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Patient Safety Tip
of the Week
February 9, 2021 Nursing Burnout
Burnout
is a phenomenon that has impacted virtually every type of healthcare worker and
the COVID-19 pandemic has clearly accentuated this problem. While we are
concerned about burnout among our physician colleagues, we are even more
concerned about the impact burnout is having among our nursing colleagues.
A
2019 survey (King 2019) found that 15.6% of all nurses reported
feelings of burnout, and that increased to 41% in unengaged nurses. That
report focused on nurse engagement and found the top three key drivers predicting
nurses engagement were: autonomy, RN to RN Teamwork and collaboration, and leadership
access & responsiveness.
Perhaps
more bothersome in the report was that 50% of nurses who reported feeling burned
out had no plans to leave their organization. Thats
concerning since we know that burnout is associated with increased frequency of
errors and missed care.
As youd probably expect, burnout is more common in very high
stress environments, such as ICUs, the ER, and the OR.
The
Joint Commission recognized nurse burnout as a significant issue and suggested
multiple strategies to promote resilience to combat nurse burnout in a Quick
Safety Issue in 2019 (TJC 2019).
Our
numerous columns on nursing shifts and nurse workloads have highlighted the
negative impacts the nursing work environment may have on job satisfaction,
burnout, and staff turnover. Ultimately, negative impacts on nursing also get
reflected in patient satisfaction and patient safety. Unless we mitigate the
factors contributing to nurse burnout, we are destined for serious problems in
patient care in the not-so-distant future.
A
timely study in JAMA Network Open (Shah 2021) examined some of those factors contributing
to nurse burnout. The researchers used data on almost 4 million nurses collected
in 2018 in the National Sample Survey of Registered Nurses (NSSRN) in the US. Among
nurses who reported leaving their job in 2017 (n = 418,769), 31.5%
reported burnout as a reason. That is an increase from the 2008 NSSRN survey
which showed that approximately 17% of nurses who left their position in 2007
cited burnout as the reason for leaving.
Work
hours clearly play a role. Nurses who worked more than 40 hr/wk had a higher likelihood
identifying burnout as a reason they left their job, compared with working less
than 20 hr/wk (odds ratio 3.28).
Long
shifts foster nurse burnout and job dissatisfaction. Multiple studies,
discussed in our prior columns, have described the negative effects of 12-hour shifts
on nurse health, well-being, and job satisfaction. In our September 29, 2015
Patient Safety Tip of the Week More
on the 12-Hour Nursing Shift we noted another RN4CAST study that
provides insight into the impact of 12-hour shifts on nurse well-being (DallOra
2015).
Those researchers found that, while all shift lengths greater than 8 hours were
associated with more nurse adverse outcomes, nurses working shifts ≥12 h
were more likely to experience burnout, have emotional exhaustion,
depersonalization, and low personal accomplishment. Moreover, they were more
likely to have job dissatisfaction, dissatisfaction with work schedule
flexibility, and report intention to leave their job due to dissatisfaction.
Nurses working shifts of 12 hours or more were 40% more likely to report job
dissatisfaction and 29% more likely to report their intention to leave their
job due to dissatisfaction. (Note: Long shifts can include both scheduled 12-hour
shifts and instances of forced overtime. We suspect the latter give rise to
even more job dissatisfaction and burnout than the former.)
Staffing
levels and the work environment were important factors in the Shah
study as well. Respondents who reported leaving or considering leaving their
job owing to burnout reported a stressful work environment (68.6% and 59.5%,
respectively) and inadequate staffing (63.0% and 60.9%, respectively).
There
were some geographic differences in some of the findings. For example, of those
nurses who left their jobs in 2017, there were lower proportions of nurses
reporting burnout in the West (16.6%) and higher proportions in the Southeast
(30.0%).
While
better pay or benefits were often cited as reasons for leaving or considering
leaving jobs, more frequently cited reasons were stressful work environments,
inadequate staffing, and lack of good management or leadership.
Lack
of collaboration/communication between health care professionals was another
reason sometimes cited. Weve done multiple columns on
the culture of disrespect and how even subtle physician behaviors can have a
toxic influence on the workplace. Interpersonal differences with colleagues
or supervisors was also mentioned by some. We note that there has been an
increasingly frequent literature on bullying and lateral violence in the
nursing literature.
The
most common signs of burnout, which define burnout syndrome include: emotional exhaustion, depersonalization, and lack
of personal accomplishment (LeVeck 2018). LeVeck also
noted some other risk factors for nurse burnout:
- Women
are at a higher risk of burnout
- Working
in the ICU or in another high-stress environment like ER or Trauma
- Being
single or divorced
- Lacking
spirituality of any kind
- Holding
an Associates versus a Bachelors degree
- Working
full-time at the bedside
Notably
absent in the Shah study is any mention of the role of the electronic health
record (EHR), which is a major factor in promoting burnout in physicians. A
recent systematic review on factors associated with nurse well-being in
relation to electronic health record use (Nguyen 2020) found worse nurse well-being was associated
with EHRs compared with paper charts. Moreover, the researchers found that
nurses have valuable insight into ways to reduce EHR-related burden. Studies on
nurse-level factors suggest that personal digital literacy is one modifiable
factor to improving well-being. Additionally, EHRs with integrated displays
were associated with improved well-being.
A
survey of nurses (Frellick 2019) had some very interesting findings. It found
licensed practical nurses (LPNs) and registered nurses (RNs) all had
satisfaction rates from 94% to 96%. But, when the question was asked a
different way (whether respondents would choose nursing again if they could do
it over), fewer among the 10,284 total nurses who responded to the online
survey said yes. Only 76% of RNs answered this question yes. Even fewer
would choose the same practice setting again. Helping people was the most
common answer when asked about the most rewarding aspect of their job. Least
rewarding aspects for LPNs and RNs were administrative tasks and workplace
politics, with about a quarter stating that choice, and paperwork. So, somewhat
similar to those factors leading to physician burnout,
the EHR, paperwork, and administrative tasks had a negative impact on nurses.
While
it is not clear what exactly was meant by workplace politics in the above
survey, we surmise that includes things like the culture of disrespect,
hierarchical structures, bullying, and lateral or horizontal violence.
So,
how do we avoid nurse burnout? Shah and colleagues recommend health systems
should focus on implementing known strategies to alleviate burnout, including
adequate nurse staffing and limiting the number of
hours worked per shift.
Several
other strategies have been suggested to combat burnout in nursing and increase
nurse resiliency.
LeVeck (LeVeck 2018) notes her Top 4 Tips For
Burnout Prevention:
- Resilience
Resilience is defined as, the development of coping mechanisms to lessen the impact of trauma or emotional stress. Nurses who possessed resiliency were at less of a risk for burnout. - Self-Care
Regular exercise
Extra-curricular activities away from the job
PTO days for mental - Recognizing
triggers
Its important to acknowledge those times when you are feeling burned out and to take action to relieve yourself of those feelings. That might include asking for easier patient assignments when they needed to recover from a previous emotional week, working occasionally on other units, switch to lower acuity areas of the hospital, performing administrative duties part-time, etc. - Strong
coworker relationships
Nurses who felt they could trust their coworkers and enjoyed going to work were at a lower risk for burnout. Activities that include the whole team may be helpful. Importantly, when toxicity is identified on a unit, it should be dealt with quickly, because one negative person can increase the risk of burnout within your unit.
Cheryl
Commors (Connors 2019) described the RISE (Resilience in Stressful
Events) program at Johns Hopkins Hospital to help care providers dealing with
the trauma of a tragic patient event (we described that program in our August
2017 What's New in the Patient Safety World column ROI for a Second Victim Program). She notes that debriefing after
stressful incidents is important and that nurses need an outlet to talk about a
stressful experience and receive support from a peer. The debrief should focus
on the nurse's emotional and/or psychological experience associated with the
event, not details of the event itself. This really fits under the category strong
coworker relationships noted by LeVeck.
The Joint Commission (TJC
2019) recommends the following safety actions directed
toward leaders:
Inform leaders in your organization about the
professional factors that foster resilience:
- Feeling valued professionally
- Colleague support
- Use of mentors/role models
- Feeling of making a difference
- Team support. Organizational support
- Use of debriefings
- Feeling competent to meet needs of the job
- Positive reappraisal
- Empowerment
- Sense of accomplishment
Develop and practice leader empowering
behaviors by:
- Creating a safe and positive work
environment. Security concerns have been identified as a risk factor for
development of staff burnout. Engage with your staff around their
perceived environmental threats and develop action plans to address
concerns.
- Enabling employees to participate in
decisions related to their work. Shared decision making strengthens the
voice of the clinical nurse as they collaborate with leaders around optimal
staffing plans
- Expressing confidence in employees
ability to perform at a high level
- Facilitating goal attainment.
- Providing autonomy.
Ensure that leaders engage in discussions and
have a physical presence in the department.
They also
note actions to help nurses develop resilience in order to
combat burnout:
- Provide
education for nurses, preceptors and nurse
leaders to:
- Identify
behaviors caused by burnout and compassion fatigue (stress related to
repeated exposure to high acuity and high patient volumes).
- Become
aware of their personal stressors and triggers
- Take
part in self-care activities/techniques (such as sleep, fitness and
eating habits)
- Discuss
resiliency
- Improve
clinician well-being by measuring it, developing
and implementing interventions, and then re-measuring it. (The National
Academy of Medicine provides a summary of established tools to measure work-related
dimensions of well-being)
- Provide
nurses with opportunities to reflect on and learn from practice and other
practitioners (e.g., positive role models)
- Develop
or utilize current tools for staff to use to anticipate opportunities and problems
- Work
with your internal team to assess if your current electronic health record
(EHR) system may be customized so that it optimally supports nursing workflow
- Hold
regular staff meetings. Include discussions regarding new organizational
policies, processes and outcomes from higher
leadership meetings. Engage nursing input in staff meetings by posting an
agenda and asking for additional items the nurses would like to discuss or
present
- Cultivate
a health professional culture that is based on altruism, setting a good
example, mentoring, leading, coaching and motivating others
- Recognize
nurses in a meaningful way (find out from nursing staff how your
organization can best demonstrate that it is invested and interested in recognizing
nursing staff for the work that they do)
Lastly, its
important to recognize the role for medical leadership in combating burnout,
not just physician burnout but also nursing burnout. For medical directors and
medical staff leaders, its critical that a culture of
respect be fostered. That means zero tolerance for behaviors that are
disruptive or degrading. It means establishing an environment where nurses are
encouraged to speak up without concern for retribution. There is nothing worse
for nursing morale than when a nurse speaks up about counterproductive
physician behavior and then nothing is done, or worse yet, the nurse is somehow
treated badly because he/she raised the issue. That sort of toxic environment
has a lasting impact on morale and is a major reason for nurses leaving their
positions.
Our previous columns on the 12-hour nursing
shift:
November
9, 2010 12-Hour Nursing Shifts and Patient Safety
February
2011 Update on 12-hour Nursing Shifts
November
13, 2012 The
12-Hour Nursing Shift: More Downsides
July 29, 2014 The
12-Hour Nursing Shift: Debate Continues
October 2014 Another
Rap on the 12-Hour Nursing Shift
December 2, 2014 ANA
Position Statement on Nurse Fatigue
September 29, 2015 More
on the 12-Hour Nursing Shift
July 11, 2017
The 12-Hour Shift Takes More Hits
May 29, 2018
More on Nursing Workload and Patient Safety
September 4, 2018 The 12-Hour Nursing Shift: Another Nail in
the Coffin
Some
of our other columns on nursing workload and missed nursing care/care left undone:
November 26, 2013 Missed
Care: New Opportunities?
May 9, 2017 Missed Nursing Care and Mortality Risk
March 6, 2018
Nurse Workload and Mortality
May 29, 2018
More on Nursing Workload and Patient Safety
October 2018 Nurse Staffing Legislative Efforts
February 2019 Nurse Staffing, Workload, Missed Care,
Mortality
July
2019 HAIs and Nurse Staffing
September
1, 2020 NY
State and Nurse Staffing Issues
Some of our prior columns on the impact of
bad behavior of healthcare workers:
January 2011 No
Improvement in Patient Safety: Why Not?
March 29, 2011 The
Silent Treatment: A Dose of Reality
July
2012 A Culture of Disrespect
July 2013 "Bad
Apples" Back In?
July 7, 2015 Medical
Staff Risk Issues
September 22, 2015 The
Cost of Being Rude
April 2017 Relation of Complaints about Physicians to
Outcomes
October 2, 2018 Speaking Up About Disruptive Behavior
August
2019 More on the Cost of Rudeness
January
21, 2020 Disruptive
Behavior and Patient Safety: Cause or Effect?
References:
King C, Bradley LA. PRC National Nursing Engagement Report.
PRCCustomResearch.com 2019
The Joint Commission. Developing Resilience
to Combat Nurse Burnout. The Joint Commission 2019; Quick Safety Issue 50: 1-4
Shah MK, Gandrakota
N, Cimiotti JP, Ghose N, Moore M, Ali MK. Prevalence
of and Factors Associated With Nurse Burnout in the
US. JAMA Netw Open 2021; 4(2): e2036469
Dall'Ora C, Griffiths
P, Ball J, et al Association of 12 h shifts and nurses job satisfaction,
burnout and intention to leave: findings from a
cross-sectional study of 12 European countries. BMJ Open 2015; 5: e008331
https://bmjopen.bmj.com/content/5/9/e008331
LeVeck D. Nurse
Burnout Is Real: 7 Risk Factors And The Top 3
Symptoms. Nurse.org 2018; October 2, 2018
https://nurse.org/articles/risks-for-nurse-burnout-symptoms/
Nguyen OT, Shah S, Gartland
AJ, et al. Factors associated with nurse well-being in relation to electronic health
record use: A systematic review. Journal of the American Medical Informatics
Association 2020; Published: 23 December 2020
Frellick M. Nurses
Largely Satisfied, but Many Would Change Path. Medscape Medical News 2019; January 24, 2019
Connors C. 3 Ways to Build Nurse Resiliency
in 2019. AORN The Periop Life Blog 2019; January 27,
2019
https://www.aorn.org/blog/nurse-resiliency
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