Nursing Burnout: A System-Wide Response Needed

By Dr. Crissy Hunter

Southern New Hampshire University

Nursing is the largest sector of healthcare professionals, with almost four times the number of physicians. Someone who seeks care in a medical office, walk-in clinic, urgent care, emergency room or hospital will interact more with nurses than any other healthcare provider. Depending on the healthcare institution, a person may only ever encounter a nurse. When reflecting on healthcare today, nurses are at the center. The main reason hospitals can provide 24/7 care is because of nurses.

Over the past decade, nursing has focused on proactively addressing the predicted nursing shortage. This focus has led to education initiatives, scholarships to increase enrollment into education programs, and innovative strategies to promote advanced opportunities within healthcare organizations. Despite this initiative, as the complexity of healthcare today increased, the demand for nurses increased, as has the overall shortage.

According to the U.S. Department of Labor, there is a predicted need for more than 275,000 nurses over the next 5 years. A broad search on Indeed.com for registered nurse positions throughout the United States pulls over 475,000 open opportunities. One must ask why there is such a high number of open positions when there are over 2,500 schools of nursing graduating nurses every year.  Twenty years ago, the nursing shortage was attributed to aging and waves of retirement. Today, the nursing shortage is referenced to the sweeping impact of the pandemic.

COVID-19 hugely impacted the nursing profession. Whereas the pandemic affected all healthcare professionals with endless hours, extreme sadness and exhaustion from mandatory overtime, registered nurses were stretched beyond reason due to an already short-staffed profession. There were so many critically ill patients that there were makeshift hospitals, hospital units, and even medical tents to provide care to all of them, all with the need to be staffed by registered nurses. Nurses worked around the clock throughout the pandemic to care for those in need and save countless lives, often risking their health and well-being.

At the beginning of the pandemic, healthcare professionals were seen as heroes, only to be ostracized at the end due to community fear and political agendas. By the end of the pandemic, the nursing profession had a mass exodus due to pure exhaustion, poor community image, system-level factors and overall low morale.

In one post-pandemic survey, 71% of nurses reported intentions to leave the profession and expressed that all nurses felt some level of burnout. One large hospital in Massachusetts states that pre-pandemic, they experienced the impact of the nursing shortage with open positions but would not find themselves panicking until the open positions were up around the 700s; now, post-pandemic, they have more than 1,500 open positions. This Massachusetts medical center outright states, “There is not much you can do without nurses.”

How do we prevent more exits? Healthcare leaders need to target nursing burnout by increasing awareness, combating system failures, and implementing strategies aimed at both prevention and healing.

Increasing Awareness

Burnout is a stress syndrome related to chronic stress from a job, according to the U.S. Department of Health and Human Services (HHS PDF source). One can feel periodic stress from a job that is temporary or situational, but burnout is due to chronic stress and will not ease up without intervention. Burnout has three associated qualitative components:

1. Emotional exhaustion and cynicism
2. A low sense of professional efficacy, and
3. A low sense of personal accomplishment at work.

Burnout can occur in any profession but is extremely common in healthcare. With burnout so widespread in healthcare, Mental Health America has focused on identifying and preventing burnout among healthcare providers. Symptoms of burnout include sleep trouble, physical and emotional exhaustion, and work-related dread, according to a study by Mental Health America. Burnout among healthcare workers was evident pre-pandemic; however, it is more prevalent and impacts current practicing nurses and overall enrollment in nursing schools.

According to a national survey published in the Journal of Emergency Nursing exploring burnout and turnover, the authors conclude that “burnout in nurses has been associated with not only adverse individual health outcomes such as the increased risk of depression, drug abuse, and suicidal ideation, but also suboptimal professional and patient care outcomes, including increased workforce turnover, decreased quality of care, increased hospital-acquired infections, and reduced patient satisfaction.” Patients must be able to trust in the care they are receiving, and nurses are at the center of that care.

A statement released last year from the Surgeon General (HHS PDF source) to the American people for a call to action says, “Addressing health worker burnout is about more than health. It’s about reflecting the deeper values that we aspire to as a society – values that guide us to look out for one another and support those seeking to do the same. Health workers have had our backs during the most difficult moments of the pandemic. It’s time for us to have theirs.”

Nursing burnout is not just a nursing problem but a healthcare system problem. It is a community problem. Burnout is a long-standing and fundamental barrier to nurses’ professional well-being. Awareness is the first line of defense in addressing burnout.

System Improvements

Patients are sicker today than ever before. This increase is known as rising patient acuity. The patients treated in the intensive care unit 20 years ago are now the patients of a standard medical-surgical unit. The patients treated on the medical-surgical units 20 years ago are now treated in primary care clinics and home care.

Not only are patients requiring more complex care, but they are also staying in hospitals longer. Lengths of stays can be increased due to the patient’s comorbidities, hospital-acquired infections, or inability to get timely services due to decreased healthcare staff (physicians, mid-level providers, nurses, medical assistants, radiology techs, phlebotomists, etc.). If you look at the average length of stay in a hospital right now, it is approximately a day and a half longer than it used to be. Despite patients needing more care and an increased number of days hospitalized, insurance companies and Medicare/Medicaid only pay for a specific number. This leads to hospitals providing much care for which they are not paid. If hospitals are not being reimbursed for care, they have less money to invest in their workforce. This vicious cycle leads to decreased patient outcomes and patient satisfaction and is a huge contributor to why the nursing profession feels burned out.

This rising acuity of patients requires healthcare institutions to make system-wide changes. In one from late November 2021, 80% of nurses said their units were inadequately staffed. Regardless of inappropriate staffing, patient care must be provided. Nurses are overextended. There is mandatory overtime, minimal time for breaks forcing nurses to eat at the same time as catching up on charting or doing other miscellaneous tasks, and no time for social connection to co-workers, which is necessary to enjoy your work environment.

One system-wide change should be safer staffing policies. Democrats introduced a House Bill to Congress, Nurse Staffing Standards for Hospital Patient Safety and Quality Care Act of 2021, in May 2021 that expressly defines strict staffing guidelines. This bill requires hospitals to implement and submit to the Department of Health and Human Services (HHS) a staffing plan that complies with specified minimum nurse-to-patient ratios by unit. Hospitals also must post a notice of nurse-to-patient ratios in each unit and maintain records of actual ratios for each shift in each unit. The bill also requires hospitals to follow specific procedures for determining ratios. Other staff is prohibited from performing nurse functions unless authorized explicitly within a state’s scope of practice rules, among other requirements.

With a strict federal mandate such as this, reimbursement to healthcare facilities would also increase. Lastly, this bill promotes federal grants and scholarships for nursing education and training. This bill needs attention as it was introduced in May of 2021, and we are almost at the 2-year mark, and there is no approval. Without a strict mandate, the cycle noted above will prevent changes.

Prevention & Healing

Over the last year, burnout has been a topic of discussion, with wellness initiatives such as promoting sleep, exercise and therapy at the top of the list.

However, changes to how nurses work and deliver patient care are just as significant. This is not simply a personal problem that is treated by self-care; healthcare institutions need to take the lead and focus on prevention strategies while at the same time investing in healing for all practicing nurses.

To promote healing and prevention of further burnout, emphasis should be placed on reimagining nurses for the future and being innovative in building a resilient nursing workforce – healthcare systems need to look outside the current models of staffing and work environments.

According to Vocera’s  Chief Nursing Officer [CNO] Dr. Rhonda Collins, “Nursing has held a long-prevailing position that the hospital environment is set and defined and, no matter how inefficient it is, the individual must work within it. We must acknowledge that the burnout nurses are experiencing is a work-related injury, and the environment is the mechanism that delivers the injury.”

When considering nursing burnout as a work-related injury, strategies for prevention and healing now look different. Ownership of the problem becomes the work environment. Identified issues (or barriers) within the work environment, outside of the complaint of being short-staffed, include:

• Communication barriers
• Electronic charting distracting from real time with patients
• Alarm fatigue
• Inflexible schedules
• Inability to take sufficient breaks
• Lack of resources
• Workload and work-related hazards
• Lack of support, awards and recognition from management/leadership

Healthcare stakeholders could take the lead to innovatively address these work-environment conditions. The National Academy of Medicine, recognizing burnout among all healthcare workers, published a National Plan for Health Workforce Wellbeing on October 22, identifying several healthcare institutional strategies to decrease burnout and promote professional wellbeing. The priority areas of the plan are:

1. Create and sustain positive work and learning environments and culture
2. Support mental health and reduce stigma
3. Engage effective technology tools
4. Invest in measurement, assessment, strategies, and research
5. Address compliance, regulatory, and policy barriers for daily work
6. Institutionalize well-being as a long-term value
7. Recruit and retain a diverse and inclusive health workforce.

What is crucial for all to know is that nursing burnout is not just a personal problem but a national issue. The National Academy of Medicine recognizes that to reverse the fallout from burnout, all the major stakeholders must take action to restore the well-being of the healthcare workforce. Improving the well-being of the profession is a shared responsibility that requires a collective effort by all stakeholders of the U.S. health system and those who influence health. With awareness, we all can support the coordinated national plan to ensure a transition from burnout to well-being.

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