We frequently hear of rampant stress and resulting burnout in nurses. What causes it? Employee health professionals are well aware of the threats of occupational injury and illness, but other factors in the work environment require considerable resilience to withstand daily. Consider this incomplete list, summarized from a new book called Nurse Burnout: Overcoming Stress in Nursing.

  • Insufficient staffing, long, rotating shifts, excessive workload, and time pressure.
  • Lack of teamwork with co-workers, and reporting to supervisors who may be unqualified.
  • Sicker patients, and families with unrealistic expectations.
  • A lack of control in the work environment due to mandates driven by others, floating to new work areas with little or no orientation.
  • The threat of hostility or violence by patients, visitors, and co-workers.

Know What You Cannot Control

Hospital Employee Health discussed some issues of nurse burnout in an interview with the book’s author, Suzanne Waddill-Goad, DNP, MBA, BSN, RN, CEN. She has 31 years of experience in nursing and is a consultant to hospitals and other healthcare settings.

HEH: How is nurse burnout different from physician burnout — or is it?

Waddill-Goad: I think some of the stress is similar, but if you contrast the physicians’ and nurses’ practice, the nurses are with the patients — especially in a hospital setting — 24/7. It’s obviously a different role in terms of education and training, and also, there is a different level of stress. Typically, nurses in a lot of states work 12-hour shifts, which are good for work-life balance because they have days off if they don’t fill them up with other hospital work, which nurses have a tendency to do — working overtime.

HEH: You refer to the adage of knowing what you can control and what you can’t. How does this apply to nursing burnout?

Waddill-Goad: Most physician providers are trained to be the captain of the ship, so to speak. Nurses, on the other hand, often are employed [by a hospital or organization] where others — the leaders — are making the rules. And sometimes they have to live with it, whether they like it or not. The best scenario is to have nursing leaders that are really engaged with those doing the work. They can help a great deal by listening to the people who are providing care, who are really at the sharp point of “quality” and some of the other [QI] nomenclature. Nurses are with the patient at that point of service. That’s where the rubber meets the road, and we need to know how that work is conducted and what kinds of things aren’t working. I have always felt the responsibility as a nurse leader to make sure we are making changes not only in the best interest of patients, but also for the staff providing the care. There is a lot of interesting research on the connection between staff satisfaction and patient satisfaction.

HEH: What kind of trends are you seeing in nursing that you discuss in the book?

Waddill-Goad: I have seen more stress leaves in the last decade than probably the previous two. In some cases, even management is going on stress leave and reporting to employee health. That should really be a red flag for a broken system. People feel they are out of control, or their job is so stressful that they just can’t see the forest through the trees. They are feeling so overwhelmed standing in the middle of a tornado. Sometimes, you just have to step out.

HEH: Just to clarify, you’re talking about reporting stress as a medical condition and taking leave from work?

Waddill-Goad: Yes, and I have actually seen a lot of that when consulting, at both the staff level and the leadership level. I would say middle management, not the senior leadership. Things have changed so much with this focus on outcomes. You can directly tie the patient outcomes to things nurses are or are not doing. That typically hasn’t been the case in the past. We haven’t been graded on how we provide care and what we are like as customer service agents. Do your patients have bedsores or outcomes that are secondary to the reason the patient was admitted? Now with [CMS] Value-Based Purchasing, the hospital may not get paid [for adverse outcomes]. That’s a lot of pressure for nurses who have been in the profession in times when that wasn’t the case. We were always considered overhead.

HEH: Does fatigue, stress, and burnout in nurses produce a cumulative effect, a sort of linear progression?

Waddill-Goad: I kind of liken it to a circle. I mention in the book that my doctoral research was on leadership fatigue. And I did that because I saw my consulting clients and they looked like they have been dragged through a keyhole backwards. Everyone looked exhausted. That’s not good, so I started looking at this topic.

Being a nurse leader in a hospital, it’s 24/7. You just don’t turn it off. And a lot of people even on vacation don’t turn it off. They take their phone, answer email, and continue to be available. Personally, I think that is unwarranted. There are other people in the hospital that you can turn over your responsibilities to. You need the time off for rest and relaxation and to become more resilient. Otherwise, it is like a circle of stress and fatigue — and if you don’t manage it, people will burn out.

HEH: What are some interventions and strategies the employee health professionals can adopt to help nursing staff?

Waddill-Goad: More hospitals have begun wellness-focused activities. For example, making sure that you take time to recover if you’re sick — don’t come to work sick. There are more policies now that if you have a fever, for example, don’t come to work. I can tell you many times in my career I worked sick because I knew it was going to be difficult to replace me. So, the whole wellness arena, I think, is great.

Let’s focus on being well and healthy — looking at the workforce from a health standpoint. Do we have a heathy workforce? Are we scheduling people so you are not working 12 days in a row? We [should be] promoting weight management, keeping blood pressure in check, eating right, exercising, and getting a good night’s sleep. We see smoking cessation, diabetes management — all of those employee health-related activities. Another area is vacation time. For example, some organizations say you either use it or lose it. Or they cap it at 200 hours [of leave], which means you have to go on vacation, which I think is great.

HEH: Does the highly publicized bullying aspect of nursing contribute to burnout?

Waddill-Goad: Certainly, it causes stress for the people being bullied. As you say, there has been a lot in the literature, and I think a lot of hospital leaders have taken the position of zero tolerance. I was at a client site and one of the nurse managers in one of the critical care areas was having difficult time with some of her staff. She was a new leader and asked me, “What I should do?” Basically, in about five minutes [online] I found about 60 articles on nurse bullying. It’s a huge problem. I said, “You as the nurse leader have to own it and manage it. You must take the tone that we are not going to tolerate that in our department. If you are a good nurse but have bad behavior, you can’t work here.” Nurse leaders really have to be vigilant in not allowing it.

HEH: Any point of emphasis you would like to make about the book and nursing health?

Waddill-Goad: As caregivers, we take good care of others, but often we don’t consider our needs. Early in my career [a supervisor] asked me something that has stuck with me ever since. She asked me, “What do you need to do your best work?” Honestly, it had never occurred to me. I had never thought about it. That’s a great take-home message. We nurses are at risk because of the kind of profession we have chosen. We need to raise the bar as far as what our expectations are for people. Know what people need to do their best work and promote safety and healthiness, just like we do quality.