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 stress of nursing can take quite a toll on nurses emotionally and psychologically. Learn to recognize the signs, what to do, and when to seek help.
Abbegail Eason, RN, remembers some of the most devastating moments she’s witnessed as a nurse: a teenage girl learning she would never walk again after being shot by a gang member, a mom who gave birth but then died from a cerebral aneurysm just days later, and a baby who was left in a store’s parking lot and ended up dying.
“In these types of situations, it’s almost impossible not to be affected after your shift is over,” says Eason, a holistic coach at Abbegail Eason, LLC.
“Every nurse is susceptible to suffering from emotional distress,” explains Lucia M. Thornton, RN, MSN, AHN-BC, a consultant, educator, and author of Whole Person Caring: An Interprofessional Model for Healing and Wellness. Thornton and other sources we interviewed say that while all nurses can be affected emotionally, those in particular specialties may be more apt to experience this kind of issue. Some of the areas where nurses are especially at risk: emergency departments and trauma, intensive care unit (ICU), hospice, oncology, pediatrics, HIV clinics, homeless medicine, high-risk pregnancy clinics, palliative care, and neonatal intensive care unit (NICU), among many others.
“Anyone who is empathetic and works in a caregiving role—including nurses and certified nursing assistants—are at risk for developing compassion fatigue and increased caregiver stress, which affects emotional health,” explains Karen Whitehead, MS, LMSW, DCC, CCFP, who provides counseling in the greater Atlanta area and at TurningPoint Breast Cancer Rehabilitation. “Nurses who over-identify with patients and blur boundaries, as well as nurses with personal trauma histories, poor social support, isolated working conditions, or a previous history of unmanaged anxiety are at greater risk. Feeling a lack of control about your work environment—including schedule, lack of recognition, or sense of community—can also contribute to caregiver stress.”
“Working in these areas with these types of patients triggers the sympathetic nervous system and keeps the body in fight or flight mode. This heightened stress reaction can, over time, lead to compassion fatigue and ongoing emotional distress,” she adds.
It can also be especially difficult for nurses because they are on the frontline of patient care, says Carl J. Sheperis, PhD, NCC, CCMHC, MAC, ACS, LPC. “Aside from the ongoing stressors of variable schedules, budget cuts, and constant technology changes, nurses are faced with a broad range of emotions experienced by patients,” explains Sheperis, a licensed professional counselor as well as the program dean for the College of Social Sciences at the University of Phoenix. “According to the American Nurses Association 2011 Health and Safety Survey, over 56% of participating nurses had experienced some type of threat or verbal abuse from patients. All of these stressors compound and result in high incidences of compassion fatigue and burnout for nurses.”
Compassion Fatigue, Moral Resilience, and Burnout
Mary Bylone, RN, MSM, CNML, president of Leaders Within, LLC, and a former board member of the American Association of Critical-Care Nurses (AACN) often lectures and writes about the AACN’s healthy work environment standards. Bylone says that while compassion fatigue, moral resilience, and burnout are terms often used interchangeably because they do have a lot of overlap, they also have some differences.
“Burnout is best used to describe a situation in which an individual feels overwhelmed and exhausted. It can be seen when people sacrifice themselves for work or become overwhelmed with the feeling that the work is never done. Compassion fatigue refers to the weariness that develops from caring for individuals when the caregiver feels saddened that they cannot change the situation and give of themselves in the hope of relieving pain or suffering in the patient,” explains Bylone. “Moral resilience refers to the aspect of an individual’s character to rise above situations creating moral distress, such as being asked to provide futile care or care against a patient’s wishes. Resilience comes when the nurse is able to restore and maintain their integrity by challenging or pushing back when asked to do things they do not feel are right. It involves using one’s bold voice to speak up when others would remain silent—to ensure that the morally right thing is done.”
For the past decade, the AACN has addressed all these issues. Its National Teaching Institute recently held a special interactive session during which more than 300 nurses spent an afternoon sharing the types of experiences that would cause these feelings and sharing their solutions with their colleagues as well. “The AACN puts a lot of energy into hope and resilience rather than dwelling on the negative,” says Bylone.
Recognizing the Signs
“Experiencing emotional reactions is human and appropriate,” says Sheperis. “The key is recognizing when the emotional reactions are out of proportion to a situation or when they have a negative impact on you or others around you. Nurses are often good at compartmentalizing emotional reactions, but sometimes the compartments become full, and the emotions spill out.”
Some of the signs that a nurse is experiencing negative effects from emotional overload are: using a greater number of sick days and/or dreading going to work; feeling exhausted; problems sleeping; using drugs or alcohol to sleep; having work-related dreams, nightmares, or intrusive thoughts; being angry a lot either at work or home; yelling at patients or families; changes in mood or behavior at work; crying all the time; feeling angry at supervisors or coworkers; developing fears about the safety of friends or family; feeling less engaged in their personal and/or professional life; the inability to think clearly; headaches; gastrointestinal problems; irregular breathing patterns, feeling devalued, and losing the capacity to care about themselves, their patients, their family members, or really anyone.
This doesn’t even touch on the signs of clinical depression, which nurses may also experience. The point is that if nurses notice vast changes in themselves or in their coworkers, they may need to seek or suggest help.
The first action that nurses can take to keep their emotional health intact is to set boundaries, says Gail Trauco, RN, BSN-OCN, a grief mediator, owner of Front Porch Therapy, and author of Conquering Grief from Your Own Front Porch. Nurses can do small things to make themselves happy. “Be sure you have things that you visually see which create an immediate ‘happy sensation,’” suggests Trauco. “This can be a favorite coffee mug, bright-colored scrubs, flowers on your desk, or even a funny stethoscope cover.”
One of the biggest problems nurses have is that they tend to put everyone else’s care above their own, says Jill Howell, MA, ATR-C, LPC, a board-certified registered art therapist, professional counselor, and author of Color, Draw, Collage: Create Your Way to a Less Stressful Life. While she works at Pocono Psychiatric Associates, Howell worked with many nurses at the Pocono Medical Center. “It’s all about self-care—nurses will, of course, react by saying that they don’t have time,” says Howell. “Please remember what they say on the airplane—put your oxygen mask on first before you try to help others.”
When working with nurses, Howell would check in with them to see how they were dealing with work, give them an opportunity to vent, and make small self-care suggestions. She would also do quick guided meditations with them, teach a relaxation technique, or set up large sheets of mural paper and have them draw out their frustrations.
“I have found that most nurses, while they can care for others continuously, have a very difficult time in caring for themselves,” says Thornton. “Self-compassion is an important and useful practice for nurses to develop.”
“Nurses are givers. We go into the field because we are caretakers,” says Eason. “Many of us feel we are at our best when taking care of others.” She says that it’s important, though, for nurses to understand that they have to take care of themselves first. “Ensure you are getting adequate, quality sleep. You are eating a well-balanced meal. You are getting adequate exercise. You are spending time cultivating a life that is meaningful, rich, and deep outside of work,” says Eason.
After a particularly stressful experience at work, Lisa Radesi, DNP, CNS, RN, academic dean at the School of Nursing, College of Health Professions, University of Phoenix, says that nurses and other staff should have a debriefing session and remember that, despite all of the “bad” that occurs in their jobs, the “good” is the most rewarding part of what they do.
“Nurses should work together to ensure that they are okay after an incident. If a nurse notices a coworker is not doing well, they should talk with the coworker and bring it to the attention of the supervisor or manager,” says Radesi. “Above all, nurses should feel comfortable seeking treatment and communicating about emotional issues they may experience. Keeping this information bottled up can lead to issues and stress that have long-lasting effects. Know that it is not weakness, but strength, to acknowledge emotional disturbances and respond to them accordingly.”
If you see a coworker in distress, you can do something as simple as strike up a conversation with her or him, advises Bylone. “Use open-ended questions to find out how they are doing. Sometimes hearing the other person’s story really puts things into perspective. Let them know you care, and you are there to help, if only to listen. Please do not watch them suffer alone. Left unattended, these feelings only deepen and create lasting impact, often causing them to leave the profession,” she says.
Seeking Professional Help
Let’s face it: there are times when a spa day, time out with friends, or a bubble bath just won’t cut it in alleviating emotional problems. That’s when nurses need to seek professional help.
“If you are experiencing distressing symptoms over an extended period of time, it’s a good idea to check in with a professional therapist or counselor,” says Whitehead. “Whether it is distress from work or something related to your life outside of work, connecting with a professional can help you be a more effective caregiver and build your own resilience to mitigate the effects of your chosen population at work.”
If you need professional help, first see if your workplace has a program for staff members. If not, Sheperis says that the National Board for Certified Counselors has a directory of board-certified counselors across the United States (visit nbcc.org for more info). PsychologyToday.com also has a therapist directory that includes profiles of providers who can help.
There’s no shame in seeking help to get better. Sheperis says, though, that all nurses should do whatever they can to prevent their emotional stress from getting to this level. “Most people only seek professional help after something in their life had caused significant distress. While it is important to seek help if you are reaching a level of burnout or compassion fatigue, it is much better to take proactive steps and to work with a counselor to build resilience prior to hitting an emotional wall,” he says.
Sheperis also suggests that nurses focus on wellness practices at the onset of their careers. “It is easy to become engrained in a high-pressure system and to become emotionally overwhelmed if you don’t have a set of wellness practices in place.”
During National Nurses Week, nurses are honored and thanked for all the different and essential ways they touch lives. From a compassionate hand on a shoulder to life-saving emergency treatment, nurses are at the forefront of the nation’s well being.
But nurses, caretakers of everyone, are notorious for pushing aside their own needs. If they aren’t able to refresh every now and then, they can experience a fast and often personally upsetting burnout.
“A compassionate heart is a gift from the universe and should be honored as a gift,” says Phyllis Quinlan, RN-Bc, PhD, LNC, CEN, CCRN, a career coach with MFW Consultants, and author of The Delicate Balance: A Mindful Approach to Self-Care for Professional and Family Caregivers. “You need to protect it.”
Quinlan who is a presenter in this week’s The Art of Nursing video series event, says caregivers in all positions are particularly vulnerable to compassion fatigue, but it’s something that can be helped. Various programs during National Nurses Week are highlighting all the ways nurses can take care of themselves and encouraging nurses to put themselves at the top of their own priority list.
For nurses, putting themselves first is nearly impossible. “I hear from people when things are becoming a bit unmanageable, and they can sense it happening,” Quinlan says. “Maybe they have tried switching units and that didn’t help.” Such lateral moves, she says, are often a signal that a nurse is looking for a change to get out of whatever funk he or she might be in, but such moves don’t address the root of the problem.
“It’s important for nurses to know this is common among professional caregivers,” Quinlan says. “Nurses are incredibly generous and special souls. There are few on the planet who can mobilize their compassion into action. They need to reconnect with how incredible and special they are.”
One of the best ways for nurses to recognize that they might be approaching burnout is to listen – to themselves and to those who are close to them. “Nurses will go along and think everything is going fine and then people start to say, ‘Is everything okay?’” says Quinlan. “They might start to get hints from their personal or professional inner circle.”
But most nurses brush off concern. “A nurse will say, ‘No, I’m fine. What can I do for you?’” says Quinlan. But if any nurse feels an inner sense that something is just off, he or she must honor that. They can do that by overcoming their reluctance to accept that there might be a problem, says Quinlan, and then accepting help to fix it.
“Your compassionate well can go dry if you don’t replenish it,” says Quinlan. To reconnect with the joy of nursing, you can do several things. Time off is always a good bet. Even if you can’t go on vacation, a day devoted to something you love – whether that’s an afternoon of back-to-back movies or a long bike ride – will give you welcome space, a little freedom, and a new perspective.
Quinlan recommends trying to find time to just be still, despite knowing how very difficult that is for nurses who are always in motion. “You want to find still time for self reflection and introspection,” she says. “It should be quiet and benevolent.” With enough quality quiet time, your resilience will grow stronger.
“Nurses are indispensable, but not indestructible,” says Quinlan. “Be as gentle and as kind with yourself as you would with a patient.”
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