Nurse Burnout and Work Stress

Introduction

The transitional period from being a student to becoming a healthcare provider can be challenging (Ankers, et al 2017). As a new nurse staff, moving from the university life to the work environment is overwhelming and stressful starting from the new responsibilities towards patients, co-workers and the organization, becoming part of the team, coping with the new role and adjusting to the workload and duties (Liselotte N. et al, 2018). Stress developed over time could affect staff performance which in turn limits the quality of care delivered to the patient. This is occupational burnout (Cohen M. Z. et al, 2019). Seeking healthcare dissertation help can provide valuable insights into managing these transitions effectively.

According to the World Health Organization (2019) who have recently acknowledged a detailed definition of a burnout as a work related phenomenon. Under the International Classification of Diseases it is known as “a syndrome conceptualized as resulting from chronic workplace stress that has not been successfully managed”. It is characterized by three dimensions; feelings of energy depletion or exhaustion, increased mental distance from one’s job or feelings of negativism or cynicism related to the job or reduced professional efficacy (Poghosyan, Lusine et al 2018). This phenomenon is becoming a widespread issue among workers in all professions. Nursing practice and environment is often characterized by professional expectation and inclination that make them susceptible to burnouts such as work overload coupled with long shifts, role ambiguity despite heavy training, lack of autonomy and inadequate salaries and allowance (Isikhan V. et al, 2017). Getting into the nursing field requires a special calling especially for people who are empathetic and sensitive, humane and dedicated, self-driving and enthusiastic. These same virtues end up driving them into severe burnouts. 49% of the nurses below 30 years and 40% of the nurses over 30 years of age experience severe burnout during practice (Sehlen S. et al, 2018). According to the World Health Organization (2018) the official medical diagnosis on nurses revealed that 4.5 out of 10 new nurses dreaded there work shifts, 4.0 out of 10 new nurses lacked empathy during their shifts and 4.5 out of 10 new nurses are dissatisfied with their jobs (Adriaenssens J. et al, 2018).

Students studying nursing undergo rigorous training before getting into the work environment. They learn how to balance their classwork and their practical work and spend most of their time in the wards, applying what they have been taught (Poghosyan, Lusine et al, 2018). 44% of nurses in the world undergo burnout per year and 62% of them are new university graduates who just got into the job market (Elsevier et al, 2017). Most of those who experience burnouts may experience some early indications such as a feeling of unpreparedness for the nursing job, decreased or no study interest, increased levels of classroom and ward performance based on self-esteem and a depressive mood in the final year of education (Aiken L. H. et al,2018). Burnouts are normally accompanied by emotional exhaustion mostly expressed as fatigue and weakness, decreased personal accomplishment and depersonalization where there is a loss of personal identity (Matthew McHugh et al., 2017). These burnouts can be differentiated depending on the clinical duties and the specialty of these nurses. Those who take care of the vulnerable age groups including the old, the children and those with terminal illnesses being affected the most (Altun et al., 2018). In recent years, studies have been undertaken to measure the level of burnout by using the Maslach Burnout Inventory (MBI) questionnaire which shows that nursing professionals have an initial danger of experiencing exhaustion and stress due to the work environment (Maslach C. et al 2016).

METHODOLOGY

The methodology gives an in-depth explanation of the approach taken during the research of this critical review in order to come up with essential results and evidence for the analysis, review and conclusion of the factors related to the burnout in newly qualified nurses and how to avoid it.

Search strategies

Online databases were used as secondary sources of information for this critical review. Most of the scholarly work on Google Scholar were obtained after signing up into many various online web pages. Other online databases such as the National Center for Biotechnology Information (NCBI), PubMed, Sciencedirect, MEDINE, Cinahl Plus and CINHAI were essential with further information that complemented that from Google Scholar. The keywords were very essential in the searches in these databases to narrow down on the relevant study topic of the critical review: Factors related to burnout among newly qualified nurses and how to avoid it.

Inclusion and Exclusion Criteria

On the databases, the search for studies and articles was narrowed down to between January 2010 to December 2019 with higher preference being given to studies conducted in the last 4 years between December 2015 and December 2019 due to the dynamic changes that the medical field and the nursing field has been undergoing. A total of 5451 academic and scientific articles were obtained on burnouts among people of various working groups and 667 scientific articles and academic books were specifically on nurses. 356 of them were from the past 4 years because there has been a rise of reported cases from the nurses. In further analyzing the data to narrow down into the critical review, only the papers which were specifically about the factors related to burnouts among newly qualified nurses and solutions for the rising cases of burnouts for the nurses were considered. Papers which also had the keywords used in the database search were included into the selected articles.

An inclusion criteria was further used to get the necessary papers which were written with primary sources of information:

1. The papers and articles should have been written in English

2. The study should have been conducted with source of information for different specialty of nurses who are newly qualified

3. They should have been used for empirical studies.

4. They should have thoroughly described these factors with back up evidence from primary sources.

The articles and papers were then further screened with the original authors name to remove any duplicate that was made by other others using secondary source of information. A total of 44 articles qualified to be used after the inclusion criteria was applied. The factors from these articles were then scrutinized and classified in line with theMaslach Burnout Inventory which is used to compare the increasing reported cases of nurse burnout over the years. The factors obtained were classified to be either situational factors which were based on the environment including work environment, occupational characteristics and organizational and institutional factors or individual factors which were either demographic or personality factors. The importance of these factors was determined by the e-Delphi technique which considered a group of opinions on each factor, collects information on each factor and further condenses the knowledge on these opinion until there is an overall agreement and ranking of each factor by importance.

DISCUSSION

Situational factors related to burnouts in newly qualified nurses

a. Job Characteristic

The specialty of the newly qualified nurses or the department they join to work greatly influences the rate at which they get burnouts (Liselotte N. et al., 2018). Those on oncology and intensive care unit wards are the most affected by emotional exhaustion, depersonalization and low personal accomplishment. Turkish nurses although 66.3% of the oncology nurses have increased personal accomplishment, 94.6% of them have a very low level of depersonalization (Aiken L.H. et al, 2018). The French correspondingly show that the newly qualified oncology nurses have emotional exhaustion and depersonalization more compared to a decreased sense of personal accomplishment (Matthew McHugh et al., 2017). New Zealand has 29.7% of the newly qualified oncology nurses experiencing emotional exhaustion, 24.2% of them having depersonalization and 31.2% of them having a sense of personal accomplishment (Altun et al., 2018). The nurses on the emergency services unit have 32.2% of them experiencing depression and burnouts annually with majority of them being the newly qualified nurses. Hence, specialty affects mental health and the frequency of burnouts among the nurses. Bulgarian study illustrates the new nurses are more likely to go into depression (Cohen M. Z. et al, 2019). Newly qualified nurses in other less stressful departments and less likely to get frequent burnouts within the first three years of their practice due to the ease of their work (Manojlovich M. et al, 2017).

b. Occupational factors

Nurses are considered to be the people who make most of the health facilities run efficiently (Schraub S. et al, 2017). They are the bridge between the patients and the doctors and they also influence the recovery of half of the admitted patients in the hospitals and clinics. New nurses have experienced shock due to the increased workload they have to handle on daily basis such as charting, patient care, patient follow up for those who have been discharged, manning the phone triage and communication with the administration of the respective health facility they work in (Cohen M. Z. et al 2017). Some of these nurses even have more than these duties added onto their plates resulting in physical and mental exhaustion months after beginning their practice as new nurses. In majority of these health facilities, there is a crisis of role ambiguity in the nurses as they have to go past their normal responsibilities to enable a lot of things to run in the hospitals. This eventually leads to exhaustion which further results early burnouts in the newly qualified nurses. The hospitals with clear information given about the role of every personnel have low reports of burnouts in newly qualified nurses (Abdo S. A. et al, 2016).

c. Organizational factors

Economicreview of the health facilities these newly qualified nurses are posted to is important, especially due of the presence of third world countries, middle income countries and first world countries (Aiken L. H. et al., 2018). Countries and regions where there is a high nurse to patient ratio have a very high rate of nurses’ burnouts. This is due to the long working hours of up to 12 hour shifts that these nurses have to keep on working. These long shifts results in very quick mental and physical exhaustion that result in burnouts especially for the new nurses (Altun et al., 2018). They experience severe fatigue, poor work life environments and this results in no work integration with other workmates hence there is no teamwork. The long working hours also increase stress which eventually decreases performance at work (Elsevier et al., 2017). This is mostly seen in third world countries and middle income countries. First world countries have adequate nurses for each patient and the newly qualified nurses do not get so stressed hence the burnout levels are low.

The regions with high nurse to patient ratio frequently experience staff shortages because of the high demand of these few new nurses. There has been an increase by about 7% of the patients’death in facilities with few staff within 30 days of their admission due to poor patient care (Chen Tian-yan, 2018). There is also a corresponding increase in hospital acquired infections, injury of the patients in the hospitals and delayed care of any patient in these facilities (Maslach C. et al, 2019). New nurses posted to these areas are stretched as soon as they get to these places and exhaustion occurs in less than a year for them (Poghosan, Lusine et al, 2018). This contributes to the rise in burnouts in these new nurses. Organizational factors refer to work related situation which are created by stress events and these factors are physical, psychological or social in nature (Burke, R. J., & Greenglass, E. R., 2001). Stress factors and nurse burnouts are generated also by work related factors such as scheduling, number of deaths in the unit, conflictual demands, and interaction of patients with their families (Duquette, A. et al, 1994). Those nurses with exposure to stress generating factors are more prone to nurse burnout. Organizations and institutions mostly assume the marital status and persona responsibilities of their nurses (Constable, J. F., & Russell, D. W., 1986). A test carried out in China found out that nurses who are older, married, previously worked in higher positions and have more responsibilities in their lives are vulnerable to emotional exhaustion a secondary element of burnout (Lin, F., St John, W., & McVeigh, C., 2009). The social demographic factor such as age is an essential element factor of burnout.

Organizations with low forums on developing team work and support groups has cases of their newly qualified nurses experiencing burnout symptoms widely (Burke, R. J., & Greenglass, E. R., 2001). Organization with strict policies where nurses are restricted from expressing their freedom of ideas and the aid of nurse to nurse are more susceptible to nurse burnout cases. A support system can be accrued by both superiors and colleagues (Duquette, A.et al., 1994). Lack of a support system, group or forum leads to nurse burnout among the newly qualified nurses in an organization.

d. Institutional factors

There are several nursing schools in the world and although their mission is to produce competent nurses, the quality of these nurses may vary depending on the training they went through (Robinson J. R. et al, 2019). Educational characteristics of theses nurses influence their ability to cope with the work environment and hence influence the rate and intensity of burnout they may experience (Liselotte N. et al, 2018). Those who were trained and exposed to the dynamics of the nursing field cope with the dynamic nature of the work environment and often end up emerging as very competent and skilled personnel in their area of specialty. However, those who barely got enough time in the wards and graduated with more theory knowledge than skill are hit by burnouts within the first year of work and may even quit nursing as a practice due to the sense of no personal accomplishment they experience (Matthew McHugh et al, 2017). The new nurses sometimes move from a comfortable school environment and get posted to harsh environments with very bad working conditions due to poor leadership and teamwork (Surqenor L. J. et al, 2019). These eventually strain them because of they will not be able to work efficiently and the patients may even have an increase in hospital acquired infections which further increases the number of patients they have to attend to (Matthew McHugh et al, 2017). This leads to both physical and mental burnout for the nurses.

Individual factors related to burnouts in newly qualified nurses

a. Personality

Personality is a very important factor that determines how effective a newly qualified nurse will be (Schwarzkopf K. et al, 2018). Most nurses are expected to have personality qualities to enable them to efficiently tend to the patients. They should be enthusiastic while working, empathetic, idealistic, self-driven and sensitive (Allen J. et al, 2017). Some personality types in the newly qualified nurses are linked to the quick development of burnouts within the first year of work. Those especially of personality type A have been observed to be the most susceptible to develop burnouts than other personalities (Seligman M. E. P. et al, 2018). They have a mentality that the current environment and the people around them are contrary to their goals in life and they are a threat to their self-esteem and self-drive. Their actions involves them deliberately trying to stand out and significantly dominate over the rest and as a result they have a hostile reaction towards their co-workers and the patients (Wu S. et al, 2019). After a while they may lack support from others and may develop a feeling of low personal achievement which may lead to burnouts (Spreitzer G. M., 2019).

Newly qualified nurses may also work according to Kanter’s Theory where they approach work with a positive mindset and consider it a place to learn and further improve their skills in the medical field (Leineweber C. et al, 2018). The nurses with this mindset consider their work as a source of information, a place of empowerment and a place to seek refuge when they need support. According to this theory most of these nurses end up having minimal cases of burnout and their efficacy at work is better than most other people (Tausch N. et al, 2017). The Spreitzertheory however shows that some nurses depend on psychological empowerment. They consider their work to be extremely important to them. The newly qualified nurses who see this as the best approach are highly likely to develop burnouts quickly and frequently (Pratto F. et al, 2018). The newly qualified nurses who act by compassion satisfaction also develop a lot of personal satisfaction and self-fulfillment hence they are more likely to get satisfied with their work and rarely get burnouts (Kiekkas P. et al, 2019). Those newly qualified nurses who act by compassion fatigue in turn do not do well in their responsibilities and end up straining themselves hence quickly develop burnouts in the first year of their work (Tunlind A. et al, 2017). Newly qualified nurses who use coping strategies of planful problem solving, positive reappraisal, seeking social support and self-control experience low levels of burnout. Those nurses who are not able to inhibit expression of feeling are prone to burnout since their coping mechanism is very low. Those nurses who are less likely to anticipate problems at work suffer more burnout.

Newly qualified nurses who show specific attitudes towards life for example openness to change, a strong commitment to all their endeavors, and a deep controlling feeling of their situation have a lower vulnerability towards burnout (Frögéli, E et al., 2018). Those nurses who are incapable of handling difficult situation lack hardiness and are susceptible to burnout. Strong willed and committed nurses are less likely to be affected by nurse burnout.

b. Professional values

Nurses have professional values that guide their decisions and actions in their career. It is a principle that entails a collection of attitudes and beliefsthat govern their feelings and actions in their practice (Kanter R. M., 2018). Caring is highly rated as one of the most important professional values because it helps the nurses prioritize patient care despite the ever-changing health sector environment (Cohen M. Z. et al., 2019). Maintaining confidentiality of the patient, respecting the ethical decision to refuse care, competence in the line of work and the right of the patient to privacy during treatment have also been highly rated and considered important in the medical field (Peteova G. G. et al., 2019). There is a correlation between the professional values of these new nurses and the job burnouts they experience. Most of the new nurses experience their burnouts in the first 3 years of practice (Aiken L. H. et al., 2018). Without a strong foundation of professional values, a nurses is more likely to be depersonalized and experience emotional exhaustion hence a severe burnout. Some of these professional values have also been neglected for some time by new nurses and contribute to the increasing rates of burnout among them. They include, not acting as the advocate of the patient in the hospital setting, failure to participating in frequent peer review to identify personal weakness of each nurse and no effort actively ensuring the mental health needs of the diverse patients are met accordingly (Altun et al., 2018).Professional value relates negatively with depersonalization and emotional exhaustion and relates positively with personal accomplishment. These neglect of professional values have led to a decrease in their personal accomplishment that has contributed to the rise in burnouts in these nurses. The rate of burnouts in newly qualified nurses who hold highly their professional values is significantly lower (Laschinger H. K. S. et al, 2017).

Solutions to prevent burnouts in newly qualified nurses and how to avoid situational and individual factors related to burnouts

It is important for a health facility to be constantly monitoring their nurses to be able to know those who are experiencing burnouts (Fredeunberger H. J., 2018). Some of the symptoms include exhaustion within a short period during their normal shifts, anxiety in and out of work, frequent illness that cannot exactly be identified with a specific disease, occasional headaches, muscle pains, a drastic change in appetite or even loss of appetite and a change in sleeping habits and oversleeping (Maslach C. et al, 2018). Some nurses may be withdrawn, they may have an increased preference to be isolated from the rest of the staff, their decisions during work may be of poor judgement and may endanger the patient’s life, procrastination and sometimes substance abuse (Aiken L. H., 2018). Burnouts have an effect not only on the nurses’ health but also on the health facility and the patients they attend to (Demir A. et al, 2017). There is a fall in the standards of patient care that may in turn result in increased patient mortality. There is poor patient engagement hence they end up feeling depersonalized, most of the nurses end up lacking empathy, they feel insensitive and they lack of compassion (Cohen M. Z. et al, 2019). There is also an increase in the cost of operations for the health facilities because they in turn have to keep on recruiting and training other new nurses because some of those who experience burnouts end up quitting the job (Grzywacz J. G. et al, 2018). The administration running health facilities have to invest in methods that effectively reduce the factors that result in the increased cases of burnouts among the new nurses (Kapucu S. S. et al, 2019). Most of these facilities have actively implemented positive wellness programs through the human resource department. It includes exercise incentives such as free gym services because exercise considerably reduces stress levels of an individual (FradeMera M. J. et al, 2019). Food and snack rooms have been created to enable them to physically nourish themselves during the work hours which considerably reduces there hustles on good food. Good food also relaxes the mind which enables them to be mentally active during their shifts (Gordon S., 2019).

Most symptoms of burnouts are silent but progress over time hence counselling groups within these health facilities need to be set up for these newly qualified nurses to enable them to feel part of the team that has been present in the facility so that they can easily talk about the stress that is building up inside them (Yu H. et al, 2017). The counselling group is also helpful in assuring the personal accomplishment of these nurses so that they can get empowered to do their duties better. Team building retreats should also be organized for the new nurses in the same shifts to be able to grow their team work skills (Altun I., 2017). Some health facilities have also worked into increasing the time off for some nurses without necessarily increasing their shifts to ensure they are mentally and physically fit (Stuart P., 2018). Organizations should correspondingly organize retreats and training for the newly qualified nurses to empower them about professional values (Aranda K. et al, 2018). Professional values are important to help them increase their personal accomplishment while they work so that they can be more enthusiastic (Currie E. J. et al, 2018). This also helps reduce emotional exhaustion and prevent depersonalization.

The administration in health facilities should consider taking up more newly qualified nurses and training them than opting to retain the old and the qualified (Mullan B. et al, 2017). This will greatly reduce the workload of the nurses and reduce the hours of their shifts enabling them to rest enough and get refreshed physically and mentally before approaching the patients (MeadusR. J. et al, 2018). This will also enable them to communicate with patients effectively, attend to them more efficiently and consequently the recovery rate doubles and mortality rate reduces. There is need for authentic leadership in the medical field administration and subsequently practitioners in this field should also step up as leaders (Lanquetin J. P., 2017). If the leaders understand the strain on the nurses and their workload they will be able to introduce policies that create a good work environment for them which will in turn encourage them to work better and eventually the patients will be the greater beneficiaries (Li H. et al, 2018). The administration of these health facilities should also work towards identifying the core areas of stress in the respective areas and work towards reducing them individually (Kearns S., 2017). Nursing colleges universally should also be urged to revise their curriculum to enable the students to effectively train to attend to patients which will increase their competence in the field and eventually decrease the number of burnouts (Charanjit S., 2016).

Nurses work with other nurses all the time it is only practical that nurses should create a support group which is both beneficial and progressive .Nurse support group will include an emotional and professional help group where nurses share ideas, share ordeals, share experiences with patients and also share personal experiences (Burke, R. J., & Greenglass, E. R., 2001). By doing so they are able to strengthen the bond with each other and the hardship they face during their time in the hospital decreases.

Organizations should be keener on the age group and the personal status of the nurses they hire (Kim, H., & Stoner, M., 2008). Older nurses are reported to be more susceptible to burnout therefore the organization should enact a policy where it is able to hire a certain age group of nurses who will be able to work for long hours without experiencing symptoms of burnout (Frögéli, E. et al, 2018). Furthermore nurses who have more responsibilities are more prone to burnout therefore should be given priority in terms of day off, payment and overtime hours by their hiring organizations.

Nurses should take initiatives to be able to prevent themselves from burnout. They should be able to have high coping mechanism (Lin, F. et al., 2009). They should pay attention to their feelings. These nurses should be able to control their environment, be able to create a mechanism of how to deal with death and loss of a client (Burke, R. J., & Greenglass, E.R., 2001). Newly qualified nurses with exposure to frequent interacting with grieving families should be hired professional help by their employees. Nurses who work long hours and longer shifts spend most of their time in the hospital. Extreme and a lot of pressure can lead to burnout therefore it is the organization which should take necessary steps to ensure the working nurse is comfortable (Kim, H., & Stoner, M., 2008). The facility should have sufficient resources such as hospital beds, gloves, scanning equipments and all amenities in the ER.

Organizations should implement clinical ladder programs to provide salary increments (Lin, F., St John, W., & McVeigh, C., 2009). By offering rewards such professional organization dues, reimbursement, travel or tuition for educational workshop or advanced degree class work. Organizations will be able to curb the feeling of anger, frustration, and resentment towards them from nurses and more so reduce burnout among newly qualified nurses. By offering staff support and bereavement groups an organization is able to support ailing clients and nurses. An organization can do this by putting up bulletin board for sympathy cards, funeral cards and patient thank you notes (Enoch L. et al., 2013). The hiring organization can also provide onsite counselors, and psychiatric advanced practice nurses, provide pastoral care for staff, patients, and families.

An organization should first look at the nurses they are hiring for most of them are not qualified and end up causing the organization much more than a qualified hired nurse (Lin, F., St John, W., & McVeigh, C., 2009). Most organizations especially public hospitals, run a very low budget therefore hiring qualified nurses can be difficult. The government of such countries should take into consideration the health facilities program since nurses are the most important care givers in the hospitals. Nurses take 90 of the staff (Burke, R. J., & Greenglass, E. R., 2001). Unqualified nurses do not only result in customer unsatisfactory but can also spread nurse burnout to other nurses and the families of the patients as well as other unprofessional and unethical demerits to the hospital.

CONCLUSION

There are several factors both situational and individual factors that contribute to the rising cases of burnouts in newly qualified nurses (Hamaiden S. H., 2017). Situational factors include the job characteristics such as the departments these newly qualified nurses work, occupational factors which narrows down to the role definition of the nurses, organizational factors such as authentic leadership and economic empowerment of these health facilities and institutional factors where these newly qualified nurses got their qualifications (Finfgeld-Connett D., 2018). Individual factors include the personalities and mindset of the newly qualified nurses and their professional values.

It is important for health facilities to quickly identify the nurses having burnouts to avoid endangering the lives of patients’ and to prevent shutting down the facilities due to incompetent staff. The only way to reduce and avoid cases of burnouts is for administration and the nurses themselves step-up and proactively act on the core of these factors to provide a conducive work environment for their own benefit and the patients’ benefit (Brady M., 2018). Solutions include positive wellness programs in the organization such as counselling groups, ensuring there is authentic dependable leadership and adequately training nurses (Furingsten L. et al, 2019).

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