A nurse leader is a forgotten warrior. The role expectations are based on the premise that nurse leaders can function flawlessly in today's chaotic and demanding healthcare environment.1,2 The belief is that a true nurse leader is inherently invincible and unequaled strategically in human interaction, being technological savvy, budgetary skills, and stamina.2 Most leaders rise through the ranks beginning as novice nurses, excelling into the class of expert staff nurses, and naturally progressing onward and upward. Many nurses are thrust into leadership positions for which they are inadequately prepared to assume because of unclear expectations, role ambiguity, and inadequate training or support.1,3 Commonly, new nurse leaders feel isolated from their staff nurse peers. Having inadequate support leads to apprehension and not feeling worthy of the nurse leader title.4 Asking for assistance may even be perceived as a sign of a weak leader or being unprepared for the role. Unending mental, physical, and emotional stress can lead to nurse leader fatigue, burnout, and, regrettably, nurse leaders who are too tired to lead.5
The effects of nurse fatigue are neither a new phenomenon nor isolated to the clinical nurse. Addressing nurse leader fatigue has grown in importance as organizations recognize its detrimental impact.6 Implementing a fatigue risk management system (FRMS) within healthcare organizations focused specifically on identifying, monitoring, and mitigating causation of nurse leader fatigue can improve performance overall, reduce care costs, and contribute to nurse leader retention.6 Functioning in a high-stress role and being inadequately prepared for the demands of leadership can be detrimental to one's health and the health of the organization. Expectations are that one must be skilled clinically while mastering budgets, technology, incivility, mentoring, and interprofessional demands. Nurse leaders play a critical role in forming a healthy work environment and must realize they will need to put on their “own oxygen mask” before they can help others.5
The project site's executive leadership team defines the formal nurse leader role by their position within the healthcare organization. The executive leadership team is composed of 4 vice presidents (VPs) and the chief nursing officer who serve as administrators over the healthcare organization's operations and facilitators to the nurse leaders. Nurse leaders in the organization include a total of 56 nurse directors, assistant directors, and clinical instructors. All nurse leaders serve within their specific nursing care units at the tertiary care organization.
Fatigue Operational Definitions
Winwood et al7 describe acute fatigue as the tiredness related to doing one's job every day and becoming stressful when there is inadequate time to recover. Acute fatigue associated with adequate recovery is not particularly stressful. Evaluation of acute fatigue involves the amount and duration of fatigue exposure associated with one's leadership role. Without appropriate recovery time between stressful events, acute fatigue triggers maladaptive biophysical responses similar to an illness. Sustained acute fatigue response becomes similar in characteristics to chronic fatigue.7
Chronic fatigue is a dysfunctional response to extended periods of exposure to stressors.7,8 Chronic fatigue is associated with longer periods of exposure to stress than the day-to-day stressors associated with acute fatigue. Physical, emotional, and mental exhaustion, similar to clinical depression, characterizes nurse leaders experiencing chronic fatigue. Leaders' decision-making processes are hindered, disengagement predominates, and a negative mindset prevails. The ability of the nurse leader to recover from chronic fatigue is uncertain and is associated with high rates of burnout. Recovery from chronic fatigue is difficult but achievable.7,8
Persistent fatigue is a continuous state of exhaustion without adequate means to rest and recover.7,8 The leader's role may entail always being readily accessible even when not at work. The strain of constant accessibility, in combination with other stressors, can lead to persistent fatigue. Where chronic fatigue is recoverable, persistent fatigue generally is not. To avoid burnout due to persistent fatigue, nurses must have time to recuperate between regular work hours.
The loss of nurse leaders at a rate of 10% or more per year was disconcerting to the organization's executive leadership team. Priority goals were established to measure and lessen the stress and fatigue among the nurse leaders. Plans to implement roundtable style meetings began after collaborative executive leadership discussions. Overarching objectives were to create a safe venue for transparent, collaborative discussions; address attrition; and improve the working relationships between executive leadership and nurse leaders. The aim of this quality improvement (QI) project was to implement an evidence-based approach to identify, monitor, and reduce nurse-leader fatigue and increase retention rates within 12 months at a large tertiary care medical center.
The American Nurses Association white paper9 states nurse fatigue across the industry has a detrimental impact on caregiver health, patient outcomes, and organization performance. Emphasis has been on the effects of fatigue on nurses involved with direct patient care.5 Evaluation of the nurse's work environment and the stress of delivering nursing care measures the effects on staff nurses, but not necessarily nurse leaders.6 Emphasis on improvement of nurse leader job satisfaction and retention is instrumental in reducing healthcare costs and improving patient safety.3,5,9-11
Healthy, vigorous nurse leaders are essential to a productive work environment.3,9,12 Cost estimates to replace a nurse leader range from 75% to 125% of their annual salary.13 Nurse leaders can reduce fatigue and burnout through self-awareness, healthy lifestyle choices, improving work-life balance, and emphasizing personal needs; the focus of leaders cannot be solely on meeting work demands.14 Fatigue and exhaustion manifest differently in nurse leaders and staff nurses.15 Leaders experience multiple workplace stressors from organizational pressures, staffing and budget issues, role responsibility ambiguity, and excessive work hours.5
Nurse Leader Contribution
Nurse leaders, numbering approximately 400 000 in the United States, are instrumental in impacting the quadruple aim, which focuses on improving the patient care experience, population health, cost of delivering care, and the overall health of caregivers.16-18 The increase in role responsibilities takes a toll on the nurse leader as exemplified in increases in fatigue and decreases in resiliency.11,14 Increasing retention of nurses in leadership roles is as important in addressing patient safety goals as is retaining staff nurses. Implementing a method to build trusting relationships and mitigate fatigue must be a priority to accomplish the goal of leadership retention.5
Fatigue Risk Management System
The airline industry's FRMS guidelines for pilots and crew give applicable insight into the goals of addressing nurse fatigue in healthcare.19 Recoverability is a key element for improving client safety in both the airline industry and healthcare.5,7,19 Steege et al5 conceptualized the multidimensional nurse occupational fatigue model beyond the airline industry's circadian aspect. Mental, physical, and emotional components were identified as critical facets of fatigue.5 A variety of work-related stressors cause acute fatigue and can ultimately lead to the expression of chronic or persistent exhaustion. The coping capacity of the leadership team determines the level of negative impact on the individual leader and the organization overall.5 The expectations of the nurse leader role are intrinsically demanding.20 Identification of available interventions to enhance the leaders' work environment requires evaluation for efficacy and reliability from a practical application perspective.9,15 Developing a collaborative, supportive relationship between executive leadership and nurse leaders was a key element of the roundtable design.
The QI project participants were a single group composed of the 61 organizational leaders, and participation was voluntary. Participants could choose to not participate or withdraw from inclusion in the project at any time. All participants were given equal opportunity to attend and participate in the roundtable meetings. Electronic project data were deidentified and secured per the project site's QI review board rules and organizational security policies.
The conceptual framework for the QI project is based on Steege and Pinekenstein's multilevel perspective of fatigue risk management.6 Contributing factors include elements of the nurse leader environment with respect to the traits of the leader, a transparent and trusting organizational relationship, availability of mitigating resources, and having support to develop leadership coping skills and recovery mechanisms.6
The design was a QI project using the Occupational Fatigue and Exhaustion Recovery (OFER15) scale7 in a pre-post roundtable intervention survey format. Project objectives included assessing acute, chronic, and persistent fatigue in addition to recoverability among nurse leaders. The OFER15 scale is a 15-question, valid, and reliable scale for measuring the subscale levels of acute fatigue (OFER15-AF), chronic fatigue (OFER15-CF), and intershift recovery (OFER15-IR). OFER scoring ranges (1-100 points) are divided into quartiles (1st, 1-25; 2nd, 26-50; 3rd, 51-75; 4th, 76-100).7 Nurse leaders were asked to rate their perceived stress level on a 1- to 10-point scale and identify major contributing factors. Descriptive statistical analysis was conducted to illustrate the characteristics of the nurse leadership team. Open-ended questioning in the postsurvey assessed the nurse leader's impressions of the roundtable experience.
A cyclical Plan-Do-Study-Act model21 was implemented to evaluate the roundtable process and revise it as necessary. Fatigue was assessed before and after implementing the roundtable over a 10-month time span. An online survey was created using the OFER scale with additional demographic, scaled, and open-ended questions. The leadership roundtable meetings were scheduled monthly. The 5 executive leaders divided the 56 nurse leaders into 5 similar-sized groups and then facilitated their designated group's monthly meetings using identical agendas and resources. The topics for each meeting were chronologically placed to facilitate fatigue reduction by addressing identified issues (Table 1). Roundtable discussions focused on identifying and addressing work environment fatigue and contributing factors. As part of the study phase, the following data were collected and analyzed: annual nurse leader attrition, levels of each OFER fatigue subscale, and remarks regarding the roundtable experience. The final phase included identifying and implementing revised approaches to improve 3 priority areas: creating a venue for transparent and collaborative discussions, addressing attrition and improving the relationships between executive leaders and nurse leaders.
An α level of .05 was used for independent t test and descriptive-analytic data analysis. The participation rate was 60% (n = 30) on the presurvey and 89% (n = 50) on the postsurvey. The descriptive statistical analysis illustrated the group demographics (Table 2). An overview of the results described the project participants as well-educated, predominantly millennial females with a significant number of leaders having children at home. Relatively novice nurse leaders (51% with ≤3-year experience) were nearly equal to the numbers of experienced nurse leaders. Seventy percent of the participants reported getting less than their needed amount of sleep to be adequately rested before returning to work.
OFER15 Scale Pre and Post-Scores
Cronbach's α's for the roundtable project (n = 50) OFER15 subscales were highly reliable with AF α = .87, CF α = .92, and IR α = .89. Following the roundtable intervention, the OFER subscale change in scores from the preintervention survey in February to the postsurvey in December 2018 was not statistically significant (Figure 1). Fatigue subscale scores ranked in the 2nd and 3rd quartiles (AF, CF, persistent fatigue score range 49-68) overall. Scores in the 3rd and 4th quartiles (51-75; 76-100) would indicate a moderate to a high degree of fatigue, with scores in the 1st or 2nd quartiles (1-25, 26-50) being most desirable.8 Recoverability scores in the 2nd quartile showed a slight decline (46 preimplementation to 40 postimplementation). Scores in the 1st and 2nd quartiles indicate recoverability are lacking, whereas scores in the 3rd and 4th quartiles would be positive indicators.8 A positive linear relationship exists between the education level and the level of acute fatigue (P = .041) for the group. Neither the number of years of experience in a leadership position nor having children living at home had a significant impact on fatigue levels in any subcategory (not statistically significant).
Stressors and Perceived Stress
Participants (n = 50) identified 8 sources of stress (Figure 2) in order of frequency: “work” (100%, n = 50); “children” and “finances” each scored equally as sources of stress (43%, n = 22); “home life” and “work relationship” also were selected equally (27%, n = 14). “Personal health” (22%, n = 11), “currently a student” (14%, n = 7), and “personal relationship” (12%, n = 6) rounded out the 8 categories. Of the listed stressors, 58% (n = 29) reported having a combination of 3 or more of the sources of stress (Supplemental Digital Content 1, http://links.lww.com/JONA/A732, which shows the percentage of leaders selecting the number of stressors ranging from 1 to 8).
Perceived stress levels prior to the roundtable intervention (Supplemental Digital Content 2, http://links.lww.com/JONA/A733, which shows the perceived stress levels pre–roundtable intervention) had 80% (n = 30) of leaders rating stress at 7 or greater (on a 0-10 scale with 10 being very high stress), whereas postintervention (Supplemental Digital Content 3, http://links.lww.com/JONA/A734, which shows the perceived stress levels post–roundtable intervention) results showed leader stress levels at 7 or greater reduced to 69% (n = 50). Notable is, even as OFER fatigue levels rose slightly from February to December, the nurse leader's perceived stress levels in the highest categories (stress levels 7-10) declined a clinically significant 11%.
Attrition Rate and Work Hours
Nurse leader attrition in 2017 prior to the QI project startup was 11% (n = 6) compared with 7% (n = 4) after roundtable implementation in 2018, saving an estimated $120 000 to $200 000.13 Regarding work hours, 95% of the nurse leaders (n = 50) reported working more than 40 hours per week, with 17% regularly working greater than 50 hours. Work hours per week had a strong, positive correlation with chronic fatigue (n = 81, P = .028, r = 0.245). Inversely, work hours had a negative correlation with recoverability (n = 81, P = .026, r = −0.248).
The use of the roundtable format was reported to be a positive intervention process for creating a safe place to build trust among the nursing leaders. The collaborative and engaging environment created by the leadership team promoted the sharing of individual challenges, barriers, and needs of specific units. Leaders identified 3 priority areas of concern: dealing with continuous change, efficient use of time while always being accessible, and dealing with difficult employees. Reflective comments from the nurse leaders were more than 95% positive. Representative examples included “It was encouraging and inspiring. I feel like my relationship with my VP is very different now… more positive. I have built allies in leadership.” “It was a great experience. I enjoyed how [you are] encouraged to be honest and provide feedback with [executive] leadership present. Leadership did a great job making the environment safe to share.” “It was a very supportive environment. Many of us leaders deal with the same issues.” “I like that senior leadership is concerned for our well-being and has strategies to help us find work/life balance. I like having other leaders to ask questions and confide/vent to. I look forward to next year!”
Cyclical Nature of Stress and Fatigue
The time of year the surveys were given may have impacted the level of nurse leader fatigue. The OFER fatigue assessment was conducted twice during the 10 months of the project. Stress and fatigue levels may be less during months other than the beginning and at year-end. Discussion with executive leadership indicated a cyclical pattern to work-related stress levels, whereas multiple confounding variables affecting the nurse leader group may have also existed. The results support the complexities of fatigue described by Steege et al.5 For instance, the organization recently received Magnet® designation. Leadership on all levels had been working diligently on obtaining the designation for the past 5 years and were in the completion stages during the OFER presurvey period. The postsurvey was conducted in December during the week before the holidays. Executive leadership reported hospital census and anecdotal fatigue levels historically being high during this time frame. Further work is required to identify the specific periods of peak stress and related fatigue to better understand the unique cyclical nature of the organization's stress levels. Forecasting the organization's peak fatigue levels could help identify periods requiring increased interventions to mitigate the leader's stress.
Based on remarks from the leadership groups, the roundtable meetings generate positive, supportive working relationships and a collaborative approach to reducing fatigue, burnout, and intent to leave the leadership role. Executive leadership has chosen to continue the roundtable meetings after conducting a sustainability analysis of the project. In general, nurse leaders have the unique challenge of not only meeting the needs of their staff but also meeting the performance expectations of their executive leaders. Nurse leaders can be described as the lost warriors in the middle, feeling pressure from both executive leaders above and direct care providers below. Because of the varying required skill sets of leaders at different levels22 and the complexities of the various nursing departments, a single intervention to address everyone's needs and mitigate fatigue, although highly desirable, does not currently exist. The use of the roundtable process facilitated identifying the uniquely appropriate interventions to address nurse leader fatigue based on the specific needs of the leader and the unit they manage. A multifaceted approach for building relationships between nurse leaders and executive leadership is an essential step to managing fatigue and for a leader to no longer be a forgotten warrior.
Implications to Nursing
Today's healthcare environment puts tremendous strain on nursing leadership. The interactive roundtable meetings are a unique opportunity for nurse leaders to build trusting, engaging relationships. To overcome the multilevel stressors of the leader role, an environment of trust and collaboration is essential. Nurse leaders must understand the complexities of not only their position, but also the unique and shared challenges of their peers, executive leadership, and the organization. Executive leadership can create and facilitate opportunities for their nurse leaders to safely exchange concerns, ideas, and support for one another. The roundtable format has shown to be a promising venue to achieve this goal. Further work is needed to understand the cyclical nature of fatigue and the long-term effect of the roundtable process on recoverability and stress relief. Other aspects to consider are the effects of the multigenerational workforce, the pressures of doing more with less, and how changes at the executive leadership level affect nurse leaders.
The authors acknowledge the nurse leaders who participated in the roundtable project for their ongoing commitment to achieving leadership excellence. The authors also thank Linsey Steege, PhD, for her insight on nurse leader fatigue; Peter C. Winwood, BDS, BPsych (Hons), for his guidance in the use of the OFER tool; and Jeannette T. Crenshaw, DNP, RN, LCCE, IBCLC, NEA-BC, FACCE, FAAN, for her ongoing support of our project.
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