Nurses have incredible duties and encounter several trials (Scott, Matthews, & Kirwan, 2014). Aiken et al. (2012) observe that nurses are at a greater risk of developing stress than all other health care providers. The US Bureau of Labour Statistics showed that in 2014, 2.8 million Registered Nurses (RN) were involved in the delivery of healthcare services against 708,300 doctors (BLS, 2015). Thus, nurses play a central role in the provision of quality healthcare. However, one of the most common challenges that nurse’s face while executing their functions is burnout (Poghosyan, Clarke, Finlayson, & Aiken, 2010). Reports have indicated increased cases of nurses resigning from their jobs due to work-related stress and lack of the assessment of quality care provided by nurses (Heinen et al., 2013). Heinen et al. (2013) conducted a cross-sectional study in ten European nations consisting of 23,159 RN. The authors found out the intention to depart from the profession was significantly high especially among those undergoing burnout. This report seeks to draw attention on and explore burnout in the nursing workforce by critically assessing existing relevant literature. The first part will provide an in-depth description of burnout in the nursing workforce, then followed by three major factors that affect the issue. After that, the report will explore one appropriate program to solve the syndrome of nurse burnout in addition to two recommendations aimed at improving the program.
The present-day nurse has multiple responsibilities beginning from offering care (considering all the progressive development stages of a patient), an instructor (disseminating knowledge that is critical to the wellbeing of the patients), representative (emphasizing on the rights of the patients and making legal decisions for patients that are not able to). Furthermore, a correspondent (forms a vital link between the patient and the families and its significant in fostering healing), decision maker and leaders (Potter, Perry, Stockert, & Hall, 2016). These are essential functions which rely on each other for the success of the healing process. Potter et al. (2010) note that the nursing workforce involves tremendous duties that call for different demands and thus making the profession more demanding and intricate.
There is a need for more emphasis on modern structures and organizations in the nursing workforce to provide in-depth insight into the dynamics of the intricate nursing workforce. The nursing profession has significantly evolved in the past decade and continues to develop, and the current nursing is highly structured and organized. As a result, several models have been designed to help in understanding the current nursing practice; these include primary, team and functional nursing (Tomey, 2009). Under functional nursing the administration and leadership assign responsibilities. The leader has the duty of assigning tasks, and this can be a head nurse or ward manager. All decisions are approved by the leader, and the nurse is required to possess clinical skills so as to execute the allocated tasks effectively. Under primary nursing, each nurse is assigned to specific patients and thus is the primary caregiver to the patients. Team nursing is perceived to be the most used mode, and the focus is based on teamwork. This mode involves administration, and the team leader assigns work to nurses (Tomey, 2009).
Studies have pointed out burnout as the most common challenge facing the nursing profession. Burnout is the last reaction that is expressed as a result of chronic stressors from work and evidenced in the form of exhaustion and inefficiency (Kim & Lee, 2009). The problem of burnout and stress in the nursing profession is common, and Kama Azida (2015) attributes this to the nature of nursing which is undoubtedly stressful. The pervasiveness of burnout in nursing is an existent issue that is threatening the health care system. Multiple studies have been carried out globally and evidenced the high incidences of burnout among nurses, especially the staff nurses employed in hospitals (Poghosyan et al., 2010). Sahraian, Fazelzadeh, Mehdizadeh, and Toobaee (2008) undertook a cross-sectional study among Iranian nurses employed in government health centers with most of the participants being female. The objective of the research was to ascertain the extent of burnout in different hospital settings. The authors measured the burnout levels using the Maslach burnout inventory instrument. The findings showed that the nurses attached to psychiatric wards had higher levels of burnout than those in other units. Nurses under the night shift program and single had high incidences of burnout when compared to those in a relationship and not in the night shift.
Cross-Sectional research carried out in six nations by Poghosyan et al. (2010) in 2010 was aimed at examining the association between burnout among nurses and its impact on the quality of healthcare cares services provided by the nurses. A total of 53,846 nurses were involved in the study and burnout level measured using the Maslach burnout inventory tool. The authors found out that Japan was leading in burnout among nurses, with average incidences being observed in UK, Canada, and New Zealand. Moreover, there was a consensus across the six countries that exhaustion negatively affected the quality of care provided by the nurses.
Burnout among nurses affects the health and productivity of the nurses themselves, patient safety, quality of healthcare and the hospital management. Several studies have indicated that burnout among nurses affects the quality of care because it impacts the intention to leave the job, job satisfaction, retention and a sense of moral cohesion among the nurses (Van Bogaert, Kowalski, Weeks, & Clarke, 2013; Van Bogaert et al., 2014). The most significant indicator of quality in healthcare is the patient outcomes, and therefore burnout leads to organizational ineffectiveness because it compromises patient safety (Stimpfel, Sloane, & Aiken, 2012).
Workload is the expected quantity of output in a given work. Heavy workload has generally been perceived to be the primary cause of work-related stress and burnout, whereas supervision and organizational support have been regarded as the factors which help minimize job stress and burnout and affect employee commitment (Adriaenssens, De Gucht, & Maes, 2015). Role ambiguity is the absence of vital information regarding a specific work position. More specifically, it is associated with the precision of authority, duty, time and objective (Yürür & Sarikaya, 2012). Studies on burnout in the nursing profession show that excessive workload and lack of clarity in roles have a substantive impact on job stress which leads to burnout (Yürür & Sarikaya, 2012). Ideally, burnout is caused by instances of prolonged imbalance whereby the work demands are higher than the company can offer and provides inadequate resources required by the employee to perform effectively.
The heavy workload in nursing takes place when a nurse perceives that the tasks assigned to him or her are too many to be completed within the allotted time. Several studies have indicated that heavy workloads foster burnout, especially emotional exhaustion. Khamisa, Peltzer, and Oldenburg (2013) conducted a systematic review of the relationship between burnout and factors that influence burnout among health workers. The findings indicated that most nurses experienced burnout due to the long working hours in addition to the constant and direct, individual and emotional contact with multiple patients than other healthcare providers. Van der Doef, Mbazzi, and Verhoeven (2012) carried out a study on East African nurses to ascertain the association between job conditions and their well-being. The outcomes showed that over 30% of the East African nurses had excessive somatic complaints that were regarded as burnout. The specific job conditions that contributed to high levels of burn out were low supervisor support and poor financial rewards.
Studies have indicated that stressful work environments and high work demands, which characterize the nursing profession, can lead to burnout (Kama Azida, 2015; Toh, Ang, & Devi, 2012). Such work environments require organizational support to buffer moral distress which leads to stress burnout among nurses. Perceived corporate support among the employees is an indication of how the employees are valued with regard to their needs and well-being. Robaee et al. (2018) observed that organizational support was significant reducing work-related stress that is common in the nursing profession. Lack of corporate support in the nursing work environment, which is already depressive, increases pressure in the workplace leading to job dissatisfaction among nurses (Schaufeli, Leiter, & Maslach, 2009). Woodhead, Northrop, and Edelstein (2016) found out that a work environment that is not supportive increases occupational tension which increases burnout and the intention of the nurses to quit work. Organization support in the form of superior supervision has also been found to affect burnout in the nursing profession. (Choi & Kim, 2014) Found out that nurses that had undergone supervision at work reported substantially low burnout levels, thus making it the practical approach in minimizing excessive stress and burnout among nurses. Moreover, Supervision influences the positive attitude of employees such as employee devotion and is a significant aspect in empowering staff. Nurses that are not supervised express negative attitude and are cynical and experience excessive burnout (Choi & Kim, 2014). This is because supervision helps nurses to improve their professional capacity. Choi and Kim,(2014) shows that supervision from more experienced nurses helps the subjects of supervision to enhance their professional development, work attitude, and nursing capacity.
Burnout is common in work settings that experience understaffing. Research conducted by Schulz et al. (2009) on the American Organization of Nurse Executives found out that 37% of nurses cited understaffing, and 57% of them recognized that tasks were not equally allocated among them leading to high levels of workloads and burnouts. Burnout increases turnover among nurse employees because it makes them feel burnout and so ready to quit working. The turnover leads to understaffing which contributes to nursing shortage or insufficient nurses to effectively accomplish tasks. Nursing shortage causes job dissatisfaction among the remaining nurses due to additional work that is assigned them. Job dissatisfaction may rise to excessive levels so that despite the hard work by nurses, they may end up feeling that their work has no effect, and this marks the beginning of burnout. Additionally, the increased turnover rate implies that the more inexperienced graduates will be left and others employed leading to cultural incompetency; an aspect that leads to burnout.
The systematic review by Adriaenssens, De Gucht, and Maes (2015) found out that understaffing issues such as qualification of staff, shift work, and appropriateness of work schedules were substantially linked to exhaustion and decreased concentration which ultimately led to burnout. Cimiotti, Aiken, Sloane, and Wu (2012) the association between nurses staffing levels, burnout and disease infection using survey data. The authors found out that urinary tract infection was closely associated with the patient-to-nurse ratio. In other words, understaffing increased burnout as well as disease infections.
It is the duty of nursing management at all unit levels to ensure that job health standards are met at the workplace. The leadership of nursing has the role of assessing the high expectations from nurses and supply resources to help meet these demands. It is the responsibility of the management to make policies that impact the organization. The provision of quality healthcare services by the nurses and the corresponding positive outcomes can be realized through effective leadership that is focused on providing supportive structures that can offer innovations and growth (Ndawula, 2016). Organizations should endeavor to provide the right working conditions such as sufficient staffing to improve nurse-patient ratios and thus lower workload which has been reported to be the most common cause of burnout in nursing profession (Myhren, Ekeberg, & Stokland, 2013). The study by Robaee, Atashzadeh-Shoorideh, Ashktorab, Baghestani, and Barkhordari-Sharifabad, (2018) found out that appropriate leadership and administration reduces stress in the healthcare system. The administration in the healthcare system should have an in-depth understanding of the working conditions of the nurses, be ready to accept responses in addition to develop an interest in acting on it, for example by showing support. The management should incorporate nurses in the decision-making process on matters that touch on their work in order to do away with the sense of being disregarded (Robaee et al., 2018). According to Fearon and Nicol (2011), nursing leadership should emphasize clinical supervision as a way of managing stress and burnout. Multiple studies have recommended the utilization of clinical supervision because it promotes guidance for nurses; an aspect that is required in work settings that are stressful. Consequently, clinical supervision makes nurses feel that they are being appreciated valued (Fearon & Nicol, 2011).
Organizational support in improving the work settings of nurses has been cited as one of the most effective approaches in reducing burnout. According to Van Bogaert, Meulemans, Clarke, Vermeyen, and Van de Heyning (2009), organizational support by the nursing management is crucial as it contributes to a productive working environment which also improves the quality of healthcare and alleviates any source of burn out among the nurses. Organizational support in the form of superior supervision will enhance the relationship between nurses and nurse management which will also have a positive impact on the quality of healthcare (Fearon & Nicol, 2011). Organizational support in the form of making policies that improve the working conditions of nurses will ensure that there is an equal allocation of staff, adequate number of staff are employed, and the welfare of the nurses is generally improved. Cases of depression, workload and the intention to quit nursing will be well addressed by the formulation of appropriate policies by the organization.
However, organizational support approach in alleviating burnout has one major weakness, and that is costs or insufficient resources for implementation. Various forms of corporate support such as employing adequate staff, proper remuneration, and superior supervision have cost implications and can only be realized once there are sufficient financial resources. The study conducted by Van Bogaert, Kowalski, Weeks, and Clarke (2013) found out that excessive workload in the healthcare system was as a result of understaffing which led to burnout among nurses. Additionally, the nursing shortage has been attributed to burnout which is caused by inefficiencies in the nursing management. Excessive workload due to nursing shortage or burnout has also contributed to a lack of organizational support (Toh, Ang, & Devi, 2012).
Organizational support can also be achieved at no cost by involving the nurses in the decision-making process on matters that are work-related. Nurses can be included in the decision-making process by forming a committee of representation. This committee will consist of members from different units and will consolidate the suggestions and issues raised by members of the respective departments. The committee can then discuss the matters raised by the members and the recommendation of the most appropriate solution can be forwarded to the executive meeting with a few representatives. This will ensure that the nurses’ feeling of lack of authority and feelings of burnout is reduced. Additionally, the incorporation of nurses in the process of work-related decision making makes them feel valued, and their efforts appreciated, and this improves their attitudes towards work (Teixeira, Ribeiro, Fonseca, & Carvalho, 2014). Mudallal, Othman, and Al Hassan (2017) carried out a study on Jordanian nurses to ascertain the impact of leaders empowering conducts on nurses’ burnout. The findings indicated that the conduct of the leadership in empowering the nurses was significant in reducing burnout. The leadership behaviors that promoted opportunities for decision making where nurses were allowed to air their opinions freely decreased burnout. The study also found out that the involvement in decision-making process increased the trust of the nurses on the leadership. This led to a positive attitude towards work and increased job satisfaction among nurses. Therefore, the involvement of nurses in the decision-making process on work-related issues will empower organizational support by providing solutions that are nurse-centered and geared towards meeting their needs. Additionally, this approach doesn’t need additional financial resources to implement, thus in case other forms of organizational support fail, and this approach can work effectively.
The organization can also offer support by offering social support in the form of recreational activities to the nurses. Recreational activities can be organized in such a way that the nurses get some time away from the routine schedule to relax and self-reflect. Studies have shown that retreats that are aimed at teambuilding are effective in reducing burnout. The study review carried out by Potter et al. (2010) found out that 150 oncology nurses who were engaged in retreat activities such as relaxation, social support, and self-meditation experienced individual growth and reduced stress. The utilization of retreats and team-building strategies will strengthen organizational support because such social supports improve work relationships and individual well-being. This will ensure that there is cohesion at work and incidences of work-related depression are adequately handled.
Conclusion
Nurses are at a higher risk of developing stress in the healthcare system across the globe. Additionally, nurses play a critical role in the provision of quality healthcare. However, the effectiveness of delivering quality healthcare and the well-being of nurses is significantly affected by burnout. Burnout in the nursing workforce is prevalent due to several factors especially due to the nature of the nursing profession. Nurses play the responsibilities of an instructor, representative, correspondent and decision making. This makes the work of nurses more demanding. Excessive workload is another factor that contributes to workload due to the nature of the nursing job. Heavy workload among the nurses has been attributed to role ambiguity, whereby there is a lack of clarity on the roles and each unit nurse and other healthcare providers. The heavy workload has also been attributed to a shortage in nurses due to the overbearing demand of the work coupled with low financial reward. Lack of organizational support is another cause for burnout among nurses. The stressful work setting in the nursing workforce requires organizational support in different forms be it in the form of superior supervision or social support. This will ensure that the nurses feel valued and appreciated. Understaffing of nurses leads to excessive workload among few nurses and thus causing burnout. The study recommends the provision of organizational support as the key approach in alleviating burnout among nurses, and this can be strengthened by involving nurses in decision-making process and providing retreats and team-building activities.
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