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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. That’s concerning since we know that burnout is associated with increased frequency of errors and missed care.
As you’d probably expect, burnout is more common in very high stress environments, such as ICU’s, 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 (Dall’Ora 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. We’ve 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:
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 EHR’s 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, EHR’s 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 (LPN’s) and registered nurses (RN’s) 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 RN’s 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 LPN’s and RN’s 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”:
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.
Inform leaders in your organization about the professional factors that foster resilience:
Develop and practice leader empowering behaviors by:
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:
Lastly, it’s 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, it’s 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 “HAI’s 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?”
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
LeVeck D. Nurse Burnout Is Real: 7 Risk Factors And The Top 3 Symptoms. Nurse.org 2018; October 2, 2018
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
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