Preventing Burnout, Compassion Fatigue, and Vicarious Trauma
Online Continuing Education Course
3.5-hour CEU course on managing work-related stress and burnout prevention. Identify different types of work stressors common to nurses and other healthcare professionals. Learn about creating a healthy workplace setting, the effects of stress on the body, and symptoms and stages of burnout. Identify individual and organizational prevention strategies and actions for responding to burnout, compassion fatigue, and vicarious trauma. Applicable for nurses, occupational therapists, physical therapists, and EMS personnel.
Course Price: $14.00
Exclusive 50% Discount
Contact Hours: 3.5
Course updated on
December 7, 2021
4.3 / 860 ratings
"Great course. It gives great insight into burnout and stress on the job. It also offers great advice on how to prevent stress and burnout. " - Shawn, OTA in California
"Good information. Wish I had this knowledge earlier so I could have prevented becoming burnt out. It is horrible!" - Mary, NP in Alabama
"I wish I had studied this course 10 years ago. It was very informative and helpful — and would have saved me some therapy money, too!" - Martha, RN in Georgia
"Timely course. I need to regroup and avoid burnout, as well as look out for coworkers!" - Mary, RN in California
Accreditation / Approval Information
EXCLUSIVE DISCOUNT: 50% off! Pass this course and register for your certificate to get this course for $14 instead of the regular price of $28.
Preventing Burnout, Compassion Fatigue, and Vicarious Trauma
Copyright © 2021 Wild Iris Medical Education, Inc. All Rights Reserved.
LEARNING OUTCOME AND OBJECTIVES: Upon completion of this course, you will be able to identify the causes, symptoms, stages, management, and prevention of work-related stress and components of a healthy workplace. Specific learning objectives to address potential knowledge gaps include:
- Define “stress.”
- Describe the potential health impacts of stress.
- Differentiate between burnout, compassion fatigue, and vicarious trauma as work-related stressors.
- Discuss individual and organizational strategies to minimize the effects of work-related stress.
- Explain how stress contributes to suicidal ideation.
TABLE OF CONTENTS
Healthcare professionals are challenged on a daily basis with a variety of stressors as they care for patients. These work-related stresses can take a toll on the mind and body of these professionals, which in turn may affect the quality of patient care and outcomes. Work-related stress may also impact job satisfaction, workforce stability, and safety in the healthcare environment (AHRQ, 2019).
Many healthcare professionals work in demanding situations, hold high expectations for themselves, and believe they should be able to handle anything no matter what the challenge. But burnout, compassion fatigue, and vicarious trauma are common risks they may face in their stressful work environment. Fortunately, work-related stress is both “treatable” and preventable. Professionals can learn to cope with different forms of stress by gaining an understanding of stress and stressors, recognizing their signs and symptoms, acquiring skills to manage the destructive effects of stress, and preventing or reducing its impact in the future.
Recently, healthcare workers have faced the stress of dealing with a pandemic. COVID-19 has exposed healthcare professionals to circumstances that threaten their health, well-being, and ability to work. Providing care to patients with COVID-19 may also expose healthcare professionals’ families to the virus and/or the need to isolate from family and friends, which further adds to their stress. COVID-19 has also greatly stressed healthcare systems throughout the world, many of which were unprepared for a pandemic, leaving them to desperately search for essentials such as personal protective equipment (PPE), ventilators, and even sufficient beds for sick patients (Arnetz et al., 2020).
It is imperative that all healthcare professionals work to help alleviate work-related stress. Unless it is managed effectively, stress will continue to have adverse effects on staff as well as patients and visitors.
What Is Stress?
Stress is the body’s response to pressure. It is the feeling of being overwhelmed or unable to deal with physical or mental pressure. Everyone deals with stress in different ways. The ability to respond effectively to stress depends on genetics, childhood events, personality, traumatic life experiences, and social and economic circumstances (MHF, 2021).
Work-related stress is defined as the “response people may have when presented with work demands and pressures that are not matched to their knowledge and abilities and which challenge their ability to cope.” Work-related stress is often unavoidable in the healthcare field due to the demands of the work environment. In fact, some work demands may be perceived as acceptable since they may keep healthcare workers alert and motivated. However, when these demands lead to excessive or unmanageable stress, the results can be devastating (WHO, 2020).
EARLY RESEARCH ON STRESS
In his pioneering work, Walter Cannon (1871–1945) investigated the sympathetic nervous system as it reacts to heat and noticed that the body responds in a predictable sequence, which he called the fight-or-flight response (also known as the stress response). This automatic reaction to stressful (and possibly dangerous) circumstances is considered a survival mechanism that enables people to react swiftly to threatening situations (Harvard Medical School, 2020).
Causes of Work-Related Stress in Healthcare
Healthcare environments are busy and complex. Meeting the needs of patients, some of whom are critically ill or injured, can become overwhelming. Some of the causes of stress in the healthcare profession include:
- Long work hours. Many healthcare professionals work long, 10- or 12-hour shifts and often put in overtime. Additionally, it is frequently hard to leave work on time when shifts end. Shift rotation as well as planned and unplanned overtime can increase job-related stress by triggering such problems as fatigue and inability to plan for activities outside the workplace (e.g., family obligations, pursuit of academic education).
- Putting others first. Many healthcare professionals feel compelled to put the needs of others before their own needs. This can be characterized by a drive to take care of others. Combining this drive with family obligations and, for some, the pursuit of academic education can increase the risk of stress.
- Busy, high-stress environments. Thanks to technology advances, improvements in diagnosis and treatment, patient acuity, and ongoing pursuit of academic and/or continuing education to increase their knowledge, healthcare professionals’ responsibilities in the workplace have increased significantly over the past several decades. The fast-paced, complex workplace can cause them to feel overwhelmed and stressed.
- Coping with sickness and death. Daily exposure to illness and death, as well as to the emotional toll illness and death takes on patients and families, can be overwhelming and physically and emotionally exhausting. Healthcare professionals may not have time to decompress or grieve over taxing workplace situations.
- Additive effects of stress. Research has established that the cumulative effects of stress impact both family functioning and job performance. Job conditions associated with work-to-family conflict may have broad impacts across the workforce.
- Lack of control. Feeling unable to influence decisions that affect job performance, assignments, work load, etc., can contribute to burnout.
- Unclear job expectations. Being uncertain of what is expected regarding one’s job performance contributes to burnout.
- Dysfunctional workplace dynamics. For example, if a workplace is affected by bullying, the risk for stress increases.
- Lack of social support. Feelings of isolation at work and/or at home add to stress.
(Ericksen, 2018; Mayo Clinic, 2021)
Additional pandemic-related stressors for health professionals may include:
- Dealing with an overwhelming surge of patients
- Inability to save lives despite maximal effort
- Experiencing death on a mass scale
- Observing population-wide bereavement
- Dealing with chronic shortages of supplies, vaccines, treatments, or facilities
- Elevated and/or extreme risk for infection, illness, and death
- Overwork and fatigue
- Witnessing illness and death of colleagues
- Constantly working in PPE
- Enforced separation from family and loved ones
- Ongoing and seemingly unending duration of work shifts
- Inability to be home to support ailing, dying, or bereaved loved ones
- Fear of spreading infection from exposure at work to loved ones at home
- Witnessing illness on a mass scale
- Witnessing persons suffering with extreme symptoms
- Dealing with extreme reactions and possible panic
- Threats of violence from persons seeking scarce or limited services
- Lack of communications
STRESS AMONG MANAGERS
It is not only front-line professionals who deal with stress. Managers must deal with these issues, too. Managers have one of the most demanding jobs in the healthcare setting. They are pushed to increase productivity while simultaneously decreasing costs, supporting their staff members, and ensuring the delivery of quality patient care. The turnover rates of managers is significant, and their intent to leave their positions, in part due to stress, within the next five years has reached over 70% (Loveridge, 2017; Warshawsky & Havens, 2014).
STRESS AND VIOLENCE
Adding to the stress found in the healthcare setting is the threat of violence. Violence in the workplace is a serious problem. According to the Occupational Safety and Health Administration (OSHA), about 75% of the nearly 25,000 workplace assaults reported annually occurred in healthcare and social service settings. Research data show that persons who work in healthcare settings are four times more likely to be victimized than workers in private work settings. Additionally, healthcare workers have a 20% higher chance of being the victim of workplace violence than workers in other settings (Joint Commission, 2018).
When talking about violence in the healthcare setting, physical and verbal abuse by patients and visitors quickly comes to mind. However, there are other types of violence. Stress and burnout can be caused by horizontal violence (also referred to as HV or lateral violence), which is defined as aggression against peers and coworkers who are on the same hierarchical level of an organization (Bartholomew, 2014; Dellasega, 2021). Additionally, aggression may take the form of those in powerful positions bullying subordinates and even subordinates bullying managers.
Impacts of Stress
In early research into stress, published in 1946, Hans Selye observed that stress caused patients to suffer physical effects not caused directly by a disease or medical condition. Selye found that stressors may be physical (such as infection, injury, and pain) or psychological (such as fear, anger, and sadness) and that stress also has both physical and mental impacts. Selye described what he called a general adaptation syndrome, whereby the body seeks to maintain homeostasis, or balance. He divided his general adaptation syndrome into three stages (see box below) (APA, 2021).
Stress can have a major impact on the physical functioning of the human body. It raises the levels of adrenaline and corticosterone, which in turn increases the heart rate, respiration, and blood pressure and puts more physical stress on bodily organs. In the short term, this allows a person to perform at levels beyond their normal limits (Burgess, 2017; Office on Women’s Health, 2019).
Stressors may, at times, lead to a useful response such as helping people to address and move on from fear, disappointment, pain, and emotional distress. Stress may also help individuals deal with challenging situations, such as speaking in public. In these types of cases, stress hormones quickly return to normal as the stress dissipates.
Too much stress, however, can have a significant physical and mental impact. It can leave the body in a permanent state of “flight or fight,” which leads to feelings of being overwhelmed and/or unable to cope not only with stress but with activities of daily living (MHF, 2021).
GENERAL ADAPTATION SYNDROME (GAS)
Alarm Reaction (the body detects the external stimulus)
- A “threat-to-survival” message is conveyed by nerves to the hypothalamus in the brain, which chemically communicates with the pineal gland and the pituitary gland, the “master control center.”
- The pituitary gland begins mobilizing the release of adrenocorticotropic hormone (ACTH) and activating hormone release from the adrenal medulla.
- The adrenal medulla pumps epinephrine, norepinephrine, and other catecholamines into the bloodstream. This causes:
- Heart rate and blood pressure to rise, increasing blood circulation throughout the body
- Airways in the lungs to dilate, facilitating oxygenation of blood
- Plasma levels of glucose, triglycerides, and free fatty acids to elevate, giving the body more fuel
- Platelet aggregation, increasing blood clotting
- Kidney clearance to reduce, preventing water loss
- Blood flow to shift from intestinal smooth muscles to skeletal muscles, enabling fight or flight
Adaptation/Resistance (the body engages defensive countermeasures against the stressor)
- Body systems stabilize.
- Hormone levels return to normal.
- Parasympathetic nervous system activates.
- Individual adapts to stress and recovers; however, when the threat continues without relief, then …
Exhaustion (the body begins to run out of defenses and the individual fails to adapt to stressors)
- A physiological response occurs, as in the earlier alarm reaction.
- Energy levels decrease.
- Physiologic adaptation decreases.
- Death occurs.
(Adapted from Selye, 1956; APA, 2021)
IMPACTS OF STRESS ON PHYSICAL HEALTH
Stress can have significant negative health impacts on the human body. The impact of stress on cardiovascular status has been well documented. Studies show that workplace stress is a significant risk factor for cardiovascular disease. Stress is linked to obesity, elevated cholesterol, hypertension, heart attack, and stroke (Corporate Wellness Magazine, 2021).
Stress causes the muscles to tense, which can lead to headaches, migraine, and generalized body aches and pains. Tension-type headaches are common in women (Office on Women’s Health, 2019).
Stress is also linked to gastrointestinal problems. Short-term stress can cause nausea, vomiting, and/or diarrhea. Long-term stress can trigger the development of irritable bowel syndrome (IBS), which is twice as common in women as in men. Additionally, stress can exacerbate IBS symptoms such as flatulence and bloating (Office on Women’s Health, 2019).
Stress increases the amount of the hormone cortisol, which can lead to overeating. In turn, this causes the body to store fat and can lead to obesity, which is linked to a large number of health issues such as heart disease and cancer (Office on Women’s Health, 2019).
The respiratory system is also negatively impacted by stress. Stress can cause hyperventilation and shortness of breath, which exacerbates conditions such as asthma and chronic obstructive pulmonary disease (COPD) (APA, 2018).
Stress can also affect reproductive functioning. Women who experience chronic or long-term stress are vulnerable to more severe premenstrual syndrome symptoms or irregular menstrual cycles. Stress can interfere with the ability of a woman to become pregnant and may also decrease the sex drive. Additionally, women dealing with stress may take longer to become aroused during sexual activity (Office on Women’s Health, 2019).
Stress may also cause infertility problems in men. Studies have confirmed a link between stress and sperm concentration, appearance, and mobility in semen. It is hypothesized that the release of steroid hormone during periods of stress can decrease both testosterone levels and sperm production (Cheriyedath, 2019).
IMPACTS OF STRESS ON MENTAL AND BEHAVIORAL HEALTH
Long-term stress increases the risk for depression and anxiety. In the workplace, in addition to the risk for anxiety and depression, the risk of burnout increases. In an effort to cope with stress, people may turn to substance use to alleviate its effects. Employees who are stressed at the workplace are more likely to take part in unhealthy behaviors such as smoking cigarettes, vaping, alcohol and drug abuse, and poor dietary intake (Corporate Wellness Magazine, 2021).
Stress can lead to a number of signs and symptoms of mental and behavioral health impacts. Cognitive symptoms include:
- Problems concentrating and/or thinking
- Memory problems
- Lack of self-confidence
- Negative self-perception
- Ongoing anxiety and worrying
- Difficulty making decisions
Emotional symptoms may include:
- Low morale
- Feelings of hopelessness
- Feelings of helplessness
- Feelings of apprehension, anxiety, and/or nervousness
- Feelings of depression
- Feelings of unhappiness
- Feelings of guilt
- Being unable to relax
Behavioral symptoms may include:
- Changes in appetite
- Changes in sleeping patterns
- Nervous habits (e.g., biting nails, grinding teeth, tapping one’s foot)
- Increase in use of caffeine, cigarettes, alcohol, and/or other drugs
- Neglect of family
- Neglect of work responsibilities
- Decline in productivity
IMPACTS DUE TO A PANDEMIC
Healthcare workers have been at the center of the crisis caused by the COVID-19 pandemic. In addition to taking care of patients who have COVID-19, they must also take care of non-COVID-19 patients. The stress and exhaustion experienced by healthcare workers due to the pandemic may lead to medical errors, a decrease in empathy, decreased productivity, and higher turnover rates. Additionally, fears of exposure to COVID-19 and the possibility of bringing infection home to families and friends compound this hyperstressful situation.
Research conducted on the impact of COVID-19 shows that healthcare professionals display high rates of psychological stress, fear, anxiety, depression, and suicide. A 2020 survey of 695 U.S. nurses on the most stressful situations they had experienced during the pandemic identified six distinct themes that are similar to previous research findings among healthcare professionals:
- Exposure/infection: Fear of being exposed to COVID-19 and becoming sick oneself as well as the fear of passing the virus on to family, friends, and other patients
- Illness/death: Dealing with serious illness and death of others, most often patients, co-workers, or loved ones
- Workplace: A high workload of extremely ill patients and/or being assigned to new departments without sufficient training, problems in relationships with coworkers, perceived administrative failings
- PPE/supplies: Not having enough or having to re-wear PPE; insufficient cleaning supplies, ventilators, and testing supplies
- Unknowns: Constant unknowns of a pandemic, including changing symptoms and guidelines, and fears related to job and financial/economic security
- Opinions/politics: Opinions and the politicization related to COVID-19, including having to deal with perceived failings of government, the spread of false information, people who believe that COVID-19 is a hoax, and verbal and physical assaults on healthcare workers
(Arnetz et al., 2020; Shreffler et al., 2020)
Carol Williams, Ph.D, is a clinical psychologist on the spinal cord injury unit in a large rehabilitation hospital. Because of recent staff shortages, she has been required to work extremely long hours and has been assigned dangerously high patient-to-staff ratios. She previously felt good about her job and confident that even though her patients were severely injured she was making a difference in their lives. Lately, however, she has been emotionally and physically exhausted and can’t seem to relax. She has been having “nervous headaches,” stomach pains, and mood swings, exploding in a rage of anger one moment and bursting into tears the next.
To cope with the stress, Carol has become distant and detached from her team members and patients. She does not actively engage with her coworkers during her shift and has insufficient time to meet all of the needs of the patients. She has expressed her frustration and anger during team meetings when discussing cases, verbally accusing her coworkers of being lax in their commitment to patients.
Because of her behaviors, Carol’s coworkers have complained to their supervisor about her attitude. Carol knows she is not managing the situation well, but the stress of the job and lack of support from her supervisor are wearing her down. She feels angry, trapped, insecure, inadequate, and a bit fearful she will lose her job.
Carol decides to visit her primary healthcare provider for help because of all the impacts she’s been experiencing related to her work-related stress. When asked by her physician, Carol describes her nausea, vomiting, diarrhea, and frequent tension-type headaches. Her exam also indicates an elevated blood pressure (physical health impacts). Carol also describes having trouble making work-related decisions and difficulty concentrating (cognitive symptoms). Emotionally, Carol is also experiencing anxiety, moodiness, feelings of helplessness, irritability, and unhappiness (emotional symptoms).
Carol feels overworked and underappreciated. At some point she realized that she was overwhelmed by circumstances related to workload and staffing. She knew she was not performing at the level she expected of herself, and she recognized the physical, cognitive, and emotional symptoms related to the impact of her work-related stress. Carol needed to take steps to improve her work situation to avoid serious physical and emotional consequences. By acknowledging her difficulties and seeking appropriate help, Carol is beginning to learn how to respond and adapt to the stress. Otherwise, if her stress reaction continues unchecked, a state of exhaustion can develop. It is imperative that, for her physical and emotional health, Carol addresses what is causing her stress and that she develops effective coping strategies.
COMMON STRESS-RELATED CONDITIONS
Work-related stress in the healthcare profession commonly manifests in one of several distinct, identifiable conditions. These include:
- Burnout: A syndrome that results from unmanaged chronic workplace stress (WHO, 2019)
- Compassion fatigue (or empathy distress fatigue): A state of declining empathetic ability due to repeated exposure to the suffering of others (Peters, 2018)
- Vicarious trauma: An ongoing process of change over time that is due to witnessing or hearing about the pain and suffering of other people (Trish, 2021)
Within both healthcare literature and common usage, these terms are sometimes used interchangeably. In general conversation, this may not be an issue, especially if the intent is to share personal experiences or to express concern or empathy. But healthcare providers are more likely to be seeking to understand their reactions or to formulate personal care or prevention plans. In this case, understanding the similarities and differences between these stress reactions is important.
According to the World Health Organization (WHO, 2019) in the International Classification of Diseases, 11th revision (ICD-11), burnout is defined as:
A syndrome conceptualized as resulting from chronic workplace stress that has not been successfully managed. It is characterized by three dimensions: 1) feelings of energy depletion or exhaustion; 2) increased mental distance from one’s job, or feelings of negativism or cynicism related to one’s job; and 3) a sense of ineffectiveness and lack of accomplishment. Burnout refers specifically to phenomena in the occupational context and should not be applied to describe experiences in other areas of life.
STAGES OF BURNOUT
Burnout has been described as having five stages:
- Honeymoon phase
- Onset of stress
- Chronic stress
- Habitual burnout
(Calmer, 2020; De Hert, 2020)
Stage 1: Honeymoon Phase
This phase is characterized by high job satisfaction. The employee is committed to the job, energetic, and creative. Although employees may believe that this stage will last indefinitely, job stress is inevitable. Employees should anticipate eventual job stress during the honeymoon phase. Coping strategies should be established in order to support personal and professional well-being.
Characteristics of this phase include:
- Job satisfaction
- Happily accepting responsibility
- High energy levels
- Commitment to the job
- Desire to prove oneself
- High productivity
(Calm, 2020; De Hert, 2020)
Stage 2: Onset of Stress
The second stage of burnout is characterized by an awareness that the employee is experiencing some difficult days at work. Optimism starts to decrease, and symptoms of stress begin to appear, including:
- Sleep disturbances
- Trouble focusing
- Reduced social interaction
- Heart palpitations
- Changes in appetite
(Calm, 2020; De Hert, 2020)
Stage 3: Chronic Stress
In the third stage of burnout, chronic stress develops. Symptoms from stage two become more intense, and additional symptoms develop, including:
- Persistent fatigue
- Missed work deadlines
- Procrastination at work as well as at home
- Physical illness
- Social withdrawal
- Decreased libido
- Feeling out of control
- Increased alcohol, drug, and/or caffeine intake
(Calm, 2020; De Hert, 2020)
Stage 4: Burnout
Stage four is actual burnout. Symptoms become critical, and one’s ability to cope is crumbling. Professional mental health counseling is essential at this stage. People in stage four may exhibit:
- Obsession over problems at work and/or in life
- Physical symptoms increasing in intensity
- Social isolation
- Chronic headaches
- Chronic gastrointestinal problems
- Neglect of personal needs
- Desire to move away from work or friends and family
- Desire to escape from society
(Calm, 2020; De Hert, 2020)
Stage 5: Habitual Burnout
The final stage, habitual burnout, is characterized by the ongoing mental and/or physical problems described above. Addition symptoms include:
- Chronic sadness
- Chronic mental and physical fatigue
(Calm, 2020; De Heret, 2020)
About a year ago Dan Ramirez, RN, got his first job as a nurse working in a long-term care facility. Dan’s many responsibilities include administering medications, providing wound care, writing care plans, maintaining patient records, and supervising patient care assistants. When Dan began in the job, he felt challenged and proud of his ability to manage so many duties. After a few weeks, when one staff member went on sick leave and another quit, Dan sympathized with his supervisor’s difficulty finding qualified help. He enthusiastically assumed additional duties because of insufficient staffing, expecting the situation would last only a few weeks (“honeymoon phase”).
But soon Dan found himself working overtime almost every day and felt obliged to “do it all.” He began having trouble sleeping, became irritable and anxious, and complained of frequent headaches (onset of stress). The additional work hours began to cause trouble at home, with his wife and children saying that they never see him, and when they do, complaining that he is irritable and impatient.
As the weeks went on, Dan started to feel fatigued almost all day, every day. He discussed his concerns with his supervisor, who told him he was doing a good job and to just “hang in there” until more staff members were hired. Dan resented having to do so much additional work, with no end in sight. He started self-medicating by drinking a couple of glasses of wine before bed and began to feel apathetic toward his job and his colleagues. Dan felt that he no longer had control over his work or personal life (chronic stress).
Then, one day, Dan made a medication error. Fortunately, the patient was not harmed, but the physician scolded Dan loudly in front of other staff members. He was humiliated and began to doubt his abilities and to think of himself as a professional failure, an imposter. He even began to question his decision to become a nurse. As his self-confidence decreased, Dan’s self-doubt and detachment increased, and he began distancing himself from his coworkers, family, and friends. He frequently felt nauseous, and his headaches became chronic. He felt that his marriage was also coming under significant strain (burnout).
As the situation continued, Dan became more and more irritable, cynical, and callous. He now felt sad and depressed most of the time. One afternoon he hurt his back lifting a patient and went out on sick leave. After months of physical therapy, surgery, and then more physical therapy, Dan went back to work part-time, but he just couldn’t keep up the pace. He felt like a failure, unable to carry on. On the verge of collapse, he quit his job, disillusioned with the nursing profession and the entire healthcare system (habitual burnout).
Dan’s case illustrates the five stages of burnout. By assuming the duties of the absent attendants rather than assertively addressing the issue of inadequate staffing with his supervisor, Dan became physically and emotionally exhausted. The resulting impacts on his job performance soon caused him feelings of cynicism and self-doubt. This in turn caused him to become cynical and callous, finally leading to a sense of failure and quitting his job entirely.
RISK FACTORS FOR BURNOUT
Job burnout is caused by many interactive factors; some are due to the personality and lifestyle of workers, and some are due to the work environment.
Individual Risk Factors
Individual risk factors for burnout mirror many of the individual risk factors noted in other sections of this course. Work-related risk factors for burnout include:
- Lacking control over one’s schedule, assignments, and workload
- Having unclear expectations about one’s job
- Working long hours (e.g., 12-hour shifts, overtime, being called in when staffing is short, finding it difficult to leave work when the shift is over, being on call)
- Working in busy, high-stress environments
- Lacking the skills needed to do the job
- Lacking social support (isolation)
- Having a work-life imbalance
(Erickson, 2018; Cleveland Clinic, 2021; Mayo Clinic, 2021)
Individual personality traits also play a role in the development of burnout. These may include:
- Putting others first. When caring for patients, dealing with family responsibilities, and working long hours, it is easy to fail to meet one’s own needs. When this continues unabated, burnout is likely to be a consequence.
- Having perfectionist tendencies. Most healthcare professionals strive to do their best to provide excellent patient care. Perfectionists, however, criticize themselves mercilessly if everything is not perfect. Sometimes perfectionists avoid certain responsibilities because they are so afraid of failing, of not being perfect.
- Being pessimistic. Pessimists tend to see the world as threatening. They worry about things going wrong, expect bad things to occur more often than good things, and place unnecessary stress on themselves by anticipating the worst in most circumstances.
- Being excitable. People who are more excitable than others have a greater response to stress and experience stress more easily.
- Having a type A personality. Some characteristics of a type A personality are associated with increased levels of stress and susceptibility to burnout, including lack of patience and free-floating hostility.
(Ericksen, 2018; Scott, 2018)
Organizational Risk Factors
Increasing attention is being paid to the organizational environment and the development of burnout. Researchers have identified the following organizational risk factors for burnout among healthcare professionals:
- Work process inefficiencies (e.g., computerized order entry and documentation)
- Excessive workloads/caseloads
- Inadequate staffing
- Long working hours
- Shift rotation
- Unrealistic goals for employees
- Dysfunctional workplace dynamics
- Unclear job expectations
- Organizational climates characterized by high levels of role overload (when an individual is called upon to fulfill multiple roles simultaneously but does not have the resources to do so) and role conflict
- Lack of opportunities for professional growth
(Calmer, 2020; Dyrbye et al., 2017; Mayo Clinic, 2021)
PATIENT SAFETY AND BURNOUT
Promotion of patient safety is one of the most important goals in healthcare. Research shows that compromised patient safety is an organizational factor that contributes to burnout and stress. What is described as a “better” work environment is associated with enhanced patient safety. Factors that contribute to such an environment include lowered patient loads, ability to complete tasks safely, and reduced burnout. Thus, increasing staffing levels and providing adequate support for caregivers to spend more time on direct patient care increases the safety of the organization and contributes to a lowered incidence of burnout (Liu et al, 2018).
GENDER BIAS AND STRESS
Women may face barriers to communication with an organization’s management because of workplace cultures that often exclude women from leadership positions and/or covertly support an atmosphere that views women as secondary to their male colleagues. Male leaders may believe that women do not succeed or attain managerial and executive positions because they are not qualified or capable of fulfilling the responsibilities associated with leadership positions or even of effective communication.
Most workplaces were created by men, for men, and are run by men. Hiring women to increase the number of females in leadership roles without changing a male hierarchy–focused culture is futile. The most powerful people in the workplace set the standards of behaviors and communication. Without respect and equality in the workplace, adverse working conditions related to gender bias will continue to increase both stress and burnout (King, 2020).
Compassion Fatigue / Empathy Distress Fatigue
The ability to feel what someone else is experiencing or to “put oneself in another person’s shoes” is generally considered to be an essential characteristic of healthcare professionals. However, feeling what patients are feeling can lead to overidentying with a patient’s sufferings and stressors, which can then cause healthcare professionals themselves to experience undue stress (Cleveland Clinic, 2021; Dowling, 2018; Amplion Clinical Communications, 2019).
Compassion fatigue is described as a state of deep emotional exhaustion resulting from repeated exposures to traumatic situations or stories. This type of exhaustion reduces the healthcare professional’s ability to feel empathy for their patients, family, and coworkers. People who are very empathic are at increased risk for developing compassion fatigue. They associate themselves with traumatic situations and stories more definitively than other persons (Intraconnections Counseling, 2019).
A considerable part of compassion fatigue involves becoming emotionally distraught when exposed to another’s traumatic experiences and/or someone else’s suffering. These distraught feelings are also referred to as secondary traumatic stress (Sheppard, 2016).
The term compassion fatigue was first coined by Charles Figley in the 1980s. Since its inception, the concept of compassion fatigue has been widely embraced by the psychological community. Despite this acceptance, however, it has never merited its own diagnostic category by any edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) (Boyle, 2015).
Empathic distress, which is another term for this phenomenon, “refers to a strong aversive and self-oriented response to the suffering of others, accompanied by the desire to withdraw from a situation, disconnect from those who are suffering, and adopt depersonalizing behaviors in order to protect oneself from excessive negative feelings” (Singer & Klimecki, 2014). In healthcare, empathy distress fatigue is the emotional and physical exhaustion that occurs when healthcare professionals care for people day after day under extremely stressful conditions (Cleveland Clinic, 2021).
COMPASSION FATIGUE OR EMPATHY DISTRESS FATIGUE?
The term compassion fatigue is used most often to describe the phenomena discussed above. However, some experts in psychology and neuroscience now question this term and believe that this form of fatigue is caused not by compassion but by empathizing with patients.
Compassion is the ability to understanding and show concern for the suffering of others while using emotion regulation skills so as not to actually feeling their suffering oneself. Empathy more commonly refers to sharing the feelings of others, including their fears and stressors, blurring the “self-other” distinction and absorbing another’s suffering as one’s own.
Thus, these experts recommend using the newer term empathy distress fatigue rather than compassion fatigue. To date, however, most of the literature continues to use the older term (Cleveland Clinic, 2021; Dowling, 2018; Hofmeyer et al., 2020).
RISK FACTORS FOR COMPASSION FATIGUE
Both individual and organizational issues contribute to compassion fatigue. Some of these overlap with the risk factors for burnout described earlier in this course.
Individual Risk Factors
Healthcare professionals at greater risk for compassion fatigue include those who:
- Are in situations where they fear for their safety or the safety of their patients
- Have a lack of or are separated from personal support systems
- Perform physically difficult or exhausting tasks
- Have a heavy workload
- Do not get enough sleep
- Have substance use issues
- Are exposed to anger or lack of gratitude
- Have excessive empathy
- Feel helpless to deal with work circumstances
(Local Public Health Institute of Massachusetts, 2021)
Others at high risk for compassion fatigue are healthcare professionals who form close, personal relationships with patients and/or families, especially when personal boundaries are crossed (Sheppard, 2016). Sometimes, in an effort to be supportive and empathetic, healthcare professionals begin to slowly cross professional boundaries without actually being aware of what they are doing. Every relationship between a patient and a healthcare professional must be based on the premise of professional behavior.
CROSSING PROFESSIONAL BOUNDARIES
The National Council of State Boards of Nursing (NCSBN, 2018) cautions that inappropriate behavior can be subtle at first. However, healthcare professionals should be aware of the following “red flags” that warn of the dangers of crossing professional boundaries, which may occur when a professional:
- Discusses their own intimate or personal issues with a patient
- Engages in actions that could be interpreted as flirting
- Keeps secrets with patients or family members
- Believes that they are the only one who understands or can help the patient or family members
- Spends more time than is necessary with certain patients
- Speaks poorly about colleagues or employers with patients or families
- Shows favoritism toward certain patients or family members
- Meets with patients in settings besides those needed to provide direct patient care
Organizational Risk Factors
Anyone who works in a difficult work environment is at risk for stress-related conditions, including compassion fatigue. Organizational factors that contribute to a difficult work environment include:
- Rotating shifts
- Changing job assignments
- Long working hours
- Asking employees to do more with less
Researchers investigating compassion fatigue among critical care nurses have identified several other organizational factors that increase this form of job-related stress:
- Lack of support (organizational, leadership) when nurses deal with difficult situations
- Failure to receive acknowledgment/accolades for their work
- Not having their input considered regarding removing or modifying system-based obstacles
(Arnetz, 2020; Shreffler et al., 2020)
SIGNS AND SYMPTOMS OF COMPASSION FATIGUE
Symptoms associated with compassion fatigue include:
- Feeling bored with work
- Feeling exhausted most of the time
- Self-medicating with drugs or alcohol
- Feeling detached and distant from patients and colleagues
- Conflicts in interpersonal relationships
- Being irritable and short-tempered
- Difficulty sleeping
- When off duty, worrying about things that may have been forgotten at work or thinking about disturbing events that took place at work
- Mental and physical exhaustion
- Headaches and/or backaches
- Nausea, especially when going to work
(Cleveland Clinic, 2021; Sheppard, 2016)
COMPARING COMPASSION FATIGUE AND BURNOUT
The most important step in combatting compassion fatigue is recognizing it. First and foremost, compassion fatigue must be distinguished from burnout. While healthcare professionals can experience both, these are two distinct issues. Burnout is associated with workplace stressors such as manager unresponsiveness, lack of camaraderie and teamwork, staffing shortages, working long hours, intense workloads, conflicts with other nurses and healthcare providers, and time pressures. Compassion fatigue, on the other hand, emanates from the stress healthcare professionals experience from their relationships with patients and families (Boyle, 2015).
Vicarious trauma, also referred to as trauma by proxy, occurs when healthcare professionals experience secondary traumatic stress reactions triggered by helping, or wanting to help, traumatized patients and families. Vicarious trauma refers to negative changes in the healthcare professional’s view of self, others, and the world that occur as a result of repeated empathetic involvement with patients’ traumas. Healthcare professionals may develop symptoms of posttraumatic stress disorder (PTSD) as a result of caring for these patients and families (Quitangon, 2019). Vicarious trauma tends to make it difficult to focus and perform duties as assigned.
RISK FACTORS FOR VICARIOUS TRAUMA
Individual Risk Factors
Vicarious trauma is influenced by individuals’ personal experiences with traumatic events that have impacted them, their family members, and/or close friends. Such personal experiences can make someone more vulnerable to vicarious trauma. People are also at risk for vicarious trauma if others who work with them are experiencing the phenomenon, thereby becoming a negative influence on those around them. That is, vicarious trauma can “spread” from one person to another (NCADV, 2018).
Persons who work in helping professions are especially vulnerable to vicarious trauma as well as compassion fatigue. Those at high risk for developing either vicarious trauma or compassion fatigue are persons who:
- Have a personal history of trauma
- Care for patients who have suffered trauma
- Are repeatedly exposed to patients’ narratives of trauma
- Are preoccupied with the traumatic stories of the people they care for and work with
- Display emotional symptoms of anger, grief, mood swings, anxiety, or depression (which may also indicate that the person is already experiencing vicarious trauma)
- Have physical issues related to stress (e.g., headaches, fatigue, gastrointestinal problems) (which may indicate that the person is already experiencing vicarious trauma)
- Have feelings of powerlessness, hopelessness, and disillusionment
(Quitangon, 2019; Salazar, 2016)
Organizational Risk Factors
A workplace that fails to support its employees increases the risk for vicarious trauma. Specific organizational factors that increase the risk of vicarious trauma in the workplace include:
- Failing to acknowledge the problem and develop a strategy for reducing it
- Failing to provide support services (e.g., mental health resources) to staff who are experiencing patient/family trauma
- Failing to create an environment where persons experiencing vicarious trauma can acknowledge it without fear of ridicule or job compromise
- Failing to know what vicarious trauma is, what strategies can prevent it, and what actions are needed to help those experiencing it
- Failing to acknowledge that managers and supervisors also experience vicarious trauma and require appropriate support
SIGNS AND SYMPTOMS OF VICARIOUS TRAUMA
Among the physical manifestations of vicarious trauma are anorexia and direct gastrointestinal (GI) symptoms such as nausea, stomach pain, and diarrhea. If the person reacts to this GI upset by not eating or eating less than usual, fatigue and reduced energy can result. Paradoxically, both insomnia and hyperactivity are also possible. Headache and chest pain may present (Joyful Heart Foundation, 2018).
Psychological signs may present as exaggerated forms of a person’s usual behavior or as reactions not usually seen, at least in the workplace. As the situation continues, these responses may become more frequent and/or stronger and/or require less and less to trigger them.
Among the common presentations of vicarious trauma are the following:
- Irritability, anger, resentment, and/or cynicism
- Feeling that no matter how much you try or give, it is never enough
- Feelings of hopelessness and helplessness
- Feeling disconnected from emotions
- Difficulty in seeing multiple points of view or new solutions to problems
- Having intrusive thoughts and/or images related to the traumatic events you have seen or heard about
- Absenteeism from work
- Avoidance of work, responsibilities, or engaging in interpersonal relationships
- Dread of activities that used to be positive
- Lacking a personal life outside of work
- Extreme concern about the safety of loved ones
(Joyful Heart Foundation, 2018; Quitangon, 2019)
Sara, a respiratory therapist, and Josie, an emergency department (ED) nurse, are both involved in caring for multiple critically ill patients who have COVID-19.
Sara has found herself strongly shaken by the sight of so many of her patients struggling to breathe and the large numbers of patients on ventilators. Sara has also been struggling to deal with the many fatalities due to COVID-19. Despite postincident counseling, continuing her meditation practice, and taking time off with her family, Sara has not yet worked through her feelings. She is also finding herself unable to concentrate and experiencing images of her younger brother, who has severe asthma, struggling to breathe as he battles COVID-19. She has also had dreams in which her elderly grandfather is on a ventilator at the point of death.
Josie is frequently on duty in the ED when critically ill COVID-19 patients arrive. In addition to being an ED team leader, she provides patient care, often holding patients’ hands as they are intubated or as they die. Caring for so many critically ill patients hour after hour, day after day, has begun to take a toll on Josie. She is unable to recharge and has begun feeling detached from her patients, a loss of interest in ordinary activities, and insomnia.
Sara is experiencing vicarious trauma as the result of both her ongoing exposure to traumatized, critically ill patients and their families. A unique symptom to this form of job-related stress is Sara’s recurring, intrusive images of her vulnerable relatives struggling to survive COVID-19.
Josie is displaying symptoms more characteristic of compassion fatigue brought about by her constant exposure to suffering patients and characterized by her feeling of detachment from her patients.
Both women need help to address their stress-related issues due to the ongoing pandemic, especially since the circumstances surrounding patient care may not improve anytime in the near future.
INDIVIDUAL ACTIONS TO ADDRESS AND RECOVER FROM WORK-RELATED STRESS
Strategies to address work-related stress include the following:
- Apply prevention strategies in the workplace
- Employ problem-solving strategies
- Practice assertiveness
- Practice self-care
- Take a break and get help
- Identify and grieve for losses
- Confront denial and cynicism
- Acknowledge one’s limitations
- Establish personal boundaries
(Blazey, 2016; Mayo Clinic, 2021)
Apply Stress-Prevention Strategies in the Workplace
It is vitally important for healthcare workers to be active in taking good care of themselves while on the job. The following are recommendations to help reduce or prevent stress in the workplace:
- Make a list of work demands/responsibilities, prioritize them, and determine the time needed to complete them.
- Look for opportunities to acquire new skills and participate in continuing education.
- Take breaks and meal times in order to relax and refresh one’s ability to go back to work.
- Get outdoors in the sunlight or take a short walk to improve energy and focus.
- Connect with coworkers, even if it is just a greeting at the beginning and end of one’s shift.
- Pace oneself and monitor for excessive fatigue, irritability, poor focus, or anxiety.
- Take time to breathe slowly before entering a patient room or a work area, since slow breathing is calming and helps the body cope with symptoms of stress.
- Reframe anxiety-provoking statements (e.g., say, “A great many people get sick and recover” instead of “I might get sick and die”).
(Workplace Strategies for Mental Health, n.d.; Benyon, 2020; NCCN, 2020)
Employ Problem-Solving Strategies
Problem-solving is especially difficult for individuals who are stressed because they are emotionally and physically exhausted. Nonetheless, when individuals employ such strategies, they can help prevent the negative impacts of stress. Four common steps in problem-solving are as follows:
- Define the problem. Ask, “What work-related area is causing me stress?” If there are several problem areas, prioritize the list and address the one most amenable to solution. The goal is to identify the problem, not the symptoms of the problem.
- Generate alternative solutions. Consider multiple alternatives. Do not become focused on only one way to solve a problem.
- Evaluate and select an alternative. Choose an alternative that will solve the problem without causing other problems, will be accepted by the individuals involved, can likely be implemented, and fits within organizational goals and constraints.
- Implement and follow up on the solution. Establish a process to evaluate and measure the effectiveness of the alternative chosen.
Many individuals who experience burnout cite working conditions such as inadequate staffing or lack of manager or collegial support. In order to deal with these types of difficult situations, it is important to be able to communicate concerns clearly without becoming angry and accusatory.
If the problem is with staffing, for example, do not start by blaming the manager. Always come prepared with recommendations for helping to defuse the problem (Fry, 2016; Mayo Clinic, 2020). Do not, for example, simply demand that more staff be hired. There may be budgetary constraints or lack of qualified candidates. What actions could the staff take, working as a team, to resolve these issues? How should communication take place?
Make sure not to engage in negativity or complaining about managers or colleagues. Negativity spreads rapidly, may cause people to become aggressive and have hurt feelings, and generally does nothing to help the situation. Consider that it is important to:
- Avoid complaining. It may be tempting to vent frustrations at work, but one’s comments will be spread among colleagues and probably exaggerated. Complaining may also result in receiving some of the blame for current work-related difficulties and lead to a reputation as a complainer. Vent frustrations and concerns to trusted friends or family members outside of the workplace.
- Follow the chain of command. Most, if not all, organizations have a chain of command for expressing concerns and proposing solutions. This usually means starting with one’s immediate supervisor. It is important not to bypass the immediate supervisor and go to the next person in the chain of command unless one has already followed the organization’s policies and procedures for problem resolution. In cases where one may think, “But the supervisor never listens to anything I have to say,” it can be useful to analyze the way one is approaching the supervisor: Do you ask in advance to have a particular topic addressed during a staff meeting, or do you surprise the manager with unexpected complaints? Are you aggressive instead of assertive in your communication (see box below)?
- Promote a healthy work environment. Voice your concerns skillfully to your manager and cooperate with your coworkers on addressing areas for improvement.
- Analyze your communication style. Aim to come across as confident and assertive, not angry and aggressive. Before you walk into a staff meeting, consider constructive ways to contribute. For instance, if staffing issues are on the agenda, begin by making recommendations to deal with current shortages.
(Fry, 2016; Mayo Clinic, 2020)
It may be challenging to maintain assertiveness. Assertiveness training can help enhance confidence, improve problem-solving skills, and increase one’s ability to improve the workplace environment.
|Stating opinions while being respectful of others||Attacking or ignoring others’ opinions|
|Speaking in a calm tone of voice and actively listening to the opinions and concerns of others||Interrupting and talking over others, often in loud, even shouting ways|
|Making good eye contact||Frowning and staring at others in an attempt to make them uncomfortable and/or intimidate them|
|Having a relaxed posture and respecting others’ personal space||Displaying a rigid posture, crossing the arms, and invading the personal space of others|
|Remaining calm||Shouting and losing one’s temper|
|Listening respectfully to what others have to say||Ignoring others or discounting what others say|
|Adopting a problem-solving approach so that all parties involved in conflict or problem resolution come to an agreement that benefits, as much as possible, everyone involved||Wanting to “win”; seeing only one’s own point of view and wanting to achieve it without caring if others are hurt in the process; not looking at the whole picture to benefit everyone|
BODY LANGUAGE AND ASSERTIVENESS
Assertive people make sure that their body language is consistent with their verbal communications and portray themselves as open and caring. For example:
- Be alert to your facial expressions.
- Avoid closed body postures such as crossing your arms over your chest or crossing your legs.
- Assume an “accepting” body posture with both feet on the floor, knees parallel, and hands at your sides.
- Keep your voice calm and audible.
- Maintain eye contact.
Self-care means caring for oneself. When people who are burned out finally stop what they are doing and get help, they are beginning to nurture themselves. Self-care is a conscious awareness of personal needs, with the focus on taking responsibility for oneself.
Ultimately, such self-nurturance is a measure of maturity. It means taking care of one’s own basic needs for survival, safety and security, belonging and affection, respect and self-respect, and self-actualization. Practically speaking, self-care means creating a healthy lifestyle, finding a good work-life balance, and engaging in self-actualizing activities. Strategies include:
- Making a life beyond work by engaging in nonwork activities and developing interpersonal relationships outside of the workplace
- Maintaining a healthy diet and participating in regular exercise (e.g., biking or walking to work if possible)
- Avoiding alcohol, drugs, and excessive amounts of caffeine
- Getting an adequate amount of sleep
- Keeping up connections with friends and family, since meaningful interactions with loved ones is important for well-being
- Asking for help from a support network of friends, families, and colleagues in order to problem-solve together
- Evaluating other career options
- Seeking out services from a mental health professional when needed
(Blazey, 2016; Mayo Clinic, 2021; APA, 2018; Cleveland Clinic, 2021)
RELAXATION AND MINDFULNESS PRACTICES
Healthcare professionals may have experienced high levels of stress for such a long time that they no longer know how to relax. Their home and work environment may be so demanding that they can no longer take time for themselves, or they may feel guilty when they take a moment to relax.
The following breathing exercise is one example of a practice that can help one relax in a stressful situation:
- Wearing comfortable clothing, find a quiet place and stretch your whole body. Then, sit down in a comfortable chair where you will not be disturbed. It is best to uncross your legs and rest your hands on your lap, separately. You may also lie down if you like.
- Close your eyes.
- Breathe in while imagining that the air is filled with a sense of peace and calm.
- Breathe out while imagining stress leaving your body with the exhalation.
- Use a word or phrase as you breathe. For example, you might think “I am calm and without stress.”
- Continue for about 10 minutes.
Mindfulness meditation is another increasingly popular form of therapy. It is characterized by achieving a mental state of calm concentration and positive emotions. Mindfulness consists of two steps. The first is attention. This involves directing one’s focus on the breath, thoughts, and physical sensations one is currently experiencing. The second step is acceptance. This involves observing one’s feelings and sensations without judgment. Instead of responding negatively to feelings, the goal is to take note of them and let them go (Creswell & Bassam, 2019).
Take a Break and Ask for Help
Stressed individuals may find that they have used up their emotional and physical reserves. When people acknowledge they are stressed, they need to take a break and get help. It is important that healthcare professionals realize that taking care of themselves is the most important step for them to continue to care for others.
It is normal to feel anxious when needing help from a supervisor or colleague, because one may fear receiving unwanted advice, shaming, or rejection. All relationships benefit when people admit they are struggling and express their needs. This allows others to do the same. It is important for healthcare professionals to acknowledge when they are hurting and to return support and caring to colleagues as well as patients (Blazey, 2016; Mayo Clinic, 2021).
Identify and Grieve for Loss
As burned-out individuals scrutinize each part of their story, it is not unusual to find that one or more of the pieces is a jagged, unhealed, unresolved loss. That loss may be their reputation, a cherished loved one, a prized possession, their health, an opportunity, or some other treasured thing.
When unresolved bereavement is a factor in burnout, it is important to engage in what some call grief work. This is an emotional process through which bereaved individuals re-experience their loss, loosen the ties to it, and gradually adjust to life without the cherished person, item, or situation. To facilitate the grieving process, individuals set aside a time to grieve during which they allow themselves to re-experience the loss. At the end of the allotted time, they “close the book,” dry their tears, and return to activities of daily living. They do this repeatedly and over time. Such grief work facilitates a separation from what has been lost (Joyful Heart Foundation, 2018; Sheppard, 2016).
Confront Denial and Cynicism
When individuals are in positions of high stress and overwhelming anxiety, they may not realize just how stressed they have become. They may insist they can “handle it,” whatever “it” may be. Over time, they become distraught, distrustful, and skeptical of the goodwill of others. They may attempt to protect themselves with a defense of cynicism and denial. This does not work because denial is a lie they tell themselves.
When people confront the truth and admit their exhaustion, cynicism, and vulnerability, they open the door to health and healing. In fact, truth does set people free. As soon as they accept themselves just as they are, honestly admitting their frailty, failures, and fatigue, they are relieved of the burden of being perfect and are able to replace denial, cynicism, and fear with acceptance, joy, and hope (Blazey, 2016; Mayo Clinic, 2021).
Often, individuals who are burned out have been trying to be “super-beings.” They have been strong and accommodating, worked diligently, and persevered no matter what was asked of them. Things are different now. When people reach the end-stage of burnout, they must admit that they are not super-beings; they are human beings and have limits. These limits may be different from other people, but they are real for that individual. As with denial, when people admit they are less than perfect, they are wonderfully liberated. In the future, they will be better equipped to heed the signs and symptoms of emotional and physical exhaustion (Blazey, 2016; Mayo Clinic, 2021).
Establish Personal Boundaries
Setting personal boundaries means knowing who you are, where you begin and where you end, and when to say, “This is my responsibility and that is yours.” Typically, healthcare professionals are empathetic, understanding, and nurturing. When individuals fail to maintain personal boundaries, they may exercise inappropriate control over others and become unwittingly codependent (Blazey, 2016; Mayo Clinic, 2021; NCSNB, 2018).
Sierra, a physical therapist, is the rehab director in a community hospital. She loves her job and has been able to earn the respect of both her staff and her administrative supervisors.
Recently, the hospital underwent an upper management change, and Sierra’s new boss made drastic cuts in staffing until the next fiscal year, reducing the PT staff from 16 therapists to 10. He informed Sierra that she must now assume a full caseload of patients while continuing to fulfill her directorial responsibilities. Lately, she has increasingly found herself staying at work until after 9 p.m. in order to make sure that all patient consults and treatments have been addressed and all required paperwork and billing was completed.
At home, Sierra has begun to have trouble sleeping and can’t seem to stop worrying about things she may have left undone at the hospital that day. Her fiancé, Jamal, has noticed that she is growing shorter-tempered, frequently exploding over things that never would have bothered her before, and refusing invitations from their friends in order to stay late at the hospital.
Late one evening Jamal became concerned that Sierra was not yet home from work and was not answering her cellphone. Finally, he drove to the hospital and found Sierra surrounded by patient files, frantically completing notes. When Jamal walked into the room, Sierra burst into tears and said, “I don’t think I can do this anymore.” Jamal drove Sierra home, served her dinner, and drew her a hot bath. Then, they sat down on the sofa, and Sierra admitted that she was in over her head. She was experiencing burnout and needed to address her situation and recover her balance.
The next day, Sierra met with her boss and said that she simply could not continue both to manage the rehab department and to assume responsibility for a full patient caseload. Sierra explained that, while she took patient care and the needs of the department very seriously, her own health had started to suffer and that she was no longer willing to sacrifice herself. She asked the administrator if a compromise could be reached, or if she should begin seeking employment elsewhere.
The administrator, recognizing signs of employee burnout and not wanting to risk losing Sierra, agreed to contact a staffing agency and arranged for a per diem PT to join the department on a temporary basis until staffing issues were resolved. Sierra agreed to keep a small patient caseload while fulfilling her managerial role, with the caveat that she be offered fair financial compensation for doing so.
With a per diem PT in place, Sierra returned to working a fairly typical 40-hour workweek most of the time, although she occasionally stayed late to work on managerial duties. Sierra and Jamal used some of the extra money from her raise to enroll together in a weekly yoga and meditation class at the local YMCA.
Sierra took several actions to address and recover from burnout. First, she acknowledged her limitations and established boundaries during her discussion with the hospital administrator. She employed a problem-solving approach by setting an objective of reducing her responsibilities and by leveraging the administrator’s ability to make a change to her situation. Sierra reduced her stress by enrolling in a yoga and meditation class. She also had the benefit of a strong support system at home, which facilitated her recovery from burnout.
CREATING A HEALTHY WORK ENVIRONMENT
The causes and prevention of stress are interrelated, involving both workers who suffer burnout and the environment in which they work. To prevent stress, individuals must identify and resolve stress-producing issues, and employers must also identify and address workplace factors that cause stress. When healthcare professionals and their organizations both address these matters, both will benefit. Individuals experience less stress and organizations maintain a staff that provides patients with the highest quality care.
Providing assistance and effective interventions to protect healthcare professionals from the effects of workplace stress are of prime importance in addressing these stresses on an organizational level.
What Organizations Can Do to Improve the Work Environment
When employees suffer from stress and become cynical, detached, and exhausted, productivity is reduced, standards are compromised, and the reputation of the organization is diminished. This is particularly true in service industries such as those that provide healthcare.
Positive organizational climates are characterized by ensuring that employees have the necessary support (e.g., staffing, equipment, orientation) to provide safe patient care. In order to establish such a climate, organizations must address the factors that lead to stress and burnout. It is important that an organization’s senior leaders:
- Know the different forms of workplace stress, including burnout, compassion fatigue, and vicarious trauma
- Understand the impacts of stress on both the organization and employees, how to recognize stress, and how to prevent it
- Ensure that mental health services are available to employees, since mental health interventions can help alleviate workplace stress
- Evaluate the working climate of the organization on a regular basis, soliciting input from all employees
- Initiate education and training on the topics of burnout, vicarious trauma, and compassion fatigue
(Dyrbye et al., 2017; Haik et al., 2017; NCADV, 2018)
Research has found that organizations can reduce the development of burnout by providing employees with:
- The resources needed to do the work
- Training to safely provide patient care
- Fair pay
(Yeatts et al., 2018)
IDENTIFYING INSTITUTIONAL ISSUES
To prevent burnout in employees, managers in organizations also work to identify the specific institutional issues that create stress and then take measures to alleviate them, namely:
- Unclear job descriptions
- Unreasonable job expectations
- Ambiguous chain of command
- Scant recognition and rewards
- Chaotic or high-pressure environments
- Destructive interpersonal dynamics
- Mismatch of employee strengths with work assignments
- Dubious ethical practices regarding honesty, integrity, kindness, respect, and confidentiality
Management asks—and acts upon—the following questions as a strategy to prevent caregiver burnout:
- Workload. Are job expectations reasonable? If not, how can they be changed to match the need? Are job descriptions current, clear, and accurate? Is there a mismatch between employee strengths and work assignments? Is the work environment chaotic or high-pressured? If so, how can it be moderated to reduce worker stress?
- Control. Is the chain of command clear and understandable? Does it foster efficiency, collegiality, and fulfillment of the organization’s mission? Is it being followed? If not, why not?
- Rewards and recognition. Are performance standards clearly stated and known by employees? Are workers recognized and rewarded for meeting their performance standards? What else can the organization do to support and encourage employees?
- Social community. Is there a positive, collegial work environment? If not, what is hampering its development? What can the organization do to foster a cooperative, supportive environment?
- Fairness. Do workers feel they are treated with respect and fairness? Are work schedules flexible enough to get the job done yet meet the needs of staff members? Is there a fair wage for every category of worker? How do wages compare to other similar organizations?
- Values. Is the institution known for its integrity? Are honesty, respect for human dignity, benevolence, autonomy, and justice encouraged and rewarded?
(Blazey, 2016; Mayo Clinic, 2021)
PROVIDING EDUCATION AND TRAINING DURING A PANDEMIC
All employees require adequate education and training to achieve and maintain competency at work. This is particularly true during a pandemic. Formal and informal training during a pandemic can prepare healthcare workers to face the unique stressors involved in working under such conditions. Such training can include:
- Specific and accurate information about transmission of the infectious agent and methods of containment
- When and how to screen patients and, potentially, family members and visitors
- When to institute quarantine and isolation
- Ethical decision-making about triage and surge capacity issues
In order to increase the sense of confidence in one’s work-related performance, workers can also take part in training and/or planning exercises such as:
- Managing limited resources
- Implementing various levels of quarantine
- Enforcing movement restrictions in the facility
- Handling mass fatalities
- Conducting mental health screening
- Coping with high stress demands
- Preparing for personal and family needs when required to be more involved at work or when in quarantine
- Providing psychosocial support to colleagues
ADDRESSING BURNOUT AMONG MANAGERS
Managers are also at risk for stress and burnout. A study on nurse-manager role stress identified four essential themes describing stress and what is needed to alleviate that stress:
- Sink or swim. Study participants recounted being “thrown” into a management position without any orientation or mentor. They struggled with the transition from peer to manager without support from the organization and no feedback regarding how they were performing their new duties. Successful organizations develop an orientation program for managers and establish a mentor program for managers.
- There is no end. Managers often assume 24-hour-a-day accountability for the unit(s) they oversee. Study participants described feeling overwhelmed by this responsibility in conjunction with the workload of a manager and the constant additions of new or changing responsibilities. Successful organizations offer support to managers in the form of adequate clerical and ancillary staff and by establishing realistic goals.
- Support me. Participants expressed the need for balancing their work lives with their personal lives and requested that organizational leadership not reach out to them after hours unless it is an emergency. They also asked for overt support and the trust that they would oversee their units safely and professionally. Participants also described a need for clear expectations regarding their roles and responsibilities as well as feedback on their job performance.
- Finding balance. Managers expressed the need for support and assistance to “grow” into their roles as managers (e.g., mentors, adequate orientation). They described ways they had learned to achieve balance (e.g., not answering emails at home, decreasing the amount of paperwork they took home in the evenings, participating in some form of exercise).
What Individuals Can Do to Improve the Work Environment
Healthcare professionals can create a healthy work environment by addressing the same causal factors as employers. This includes asking the following questions:
- Workload. Am I assuming too many responsibilities? Am I getting enough sleep, rest, and relaxation? Am I taking care of myself? What can I do to balance the demands of my work with my energy, rest, and relaxation? Do I have unrealistic achievement goals and aspirations?
- Control. Do I have to be “in charge” at all times and in all circumstances? Do I need to be perfect all times? Is the cost of perfection worth the reward it gives? What can I do to reduce the stress it creates?
- Rewards and recognition. Does my work give me emotional and monetary rewards? Are they adequate for my needs? Am I appreciated and recognized by my colleagues and employer? If not, what can I do to receive recognition and feel good about myself?
- Social community. Is my work environment chaotic and unstructured? Do I have a collegial working relationship with staff members? If not, what can I do to increase mutual respect and support and thus nurture myself and my coworkers?
- Fairness. Do I feel that I am being treated fairly in work assignments, wages, or recognition? If not, are any institutional measures available to challenge the status quo and make things fair?
- Values. Is there a mismatch of ethical values between me and my workplace? If so, is the problem systemic or is it limited to one person or one circumstance? What institutional measures are available to address the issue?
A group of nurse managers has been troubled by an increase in signs and symptoms of burnout being exhibited among staff nurses. They realize that if they do not do something to curtail this increase, patient care will suffer, nurses may quit, and the workplace environment will become increasingly negative.
Some of the managers want to confine their problem-solving discussions to their managerial group. However, the majority of managers want to include staff members in the process. As one manager puts it, “If we don’t ask them for input, we will end up failing to address their concerns, and a bad situation will become worse.”
A focus group consisting of nurse managers and staff nurses is formed. Although the staff nurses are at first reluctant to speak freely about their concerns, the managers develop an environment for discussion in which the staff nurses eventually provide honest feedback and relay their concerns frankly.
Some initiatives agreed upon by the committee include:
- Developing a staff-driven method of scheduling
- Involving staff nurses in recruitment and retention efforts
- Evaluating job descriptions for clarity
- Establishing a rewards and recognition program
The nurse manager group was correct in including staff nurses as part of the problem-solving effort. This helped to gain cooperation and accurately identify areas for improvement. Initiatives were then developed that were important to staff nurses while also helping nurse managers to increase positivity in the work environment.
Sandra is the staff development coordinator for a volunteer outreach clinic as well as the manager of the clinic’s vaccination program. This is in addition to her part-time job at a family practice office. She has also been approached about overseeing an annual health and wellness fair at her church and is seriously considering accepting the position.
Recently, the outreach clinic has been mandated to provide all volunteers with safety and diversity training similar to that required for county employees working in comparable positions. The clinic is given a two-month window in which to complete the training, and Sandra must oversee this effort.
With all that is on her plate, Sandra realizes that her work responsibilities, in addition to her personal and family life, have become overwhelming and that she is perilously close to burning out. Sandra looks at her behavior and realizes there are warning signs she has ignored: her sleep is not restorative, she is much less motivated than usual, she is unusually irritable, and she has stopped doing the “fun” things that were her recreational outlets.
At the monthly clinic staff meeting, Sandra grumpily admits that she has made very little progress implementing the volunteer training effort. Since both the tenor of her response and her reported lack of progress are not “typical Sandra,” her manager, Phong, calls a meeting with Sandra to discuss strategies. At the meeting, they write out all of the tasks currently on Sandra’s plate, both those associated with the clinic and others.
Phong remembers that Jorge, a new volunteer, is the trainer for the county afterschool program and recently conducted similar training for that group. She decides to assign Jorge to help Sandra and says she will set up a meeting between the two of them so that they can pool their skills and ideas.
Sandra also admits that she does not really want to volunteer for her church’s health fair but would feel guilty saying no since she was told that she was “the only one who could do a good job of it.” Sandra realizes this is not the case and identifies several others in her church who have the demonstrated ability to take on this project, resolving to recommend one of them to the pastor.
Sandra leaves the meeting with her manager knowing that she has dodged the bullet of burnout by being proactive in addressing her situation. She resolves to implement the ideas she and Phong came up with, both taking advantage of Jorge’s help with the volunteer training and declining to organize the church health fair. She also decides she will talk with her husband about finding ways to have fun together.
Sandra and her employer both took preventative steps to avoid her burning out. Together, they assessed her workload and came up with a strategy involving her getting help from a coworker and reducing her other personal commitments.
STRESS AND SUICIDAL IDEATION IN HEALTHCARE PROFESSIONALS
Suicide rates among healthcare professionals have reached staggering levels. Therefore, experts are warning healthcare systems to focus more on emotional support programs designed to reduce stress, burnout, and compassion and empathy fatigue (Chard, 2021).
A study conducted by the University of Michigan determined that the incidence of death by suicide between 2017–2018 (per 100,000) was:
- Nurses: 17.1 (women), 31.1 (men)
- Physicians: 10.1 (women), 31.5 (men)
- General population: 8.6 (women), 32.6 (men)
(Davis et al., 2021)
In any given year, almost 7% of physicians report suicidal ideation or impulses (Chard, 2021). Female nurses die by suicide at about twice the rate of females in the general population. One of the strongest characteristics linked to nurse suicide is workplace problems (Davidson et al., 2020).
Risk Factors for Suicidal Ideation
The risk factors for suicidal ideation among healthcare professionals can be subdivided into the categories of workplace stressors and home-life stressors:
- Shift work/working hours
- Management issues
- Lateral violence (horizontal violence)
- Workplace conflict
- Inadequate preparation for role
Home life stressors:
- Financial stressors
- Relationship stressors
- Drug/alcohol use by self, family, and/or significant others
- Being the primary caregiver for children and/or parents
- Lack of an adequate support system
(Davidson et al., 2020)
SUICIDE AND COVID-19
The COVID-19 pandemic has caused a significant increase in suicide rates, especially among healthcare professionals. For COVID-19, precipitating factors for suicide include uncertainty about the future, high mortality rate, worldwide panic, fears of getting COVID-19, and fear of passing the infection to loved ones (Omnisure, 2021).
Warning Signs of Suicidal Ideation
The American Foundation for Suicide Prevention has published the following list of warning signs for suicide attempts:
(topics an individual talks about)
It is also important to take note if a coworker has a sudden improvement in mood and behaviors. This may indicate that the person has made the decision to die by suicide and is relieved about the decision.
What to Do When Someone Is Suicidal
Healthcare professionals begin an assessment for potential suicide by asking the individual direct questions about suicidal thoughts or feelings. Asking direct questions will not prompt someone do something that is self-destructive. On the contrary, it may help the healthcare professional to identify persons at risk for death by suicide. Examples of questions to ask include:
- Are you thinking about hurting yourself?
- Have you ever thought about suicide?
- Are you thinking about dying?
- Do you have a plan to harm yourself?
- Do you have access to weapons or things that can be used to harm yourself?
(Mayo Clinic, 2018)
It is also important to be alert to warning signs described previously. If someone is on the verge of death by suicide, immediate help is needed.
- Do not leave the person alone.
- Call 911. The person needs emergency intervention.
- Assess whether the person is under the influence of drugs or alcohol or has taken an overdose.
If someone talks about suicide and suicide is a possibility, help should be obtained from a trained professional as quickly as possible. The person may need hospitalization until the suicidal crisis has resolved. The person is also encouraged to call a suicide hotline number (see “Resources” at the end of this course) (Mayo Clinic, 2018).
Stress and burnout can significantly affect individual healthcare professionals, the organizations for which they work, and the people to whom they give care. Healthcare professionals are at an increased risk for workplace stress because of the demanding nature of the job. By understanding and addressing its causes, job-related stress can be reduced. Both individual and institutional strategies can be employed to address and prevent workplace stress, thereby creating a healthier environment for both healthcare professionals and their patients.
Burnout prevention and treatment (Helpguide.org)
Job burnout: how to spot it and take action (Mayo Clinic)
National Suicide Prevention Lifeline
988 or 800-273-TALK (8255)
866-833-6546 (teen link)
741741 (crisis text line)
Resources to enhance practice (American Holistic Nurses Association)
NOTE: Complete URLs for references retrieved from online sources are provided in the PDF of this course.
Agency for Healthcare Research and Quality (AHRQ). (2019). Burnout. Retrieved from https://psnet.ahrq.gov
American Foundation for Suicide Prevention (AFSP). (2021). Risk factors, protective factors, and warning signs. Retrieved from https://afsp.org
American Psychological Association (APA). (2021). General adaptation syndrome (GAS). Retrieved from https://dictionary.apa.org
American Psychological Association (APA). (2018). Stress effects on the body. Retrieved from https://www.apa.org
American Society for Quality (ASQ). (2021). Problem solving. Retrieved from http://asq.org
Amplion Clinical Communications. (2019). The importance of empathy in nurses and caregivers. Retrieved from https://amplioncare.com
Arnetz JE, Goetz CM, Arnetz BB, & Arble E. (2020). Nurse reports of stressful situations during the COVID-19 pandemic: qualitative analysis of survey responses. International Journal of Environmental Research and Public Health, 17(21), 8126. Retrieved from https://www.ncbi.nlm.nih.gov
Bartholomew K. (2014). Ending nurse-to-nurse hostility (2nd ed.). Brentwood, TN: HCPro.
Benyon B. (2020). Stress management and self-care during COVID-19: NCCN publishes guidelines. Retrieved from https://www.oncnursingnews.com
Blazey H. (2016). Strategies for alleviating nurse burnout. Retrieved from https://consultqd.clevelandclinic.org
Boyle D. (2015). Compassion fatigue. Nursing, 45(7), 48–51. doi:10.1097/01.NURSE.0000461857.48809.a1
Burgess L. (2017). What to know about general adaptation syndrome. Retrieved from https://www.medicalnewstoday.com
Calmer. (2020). What are the 5 stages of burnout? Retrieved from https://www.thisiscalmer.com/blog/5-stages-of-burnout
Centre for Addiction and Mental Health (CAMH). (2021). Stress. Retrieved from https://www.camh.ca
Chard P. (2021). Addressing the alarming trend in suicides among healthcare professionals. Retrieved from https://www.corporatewellnessmagazine.com
Cheriyedath S. (2019). Do stress and anxiety affect sperm quality? Retrieved from https://www.news-medical.net
Cleveland Clinic. (2021). Empathy fatigue: how stress and trauma can take a toll on you. Retrieved from https://health.clevelandclinic.org
Corporate Wellness Magazine. (2021). Workplace stress: a silent killer of employee health and productivity. Retrieved from https://www.corporatewellnessmagazine.com
Davidson JE, Proudfoot J, Lee K, Terterian G, & Zisook S. (2020). A longitudinal analysis of nurse suicide in the Unites States (2005–2016) with recommendations for action. Worldviews on Evidence-Based Nursing, 17(1), 6–15. Retrieved from https://pubmed.ncbi.nlm.nih.gov/32017434/
Davis MA, Cher BAY, Friese CR, et al. (2021). Association of U.S. nurse and physician occupation with risk of suicide. JAMA Psychiatry, 78(6), 651–8. doi:10.1001/jamapsychiatry.2021.0154
De Hert S. (2020). Burnout in healthcare workers: prevalence, impact, and preventive strategies. Local Regional Anesthesia, 13, 171–83. doi:10.2147/LRA.S240564
Dellasega C. (2021). Toxic nursing: managing bullying, bad attitudes, and total turmoil. Indianapolis: Sigma Theta Tau International.
Dowling T. (2018). Compassion does not fatigue! Canadian Veterinary Journal, 59(7). Retrieved from https://www.ncbi.nlm.nih.gov
Dyrbye LN, Shanafelt TD, Sinsky CA, Cipriano PF, Bhatt J, Ommaya A, West CP, & Meyers D. (2017). Burnout among health care professionals: a call to explore and address this underrecognized threat to safe, high-quality care. Retrieved from https://nam.edu
Ericksen K. (2018). Nursing burnout: why it happens and how to avoid it. Retrieved from https://www.rasmussen.edu
Fowler P. (2020). Breathing techniques for stress relief. Retrieved from https://www.webmd.com
Fry BJ. (2016). Fast facts for the clinical nurse manager (2nd ed.). New York: Springer.
Haik J, Brown S, Liran A, Visentin D, Sokolov A, Zilinsky I, & Kornhaber R. (2017). Burnout and compassion fatigue: prevalence and associations among Israeli burn clinicians. Neuropsychiatric Disease Treatment, 13, 1533–40. Retrieved from https://www.ncbi.nlm.nih.gov
Harvard Medical School. (2020). Understanding the stress response: chronic activation of this survival mechanism impairs health. Retrieved from https://www.health.harvard.edu
Hofmeyer A, Kennedy K, & Taylor R. (2020). Contesting the term “compassion fatigue”: integrating findings from social neuroscience and self-care research, Collegian, 27(2), 232–7. Retrieved from https://www.sciencedirect.com
Intraconnections Counseling. (2019). Burnout, compassion fatigue, vicarious trauma. Retrieved from https://www.intraconnectionscounseling.com
The Joint Commission. (2018). Sentinel event: physical and verbal violence against healthcare workers. Retrieved from https://www.jointcommission.org
Joyful Heart Foundation. (2018). Signs of vicarious trauma. Retrieved from http://www.joyfulheartfoundation.org
King M. (2020). Leaders, stop denying the gender inequity in your organization. Retrieved from https://hbr.org
Liu X, Zheng J, Liu K, Baggs JG, Liu J, Wu Y, You L. (2018). Hospital nursing organizational factors, nursing care left undone, and nurse burnout as predictors of patient safety: a structural equation modeling analysis. International Journal of Nursing Studies, 86, 82–9. Retrieved from https://www.sciencedirect.com
Local Public Health Institute of Massachusetts. (2021). Compassion fatigue. Retrieved from http://www.masslocalinstitute.info
Loveridge S. (2017). Straight talk: nurse manager role stress. Nursing Management, 48(4), 20–7. Retrieved from https://journals.lww.com
Mayo Clinic. (2021). Job burnout: how to spot it and take action. Retrieved from https://www.mayoclinic.org
Mayo Clinic. (2020). Being assertive: reduce stress, communicate better. Retrieved from https://www.mayoclinic.org
Mayo Clinic. (2018). Suicide: what to do when someone is suicidal. Retrieved from https://www.mayoclinic.org
McHolm F. (2018). Rx for compassion fatigue. Retrieved from https://www.nursingcenter.com
Mental Health Foundation (MHF). (2021). Stress. Retrieved from https://www.mentalhealth.org.uk
Mountain State Center for Independent Living (MSCIL). (2017). Assertive versus unassertive and aggressive behavior. Retrieved from http://executivesecretary.com
National Coalition Against Domestic Violence (NCADV). (2018). What supervisors and leadership need to know about vicarious trauma and supporting your staff. Retrieved from https://ncadv.org
National Comprehensive Cancer Network (NCCN). (2020). JNCCN: how to manage cancer care during COVID-19 pandemic. Retrieved from https://www.nccn.org
National Council of State Boards of Nursing (NCSBN). (2018). A nurse’s guide to professional boundaries. Retrieved from https://www.ncsbn.org
Office on Women’s Health. (2019). Stress and your health. Retrieved from https://www.womenshealth.gov
Omnisure. (2021). Suicide rates increase during COVID-19, especially among healthcare workers. Retrieved from https://www.omnisure.com
Peters E. (2018). Compassion fatigue in nursing: a concept analysis. Nursing Forum, 53(4), 466–80. doi:10.1111/nuf.12274
Quitangon G. (2019). Vicarious trauma in clinicians: fostering resilience and preventing burnout. Psychiatric Times, 36(7). Retrieved from https://www.psychiatrictimes.com
Salazar W. (2016). Vicarious trauma and the value of self-care for therapists. Retrieved from https://www.goodtherapy.org
Scott E. (2020). Traits and attitudes that increase burnout risk. Retrieved from https://www.verywellmind.com
Selye H. (1956). The stress of life (rev. ed.). New York: McGraw-Hill.
Sheppard K. (2016). Compassion fatigue: are you at risk? American Nurse Today, 11(1), 53–5.
Shreffler J, Petrey J, & Huecker M. (2020). The impact of COVID-19 on healthcare worker wellness: a scoping review. Western Journal of Emergency Medicine, 21(5). doi:10.5811/westjem.2020.7.48684
Shultz J. (n.d.). Mental health consequences of infectious disease outbreaks. Retrieved from https://www.urmc.rochester.edu
Singer T & Klimecki OM. (2014). Empathy and compassion. Current Biology, 24(18), R875–8.
Trish H. (2021). What is vicarious trauma? Retrieved from https://www.jcmh.org
U.S. Department of Veterans Affairs (VA). (2020). Managing healthcare workers’ stress associated with COVID-10 virus outbreak. Retrieved from https://www.ptsd.va.gov
Videbeck SL. (2020). Psychiatric-mental health nursing (8th ed). Philadelphia: Wolters Kluwer.
Warshawsky NE & Havens DS. (2014). Nurse manager job satisfaction and intent to leave. Nursing Economics, 32(1), 32–9.
Workplace Strategies for Mental Health. (n.d.). Prevent burnout. Retrieved from https://www.workplacestrategiesformentalhealth.com
World Health Organization (WHO). (2020). Occupational health: stress at the workplace. Retrieved from https://www.who.int
World Health Organization (WHO). (2019). QD85 burnout. Retrieved from https://icd.who.int
Yeatts DE, Seckin G, Shen Y, Thompson M, Auden D, & Cready CM. (2018). Burnout among direct-care workers in nursing homes: influences of organizational, workplace, interpersonal and personal characteristics. Journal of Clinical Nursing, 27, 19–20. Retrieved from https://onlinelibrary.wiley.com