nurse burnout argumentative essay

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Guest Essay

Nurses Deserve Better. So Do Their Patients.

By Linda H. Aiken

Dr. Aiken is a professor of nursing and sociology and the founding director of the Center for Health Outcomes and Policy Research at the University of Pennsylvania School of Nursing.

The Covid-19 pandemic exposed strengths in the nation’s health care system — one of the greatest being our awesome nurses. But it also exposed many weaknesses, foremost among them being chronic nurse understaffing in hospitals , nursing homes and schools .

More nurses died of job-related Covid than any other type of health care worker. The more than 1,140 U.S. nurses who lost their lives in the first year of the pandemic knew the risks to themselves and their families. And yet they stayed in harm’s way. They cared for their fallen co-workers. They went to New York from around the country to fight on the front lines in the first Covid surge. Nurses from Northwell Health in New York returned that support by deploying to the Henry Ford Health System in Detroit in December when a surge occurred there.

We celebrate nurses now. We call them heroes. But if we value their sacrifices and want them to be there when we need them, we must prevent a return to the poor prepandemic working conditions that led to high nurse burnout and turnover rates even before Covid.

As a nurse with extensive clinical experience in hospitals, I found it nearly impossible to guarantee safe, effective and humane care to my patients. And so I established the world’s leading research center on nursing outcomes to understand the causes of nurse understaffing in the United States and abroad and to find solutions to the problem.

The United States has a robust supply of nurses . And there is no evidence that recruits to nursing have been deterred by Covid. To the contrary, applications to nursing schools increased during the pandemic.

Death, Through a Nurse’s Eyes

A short film offering a firsthand perspective of the brutality of the pandemic inside a covid-19 i.c.u..

I was looking through the window of a Covid I.C.U. And that’s when I realized I might see someone die. I didn’t even know who she was. But I was filled with immense grief as she edged closer to death by the hour. What I didn’t know yet was that by the time I left just two days later, at least three patients would be dead. The vaccine offers hope, but the sad truth is that the virus continues its brutal slaughter in I.C.U.s like this one in Phoenix, Ariz. The only people allowed in are health care workers. They’re overworked and underpaid in a deluged hospital. I wanted to know what it is like for them now, after a year of witnessing so much death. Eager to show us their daily reality, two nurses wore cameras so that for the first time we could see the I.C.U. through their eyes. “Unless you’re actually in there, you have no idea. Nobody can ever even imagine what goes on in there.” [MUSIC PLAYING] This I.C.U. contains 11 of the hospital’s sickest Covid patients. Most of them are in their 40s and 50s. And they are all on death’s door. It’s an incredibly depressing place. I blurred the patients faces to protect their privacy. But I also worried that blurring would rob them of their humanity. The family of this patient, the one who is rapidly declining, allowed her face to be shown. And they readily told me about her. Her name is Ana Maria Aragon. She’s a school administrator and a 65-year-old grandmother. Sara Reynolds, the nurse in charge of this I.C.U., organized a video call with Ana’s family to give them a chance to be with her just in case she didn’t make it. “It just breaks my heart when I hear families saying goodbye.” You might expect the doctors to be running the show. But it is really the nurses who are providing the vast majority of the care. “We do everything. We give them baths every night.” “Rubbing lotion on their feet.” “Shave the guys’ faces.” “Cleaning somebody up that had a bowel movement. It doesn’t even register as something gross.” “Look, I walk into the room. I say, hey, sounds like you have Covid. And I might order a chest X-ray. I might order blood work. I might order catheters. All that stuff is done by the nurse. I may have spent 10 minutes. The nurse might spend seven or eight hours actually in the room, caring for them. Let’s say there was a day that nurses didn’t come to the hospital. It’s like, why are you even opening?” “Ibuprofen.” 12-hour-plus shifts, isolated in this windowless room, these nurses survive by taking care of each other. “Aww, thank you.” And by finding small doses of levity. [MUSIC - JAMES BAY, “LET IT GO”] “(SINGING) Wrong. Breeze.” “I’m getting older now, and there’s all these new young nurses coming out. And I feel like a mom to all of them. Morgan, she’s got big aspirations. She loves to snowboard, and she’s so smart. And Deb, Deb’s just— she’s funny.” “I tease her all the time. I can tell her to do anything, and she’ll just do it because I think she’s scared of me because I just always say, make sure you have no wrinkles in those sheets.” The patients spend most of their time on their stomachs because it makes it easier to breathe. But the nurses have to turn them often to prevent pressure sores. There was one woman in her 50s who was so critical that this simple procedure risked killing her. “Even just turning them on their side, their blood pressure will drop. Their oxygen levels will drop.” “Her heart had actually stopped the day before. And so the concern was if it was going to make her heart stop again.” “Then come over. Push.” “We were all watching the monitors.” “I felt relieved like, whew, we did it.” Arizona’s a notoriously anti-mask state. And it faced a huge post-holiday surge in Covid cases. In January, the month I was there, Arizona had the highest rate of Covid in the world. As a result, I.C.U.s like this one have too many patients and not enough nurses. “Because they’re so critical, they need continuous monitoring, sometimes just one nurse to one patient with normally what we have is two patients to one nurse. But there definitely are times when we’re super stretched and have to have a three-to-one assignment.” A nurse shortage has plagued hospitals over the past year. To help, traveler nurses have had to fly into hotspots. Others have been forced out of retirement. Especially strained are poorer hospitals like Valleywise, which serves a low-income, predominantly Latino community. “Many of our patients are uninsured. Some of them have Medicaid, which pays something but unfortunately not enough.” This means they simply can’t compete with wealthier hospitals for nurses. “There is a bidding war. The average nurse here, give or take, makes about $35 an hour. Other hospitals, a short mile or two away, might pay them $100.” “We lost a lot of staff because they took the travel contracts. How can you blame them? It’s sometimes a once-in-a-lifetime opportunity to make a lot of money.” “Every single day I’m off, I get a call or a text. ‘Hey, we desperately need help. We need nurses. Can you come in?’” This nursing shortage isn’t just about numbers. “Physically it’s exhausting. We’re just running. We don’t have time to eat or drink or use the restroom.” “They have kids at home, doing online school. And I think, gosh, they haven’t even been able to check on their kids to see how they’re doing.” “My days off, I spend sleeping half the day because you’re exhausted. And eating because we don’t get to eat here often.” Nurses have been proud to be ranked the most trusted profession in America for nearly two decades. But during Covid, many worry they aren’t able to uphold the standards that earned them such respect. “I can’t give the quality of care that I normally would give.” “It’s absolutely dangerous.” “That’s demoralizing because we care. We’re nurses. It’s our DNA.” Ana had been in the hospital for over a month. Her family told me she was born in Mexico. She came to the States 34 years ago, first working in the fields before eventually landing her dream job in education. She’s beloved at her school. Former students often stop her in town and excitedly shout, Miss Anita. She was very cautious about Covid. She demanded her family always wear a mask and yelled at them to stay home. Yet, tragically, she somehow still caught it. “She had been declining over the course of several days. It’s a picture we have seen far too often that we know, this one is going to be coming soon.” Because there is no cure for Covid, the staff can only do so much. Once all the ventilator settings and the medications are maxed out, keeping a patient alive will only do more harm than good. So Ana’s family was forced to make a tough decision. “And I talked to family and let them know that we have offered her, we have given, we have done everything that we can, there’s nothing more that we can do. The family made the decision to move to comfort care.” “If I’m there while someone’s passing, I always hold their hand. I don’t want somebody to die alone. That’s something that brings me peace.” “Thank you.” “Thank you.” “Dance floor is packed. People hugging, holding hands, and almost no one wearing a face mask.” “I think like many health care workers, I’m angry a lot. And my faith in humanity has dwindled.” “How can you think this isn’t a real thing? How can you think that it’s not a big deal?” “Free your face. Free your face.” Arizona Gov. Doug Ducey has advocated for personal responsibility over mask mandates even though he’s been photographed maskless at a gathering and his son posted a video of a crowded dance party. “Even on the outside, they go, I don’t care. I’m not wearing a mask. I’m not getting the vaccine. That’s bullshit. The second they come into the hospital, they want to be saved. Never do they say, ‘I made the decision. I’m accepting this. Don’t do anything, doctor.’” Half a million people in this country have died from Covid. Many have been in I.C.U.s with nurses, not family members holding patients’ hands. “I always wonder, are they still going to be there when I get to work? It’s on my mind when I get home. Are they going to make it through the night? There’s one that I can think of right now.” One patient in his late 50s was so critical that he required constant supervision. Each of his breaths looked painful. “There was one day that he was kind of— he was looking a little bit better. And so he was able to shake his head and smile. And we set up a video call for him. And it was just the sweetest thing ever. I could hear his little grandson— he was probably 4 years old or so. And I saw him on the screen, too. And he was just jumping up and down, so excited. ‘You’re doing it, Grandpa. You’re doing it. We love you. Look at you. You’re getting better.’ It just broke my heart. It broke my heart. He’s one that I don’t think is going to be there when I get back on Sunday.” But I’d already been told something Sara hadn’t. The patient’s family had decided to take him off life support. “Yesterday they did? Oh. And I just think of his little grandson. And ‘you’re doing it, Grandpa. You’re doing it.’” He wasn’t the only patient who didn’t make it. When I went back to the hospital, I noticed that the bed of the patient I’d seen get flipped over was empty. My heart sank. I knew this meant she’d passed away. “What’s sad is when I go back, those beds will be full. They’ll have somebody else there just as sick with another long stretch of a few weeks ahead of them before it’s time for their family to make that decision.” I’d never before seen someone die. And even though I didn’t know these people, witnessing their deaths left me sleepless, exhausted, and depressed. It’s unfathomable to me that these nurses have gone through that every single week, sometimes every single day for an entire year. I assumed the nurses must block out all the deaths to be able to keep going, but they don’t. They grieve every single one. “I’ve always loved being a nurse. It’s what I’ve always wanted to do. And these last couple months, it’s definitely made me question my career choice.” And what makes their situation so tragic is that many of these nurses hide their trauma, leaving them feeling isolated and alone. “We’re the only ones that know what we’re going through. I don’t really want to tell my family about everything because I don’t want them to feel the same emotions that I feel. I don’t want them to know that I carry that burden when it— that it is a lot. I’m Mom. I’m strong. I can do anything. And I don’t want them to see that.” Leadership in the pandemic hasn’t come from elected officials or spiritual guides but from a group that is underpaid, overworked and considered secondary, even in their own workplaces. As so many others have dropped the ball, nurses have worked tirelessly out of the spotlight to save lives, often showing more concern for their patients than for themselves. I worry their trauma will persist long after we re-emerge from hibernation. Covid’s legacy will include a mass PTSD on a scale not felt since World War II. This burden should not be ignored. “Thank you. Thank you. I feel, yeah. And you’re all amazing.” [MUSIC PLAYING]

Nevertheless, we find ourselves too often with a shortage of nursing care. Many decades of research reveal two major reasons: First, poor working conditions, including not enough permanent employer-funded positions for nurses in hospitals, nursing homes and schools. And second, the failure of states to enact policies that establish and enforce safe nurse staffing; enable nurses to practice where they are needed, which is often across state borders; and modernize nurse licensing rules so that nurses can use their full education and expertise.

Training more nurses cannot solve these problems. But more responsible management practices in health care, along with better state policies, could.

Not only are states not requiring safe nurse staffing, but individuals also do not have the information and tools they need to pick hospitals and nursing homes based on nurse staffing or to advocate better staffing at their hospitals and nursing homes.

Ninety percent of the public in a recent Harris Poll agreed that hospitals and nursing homes should be required to meet safe nurse staffing standards. But powerful industry stakeholders — such as hospital and nursing home organizations and, often, medical societies — are strongly opposed and usually defeat legislation.

The New York State Legislature is the first in the postpandemic era to fail to approve proposed safe nurse staffing standards for hospitals. The legislature passed a bill that did not require safe nursing ratios, opting instead for internal committees at hospitals to oversee nursing and patient safety. This happened despite compelling evidence that the legislation would have resulted in more than 4,370 fewer deaths and saved more than $720 million over a two-year study period through shorter hospital stays.

What are the solutions? While there are some actions the federal government could take, the states have most of the power because of their licensing authority over occupations and facilities. The hospital and nursing home industries have long failed to police their members to remove the risk of nurse understaffing. So states should set meaningful safe nurse staffing standards, following the example of California, where hospital nurses cannot care for more than five adult patients at a time outside of intensive care. State policies are tremendously influential in health care delivery and deserve greater public attention and advocacy, as they are also ripe for exploitation by special interests.

In states with restrictive nurse licensing rules, many governors used their emergency powers during Covid surges to waive restrictions. If they were not needed during a national medical emergency, why are they needed at all?

Still, the federal government has a role to play: It should require hospitals to report patient-to-nurse staffing ratios on the Medicare Hospital Compare website, because transparency motivates improvement. The federal government could incentivize the states to pass model nurse practice acts.

We need influential champions taking on special interests so that states will make policy changes that are in the public’s interest. AARP is using its clout to advocate nurse-friendly policies. But health insurers and companies such as CVS, Walgreens and Walmart that provide health care have been on the sidelines.

While we long to go back to pre-Covid life, returning to chronic nurse understaffing in hospitals, nursing homes and schools would be a big mistake. We owe nurses and ourselves better health care resources. The so-called nurse shortage has become an excuse for not doing more to make health care safe, effective and patient-centered. State legislators must do their job. Health care leaders must fund enough positions for nurses and create reasonable working conditions so that nurses will be there to care for us all.

Linda H. Aiken is a professor of nursing and sociology and the founding director of the Center for Health Outcomes and Policy Research at the University of Pennsylvania School of Nursing.

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An earlier version of this article misstated the status of legislation on nurse staffing standards in New York State. The bill passed without setting minimum nursing ratios; it did not fail to pass.

How we handle corrections

Understanding and prioritizing nurses’ mental health and well-being

Healthcare organizations continue to feel the effects of the COVID-19 pandemic, including prolonged workforce shortages, rising labor costs, and increased staff burnout. 1 The World Health Organization defines burnout as “a syndrome conceptualized as resulting from chronic workplace stress that has not been successfully managed,” with symptoms including “feelings of energy depletion or exhaustion; increased mental distance from one’s job, or feelings of negativism or cynicism related to one’s job; and reduced professional efficacy.” For more, see “Burn-out an ‘occupational phenomenon’: International Classification of Diseases,” World Health Organization, May 28, 2019; and “Doctors not the only ones feeling burned out,” Harvard Gazette , March 31, 2023. Although nurses routinely experience job-related stress and symptoms of burnout, the COVID-19 pandemic exacerbated the challenges of this high-intensity role.

About the research collaboration between the American Nurses Foundation and McKinsey

The American Nurses Foundation is a national research, educational, and philanthropic affiliate of the American Nurses Association committed to advancing the nursing profession by serving as a thought leader, catalyst for action, convener, and funding conduit. The American Nurses Foundation and McKinsey are partnering to assess and report on trends related to the nursing profession. A foundational part of this effort is jointly publishing novel insights related to supporting nurses throughout their careers.

In April and May 2023, the American Nurses Foundation and McKinsey surveyed 7,419 nurses in the United States to better understand their experiences, needs, preferences, and career intentions. All survey questions were based on the experiences of the individual professional. All questions were also optional for survey respondents; therefore, the number of responses may vary by question. Additionally, publicly shared examples, tools, and healthcare systems referenced in this article are representative of actions that stakeholders are taking to address workforce challenges.

As part of an ongoing, collaborative research effort, the American Nurses Foundation (the Foundation) and McKinsey surveyed more than 7,000 nurses in April and May 2023 to better understand mental health and well-being in the nursing workforce (see sidebar “About the research collaboration between the American Nurses Foundation and McKinsey”). The survey results revealed that symptoms of burnout and mental-health challenges among nurses remain high; the potential long-term workforce and health implications of these persistent pressures are not yet fully understood.

In this report, we share the highlights of our most recent survey and trends over the past few years. As healthcare organizations and other stakeholders continue to evolve their approaches to these important issues, this research provides additional insight into the challenges nurses face today and highlights opportunities to ensure adequate support to sustain the profession and ensure access to care for patients.

Current state of the nursing workforce

Although many organizations have taken steps to address the challenges facing the nursing workforce, findings from the joint American Nurses Foundation and McKinsey survey from May 2023 indicate that continued action is required. Nursing turnover is beginning to decline from its 2021 high but remains above prepandemic levels. 2 2023 NSI national health care retention & RN staffing report , NSI Nursing Solutions, 2023. Intent to leave also remains high: about 20 percent of surveyed nurses indicated they had changed positions in the past six months, and about 39 percent indicated they were likely to leave their current position in the next six months. 3 Based on data from Pulse on the Nation’s Nurses Survey Series: Mental Health and Wellness Survey 4. Intent to leave was roughly 41 percent among nurses who provide direct care to patients, compared with 30 percent for nurses not in direct-patient-care roles. 4 Based on data from Pulse on the Nation’s Nurses Survey Series: Mental Health and Wellness Survey 4.

Surveyed nurses who indicated they were likely to leave cited not feeling valued by their organizations, insufficient staffing, and inadequate compensation as the top three factors influencing their decisions. 5 Based on data from Pulse on the Nation’s Nurses Survey Series: Mental Health and Wellness Survey 4. Insufficient staffing was especially important to respondents with less than ten years of experience 6 Based on data from Pulse on the Nation’s Nurses Survey Series: Mental Health and Wellness Survey 4. —a population that will be critical to retain to ensure future workforce stability.

Key survey insights on mental health and well-being

Our joint research highlighted the magnitude of the health and well-being challenges, both physical and mental, facing the nursing workforce. More than 57 percent of surveyed nurses indicated they had been diagnosed with COVID-19, and 11 percent of those indicated they had been diagnosed with post-COVID-19 conditions (PCC or “long COVID”). Additional research may be needed to fully understand the impact of PCC on nurses, but in the meantime, employers could consider augmenting their PCC services for clinicians.

Research conducted by both the Foundation and McKinsey over the past three years has identified sustained feelings of burnout among surveyed nurses—a trend that continued this year. 7 For more, see the following articles: “Mental health and wellness survey 1,” American Nurses Foundation, August 2020; “Mental health and wellness survey 2,” American Nurses Foundation, December 2020; “Mental health and wellness survey 3,” American Nurses Foundation, September 2021; Gretchen Berlin, Meredith Lapointe, Mhoire Murphy, and Molly Viscardi, “ Nursing in 2021: Retaining the healthcare workforce when we need it most ,” McKinsey, May 11, 2021; Gretchen Berlin, Meredith Lapointe, Mhoire Murphy, and Joanna Wexler, “ Assessing the lingering impact of COVID-19 on the nursing workforce ,” McKinsey, May 11, 2022; “ Nursing in 2023: How hospitals are confronting shortages ,” McKinsey, May 5, 2023. Reported contributors to burnout include insufficient staffing, high patient loads, poor and difficult leadership, and too much time spent on administrative tasks. In our joint survey, 56 percent of nurses reported experiencing symptoms of burnout, such as emotional exhaustion (Exhibit 1). Well more than half (64 percent) indicated they feel “a great deal of stress” because of their jobs. Additionally, although there have been slight improvements year over year in respondents’ reports of stress, anxiety, and feeling overwhelmed, reports of positive emotions such as feeling empowered, grateful, and confident have declined. 8 “Pulse on the Nation’s Nurses Survey Series results,” American Nurses Foundation, accessed October 20, 2023.

Our results indicate that mental health and well-being vary by nurse experience levels (Exhibit 2). Less-tenured nurse respondents were more likely to report less satisfaction with their role, had a higher likelihood of leaving their role, and were more likely to be experiencing burnout.

Despite these sustained and high levels of burnout, approximately two-thirds of surveyed nurses indicated they were not currently receiving mental-health support (a figure that remained relatively consistent in Foundation surveys over the past two years), and 56 percent of surveyed nurses believe there is stigma attached to mental-health challenges. 9 Based on data from Pulse on the Nation’s Nurses Survey Series: Mental Health and Wellness Survey 4; “Pulse on the Nation’s Nurses,” accessed October 20, 2023.

Reasons cited by nurse respondents for not seeking professional mental-health support have remained consistent over the past two years, 10 “Mental health and wellness survey 3,” September 2021. with 29 percent indicating a lack of time, 23 percent indicating they feel they should be able to handle their own mental health, and 10 percent citing cost or a lack of financial resources (Exhibit 3). For nurses with ten or fewer years of experience, lack of time ranked as the top reason for not seeking professional mental help.

Despite slight improvements to the most severe symptoms over the past six to 12 months, reported levels of sustained burnout and well-being challenges have remained consistently high since we began assessing this population in 2021. Moreover, research indicates that burnout has several adverse, long-term health effects; for example, it is a predictor of a wide range of illnesses. 11 Denise Albieri Jodas Salvagioni et al., “Physical, psychological and occupational consequences of job burnout: A systematic review of prospective studies,” PLoS One , October 2017, Volume 12, Number 10; D. Smith Bailey, “Burnout harms workers’ physical health through many pathways,” Monitor on Psychology , June 2006, Volume 37, Number 7. These health conditions incur not only personal costs but also societal and organizational costs because they influence productivity, employee retention, presence at work, and career longevity. 12 Prioritise people: Unlock the value of a thriving workforce , Business in the Community and the McKinsey Health Institute, April 2023.

Actions stakeholders can take to address mental health and well-being

To address these sustained levels of burnout, stakeholders will need to take steps to support nurses’ mental health and well-being. They will also need to address the underlying structural issues—for example, workload and administrative burden—that affect the nursing profession and that have been consistently acknowledged as root causes of burnout. Simultaneously reducing workload demands and increasing resources available to meet those demands will be critical.

A variety of interventions could address the drivers and effects of adverse nursing mental health and well-being, bolstering support for individuals, organizations, and the healthcare system at large. Various stakeholders are deploying a number of initiatives.

Applying process and operating-model interventions

Addressing the underlying drivers of burnout could help to prevent it in the first place. Research from the McKinsey Health Institute shows that the day-to-day work environment has a substantial impact on the mental health and well-being of employees. 13 “ Addressing employee burnout: Are you solving the right problem? ,” McKinsey Health Institute, May 27, 2022. Process and operating-model shifts—in the context of ongoing broader shifts in care models—could enable organizations and care teams to evolve working practices to better support job satisfaction and sustainability.

In our most recent collaborative research, almost a quarter of surveyed nurses believed their teams were not working efficiently; more than 40 percent reported that they had poor control over their workloads and that their day-to-day work was hectic and intense. 14 Based on data from Pulse on the Nation’s Nurses Survey Series: Mental Health and Wellness Survey 4. Evaluating and addressing structural aspects of the job that contribute to workload—for example, by identifying opportunities to delegate activities and enable nurses to use technology—could help support these themes. 15 Gretchen Berlin, Ani Bilazarian, Joyce Chang, and Stephanie Hammer, “ Reimagining the nursing workload: Finding time to close the workforce gap ,” McKinsey, May 26, 2023. However, providing these resources without also addressing the underlying structural drivers contributing to mental-health and well-being challenges is insufficient and can unintentionally appear to place the burden for solving problems on employees themselves. Both individual-level supports and collaborative efforts to drive structural change are required.

In addition to addressing workload challenges, employers could provide flexible work options—for example, in shift length, start time, shift commitments, and virtual activities 16 Erica Carbajal, “‘Resilience isn’t a pillar by itself’: CommonSpirit’s plan to support 44,000 nurses in 2023,” Becker’s Clinical Leadership, December 9, 2022. —to better enable employees to recharge from high levels of demands and to reduce conflicts with demands outside of work.

Finally, employers could take steps to reduce the administrative burden on nurses. More than a third of nursing respondents in our joint survey felt they spent excessive time working on electronic health records on breaks or after shifts, and 45 percent reported this activity adds frustration to their day. 17 Based on data from Pulse on the Nation’s Nurses Survey Series: Mental Health and Wellness Survey 4. Employers can look for opportunities to delegate some documentation to nursing scribes, reduce documentation requirements, or use AI to aid with documentation to help reduce this burden.

Increasing availability, awareness, and accessibility of evidence-based resources

When nurses experience symptoms of burnout or other mental-health and well-being challenges, evidence-based resources need to be available. In addition, employees need to know these resources are available, and they need to feel comfortable accessing them within the organization’s cultural context.

Investments in resources for mental health and well-being span the continuum—from mental healthcare for those experiencing clinical symptoms to well-being support tools and programs to promote healthy behaviors and mitigate sources of stress. On the higher-acuity end of the continuum, providing employees with free or subsidized access to professionally provided therapy or counseling services could help reduce the barriers employees face in getting the care they need. On the lower-acuity end, providing access to resources and training on mental-health literacy, self-monitoring, and adaptability skills could help nurses identify and mitigate sources of stress.

Investments in awareness and accessibility are important to ensure available resources are used. Roughly 19 percent of surveyed nurses who indicated they had not sought mental-health support in the past 12 months cited lack of knowledge, lack of resources, fear of losing their job, or concern about colleagues finding out as reasons for not seeking support. 18 Based on data from Pulse on the Nation’s Nurses Survey Series: Mental Health and Wellness Survey 4. To reinforce their support, employers can take steps such as establishing support networks for communities and allies, providing forums to share stories of mental health, and introducing avenues for peer-to-peer support. Additionally, resources such as a behavioral-health concierge can help all employees (including nurses) navigate, find, and access care and support.

Resources available through the Foundation

The American Nurses Foundation (the Foundation) and the American Nurses Association (ANA) provide numerous free support resources, including the following:

Well-Being Initiative. The Foundation launched the Well-Being Initiative to offer resources that focus on caring for nurses as they tirelessly care for others. 1 “Well-Being Initiative,” American Nurses Foundation, accessed October 20, 2023. These free, multimodal resources are accessible to all US nurses at any time and are completely anonymous.

Stress and Burnout Prevention Pilot Program. The Foundation launched the Stress and Burnout Prevention Pilot Program with support from the United Health Foundation to address nurse burnout and manage stress, among other goals. 2 “Stress & Burnout Prevention Program,” American Nurses Foundation, accessed October 20, 2023. The program uses the “Stress First Aid” model to facilitate discussions about stress and burnout and reduce stigma for nurses in need of support. The program goes beyond identification of burnout to intervention by helping nurses speak about stress and burnout using a common language, normalizing talking about and understanding support resources for them and their peers.

Healthy Nurse, Healthy Nation (HNHN). This ANA Enterprise program is designed to improve the nation’s health, “one nurse at a time.” 3 “Healthy Nurse, Healthy Nation,” American Nurses Foundation, accessed October 20, 2023. HNHN supports nurses in six areas: physical activity, rest, nutrition, quality of life, safety, and mental health. An online platform offers nurses inspiration, friendly competition, content and resources, and connections with other nurses, employers, and organizations.

Nurse suicide prevention. Nurses are at higher risk of suicide than the general population. 4 Christopher R. Friese and Kathryn A. Lee, “Deaths by suicide among nurses: A rapid response call,” Journal of Psychosocial Nursing and Mental Health Services , August 2021, Volume 59, Number 8. The multiple stressors they face in their profession may lead to emotional turmoil, moral distress or injury, and cognitive overload. ANA offers resources to educate nurses about suicide prevention and strategies to help them support themselves and one another. 5 “Nurse suicide prevention/resilience,” American Nurses Association, accessed October 20, 2023; “Suicide among nurses: What we don’t know might hurt us,” American Nurses Association, accessed October 20, 2023.

Accessibility of resources within the organization’s cultural context is also important, given that stigmatization of beliefs, behaviors, and policies can prevent people from feeling able to seek help when they need it. Because mental-illness stigma includes self-stigma, public stigma, and structural stigma, companies can take a holistic approach to root it out, 19 Erica Coe, Jenny Cordina, Kana Enomoto, and Nikhil Seshan, “ Overcoming stigma: Three strategies toward better mental health in the workplace ,” McKinsey Quarterly , July 23, 2021. including with education, leadership role modeling, and policies addressing discriminatory behaviors. 20 Allison Nordberg and Marla J. Weston, “Stigma: A barrier in supporting nurse well-being during the pandemic,” Nurse Leader , April 2022, Volume 20, Number 2. They can also provide information about free support resources, such as those provided by the American Nurses Foundation and the American Nurses Association (see sidebar “Resources available through the Foundation”).

Bolstering skills and capabilities

Efforts to address structural issues can be advanced by investing in training opportunities to help individuals and teams proactively support their own mental health and that of their colleagues. Training areas could include workplace mental-health intervention; critical skills for leaders and managers, such as conflict resolution and bystander intervention; and resilience and adaptability training to inculcate mindsets and behaviors across the organization that ultimately support employee mental health and well-being.

Toward a healthier future for nurses

Tackling these sustained challenges for mental health and well-being will be critical for addressing near-term workforce shortages and ensuring the health and well-being of the nursing profession in the long term. In our joint survey, many surveyed nurses indicated they chose the profession because they wanted to make a difference—by helping improve patients’ lives and care for patients in their most vulnerable moments. They value their colleagues and the care and trust of their teams. However, with less than half of surveyed nurses feeling satisfied with their jobs, they clearly need more in return to sustain them in the profession. There isn’t a one-size-fits-all approach to tackling some of the sustained well-being challenges that face nurses, but now is the time to bring additional energy and commitment to tackle the multifaceted drivers of symptoms of burnout and to support the profession in improving sustainability and fulfillment for years to come.

Gretchen Berlin, RN , is a senior partner in McKinsey’s Washington, DC, office, where Faith Burns is an associate partner; Brad Herbig is an associate partner in the Philadelphia office; and Mhoire Murphy is a partner in the Boston office. Amy Hanley is a program manager at the American Nurses Foundation, and Kate Judge is the executive director of the American Nurses Foundation.

The authors wish to thank the nurses, physicians, and staff on the front lines who are caring for patients and communities. They also wish to thank Nitzy Bustamante, Stephanie Hammer, and Brooke Tobin for their contributions to this article.

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• Published: 05 June 2020

Burnout in nursing: a theoretical review

• Chiara Dall’Ora 1 ,
• Jane Ball 2 ,
• Maria Reinius 2 &
• Peter Griffiths 1 , 2  

Human Resources for Health volume  18 , Article number:  41 ( 2020 ) Cite this article

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Workforce studies often identify burnout as a nursing ‘outcome’. Yet, burnout itself—what constitutes it, what factors contribute to its development, and what the wider consequences are for individuals, organisations, or their patients—is rarely made explicit. We aimed to provide a comprehensive summary of research that examines theorised relationships between burnout and other variables, in order to determine what is known (and not known) about the causes and consequences of burnout in nursing, and how this relates to theories of burnout.

We searched MEDLINE, CINAHL, and PsycINFO. We included quantitative primary empirical studies (published in English) which examined associations between burnout and work-related factors in the nursing workforce.

Ninety-one papers were identified. The majority ( n = 87) were cross-sectional studies; 39 studies used all three subscales of the Maslach Burnout Inventory (MBI) Scale to measure burnout. As hypothesised by Maslach, we identified high workload, value incongruence, low control over the job, low decision latitude, poor social climate/social support, and low rewards as predictors of burnout. Maslach suggested that turnover, sickness absence, and general health were effects of burnout; however, we identified relationships only with general health and sickness absence. Other factors that were classified as predictors of burnout in the nursing literature were low/inadequate nurse staffing levels, ≥ 12-h shifts, low schedule flexibility, time pressure, high job and psychological demands, low task variety, role conflict, low autonomy, negative nurse-physician relationship, poor supervisor/leader support, poor leadership, negative team relationship, and job insecurity. Among the outcomes of burnout, we found reduced job performance, poor quality of care, poor patient safety, adverse events, patient negative experience, medication errors, infections, patient falls, and intention to leave.

Conclusions

The patterns identified by these studies consistently show that adverse job characteristics—high workload, low staffing levels, long shifts, and low control—are associated with burnout in nursing. The potential consequences for staff and patients are severe. The literature on burnout in nursing partly supports Maslach’s theory, but some areas are insufficiently tested, in particular, the association between burnout and turnover, and relationships were found for some MBI dimensions only.

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Introduction

The past decades have seen a growing research and policy interest around how work organisation characteristics impact upon different outcomes in nursing. Several studies and reviews have considered relationships between work organisation variables and outcomes such as quality of care, patient safety, sickness absence, turnover, and job dissatisfaction [ 1 , 2 , 3 , 4 ]. Burnout is often identified as a nursing ‘outcome’ in workforce studies that seek to understand the effect of context and ‘inputs’ on outcomes in health care environments. Yet, burnout itself—what constitutes it, what factors contribute to its development, and what the wider consequences are for individuals, organisations, or their patients—is not always elucidated in these studies.

The term burnout was introduced by Freudenberger in 1974 when he observed a loss of motivation and reduced commitment among volunteers at a mental health clinic [ 5 ]. It was Maslach who developed a scale, the Maslach Burnout Inventory (MBI), which internationally is the most widely used instrument to measure burnout [ 6 ]. According to Maslach’s conceptualisation, burnout is a response to excessive stress at work, which is characterised by feelings of being emotionally drained and lacking emotional resources—Emotional Exhaustion; by a negative and detached response to other people and loss of idealism—Depersonalisation; and by a decline in feelings of competence and performance at work—reduced Personal Accomplishment [ 7 ].

Maslach theorised that burnout is a state, which occurs as a result of a prolonged mismatch between a person and at least one of the following six dimensions of work [ 7 , 8 , 9 ]:

Workload: excessive workload and demands, so that recovery cannot be achieved.

Control: employees do not have sufficient control over the resources needed to complete or accomplish their job.

Reward: lack of adequate reward for the job done. Rewards can be financial, social, and intrinsic (i.e. the pride one may experience when doing a job).

Community: employees do not perceive a sense of positive connections with their colleagues and managers, leading to frustration and reducing the likelihood of social support.

Fairness: a person perceiving unfairness at the workplace, including inequity of workload and pay.

Values: employees feeling constrained by their job to act against their own values and their aspiration or when they experience conflicts between the organisation’s values.

Maslach theorised these six work characteristics as factors causing burnout and placed deterioration in employees’ health and job performance as outcomes arising from burnout [ 7 ].

Subsequent models of burnout differ from Maslach’s in one of two ways: they do not conceptualise burnout as an exclusively work-related syndrome; they view burnout as a process rather than a state [ 10 ].

The job resources-demands model [ 11 ] builds on the view of burnout as a work-based mismatch but differs from Maslach’s model in that it posits that burnout develops via two separate pathways: excessive job demands leading to exhaustion, and insufficient job resources leading to disengagement. Along with Maslach and Schaufeli, this model sees burnout as the negative pole of a continuum of employee’s well-being, with ‘work engagement’ as the positive pole [ 12 ].

Among those who regard burnout as a process, Cherniss used a longitudinal approach to investigate the development of burnout in early career human services workers. Burnout is presented as a process characterised by negative changes in attitudes and behaviours towards clients that occur over time, often associated with workers’ disillusionment about the ideals that had led them to the job [ 13 ]. Gustavsson and colleagues used this model in examining longitudinal data on early career nurses and found that exhaustion was a first phase in the burnout process, proceeding further only if nurses present dysfunctional coping (i.e. cynicism and disengagement) [ 14 ].

Shirom and colleagues suggested that burnout occurs when individuals exhaust their resources due to long-term exposures to emotionally demanding circumstances in both work and life settings, suggesting that burnout is not exclusively an occupational syndrome [ 15 , 16 ].

This review aims to identify research that has examined theorised relationships with burnout, in order to determine what is known (and not known) about the factors associated with burnout in nursing and to determine the extent to which studies have been underpinned by, and/or have supported or refuted, theories of burnout.

This was a theoretical review conducted according to the methodology outlined by Campbell et al. and Pare et al. [ 17 , 18 ]. Theoretical reviews draw on empirical studies to understand a concept from a theoretical perspective and highlight knowledge gaps. Theoretical reviews are systematic in terms of searching and inclusion/exclusion criteria and do not include a formal appraisal of quality. They have been previously used in nursing, but not focussing on burnout [ 19 ]. While no reporting guideline for theoretical reviews currently exists, the PRISMA-ScR was deemed to be suitable, with some modifications, to enhance the transparency of reporting for the purposes of this review. The checklist, which can be found as Additional file 2 , has been modified as follows:

Checklist title has been modified to indicate that the checklist has been adapted for theoretical reviews.

Introduction (item 3) has been modified to reflect that the review questions lend themselves to a theoretical review approach.

Selection of sources of evidence (item 9) has been modified to state the process for selecting sources of evidence in the theoretical review.

Limitations (item 20) has been amended to discuss the limitations of the theoretical review process.

Funding (item 22) has been amended to describe sources of funding and the role of funders in the theoretical review.

All changes from the original version have been highlighted.

Literature search

A systematic search of empirical studies examining burnout in nursing published in journal articles since 1975 was performed in May 2019, using MEDLINE, CINAHL, and PsycINFO. The main search terms were ‘burnout’ and ‘nursing’, using both free-search terms and indexed terms, synonyms, and abbreviations. The full search and the total number of papers identified are in Additional file 1 .

We included papers written in English that measured the association between burnout and work-related factors or outcomes in all types of nurses or nursing assistants working in a healthcare setting, including hospitals, care homes, primary care, the community, and ambulance services. Because there are different theories of burnout, we did not restrict the definition of burnout according to any specific theory. Burnout is a work-related phenomenon [ 8 ], so we excluded studies focussing exclusively on personal factors (e.g. gender, age). Our aim was to identify theorised relationships; therefore, we excluded studies which were only comparing the levels of burnout among different settings (e.g. in cancer services vs emergency departments). We excluded literature reviews, commentaries, and editorials.

Data extraction and quality appraisal

The following data were extracted from included studies: country, setting, sample size, staff group, measure of burnout, variables the relationship with burnout was tested against, and findings against the hypothesised relationships. One reviewer (MEB) extracted data from all the studies, with CDO and JEB extracting 10 studies each to check for agreement in data extraction. In line with the theoretical review methodology, we did not formally assess the quality of studies [ 19 ]. However, in Additional file 3 , we have summarised the key aspects of quality for each study, covering generalisability (e.g. a multisite study with more than 500 participants); risk of bias from common methods variance (e.g. burnout and correlates assessed with the same survey. This bias arises when there is a shared (common) variance because of the common method rather than a true (causal) association between variables); evidence of clustering (e.g. nurses nested in wards, wards nested in hospitals); and evidence of statistical adjustment (e.g. the association between burnout and correlates has been adjusted to control for potentially influencing variables). It should be noted that cells are shaded in green when the above-mentioned quality standards have been met, and in red when they have not. In the ‘Discussion’ section, we offer a reflection on the common limitations of research in the field and present a graphic summary of the ‘strength of evidence’ in Fig. 1 .

Graphical representation of strength of relationships with burnout

Data synthesis

Due to the breadth of the evidence, we summarised extracted data by identifying common categories through a coding frame. The starting point of the coding frame was the burnout multidimensional theory outlined by Maslach [ 7 ]. We then considered whether the studies’ variables fit into Maslach’s categorisation, and where they did not, we created new categories. We identified nine broad categories: (1) Areas of Worklife; (2) Workload and Staffing Levels; (3) Job Control, Reward, Values, Fairness, and Community; (4) Shift Work and Working Patterns; (5) Psychological Demands and Job Complexity; (6) Support Factors: Working Relationships and Leadership; (7) Work Environment and Hospital Characteristics; (8) Staff Outcomes and Job Performance; and (9) Patient Care and Outcomes. In the literature, categories 1–7 were treated as predictors of burnout and categories 8 and 9 as outcomes, with the exception of missed care and job satisfaction which were treated both as predictors and outcomes.

When the coding frame was finalised, CDO and MLR applied it to all studies. Where there was disagreement, a third reviewer (JEB) made the final decision.

The database search yielded 12 248 studies, of which 11 870 were rapidly excluded as either duplicates or titles and/or abstract not meeting the inclusion criteria. Of the 368 studies accessed in full text, 277 were excluded, and 91 studies were included in the review. Figure 2 presents a flow chart of the study selection.

Study selection flow chart

The 91 studies identified covered 28 countries; four studies included multiple countries, and in one, the country was not reported. Most were from North America ( n = 35), Europe ( n = 28), and Asia ( n = 18).

The majority had cross-sectional designs ( n = 87, 97%); of these, 84 were entirely survey-based. Three studies were longitudinal. Most studies were undertaken in hospitals ( n = 82). Eight studies surveyed nurses at a national level, regardless of their work setting.

Sample sizes ranged from hundreds of hospitals (max = 927) with hundreds of thousands of nurses (max = 326 750) [ 20 ] to small single-site studies with the smallest sample being 73 nurses [ 21 ] (see Additional file 3 ).

The relationships examined are summarised in Table 1 .

Measures of burnout

Most studies used the Maslach Burnout Inventory Scale ( n = 81), which comprises three subscales reflecting the theoretical model: Emotional Exhaustion, Depersonalisation, and reduced Personal Accomplishment. However, less than half (47%, n = 39) of the papers measured and reported results with all three subscales. Twenty-three papers used the Emotional Exhaustion subscale only, and 11 papers used the Emotional Exhaustion and Depersonalisation subscales. In nine studies, the three MBI subscales were summed up to provide a composite score of burnout, despite Maslach and colleagues advising against such an approach [ 22 ].

Five studies used the Copenhagen Burnout Inventory (CBI) [ 23 ]. This scale consists of three dimensions of burnout: personal, work-related, and client-related. Two studies used the Malach-Pines Scale [ 24 ], and one used the burnout subscale of the Professional Quality of Life Measure (ProQoL5) scale, which posits burnout as an element of compassion fatigue [ 25 ]. Two studies used idiosyncratic measures of burnout based on items from other instruments [ 20 , 26 ].

Factors examined in relation to burnout: an overview

The studies which tested the relationships between burnout and Maslach’s six areas of worklife—workload, control, reward, community, fairness, and values—typically supported Maslach’s theory that these areas are predictors of burnout. However, some evidence is based only on certain MBI dimensions. High scores on the Areas of Worklife Scale [ 27 ] (indicating a higher degree of congruence between the job and the respondent) were associated with less likelihood of burnout, either directly [ 28 , 29 ] or through high occupational coping self-efficacy [ 30 ] and presence of civility norms and co-worker incivility [ 31 ].

The majority of studies looking at job characteristics hypothesised by the Maslach model considered workload ( n = 31) and job control and reward ( n = 10). While only a few studies ( n = 9) explicitly examined the hypothesised relationships between burnout and community, fairness, or values, we identified 39 studies that covered ‘supportive factors’ including relationships with colleagues and leadership.

A large number of studies included factors that fall outside of the Maslach model. Six main areas were identified:

Working patterns and shifts working ( n = 15)

Features inherent in the job such as psychological demand and complexity ( n = 24)

Job support from working relationships and leadership ( n = 39)

Hospital or environmental characteristics ( n = 28)

Staff outcomes and job performance ( n = 33)

Patient outcomes ( n = 17)

Individual attributes (personal or professional) ( n = 16)

Workload and staffing levels

Workload and characteristics of jobs that contribute to workload, such as staffing levels, were the most frequently examined factor in relation to burnout. Thirty studies found an association between high workload and burnout.

Of these, 13 studies looked specifically at measures of workload as a predictor of burnout. Workload was associated with Emotional Exhaustion in five studies [ 32 , 33 , 34 , 35 , 36 ], with some studies also reporting a relationship with Depersonalisation, and others Cynicism. Janssen reported that ‘mental work overload’ predicted Emotional Exhaustion [ 37 ]. Three studies concluded that workload is associated with both Emotional Exhaustion and Depersonalisation [ 38 , 39 , 40 ]. Kitaoka-Higashiguchi tested a model of burnout and found that heavy workload predicted Emotional Exhaustion, which in turn predicted Cynicism [ 41 ]. This was also observed in a larger study by Greengrass et al. who found that high workload was associated with Emotional Exhaustion, which consequently predicted Cynicism [ 42 ]. One study reported no association between workload and burnout components [ 43 ], and one study found an association between manageable workload and a composite burnout score [ 44 ].

Further 15 studies looked specifically at nurse staffing levels, and most reported that when nurses were caring for a higher number of patients or were reporting staffing inadequacy, they were more likely to experience burnout. No studies found an association between better staffing levels and burnout.

While three studies did not find a significant association with staffing levels [ 32 , 45 , 46 ], three studies found that higher patient-to-nurse ratios were associated with Emotional Exhaustion [ 47 , 48 , 49 ], and in one study, higher patient-to-nurse-ratios were associated with Emotional Exhaustion, Depersonalisation, and Personal Accomplishment [ 50 ]. One study concluded that Emotional Exhaustion mediated the relationship between patient-to-nurse ratios and patient safety [ 51 ]. Akman and colleagues found that the lower the number of patients nurses were responsible for, the lower the burnout composite score [ 52 ]. Similar results were highlighted by Faller and colleagues [ 53 ]. Lower RN hours per patient day were associated with burnout in a study by Thompson [ 20 ].

When newly qualified RNs reported being short-staffed, they were more likely to report Emotional Exhaustion and Cynicism 1 year later [ 54 ]. In a further study, low staffing adequacy was associated with Emotional Exhaustion [ 55 ]. Similarly, Leineweber and colleagues found that poor staff adequacy was associated with Emotional Exhaustion, Depersonalisation, and Personal Accomplishment [ 56 ]. Leiter and Spence Laschinger explored the relationship between staffing adequacy and all MBI subscales and found that Emotional Exhaustion mediated the relationship between staffing adequacy and Depersonalisation [ 57 ]. Time pressure was investigated in three studies, which all concluded that reported time pressure was associated with Emotional Exhaustion [ 58 , 59 , 60 ].

In summary, there is evidence that high workload is associated with Emotional Exhaustion, nurse staffing levels are associated with burnout, and time pressure is associated with Emotional Exhaustion.

Job control, reward, values, fairness, and community

Having control over the job was examined in seven studies. Galletta et al. found that low job control was associated with all MBI subscales [ 40 ], as did Gandi et al. [ 61 ]. Leiter and Maslach found that control predicted fairness, reward, and community, and in turn, fairness predicted values, and values predicted all MBI subscales [ 35 ]. Low control predicted Emotional Exhaustion only for nurses working the day shift [ 62 ], and Emotional Exhaustion was significantly related to control over practice setting [ 63 ]; two studies reported no effect of job control on burnout [ 44 , 64 ].

Reward predicted Cynicism [ 35 ] and burnout on a composite score [ 44 ]. Shamian and colleagues found that a higher score in the effort and reward imbalance scale was associated with Emotional Exhaustion, and higher scores in the effort and reward imbalance scale were associated with burnout measured by the CBI [ 65 ].

Value congruence refers to a match between the requirements of the job and people’s personal principles [ 7 ]. Value conflicts were related with a composite score of burnout [ 44 ], and one study concluded that nurses with a high value congruence reported lower Emotional Exhaustion than those with a low value congruence, and nurses with a low value congruence experienced more severe Depersonalisation than nurses with a high value congruence [ 66 ]. Low value congruence was a predictor of all three MBI dimensions [ 35 ] and of burnout measured with the Malach-Pines Burnout Scale [ 67 ]. Two studies considered social capital, defined as a social structure that benefits its members including trust, reciprocity, and a set of shared values, and they both concluded that lower social capital in the hospital-predicted Emotional Exhaustion [ 33 , 36 ]. A single study showed fairness predicted values, which in turn predicted all MBI Scales [ 35 ]. Two studies looked at community, and one found that community predicts a composite score of burnout [ 44 ], while the other found no relationships [ 35 ].

While not directly expressed in the terms described by Maslach, other studies demonstrate associations with possible causal factors, many of which are reflected in Maslach’s theory.

In summary, there is evidence that control over the job is associated with reduced burnout, and value congruence is associated with reduced Emotional Exhaustion and Depersonalisation.

Working patterns and shift work

Shift work and working patterns variables were considered by 15 studies. Overall, there was mixed evidence on the relationship between night work, number of hours worked per week, and burnout, with more conclusive results regarding the association between long shifts and burnout, and the potential protective effect of schedule flexibility.

Working night shifts was associated with burnout (composite score) [ 68 ] and Emotional Exhaustion [ 62 ], but the relationship was not significant in two studies [ 69 , 70 ]. Working on permanent as opposed to rotating shift patterns did not impact burnout [ 71 ], but working irregular shifts did impact a composite burnout score [ 72 ]. When nurses reported working a higher number of shifts, they were more likely to report higher burnout composite scores [ 68 ], but results did not generalise in a further study [ 69 ]. One study found working that overtime was associated with composite MBI score [ 73 ]. On-call requirement was not significantly associated with any MBI dimensions [ 71 ].

The number of hours worked per week was not a significant predictor of burnout according to two studies [ 25 , 53 ], but having a higher number of weekly hours was associated with Emotional Exhaustion and Depersonalisation in one study [ 70 ]. Long shifts of 12 h or more were associated with all MBI subscales [ 74 ] and with Emotional Exhaustion [ 49 , 75 ]. A study using the ProQoL5 burnout scale found that shorter shifts were protective of burnout [ 25 ].

Having higher schedule flexibility was protective of Emotional Exhaustion [ 46 ], and so was the ability to schedule days off for a burnout composite score [ 76 ]. Having more than 8 days off per month was associated with lower burnout [ 69 ]. Stone et al. found that a positive scheduling climate was protective of Emotional Exhaustion only [ 77 ].

In summary, we found an association between ≥ 12-h shifts and Emotional Exhaustion and between schedule flexibility and reduced Emotional Exhaustion.

Psychological demands and job complexity

There is evidence from 24 studies that job demands and aspects intrinsic to the job, including role conflict, autonomy, and task variety, are associated with some burnout dimensions.

Eight studies considered psychological demands. The higher the psychological demands, the higher the likelihood of experiencing all burnout dimensions [ 72 ], and high psychological demands were associated with higher odds of Emotional Exhaustion [ 62 , 78 ]. Emotional demands, in terms of hindrances, had an effect on burnout [ 67 ]. One study reported that job demands, measured with the Effort-Reward Imbalance Questionnaire, were correlated with all burnout dimensions [ 79 ], and similarly, Garcia-Sierra et al. found that demands predict burnout, measured with a composite scale of Emotional Exhaustion and Cynicism [ 80 ]. According to one study, job demands were not associated with burnout [ 73 ], and Rouxel et al. concluded that the higher the job demands, the higher the impact on both Emotional Exhaustion and Depersonalisation [ 64 ].

Four studies looked at task nature and variety, quality of job content, in terms of skill variety, skill discretion, task identity, task significance, influenced Emotional Exhaustion through intrinsic work motivation [ 37 ]. Skill variety and task significance were related to Emotional Exhaustion; task significance was also related to Personal Accomplishment [ 60 ]. Having no administrative tasks in the job was associated with a reduced likelihood to experience Depersonalisation [ 71 ]. Higher task clarity was associated with reduced levels of Emotional Exhaustion and increased Personal Accomplishment [ 58 ].

Patient characteristics/requirements were investigated in four papers. When nurses were caring for suffering patients and patients who had multiple requirements, they were more likely to experience Emotional Exhaustion and Cynicism. Similarly, caring for a dying patient and having a high number of decisions to forego life-sustaining treatments were associated with a higher likelihood of burnout (measured with a composite score) [ 76 ]. Stress resulting from patient care was associated with a composite burnout score [ 73 ]. Patient violence also had an impact on burnout, measured with CBI [ 81 ], as did conflict with patients [ 76 ].

Role conflict is a situation in which contradictory, competing, or incompatible expectations are placed on an individual by two or more roles held at the same time. Role conflict predicted Emotional Exhaustion [ 41 ], and so it did in a study by Konstantinou et al., who found that role conflict was associated with Emotional Exhaustion and Depersonalisation [ 34 ]; Levert and colleagues reported that role conflict correlated with Emotional Exhaustion, Depersonalisation, and Personal Accomplishment. They also considered role ambiguity, which correlated with Emotional Exhaustion and Depersonalisation, but not Personal Accomplishment [ 39 ]. Andela et al. investigated the impact of emotional dissonance, defined as the mismatch between the emotions that are felt and the emotions required to be displayed by organisations. They reported that emotional dissonance is a mediator between job aspects (i.e. workload, patient characteristics, and team issues) and Emotional Exhaustion and Cynicism. Rouxel et al. found that perceived negative display rules were associated with Emotional Exhaustion [ 64 ].

Autonomy related to Emotional Exhaustion and Depersonalisation [ 60 ], and in another study, it only related to Depersonalisation [ 43 ]. Low autonomy impacted Emotional Exhaustion via organisational trust [ 82 ]. Autonomy correlated with burnout [ 67 ]. There was no effect of autonomy on burnout according to two studies [ 58 , 63 ]. Low decision-making at the ward level was associated with all MBI subscales [ 77 ]. Decision latitude impacted Personal Accomplishment only [ 36 ], and in one study, it was found to be related to Emotional Exhaustion [ 78 ]. High decision latitude was associated with Personal Accomplishment [ 41 ] and low Emotional Exhaustion [ 33 ].

Overall, high job and psychological demands were associated with Emotional Exhaustion, as was role conflict. Patient complexity was associated with burnout, while task variety, autonomy, and decision latitude were protective of burnout.

Working relationships and leadership

Overall, evidence from 39 studies supports that having positive support factors and working relationships in place, including positive relationships with physicians, support from the leader, positive leadership style, and teamwork, might play a protective role towards burnout.

The quality of the relationship with physicians was investigated by 12 studies. In two studies, having negative relationships with physicians was associated with all MBI dimensions [ 77 , 83 ]; quality of nurse-physician relationship was associated with Emotional Exhaustion and Depersonalisation, but not PA [ 50 ]. Two studies found an association with Emotional Exhaustion only [ 55 , 84 ], and one concluded that quality of relationship with physicians indirectly supported PA [ 36 ]. This was also found by Leiter and Laschinger, who found that positive nurse-physician collaborations predicted Personal Accomplishment [ 57 , 85 ]. When burnout was measured with composite scores of MBI and a not validated scale, two studies reported an association with nurse-physician relationship [ 20 , 76 ], and two studies found no associations [ 56 , 63 ].

Having support from the supervisor or leader was considered in 12 studies, which found relationships with different MBI dimensions. A relationship between low support from nurse managers and all MBI subscales was observed in one study [ 77 ], while two studies reported it is a protective factor from Emotional Exhaustion only [ 58 , 83 ], and one that it was also associated with Depersonalisation [ 86 ]. Kitaoka-Higashiguchi reported an association only with Cynicism [ 41 ], and Jansen et al. found it was only associated with Depersonalisation and Personal Accomplishment [ 60 ]. Van Bogaert and colleagues found that support from managers predicted low Emotional Exhaustion and high Personal Accomplishment [ 84 ], but in a later study, it only predicted high Personal Accomplishment [ 36 ]. Regarding the relationship with the manager, it had a direct effect on Depersonalisation, and it moderated the effect of time pressure on Emotional Exhaustion and Depersonalisation [ 59 ]; a protective effect of a quality relationship with the head nurse on a composite burnout score was also reported [ 76 ]. Two studies using different burnout scales found an association between manager support and reduced burnout [ 25 , 67 ]. Low trust in the leader showed a negative impact on burnout, measured with a composite score [ 87 ]. Two further studies focused on the perceived nurse manager’s ability: authors found that it was related to Emotional Exhaustion [ 46 ], and Emotional Exhaustion and Personal Accomplishment [ 50 ].

Fourteen studies looked at the leadership style and found that it affects burnout through different pathways and mechanisms. Boamah et al. found that authentic leadership—described as leaders who have high self-awareness, balanced processing, an internalised moral perspective, and transparency—predicted higher empowerment, which in turn predicted lower levels of Emotional Exhaustion and Cynicism a year later [ 54 ]. Authentic leadership had a negative direct effect on workplace bullying, which in turn had a direct positive effect on Emotional Exhaustion [ 88 ]. Effective leadership predicted staffing adequacy, which in turn predicted Emotional Exhaustion [ 57 , 85 ]. Authentic leadership predicted all areas of worklife, which in turn predicted all MBI dimensions of burnout [ 30 ], and a similar pathway was identified by Laschiner and Read, although authentic leadership impacted Emotional Exhaustion only and it was also through civility norms and co-worker incivility [ 31 ]. Emotional Exhaustion mediated the relationship between authentic leadership and intention to leave the job [ 89 ]. ‘Leader empowering behaviour’ had an indirect effect on Emotional Exhaustion through structural empowerment [ 29 ], and empowering leadership predicted trust in the leader, which in turn was associated with burnout composite score [ 87 ]. Active management-by-exception was beneficial for Depersonalisation and Personal Accomplishment, passive laissez-faire leadership negatively affected Emotional Exhaustion and Personal Accomplishment, and rewarding transformational leadership protected from Depersonalisation [ 90 ]. Contrary to this, Madathil et al. found that transformational leadership protected against Emotional Exhaustion, but not Depersonalisation, and promoted Personal Accomplishment [ 43 ]. Transformational leadership predicted positive work environments, which in turn predicted lower burnout (composite score) [ 44 ]. Positive leadership affected Emotional Exhaustion and Depersonalisation [ 56 ] and burnout measured with a non-validated scale [ 20 ].

Teamwork and social support were also explored. Co-worker cohesion was only related to Depersonalisation [ 58 ]; team collaboration problems predicted negative scores on all MBI subscales [ 38 ], and workplace support protected from Emotional Exhaustion [ 72 ]. Similarly, support received from peers had a protective effect on Emotional Exhaustion [ 60 ]. Collegial support was related to Emotional Exhaustion and Personal Accomplishment [ 39 ], and colleague support protected from burnout [ 67 ]. Interpersonal conflict affected Emotional Exhaustion through role conflict, but co-worker support had no effect on any burnout dimensions [ 41 ], and similarly, co-worker incivility predicted Emotional Exhaustion [ 31 ], and so did bullying [ 88 ]. Poor team communication was associated with all MBI dimensions [ 40 ], staff issues predicted burnout measured with a composite score [ 73 ], and so did verbal violence from colleagues [ 68 ]. One study found that seeking social support was not associated with any of the burnout dimensions, while another study found that low social support predicted Emotional Exhaustion [ 37 ], and social support was associated with lower Emotional Exhaustion and higher Personal Accomplishment [ 21 ]. Vidotti et al. found an association between low social support and all MBI dimensions [ 62 ].

Work environment and hospital characteristics

Eleven studies were considering the work environment measured with the PES-NWI scale [ 91 ], where higher scores indicate positive work environments. Five studies comprising diverse samples and settings concluded that the better rated the work environment, the lower the likelihood of experiencing Emotional Exhaustion [ 32 , 47 , 49 , 51 , 92 ], and four studies found the same relationship, but on both Emotional Exhaustion and Depersonalisation [ 50 , 66 , 93 , 94 ]; only one study concluded there is an association between work environment and all MBI dimensions [ 95 ]. Negative work environments affected burnout (measured with a composite score) via job dissatisfaction [ 96 ]. One study looked at organisational characteristics on a single scale and found that a higher rating of organisational characteristics predicted lower Emotional Exhaustion [ 82 ]. Environmental uncertainty was related to all MBI dimensions [ 86 ].

Structural empowerment was also considered in relation to burnout: high structural empowerment led to lower Emotional Exhaustion and Cynicism via staffing levels and worklife interference [ 54 ]; in a study using a similar methodology, structural empowerment affected Emotional Exhaustion via Areas of Worklife [ 29 ]. The relationship between Emotional Exhaustion and Cynicism was moderated by organisational empowerment [ 40 ], and organisational support had a protective effect on burnout [ 67 ]. Hospital management and organisational support had a direct effect on Emotional Exhaustion and Personal Accomplishment [ 84 ]. Trust in the organisation predicted lower levels of Emotional Exhaustion [ 82 ] and of burnout measured with a composite MBI score [ 87 ].

Three studies considered whether policy involvement had an effect on burnout. Two studies on the same sample found that having the opportunity to participate in policy decisions was associated with reduced burnout (all subscales) [ 57 , 85 ], and one study did not report results for the association [ 20 ]. Emotional Exhaustion mediated the relationship between nurses’ participation in hospital affairs and their intention to leave the job [ 97 ]; a further study did not found an association between participation in hospital affairs and Emotional Exhaustion, but only with Personal Accomplishment [ 50 ]. Lastly, one study investigated participation in research groups and concluded it was associated with reduced burnout measured with a composite score [ 76 ].

There was an association between opportunity for career advancement and all MBI dimensions [ 77 ]; however, another study found that having promotion opportunities was not related to burnout [ 79 ]. Moloney et al. found that professional development was not related to burnout [ 67 ]. Two studies considered pay. In one study, no effect was found on any MBI dimension [ 73 ], and a very small study ( n = 78 nurses) reported an effect of satisfaction with pay on Emotional Exhaustion and Depersonalisation [ 34 ]. Job insecurity predicted Depersonalisation and PA [ 79 ].

When the hospital adopted nursing models of care rather than medical models of care, nurses were more likely to report high levels of Personal Accomplishment [ 57 , 85 ]. However, another study found no significant relationship [ 20 ]. Regarding ward and hospital type, Aiken and Sloane found that RNs working in specialised AIDS units reported lower levels of Emotional Exhaustion [ 98 ]; however, ward type was not found to be significantly associated with burnout in a study on temporary nurses [ 53 ]. Working in different ward settings was not associated with burnout, but working in hospitals as opposed to in primary care was associated with lower Emotional Exhaustion [ 71 ]. Working in a small hospital was associated with a lower likelihood of Emotional Exhaustion, when compared to working in a community hospital [ 63 ]. Faller’s study also concluded that working in California was a significant predictor of reduced burnout.

When the hospitals’ investment in the quality of care was considered, one study found that having foundations for quality of care was associated with reduced Emotional Exhaustion only [ 50 ], but in another study, foundations for quality of care were associated with all MBI dimensions [ 83 ]. Working in a Magnet hospital was not associated with burnout [ 53 ].

In summary, having a positive work environment (generally work environments scoring higher on the PES-NWI scale) was associated with reduced Emotional Exhaustion, and so was higher structural empowerment. However, none of the organisational characteristics at the hospital level was consistently associated with burnout.

Staff outcomes and job performance

Nineteen studies considered the impact of burnout on intention to leave. Two studies found that Emotional Exhaustion and Cynicism had a direct effect on turnover intentions [ 28 , 99 ], and four studies reported that only Emotional Exhaustion affected intentions to leave the job [ 21 , 32 , 37 , 100 ], with one of these indicating that Emotional Exhaustion affected also intention to leave the organisation [ 32 ], but one study did not replicate such findings [ 101 ] and concluded that only Cynicism was associated with intention to leave the job and nursing. Similarly, one study found that Cynicism was directly related to intention to leave [ 35 ]. A further study found that Emotional Exhaustion affected turnover intentions via job satisfaction [ 88 ], and one article reported that Emotional Exhaustion mediated the effect of authentic leadership on intention to leave [ 89 ]. Emotional Exhaustion was a mediator between nurses’ involvement with decisions and intention to leave the organisation [ 97 ]. Burnout measured on a composite score was associated with a higher intention to leave [ 96 ]. Laeeque et al. reported that burnout, captured with CBI, related to intention to leave [ 81 ]; Estryn-Behar et al. used the same scale to measure burnout and found that high burnout was associated with higher intention to leave in all countries, except for Slovakia [ 102 ]. Burnout, measured with the Malach-Pines Scale, was associated with intention to quit, and stronger associations were found for nurses who had higher perceptions of organisational politics [ 103 ]. Burnout (Malach-Pines Scale) predicted both the intention to leave the job and nursing [ 67 ]. Three studies investigated the relationship between burnout and intention to leave; one of these aggregated all job outcomes in a single variable (i.e. job satisfaction, intention to leave the hospital, applied for another job, and intention to leave nursing) and reported that Depersonalisation and Personal Accomplishment predict job outcomes [ 84 ]; they replicated a similar approach and found the same associations [ 36 ]. They later found that all MBI dimensions were associated with leaving the nursing profession [ 104 ]. Only one study in a sample of 106 nurses from one hospital found an association between Depersonalisation and turnover within 2 years [ 105 ].

Two studies looked at the effect of burnout on job performance: one found a negative association between burnout (measured with CBI) and both task performance and contextual performance [ 106 ]. Only Emotional Exhaustion was associated with self-rated and supervisor-rated job performance of 73 RNs [ 21 ]. Missed care was investigated in three studies, and it was found to be both predictor of Emotional Exhaustion [ 32 ], an outcome of burnout [ 20 , 103 ].

Four studies considered sickness absence. When RNs had high levels of Emotional Exhaustion, they were more likely to experience short-term sickness absence (i.e. 1–10 days of absence), which was obtained from hospital administrative records. Similarly, Emotional Exhaustion was associated with seven or more days of absence in a longitudinal study [ 105 ]. Emotional Exhaustion was significantly associated with reported mental health absenteeism, but not reported physical health absenteeism, and sickness absence from administrative records [ 21 ]. One study did not find any meaningful relationships between burnout and absenteeism [ 107 ].

Emotional Exhaustion was a significant predictor of general health [ 73 ], and in a further study, both Emotional Exhaustion and Personal Accomplishment were associated with perceived health [ 70 ]. Final-year nursing students who experienced health issues were more likely to develop high burnout when entering the profession [ 26 ]. When quality of sleep was treated both as a predictor and outcome of burnout, relationships were found in both instances [ 106 ].

Focussing on mental health, one study found that burnout predicted mental health problems for newly qualified nurses [ 30 ], and Emotional Exhaustion and Cynicism predicted somatisation [ 42 ]. Depressive symptoms were predictive of Emotional Exhaustion and Depersonalisation, considering therefore depression as a predictor of burnout [ 108 ]. Rudman and Gustavsson also found that having depressive mood and depressive episodes were common features of newly qualified nurses who developed or got worse levels of burnout throughout their first years in the profession [ 26 ]. Tourigny et al. considered depression as a predictor and found it was significantly related to Emotional Exhaustion [ 107 ].

Eleven studies considered job satisfaction: of these, three treated job satisfaction as a predictor of burnout and concluded that higher levels of job satisfaction were associated with a lower level of composite burnout scores [ 52 , 96 ] and all MBI dimensions [ 94 ]. According to two studies, Emotional Exhaustion and Cynicism predicted job dissatisfaction [ 54 , 101 ], while four studies reported that Emotional Exhaustion only was associated with increased odds to report job dissatisfaction [ 73 , 82 , 88 , 100 ]; one study reported that Cynicism only was associated with job dissatisfaction [ 99 ]. Rouxel et al. did not find support in their hypothesised model that Emotional Exhaustion and Depersonalisation predicted job satisfaction [ 64 ].

In summary, considering 39 studies, there is conflicting evidence on the direction of the relationship between burnout and missed care, mental health, and job satisfaction. An association between burnout and intention to leave was found, although only one small study reported an association between burnout and turnover. A moderate relationship was found for the effect of burnout on sickness absence, job performance, and general health.

Patient care and outcomes

Among the patient outcomes of burnout, quality of care was investigated by eight studies. Two studies in diverse samples and settings reported that high Emotional Exhaustion, high Depersonalisation, and low Personal Accomplishment were associated with poor quality of care [ 109 , 110 ], but one study found that only Personal Accomplishment was related to better quality of care at the last shift [ 104 ]; Emotional Exhaustion and Cynicism predict low quality of care [ 54 ]; two articles reported that Emotional Exhaustion predicts poor nurse ratings of quality of care [ 82 , 84 ]. A high burnout composite score predicted poor nurse-assessed quality of care [ 96 ]. In one instance, no associations were found between any of the burnout dimensions and quality of care [ 36 ].

Five studies considered aspects of patient safety: burnout was correlated with negative patient safety climate [ 111 ]. Emotional Exhaustion and Depersonalisation were both associated with negative patient safety grades and safety perceptions [ 112 ], and burnout fully mediated the relationship between depression and individual-level safety perceptions and work area/unit level safety perceptions [ 108 ]. Emotional Exhaustion mediated the relationship between workload and patient safety [ 51 ], and a higher composite burnout score was associated with lower patient safety ratings [ 113 ].

Regarding adverse events, high DEP and low Personal Accomplishment predicted a higher rate of adverse events [ 85 ], but in another study, only Emotional Exhaustion predicted adverse events [ 51 ]. When nurses were experiencing high levels of Emotional Exhaustion, they were less likely to report near misses and adverse events, and when they were experiencing high levels of Depersonalisation, they were less likely to report near misses [ 112 ].

All three MBI dimensions predicted medication errors in one study [ 109 ], but Van Bogaert et al. found that only high levels of Depersonalisation were associated with medication errors [ 104 ]. High scores in Emotional Exhaustion and Depersonalisation predicted infections [ 109 ]. Cimiotti et al. found that Emotional Exhaustion was associated with catheter-associated urinary tract infections and surgical site infections [ 114 ], while in another study, Depersonalisation was associated with nosocomial infections [ 104 ]. Lastly, patient falls were also explored, and Depersonalisation and low Personal Accomplishment were significant predictors in one study [ 109 ], while in a further study, only Depersonalisation was associated with patient falls [ 104 ]. There was no association between burnout and hospital-acquired pressure ulcers [ 20 ].

Considering patient experience, Vahey et al. concluded that higher Emotional Exhaustion and low Personal Accomplishment levels were associated with patient dissatisfaction [ 93 ], and Van Bogaert et al. found that Emotional Exhaustion was related to patient and family verbal abuse, and Depersonalisation was related to both patient and family verbal abuse and patient and family complaints [ 104 ].

In summary, evidence deriving from 17 studies points to a negative effect of burnout on quality of care, patient safety, adverse events, error reporting, medication error, infections, patient falls, patient dissatisfaction, and family complaints, but not on pressure ulcers.

Individual characteristics

In total, 16 studies, which had examined work characteristics related to burnout, also considered the relationship between characteristics of the individual and burnout. Relationships were tested on demographic variables, including gender, age, and family status; on personality aspects; on work-life interference; and on professional attributes including length of experience and educational level. Because our focus on burnout is as a job-related phenomenon, we have not reported results of these studies into detail, but overall evidence on demographic and personality factors was inconclusive, and having family issues and high work-life interference was associated with different burnout dimensions. Being younger and not having a bachelor’s degree were found to be associated with a higher incidence of burnout.

This review aimed to identify research that had examined theorised relationships with burnout, in order to determine what is known (and not known) about the factors associated with burnout in nursing and to determine the extent to which studies have been underpinned by, and/or have supported or refuted, theories of burnout. We found that the associations hypothesised by Maslach’s theory between mismatches in areas of worklife and burnout were generally supported.

Research consistently found that adverse job characteristics—high workload, low staffing levels, long shifts, low control, low schedule flexibility, time pressure, high job and psychological demands, low task variety, role conflict, low autonomy, negative nurse-physician relationship, poor supervisor/leader support, poor leadership, negative team relationship, and job insecurity—were associated with burnout in nursing.

However few studies used all three MBI subscales in the way intended, and nine used different approaches to measuring burnout.

The field has been dominated by cross-sectional studies that seek to identify associations with one or two factors, rarely going beyond establishing correlation. Most studies were limited by their cross-sectional nature, the use of different or incorrectly applied burnout measures, the use of common methods (i.e. survey to capture both burnout and correlates), and omitted variables in the models. The 91 studies reviewed, while highlighting the importance of burnout as a feature affecting nurses and patient care, have generally lacked a theoretical approach, or identified mechanisms to test and develop a theory on the causes and consequences of burnout, but were limited in their testing of likely mechanisms due to cross-sectional and observational designs.

For example, 19 studies showed relationships between burnout and job satisfaction, missed care, and mental health. But while some studies treated these as predictors of burnout, others handled as outcomes of burnout. This highlights a further issue that characterises the burnout literature in nursing: the simultaneity bias, due to the cross-sectional nature of the evidence. The inability to establish a temporal link means limits the inference of causality [ 115 ]. Thus, a factor such as ‘missed care’ could lead to a growing sense of compromise and ‘crushed ideals’ in nurses [ 116 ], which causes burnout. Equally, it could be that job performance of nurses experiencing burnout is reduced, leading to increased levels of ‘missed care’. Both are plausible in relation to Maslach’s original theory of burnout, but research is insufficient to determine which is most likely, and thereby develop the theory.

To help address this, three areas of development within research are proposed. Future research adopting longitudinal designs that follow individuals over time would improve the potential to understand the direction of the relationships observed. Research using Maslach’s theory should use and report all three MBI dimensions; where only the Emotional Exhaustion subscale is used, this should be explicit and it should not be treated as being synonymous to burnout. Finally, to move our theoretical understanding of burnout forward, research needs to prioritise the use of empirical data on employee behaviours (such as absenteeism, turnover) rather than self-report intentions or predictions.

Addressing these gaps would provide better evidence of the nature of burnout in nursing, what causes it and its potential consequences, helping to develop evidence-based solutions and motivate work-place change. With better insight, health care organisations can set about reducing the negative consequences of having patient care provided by staff whose work has led them to become emotionally exhausted, detached, and less able to do the job, that is, burnout.

Limitations

Our theoretical review of the literature aimed to summarise information from a large quantity of studies; this meant that we had to report studies without describing their context in the text and also without providing estimates (i.e. ORs and 95% CIs). In appraising studies, we did not apply a formal quality appraisal instrument, although we noted key omissions of important details. However, the results of the review serve to illustrate the variety of factors that may influence/result from burnout and demonstrate where information is missing. We did not consider personality and other individual variables when extracting data from studies. However, Maslach and Leiter recently reiterated that although some connections have been made between burnout and personality characteristics, the evidence firmly points towards work characteristics as the primary drivers of burnout [ 8 ].

While we used a reproducible search strategy searching MEDLINE, CINAHL, and PsycINFO, it is possible that there are studies indexed elsewhere and we did not identify them, and we did not include grey literature. It seems unlikely that these exist in sufficient quantity to substantively change our conclusions.

Patterns identified across 91 studies consistently show that adverse job characteristics are associated with burnout in nursing. The potential consequences for staff and patients are severe. Maslach’s theory offers a plausible mechanism to explain the associations observed. However incomplete measurement of burnout and limited research on some relationships means that the causes and consequences of burnout cannot be reliably identified and distinguished, which makes it difficult to use the evidence to design interventions to reduce burnout.

Availability of data and materials

Not applicable

Abbreviations

• Maslach Burnout Inventory

Copenhagen Burnout Inventory

Professional Quality of Life Measure

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CDO led the paper write-up at all stages, designed and conducted the search strategy, completed the initial screening of papers, co-developed the coding frame, and applied the coding frame to all studies. JB conceived the review, co-developed the coding frame, applied the coding frame to all studies, and contributed substantially to drafting the paper at various stages. MR extracted all the data from studies and produced evidence tables. PG conceived the review and contributed substantially to the drafting of the paper at various stages. All authors read and approved the final manuscript.

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Top Nursing Argumentative Essay Topics: Engage in Thought-Provoking Debates

This article was written in collaboration with Christine T. and ChatGPT, our little helper developed by OpenAI.

Nursing is a diverse and evolving field, constantly presenting new challenges and debates. As a nursing student or professional, engaging in these discussions allows you to develop critical thinking and writing skills while expanding your field knowledge. This blog post will explore various nursing argumentative essay topics to help you find inspiration for your next paper.

Patient Care and Ethics

• The ethics of administering experimental treatments to terminally ill patients
• Balancing patient autonomy and nurse responsibility in care decisions
• Addressing cultural and religious beliefs in end-of-life care
• The role of informed consent in patient care and treatment decisions
• Ethical considerations in the allocation of scarce medical resources
• The ethics of withholding information from patients for their benefit
• Patient privacy and confidentiality in the age of electronic health records
• Comparing faith practices in healthcare: Sikhism, Judaism, Bahaism, and Christianity
• The ethics of using restraints in patient care
• The ethical implications of non-compliance with prescribed treatments
• The role of nursing in advocating for patients’ rights
• Ethical considerations in caring for patients with mental health disorders
• The ethics of mandatory vaccinations for healthcare workers
• Addressing moral distress among nurses in patient care situations
• The ethics of caring for patients who refuse life-saving treatments
• The role of advance directives in ethical decision-making for patient care
• Ethical considerations in the care of patients with substance use disorders
• The ethics of healthcare rationing in times of crisis
• The ethical implications of assisted reproductive technologies
• Addressing ethical dilemmas in neonatal and pediatric nursing
• The ethics of pain management in nursing practice
• Pediatric oncology: working towards better treatment through evidence-based research
• Ethical considerations in the care of patients with dementia and cognitive decline
• The ethics of genetic testing and personalized medicine in patient care
• The ethical implications of clinical trials and research involving human subjects
• The role of nursing in addressing ethical issues related to organ transplantation
• Ethical considerations in the care of prisoners and detainees
• The ethics of involuntary treatment and psychiatric care
• Euthanasia: an analysis of utilitarian approach
• Addressing ethical challenges in the care of patients with disabilities
• The ethical implications of medical tourism and cross-border healthcare
• The role of nursing in addressing ethical issues related to global health
• Ethical considerations in the care of military veterans and their families
• The ethics of surrogate decision-making in patient care
• Addressing ethical challenges in the care of patients with chronic and terminal illnesses
• The role of nursing in promoting patient advocacy and self-determination
• Ethical considerations in the care of patients with rare diseases and conditions
• The ethics of care rationing in the context of an aging population
• The role of nursing in addressing ethical issues related to access to healthcare
• Ethical considerations in the care of patients during public health emergencies
• The ethics of triage and prioritization of care in emergencies
• The role of nursing in promoting environmental sustainability and addressing ethical issues related to climate change
• Ethical challenges in the care of patients at the end of life

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Technological Advancements in Nursing

• The impact of electronic health records on nursing practice and patient care
• The role of telemedicine in expanding access to healthcare services
• How wearables and remote monitoring devices are changing nursing care
• The integration of artificial intelligence in nursing practice and decision-making
• The use of virtual reality in nursing education and training
• Ethical considerations in the use of advanced technologies in nursing practice
• The role of robotics in patient care and nursing support
• The impact of mobile health apps on nursing practice and patient engagement
• The use of big data and analytics in improving patient outcomes and nursing practice
• The role of 3D printing in medical device innovation and patient care
• The integration of telehealth in the management of chronic conditions
• The use of social media and online platforms for professional development and networking in nursing
• Usability, integration, and interoperability of healthcare technology
• The impact of advanced diagnostics and imaging technologies on nursing practice
• The role of blockchain technology in improving healthcare data security and management
• The use of gamification in nursing education and patient engagement
• The impact of technology on nursing workflow and time management
• The role of virtual assistants and chatbots in patient care and nursing support
• Clinical laboratory IT security: challenges, implications, and solutions
• The use of augmented reality in nursing education and practice
• The integration of telepsychiatry and mental health services in nursing care
• The impact of technology on nurse-patient communication and relationship-building
• The role of electronic prescribing and medication management systems in reducing medication errors
• The use of telemonitoring and remote care in the management of high-risk pregnancies
• The impact of technology on infection control and prevention in healthcare settings
• The role of smart home technologies in supporting aging-in-place and home-based care
• The use of technology in promoting self-care and patient empowerment
• Safeguarding patient information: nursing informatics best practices for privacy and security in healthcare
• The integration of genomics and personalized medicine in nursing practice
• The role of technology in addressing healthcare disparities and promoting health equity
• The impact of technology on nursing workforce planning and resource allocation
• The use of predictive analytics in identifying high-risk patients and improving care coordination
• The role of technology in promoting interprofessional collaboration and communication in healthcare
• The impact of technology on nursing education and the development of future nursing competencies
• The role of technology in supporting disaster response and emergency preparedness in nursing
• The use of technology in promoting patient safety and reducing medical errors
• The impact of technology on nursing leadership and management
• The role of technology in addressing the social determinants of health and promoting community health
• The integration of technology in palliative and end-of-life care
• The use of technology in enhancing patient engagement and satisfaction in nursing care
• The role of technology in promoting evidence-based practice and research in nursing
• The impact of technology on nursing ethics and professional boundaries
• The role of technology in addressing the global nursing shortage and promoting workforce sustainability

Nursing Education and Professional Development

• The role of simulation-based learning in nursing education
• The impact of online learning on nursing education outcomes
• Integrating cultural competence in nursing curricula
• Strategies for promoting lifelong learning in nursing practice
• The role of mentorship in nursing professional development
• Addressing the transition from student nurse to professional nurse
• The impact of interprofessional education on nursing practice and patient outcomes
• The role of nursing preceptorship in clinical education
• Strategies for reducing nursing student attrition and promoting retention
• The integration of evidence-based practice in nursing education
• The role of reflective practice in nursing professional development
• Addressing the nursing faculty shortage: Challenges and solutions
• The impact of standardized testing on nursing education and practice
• The role of nursing leadership development in healthcare transformation
• Strategies for enhancing critical thinking skills in nursing education
• Global health learning in nursing and health care disparities
• The impact of clinical experience on nursing students’ confidence and competence
• The role of continuing education in maintaining nursing competency and licensure
• Addressing the needs of diverse learners in nursing education
• The impact of technology on nursing education and the development of digital literacy skills
• Digital healthcare and organizational learning: enhancing patient care through technology and knowledge management
• The role of nursing education in promoting health literacy and patient education
• Strategies for promoting resilience and self-care in nursing education
• The impact of global health experiences on nursing students’ cultural competence and professional development
• The role of nurse educators in shaping the future of nursing practice
• Addressing the challenges of teaching nursing ethics and professional values
• The impact of accreditation standards on nursing education and program quality
• The role of professional nursing organizations in supporting continuing education and development
• Strategies for fostering a culture of learning and professional growth in nursing practice
• The impact of nursing education on patient outcomes and quality of care
• The role of nursing education in addressing healthcare disparities and promoting health equity
• The integral role of nurses in healthcare systems: the importance of education and experience
• Addressing the challenges of teaching and assessing clinical judgment in nursing education
• The impact of nursing education on workforce development and nursing shortages
• The role of nursing education in promoting environmental sustainability and planetary health
• Strategies for promoting effective communication and teamwork in nursing education
• The impact of nursing education on patient safety and error prevention
• The role of nursing education in promoting innovation and entrepreneurship in healthcare
• Addressing the needs of adult learners and nontraditional students in nursing education
• The impact of nursing education on interprofessional collaboration and healthcare team dynamics
• The role of nursing education in promoting ethical decision-making and moral courage in practice
• Strategies for enhancing nursing students’ clinical reasoning and decision-making skills
• The impact of nursing education on the development of professional identity and role socialization

Healthcare Policies and Nursing Practice

• The role of nurses in shaping healthcare policy and advocating for reform
• The impact of the Affordable Care Act on nursing practice and patient care
• Addressing the nursing shortage: policy initiatives and workforce strategies
• Understanding the impact of the American Healthcare System Regulatory Acts
• The role of nursing scope of practice regulations on healthcare delivery and outcomes
• The impact of healthcare reimbursement policies on nursing practice and patient care
• The role of nursing in addressing the opioid crisis: policy and practice implications
• The impact of public health policies on nursing practice and community health
• The role of nursing in promoting healthcare access and reducing disparities
• The impact of healthcare quality and safety regulations on nursing practice
• The role of nursing in implementing evidence-based practice guidelines and policies
• The impact of health information technology policies on nursing practice and patient care
• The role of nursing in addressing social determinants of health through policy and practice interventions
• The impact of nurse staffing regulations on patient outcomes and workforce planning
• The role of nursing in promoting health literacy and patient-centered care through policy and practice initiatives
• Healthcare management: career paths and requirements
• The impact of healthcare privacy and confidentiality policies on nursing practice and patient trust
• The role of nursing in promoting environmental sustainability and climate change policies in healthcare
• The impact of healthcare workforce diversity policies on nursing practice and cultural competence
• The role of nursing in promoting global health and addressing international healthcare challenges
• The impact of mental health policies on nursing practice and the care of patients with mental health disorders
• The role of nursing in promoting value-based care and payment models in healthcare
• The impact of healthcare cost containment policies on nursing practice and resource allocation
• The role of nursing in promoting patient safety and quality improvement through policy and practice initiatives
• The impact of healthcare reform on nursing education and workforce development
• Understanding the US health care reform: necessity, challenges, and implementation
• The role of nursing in promoting health equity and addressing healthcare disparities through policy and practice interventions
• The impact of healthcare policies on nursing leadership and management roles
• The role of nursing in promoting interprofessional collaboration and teamwork through policy and practice initiatives
• The impact of healthcare policies on the integration of technology in nursing practice and patient care
• The role of nursing in promoting ethical decision-making and moral courage through policy and practice initiatives
• The impact of healthcare policies on nursing practice in rural and underserved communities
• The role of nursing in promoting innovation and entrepreneurship in healthcare through policy and practice initiatives
• Combating health care-associated infections: a community-based approach
• The impact of healthcare policies on advanced practice nursing roles and scope of practice
• The role of nursing in promoting palliative and end-of-life care through policy and practice initiatives
• The impact of healthcare policies on infection control and prevention in nursing practice and patient care
• The role of nursing in addressing the challenges of an aging population through policy and practice initiatives
• The impact of healthcare policies on nursing practice in the care of patients with chronic and complex conditions
• The role of nursing in promoting patient advocacy and self-determination through policy and practice initiatives
• The impact of healthcare policies on nursing practice in disaster response and emergency preparedness
• The role of nursing in promoting evidence-based practice and research through policy and practice initiatives
• The impact of healthcare policies on nursing practice in the care of vulnerable and high-risk populations
• The role of nursing in addressing the global nursing shortage and promoting workforce sustainability through policy and practice initiatives

Cultural Competence and Health Equity

• The role of cultural competence in reducing healthcare disparities
• Integrating cultural competence into nursing education and practice
• Addressing implicit bias in nursing practice and patient care
• The impact of cultural competence on patient satisfaction and outcomes
• The role of nursing in promoting health literacy among diverse populations
• Strategies for effective communication with patients from diverse backgrounds
• Mental health and gender inequality
• The impact of cultural competence on nurse-patient relationship-building and trust
• The role of nursing in addressing social determinants of health and promoting health equity
• Addressing the challenges of providing culturally competent care in rural and remote settings
• The impact of cultural competence on interprofessional collaboration and teamwork
• Bridging the gap: tackling maternal and child health disparities between developed and underdeveloped countries
• The role of nursing in promoting cultural competence in healthcare organizations
• Addressing health disparities among LGBTQ+ populations through culturally competent nursing care
• The impact of cultural competence on the prevention and management of chronic diseases
• The role of nursing in promoting culturally competent mental health care
• Addressing health disparities among immigrant and refugee populations through culturally competent nursing care
• The impact of cultural competence on patient safety and error prevention
• The role of nursing in promoting cultural competence in palliative and end-of-life care
• Addressing health disparities among indigenous populations through culturally competent nursing care
• The impact of cultural competence on the care of patients with disabilities
• The role of nursing in promoting culturally competent care for patients with substance use disorders
• Addressing health disparities among racial and ethnic minority populations through culturally competent nursing care
• The impact of cultural competence on the care of patients with rare diseases and conditions
• The role of nursing in promoting culturally competent care in global health settings
• Addressing the challenges of providing culturally competent care in disaster response and emergency preparedness
• The impact of cultural competence on nursing leadership and management
• The role of nursing in promoting culturally competent care in the context of an aging population
• Addressing health disparities among low-income populations through culturally competent nursing care
• The impact of cultural competence on nursing practice in the care of patients with complex and chronic conditions
• The role of nursing in promoting culturally competent care for military veterans and their families
• Addressing health disparities among women and girls through culturally competent nursing care
• The impact of cultural competence on nursing practice in the care of patients with infectious diseases
• The role of nursing in promoting culturally competent care for incarcerated individuals and detainees
• Addressing health disparities among individuals with limited English proficiency through culturally competent nursing care
• The impact of cultural competence on nursing practice in the care of patients at the end of life
• The role of nursing in promoting culturally competent care in the context of climate change and environmental health
• Addressing health disparities among individuals experiencing homelessness through culturally competent nursing care
• The impact of cultural competence on nursing practice in the care of patients with traumatic experiences
• The role of nursing in promoting culturally competent care in the context of medical tourism and cross-border healthcare
• Addressing health disparities among individuals with low health literacy through culturally competent nursing care
• The impact of cultural competence on nursing practice in the care of vulnerable and high-risk populations

Mental Health and Burnout in Nursing

• The prevalence of burnout among nursing professionals
• Strategies for preventing and addressing nurse burnout
• The impact of nurse burnout on patient care and outcomes
• The role of nursing leadership in addressing mental health and burnout
• Promoting self-care and resilience among nursing professionals
• The impact of nurse burnout on job satisfaction and retention
• The role of nursing education in addressing mental health and burnout
• Strategies for fostering a healthy work-life balance in nursing
• The impact of nurse burnout on interprofessional collaboration and teamwork
• The role of peer support and mentorship in addressing mental health and burnout
• The impact of nurse burnout on nursing errors and patient safety
• The role of workplace wellness programs in addressing mental health and burnout
• Strategies for managing stress and anxiety in nursing practice
• The impact of nurse burnout on professional development and career progression
• The role of professional nursing organizations in addressing mental health and burnout
• The impact of nurse burnout on healthcare costs and resource allocation
• The role of nursing research in understanding and addressing mental health and burnout
• Strategies for promoting emotional intelligence and self-awareness in nursing practice
• The impact of nurse burnout on the nursing workforce and workforce planning
• The role of nursing in promoting mental health and well-being among patients and families
• The impact of nurse burnout on ethical decision-making and moral distress
• The role of nursing in addressing mental health disparities and stigma
• Strategies for promoting a culture of empathy and compassion in nursing practice
• The impact of nurse burnout on nurse-patient communication and relationship-building
• The role of nursing in addressing mental health needs in rural and underserved communities
• The impact of nurse burnout on nursing advocacy and policy engagement
• The role of nursing in promoting mental health and well-being in global health settings
• Strategies for addressing mental health and burnout among nursing students and new graduates
• The impact of nurse burnout on nursing education and faculty well-being
• The role of nursing in addressing mental health needs in disaster response and emergency preparedness
• The impact of nurse burnout on nursing practice in the care of patients with mental health disorders
• The role of nursing in promoting mental health and well-being in the context of an aging population
• Strategies for addressing mental health and burnout among advanced practice nurses
• The impact of nurse burnout on nursing practice in the care of patients with chronic and complex conditions
• The role of nursing in promoting mental health and well-being among military veterans and their families
• The impact of nurse burnout on nursing practice in the care of patients with substance use disorders
• The role of nursing in addressing mental health needs in the context of climate change and environmental health
• Strategies for addressing mental health and burnout among nurses working with vulnerable and high-risk populations
• The impact of nurse burnout on nursing practice in the care of patients at the end of life
• The role of nursing in promoting mental health and well-being in the context of healthcare innovation and change

Now that you have a list of thought-provoking nursing argumentative essay topics, you can engage in meaningful debates and expand your knowledge in the field. Consider various perspectives, use credible sources to support your arguments, and practice clear, concise writing. Happy writing!

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Preventing Nurse Burnout With Workplace Interventions Essay

Introduction.

This capstone project’s goal is to explore the issue of nurse burnout in the healthcare industry. Burnout is a widespread problem that affects not only the health and well-being of nurses but also the quality of patient care (Fitzpatrick et al., 2019). According to Bogue and Bogue (2020), burnout emerges as an epidemic in healthcare. This research will look at the origins and consequences of nurse burnout and identify strategies for preventing and managing burnout in the workplace. The research is conducted through a review of relevant literature and a survey of healthcare facilities and nurses.

Project Proposal Topic

The project proposal focuses on the exploration of nurse burnout in the healthcare industry. The aim is to understand the causes, consequences, and strategies for preventing and managing nurse burnout in the workplace. According to Buckley et al. (2020), peer-reviewed literature ensures the quality of the data reviewed. Therefore, the research will include a literature review and a survey of healthcare facilities and nurses. This project aims to contribute to developing practical solutions for reducing nurse burnout and improving the quality of patient care.

Capstone Proposal

Project Question (PICOT): What is the impact of workplace interventions on reducing nurse burnout in the healthcare industry? Title of the Project: Preventing Nurse Burnout: An Examination of Workplace Interventions. Proposal: Nurse burnout is a serious issue that affects not only the health and well-being of nurses but also the quality of patient care (Fitzpatrick et al., 2019). This capstone project examines workplace interventions’ impact on reducing nurse burnout in the healthcare industry. It sheds light on the effectiveness of workplace interventions in reducing nurse burnout.

One of the interventions that will be explored is the implementation of workplace wellness programs. These programs can include activities such as exercise classes, stress management workshops, and counseling services. Another intervention that will be studied is flexible scheduling, allowing nurses more control over their work-life balance (Mlambo et al., 2021). Generally, the role of nurse managers in promoting a healthy work environment and addressing nurse burnout will also be examined. This project aims to explore the effectiveness of workplace wellness programs.

The findings provide valuable insight into the effectiveness of workplace interventions in reducing nurse burnout. It informs the development of strategies to promote a healthier work environment for nurses. The work environment is the conditions in which nurses work (Buckley et al., 2020). Ultimately, this project aims to improve the quality of patient care by reducing nurse burnout. It also promotes a sustainable work environment for nurses and other healthcare practitioners.

The issue of nurse burnout is a pressing concern in the healthcare industry, affecting the standard of patient care and the nurses’ health and well-being. The signs of burnout entail emotional exhaustion, depersonalization, and decreased personal accomplishment (Bogue & Bogue, 2020). It can lead to reduced job satisfaction and increased healthcare costs. This capstone project aims to address nurse burnout by exploring the impact of workplace interventions on reducing burnout levels. The project addresses nurse burnout by examining the effect of workplace interventions.

A literature study and a survey of hospitals and nurses will be used to conduct the research. It will focus on identifying effective strategies for preventing and managing nurse burnout in the workplace. This project was selected because nurse burnout is a critical issue in the healthcare industry and significantly impacts nurses’ and patients’ care quality (Johnson et al., 2017). Nurses have witnessed the toll that burnout can take on their colleagues. Finding ways to address this issue is crucial for nurses’ well-being and the healthcare industry’s sustainability.

Nurse burnout has multiple causes, including extended hours and high stress. It results in burnout symptoms like exhaustion and feeling overwhelmed. It can also result in excessive workload and increased pressure on nurses to perform their duties efficiently. The study will explore ways to enhance the work environment for nurses and reduce burnout through practical solutions. It aims to contribute to a healthier and more sustainable workplace for nursing professionals.

Literature Review

The literature review plays a crucial role in this capstone project. It provides a comprehensive understanding of the current research on nurse burnout and workplace interventions to reduce burnout levels (Bogue & Bogue, 2020). It will examine peer-reviewed articles and other academic sources to identify the key themes and findings related to the problem of nurse burnout and effective strategies for reducing it (Buckley et al., 2020). This information will inform the design of the survey component and the development of recommendations for improving the work environment for nurses. It serves as a foundation for the project, ensuring that the methodology is well-informed and based on the latest scientific evidence.

Methods of Searching

A literature review was conducted using both electronic and manual resources. Relevant databases such as PubMed, CINAHL, and ProQuest were searched using keywords related to nursing burnout and workplace interventions (Norful et al., 2018). The manual search involved reviewing reference lists of relevant articles and books. The investigation was limited to English language sources published in the last five years. The sources were then evaluated for relevance, quality, and credibility before being included in the literature review. This comprehensive and systematic approach ensured that the information gathered was up-to-date and relevant to the current state of the research.

Review of the Literature

The literature review examined the growing issue of nurse burnout and the potential solutions to address this problem. The study used electronic and manual resources, including PubMed, CINAHL, and ProQuest databases, to compile the most recent information. It was restricted to sources published within the last five years. The restriction ensured that the information gathered was up-to-date and relevant to the current state of the research. Filtering occurred in the database used to produce peer-reviewed articles.

The literature found that nurse burnout is a growing concern in nursing. High levels of burnout impact the quality of care and contribute to high turnover rates. Contributing factors to nurse burnout include heavy workloads, lack of support from colleagues and supervisors, and poor working conditions (Dall’Ora et al., 2020). The nurse will ultimately reduce their work performance, and some will desire to quit. Eventually, the healthcare system faces challenges whenever there are scarce nurses.

The literature review identified several workplace interventions that have shown promise in reducing burnout. These include programs to improve work-life balance and provide nurses with support and resources. Another intervention is to improve the working conditions of the nurses. One study found that a workplace wellness program, which provided education and resources for stress management and self-care, significantly reduced nurse burnout (Johnson et al., 2017). It highlights the significance of nurse burnout and the need for effective interventions to address this issue.

Further research shows more interventions that could reduce nurse burnout. According to another study, offering opportunities for professional development and growth, such as continuing education and leadership training, reduced burnout and improved job satisfaction among nurses (Fitzpatrick et al., 2019). Regular skill renewal and upgrading are necessary for healthcare workers. The literature review also highlighted the importance of addressing burnout at the organizational level. It includes creating a supportive work environment, promoting work-life balance, and providing resources and support for nurses.

Nurse burnout is a significant problem in the healthcare industry. It affects both the well-being of nurses and the quality of patient care. Workplace interventions, such as wellness programs and professional development opportunities, have shown promise in reducing burnout and improving nurses’ job satisfaction (Johnson et al., 2017). However, the most practical methods for reducing nurse burnout and enhancing the working conditions for nurses require more investigation. This capstone project aims to contribute to the ongoing effort to reduce nurse burnout and improve the work environment for nurses.

The literature has shown that nurse burnout is a growing concern in nursing. Burnout harms the quality of care nurses provide. Heavy workloads, a lack of support from peers and managers, and unfavorable working circumstances are all factors that contribute to nursing burnout (Dall’Ora et al., 2020). The literature review identified several workplace interventions that have shown promise in reducing burnout. These include programs to improve work-life balance, provide nurses with support and resources, and improve working conditions.

Additionally, addressing nurse burnout at the organizational level through supportive work environments and involving nurses in decision-making can help reduce burnout. It is found that continued professional development in nursing is an effective strategy for reducing nurse burnout and enhancing the nursing workforce (Mlambo et al., 2021). A nurse practitioner is an example of a registered nurse holding a doctoral degree. The findings intend to lessen nurse burnout and enhance the working conditions for nurses. These findings provide valuable insight into the most successful strategies for promoting a healthy and sustainable work environment for nurses.

The project targets nurse burnout with three objectives. Objective 1: Evaluate the workplace wellness program’s impact on nurse burnout (Ernawati et al., 2022). Objective 2: Boost nurse engagement by involving them in decision-making (Fitzpatrick et al., 2019). Objective 3: Improve nurse work-life balance with flexible arrangements and resources for stress management. These objectives ensure that the project is focused and aligned to reduce nurse burnout.

Two strategies will be employed to achieve the first objective: to identify the extent of nurse burnout in healthcare facilities. Firstly, a survey will be administered to a sample of nurses to assess their level of burnout (Ernawati et al., 2022). The survey will include questions about the frequency and intensity of symptoms associated with burnout. These may entail emotional exhaustion, depersonalization, and a reduced sense of personal accomplishment. Secondly, a focus group will be organized to allow nurses to share their experiences and perspectives on nurse burnout.

The second objective is to understand the contributing factors to nurse burnout. Two strategies will be used in order to achieve this. Firstly, the survey and focus group results will be analyzed to identify patterns or trends. Secondly, a review of the relevant literature will be conducted to identify gaps in the current understanding of nurse burnout (Buckley et al., 2020). All this will ensure that all relevant factors are considered when developing strategies to reduce nurse burnout.

The third objective is to develop and implement an intervention to reduce nurse burnout. A customized program will be designed that addresses the contributing factors identified in the analysis of the survey and focus group results. It may include training sessions on stress management for nurses and healthcare administrators (Ernawati et al., 2022). Secondly, workplace practices will be implemented to support work-life balance for nurses. It includes flexible schedules and opportunities for professional development for nurses.

Evaluation of the project will be crucial to determine its success in achieving the objectives and improving patient outcomes/safety. Several methods will be used to evaluate the capstone project. These include data analysis, surveys, random interviews, and focus groups. The data collected from these methods will be used to determine the effectiveness of the strategies implemented in addressing the objectives (Dall’Ora et al., 2020). One of the required evaluation methods will be data analysis.

The patient data is analyzed to determine any improved outcomes and safety. It includes patient satisfaction levels, patient outcomes, and the number of adverse events. The collection of data is before and after the implementation of the strategies. A comparison of the two data sets will be used to determine if there has been any improvement. In addition to data analysis, surveys and focus groups will gather feedback from patients and healthcare providers.

The evaluations will provide insight into the perceived effectiveness of the strategies and any potential areas for improvement. This feedback will refine the plan and make any necessary changes to improve patient safety (Fitzpatrick et al., 2019). The project evaluation will be ongoing and will provide valuable information on its effectiveness. The assessment results will be used to make necessary changes to the project and ensure that it continues improving patient outcomes and safety. Upon thorough evaluation, the project is ready to be actualized.

The budget for this project will include various items necessary for its successful implementation. These items include resources for conducting workshops and training sessions for the nursing staff, materials for disseminating information and awareness, and software and tools required for data collection and analysis. The funding for these budget items will come from various sources, such as grants, sponsorships, and in-kind contributions from the healthcare organization where the project will be implemented. The total budget required for the successful completion of the project will be determined after carefully considering all the necessary expenses. It will be subject to change as per the needs of the project.

Nurse burnout is a pressing issue affecting the quality of patient care and nursing professionals’ overall health and well-being. The capstone project aims to combat nurse burnout, which affects patient care and health (Ernawati et al., 2022). Evidence supports the need for stress-reducing interventions to enhance work-life balance. The project targets the issue of nurse burnout and its negative impact on patients and healthcare workers. The study aims to offer a solution to improve outcomes for both patients and healthcare professionals.

The objectives and strategies outlined in this proposal are well-defined and achievable. The evaluation plan will help determine the effectiveness of the interventions. The initiative has the potential to significantly influence many people’s lives and the healthcare system as a whole, with sufficient financing and support. It is a valuable contribution to the field of nursing and healthcare. The project will help advance the understanding of mitigating nurse burnout and promoting better patient care outcomes.

The project aims to address the issue of nurse burnout through research and interventions. It, therefore, offers solutions to promote healthy work environments for nurses. New nurses face challenges and often lack resilience, but this project can guide the healthcare industry in supporting these professionals (Buckley et al., 2020). The insights gained will benefit nurses and patients, creating a brighter future in the healthcare field. This project serves as a blueprint for governments and institutions to follow in preventing nurse burnout.

Bogue, T. L., & Bogue, R. L. (2020). Extinguish Burnout in Critical Care Nursing . Critical Care Nursing Clinics of North America , 32 (3), 451–463. Web.

Buckley, L., Berta, W., Cleverley, K., Medeiros, C., & Widger, K. (2020). What is known about paediatric nurse burnout: a scoping review . Human Resources for Health , 18 (1). Web.

Dall’Ora, C., Ball, J., Reinius, M., & Griffiths, P. (2020). Burnout in nursing: a theoretical review . Human Resources for Health , 18 (1). Web.

Ernawati, E., Mawardi, F., Roswiyani, R., Melissa, M., Wiwaha, G., Tiatri, S., & Hilmanto, D. (2022). Workplace wellness programs for working mothers: A systematic review . Journal of Occupational Health , 64 (1). Web.

Fitzpatrick, B., Bloore, K., & Blake, N. (2019). Joy in Work and Reducing Nurse Burnout: From Triple Aim to Quadruple Aim . AACN Advanced Critical Care , 30 (2), 185–188. Web.

Johnson, J., Hall, L. H., Berzins, K., Baker, J., Melling, K., & Thompson, C. (2017). Mental healthcare staff well-being and burnout: A narrative review of trends, causes, implications, and recommendations for future interventions . International Journal of Mental Health Nursing , 27 (1), 20–32. Web.

Mlambo, M., Silén, C., & McGrath, C. (2021). Lifelong learning and nurses’ continuing professional development, a metasynthesis of the literature . BMC Nursing , 20 (1). Web.

Norful, A. A., De Jacq, K., Carlino, R., & Poghosyan, L. (2018). Nurse Practitioner–Physician Comanagement: A Theoretical Model to Alleviate Primary Care Strain . The Annals of Family Medicine , 16 (3), 250–256. Web.

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IvyPanda. (2024, January 30). Preventing Nurse Burnout With Workplace Interventions. https://ivypanda.com/essays/preventing-nurse-burnout-with-workplace-interventions/

"Preventing Nurse Burnout With Workplace Interventions." IvyPanda , 30 Jan. 2024, ivypanda.com/essays/preventing-nurse-burnout-with-workplace-interventions/.

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IvyPanda . 2024. "Preventing Nurse Burnout With Workplace Interventions." January 30, 2024. https://ivypanda.com/essays/preventing-nurse-burnout-with-workplace-interventions/.

1. IvyPanda . "Preventing Nurse Burnout With Workplace Interventions." January 30, 2024. https://ivypanda.com/essays/preventing-nurse-burnout-with-workplace-interventions/.

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IvyPanda . "Preventing Nurse Burnout With Workplace Interventions." January 30, 2024. https://ivypanda.com/essays/preventing-nurse-burnout-with-workplace-interventions/.

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Peer-reviewed

Research Article

The relationship between workload and burnout among nurses: The buffering role of personal, social and organisational resources

Roles Conceptualization, Data curation, Formal analysis, Investigation, Methodology, Project administration, Resources, Software, Validation, Visualization, Writing – original draft, Writing – review & editing

Affiliation Institute of Occupational, Social and Environmental Medicine, University Medical Center of the Johannes Gutenberg University Mainz, Mainz, Germany

Roles Conceptualization, Data curation, Investigation, Methodology, Project administration, Resources, Software, Writing – review & editing

Roles Conceptualization, Funding acquisition, Investigation, Resources, Writing – review & editing

Roles Conceptualization, Investigation, Methodology, Project administration, Resources, Supervision, Writing – review & editing

Affiliation Institute for Health Services Research in Dermatology and Nursing (IVDP), University Medical Center Hamburg-Eppendorf, Hamburg, Germany

Roles Conceptualization, Investigation, Methodology, Resources, Supervision, Writing – review & editing

Affiliations Institute for Health Services Research in Dermatology and Nursing (IVDP), University Medical Center Hamburg-Eppendorf, Hamburg, Germany, Department for Occupational Medicine, Hazardous Substances and Health Science, Institution for Accident Insurance and Prevention in the Health and Welfare Services (BGW), Hamburg, Germany

Roles Conceptualization, Funding acquisition, Investigation, Methodology, Project administration, Resources, Supervision, Writing – review & editing

¶ ‡ These authors are joint senior authors on this work.

Affiliations Institute of Occupational, Social and Environmental Medicine, University Medical Center of the Johannes Gutenberg University Mainz, Mainz, Germany, Federal Institute for Occupational Safety and Health (BAuA), Berlin, Germany

Roles Supervision, Writing – review & editing

* E-mail: [email protected]

• Elisabeth Diehl, 
• Sandra Rieger, 
• Stephan Letzel, 
• Anja Schablon, 
• Albert Nienhaus, 
• Luis Carlos Escobar Pinzon, 
• Pavel Dietz

• Published: January 22, 2021
• https://doi.org/10.1371/journal.pone.0245798
• Peer Review
• Reader Comments

Workload in the nursing profession is high, which is associated with poor health. Thus, it is important to get a proper understanding of the working situation and to analyse factors which might be able to mitigate the negative effects of such a high workload. In Germany, many people with serious or life-threatening illnesses are treated in non-specialized palliative care settings such as nursing homes, hospitals and outpatient care. The purpose of the present study was to investigate the buffering role of resources on the relationship between workload and burnout among nurses. A nationwide cross-sectional survey was applied. The questionnaire included parts of the Copenhagen Psychosocial Questionnaire (COPSOQ) (scale ‘quantitative demands’ measuring workload, scale ‘burnout’, various scales to resources), the resilience questionnaire RS-13 and single self-developed questions. Bivariate and moderator analyses were performed. Palliative care aspects, such as the ‘extent of palliative care’, were incorporated to the analyses as covariates. 497 nurses participated. Nurses who reported ‘workplace commitment’, a ‘good working team’ and ‘recognition from supervisor’ conveyed a weaker association between ‘quantitative demands’ and ‘burnout’ than those who did not. On average, nurses spend 20% of their working time with palliative care. Spending more time than this was associated with ‘burnout’. The results of our study imply a buffering role of different resources on burnout. Additionally, the study reveals that the ‘extent of palliative care’ may have an impact on nurse burnout, and should be considered in future studies.

Citation: Diehl E, Rieger S, Letzel S, Schablon A, Nienhaus A, Escobar Pinzon LC, et al. (2021) The relationship between workload and burnout among nurses: The buffering role of personal, social and organisational resources. PLoS ONE 16(1): e0245798. https://doi.org/10.1371/journal.pone.0245798

Editor: Adrian Loerbroks, Universtiy of Düsseldorf, GERMANY

Received: July 30, 2020; Accepted: January 7, 2021; Published: January 22, 2021

Copyright: © 2021 Diehl et al. This is an open access article distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

Data Availability: According to the Ethics Committee of the Medical Association of Rhineland-Palatinate (Study ID: 837.326.16 (10645)), the Institute of Occupational, Social and Environmental Medicine of the University Medical Center of the University Mainz is specified as data holding organization. The institution is not allowed to share the data publically in order to guarantee anonymity to the institutions that participated in the survey because some institution-specific information could be linked to specific institutions. The data set of the present study is stored on the institution server at the University Medical Centre of the University of Mainz and can be requested for scientific purposes via the institution office. This ensures that data will be accessible even if the authors of the present paper change affiliation. Postal address: University Medical Center of the University of Mainz, Institute of Occupational, Social and Environmental Medicine, Obere Zahlbacher Str. 67, D-55131 Mainz. Email address: [email protected] .

Funding: The research was funded by the BGW - Berufsgenossenschaft für Gesundheitsdienst und Wohlfahrtspflege (Institution for Statutory Accident Insurance and Prevention in Health and Welfare Services). The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.

Competing interests: I have read the journal’s policy and the authors of this manuscript have the following competing interests: The project was funded by the BGW - Berufsgenossenschaft für Gesundheitsdienst und Wohlfahrtspflege (Institution for Statutory Accident Insurance and Prevention in Health and Welfare Services). The BGW is responsible for the health concerns of the target group investigated in the present study, namely nurses. Prof. Dr. A. Nienhaus is head of the Department for Occupational Medicine, Hazardous Substances and Health Science of the BGW and co-author of this publication. All other authors declare to have no potential conflict of interest. This does not alter our adherence to PLOS ONE policies on sharing data and materials.

Introduction

Our society has to face the challenge of a growing number of older people [ 1 ], combined with an expected shortage of skilled workers, especially in nursing care [ 2 ]. At the same time, cancer patients, patients with non-oncological diseases, multimorbid patients [ 3 ] and patients suffering from dementia [ 4 ] are to benefit from palliative care. In Germany, palliative care is divided into specialised and general palliative care ( Table 1 ). The German Society for Palliative Medicine (DGP) estimated that 90% of dying people are in need of palliative care, but only 10% of them are in need of specialised palliative care, because of more complex needs, such as complex pain management [ 5 ]. The framework of specialised palliative care encompasses specialist outpatient palliative care, inpatient hospices and palliative care units in hospitals. In Germany, most nurses in specialised palliative care have an additional qualification [ 6 ]. Further, nurses in specialist palliative care in Germany have fewer patients to care for than nurses in other fields which results in more time for the patients [ 7 ]. Most people are treated within general palliative care in non-specialized palliative care settings, which is provided by primary care suppliers with fundamental knowledge of palliative care. These are GPs, specialists (e.g. oncologists) and, above all, staff in nursing homes, hospitals and outpatient care [ 8 ]. Nurses in general palliative care have basic skills in palliative care from their education. However, there is no data available on the extent of palliative care they provide, or information on an additional qualification in palliative care. Palliative care experts from around the world consider the education and training of all staff in the fundamentals of palliative care to be essential [ 9 ] and a study conducted in Italy revealed that professional competency of palliative care nurses was positively associated with job satisfaction [ 10 ]. Thus, it is possible that the extent of palliative care or an additional qualification in palliative care may have implications on the working situation and health status of nurses. In Germany, there are different studies which concentrate on people dying in hospitals or nursing homes and the associated burden on the institution’s staff [ 11 , 12 ], but studies considering palliative care aspects concentrate on specialised palliative care settings [ 6 , 13 , 14 ]. Because the working conditions of nurses in specialised and general palliative care are somewhat different, as stated above, this paper focuses on nurses working in general palliative care, in other words, in non-specialized palliative care settings.

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https://doi.org/10.1371/journal.pone.0245798.t001

Burnout is a large problem in social professions, especially in health care worldwide [ 19 ] and is consistently associated with nurses intention to leave their profession [ 20 ]. Burnout is a state of emotional, physical, and mental exhaustion caused by a long-term mismatch of the demands associated with the job and the resources of the worker [ 21 ]. One of the causes for the alarming increase in nursing burnout is their workload [ 22 , 23 ]. Workload can be either qualitative (pertaining to the type of skills and/or effort needed in order to perform work tasks) or quantitative (the amount of work to be done and the speed at which it has to be performed) [ 24 ].

Studies analysing burnout in nursing have recognised different coping strategies, self-efficacy, emotional intelligence factors, social support [ 25 , 26 ], the meaning of work and role clarity [ 27 ] as protective factors. Studies conducted in the palliative care sector identified empathy [ 28 ], attitudes toward death, secure attachment styles, and meaning and purpose in life as protective factors [ 29 ]. Individual factors such as spirituality and hobbies [ 30 ], self-care [ 31 ], coping strategies for facing the death of a patient [ 32 ], physical activity [ 33 ] and social resources, like social support [ 33 , 34 ], the team [ 6 , 13 ] and time for patients [ 32 ] were identified, as effectively protecting against burnout. These studies used qualitative or descriptive methods or correlation analyses in order to investigate the relationship between variables. In contrast to this statistical approach, fewer studies examined the buffering/moderating role of resources on the relationship between workload and burnout in nursing. A moderator variable affects the direction and/or the strength of the relationship between two other variables [ 35 ]. A previous study has showed resilience as being a moderator for emotional exhaustion on health [ 36 ], and other studies revealed professional commitment or social support moderating job demands on emotional exhaustion [ 37 , 38 ]. Furthermore, work engagement and emotional intelligence was recognised as a moderator in the work demand and burnout relationship [ 39 , 40 ].

We have analysed the working situation of nurses using the Rudow Stress-Strain-Resources model [ 41 ]. According to this model, the same stressor can lead to different strains in different people depending on available resources. These resources can be either individual, social or organisational. Individual resources are those resources which are owned by an individual. This includes for example personal capacities such as positive thinking as well as personal qualifications. Social resources consist of the relationships an individual has, this includes for example relationships at work as well as in his private life. Organisational resources refer to the concrete design of the workplace and work organisation. For example, nurses reporting a good working team may experience workload as less threatening and disruptive because a good working team gives them a feeling of security, stability and belonging. According to Rudow, individual, social or organisational resources can buffer/moderate the negative effects of job demands (stressors) on, for example, burnout (strain).

Nurses’ health may have an effect on the quality of the services offered by the health care system [ 42 ], therefore, it is of great interest to do everything possible to preserve their health. This may be achieved by reducing the workload and by strengthening the available resources. However, to the best of our knowledge, we are not aware of any study which considers palliative care aspects within general palliative care in Germany. Therefore, the aim of the study was to investigate the buffering role of resources on the relationship between workload (‘quantitative demands’) and burnout among nurses. Palliative care aspects, such as information on the extent of palliative care were incorporated to the analyses as covariates.

Study design and participants

An exploratory cross-sectional study was conducted in 2017. In Germany, there is no national register for nurses. Data for this study were collected from a stratified 10% random sample of a database with outpatient facilities, hospitals and nursing homes in Germany from the Institution for Statutory Accident Insurance and Prevention in Health and Welfare Services in Germany. This institution is part of the German social security system. It is the statutory accident insurer for nonstate institutions in the health and welfare services in Germany and thus responsible for the health concerns of the target group investigated in the present study, namely nurses. Due to data protection rules, this institution was also responsible for the first contact with the health facilities. 126 of 3,278 (3.8%) health facilities agreed to participate in the survey. They informed the study team about how many nurses worked in their institution, and whether the nurses would prefer to answer a paper-and-pencil questionnaire (with a pre-franked envelope) or an online survey (with an access code ). 2,982 questionnaires/access codes were sent out to the participating health facilities (656 to outpatient care, 160 to hospitals and 2,166 to nursing homes), where they were distributed to the nurses ( S1 Table ). Participation was voluntary and anonymous. Informed consent was obtained written at the beginning of the questionnaire. Approval to perform the study was obtained by the ethics committee of the State Chamber of Medicine in Rhineland-Palatinate (Clearance number 837.326.16 (10645)).

Questionnaire

The questionnaire contained questions regarding i) nurse’s sociodemographic information and information on current profession as well as ii) palliative care aspects. Furthermore, iii) parts of the German version of the Copenhagen Psychosocial Questionnaire (COPSOQ), iv) a resilience questionnaire [RS-13] and v) single questions relating to resources were added.

i) Sociodemographic information and information on current profession.

The nurse’s sociodemographic information and information on current profession included the variables ‘age’, ‘gender’, ‘marital status’, ‘education’, ‘professional qualification’, ‘working area’, ‘professional experience’ and ‘extent of employment’.

ii) Palliative care aspects.

Palliative care aspects included self-developed questions on ‘additional qualification in palliative care’, the ‘number of patients’ deaths within the last month (that the nurses cared for personally)’ and the ‘extent of palliative care’. The latter was evaluated by asking: how much of your working time (as a percentage) do you spend with care of palliative patients? The first two items were already used in the pilot study. The pilot study consisted of a qualitative part, where interviews with experts in general and specialised palliative care were performed [ 43 ]. These interviews were used to develop a standardized questionnaire which was used for a cross-sectional pilot survey [ 6 , 44 ].

iii) Copenhagen Psychosocial Questionnaire (COPSOQ).

The questionnaire included parts of the German standard version of the Copenhagen Psychosocial Questionnaire (COPSOQ) [ 45 ]. The COPSOQ is a valid and reliable questionnaire for the assessment of psychosocial work environmental factors and health in the workplace [ 46 , 47 ]. The scales selected were ‘quantitative demands’ (four items, for example: “Do you have to work very fast?”) measuring workload, ‘burnout’ (six items, for example: “How often do you feel emotionally exhausted?”), ‘meaning of work’ (three items, for example: “Do you feel that the work you do is important?”) and ‘workplace commitment’ (four items, for example: “Do you enjoy telling others about your place of work?”).

iv) Resilience questionnaire RS-13.

The RS-13 questionnaire is the short German version of the RS-25 questionnaire developed by Wagnild & Young [ 48 ]. The questionnaire postulates a two-dimensional structure of resilience formed by the factors “personal competence” and “acceptance of self and life”. The RS-13 questionnaire measures resilience with 13 items on a 7-point scale (1 = I do not agree, 7 = I totally agree with different statements) and has been validated in representative samples [ 49 , 50 ]. The results of the questionnaire were grouped into persons with low, moderate or high resilience.

v) Questions on resources.

Single questions on personal, social and organizational resources assessed the nurses’ views of these resources in being helpful in dealing with the demands of their work. Further, single questions collected the agreement to different statements such as ‘Do you receive recognition for your work from the supervisor? ’ (see Table 4 ). These resources were frequently reported in the pilot study by nurses in specialised palliative care [ 6 ].

Data preparation and analysis

The data from the paper-and-pencil and online questionnaires were merged, and data cleaning was done (e.g. questionnaires without specification to nursing homes, hospitals or outpatient care were excluded). The scales selected from the COPSOQ were prepared according to the COPSOQ guidelines. In general, COPSOQ items have a 5-point Likert format, which are then transformed into a 0 to 100 scale. The scale score is calculated as the mean of the items for each scale, if at least half of the single items had valid answers. Nurses who answered less than half of the items in a scale were recorded as missing. If at least half of the items were answered, the scale value was calculated as the average of the items answered [ 46 ]. High values for the scales ‘quantitative demands‘ and ‘burnout‘ were considered negative, while high values for the scales ‘meaning of work’ and ‘workplace commitment’ were considered positive. The proportion of missing values for single scale items was between 0.5% and 2.7%. Cronbach’s Alpha was used to assess the internal consistency of the scales. A Cronbach’s Alpha > 0.7 was regarded as acceptable [ 35 ]. The score of the RS-13 questionnaire ranges from 13 to 91. The answers were grouped according to the specifications in groups with low resilience (score 13–66), moderate resilience (67–72) and high resilience (73–91) [ 49 ]. The categorical resource variables were dichotomised (example: not helpful/little helpful vs. quite helpful/very helpful).

The study was conceptualised as an exploratory study. Consequently, no prior hypotheses were formulated, so the p-values merely enable the recognition of any statistically noteworthy findings [ 51 ]. Descriptive statistics (absolute and relative frequency, M = mean, SD = standard deviation) were used to depict the data. Bivariate analyses (Pearson correlation, t-tests, analysis of variance) were performed to infer important variables for the regression-based moderation analysis. Variables which did not fulfil all the conditions for linear regression analysis were recoded as categorical variables [ 35 ]. The variable ‘extent of palliative care’ was categorised as ‘≤ 20 percent of working time’ vs. ‘> 20 percent of working time’ due to the median of the variable (median = 20).

The first step with regard to the moderation analysis was to determine the resource variables. Therefore all resource variables that reached a p-value < 0.05 in the bivariate analysis with the scale ‘burnout’ were further analysed (scale ‘meaning of work’, scale ‘workplace commitment’, variables presented in Table 4 ). The moderator analysis was conducted using the PROCESS program developed by Andrew F. Hayes. First, scales were mean-centred to reduce possible scaling problems and multicollinearity. Secondly, for all significant resource variables the following analysis were done: the ‘quantitative demand’, one resource (one per model) and the interaction term between the ‘quantitative demand’ and the resource, as well as the covariates ‘age’, ‘gender’, ‘working area’, ‘extent of employment’, the ‘extent of palliative care’ and the ‘number of patient deaths within the last month’ were added to the moderator analysis, in order to control for confounding influence. If the interaction term between the ‘quantitative demand’ and the resource accounted for significantly more variance than without interaction term (change in R 2 denoted as ΔR 2 , p < 0.05), a moderator effect of the resource was present. The interaction of the variables (± 1 SD the mean or variable manifestation such as yes and no) was plotted.

All the statistical calculations were performed using the Statistical Package for Social Science (SPSS, version 23.5) and the PROCESS macro for SPSS (version 3.5 by Hayes) for the moderator analysis.

Of the 2,982 questionnaires/access codes sent out, 497 were eligible for the analysis. The response rate was 16.7% (response rate of outpatient care 14.6%, response rate of hospitals 18.1% and response rate of nursing homes 16.0%). Since only n = 29 nurses from hospitals participated, these were excluded from data analysis. After data cleaning , the final number of participants was n = 437.

Descriptive results

The basic characteristics of the study population are presented in Table 2 . The average age of the nurses was 42.8 years, and 388 (89.6%) were female. In total, 316 nurses answered the question how much working time they spend caring for palliative patients. Sixteen (5.1%) nurses reported spending no time caring for palliative patients, 124 (39.2%) nurses reported between 1% to 10%, 61 (19.30%) nurses reported between 11% to 20% and 115 (36.4%) nurses reported spending more than 20% of their working time for caring for palliative patients. Approximately one-third (n = 121, 27.7%) of the nurses in this study did not answer this question. One hundred seventeen (29.5%) nurses reported 4 or more patient deaths, 218 (54.9%) reported 1 to 3 patient deaths and 62 (15.6%) reported 0 patient deaths within the last month.

https://doi.org/10.1371/journal.pone.0245798.t002

Table 3 presents the mean values and standard deviations of the scales ‘quantitative demands’, ‘burnout’, and the resource scales ‘meaning of work’ and ‘workplace commitment’. All scales achieved a satisfactory level of internal consistency.

https://doi.org/10.1371/journal.pone.0245798.t003

Bivariate analyses

There was a strong positive correlation between the ‘quantitative demands’ and ‘burnout’ scales (r = 0.498, p ≤ 0.01), and a small negative correlation between ‘burnout’ and ‘meaning of work’ (r = -0.222, p ≤ 0.01) and ‘workplace commitment’ (r = -0.240, p ≤ 0.01). Regarding the basic and job-related characteristics of the sample shown in Table 2 , ‘burnout’ was significantly related to ‘extent of palliative care’ (≤ 20% of working time: n = 199, M = 46.06, SD = 20.28; > 20% of working time: n = 115, M = 53.80, SD = 20.24, t(312) = -3.261, p = 0.001). Furthermore, there was a significant effect regarding the ‘number of patient deaths during the last month’ (F (2, 393) = 5.197, p = 0.006). The mean of the burnout score was lower for nurses reporting no patient deaths within the last month than for nurses reporting four or more deaths (n = 62, M = 42.47, SD = 21.66 versus n = 116, M = 52.71, SD = 20.03). There was no association between ‘quantitative demands’ and an ‘additional qualification in palliative care’ (no qualification: n = 328, M = 55.77, SD = 21.10; additional qualification: n = 103, M = 54.39, SD = 20.44, p = 0.559).

The association between ‘burnout’ and the evaluated (categorical) resource variables is presented in Table 4 . Nurses mostly had a lower value on the ‘burnout’ scale when reporting various resources. Only the resources ‘family’, ‘religiosity/spirituality’, ‘gratitude of patients’, ‘recognition through patients/relatives’ and an ‘additional qualification in palliative care’ were not associated with ‘burnout’.

https://doi.org/10.1371/journal.pone.0245798.t004

Moderator analyses

In total, 16 moderation analyses were conducted. Table 5 presents the results of the moderation analyses where a significant moderation was found. For ‘workplace commitment’, there was a positive and significant association between ‘quantitative demands’ and ‘burnout’ (b = 0.47, SE = 0.051, p < 0.001). An increase of one value on the scale ‘quantitative demands’ increased the scale ‘burnout’ by 0.47. ‘Workplace commitment’ was negatively related to ‘burnout’, meaning that a higher degree of ‘workplace commitment’ was related to a lower level of ‘burnout’ (b = -0.11, SE = 0.048, p = 0.030). A model with the interaction term of ‘quantitative demands’ and the resource ‘workplace commitment’ accounted for significantly more variance in ‘burnout’ than a model without interaction term (ΔR 2 = 0.021, p = 0.004). The impact of ‘quantitative demands’ on ‘burnout’ was dependent on ‘workplace commitment’ (b = -0.01, SE = 0.002 p = 0.004). The variables explained 31.9% of the variance in ‘burnout’.

https://doi.org/10.1371/journal.pone.0245798.t005

Regarding the ‘good working team’ resource, the variables ‘quantitative demands’ and ‘burnout’ were positively and significantly associated (b = 0.76, SE = 0.154, p < 0.001), and the variables ‘good working team’ and ‘burnout’ were not associated (b = -3.15, SE = 3.52, p = 0.372). A model with the interaction term of ‘quantitative demands’ and the ‘good working team’ resource accounted for significantly more variance in ‘burnout’ than a model without interaction term (ΔR 2 = 0.011, p = 0.040). The ‘good working team’ resource moderated the impact of ‘quantitative demands’ on ‘burnout’ (b = -0.34, SE = 0.165, p = 0.004). The variables explained 29.7% of the variance in ‘burnout’.

The associations between ‘quantitative demands’ and ‘burnout’ (b = 0.63, SE = 0.085, p < 0.001), between ‘recognition supervisor’ and ‘burnout’ (b = -7.29, SE = 2.27, p = 0.001), and the interaction term of ‘quantitative demands’ and the resource ‘recognition supervisor’ (b = -0.34, SE = 0.108, p = 0.002) were significant. Again, a model with the interaction term accounted for significantly more variance in ‘burnout’ than a model without interaction term (ΔR 2 = 0.024, p = 0.002). ‘Recognition from supervisor’ influenced the impact of ‘quantitative demands’ on burnout for -0.34 on the 0 to 100 scale. The variables explained 33.7% of the variance in ‘burnout’.

Figs 1 – 3 demonstrates simple slopes of the interaction effects of ‘workplace commitment’ predicting ‘burnout’ at high, average and low levels ( Fig 1 ) respectively with and without the resource ‘good working team’ ( Fig 2 ) and ‘recognition from supervisor’ ( Fig 3 ). Higher ‘quantitative demands’ were associated with higher levels of ‘burnout’. At low ‘quantitative demands’, the ‘burnout’ level was quite similar for all nurses. However, when ‘quantitative demands’ increased, nurses who confirmed that they had the resources stated a lower ‘burnout’ level than nurses who denied having them. This trend is repeated by the resources ‘workplace commitment’, ‘good working team’ and ‘recognition from supervisor’.

https://doi.org/10.1371/journal.pone.0245798.g001

https://doi.org/10.1371/journal.pone.0245798.g002

https://doi.org/10.1371/journal.pone.0245798.g003

The palliative care aspect ‘extent of palliative care’ showed that spending more than 20 percent of working time in care for palliative patients increased burnout significantly by a value of approximately 5 on a 0 to 100 scale ( Table 5 ).

The aim of the present study was to analyse the buffering role of resources on the relationship between workload and burnout among nurses. This was done for the first time by considering palliative care aspects, such as information on the extent of palliative care.

The study shows that higher quantitative demands were associated with higher levels of burnout, which is in line with other studies [ 37 , 39 ]. Furthermore, the results of this study indicate that working in a good team, recognition from supervisor and workplace commitment is a moderator within the workload—burnout relationship. Although the moderator analyses revealed low buffering effect values, social resources were identified once more as important resources. This is consistent with the results of a study conducted in the field of specialised palliative care in Germany, where a good working team and workplace commitment moderated the impact of quantitative demands on nurses burnout [ 52 ]. A recently published review also describes social support from co-workers and supervisors as a fundamental resource in preventing burnout in nurses [ 53 ]. Workplace commitment was not only reported as a moderator between workload and health in the nurse setting [ 37 ], but also as a moderator between work stress and burnout [ 54 ] and between work stress and other health related aspects outside the nurse setting [ 55 ]. In the present study, the effect of high workload on burnout was reduced with increasing workplace commitment. Nurses reporting a high work commitment may experience workload as less threatening and disruptive because workplace commitment gives them a feeling of belonging, security and stability. However, there are also some correlation studies which observed no direct relationship between workplace commitment and burnout for occupations in the health sector [ 56 ]. A study from Serbia assessed workplace commitment by nurses and medical technicians as a protective factor against patient-related burnout, but not against personal and work-related burnout [ 57 ]. Furthermore, a study conducted in Estonia reported no relationship between workplace commitment and burnout amongst nurses [ 58 ]. As there are indications that workplace commitment is correlated with patient safety [ 59 ], the development and improving of workplace commitment needs further scientific investigation.

This study observed slightly higher burnout rates among nurses who reported a ‘good working team’ for low workload. This fact is not decisive for the interpretation of the moderation effect of this resource because moderation is present. When workload increased, nurses who confirmed that they worked in a good working team stated a lower burnout level. However, the result of the current study showed that a good working team is particularly important when workload increases, in the most extreme cases team work in palliative care is necessary to save a person’s life. Because team work in today’s health care system is essential, health care organisations should foster team work in order to enhance their clinical outcomes [ 60 ], improve the quality of patient care as well as health [ 61 ] and satisfaction of nurses [ 62 ].

The bivariate analysis revealed that nurses who reported getting recognition from colleagues, through the social context, salary and gratitude from relatives of patients stated a lower value on the burnout scale. This is in accordance with the results of a qualitative study, which indicated that the feeling of recognition, and that one’s work is useful and worthwhile, is very important for nurses and a source of satisfaction [ 63 ]. Furthermore, self-care, self-reflection [ 64 ] and professional attitude/dissociation seem to play an important role in preventing burnout. The bivariate analysis also revealed a relationship between resilience and burnout. Nurses with high resilience reported lower values on the burnout scale, but a buffering role of resilience on burnout was not assessed. The present paper focuses solely on quantitative demands and burnout. In future studies, the different fields of nursing demands, like organisational or emotional demands, should be assessed in relation to burnout, job satisfaction and health.

Finally, we observed whether the consideration of palliative care aspects is associated with burnout. The bivariate analysis revealed a relationship between the extent of palliative care, number of patient deaths within the last month and burnout. Using regression analyses, only the extent of palliative care was associated with burnout. Since, to the best of our knowledge, the present study is the first study to consider palliative care aspects within general palliative care in Germany, these variables need further scientific investigation, not only within the demand—burnout relationship but also between the demand—health and the demand—job satisfaction relationship. Furthermore, palliative care experts from around the world considered the education and training of all members of staff in the fundamentals of palliative care to be essential [ 9 ]. One-fourth of the respondents in the present study had an additional qualification in palliative care, which was not obligatory. We assessed a relationship between quantitative demands and burnout but no relationship between an additional qualification and quantitative demands nor burnout. Nevertheless, we assessed a protective effect of the additional qualification within the pilot study in specialised palliative care, in relation both to organisational demands and demands regarding the care of relatives [ 6 ]. This suggests that the additional qualification is a resource, but one which depends on the field of demand. Further analyses would be required to review benefits achieved by additional qualifications in general palliative care.

The variable extent of palliative care is the one with the most missing values in the survey, thus future analyses should not only study larger samples but also reconsider the question on extent of palliative care.

Finally, it can be said that the main contribution of the present study is to make palliative care aspects in non-specialised palliative care settings a subject of discussion.

Limitations

The following potential limitations need to be stated: although a random sample was drawn, the sample is not representative for general palliative care in Germany due to a low participation rate of the health facilities, a low response rate of the nurses, the different responses of the health facilities and the exclusion of hospitals. One possible explanation for the low participation rate of the health facilities is the sampling procedure and data protection rules, which did not allowed the study team to contact the institutions in the sample. Due to the low participation rate, the results of the present study may be labelled as preliminary. Further, the data are based on a detailed and anonymous survey, and therefore the potential for selection bias has to be considered. It is possible that the institutions and nurses with the highest burden had no time for or interest in answering the questionnaire. It is also possible that the institutions which care for a high number of palliative patients may have taken particular interest in the survey. Additionally, some items of the questionnaire were self-developed and not validated but were considered valuable for our study as they answered certain questions that standardized questionnaires could not. The moderator analyses revealed low effect values and the variance explained by the interaction terms is rather low. However, moderator effects are difficult to detect, therefore, even those explaining as little as one percent of the total variance should be considered [ 65 ]. Consequently, the additional amount of variance explained by the interaction in the current study (2% for workplace commitment and recognition of supervisor and 1% for good working team) is not only statistically significant but also practically and theoretically relevant. When considering the results of the current study, it must be taken into account that the present paper focuses solely on quantitative demands and burnout. In future studies, the different fields of nursing demands have to be carried out on the role of resources. This not only pertains for burnout, but also for other outcomes such as job satisfaction and health. Finally, the cross-sectional design does not allow for casual inferences. Longitudinal and interventional studies are needed to support causality in the relationships examined.

Conclusions

The present study provides support to a buffering role of workplace commitment, good working teams and recognition from supervisors on the relationship between workload and burnout. Initiatives to develop or improve workplace commitment and strengthen collaboration with colleagues and supervisors should be implemented in order to reduce burnout levels. Furthermore, the results of the study provides first insights that palliative care aspects in general palliative care may have an impact on nurse burnout, and therefore they have gone unrecognised for too long in the scientific literature. They have to be considered in future studies, in order to improve the working conditions, health and satisfaction of nurses. As our study was exploratory, the results should be confirmed in future studies.

Supporting information

S1 table. number of questionnaires sent out to facilites and response rate..

https://doi.org/10.1371/journal.pone.0245798.s001

Acknowledgments

We thank the nurses and the health care institutions for taking part in the study. We thank D. Wendeler, O. Kleinmüller, E. Muth, R. Amma and C. Kohring who were helpful in the recruitment of the participants and data collection.

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How Do We Reduce Burnout In Nursing?

Affiliations.

• 1 American Association of Colleges of Nursing, 655 K Street, NW, Suite 750 Washington, DC 20001, USA. Electronic address: [email protected].
• 2 Walden University, College of Nursing, 100 Washington Avenue South, Suite 1210, Minneapolis, MN 55401, USA.
• PMID: 35236601
• DOI: 10.1016/j.cnur.2021.11.007

Burnout syndrome has been defined as a state of chronic stress characterized by high levels of emotional exhaustion and depersonalization with low levels of professional efficacy. The effects of nurse burnout include poor job satisfaction and turnover. Nurses' physical and mental well-being are both essential to sustaining a healthy nursing workforce with factors such as an empowering work environment showing positive effects on reducing burnout. Formal and informal individual and organizational approaches to supporting novice nurses' transition and experienced nurses' sustained practice fulfillment are key to addressing burnout and fostering retention.

Keywords: Compassion satisfaction; Gratitude; Mindfulness; Nurse burnout; Preceptors; Residencies.

Copyright © 2021 Elsevier Inc. All rights reserved.

Publication types

• Burnout, Professional* / prevention & control
• Burnout, Professional* / psychology
• Cross-Sectional Studies
• Job Satisfaction
• Nursing Staff, Hospital* / psychology
• Personnel Turnover
• Surveys and Questionnaires

Impact of Burnout in Nursing Shortage

This essay will discuss how burnout among nurses contributes to the nursing shortage crisis. It will explore factors leading to nurse burnout, including long hours, high-stress environments, and emotional demands. The piece will examine the consequences of burnout on patient care, staff turnover, and the healthcare system, and suggest strategies for mitigating these effects. More free essay examples are accessible at PapersOwl about Employment.

How it works

• 1 Role Strain and Burnout in Nursing
• 2 Causes, effects of role strain and Burnout among the nurses
• 3 Issues that lead to nurse burnout and their solutions
• 4 Stressing experience as a nurse

Role Strain and Burnout in Nursing

Causes, effects of role strain and burnout among the nurses.

Nurses face a lot of challenges in their work. Among the most common challenges is stress. Psychologists and other experts point out that stress in workplace is an occupational hazard. Despite this recognition, nurses still experience stress in their workplace. These professionals work for long and engage in different activities under difficult environment making the job to be a challenge.

Stress causes burnout among workers including nurses.

Burnout is a terminology that is used to describe how workers react to chronic stress that characterizes jobs which involve direct interaction with human beings (Callara & Callara, 2008). A worker suffering from burnout displays emotional exhaustion, reduced productivity, and depersonalization. Workplace problems sometimes spill over to personal life thus affecting families since a worker may have other responsibilities such maintaining marriage and caring for children. Majority of nurses universally are females who are forced to divide their time between performing their job duties and managing other responsibilities such as home and families, further leading to burnout among them.

Nurse burnout affects patients and the institutions as well as the nurses themselves. To begin with, stressed nurses provide substandard and inadequate patient care (Lindberg, Hunter, & Kruszewski, 2009). When nurses are exhausted, they tend to make wrong choices and poor decisions. It is also quite common to see burnt out nurses with changed bedside manners accompanied by cynicism, depersonalization, lack of compassion, insensitivity, and lack of empathy. A nurse who may have been vibrant can suddenly become rude to patients, and stop being helpful to patients needing help. The change in the nurse’s behavior may affect the recovery rate of the patients; the relationship between burnt out staff and patients deteriorate and the sick that get poor treatment may opt to seek medical attention elsewhere.

Secondly, burnout among nurses makes some of them resign and seek job elsewhere. The remaining nurses are forced to take more patients under their care. Statistics show that a high patient to nurse ratio leads to patients contracting infectious diseases, getting injuries, failing to get timely care, while some patients are discharged without proper plans of home care (Callara et all, 2008). Nurse burnout also affects the organizations since they are forced recruit new staff when some resign due to work challenges. Additionally, other staff working within the same institutions with the nurses may also suffer from the effects of the burnout due to poor relationship between them and the nurses. This inconsistent change in the workers due to resigning and burn out greatly affects proper care and recovery of the patients.

There are several ways through which nurses can control and reduce role stress and role strain. The nurses need to recognize the source of stress and make plans on the best ways of overcoming them. They need to also know how strike a balance between work and social life. The health professionals can also seek help from support groups such as family members, friends, and colleagues. Finding ways of releasing stress such as practicing art or other hobbies can assist in reducing work related stress. If all these options fail, considering other jobs options can also assist to manage stress and prevent escalation of the problem into depression.

Issues that lead to nurse burnout and their solutions

One of the leading causes of nurse burnout is gender and obligation to one’s family. Studies have shown that the rate of burnout is higher among female nurses than that of their male counterparts (May & Holmes, 2012). Furthermore, the females who worked for the number of hours against their wishes were more likely to develop burnout. Work-family conflict leads to burnout if one interferes with the other, particularly when work interfered with the family nurse of the health practitioner. Nurses with young children and elderly parents to take care of can sometimes project their stress to workplace.

This challenge can be countered by the management of the organization where the nurse works organizing a positive wellness program to handle the issues affecting the nurses. Incentives such as counseling, time off, and food program can assist the workers to know how to strike a balance between private and work life.

The second cause of nurse burnout is poor management style. How nurses and their managers relate directly affects the rate of nurse burnout in organizations. Factors such as inadequate leadership, absent supervisors, poor communications, inability to respond to problems of the health practitioners, and frequent leadership change raised stress level among the nurses (Daly, 2005) The adoption of participatory form of leadership in organizations where nurses work also reduces stress among the nurses. The position the nurse holds also determines the level of stress among the nurses with those in management positions suffering from stress more compared to the other nurses.

To overcome this challenge of leadership, organizations should appoint nurses with experience and knowledge to serve in managerial positions. Institutions can also lay down polices to guide the managers on how to treat the workers. Finally, an organization can adopt a method of gathering views from all the employees to make them feel as part of the company.

Stressing experience as a nurse

There was one time I was working in the hospital and served during the nightshift. The nurses were few in the organization so the ten employed nurses worked for twelve hour shift; five during the day time and the other staff during the night. On this particular day, I had served the night shift and exhausted, was ready to go home and catch sleep before preparing to resume later during my night shift. Just as I was preparing to leave, the head nurse summoned me to her office and said that two of our colleagues had resigned without giving any form of notice to allow for preparation. I was expected to serve for additional six-hour period until midday. My love for the patients and dedication to the hospital made me work for the extra six hours. The experience was unpleasant since I offered poor service due to fatigue and sleep.

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