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Burnout

Going beyond mindfulness to NP-led interprofessional teams

Corbridge, Susan J., PhD, ACNP, FAANP, FAAN; Melander, Sheila, PhD, ACNP, FCCM, FAANP, FAAN

doi: 10.1097/01.NPR.0000554681.87353.2d
Department: Acute Care Advisor
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Susan J. Corbridge is an associate dean of practice and partnerships, College of Nursing, and clinical associate professor, College of Nursing and Department of Medicine, Division of Pulmonary, Critical Care, Sleep & Allergy at the University of Illinois at Chicago, Chicago, Ill.

Sheila Melander is an associate dean of MSN and DNP faculty and practice affairs at the University of Kentucky College of Nursing, Lexington, KY.

Tune in for more of the conversation on burnout for acute care NPs in The Nurse Practitioner podcast at www.tnpj.com.

The authors would like to acknowledge Kevin Grandfield for his editorial assistance with this manuscript.

The authors have disclosed no financial relationships related to this article.

Burnout has become one of the nation's fastest growing public health concerns. It is characterized by a high degree of emotional exhaustion, depersonalization, and a low sense of personal accomplishment from work.1 Most research examining burnout has focused on physicians. As many as 78% of physicians report symptoms of burnout.2 In addition, physicians report high rates of depression and drug and alcohol use. Approximately 400 physicians die each year by suicide—this is a rate more than twice as high as the general population.3

However, physicians are not the only ones battling burnout. Nurses, particularly those in critical care, have a high rate of posttraumatic stress disorder and burnout, and as many as 86% have at least one of the three classic symptoms.4 Although inadequately studied, available data on nurse suicide suggest that nurses are at risk.5 In addition, pharmacists and social workers are experiencing higher rates of burnout than ever before (see Three classic symptoms of burnout syndrome). Data also show that burnout extends to healthcare students and trainees.6,7

Although there are data showing high levels of burnout in nurses—particularly those in critical care—there are limited data specific to burnout among NPs.8,9 In the acute and critical care arenas, one study of NPs working in ventricular assist device programs in the US found that work-related burnout was negatively associated with low quality of work life (QOWL) among NPs, with the hospital/work environment being a contributing factor to high burnout and low QOWL.10 Although data are limited, caring for complex, acutely ill patients makes it highly likely that NPs in acute care are affected by burnout. Given the data from other healthcare providers (including critical care nurses), burnout is likely increasing for acute care NPs as well.

Burnout not only affects the lives of providers and their families but also has a major impact on quality of care and patient safety. Burnout is associated with lower levels of patient satisfaction and reduced adherence to treatment plans.11,12 It is also associated with an increased risk of medical errors and being involved in a malpractice suit.1,13

In addition, healthcare provider turnover from burnout has negative financial implications for healthcare organizations. Studies have also linked the possibility of physicians experiencing burnout or high workloads to making more referrals and ordering more tests, which may worsen patient outcomes.14,15 Burnout may also result in healthcare professionals leaving their profession. High turnover rates increase cost, decrease productivity, lower staff morale, and decrease quality of care.4 Burnout also plays a role in career advice to future generations. In a recent survey, 7 out of 10 physicians were unwilling to recommend healthcare as a profession.16 This alone will certainly impact the future of healthcare.

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Causes of burnout

The etiology of burnout is multifactorial. Electronic medical records (EMRs) are one of the top contributors to burnout.17 Not only do EMRs require increased time for documentation, but also reliance on the EMR for healthcare delivery limits direct time for patient and family interaction, which further contributes to burnout. One recent study in Academic Medicine cited that residents spent less than 10% of a typical day shift interacting with patients and over 50% interacting with computers.18 Less interaction with patients and families may be especially difficult for NPs because nurse–patient communication is at the center of the nursing profession.

Other factors contributing to burnout include high patient numbers, malpractice concerns, dealing with payers, student loan debt, physical and emotional stress, and work-life imbalance. In addition, for those working in critical care, interpersonal conflict among professionals is cited as a risk factor for burnout.9 Personal animosity, mistrust, and communication gaps are the most common factors causing interprofessional conflict.19

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Mitigating burnout

Articles have been published encouraging providers to practice mindfulness, and such approaches can help. However, the onus to fix problems associated with burnout should not lie solely with the individual provider. Burnout needs to be addressed at the organizational and system levels to get at its root causes (see Interventions for burnout syndrome). The National Academy of Medicine (NAM), which recently launched an Action Collaborative on Clinician Well-Being and Resilience, is spearheading an initiative to reduce burnout by conducting research in this area. The NAM has an online resource kit focused on clinician well-being and has released several discussion papers on clinician well-being and burnout.20 The NAM discussion paper, titled “Implementing Optimal Team-Based Care to Reduce Clinician Burnout,” provides a thoughtful approach to care delivery.21

The idea of workflow redesign with a focus on team-based care is of interest at the organizational level. Team-based care has been linked to improved patient outcomes and may mitigate burnout. Although more research is needed, high-functioning teams have great potential to promote clinician well-being, which is imperative to quality healthcare. Correcting the root causes of burnout will certainly not be easy, but focusing on a shift toward workflow redesign to include highly functioning teams and an interprofessional, collaborative, team-based approach to care is an immediate strategy that providers and organizations can employ.

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The NP's role in addressing systemic burnout

Because NPs—particularly those in critical care—frequently practice in teams, they are well positioned to be leaders in ensuring high-functioning teams as part of workflow redesign, with the overarching goals of improving quality of care and clinician well-being. Doctor of Nursing Practice (DNP)-prepared NPs are specially equipped to lead interprofessional teams. The American Association of Colleges of Nursing considers interprofessional collaboration for improving patient and population health outcomes to be an essential part of doctoral education, and the concept has been incorporated into The Essentials of Doctoral Education for Advanced Nursing Practice, which outlines necessary curriculum and expected competencies.22

Doctorally prepared NPs have skills in how to use interprofessional and intraprofessional communication and collaborative skills to deliver evidence-based, patient-centered care; contribute the unique nursing perspective to interprofessional teams to optimize patient outcomes; and demonstrate appropriate teambuilding and collaborative strategies when working with interprofessional teams.22

Being equipped with these skills makes it apparent that the DNP degree is more than a mechanism to increase the NP's level of clinical skills; the degree was also designed to increase the NP's organizational, economic, interprofessional, and leadership skills. This makes DNP-prepared NPs the change agents perhaps best situated to impact quality of practice, patient care, and outcomes across the continuum of care, making them the perfect fit with the skillset to lead interprofessional teams. This is aligned with the position statement from the National Organization of Nurse Practitioner Faculties to move all entry-level NP education to the DNP degree.23

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Conclusion

Data are lacking on burnout in acute care NPs. More research is needed to better inform acute care educational program directors on enhancing curriculum redesign to prepare NPs to deal with the professional challenges that lead to burnout. More data would also help employers improve employee onboarding and workflow, which might mitigate burnout. In addition, research focused in this area would help the profession develop an evidence-based advocacy policy that focuses on top-of-license practice for NPs, which would help to meet the quadruple aim: quality, patient experience, cost, and provider well-being.

An interprofessional, team-based approach to care is now advocated and could help burnout by creating a culture where all individuals on the healthcare team are recognized equally for their unique skillset and contributions to patient care; sharing care-taking responsibilities so one healthcare profession is not unduly burdened; and instilling mutual respect and trust. Earlier and more effective interprofessional education must occur to ensure that a sense of mutual respect and trust is built from the beginning.

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Three classic symptoms of burnout syndrome4

  • Emotional exhaustion
  • Depersonalization (a distant or indifferent attitude toward work)
  • Feelings of inadequate performance or a decreased sense of personal accomplishment
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Interventions for burnout syndrome4,21,24

Individual interventions

  • Take breaks from work
  • Practice self-care and get rest
  • Exercise and practice mindfulness
  • Engage the support of management, coworkers, and friends
  • Practice resiliency techniques, including having an optimistic attitude
  • Promote collaboration and team-based care
  • Become a skilled communicator

Organizational interventions

  • Establish and maintain a healthy work environment by improving skilled communication, collaboration, appropriate staffing, meaningful recognition, authentic leadership, and effective decision-making
  • Promote workflow redesign with a focus on interprofessional, team-based, collaborative care
  • Advocate for policy changes that include top-of-license practice and decreased electronic medical record documentation requirements
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REFERENCES

1. Dyrbye LN, Shanafelt TD, Sinsky CA, et al Burnout among health care professionals: a call to explore and address this underrecognized threat to safe, high-quality care. NAM Perspectives. 2017.
2. The Physicians Foundation. 2018 Survey of America's Physicians: Practice Patterns & Perspectives. 2018. http://www.physiciansfoundation.org/wp-content/uploads/2018/09/physicians-survey-results-final-2018.pdf.
3. Andrew LB, Brenner BE. Physician suicide. Medscape. 2018. http://www.emedicine.medscape.com/article/806779-overview.
4. Mealer M, Moss M, Good V, Gozal D, Kleinpell R, Sessler C. What is burnout syndrome (BOS). Am J Respir Crit Care Med. 2016;194(1):P1–P2.
5. Davidson J, Mendis J, Stuck AR, DeMichele G, Zisook S. Nurse suicide: breaking the silence. NAM Perspectives. Discussion Paper. Washington, DC: National Academy of Medicine; 2018.
6. Kashani K, Carrera P, De Moraes AG, Sood A, Onigkeit JA, Ramar K. Stress and burnout among critical care fellows: preliminary evaluation of an educational intervention. Med Educ Online. 2015;20:27840.
7. Ríos-Risquez MI, García-Izquierdo M, Sabuco-Tebar ELÁ Carrillo-Garcia C, Solano-Ruiz C. Connections between academic burnout, resilience, and psychological well-being in nursing students: a longitudinal study. J Adv Nurs. 2018;74(12):2777–2784.
8. Bakhamis L, Paul DP 3rd, Smith H, Coustasse A. Still an epidemic: the burnout syndrome in hospital registered nurses. Health Care Manag (Frederick). 2019;38(1):3–10.
9. Poncet MC, Toullic P, Papazian L, et al Burnout syndrome in critical care nursing staff. Am J Respir Crit Care Med. 2007;175(7):698–704.
10. Casida JM, Combs P, Schroeder SE, Johnson C. Burnout and quality of work life among nurse practitioners in ventricular assist device programs in the United States. Prog Transplant. 2018:1526924818817018.
11. McHugh MD, Kutney-Lee A, Cimiotti JP, Sloane DM, Aiken LH. Nurses' widespread job dissatisfaction, burnout, and frustration with health benefits signal problems for patient care. Health Aff (Millwood). 2011;30(2):202–210.
12. Dyrbye LN, Massie FS Jr, Eacker A, et al Relationship between burnout and professional conduct and attitudes among US medical students. JAMA. 2010;304(11):1173–1180.
13. Shanafelt TD, Balch CM, Bechamps G, et al Burnout and medical errors among American surgeons. Ann Surg. 2010;251(6):995–1000.
14. Bachman KH, Freeborn DK. HMO physicians' use of referrals. Soc Sci Med. 1999;48(4):547–557.
15. Kushnir T, Greenberg D, Madjar N, Hadari I, Yermiahu Y, Bachner YG. Is burnout associated with referral rates among primary care physicians in community clinics. Fam Pract. 2014;31(1):44–50.
16. The Doctors Company. The future of healthcare: a national survey of physicians. 2018. http://www.thedoctors.com/contentassets/23c0cee958364c6582d4ba95afa47fcc/11724b_fohc-survey_0918_nomarks_spread_fr-1.pdf.
17. Collier R. Electronic health records contributing to physician burnout. CMAJ. 2017;189(45):E1405–E1406.
18. Mamykina L, Vawdrey DK, Hripcsak G. How do residents spend their shift time? A time and motion study with a particular focus on the use of computers. Acad Med. 2016;91(6):827–832.
19. Azoulay E, Timsit JF, Sprung CL, et al Prevalence and factors of intensive care unit conflicts: the conflicus study. Am J Respir Crit Care Med. 2009;180(9):853–860.
20. National Academy of Medicine. Action collaboration on clinician well-being and resilience. 2018. https://nam.edu/initiatives/clinician-resilience-and-well-being/.
21. Smith CD, Balatbat C, Corbridge SJ, et al Implementing optimal team-based care to reduce clinician burnout. 2018. https://nam.edu/implementing-optimal-team-based-care-to-reduce-clinician-burnout.
22. American Association of Colleges of Nursing. The Essentials of Doctoral Education for Advanced Nursing Practice. Washington, DC: Author; 2006.
23. National Organization of Nurse Practitioner Faculties. The Doctor of Nursing Practice Degree: Entry to Nurse Practitioner Practice by 2025. 2018. https://cdn.ymaws.com/www.nonpf.org/resource/resmgr/dnp/v3_05.2018_NONPF_DNP_Stateme.pdf.
24. AACN Standards for Establishing and Sustaining Healthy Work Environments. 2016. http://www.aacn.org/WD/HWE/Docs/HWEStandards.pdf.
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