Study Points

Burnout: Impact on Nursing and Quality of Care

Course #31433 - $25 • 5 Hours/Credits

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  • Participation Instructions
    • Review the course material online or in print.
    • Complete the course evaluation.
    • Review your Transcript to view and print your Certificate of Completion. Your date of completion will be the date (Pacific Time) the course was electronically submitted for credit, with no exceptions. Partial credit is not available.
  1. Burnout is described by Maslach as

    HISTORY AND DEFINITION OF BURNOUT

    Maslach emphasizes that burnout is not a problem related to an individual [21]. 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 [21]. 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" [21]. 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 [18].

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  2. Isolation and apathy characterize which stage of burnout?

    DEVELOPMENT OF BURNOUT

    FIVE STAGES OF BURNOUT IN NURSING

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  3. The root of burnout is in

    DEVELOPMENT OF BURNOUT

    The specific factors within the work environment that lead to stress and subsequent burnout vary across 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) [13,18,25,26,27].

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  4. Which of the following statements regarding personal risk factors for burnout is TRUE?

    DEVELOPMENT OF BURNOUT

    Burnout is less prevalent among older individuals because they tend to be more stable and have a more balanced perspective on life [18]. 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 one to five years), and many young, burned out individuals leave the profession; as a result, the remaining individuals in an occupation are the "survivors" [18].

    Comparing burnout across racial/ethnic groups is difficult, as most studies have been small or have not involved sufficient numbers of minority workers [18]. For example, one study involved 180 childcare professionals (131 white and 49 black women), in which the scores for components of burnout were higher among black professionals than among white professionals [28]. 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 [18]. 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 [18]. This difference could be the result of the expectations associated with advanced education and job choices [18].

    Across most work settings, levels of burnout have been somewhat consistent among men and women. One meta-analysis demonstrated similar overall rates of burnout among men and women, but there were gender differences in burnout components, with slightly higher levels of emotional exhaustion among women and somewhat higher levels of depersonalization among men [29]. Gender differences have also been found with respect to other demographic variables [18]. For example, a survey of 3,424 employees in a Finnish study 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 [30].

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  5. What is the most common physical symptom of stress?

    IDENTIFICATION AND MEASUREMENT OF BURNOUT

    MOST COMMON PHYSICAL AND PSYCHOLOGIC SYMPTOMS RELATED TO STRESS

    SymptomsFrequency
    Physical
    Fatigue51%
    Headache44%
    Upset stomach34%
    Muscle tension30%
    Change in appetite23%
    Teeth grinding17%
    Change in sex drive15%
    Dizziness13%
    Psychologic
    Irritability or anger50%
    Nervousness45%
    Lack of energy45%
    Feeling of wanting to cry35%
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  6. In measuring burnout, which of the following is the best approach to gain a better understanding of the sources of stress for an individual?

    IDENTIFICATION AND MEASUREMENT OF BURNOUT

    The use of psychologic assessment tools in conjunction with the MBI 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 [53]. The General Health Questionnaire is frequently used in conjunction with the MBI to evaluate psychologic morbidity and burnout, as the pathways to both are related [54].

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  7. According to the most recent data for nurses, the overall burnout rate is

    BURNOUT AMONG NURSES

    As with physicians, the rate of burnout among nurses is higher than the average rate among other workers. According to the most recent data for nurses, the overall burnout rate is 34% to 43%, with rates varying according to several factors [67,68,69,108].

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  8. The prevalence of burnout is higher in which of the following specialties?

    BURNOUT AMONG NURSES

    As has been reported for physicians, many studies have indicated that the prevalence of burnout among nurses is higher in some specialties, such as oncology, mental health, emergency medicine, and critical care [79,82]. Factors contributing to stress and burnout may differ according to specialty. For example, substandard staffing was associated with burnout among oncology nurses whereas low manager support was a significant predictor of burnout among emergency room nurses [79,83].

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  9. Which of the following has been the most common reason given for leaving a nursing job or position?

    BURNOUT AMONG NURSES

    REASONS GIVEN FOR LEAVING A NURSING JOB OR POSITION IN THE 2008 NATIONAL SAMPLE SURVEY OF REGISTERED NURSES

    Specific Work-Related Reason Percentage
    Too many hours27%
    Low salary22%
    Inadequate staffing21%
    Lack of good management/leadership13%
    Lack of collaboration/communication10%
    Lack of advancement opportunities8%
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  10. According to studies, the mean patient-to-nurse ratio in U.S. hospitals is

    BURNOUT AMONG NURSES

    The most common source of burnout, work overload, is created primarily by inadequate staffing, a prevalent problem in today's hospitals and nursing homes [65,69,79,84,90]. A 2011 study of 665 hospitals demonstrated that 20% had a patient-to-nurse ratio of seven or more, whereas 25% had a ratio of four or less [14]. Other studies have shown that the mean patient-to-nurse ratio in U.S. hospitals is approximately 5:1 [69,91]. Nurses have consistently reported that these ratios are inadequate for providing high-quality care. In a study of 534 hospitals (26,005 nurses), staffing was considered to be poor in 25% [69]. In a survey of nearly 11,000 registered nurses, only 46% said there was enough staff to accomplish the necessary work, and 48% said there were enough registered nurses on staff to provide high-quality care [67]. Other surveys have shown that less than half of nurses had the time needed to spend with patients [73]. Increased patient-to-nurse ratios are associated with lower rates of job satisfaction and higher rates of burnout; inadequate staffing was the reason that 21% of nurses gave for changing their position or employer in 2007–2008, and adequate staffing is the second-leading consideration of nurses seeking a new position [7,70,72,92]. In a study of more than 10,000 nurses, the rate of burnout increased 23% for every additional patient per nurse [7].

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  11. In a large survey of nurses, the highest level of satisfaction was given to relationships with

    BURNOUT AMONG NURSES

    In one survey of 76,000 registered nurses, the highest level of satisfaction was given to relationships with other nurses [112]. Still, the survey showed that one-third of nurses were dissatisfied with interactions with their peers [112]. A 2017 survey of 600 nurses found that 45% had been verbally harassed by other nurses [65]. 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 lack of support 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 MBI [86]. Similarly, lack of peer cohesion has correlated with high levels of emotional exhaustion and depersonalization [87].

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  12. Which of the following conflict resolution styles has associated with a lower rate of burnout among nurses?

    BURNOUT AMONG NURSES

    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 [113].

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  13. Levels of emotional exhaustion on the Maslach Burnout Inventory have been higher among nurses who

    BURNOUT AMONG NURSES

    The emotional demands of the nursing profession are well recognized, and human suffering has been noted to be a stressor for nurses [90]. In a 2002 American Nurses Association (ANA) survey, 44% of nurses said they left their job each day feeling discouraged and saddened by what they could not provide for their patients [75]. Despite this prevailing emotion, 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 [75]. Levels of emotional exhaustion on the MBI were higher among nurses who masked their emotions or who pretended to feel "expected" emotions [75].

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  14. In a meta-analysis, job dissatisfaction among nurses was associated with which of the following health issues?

    CONSEQUENCES OF STRESS AND BURNOUT

    Data are limited on the health effects of burnout among nurses specifically, but some studies have evaluated the effect of its predecessor, job dissatisfaction. One meta-analysis showed higher rates of musculoskeletal disorders and musculoskeletal injuries reported by nurses who also reported dissatisfaction with staffing, scheduling, interpersonal relations, or decision making [87]. In addition, more needlestick injuries occurred among nurses dissatisfied with these same work-related factors [87]. A weak but significant association between burnout and depression among nurses has also been noted [70].

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  15. All of the following are part of the nursing shortage/burnout cycle, EXCEPT:

    CONSEQUENCES OF STRESS AND BURNOUT

    THE NURSING SHORTAGE/BURNOUT CYCLE

    The relationship between burnout and the nursing shortage is cyclical: job dissatisfaction leads to burnout, which in turn leads to nursing turnover and subsequent nursing shortage, and the inadequate staffing further increases job dissatisfaction.
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  16. Which of the following is the most essential element of self-care in preventing burnout among nurses?

    STRATEGIES TO PREVENT AND COPE WITH STRESS AND BURNOUT

    Self-care involves several universal lifestyle habits, such as proper diet, exercise, sleep, and regular health care [24,131,138]. Maintaining a healthy lifestyle through these habits is vital to avoiding the physical effects of stress [2]. The need for appropriate sleep hygiene is the most essential element for nurses, as in one survey, 64% of nurses said they rarely get seven to eight hours of sleep per night [104]. There is widespread documentation that this lack of sleep is associated with a high risk of fatigue, which is linked to job satisfaction and burnout [94,97,128,132]. In its white paper on nurse fatigue, the Emergency Nurses Association offers several recommendations for nutrition, exercise, and proper sleep [128]:

    • Avoid unhealthy foods—decrease the amount of sugars and foods with empty calories

    • Participate in regular exercise—find activities that fit into your daily routine

    • Do not eat a heavy meal before going to bed

    • Avoid caffeine for at least five hours before going to bed (consider all sources of caffeine, such chocolate, gum, sodas)

    • Do not rely on medications to enhance alertness

    • Eat nutritious foods during your work shift to avoid large fluctuations in blood glucose levels

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  17. All of the following tactics for "working smarter" should be especially emphasized to nurses, EXCEPT:

    STRATEGIES TO PREVENT AND COPE WITH STRESS AND BURNOUT

    Maslach defined working smarter as setting realistic goals, doing things differently (when possible), not taking things personally, and taking time away [18]. 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.

    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" [18]. However, this approach will only exacerbate stress and burnout, not relieve it. The need to take some time away from work must be especially emphasized to nurses, most of whom do not routinely take breaks; in one survey, 37% of nurses said they "usually" took time for a meal and 24% said they "usually" took a break during their shift [92]. Other studies have shown that appropriate breaks are least likely among nurses working the longest hours, and that nurses are usually not completely free of patient care responsibilities during breaks for rest or meals [97]. Rest breaks are particularly important for nurses working the night shift, to relieve symptoms of fatigue, which can be detrimental to both nurses' well-being and patient safety [97]. Taking 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 can help nurses "recharge" and will improve performance and increase productivity more effectively than working continuously [1,24]. Facilities must help ensure that nurses take breaks and meals appropriately, as will be discussed later. Other time management techniques include scheduling a block of unplugged, 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 [1,134].

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  18. Which of the following is NOT one of the components of the American Association of Critical-Care Nurses' standards for a healthy work environment?

    STRATEGIES TO PREVENT AND COPE WITH STRESS AND BURNOUT

    Organizations and institutions can help protect nurses from burnout by creating an organizational culture of trust, support, and open communication and fostering a healthy work environment [18,32]. Creating a healthy work environment has become a priority for enhancing nurse job satisfaction and retention and improving patient safety and satisfaction [110]. The American Association of Critical-Care Nurses (AACN) developed 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 [153]:

    • Appropriate staffing

    • Meaningful recognition

    • True collaboration

    • Skilled communication

    • Effective decision making

    • Authentic leadership

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  19. Which of the following approaches to nurse staffing does the American Nurses Association support?

    STRATEGIES TO PREVENT AND COPE WITH STRESS AND BURNOUT

    Nurses' work schedules and appropriate staffing should be the highest priority for reducing burnout. Defining "appropriate staffing" has been subject to debate, however. Some have argued for specific patient-nurse ratios, while others have advocated for hospitals to establish staffing committees, with nurses as members, charged with creating staffing plans that reflect the specific needs of the institution [144]. The ANA supports the committee approach [144]. The Registered Nurse Safe Staffing Act (later renamed The Nurse Staffing Standards for Hospital Patient Safety and Quality Care Act), which calls for the committee approach to safe staffing, has been introduced in Congress several times since 2007, but no action has been taken [158]. As of 2021, 14 states have passed laws or regulations addressing nurse staffing: California, Connecticut, Illinois, Massachusetts, Minnesota, Nevada, New Jersey, New York, Ohio, Oregon, Rhode Island, Texas, Vermont, and Washington [144]. Of these, seven states have laws or regulations requiring staffing policies that are developed by committees. Only California stipulates in law and regulations a required minimum nurse-to-patient ratio be maintained at all times, that ratio being dependent on the unit of care. Massachusetts is the only other state to have a specific staff ratio legislation enacted; however, that law applies to the intensive care unit only [144]. Hospital administrators and nursing leaders should be familiar with staffing ratios mandated in their state.

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  20. Which of the following has been recommended by many nursing associations to address fatigue?

    STRATEGIES TO PREVENT AND COPE WITH STRESS AND BURNOUT

    Institutions should also implement staffing policies that address nurse fatigue. In 2014, the ANA revised its position statement on nurse fatigue and noted the following evidence-based recommendations [127]:

    • Employers should include nurse input when designing work schedules and implement a "regular and predictable schedule" that allows nurses to plan for work and personal obligations.

    • Nurses should work no more than 40 hours in a seven-day period and limit work shifts to 12 hours in a 24-hour period, including on-call hours worked.

    • Employers should stop using mandatory overtime as a "staffing solution."

    • Employers should encourage "frequent, uninterrupted rest breaks during work shifts."

    • Employers should adopt official policy that gives RNs the "right to accept or reject a work assignment" to prevent risks from fatigue. The policy should be clear that rejecting an assignment under these conditions is not patient abandonment and that RNs will not be retaliated against or face negative consequences for rejecting such an assignment.

    • Employers should encourage nurses to be proactive about managing their health and rest, including getting seven to nine hours of sleep per day; managing stress effectively; developing healthy nutrition and exercise habits; and using naps according to employer policy.

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  • Back to Course Home
  • Participation Instructions
    • Review the course material online or in print.
    • Complete the course evaluation.
    • Review your Transcript to view and print your Certificate of Completion. Your date of completion will be the date (Pacific Time) the course was electronically submitted for credit, with no exceptions. Partial credit is not available.