Burnout can steal the enthusiasm, satisfaction, and joy that prompted you to become an NP. It can rob you of the joy of caring and potentially deprive your patients of the care they need.
As a nation, the U.S. can ill afford to have NPs burn out. A national survey of U.S. adults conducted by the American Association of Nurse Practitioners (AANP) in April 2023 found that more than 40% of respondents have experienced a “longer than reasonable” wait for healthcare. In a press release, 26% of those surveyed reported waiting more than two months to gain access to a healthcare provider. NPs, notes the AANP, can help fill that void.
At the same time, NPs deliver more of the care patients receive in the U.S., according to a study published in September in The BMJ. From 2013 to 2019, the researchers found the proportion of all traditional healthcare visits delivered by NPs and physician assistants (PAs) increased from 14.0% to 25.6%.
We’ll look at some factors that cause burnout and ways to prevent it from diminishing your enthusiasm or leaving practice entirely.
First, let’s take a brief look at the signs of burnout.
Signs of Strain
Burnout is characterized by emotional, physical, and mental exhaustion, notes April N. Kapu, DNP, APRN, ACNP-BC, FAANP, FCCM, FAAN, immediate past president of the AANP. A practitioner can feel less valued and lose interest in their work.
You may have trouble sleeping, experience tension and stress, and potentially have prolonged feelings of depression, according to Sunny G. Hallowell, PhD, APRN, PPCNP-BC, associate professor, pediatric nurse practitioner, M. Louise Fitzpatrick College of Nursing, Villanova University.
COVID Makes it Worse
While blaming the pandemic for NP burnout would be easy, burnout was a phenomenon before COVID. “What happened during the pandemic is the phenomenon of burnout, which has been consistently well documented in the healthcare literature for decades before COVID. Those events were exacerbated by the pandemic,” according to Hallowell. “It was already there. It just got so much worse.”
One data point of burnout before the pandemic comes from a study conducted in early 2018, which examined advanced practice registered nurses, including NPs and PAs. It found that 59% of respondents experienced or formerly experienced burnout. The pandemic “really blew everything up,” says Kapu, the study’s lead author, published in the Journal of the American Association of Nurse Practitioners.
Forces of Stress
Besides the pandemic, unhealthy work environments can lead to burnout. In those environments, notes Kapu, staff shortages continue to take a toll, overtime may be needed, and there needs to be more opportunity for professional growth, development, or change.
Furthermore, the back-and-forth involving full practice authority for NPs may also cause stress. During the pandemic, various states provided temporary waivers allowing full practice authority for NPs. Since then, some states have reverted to reduced or restricted practice laws. This sends a “mixed message,” notes Hallowell, breeding mistrust, uncertainty, and confusion.
“In states that have moved to full practice authority, we’ve seen an increase in the workforce; NPs enjoy working there,” says Kapu. “We’ve seen those states move up in terms of overall healthcare outcomes. The top five states in the U.S. in terms of healthcare outcomes are all states where nurse practitioners can practice to what they’ve been educated and trained to do.”
NPs might also suffer from stress in dealing with inexperienced healthcare colleagues. “The distribution of healthcare delivery has shifted in such a way that we have a lot of inexperienced folks at the frontline now,” Hallowell notes.
“We need to create a structure to onboard and train and bring these new workers into the work environment, help them develop confidence in their skills, make sure that they’re competent in what they’re doing,” notes Kapu .” We’ve done this as nurse practitioners for years. We have onboarding, orientation, and training programs, and we support them through that so that they feel competent and integrated into the team. They have a supportive environment where they can reach out and ask questions as needed.”
Self-care is Key
When it comes to preventing burnout, tactics involve self-care, notes Hallowell. They include:
Rest.
Asking for help. Hopefully, you can call on experienced colleagues who can provide emotional support to offset the stress, demands, and mental load of patient care.
Requesting training. If you are doing something unfamiliar, ask for education.
Exercise.
Good nutrition.
Having interests outside the profession.
Socializing with friends and family
Mindfulness.
“We need to make sure that we recognize the signs and symptoms and then determine what will be our change,” says Kapu. “Do we need to work in a better environment? Can we help contribute to making our work environment better? What are we doing in terms of self-care?”
Addressing the exhaustion that can lead to burnout is similar to exercising a muscle, notes Kapu. “You work a muscle to a critical mass and then recover. That’s how it gets stronger. It’s the same thing with stress,” she notes, where some stress is good, but it may get to a point where you have to take time away.
“We have to give ourselves time to recover, to refuel, to constantly check in and say, Am I taking care of myself so I can bring my very best self to my patients?”
Nursing has always held health equity as a critical value in many ways. Nurses strive to deliver the best care to all patients, independent of socioeconomic status, gender, race, or other factors.
Health equity arguably gets even more attention than in the past. And that attention also occurs in nursing schools, where nurses are presented with the concept of health equity.
In this article, we examine how various schools teach health equity. But first, let’s define the term.
“Equity should mean that people have the opportunity to get what they need when they need it,” notes Alicea-Planas, associate professor of nursing at Egan and practicing nurse at a community health center in Bridgeport, CT. “That’s something that has historically been lacking for certain communities within our healthcare system.”
Health equity means that “everyone has the ability and opportunity to be healthy and to access healthcare to help them maintain health,” says Latina Brooks, PhD, CNP, FAANP, associate professor at Frances Payne Bolton School of Nursing, Case Western Reserve University, Cleveland, Ohio. Brooks also directs the MSN and DNP programs at Frances Payne.
Beyond Accessibility
The CDC notes that achieving health equity requires ongoing efforts to address historical and contemporary injustices; overcome economic, social, and other obstacles to health and healthcare; and eliminate preventable health disparities.
Health equity isn’t just about access to healthcare, notes Elaine Foster, PhD, MSN, RN, vice president of nursing, Education Affiliates. It can also relate to whether a diabetic patient, for instance, knows what to get checked. “I think sometimes we’ve put a very narrow description on health equity, and I think if you were to flesh it out, it goes beyond that accessibility,” Foster notes.
“You can even take health equity that next step and say, Do you have an advocate or do you have someone who knows to push the envelope?” says Foster. “We have to be active participants in our healthcare these days to get what we need.”
Besides accessing resources, health equity involves “understanding how to navigate our healthcare system,” says Alicea-Planas. “It is understanding the information that’s being provided to us by healthcare providers and being able to use it for patients to do well on their health and wellness journey.”
Teaching Equity
At various schools, health equity is integrated throughout the course of study. For instance, at Adelphi University College of Nursing and Public Health, Long Island, New York, health equity is threaded throughout the undergraduate and graduate curriculum in various courses, notes Deborah Hunt, PhD, RN, Dr. Betty L. Forest dean and professor. For example, in the school’s community health course, there is a focus on vulnerable and underserved populations. In the childbearing course, Hunt notes, there is a focus on health disparities and maternal and infant mortality.
Foster notes that health equity is threaded into the curriculum at the 21 nursing schools within the Education Affiliates system. Likewise, at Frances Payne Bolton, health equity is integrated into courses. However, Brooks notes that some courses go more in-depth, such as discussing health equity in vulnerable populations.
At Egan, introductory courses talk a lot about health equity and social determinants of health, notes Alicea-Planas, as do clinical courses. “I think a big part of understanding health equity is also understanding social determinants of health,” says Alicea-Planas. “I am super excited that now in the nursing curriculum, we have lots of conversations around those social determinants of health and how they influence people’s ability to attain their highest level of health.”
The Takeaways
One crucial learning that Alicea-Planas hopes students take away is that for students who haven’t been exposed to many people from different backgrounds, it’s essential “to understand how historically our healthcare system has treated certain communities of color. That factors into people’s feelings about how doctors or nurses treat them, influencing their ability to seek care.”
Foster hopes that students learn that no matter what the patient’s background, “Everyone is entitled to good, nonjudgmental care within the healthcare system.” Students must learn “not to impose our beliefs, our judgment on someone. Because until we get rid of that type of judgment, we will never overcome issues with health equity because we’ve got to first check our beliefs and opinions at the door and say I’m going to give the best care possible to these patients.”
You may not naturally think of becoming a nurse executive, which may seem far removed from the bedside and benefiting patients. Yet, you can significantly impact patient care as a nurse executive, such as a chief nursing officer.
“When you’re caring for patients, as a nurse, you’re caring for a set cadre of individuals,” says Elizabeth Speakman, EdD, RN, FNAP, ANEF, FAAN, senior associate dean, professor, and chief academic officer, School of Nursing, University of Delaware. “When you’re in a leadership role in the clinical environment, you may have thousands of patients you are responsible for.”
If that appeals to you, read on. In this article, we’ll examine a few programs available to prepare for the nurse executive role.
Students at the 28-month program “typically come with a master’s degree already and have some experience at a leadership level,” according to Kimberly Nerud, PhD, RN, dean at Post University’s American Sentinel College of Nursing and Health Sciences. Perhaps they have worked as a charge nurse or directed a healthcare unit, and “they’re looking to build on those skills that will help prepare them for those advanced opportunities within a healthcare system.”
At the Frances Payne Bolton School of Nursing at Case Western Reserve University, students who want to pursue a role as a nurse executive can choose from a range of programs, according to Joyce J. Fitzpatrick, PhD, MBA, RN, FAAN, Elizabeth Brooks Ford professor of nursing, Frances Payne Bolton School of Nursing and distinguished university professor, Case Western. Those programs include a doctoral program with an executive focus and a postdoctoral and senior executive program. These programs are housed within Case Western’s Marian K. Shaughnessy Nurse Leadership Academy.
Although students need a doctoral degree to enter the postdoctoral program, for instance, the academy believes that “every nurse is a leader,” notes Dr. Fitzpatrick. “Our philosophy is you’ve already got the leadership skills. You may not know how you have been leading, but you have been leading as a clinical nurse.”
For example, Dr. Fitzpatrick notes, “Nurses are leading care at the bedside for the patient. They’re leading care for the patient’s families. So as they become nurses, they learn to lead in clinical care. We capitalize on the experiences they’ve already had as clinical nurses and help them to understand how they’ve been leading all along.”
The school emphasizes a relationship-based leadership model, according to Dr. Fitzpatrick. That includes components such as communication, executive presence, intentional communication, and helping the leader understand any individual’s influence in a leadership role.
The academy, says Dr. Fitzpatrick, is especially interested in identifying individuals to join the program who come from under-represented groups. The school also seeks to engage minority nurses in mentoring the next generation.
“Stackable Credentials”
According to Dr. Speakman, nurses considering executive leadership positions can benefit by focusing on two actions. First, “they need to know that leadership is not just your title. Leadership can be very informal. How you lead is more important than your position. How you hold yourself pedagogically in life and how you present yourself. I think that’s the first and foremost conversation.”
The second involves earning what Dr. Speakman calls “stackable credentials.” That can include fellowships, earning certificates, and joining leadership programs – gaining new skills. Another word of advice: “Before you decide you want to be the top executive, spend time with the top executive.”
Leading After COVID
In considering a role as a nurse executive, know that COVID took a toll on nurse leaders, making the need to prepare nurses for executive roles even more important. Dr. Nerud hopes that “we can help to rebuild that area of nurse leadership that decided to take a step back or step out or retire early because of all of the demands that came from the pandemic.”
Dr. Nerud stresses the need to have nurse executives view problems from a policy perspective “that we’re helping these leaders go in to help be able to think fast and be able to talk about the policies that need to be made to move quickly because we learned during the pandemic that that was huge. We needed to be able to focus on quick changes and quick policies and quick things that needed to happen.”
During the pandemic, leaders faced significant challenges, notes Dr. Fitzpatrick, as did clinical nurses. “We need to continue recruiting nurses into leadership roles because the challenges are still there,” she says.
Even though the worst of the pandemic is over, we still have to rebuild and revitalize the clinical systems,” says Dr. Fitzpatrick. “We want to be sure that we focus on nurses staying in the workplace, which falls to the leader. We know from the research that if you have good leaders, you have higher nurse satisfaction–that leadership is key to keeping the clinical nurses engaged.”
“There is No Box”
Nurse executives and leaders have opportunities in traditional healthcare systems, industries, and corporations. “We shouldn’t just think of nurse leaders being positioned in the traditional healthcare environments, but engaging them outside of the traditional healthcare environments into executive positions in corporations as well as in community health,” says Dr. Fitzpatrick.
“The potential is unlimited because nurses come with skills that help them to help others. I like to teach my students, we often talk about thinking outside the box, but what we try to communicate to our nurse leaders is there is no box.”
If you’ve seen an increase in your paycheck in the past few years––and hopefully you have––you are part of an overall trend of increases in salaries for nurses. And, as you might expect, some of that has to do with the effects of the COVID pandemic.
“We’ve seen an increase in nursing salaries, particularly since the pandemic,” says Katie Boston-Leary, PhD, MBA, MHA, RN, NEA-BC, director of nursing programs and co-lead for Project Firstline at the American Nurses Association (ANA).
Registered Nurses (RNs) earned a median salary of $81,220 in May 2022, according to the Occupational Employment and Wage Statistics (OEWS) program from the Bureau of Labor Statistics (BLS). That’s up from a median salary of $77,600 in 2021. The mean (as opposed to median) annual wage for RNs as of May 2022 was $89,010.
Katie Boston-Leary, PhD, MBA, MHA, RN, NEA-BC, is the director of nursing programs and co-lead for Project Firstline at the American Nurses Association (ANA)
Nurses on the West Coast and Northeast generally enjoy higher salaries than nurses in other areas of the country, with an annual mean wage of $87,990 to $133,340. The top-paying states for RNs included California, Hawaii, Oregon, Massachusetts, and Alaska. The lowest salaries were clustered in the middle of the country, where the annual mean wage of $37,360 to $74,330 was indicated for nurses in states such as South Dakota, Missouri, Tennessee, and South Carolina.
Some 46% of surveyed nurses earned a salary between $80,000 and $139,999, according to the2022 Nursing Trends and Salary Survey Results published in American Nurse, the official journal of the ANA. Those figures were up from 39% in 2021 and 41% in 2020. Nearly half (47%), notes the report, earn less than $80,000, but 62% reported that their salary was higher than the prior year.
Pandemic Effects
Before the pandemic, healthcare organizations were moving away from merit increases for nurses and shifting more toward bonuses and cost of living increases, according to Boston-Leary. But that has been problematic, she notes, because a great deal of data indicates that, to a certain degree, nurses live barely above livable wage in some markets. As a result, some nurses work overtime or take on second jobs.
The pandemic encouraged nurses to feel justified in asking for fair compensation. “It’s important to recognize also that, culturally, it has been taboo for nurses to raise the salary issue because the thinking around nursing has always been that it’s altruistic. It’s about serving others. It’s not about money. It’s true. Many of us didn’t get into nursing to get rich. But you hope you’ll get compensated appropriately, and it’s always been a struggle for nurses to advocate for what they deserve in terms of their salaries. So I think some of that broke through with the pandemic.”
Not only were nurses who were incumbents in organizations making less than the staff they were training, notes Boston-Leary, but also agency nurses were making a lot more than they were. “That created this untenable situation where many nurses rallied,” some striking or entering new bargaining agreements.
“Now we’re in this place where there’s a reckoning point, and there is some making up that’s happening,” says Boston-Leary.
Minority Challenges
Nurses of color face challenges when it comes to salaries. “The difference is that many nurses of color don’t get the opportunities to climb the career ladders as quickly as their white counterparts,” says Boston-Leary. “That in itself presents a salary discrepancy. And there are many more minoritized nurses with multiple degrees and academic achievements that are not in leadership roles compared to their white counterparts with lesser credentials.”
Organizations have had the reluctance to track such data as turnover for nurses of color and nurse satisfaction by race, notes Boston-Leary. “There’s been an unwillingness over the years to look at that because when you look at it, you must deal with it. That is starting to change, but we’re still not fully there.”
In the long struggle to gain full practice authority (FPA), nurse practitioners (NPs) can point to notable advances in the last few years. Now, patients in more than half of the states, the District of Columbia, and two U.S. territories have full, direct healthcare access from NPs.
In April 2022, New York and Kansas granted FPA to NPs. That brings to 26 the number of states where NPs can practice to the top of their license without restriction. In this article, we’ll look at how that progress was made, the impact of COVID, and how newly proposed federal legislation would strengthen NP practice. But first, let’s have a look at what FPA means.
Defining FPA
“Full practice authority is essentially that the nurse practitioner can practice to the full extent of their education and training,” says April N. Kapu, DNP, APRN, ACNP-BC, FAANP, FCCM, FAAN, president of the American Association of Nurse Practitioners (AANP). “Nurse practitioners are trained to evaluate patients, make diagnoses, order and interpret tests, prescribe medications, coordinate care, and educate. We are educated and trained to do these things,” says Kapu.
In the past few years, the pace has “really picked up as we have seen more and more states move to full practice authority,” according to Kapu. She notes that four states moved to full practice authority through the pandemic: Delaware and Massachusetts in 2021 and New York and Kansas in 2022. “It’s because we demonstrate our commitment to quality and equitable care and ensuring care is provided in all communities.”
In states that have moved to full practice authority, “we’ve seen improved patient care outcomes. We’ve seen an increase in the workforce. We’ve seen an increase in nurse practitioners working in historically underserved urban and rural areas,” Kapu says.
COVID and Care
While devastating, COVID helped bring to light the high-quality care that NPs provide and boosted efforts to gain FPA. In some states where NPs worked under less than full practice authority, the governors signed executive orders waiving various restrictions, notes Kapu.
“That’s where we saw the opportunity for nurse practitioners to continue providing care. They provided very high-quality care. They were able to provide more accessible care. As you saw throughout the pandemic, they were in communities and churches, going door to door, seeing patients in their homes, and doing everything they did in the hospital and the ICUs. So we demonstrated that continued quality of care. And that is what quickened the momentum during the pandemic; the executive orders provided that opportunity,” Kapu says.
Ohio Experience
In Ohio, a reduced practice state, an emergency authorization during COVID allowed NPs to deliver care via telehealth, notes Evelyn Duffy, DNP, AGPCNP-BC, APRN-NP. However, she notes that NPs can still practice via telehealth, and that ability is no longer contingent on emergency authorization. Based in Cleveland, Duffy is an NP in the University Hospitals Geriatric Medical Group and a professor at the Frances Payne Bolton School of Nursing.
An NP since 1981, Duffy notes that “we’ve come a long way in Ohio. We got full prescriptive authority at the end of the 1990s.”
However, like all Ohio NPs, Duffy needs a collaborative agreement with a doctor. “Ohio is in the reduced practice category,” she notes. “Not a lot obstructs me from doing what I want. The only thing that gets in the way is having to make that collaborative arrangement.”
Overcoming Obstacles
Kapu stresses the need to get out the message that laws limiting NP practice need to be revised. Laws need to be updated to “allow NPs to practice to the extent of their education and training, not beyond that, but to the extent of their education and training, as they are very capable of doing and have decades and decades of evidence demonstrating their quality-of-care outcomes. So it’s getting that message out that all we have to do is update those laws. It’s no cost or delay and can be put into place, and you would see much-increased access.”
Kapu points to Arizona as an example of what may happen for states that grant FPA. Arizona, she notes, moved to FPA in 2001. Five years later, the NP workforce doubled, and rural areas saw a 70% increase in NPs.
Federal Legislation
On the federal level, new legislation, the Improving Care and Access to Nurses (ICAN) Act, was introduced in September in the House of Representatives. Supported by the AANP and other major nursing organizations, the act would update Medicare and Medicaid to enable advanced practice nurses to practice to the top of their education and clinical training, according to a press release from the American Nurses Association.
Maintaining Momentum
Although getting FPA in all states has taken a little longer than wanted, “we have momentum,” says Kapu. “I believe we’ll get there, especially with the increasing access to care needs that we’re seeing in the United States today.”
