the nursing shortage [7,117]. With regard to medications, 78% of the surveyed nurses in one study said they had not given a prescribed medication or had given it at the wrong time, and 69% of these nurses believed the error was somewhat or strongly related to the nursing shortage . In the other study, a 67% increase in medication errors was reported to be due to understaffing . In addition to the harm to patients, medication and treatment errors caused moral distress for 73% and 61% of the nurses involved, respectively .
The findings of studies have indicated a relationship between inadequate staffing and higher rates of other adverse events [9,10,11]. An observational study in Switzerland found that a higher staffing level was associated with a greater than 30% reduction in the risk of infection (central line-related bloodstream infection, ventilator-associated pneumonia, and urinary catheter-related infection) . The authors of the study found that infection was 68% less likely to develop in patients cared for in hospitals with higher staffing levels . Among 15,846 patients and 1,095 nurses (in 51 adult intensive care units in 31 hospitals in the United States), rates of central line-associated bloodstream infections and ventilator-associated pneumonia were significantly higher in units with lower staffing . A review of 28 studies on the relationship between nurse-to-patient ratios and outcomes demonstrated that an increase of one registered nurse per patient per day was associated with decreased odds of hospital-acquired pneumonia, unplanned extubation, respiratory failure, and cardiac arrest in intensive care units; of failure to rescue among postoperative patients; and of shorter stays in the intensive care unit and hospital .
Mortality is also influenced by nurses' patient volume. In one study, the addition of one patient per nurse was associated with a 7% increase in the likelihood of the patient dying within 30 days after admission . Analysis of pooled data has indicated that, if a causal relationship exists between patient-nurse ratios and patient outcomes (such a relationship has not been clearly established), decreasing the ratio from more than six patients per nurse to one or two patients per nurse would save an estimated 25 lives per 1,000 hospitalized patients and 15 lives per 1,000 surgical patients . In short, increasing the availability of nurses by reducing the frequency of burnout can have a substantial effect on patient safety and the quality of care.
There are two primary approaches to preventing and/or coping with work-related stress and burnout. Given that the most significant factors in stress and burnout are related to the work environment, modifying the environment to eliminate the factors has the potential for the most success. However, it is often difficult to change organizational structure, which means individuals must make changes themselves.
The primary goal in any setting is to stop the burnout cycle early by preventing the accumulation of stress. When implemented appropriately, preventing burnout is easier and more cost-effective than resolving it once it has occurred . Burnout that is addressed in later stages may take months or years to resolve fully . Thus, stress management techniques and other interventions to ensure psychosocial well-being should be a priority for both individuals and institutions/organizations, with a goal of preventing stress and managing it while in its early stages. Many of the strategies described in this course have been designed or suggested for the general population or for other subgroups within the healthcare setting (e.g., physicians). Some interventions are specifically well-suited for healthcare professionals.
Attention to personal and professional lifestyle habits is essential for individuals to prevent and manage stress effectively. Self-care, time management, and strong interpersonal relationships are key elements for maintaining physical and psychosocial well-being (Table 7). In addition, care must be taken to protect an individual's professional lifestyle. Institutions and organizations have an obligation to maintain a healthy work environment for nurses and other healthcare professionals, not only to minimize the risk of burnout but also to ensure patient safety and high-quality patient care.
STRATEGIES FOR MANAGING STRESS AND AVOIDING BURNOUT
|Strategy Classification||Specific Strategies|
The concept of self-care is one that is emphasized in every book or article on preventing job stress and burnout. Self-care needs particular emphasis for healthcare professionals, as they have been trained to put the care of others ahead of themselves. It is important for nurses to recognize that self-care is not equivalent to selfishness; rather, self-care is essential for energizing, restoring, and maintaining the physical and emotional stamina to manage stress [3,19].
Self-care involves several universal lifestyle habits, such as proper diet, exercise, rest, and regular health care [118,119]. Maintaining a healthy lifestyle is vital to avoiding the physical effects of stress [2,40]. Individuals should also seek activities that will help them disengage from their professional routine and provide enjoyment; individuals have effectively managed stress in a variety of ways, including mindful meditation, yoga, relaxation techniques, music, art, reading, writing (journaling), sports, hobbies, and volunteerism [120,121,122]. Self-reflection has been suggested as a way to remind oneself why he or she entered the healthcare profession and what feels good about the job [3,42]. Spirituality may help some individuals derive a sense of purpose or meaning in life and enhance coping skills, especially for healthcare professionals who care for dying patients [35,121].
Managing stress requires a high level of self-awareness . An individual should recognize the specific factors that cause stress and how he or she deals with it. Many informal self-assessment exercises are available to help individuals determine their own level of work-related stress. For example, a simple exercise in Controlling Stress and Tension asks individuals to describe how frequently (almost always, often, seldom, or almost never) they experience signs or symptoms associated with burnout :
How often do you…
find yourself with insufficient time to do things you really enjoy?
wish you had more support/assistance?
lack sufficient time to complete your work most effectively?
have difficulty falling asleep because you have too much on your mind?
feel people simply expect too much of you?
find yourself becoming forgetful or indecisive because you have too much on your mind?
consider yourself in a high pressure situation?
feel you have too much responsibility for one person?
feel exhausted at the end of the day?
A score for the exercise is calculated by assigning 1 to 4 points for each answer (with 4 representing the "almost always" response); a total of 25 to 40 points indicates a high level of stress that could be psychologically or physically debilitating .
Staying in tune with the signs and symptoms of stress overload and burnout is a continuous process, and individuals should remain alert to their use of unhealthy coping mechanisms, such as excessive use of caffeine, alcohol, or prescription medication; overeating or undereating; smoking; inactivity; or social withdrawal. Such habits can be difficult to change, and individuals should focus on changing one behavior at a time and seek help from professional counseling if necessary .
The pressure of time is a common source of burnout among healthcare professionals . Time management extends beyond techniques to use time efficiently. The broader definition of time management carries more importance, as it relates to effectively managing the balance between personal and professional time. More time away from work has been the most common suggestion from healthcare professionals for reducing stress and preventing burnout [58,63,118,124]. A first step in creating a better work/life balance is to quantify the amount of time currently spent in each primary aspect of life—work, home, leisure, and vacation—and then determine priorities and assign preferred amounts of time for each aspect [19,124,125]. Creating such a time budget can help to prevent work life from overshadowing all other aspects of life, which can be harmful to self-esteem, self-identity, and overall well-being .
In a yearlong study of the work/personal priorities of executive men and women from 10 multinational companies, 62% of the subjects were found to be work-centric (more apt to put work above personal life) and 32% were found to be dual-centric (more apt to set work and personal life as equal priorities) . Dual-centric subjects reported less stress than the work-centric subjects (26% vs. 42%) . In addition, dual-centric individuals felt more successful at work and had achieved higher professional levels . The dual-centric subjects used several strategies to maintain their priorities :
Set strict boundaries between work and nonwork (not bringing work home)
Remained emotionally present in each aspect of life
Took time to "recover" after a particularly difficult time at work
Engaged in personal activities that require focus (such as sports, hobbies, or community volunteering)
Remained clear about priorities
Remaining "connected" to people is also important in managing stress and preventing burnout [35,118,119]. Healthcare professionals should strengthen relationships with family and friends and seek support from them as needed [19,35,119]. Expanding the social network to involve community and volunteer activities can help increase self-esteem and provide focus and fulfillment outside of the profession .
Persistent symptoms of unresolved stress or burnout, such as sadness, anger, worthlessness, hopelessness, anxiety, sleep disturbances, or exhaustion, should prompt an individual to seek counseling, especially if these feelings interfere with interpersonal relationships or affect job performance . Substance misuse or addictive behaviors also indicate the need for professional counseling. Healthcare professionals should be alert to the signs of burnout in not only themselves but also in their colleagues and should talk openly with those who exhibit severe symptoms [104,111,112].
Colleagues are in a unique position to understand each other's professional needs and stressors, and a supportive work environment protects against burnout . Social support from colleagues is especially important during times of change and uncertainty in the work environment and can provide comfort, insight, rewards, humor, help, and escape [3,29,99]. In particularly stressful settings, informal social support gatherings can help nurses and other healthcare professionals deal with emotionally demanding events (such as the loss of a patient) [104,126].
Maslach defined working smarter as setting realistic goals, doing things differently (when possible), not taking things personally, and taking time away . Setting realistic goals involves moving from abstract, idealistic goals to well-defined specific goals, which can help individuals gain a better sense of accomplishment. Varying work routines can help avoid feelings of being in a rut and provide a sense of better control. Taking things less personally involves objectifying negative interactions and situations to help decrease emotional involvement, thereby reducing stress. Emotional involvement can also be decreased by not bringing patient problems home .
Working smarter also means taking time away and organizing time more effectively. A typical response to work overload is to work longer or harder to help make the situation "get better" . However, this approach will only exacerbate stress and burnout, not relieve it. In addition, long stretches of work time and increased hours per day lead to fatigue and the potential for errors in care [79,91]. Instead, nurses should take some time away from work—even if only a few minutes at a time—to stretch, take a walk, make a personal phone call, read, meditate, or just sit and relax; these simple strategies to "recharge" will increase productivity more effectively than working continuously [1,19,118,124]. Other time management techniques include scheduling a block of uninterrupted time (no phones, pagers, or e-mails) to complete paperwork more efficiently, creating "to do" lists to maintain control over tasks, and increasing organizational skills [1,124].
Advocating for changes in the work environment or in the healthcare profession overall can help nurses increase a sense of control . Assessing the potential for burnout and taking steps toward prevention is a process that begins with one person who assumes a leadership role in a group effort . The individual leader engages a group of colleagues to work with organizational leaders to heighten awareness of common stress factors within the organization and to address issues that compromise patient safety and quality of care.
The ANA encourages nurses to be familiar with its position statements designed to ensure the health and safety of nurses and patients. For example, the ANA notes that "regardless of the number of hours worked, each registered nurse has an ethical responsibility to carefully consider her/his level of fatigue when deciding whether to accept any assignment extending beyond the regularly scheduled work day or week, including a mandatory or voluntary overtime assignment" . ANA position statements can be found on the association's website (http://www.nursingworld.org), and resources on safe staffing patterns can be found at http://www.safestaffingsaveslives.org.
Healthcare professionals learn to control their emotions to maintain a professional demeanor, but they are not immune to grief. A healthy response to the stresses associated with loss is important for avoiding burnout. As noted, burnout levels were higher among nurses who masked their emotions . Instead of masking emotions, healthcare professionals must learn how to grieve well [104,126]. This involves accepting the reality of the loss, experiencing the pain of grief, adjusting to the absence, and moving on with life . Nurses can draw strength from colleagues and others by communicating sadness, frustration, and grief and can find solace in discussing what they were able to achieve with their dying patients, such as the ability to help manage pain and other symptoms .
Maintaining positive relationships with colleagues, physicians, and patients is often challenging and requires strong communication skills. Nurses can decrease their vulnerability to stress by taking advantage of programs that strengthen their communication skills and help them to become more adept at handling difficult situations. Nurses should also learn how to better communicate across language and culture. They should ask their patients what language they prefer for their medical care information and should seek the use of professional interpreters as much as possible . The use of professional interpreters has been associated with improvements in communication (errors and comprehension), clinical outcomes, and patient satisfaction with care [129,130]. In addition, a systematic review of the literature has shown that the use of professional interpreters provides better clinical care than the use of ad hoc interpreters (untrained staff members, family members, friends, strangers in the hospital), with the former improving the quality of care for patients with limited English language skills to a level equal to that for patients with no language barriers .
Among the best ways for an institution to prevent burnout is to promote engagement by implementing strategies that enhance energy, involvement, and efficacy . Promoting engagement involves increasing positive aspects as well as reducing negative ones. As a first step, Maslach suggests transforming the six mismatches to fit a sense of engagement :
Feelings of choice and control
Recognition and reward
A sense of community
Fairness, respect, and justice
Meaningful and valued work
Another integral step in preventing burnout is to survey staff about important aspects of the organizational culture . Maslach has developed a Staff Survey that incorporates the Maslach Burnout Inventory with questions related to the six mismatches that lead to burnout (work overload, lack of control, insufficient reward, absence of community, lack of fairness, and conflict in values) and questions about management structures and processes (such as direct supervision and distant management), communication networks, health and safety concerns, and performance appraisal. Questions customized for a specific setting may also be helpful. After the survey data have been collected, the responses are analyzed to identify the issues that should be addressed .
Organizations and institutions can help protect nurses and other healthcare professionals from burnout by creating an organizational culture of trust, support, and open communication and fostering a healthy work environment [3,29,131]. In 2005, the American Association of Critical-Care Nurses published standards for a "healthy" work environment, noting that such an environment is necessary for clinical excellence and good patient outcomes. Six components were noted to be essential for establishing and sustaining a healthy work environment :
Effective decision making
Express a caring, sensitive attitude
Communicate with staff
Allow opportunities for growth
Seek nurses' input on decisions
Appropriate staffing should be the highest priority set to ensure high-quality patient care and to reduce nursing burnout. Among the "10 Patient Safety Tips for Hospitals" developed by the Agency for Healthcare Research and Quality is the recommendation to "consider options to minimize shifts of more than 16 consecutive hours by residents, interns, and nurses" . The ANA has been instrumental in heightening awareness about the need to establish safe staffing patterns. The association issued a position statement in 2006 stating that employers of registered nurses should ensure sufficient resources for :
…a work schedule that provides for adequate rest and recuperation between scheduled work and sufficient compensation and appropriate staffing systems that foster a safe and healthful environment in which the registered nurse does not feel compelled to seek supplemental income through overtime, extra shifts, and other practices that contribute to worker fatigue.
The ANA also supports federal legislation, the Registered Nurse Safe Staffing Act of 2010 (S.3491/H.R.5527), that would require that "hospitals establish committees that would create unit-by-unit nurse staffing plans based on multiple factors, such as the number of patients on the unit, severity of the patients' conditions, experience and skill level of the RNs, availability of support staff, and technological resources" . As of 2011, seven states have passed laws that reflect ANA's preferred approach to safe staffing: Connecticut, Illinois, Ohio, Oregon, Nevada, Texas, and Washington . An additional six states have addressed such issues as mandatory overtime, effect of staffing level on adverse outcomes, and public disclosure of staffing levels . Hospital administrators and nursing leaders should be familiar with staffing ratios mandated in their state. Nursing leadership should work with administrators to enhance recruitment campaigns and retention strategies and to explore innovative ways to address nurses' working hours, such as flexible schedules and shared job positions [42,84].
Another priority is to make available programs designed to help nurses manage the emotional demands of the job and enhance their psychosocial well-being. Nurses in all settings can benefit from programs designed to enhance stress management, coping techniques, and counseling skills and to facilitate work-related grief and bereavement [85,105].
The importance of positive interpersonal relationships with peers, physicians, and patients to both nurses' job satisfaction and patient outcomes requires a commitment from administrators and nursing leadership to foster better collaboration and communication within the working environment. Enhancing skills in conflict resolution and assertiveness can help nurses deal more effectively with peers and physicians . Formal staff support groups should be established to help foster supportive relationships among nurses, and these groups should be structured to allow nurses to discuss their concerns constructively rather than negatively [69,105].
Administration should also offer training programs that focus on effective communication between nurses and physicians and forums that allow healthcare professionals to interact outside of the patient's bedside [83,137]. Interdisciplinary rounds, patient care seminars, continuing education lectures, and hospital committees can provide opportunities for nurses and physicians to collaborate on projects and gain a better understanding and respect for each other [137,138]. Developing mutual respect early in the career may be of value; medical students who were required (as part of their curriculum) to shadow a nurse for one day gained a better appreciation of the nurse's role .
Nurses should be encouraged to participate in workshops that address challenges such as overcoming cultural and language barriers, responding to emotions, and dealing with angry patients and their families. Training has been advocated primarily for healthcare professionals in oncology and has been shown to improve some areas of communication skills, to help alleviate stress, and to improve the coping skills of patients with cancer [60,140,141,142,143].
Ms. C and Ms. M had been best friends growing up, and they shared a lifelong dream of becoming nurses. Various family and other commitments separated them after nursing school, and they began their nursing careers at different hospitals in different states. As new graduates on medical-surgical units, both were energetic and enthusiastic nurses, committed to excellence in caring for their patients.
Over the course of her first year, the hospital where Ms. C worked dealt with budget cuts and resources began to decline. Staffing on her unit decreased, and Ms. C's daily patient load went from three patients to six patients. She struggled to keep up with the increasing workload and found herself unable to spend as much time as she wanted with her patients. The hospital instituted mandatory overtime to help overcome the staffing shortage, and Ms. C soon began working a few hours beyond her usual 12-hour shifts and often worked 6 or 7 days in a row. She was tired all the time and frequently found it difficult to focus, especially near the end of her shift. Her personal life was affected; she called her family less often and never seemed to have time for her friends.
Ms. C has many of the personal risk factors for burnout: she is young, early in her career, single, and highly educated . Her unsupportive work environment, however, is the key, with work overload leading her to become frustrated and disappointed with her job. Ms. C is among the 25% to 56% of nurses who work 12 hours or more per day and the 33% who work 6 or more consecutive days [75,76,89]. As a result, she is experiencing the first stage of burnout, characterized by job dissatisfaction and mental and physical exhaustion [3,19,20]. Unless she addresses her stress and dissatisfaction, she will continue through the subsequent stages of burnout.
Ms. C did make time for a phone call from her friend Ms. M and couldn't believe how happy Ms. M was in her job. Ms. M listened as Ms. C described all her dissatisfactions with her work. Ms. M sympathized with her situation and talked enthusiastically about her own recent transfer to the medical intensive care unit. She urged Ms. C to transfer to the intensive care unit at her hospital because of the professional challenges and lower patient load. "You'll really feel like you're making a difference," Ms. M told her. Encouraged, Ms. C submitted a request for a transfer to the medical intensive care unit.
Ms. C gained renewed interest and energy during her orientation and training in the intensive care unit. She enjoyed the technical challenges of the more complex patient care, and she again looked forward to work. However, after she was fully oriented to the unit, her patient load increased and she again found herself working long hours and overtime. She went home every day with a headache and backache, she never felt fully rested, and she experienced extreme mood swings. She again withdrew from family and friends and found herself frequently overeating. She also began to have a glass or two of wine every night as a way to cope with her stress. The "last straw" for Ms. C was a medication error she made. No substantial harm came to the patient, but the patient's physician yelled at Ms. C and several other nurses in the unit. As a result, Ms. C felt like a professional failure and questioned her decision to become a nurse. She distanced herself even further from her colleagues, her family, and her friends and contemplated leaving the profession.
Changing the work setting is a frequent response to job dissatisfaction. However, different environments can have the same inherent stress factors, which means that the potential for burnout can continue. Within nursing environments, work overload brought on by inadequate staffing is the most common source of stress and burnout [84,87,88]. Work overload refers to more than patient volume and also encompasses work schedule (long hours, many consecutive days of work, etc.) [75,76,89]. High levels of fatigue brought on by such work schedule factors have been associated with an increased risk of errors, and these errors frequently cause moral distress for nurses [7,79,91]. In addition, difficulties in nurse-physician relationships also affect nurses' morale, and job satisfaction decreases when nurse-physician collaboration is poor [98,102,103]. Ms. C is moving through the next stages of burnout, marked by indifference and feelings of failure as a professional .
Ms. M surprised Ms. C with a visit and was distressed about what had happened to Ms. C. Her friend had dark circles under her eyes, was overweight, and lacked her usual passion for life. Ms. M forced Ms. C to tell her about her situation at work. When Ms. M heard about Ms. C's work schedule and patient load, she became angry at the situation and told Ms. C that she needed to take better care of herself and become an advocate for change at her hospital. Ms. M explained that not all hospitals are the same, and she described her own positive work environment. In her unit, the nurses have a weekly get-together during which they talk about their most challenging patients and how they cope with loss. The Human Resources department sends out flyers about stress management programs, and the supervisors rearrange schedules to allow nurses to attend. Although there can be heavy workloads, the head nurse works with the staff as she develops the schedule so nurses have some say in the shifts and the number of days they work. The head nurse also anticipates needs and requests per diem nurses to help keep the patient load low.
Ms. C was surprised at the differences between her hospital and Ms. M's hospital. But she expressed doubt that she could change how her hospital functioned. Ms. M acknowledged that it is difficult to change organizations but she encouraged her to talk with other nurses about the situation and to band together to approach administration and request changes in scheduling and to emphasize the detrimental effect of heavy patient load on patient outcomes and quality of care. Ms. M noted that, equally as important as working for change in her hospital, Ms. C must make changes in her personal and professional lifestyles to help her better manage stress and avoid burning out completely. Ms. M told her about the importance of finding healthier ways to cope with stress, evaluating her work/life balance, seeking support from friends and family, working "smarter," and engaging in nonwork activities. Ms. M also reminded Ms. C about how excited the two of them had always been about becoming nurses.
Because it is difficult to change organizational structure, individuals must make changes in themselves to avoid stress and burnout. Attention to personal and professional lifestyle habits are integral steps in preventing and managing stress effectively. Self-care, time management, and strong interpersonal relationships are key elements for maintaining physical and psychosocial well-being.
Maintaining a healthy lifestyle, with proper diet, exercise, and rest, is vital to avoiding the physical effects of stress, as is seeking activities that help to disengage individuals from their professional routine and provide enjoyment [2,3,19,40]. Self-reflection as a way to remind oneself why he or she entered the healthcare profession and remaining "connected" to people are also important in managing stress and preventing burnout. Adequate time away from work is essential for maintaining a positive work/life balance and has been the most common suggestion from healthcare professionals about how to avoid stress and burnout [58,63,118,124].
Working smarter refers to taking frequent "mini-breaks" to escape work stresses, varying daily work routines, and setting realistic goals . Nurses can also increase their sense of control by advocating for changes in the work environment and should abide by the ANA position statement [3,91].
Over the next few months, Ms. C starts to pay better attention to her health by eating a balanced diet and finding time for regular exercise, including a twice-weekly yoga class. She starts an informal support group with her peers on her unit, and the number of participants increases as the sessions become more popular. She also visits with the Human Resources staff to ask about workshops in stress management techniques. In addition, Ms. C leads a small group of her peers in approaching their nursing supervisor to discuss their concerns about the quality of patient care and staffing. With time, Ms. C has a renewed sense of purpose at work and has become involved in a multidisciplinary committee that is addressing quality of care. She also has become more active in her personal life, spending more time with friends and family and volunteering as a coach for a youth soccer team. She has scheduled her first vacation in 2 years, planning a 10-day cruise with her best friend, Ms. M.
Burnout is a syndrome of emotional exhaustion, depersonalization, and reduced personal accomplishment. Levels of burnout are high among healthcare professionals, and the effects of burnout have serious consequences in the nursing profession. In addition to the detrimental physical, psychologic, and interpersonal/social effects, high levels of burnout among nurses have led to an ongoing nursing shortage that poses a threat to patient safety and quality of patient care.
At the root of burnout is job dissatisfaction. If left unaddressed, this dissatisfaction can lead to prolonged stress and subsequent burnout. Several sources of job dissatisfaction among nurses have been identified, including staffing inadequacy, work schedule, lack of involvement in decision making, lack of support from nursing leadership and administration, interpersonal conflict (interactions with physicians and peers), and inadequate pay. These sources of dissatisfactions can be correlated with four of the mismatches (work overload, lack of control, insufficient reward, and absence of community) identified by Maslach, the foremost authority on burnout. By far the most often cited source of dissatisfaction is inadequate staffing, which creates a cycle of increased job dissatisfaction, burnout, and turnover. The rate of burnout has been found to increase 23% for every additional patient per nurse, and patient-nurse volumes have also been related to an increased frequency of adverse events, nursing errors, and higher patient mortality.
Because studies have shown that factors within the work environment are the greatest predictors of job dissatisfaction and stress, it is incumbent on nursing management and administration, as well as individual nurses themselves, to address issues of job dissatisfaction to prevent burnout early in the cycle. Nurses must maintain personal and professional lifestyle habits that will keep them healthy, engaged in pursuits other than their profession, and connected with family, friends, and colleagues. In addition, nurses should seek supportive relationships with colleagues and ensure a work/life balance that fits their overall priorities.
Institutions and organizations should focus on creating a healthy work environment in which nurses feel supported by their peers, their supervisors, and physicians. In addition, organizations should make available stress management workshops and other educational programs that target nurses' psychosocial well-being and interpersonal skills. Above all, organizations must ensure that safe nurse staffing patterns are in place.
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