Those who become nurses are often drawn to the profession because of a desire to do meaningful work and to relieve suffering. But instead of finding professional fulfillment in a career dedicated to caring for others, nurses may find themselves struggling with professional burnout. The nursing profession, like firefighting or military work, is a high-stress occupation where burnout is not an unusual, irregular or rare phenomenon. Rather nurse burnout is a commonplace and growing occupational hazard.

Today, nurses are quitting in record numbers leading to nursing shortages, which in turn places greater strain on remaining nursing staff, nurse leaders, and healthcare organizations.  Most importantly, nurse burnout directly affects patient safety and the quality of care experienced by patients and their caregivers.  

The Covid-19 pandemic has shone a light on the mental health struggles of healthcare providers.  For example, Sarah Flanagan, a Registered Nurse caring for Covid-19 patients in Florida stated in the New York Times, 

“I feel undervalued and disposable... colleagues are telling me, ‘I want to leave the bedside, I feel exhausted and I don’t know what to do,'... It makes me afraid for the future.”(1)

A 2020 meta analysis which included 45,539 nurses from 49 countries reported a global prevalence of 11.23% for high burnout symptoms.(2) While there has been a flood of frightening statistics on burnout, increased awareness and calls to “heal the healers,” solutions are harder to find.

At Resilience in Healthcare (RIH), we know that nursing burnout is predictable and preventable. Our co-founders, Dr. Christophe Gimmler, an outpatient internist and community psychotherapist, and Dr. Teja Patil, a hospitalist and clinician coach, have spent over five years at the intersection of medicine, psychology, and education. RIH has  developed a unique curriculum teaching cognitive, emotional, and relational skills which are foundational to preventing burnout and fostering well-being for healthcare workers at every level. These skills enable providers including nurses and nurse practitioners to manage daily stressors, connect effectively with patients and colleagues, navigate conflict, access compassion under pressure, and maintain intellectual curiosity and creativity in the midst of challenging circumstances. 

In this article, we will focus on nurses in particular, and discuss the symptoms of burnout as well as causes and impact of nurse burnout. Most importantly, we will share key strategies for burnout prevention which are highly practical and actionable. 

What is Nurse Burnout?

Burnout has become an increasingly hot topic in today’s world as evidenced by the deluge of popular articles on burnout in parents, executives, gig workers, and social media influencers; millennials have even been dubbed by social media as “the burnout generation.”(3) However, burnout was originally defined in the 1970s as a syndrome that affects people who work in the “helping professions” such as medicine, teaching and social work. The leading definition, created by social psychologist Maslach, defines burnout syndrome as combination of overwhelming exhaustion, depersonalization and loss of efficacy or sense of personal accomplishment. (4) 

Emotional exhaustion is the state of being emotionally overextended and depleted by attending to the needs of others without adequate rest and recovery for oneself. When stress persists for a long period, our nervous systems move from an initial state of hyper-activation (i.e. “running on adrenaline”) to eventually, hypo-activation, a state of physical and emotional withdrawal or collapse. 

Depersonalization is an attitude of cynicism, negativity and dehumanization towards patients and colleagues. This aspect of burnout is marked by detachment from others (a feeling of “me against them”) and seeing patients less as people and more as problems. For example, a provider may start seeing a patient as “dementia in bed 12” instead of “Mr. Smith.”

Low personal achievement is a state of feeling that one’s efforts are inadequate and do not make a difference; there is a sense of futility, negative self-image, hopelessness and helplessness. Low self-efficacy is often augmented by a lack of support and needed resources and ultimately leads to job dissatisfaction and low job performance.

Maslach's three-part definition is widely used especially for academic and research purposes. But for the individual nurse, burnout can look and feel very similar to clinical depression. In addition, burnout does not present in the same manner for every person; instead, different people show different flavors of burnout marked by different dominant emotions. For some people the dominant emotion may be anger and frustration accompanied by angry outbursts and intense judgement or criticism of others and themselves. For others, burnout may present as increasing avoidance and disassociation; this group may seek out distraction and tend to develop addictive behaviors (alcohol, drugs, shopping or gambling). Another flavor of burnout is marked by intense anxiety; these clinicians may find themselves ruminating and feeling stuck, unable to make a decision and almost frozen with fear. All of these patterns are different manifestations of one phenomenon, burnout. 

It should be noted that the terminology of “burnout” and even “resilience” have been described as problematic as they imply a personal failing on the part of the individual, an implicit judgement that the provider is “not resilient enough.” It is very important to recognize that burnout is not the fault of the individual provider but instead a common and often, predictable consequence of chronic interpersonal stressors and overwork that results from caring for others within an inequitable or unjust system. Nurse burnout is not just an individual provider problem, but a collective phenomenon that affects the entire healthcare system. 

7 Causes of Nurse Burnout

1. Time Pressures

   a) High nurse:patient ratios mean less time per patient; nurses can feel that they are not able to provide the quality of patient care they would want to provide leading to feelings of inadequacy or failure.  

   b) Long hours: Nurses who work 12 hour shifts are at higher risk of burnout than nurses who work 8 hour shifts. Irregular shifts also lead to sleep deprivation and poor sleep quality. Infrequent or insufficient breaks for rest or meals is common.

   c) “Voluntary” overtime: As a result of chronic deficits in nurse staffing, many nurses report being expected to take on extra shifts to fill gaps in coverage. Not having controlof one’s work schedule is a big source of frustration.  

2. Incivility and Violence: Because nurses are the most patient-facing providers, they are most likely to be the subjects of verbal and physical abuse from patients and families. Nurses also report rudeness, bullying and incivility from their own colleagues which erodes their sense of wellbeing.

3. Lack of control over work processes. Nurses can feel that the administration makes decisions without their buy-in thus eroding their sense of autonomy and their sense that they are valued members of the team. Increased demands on tasks such as charting, staff meetings and quality improvement initiatives take time away from direct patient care duties. Time spent with patients and families can be a source of joy and fulfillment but increased administrative expectations can lead nurses to feel they must be task focused instead of patient focused.

4. Absence of a sense of community: Nurses report poor relationship between nursing and leadership and nursing and physicians. There is often an attitude of “us against them” which may be bonding for nurses but erodes the sense of teamwork or belonging to a larger community within the clinic or hospital. 

5. Lack of support when errors occur. Some teams do not prioritize cultivating a culture of support and a growth mindset (i.e. “How can we do better next time?”) In this case when an error occurs, a nurse may experience criticism and be reprimanded, leading them to feel they must be hyper-vigilant and defensive. Certain nurses may struggle with tendencies of perfectionism making them particularly vulnerable to self-doubt, shame and isolation when errors occur.(5)

6. Moral Distress: Moral distress occurs when nurses are tasked to enact decisions of a physician or the administration which do not reflect their own values.  Nurses may be asked to do things that from their perspective are morally wrong or morally ambiguous, and this tension creates moral distress. For example, a nurse may be tasked with discharging and escorting out a patient who is homeless when they are “medically cleared for discharge.” This experience of not being able to adequately protect or care for a vulnerable individual can trigger an experience of moral distress. These experiences are especially common for nurses who care for patients in resource poor settings, in critical care and at end-of-life. (6)

7. Compassion fatigue: Compassion fatigue, also known as secondary traumatic stress disorder, is a syndrome that arises from witnessing and taking on the suffering of others. This secondary traumatization can happen when a nurse is exposed repeatedly to disturbing cases (i.e. young patients dying, victims of gun violence) or can happen when the nurse identifies very closely with a patient. Providers with loose or porous boundaries who feel very empathetic towards patient’s can experience the patient’s suffering as their own. Compassion fatigue is not technically a cause of burnout but it frequently coincides with burnout. (7)

Effects of Nurse Burnout on the Healthcare System

Beyond the negative effects of burnout on quality of life of the individual nurse, studies have linked nurse burnout to decreased quality of care. For example, nurse burnout is associated with increased rates of hospital acquired infections, increased medication errors, lower patient satisfaction scores and even higher mortality. From an institutional standpoint, burnout results in absenteeism and high turnover rates, resulting in financial losses and staffing shortages. (8, 9, 10) As a result of the financial costs and detrimental effects on patient safety, preventing and treating burnout has become a top priority for healthcare organizations worldwide. 

Most Common Symptoms and Signs of Burnout

The Mayo Clinic (11) offers the following screening questions to help spot job burnout:

• Have you become cynical or critical at work

• Do you drag yourself to work and have trouble getting started?

• Have you become irritable or impatient with co-workers, customers or clients?

• Do you lack the energy to be consistently productive?

• Do you find it hard to concentrate?

• Do you lack satisfaction from your achievements?

• Do you feel disillusioned about your job?

• Are you using food, drugs or alcohol to feel better or to simply not feel?

• Have your sleep habits changed?

• Are you troubled by unexplained headaches, stomach or bowel problems, or other physical complaints?

In addition to the Mayo Clinic questionnaire which helps to self-identify signs of burnout, nurses can also identify signs of burnout in their colleagues. Common behavioral signs of burnout include:

• Increased preference towards isolation (not engaging in conversation, avoiding opportunities to socialize)

• Flat affect/ being withdrawn

• Poor judgment calls

• Procrastination

• Frustration (Easy to anger, disproportionate emotional outbursts to small triggers)

• Substance abuse

• Skipping work

Seven Strategies to Prevent Nurse Burnout

Burnout is a predictable and common occupational hazard that will challenge many through their nursing career. Therefore, burnout prevention and resiliency strategies should be taught and practiced just as any other professional nursing capacity. The seven capacities described below are difficult to develop on one's own. Nurses and all healthcare professionals need dedicated training and ongoing support in order to learn, cultivate and master these core resiliency skills. 

1. Self-care: Human beings need mental and physical rest. Instead of putting your needs at the bottom of your priorities, move them to the top. Take time for sleep (most people need 7-9 hours of sleep per night), exercise, nutritious meals, time with loved ones and time on your hobbies. These self-care practices are universal needs that are foundational to long-term wellbeing. This strategy is not easy to enact consistently but if you are not caring for yourself, you are not able to care for others.

2. Healthy Professional Boundaries: Maintaining healthy boundaries between oneself and one’s patients, one’s colleagues, one’s supervisor and the hospital administration takes intention and practice. Nurses tend to have loose or porous boundaries meaning it is easy for them to empathize with the other person’s perspective, to feel their distress and to want to fix the problem. This is augmented by the fact that in the helping professions, we are implicitly and explicitly taught that saying “yes” makes one a team player and an excellent provider. Nurses who extend themselves to take on extra shifts, more patients, more quality improvement projects are congratulated for their selflessness and dedication. Naturally, the system wants to extract maximum value from the individual. As a result, saying no can feel extremely uncomfortable and lead to feelings of insecurity, inadequacy and wondering, “Am I being selfish?” “Am I a bad nurse for telling my patient/coworker/ nurse manager no?”  Stretching oneself to help others can feel really good in the short term because it feels like we are being a team player. But in the long-term, repeatedly prioritizing the hospital’s needs or the patient’s needs by overextending ourselves can lead to overwork and this can build resentment. Understanding the short term and long term consequences of cultivating and maintaining healthy professional boundaries can lead to more flexibility and a greater sense of choice and control over our relationships and our work environment.

3. Science of emotion. Emotions, especially strong emotional reactions such as anger, grief or shame, can feel uncontrollable, random and uncomfortable. But there is a science behind emotions and understanding them can shed a great deal of light on our own motivations, values and priorities. At RIH, we teach the science of emotions using the framework of the emotional episode timeline (EET). The EET is a powerful tool that gives providers a step-by-step approach to unpacking their own strong emotional episodes. Nurses can use the EET to become more aware of their own individual triggers or stressors and more aware of their own thoughts and behaviors; with this understanding, we can begin to consciously modify our responses. Developing this awareness and flexibility in choosing our own response can profoundly impact a provider’s energy, mood and quality of life over the long term. 

4. Navigating Conflict: Working in patient care where we are met with tragic and emotionally charged circumstances and confronted by many different personalities and priorities in a high-stress environment, interpersonal conflict is absolutely inevitable.  Learning how to manage conflict without avoidance or stress is a key professional capacity. Many times, when conflict arises we fall back on patterned stress responses, such as fight, flight, freeze or please. These responses are built-in conditioning that all humans share but in the workplace our knee-jerk reactions can be maladaptive. At RIH, we teach an approach to conflict that focuses on moving away from these automatic reflexive reactions to a conscious approach to negotiating conflict. Nurses can practice observing how they typically respond to different stressors and with time, can learn that their natural conditioning is not permanent. In fact, there are many ways to respond and we can learn to break out of our narrow patterned reactions and choose more intentional and adaptive responses. Recognizing that conflict is normal can in itself be incredibly liberating. Developing a conceptual framework for how to manage conflict in the workplace, is even more powerful.

5. Cultivate a resilient mindset by practicing gratitude and self-compassion. Our brains over-index on negative events but we can rewire our thoughts with intentional practice. Many of us have perfectionist tendencies and tend to self-doubt and self-criticize. Instead of assigning blame to ourselves, aim to cultivate a growth mindset which focuses on the idea that all of us are in the process of becoming. When we are having difficulty, a helpful frame is to speak to ourselves as we would if we were speaking to a friend. Meeting ourselves with kindness and understanding is just as important as showing compassion to others.Taking time every shift to reflect on what we have to be thankful for can reduce stress and increase our sense of shared humanity and connection with others.

6. Mindfulness practice: Our nervous systems are in a constant state of hyper-activation, hypo-activation or a middle ground, called the window of optimal functioning (i.e. the sweet spot). When we are hyper-activated, our nervous systems are overstimulated, we are quick to judgement and we are running on adrenaline. When we are hypo-activated, our nervous systems are under-stimulated, overworked and slowing or shutting down. At RIH, we teach providers how to detect the signs of hyper-activation and hypo-activation in themselves and then use calming practices to soothe the hyper-activated nervous system and enlivening practices to energize the hypo-activated one. Many of these mindfulness practices take just minutes and thus are powerful tools for regulating stress in the workplace in real time. 

7. Community of Support: Find colleagues, mentors or coaches who support your emotional resilience and your personal development. It is important for nurses to have a safe space where one can debrief about difficult patient encounters or talk through how we responded to a stressful event. It is ideal if one can find colleagues who are not trying to “fix” the problem for you.

   At RIH, we offer a peer-to-peer mentorship training where providers can learn how to support one another. A great peer mentor can validate their colleague’s experience, meet them with compassion and non-judgement and ask thoughtful questions that help the colleague to gain a deeper understanding of their own thought patterns and behaviors.

   Another powerful tool for building community is the process of a Balint Group (12), a group discussion amongst clinicians where they discuss difficult patient encounters. RIH is trained in facilitating Balint groups which explore the patient-provider relationship, enhance the provider’s self-awareness and capacity for empathy and sense of self-efficacy.

The Bottom Line

Nurse burnout is a significant problem causing financial losses for healthcare systems, decreased job satisfaction and quality of life for healthcare workers, and decreased patient safety and worsened patient experience for patients and their families. Today, there is widespread awareness that nurse burnout is a growing problem but little consensus on what should be done to address it. In the debate over solutions, some have warned that the burden of preventing burnout should not be placed on the frontline provider and that instead, the focus should be on systems-level change. 

Implementing systematic changes is essential in order to help address issues such as staffing shortages, unsupportive work environments, decreasing bureaucratic burdens and promoting nursing participation in decision-making. However, these system changes take a great deal of time to implement and the work of many stakeholders. In addition, some stressors such as compassion fatigue and moral injury are intrinsic to the work of patient care and will never be fully alleviated by systems change alone. 

Luckily, the individual provider has many tools at their disposal to protect themselves from burnout without waiting for workplace reforms. In order to support frontline providers, RIH has developed a resiliency curriculum which focuses on augmenting healthcare workers’ emotional and social intelligence. The curriculum is composed of a foundational set of psychological and relational skills that foster the provider’s longterm wellbeing and foster a culture of wellness amongst their group. We believe these skills are essential professional capacities which empower healthcare providers at every level to enjoy a fulfilling and sustainable career in medicine. 

References:

1. Trianni, F. (2020). Doctors and Nurses Talk About Burnout as Another Wave of COVID-19 Hits U.S. Time. Retrieved from https://time.com/5914409/covid-19-health-care-worker-burnout/

2. Woo, T., Ho, R., Tang, A., & Tam, W. (2020). Global prevalence of burnout symptoms among nurses: A systematic review and meta-analysis. Journal Of Psychiatric Research, 123, 9-20. doi: 10.1016/j.jpsychires.2019.12.015

3. Petersen, A. (2020). Can't Even: How Millennials Became the Burnout Generation. Houghton Mifflin.

4. Maslach, C., & Leiter, M. (2016). Understanding the burnout experience: recent research and its implications for psychiatry. World Psychiatry, 15(2), 103-111. doi: 10.1002/wps.20311

5. Fitzpatrick, B., Bloore, K., & Blake, N. (2019). Joy in Work and Reducing Nurse Burnout: From Triple Aim to Quadruple Aim. AACN Advanced Critical Care, 30(2), 185-188. doi: 10.4037/aacnacc2019833

6. Moral Distress: What It Is And What To Do About It - Blog - Healthy Nurse, Healthy Nation™. (2017). Retrieved 14 June 2021, from https://engage.healthynursehealthynation.org/blogs/8/531

7. What is burnout vs. compassion fatigue?. (2009). Retrieved 14 June 2021, from https://www.reliasmedia.com/articles/113896-what-is-burnout-vs-compassion-fatigue

8. Emotional exhaustion and workload predict clinician-rated and objective patient safety. Welp A, Meier LL, Manser T. Front Psychol. 2015;5:1573

9. Nurse staffing, burnout, and health care-associated infection. Cimiotti JP, Aiken LH, Sloane DM, Wu ES. Am J Infect Control. 2012;40:486–490.

10. Nurse turnover: the mediating role of burnout. Leiter MP, Maslach C. J Nurs Manag. 2009;17:331–339.

11. Know the signs of job burnout. (2021). Retrieved 14 June 2021, from https://www.mayoclinic.org/healthy-lifestyle/adult-health/in-depth/burnout/art-20046642

12. Balint groups - The American Balint Society. Retrieved 14 June 2021, from https://www.americanbalintsociety.org/content.aspx?page_id=22&club_id=445043&module_id=406070