By Noreen McLoughlin

LEARNING OBJECTIVES

Reading and reflecting on this article will enable you to:

• Define negative stress and burnout.
• Identify burnout causes, signs, symptoms and adverse professional impacts.
• Understand and apply Te Whare Tapa Whā holistic health assessment model.
• Identify professional self-care deficits.
• Explain effective professional self-care strategies.

Stress and Burnout

Stress is a natural physiological response to any stressor or demand.

Stress can be classified as a positive (eustress) or negative (distress) experience¹. Positive stress can be an impetus to motivate action. Once the action has been accomplished, high levels of satisfaction are often experienced. An example of this could be studying to prepare for an exam and the outcome is achieving the desired ‘pass’ mark.

Negative stress can also involve a similarly substantial investment of energy and action but the outcomes experienced are often unsatisfying or undesirable. Both types of stress can involve a substantial investment of energy and action but the outcomes differentiate the experience achieved.

Specific work-related stress may occur when the demands of the work environment exceed a person’s capacity and capability to cope and can be associated with negative emotional responses². Nursing is a profession with recognised innate high stress due to high levels of engagement with people.

Burnout is a state of emotional, mental, and physical exhaustion caused by excessive and prolonged stress. Burnout was first identified in the mid 1970s and is characterised by high emotional exhaustion and high de-personalisation in the presence of reduced personal accomplishment.

These factors comprise what is termed global burnout factor and are part of a formally recognised survey tool used to identify and measure burnout. Burnout is recognised as a significant cause of nursing shortages globally3.

Emotional exhaustion can include feelings of depression, irritability, having a sense of nothing more to give, and being emotionally overwhelmed by work. Depersonalisation can include unkind, indifferent, uninterested, deprecating, belittling, and distant responses to clients. Reduced personal accomplishment can include nurses expressing feelings of ineffectiveness, ineptitude, low satisfaction, and a perceived lack of success in work4.

Causes of burnout: work, lifestyle, and personality traits

• Contributing factors implicated in burnout involve the nurse themselves, their practice environment and lifestyle factors5,6,7.
• Work related causes: Feeling little or no control over your work, lack of recognition or rewards for good work, doing work that is monotonous or unchallenging, working in chaotic or high pressure environments, heavy, demanding, or consistently challenging and unrealistic workloads, insufficient staffing levels for service requirements, and nurse inexperience.
• Lifestyle causes: Working too much without sufficient relaxation or socialising, unrealistic expectations of self and others, taking on too many responsibilities without enough help from others, inadequate sleep, and inadequate supportive relationships.
• Personality traits: Perfectionist tendencies, pessimistic view of yourself and the world, need for control, reluctance to delegate, high activity, and Type A personality.

Some signs and symptoms of burnout^8,9

• Physical: Lethargy, fatigue, lowered immunity, frequent headaches, back pain, muscle aches, changes in appetite and sleep patterns, obesity, and anorexia.
• Emotional: Sense of failure and self-doubt, feeling helpless, trapped and defeated, detachment, feeling alone in the world, loss of motivation, increased cynicism and negative outlook, decreased satisfaction and sense of accomplishment, feeling unsupported (especially by colleagues), loss of confidence, indecisive, and altered level of interest in professional role.
• Behavioural: Withdrawing from responsibilities, isolating self, procrastinating, taking longer to get things done, using food to cope, taking out frustrations on others, irritability, coming to work late and leaving early, and low motivation.
• Spiritual: Loss of hope and sense of meaning or purpose.

Some key impacts of burnout:

• Individual and organisational10: Low staff morale, reduced quality of nursing care, poor team work and focus, critical and dysfunctional team cultures, high staff turnover, staff absenteeism, poor employment relations, nursing shortages, low productivity, increased consumer complaints, and higher accident and illness rates.

Taking responsibility for avoiding burnout and maintaining professional wellness

Nurses themselves are responsible for managing their professional health and wellbeing. This includes frequently monitoring their own professional practice behaviours and responses for any potentially adverse changes that can be influenced by the environment in which they work. Critical reflection can assist nurses to identify their stressors, responses to these, and their ability to recognise when coping strategies are diminishing or ineffective (more strategies are identified in Table One). When working conditions are less than ideal, nurses need to communicate this to their employers in a timely manner and then take the necessary steps to resolve negative stressors.

Employers also have a responsibility to ensure that the environments within which health professionals work are conducive to maximising their wellness and effective productivity11 (see Table Two). Many legislative and regulatory considerations govern and guide health professional practice expectations in this regard – e.g. the Health and Safety in Employment 1992 (HSE Act) and the Health Practitioners Competence Assurance Act 2003 (HPCA Act), among others.

The HSE Act aims to protect the health and safety of employees and employers by effectively managing workplace hazards and risks. Employers and employees share responsibility in this regard. In 2002 the act was expanded to include broadening definitions of workplace hazards to include negative physical and mental work outcomes and mental stress. The aim of the HPCA Act is to protect the health and safety of members of the public by ensuring health practitioners are fit to practice in their professions.

Read the Health Assessment Framework: Te Whare Tapa Whā box on the right before the conclusion.

Conclusion

Nurses and allied health professionals can be challenged to ‘walk their talk’ as this relates to the pursuit, achievement, and maintenance of healthy lifestyles. Stressors inherent within their professional world demand that nurses accept greater responsibility for managing ‘at risk’ behaviours that contribute to professional ill health. This includes both an awareness of individual and environmental factors that can adversely impact on personal and professional outcomes. Burnout is one recognised impact of exposure to prolonged negative stress. It is characterised by high emotional exhaustion, high de-personalisation, and reduced personal accomplishment. Burnout is a globally-recognised phenomenon that is contributing to nursing shortages. Responsibility for managing professional self-care and avoiding burnout is the shared responsibility of nurses and their employers. Many strategies are available to assist nurses in the promotion and achievement of their professional self-care and wellness. Te Whare Tapa Whā is one holistic health assessment framework that can be useful in assisting nurses to critically reflect upon professional and personal practices that may enhance or adversely impact on their own health and wellbeing. Nurses would greatly benefit from investing regular time and sufficient attention to identifying and honouring their own needs as part of professional self-care. In doing so, they can claim a level of health and wellbeing that is their rightful entitlement and stop settling for the crumbs!

Download the learning activity here>>

STRATEGIES FOR MAXIMISING NURSES’ PROFESSIONAL HEALTH INCLUDE^12,13:

Table One:

Nursing strategies to maximise wellness and minimise ill health

• Avoid mixing shifts from am, pm, nights within the same rostered shift set.
• Pay close attention to workload achievability, employer expectation, and ability to cope with workload demands.
• Ask for help promptly if needed and offer help to others who need it.
• Ensure effective supportive communication with peers each duty.
• Take regular allocated rest and meal breaks away from the work environment.
• Attend regular supervision (no less than one monthly).
• Develop supportive and nurturing professional relationships.
• Utilise sick leave when unwell and remain off work until fully recovered.
• Foster a collegial attitude of gratitude within your workplace culture.
• Praise individual and team efforts and achievement.
• Ensure adequate annual leave breaks are regularly scheduled and avoid accumulating leave for extended periods of time.
• Plan, implement, and evaluate work/life balance activities.
• Fit leisure activities around shift work and study.
• Nurture and care for the physical, mental/emotional, spiritual, and social self needs.
• Slow down and re-evaluate your priorities.
• Avoid enabling unsafe workload allocation, say “no”.
• Take responsibility for driving organisational change towards more healthy and functional workplace practices.

Table Two:

• Employer Strategies to maximise health professional wellness
• Monitor rosters and identify manageable shifts for employees.
• Monitor workloads ensuring they are manageable for staff allocation.
• Ensure sufficient staffing levels to meet care requirement and service provision.
• Ensure adequate equipment and relevant resources are available for use.
• Ensure staff are encouraged to use allocated sick leave entitlements when unwell.
• Monitor sick leave allocation ensuring it is sufficient to meet common illness incidents.
• Monitor absenteeism rates among employees where appropriate and identify emergent patterns that need further investigation for those staff members causing concern.
• Nurture sincere empathetic professional relationships with staff.
• Funding regular and appropriate professional supervision and mentorship for staff (rather than just an Employee Assistance Programme (EAP) offering a limited number of counseling sessions for crisis intervention).

About the author:

Noreen McLoughlin RN MA, NZQA Diploma Adult Education & Training, Nursing Council of New Zealand approved assessor/auditor, self-employed professional development consultant for the last seven years, and registered nurse for 30 years. www.mcloughlinconsulting.co.nz

This article was peer reviewed by:

Darren Gwynn RN CompDip BN, owner/operator Rata Park Rest Home, Winton.

Mary Massey RN, community palliative care nurse, Hospice Southland.

REFERENCES

1 CHIPAS A, CORDREY D, FLOYD D, GRUBBS L, MILLER S, & TYRE B (2012) Stress: perceptions, manifestations & coping mechanisms of student registered nurse anaesthetists. American Association of Nurse Anaesthetists Journal 80(4 Supple):49-55

2 OCCUPATIONAL SAFETY AND HEALTH Stress defined. www.dol.govt.nz Retrieved 02/02/13

3 MESZAROS V, ADAM S, SZABO M, SZIQETI R, & URBAN R (2013) The bifactor model of the Maslach Burnout Inventory Human Services Survey (MBI-HSS) – An alternative measurement model of burnout Stress Health Jan 24 (ePub ahead of print)

4 ELDER R, EVANS K & NIZETTE D (2013) Psychiatric and Mental Health Nursing 3rd edition, p9,Elsvier, Australia

5 COETZEE SK, KLOPPER HC, ELLIS SM, & AITKEN LH (2013) A tale of two systems – Nurses practice environment, wellbeing, perceived quality of care & patient safety in private and public hospitals in South Africa: A questionnaire survey.

International Journal of Nursing Studies 50(2): 162-73

6 KANAI-PAK M, AIKEN, LH, SLOANE DM, & POGHOSYAN L (2008) Poor work environments and nurse inexperience are associated with burnout, job dissatisfaction and quality deficits in Japanese Hospitals.  Journal Clinical Nursing17(24):3324-9

7 DITZEL EM (2008) A study of perceived occupational stress, burnout and sense of community among New Zealand Nurses. PhD Thesis, University of Otago

8 HAN K, TRINKOFF AM, STORR CL & GEIGER-BROWN J(2011) Job stress and work schedules in relation to nurse obesity.  Journal of Nursing Administration 41(11):488-95

9 COHEN J (2000) Stress and mental health: a bio-behavioural perspective. Issues in Mental Health Nursing 21(2):185-202

10 SMITH, M (MA), SEGOL J (PhD), SEGOL R (MA) (2012)
www.helpguide.org (Not for profit health resource organisation.) Information retrieved 30/01/13

11 SEYMOUR F, BLACKWELL S, & THORBURN J (Eds) (2011) Psychology and the Law in Aotearoa New Zealand The New Zealand Psychological Society, Wellington, New Zealand

12 OCCUPATIONAL SAFETY AND HEALTH (2003) Healthy work: managing stress in the workplace. www.osh.dol.govt.nz Retrieved 02/02/13

13 BROWN D (2004) Beating stress at work: a safeguard survival guide Brookers Ltd, Wellington, New Zealand

14 Durie M (1982) Te Whare Tapa Whā, www.health.govt.nz/maori health models, retrieved 31/01/13

15 NURSING COUNCIL OF NEW ZEALAND (2007) Competencies for registered nurses Wellington, New Zealand