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.
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?”
Black women are almost twice as likely to experience infertility as their white counterparts, but only 8% of Black women seek fertility treatment, compared to 15% of white women. Statistics like these, compounded by the fact that Black women are three times as likely to die from pregnancy-related causes, highlight inequalities in reproductive healthcare that the medical community must address.
The higher incidence of infertility among Black women is due in part to a higher prevalence of uterine fibroids, ovulatory dysfunction, and tubal disease. Studies show that Black women also have higher rates of pregnancy loss, including miscarriages and stillbirths when compared to white women. This is likely because Black women have higher rates of risk factors that are associated with pregnancy loss, such as obesity, diabetes, and low socioeconomic status.
For Black women, the isolation of infertility is compounded by various factors (for example, cultural stigma, socioeconomic barriers, and racial bias) that prevent them from getting the care they need. Those who do end up seeking care often find themselves feeling deeply uncomfortable in the medical space, which is still predominantly white.
Diversity in Healthcare Providers
People of color need to have access to BIPOC (Black, Indigenous, and People of Color) healthcare providers because it provides a sense of comfort and familiarity. This can encourage patients to access available fertility care and can even improve treatment outcomes. BIPOC healthcare providers possess culturally specific knowledge, skills, and experiences that help with communication and health management processes involving people of color.
Diversity in providers also helps reduce barriers to the patient-physician relationship for racial/ethnic and linguistic minority patients. In many situations, seeing someone who looks like you and understands your cultural background offers reassurance.
Many studies have demonstrated better health outcomes when BIPOC providers see patients of color. A result of this is increased trust and communication developed between the patient and provider. The patient may feel more comfortable sharing sensitive information with someone who has an unspoken understanding of what the patient might be going through. Research has shown that Black women who have a provider with a similar cultural history may feel more comfortable speaking up and advocating for themselves.
Many people of color have a (warranted) sense of mistrust when it comes to our healthcare system due to historical practices based on racist ideals. As healthcare providers, we must remain dedicated to bridging the gap to improve outcomes for patients of color.
What Factors Most Impact Black Patients?
Long-held beliefs, stereotypes, cultural stigma, and other issues continue to uphold these racial disparities around fertility and family-building. Here are some examples of the various factors that contribute to widening the gap in care for Black women:
Structural racism: This heavily contributes to racial disparities in fertility and maternal healthcare in various ways, as structural racism goes beyond the individual. It refers to inherently racist laws, rules, economic practices, and cultural and societal norms that are embedded in the system itself.
Implicit or unconscious bias: This occurs automatically and unintentionally, affecting our judgments, decisions, and behaviors. For example, a white doctor might downplay complaints of pain after surgery from a patient of color due to engrained, inaccurate stereotypes about the strength or pain tolerance of BIPOC people, only to discover the patient is genuinely experiencing discomfort.
Accessibility: Many people of color encounter barriers to accessing the healthcare they need due to a lack of insurance or insurance coverage that excludes fertility treatment. Financial roadblocks and accessibility to quality reproductive care are often limited by location (rural or underserved areas may not have fertility clinics nearby) and employment (not everyone can take time off of work to go in for morning monitoring appointments, which are often required during fertility treatment).
The myth of hyperfertility: The long-held myth that Black women (and men) are “hyper-fertile” causes considerable harm, leading to a resulting cascade of issues.
Religious beliefs: Many people in the Black community are taught to “pray your way” through difficult situations. And while it’s wonderful to have faith, sometimes it’s necessary to seek professional help. Trusting that a higher power will correct infertility leads some people to delay or avoid treatment altogether.
Harmful stereotypes: Black women are thought of as being incredibly strong ― and we are ― but when we are elevated to “Superwoman” status and need to take off our proverbial capes to ask for help, we are often judged harshly or perceived as weak.
Mental health: Shame, guilt, or anxiety about how people in our community may react prevents or delays many women of color from seeking infertility treatment. The stigma of mental illness is also a concern when addressing infertility. Many people coping with infertility experience depression, anxiety, and grief, and cultural norms can discourage people from sharing that they are struggling with their mental health.
Isolation: Many people hesitate to talk about their personal experiences with infertility, which often leaves Black women with the impression that they are alone in their struggles or that infertility is a reflection of their character or a personal failing. That’s why sharing fertility stories is so important, especially in communities of color.
Black Maternal Mortality Rates
Many women of color might lack insurance coverage for maternal health or be afraid to advocate for themselves with their doctor. But the starkest evidence of the healthcare system failing people of color is Black maternal mortality rates in the United States, which are alarmingly high.
Studies have shown that Black women are three times more likely to die from pregnancy-related causes than white women. Worse yet, even though multiple factors contribute to this disparity, most are preventable. These factors include access to quality healthcare, underlying chronic illnesses, and two of the most easily preventable: implicit bias and structural racism. As a healthcare system, we need to focus on listening to the concerns of patients of color without allowing unconscious bias to play a role in our treatment decisions.
Responsibility to Patients
In vitro fertilization (IVF) and other fertility treatment options can be very expensive, which makes it exponentially more challenging for individuals with lower median household incomes to afford this path to parenthood. With lower incomes in comparison to white and Asian couples, Black and Hispanic couples may have a hard time affording fertility care if they have to pay out-of-pocket.
Knocking down the roadblock of affordability often goes beyond the scope of the medical community’s responsibility. However, bridging the gap of distrust with people of color and providing culturally competent care does not. One important step hospitals and health systems can take is to increase the diversity of providers within reproductive health specialties. Collectively, we must work to dismantle structural racism, educate ourselves, and listen to people of color. Only then will we start to make progress toward lessening racial disparities in fertility and maternal healthcare.
Vanderbilt University School of Nursing has received a four-year, $2.8 million Health Resources and Services Administration (HRSA) Bureau of Health Workforce grant for a primary care nurse practitioner residency program that will recruit, train, and retain primary care providers with a passion for helping rural and underserved communities. Associate Professor Pam Jones, BSN’81, MSN’92, DNP’13, FAAN, is the grant’s project director, with Associate Professor Christian Ketel, DNP’14, FNAP, serving as primary author and evaluator.
The award builds on a $2.4 million HRSA grant the school received four years ago to develop its Community-Based Nurse Practitioner Fellowship, a postgraduate nurse practitioner/nurse-midwife resident training, hiring, and retention plan for community-based health clinics.
The new grant funds five additional advanced practice nurse fellows—three trained in family or adult gerontology primary care, one trained in psychiatric/mental health, and one trained in nurse-midwifery—to work full-time for one year at a participating community-based health clinic.
The fellows benefit from specialized training in behavioral health and psychopharmacology, maternal health, cultural competency, and mitigating issues caused by social determinants of health. They also learn from clinical immersion experiences, mentoring, collaboration with other providers, and providing evidence-based treatments for rural or medically underserved clinics.
Nationally, many new providers based in clinics serving rural or underserved populations become overwhelmed and leave their positions within the first few years. The CBNP Fellows effort is poised to tackle that issue and help new practitioners build confidence and resilience and increase job satisfaction so they continue to practice in communities where they are most needed.
“This program provides, in partnership with our community agencies, a gradual and structured onboarding and an educational program that gives the new provider additional knowledge and ongoing support from the grant team,” Jones explains.
The fellowship will increase access to primary care nurse practitioners for general physical health issues. Behavioral health assistance will be offered as part of holistic primary care and support for people with psychiatric conditions that often aggravate other health conditions. Certified nurse-midwives will promote maternal health through patient education and increased access to providers.
“Chronic diseases, including cardiovascular disease, diabetes, arthritis, and depression, contribute significantly to healthcare costs and affect six out of ten adults, with multiple chronic conditions being common,” Ketel says. “Risk factors such as tobacco use, poor nutrition, sedentary lifestyle, and alcohol consumption exacerbate the situation.”
This program is a part of the Vanderbilt School of Nursing’s programs and educational opportunities that focus on community needs and health equity, helping people overcome disparities to live healthy lives.
“VUSN has a long history of developing and managing nurse-managed practices with APRNs and programs that meet the needs of underserved populations,” says Jones, who has seen the good these types of programs can do and how much they are needed. “In my former role as a chief nursing officer, I saw the profound impact of the lack of appropriate primary care in our underserved communities.”
Ketel continued, “Underserved populations often face significant healthcare disparities, including limited access to quality care and higher rates of chronic diseases. By supporting this program, Vanderbilt School of Nursing demonstrates its commitment to addressing healthcare disparities, working towards health equity, and producing culturally sensitive healthcare providers.”
The program seeks new nurse practitioners and nurse-midwives within 18 months of graduation. After a screening process through the Vanderbilt School of Nursing, applicants may be chosen to interview with a partner community-based health clinic, where those hired will become full-time employees for one year under the supervision of a mentor. They will also have access to continuing education opportunities, monthly conferences, and support/coaching from the School of Nursing faculty.
The School of Nursing team includes Jones, Ketel, Instructor Tonya Elkins, and Associate Professor of Nursing Natasha McClure, DNP, MSN’11. For more information, visit https://nursing.vanderbilt.edu/projects/cbnpf/index.php.
As an innovative program created to collaborate with community partners and support healthcare needs, the Community-Based Nurse Practitioner Fellowship is one way the School of Nursing supports Vanderbilt’s Dare to Grow philosophy, and it supports the passion Vanderbilt nursing faculty and staff have for helping others.
The Office of Minority Health, a division of the U.S. Department of Health and Human Services, designates each July as Minority Mental Health Awareness Month. By calling attention to the specifics of mental health in minority communities, the awareness campaign helps spread information about the importance of good mental health practices, shares resources for finding help, and removes some of the stigma around seeking treatment for conditions including depression or anxiety.
As the COVID pandemic has retreated, many folks are left with lingering feelings of trauma, particularly in minority communities that were impacted more than others. Many people lost loved ones during the past few years and others are coping with the lingering health impacts of having had COVID or caring for those who did. The pandemic exposed glaring health disparities in which racial and ethnic minority patients had less access to high-quality health care, more severe illness, and higher numbers of severe COVID.
Beyond healthcare and within a society that has structural racism, the pandemic caused far-reaching impacts from a disease that upended employment, income, insurance coverage, childcare, transportation, and family structure. The long-term impacts of the trauma people experienced, and are still experiencing, is something that will influence minority mental health for years to come.
During Minority Mental Health Awareness Month, nurses can help spread information about the importance of good mental health by discussing it with patients. They can offer resources, talk about how mental health changes physical health, and normalize discussions around emotions and trauma.
Because nurses educate patients, they can call attention to symptoms that patients might associate with mental health struggles including
new or marked sadness or crying
changes in eating (too little or too much)
changes in sleep patterns (difficulty falling asleep or getting out of bed)
lack of interest in hobbies, relationships, work
thoughts of suicide
They can also verbalize symptoms that aren’t always recognized as symptoms of something like depression or anxiety including
anger and rage
increased substance use and abuse
new or increased compulsive actions (checking locks, food patterns)
Talking about minority mental health with nurses encourages patients to recognize their feelings, be attentive to changes, and understand that they aren’t alone. These efforts might not always seem significant, but nurses can keep in mind that their conversation about mental health might be the only time a patient discusses their concerns. Some minority communities have such a barrier to openly discussing mental health that it is a subject that is just never brought up.
When nurses identify symptoms, highlight resources, make connections for therapy or medication providers, and show support, patients feel seen and heard. Emphasizing that mental health is a physical condition and that effective treatment is available is a beacon of hope for people who are feeling like they aren’t sure what to do. Nurses can make a meaningful difference to patients with a caring conversation about minority mental health and some resources to get started.
Many nurses feel stuck and need help figuring out why. Alright, no worries. I can reassure you that you are not the only nurse feeling this way. Here are some reasons you may feel stuck and how to get out of that rut.
Lack of Career Advancement and Growth
You may not be experiencing growth in your current position. Or you are not getting the opportunities you want due to different circumstances.
The Fix: Keep learning and growing from a personal and professional standpoint. Seek opportunities to learn, go to conferences, return to school, or get certified in your specialty area.
The bottom line:
Continue to increase your skills and knowledge.
Articulate your desire to be promoted and advance in your career.
Make sure you keep all your receipts and be ready to present why you deserve to be promoted.
Sitting in the corner and working hard will not automatically get you promoted. Instead, make yourself visible and highlight your accomplishments. Network with other nurses and other industries. Network in person and on social media and search for different opportunities. If all fails, then you can take your talents somewhere else.
Learn to say no in your personal and professional life.
Ask for help and support from colleagues.
Prioritize self-care activities such as sleep, exercise, rest, and eating healthy. If you take a break and return, still not feeling well, it may be time to find another position.
Seek medical attention for an assessment and speak to a licensed professional regarding mental health concerns.
Limited Scope of Practice and Not Feeling Challenged
The Fix: Nurses can feel stuck due to the limitations of their current practice. Recommend taking on a different assignment or project.
Precepting or mentoring can be a great way to reignite your passion and keep you on your toes. Seek out work that is fulfilling and aligned with your purpose and values. Consider going back to school to pursue advanced practice roles such as a nurse practitioner. You may be bored of the same thing day in and day out. Starting your own side business, such as writing, tutoring, or speaking, could add something new and exciting to your career.
Feeling Unappreciated
You may not realize it, but perhaps you feel underpaid, undervalued, and unappreciated.
The Fix:
Join or start a recognition and appreciation committee within your organization.
Ask for feedback from colleagues, patients, families, and the leadership team.
Engage in nursing organizations that promote recognition and support for nurses.
Lack Clarity
You may not know exactly what you want, and that’s ok. However, this uncertainty may lead to you feeling stuck.
The Fix: Take the time to reflect and see what you want to do. Try to be strategic by looking at your end goal and working backward to how you will get there. Create career goals and a list of what is most important in your life this season. Determine what type of life you want to have and create your career around that lifestyle. Define what success means to you. Seek guidance from mentors and career coaches to gain clarity and develop a career advancement and success roadmap. Career coaches like me can help you get crystal clear about your priorities and your next moves.
Remember:
Compare yourself to only yourself
Do what you want, and do you
Be patient with yourself
Invest in yourself
Ask for help
Stop overthinking, make a decision, and take action. Part of feeling stuck is all in our heads, and this indecisiveness can lead to anxiety and, obviously, inaction. Nursing is the greatest profession in the world, with so many opportunities. Be comfortable knowing you can always redirect yourself to another path in whatever direction you take. So go ahead and take action. Get unstuck.
