Eight Ways Nurses Can Manage a Burnt-Out Leader.

Health professionals, including nurses, are vulnerable to burnout, which occurs when chronic stress is not managed. COVID-19 led to nurses working in stressful environments, and being required to work mandatory overtime. The result was an increase in burnout. Nurses exhibited physical, psychological, emotional, and behavioral signs of burnout. There are several ways that nurses can mitigate the situation and have more control over burnout. Nurses need to work together to support each other, including supporting the leader. There are several actions, such as mindfulness activities and maintaining a healthy lifestyle that can help prevent burnout.

Key points

Nurse burnout is a serious problem for America.

The signs of a burnt-out nurse are not always easy to identify and may be physical, psychological, emotional, and/or behavioral.

Nurses can support their peers and leaders during difficult times to reduce the effects of burnout and promote a healthy work environment.

Introduction

Nurses at all levels are leaving their jobs and the profession because of stress and burnout. Shah and colleagues found that of 50,273 US registered nurses (RNs), 31.5% left their job because of burnout. This is especially alarming because the United States is facing a shortage of nurses. COVID-19 added to stress and burnout in nurses, so nurses must learn to recognize and decrease the chance of burnout. The purpose of the article is to identify the signs of a burnt-out leader and strategies to effectively manage or survive in this stressful environment.

Background

Burnout results from chronic job stress that is not well managed. It is characterized as feelings of lack of energy, cynicism toward the job, decreased quality of care, and decreased professionalism. Other negative effects of burnout are irritability, insomnia, and substance abuse. Burnout is a work-related issue that occurs among health care professionals and may result in some people choosing to leave the profession. Kelly and colleagues found that all levels of nurse leaders are experiencing burnout. Resiliency training and support are needed for all nurses. The factors associated with burnout need to be ameliorated to ensure an adequate supply of nurses to provide quality care to patients.

Chronic stress during COVID-19

Although the rate of COVID-19 hospitalizations is decreasing, one residual concern is still facing nursing. That is, the burnout rate has increased among 10,000 nurses in the Medscape Career Satisfaction Report 2020. Frellick reported that before COVID-19, the burnout rate for RNs was 4%, and 6 months later it was up to 18%. Advanced practice registered nurses (APRNs), RNs, and licensed practical nurses (LPNs) in Frellick’s study increased in burnout rates but LPNs in nursing homes felt the most burnout. Of the 418,769 nurses who left their jobs in 2018, almost a third identified burnout as the reason for leaving, and 80% of those who reported burnout worked in a hospital. At a time when nurses are desperately needed, precautions need to be taken to strengthen nurses and prevent burnout. COVID-19 was a stressful time for nurses and the focus now needs to turn to supporting nurses, and especially nurse leaders.

A nurse’s clinical position is physically and emotionally demanding. A meta-analysis with 16 COVID-19 studies and 18,935 nurses found that the prevalence of emotional exhaustion (EE) was 34%, depersonalization (DP) was 12.6%, and feeling a lack of personal accomplishment (PA) was 15%. Those at the greatest risk were younger nurses, those with less social support, and those working in a quarantine area with a high risk of contracting COVID-19. Lagasse reported that in a survey by Mental Health America, which sampled 1119 health care workers, 84% of nurses in clinical positions were at mildly burned out. The ramification of this is that 48% of clinical nurses have considered retiring, quitting their present job, or changing careers. Nurses leaving puts more stress on the nurse leader and remaining nurses. The nurses and leader need to work together to create a positive work situation or burnout could occur in more nurses.

During COVID-19, employers were noticing the need for intervention. Through employee assistance programs (EAPs) or health care insurance, mental health programs were offered. Some programs offered by mental health staff are stress reduction, cognitive restructuring and reframing, and grief counseling. Mental health can also help a nurse to recognize and admit to symptoms of burnout. COVID-19 was an introduction of EAPs and mental health checks that should occur routinely. Nurses will not always admit or even recognize that they need mental health support. However, if one knows the signs of burnout, they can see it in nurses.

Signs of a burned-out leader

The signs of a burnt-out manager are not always easy to identify. The World Health Organization defines burnout as a syndrome resulting from prolonged workplace stress that is not being managed appropriately. The staff nurse needs to be attentive to the signs of burnout in their leader and peers. Table 1 provides physical, psychological, emotional, and behavioral signs of burnout. Maslach and colleagues developed the Maslach Burnout Inventory-Human Services Survey (MBI-HSS) to measure burnout in health care professionals. Over the past 30 years, the MBI-HSS has become the gold standard to assess burnout in health care professionals. The instrument focuses on 3 distinct aspects of burnout: EE, DP, and PAs. Nurses who are displaying signs of exhaustion, decreased sense of accomplishment, increased DP, as well as other symptoms described in Table 1 are likely experiencing burnout.

Table 1

Signs of burnout

Physical	Psychological	Emotional	Behavioral
Exhaustion	Fatigue	Decreased personal accomplishment	Calling in sick, arriving late, leaving early to work
Feeling tired	Difficulty concentrating	Lack of motivation	Procrastinating
Headaches	Detached from staff and family	Self-doubt	Withdrawn
Muscle tension	Decreased productivity	Cynical outlook	Intolerance to change
Decreased appetite	Decline in performance	Feeling trapped in a job	Taking frustrations out on staff
Gastrointestinal issues	Decreased creativity	Feeling alone	Increased use of alcohol
Hypertension	Negative attitude	Sense of failure	Substance misuse
Insomnia	Decreased commitment	Decreased job satisfaction	Social isolation from coworkers and family
Generalized body aches	Loss of purpose	Feeling defeated
Weight gain	Anger, irritability
Increased illnesses	Increased anxiety

Implications of a burned-out leader

A burned-out leader may experience diminished decision-making abilities, which can have negative consequences on the staff and the organization. When staff are feeling unappreciated or unsupported by their leader, they may consider other employment, which can be extremely expensive to the organization. In 2021, NSI Nursing Solutions, Inc. reported the results of a survey of hospitals across the United States and estimates the average cost of turnover for a bedside RNs is $40,038 and ranges from $28,400 to $51,700, resulting in the average hospital losing between $3.6 m and $6.5 m/y The cost of turnover is staggering, and increased turnover can have a major impact on the organization’s bottom line.

Another implication of burnout is an increase in absenteeism that disrupts the work environment, quality of care, innovation, employee morale, and increased hospital costs. The nurse manager guides and leads staff nurses on a unit or in a department, and if the nurse manager is suffering from symptoms of burnout, this will transfer to the staff and create a poor work environment. Nurse managers are responsible for leading change and quality improvement to enhance patient outcomes, but if they are burned out, efficiency and productivity will be compromised as well as patient care and staff well-being. To ensure productivity and safe, quality patient care is being delivered, leaders in organizations must ensure that appropriate resources, both material and immaterial, are available to assist nurse managers as well as staff nurses with lessening burnout. Promoting prevention and providing appropriate support to nurse managers will significantly reduce the effects of burnout in an organization and will benefit the staff that they lead as well as the patients who are being cared for.

Ways nurses can mitigate the situation

Each of the suggestions below are ways to build resilience. They are a nurse’s armor against stress and burnout. Nurses enjoy caring for others, but nurses also need to care for themselves and their nurse leaders. Nurses cannot control every situation and perfection is impossible with complex patients. Having a routine at work home helps one to feel more in control. However, unexpected patient health situations, admissions, and a coworker getting sick can through off a routine. Talking to others may help a nurse to realize what can and cannot be accomplished and how to prioritize tasks.

Strong interpersonal relationships outside of work

Positive social interactions with a spouse, friend, or family member have the ability to reduce stress. In a large study (N = 32,417), Sørensen and colleagues found that having adequate social support modified work and nonwork stress. People need a relationship where the person can talk about stressors and the listener can understand and empathize. Gallagher and colleagues found that both giving and receiving emotional support modified stress. Nurses could definitely do this if they were not so tired at the end of a shift. Bryson and Bogart also found that social support helped people cope with rare diseases. Nurses need family, friends, and coworkers for social and emotional support. Patients going through stressful life events required a nurse to be compassionate and caring, which becomes more difficult if the nurse is burnt-out.

Work-life balance

Nurses need to balance the stress of work with fun times with family or friends. Nurses at different levels, clinical, management, or director are each affected similarly by burnout. Kelly and colleagues sampled 672 nurse leaders and 2 qualitative themes emerged: the emotional drain and the negative impact on work-life balance. Being intentional about setting times for friends and family is emotionally charging. Days off need to be planned to accommodate positive time. More years working as a nurse or nurse leader led to more satisfaction in the position. Experience helps nurses face uncertainty. At the higher position levels, nurses had more difficulty achieving a work-life balance. With shift work, a nurse’s hours are better defined, but with more administrative work, a nurse may work extra hours trying to keep up with requirements. Nurse leaders find themselves coming in early and staying late. Occasionally, nurses, including nurse leaders, should be assessed for burnout. Nurses may not want to admit to signs of burnout or even recognize how close to burnout they are feeling. A numerical score can show nurses if they are reaching burnout. Maybe some work could be shared with a coworker or discussing the workload with a supervisor may help. The boundaries between work and home may be blurred because of mission creep. Handing off assignments to junior nurses helps a junior nurse to prepare for a nurse leader role. Staff nurses need to accept committee assignments, audits, unit education, and other tasks. This is a growing opportunity and an opportunity to support nurse leaders. Nurses also have an opportunity to support each other with healthy lifestyles.

Healthy lifestyle

A healthy lifestyle includes several components such as getting enough fluids, exercise, getting adequate sleep, and avoiding stress. Only about 25% of Americans get 6 to 8 glasses of water per day, resulting in fatigue, headaches, or difficulty focusing. Aerobic exercise is another healthy activity that Americans participate in. Insufficient exercise contributes to diabetes, osteoporosis, hypertension, and arthritis. Exercise also reduces stress, which is necessary to help prevent burnout. Burnout may still occur with a healthy lifestyle but with the prevalence of burnout so high in nursing, it is important to live as healthily as possible.

Bogue and Carter created a model for nurse well-being because of the stress and burnout that nurses encounter. Well-being may be enhanced with different approaches for different people, like some may focus on biophysical through adequate staffing, decreased overtime, or patient loads; some may do better with the psychoemotional by engaging with EAP, counseling, and stress management support; sociorelational by meaningful communication and inclusivity; or religiospiritual through faith services, animal therapy, or mindfulness. The sociorelational area was the strongest predictor for burnout.

Many nurses do not get enough sleep. Of those nurses in Lagasse’s study, 90% said they were not getting 8 hours of sleep each night. Adults need 7 to 9 hours of sleep and seniors need 7 to 8 hours. Nurses have varied shifts and overtime, which may prohibit staying on a regular sleep schedule, leaving the nurse feeling continually tired.

If falling or staying asleep is a concern, talking to the primary care provider could be a first step to identifying and treating problems like breathing problems, leg cramps, or insomnia that may be associated with inadequate sleep. Other tips that might help are keeping a sleep diary or using a sleep app. Symptoms of sufficient sleep include decreased reaction time, a poor attitude, poor decision-making, and ineffective communication. Nurses may need better boundaries at home to keep people and sounds from disrupting sleep time.

Decrease stress

Nurses face stressors at work and home. There are toxic people and environmental situations that trigger a reaction in nurses. Some brain chemicals can help nurses to relax. Two actions that release brain chemicals, such as epinephrine, norepinephrine, serotonin, and cortisol, are relaxation breathing and laughter. They seem like opposites and yet both help to reduce stress hormones, increase memory, and decrease blood pressure. Try to recall happy, positive times and times when you laughed. Make the event as colorful and vivid in your mind as possible. Write down happy remembrances as you think of them to help you when you are facing a stressful time. Then you can use these thoughts to help you decrease stress.

Nurses are under considerable stress, which may lead to burnout, no matter which type of nursing position they are in. However, oncology nurses are one type of nurses who deal with significant emotional stress. Cañadas-De la Fuente and colleagues performed a meta-analysis with 17 studies and found that oncology nurses (n = 9959) were at risk for EE and decreased PA. Considering this, nurses need to encourage oncology units to participate in compassion fatigue resiliency training and a psychological skills survey for managing difficult situations. Also, at orientation and group meetings, nurses need to remind one another of the symptoms of burnout.

Mindfulness

Mindfulness-based interventions and self-care practices have been shown to be very effective strategies for reducing burnout and stress levels among nurses. Part of the responsibility for reducing burnout and stress rests with the organization and promoting mindfulness-based activities for the staff has been shown to be a very effective approach to reducing burnout and stress. , Activities such as meditation, stretching, and yoga are effective approaches to reducing stress and burnout in nurses. If organizations prioritize the well-being of their employees and allow them to engage in mindfulness activities to reduce stress, this will impact the care being provided in a complex health care environment.

Education

Nurses who are reporting to a burned-out manager will generally become disillusioned and burned-out. Providing education to nurses about how to manage burnout, how to recognize stress and signs of burnout will have a positive effect on the professional well-being of the nurses. Increasing awareness of burnout and implementing strategies to prevent and/or reduce stressors in the work environment will improve resilience among nurses. When a nurse has specific concerns about workload or the work environment, approach the nurse manager and try to work together to reach a compromise or a solution. In some cases, nurses may determine that the only way to heal is to transition to another job either within the same organization or outside the current organization.

Recognize achievements

Leaders are motivated by significant recognition, organizational equality in rewards, and acknowledgments for a job well done. However, staff nurses are also motivated by the same factors, and it is imperative that all levels of leadership and staff are appropriately recognized for achievements. The leadership in the organization should make themselves visible to the staff, conduct regular rounds to talk with nurses, and understand the stressors in the work environment that are leading to decreased engagement and productivity. The transformational leader fosters a culture of shared decision-making and seeks input from nurses at all levels in the organization to address concerns and build trust among the team. These simple approaches are cost-effective ways to decrease burnout and create a supportive and healthy work environment.

Create a healthy work environment

The work environment is a critical factor when assessing and/or managing burnout. A work environment where nurses feel happy/fulfilled and valued by leadership and their peers is a healthy environment where nurses are productive and engaged. Creating a culture where nurses are caring for nurses and support each other while working in a fast-paced environment is one approach to reducing burnout. Open communication, empathy, and active listening are critical to providing support to your peers. A leader may not be able to immediately remove a stressor from the environment but can provide authentic, emotional support, which can also lessen feelings of burnout. Nurse managers should also offer external support, as appropriate, through an EAP so that the employee has an outlet outside of their coworkers and family.

Recommendations

Nursing has done an excellent job in providing training to new graduate nurses to allow them to successfully begin their nursing career. Often, staff nurses progress to charge nurses, nurse managers, and beyond without having adequate leadership training. Leadership training is essential for all levels of nursing leadership. Kelly and colleagues found that higher levels of burnout in nurse leaders were associated with less experience in leadership, which is why nursing should ensure adequate training is provided to new and existing nurse leaders. Underdeveloped leaders struggle to meet the day-to-day organizational demands and experience extreme stress while attempting to manage the staff, attend committee meetings, and be available 24/7 to support the department/unit and these issues lead to burnout.

The next generation of nurses who will be moving into leadership positions are Generation Xers and Millennials. Generation Xers were entering the workforce at a time when there were expanded career opportunities in other professions and as a result, they were less interested in a nursing career. The Millennials are surprisingly very interested in nursing and have been entering nursing at a rate almost twice that of the Baby Boomers. When the Millennial generation reached age 33 years, there were almost 2 times as many who entered nursing as compared with the Generation X at an equivalent time point. A major concern with the upcoming generation of leaders is the career trend that Generation Xers and Millennials will change jobs if they do not feel supported by leadership and if they are not able to maintain a quality work-life balance. These generations want to be able to have flexibility in their work schedules, control over how and when they will be at work, and desire autonomy. To effectively recruit and retain Generation X and Millennial nurses in leadership positions, current nursing leaders must consider the organizational and work-life balance factors that are important to these generations. Given the continuing need for future nurse leaders, it is critical that succession planning takes place, and the next generations of nurses are mentored and adequately prepared to assume leadership positions.

Succession planning is essential for the nursing profession because of the nursing shortage, expected retirement of baby boomers, an increase in the number of gaps in leadership positions, and the key roles nurses play in creating policy for education, practice, and nursing science. Succession planning should not be solely for the purpose of filling a particular position. Leaders should identify and prepare individuals who have demonstrated leadership in their current role to be able to accept future roles within or outside of the organization. Organizational leadership must create a culture for succession planning, be willing to invest in the employees, and carefully design and implement a structured process for employees to be mentored and coached to assume new leadership roles. In health care organizations, the development of the next generation of nursing leaders is a wise business strategy because gaps in nursing leadership can have an impact on the quality of patient care, success in meeting regulatory requirements, and organizational revenue.

Supporting nurse leaders

Burnout causes nurses to lose decision-making effectiveness and emotional intelligence may decrease. The Institute for Healthcare Improvement's framework for improving “joy at work,” promotes teamwork and teamwork and resilience activities. Nurses have traditionally divided workloads by patients. However, there may be other methods to divide the workload, such as having an IV nurse or an admissions nurse. If 2 nurses were working together, they may feel supported and there would be help with decision-making.

Nurses, especially informal leaders, can support their actual leaders, even if the leader has some indication burnout. Wiernikowski shows how staff nurses can offer support in several ways. One way is to understand and accept the leader’s vision. What does the leader see for the unit in 5 year? What improvements are required? What does the leader envision for the nursing staff? Offering constructive ideas rather than complaints or roadblocks is helpful. Another way informal leaders can support their leaders is to embrace change. Instead of the common “it will not work” answer, offer to help with designing the program or policy to help ensure that nurses are successful. Informal leaders can help gather the input of as many nurses as possible to get buy-in and design a workable program.

Age is one of the key individual predictor variables in burnout. In a recent meta-analysis of 51 studies, Gomez-Urquiza et al. found that older nurses reported lower EE and DP than younger nurses, but the association of age with reduced PA was not significant. Age and adequate coping skills provide protection from burnout. Older nurses can help younger nurses to learn to cope with difficult patient care situations. Older nurses could also help nurse leaders with decisions, stressful events, and dealing with difficult people.

Nurse leaders should receive education for leadership. However, many nurses earn midlevel leadership roles because they were strong and experienced clinical nurses. To help leaders as well as staff nurses, the buddy system works well. Buddy up for safety, buddy for connectedness, perform buddy checks regularly, listen to a buddy, and provide hope for a buddy. Buddies can help with reframing a problem, helping to find resources, and empathetic listening. At the beginning and ending of a shift, a huddle is helpful to not only go over what was done well and what could be improved but mostly to let each other know that their work was appreciated. Celebrations, thank-you notes, a flower, and candy are also ways to show appreciation. Nurses can show the support of their leader in multiple ways.

Nurses need to realize that the fight is against burnout, not against the leader or other nurses. Burnout may negatively impact decision-making and critical thinking. Therefore, nurses need to band together to make unit decisions, set goals, and enhance transformation. A suggestion for transforming a unit would be to study as a group to have every eligible nurse certified in their specialty. Nurses can motivate each other, intellectually stimulate each other, and celebrate accomplishments together. Another option is for nurses to join their professional organization. Finding solutions to problems becomes a shared goal. Looking through the literature, checking with others through professional organizations, and thinking outside the box stimulates nurses and transforms patient care. Poor staffing contributes to burnout, so the informal leaders need to keep up morale so that nurses are not quitting their job. A good working environment helps to decrease EE.

Therapy

Before nurses will accept any type of therapy, a need for therapy must be realized. The Maslach Burnout Inventory (MBI) should be administered periodically to nurses. Individuals need to know and understand their scores. Based on the score, the unit may benefit from resiliency training, mindfulness training, cognitive-behavioral therapy, or another intervention. Individual scores may help nurses to realize their own potential for burnout. Awareness is needed before actions will be taken.

Preventive practices such as those previously discussed should be included. However, a healthy lifestyle may not be enough to prevent burnout. A meta-analysis by Ochentel and colleagues found that exercise was not enough to decrease burnout symptoms. Combining several healthy lifestyle behaviors may increase the likelihood of reducing burnout, but other interventions may be needed.

Potard and Landais found that nurses who used negative coping strategies such as self-blame, rumination, and catastrophizing scored higher in EE and DP. The goal should be for nurses to help identify when a colleague is using negative strategies. Potard and Landais found that nurses who could focus on planning, putting the problem (challenge) into proper perspective, and positive reappraisal could improve their EE and DP scores. Providing educational interventions with practice to help nurses identify when a negative coping strategy is being used may be helpful. Nurses would then begin to change the negative coping strategies with positive strategies.

Bagheri and colleagues also found that positive coping strategies could decrease burnout scores. Bagheri and colleagues taught stress-coping strategies and group cognitive-behavioral therapy to nurses. The MBI was used to assess burnout before, immediately after training, and 1 month after training. There was significantly less burnout immediately after training and again after 1 month. Cognitive restructuring or reframing is another technique that nurses may need education and practice with. Could nurses help to bring this type of training to their units? Without an intervention, some nurses will be victims of burnout.

A meta-analysis by Lee and colleagues also found that coping strategies taught to nurses could reduce burnout for at least 6 months to a year after the training. Examples of coping strategies include cognitive-behavior training, stress management, mindfulness-based programs, and a team-based support group. Again, nurses need to help their leaders and each other by suggesting this type of training for the workplace. This might be linked with continuing education to help with the cost. Depression and anxiety are closely related to burnout. Those and other mental health conditions need to be handled by a professional. For nurses scoring high on the MBI, they may be encouraged to seek more testing.

Future research

Most studies on nurse burnout have been conducted with staff nurses. More research on nurse leader burnout is needed, specifically measuring burnout in nurse leaders and the factors contributing to burnout. Nurse managers' factors associated with burnout are likely very different from staff nurses and researchers should consider this comparison. Burnout is not necessarily an individual problem and future research should focus on assessing the work environment and the resiliency of the organization as well as burnout. Additional research is also needed on strategies to prevent or reduce burnout in an organization. Burnout can occur throughout an organization, and it becomes the organization’s responsibility to promote and sustain a healthy work environment and reduce burnout.

The second victim phenomenon is one in which nurses and other health care providers use dysfunctional mechanisms, such as anger, projection of blame, or drugs and/or alcohol, to cope with serious mistakes in the absence of a healthier means for healing. The main purpose of this article is to provide evidence and practices that support the need for caring organizational support systems following serious adverse clinical events. Recommendations are provided on key elements of programs to prevent the prevalence, symptoms, and impact of the second victim phenomenon on our health care professionals, patients, and health care system.

Summary

Rapidly increasing health care demands for an aging population, stressful hospital policies, and high-pressure work environments currently make burnout a possibility for nurse leaders. However, with mitigation, burnout does not need to be the ending of a promising nursing career. Every nurse should know the signs of burnout and continually practice methods that have demonstrated the ability to decrease burnout.

Clinics care points

A vision is needed for nurses to strive for delivering the best possible patient care in a healthy work environment.

Nurses should recognize the signs of burnout to protect each other from burnout, which results in compromised patient care.

Nurses who face increased stress from work may find mindfulness or other actions helpful to relax and provide better patient care.

Nurses facing burnout can evaluate their emotional exhaustion level to facilitate empathy with their patients.

Nurses at every level should work together and share tasks to deliver optimal patient care.