COMPASSION FATIGUE & BURNOUT PREVENTION RESOURCES

HOW TO HOLISTICALLY PREPARE OUR Nurses & STUDENTS FOR THE STRESS OF THE JOB.

 
 

OVERVIEW

Across the globe, concern for our nurses is rising.  "Burnout and poor well-being in healthcare staff are a growing problem" (Royal College of Physicians, 2015). Burnout by definition is considered to be the end result when one is experiencing "emotional exhaustion with work, disengagement from patients and low personal accomplishment (Maslach & Jackson 1981."; Johnson, J. , Hall, L. H., Berzins, K. , Baker, J. , Melling, K. and Thompson, C. (2018)). There is imminent concern that the rate of burnout for healthcare staff is increasing each year and in turn, resulting in worsening outcomes for institutions, patients and nurses themselves.


Why is burnout important?

daan-stevens-282446-unsplash.jpg

Burnout has been proven to yield several concerning outcomes for nurses (and other health care workers) including unhealthy stress-coping behaviors (Hansen et al. 2018), mental and physical health issues (Adriaenssens et al., 2015; Ross-Adjie et al., 2007; Adriaenssens et al,. 2018), lower levels of well-being (Hall et al. 2016; Johnson et al. 2017a;), and pyschosocial issues such as depression, anxiety and stress disorders (Westphal et al., 2015; Abellanoz et al., 2018). 

Institutionally, burnout and poor well-being amongst healthcare workers has also proven to be a very concerning issue for patients, as it has been proven to negatively impact safety, patient satisfaction, quality of patient care and consistency of care. (Johnson et al., 2018). In a recent review of the literature, it was found that "22 of 27 studies reported a significant association between poor well-being and poorer patient safety outcomes, and 25 of 30 studies found a significant link between higher levels of burnout and increased adverse events (Hall et al., 2016; Johnson et al., 2018)". 

From an institutions perspective, burnout has also lead to significant financial troubles. Burnout has been tied to increasing staffing turn over rates which has lead to financial strains on the institutions as "the average cost to replace nursing staff ranges from $37,500 to $58,400... furthermore, the average time to replace an RN can range from 54 to 109 days- plenty of time for hospitals to feel the burden of staffing shortages (Colosi, 2016; Abellanoz et al., 2018)". Hospitals are in turn spending more money, dealing with more staffing shortages and the affiliated consequences due to staffing burnout and it's effects.

Resultantly, it is in the best interest of the patient, the staff and the institution that we both understand the factors leading up to burnout and find a comprehensive tool to address this imminent international concern.


What Are some factors causing burnout?

Some of the factors that can cause burnout include job demands, job control, social support and exposure to traumatic events, along with several other factors (Adriaenssens (2014) including; institutional predictors such as; inadequate staffing, excessive workload, poor leadership, lack of support and lack of opportunity for skills development (Bressi et al. 2009; Graber et al. 2008; Pinikahana & Happell 2004; Willard-Grace et al. 2014; Johnston et al. 2017). 

The above factors apply to all units, however, special attention and study needs to be dedicated to mental health clinicians who are found to be the most at risk for burnout amongst the various clinical specialities. Factors causing burnout pertaining to mental health care workers include the "emotional labor of caring for suicidal and mentally unwell patients, poor staffing ratios, lack of training, high levels of violence, detaining and treating patients against their will, caring for patients who may harm themselves and the lack of funding of mental health services (Knickman & Snell 2002; Letvak & Buck 2008; Seago et al. 2001; Johnson et al. 2018)".

rawpixel-567015-unsplash.jpg

It is important to note that all nurses are now also face similar factors and stressors that mental health clinicians face in some respect, due to the increasing mental health crisis in our nation that is impacting patients on every floor in some capacity. ER nurses in particular are subject to many of the same burnout factors that mental health clinicians face due to the lack of inpatient psychiatric facility beds, as a result of inadequate funding, which leaves psychiatric patients in the care of ER nurses for often several days. Some other factors that ER nurses face that put them at risk for burn out also include "the workload; exposure to injury and death of patients and stressful interpersonal interactions (Abellanoza et al., 2018)". Verbal abuse from their patients and families also is extremely negatively impactful on ER nurses and leads them to experience "depersonalization and emotional exhaustion" which has been attributed to "predicted patient falls, nosocomial infections and medications errors (Van Bogaert et al., 2014; Abellanoza et al., 2018)."

Although this review of factors causing burnout is not all encompassing, it provides a broad based understanding for the stressors facing our nurses. Many of these factors listed are essentially "parts of the job" and it is important to acknowledge that many of these factors are "practically unavoidably in a fast-paced, high-stakes environment (Abellanoza et al., 2018)". However, some factors are avoidable. For instance, across all disciplines it is found that "employees who “fake” their emotions at work also suffer from emotional exhaustion, a key component of job burnout (Kenworthy et al., 2014)." As a result, it is essential that we shift our attention and energy to understand the factors that are able to be controlled in some respect, and find positive coping tools to deal with the unavoidable challenges of the job that can cause toxic stress.


the cause and effect = toxic stress

Toxic chronic stress is both a cause and effect of burnout. Toxic chronic stress can be caused by any of the factors highlighted in the section above, in conjunction with any other stressful events transpiring in the nurses life. Toxic chronic stress is very potent and dangerous however, as it can lead to several other negative outcomes such as neurocognitive changes. It has been proven that long term exposure to toxic stress can cause structural changes to the areas of the brain associated with executive functioning, fight or flight responses and memory (Arnsten, 2009; Abellanoz et al., 2018). To be more specific, "the same neurochemical events that impair prefrontal working memory abilities actually strengthen the emotional operations of the amygdala. Thus, uncontrollable stress swithces control of behavior from the thoughtful prefrontal cortex (PFC) to the more primitive conditions responses of the amygdala (Arnsten, 2009)." Another concern regarding long term stress is it's ability to worsen pre-existing mental illnesses. Genetic studies have also found that individuals with mental illness can have altered molecules that control stress response, which in turn makes their susceptibility to neurocognitive structural changes even greater. (Arnsten, 2009). 

Toxic stress also significantly impacts the cardiovascular system, immune system, immune mediated responses, endocrine functions, aging process, ability to fight off infection and stress response (Glaser & Kiecolt-Glaser, 2005; Miller, Chen, & Parker, 2011). In a study with ER nurses, toxic chronic stress increases "maladaptive coping behaviors" and increases the frequency of smoking and drinking alcohol. These mentioned maladaptive coping mechanisms, in conjunction with the impacts of toxic chronic stress highlighted above, may directly relate to poor overall health for nurses in general, which can again, result in suboptimal patient care. (Ross-Adjie et al., 2007; Abellanoz et al., 2018). 

In summary, toxic chronic stress is destroying the overall physical, mental and emotional health of our nurses. As a result, nurses are unable to do their jobs to the best of their ability nor provide their highest level of patient care. In turn, patient outcomes and patient satisfaction decline which leads to more frustration for the nurses, patients and institution... and so the toxic stress cycle continues.


Proposed solution/intervention

Reiki (one of many MBTs) are proven to help nurses improve with their “perceive(d) stress, coping, burnout exhaustion subscale and mindfulness.” (Debile et al., 2015). Reiki is also proven to help with several other ailments and stressors that the body faces, as it promotes a natural healing response. Hospitals throughout are beginning to provide more holistic therapies, such as Reiki, to their staff in response to the findings above, and the noted correlation between nursing wellness and patient outcomes (Hall et al., 2016; Johnson et al., 2018)". 

As nurses, it is imperative to prioritize our self care practice and seek opportunities to learn various mind body therapy practices. As Reiki practice (and other MBT practice) grows within nursing, it is suggested in the literature that the effects of toxic stress and burnout will be less prevalent in the field. It is also suggested that in turn, as nursing wellness improves, patient outcomes and satisfaction will also improved as they have been proven to be directly correlated.

Overall, nursing schools, employers and educators are in an optimal position to provide staff with exposure and continuing education opportunities in Mind Body Therapies, such as Reiki. There is significant hope that we can help reverse the concerning trend of burnout, poor staff well-being and the associated concerning patient implications with the implementation of MBT. It is important we holistically prepare our nursing community and students early on, so they have the the proper tools to take care of themselves, and in turn continue to help take care of others without the negative and distressing effects of wide spread compassion fatigue and burnout that exist today.


Citations

Abellanoz, A., Provenzano‐Hass, N., Gatchel, RJ. (2018) Burnout in ER nurses: Review of the literature and interview themes. J Appl Behav Res. 2018;23:e12117. https://doi.org/10.1111/jabr.12117

Adriaenssens, Jef., De Gucht, V., Maes, S. (2014). Determinants and prevalence of burnout in emergency nurses: A systemic review of 25 years of research. International Journal of Nursing Studies, 52(2), 649-661. doi:  https://doi.org/10.1016/j.ijnurstu.2014.11.004

Arnsten, A. (2009). Stress signaling pathways that impair prefrontal cortex structure and function. Nature Reviews Neuroscience, 10, 410-422 

Bressi, C., Porcellana, M., Gambini, O. et al. (2009). Burnout among psychiatrists in Milan: A multicenter survey. Psychiatric Services, 60, 985–988. Google Scholar

Deible, S., Fioravanti, M., Tarantino, B., & Cohen, S. (2015). Implementation of an Integrative Coping and Resiliency Program for Nurses. Global Advances in Health and Medicine, 28–33. https://doi.org/10.7453/gahmj.2014.057

Graber, J. E., Huang, E. S., Drum, M. L. et al. (2008). Predicting changes in staff morale and burnout at community health centers participating in the health disparities collaboratives. Health Services Research, 43, 1403–1423. Google Scholar

Hall, L., Johnson, J., Watt, I., Tsipa, A., O'Connor, D. (2016). Healthcare Staff Wellbeing, Burnout, and Patient Safety: A Systemic Review. PLos ONE 11(7). doi:https://doi.org/10.1371/journal.pone.0159015

Idris, M.A., Dollard, M.F., & Winefield, A.H. (2011). Integrating psychosocial safety climate in the JD-R model: A study amongst Malaysian workers. SA Journal of Industrial Psychology/SA Tydskrif vir Bedryfsielkunde37(2), Art. #851, 11 pages. doi:10.4102/sajip.v37i2.851

Johnson, J. , Hall, L. H., Berzins, K. , Baker, J. , Melling, K. and Thompson, C. (2018), Mental healthcare staff well‐being and burnout: A narrative review of trends, causes, implications, and recommendations for future interventions. Int J Mental Health Nurs, 27: 20-32. doi:10.1111/inm.12416

Jones, R., Hansen, M., Kaddoura, M., Schwabe-McCoy, A., Tocchini, K. (2018), The incidence of nursing students' perceived stress and burnout levels at a private university in California. Journal of Nursing Education and Practice, 8(10): 1-14. doi:10.5430/jnep.v8n10p138

Kenworthy, J., Fay, C., Frame, M., & Petree, R. (2014). A meta‐analytic review of the relationship between emotional dissonance and emotional exhaustion. Journal of Applied Social Psychology, 44(2), 94–105. doi: https://doi.org/10.1111/jasp.12211 

Knickman, J. R. & Snell, E. K. (2002). The 2030 problem: Caring for aging baby boomers. Health Services Research, 37, 849–884. Google Scholar

Letvak, S. & Buck, R. (2008). Factors influencing work productivity and intent to stay in nursing. Nursing Economics, 26, 159. Google Scholar

Royal College of Physicians (2015). Work and Wellbeing in the NHS: Why Staff Health Matters to Patient Care. London: Royal College of Physicians. Google Scholar

Ross-Adjie, G., Leslie, G., Gillman, L. (2007). Occupational stress in the ED: What matters to nurses? Australasian Emergency Nursing Journal, 10(3), 117-123. doi: https://doi.org/10.1016/j.aenj.2007.05.005

Westphal, M., Bingisser, M., Feng, T., Wall, M., Blakley, E., Bingisser, R., Kleim, B. (2014). Protective benefits of mindfulness in emergency room personnel. Journal of Affective Disorders, 175, 79-85. doi: https://doi.org/10.1016/j.jad.2014.12.038

Pinikahana, J. & Happell, B. (2004). Stress, burnout and job satisfaction in rural psychiatric nurses: A Victorian study. Australian Journal of Rural Health, 12, 120–125. Google Scholar

Seago, J. A., Ash, M., Spetz, J., Coffman, J. & Grumbach, K. (2001). Hospital registered nurse shortages: Environmental, patient, and institutional predictors. Health Services Research, 36, 831. Google Scholar

Van Bogaert, P., Timmermans, O., Weeks, S. M., van Heusden, D., Wouters, K. & Franck, E. (2014). Nursing unit teams matter: Impact of unit‐level nurse practice environment, nurse work characteristics, and burnout on nurse reported job outcomes, and quality of care, and patient adverse events—A cross‐sectional survey. International Journal of Nursing Studies, 51, 1123–1134. Google Scholar

Willard‐Grace, R., Hessler, D., Rogers, E., Dubé, K., Bodenheimer, T. & Grumbach, K. (2014). Team structure and culture are associated with lower burnout in primary care. The Journal of the American Board of Family Medicine, 27, 229–238. Google Scholar