Nurses and other healthcare professionals, often work in a busy and fast-paced environment. Caring for patients who are often critically ill can be rewarding. However, the multiple demands on the nurse’s time throughout the workday can sometimes leave them feeling frustrated, overwhelmed and overextended. The nurse’s inability to adequately meet all of the competing demands on their time can result in burnout (Clark, 2013; Russell, 2016).
What is Burnout?
Dr. Christina Maslach, a professor of Psychology at the University of California at Berkley has studied burnout for over 40 years. She and her colleagues developed the Maslach Burnout Inventory (1996), a reliable and valid twenty-two item tool that can be used to measure burnout.
Burnout is defined as “a syndrome of emotional exhaustion, depersonalization, and reduced personal accomplishment that can occur in individuals who do ‘people work ‘of some kind” (Maslach, 2003, p. 2). In addition to nurses and other healthcare workers, teachers, social workers and anyone who works in a field where they help people are at risk for burnout.
Maslach and Leiter (2017) expand upon Dr. Maslach’s earlier work on burnout and provide some additional insight into the three dimensions of burnout syndrome: emotional exhaustion, depersonalization, and reduced personal accomplishment. The first dimension, emotional exhaustion, is described as the first sign of burnout or burnout syndrome. Individual workers are “overextended by work demand and depleted of physical or emotional resources……...drained without any source of recovery” (p. ). This dimension is characterized by the individual’s lack of physical or emotional energy and inability to deal with workplace demands or face another day on the job. The second dimension of burnout, depersonalization (Maslach, 2003) or cynicism (Maslach & Leiter, 2017) is described as “a negative, callous, or excessively detached response to various aspects of the job…...in response to overload or exhaustion” (p. 160). Cynicism with the resulting detachment results in nurses doing just enough to get by rather than doing their best work. The third dimension of burnout, reduced personal accomplishment (Maslach, 2003) or inefficacy (Maslach & Leiter 2017), includes “a feeling of incompetence and lack of achievement and productivity at work” (p.160). Inefficacy can be exacerbated in a work environment that lacks adequate resources; such as supplies, equipment and staff (Maslach & Leiter, 2017, p. 160).
Burnout in the Healthcare Professional
The prevalence of burnout in healthcare professionals ranges from 10-70% in nurses, and from 30-50% in physicians, nurse practitioners and physician assistants (Lyndon, 2016). According to Adriaenssens, De Gucht and Maes (2016) more than 25% of emergency room nurses experience burnout. Russell (2016) found a moderate level of nurse burnout in inpatient oncology nurses. Jesse, Abouljoud, Hogan and Eshelman (2015) studied the three dimensions of burnout: emotional exhaustion, cynicism and inefficacy in transplant nurses and found “strong evidence of the presence of burnout” (p. 196).
Nurse burnout is a global issue. Sillero and Zabalegui (2018) surveyed 136 perioperative nurses in Barcelona, Spain and found “moderate-high levels of burnout” (p. 135). Khamisa, Oldenburg, Peltzer, and Ilic (2015) examined burnout in 895 nurses employed in four hospitals located in South Africa; and concluded that “burnout clearly impacts the mental health and wellbeing of nurses……compromising productivity, performance and the quality of patient care” (p. 661). EzenwajI, et al. (2019) studied 393 nurses employed in hospitals in southeast Nigeria and reached a similar conclusion. The World Health Organization (2019) included burnout as an occupational factor influencing health status, but not a medical condition, in the 11th Revision of the International Classification of Diseases (ICD-11).
Compassion fatigue, which is described as job-related distress that is greater than job satisfaction, is associated with nurse burnout. Frequently caring for critically ill or dying patients, working overtime, skipping breaks, and a lack of focus on self-care (getting adequate sleep, eating nutritious meals, engaging in regular exercise) are all factors associated with a nurse’s increased risk for compassion fatigue and burnout (Sheppard, 2016; Melnyk & Neale, 2018).
In order to avoid burnout, nurses need to be able to recognize burnout. The signs and symptoms of burnout include: insomnia, fatigue, headaches, muscle tension, excessive worry, forgetfulness, intestinal problems, changes in appetite, nervousness, irritability/anger, frequent colds or infections, missing time with family and friends (Sheppard, 2016; Clark 2013).
Burnout in the Healthcare Organization
Burnout has significant impact on the healthcare organization. Compassion fatigue and burnout can negatively impact patient care (Russell, 2016). Burnout in nurses and other members of the health care team has been linked with decreased job satisfaction, increased turnover, decreased patient satisfaction, patient safety issues, and an increase in medication error (Whichello & Price, 2018; Maslach & Leiter, 2017; Sheppard, 2016).
Decreased job satisfaction can result in increased turnover, as nurses choose to leave their current job due to burnout. Nurse turnover is expensive for the healthcare organization. Significant expenses are incurred to recruit, hire and orient new nurses. In the interim, the healthcare facility needs to fill that nurse’s position, either by paying overtime to current staff nurses or by hiring agency or travel nurses on short term contract. There may be days or shifts where the unit works in a short-staffed situation, with less than the required number of nurses on the unit. This negatively impacts patient safety and decreases patient satisfaction (Dyrbye, et al., 2017; Lyndon, 2016).
Sources of Burnout in the Healthcare Organization
The work environment is one source of burnout within the healthcare organization. Fast-paced work environments are often the standard for nurses; whether their employment setting is an ambulatory surgery center, an emergency room or a busy inpatient unit. Many of the patients that nurses care for are critically ill and have complex healthcare needs. It can be challenging for nurses to provide high-quality, comprehensive patient care when they are working nonstop and prioritizing care needs (Tips for Preventing Staff Stress, 2017; Moss, et al.; 2016).
Increased workload without sufficient staffing, or being short-staffed, is a second source of burnout attributed to the healthcare organization. This is particularly the case when increased workload without adequate staffing levels is a frequent occurrence (Sillero & Zabalegui, 2018; Moss, et al, 2016).
Incivility in the healthcare organization is a third source of burnout within the healthcare organization. Incivility increases the stress level on the nursing unit and within the healthcare organization. Incivility can also impact the individual nurse’s stress level and increase their level of burnout (Clark, 2013; Maslach & Leiter, 2017; Tips for Preventing Nurse Burnout, 2017). It is recommended that all healthcare organizations have a zero-tolerance policy for incivility or bullying in the workplace (Tips for Preventing Nurse Burnout, 2017).
Sources of Burnout in the Nurse
Overwork is one source of burnout in the individual nurse. A number of factors contribute to overwork: nurses who often volunteer for overtime or extra shifts, come in to work on their days off, and/or frequently skip their breaks. Skipping breaks includes not taking frequent enough or long enough breaks, missing meals, and/or nurses who don’t step away from their job responsibilities and eat at their desks. While the willingness of individual nurses to volunteer for extra shifts or overtime may positively impact the unit’s staffing level, a continuing pattern of overwork contributes to the development of burnout (Sheppard, 2016; “Worried About Staff Burnout?”, 2016).
Lack of focus on self-care is another source of burnout in nurses. Nurses have a tendency to focus on their patient’s healthcare needs to the extent that they ignore their own self-care. Regular exercise, healthy eating, meditation, relaxation breathing, getting adequate sleep, and taking regular vacations are self-care strategies that nurses need to embrace (Buffington, Melnyk & Neal, 2018). Clark (2013) recommends that nurses put self-care on their calendars in order to make this a priority.
Strategies to Prevent Burnout
There is an old adage that states an ounce of prevention is worth a pound of cure. In the context of nurse burnout, that is certainly the case. It is better for the nurse and for the healthcare organization to be able to implement strategies to prevent burnout. Nurse burnout can occur due to factors within the healthcare organization, individual factors within the nurse, or a combination of both. Leadership within the healthcare organization needs to identify and address the organizational factors that can cause burnout in nurses; and the individual nurse also needs to be able to recognize burnout in themselves in order to improve their work-life balance.
There are several strategies that the healthcare organization can implement to prevent nurse burnout. The first organizational strategy is to provide administrative support for education on the recognition and prevention of burnout. “Know the problem: get educated about what burnout is, and what to do about it” (Maslach and Leiter, 2017, p. 160). Another organizational strategy to prevent burnout is promoting a positive work environment. A positive work environment includes: zero tolerance for workplace incivility, providing recognition for staff nurses who excel at their jobs, and an environment where teamwork and peer support are the norm, not the exception (Clark, 2013; Tips for Preventing Staff Stress, 2017; Adriaenssens, et al., 2015).
Implementing strategies to improve scheduling and staffing is an organizational strategy that needs to be consistently implemented to prevent nurse burnout. Nurse managers need to be knowledgeable about the workflow in their units and able to adjust staffing appropriately. Nurse managers need to be accessible to their staff and willing to pitch in when needed. If the unit typically receives numerous admissions, or there are a larger number of cases on the ambulatory surgery center schedule on certain days of the week, nurse managers should schedule some of their nurses to start later in the day so that there is sufficient staffing to handle the workload. Nurse administrators could also implement an as-needed pool of nurses who can be scheduled during periods of higher workload (Sillero & Zabalegui, 2018; “Worried about Staff Burnout?”, 2016).
Providing wellness benefits for nursing staff is another organizational strategy to prevent burnout. Examples of wellness benefits include: funding smoking cessation programs, free or reduced fees for gym memberships, providing calorie count information and healthy food options in the hospital cafeteria, stress reduction training and meditation programs (Moss et al., 2016; Doré, Duffett-Leger, McKenna, & Breau, 2017).
Training in holistic nursing is an innovative burnout prevention strategy that has been implemented by Adrienne Schultz, RN, HN-BC, assistant vice president, patient care services at Cancer Treatment Centers of America (“Worried About Staff Burnout?”, 2016). According to Shultz “holistic nursing can benefit both nurses who learn more about self-care, and patients” (“Worried About Staff Burnout?”, 2016, p. 136).
Another important aspect of training are the universities and medical schools that educate the next generation of healthcare providers and nurses. Academic institutions that educate nurses and healthcare professionals need to educate students about burnout and burnout prevention strategies. This will enable preprofessional students to be aware of burnout syndrome and how to cope with it (Moss et al., 2016; Ezenwaji, et al., 2019).
While there are organizational factors that contribute to the development of nurse burnout, there are factors that can be attributed to the individual nurse that can result in burnout.
First, it is important that the individual nurse be able to recognize the signs of burnout (Melnyk & Neale, 2018). Next, nurses need to embrace the concept of work-life balance (Melnyk & Neale, 2018). Nurses are caregivers who often put the needs of their patients ahead of their own needs and this can be difficult (Melnyk & Neale, 2018). However, a nurse who prioritizes self-care and embraces work-life balance will be more content and able to function effectively in the workplace (Melnyk & Neale, 2018).
Strategies to Manage Burnout
The global prevalence of burnout in nurses and healthcare professionals provides evidence that while burnout prevention is preferable (for both the health and well-being of the nurse and the healthcare organization), burnout still occurs. According to Maslach and Leiter (2017), Melnyk and Neale (2018), and Russell (2016) several strategies can be implemented to handle nurse burnout. These include:
- Change work patterns: avoid overtime, work less, take breaks, work-life balance.
- Develop coping skills: time management, conflict resolution, cognitive behavioral therapy (provided and funded by the healthcare organization).
- Focus on teamwork and nurse collaboration.
- Foster a strong network of social support: from nurse manager, nurse colleagues, and family.
- Utilize relaxation techniques: deep breathing, yoga stretches.
- Prioritize physical wellness: healthy eating, regular exercise, sleeping at least seven hours per night, smoking cessation, limit alcohol intake (Maslach & Leitner, 2017; Melnyk & Neale, 2018; Russell, 2016).
Burnout and compassion fatigue can negatively impact patient care. The nurse needs to be able to recognize the symptoms of burnout in order to implement individual burnout prevention strategies. Hospital administrators and nurse managers must be aware of the sources of burnout within the healthcare organization in order to address these proactively and avoid nurse burnout.
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