Is resilience training the answer to burnout?

Angela C. Brittain

Clinical Assistant Professor

College of Nursing, Washington State University, United States of America

angela.brittain@wsu.edu

Year after year, nurses have continued to be rated as the most trusted profession in the United States (Milton, 2018). The COVID-19 pandemic has served to exemplify this, as the stories of nurses fighting on the frontlines in hospitals across the country have been told. What many people outside of healthcare may not know, is that nurses were in battle long before COVID-19 was making headlines.

The primary battle that nurses have fought against for many years has been the enemy of “burnout.” Other terms that have been used for this nemesis include “compassion fatigue” and “moral injury” (Dean et al., 2019; Pehlivan & Güner, 2018). Pre-COVID, it was suggested that characteristics of work environments (as opposed to nurse characteristics) precede this phenomenon. Relevant precursors that have been suggested include understaffing, increased workload (both duties and hours worked), and reduced autonomy (Dall'Ora et al., 2020). Since the onset of COVID, heavy workload continues to be discussed as a precursor of burnout in addition to inadequate resources and prolonged exposure to high-risk environments (Galanis et al., 2021). Burnout is a pressing issue that impacts both the immediate and long-term well-being of nurses, as they are experiencing prolonged trauma, lasting post-traumatic stress disorder symptoms, and increased rates of suicide (Chen et al., 2020; Davidson et al., 2019). Equally distressing is the knowledge that nurse burnout is resulting in a degradation of patient safety (Garcia et al., 2019).

The phenomenon of burnout is not unique to nurses working on the frontlines but is something that has also been described for years as a precipitating factor of the ongoing nursing faculty shortage (Aquino et al., 2018; Shirey, 2006; Thomas et al., 2019). Precipitating factors of nursing faculty burnout include stress related to lack of work-life balance and mounting expectations related to service, teaching, and research commitments. Nursing faculty burnout has been further exacerbated by the preponderance of online education models that have blurred the boundaries between work and home life as faculty have work-related duties that frequently extend beyond traditional business hours (Thomas et al., 2019). Symptoms of nursing faculty burnout include difficulty concentrating, feelings of anger and frustration, headaches, gastrointestinal dysregulation, anorexia, and depression (Thomas et al., 2019).

Despite evidence to suggest that burnout is precipitated by elements in the work environment – interventions to combat this dilemma have been largely directed at nurses. The American Nurses Association (ANA) and the American Association of Colleges of Nursing (AACN) are calling for nurses to be taught skills pertaining to resiliency in order to combat burnout, boost mental wellness, and prevent suicides (AACN, 2021; ANA, 2021). If we understand that burnout is related to factors in the work environment, and one of those primary factors is workload – why are we advocating for an increase in workload for faculty and nurses through resiliency training? The mere suggestion that nurses and faculty should provide and undergo training in order to prevent burnout implies that the fault originates with them. Rather than putting the onus on nurses – it is time to shift our attention to the environments that these individuals are working in.

Pertinent environmental interventions for nurses working on the frontlines include mandated nurse-to-patient ratios that account for patient acuity, adequate staffing, increased nurse autonomy, and discontinuation of mandatory overtime (Dall'Ora et al., 2020). A systematic review conducted in 2018 found that even increasing a nurse's workload by one patient was associated with an 8% increase in job dissatisfaction and more than a one-fold increase in intent to leave employment (Sujin et al., 2018). Conversely, state-mandated nurse-to-patient ratios implemented in the state of California have been associated with a significant lowering of patient mortality and mitigation of emotional exhaustion in nurses (McHugh et al., 2020). Affording nurses the autonomy to work within the full scope of their nursing license for the betterment of patient care has also been positively associated with nurses' overall job satisfaction and reduced patient mortality (Dilig-Ruiz et al., 2018; Rao et al., 2016). Furthermore, care should be given to the number of hours and shifts that nurses are expected to work, as fatigue impairments cumulatively increase with each additional 12+ hour shift. Such overtime-related impairments subsequently perpetuate burnout and compromise patient safety (Thompson, 2019). Unduly heavy workloads are not relegated to those working at the bedside. Nursing faculty have been reported to work up to 56-h a week, including many weekends and holidays – making the maintenance of a healthy work-life balance extremely challenging (Thomas et al., 2019).

Suggestions to mitigate faculty working environments include effective communication and practical collaboration (Thomas et al., 2019). Effective communication is a reciprocal exchange of information that involves members throughout the hierarchy of an organization and results in the receipt of intended messages and positive change efforts (Brittain & Carrington, 2019; Fairholm & Fairholm, 2000; Fridrich et al., 2015). Collaboration can be encouraged and cultivated amongst faculty to reduce the potential for burnout (Thomas et al., 2019). For example, partnering for teaching assignments, research activities, and publishing endeavors can be mutually helpful while reducing the workload burden. Additionally, the incorporation of mentoring partnerships can help reduce burnout amongst newer faculty as veteran academics can impart valuable wisdom about how to navigate the world of academia from their own lived experience (Thomas et al., 2019).

The described changes for nurses working at the bedside as well as nursing faculty are effectively supported and sustained through the integration of transformational leadership models. Transformational leaders are characterized by their ability to creatively inspire and energize employees through a sensitive consideration of the working environment and employees' individualized needs (Bass & Avolio, 1993; Wei et al., 2020). The presence of transformational leaders has been positively associated with psychological empowerment, reduced stress, and perceived quality of patient care while being negatively associated with reduced productivity, emotional exhaustion, and burnout (Liu et al., 2019; Wei et al., 2020).

It is time to listen to nurses and nursing faculty about what they are experiencing and what they need. Research, the funding to support that research, and mitigating efforts directed to care environments are desperately needed. Nurses across the nation are crying out for help – are we listening (Ross, 2020)?