Managers hold key to curbing stress and reducing burnout in the ICU

Simple programs, creative caring work best with staff

Despite years of concern, stress and burnout in critical care nursing are on the rise. While hospitals could do more to address nurse complaints, nurse managers are in the best position to create internal peer support programs, experts say.

In 1996, a British nursing journal declared something that every critical care nurse in the United States already knew: ICU nurses across America were stressed out. The article, authored by a group of U.S. critical care nurses in the upper Midwest, looked at factors that contributed to workplace stress in neonatal intensive care units (NICUs).

What was surprising about the report wasn’t that ICUs were stressful places, but what nurses perceived to be the biggest stress factors in their work lives. "Floating out of the unit for a shift to another [unit] was perceived as very stressful," according to the article published in the British Journal of Nursing.

On a less acute level, dealing with pressures from management was considered another big stress factor.1 "Things haven’t changed for the better," says Vicki W. Downey, RN, PhD, associate professor of nursing at the University of Northern Colorado in Greeley, one of the report’s authors.

What has changed is the working environment. ICU nurses today face more stress than ever, Downey says. Nurses are being used as floaters to other units more often, and a work force shortage in trained nurses is making matters worse.

Managed care is only part of it, Downey says. The other part is that hospitals in general could do more to address the needs of overworked, burned-out nurses, and they aren’t doing so mainly because of overriding cost concerns.

Hospitals slow to respond to nurses’ needs

Support activities such as more time off, stress reduction inservices, and caring, compassionate shows of support by management are usually undertaken within the units themselves, if at all. According to nurses contacted by Critical Care Management, while most hospitals operate internal infection control and employee safety programs, most pay little attention to nurse burnout.

According to the Chicago-based American Hospital Association, nurse support programs exist at many hospitals, but are difficult to number or describe because they can take different forms. They can range from informal activities within employee relations or human resources to specific departments with their own management and staff.

But veteran ICU nurses see things differently. Judging a hospital’s nursing support program isn’t difficult to do because most hospitals don’t have any formal program in place, according to Maureen Harvey, RN, MPH, CCRN, a principal of Consultants in Critical Care, a Lake Tahoe, NV, nursing adviser. (See related article on p. 88.)

But many ICUs don’t fare any better, says Harvey. Managers often don’t have time to give their staff the attention they need over work-related problems.

If your hospital is among those that have a dedicated employee health program willing to help nurses with burnout and stress, you’re probably lucky. If not, you may want to consider developing an internal stress diversion program, which isn’t expensive but does take some management involvement, Harvey says.

Following are several easy-to-implement suggestions that emphasize fundamentals:

Keep support services simple and focused on nurses. In 1990, a group of nurses who formed the Consensus Conference on Fostering a More Humane Critical Care adopted several recommendations to address burnout. Chief among them was the formation of peer support groups within the unit.

These were nurses who volunteer for training as peer counselors to assist each other with workplace stress factors, says Diane Kennedy, RN, MN, CCRN, clinical assistant professor of nursing at the University of Kansas Medical Center in Kansas City, MO.

However, to be effective, the activity must be voluntary, and the peer support leaders must not be in a supervisory role at the hospital, Kennedy cautions. The support must be free of coercion or inhibition.

Develop a method for early detection of stress. Managers can play a key role in working with staff to identify early signs of burnout or stress, says Carma Twete-Hanson, RN, MS, manager of the NICU and pediatric unit at Altru Health System in Grand Forks, ND. Twete-Hanson helped develop a successful support program at her hospital that involves preventative care. (See charts, above and on p. 87, for a list of known stress factors and a list of symptoms that affect nurses.)

During regular evaluations or promotional interviews, you can ask nurses how they feel about their work and what they would change if they could, Twete-Hanson says. The questions should be framed in a collegial, non-authoritarian manner. "The goal is to create an environment for expressing positive and negative feelings, which allows for self-discovery," Kennedy says.

Give staff a creative outlet for their feelings. Presentations of poetry, a short skit, or a monologue during a peer support meeting can stimulate discussion that may lead to problem resolutions, says Kennedy. These expressions foster a sense of shared experience and a "sensitivity to self and others," she adds.

But to do this, nurses and managers should work collaboratively. The process can begin by allowing staff nurses to be represented at administrative meetings where they can share the nurses’ views and position on issues.

Rotate nurses to other assignments for training. "People need a break from the ICU sometimes," says Twete-Hanson. At her facility, about 75% of the NICU nurses have been cross-trained in pediatrics. "The cross-training takes the nurse away from the usual surroundings, introduces her or him to a new environment, and creates learning opportunities in something new and valuable," she adds.

However, the rotation doesn’t mean the nurse is used as a floater or an on-call nurse. And the cross-training must be done in something the nurse already knows. "The purpose of the training is to teach the nurse new skills within her own areas of expertise. But it also acts as a stress reducer," Twete-Hanson indicates.

Encourage and support continuing education. Many nurses would be pleased to find their employers receptive to higher education. Downey recalls one hospital that gave nurses incentives to act as mentors and preceptors to younger, newer nurses to prevent stress and burnout.

Nurses who volunteered for these duties were able to earn points, which enabled them at year’s end to attend conferences paid for by the hospital. Others facilities openly encourage nurses to seek graduate degrees and allow them time off to pursue course work, Downey says.

Being there helps, too

Increase your presence and availability. Something as simple as spending more time with staff members on the floor, joining them on rounds occasionally, being available at certain times to answer questions, or troubleshoot problems can help foster teamwork and support, says Twete-Hanson.

Attend debriefings and staff meetings in the wake of a patient’s death or a difficult confrontation with an angry family member. The unit manager’s presence at these seminal events demonstrates that the nurses aren’t going through the difficult experience alone, Twete-Hanson adds.

Whether the administration takes a direct hand or simply gives tacit approval to these measures doesn’t matter, says Twete-Hanson. Before anything can work, managers must elicit the hospital’s support in some way when administering a stress reduction program.

"Administrators must be committed to a supportive, protective, and corrective environment," Kennedy says.

Stress-Related Symptoms Self-reported frequency following an NICU death

Symptom Mean Score*
Loss of interest in physical exercise 1.55
Chronic fatigue 1.36
Headaches 1.34
Irritability 1.29
Overcritical 1.22
Increase susceptibility to illness 0.76
Frequent somatic complaints 0.75
Conflict-laden dreams 0.73
Prone to accidents 0.64
Rigid with others 0.64
Withdrawn 0.61
Increased use of sick days 0.27
*Note: 2.0 = highest frequency; 0.0 score = lowest frequency
Source: Downey V, Bengiamin MA, Heuer L, et al. Dying babies and associated stress in NICU nurses. Neo Netw 1995; 14:41-45.


1. Heuer L, Benjamin M, Downey VW, et al. Neonatal intensive care nurse stressors: an American study. Br J Nurs 1996; 5:1,126-1,130.