Avoiding Nurse Burnout Nursing CE Course

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This course reviews relevant terminology and statistics related to nurse burnout, including the impact of burnout on the nurse and the healthcare organization. This course will also examine the risk factors and clinical manifestations of burnout. Finally, this course will review prevention and management strategies that can reduce the incidence of nurse burnout.  

After this activity, learners will be prepared to: 

• review relevant terminology and statistics related to nurse burnout 

• identify risk factors associated with burnout 

• describe the clinical manifestations of burnout 

• discuss various strategies for the prevention and management of nurse burnout 

Nurses and other healthcare professionals (HCPs) work in busy, fast-paced, and stressful environments. Caring for patients from birth to death and during times of wellness and illness can be one of the most rewarding jobs. Nurses often describe choosing to enter the healthcare field as a calling to serve others. However, the multiple demands on the nurse’s time throughout the workday can sometimes leave them frustrated, overwhelmed, and overextended. The nurse’s inability to adequately meet all the competing demands on their time can result in burnout. When nurses experience burnout, it has negative consequences for the nurse, the healthcare organization, and patients. Nurses can experience physical and emotional manifestations of burnout that impact their work and home life. In addition, high rates of nurse and HCP burnout can lead to staffing concerns and turnover. When healthcare organizations are affected by HCP burnout, there can be a decrease in the quality of care provided and an increase in safety events (Clark, 2021; The University of St. Augustine for Healthcare Sciences [USAHS], 2020).  

HCP burnout has been a recognized problem for decades. However, the COVID-19 pandemic has brought HCP burnout to the forefront of global and national priorities. In 2007, the Institute for Healthcare Improvement (IHI) presented the Triple Aim framework to optimize healthcare system performance. The three dimensions of the Triple Aim include: improving the patient care experience, improving the health of populations, and reducing the per capita cost of health care. Healthcare organizations and national leaders have recently highlighted that a critical component to achieving the Triple Aim is the HCP’s work environment. Therefore, many organizations have advocated expanding the Triple Aim to include a fourth dimension of attaining joy in work. The evolution of the Quadruple Aim addresses the importance of a healthy work-life for HCPs as a foundation for achieving the Triple Aim. Addressing burnout and promoting joy in the workplace can improve patient outcomes and safety (Feeley, 2017; Fitzpatrick et al., 2019; White, 2021).   

What is Burnout? 

Burnout is “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). This phenomenon involves the emotional and physical exhaustion from a stressful work environment and the important responsibilities of caring for others. Maslach and Leiter (2017) expanded upon Dr. Maslach’s earlier work on burnout and provided additional insights into burnout syndrome's three dimensions: emotional exhaustion, depersonalization, and the loss of personal accomplishment. The first dimension, emotional exhaustion, is described as the first sign of burnout or burnout syndrome. Individual workers are “overextended by work demands and are depleted of physical or emotional resources…drained without any source of recovery” (p. 160). This dimension is characterized by a lack of physical or emotional energy and an inability to deal with workplace demands or face another day on the job. The second dimension of burnout, depersonalization or cynicism, is “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 or inefficacy, 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). 

In addition to nurses and other HCPs, teachers, social workers, and anyone who works in a field where they help people are at risk for burnout. The prevalence of burnout in these groups has been widely researched. 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 22-item tool to measure burnout. Although burnout is similar to stress, it does have unique elements, including disengagement and detachment. Conversely, work stress is the over-engagement with a job, leading to burnout. The World Health Organization (WHO) has included burnout in the 11th Revision of the International Classification of Diseases (ICD-11), not as a medical condition but as an occupational phenomenon. The WHO specifies that burnout results from chronic workplace stress that has not been successfully managed (Nightingale College, 2021; Western Governors University [WGU], 2019; WHO, 2019).   

Compassion Fatigue 

Although burnout and compassion fatigue (CF) have some similarities, they are fundamentally different phenomena. CF is the emotional, physical, and spiritual distress resulting from caring for others. HCPs are impacted by burnout from a stressful work environment and working conditions. In contrast, CF affects HCPs due to caring for victims that have experienced trauma or critical illness and death. The emotional strain from caring for those who experience suffering can culminate in detachment and a loss of empathy. In addition, CF can manifest quickly, whereas burnout is usually more gradual. HCPs suffering from CF can experience emotional and mental exhaustion, self-isolation, and lack of fulfillment in the professional setting. Burnout and CF can manifest with similar signs and symptoms, making it hard to differentiate them. In addition, HCPs can experience one or both phenomena simultaneously (Clark, 2021; Compassion Fatigue Awareness Project, 2022).     

The Impact of Burnout 

The prevalence of burnout in healthcare professionals ranges from 10-70% in nurses and 30-50% in physicians, advanced practice registered nurses (APRNs), and physician assistants (PAs). Although these numbers can vary across time and healthcare institutions, researchers have concluded that most nurses experience burnout during their careers. For example, in the 2017 Kronos study, researchers found that 63% of nurses working in the hospital have experienced burnout (Clark, 2021; Lyndon, 2016). Additional statistics to highlight the prevalence of nurse burnout in the US include: 

• 43% of nurses in the hospital setting experience emotional exhaustion 

• 33% of nurses providing direct care in hospitals experience burnout 

• 18% of nurses in the hospital have considered leaving the bedside 

• 50% of nurses have considered leaving the profession; of the nurses considering leaving the profession, 31% reported burnout as the reason 

• nurses working more than 40 hours a week are more likely to leave their job due to burnout 

• 37% of nurses in long-term care experience burnout 

• 36% of nurses in the hospital setting and 47% in the long-term care setting reported that workload had impacted their ability to recognize changes in patient conditions (Clark, 2021; Shah et al., 2021; WGU, 2019) 

Nurse burnout has also been identified globally. For example, Sillero and Zabalegui (2018) surveyed 136 perioperative nurses in Barcelona, Spain, and found moderate-high levels of burnout. Similarly, EzenwajI et al. (2019) studied 393 nurses employed in hospitals in southeast Nigeria. They concluded that burnout impacts nurses' mental health and well-being, compromising the productivity, performance, and quality of patient care (EzenwajI et al., 2019). 

Impact on the Healthcare Organization 

Burnout has a significant impact on healthcare organizations. For example, burnout in nurses and other health care team members has been linked with decreased job satisfaction, increased turnover, decreased patient satisfaction, patient safety issues, and an increase in medication errors. Diminished job satisfaction can increase turnover, as nurses choose to leave their current job due to burnout. Nurse turnover is expensive for healthcare organizations, and the national average for turnover is between 8.8 and 37%, depending on nursing specialty and geographic location. Significant expenses are incurred to recruit, hire, and orient new nurses. It is estimated that it costs healthcare organizations approximately $328,400 for each percent change in nurse turnover. In the interim, the healthcare facility must fill that nurse’s position by paying overtime to current staff nurses or hiring agency or travel nurses on short-term contracts. As a result, 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. These inadequate staffing situations negatively impact patient safety and decrease patient satisfaction. A nurse-to-patient ratio of 1:4 (i.e., not including some specialty units such as intensive care) is recommended for safe and quality care. For every additional patient the nurse cares for on their shift, there is a 7% increase in patient mortality. In addition, researchers have found that when nurses are experiencing burnout, their patients often have a higher risk of surgical site infections, and they often receive lower patient satisfaction scores (Dyrbye et al., 2017; Haddad, 2022.; Jun et al., 2021; Shaffer & Curtin, 2020; USAHS, 2020).    

Risk Factors for Burnout 

Various individual and work environment factors contribute to prolonged stress that can lead to burnout in nurses. The work environment is one source of burnout within the healthcare organization. Fast-paced work environments are often the standard for nurses, whether their workplace is an ambulatory surgery center, an emergency department (ED), or a busy inpatient unit.  Many of the patients are critically ill and have complex healthcare needs. It can be challenging for nurses to provide high-quality, comprehensive patient care when working nonstop and prioritizing care needs. Increased workload without sufficient staffing is another source of burnout attributed to the healthcare organization. Research has shown that nurses with more than four patients have higher rates of burnout. In addition, nurses are twice as likely to experience burnout when they work longer shifts (i.e., 10 to 13 hours) than shorter shifts (i.e., 8 to 9 hours). Specialty settings such as the EDs and intensive care units (ICUs) have the most significant rates of nurse burnout. Working in areas where patients have low recovery and high mortality rates can take an emotional toll on nurses, leading to burnout and compassion fatigue (Nightingale College, 2021; USAHS, 2020; WGU, 2019).  

Workplace culture can significantly impact the stress level of nurses or other HCPs. Burnout is more prevalent when healthcare organizations and clinical units do not have a culture that promotes teamwork and collaboration. Poor teamwork and communication can also increase the risk of serious safety events. Incivility in the healthcare organization is also a source of burnout. Incivility increases the stress level in the nursing unit and healthcare organization. Incivility can also impact the individual nurse’s stress level and increase their risk for burnout. Therefore, it is recommended that all healthcare organizations have a zero-tolerance policy for incivility in the workplace (Nightingale College, 2021; USAHS, 2020; WGU, 2019). 

 Individual factors can also increase the risk of experiencing burnout. Nurses often have many opportunities to work additional hours due to the widespread nursing shortage. As a result, many nurses often volunteer for overtime or extra shifts and frequently skip their breaks. Skipping breaks includes not taking frequent enough or long enough breaks, missing meals, not stepping away from job responsibilities, and eating at the desk or nurses’ station. While the willingness of individual nurses to volunteer for extra shifts or overtime may positively impact the unit’s staffing level, a persistent pattern of overwork contributes to the development of burnout (Nightingale College, 2021; USAHS, 2020; WGU, 2019). 

Inadequate self-care behaviors are another source of burnout in nurses. Nurses tend to focus on their patient’s healthcare needs to the extent that they ignore their own. Consistent exercise, healthy eating, relaxation techniques (e.g., meditation, mindfulness, breathing techniques), adequate sleep, and regular vacations are self-care strategies that nurses need to embrace. Nurses often work long, consecutive shifts that interfere with adequate sleep hygiene. Researchers have found that 25% of nurses reported that they could not get enough sleep between shifts (Nightingale College, 2021; USAHS, 2020; WGU, 2019).  

Clinical Manifestations of Burnout 

Nurses need to recognize the signs and symptoms that may indicate that they or another HCP is experiencing burnout. Therefore, nurses must be aware of the manifestations of burnout, and healthcare leaders must also be adept at recognizing when staff is experiencing burnout (WGU, 2019). The signs and symptoms of burnout can include:  

• chronic fatigue 

• emotional and physical exhaustion 

• dreading going to work 

• constant dread or panic when at work 

• loss of appetite 

• loss of sleep 

• apathy towards others 

• frequent absenteeism or tardiness 

• negative attitude at work 

• lack of engagement with friends and family 

• resistance to change 

• poor work quality 

• patient safety issues 

• increased anxiety or depression (Nightingale, 2021; Singh et al., 2021; WGU, 2019) 

As discussed above, CF and burnout have similarities but are fundamentally different phenomena. However, these phenomena can manifest with the same signs and symptoms, making distinguishing them challenging. The fundamental distinguishing factor is the precipitating factors (i.e., burnout due to demanding work conditions and CF due to caregiver burden and trauma associated with watching patients suffer). Nurses can simultaneously suffer from burnout and CF (Psychology Today, n.d.; Walters, 2022). The signs and symptoms of CF can include: 

• exhaustion 

• disrupted sleep patterns 

• anxiety, depression, and post-traumatic stress disorder (PTSD) 

• headaches and upset stomach 

• irritability 

• numbness 

• a decreased sense of purpose 

• emotional disconnection 

• difficulty with personal relationships 

• self-contempt 

• impaired judgment and behavior 

• a decline in morale 

• a decrease in cognitive function (Psychology Today, n.d.; Walters, 2022)  

Strategies to Prevent and Manage Burnout  

A common adage states that an ounce of prevention is worth a pound of cure. In the context of nurse burnout, that is undoubtedly the case. Therefore, it is more effective for nurses and healthcare organizations to implement strategies to prevent burnout. Nurse burnout can occur due to factors within the healthcare organization, individual factors within the nurse, or both. Leadership within the healthcare organization must identify and address the organizational factors that can cause burnout in nurses. Individual nurses also need to recognize risk factors to improve their work-life balance. Various organizations, including the Centers for Disease Control and Prevention (CDC) and The Joint Commission (TJC), have put forth recommendations for improving HCP well-being to reduce burnout and manage fatigue and stress during times of crisis. HCPs continue to provide care despite challenging work demands, increased stress, and more complex care needs in times of crisis. Healthcare organizations are faced with the challenge of caring for patients while also considering the needs of their staff. This delicate balance is challenging to achieve, and there may be times when stress is unavoidable, but burnout can be prevented. Managing stress and exhaustion is a shared responsibility between the individual HCP and the healthcare organization. By working together, effective prevention and treatment strategies can be instituted (Hittle et al., 2020; TJC, 2021). TJC outlines a four-step approach to address the challenge of improving clinician well-being (TJC, 2021):  

• Change what we measure: Numerous studies have evaluated burnout among HCPs. Of course, it is essential to continue to capture burnout statistics, but the professional and emotional thriving of HCPs is the goal. Therefore, the National Taskforce for Humanity in Healthcare (NTH) has worked with national experts to develop and employ new, validated measures to provide insight into the HCP’s current state along a continuum from burnout to thriving.  

• Targeted interventions: Healthcare organizations should create customized solutions tied directly to the HCP’s current emotional state. 

• Customized interventions should be part of a holistic approach: While targeted interventions are essential, these interventions must address a broader, holistic approach to reduce burnout and improve thriving. This approach requires leadership to foster an optimal nurturing environment and build relationship skills for the HCPs. Healthcare organizations should remove barriers and instill joy into daily work responsibilities/activities.  

• Focus on positive emotions: Healthcare leaders should be mindful that staff often focus on negative experiences and emotions. Therefore, strategic focus on what is going well is critical for leaders within healthcare organizations. In addition, interventions to reduce burnout and promote thriving must regularly connect HCPs with positive emotions.  

There are several additional strategies that the healthcare organization can implement to prevent nurse burnout. The first organizational strategy provides administrative support for education on recognizing and preventing burnout. “Know the problem and 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, recognition of staff nurses who excel at their jobs, and a culture of teamwork and collaboration (Hittle et al., 2020; Sillero & Zabalegui, 2018; USAHS, 2020). 

Implementing strategies to improve scheduling and staffing is an organizational technique that must be implemented consistently to prevent nurse burnout. Nurse managers need to be knowledgeable about the workflow in their units and adjust staffing appropriately.  Nurse managers should be accessible and willing to pitch in when needed. For example, if the unit typically receives numerous admissions, or there are more 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 there is sufficient staffing to handle the workload. Nurse administrators could also implement a pool of as-needed/per diem nurses who can be scheduled during periods of higher workload (Hittle et al., 2020; Sillero & Zabalegui, 2018; USAHS, 2020).  

Providing wellness benefits for nursing staff is another organizational strategy to prevent burnout. Wellness benefits include funding smoking cessation programs, free or reduced gym membership fees, calorie count information, healthy food options in the hospital cafeteria, stress reduction training, and meditation programs. Another critical aspect of training occurs at the universities and medical schools that educate the next generation of HCPs and nurses. Academic institutions need to educate students about burnout and burnout prevention strategies. This training will make preprofessional students aware of burnout syndrome and how to cope with it when they enter the workforce (USAHS, 2020; WGU, 2019; Ezenwaji et al., 2019). 

While organizational factors contribute to nurse burnout, factors attributed to the individual nurse can also result in burnout. First, the individual nurse must recognize the signs of burnout. Nurses should identify the changes in their mind and body when they start to feel burned out to better care for themselves. Next, nurses need to embrace the concept of work-life balance. Nurses are caregivers who often put the needs of their patients ahead of their own, which can be difficult. However, a nurse who prioritizes self-care and embraces work-life balance will be more content and able to function effectively in the workplace (WGU, 2019). Additional strategies that nurses can use to prevent burnout can include (USAHS, 2020; WGU, 2019): 

• Improve schedules: nurses should minimize rotating between shifts throughout the week. Also, HCPs should avoid working overtime or extended shifts.  

• Take breaks: nurses should utilize their vacation time to get away from the workplace. During the workday, nurses should not skip breaks or their scheduled mealtime. Getting away from the unit for brief periods throughout the day is crucial.  

• Learn to say “no”: nurses naturally want to help others, which can sometimes be problematic when the nurse overextends themselves. Learning to say no and setting boundaries can prevent burnout.  

• Ask for help: nurses who are feeling signs and symptoms of burnout should be empowered to speak up. Making their needs known can help healthcare leaders make appropriate changes to ensure the nurse's or HCP's well-being.  

• Reignite the passion for nursing: when nurses experience signs and symptoms of burnout, reflecting on why they chose nursing can be helpful. Sometimes getting involved in a new initiative they are passionate about can change those feelings of burnout into personal accomplishment. Nurses may also consider going back to school to advance their careers.  

• Seek support: nurses should seek out support groups, buddies, or mentors that can serve as an outlet to vent frustrations or discuss challenges. Creating peer mentors encourages teamwork and collaboration, decreasing the risk of burnout.  

• Learn coping methods: resilient nurses are less likely to become burned out. Therefore, effective coping is critical to HCP well-being. Potential approaches include breathing techniques, mindfulness, meditation, restorative exercise, journaling, and a post-work relaxation routine. 

• Changing specialties or focus: one of the unique features of nursing is that there are numerous different specialty areas. If the current work environment is causing significant stress, a change of pace or setting may be necessary. Strategies could include changing units or facilities, moving from inpatient to outpatient, or changing roles.  

• Prioritize physical wellness: basic strategies could include healthy eating, regular exercise, sleeping at least seven hours per night, smoking cessation, and limiting alcohol intake. 

The prevention strategies discussed above can also be used as management strategies for nurses experiencing burnout. Nurses should focus on work-life balance, self-care strategies, and reducing workplace stressors. Mindfulness-based stress reduction (MBSR) programs have effectively mitigated the signs and symptoms of burnout in nurses and other healthcare professionals. In addition, Healthcare organizations should leverage their leadership personnel to create workplace environments that foster resilience and self-care for their staff. Some strategies that leadership can use to create a nurturing environment to manage burnout can include (Wolotira, 2022): 

• encourage staff participation in self-care activities at work (e.g., walking, mindfulness, meditation, journaling) 

• invite staff to go on a walk and listen to their stories 

• have crucial conversations with staff about signs and symptoms of burnout 

• diversify or decrease staff workload 

• support staff In having time off, including vacations 

• encourage participation in debriefing after traumatic events 

• provide positive recognition of staff 

• acknowledge and recognize the loyalty of staff members 

• promote peer support, teamwork, and collaboration 

• empower staff in professional development 

• support employee autonomy 

Conclusion 

Burnout and compassion fatigue can negatively impact patient care. Therefore, the nurse needs to be able to recognize the symptoms of burnout to implement individual burnout prevention strategies. In addition, hospital administrators and nurse managers must be aware of the sources of burnout within the healthcare organization to address these proactively and avoid nurse burnout (USAHS, 2020; WGU, 2019).  

References 

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