Nurses in the United States are facing unprecedented hardships that increase the risk that they will experience burnout. Health care workers, especially nurses, often experience high levels of stress due to the long hours they put in and the sheer number of patients that they interact with.
Avoiding burnout is necessary for a long career in nursing and it is important that nurses do their research when it comes to methods for preventing burnout. While there is a pharmaceutical answer in the use of antidepressants, this method merely treats the symptoms that can lead to burnout. For many nurses, the answer lies in a more natural path that will give them the tools they need to combat burnout holistically.
Health care workers have been shown to be particularly susceptible to experiencing burnout due to the fact that they are expected to perform patient care with consistent and constant empathy and patience. This can lead to emotional exhaustion which, coupled with the physical exhaustion that comes with working in the medical field, eventually morphs into what we know as burnout. Naturally, the stresses of this line of work can lead to fatigue that impacts motivation in the workplace and a misplaced sense of failure.
One of the best tools available to nurses in the fight against burnout is the development and strengthening of resiliency skills. When nurses possess a solid foundation of resiliency skills they are better equipped to bounce back from a particularly intense shift more easily and are able to maintain their ability to work effectively. Taking breaks during shifts, scheduling time to hang out with coworkers outside of work, and learning how to say no to taking extra shifts if they need breaks are all ways to increase resiliency.
The prevalence of burnout and resiliency’s effectiveness in combating it has led to the development of nurse resilience programs designed to arm nurses with the proper tools before they begin their careers. Through cognitive-behavioral training, stress inoculation therapy, and various other methods, nurse resilience programs are effective in preparing nurses for what lies ahead of them in their career and can be invaluable in the fight against burnout.
Taking Care of Mental Health
Another natural proven method for nurses avoiding burnout is simply taking care of their own mental health and well-being. While it might seem like obvious advice, for those working in high-stress environments like health care can find it far too easy to forget to take care of themselves. Self-care is vital for nurses who want to dodge burnout, and even something as simple as keeping a journal to acknowledge positive things that happen in life can be enough to stymie burnout.
Many nurses suffering from burnout experience feelings of inadequacy, low self-worth, and depression. It is important that nurses recognize that these feelings, while they can be intense, do not represent the reality of the situation and do not reflect their actual performance or capabilities either at work or life in general. Quieting that negative inner-voice is an effective way for nurses experiencing burnout to boost their self-esteem and sense of self-worth.
Learning how to practice mindfulness meditation is another excellent natural way to look after one’s own mental health in even the most stressful of situations. Mindfulness meditation has a whole host of benefits from helping to increase attention and concentration to improving practitioners’ heart rates and blood pressure, all of which can help to manage stress and fight off burnout. While there are plenty of books on the subject, there are also a multitude of free resources available online that are secular, simple, and can get a struggling nurse on the right track.
Looking Towards Nature
Should building resiliency skills and working on maintaining good mental health fail to do the trick, spending time in the great outdoors has also been proven to help prevent occupational burnout. Engaging in physical exercise outdoors helps to reduce fatigue and improve overall cognitive function and can result in a marked reduction in tension, depression, and anger. While nurses do indeed have wildly busy schedules, making an effort to set aside time for themselves in the outdoors can yield incredibly positive results for them.
If a nurse finds themselves unable to break away from the concrete jungle, there are still ways in which stress can be reduced naturally without going outside. Taking the time to unplug from technology frequently can reduce stress and allow for moments of silent self-reflection untainted by the constant and looming force of the internet and social media.
Finally, nurses that are looking for a way to combat burnout but are wary of getting a pharmaceutical prescription to manage its symptoms can always turn to mother nature. Cannabidiol, or CBD, is a compound found in cannabis that has no deleterious or psychoactive effects and is becoming a popular stress-reduction tool for many. While the science regarding CBD is still in its infancy, there is a huge amount of anecdotal evidence that points to the compound being an effective treatment for stress and a host of other symptoms and disorders.
At the end of the day, nurses and health care practitioners are some of the most important people in a functioning society. It is vital that they receive all possible help when fighting against burnout, whether that comes in the form of resilience training, mindfulness practices, or spending time with mother nature.
Nurses need to be prepared for every eventuality in patient care: they welcome life into the world, and hold patients’ hands as their lives come to an end. The core job duties are physically, emotionally, and spiritually taxing — and sometimes dangerous — so it’s no surprise that nurses experience burnout at an alarming rate.
In fact, the National Nursing Engagement Report for 2019 found that 15.6% of all nurses were feeling burned out at the time of reporting, with 41% of nurses who reported themselves as feeling unengaged also reporting feeling burned out. But many nurses also know they can’t leave — or even take time off — because the nursing shortage is so critical that every hour counts.
We’ve written before about how to combat nurse burnout, but it’s just as important to recognize the dangerous signs of burnout when it starts.
What Are the Signs of Burnout?
Between the long hours, the demands of the job, and just being human, most nurses will experience either the signs of burnout or full Burnout Syndrome (BOS) at some point during their careers. As the National Nursing Engagement Report showed, even fully-engaged nurses report these symptoms. The first step to combating BOS is to recognize the symptoms.
Perhaps the first sign and highest predictor of burnout is emotional exhaustion. Nurses know what it’s like to be tired, but emotional exhaustion leaves you feeling completely drained as a result of the stress of your job. In addition to feeling fatigued in every way, people who are emotionally exhausted often feel like they’ve lost control of their lives — they often report feeling trapped in their situation, whether it’s at work or in an outside relationship.
Another sign of burnout is depersonalization. When you become so exhausted that you have to detach from your surroundings to survive, then you are burnt out. Your outlook may be negative or even calloused, and it can express itself in unprofessional comments directed at colleagues, feeling nothing when a patient dies, or even blaming patients for their problems.
The final major predictor of burnout is a reduced feeling of personal accomplishment. You may not feel that you’re a good nurse or that you make any difference at all in patients’ lives. Nurses working in high-intensity settings, like the ICU or emergency room, may experience this more often as they receive a greater proportion of cases where little can be done for the patient.
Why Burnout is Dangerous for Nurses and Patients
Burnout is more than having a bad day; it’s an impaired outlook on nursing and life in general. Experiencing burnout doesn’t mean you don’t love your job, nor does it mean that you aren’t good at what you do. In fact, this reality makes it even more difficult for nurses who experience burnout because leaving is just another impossible choice.
At the same time, burnout is as dangerous for nurses as it is for their patients. A nurse in the throes of BOS is both less likely to have life satisfaction and more likely to provide a poorer standard of patient care. In a study published in Research in Nursing & Health, researchers explored the correlation between the quality of care and nurse burnout among 53,846 nurses from six countries. They found a strong correlation between higher levels of burnout and nurse-rated quality of care.
In other words, burnout can become a self-fulfilling prophecy. Burnout can result in lower standards of patient care, which further informs the reduced feelings of personal accomplishment. As nurses make mistakes, they feel even lower job satisfaction and an even greater intensity of burnout, which goes around again to manifest itself once again in patient care.
How Nurses and Nursing Leaders Can Combat Burnout
Nurses are caught between a rock and a hard place — the nature of the job is stressful, but if you love what you do, you can’t quit. Although almost all nurses will go through burnout at some point, there are things that both practitioners and health care organizations can do to stave it off and help re-engage burned-out nurses.
Education is one of the critical ways that nurses can empower themselves and avoid burnout. Pursuing further education can renew your passion for what you do and help you overcome roadblocks. It also puts you in a better position to provide the latest evidence-based care to patients, which correlates to better patient outcomes and increased job satisfaction.
Nursing leaders and administrators also have a strategic role to play, as the environment in which nurses practice needs to be a supportive one. Creating a positive work environment that limits unnecessary stress and allows nurses to care for themselves and recharge can do wonders in both reducing burnout and igniting engagement.
Those same leaders and administrators can also take notes from other industries’ workplace safety practices. You can’t just say you have a safety culture, you need to commit to it by formalizing the ways in which you intend to create and maintain the culture and creating avenues to accept employee input.
There’s Always More Work to Do to Prevent Burnout
Nurses can’t get rid of the high-stress, high-stakes environments they work in. They can’t wave a magic wand and save every patient no matter how severe their condition, and they can’t stop feeling to cope.
In other words, burnout is a given part of being a nurse. While these feelings are normal, nurses also need support in preventing the bad (and downright dangerous) days from outweighing the good ones. Nurses and administrators can and must work together to prevent burnout — and while the challenge is a significant one, it is achievable if we all listen to each other.
You may have heard the term moral injury more frequently these days than ever before. Between the TEDx talks, the YouTube rants, and the LinkedIn articles, moral injury is being compared to post-traumatic stress disorder (PTSD) symptoms and is heading to replace one of our favorite words in the nursing world: burnout. However, there is a growing movement that believes that moral injury is the root-cause of burnout and PTSD. In other words, if burnout or emotional exhaustion is organ failure, moral injury is sepsis.
In the August 2018 issue of STAT News, Dr. Simon Talbot and Dr. Wendy Dean associated the term moral injury as the true cause of burnout; the cynicism, emotional or physical exhaustion, and diminished productivity that can be prevalent in many health care organizations. However, burnout implies that the clinician is not resilient enough to manage the components of the job, or perhaps is not participating in enough hot-yoga-self-care practice, whereas the actual root cause of the emotional discord is moral injury.
Historically, moral injury is associated with military personnel who have witnessed, participated in, or failed to prevent transgressions against humanity or acted contrary to “deeply held moral beliefs and expectations” according to a study published in 2009 in Clinical Psychology Review. While civilian clinicians in the U.S. are not necessarily bearing witness to the horrors of war, they are attempting to provide care, compassion, and healing in health systems that are broken and, oftentimes, focused on compensation rather than the patient or clinicians.
The slope of document-for-maximum-reimbursement vs. document-the-excellent-care-provided is slippery. The fact is, health care is a business. To take it one step further, given the publicly reported information on patient satisfaction scores, readmission rates, infection rates – not to mention social media – health care is a commodity and patients can trade their provider with the click of a mouse. Organizations simply must maximize revenues from the ever-changing world of insurance coverages to keep the doors open, let alone to fund strategic initiatives to make improvements or plan for growth.
Clinicians find themselves in the middle of the battle between care and compensation. For example, when a patient presents with a wound and, after they are seen and treated, the nurse knows the patient cannot afford the appropriate dressings, but the organization does not allow staff to offer long-term supplies (brown-bagging). Or a patient who needs an expensive biologic medicine that the clinician knows is the best on the market for the diagnosis yet is required to order the cheaper medication that is on formulary. These betrayals to the calling of medicine to provide excellent care in and of themselves are not impactful. But numerous and repeated injuries to the morality of health care takes a toll.
Cases of moral injury occur at all levels of the health care organization. While working as a Certified Nursing Assistant (CNA), Doug McGann experienced emotional exhaustion. “I felt very undervalued in my role as a nursing assistant. I knew that I worked hard and provided compassionate care, but the organization really didn’t do anything to recognize the role. In fact, when they removed tasks from the assistants, like measuring and recording vital signs, it felt insulting. We were providing less support to the team when most of us wanted to contribute more. Eventually, I left the role as it became too mundane and repetitive and went to nursing school.”
How do clinicians guard themselves against moral injury? What can organizations do to combat the insult? The answers are still being hypothesized and churned by many articles in the health care space. One answer could be to encourage clinicians to embrace nurturing practices such as meditation and other stress-relieving activities while acknowledging that self-care means something different to each person. But a “Code Lavender” approach to increasing stress is not always that simple, and once again puts the onus on the clinician to improve their coping mechanisms.
What needs to improve are the institutional patterns that perpetrate the moral injuries. Organizations need to reduce the competing demands on health care workers and strive to treat each discipline with the respect it deserves so that providers can practice at the top of their scope. Institutions should provide, advertise, and encourage employees to utilize employee health services that include a behavioral medicine practitioner for debriefing and centering. Also, there is strong data emerging related to the effects of supportive, competent, and empathetic leadership on reducing the effects of moral injury.
By changing the language and mindset of how we approach burnout to address the root of the issue, the business of health care can move away from moral injury and into a place of mutual respect, acknowledgement, and empowerment towards all levels of the medical team.
Working as a nurse can be tough. Because they are so focused on patients, they may not see when they’re experiencing burnout—and that can lead to problems with themselves or with being able to properly care for patients.
But there are ways to recognize it and to counteract it. Sarah A. Delgado, MSN, RN, ACNP, a Clinical Practice Specialist with the American Association of Critical-Care Nurses says that there are ways to identify burnout as well as ways of coping with it.
What are some tips for nurses so that they can prevent burnout?
The first step with burnout is to recognize when it’s happening. Some signs of burnout include:
- Feeling that you have to drag yourself to work, and that tasks at work take more energy than you can muster
- Feeling irritable, critical, or cynical with coworkers
- Having physical symptoms such as headaches or stomach pains or trouble sleeping
Nurses may try to dismiss these symptoms, especially in the busyness of the holidays, because they feel compelled to power through, no matter what. The truth is that recognizing and addressing burnout can actually be energizing; just realizing that you deserve to feel better is the first step toward positive change.
Coworkers can help each other call attention to burnout. If you notice someone is struggling, it may be worthwhile to check in and ask how they are doing. Burnout can be a team problem if it is pervasive on a unit because it’s hard to come to work when the people you work with are dissatisfied, short tempered, or unable to sense the value of their work. So recognizing the symptoms and checking in with colleagues is an essential strategy.
Burnout is a complex phenomenon and while there are self-care actions that nurses can take to address it, factors in the work environment contribute to burnout. Worry that patient care is compromised by an inadequate staffing mix, feeling that administrators are not responsive to clinical issues, and poor communication among health care team members are examples of issues in the work environment that can led to the mental, physical, and emotional exhaustion of burnout.
Issues in the work environment are not insurmountable but a single member of the environment cannot address all of these issues alone. If you are a nurse working in an unhealthy work environment that contributes to burnout, maybe create a New Year’s resolution to talk to your colleagues about it. If you find that they share your feelings, there may be factors beyond your control contributing to the problem.
Consider forming a group and seeking support from management to identify specific steps toward a healthy work environment. The American Association for Critical Care Nurses has resources including the AACN Standards for Establishing and Sustaining Healthy Work Environments and an online assessment tool that units can use to evaluate their environment and identify ways to make it healthier.
What are the best action steps they can to take?
There is some evidence that mediation and mindfulness practices can significantly reduce anxiety and worry. There are resources online and applications to help learn these techniques. The National Academy of Medicine provides a list of resources.
Attending to the basics—sleep, exercise, and nutrition—also helps with the physical, mental, and emotional exhaustion of burnout. Sometimes, it is easier to advise others on self-care than to take the time to do it for ourselves. The American Nurses Association initiative Healthy Nurse, Healthy Nation provides a structure for nurses to think about their own self-care and develop healthy habits.
When you find yourself feeling relaxed and rested, think back to what you were doing at that time. Were you talking to a friend, exercising, drawing, spending time with family, reading a novel, or watching a movie? Being deliberate in engaging in the activities that bring joy can reduce the stress of burnout.
What kind of self-care should they do?
I think a key antidote to burnout is satisfaction in your work. There are some shifts that are so frustrating and so exhausting! Then there are also moments when you comfort a frightened family member, catch a change in a patient’s condition, or hear “thank you” from a colleague—moments when you know your actions have a positive impact on someone else. Those moments are priceless. Keep a log or a journal by your bed or create a note in your phone with a list of your priceless moments as a nurse, and take time to re-visit them from time to time. The way you felt in those moments is as real and as powerful as the negative emotions.
What else do they need to be aware of?
Leaders and organizations in health care are increasingly taking action on the issue of burnout. As mentioned, the ANA launched the Healthy Nurse, Healthy Nation project. The Critical Care Societies Collaborative, a collection of four professional organizations, also identified burnout as a priority issue. Information and videos from their summit on this topic can be found here. Finally, the National Academy of Medicine created an online resource, the Clinician Well-Being Knowledge Hub, that offers individual and system level strategies to combat burnout. I think this website can be validating; it is important to recognize that you are not alone in feeling burnout as a member of the health care workforce.
The Josie King Foundation believes that nurses are leading the charge for a safer, more compassionate health care system. But they realize that in addition to the joys of healing, nurses face many emotional upheavals related to patient suffering, a complex workplace, new technologies, and fear of clinical errors. When personal pressures from everyday living are added to the already heavy load, the weight can lead to nurse stress, anxiety, depression, or burnout.
The Josie King Foundation developed the Nurse’s Journal in 2004, to help alleviate stress through expressive writing. (The journal was a response to results from a research project, Care for the Caregiver, that indicated it was sorely needed.) Created with the help of experts on the topic and specifically for nurses, it is offered by the nonprofit as a tool for self-directed writing or through facilitated journaling workshops.
The Nurse’s Journal is an attractive 61-page spiral bound notebook and is filled with helpful content such as evidence-based theories about journaling, before and after stress evaluation forms, and suggested resources to help nurses cope with work-related stress.
The majority of pages are low-content, with just short guided writing exercises to help you reflect on the stresses of your work life and personal life. For instance, the first one is titled “Guided Writing: Signs of Stress,” and includes the following prompt:
“Things to consider. Do you notice stress-related symptoms in your life? Is there a particular time of day or day of the week in which you feel more stress? Do your stress symptoms affect your job performance or your quality of life? What do you do to combat your stress?”
The page ends with a quote from the Dalai Lama about avoiding the burnout associated with witnessing great suffering.
In between the prompt and the quote, the page is empty so that a nurse is free to write out their own personal thoughts and feelings, as an antidote to workplace and life stressors.
Since launching the Nurse’s Journal in 2004, the Josie King Foundation has distributed them to more than 15,000 nurses. Many hospitals buy the journals in bulk as a gift for nurses during the winter holidays, or to mark Nurses Week, or at anytime for staff training and development purposes.In addition, they offer a companion Nurse’s Journal Guidebook for anyone who would like to facilitate journaling workshops for nurses.
For more information about the mission of the Josie King Foundation and their line of specialty journals for nurses, caregivers, and patients, visit http://josieking.org.