Nursing Burnout - Essay Example

Running Head Nursing Burnout Nursing Burnout Occupational stress and dissatisfaction lead to burnout in nursing profession. Changes in health status, illness, and hospitalization are just some sources of distress in clients. The work of nurses and allied health professionals is known to be stressful and ripe for causing distress. The changing health care climate causes stress for nurses. In addition, nurses may pick up the sadness of clients, called shadow grief which can lead to burnout. Interpersonal problems experienced by health professionals clearly reveal that reactions to emotionally laden situations interfere with ability to act effectively. Untoward reactions can come from feeling unsure or inadequate about how to act, the situation (feeling overcome or impotent), or the distressed person (distress invades the health care professional). Emotional involvement and empathy are the main causes of stress and burnout among nurses. If nurses become too involved with others' distress, they overload themselves emotionally and become ineffective (Johnston and Swanson 2004). If nurses avoid the distress of others by ignoring or belittling it, they are left with the feeling of not giving the attention and support that is expected. Some nurses feel helpless about how to be therapeutic with distressed persons. Others feel annoyed or irritated that clients or colleagues cannot solve their own problems. Thoughts about their own inadequacies, or judgments about the appropriateness of others' behavior, prevent nurses from acting in the best interests of the distressed person (Carroll and Arneson 2003). Four common events that can cause burnout are: loss of control, change, sense of threat, and unrealized expectations. When nurses face distressed clients, these are the issues. Remember that it is not the situation itself that causes problems, but our reaction to it. The teaching of communication skills implies that if we say the right thing, clients or colleagues will have an unpleasant experience. On the other hand, stress can be the opportunity for nurses to learn from others' experiences and to build new skills that will increase communication effectiveness. Ideally, nurses need to keep calm enough to be able to understand the reason for another person's distress, to remain nonjudgmental so that they can convey appropriate compassion for the situation at hand, and to be clearheaded enough to act responsibly on behalf of the other person (Johnston and Swanson 2004). The literature abounds with documentation of the stressors nurses experience. Johnston and Swanson (2004) cite four main events responsible for workplace stress and conflict: multiple levels of authority, heterogeneity of personnel, work interdependence, and specialization. All four criteria apply to the nursing profession. As a nurse, an employee navigates several organizational structures to ensure client well-being: the nursing hierarchy; the medical hierarchy; and the agency's bureaucracy. To survive this organizational maze, a nurse needs effective interpersonal communication techniques and efficient management skills (Koller and Bertel 2006). Not only do nurses require a sound knowledge in their own area of expertise but, in order to be effective in helping clients, they need to know the role and functions of other health care professionals, how to communicate clearly with other members of the health care team, and how to coordinate work efforts of all these disciplines. The changing exposure to different personnel demands that a nurse quickly sizes up how to relate to colleagues effectively, adding one more stress to an already complex working environment (Koller and Bertel 2006). One of the most frequently cited sources of stress in nursing is the excessive workload demand, giving nurses the feeling that they are always in a hurry, as if in a race with time. These factors are overlaid by nurses' day-to-day encounters with distressing and anxiety-provoking situations, as well as insufficient resources in these times of health care restraint (Poncet et al 2007). Overriding all of these specific sources of stress is the well-documented strain of being a helping professional. As helping professionals, a nurse has a vision of what workplace, colleagues, and clients will be like, and these images may not prepare a nurse for the reality a person encounters (Poncet et al 2007). Nurses today who want to know where the health care industry is headed must read widely beyond nursing literature in such areas as business and industry. Part of health teaching with any client is reviewing the basics of health promotion such as eating nutritiously, exercising regularly, securing adequate sleep, engaging in supportive social encounters, and making time for solitude and/or spiritual contemplation. Knowledge of the benefits of taking care of oneself physically, emotionally, socially, and spiritually is sound. With the investment nurses have in health, they likely try to incorporate these health behaviors in their own daily life. The return on their investment is an enhanced feeling of well-being and a readiness to handle the stress of working as a nurse. Both of the techniques, relax and prepare for stress in their interpersonal relationships, are designed to relax a body, putting it in a state where the fight-or-flight response or the defense-alarm syndrome of arousal is greatly diminished or eliminated, freeing their energy for communicating effectively (Mizrahi and Berger 2005). To belong to people is to have a few people in life who are a permanent part of nurse's life, people with whom she shares herself. Nurses sometimes lament their poor relationships with family members. Until a nurse can work these relationships through, claim close friends as new relatives. To accept pain as a part of life is also to be able to experience the contrasting joy (Mizrahi and Berger 2005). To be fully present with a client or family member is to be open to sharing suffering, but also to be open to rejoicing in the triumph of coping and changing in the face of crisis. It can be argued that empathic responses from nurses can enhance healing and well-being in all clients. Illness and hospitalization cause fear, dependency, and upheaval in clients' daily lifestyle and relationships, whether the health problem is surgical, medical, obstetrical, or psychiatric. Empathic nurses can tune into their clients' feelings in a helpful way. Empathy in health professionals can improve the success of the complete clinical problem-solving process and enhance client compliance because of increased client involvement (Koller and Bertel 2006). Work burnout result from a complex interaction of characteristics of the person and the work environment. Nurses, particularly those with limited knowledge of work settings other than in the mental health field, should caution against automatically or simplistically applying psychodynamic explanations as the exclusive means for understanding work-related problems. What can be very exasperating to the industrial psychologist or the manager is the mental health professional's attempt to psychologize everything and to apply psychodynamic explanations even when the fit is procrustean. On the other hand, several studies that suggested the primacy of emotional exhaustion in the burnout construct. Although (Koller and Bertel 2006) agreed that exhaustion was the primary aspect of burnout, they also found personal accomplishment and depersonalization to be separable scales, although they did not concur that they should be regarded as elements of burnout. Other researcher have found work stress to be related only to emotional exhaustion in a sample of teachers; the other two components of burnout were related to recognition and status factors (Upenieks, 2003). In nursing, concerning individual differences, burnout is reportedly higher among younger, more junior nurses and among Whites compared with Blacks. Burnout in male workers was more strongly related to doubts about their work performance than was the case for female workers (Upenieks, 2003). Women may be more likely than men to experience conflict between family and work as a cause of burnout and to have social support moderate the experience of burnout; for men, work stress alone may be more determinative of burnout. However, having children may also moderate the experience of burnout. Nurses with children to be at lower risk for job burnout than those without (Silverstein, 2006). In addition to the differences in causes of burnout for men and women, occupational differences presumably interact with gender to moderate the propensity for burnout and the ability to cope with factors predisposing to burnout. Women reported themselves to be more sensitive to hurt feelings than did men, but the men were more likely to experience a discrepancy between their actual and their ideal accomplishments at work. The effects of burnout on work performance are predominantly negative (Silverstein, 2006). Burned-out workers may cope by withdrawal and rigidity in decision making; however, they may not self-rate their job performance as being affected because denial may be part of the pattern. The ability to develop a belief system, an inner process, as a way of understanding or explaining events that seem beyond human understanding, is reflected in interpersonal communication with clients and family. A nurse who isn't exactly sure what she believes reports that when a client's family was distressed, she spontaneously said, "There are some things that are beyond our understanding that life has a purpose." Listen to colleagues as they comfort family and clients and nurses will hear a demonstration of their belief system. Honest, clear communication takes a commitment to continue to grow, to deal with change, to stay connected with people. The rewards are substantial. Work can bring joy, but the cost is too great if nurses lose the joy that comes from having a rich personal life, interests to pursue, and people to whom nurses are connected. A major job and organizational factor implicated in burnout and stress more generally is work stress that is perceived as resulting from such job features as role ambiguity, conflict, and overload (Reese and Raymer 2004). In nursing, organizational climate and type of work setting may influence the extent of burnout. In the social services, working in an agency setting (versus private practice) is apparently much more likely to be associated with burnout. The mechanisms by which job conditions interact with personality variables to cause burnout and its presumed psychological consequences also remain to be established. Emotional exhaustion precedes depersonalization, which in turn leads to burnout (Reese and Raymer 2004). Because of the positive and societally sanctioned rewards associated with compulsive behavior and overachievement syndromes, change is not easy. People seeking mental health assistance are likely to be individuals who (a) have lost their employment and thus their major, if not only, source of self- esteem; (b) have lost (or are threatened with losing) their spouses or significant others because of their unavailability in the relationship; (c) are experiencing drug or alcohol abuse adopted as a means of coping with excessive stress associated with the overcommitment pattern; (d) have had a health crisis (e.g., myocardial infarction) possibly at least partly attributable to compulsivity; or (e) are typically of middle age or beyond who have reached a point at which they are unhappy with their life-style and seek change as part of a midlife transition or crisis (Reese and Raymer 2004). Values counseling-namely, helping the client put the work role in context and move away from overly ambitious striving (particularly when associated with little sense of personal satisfaction)-is a therapeutic strategy that is effective with many such clients. Workplace factors appear to be at least as important as individual differences in understanding the construct of burnout (Raingruber, 2003). To the extent that emotional exhaustion is a major if not primary factor in burnout, addressing the job components associated with it may be significant. For some seriously afflicted employees, temporary withdrawal from the job (or certain phases of it) may be necessary. For others, less drastic approaches may be taken, including physical exercise, relaxation techniques, and other exhaustion-combatting activities; viewing the job and what one can realistically accomplish in it more objectively; and reducing role overload, ambiguity, and conflict. Nurses in high-stress situations can also be assisted in changing their perceptions about distressing events that occur at work and that might otherwise contribute to burnout. At this time, there is no validated targeted approach through which specific symptoms or conditions can be paired with specific interventions (Clark et al 2006). Performance anxiety is typically situation specific and can be directly relevant to work. It can affect a variety of performance areas or be limited to certain aspects of work. For example, a business executive may be well-suited to the role of management and generally well-adjusted in interacting with peers but may experience "stage fright" when making an important presentation to superiors. Anxiety, performance or otherwise, does not appear to be a unidimensional phenomenon that can be described accurately and universally by one model, nor is the relation between anxiety and performance clear-cut or unambiguously established. Performance anxiety can also be part of a more generalized concern with career stress, including the tendency to exaggerate the importance to one's career of any single performance (Mcmillen et al 2005). As Clark et al (2006) describes, nurses may cope with stress in various ways. The phenomenon of burnout has been discussed previously. Clark et al note that health professionals can avoid this "'caregiver's plight'" by effectively coping with the stressors they experience. Individual coping strategies include constructively using denial (ignoring permanent disfigurement and focusing on a patient's assets), achieving satisfaction from the challenge of a difficult job, using humor, accepting one's own feelings (depression or anger) as natural human reactions, and finding peer support (Upenieks, 2003). Organizations can enhance stress reduction by providing support groups and stress reduction resources. Further, hospital policies and structures can be altered to reduce stress. Increasing numbers of health care workers recognize the positive effects of exercise and relaxation and are incorporating these behaviors into their lifestyle patterns. Effective communication, assertiveness training and limit setting for and by nurses, and self-care activities can also be helpful (Johnston and Swanson 2004). Furthermore, the increase in medical specialization decreased the numbers of general practitioners and created a gap in primary care. Nursing responded to this crisis by placing practitioners in clinic settings. These nurses were, in fact, often diagnosing and treating patients in direct violation of nurse practice acts. The development of coronary care units and intensive care units placed hospital nurses in the same violation of practice acts as the nurses in primary care, including making diagnoses and differentiating signs and systems for the purpose of initiating treatment. Many state nursing and medical associations attempted to resolve this dilemma, but laws in some states continued to prohibit nurses from diagnosing or initiating treatment in any circumstances, despite long-standing acceptance of this reality by both medicine and nursing (Raingruber, 2003). Nurses indicated that many stresses exist in these environments. These stresses include: feeling responsible and in fact being expected to meet the totality of a person's needs when the nurse has limited authority for autonomous decision making; the care itself (for example, being constantly involved with dying patients); the constraints of the job; and the rapidly changing and complex technology, especially if indecision regarding its use results in prolonged patient suffering (Carroll and Arneson 2003). Nurses expressed great satisfaction when patients were allowed to die with some element of humanity and dignity, if death was inevitable. As painful as dying could be, artificial life support was worse, especially for nurses, because they provide the care that they may perceive as "torture" and "dehumanizing" (Carroll and Arneson 2003). Nurses felt so personally involved with patients that participation in such care was seen as a violation of patient wishes and a betrayal of trust. Conflicts in decision making among patients, families, and physicians were the major sources of stress in these situations. Nurses perceived that they often facilitated decision making and communication at these difficult times. They often recognized when patients were tired and helped communicate this to families or physicians. They also reported that they provided support to physicians when "it was time to quit." The economics of nursing as a predominantly female occupation, the current nursing shortage, and the value of caring ascribed by society and by nurses themselves are some of the issues related to the altruism of nursing that scholars have not sufficiently explored. The link between altruism and professional skills peculiar to critical care nursing remains underdeveloped in a systematic way (Johnston and Swanson 2004). For example, the death of one patient in critical care may influence nurses more adversely than the daily pressures related to caring for acutely ill patients. Also, significant life events in the presence of high job stress contribute to burnout (Mcmillen et al 2005). Following Carroll and Arneson (2003) critical care units are environments fraught with potential stress for nurses, Carroll and Arneson found that nursing in general was described as stressful before critical care nursing was linked to stress and anxiety. Their study identified tensions of hospital nursing as patient suffering and death, heavy demands, frightening tasks, and disturbing relationships with patients. Koller and Bertel (2006) identified the following areas of high emotional risk in nursing: the inability to restore patients to well-being and feelings of loss for patients with, for example, kidney transplantation, surgical risk, severe disability, rehabilitation problems, psychiatric difficulties, terminal illness, and critical illness. Other demands and stressors for critical care nurses result from patient care. Other sources of stress for nurses stem from the interpersonal aspects of the nurse's role as mediator and coordinator of the many individuals who come into an each day. These persons include distraught families, frightened patients, and physicians who may cope with their own distress by diverting anger to nurses or by abdicating their responsibility and leaving the nurse to communicate medical issues to the patient's family. Koller and Bertel (2006) note that when doctors use distancing as their main coping strategy they shift responsibility for the patient's emotional health to the nurses (Upenieks, 2003). Generalized (rather than narrowly specific) anxiety is a more serious condition than occasional performance anxiety and presumably predisposes the client to the experience of anxiety in a variety of work settings. Moreover, work disinterest or impairment may be a prodromal sign of a major affective or anxious disorder; this implies the need to clinically differentiate between generalized anxiety that is part of a more pervasive psychopathological syndrome and anxiety that is secondary to work dysfunctions. A common distinction in the clinical and research literature differentiates between state and trait anxiety the latter being associated with cross-situational dysfunction. Several studies have, in essence, extended this differentiation to the world of work and performance. That the relation between state anxiety and performance may be more complex than a simple correlation was suggested by Mcmillen et al (2005), who demonstrated that, in a group of graduate counseling students, those scoring high in state anxiety exhibited poorer performance only under conditions perceived to be threatening. When threat was absent, the performance did not vary according to state anxiety. Depression, of course, can be affected by both work and non- work factors. Depression can lower work performance, although its manner of operation may be more complex than imagined. Depressed nurses are more likely to have an overall negative impression of their performance, they do not evaluate their individual performances any more negatively than do nondepressed employees (Mcmillen et al 2005). In other words, it is the subjective impression that matters most, and people who are high achievers may still experience depression. Although jobs and occupations appear to differ systematically in the propensity of their members to report work-related depression, it is important to note that individual workers also differ in their capacities to tolerate dysfunctional working conditions, some being more "hardy" than others (Mizrahi and Berger, 2005). In sum, work-related anxiety and depression are complex and multi-determined phenomena. Performance anxiety and generalized anxiety can both be related to work concerns. The former has been more thoroughly examined in the literature and may lend itself more readily to treatment. The frequency with which depression occurs in connection with work-related issues suggests that psychotherapists need to become familiar with differentiating depression that is caused by work problems from work problems that are caused by depression. When work is the source of depression, correcting the difficulties in the work situation may cause the depression to spontaneously lift. In cases in which work problems are caused by the depression, successful treatment of depression may ameliorate the work concerns, or the work concerns may effectively be dealt with as a circumscribed problem after the depression has been successfully treated. A few suggestions may aid the clinician in diagnosing character pathology with workplace implications. To be considered a personality disorder with workplace relevance, the problematic condition or set of characteristics should be persistent across a variety of situations including the workplace, should demonstrably interfere with the implementation of the work role, and should be relatively unresponsive to efforts at change and control through informal or advisory methods used in routine supervision. The inability to learn from experience, to adapt appropriately to new situations or conditions, and to consider the reactions of others are all characteristics that are likely to characterize personality disorders with workplace relevance. References 1. Carroll, L. A., Arneson, P. (2003). Communication in a Shared Governance Hospital: Managing Emergent Paradoxes. Communication Studies, 54 (1), 35-37. 2. Clark, P. F., Stewart, J. B., Clark, D. A. (2006). The Globalization of the Labor Market for Health-Care Professionals. International Labor Review, 145 (1-2), 37-39. 3. Johnston, D. D., Swanson, D. H. (2004). Moms Hating Moms: The Internalization of Mother War Rhetoric. Sex Roles: A Journal of Research, 51 (1), 497. 4. Koller, J. R., Bertel, J. M. (2006). Responding to Today's Mental Health Needs of Children, Families and Schools: Revisiting the Preservice Training and Preparation of School-Based Personnel. Education & Treatment of Children, 29 (2), 197. 5. Mcmillen, J. C., Proctor, E. K., Megivern, D., Striley, C. W. (2005). Quality of Care in the Social Services: Research Agenda and Methods. Social Work Research, 29 (1), 92. 6. Mizrahi, T. Berger, C. S. (2005). A Longitudinal Look at Social Work Leadership in Hospitals: The Impact of a Changing Health Care System. Health and Social Work, 30 (2), 155. 7. Poncet, C.Toullic, Ph., Laurent, P., barnes, N., (2007). Burnout Syndrome in Critical Care Nursing Staff. American Journal of Resporatory and Critical Care medicine 1 (2), 3-6. 8. Raingruber, B. (2003). Nurture: The Fundamental Significance of Relationship as a Paradigm for Mental Health Nursing. Perspectives in Psychiatric Care 39 (1), 104-109. 9. Reese, D. J., Raymer, D. J. (2004). Relationships between Social Work Involvement and Hospice Outcomes: Results of the National Hospice Social Work Survey. Social Work, 49 (3), 415. 10. Silverstein, Ch. M. (2006). Therapeutic Interpersonal Interactions: The Sacrificial Lamb Perspectives in Psychiatric Care, 42 (1), 65. 11. Upenieks, V. (2003). What Constitutes effective Leadership. Journal of Nursing Administration 33 (1), 457-467. Read More