nursing burnout: a communicable disease

Running head: NURSING BURNOUT: A COMMUNICABLE DISEASE 1

Nursing burnout: A communicable disease

Edward Struzinski, RN

Kaplan University

NURSING BURNOUT: A COMMUNICABLE DISEASE 2

The career of nursing can frequently prove to be very challenging. As new graduates

come into the field they are met with a host of responsibilities that can seem endless and

unwarranted. Eyes are opened and they suddenly have a new understanding of their nursing role

that they did not have as great an appreciation for while in school. New graduates are a valuable

resource needed to a healthcare field currently plagued by a nursing shortage reportedly due to

only worsen in the coming years; however, research has shown many new nurses to leave their

positions within their first year often because of poor working conditions and destructive

influences seen on their units (Laschinger, Wong, & Grau, 2013). Combined with the physical

requirements of the job and psychological demands, as well as incivility encountered in the

workplace and other incidents invoking moral distress, all of these factors may lead to an undue

amount of psychological stress. Even with proper reduction exercises, compassion fatigue may

begin to take course. Over time, this may also lead to burnout.

Burnout is a significant issue in nursing, with effects that can spread like a communicable

disease in the organization, such as destroying employee morale on the unit, poorly affecting the

retaining of experienced nurses for a quality workforce, causing budgetary financial costs to the

organization in missed days, and ultimately affecting the delivery of quality patient care. It has

been determined to also be a factor increasing patient mortality and admission length of stays, as

well as a drop in Press Ganey scores referring to general patient satisfaction of their care. This

essay aims to discuss the concept of burnout in nursing, beginning with definitions and further

discussing its implications and hopeful solutions. The goal of this essay is to shed light on the

issue of burnout, increase awareness and understanding, and hopefully invoke positive change in

the current culture seen in nursing.


Definitions

What is burnout? A literature review found multiple descriptions and, although no true

definition exists that is specific to the nursing career, “the most widely used definition of burnout

is Maslach and Jackson’s (1996), who defined it as a syndrome of emotional exhaustion,

depersonalisation [sic] and reduced personal accomplishment” (Mahony, 2011, p.30). Burnout is

essentially referred as a psychological syndrome, occupationally induced, and being at the

extreme opposite of engagement whereby the individual experiences a collapse of their human

spirit (Epp, 2012). It is a state of emotional, mental, and physical exhaustion resulting from long-

term involvement in situations that are emotionally demanding, such as found in nursing

(Fradelos et al, 2014). It is also described as a syndrome comprised of depersonalization,

emotional exhaustion, and a feeling of reduced or poor personal accomplishment (Lang,

Patrician, & Steele, 2012; Stewart & Terry, 2014) and also a syndrome of emotional exhaustion

and desensitization that is seen particularly among those serving as support service to the general

public (Tekindal, B., Tekindal, M., Pinar, Ozturk, & Alan, 2012). One psychologist expressed

burnout as a state of disappointment, physical and psychological fatigue, a feeling of

underachievement, general tiredness, and having the desire to leave work, and that it is more

common in care-taking careers (Aytekin, Yilmaz, & Kuguoglu, 2013).

Breen and Sweeney (2013) describe burnout to be the experience of emotional, physical,

and spiritual fatigue resulting from chronic exposure to demanding work stressors that are found

in healthcare. In the hospital, primary care, and residential elderly care settings, it is seen as the

mental fatigue associated from the stress on the individual’s conscience of caretaking (Juthberg,

Eriksson, Norberg, & Sundin, 2010). Burnout is further described in another relevant study as

feelings of psychological deprivation, poor or lack of accomplishment, efficacy and fatigue


(Özcakar, Kartal, Dirik, Tekin, & Guldal, 2012). And finally, in the most broad sense or

definition, nursing burnout is understood to be a severe psychological reaction to chronic work

stress encountered in the environment (Kalicińska, Chylińska, & Wilczek-Różyczka, 2012).

Attributes, theoretical and operational definitions

The signs and symptoms of a nurse experiencing burnout of their profession are

individualistic. They are listed here in no particular order: fatigue, frustration, argumentative,

overall job negativity, despair, lack of compassion or empathy, increasing conflicts with staff,

habitual tardiness and/or sick outs, carelessness, incivility behaviors, increasing errors, cynicism,

depression, crying, spousal or relationship difficulties, alcohol and/or substance abuse, suicidal

ideation, multiple patient complaints, blaming others, etc.

The burnout concept, whether in nursing or other related field, or another field entirely

outside of healthcare, is the same. It can be theoretically defined as a state of mind in which the

individual may have feelings of loss, sadness, depression, frustration, or even anger. Used in

research studies, operational definitions of concepts look more closely at the forms of distress

felt by the subjects being studied and also have a measurable scale or means to quantify the

results. The most widely used research measure in the burnout field is the Maslach Burnout

Inventory (MBI) survey (University of California, Berkeley, 2013), an indexing tool designed to

measure hypothesized characteristics of the burnout syndrome, notably: emotional exhaustion,

personal accomplishment, and depersonalization (Maslach & Jackson, 2007). Questions found

on the survey offer a subjective assessment to rank the individual’s potential or present level of

burnout and aims to calculate the most validated score.


Cause and effect

Burnout is the end result of a process of events leading up to it. An assessment of peer-

reviewed literature states that it is a syndrome having three key elements: emotional exhaustion,

depersonalization, and a reduction of personal accomplishment. Job satisfaction is but one factor

involved in the burnout process, with the individual feeling less and less of it than is needed to

maintain their energy for job performance and work relationships. Job stress increases as the

individual’s emotional and psychological well-being decreases, worsening the situation; without

appropriate therapeutic interventions, the process continues to escalate. Even the most caring

professionals may develop compassion fatigue, a feeling of indifference to the condition that an

individual is suffering from. This occurs after frequent and repeated exposure to caring for the

same. Compassion fatigue is not the same as the burnout syndrome, which occurs insidiously

over a period of time rather than the more rapid onset usually seen in compassion fatigue (The

American Institute of Stress, 2014). Burnout can happen in any nursing discipline although it is

associated with higher prevalence in areas of increased patient acuity, such as emergency

departments, intensive care units, and operating rooms. It can have an impact on patient care as

well as the nursing unit atmosphere, and it has been shown to have a direct, negative effect on

the nurse’s quality of life. One study that researched subjects in a neonatal critical care

environment positively showed the nurses experienced a moderate amount of emotional

exhaustion and personal achievement, and that as the burnout level increased, the quality of life

for the nurses decreased at significant levels (Aytekin et al., 2013). Burnout results in poor health

outcomes, such as depression and debilitated physical health; it is also a viable threat to patient

care and organizational performance (Laschinger et al., 2013).


The consequences of burnout are equally concerning, bearing significant weights that can

have a domino effect on others. These include a decline in resource effectiveness and employee

productivity, increased absenteeism due to reported sickness (whether real or perceived), low

morale on the unit, poor job performance and patient care, and increased staff attrition

(downsizing) and turnover of nurses. However, nurse turnover is not necessarily a completely

negative situation to occur. Marquis and Huston (2012) explain some turnover to be normal and

actually desirable as it infuses the atmosphere with freshness, new ideas, and reduces a

“groupthink” situation in which everyone is sharing a similar pattern of thinking and ideas. All of

these issues feed upon each other and impact the organization in more than one dimension, and

they are also as costly as much as they are preventable.

Workplace incivility

Incivility can be identified as another cause for job dissatisfaction and a factor of burnout,

with either the nurse being the recipient or the initiator of the behavior. In either case, incivility,

which is globally defined in many resources as being rude, brash, unnecessary and often

unwarranted behavior toward another individual, generates an unhealthy and unhappy

atmosphere. A previous literature review has demonstrated incivility to be commonplace in

healthcare environments, especially nursing. Using inductive reasoning, incivility cannot be

discounted as a factor leading to nursing burnout. It would, in fact, escalate it. Overwhelming

evidence in both nursing and management literature shows common links between nursing staff

turnover related to attitudes and behaviors like empowerment (positive correlation) and

workplace incivility and burnout (negative association) (Spence Laschinger, Leiter, Day, &

Gilin, 2009). Job satisfaction and a commitment to nursing staff by hospital administration are

consistently found to be important qualities that positively affect outcomes in turnover. Studies


show job satisfaction was consistently projected to occur by autonomy, good communication

between management and bedside nursing staff and organizational commitment. Another

revealed it indirectly affects turnover by nurses wanting to stay with the organization (Spence

Laschinger, et al., 2009). These studies help to shed light on the positive correlation between the

incivility behaviors experienced in nursing, or the general disrespect and professional disregard

for colleagues, and its contribution to burnout.

Empowerment and collaboration

Two powerful tools that can be found in the arsenal against burnout in nursing are the

impressionable skills of empowerment and collaboration. Each is an effective talent shown to

have positive outcomes when utilized in solutions. Empowerment is recognized to be excellent

attribute that is important to the effective functioning of an organization, such as a hospital; it is

evidenced by nurses who are inspired and motivated to contribute their talents and who are

confident that they will be acknowledged and valued for doing so (Larkin, Cierpial, Stack,

Morrison, & Griffith, 2008). Empowerment can be accomplished through the following four

practices, as outlined in Rosabeth Kanter’s theory of structural empowerment: providing access

to information, access to resources, receiving support, and being given the opportunity for

learning and professional growth (Blais & Hayes, 2011). The benefits of empowering the nursing

staff are noteworthy. It has been shown to substantially lessen the disempowering effects of

stressful working conditions commonly experienced in healthcare (Laschinger et al., 2013)

which are known contributors to the burnout syndrome. Conversely, additional research has

shown higher levels of burnout in which there were significantly lower levels of empowerment

provided to nurses (Laschinger et al., 2013).


Collaboration among co-workers is another outstanding approach to take in an effort to

prevent nurses from leading toward a burnout syndrome due to the daily stressors of the job.

Collaborative environments require mutual respect of all individuals, but most importantly, it

requires all staff to share responsibilities of one common goal equally and hold each other

accountable in reaching it. Although the idea of working in collaboration with each other would

seem obvious, the reality of it occurring in clinical practice is quite different. It means bringing

all professional positions, men and women alike, across all ages and cultural backgrounds, to

drop their preconceptions of each other and learn to get along as true professionals are expected

to, and should be doing. It means eliminating an inequality barrier that is still very present in our

world that has come so yet still has evidence of racial and gender biases.

Working together collaboratively also warrants the eradication of power of all involved:

that no one individual holds power over the other. This can be a difficult and humbling change

for many who take great pleasure in the feeling of owning authority. But it is necessary if a

group of individuals are to band together as one united team. Wilmot and Hocker (2007) state the

advantages to promoting this type of atmosphere are that it encourages mutual respect and

drawing ideas from each individual party, and that disadvantages include the fact that individuals

having better verbal skills can be manipulative, steering the direction of the group.

Each of the aforementioned qualities that are associated with improved job satisfaction

(collaboration and empowerment) is not surprisingly also noted to be qualities found in hospitals

holding Magnet status. Magnet is the leading source of best nursing practices and strategies

worldwide, recognizing hospitals for their nursing excellence and quality patient care. Reaching

this designation is the ultimate credential for high quality nursing (American Nurses

Credentialing Center, 2014). Hospitals achieving this highly acclaimed status have been proven


through research to have lower rates of nursing burnout versus non-Magnet designated facilities.

They also reveal higher job satisfaction scores, have better staff retaining ability, reduced

needlestick exposures, and lower patient mortality rates congruent with lower lengths of

admission stays (O’Mahony, 2011).

Concept application into clinical practice

Understanding and practicing these ideas of collaboration and empowerment in the

clinical setting coincides with Rosemarie Parse’s Theory of Humanbecoming, in the sense that

people are intentional beings. They choose attitudes, directions, and ways of thinking and acting;

that humans are fluent and must have an enduring respect for another individual’s ability for

change and possibilities (Alligood & Tomey, 2010). Placing into practice these skills, combined

with an understanding of behaviors that delineate workplace incivility and steering clear from

them, supports Parse’s theory by showing a deeper concern for each other, another’s feelings,

and acknowledging their human dignity.

Conclusion

Burnout in nursing is an insidious problem, progressing slowly over time from any

variety of factors causing psychological, emotional, or other form of distress, including

compassion fatigue. Research is increasingly showing that burnout occurs out of a disparity

between the individual and the job (Sabo, 2011). It can occur in any discipline of nursing

although areas of critical care interventions have higher proportions than most. Several

definitions exist but all revolve around three key elements that characterize the burnout

syndrome: emotional exhaustion, depersonalization, and poor personal accomplishment.


People need to feel a sense of achievement to maintain psychological motivation for

personal and professional expansion: stagnancy is mentally exhausting and detrimental to the

human psychological perspective. When opportunities to advance are lacking in the organization,

nurses’ efforts may go unnoticed and unacknowledged; professional development may be

hindered, creating feelings of inadequacy and hunger for personal growth; left as unsupported,

this may eventually be expressed as burnout (Ushiro & Nakayama, 2010). Job satisfaction,

another cause for burnout, can be related to other issues happening in the workplace, such as:

incivility among co-workers or hostile working environments, a non-collaborative style

atmosphere in which nurses do not feel respected by their peers for their education or experience,

or not feeling empowered in their positions as primary caretakers.

The importance of fostering a supportive environment filled with charisma,

empowerment, and collaboration cannot be over-emphasized. Not only as an intervention for

those nurses already experiencing feelings of burnout in their jobs but also for new graduates

entering the career. They represent the new age, and with them, new ideas. Collaboration in

working together is not entirely targeted for patient care but also providing a lighted path for the

new, inexperienced nurses to follow. This promotes good will that reflects good patient care, and

progressively over time it can promote a much-needed growing workforce of nurses that

continue to breed a positive culture: all of which can help prevent burnout in nursing and its

associated negative effects that have the ability to spread like a communicable disease.


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nursing burnout: a communicable disease

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