Nurses—especially in the last year during the pandemic—have been experiencing burnout. Often, articles focus on what they can do to make themselves feel better. But what can their workplaces do?
Anne Dabrow Woods, DNP, RN, CRNP, ANP-BC, AGACNP-BC, FAAN, Chief Nurse of Wolters Kluwer, Health Learning, Research & Practice, a Critical Care Nurse Practitioner at Penn Medicine Chester County Hospital, and a Clinical Adjunct Faculty member at Drexel University. She’s also authored and presented on many clinical and professional topics including a recently published eBook, COVID-19: Transforming the Nursing Workforce in the New Paradigm of Care.
She took time to answer our questions about what hospital leadership can do to prevent nurse burnout.
From a hospital leadership standpoint, what are some of the steps they can take to help prevent nurses from burning out?
Health care systems need to recognize that their most valuable commodity is their workforce. For years, health care systems have focused on patient well-being, but now many of those institutions are beginning to see the importance of focusing on workforce well-being too. Hospitals need to provide a safe environment for their workers, recognizing when they’re exhausted, burnt out and/or experiencing moral distress on the job. Safe environments should include the assurance of personal as well as patient safety and having adequate personal protective equipment, clinical decision support resources, and adequate staff to appropriately care for patients.
Staffing needs must be based on clinical acuity and severity of illness, not just on the number of patients. And having an agile workforce that can work in a variety of units as well as be shifted to other units when and where they are needed the most, is also a new essential, thanks to COVID. What we want, and need, are multispecialty nurses who can work across multiple units, not just single-specialty nurses working only with one patient population. Cross-training and upskilling staff to care for patients in a variety of units with a variety of care needs brings flexibility and efficacy to the workforce so managers will not need to overwork staff and can provide necessary time off.
Health care systems need to recognize when a member of their workforce is experiencing burnout and moral distress by having leadership and those trained in recognizing emotional distress available and on the unit to assess for it. Social workers and mental health workers are excellent resources to utilize for this kind of assessment. Taking the time to debrief and discuss what went right and what could have gone better in emergencies is a great opportunity to decompress after stressful situations. Many hospitals have instituted a moment of silence after a death where everyone in the room stops to acknowledge the life that was just lost.
Employee assistance programs (EAP) are good, but only if they can be easily accessed by those who need them. Too often EAP programs are difficult to find on the health care system website, and once they are found, the paperwork and or searching for an available care provider is incredibly challenging. EAP programs need to be made readily accessible and usable.
What should they do first?
The most important first step is to recognize that there is a problem with burnout. If staff are quitting, retiring early, or are becoming less engaged, there is a real problem. Be present! The leaders within the organization must be up on the units to experience what is going on firsthand. You need to find out if staff able to take breaks and leave the unit to have a meal. Are they able to sit down or are they constantly moving and up on their feet? Are they working as a team or as individuals? Health care is a team activity. It takes an interdisciplinary approach to provide the highest quality care and facilitate the best outcomes. If patient outcomes are not where they need to be, the first place to look is at your caregivers to see if they are exhausted, burned out, or experiencing moral distress.
What action steps should leaders recommend that nurses take? How can they get this information to them?
The question should not be what steps leaders should recommend to nurses to combat burnout, but how can health care organizations facilitate workforce well-being and prevent burnout? It is the obligation of leaders to assess the situation, make a plan, implement it, and then evaluate if the plan and interventions are working.
Start meeting with the staff, watch and listen to what they have to say, and start implementing these 10 steps:
Assess if the staff are burned out or experiencing moral distress.
Make employee assistance programs easy to access and utilize.
Adequately staff the patient care units with the right staff for the right patient populations.
Cross-train the workforce so they are more agile and can go when and where they are needed.
Provide adequate support systems, unit coordinators, unlicensed assistive personnel, and transporters.
Make sure the workforce takes their breaks and mealtimes.
Offer healthy food. Get a cart and take healthy options to the unit if the staff is too busy to get to the cafeteria at mealtime.
Give the staff time to debrief and collect themselves after a challenging situation.
Decrease documentation burden and make sure nurses have input on what is added to required documentation in the electronic health record.
Offer continuing professional development activities and career ladders to meet the staff’s professional needs.
Remember, nurses have family and financial concerns; offer care alternatives and financial counseling if and when it’s needed.
If nurses are already experiencing burnout, what should hospital leaders do? How can they help? And how can they let nurses know that their jobs aren’t in jeopardy if they need to take time off for their mental health because of burnout?
Take the time to see, hear, and experience what nurses are experiencing. You can’t do that from an office, so get up on the patient care units and look around. If the workforce doesn’t feel valued by the organization, they will leave, and there will be fewer caregivers left to care for the patients. Develop a “care without judgement model,” meaning that to whomever is in need of care—a patient, a nurse, or another employee—care will be delivered, without judgment. No one’s job should be at risk if they need to take time to step away and focus on self-care. You cannot be a good clinician unless you care for yourself first. Again, make it easy to access employee assistance and mental and physical health resources.
What should hospital leaders absolutely *not do when trying to prevent their nurses from burning out? What are the biggest mistakes they can make?
The biggest mistake health care leaders make is not recognizing that the health care workers are the most important commodity within their organization. Patient outcomes are optimized only if the staff feels valued, have adequate resources, are properly trained, and feel safe in their work environment—both physically and emotionally. Everyone on the health care team needs time to be able to take a moment to step away and recharge.
During COVID-19, what have been the biggest challenges that nurses are facing in terms of burnout? Is there anything that hospital leadership can do to help?
The biggest challenges have been fear and uncertainty. Fear that we initially didn’t know enough about the COVID-19 virus, and we might bring it home to our families or become infected ourselves, and fear that the death we experienced day after day wouldn’t stop. And uncertainty that we wouldn’t be strong enough to keep delivering care to our patients as we fought this seemingly unending pandemic. Yet we did. We looked fear and uncertainty in the face and said—”we will not be daunted!” That’s who we are—we are nurses, and our passion is to care for those in need.
Health care systems need to invest in workforce well-being, retaining the talent they have and recruiting new nurses to take the place of those who have left the profession. Care begins with those in our family. In health care, the workforce is our extended family.
The vaccine is a game-changer for nurses. The more shots in arms, the lower the number of patients we will see fighting for their lives because of COVID-19. Let’s trust in the science and use the evidence to educate people about COVID-19 and how to prevent it.
And finally, nurses need to invest in their own well-being so they can invest in caring for others.
Often, nurses are referred to as heroes for the amazing work they do. Now, a new television special will bring them to the living rooms of families across the nation.
Premiering on June 24 at 8 p.m. ET on Discovery Life, American Nurse Heroes will feature inspirational, true stories about nurses providing care. Produced by the American Nurses Association, Al Roker Entertainment, and HealthCom Media, the show will have additional airings on June 26, 10 a.m. ET on Destination America and on the American Heroes Channel at 11 a.m. ET, in addition to other NBC Markets throughout the weekend.
One of the nurses featured in the special, Fidelindo Lim, DNP, CCRN, Clinical Associate Professor at the Rory Meyers College of Nursing at New York University told us what it was like to be on the show.
What did it feel like when you were asked to be profiled on American Nurse Heroes?
Being invited to be among the nurses featured in the film was a complete surprise because I am not a frontline worker. To be featured, I felt I was taking part in something larger than myself and I was honoring the great work of nurses who came before me.
What’s your story?
I am a full-time clinical associate professor at NYU. I think I was selected because over several years I have been publishing reflective essays for the My American Nursejournal, the official journal of the American Nurses Association. In these essays, I offer a contemplative exploration of topics such as therapeutic communication, meaningful recognition of nurses, narrative medicine, empathy, and patient-centered care. They wanted me to share my perspectives on nursing education in time of the pandemic and share my insights on what nursing means to me.
How did it work? Did they come to your place of business and film you? How long did it take? Did they film you with patients, by yourself, etc.?
The film crew of six came to my place of work and filmed a scene where I was conducting a high-fidelity clinical simulation with two graduating students. We were simulating the care of a patient with COVID-19 who was having a hard time breathing. Then we had a debriefing on what went well and identified opportunities for improvement. After that, they took some B-roll shots while we were walking to my apartment. The formal interview took place in my living room. The whole process took about 7 hours.
Were you nervous or anxious about doing this?
Being filmed for an interview is a first for me. Although I have mentally prepared and visualized myself going through the filming, I get self-conscious thinking I may not sound right or my grammar might not be perfect, given that English is not my first language. The film director was supportive and made me feel relaxed, so that was great.
Did you feel like you were making a difference?
Articulating what I do as an educator during the filming gave me a confirmation that our collective professional identity as nurses is at the core of what we do on a daily basis. For me, the film is a cinematic validation of the value of nursing care and why the public trusts nurses. The pandemic enabled the public to see the value of nurses and nursing. Although I am no longer a frontline worker, I’d like to think that I made an indirect, albeit small, contribution to the patient care during the pandemic, because I helped educate so many nurses in the past 25 years.
Why do you think nurses should be recognized on this TV show? Do you think it will attract more people to become nurses?
The pandemic enabled the public to see the value of nurses and nursing. The world became very aware of what nurses do, particularly in a frenetic health crisis. There are anecdotal reports that enrollment to nursing programs remain robust and are expected to increase as the public recognition of nurses continues. I’d like to think that after watching the film, nurses will feel validated on their choice to become a nurse and be invigorated in their efforts to bring humanism to health care.
What was your favorite part about this whole experience?
Being interviewed made me feel special for being a nurse! It gave me an uncommon opportunity not only to know, but to understand myself. It is like being aware of one’s footsteps while marching towards finding meaning in the work I do, and looking back, every now and then, to make sense of the journey.
Teaching nursing is most satisfying for me because I have the privilege of transferring my knowledge and skills to the students, sharing with them the multitude of patient narratives that helped me become a competent nurse, and hearing the students tell me later, after they started working, what they have done with the science. The stories warm my heart.
Nurses all over the country have been giving vaccinations for the COVID-19 virus. As more and more settings are offering the vaccine, there are a number of risks that nurses need to be aware of before going to work and assisting with vaccine distribution.
Jennifer Flynn, CPHRM, Risk Manager, Nurses Service Organization (NSO), agreed to answer our questions about what nurses need to be aware of when they’re going to give COVID-19 vaccinations.
Overall, what do nurse need to be aware of in general?
When assisting with a vaccination program, whether through your employer or volunteering, nurses need to ensure that vaccines are administered in appropriate settings with adequate patient safety and monitoring procedures. Nurses may require additional training to participate in administering vaccines. In general, nurses will want to educate themselves on vaccine specifics, as well as other considerations including but not limited to, contraindications for administration, potential adverse reactions, dosing requirements, storage and handling requirements, documentation requirements, administration requirements such as mixing with diluent, appropriate needle size and anatomic administration sites, and post-vaccination monitoring requirements. Providers will also want to be prepared for responding to adverse events, such as anaphylaxis.
What is informed consent and informed refusal? Why do nurses need to be aware of them? If someone refuses, what should they do?
Simply put, informed consent is a two-part process: the discussion and the documentation of that discussion. From a liability perspective, it helps to manage patient expectations—it can reduce the possibility of a misunderstanding. And, it can strengthen one’s legal defense in the event of a claim.
In order for patients to give informed consent, the verbal discussion allows the provider to explain the risks of the proposed treatment, benefits, and alternatives. In order to gauge the patient’s understanding, they should have the opportunity to ask questions before any written consent is obtained.
The signed informed consent form should be placed in the patient’s health care information record.
Persistent failure to heed medical advice can lead to less than desirable results for the patient, as well as potential liability exposure for providers. Health care providers can counter this risk by adopting a standardized refusal-to-consent form, which serves to confirm in writing that the provider fully disclosed to the patient the risks of forgoing the proposed test, treatment, or procedure. By signing the form, patients acknowledge that they have discussed the proposed course of care with their practitioner and understand that failure to follow medical recommendations can have serious or even life-threatening consequences. The completed refusal-to-consent form should be placed in the health care information record.
Prior to administering the vaccine, nurses should participate as witness or be aware that the facility has performed the informed consent process that it has been properly documented. Ensure the patient received the manufacturer’s fact sheet, inform the patient of the FDA’s Emergency Use Authorization status of the vaccine, known and potential benefits and risks, option to accept or refuse the vaccine and the risks associated with refusal, any available alternatives, obtain the patient’s written informed consent and document the content of the discussion, materials provided to the patient, and the signed consent form in the patient’s health care record.
Why do they need to have adequate documentation when giving the vaccine? Does this differ is they’re doing this vaccination directly for their employer (say a hospital or rehab center/nursing home) or doing the work for a vaccine center?
A carefully documented record may prove invaluable in defending against allegations of negligence. When assisting with a vaccination program, whether through your employer or volunteering, documentation for administering vaccines should include the date and time of administration, vaccine administered, dosage and lot number, route and site of administration, and post-vaccination monitoring information.
As a reminder, the health care record is a legal document and is an essential tool to understand:
The patient’s medical event. Document thoroughly including treatment decisions made, actions taken, the corresponding rationale and information given to the patient.
The nurse’s actions. Good recordkeeping involves accurately conveying what was heard, seen and thought, what treatment was performed, why that treatment was necessary, and what future care was required—based solely on written documentation. Include patterns of noncompliance.
What the patient stated
What steps were taken to resolve or relieve the situation
Whether the patient responded favorably to those steps
The patient’s condition and mode of leaving following the appointment
The follow-up or referral instructions provided to the patient
If the record is deficient, the nurse’s credibility is weakened.
Because complete and accurate health care records are such an essential risk management measure, nurses should maintain proper documentation practices and follow their facility’s policies and procedures governing documentation.
Maintaining a consistent, professional patient health information record is essential to providing quality patient care, ensuring consistent communication among all professionals caring for the patient, and establishing the basis for an effective defense should litigation arise.
What are some tips for mitigating risk of malpractice?
Know and comply with your state scope of practice requirements, nurse practice act, and facility policies, procedures, and protocols. Follow documentation standards established by nurse professional organizations and comply with your employer’s standards. Maintain clinical competencies aligned with the relevant patient population and healthcare specialty. Develop, maintain, and practice professional written and spoken communication skills. Emphasize ongoing patient assessment and monitoring.
Can you give me some general education and infection control best practices that nurses should know?
When assisting with a vaccination program, whether through your employer or volunteering, the location should permit physical distancing between individuals who are in line to receive the vaccine in conformity with CDC guidelines. Patient appointments should be designated appointment times. Consider the creation of dedicated vaccination areas or specified hours for those at higher or severe risk associated with COVID-19. Implement strategies to manage patient flow, and limit crowding or long lines by using unidirectional signage. Limit the overall number of individuals permitted in vaccination or monitoring areas.
Anything else that is important for nurses to know?
I think it is also important for nurses to know “Do’s and “Don’ts” of what to do if they have received a legal summons/paperwork or State Board of Nursing complaint.
Contact your Risk Manager, your employer, and your insurance carrier immediately!
Secure and sequester the file to prevent alteration—Do not add or delete any information in the patient’s chart!
Comply with all investigations.
Give copies of records to patients when they request them.
Try to resolve legal/regulatory situations on your own (without legal or Risk Management guidance).
Call patient to discuss a legal/regulatory matter without talking to your attorney first.
Talk to anyone about the case other than your Risk Manager, your employer, your insurance carrier, and your attorney.
Oftentimes, nurses don’t take care of themselves like they should. While they focus on taking care of others, their self-care falls by the wayside. Especially during COVID-19 and the pandemic, they’ve put everyone else first.
Imani Wilform, MHC-LP, with Empower Your Mind Therapy, took time to answer our questions and give self-care tips on what nurses can do to make sure that they are making time for self-care. Our interview, which follows, has been edited for length and clarity.
Dealing with COVID-19 and the pandemic has been tough on everyone, but especially difficult on frontline workers such as nurses. Why should nurses be sure to practice self-care now?
As much as nurses care for everyone else, it’s crucial to pay attention to your own needs too. By its own true definition, self-care is about taking intentional care yourself: your mind, your body, your environment, and your spirit.
If we don’t practice self-care, we can become burned out, resentful, angry, and may even start feeling depressed. This also lowers your immune system and can make you feel tired and low. If you’re not feeling your best, how can you manage caring for others?
What are some things that nurses can do to be sure to remember self-care and to fit it into their busy days?
While the occasional self-indulgence like a spa day or getaway can be a great way to express some gratitude to yourself and all you accomplish, self-care is about more than an occasional treat. An intentionally cultivated daily self-care routine can make a huge difference in our lives and allow us to be balanced & more restored.
Today, ask yourself:
How do I typically take care of myself day to day?
Do I take time to regularly assess and address my needs?
How is that impacting both my mental and physical health?
I really want you to think about how (or if) you set aside time each day to take care of yourself. Do you have time to sit back and assess your needs? Do you listen to your body when it tells you that you need a break? When you’re mentally strained, do you have a routine that helps you rest and rejuvenate?
Is there anything they can do at work on a break or at home?
There are a lot of little things that are self-care, but aren’t exciting or Instagram-able. You can do these quickly:
Write down your to do list for the week to stop the constant nagging in your head.
Set a time to be done with screens before bed.
Make a meal plan that gets you excited to eat 3 meals a day.
Take a look at your calendar: are you overbooked, need a fun outing to look forward to, need to make a doctor’s appointment?
Call a friend to catch up.
Spend time outside.
What are absolute must-dos regarding self-care?
Assess your true needs: when we’re talking about daily self-care we’re talking mainly about wellness (mental & physical). For a week, keep a log of your physical and mental expressions of stress or strain. Are you tired? Do you have frequent headaches? Look at what comes up for you and come up with small, incremental steps to take action. Maybe you have constant headaches because you’re dehydrated. Start carrying a water bottle, set some reminders on your phone to actually drink from it.
Take a critical look at your routine: What is taking up your time on a daily basis? Often times we fall so behind on creating an actual daily routine that serves us that we end up playing perpetual catch up. Finding the right way to balance what you need day to day will help ease stress and keep you feeling more balanced and in control.
Prioritize rest: if you have to put it in your schedule or “to do” list to make sure you get time to rest and recharge then do it. Maybe it’s yoga, reading, taking a bath. Rest and rejuvenation should be a priority in your daily routine. Set aside small chunks of time each day where you stop the machine, ignore “productivity” and let yourself rest.
What would you say to a nurse who says s/he doesn’t have time for self-care because too much is going on?
Self-care can be something quick and small to help yourself with your own mental and physical well-being. As a nurse, it’s important to remember that you are just as important as your patients and family. Others rely on you, so rely on yourself too. Even if it’s a quick walk around the block during lunchtime or outsourcing personal to-dos to another family member—such as creating a shopping list or picking up a birthday gift for someone—try to take some time for yourself. Also remember that self-care shouldn’t create more pressure. If it’s too much to take time every day, start with setting aside some time once a month to check in with yourself.
Unfortunately, some issues or diseases are more prone to affect people in certain communities—case in point, colorectal cancer has been known to disproportionately affect the Black community as compared with white communities. In fact, according to the American Cancer Society, Black people are up to 20% more likely to get colorectal cancer and are also about 40% more likely to die from it.
We interviewed Phyllis Morgan, PhD, FNP-BC, CNE, FAANP, academic coordinator for Walden University’s MSN-FNP program, as she has conducted research on colorectal cancer in men as well as Black men and women’s health issues, including disparity in health and health care.
Phyllis Morgan, PhD, FNP-BC, CNE, FAANP
Why does colorectal cancer disproportionately affect the Black community?
There are several reasons why colorectal cancer disproportionately affects the Black community. First, there is a general lack of knowledge about screening for colorectal cancer, which contributes to inadequate prevention and screening behaviors. There are also various fears that come into play, such as fear of cancer and of a cancer diagnosis, and fatalistic views about cancer.
A recent study showed that in Black Americans, the right side of the colon ages much faster than the left side, which could contribute to this population’s increased risk for colorectal cancer, particularly on the right side of the colon, and at a younger age.
Other factors may include delayed treatment and the fact that Black individuals have a higher incidence of obesity and more often consume a high fat, low fiber diet, which increases risk.
Why are Black people who get colorectal cancer about 40% more likely to die of it than other groups?
In addition to factors such as inadequate prevention and screening behaviors as well as delayed treatment, racial inequities in care also contribute to the fact that Black people who get colorectal cancer are more likely to die of it than other groups. There is a widespread lack of access to care for many people in this population, and some have no health insurance or inadequate health insurance for treatment.
Additionally, lifestyle factors such as diet and exercise can contribute to this.
What are the challenges facing the Black community regarding colorectal cancer?
Some challenges facing the Black community regarding colorectal cancer include inequities in health care, lack of access to quality care, and a lack of adequate resources to educate about the importance of colorectal cancer screening. It is crucial that we increase screening by providing better education for the Black community regarding screening and the importance of polyps being removed from the colon.
Additionally, we need more diverse health care providers, so patients can have providers who look like them and with whom they can connect and relate. Black health care providers can play an important role in helping patients to understand the seriousness of colorectal cancer in their community.
What can nurses do in order to get people in minority communities to go for tests, pay attention to symptoms, etc.?
First, nurses can help by providing more colorectal cancer resources for their communities. In addition, culturally appropriate educational programs and community or faith-based educational programs can be helpful in encouraging people in minority communities to undergo screening.
As an African American woman and advanced practice nurse, I have participated in many projects and studies to identify ways to increase awareness, prevention, and treatment of health issues that impact the Black community. Specifically, I worked on a community and faith-based education program to increase awareness of prostate cancer among Black men, which resulted in an increase in participants’ general knowledge of prostate cancer and treatment by over 40%. I have also implemented successful community and faith-based education programs in North Carolina and Virginia to help educate Black people about colorectal cancer and increase screening behaviors. These types of programs are proven to make a difference.
Nurses can play a vital role in helping community and faith-based organizations develop and execute programs to address health disparities. It’s critically important for research to be conducted, especially in developing culturally appropriate models for diverse communities, so more contributions toward reducing health disparities can be made available to effect positive social change.
Last but not least, Walden University and the National League for Nursing are excited to launch the Institute for Social Determinants of Health and Social Change, where nurse educators and inter-professional colleagues will play an instrumental role in achieving health equity across various demographics. The institute is designed to cultivate these health care professionals into leaders who address the impact of structural racism, socioeconomic status, environment, education, adequate housing, and food insecurity on health and well-being.