ANMJ Featured Story

The Rise of Burnout: An emerging challenge facing Nurses and Midwives

Tuesday 24th October, 2017

Stress. Physical and emotional exhaustion. Irritability. Loss of motivation. Reduced productivity. Detachment. Skipping work. Using food, drugs or alcohol to cope. Burnout is a debilitating condition which research shows is increasingly affecting nurses and midwives. Robert Fedele investigates the rise of burnout and need for key stakeholders charged with managing the workforce and sector to recognise its importance and find solutions.

It knocked the stuffing out of her seemingly overnight. The alarm bells thundered when sitting in her car and crying before shifts became the norm.

Enrolled Nurse Carol Hyndes suffered burnout over a year ago.

The condition turned a job she once cherished and found meaningful into an unrelenting uphill struggle.

Initially, the 51-year-old attributed her deteriorating physical and mental state to being run down from the inherent pressures of the job.

“After a while you get to a point where you just can’t shake it off,” Carol explains.

“It affects your work. It affects your home life. You don’t want to go to work.”

Carol has been an EN for three decades and aside from time out to have children has worked nonstop across everything from aged care to the surgical ward.

She currently works in Mental Health, Drug & Alcohol at a New South Wales hospital where she says problematic nurse to patient ratios make delivering quality care challenging.

Carol’s husband raised red flags when he noted her irregular sleeping patterns and fluctuating moods. Soon she stopped socialising with family and friends.

“I had no incentive to get up,” she recalls.

After divulging her symptoms to both her workplace’s Employee Assistance Program (EAP) and her GP, Carol took a month-long holiday. But the situation did not improve.

At the time she remembers speaking to one manager who suggested changing wards might help. “I thought to myself, really? We are working short everywhere. The demands are the same it’s just that the age group changes. I didn’t feel that was an answer to the problem.”

One day Carol came across a social media post detailing nurse burnout and recognising the warning signs. “I thought ‘Oh lord! I’ve got seven of the eight of these!’”

A trip back to the GP led Carol to a psychologist, who diagnosed severe burnout.

Carol blames developing burnout on a combination of factors including increased workloads and demands, inadequate skills mix and workplace culture.

She says the scope of an EN has changed considerably throughout her career and now includes tasks such as drawing blood and cannulating.

Most recently, Carol concedes grappling with having to learn new electronic systems and juggling ever-increasing paperwork, rising work demands and obligations surrounding continual professional development (CPD).

“I’ve just battled through. My sick leave’s spiked. Once a month I was having a mental health day and my health did suffer; constant colds, getting run down, not eating properly, not drinking enough water. So physically, I started not looking looking after myself as well as I had been. I lost all interest in out of work activities so that down time that I made sure I was having right through my career suddenly all stopped.”

Carol visits a psychologist regularly and has taken up meditation. Her self-awareness has grown, allowing her to spot triggers and tweak her roster so she gets enough days off to manage.

Despite coping with burnout and remaining passionate about the profession, she plans to leave nursing within the next three years.

“I’ve actually looked around and applied for packing shelves at Woolworths. Just anything at this point. The more mundane it could be the better because I don’t want to get to a point where I’m not the nurse I want to be.

“I still have the passion for it. I really do. I love what I do. But I’m just feeling like it’s all becoming too much. There’s got to be a trade-off. I’m either going to lose my husband and have a job or I give up the job and concentrate on my family which has gone by the by.”

Carol estimates half her colleagues are also experiencing burnout but invariably soldier on. “It’s something people are frightened to talk about for fear of getting judged. Feeling that you are incompetent. That you’re not doing your job well. You can see other staff members
going through the same thing but no one is willing to talk.”

WHAT IS BURNOUT?

Nursing and midwifery are stressful professions that can take a mental and physical toll.

Burnout saps energy, leaves you feeling hopeless and at its most damaging can lead to mental health issues like depression.

Signs and symptoms include physical and emotional fatigue, loss of motivation, detachment, reduced productivity, cynicism and low self-esteem.

The effects of burnout contribute to more mistakes, absenteeism and turning to food, drugs or alcohol to cope.

Burnout is fundamentally different to regular stress. It is characterised instead by feelings of emptiness, loss of motivation and as though life is not worth living.

The causes of burnout range from unrealistic workloads to shift work, exposure to trauma, staffing shortages, and lack of recognition.

Regrettably, nurses and midwives who suffer burnout often feel they are no longer able to fully commit to the job, begin to view it as a chore and eventually slowly fall apart, some of them unable to return.

Registered Nurse Carolyn McDonald, who supports nurses and midwives experiencing mental health or substance abuse at the Nursing and Midwifery Health Program Victoria (NMHPV), likens burnout to the petrol gauge reading empty.

Carolyn says half the clients the confidential service treats display burnout symptoms. “Someone just being exhausted. Lack of motivation. Feeling isolated. Potentially using coping strategies that are not great, like food. There’s a lot of nurses that tend to use food just to try and stay on top of stuff and it can end up with weight issues or using drugs and alcohol as well.”

RISING TOLL

Monash University’s Business School began conducting national surveys examining the workplace climate and wellbeing of nurses and midwives several years ago.

Releasing data every three years from 2010, the collective research paints an increasingly bleak picture of workforce perceptions.

The latest survey released in 2016, What Nurses & Midwives Want: Findings from the National Survey on Workplace Climate and Well-being, alarmingly found almost a third of nurses and midwives have considered leaving the professions due to rising work demands and burnout.

According to the report, increasing workloads, work intensification and budget cuts leading to unrealistic nurse to patient ratios underscore leading triggers.

Data revealed 71% of nurses and midwives feel they often have to do more work than they can do properly several times a day, while 67% listed work intensification as a major issue.

Disturbingly, 54% of nurses and midwives felt reluctant about voicing their concerns to management due to fear of negative consequences.

Study co-author Tse Leng Tham said mounting evidence now provides a platform for intervention strategies.

The nursing and midwifery workforce is reaching a tipping point in regards to work intensification, she says, and management, health organisations and policymakers must take action.

“Contributing factors of such increasing workloads largely relate to aspects controllable by either management or policymakers,” Ms Tham claims. “These include inadequate nurse-to-patient ratios, poor scheduling of shifts not allowing sufficient recovery time, increasing administrative work and unrealistic expectations of nurses/midwives to shoulder added work tasks without the provision of additional time or resources.

“In an environment where respondents indicate they receive little support from management and are faced with declining opportunities for effective voice, qualitative data suggests such factors are pushing nurses and midwives to the point of exhaustion, burnout, and likely departure from the professions.”

TICKING TIME BOMB

“I didn’t realise until after I’d fallen in a bit of heap,” reveals nurse practitioner Kate Sloan of her encounter with burnout.

“I had a lot of stuff going on in my personal life. My Dad was sick and my daughter’s partner died and it went on and on – all these things.

“It was cumulative. I’ve always dealt with work by coming home. Home’s been terrific and then home wasn’t that terrific. I sort of didn’t get that balance right.”

Kate has been a nurse for 34 years and currently works as a NP in the emergency department at the Warrnambool Base Hospital in Victoria.

It’s a bustling unit which treats rising numbers of patients with increased acuity.

Kate believes the challenging environment within the ED, where she is exposed to trauma and sorrow, geared her to burnout.

She knew she had a problem when a child being treated at the hospital died and she “did not feel a thing”.

Kate exhibited typical signs of burnout including lack of emotion and detachment.

She also developed anxiety and had trouble sleeping. The situation soon spiralled out of control to the point where she struggled to cope.

“You’re just exposed to so much sadness [in the ED]. I don’t think it was about working too hard. I love working hard. I go home at the end of a shift buggered, but I expect to do that. That’s part of my job.

“I think a lot of it is the trauma. You see terrible things often. You’re dealing with a lot of heightened emotions in patients and I think certainly the aggression has got so much worse over the last number of years. People are very intolerant of waiting or not getting what they want. When I first started nursing no one would have ever been rude to a nurse.”

After reaching a tipping point, Kate accessed counselling through the hospital’s wellbeing program, then took a few months off.

She was diagnosed with depression, a condition she now manages with medication, and got back on track by starting meditation and exercising more.

Initially fearing stigma, Kate chose to own her experience by opening up to her colleagues and thankfully discovered crucial support.

She now prevents future episodes by looking out for warning signs and taking a step back when needed, like last month, when she reduced her hours for a short period.

“I guess I’m wary of it happening again,” she admits. “I’m a bit more protective of myself. Making sure I leave work on time. Having breaks. Not letting myself get overwhelmed by things.”

“It [burnout] is very under-recognised. I think I’ve become much better at picking up the symptoms. I think we just all press on and think we’re bulletproof. But we’re not.”

WHY NURSES AND MIDWIVES SUFFER BURNOUT

Professor of Health Research at Murdoch University, Anne Williams, runs education sessions at Sir Charles Gairdner Hospital in Perth on identifying and managing stress, developing coping mechanisms and resilience, and analysing wellbeing.

“Just about every single group I go to, when you ask them what stresses them out at work, the main thing that will come up will be the workloads and things about the environment in the hospital,” Professor Williams says.

“Very rarely will they ever mention the stress related to caring for dying patients or patients in pain.”

Professor Williams began a career in nursing in London in the early 90s, working on general surgical wards, then moved into research. She began researching nurse burnout in 1998 when undertaking her Masters on the perceptions of quality care.

“The results showed nurses were struggling to deliver quality nursing care because of various reasons such as excessive workloads and then the relationship with that impacting on their personal satisfaction and causing them stress.”

Professor Williams believes unrealistic workloads are the main cause of burnout.

Her latest project examining the condition began last year, a pilot education program set to be rolled out at two Western Australian hospitals, which will arm cancer nurses with coping skills to deal with stress and burnout. The project was prompted by a survey of cancer nurses which confirmed high levels of workplace stress and substantial scope to improve resilience through an education program.

The program will target four key areas – knowledge and understanding, self-discipline and motivation, organisational culture and environment, and strategies
and resources.

Professor Williams says nurses and midwives are driven by the value of caring and that the ideal can be hard to turn off.

When the body is stressed, she says it produces excessive levels of adrenalin and cortisol that can lead to high blood pressure, muscle pain, sleep disturbance, headaches, depression and anxiety.

“Nurses get to a point where they just can’t provide the care that’s needed by the patient because they’re in such a poor condition psychologically themselves.”

Professor Williams’ project draws on past literature surrounding wellbeing and aims to help nurses understand what stress is, why they’re experiencing it, and how to cope.

“Psychologically, the more control you have over a situation, the better your wellbeing. Often in the nursing environment, nurses don’t have a lot of control.”

She says simple strategies like eating healthy, getting enough sleep and exercising can boost wellbeing.

She believes more and more nurses and midwives will leave the professions unless burnout is addressed.

“We can’t just say toughen up. We’ve got to be realistic about the conditions they’re working in and perhaps what’s needed is more research and a rethink in terms of the changing environment and what are patterns of work and what might be better ways of working that are less stressful for people.”

MANAGING BURNOUT

Victorian nurse Linda (not her real name) has endured burnout at different stages of her career.

She describes nursing as a difficult job to switch off and one that can easily fall apart when you lose your support mechanisms.

“It’s a job where you’re looking after someone but then you’ve got all the other people you work with that you have to communicate with and you’ve got families that are distressed. Hospitals are pressure cookers I think.”

The death of her daughter and subsequent separation from her partner sparked one episode of burnout about 10 years ago.

Linda took a couple of years off from work, and then returned to the profession wanting to make a difference.

Her most recent bout of burnout struck two years ago. It was triggered by a combination of factors including a toxic workplace culture, changing hospital policies and work intensification.There were countless symptoms.

“I think it was low self-esteem. You’re just trying and you’re trying and you’re not getting there and you just start questioning yourself. You keep trying harder when you’ve got less and less reserves to give out and then you don’t sleep well and you don’t eat well and you put on weight and they all make it harder. Some people use food. Some use drugs. I know quite a lot of nurses that suicide as well.”

Linda often uses food to cope with burnout. When she’s feeling overwhelmed, her good intentions fly out the window and her weight balloons.

Linda accessed the Nursing and Midwifery Health Program Victoria (NMHPV) two years ago and regularly sees one of its counsellors, RN Carolyn McDonald.

As well as discovering mindfulness and yoga, Linda has also learned to manage her expectations.

“What I really like about it [the NMHPV] is that I get encouragement, first of all. Because that’s rare in nursing and it’s really nice to have. To be told your work’s valuable. Usually you’re being told you’re not working hard enough or doing good enough or you forgot this or that. So it’s really nice to stop and reflect on the fact that I am a good nurse.”

Linda’s advice to other nurses experiencing burnout is to seek out support and develop coping mechanisms.

For example, Linda puts a lot of preparation into getting into the right mindset for work the day before, making sure her clothes are ready, she has the right food and gets to work on time so she can tackle the day’s challenges.

“I think it’s important to look for support and keep looking. To resource yourself.”

PRIORITISING HEALTH

Registered Nurse Carolyn McDonald is a counsellor at the NMHPV, supporting nurses and midwives like Linda experiencing health issues relating to mental health or substance abuse.

When it comes to combatting burnout, Carolyn specialises in building resilience and helping nurses and midwives reframe the way they view work.

Carolyn says nurses and midwives are often the ones always giving and the NMHPV offers them an outlet where they can be heard, collaboratively re-evaluate their priorities and build on their strengths and resources.

“It’s building that relationship with someone and being a good listener. A lot of the work that’s been done in burnout is that someone needs to have someone listen,” she says. “It can just be giving someone some encouragement and some value. Some self-worth so that they realise that actually they’re worthy of setting boundaries and they’re worthy of actually doing the things that are going to keep them well.”

To deal with burnout, Carolyn encourages nurses and midwives to take time out immediately if required, before taking steps to prioritise health. Investing time in social relationships, trying to find value in the job and reassessing hopes, goals and dreams are important steps.

So too is maintaining a healthy diet and getting enough sleep and exercise in order to stabilise mood and boost one’s ability to manage tasks.

Carolyn regards resilience as nurses and midwives being able to respond to stressful situations with the ability and resources to ‘bounce back’.

“When nurses have very little psychological flexibility and are faced with stressful situations and lack of resources, their sympathetic nervous system is activated, the ‘flight or fight’ response. This leads to one becoming reactive, not responsive. A consequence of this is hyper arousal.

“Nurses can add to their own anxieties about things because of the future thinking. Anticipating what’s going to happen on the day when you don’t actually know what’s going to happen on the day. The body wears that. Even thoughts of stressful situations can trigger the sympathetic nervous system.”

However, while building resilience is progressive, Carolyn stresses it’s worth little if nurses and midwives are thrown back into traumatic situations.

“It’s really hard to build someone’s resilience up and then put them back in the firing line. When places where people work are unsafe or under-resourced and the system is failing the nurses themselves; it’s really tough.”

A qualified yoga teacher, Carolyn was one of the speakers at this year’s ANMF (Vic Branch) Wellness Conference and was buoyed by the sizeable turnout, which she says indicates a significant shift in nurses and midwives taking ownership of their health and wellbeing.

Carolyn imparted one of her strategies on the audience, a simple, five-minute mindfulness technique that uses controlled breathing to reduce stress.

She says it’s crucial nurses and midwives experiencing burnout put themselves first.

“I think once you’ve had that experience of getting to that point [burnout] you will no longer nurse in the same way as you ever did before,” she says. “Then you have to be really careful about what you do and how you look after yourself. It’s got to take priority or else you won’t have any fuel left.”

5 tell tale signs of burnout

Burnout is a state of emotional, physical and mental exhaustion caused by prolonged stress. It can emerge due to a variety of reasons – excessive workloads, a traumatic event, toxic workplace cultures or outside pressures. Nurses and midwives are susceptible to burnout and should watch out for warning signs to avoid reaching breaking point.

1. Fatigue: Burnout saps energy, leaving nurses and midwives feeling physically and emotionally drained and unable to cope with constant demands. This usually leads to diminished immunity and increased illnesses like colds and flu, as well as frequent headaches or muscle pain, changes in appetite and sleep habits, and skipping work.

2. Loss of motivation: Nurses and midwives suffering burnout tend to find it difficult to muster up the energy to care and eventually may feel like they have nothing left to give. Once inspired and motivated, they dread going to work and go through the motions, pulling back, and avoiding any unnecessary interactions with patients or colleagues.

3. Irritability and cynicism: The negative effects of burnout can spill over into every area of one’s life, including work, home, and social networks. Common indications of burnout include exhibiting an increasingly cynical and negative outlook when it comes to the job and feeling irritable and angry. Nurses and midwives sometimes feel overworked and undervalued, and quickly become disenchanted, viewing patients as objects. 

4. Mistakes: Nurses and midwives work in high-pressured environments and when burnout strikes, mistakes become more frequent. Every day starts to feel like a bad day and the unrelenting stress associated with reduced productivity can bring about a sense of failure and self-doubt and feelings of helplessness and as though the work is meaningless.

5. Detachment: When nurses and midwives reach a tipping point they often withdraw from responsibilities, isolate themselves from others and feel like they are alone. In the thick of burnout, many nurses use food, alcohol or drugs to cope. At work, they can feel empty and beyond caring, losing all sense of compassion for their patients, viewing them as objects and displaying apathy.

To read more articles from ANMJ, view the full journal online at https://issuu.com/australiannursingfederation/docs/anmj_november_issuu