The Shared Responsibility in Reducing Burnout: Moving Beyond Individual Intervention

In 2018, healthcare professionals were already experiencing high levels of burnout. In the United States, over one-half of physicians and one-third of nurses reported experiencing symptoms of burnout—and this was before the pandemic.

Covid-19 has been an enormous stressor upon our healthcare system and those of us who work within it. Historically I have been an eternal optimist. I rarely complained. I loved the most difficult patients, and I had boundless energy. 

Recently I have struggled to maintain my faith in humanity, felt more irritable, less patient, and felt emotionally, and physically exhausted. Like many others, I have been struggling with burnout.

How Burnout Has Affected Me Personally

I was asked what I would say to myself if I were my own patient. It changed my perspective.

I kept pushing myself to “just work harder,” without taking the time to care for myself. I failed a depression screening at a routine health examination. I was asked what I would say to myself if I were my own patient. It changed my perspective because I had never stopped to acknowledge how difficult my job, maintaining a healthy marriage, and parenting four children under normal circumstances is—and how much more difficult it has been over the past two years of working through a global pandemic. 

I had not stopped to acknowledge how emotionally difficult it has been. I took the advice I would give my patients which is often, “Treat yourself to some counseling, practice self-care and compassion, let go of the things you don’t need, and do things that nourish your soul. You can’t pour from an empty cup.”

While the Covid-19 pandemic has exacerbated, burnout, this was a problem prior to the pandemic. Some studies further describe burnout as emotional exhaustion, dissatisfaction with one’s accomplishments, and depersonalization. Burnout can have physical and mental consequences such as high blood pressure, cardiovascular disease, anxiety, and major depression.

There is overlap in the symptoms observed in burnout and unipolar major depression, including fatigue, dysphoria, and suicidal ideation; however, there is specific diagnostic criteria for depression. Often by the time a person has symptoms of burnout, it may be time to seek the help of a mental health professional. 

In the United States, the “suicide incidence rates per 100 000 in 2017-2018 among women were 17.1 for nurses, 10.1 for physicians, and 8.6 for the general population, and the suicide incidence rates per 100 000 in 2017-2018 among men were 31.1 for nurses, 31.5 for physicians, and 32.6 for the general population.”

Intervention and Finding Solutions to Burnout

There are three areas to contemplate and research for burnout prevention and amelioration. What can be done at the individual, as a team, and institutional level to promote mental wellbeing and to reduce burnout? There is a shared responsibility to promote a healthy workforce and a workplace in which workers can thrive. 

There is a large body of evidence for interventions directed at the individual. I believe there is a need for expanding research in the direction of team and institutional support and responsibility. My observation in reviewing current literature is that our culture of individualism and a “pull yourself up by the bootstraps” mentality is also reflected in the focus on individual interventions as compared to team or institutional approaches. 

The work being done by nurse practitioners and all healthcare professionals is hard. Individual interventions are important; however, failing to examine the entire industry and healthcare system culture further disempowers all healthcare workers and leads to a deepened sense of powerlessness. Being able to address needed system changes is empowering and is an area in need of additional research.  

The American Medical Association and a group of leading medical centers have signed on to a charter on physician wellbeing—nurse practitioners, nurses at all levels of practice, and other healthcare professionals need the same professional, institutional, and organizational commitment.

Individual Interventions

We all have a story as to why we chose to become a nurse, and how we became the nurse practitioner we are today. As a young nurse, I experienced several personal stressors and while working as a new ICU nurse, I witnessed unimaginable suffering leading to a crisis of faith and emotional distress. I questioned the existence of a God who would allow such suffering, but at some point, the initial question seemed less salient than my own answer to a new question: What am I going to do about it? 

It has been my personal calling and mission to do all that I can to reduce the suffering of the person I see before me. But what do I do when the person suffering is me? 

We as nurse practitioners counsel our patients to work on lifestyle modification, that recommendation has to be applied to our own life. 

Exercise reduces the risk of all-cause mortality, cardiovascular disease, stroke, and diabetes. Exercise also improves mental health. In a study of 1.2 million people in the United States, it was found that Individuals who exercised had 43.2 percent fewer days of poor mental health in the past month as compared to individuals who did not exercise (but were comparably matched for physical and sociodemographic characteristics). 

A healthy diet also decreases depression. To quote my mother: “We all know what to do; it’s the doing it that’s hard.” Observational studies have shown that following a healthy diet, particularly a traditional Mediterranean diet, or avoiding a pro-inflammatory diet, appears to confer some protection against depression.

Social connection improves our mental and physical health. Martino et al. (2017) found significant evidence that feeling connected and social support can decrease the symptoms of depression, mitigate symptoms of posttraumatic stress disorder, improve overall mental health, help people maintain a healthy body mass index, control blood sugars, improve cancer survival, and decrease cardiovascular mortality. 

Low social interaction has similar health effects to smoking 15 cigarettes a day and being an alcoholic. It is more harmful than not exercising and twice as harmful as obesity. In an assessment of social connection, it is important to assess close friendships, organizational membership or group belonging with regular meeting opportunities, and how often time is spent socializing with others. Humans are meant to connect and the practice of sharing ourselves and our burdens helps us persevere in times of difficulty and protects us from burnout.

There is strong evidence that the practice of mindfulness helps to reduce burnout among healthcare professionals. Researcher Kristen Neff describes self-compassion as treating yourself as you would a friend. 

There are three elements of self-compassion: self-kindness, common humanity, and mindfulness. Self-kindness can be used when we make a mistake or fail at something. It is acknowledging the difficulty and encouraging ourselves rather than berating or turning to negative thoughts about ourselves. Common humanity involves the sense of interconnectedness, recognizing that all humans (including ourselves) are flawed works in progress. Self-compassion allows us to honor the commonality of suffering within the human experience. Mindfulness is a practice of awareness and working to maintain presence within the moment.

Team Approaches

Healthcare uses a team approach and must consider the team involved, whether in a clinic or in the hospital setting. Sulea hypothesized that strengthening interpersonal relationships can provide an antidote to burnout. The workplace provides a sense of community. Dysfunctional relationships at work can contribute to burnout. Right-relationships or positive interpersonal relationships can improve communication and strengthen the team. 

A healthcare team that treats its individual members with respect, support, and fairness deepens the sense of shared purpose and meaning healthcare workers experience through their work and the care they provide. Healthy interpersonal relationships within the team promote well-being and positive organizational outcomes. 

Utilization of optimal staffing models and improvement initiatives to appropriately distribute workload, define expectations, manage work intensity, and allow variety in practice could mitigate burnout symptoms for all members of the healthcare team. Reviewing each team member’s contribution to workflow and patient care helps to clarify and better understand each team member’s contribution, as well as to identify and address barriers they face in their work or practice. Interprofessional teams can optimize patient care by enabling all members of the team to function at their highest level, each doing the work for which they are uniquely trained. 

There are many factors that increase workplace stress and also reduce quality of care. Job stressors include demands (work overload, time pressures, work environment, patient contact, shift work) and resources (job control, participation, rewards, feedback, job security, supervisor support). 

There is scientific evidence that burned-out physicians can experience depersonalization, withdraw from their patients, demonstrate sub-optimal care, and contribute to serious mistakes and patient death. It is likely that these same negative outcomes of physician burnout also apply to nurse practitioners. 

Organizational commitment to creating systems of support for well-being includes adequate practice resources to manage the volume and pace of work and designing spaces that streamline work and communication. Leaders within the healthcare team can implement quality improvement initiatives to decrease time spent on documentation and may enhance meaning and improve the patient experience by increasing the time nurse practitioners can dedicate to direct patient care.  

Additional team commitments include coverage for time off during illness, adequate staffing, provisions for family leave, flexibility for time off to address non-work interests and obligations, and promoting overall well-being and adequate rest. 

Institutional Interventions

Organizational leaders must have a sense of responsibility and commitment to doing their part to promote wellness. By fostering opportunities for social connection and shared decision-making, leaders can build engagement and develop a healthier, more productive workforce. 

Ongoing organizational assessment and awareness of wellbeing challenges lead to timely identification and responses to emerging factors that contribute to burnout and decrease engagement. In the case of nurses, if hospital management implements specific strategies that prevent burnout and promote work engagement, these interventions, in turn, promote nurses’ mental health, patient safety, and improved quality of care.

There is a business argument to be made: reducing burnout saves money. It is estimated to cost two to three times the annual salary to recruit, onboard, relocate, and ramp up the practice for a physician. APRNs tend to have lower turnover. One survey found that in 2016, the average cost of turnover for a bedside RN ranged from $37,700 to $58,400 and resulted in the average hospital losing $5.2 to $8.1 million annually. One could hypothesize that the cost of replacing an APRN would be somewhere between those estimates.

Engagement is the opposite of burnout and is characterized by dedication, vigor, and absorption in work. The work being done at Mayo Health inspires a sense of hope for the future of the healthcare work environment. Researchers there put forth nine strategies hospital administrators can adopt to reduce burnout and increase engagement in physicians. These strategies should be adopted to include nurse practitioners and all members of the healthcare team. Further details can be found within the study:

• Acknowledge and assess the problem
• Harness the power of leadership
• Develop and implement targeted interventions
• Cultivate community at work
• Use rewards and incentives wisely
• Align values and strengthen culture
• Promote flexibility and work-life integration
• Provide resources to promote resilience and self-care
• Facilitate and fund organizational science