The Joint Commission (TJC) has identified nurse staffing, recruitment, and retention as “priorities for further evaluation in the coming year” to prevent nursing burnout, Hospital Employee Health has learned.

TJC recently issued a Quick Safety alert,¹ emphasizing that nursing burnout can worsen patient outcomes, including mortality. The report cited a 2017 literature review on preventing nursing burnout that identified six studies, representing 3,248 nurses worldwide.² These studies revealed that the most common factors related to burnout are exclusion from the decision-making process, the need for greater autonomy, security risks, and staffing issues.

Encouraging a “resilience-promoting environment,” TJC cited a study⁴ that revealed the following factors affect nurse resilience:

• Experience;
• Amount of satisfaction attained;
• Positive attitude or sense of faith;
• Feeling of making a difference;
• Leadership methods, such as debriefing, validating, and self-reflection;
• Support from colleagues, mentors, and teams;
• Insight in ability to recognize stressors;
• Maintaining work-life balance.

Q&A

Hospital Employee Health spoke to Lisa DiBlasi Moorehead, EdD, MSN, RN, CENP, associate nurse executive for TJC’s Accreditation and Certification Operations. The following interview has been edited for length and clarity.

HEH: Is healthcare worker burnout a patient safety issue? Is this a case where protecting the worker protects the patient?

Moorehead: It is absolutely a case of “protecting the worker protects the patient.” The literature well documents that burnout leads to turnover. Organizations need skilled nursing staff to meet care needs of patients they serve. Nurses make up the largest group of healthcare providers and are often thought of as the first line of defense in protecting patients from harm events or medical errors. If there are not enough skilled nurses present, patients are at greater risk of harm.

HEH: The paper mentions “developing support systems to combat stressors and to promote a culture of mutual openness.” Can you comment on why this culture of openness is important?

Moorehead: A culture of openness allows for identification and naming of burnout. Identification and acknowledgment of an issue is necessary before it can be addressed. Organizational leaders need to support a reporting culture so that issues like burnout can be openly discussed, solutions identified, and then implemented.

I remember when I first became a nurse and the role socialization that occurred. Fellow nurses and I learned that a “good nurse” didn’t take breaks, worked extra hours, and in no way asked for help in completing assignments, no matter how busy we were. We, as a profession, must do better at removing the stigma of needing help. In addition, we must better recognize the signs of burnout and foster resilience in ourselves and others.

HEH: Why is important to believe one is “making a difference?” How can healthcare facilities reinforce this feeling in the work place?

Moorehead: “Making a difference” has long been part of the narrative in enhancing employees, including nurses’ job satisfaction. Knowing that the work one does is valued makes the challenges of a stressful environment worth the stress. Literature supports that satisfaction of performing meaningful work is a primary motivator in choosing nursing as a profession. I believe organizations that foster environments where nurses continue to experience satisfaction in their work, and feel it is viewed as meaningful, produce more satisfied nurses and experience less turnover.

Organizations reinforce the importance of nurses in a variety of ways. Shared governance is one such strategy. Nurses want to participate in making decisions that impact their work lives. Who better to ask how to improve medication administration processes than the person administering medications several times a day? Asking for nurses’ input validates the value of nurses as skilled caregivers, improves the process, and impacts the quality of work life.

HEH: Is “the ability to recognize stressors” something that can be addressed in education and training?

Moorehead: Educating staff and leadership on recognizing stressors precipitating burnout should be taught and regularly reinforced. All should be trained to look for signs of burnout in themselves and others. Not only should nurses know how to recognize burnout, but they should also be able to identify steps to enhance resiliency. Knowing how to foster resiliency is crucial in combating burnout.

HEH: Mindfulness is an option many work places are using, but the paper notes “mindfulness and resilience training alone” are not enough if system barriers and impediments are not addressed. Does TJC expect that these problems will be addressed under leadership accreditation and/or patient safety standards?

Moorehead: Yes, The Joint Commission has several standards addressing nursing leadership’s responsibility for the provision of nursing care along with adequate staffing to meet patient care needs. For example, nurse leaders are required to develop programs, policies, and procedures that determine how nursing care is provided and how care can be improved.

The nurse executive also has responsibility for implementing staffing plans to ensure quality care is provided.

HEH: Given the epidemic nature of burnout in healthcare, are you considering requiring more burnout prevention efforts or other interventions?

Moorehead: Joint Commission surveyors already evaluate the adequacy of staffing patterns, including the numbers and skill of nurses with related care impact. Efforts around recruitment and retention are also assessed. The Joint Commission’s Chief Nurse Executive Council has also identified staffing, recruitment, and retention as priorities for further evaluation in the coming year.

HEH: Should employee health professionals consider forming a committee or adopting some other approach to address burnout prevention?

Moorehead: Yes, forming a committee with the authority to evaluate an organization’s causes of burnout is a great first step. Getting nurses involved in this process will improve the likelihood of the committee’s success. Remedying issues that stand in the way of providing care is usually the first element that comes to mind in addressing burnout.

Another, perhaps parallel, path is to identify additional strategies to value nurses and support them in their work and in building personal resilience.

As a Joint Commission surveyor, I have been to hospitals that created nurse lounges with refreshments and work stations for nurses to regroup and recharge. I have also visited organizations where nurses dictate narrative documentation and care planning notes to save valuable time. Other organizations provide creative scheduling options, or distribute laundry and housekeeping vouchers if certain overtime thresholds are met.

REFERENCES

1. The Joint Commission. Quick Safety 50: Developing resilience to combat nurse burnout. July 15, 2019. Available at: https://bit.ly/2LEfcDc.
2. Friganovic A, Kovacevic I, Ilic B, et al. Healthy settings in hospital-how to prevent burnout syndrome in nurses: Literature review. Acta Clin Croat 2017;56:292-298
3. Rakesh G, et al. A call for action: Cultivating resilience in healthcare providers. Am J Psychiatry Residents’ Journal 2017;12:4,3-5. Available at: https://bit.ly/2LFEvoA.
4. Cameron F, Brownie S. Enhancing resilience in registered aged care nurses. Australas J Ageing 2010 Jun;29:66-71.