Nurse C and Nurse M had been best friends growing up, and they shared a lifelong dream of becoming nurses. Various family and other commitments separated them after college, and they began their nursing careers at different hospitals in different states. As new graduates on medical-surgical units, both were energetic and enthusiastic nurses, committed to excellence in caring for their patients.

Over the course of the first year, the hospital where Nurse C worked dealt with budget cuts and resources began to decline. Staffing on Nurse C's unit decreased, and daily patient load went from four patients to seven patients. She struggled to keep up with the increasing workload and found herself unable to spend as much time as she wanted with her patients. The hospital instituted mandatory overtime to help overcome the staffing shortage, and Nurse C soon began working a few hours beyond her usual 12-hour shifts and often worked six or seven days in a row. She was tired all the time and frequently found it difficult to focus, especially near the end of her shift. Her personal life was affected; she called her family less often and never seemed to have time for her friends.

Nurse C has many of the personal risk factors for burnout: she is young, early in her career, single, and highly educated. Her unsupportive work environment, however, is the key, with work overload leading her to become frustrated and disappointed with her job. Nurse C is among the approximately 65% to 80% of nurses who work 12 hours or more per day. As a result, she is experiencing the first stage of burnout, characterized by mental and physical exhaustion. Unless she addresses her stress and job dissatisfaction, the subsequent stages of burnout will evolve.

Nurse C did make time for a phone call from her friend Nurse M and couldn't believe how happy Nurse M was in her job. Nurse M listened as Nurse C described all her dissatisfactions with her work. Nurse M sympathized with her situation and talked enthusiastically about her own recent transfer to the medical intensive care unit. She urged Nurse C to transfer to the intensive care unit at her hospital because of the professional challenges and lower patient load. "You'll really feel like you're making a difference," Nurse M told her. Encouraged, Nurse C submitted a request for a transfer to the medical intensive care unit.

Nurse C gained renewed interest and energy during her orientation and training in the intensive care unit. She enjoyed the technical challenges of the more complex patient care, and she again looked forward to work. However, after she was fully oriented to the unit, her patient load increased and she again found herself working long hours and overtime. She went home every day with a headache and backache, she never felt fully rested, and she experienced extreme mood swings. She again withdrew from family and friends and found herself frequently overeating. She also began to have a glass or two of wine every night as a way to cope with her stress. The "last straw" for Nurse C was a medication error she made. No substantial harm came to the patient, but the patient's physician yelled at Nurse C and several other nurses in the unit. As a result, Nurse C felt like a professional failure and questioned her decision to become a nurse. She distanced herself even further from her colleagues, her family, and her friends.

Changing the work setting is a frequent response to job dissatisfaction. However, different environments can have the same inherent stress factors, which means that the potential for burnout can continue. Within nursing environments, work overload brought on by inadequate staffing is the most common source of stress and burnout. High levels of fatigue brought on by work schedule factors have been associated with an increased risk of errors, and these errors frequently cause moral distress for nurses. In addition, difficulties in nurse-physician relationships also affect nurses' morale, and job satisfaction decreases when nurse-physician collaboration is poor. Nurse C is moving through the next stages of burnout, marked by indifference and feelings of failure as a professional.

Nurse M surprised Nurse C with a visit and was distressed about what had happened to Nurse C. Her friend had dark circles under her eyes, was overweight, and lacked her usual passion for life. Nurse M convinced Nurse C to tell her about her situation at work. When Nurse M heard about Nurse C's work schedule and patient load, she became angry at the situation and told Nurse C that she needed to take better care of herself and become an advocate for change at her hospital. Nurse M explained that not all hospitals are the same, and she described her own positive work environment. In her unit, the nurses have a weekly get-together during which they talk about their most challenging patients and how they cope with loss. The Human Resources department sends out flyers about stress management programs, and the supervisors rearrange schedules to allow nurses to attend. Although there can be heavy workloads, the head nurse works with the staff as she develops the schedule so nurses have some say in the shifts and the number of days they work. The head nurse also anticipates needs and requests per diem nurses to help keep the patient load low.

Nurse C was surprised at the differences between her hospital and Nurse M's hospital, but she expressed doubt that she could change how her hospital functioned. Nurse M acknowledged that it is difficult to change organizations but she encouraged her to talk with other nurses about the situation and to band together to approach administration and request changes in scheduling and to emphasize the detrimental effect of heavy patient load on patient outcomes and quality of care. Nurse M noted that, equally as important as working for change in her hospital, Nurse C must make changes in her personal and professional lifestyles to help her better manage stress and avoid burning out completely. Nurse M told her about the importance of finding healthier ways to cope with stress, evaluating her work/life satisfaction, seeking support from friends and family, working "smarter," and engaging in nonwork activities. Nurse M also reminded Nurse C about how excited the two of them had always been about becoming nurses.

Because it is difficult to change organizational structure, individuals must make changes in themselves to avoid stress and burnout. Attention to personal and professional lifestyle habits are integral steps in preventing and managing stress effectively. Self-care, time management, and strong interpersonal relationships are key elements for maintaining physical and psychosocial well-being.

Maintaining a healthy lifestyle, with proper diet, exercise, and sleep, is vital to avoiding the physical effects of stress, as is seeking activities that help to disengage individuals from their professional routine and provide enjoyment. Self-reflection as a way to remind oneself why he or she entered the healthcare profession and remaining "connected" to people are also important in managing stress and preventing burnout. Adequate time away from work is essential for maintaining positive work/life satisfaction and has been the most common suggestion about how to avoid stress and burnout.

Working smarter refers to taking frequent "mini-breaks" to escape work stresses, varying daily work routines, and setting realistic goals. Nurses can also increase their sense of control by advocating for changes in the work environment and for adherence to institution policies, state and federal laws and regulations, and nursing association statements and principles.

Over the next few months, Nurse C starts to pay better attention to her health by eating a balanced diet and finding time for regular exercise, including a twice-weekly yoga class. She starts an informal support group with her peers on her unit, and the number of participants increases as the sessions become more popular. She also visits with the Human Resources staff to ask about workshops in stress management techniques. In addition, Nurse C leads a small group of her peers in approaching their nursing supervisor to discuss their concerns about the quality of patient care and staffing. With time, Nurse C has a renewed sense of purpose at work and has become involved in a multidisciplinary committee that is addressing quality of care. She also has become more active in her personal life, spending more time with friends and family and volunteering as a coach for a youth soccer team. She has scheduled her first vacation in two years, planning a 10-day cruise with her best friend, Nurse M.