Feeling overwhelmed? Heavy patient load, blazing speed, 24/7 shifts, and an ever-evolving field have long been complaints among nursing professionals. Add the stress of a slumping economy, budget cuts, and staff re-jiggering, and job fatigue can hit critical mass in the workplace.
Here are some ways to sidestep the most common pitfalls, so that stress doesn’t torpedo your efforts to serve patients, their families, and your co-workers.
How nurses are affected by workplace fatigue
What are the classic warning signs of fatigue? “Nurses exhibit frequent tardiness, calling in sick a lot, demonstrating a lack of empathy, or a ‘flat affect’ when taking care of patients—being more focused on tasks than the whole person,” says Michelle Bragazzi, RN, BS, community editor of TheONC.org. Job dissatisfaction is high. Departmental morale is low. Chronic fatigue is also associated with rising medical errors, and even patient deaths.
Anecdotal accounts of burnout point to the stress of a demanding profession, often with extended or rotating shifts, and little time for rest breaks. Besides plummeting job performance, there are harmful health-related outcomes. These include disturbed sleep patterns, elevated stress hormones, expanding waistlines, and mental health issues, such as depression.
Workplace stress affects every aspect of a nurse’s being: physical, mental, and spiritual. And it can overflow into every area of a nurse’s life, upsetting relations at home or out in the community.
A popular topic in the press, HR departments, and staff lunchrooms, burnout is a still a fuzzy medical concept. It is not a recognized disorder in the DSM-IV, for instance. The Maslach Burnout Inventory (MBI), developed by Christina Maslach, one of the leading researchers of burnout, is the most rigorously validated measure. A recent study using the MBI showed that more than one-third of nurses report levels of job-related burnout.1
When nurses are chronically stressed and feel unsupported by the work environment, it can lead to lapses in infection control practices. The research shows that the busy schedules and heavy workloads of nurses are contributing factors to the rise in infections.
The organization itself suffers when its nurses suffer chronic fatigue. Spiraling absenteeism, high staff turnover, and rising Workers’ Compensation costs take a heavy financial toll. Conflict between staff members as well as friction between management and workers can create additional workplace dysfunction and stress.
Which specialties are most or least at risk?
“School nurses have the highest satisfaction of all specialties,” says Linda Davis-Alldritt, RN, MA, PHN, FNASN, FASHA, president of the National Association of School Nurses (NASN). That’s even more noteworthy, considering “their average salary is $20,000 less than what nurses earn in hospitals.” Typically, school nurses work a schedule like other school district employees: Monday to Friday, an average of 39 hours a week, and capped at about 180 days a year.
A stress-free specialty? Hardly. Running an autonomous practice can be tough, especially for inexperienced nurses. Mainly, though, school nurses shoulder a heavy case load. “Nationwide, it averages one nurse for every 4,000 students,” says Davis-Alldritt. “The numbers are the biggest stressor.”
Nurses in certain specialties, where they continually witness trauma or death, may believe they likely experience worse job-related fatigue, or that they experience it in a unique way.
“Oncology nurses love what they do but they face chronic stress and compassion fatigue,” says Bragazzi, after 16 years in the field. “There’s a difference between compassion fatigue and nurse burnout. Symptoms tend to appear over a longer period of time. They witness trauma—not like in an ER—our patients are very ill for a long time, and then there’s often death.”
Experienced nurses in similar “high stress” specialties disagree. “No specialty has cornered the market on compassion,” says Ramón Lavandero, RN, MA, MSN, FAAN, senior director of the American Association of Critical-Care Nurses (AACN). “All nurses are compassionate. That’s in the DNA of nursing. But then sometimes when they burn out, they find they’ve run out of compassion.” Lavandero doubts that any specialty is intrinsically stressful, just in and of itself. “It’s not the situation that’s stressful; it’s how we respond to it. So if you’re experiencing burnout or fatigue, look at it deeply—don’t say ‘oh, it’s a trauma unit, of course I’m stressed.’”
He advises fatigued nurses to reflect about the source of their work strain. Ask yourself: “Is this the right place? Right time? Right tasks? Right now?” According to Lavandero, when nurses are willing to reflect honestly, they can identify the root cause of stress. Often it’s about keeping a balance between work and non-work, and the relationship between the two. “They may realize that ‘you know, I’m in a healthy work environment, communication is excellent, leadership is authentic, but I’m stressed because my spouse just left, or my parents passed away, or my child developed an illness,’” he says. We are multifaceted beings so often when one part of our lives is off-kilter, the whole of it overturns and we aren’t entirely sure why it has happened.
What can nurses do to avoid burnout?
“You won’t be happy in the profession if you don’t go into it for the right reasons,” says Anna Dermenchyan, RN, BSN, CCRN-CSC, staff nurse in the cardiothoracic ICU at Ronald Reagan UCLA Medical Center. A nice paycheck or job security isn’t enough to keep the passion alive when reality kicks in. “I do see a lot of nurses who just show up for work. It’s just sad to see.”
Dermenchyan says that burnout can happen right away. “Energized new grads enter the field, but then it’s just so stressful, they kind of lose interest in the profession.” She advises getting involved in something outside of work to get re-energized. “Some people love their family, so that’s what they should do. It’s whatever gives your life meaning, happiness, and balance.”
Lavandero encourages stressed nurses to lean on constructive peers and mentors, as “positive people who point out possibilities are one of your biggest supports.” He also suggests expanding your social circle to include folks in other professions. “It’s common to hang out with fellow nurses outside of work. While that can be reassuring, work conversations tend to continue, so they shouldn’t be the only people you talk to.”
Over and over, nurses credit involvement with a professional organization—related to their specialty or ethnicity—as a personal lifesaver. “At our organizational meetings we listen to one another and guide each other when that is asked for,” says Arilma St. Clair, RN, MSN, president of National Association of Hispanic Nurses District of Columbia Chapter and occupational health nurse. “Sometimes we just need to listen and allow ourselves to vent without action or recommendations.”
Other times, St. Clair nudges nurses to take direct action—in addition to letting off steam. “If they complain ‘the nurse in charge always gives me the heaviest duty,’ then I suggest ‘if you see a trend, bring it to the supervisor. If it’s not taken care of, go to the next level,’” she says. The association endeavors to be the voice of its members, and St. Clair offers to write a letter or help file a complaint on behalf of aggrieved nurses.
After a while, nurses learn they must take a continual stress “temperature” to check how they’re holding up. “I’ve been in practice over 30 years, so now I understand when I’ve reached the point when I don’t function well,” says Steve Wooden, DNP, CRNA, president of Wooden Anesthesia PC in Albion, Nebraska. “Then I remind myself to slow down and double-check, because a major focus under stress should be to avoid harming patients.”
Wooden is one of only two anesthesia practitioners in a rural community 100 miles west of Omaha. “Obstetrics is unscheduled, takes a long time, and a lot of care, so we will go without rest or sleep for long periods. If I’m on-call, there’s nobody to back me up.”
Awareness isn’t enough, says Riza V. Mauricio, RN, PhD, CCRN, CPNP-AC, director of the AACN National Board of Directors and pediatric ICU nurse practitioner at The Children’s Hospital of the University of Texas, MD Anderson Cancer Center in Houston. “As health care professionals, we know all about fatigue but often don’t apply that knowledge to ourselves. We underestimate our degree of fatigue, we just keep going, keep going—like the Energizer Bunny—taking care of patients without thinking of our own well-being.”
The solution can be on an individual basis, and as simple as taking care of ourselves in the most basic ways. “We hardly even go to the bathroom. Or we’ll take a meal break late—instead of at noon, at 2:00 p.m., or not at all. Take a deep breath, do a physical activity, stretch or walk. Take time for yourself. Nurses don’t take care of ourselves, we take care of others,” she explains.
Mauricio says we can use that altruism to our advantage, by helping fellow nurses practice self-care. “We have a shared responsibility to take care of one another and take care of our patients.”
Wooden concurs. “We all need to be aware of when individuals are tired, and step in so they don’t harm patients. It’s not just nurses, but also doctors who may be fatigued.”
Preventive measures already in place
Most organizations offer employee assistance, wellness, or stress management programs. Don’t hesitate to access these offerings, which are often free or low-cost. Talk to your peers, supervisors, or allied staff members. “The pastoral care team is trained to provide support in stressful situations, especially ones that test someone’s faith,” says Lavandero. “Social workers in the hospital may also be very helpful.”
Some workplaces have instituted extraordinary programs to deal with employee stress. “Our facility—MD Anderson, a huge institution—is big on fatigue prevention,” says Mauricio. “They promote health in body, mind, and spirit. They know prevention is much better than aftercare.”
In addition to a fitness center, the hospital has what are called Be Well Stations throughout the building for employees to use. “In my ICU, there’s equipment close to me, like ellipticals, treadmills, scales, a stretch trainer, strengthening chair.” Plus the stress management program offers massage therapy sessions at a reduced rate of $20 for 20 minutes.
If that isn’t enough to combat fatigue, the counseling center can help if stress threatens to overwhelm, such as when there is a series of deaths in a unit. “That can take a toll on a person,” says Mauricio.
Off-site retreats in a restful setting may be best for reflection and renewal. “While many institutions offer wellness programs, my hospital offers Circle of Caring,” says Dermenchyan. “The Ethics Department sponsors it for health care professionals—it’s open to all—for three and a half days. It’s a wonderful community of people who discover again why you went into health care and to find meaning in their roles. It’s wonderful when holistic programs like this exist.”
Steps hospitals can take to improve safety
Ann Rogers, RN, PhD, FAAN, has conducted seminal research at the Pennsylvania School of Nursing. It overwhelmingly shows that wonky work schedules put the health of nurses—and their patients—at risk.
Nearly 400 hospitals in the United States have achieved so-called “magnet” status, and these are the ones most likely to institute evidence-based scheduling. They discourage sleep deprivation (chronic or one-night), extended work shifts, and lack of fatigue countermeasures, such as rest breaks.
Deborah Eldredge, PhD, RN, director of Nursing Quality, Research, and Magnet Recognition at Oregon Health & Science University School of Nursing inPortland, believes that proper scheduling is key to maintaining their healthy work culture.
“Nurses work 12 hours, six out of 14, four or five days in a row, but the fourth or fifth day are error prone. Some management has dictated that there be no fifth day. That requires being adequately staffed so nurses don’t need to work additional shifts,” she explains. “And talking with folks about their schedule, maintaining vigilance, and monitoring when they’re tired.”
She points to one unit that has instituted a rest break ritual of tea every afternoon. “At 4:00 p.m., snacks come out, and they sit down together while doing their charting. They’re eating, and also getting a chance to unload. They can stay close to patients, maintain their hydration, and have companionship, too,” she says.
Some states have gone as far as mandating certain safe scheduling practices. California, for instance, has a one to five nurse-to-patient ratio in surgical units. Does that small ratio help to reduce patient deaths? Apparently so. A 2010 study predicted that patient deaths in New Jersey and Pennsylvania would drop 14% each if they followed California’s lead.2
Issues unique to minority nurses
St. Clair explains that minority nurses must wear many hats—as all nurses do—but in addition, “we also wear the interpreter and translator hats. We get pulled out of our assignments to interpret for any and all providers in the care of Spanish-speaking patients. Thus, time management is a bigger challenge for us because we are still expected to complete our assignment on time.”
On the other hand, nurses who speak only English may be at a disadvantage working with immigrant patient populations. Their need to rely heavily on translators throws a monkey wrench into already tight schedules and adds to mounting stress. “It’s harder to do our work, as well as patient education, because it all has to be interpreted,” Eldredge says. “For that reason, I had a nurse who thought it might be easier for her to learn Spanish so she could communicate with her diabetes-care patients.”
St. Clair says that nurses from certain cultural backgrounds face additional hurdles because their citizenship and training are suspect. “I am Latina, thus I must be a foreign nurse and thus, have less than standard preparation.” That’s one bias that Caucasian and African American nurses, who are assumed to be American, usually don’t face, she adds.
Regardless of language and citizenship, do minority nurses experience discrimination based on their status, generally? St. Clair says about half her memberships reports that they do. When a nurse does run up against bias, St. Clair advises: “We need to reorient individuals who exhibit intolerance. They need to be taught [that] none of us can treat people differently based on our personal values.”
Other types of bias are more difficult to pin down. For instance, Wooden says it’s sometimes assumed that a male nurse will do the heavy lifting, risking strain and injury. “Now, some women would disagree and say they certainly can pull their own weight,” he says. A more worrying problem, though, is that minority nurses may miss out on the social support that other nurses enjoy. “They may not fit into a social niche,” says Wooden. “They won’t have a support system from a work group, where they understand you, you understand them. People who can help you identify when you’re having a bad day.”
Nurses who learn to handle job and life pressures can avert chronic fatigue and enjoy the flip side of burnout: Engagement. That’s the opposite of exhaustion, cynicism, and inefficacy, according to stress researcher Maslach. Engagement is a state characterized by energy, involvement, and efficacy. Good news for nurses. Good news for their patients.
Dermenchyan explains how the patient-nurse satisfaction loop works: “Patients will say ‘I know when a nurse is engaged and cares about me as a person. I know when they don’t care.’ That’s when patients complain about everything. But when they feel cared for, they won’t even complain about the hospital food.”
- Aleccia J. Burned-out nurses linked to more infections in patients. NBCNews.com. July 30, 2012. http://vitals.nbcnews.com/_news/2012/07/30/12994989-burned-out-nurses-linked-to-more-infections-in-patients?lite. Accessed November 2012.
- Carlson J. Nurse staffing study predicts Calif. mandate would save lives elsewhere. ModernHealthcare.com. April 20, 2010. http://www.modernhealthcare.com/article/20100420/NEWS/304199955#. Accessed November 2012.