All healthcare professionals, and especially nurses and physicians, have endured more stress and burnout over the past 18 months of the pandemic.

Same-Day Surgery (SDS) asked for more guidance from experts who have addressed healthcare workforce stress for a very long time on how surgery centers and their leaders can help prevent burnout and reduce stress. Marian Altman, PhD, RN, CNS-BC, CCRN-K, clinical practice specialist for American Association of Critical-Care Nurses (AACN), answered some questions by email. (Editor’s Note: This transcript has been lightly edited for length and clarity.)

SDS: How can healthcare organizations prevent burnout and retain more staff?

Altman: Preventing burnout begins with the early identification of the sources of stressors. It is important to acknowledge the problem and measure it. The Maslach Burnout Inventory is a reliable and valid tool that is free for use in the public domain and can be used to measure burnout.

The next step is to create a healthy work environment that enables nurses to provide the highest standards of patient care while being fulfilled at work. AACN Standards for Establishing and Sustaining Healthy Work Environments: A Journey to Excellence details six standards crucial to a healthy work environment [HWE]: skilled communication, true collaboration, effective decision-making, appropriate staffing, meaningful recognition, and authentic leadership. AACN’s data consistently show that units implementing HWE standards outperform those that are not in many ways, such as the overall health of the work environment, better nurse staffing and retention, fewer instances of moral distress, and lower rates of workplace violence. Hospital and unit leadership play a critical role. It’s important for leaders to know the signs of an employee being disengaged or experiencing burnout so that they can take steps to support the staff member. It’s also important for leaders to recognize that their own behaviors can increase or decrease burnout among staff. Leaders should be empowered to remove barriers and facilitate collaboration to ensure employees feel fully supported. Leaders need to lead by example and set the tone for work-life balance. Organizations also should provide resources to help staff improve their resilience. Resilience is a person’s ability to adapt to sources of stress and/or bounce back in the face of adversity. If nurses are able to increase their resiliency, they can better cope with negative conditions. Psychological resilience means the person has personality traits that have protective effects against burnout. Therefore, organizations need to put into place programs that help nurses increase their resilience. Mindfulness, stress management classes, exercise, relaxation activities (such as yoga or tai chi), and small group discussion interventions are helpful.

It’s important for organizations to integrate well-being into their culture. Organizational practices and policies should promote flexibility and work-life balance and incorporate them into regular conversations with staff as well as work practices. A quiet space should be set aside for employees to unplug, meditate, pray, or relax for a few minutes while at work.

Policies can do more than assure appropriate staffing. They can include guidelines to reduce long hours and prevent excessive overtime or shifts. Flexible scheduling can be implemented to accommodate individual schedules. Hospitals will need to relax the mandatory 12-hour shifts and become more flexible, allowing shifts of four or eight hours, or even having new shifts created when needed, such as a special shift during peak discharge times. A more flexible shift structure will also allow experienced nurses to remain involved and not leave the bedside entirely. In addition, it would close the experience gap that is currently widening due to many experienced nurses retiring and thus leaving units composed of all new nurses. Managers should monitor workloads and scheduling and encourage staff to take their paid time off. Organizations need to do more than provide access to well-being resources. Managers should encourage staff to use them.

SDS: How has the pandemic exacerbated existing stress and burnout among nurses?

Altman: Burnout is physical, mental, and emotional exhaustion caused by workplace stress that leads to disengagement and depersonalization. Burnout contributes to decreased well-being, lower retention rates, higher turnover rates, low morale, and a lack of cohesiveness in the unit and organization. Burnout and emotional exhaustion have been ongoing risks for nurses long before the pandemic. Now, it’s gotten worse.

A recent study from National Nurses United found 62% of nurses report feeling sadder and more depressed than they were before the pandemic. The pandemic not only exacerbated existing issues related to stress and burnout, but it also introduced new ones, such as fear of infection, isolation, and constant change. Nurses in COVID units worked long hours in PPE, with a high volume of high-acuity patients at the same time and for an extended period. In addition, the number of patients who died during each shift dramatically increased.

SDS: Are there ongoing wellness projects employers could use to help their staff build reserves and prepare for the next event that might take an emotional toll?

Altman: Gratitude campaigns can be effective as strategies to decrease burnout. Practicing gratitude improves how people handle stress, boosts their job satisfaction, and increases their sense of self-efficacy. Organizations can use a mix of formal and informal strategies to recognize employees’ positive impact, value, and contributions, such as gratitude letters, gratitude huddles, or a gratitude wall.

I recently represented the AACN in a collaborative effort to help develop the Gratitude Practice for Nurses toolkit from the American Nurses Foundation and the Greater Good Science Center at the University of California, Berkeley. This campaign draws on decades of research showing that practicing gratitude is good for our bodies, our minds, and our relationships — and is a valuable tool to combat the stresses faced by nurses and other healthcare professionals. Nurses and nurse managers alike can use these free resources to cultivate more gratitude in their lives and in their workday in order to experience its benefits — and to build a culture of gratitude and appreciation among colleagues.

SDS: What else is important for healthcare organizations to know about nursing burnout and stress?

Altman: The majority of the current nursing workforce is composed of Gen Z and millennials who cite commitment to well-being by their organization as the No. 1 factor in selecting an employer. A focus on well-being by organizations is not only important for nurse recruitment and retention, but for patient safety. A new study indicates a strong correlation between nurses’ mental and physical health and self-reported medical errors.

Investing in strategies to prevent employee burnout and enhance employees’ mental health has a positive return on investment. When employees are healthy and happy, benefits to the organization include improved productivity, greater engagement, and decreased absenteeism and turnover.