Ethics for Case Managers, Part 2
Burnout and Stress: Creating a Healthy Workplace
Online Continuing Education Course
Ethics for Case Management. Fulfill 2 of your required 8 contact hours on ethics. Course covers various work stressors in healthcare and their effects. Increase your knowledge of burnout symptoms, stages, and prevention.
Course Price: $20.00
Contact Hours: 2
Choose a profession below:
This course has been pre-approved by CCMC for 2 hours of ethics continuing education credit.
Ethics for Case Managers, Part 2
Burnout and Stress: Creating a Healthy Workplace
Copyright © 2019 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 job-related stress and components of a healthy workplace. Specific learning objectives include:
- Describe the effects of stress on the human body and how to relieve such stress.
- Explain the types of job stress common in healthcare workers.
- Discuss the presentation and causes of job-related stress in healthcare.
- Summarize actions for responding to different forms of job-related stress.
- Describe individual and organizational strategies to minimize job-related stress.
- Identify components of a healthy work environment.
TABLE OF CONTENTS
INTRODUCTION TO STRESS AND BURNOUT
Case managers are challenged on a daily basis with a variety of stressors as they care for patients. These job-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 (Van Bogaert et al., 2013).
Research shows that on-the-job stress is not a phenomenon unique to the healthcare professionals in the United States. Studies from various geographic locations indicate that occupational stress has a negative impact on many professionals throughout the world (Akbar et al., 2017).
Everyone experiences some level of stress at work and at home. However, unrelieved stress occurring over extended periods of time can become burnout. Burnout is described as physical, mental, and emotional exhaustion. Burnout can cause dulled emotions and detachment as well as lack of motivation and feelings of hopelessness (Ericksen, 2018).
Some of the reasons for burnout 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 are over. 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).
- 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.
- 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 burnout.
- 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, conditions that may progress to burnout.
- 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.
(Ericksen, 2018; Moen et al., 2015)
It is not only front-line professionals who deal with stress and burnout. 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 (Loveridge, 2017). For example, a 2014 study showed that 72% of nurse manager survey respondents planned to leave their positions within the next five years as a result of burnout (Warshawsky & Havens, 2014).
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. Fortunately, job-related stress is both “treatable” and preventable. Professionals can learn to cope with stress and burnout by gaining an understanding of stress and stressors, recognizing the signs and symptoms of job burnout, acquiring skills to manage its destructive effects, and preventing its occurrence in the future.
STRESS AND STRESSORS
What Is Stress?
Stress is the term used to describe a variety of physiological and psychological stimuli that cause a physiological response. The idea of stress began with the pioneering work of Walter Cannon (1871–1945). He investigated the sympathetic nervous system as it reacts to heat and noticed that the body responds in a predictable sequence. Dr. Cannon was the first investigator to use the phrase fight or flight. The fight-or-flight response, also known as the stress response, is an automatic reaction to stressful (and possibly dangerous) circumstances. Humans react quickly to such stress by either fighting the threat or fleeing from it (Study.com, 2015).
In his research, Hans Selye separated the physical effects of stress from other physical symptoms, observing that patients suffered physical effects not caused directly by their disease or by their medical condition. Selye found that stressors may be physical (such as infection, injury, and pain) or psychological (such as fear, anger, and sadness). A paper describing Selye’s theory was published in the Journal of Clinical Endocrinology in 1946 (Burgess, 2017).
Stress also has both mental and physical 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:
- Alarm reaction, where the body detects the external stimulus
- Adaptation, where the body engages defensive countermeasures against the stressor
- Exhaustion, where the body begins to run out of defenses
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. But once exhaustion is reached, even the strongest motivation loses its effect (Burgess, 2017).
GENERAL ADAPTATION SYNDROME (GAS)
- 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 glands, 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 blood stream. 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, increases blood clotting
- Kidney clearance to reduce, preventing water loss
- Blood flow to shift from intestinal smooth muscles to skeletal muscles, enabling fight or flight
- 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 …
Exhaustion sets in as the individual fails to adapt to stressors and becomes exhausted.
- A physiological response occurs, as in earlier alarm reaction.
- Energy levels decrease.
- Physiological adaptation decreases.
- Death occurs.
(Adapted from Selye, 1956.)
How Do We Cope with Stress?
Lazarus (1966) expanded our understanding of stress and the ways people deal with it when he observed that when individuals view a new or evolving situation, they first decide whether it is a threat. He called this primary appraisal. Then, as people further monitor a threat, they evaluate their ability to cope with it by what Lazarus called secondary appraisal. In this second step of appraisal, individuals judge themselves unable to handle the situation and withdraw.
Professionals working in intense clinical areas where the stakes are high are more prone to believe they “should” be able to handle anything and attempt to do so, no matter how great the cost to their body. These individuals are at high risk of reaching the end stage of stress: exhaustion.
Instead of persisting until they reach the state of exhaustion, healthcare professionals can learn more effective coping strategies, become self-aware, acknowledge their own limitations, and acquire emotion-regulation and problem-solving skills.
Leaders can provide physical and emotional support for staff members as a way to show support and acknowledge the value of their role and understand the stressful nature of their work. Work-life balance programs can provide a focus on wellness resources with strategies to prevent and manage the stress of working in an intense healthcare environment.
Carol Williams, RN, is a discharge case manager at Memorial Hospital. Because of recent staff shortages, she has been required to work double shifts with a dangerously high caseload. She previously felt good about her job and confident that she would be able to make a difference in her clients’ 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. She does not actively engage with her coworkers during her shift and has insufficient time to meet all of the needs of her clients. She has expressed her frustration and anger to her supervisor and verbally accused her coworkers of leaving work undone for her shift.
Because of her behaviors, Carol’s coworkers have complained to the 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 feels overworked and underappreciated. At some point she comes to the conclusion (primary appraisal) that she is being overpowered by an entrenched bureaucracy and out-numbered by an unsympathetic staff. She knows she is not performing at the level of a Certified Case Manager (CCM), and she feels guilty, insecure, inadequate, and fearful she might lose her job. She also realizes (secondary appraisal) that her method of coping is not solving the problem; the situation is only getting worse and she is becoming emotionally and physically exhausted.
Carol’s stress is putting her in danger of violating the Code of Professional Conduct for Case Managers. By performing her duties at a level below professional expectations, she may be failing to uphold both Principle 4 (CCMs will act with integrity and fidelity with clients and others) and Principle 5 (CCMs will maintain their competency at a level that ensures their clients will receive the highest quality of service) (CCMC, 2015).
RECOGNIZING WORK-RELATED STRESS
Healthcare professionals may experience a variety of stress responses. Common forms of such stress include compassion fatigue, vicarious trauma, and burnout.
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 subtle differences is important.
In an ideal world, all healthcare professionals derive job satisfaction from providing quality patient care. In the real world, many issues detract from such satisfaction. One such issue is compassion fatigue.
Compassion fatigue is defined as the “loss of satisfaction that comes from doing one’s job well, or job-related stress that outweighs job satisfaction” (Sheppard, 2016, p 53). 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 referred to as secondary traumatic stress (Sheppard, 2016).
RISK FACTORS FOR COMPASSION FATIGUE
Both individual and organizational issues contribute to compassion fatigue.
Individual Risk Factors
Healthcare professionals at greater risk for compassion fatigue include those who:
- Work with oncology patients
- See more patient deaths
- Work in settings where patients face severe pain, tragedies, and life-and-death situations
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.
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 his or her 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 ones who understand 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 burnout and 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
(Sacco et al., 2015)
SIGNS AND SYMPTOMS OF COMPASSION FATIGUE
Symptoms associated with compassion fatigue include:
- Feeling bored with work
- Feeling detached and distant from patients and colleagues
- 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
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. Healthcare professionals may develop symptoms of posttraumatic stress disorder (PTSD) as a result of caring for these patients and families (Stuart, 2013). 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 vicarious trauma and 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
(Salazar, 2016; Raunick, 2015)
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)
Smith and colleagues (2015) describe job burnout as “a special type of job stress, a state of physical, emotional, or mental exhaustion combined with doubts about [one’s] competence and the value of [one’s] work.” It is a gradual process by which people detach from meaningful relationships in response to protracted stress and physical, mental, and emotional strain. The result is a feeling of being drained, unproductive, and having nothing more to give. People working as healthcare professionals are especially vulnerable to job burnout.
STAGES OF BURNOUT
Burnout has been described as having four stages:
- Physical and emotional exhaustion
- Shame and doubt
- Cynicism and callousness
- Failure, helplessness, and collapse
Physical and Emotional Exhaustion
Physical and emotional exhaustion may be caused by a heavy and unrealistic workload, stress-producing time limitations, inadequate rest and sleep, unfair work assignments, and lack of respect from managers. From the manager’s point of view, exhaustion may be due to trying to obtain adequate staffing, being asked by administration to “do more with less,” trying to motivate underperforming staff members, and being “in the middle” between staff needs and administration expectations.
Examples of behaviors associated with this type of exhaustion include:
- Refusing social invitations due to lack of energy to attend
- Coming home from work and spending the rest of the evening lying on the couch and dozing in front of the television
- Overeating (e.g., junk food) or not eating enough
Exhaustion can lead to a compromised immune system, making the person more vulnerable to infection and other illnesses (Scott, 2018a). Under such stresses, the pineal gland produces melatonin, which disrupts the sleep-wake cycle, further contributing to fatigue (Duggal, 2017).
Shame and Doubt
As individuals become more and more overwhelmed at work, their sense of competence decreases and feelings of shame increase. They discount past accomplishments, even in the face of objective evidence. At this stage of burnout, individuals may sigh heavily, breathe deeply, and experience a profound sense of loss, uncertainty, and vulnerability.
Affected persons feel despondent in the present and hopeless about the future. They have lost confidence in their professional abilities and may not be able to maintain interpersonal relationships (Dusseault, 2015).
Cynicism and Callousness
As a defense against feelings of vulnerability and inadequacy, many individuals decide there is only one thing to do: protect themselves. To do so, they become cynical and callous. They develop an “attitude,” saying to themselves, “I can’t let them get to me. I’ve got to take care of myself!” At first, the strategy works because other people tend to avoid unpleasant or brusque individuals.
Feelings of defeatism occur. By being cynical and callous, affected persons attempt to use these attitudes as survival behaviors (Dusseault, 2015).
Failure, Hopelessness, and Collapse
At the fourth stage of burnout, coping skills are at their lowest level. People are worn down, vulnerable, and exhausted. Their defenses have begun to fail. Old hurts and upsetting memories of past failures and poor choices begin to seep through their protective shield. Every area of life is affected. The smallest of slights and least important omission makes them respond intensely. When someone else is recognized instead of them, the smoldered coals of rivalry ignite. Nothing is going well. Everything seems to be going wrong (Smith et al., 2015).
Dan Ramirez, RN, CCM, works in a long-term care facility owned and operated by a for-profit company, and he’s found that the administration’s primary concern seems to be keeping the beds full and the costs low. Because of this, Dan is assigned a large caseload and is often stretched beyond his ability to keep up with his many clients’ needs. He finds himself working overtime almost every day and feels obliged to “do it all.”
As the weeks go by Dan becomes more and more fatigued, frustrated, and irritable (physical and emotional exhaustion). He has trouble sleeping and begins self-medicating with alcohol. Then, one day, arriving to work with a bad hangover from drinking too much the night before, he makes a medication error. Fortunately, the patient is not harmed, but the physician scolds him loudly in front of other staff members. Dan is humiliated. He begins to doubt his abilities and to think of himself as a professional failure, an imposter (shame and doubt). He even begins to question his decision to become a nurse case manager.
As his self-confidence decreases, Dan’s self-doubt and detachment increase, and he begins distancing himself from his coworkers, family, and friends. His drinking becomes worse, and he sometimes shows up to work while under the influence. He feels tired all the time, suffers frequent headaches, and barely drags himself to work each day. Eventually, he can’t keep up the pace. On the verge of collapse, he quits his job, disillusioned with the profession and the entire healthcare system.
Dan’s case illustrates the four stages of burnout. By taking on too many patients rather than assertively addressing the issue of inadequate staffing with his supervisor, Dan becomes physically and emotionally exhausted. The resulting impacts on his job performance soon caused him feelings of shame and doubt. This in turn caused him to become cynical and callous, finally leading to a sense of failure and quitting his job entirely.
Dan’s burnout and subsequent alcohol abuse also causes him to violate provisions of the Code of Professional Conduct for Case Managers. Rule 3 of the Code specifies that a “CCM will not violate the code of ethics governing the profession upon which the individual’s eligibility for the CCM designation is based” (CCMC, 2015). For Dan, who is licensed as an RN, this means he must abide by the Code of Ethics for Nurses, published by the American Nurses Association. By working while impaired by alcohol, Dan has clearly violated the nursing code of ethics as well as the standards of practice outlined by the board of nursing in his state, thereby endangering both his clients and his own professional licensure.
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 preceding 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
(Mayo Clinic, 2015; Ericksen, 2018)
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. Characteristics of a Type A personality include lack of patience and free-floating hostility. These characteristics are associated with increased levels of stress and susceptibility to burnout.
(Ericksen, 2018; Scott, 2018b)
BURNOUT AMONG MANAGERS
Managers are also at risk for 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 about being “thrown” into their current 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).
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 work hours
- Shift rotation
- Unrealistic goals for employees
- 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
(Dyrbye et al., 2017; Green et al., 2014)
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).
SIGNS AND SYMPTOMS OF BURNOUT
Burnout does not happen overnight. It is a gradual process occurring slowly over time. It is important to recognize the early symptoms and warning signals for burnout. The signs and symptoms may be physical, emotional, or behavioral:
- Feeling tired and drained most of the time
- Lowered immunity, feeling sick a lot
- Frequent headaches, back pain, muscle aches
- Changes in appetite or sleep habits
- Sense of failure and self-doubt
- Feeling helpless, trapped, and defeated
- Losing motivation
- Feeling alone in the world and detached from others
- Becoming increasingly cynical
- Decreased satisfaction and sense of accomplishment
- Withdrawing from responsibilities
- Isolating oneself from others
- Procrastinating, taking longer to get things done
- Using food, drugs, or alcohol to cope
- Taking out one’s frustrations on others
- Skipping work or coming in late and leaving early
(HelpGuide.org, n.d.; Smith et al., 2015)
INDIVIDUAL ACTIONS TO ADDRESS AND RECOVER FROM JOB-RELATED STRESS
Responding to Compassion Fatigue
Suggestions for avoiding or resolving compassion fatigue include the following:
- Establish personal boundaries.
- Pay attention to your emotions. Acknowledge them and take steps to deal with them. This may mean talking to a professional counselor and/or working with colleagues to resolve troubling work issues (e.g., staffing).
- Take care of yourself. Take steps to avoid thinking and worrying about work during off-duty time. Discuss feelings with trusted family members or a professional counselor.
- Identify triggers that spark compassion fatigue. Take steps to deal with the feelings and emotions these triggers instill in you.
- Show compassion for yourself. Do not engage in destructive self-criticism. Schedule time for activities that you enjoy. You may feel that you do not have time for leisure activities. But these are as important to schedule as work time, doctor’s appointments, children’s sports activities, etc.
Responding to Burnout
Strategies to recover from the stress of burnout include the following:
- Take a break and get help.
- Identify and grieve for losses.
- Confront denial and cynicism.
- Acknowledge one’s limitations.
- Establish personal boundaries.
- Nurture oneself.
- Learn and use stress-reducing actions.
- Employ problem-solving strategies to prevent future burnout.
(Blazey, 2016; Mayo Clinic, 2015)
TAKE A BREAK AND ASK FOR HELP
Burned-out individuals may find that they have used up their emotional and physical reserves. When people acknowledge they are burned out, 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, 2015).
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, cherished loved one, a prized possession, their health, an opportunity, or some other treasured thing. When unresolved bereavement is a factor in burnout, individuals need to engage in what is called 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 the lost possession (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, 2015).
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 and they are theirs. As with denial, when individuals 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, 2015).
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, 2015).
Self-nurturance 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-nurturance is a conscious awareness of personal needs, with the focus on taking responsibility for oneself.
Ultimately, 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-nurturance means providing oneself with adequate sleep, a balanced diet, physical and mental exercise, human companionship, and self-actualizing activities (Blazey, 2016; Mayo Clinic, 2015).
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 stress-reducing tips may assist in maintaining work-life balance:
- Start the day with a relaxing routine.
- Eat regular, well-balanced meals.
- Exercise regularly.
- Do something relaxing and pleasurable every day.
- Socialize with family members and like-minded friends.
- Nourish creativity.
- Set boundaries and take a break from technology.
- Avoid narcotics, cigarettes, alcohol, and stress-producing environments.
- Get a good night’s sleep.
(Smith et al., 2015)
To recover from burnout or prevent burnout, many individuals find the regular practice of a relaxation exercise of great value. The following example is a breathing exercise to help one relax:
- 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 breath. For example, you might think “I am calm and without stress.”
- Continue for about 10 minutes.
EMPLOY PROBLEM-SOLVING STRATEGIES
Problem-solving is especially difficult for individuals who are burned out because they are emotionally and physically exhausted. Nonetheless, when burned-out individuals take a break, get help, grieve for losses, confront denial and cynicism, acknowledge limitations, establish personal boundaries, nurture themselves, and use stress-reducing strategies, they are ready to begin solving problems and prevent burnout in the future.
The four steps of 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. 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, 2017). 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 problematic issues? How should communication take place?
Make sure not to engage in negativity or complaining about managers or colleagues. Negativity spreads rapidly, causes 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 your comments will be spread among your colleagues and probably exaggerated. Complaining may also result in you receiving some of the blame for current work-related difficulties and lead to a reputation as a complainer. Vent frustrations and concerns to trusted 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 your immediate supervisor. You may think “but he or she never listens to anything I have to say.” Analyze the way you are approaching your supervisor. Have you asked to have a particular topic addressed during a staff meeting, or do you blindside the manager with unexpected complaints? Are you aggressive or assertive in your communication? Do not bypass your immediate supervisor to go to the next person in the chain of command unless you have followed your organization’s policies and procedures for problem resolution.
- Promote a healthy work environment. Voice your concerns with your nurse manager and work 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, 2017)
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.
|Source: MSCIL, n.d.|
|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 across 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.
After graduating from social work school and passing her board examination, Sierra took a case manager job at a small, critical-access hospital in a rural county. She looked forward to gaining experience and mentorship from her new boss, the director of case management, who was also a social worker. Soon, however, her boss abruptly left the hospital when his wife accepted a job in another city.
While the hospital searched for a new director, Sierra was on her own managing all the case management clients in both the inpatient and outpatient sections of the hospital as well as most of the day-to-day running of the case management department. She increasingly found herself staying at work until after 9 p.m. in order to make sure that all client records were updated and all required paperwork and billing were completed.
At home, Sierra began to have trouble sleeping at night and could never seem to stop worrying about things she may have left undone at the hospital that day. Her fiancé, Jamal, began to notice that she was 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.
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 client 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. I’m falling way behind, and I still have to fill out all this insurance paperwork!” Jamal drove Sierra home, gave 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 could not, she realized, continue to handle the entire client caseload and complete all the required paperwork. She was at risk of burnout and would have to take action to address her situation and recover her balance.
The next day, Sierra met with the hospital administrator and told her that she simply could not continue to manage all the tasks expected of her, especially since she was still only being paid as an entry-level case manager. Sierra explained that, while she took client care very seriously, her own health had started to suffer and that she was no longer willing to keep running the department on her own. 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 an administrative assistant to join the department in order to help. Sierra agreed to keep handling the full client caseload on a short-term basis, with the caveat that she be offered fair financial compensation for doing so.
Sierra returned to working a fairly typical 40-hour workweek most of the time, although she occasionally stayed late to help with administrative 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 by letting the hospital administrator know that she could not—and would not—run the case management department on her own. She employed a problem-solving approach by setting an objective of increased pay for her increased responsibilities and by leveraging the administrator’s ability to make a change to her situation. Sierra also reduced her stress by enrolling in a yoga and meditation class.
By taking action that resulted in solutions, Sierra and her assistant were also able to comply with Rule 1 of the Code of Professional Conduct for Case Managers (A CCM will not intentionally falsify an application or other documents) and completed the backlog of required documentation (CCMC, 2015).
CREATING A HEALTHY WORK ENVIRONMENT
The causes and prevention of burnout are interrelated, involving both workers who suffer burnout and the environment in which they work. To prevent burnout, individuals need to identify and resolve stress-producing issues, and employers need to identify and address workplace stressors that create burnout. When healthcare professionals and their organizations both address these matters, both benefit. Individuals experience less burnout 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 burnout 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 (Green et al., 2014). In order to establish such a climate, organizations must address the factors that lead to stress and burnout. It is important that organizational senior leadership:
- Knows what vicarious trauma is, how to recognize it, and how to prevent it
- Knows the definitions of compassion fatigue and burnout, how they impact the organization as well as employees, and what can be done to recognize and prevent them
- Ensures that mental health services are available to employees. Literature shows that mental health interventions can help alleviate burnout, compassion fatigue, and vicarious trauma.
- Evaluates the climate of the organization on a regular basis, soliciting input from all employees
- Initiates 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 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
(Green et al., 2015; NCADV, 2018)
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, 2015)
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?
(Blazey, 2016; Leiter & Maslach, 2009)
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 burn out because of the demanding nature of the work.
Job-related stress and burnout directly affect both the healthcare professional, the quality of patient care, and healthcare institutions. By understanding and addressing their causes, job-related stress can be reduced. Both individual and institutional strategies can also be employed to prevent burnout, thereby creating a healthier environment for both healthcare professionals and patients.
Burnout prevention and treatment (Helpguide.org)
Code of Professional Conduct for Case Managers (Commission for Case Manager Certification)
Holistic Stress Management for Nurses (American Holistic Nurses Association)
Job burnout: how to spot it and take action (Mayo Clinic)
NOTE: Complete URLs for references retrieved from online sources are provided in the PDF of this course.
Akbar RE, Elahi N, Mohammadi E, & Khoshknab MF. (2017). How do nurses cope with job stress? A study with grounded theory approach. Journal of Caring Sciences, 6(3) (online). Retrieved from https://www.ncbi.nlm.nih.gov
American Society for Quality (ASQ). (2018). Problem solving. Retrieved from http://asq.org
Blazey H. (2016). Strategies for alleviating nurse burnout. Retrieved from https://consultqd.clevelandclinic.org
Burgess L. (2017). What to know about general adaptation syndrome.Retrieved from https://www.medicalnewstoday.com
Commission for Case Manager Certification (CCMC). (2015). Code of professional conduct for case managers with standards, rules, procedures, and penalties. Retrieved from https://ccmcertification.org
Duggal N. (2017). 5 functions of the pineal gland. Retrieved from https://www.healthline.com/health/pineal-gland-function
Dusseault W. (2015). The 4 stages of burnout and how to avoid them. Retrieved from https://www.crosscountrytravcorps.com
Dyrbye LN, et al. (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
Fry BJ. (2016). Fast facts for the clinical nurse manager (2nd ed.). New York: Springer.
Green AE, Albanese, BJ, Shapiro NM, & Aarons GA. (2014). The roles of individual and organizational factors in burnout among community-based mental health service providers. Psychiatric Services, 11(1), 41–9. Retrieved from https://www.ncbi.nlm.nih.gov
Haik J, et al. (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
HelpGuide.org. (n.d.). Burnout prevention and treatment. Retrieved from https://www.helpguide.org
Joyful Heart Foundation. (2018). Signs of vicarious trauma. Retrieved from http://www.joyfulheartfoundation.org
Lazarus RS. (1966). Psychological stress and coping process. New York: McGraw-Hill.
Leiter MP & Maslach C. (2009). Banishing burnout: six strategies for improving your relationship with work. San Francisco: Jossey-Bass.
Liu X, et al. (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
Loveridge S. (2017). Straight talk: nurse manager role stress. Nursing Management, 48(4), 20–7. Retrieved from https://journals.lww.com
Mayo Clinic. (2017). Being assertive: reduce stress, communicate better. Retrieved from https://www.mayoclinic.org
Mayo Clinic. (2015). Job burnout: how to spot it and take action. Retrieved from http://www.mayoclinic.org
McHolm F. (2018). Rx for compassion fatigue. Retrieved from https://www.nursingcenter.com
Moen P, et al. (2015). Is work-family conflict a multilevel stressor linking job conditions to mental health? Evidence from the work, family and health network. Research on Social Work Practice, 26, 177–217. Retrieved from https://www.ncbi.nlm.nih.gov
Mountain State Center for Independent Living (MSCIL). (n.d.). 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 Council of State Boards of Nursing (NCSNB). (2018). A nurse’s guide to professional boundaries. Retrieved from https://www.ncsbn.org
Raunick CB. (2015). Vicarious trauma among sexual assault nurse examiners. Journal of Forensic Nursing, 11(3), 123–8. Retrieved from https://www.nursingcenter.com
Sacco TL, Ciurzynski, SM, Harvey E, & Ingersoll GL. (2015). Compassion satisfaction and compassion fatigue among critical care nurses. Critical Care Nurse, 35(4), 32–42. Retrieved from http://ccn.aacnjournals.org
Salazar W. (2016). Vicarious trauma and the value of self-care for therapists. Retrieved from https://www.goodtherapy.org
Scott E. (2018a). How to tell you have reached the point of burnout. Retrieved from https://www.verywellmind.com
Scott E. (2018b). 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.
Smith M, Segal J, & Segal R. (2015). Preventing burnout: signs, symptoms, causes, and coping strategies. Retrieved from http://www.helpguide.org
Stuart GW. (2013). Principles and practice of psychiatric nursing. St. Louis: Elsevier.
Study.com. (2015). Walter Cannon: stress & fight or flight theories. Retrieved from https://study.com
Van Bogaert P, Kowalski C, Weeks SM, Van heusden D, & Clarke SP. (2013). The relationship between nurse practice environment, nurse work characteristics, burnout and job outcome and quality of nursing care: a cross-sectional survey. International Journal of Nursing Studies, 50, 1667–77.
Videbeck SL. (2017). Psychiatric-mental health nursing (7th ed). Philadelphia: Wolters Kluwer.
Warshawsky NE & Havens DS. Nurse manager job satisfaction and intent to leave. Nursing Economics, 32(1), 32–9.
WebMD. (2018). Breathing techniques for stress relief. Retrieved from https://www.webmd.com
Yeatts D, et al. (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