Issue 50 | July 2019

Developing resilience to combat nurse burnout

Issue:
As the frontline caregivers in health care today, nurses accomplish a myriad of tasks and responsibilities, but
often at high personal cost. The need to juggle competing priorities in often high-stress situations can result
in feeling overwhelmed or burnout. The negative effect of these stressors can affect the ability of health care
professionals to care for others.1 Organizations have a responsibility to support nursing staff and address the
causes of burnout. An emerging method to do this is by developing and fostering resilient environments and
individuals.

Developing strategies for nurse resilience is a patient safety strategy, as burnout negatively affects the
physical and emotional health of staff and contributes to rising costs.2 It also has been shown to have a
negative impact on patient satisfaction, worsen patient outcomes or increase rates of safety events, and
increase mortality.2 This impact is understandable given that nursing staff responsibilities include:
• Providing direct care in a highly complex environment.
• Overseeing and coordinating care and treatment provided to patients by others.
• Educating peers, patients and families.
• Supporting patients and families at critical and life-changing times.
• Advocating for the needs of patients and communities.
• Continuing personal development and staying abreast of changing practice and evolving science.
• Managing personal needs and work-life balance.

According to a national nursing engagement report released in April 2019, of the 2,000+ health care
partners responding to the survey, 15.6% of all nurses self-reported feelings of burnout, with emergency
room nurses being at a higher risk.3

Findings from another 2019 survey reveal that burnout is among the leading patient safety and quality
concerns in their organizations (mostly hospitals and health systems). Only 5% of respondents said that their
organization was highly effective at helping staff address burnout. Approximately 39% of respondents said
their organization was slightly effective at dealing with burnout, and 56% said their facility was either
slightly ineffective or highly ineffective at helping staff address burnout.4

A 2017 literature review on preventing nursing burnout identified six studies — representing 3,248 nurses
around the world — that showed the most common factors related to burnout are exclusion from the
decision making process, the need for greater autonomy, security risks, and staffing issues.5 One of the six
studies (Van Boagaert et al6) demonstrated the importance of including nurses in the decision-making
process. The authors showed that nursing management plays a key role in promoting job satisfaction and
preventing burnout.5

Resilience in the health care professions

Burnout describes a human response to chronic emotional and interpersonal stress at work, defined by
exhaustion, cynicism and inefficiency.7 Resilience, the process of personal protection from burnout, has
several components, including:
• The ability to adapt successfully in the face of adversity or significant threat. Resiliency building
involves developing support systems to combat stressors and to promote a culture of mutual
openness and understanding to prevent burnout.7 Developing resilience-promoting environments
within health care professions may reduce negative and increase positive outcomes of stress in
health care professionals.
• The ability of systems to mount a robust response to unforeseen, unpredicted, and unexpected
demands, as well as resume or even continue normal operations. A resilient health care
organization can anticipate, cope with, recover, and learn from unexpected activities, while
handling patient loads.8

Research indicates that resilience appears to be more than preventing burnout; it involves fostering
resources to combat workplace challenges.9 Adverse workplace challenges can influence professional

Legal disclaimer: This material is meant as an information piece only; it is not a standard or a Sentinel Event Alert.
The intent of Quick Safety is to raise awareness and to be helpful to Joint Commission-accredited organizations.
The information in this publication is derived from actual events that occur in health care.

©2019 The Joint Commission, Division of Healthcare Improvement

Quick Safety
Issue 50, July 2019
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resilience.9 Issues can be the result of: challenging patients or clinical scenarios; organization-related
stressors around, for example, communication and leadership; or workplace changes requiring enhanced
education, training or required professional development. Although some individuals become overwhelmed
by these challenges, others thrive in new roles. Resilience permits nurses to manage the demands of their
role by adapting to changing circumstances and maintaining a sense of professional and personal
fulfillment.9

A study in 2010 by Cameron and Brownie identified eight themes that impact nurse resilience:10
• Experience.
• Amount of satisfaction attained.
• Positive attitude or sense of faith.
• Feeling of making a difference.
• Leadership strategies, such as debriefing, validating and self-reflection.
• Support from colleagues, mentors and teams.
• Insight in ability to recognize stressors.
• Maintaining work-life balance.

Health care organizations that implement burnout interventions — such as mindfulness and resilience
training — may experience increased employee retention, reduced staff turnover and performance problems,
and increased patient satisfaction.2 Mindfulness refers to the practice of learning to focus attention and
awareness on the moment-by-moment experience with an attitude of curiosity, openness and acceptance.2
Mindful presence could lead to decreased diagnostic and medication errors by staying focused on the task at
hand.2

However, mindfulness and resilience training alone cannot effectively address burnout unless the leadership
is simultaneously reducing and eliminating barriers and impediments to nursing work flow, such as staffing
and workplace environment concerns. Leadership is considered a key factor in creating a positive work
environment. Leadership behaviors that empower and motivate nurses to achieve the best outcomes for
patients, staff and the organization have been shown to reduce staff burnout.11

Leader Empowering Behaviors

The term workplace empowerment refers to employees’ ability to access resources, information, and
support needed to perform their work and to gain the opportunity to develop.12 Empowerment can be
achieved in the work environment through Leader Empowering Behaviors (LEB).13 Four categories of LEBs
were developed by Conger and Kanugo in 1988, and in 1994 Hui added another category.14
• Enhancing the meaningfulness of work: Leader behaviors that influence employees’ work with
purpose and give meaning to their contributions, thereby increasing sense of worth and motivating
them.
• Fostering opportunity to participate in decision making: Leader behaviors that allow employees to
express their opinion and share in decisions related to their work.
• Expressing confidence in high performance: Leader behaviors that demonstrate confidence in
employees’ abilities to fulfill expectations of high performance and that recognize
accomplishments.
• Facilitating the attainment of organizational goals: Leader behaviors that improve skills and
knowledge and provide resources for effective performance.
• Providing autonomy and freedom from bureaucratic restrictions: Leader behaviors that minimize
the constraints of rules and restrictions to allow efficiency and creativity.

In nursing, LEBs are positively associated with nurses’ feeling of empowerment in the acute care setting; in
addition, both LEBs and workplace empowerment are effective in decreasing workplace tension and
improving work effectiveness.12

More recently outside of health care, Daniel Pink has summarized the factors that influence motivation in his
2009 book, “Drive” — To motivate employees who work beyond basic tasks, give them these three factors to
increase performance and satisfaction:
• Autonomy: Our desire to be self-directed; it increases engagement over compliance.
• Mastery: The urge to get better skills.

Legal disclaimer: This material is meant as an information piece only; it is not a standard or a Sentinel Event Alert.
The intent of Quick Safety is to raise awareness and to be helpful to Joint Commission-accredited organizations.
The information in this publication is derived from actual events that occur in health care.

©2019 The Joint Commission, Division of Healthcare Improvement

Quick Safety
Issue 50, July 2019
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• Purpose: The desire to do something that has meaning and importance. Businesses that only focus
on profits without valuing purpose will end up with poor customer service and unhappy
employees.15

Safety actions to consider:

Leaders at health care organizations should take an active role in developing and fostering resilient
environments and individuals, including nurses. The following safety actions are directed toward leaders:

• Inform leaders in your organization about the professional factors that foster resilience:2
o Feeling valued professionally.
o Colleague support.
o Use of mentors/role models.
o Feeling of making a difference.
o Team support.
o Organizational support.
o Use of debriefings.
o Feeling competent to meet needs of the job.
o Positive reappraisal.
o Empowerment.
o Sense of accomplishment.
• Develop and practice LEBs by:
o Creating a safe and positive work environment. Security concerns have been identified as a
risk factor for development of staff burnout. Engage with your staff around their perceived
environmental threats and develop action plans to address concerns.
o Enabling employees to participate in decisions related to their work. Shared decision
making strengthens the voice of the clinical nurse as they collaborate with leaders around
optimal staffing plans.16
o Expressing confidence in employees’ ability to perform at a high level.
o Facilitating goal attainment.
o Providing autonomy.
• Ensure that leaders engage in discussions and have a physical presence in the department.
Engaging with nurses allows for an open dialogue and exchange of ideas, as well as providing
validation. Open dialogue provides the nursing leader a forum to foster best practices, find
workable solutions for departmental issues, and teach leadership skills through mentoring
sessions.17

In addition to the above supportive actions by leaders, health care organizations can use the following safety
actions to help nurses develop resilience in order to combat burnout.

• Provide education for nurses, preceptors and nurse leaders to:

o Identify behaviors caused by burnout and compassion fatigue (stress related to repeated
exposure to high acuity and high patient volumes).18 Compassion fatigue has been found
to intensify burnout.19
o Become aware of their personal stressors and triggers.18
o Take part in self-care activities/techniques (such as sleep, fitness and eating habits).18
o Discuss resiliency.20
• Improve clinician well-being by measuring it, developing and implementing interventions, and then
re-measuring it. A variety of dimensions of clinician well-being can be measured, including
burnout, engagement, and professional satisfaction. The National Academy of Medicine (NAM)
provides a summary of established tools to measure work-related dimensions of well-being.21
• Provide nurses with opportunities to reflect on and learn from practice and other practitioners (e.g.,
positive role models).20 Building strong relationships is a key factor in building resilience.18
• Develop or utilize current tools for staff to use to anticipate opportunities and problems.22
• Work with your internal team to assess if your current electronic health record (EHR) system may
be customized so that it optimally supports nursing workflow.23
• Hold regular staff meetings. Include discussions regarding new organizational policies, processes
and outcomes from higher leadership meetings. Engage nursing input in staff meetings by posting
an agenda and asking for additional items the nurses would like to discuss or present.

Legal disclaimer: This material is meant as an information piece only; it is not a standard or a Sentinel Event Alert.
The intent of Quick Safety is to raise awareness and to be helpful to Joint Commission-accredited organizations.
The information in this publication is derived from actual events that occur in health care.

©2019 The Joint Commission, Division of Healthcare Improvement

Quick Safety
Issue 50, June 2019
P a g e |4

• Cultivate a health professional culture that is based on altruism, setting a good example, mentoring,
leading, coaching and motivating others.20
• Recognize nurses in a meaningful way. Since individuals interpret recognition differently, find out
from nursing staff how your organization can best demonstrate that it is invested and interested in
recognizing nursing staff for the work that they do.18

Resources:
1. McCann CM, et al. Resilience in the health professions: A review of the literature. International Journal of
Wellbeing, 2013;3(1):60-81.
2. Magtibay DL and Chesak SS. Decreasing Stress and Burnout in Nurses. Efficacy of Blended Learning with
Stress Management and Resilience Training Program. The Journal of Nursing Administration,
2017;47(7/8):391-395.
3. Brusie C. Study reveals alarming statistics on nurse burnout. [Link], April 7, 2019.
4. 2019 Annual Patient Safety & Quality Industry Outlook. Kennesaw (GA): Patient Safety & Quality
Healthcare (PSQH), [Link]/intelligence
5. Friganovic A, et al. Healthy Settings in Hospital-How to Prevent Burnout Syndrome in Nurses: Literature
Review. Acta Clinica Croatica, 2017;56-292-298.
6. Van Bogaert P, et al. Nurse practice environment, burnout, job outcomes, and quality of care: Test of a
structural equation model. Journal of Advanced Nursing, 2009;65(10):2175-2185.
7. Rakesh G, et al. A Call for Action: Cultivating Resilience in Healthcare Providers. The American Journal of
Psychiatry Residents’ Journal, 3 Apr 2017, [Link]
8. Nemeth C, et al. Minding the Gaps: Creating Resilience in Health Care. Advances in Patient Safety: New
Directions and Alternative Approaches (Vol. 3: Performance and Tools). Rockville (MD): Agency for
Healthcare Research and Quality, 2008 Aug.
9. Robertson HD, et al. Resilience of primary healthcare professionals: A systematic review. British Journal
of General Practice, June 2016;e423-e432.
10. Cameron F and Brownie S. Enhancing resilience in registered aged care nurses. Australian Journal on
Ageing, 2010;29(2):66-71.
11. Mudallal RH, et al. Nurses’ Burnout: The influence on leader empowering behavior, work conditions, and
demographic traits. INQUIRY: The Journal of Health Care Organization, Provision, and Financing,
2017;54:1-10.
12. Laschinger H, et al. Leader Behavior impact on staff nurse empowerment, job tension and work
effectiveness. Journal of Nursing Administration, 1999;29(5):28-39.
13. Conger JA and Karungo RN. The empowerment process: Integrating theory and practice. Academy of
Management Review, 1988;13(3):471-482.
14. Hui C. Effects of leader empowerment behaviors and followers’ personal control, voice, and self efficacy
on in-role and extra-role performance: An extention of Conger and Kanungo’s empowerment process model.
(Unpublished doctoral dissertation). Dissertation from Proquest Information and Learning (UMI No.
9418834) Indianapolis IN: Indiana University, 1994.
15. Pink DH. Drive: The Surprising Truth About What Motivates Us. 2009: Riverhead Books, New York, New
York.
16. Halm M. The Influence of Appropriate Staffing and Healthy Work Environments on Patient and Nurse
Outcomes. American Journal of Critical Care, 2019;28-152-156.
17. Bettencourt E. Hospital impact: Nurse leadership’s role in reducing burnout. DiversityNursing blog,
April 20, 2017.
18. Kester K and Wei H. Building nurse resilience. Nursing Management, 2018:42-45.
19. Abbaszadeh A, et al. The relationship between “compassion fatigue” and “burnout” among nurses.
Annals of Tropical Medicine and Public Health, 2017;10(4):869-873.
20. McAllister M and McKinnon J. The importance of teaching and learning resilience in the health
disciplines: A critical review of the literature. Nurse Education Today, 2009;29:371-379.
21. National Academy of Medicine. Valid and Reliable Survey Instruments to Measure Burnout, Well-Being,
and Other Work-Related Dimensions. Washington, DC: National Academy of Medicine.
22. Nemeth C, et al. Minding the Gaps: Creating Resilience in Health Care. Cognitive technologies
Laboratory, The University of Chicago.
23. Turner C. 5 tools designed to prevent nurse burnout. Meditech Blog, Dec. 5, 2017.
Note: This is not an all-inclusive list.

Legal disclaimer: This material is meant as an information piece only; it is not a standard or a Sentinel Event Alert.
The intent of Quick Safety is to raise awareness and to be helpful to Joint Commission-accredited organizations.
The information in this publication is derived from actual events that occur in health care.

©2019 The Joint Commission, Division of Healthcare Improvement