Nurses burnout

NURSES BURNOUT:
IMPLICATIONS FOR NURSING
LEADERSHIP
STEVE IDUYE
DALHOUSIE UNIVERSITY

OUTLINE
 INTRODUCTION TO BURNOUT
SYNDROME AMONG NURSES
 CAUSES
 THEORETICAL FRAMEWORK
 STAGES OF BURNOUT
 IMPACTS OF BURNOUT
 BURNOUT CYCLE
 HOW TO ADDRESS BURNOUT
 MEASUREMENT AND EVALUATION
APPROACH
 RECOMMENDATIONS

A VIDEO EXCERPT ON NURSES BURNOUT

A VIDEO EXCERPT ON NURSES BURNOUT
 What can you say about Jimmy?

INTRODUCTION TO NURSES BURNOUT
 World Health Organization reported a shortage of 4.3 million healthcare workers
globally, and estimated that over the next two decades this figure would increase by
20%(Laschinger, Grau, Finegan, & Wilk, 2010).
In Canada
 As more nurses become eligible for retirement each year than those graduating from
nursing education programs, and with the alarmingly high rates of turnover
intentions, the ability of the nursing workforce to sustain itself is severely threatened
(Laschinger, Grau, Finegan, & Wilk, 2010).

 CNA (2009) warns that Canada may suffer a shortage of 60,000 full-time
equivalent RNs by 2022 (Canadian Nurses Association, 2009).
 The new graduated nurses who represent the future of the profession are
not encouraged to stay. Several studies have shown that new graduates’
working conditions are stressful and have resulted in increased levels of
burnout (Cho et al. 2006, Gustavsson et al. 2010).
 Evidence suggest that the first two years of practice influences new nurses’
desire to leave the profession due to burnout (Beecroft et al., 2008).

 A recent study of 309 new nurses in Quebec found that 43% reported a high
level of psychological distress.
 The same study revealed that 62% of respondents intended to quit their
present jobs for other jobs in nursing, and 13% intended to leave the
profession entirely
(Lavoie-Tremblay, O’Brien-Pallas, Desforges & Marchionni, 2008)

WHAT IS BURNOUT
International Classification of Diseases ICD-10 defines Burnout as a clinical
condition or a work-related neurasthenia with the following symptoms.
 A persistent and distressing complaints of exhaustion after a minor mental
effort, or a persistent and distressing complaints of fatigue and bodily
weakness after minimal physical effort.
 At least two out of the following six distress symptoms: muscular aches and
pain, dizziness, tension headaches, sleep disturbance, inability to relax, or
irritability

WHAT IS BURNOUT
 The patient is unable to recover from the symptoms by means of rest
 The duration of the disorder is at least three months
 The criteria for any more specific disorders do not apply.
SCHAUFELI & ENZMAN,
1998

WHAT IS BURNOUT
 Diagnostic and Statistical Manual of Mental Disorders DSM-IV describes
Burnout as a mental adjustment disorder which are characterized by “the
development of clinically significant emotional or behavioral symptoms in
response to an identifiable psychosocial stressor or stressors.
 The two definitions provide three hallmarks or characteristics of burnout
 Mental Exhaustion
 Depersonalization
 Lack of Career accomplishment
(Schaufeli & Enzman, 1998)

WHAT BURNOUT IS NOT
 Burnout has often been mistaken for Stress, Depression or Post-Traumatic
Disorder due to similarities in their symptoms.
IN STRESS
 Stress produces urgency and hyperactivity. Burnout, on the other hand,
produces helplessness. (Burisch, 2006)
 Emotions associated with stress are over-reactive, those associated with
burnout are more blunted.( Burisch, 2006)

WHAT BURNOUT IS NOT
IN DEPRESSION
 Depression may extend over every life domain (e.g., work, family, leisure).
Burnout, however, is specific to work context (Maslach et al., 2001).
IN POST-TRAUMATIC DISORDER
 Post traumatic stress disorder (PTSD) is “caused by the exposure to a
traumatic event or extreme stressor that is responded to with fear,
helplessness, or horror”.
 Burnout, on the other hand, is caused mainly by interpersonal and emotional
stressors in the workplace and is characterized by different reactions e.g
emotional exhaustion. (Mealer, Burnham, Goode, Rothbaum & Moss, 2009,
p. 1118).

THEORETICAL FRAMEWORK
Structural Empowerment Theory (Kanter, 1977 & 1993)
 theory of structural empowerment in organizations conceptualizes
empowering conditions as social structures in the workplace that enable
employees to accomplish their work in meaningful ways.
 The empowering conditions are derived from the ability of the leadership to
mobilize human and material resources to accomplish work and is attained
through access to information, support and resources in the work setting.
 According to Kanter (1993), when employees have access to these working
conditions, they will be empowered to accomplish their work in meaningful
ways.
 Moreover, the absence of this structural empowerment in a workplace
creates a toxic environment for nurses.

A Dualistic Model (Passion and Harmonious Theory)
 This model posits that obsessive passion produces conflict between work
and other life activities because the person cannot let go of the work
activity. Conversely, harmonious passion is expected to prevent conflict
while positively contributing to work satisfaction.
 With obsessive passion, one displays rigid persistence attitude toward work
and cannot let go of one’s work involvement. This is expected to lead to
conflict between work and other life activities and consequently to burnout.
(Vallerand, Paquet, Philippe, & Charest, 2010).

A Dualistic Model (Passion and Harmonious Theory)
 Whereas, in harmonious passion, the individual maintains control over the
passionate activity, and can physically and mentally disengage from the work
activity when needed
 Because of this sense of balance in harmonious passion, the person is
protected from the experience of conflict between work and other life
activities, one is also protected from the experience of mental and
emotional staleness, and from burnout.
 This explains why in the same organization, one individual is thriving well,
whereas another one is experiencing burnout symptoms.
(Vallerand, Paquet, Philippe, & Charest, 2010).

 To test the proposed Dualistic Model in France Hospitals. A study using
cross-sectional design with experienced registered nurses was carried out.
 It was posited that obsessive passion would positively predict conflict
between work and other life activities.On the other hand, harmonious
passion was expected to positively predict work satisfaction.
Vallerand et al, 2010

Method
 A total of 97 nurses working in France hospitals took part in the study.
 Most of them were female nurses (90 women, 6 men, and 1 missing value)
 Their ages range between 21 and 57 years (M 34.07 years, SD 9.95 years).
 The nurses were working on average of 34.15 hr per week (SD 4.16 hr) and
had been working as nurses for an average of 11.21 years (SD 10.12 years

Instrumentation
 The Passion Scale: is composed of two subscales of six items each,
assessing harmonious (HP) and obsessive (OP) passion.
 Each item is responded to a 7-point Likert scale ranging from 1
(do not agree at all) to 7 (completely agree).

 Maslach Burnout Inventory is composed of 22 items assessing
burnout with three subscales tapping emotional exhaustion,
depersonalization, and diminished personal accomplishment
 The Satisfaction at Work Scale (SAWS)assesses work satisfaction.
The SAWS contains five items responded to on a 7-point Likert
scale (1 = do not agree at all, 5= completely agree)

Result
 As predicted, with significant p-value for 0P and HP, OP predicted conflict
that was in turn associated with burnout. while, HP positively predicted
satisfaction at work.
 The former playing a facilitative role and the latter a protective role in
burnout.

SIGNS & SYMPTOMS OF BURNOUT
Affective signals:
• Depressed mood / changing moods
• Tearfulness
• Emotional exhaustion
• Increased tension / anxiety
Cognitive signals:
• Helplessness / loss of meaning and hope
• Feelings of powerlessness / feelings of being “trapped”
• Sense of failure
• lack of career fulfillment
• Guilt
• Inability to concentrate / forgetfulness / difficulty with complex tasks
Schaufeli and Enzman (1998)

Behavioral signals:
• Hyperactivity / impulsivity
• Increased consumption of: caffeine, tobacco, alcohol, illicit drugs
• Abandonment of recreational activities
• Compulsive complaining / denial
Motivational signals:
• Loss of zeal / loss of idealism
• Resignation
• Disappointment
• Boredom

Physical signals:
• Headaches
• Nausea
• Dizziness
• Muscle pain
• Sleep disturbances
• Ulcer / gastro-intestinal disorders
• Chronic fatigue

IMPACTS OF BURNOUT
The nursing shortage has far-reaching effects on the quality of care and patient safety
(Alexandra, 2015). A lot of studies have demonstrated the nurses shortage often leads
to burnout with resultant effects:
On Nurses
 Inadequate staffing and continuous overtime for nurses
 Decrease quality of care
 The potential for medication errors

IMPACTS OF BURNOUT
On Patients
 Medication adverse effects for patients and patient mortality.
 Increase patients neglect, cross infections or complications
 Patient Dissatisfaction

IMPACTS OF BURNOUT
On Management
 High rates of employee turnover
 Increased employee absenteeism due to clinical symptoms of diseases
 It creates a hostile and toxic work environments and increases lawsuits for the
management.

MEASUREMENT & EVALUATION
 The criterion standard for measuring burnout is the MBI (Maslach Burnout
Inventory), a self-assessment tool first published in 1981 by Maslach and Jackson
 The tool has been shown to be reliable, valid, and easy to administer and has
been translated into several languages for use around the world.
 The MBI is often used in conjunction with other assessments to evaluate the
relationship between burnout and organizational policies, productivity, and
social support
Maslach C, Jackson SE. (1981) Maslach Burnout Inventory.

The MBI addresses the three defining aspects of burnout syndrome with 22
statements in three subscales
 Emotional exhaustion: Nine statements to measure feelings of being emotionally
overextended and exhausted by one's work
 Depersonalization: Five statements to measure an unfeeling and impersonal
response to the recipients of one's services, care treatment, or instruction
 Personal accomplishment: Eight statements to measure feelings of competence
and successful achievement in one's work
Maslach C. (2003) Burnout: The Cost of Caring

 Another useful tools is The General Health Questionnaire in conjunction with the
MBI which can help professionals gain a better understanding of the sources of
stress for individuals.
 The General Health Questionnaire has been translated into several languages
and is available in a variety of versions. the version with 28 items (GHQ-28) has
been used most often in workplace settings.
 A score of 0 to 3 is assigned to four possible responses ("not at all," "no more
than usual," "rather more than usual," and "much more than usual")
Jackson C. (2007)The General Health Questionnaire. Occup Med.

 Another tool for measuring burnout is the Burnout Risk Survey.
 This tool is designed to demonstrate the probability of mismatches between an
individual and his or her work environment.
 A "yes" response to three or more of these items indicates a risk of burnout and
a "yes" response to four or more items indicates a high risk.
Pfifferling JH. (2015) Burnout Risk Appraisal.

RECOMMENDATIONS
Lifestyle Modification Approach
Take Care of Yourself First
 Nurses are trained to put the care of others ahead of themselves. It is
important for nurses to recognize that self-care is not equivalent to
selfishness; rather, self-care is essential for energizing, restoring, and
maintaining the physical and emotional stamina to reduce fatigue and
manage stress.
 Nurses should also seek outside activities that will help them disengage from
their professional routine and provide enjoyment, such as yoga, music, art,
reading, journaling, sports, and volunteerism.
Maslach C. (2003) Burnout: The Cost of Caring

RECOMMENDATIONS
 Quick identification of the signs and symptoms of stress overload and
burnout should be a continuous process, and individuals should remain alert
to the use of unhealthy and ineffective coping mechanisms, such as excessive
use of caffeine, alcohol, or prescription medication; overeating or
undereating; smoking; inactivity; or social withdrawal ( Carr, 2006)
 Individual should focus on changing one behavior at a time and seek help
from professional counseling if necessary (American Psychological
Association,2015)

RECOMMENDATIONS
 Enhance Interpersonal and Social Relationships by remaining connected to a
positive social network of people
 Grief Well: Grieving well involves accepting the reality of the loss,
experiencing the pain of grief, adjusting to the absence, and moving on with
life (Worden, 1991).
 Become an advocate for changes in the work environment can help nurses
increase a sense of control (Maslach, 2003)

RECOMMENDATIONS
Structural Empowerment in Organizational culture
 An integral step in preventing burnout is to survey staff about important
aspects of the organizational culture
 Organizations can protect nurses from burnout by creating an organizational
culture of trust, support, and open communication and fostering a healthy
work environment through
1. Appropriate staffing
2. Meaningful recognition
3. True collaboration
4. Skilled communication
5. Effective decision making
6. Authentic leadership (AACN, 2015)

RECOMMENDATIONS
 Improve Issues Related to Staffing and Work Hour: how?
Employers should stop using mandatory overtime as a staffing solution
 Employers should adopt official policy that gives RNs the "right to accept or
reject a work assignment" to prevent risks from fatigue. The policy should be
clear that rejecting an assignment under these conditions is not patient
abandonment and that RNs will not be retaliated against or face negative
consequences for rejecting such an assignment
Alexandra 2015

RECOMMENDATIONS
 Let bring humanity back to our workplaces

QUESTIONS?
 Questions
 Clarifications
 Contributions
 Answers
THANK YOU FOR LISTENING

References
 Alexandra, L (2015) Burnout: Impact on Nursing and Quality of Care. Retrieved on the 8th June, 2016 from http://www.netce.com/coursecontent.php?courseid=1167
 A video excerpt on nurses burnout (2015) retrieved https://www.youtube.com/watch?v=0ILcmfHmpfI
 Borgogni, L, Consiglio, G. Alessandri, W.B. Schaufeli (2012) Don’t throw the baby out with the bathwater! Interpersonal strain at work and burnout. Eur. J. Work Organ.
Psychol., 21 (6) (2012), pp. 875–898
 Burisch, M. (2006). Das Burnout-Syndrom: Theorie der inneren Erschöpfung [The Burnout- Syndrome: A Theory of inner Exhaustion]. Heidelberg: Springer Medizin Verlag.
 American Association of Critical-Care Nurses. AACN Standards for Establishing and Sustaining Healthy Work Environments. Available
athttp://www.aacn.org/wd/hwe/docs/hwestandards.pdf. Last accessed June 6, 2016
 Canadian Nurses Association (2002) Planning for the Future: Nursing Human Resource Projections. Canadian Nurses Association, Ottawa.
 Carr JL (2006) Healthy Nurse: Escape Burnout and Discover the Ultimate Life/Work Balance. Columbus, IN: Matilda Publishing; 2006.
 Cho J., Laschinger H.K.S. & Wong C. (2006) Workplace empowerment, work engagement and organizational commitment of new graduate nurses. Nursing Leadership 19(3),
43–60.
 Gustavsson J.P., Hallsten L. & Rudman A. (2010) Early career burnout among nurses: modelling a hypothesized process using an item response approach. International
Journal of Nursing Studies 47(7), 864–875.
 Laschinger, H. S., Grau, A. L., Finegan, J., & Wilk, P. (2010). New graduate nurses' experiences of bullying and burnout in hospital settings. Journal Of Advanced Nursing,
66(12), 2732-2742 11p. doi:10.1111/j.1365-2648.2010.05420.x

References
 Maslach C. (2003) Burnout: The Cost of Caring. Cambridge, MA: Malor Books.
 Maslach C, Jackson SE. (1981) Maslach Burnout Inventory. Palo Alto, CA: Consulting Psychologists Press.
 Maslach, C., Schaufeli, W. B., & Leiter, M. P. (2001). Job burnout. Annual Review of Psychology, 52, 397-422. doi:10.1146/annurev.psych.52.1.397
 Mealer, M., Burnham, E. L., Goode, C. J., Rothbaum, B. & Moss, M. (2009). The prevalence and impact of post traumatic stress disorder and burnout syndrome in
nurses. Depression & Anxiety, 26, 1118-1126.
 Pfifferling JH. Burnout Risk Appraisal. Available at http://www.cpwb.org/burnout_information.htm. Last accessed June 12, 2016
 Vallerand, R., Paquet, Y., Philippe, F., & Charest, J. (2010). On the Role of Passion for Work in Burnout: A Process Model.Journal of Personality, 78(1), 289-312.
 Worden JW. (1991)Grief Counseling and Grief Therapy: A Handbook for the Mental Health Professional. 2nd ed. New York, NY: Springer.
 Spinetta JJ, Jankovic M, Ben Arush MW, et al. Guidelines for the recognition, prevention, and remediation of burnout in health care professionals participating in the
care of children with cancer: report of the SIOP Working Committee on Psychosocial Issues in Pediatric Oncology. Med Pediatr Oncol. 2000;35(2):122-125.
 Schaufeli, W. B. & Enzman, D. (1998). The burnout companion to study & practice. London: Taylor & Francis.

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