Superb Short – Blog Post October 2021
Burnout Amongst Health Care Workers in Senior Care
Author: Chaeli Fortina, APRN-NP, BC - AGACNP, PACNP
Burnout is a hot topic that has come up quite a lot in healthcare in recent years, especially with the COVID-19 pandemic, but isn’t actually a new concept. “Burnout” was a term originally identified in the 1970s that has since been further defined to encompass the feelings of emotional, physical, or mental exhaustion, leading to qualities such as cynicism, apathy, or indifference to a person’s job duties, teammates, or to other people, even, in our case, our patients. There are multiple formal scales to define “burnout”, like the Maslach Burnout Inventory, which is considered the “gold standard” by many, and covers three main areas: emotional exhaustion, depersonalization, and low sense of personal accomplishment (Maslach, Leiter, Schaufeli), or, one can simply recognize these feelings within themselves. While this can be a phenomenon in any profession, it has always been an important discussion in healthcare as healthcare workers are at particular risk for developing burnout. Caregivers from all areas – whether nurses (RN or LPN), certified nursing assistants (CNA), certified medication aides (CMA), advanced practice providers (APP, such as a nurse practitioner or physician assistant), or physicians – can all experience burnout to varying degrees, and, especially in the field of geriatric medicine or long term care, the burnout burden can be intense.
Geriatric medicine in general has been well studied, as has burnout, but there has been fairly limited research done on burnout amongst caregivers working in Assisted Living Facilities, Skilled Nursing Facilities or Long-Term Care Facilities. The most recent formal published review of the literature in 2014 by Sanchez, et al. notes this to be a multifactorial phenomenon, which leads to a high risk of professional exhaustion within geriatric care and the healthcare workers within this discipline. Kandelman, Mazars, and Levy’s 2018 article in the Journal of Clinical Nursing was a French study that found significant numbers of burnout amongst caregivers in nursing homes, even greater than in geriatric hospital wards, at a nearly 16% increase in prevalence. A well-cited 2003 study from Cocco, Gatti, de Mendonca Lima, and Camus in the International Journal of Geriatric Psychiatry reported moderate levels of stress and burnout amongst caregivers in acute geriatric wards, but significantly higher than in nursing homes. With the COVID-19 pandemic, rates of burnout remain high and are only getting worse. A recent 2021 French study from Mohamad et al., in the Journal of Alzheimer’s Disease reported increased exhaustion, disengagement, and burnout during the second lockdown from a study they did from the same population in their first lockdown.
Why are healthcare workers so vulnerable to burnout? We know there are multiple associated factors – increased job duties and requirements with constant changes in technology; shortages in staffing with seasoned employees leaving the field, younger employees leaving to pursue higher education, and what often seems to be a steady stream of new employees requiring on-boarding; emotional over-extension within a vulnerable patient population; environmental factors such as lack of equipment or supplies, making it more difficult to do a job; a lack of support, or even basic knowledge about job duties and difficulties from administrators; deficiencies in education to staff about recognizing burnout and limited-to-no support from health care systems to support employees experiencing it. The COVID-19 pandemic has brought out stress in new ways. Certainly, the fear of the disease itself or potentially bringing it home to loved ones, as well as navigating the ever-evolving landscape of recommendations can be overwhelming and, at times, frustrating. Specifically for the geriatric patient population, or those within senior care facilities, seeing the most high-risk patients daily and caring for them if they contract the disease, often watching them die from it, and, at various times throughout the pandemic, doing all of this alone or without the emotional support of family given the need for physical distancing, all greatly contribute to feelings of increased caregiver burnout. Additionally, we have experienced a new onslaught of mistrust against healthcare workers and misinformation being shared at a rate never before seen in our lifetime, which can also play a part.
In healthcare we often refer to problems in SBAR format – defining the situation, giving the background, making an assessment, and providing a recommendation. The assessment is clear: burnout amongst health care workers in senior care, and especially amongst the frontline caregivers like nurses, CNAs, and CMAs, is high at baseline and continues to rise. But what is the recommendation? What is the plan? How can we prevent burnout and promote positive, healthy work environments? We can be inundated with statistics and research, constant talks and required education, but without a plan we cannot dig ourselves out of this hole. No matter the institution, the paramount response is recognition of the problem. Harrad and Francesco summarize it well in their 2018 paper:
“...it is shown that burnout amongst staff employed in nursing and care homes for the elderly is a significant problem reported across the globe, with implications for the wellbeing of patients, providers and staff. In the interest of patients, it is important to recognize and to address the high rates of staff burnout in practice settings. Moreover, given that burnout can result in serious health risks for staff and their families, it must also be recognized as a significant occupational health problem warranting the attention of employers, unions, policy makers, and the community of occupational health professionals”.
Sasha Shillcutt, a well-published researcher, board-certified cardiac anesthesiologist, tenured professor, and frequent national speaker on burnout, agrees. She had a great interview with Healthcare Transformers in March 2020 called “Battling burnout in healthcare: building resilience and workplace engagement”. In short, she thinks it is up to both the individual and the organization to recognize and make change. Dr. Shillcutt gives three key suggestions to health care systems and their leaders to battle burnout: first, to recognize the problem and raise awareness; second, to gain data-driven insights on what “burnout” might mean to each part of an organization (whether this means unit-to-unit, or role-to-role); and, third, to make a detailed action plan on how to realistically combat at least some, if not all, of the top issues. But, all too often, the front line workers aren’t a part of the leadership discussions, so what can an individual do to recognize and treat burnout? Arguably, the answer is the same.
First, we must recognize the problem, either within ourselves or within our teams, and simultaneously working to develop a culture where you can talk about it – whether amongst peers, with a leader, or even anonymously. Second, gaining insight as to what the exact definition of the problem is. For individuals, this might mean looking at your values and ensuring you are working in alignment with them. Dr. Shillcutt does this by what she calls “becoming your own CEO”. She schedules a weekly planning session for herself to sort out what responsibilities she has, if she has time to do everything that a mom/wife/doctor/professor/CEO/speaker needs to do (including buffer time for really difficult projects, or things that require emotional investment), or how she can delegate responsibilities to accomplish everything that is needed. When looking at all of the things to do and how they align with your values, a healthy response can be “no”, just as much as it can be “yes”. She notes, “When I started realizing that I can control what I say yes to and what I say no to, and really pushed back against work compression – responsibilities that have been added to me without another responsibility exiting my plate – I started to become less and less burned out”. Finally, coming up with a realistic and thoughtful action plan to make change is key. Maybe an action means speaking with someone about how you’re feeling and why – whether a leader within your team, or even a therapist (there are a lot of counseling resources available to healthcare workers right now – some through your health care systems, some through Apps or other technology, or with a therapist in person). Perhaps a negotiation with a supervisor might be a plan of action. For example, if you are asked to pick up the duty of checking expiration dates on the medications in the pharmacy, which you don’t like doing and/or truly don’t feel you have the time for, you can negotiate to do this if you can also have some designated time each week for a duty that brings you joy, like calling patients to check up after an appointment, or perhaps relieving yourself from time spent on a different duty, like completing prior-authorizations for insurance. This might be scary to ask, but it might also allow your leader to recognize where you are at, and if what they are asking from you is realistic. If nothing else, it may start a conversation that can point you in a direction of growth. Creating a culture of camaraderie and friendship amongst peers, or being an informal leader, is something everyone can change – asking how others are doing, creating an inviting common space, or recognizing peers for a job well done would be examples. If it makes you happy, maybe it would make others happy too, and if you’re all more happy, maybe you will all be more apt to work together as a team or help each other out when someone is down. Finally, sometimes beating burnout might even require a change. If your organization isn’t allowing you the flexibility to work when you want, or in a role that aligns with your values, checking out a company like Superb, where you can take the control to work the shifts you want, in an environment that you enjoy, might be how you can best battle burnout and stay in a profession you’ve worked so hard to join.
Burnout is real and must be identified in order to be managed, no matter how far one is on the burnout spectrum. Recognizing, defining, and developing a plan to beat burnout are three important steps to ensuring you can continue to be the resilient, talented, and worthy health care worker you are.
Chaeli Fortina, MSN, APRN-NP, BC is a dually-trained adult-geriatric acute care and pediatric acute care nurse practitioner working in solid organ transplant at Nebraska Medicine, one of the 100 greatest hospitals in America by Becker’s Hospital Review. Her first Bachelor’s degree held a concentration in writing and linguistics so, when she is not writing academic papers or preparing educational talks, she enjoys guest blogging for Superb Shifts.
Cocco E, Gatti M, de Mendonça Lima CA, Camus V. A comparative study of stress and burnout among staff caregivers in nursing homes and acute geriatric wards. Int J Geriatr Psychiatry. 2003 Jan;18(1):78-85. doi: 10.1002/gps.800. PMID: 12497560.
El Haj, Mohamad et al. ‘High Exhaustion in Geriatric Healthcare Professionals During the COVID-19 Second Lockdown’. 1 Jan. 2021 : 1 – 8.
Harrad, R., Sulla, F. “Factors associated with and impact of burnout in nursing and residential home care workers for the elderly.” Acta bio-medica : Atenei Parmensis vol. 89,7-S 60-69. 7 Dec. 2018, doi:10.23750/abm.v89i7-S.7830
Healthcare Transformers. Interview with Sasha Shillcutt. Battling burnout in healthcare: building resilience and workplace engagement. 2 Mar 2020.
Kandelman N, Mazars T, Levy A. Risk factors for burnout among caregivers working in nursing homes. J Clin Nurs. 2018 Jan;27(1-2):e147-e153. doi: 10.1111/jocn.13891. Epub 2017 Jul 17. PMID: 28543882.
Maslach, C., Leiter, M., Schaufeli, W. (2009). Measuring Burnout. 10.1093/oxfordhb/9780199211913.003.0005.
Sanchez, S., Mahmoudi, R., Moronne, I., Camonin, D., Novella, J. (2014). Burnout in the field of geriatric medicine: Review of the literature. European Geriatric Medicine. 6. 10.1016/j.eurger.2014.04.014.