Nursing

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By Suzanne Waddill-Goad

Managing Stress, Fatigue, and Burnout in

Nursing

It’s been nearly four decades since I was a nursing student. Still, I remember long days filled with activities: commuting to campus and clinical rotations, hours in class and study groups, as well as working a part-time job. When I transitioned to the workforce, my life seemed just as busy—working long shifts and overtime when necessary, and then moving into nursing leadership roles which seemed to require endless hours.

While nursing is a rewarding profession, the work can be stressful. Competing priorities, pressures from both inter- nal and external sources, unpredictability, and unintended consequences add a layer of risk most other professions do not experience. These stressors can be felt by nurses and nursing students alike.

The concept of stress was first identified in the 1930s by Dr. Hans Seyle. He dedicated his life’s work to study the body’s ability to adapt to stressful conditions. Unfortunately, most of the stress that people feel today is related to workplace condi- tions, and has progressively escalated in the last few decades (The American Institute of Stress, 2018).

In 2017, the Centers for Disease Control and Prevention cited more than $3.3 trillion was spent on healthcare in the United States (U.S.). And, the cost of stress to U.S. businesses was es- timated to be well over $300 billion for injuries and untoward health consequences (Smith, 2016).

Consequences of Stress, Fatigue, and Burnout Regrettably, nurses are prone to experience more work-related stress than the wider working population, and it often goes unnoticed (Nursing.org, 2019). Stress can be insidious; it has the potential to cause a host of health problems and negatively affect one’s well-being. Everyone knows what fatigue feels like, especially when you are a student. But too much stress can potentiate fatigue and result in burnout. According to The American Institute of Stress (2018), the severity of stress perceived depends on the magnitude of the demands and an individual’s sense of control.

The term burnout was first coined in the 1970s by the psy- chologist Dr. Herbert Freudenberger to describe changes that he saw in mood, attitude, motivation, and personality (Michel, 2016). Today, it is commonly referred to as a problem in the social environment where people work, with both personal and organizational precursors.

Burnout has been studied for nearly 50 years and encompasses more than 100 symptoms. The most commonly used defini- tion is from Maslach and Jackson (1981) who defined burnout as “a syndrome of emotional exhaustion, depersonalization, and reduced personal accomplishment.” More contemporary definitions include loss of engagement.

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Nurse researcher Nuria O’Mahoney (2011) summarized decades of research and the costly significance of nurses’ burnout in the journal, Emergency Nurse. Her summary highlighted a plethora of undesirable consequences such as low morale; increased absenteeism; adverse health conditions; decreased job performance, productivity and effectiveness; and high turnover.

The effects of unrecognized and unmanaged stress can clearly be detrimental. In the last four decades, I have ob- served that one factor remains the same: most nursing and healthcare environments are filled with stressors and have the potential to lead to fatigue and burnout.

Self-Care Takeaways When I decided to become a nurse, I knew I would have to be at my best. Caring for others can take a toll on your physical body, mental capacity, and emotional stability. Stress is a highly personal phenomenon (The American Institute of Stress, 2018) and only you can assess how you feel.

My first takeaway for you is about mindset. It is simply defined as a set of attitudes or a lens in which one views the world (Dictonary.com, 2019). Mindset has the ability to affect achievement, relationships and success. To illus- trate it, I’ll share a personal story about reorganization and sudden job loss. While losing the job was not completely unexpected, it was still a shock. I had just purchased a new home, was moving the following week, and had not yet sold my previous home. I knew I had to quickly pull myself together and assess my options.

Self-care takeaway number two is to build resilience skills. Within nine weeks, I found the courage to start my own business as a consultant in operational improvement and leadership development. Resilience is defined as the ability to recover or adjust to misfortune or change (Merriam- Webster.com, 2019). It’s like being elastic—adversity can be overcome with resilience.

Self-care takeaway number three is to create space, slow down, and take time to think. With the amount of life stressors I faced at that time, I knew I needed to process it all. Taking a break is time well spent; it is so easy to get caught up in “just doing” and not “just being.” Nurses are excellent at adapting to changing conditions and continu- ing to move forward. However, taking time for reflection was insightful and provided clarity.

Self-care takeaway number four is to build a strong network of supporters. This includes classmates, peers, mentors, neighbors, family, and friends. The people in each of these groups will add differing perspectives. In my story, I knew I couldn’t change the circumstances; it forced me to reframe my thinking and turn a negative event into a positive outcome.

Harnessing Stress for Health From a contrarian’s point of view, some think stress may be good for us. Dr. Kelly McGonigal, a psychologist who lectures on organizational behavior at Stanford University’s Graduate School of Business, asserted so in her book titled, The Upside of Stress (2015). She described how a modifica- tion in mindset may change everything. And, in a 2013 TED talk, she explained how to make stress your friend. Her talk can be found at this link: https://www.ted.com/ talks/kelly_mcgonigal_how_to_make_stress_your_ friend.

When I started my business, I noticed that most of my clients looked extremely tired. I also was suffering ill effects after leaving an executive role. These observations further spurred my entrepreneurial interest and drove me to ponder the true emotional cost of being a nurse.

Then in 2010, I began a doctor of nursing practice (DNP) program. During the first week, I proudly wrote that my re- search was going to be about Leadership Fatigue™. I defined it as mental, physical, and emotional fatigue resulting from prolonged stress due to uncontrollable forces in the work environment secondary to a leadership role, causing insidi- ous consequences to one’s performance, overall health, and life balance. My journey of study about stress has come full circle over the last decade as I continue to learn about the best ways to harness it for optimal well-being.

Unfortunately, for most people it takes a catastrophic event to change from unhealthy to healthy ways. Take time as you begin your nursing journey to think about what’s important to your own health and well-being. The American Nurses Association’s Healthy Nurse, Healthy Nation™ Grand Chal- lenge (2017) website provides a number of resources focus- ing on five key areas for health: physical activity, nutrition, rest, quality of life, and safety. Consider the following two questions to design your career plan:

1. Do you know what you need to do your best work? 2. What self-care tactics will you adopt to make health a priority?

Recognizing and addressing the potentially negative impact of stress and the signs of overwork are imperative to avoid fatigue and burnout (Waddill-Goad, 2016). A more calcu- lated approach to nursing work in relation to the thoughtful design of systems, forming efficient work processes, attaining reasonable workloads, working effectively in high-perform- ing teams, and establishing boundaries for work-life balance are key attributes for success.

Mindfulness and Intuition in Nursing Practice Research has shown how practicing mindfulness, engaging in meditation, as well as being present and aware can relieve anxiety, exhaustion, and depressive symptoms related to

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References American Nurses Association. (2017). Healthy Nurse, Healthy Nation™ Grand Challenge. Retrieved from http://www.healthynursehealthynation.org/

Centers for Disease Control and Prevention (CDC). (2017). National center for health statistics: Health expenditures. Retrieved from: https://www.cdc. gov/nchs/fastats/health-expenditures.htm/.

Dictionary.com. (2019). Definition: mindset. Retrieved from: https://www. dictionary.com/browse/mindset/.

Lyndon, A. (2016). Burnout among health professionals and its effect on patient safety. Patient Safety Network: Agency for Healthcare Research and Quality (AHRQ). Retrieved from: https://psnet.ahrq.gov/perspectives/ perspective/190/burnout-among-health-professionals-and-its- effect-on-patient-safety/.

McGonigal, Kelly. (2015). The Upside of Stress: Why Stress Is Good for You, and How to Get Good at It. Avery: New York, NY.

Merriam-Webster.com. (2019). Definition: intuition. Retrieved from: https:// www.merriam-webster.com/dictionary/intuition/.

Merriam-Webster.com. (2019). Definition: resilience. Retrieved from: https:// www.merriam-webster.com/dictionary/resilience.

Michel, Alexandra. (2016, January 29). Burnout and the Brain. Association for Psychological Science. Retrieved from: https://www.psychologicalscience. org/observer/burnout-and-the-brain

Nursing.org. (2019). Nurse burnout. Retrieved from: https://www.nursing. org/resources/nurse-burnout/.

Maslach C., Jackson. S. E. (1981) The Measurement of Experienced Burnout. J Organ Behav. 2(2):99 – 113.

O’Mahoney, N. (2011). Nurse burnout and the working environment. Emerg Nurse, 19 (5): 30-7.

Perkins, S. (2019, March 11). Why every nurse should practice mindfulness. The Atlanta Journal Constitution. Retrieved from: https://www.ajc.com/life- styles/meditation/why-every-nurse-should-practice-mindfulness- and-how/zku6oVAn9zFBtJHDIw8JRK/.

Smith, J. (2016, June 6). Here’s why workplace stress is costing employers $300 billion a year. Business Insider. Retrieved from: https://www.businessin- sider.com/how-stress-at-work-is-costing-employers-300-billion-a- year-2016-6/.

The American Institute of Stress. (2018). Workplace stress. Retrieved from: https://www.stress.org/workplace-stress/.

Waddill-Goad, S. (2016). Nurse Burnout: Overcoming Stress in Nursing. India- napolis, IN: Sigma Theta Tau International.

Suzanne Waddill-Goad, MBA, BSN, RN, DNP, CEN, is President and Principal Consultant of Suzanne M. Waddill-Goad & Company, Inc., a consulting practice specializing in operational improvement, interim leadership and leadership development.

work stressors (Perkins, 2019). Perkins (2019) quoted Susan Bauer-Wu, PhD, former Emory professor and mindfulness advocate, who pointed out that nurses can become so busy and preoccupied that they disconnect from their own body’s experience. Mind- fulness and meditation may provide a barrier to stress by potentiating improved sleep patterns, interper- sonal relationships, and lessen stress hormones. On a personal note, mindfulness and meditation have been very helpful for me in managing stress and are my next self-care takeaway; consider learning about them both.

In Perspectives on Safety, Lyndon (2016) proposed a linkage between burnout in healthcare professionals and safety. She described how emotional exhaus- tion, cynical detachment, and physical fatigue affect caregivers’ ability to feel, potentiating a threat to healthcare quality and patient safety. Other studies have cited up to one-half of all healthcare providers are feeling the effects of burnout.

Lyndon (2016) also posited that burnout can impair cognitive functions, placing patients at risk for harm. We know care providers never intend to harm a patient, but a lack of attention may result in an inad- vertent mistake. Limiting distractions, interruptions, detachment, stress, fatigue, and burnout are essential to provide mindful as well as, safe care.

The last self-care takeaway is about intuition. As a nurse, you must learn to develop it and then listen to it. Intuition is defined as the ability to understand something immediately without the need for rational thought or inference (Merriam-Webster.com, 2019). Every time I haven’t listened to my own intuition, things didn’t work out as well as they could have.

Conclusion Understanding stress and the associated consequences is crucial to learning how to think differently about it. Optimal well-being is a delicate balance between the external and internal environment and how a person responds to perceived stress.

To begin your healthful nursing journey, check your score on the Perceived Stress Scale (Cohen, 1994) which can be accessed here: https://www.mindgar- den.com/documents/PerceivedStressScale.pdf G