#31434: Burnout: Impact on Nursing and Quality of Care

A major source of burnout, work overload is created primarily by inadequate staffing, a prevalent problem in today's hospitals and nursing homes [65,69,72,79]. Studies have shown that the mean patient-to-nurse ratio in U.S. hospitals is approximately 5:1 [69,74]. Nurses have consistently reported that these ratios are inadequate for providing high-quality care. In a study of 534 hospitals (26,005 nurses), staffing was considered to be poor in 25% [69]. In a survey of nearly 11,000 RNs, only 46% said there was enough staff to accomplish the necessary work and 48% said there were not enough RNs on staff to provide high-quality care [67]. A 2022 survey showed that that only 33% of nurses had the time needed to spend with patients [43]. A 2021 study in New York State demonstrated a savings of 4,370 patient lives and a cost savings of $720 million when hospitals were staffed at a 4:1 patient-to-nurse ratio [44]. Increased patient-to-nurse ratios are associated with lower rates of job satisfaction and higher rates of burnout; inadequate staffing was the reason that 46.4% of still-employed nurses gave for changing their position or employer, and the reason that 35.8% of nurses left the profession altogether [7,45,70]. In a study of more than 10,000 nurses, the rate of burnout increased 23% for every additional patient per nurse [7].

Other factors also contribute to increased workload, including a high number of work hours per week, extended shifts, overtime (often mandatory), many consecutive days of work, rotating shifts, weekend work, and on-call requirements. Among more than 235,000 nurses in a 2022 survey, nearly 30% worked more than 40 hours per week, with 19% working 41 to 50 hours per week and 10.6% working more than 50 hours per week [37]. In addition to long work weeks, nurses typically work long workdays. Twelve-hour shifts offer many benefits to nurses and patient care, and as a result, the percentage of nurses who routinely work these shifts has increased to approximately 65% to 80% [94]. However, moderate-to-high levels of acute fatigue and moderate levels of chronic fatigue have been found among nurses working 12-hour shifts [95]. Several studies have indicated a strong relationship between long work hours or 12-hour shifts and adverse nurse outcomes, such as increased fatigue, job dissatisfaction, burnout, and intention to leave the job [94,96].

The increase in working hours for nurses has substantial professional consequences. The odds of job dissatisfaction and burnout are as much as 2.5 times higher for nurses who work longer shifts compared with nurses who worked eight- to nine-hour shifts [94]. Most importantly, fatigue and long hours have been significantly associated with nursing errors [97]. Twelve-hour shifts have been linked to up to three times a higher risk of error [97]. Long shifts (10 hours or more) have also been associated with a greater odds of nurses reporting that the quality of care is fair or poor on their unit compared with shifts of 8 to 9 hours [66].

Shift length has also been associated with patients' perceptions of the quality of care. In a study of 577 hospitals in four states, patients' ratings for 7 of the 10 outcomes on the Hospital Consumer Assessment of Healthcare Providers and Systems survey were significantly adversely affected by the proportion of nurses who worked shifts of 13 hours or more [94]. These lower ratings included the global assessments of overall rating for the hospital and whether the patient would recommend the hospital [94].

Also contributing to fatigue—and its consequences—are rotating shifts and mandatory overtime, which have often been used to solve staffing issues [97].

The amount of medical information available online has raised the levels of patient knowledge but may also increase the number of questions and/or amount of explanation required, in turn contributing to further workload. Advances in treatment have also led to nursing care that can be demanding and challenging. This high level of care, coupled with shorter stays as a result of changes in the healthcare system and reimbursement, result in nursing workloads that are not balanced across various levels of care within the patient population.

Documentation requirements with electronic health records are another source of stress and time. Studies have shown that nurses spend between 15% to 40% of their time at work on electronic health records and documentation requirements [6,80,81].

Many of these sources of dissatisfaction are directly related to nursing turnover, as they have been given as the reason for nurses leaving their job or position. In a 2022 representative survey, a stressful work environment was the reported reason that 45.3% of still-employed nurses left their jobs and the reported reason 28.3% of nurses were no longer employed in nursing [45]. A 2017 survey of 600 RNs conducted by RNnetwork found similar results, with approximately 50% of the nurses having considered leaving nursing due to feeling overworked (27%), not enjoying their job anymore (16%) and spending too much time on paperwork (15%) [65]. The survey also found that more than 50% of the RNs surveyed did not feel respected by their administration, citing that as a reason for considering leaving nursing. In addition, 43% of respondents indicated that their workplace did not support a healthy work/life balance [65].

A sense of control, or autonomy, is important to nurses, and job satisfaction is greater and job stress is lower when nurses feel as if they have some control over how they perform their job. A strong correlation has been identified between job satisfaction and autonomy, empowerment, and control [70,89]. Autonomy in nursing refers to having "the authority to make decisions and freely act in accordance with one's professional knowledge and skills to implement those decisions. It is identified with characteristics including competence, knowledge, decision-making, self-governance, freedom, self-control, responsiveness, and judgment" [89]. Autonomy within the workplace generally falls into two areas: clinical autonomy and practice autonomy. Clinical autonomy is an individual's authority to make independent judgments and decisions about patient care within their scope of practice and ability. Practice autonomy is the individual's influence over their practice setting and includes decisions about organization rules, policies, procedures, structure, and operations. Studies have found that autonomy, empowerment, and decision-making opportunities are strongly related to job satisfaction and retention among nurses [89].

The risk of burnout is increased among nurses who perceive a lack of control in their work environment [82]. A sense of control varies across nursing specialties, which in part explains the range of burnout rates among specialties. For example, in a study of nurse managers, emergency department nurses, and nurse practitioners, the least amount of control was reported by emergency department nurses, who also had the highest rate of burnout; in contrast, nurse practitioners reported having the most control and the lowest rate of burnout [82].

Insufficient reward relates to several aspects, including lack of recognition of contributions, inadequate compensation (salary), and few opportunities for advancement. Being fairly rewarded and recognized for contributions is important to nurses, and nurses who perceive respect and recognition are more likely to be satisfied with their job and to have a lower likelihood of burnout [6,60]. In multiple studies, a culture that supports the nursing profession was the factor most strongly associated with job satisfaction [45,58]. Another study found that approximately 34% of nurses feel that their employers do not treat them with respect, do not make good use of their skills and abilities, and the lack of recognition in the work environment does not motivate them to go above and beyond [59]. Lack of professional recognition and professional uncertainty have also both been significantly associated with all three subscales on the MBI [70].

Although wage has been associated with job dissatisfaction and intent to leave, it is thought to have little effect on burnout, and nurses have fairly consistently ranked other work environment factors as being of more concern than money [69]. It is important to note, however, that a 2019 survey of nearly 20,000 registered nurses found that nearly one in five nurses work a second nursing job and nearly one in ten work a second full-time job, potentially impacting both quality of care and the quality of life for nurses [49].

The nurse's community consists of peers, nursing leaders, and physicians. Positive, supportive relationships with all these constituencies have been related to job satisfaction and a decreased likelihood of stress and burnout. In contrast, lack of peer cohesion, inadequate administrative and supervisor support, and difficulties with nurse-physician interactions, have all been factors in high rates of burnout, especially on the emotional exhaustion and depersonalization subscales [6,18].

Nurse-Peer Relationships

In one survey of 76,000 registered nurses, the highest level of satisfaction was given to relationships with other nurses. Still, the survey showed that one-third of nurses were dissatisfied with interactions with their peers [112]. A 2017 survey of 600 nurses found that 45% had been verbally harassed by other nurses [65]. Interpersonal conflict with other nurses is a stress factor in and of itself, but a lack of close working relationships deprives nurses of their colleagues as a source of support. This lack of support is important, as nurses have ranked their peers as providing the most support within the hospital community, and higher levels of support from co-workers have been related to lower levels of emotional exhaustion on the MBI. Similarly, lack of peer cohesion has correlated with high levels of emotional exhaustion and depersonalization, or cynicism [6].

Although resolving conflicts can mitigate stress, the style of conflict resolution has also been a significant predictor of burnout. A study of three conflict resolution styles—avoidance, confrontational, and cooperative—showed that the avoidance and confrontational styles were associated with a higher rate of burnout, while the cooperative style was associated with a lower rate [113,114].

Nurse-Nurse Leader Relationships

Support from nursing leaders and administration is essential for nurses' job satisfaction. Studies have indicated, however, that most nurses do not have or perceive supportive leadership. Approximately 45% to 70% of nurses are dissatisfied with nursing management and administration because they do not listen to or address nurses' concerns or deal with nurses truthfully about decisions affecting their jobs [67,71,112]. One study found that 41% of nurses reported having been verbally harassed by managers or administrators [65,71]. Approximately 53% to 62% of nurses think they have a nurse manager who is a good manager and leader or have a head nurse who backs nursing staff in decision-making [67,71]. Another survey found that 82% of respondents believed that more nurse leaders are needed in health care; however, 61% of also indicated that they were not interested in moving into a leadership position [71] Leadership style and lack of administrator and supervisor support has been related to both job satisfaction and burnout. Among emergency department nurses, a low level of manager support was a significant predictor of burnout [83].

Nurse-Physician Relationships

Nurse-physician relationships and their effect on nurses have an extensive history. Daily interactions between nurses and physicians strongly influence nurses' morale, and difficulties in nurse-physician relationships are perceived by most nurses, physicians, and hospital executives as having negative or worsening effects on stress, frustration, concentration, communication, collaboration, and information transfer between nurses and physicians [47]. One study showed that nurses value collaborative relationships with physicians, and place more importance on the collaboration than do physicians [116]. The findings of surveys have varied with regard to nurses' perceptions of nurse-physician relationships at their facility. In a statewide survey, 72% of nurses said collaboration existed between nurses and physicians and 80% said nurses and physicians had good working relationships [67]. In addition, studies have shown that better nurse-physician collaboration and communication lead to faster patient throughput, shorter hospital stays, increased patient satisfaction, fewer adverse events, and improved patient outcomes [47].

Studies have indicated that positive nurse-physician relationships significantly correlate with lower emotional exhaustion and depersonalization and higher personal accomplishment [64]. Similarly, a low score on organizational climate (of which nurse-physician collaboration is a factor) has correlated with high rates of burnout.

The emotional demands of the nursing profession are well recognized, and human suffering has been noted to be a stressor for nurses. In a 2022 American Nurses Foundation survey, 33% of nurses said they were "not emotionally healthy" or "not at all emotionally healthy," and 75% reported feeling stressed, frustrated, and exhausted [48]. In addition to the stressful nature of nursing, the COVID-19 pandemic and associated loss of more than 1 million lives affected nurses emotionally and collectively unlike anything in recent history. Often being on the frontline of care, with limited knowledge of the virus in the first weeks, limited available protection equipment and resources, and mass patient influx, nurses were put in a unique and stressful situation that continues in the post-pandemic healthcare environment [48].

Emotional demands are greater in settings such as oncology, palliative care, and critical care, where grief and loss have been identified as a source for stress among nurses and other healthcare professionals. The sense of loss extends beyond the loss of the relationship with the patient to identifying with the pain of the family, past unresolved loss and anticipated future loss, and loss of one's goals and expectations. Nurses in these settings may experience stress when they cannot provide adequate care at the end of life or help a patient die a "good death" [118].

Perhaps the greatest professional consequence of nurse burnout is the nursing shortage. High turnover among nurses as a result of job dissatisfaction and burnout is a driving contributor to the nursing shortage [9,65,71]. Other factors are an aging nursing workforce and increased health demands in the general population [10]. The supply of nurses has been declining since the late 1990s, while the demand for nurses has been increasing. The downturn in the U.S. economy in the early 2000s eased the nursing shortage in the short term, but the shortage is still projected to grow to nearly 1 million by 2030 [10]. The problems of burnout and the nursing shortage escalate in a cyclical manner: job dissatisfaction leads to burnout, nursing turnover, and inadequate staffing, which further increases job dissatisfaction (Figure 2) [70].

THE NURSING SHORTAGE/BURNOUT CYCLE

The relationship between burnout and the nursing shortage is cyclical: job dissatisfaction leads to burnout, which in turn leads to nursing turnover and subsequent nursing shortage, and the inadequate staffing further increases job dissatisfaction.

Figure 2

Source: Compiled by Author

The nursing shortage has far-reaching effects on the quality of care and patient safety. A multitude of studies have demonstrated that factors caused by the shortage—primarily, inadequate staffing and hours worked—significantly affect nurses' perceived quality of care, patient satisfaction, the potential for nursing errors, adverse events for patients, and patient mortality.

Perceived Quality of Care and Patient Satisfaction

As already mentioned, high proportions of nurses have noted that there are not enough registered nurses on staff to provide high-quality patient care [10,37,65,75]. Nurses report the feeling that, in general, the quality of patient care is declining, and this feeling increases with age; 37% of nurses 19 to 39 years of age agreed that the quality of care is declining, compared with 56% of nurses 40 to 54 years of age and 66% for nurses 55 years and older [73].

Some studies have addressed nurses' perceptions about the quality of care in relation to burnout. In a study of nurses at 198 hospitals, all three subscales of the MBI were significant predictors of nurses' fair/poor quality ratings of care [13]. The findings of other studies have similarly shown a relationship between rates of burnout and nurses' ratings of fair or poor quality of care [72].

Higher levels of burnout and job dissatisfaction are also associated with lower patient satisfaction. In one study, rates of patient satisfaction were lower in hospitals with higher rates of nurses who were dissatisfied or burned out [68].

Nursing Errors

Several surveys have indicated that nursing errors are, in many cases, perceived by nurses to be a result of the nursing shortage [8,63,68]. For example, in one study, 78% of surveyed nurses said they had not given a prescribed medication or had given it at the wrong time, and 69% of these nurses believed the error was somewhat or strongly related to the nursing shortage. In addition to the harm to patients, medication and treatment errors caused moral distress for 73% and 61% of the nurses involved, respectively [8]. In the other study, 36% of hospital nurses and 47% of nursing home nurses said that their workload caused them to miss important changes in their patients' condition [68]. A different study found that 46.8% of nurses had committed a medication error within the past year, with incorrect infusion rates (33.3%) and administering two doses of medicine instead of one (23.8%) being the most common errors. Almost two-thirds of these errors were not reported by the nurse. The foremost reason cited for these errors was a shortage of nurses (47.6%) [63]. As noted earlier, long work hours and nurse fatigue have also contributed substantially to nursing errors [6,63,68,97].

Adverse Events

The findings of studies have consistently demonstrated a relationship between inadequate staffing and higher rates of patient adverse events. A review of 28 studies on the relationship between nurse-to-patient ratios and outcomes demonstrated that an increase of one registered nurse per patient per day was associated with decreased odds of hospital-acquired pneumonia, unplanned extubation, respiratory failure, and cardiac arrest in intensive care units; of failure to rescue among postoperative patients; and of shorter stays in the intensive care unit and hospital [11]. A later literature review on adverse outcomes in adult intensive care units showed that decreased staffing was associated with adverse outcomes (infection, postoperative complications, unplanned extubation) [122].

The relationship between inadequate staffing and nosocomial infection has received widespread attention, primarily because of the high rate of infection despite its preventability. In a study in neonatal intensive care units, inadequate staffing was associated with an increased risk of nosocomial infection in very-low-birth-weight infants [123]. In a study of adults, the rates of urinary tract and surgical site infections increased when a nurse's workload was increased by one patient [12]. Furthermore, the authors found a specific and significant association between nurse burnout and the rates of these infections. It was theorized that the cognitive detachment associated with burnout led to lapses in proper infection control procedures and estimated that if burnout was reduced by 30%, the annual cost savings would be nearly $28 million to more than $69 million from preventing these infections [12].

Mortality

Mortality is also influenced by nurses' patient volume and thus is linked to burnout. Several studies have shown that lower nurse workloads are associated with lower hospital mortality. In a landmark study, it was found that the addition of one patient per nurse was associated with a 7% increase in the likelihood of the patient dying within 30 days after admission [7]. Analysis of pooled data has indicated that, if a causal relationship exists between patient-nurse ratios and patient outcomes, decreasing the ratio from more than six patients per nurse to one or two patients per nurse would save an estimated 25 lives per 1,000 hospitalized patients and 15 lives per 1,000 surgical patients [11].

In addition, mortality rates can be improved in intensive care units, as shown by a 2017 retrospective analysis of nearly 900 patients in two separate units. In this study, the researchers focused on workload rather than number of patients. Workload was calculated using the Therapeutic Intervention Scoring System (TISS-76), which assigns points based on therapeutic, diagnostic, and nursing activities. Workloads scored as less than 40 per nurse produced a 95% probability that survival to hospital discharge was more likely to occur. Conversely, scores of more than 52 per nurse produced a more than 95% chance that death was more likely to occur [62].

In summary, increasing the availability of nurses by reducing the frequency of burnout can have a substantial effect on patient safety and the quality of care.

Stress has been linked to many somatic conditions of varying degrees of severity. A 2022 report by the American Psychological Association showed that 76% of the American population reported stress-related physical symptoms. Headache was the leading physical symptom, reported by more than half of the respondents, and fatigue, upset stomach, and muscle tension were other top stress-related physical symptoms (Table 5) [2,32].

Stress has also been found to contribute to poor health and coping behaviors, such as [42]:

These behaviors have been shown to increase the risk of developing chronic physical conditions such as hypertension, high cholesterol, uncontrolled glucose levels, inflammation, and arthritic conditions. Additionally, the risk of heart disease and stroke is raised, making it important to address factors causing stress [42].

Stress is also associated with a range of psychological symptoms. In the 2022 American Psychological Association survey, between 53% to 60% of respondents indicated that they felt overwhelmed, depressed, sad, nervous, anxious, and/or a constant state of worry during the past month. Other symptoms included difficulty making decisions and forgetfulness [2,32].

Interpersonal and social relationships may also be compromised by stress. Individuals experiencing acute stress and burnout may have a difficult time communicating with others in the work environment as well as with friends and family and may create emotional distance [18]. The cynicism that is characteristic of the syndrome may lead individuals to treat co-workers with suspicion and to have critical attitudes toward them [18]. Other effects include marital conflict and divorce, neglect of family and social obligations, and questioning of previously held spiritual beliefs [18].

Stress can cause many of the same physical, psychological, and interpersonal/social symptoms as burnout. However, stress is distinct from burnout in that it is usually precipitated by isolated or situational instances, whereas burnout is the result of chronic workplace stress [18,27].

The concept of self-care is one that is emphasized in every book or article on preventing job stress and burnout across occupations. Self-care warrants particular emphasis for nurses, as they have been trained to put the care of others ahead of themselves. It is important for nurses to recognize that self-care is not equivalent to selfishness; rather, self-care is essential for energizing, restoring, and maintaining the physical and emotional stamina to reduce fatigue and manage stress Research has shown that self-care strategies are associated with lower levels of burnout among nurses [18,119,124,125]. Self-care involves several universal lifestyle habits, such as proper diet, exercise, sleep, and regular health care. Maintaining a healthy lifestyle through these habits is vital to avoiding the physical effects of stress [2]. The need for appropriate sleep hygiene is the most essential element for nurses, as fatigue can have serious outcomes for both the nurse and patient. One study showed that 49% of nurses at an academic medical center averaged less than the recommended 7 hours of sleep per night, and the overall average nightly sleep time was only 6.6 hours. In addition, 27% used medication to help them sleep, and 13% used medications to stay awake. Symptoms consistent with chronic insomnia were identified in 31% of nurses sampled [33]. In 2020, the Well-Being Initiative, a collaborative effort by multiple nursing associations, published the Guide to Sleeping Better and Restoring Energy for nurses, after finding that 72.8% of nurses are suffering with sleep challenges (either excessive sleep or sleeplessness) [34]. There is widespread documentation that sleep disturbances are associated with a high risk of fatigue, which is linked to job satisfaction and burnout [117,119,124,125]. The following are recommended for proper sleep, nutrition, and exercise needed to alleviate stress and prevent burnout [34,119,125]:

Nurses should also seek outside activities that will help them disengage from their professional routine and provide enjoyment, such as yoga, music, art, reading, journaling, sports, meditation, hobbies, and volunteerism. Spirituality may help some individuals derive a sense of purpose or meaning in life and enhance coping skills, especially for nurses who care for dying patients [104].

Cognitive behavior training, physical relaxation (e.g., massage), and mental relaxation (e.g., mediation) may have limited benefit, according to a meta-analysis of interventions to reduce work-related stress in healthcare workers. The study demonstrated low-quality evidence that cognitive behavior training, with or without relaxation, reduced stress compared with no intervention, but only after more than one month of follow-up [104,106]. Similarly, physical relaxation was most effective one to six months after the intervention [106]. Little evidence supported mental relaxation as a way to reduce work-related stress after up to six months [106].

Managing stress requires a high level of self-awareness, which can also help prevent burnout [1,104]. An individual should recognize the specific factors that cause stress and how he or she deals with it. Many informal self-assessment exercises are available to help individuals determine their own level of work-related stress. For example, a simple exercise in the book Controlling Stress and Tension asks individuals to describe how frequently (almost always, often, seldom, or almost never) they experience the following signs or symptoms associated with burnout [107]:

A score for the exercise is calculated by assigning 1 to 4 points for each answer (with 4 representing the "almost always" response); a total of 25 to 40 points indicates a high level of stress that could be psychologically or physically debilitating [107].

Staying in tune with the signs and symptoms of stress overload and burnout is a continuous process, and individuals should remain alert to their use of unhealthy and ineffective coping mechanisms, such as excessive use of caffeine, alcohol, or prescription medication; overeating or undereating; smoking; inactivity; or social withdrawal [6]. Such habits can be difficult to change, and individuals should focus on changing one behavior at a time and seek help from professional counseling if necessary [1].

Work/life satisfaction is a challenge for workers in all occupations and may be particularly difficult for nurses because of their work schedules. One way to help create better work/life satisfaction is to quantify the amount of time currently spent in each primary aspect of life—work, home, leisure, and vacation—and then determine priorities and assign preferred amounts of time for each aspect [108]. Creating such a time budget can help to prevent work life from overshadowing all other aspects of life, which can be harmful to self-esteem, self-identity, and overall well-being [22].

In a year-long study of the work/personal priorities of executive men and women from 10 multinational companies, 62% of the subjects were found to be work-centric (more apt to put work above personal life) and 32% were found to be dual-centric (more apt to set work and personal life as equal priorities) [105]. Dual-centric subjects reported stress less often than work-centric subjects (26% vs. 42%) [105]. In addition, dual-centric individuals felt more successful at work and had achieved higher professional levels. The dual-centric subjects used several strategies to maintain their priorities [105]:

Other ways to enhance work/life satisfaction is to maintain a balance of friends and colleagues, set boundaries with family and friends to avoid excess expectations, limit nonessential or nonproductive activities (e.g., checking personal email or social media, playing online games), communicate personal needs, and remember that you cannot please everyone—know how much you can handle [108].

Remaining "connected" to people is important in managing stress and preventing burnout. Nurses should strengthen relationships with family and friends and seek support from them as needed. Expanding the social network to involve community and volunteer activities can help increase self-esteem and provide focus and fulfillment outside of the profession [104,105].

Persistent symptoms of unresolved stress or burnout, such as sadness, anger, worthlessness, hopelessness, anxiety, sleep disturbances, or exhaustion, should prompt an individual to seek counseling, especially if these feelings interfere with interpersonal relationships or affect job performance [1]. Substance misuse or addictive behaviors also indicate the need for professional counseling. Nurses should be alert to the signs of burnout in not only themselves but also in their colleagues and should talk openly with those who exhibit severe symptoms [109].

Social support has been found to have a beneficial effect on workers' psychological well-being and professional productivity. Colleagues are in a unique position to understand each other's professional needs and stressors, and a supportive work environment protects against burnout [108,110]. Social support from colleagues is especially important during times of change and uncertainty in the work environment and can provide comfort, insight, rewards, humor, help, and escape [18,110]. In particularly stressful settings, informal social support gatherings can help nurses and other healthcare professionals deal with emotionally demanding events (such as the loss of a patient) [6,111].

Maslach defined working smarter as setting realistic goals, doing things differently (when possible), not taking things personally, and taking time away [18]. Setting realistic goals involves moving from abstract, idealistic goals to well-defined specific goals, which can help individuals gain a better sense of accomplishment. Varying work routines can help avoid feelings of being in a rut and provide a sense of better control. Taking things less personally involves objectifying negative interactions and situations to help decrease emotional involvement, thereby reducing stress.

Working smarter also means taking time away and organizing time more effectively. A typical response to work overload is to work longer or harder to help make the situation "get better" [18]. However, this approach will only exacerbate stress and burnout, not relieve it. The need to take some time away from work must be especially emphasized to nurses, most of whom do not routinely take breaks or do not take effective breaks. One study showed that appropriate breaks were least likely among nurses working the longest hours, and that approximately 60% of nurses are usually not completely free of patient care responsibilities during breaks for rest or meals [93]. Rest breaks are particularly important for nurses working the night shift, to relieve symptoms of fatigue, which can be detrimental to both nurses' well-being and patient safety [6,97]. Taking some time away from work—even if only a few minutes at a time—to stretch, take a walk, make a personal phone call, read, meditate, or just sit and relax can help nurses "recharge" and will improve performance and increase productivity more effectively than working continuously [1]. Facilities must help ensure that nurses take breaks and meals appropriately, as will be discussed later. Other time management techniques include scheduling a block of unplugged, uninterrupted time (no phones, pagers, or e-mails) to complete paperwork more efficiently, creating "to do" lists to maintain control over tasks, and increasing organizational skills [1,104].

Engaging in lifelong learning is another way to help combat burnout. Continuing education can help infuse energy into nurses and help them renew their passion for the profession. Studies have found that continuing career development through high-quality education was correlated with greater job satisfaction and job retention among nurses [35,92]. The COVID-19 Impact Assessment Survey, which included more than 22,000 responses from nurses, asked what would better prepare nurses for future health crises and/or pandemics, and nurses indicated that continuing education in disaster preparedness (50%) and in emergency and critical care (44%) would be helpful [115]. Becoming better educated can also help nurses advance in their career and become involved in decision making that affects nurses' job satisfaction.

Advocating for changes in the work environment or in the healthcare profession overall can help nurses increase a sense of control [18]. Assessing the potential for burnout and taking steps toward prevention is a process that can begin with one person who assumes a leadership role in a group effort [18]. The individual leader engages a group of colleagues to work with organizational leaders to heighten awareness of common stress factors within the organization and to address issues that compromise patient safety and quality of care.

Becoming an advocate means becoming familiar with policies, laws, and regulations related to nursing practice. Yet, many nurses are not aware of their facility's policies regarding breaks or limits for work hours or overtime [78]. Nurses should gain a better understanding of these policies, as well as federal and state regulations and professional statements. For example, the ANA has developed a position statement on nurse fatigue and resources on staffing plans and mandatory overtime [84,85,124]. Nurse specialty organizations have also developed recommendations to address fatigue [86,87,125]. The Emergency Nurses Association lists several evidence-based recommendations concerning fatigue for staff nurses; among these recommendations are the following [125]:

In addition to helping manage fatigue, these recommendations can help nurses serve as a role model for others, as well as feel empowered and in control of their practice, two other factors that help to prevent burnout.

Nurses learn to control their emotions to maintain a professional demeanor, but they are not immune to grief. A healthy response to the stresses associated with loss is important for avoiding burnout. As noted, burnout levels were higher among nurses who masked their emotions [75]. Instead of masking emotions, nurses must learn how to grieve well [111]. Grieving well involves accepting the reality of the loss, experiencing the pain of grief, adjusting to the absence, and moving on with life. Nurses can draw strength from colleagues and others by communicating sadness, frustration, and grief and can find solace in discussing what they were able to achieve with their dying patients, such as the ability to help manage pain and other symptoms [111].

Maintaining positive relationships with colleagues, physicians, and patients is often challenging and requires strong communication skills. Skilled communication is an essential standard in nursing and is an integral aspect of a healthy work environment. Nurses can decrease their vulnerability to stress by taking advantage of programs that strengthen their communication skills and help them to become more adept at handling difficult situations.

Nurses should also learn how to better communicate with their patients across language and culture. They should ask their patients what language they prefer for their medical care information and should seek the use of professional interpreters as much as possible [98]. The use of professional interpreters has been associated with improvements in communication (errors and comprehension), clinical outcomes, and patient satisfaction with care [99,100]. In addition, a systematic review of the literature has shown that the use of professional interpreters provides better clinical care than the use of ad hoc interpreters (untrained staff members, family members, friends, strangers in the hospital), with the former improving the quality of care for patients with limited English language skills to a level equal to that for patients with no language barriers [100].

Organizations and institutions can help protect nurses from burnout by creating an organizational culture of trust, support, and open communication and fostering a healthy work environment [6,18]. Creating a healthy work environment has become a priority for enhancing nurse job satisfaction and retention and improving patient safety and satisfaction. The American Association of Critical-Care Nurses (AACN) developed standards for a healthy work environment, noting that such an environment is necessary for clinical excellence and good patient outcomes. Six components were noted to be essential for establishing and sustaining a healthy work environment [101]:

The AACN has also developed an assessment tool that institutions can use to evaluate their environment against the AACN standards.

Evidence that a healthy work environment helps improve job satisfaction is emerging. Reports from hospitals that have implemented changes to create a healthy work environment have shown that the changes led to a more engaged nursing staff, greater job satisfaction, low turnover, and high retention. The changes have included the following [6,102,103]:

Nurses' work schedules and appropriate staffing should be the highest priority for reducing burnout. Defining "appropriate staffing" has been subject to debate, however. Some have argued for specific patient-nurse ratios, while others have advocated for hospitals to establish staffing committees, with nurses as members, charged with creating staffing plans that reflect the specific needs of the institution [84]. The ANA has identified enforceable ratios as an essential approach to achieving appropriate nurse staffing through their support of theNurse Staffing Standards for Hospital Patient Safety and Quality Care Act of 2023. This act calls for establishing minimum nurse-to-patient staffing requirements at the national level and will help examine best practices for nurse staffing and provide whistleblower protections for nurses who choose to advocate for the safety of their patients [84,91]. This bill has been introduced in Congress several times since 2007, but no action has been taken; however, the need to protect nurses and patients is greater than ever [91]. As of 2022, 14 states have passed laws or regulations addressing nurse staffing: California, Connecticut, Illinois, Massachusetts, Minnesota, Nevada, New Jersey, New York, Ohio, Oregon, Rhode Island, Texas, Vermont, and Washington [46,84]. Of these, seven states have laws or regulations requiring staffing policies that are developed by committees. Only California stipulates in law and regulations a required minimum nurse-to-patient ratio be maintained at all times, with that ratio being dependent on the unit of care. Massachusetts is the only other state to have a specific staff ratio legislation enacted; however, that law applies to the intensive care unit only [84]. Hospital administrators and nursing leaders should be familiar with staffing ratios mandated in their state.

With the unexpected surge of hospitalized patients due to COVID-19, the nurse-to-patient ratio soared in most states. During the height of the pandemic, California hospitals were able to apply for waivers to bypass safe staffing ratios, placing nurse staff at higher risk for burnout and creating an increasingly unsafe environment. All waivers granted in California expired in February 2021, but the uncertainty surrounding the pandemic calls for a renewed discussion of The Nurse Staffing Standards for Hospital Patient Safety and Quality Care Act and other legislation [60,84]. In addition, in the One-Year COVID-19 Impact Assessment Survey, released in 2021, the leading response (74% of participants) when asked what would help prepare for future crises and/or pandemics was consistent and better executive national health policies and public intervention plans, followed by effective leadership communication (67%), and increased staffing (66%) [115].

Institutions should also implement staffing policies that address nurse fatigue. The ANA position statement on nurse fatigue notes the following evidence-based recommendations [124]:

These recommendations echo those developed by the Joint Commission and specialty nurse associations [85,86,87,125,117]. As of March 2024, 18 states had enacted laws or regulations restricting mandatory overtime for nurses [85].

Institutions should also consider implementing innovative measures to ensure that nurses take breaks and meal periods. Some interventions that have been successful are encouraging going outside for breaks, setting longer meal periods, adding shorter shifts to cover meal periods, a buddy system for breaks, tuning off cell phones and pagers during breaks, nurse managers' coverage of breaks, and monitoring and documentation of breaks to ensure they are taken [88,102].

Administration and nursing managers can help increase job satisfaction and nurse retention by implementing strategies to enhance nurse autonomy and control. These strategies should be based on setting clear expectations and supporting measures to increase the knowledge and expertise of nurses [89]. Nurses should be involved in participative decision making, especially as it relates to their practice. Fostering independence and autonomy can be accomplished through clear and open communication, collaboration, seeking opinions from a nursing team, providing decision-making opportunities, and encouraging professional development through education and training [89].

Given the link between ineffective management and leadership and job dissatisfaction and burnout, institutions should ensure that nursing leadership is strong and supportive.

Nurse managers should be accessible to staff, provide a supportive environment, and work to foster better relationships among nurse peers and between nurses and physicians. Nurse leaders should also empower nurses by providing them with information, resources, and opportunities. These factors have been shown to reduce work-related stress and burnout among nurses [89].

One challenge for nurse managers is that they themselves are often burned out or fatigued. Nurse managers should ensure that they practice self-care, set realistic goals, be clear about boundaries, and schedule time off [71,104,125].

The importance of positive interpersonal relationships with peers and physicians to both nurses' job satisfaction and patient outcomes requires a commitment from administrators and nursing leadership to foster better collaboration and communication within the working environment. Enhancing peer support systems and group cohesion has been identified as an important aspect of a healthy work environment [90]. And, as noted earlier, enhancing communication and collaboration between nurses and physicians is an essential element of a healthy work environment [65,101,102]. Thus, institutions should offer training programs that focus on effective communication between nurses and physicians and forums that allow healthcare professionals to interact outside of the patient's bedside [126]. Simulation training in decision making, interdisciplinary rounds, patient care seminars, continuing education lectures, and hospital committees can provide opportunities for nurses and physicians to collaborate on projects and gain a better understanding and respect for each other. Developing mutual respect early in the career may be of value; medical students who were required (as part of their curriculum) to shadow a nurse for one day gained a better appreciation of the nurse's role [6,47].

Nurses should be encouraged to participate in workshops that address challenges such as overcoming cultural and language barriers, responding to emotions, and dealing with angry patients and their families. Training has been advocated primarily for nurses in oncology and has been shown to improve some areas of communication skills, to help alleviate stress, and to improve the coping skills of patients with cancer [6,121].

Another priority is to make available programs designed to help nurses manage the emotional demands of the job and enhance their psychosocial well-being. However, developing effective programs can be a challenge. A meta-analysis of staff-support interventions showed that stress management training offers some benefit in reducing work-related stress and increasing job satisfaction among health workers, but the benefit is not maintained over the long term. High-intensity stress management training interventions did have a beneficial effect in terms of reducing burnout. More research is needed to determine if longer term interventions or refresher sessions will help improve the effectiveness of these programs [120]. Nurses in all settings can benefit from programs designed to enhance coping techniques, to facilitate work-related grief and bereavement [72].