Stress can be a blessing or a curse, and in the high-pressure areas of the ICU, stress is a constant. The stress of working in an ICU can come from high patient morbidity and mortality, challenging work routines, regular encounters with traumatic and ethical issues, the impact of end-of-life issues, miscommunication, and/or unrealistic expectations of patients and family.1
The inability to match workplace demands with personal adaptive capacity results in psychologic stress for the caregiver; over time, this results in burnout. The impact of burnout affects more than nursing turnover. It is also associated with reduced quality of care, lower patient satisfaction, increased medical errors, higher rates of healthcare-associated infections, and higher 30-day mortality.1
The true magnitude of the issue remains unclear; however, burnout prevalence estimates for healthcare professionals range from 14% to 70%.2 Approximately 25% to 33% of critical care nurses manifest symptoms of severe burnout.1 Burnout may also be contagious: Nurses who reported high rates of burnout among colleagues are most likely to experience burnout themselves.2
Ultimately, the time-honored value of attending to others before caring for oneself can be detrimental to nurses. Boundaries at work and making time for self-care are essential to feeling whole, healthy, and able to do sustainable work.3 This article discusses burnout, its effects, and why nurses and their organizations can and should invest in self-care as a way to combat this damaging phenomenon.
Burnout reflects a mismatch between personal characteristics and job demands and involves both individual and organizational aspects, which include workload, control, reward, community, fairness, and moral values.4 The Maslach Burnout Inventory is the most commonly used tool for diagnosing burnout. It asks respondents to indicate the frequency at which they experience certain feelings related to their job. Burnout is described as a combination of three factors: emotional exhaustion, depersonalization, and reduced personal accomplishment.5
Emotional exhaustion is the core symptom of burnout. It involves feeling emotionally drained and lacking the emotional energy to provide the care or service that is required, and may include physical and mental fatigue. It can be related to repeated tasks that are unlikely to have a good outcome, such as taking care of a complex patient who has a poor chance of recovery.
Depersonalization is an indifferent attitude toward work and may be displayed as negativity, cynicism, or impersonal interactions with colleagues or patients. This often manifests as detachment from a situation, and may result in behavior such as intentionally avoiding a patient's family as a means of self-preservation. Cynicism can develop from a feeling of powerlessness.
Reduced personal accomplishment is a tendency to devalue the worth of one's work, to feel unable to perform the job, and/or decreased professional self-esteem. Critical care nurses tend to have high standards and expectations of themselves—when they are not able to meet them, they may feel as if they do not make enough of a difference and experience moral distress. Feelings of ineffectiveness are compounded if the nurse feels a lack of support from nurse managers.
Burnout symptoms include both psychologic and physical elements.1,5 Psychologic symptoms are frustration, anxiety, hopelessness, disillusionment, feeling overwhelmed, and a lack of empathy. Physical symptoms are fatigue, insomnia, headaches, and gastrointestinal problems.1,5
Combatting burnout involves implementing strategies to enhance nurses' work environments and helping nurses hone their coping skills. A one-dimensional approach is unlikely to be as effective as combined individual and organizational interventions.6
The first step is to identify the area of mismatch using the categories identified above and work to narrow the gaps. Interventions may include educational programs on emotional distress, improving elements of family-centered care, improving the work environment, team building, or teaching communication strategies regarding end-of-life care.
One key component is focus on a healthy work environment. In 2005, the American Association of Critical-Care Nurses developed six standards necessary for a healthy work environment that supports excellence in nursing practice. The six standards address systemic behaviors that can result in unsafe conditions, and form a useful framework to resolve issues:7
- skilled communication
- true collaboration
- effective decision-making
- appropriate staffing
- meaningful recognition
- authentic leadership.
Nurse managers play a pivotal role in creating a supportive environment by being accessible to nurses at the bedside, fostering collegial relationships with other disciplines, and making resources available for nurses to deal with stress and process grief.8
Nurses must be accountable for maintaining their own mental and physical health. Stress reduction training can increase awareness of work-related issues and enhance coping resources. Self-care includes relaxation techniques, cognitive stress management, time management, assertiveness training, and healthy lifestyle.
Strategies that draw from the field of positive psychology include gratitude and mindfulness-based stress reduction (MBSR).9,10 Gratitude helps individuals feel more positive emotions, relish good experiences, improve their health, deal with adversity, and build strong relationships. MBSR is based on the premise that with repeated training, individuals will eventually learn to be less reactive and judgmental toward their experiences, and better able to recognize and break free from habitual and maladaptive patterns of thinking and behavior.
Building resilience is essential for coping in the face of complexity and rapid change, and involves internal and external activities.11,12 External activities include developing problem-solving skills or engaging in physical exercise, play, or art. Internal activities include adopting ways of thinking that create a sense of hope and discovery of the meaning and purpose in life under adverse circumstances. One easy way to build resilience is to take care of your SELF.
Taking care of your SELF
Nurses must balance self-care and the time, effort, and energy they give to patients. In aviation, the safety message prior to takeoff exhorts passengers to put on their own oxygen mask first before trying to help others. But how can nurses use their “oxygen masks” to thrive in today's high-stress, burnout-prone environment?
Taking care of your SELF is a step toward building resilience and allowing for engagement with the world around you. SELF is a mnemonic that identifies small actions nurses can incorporate into their daily rounds to combat stress and burnout.13
First, Schedule time to breathe. Plan to take a moment before a conversation with a colleague, family member, or patient; when responsibilities feel out of control; or during a downward turn in energy levels. Use breathing as a way to cleanse your stress palate. Take a big, deep breath and hold it for a count of three. Then exhale completely to a count of three, breathing out tension, stress, or worry. Repeat if necessary, then resume normal breathing. This small activity is equivalent to putting the oxygen mask on first.
Engage with gratitude. Gratitude allows us to see there is goodness in the world and that the source of that goodness lies outside of us. Gratitude can be developed through many different avenues: journaling on a regular basis, writing gratitude letters, creating a gratitude collage, or noticing and acknowledging gratitude in the moment.
Limit negative thoughts. Self-talk can influence emotional and physical well-being. Negative thoughts can come from misconceptions or lack of information. Common avenues for negative thoughts include focusing on the frustrating aspects of a situation, self-blame, taking problems personally, catastrophizing by assuming the worst in every situation, or polarizing situations by ignoring the middle ground. When negative thoughts occur, stop and consider how to reframe the thought and switch it to a positive perspective.
Last, Focus on mindfulness. Mindfulness means actively paying attention to what is going on in the moment; it requires focus. Multitasking is the antithesis of focus, and mindfulness helps bring attention back to whatever task is at hand. Practice reframing emotional thoughts as mental projections and allow them to pass through your mind without upsetting your balance.
Burnout is a reality but does not have to be a certainty. The triple aim introduced by the Institute for Healthcare Improvement (IHI)—enhancing patient experience, improving population health, and reducing costs—seeks to optimize health system performance, but does not address the work life of healthcare providers and staff. Adding another goal to improve the work life of caregivers (the quadruple aim) would support the IHI's mandate because burnout threatens quality patient care.14
Implementing strategies and interventions to prevent burnout requires addressing both organizational and individual factors. But as the Dalai Lama advises, on a personal level, if you feel burnout setting in—if you feel demoralized and exhausted—you should withdraw and restore yourself first.15
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