Fatigue and Burnout in the ICU

Chapter One: Introduction

The heavy workload for nurses is a major problem for the American health care system since nurses experience higher workloads than before. The reasons for the burnout are increased demand for nurses, inadequate supply of nurses, reduced staffing, and increased over time; and reduced patient length of stay. The demand for the high population of nurses is due to the aging population. Between the year 2000 and 2020, the estimated population in the United States is expected to grow by 18% and that of people aged 65 and above is expected to grow by 54 % (Ortman, Velkoff & Hogan, 2014). The number of nurses is inadequate to meet the current demand, and the shortage continues to increase since nursing schools are not able to keep up with the increasing educational demand. When the shortage occurs, the workload increases for the people on the job. In response to increased health care costs, many hospitals reduced their nursing staff and implemented the mandatory overtime policies to meet the expected high demands that led to an increase in the nursing workloads. Increased cost of operation force the healthcare organizations to lower the patient length of stay and thus, the hospital nurses take care of patients who are sicker than the past which makes their work intensive. The projected nursing shortage is expected to be more extreme than the earlier days. Aging populations need more and more nursing care, and the nursing leaders also recognize that a large proportion of the nursing workforce is getting older thereby contributing to the nursing shortage. The recent worldwide economic challenges continue to affect the cost of health care both in the U.S and across the globe and present a new challenge to retention of nurses, reducing fatigue, preventing burnout and improving on job satisfaction among the nursing workforce. The nurse managers must realize the challenges and opportunities to attract educate and retain the highly competent and satisfied nurses who ultimately influence patient outcomes. For this research project, fatigue and burnout in the Neurointensive Care Unit (ICU) is discussed and its effect on nursing retention.   

                    

Problem Statement

The significant challenges at the Neuro Intensive Care Unit (ICU) include high turnover and long training period for new Neuro-nursing staff. One of the major factors leading to the high turnover is fatigue and burnout especially for the critical care nurses (McHugh, Kutney-Lee, Cimiotti, Sloane & Aiken, 2011). High nurse turnover is associated with high costs of hiring and training new staff, loss of experienced personnel, information and technological knowledge, and impact on the continuity of care. The newly employed Neuro nurses do not have much experience to undertake their roles (Laschinger, Wong & Grau, 2012). The nursing shortage in Neuro –ICU, as well as other departments, is attributed to the high nurse turnover. The experienced nurses have to attend to intensively sick patients despite poor distribution due to inadequate staff. Nursing shortage makes the health care organizations increase the workloads for the existing nurses or hire temporary nurses who are inexperienced for the work. The nurses are forced to work overtime to fill the existing gap that increases their risk of fatigue and burnout and poor patient outcomes (Carayon & Gurses, 2008). Reduced quality of patient outcomes due to the loss of experienced nurses and inadequate personnel is the most significant cost of the high nursing turnover. The effect on patient outcome due to nursing shortage results to a decline in the institution’s operational revenues. Increased turnover for the nursing workforce is associated with reduced motivation and fatigue and burnout.                   

Problem Background

High turnover for the registered nurses is a major issue faced by the health care sector and more specifically the ICU. An appropriate organizational turnover should range between 5 percent and 10 percent since such a rate enhances a better work environment in the healthcare institution and also eliminates any inefficiencies and boredom in the workplace. The highest turnover of nursing staff occurs within one year of employment (Roussel, Harris & Thomas, 2015).  The cost of turnover of medical institutions is enormous, and the average cost of a replacement nurse is 75 000 dollars that cover for recruitment, replacement, temporary employees, overtime, and orientation.

Fatigue is identified as a symptom for the patients cared for by nurses. A close examination of the unique features of the daily routine of nurses, especially in the emergency department, reveals that mental and physical fatigue is a consequence of nursing. The advent of extended work hours as a solution to nursing shortage is a culture that puts patients and nurses at increased risk of fatigue, burnout, and compassion fatigue. Burnout is an emotional condition and is characterized by fatigue, apathy, and frustration thereby interfering with job performance (McHugh, Kutney-Lee, Cimiotti, Sloane & Aiken, 2011). There have been several studies that focused on the factors that affect the nurse’s workday, but few have looked at the emergency and intensive care unit nursing. The clinicians working in the intensive care unit (ICU) are faced with the fast-paced, high-tech, challenging work environment. The struggles of life and death are exhilarating and also emotionally and physically draining. The stressful and draining environment can result in common syndrome among the ICU clinicians called burnout. The acceptable characteristics of burnout include high emotional exhaustion, detachment, low levels of personal effectiveness and accomplishment (Raftopoulos, Charalambous & Talias, 2012). ICU nurses are studied more extensively on the incidence of burnout. The shortage of intensive care unit providers and the demands of the ICU department have led to increased awareness and recognition of burnout among physicians as well. Some previously studied cross-sectional surveys have reported that 50% of ICU physicians and 33% of the critical care nurses suffer from severe burnout syndrome (Ibid, 2012). Both nurses and physicians experience burnout, but the development of the syndrome arises from various sources in the two groups of professionals. A high number of the working time is a major contributor to burnout. The organizational culture and moral distress surrounding the end-of-life issues are identified as the major contributors to burnout syndrome. 

The major contributor to emotional fatigue in ICU nurses is the stress acquired from the high patient acuity. Another key contributor to ICU nurse burnout is the morally distressing situations encountered on a daily basis in the workplace. Distress arises from undermining one’s integrity and authenticity in their workplace. The feelings of ineffectiveness and lack of personal accomplishment can also be a significant contributor to burnout in ICU nurses. Many of the nursing staff working in the ICU have high standards of care and expectations that they cannot meet. The lack of persona accomplishment can also arise when the nurses think that other physicians have no value to their viewpoint and expertise and also are not involved in the decision-making process of patient care (Thomas, 2011).           

Description of the Practice Change, Quality Improvement, or Innovation

The challenge of high Neuro-nurse turnover significantly affects patient care outcome and quality assurance in the healthcare organization hence crucial to integrate evidence-based practices and change of quality and improvement as well as innovation, so as to enhance performance and increase staff retention. Managing the expenses and quality of patient outcomes is the driving force in the medical sector. The problem can adequately be addressed through proper guidelines, policies, regulations, procedures as well as better terms for the working staff. The effective implementation of evidence-based practice into quality improvement will ultimately result in improved performance. Quality improvement process uncovers inconsistencies or undesirable patient outcomes (Hughes, 2008). Encouraging evidence-based practice and enhancing effectiveness in healthcare requires a robust medical research enterprise, careful evaluation of the effectiveness of care technologies and practices, and strategies to promote dissemination of effective care (Houser & Oman, 2010). The medical institutions that ascribe to evidence-based practice to guide its operations, advance practice and attain outcomes are critical for the macro- to microsystem levels. Sustainability in healthcare organizations plays critical roles when planning and executing healthcare innovations since the lack of sustainability, makes the organization suffer from the same problems repeatedly.

It is necessary that the health care administrators use the available evidence-based research data to address the challenges faced by the nurses working in the ICU department. It is necessary to understand the nurse-patient ratios in the hospitals and compare it with the appropriate nurse-patient ratios for the ICU department.  Practice change will involve enacting mechanisms in place to reduce fatigue and burnout in the ICU since it affects the nurse retention ability. The mechanisms to implement include increasing the nursing staff in the ICU department, and reducing the frequency of working overtime. ICU nurses ought to have adequate time for relaxation for them to be effective in their work. Practice change will also be accomplished through enacting policies that guide on the appropriate patient-nurse ratio to avoid overworking and stressing the ICU nurses who are expected to offer quality services (Andolhe, Barbosa, Oliveira, Costa & Padilha, 2015).

Quality improvement and innovation will be achieved through proper utilization of the available resources in training staff on quality improvement strategies (Shojania, McDonald, Wachter & Owens, 2004). The hospital administration ought to invest more on staff training and providing them with a conducive working environment to ensure that they are comfortable in the workplace and avoid work-related stress types. The stakeholders involved in running the affairs of the hospital should be involved in the provision of solutions to the problem of high turnover due to fatigue and burnout of the nursing staff in the ICU. The timeline for the implementation of the proposed methods of practice change and quality improvement should not be extended beyond the scope of the project, hence necessary to use short timelines.   

Rationale for the Practice Change, Quality Improvement, or Innovation

The necessity for practice change, quality improvement, and innovation leads to better health care services. Over the last few decades, there has been increasing awareness of the need to improve the quality of health care in the general practice. It has been driven by the need to reduce the existing inequalities in health care and also an effective translation of evidence into practice. The initiatives that arise from the evidence-based methods of quality improvement and practice change tend to be effective in impacting patient care. The rationale for quality improvement is the belief that good performance reflects on the good quality practice.

According to Goldsmith (2010), there are various factors associated with the problem of high turnover in health care organization where in some facilities reach an excess of 50%. As such, there is need to address the problem of nurse fatigue and burnout in the ICU department since it leads to increased nurse-patient loads, job dissatisfaction, job stress, overtime work, and poor relations with physicians (Jennings, 2008). High turnover rate makes the patient workload for the experienced Neuro-ICU nurses’ result to fatigue and burnout. The two aspects are associated with work pressure due to the heavy patient assignment, reduced number of personnel, exhaustion, and high patient acuity ((Foglia, 2008). It is necessary to implement practice change initiatives, and quality improvement strategies since burnout and fatigue have an association with decreased quality of care and high turnover due to work inefficiencies. The individual strategies that can prevent burnout include proper time management, stress inoculation training, rational, emotional therapy, relaxation, training in interpersonal and social skills, team building and meditation, and assertiveness training (Le Gall, Azoulay, Embriaco, Poncet & Pochard, 2011). Such methods can be used as practice change initiatives to enhance nursing retention for the ICU nurses.  

Increased fatigue and stress among healthcare professionals is related to heavy workloads and extended work time thus negatively impacting quality and quantity of documentation in the medical record. The most significant risk to fatigue involves working for 12.5 hours or longer. Other contributing factors of fatigue among nurses include pain, psychological harm from doctors and hearing to what seems like a 1, 000 alarms per day of which 90 percent are not urgent results in emotional injury to a nurse. A nursing workforce that is suffering from fatigue is highly likely to make medical errors and mistakes compared to their colleagues.  Among the safety and medication errors reported relating to procedure treatment, or test, up to 88.5 percent of the cases get associated with fatigue among the nursing professionals (Boynton, 2015).  Some of the conditions exhibited by fatigued workers include reduced motivation, compromised problem-solving, lapses in attention and inability to stay focused, irritability, confusion, memory lapses, reduced reaction time, indifference and loss of empathy, impaired communication, etc. The primary approach to executing regulations and guidelines to resolve healthcare worker fatigue is ensuring targeted limiting work hours get adhered. Raising awareness of the risks associated with fatigue is vital.      

Chapter Two: Literature Review

This section focuses on a discussion of the credible sources in use, identification of best practices, an evidence summary, and the recommended practice change, quality improvement, and innovation. The project seeks to design and develop an evidence-based practice, change, quality improvement, and innovation that address the problem of fatigue and burnout among the Neuro-ICU nurses.   

Credible Sources

The search for relevant literature involved a review of credible sources that had to be published within the last five years. The review includes the aspects of the relevance of the sources, the evidence grade assigned, an appraisal of the findings, and establishing whether the source will be included or excluded in the list of those approved for the Capstone project.  

The sources used in the project are obtained from various databases that have full text and peer-reviewed research articles. The databases used include Medline with full text, ProQuest Central, EBSCOhost publishing, and CINAHAL. They are all credible databases with a rich pool of sources that are relevant to the research topic and updated. Some of the articles identified were not peer-reviewed, hence not used extensively in the research project. All the articles included in the research are applicable for the project but have varying strengths.        

Best Practices Identification

The best practices identified from the research articles used include the need to derive information from the evidence-based studies on fatigue and burnout which is essential for practice change and quality improvement. Also proposed is the need for collaborative efforts among nursing leaders in practice and education, government and care executives to ensure that there is an adequate supply of nurses. Effective communication between nurses and patients as well as nurses and other colleagues is postulated as a beneficial strategy in reducing stress among the ICU nurses (Boyle, 2011). The nurses have reduced turnover rates since they are more comfortable in their workplace when they share with others on the day-to-day work experiences. Another best practice is having counseling sessions for nurses to enhance their well-being and reduce fatigue and burnout symptoms. Large populations of ICU nurses suffer from fatigue and burnout effects but lack appropriate mechanisms to address their concerns. Other recommended best practices for the nurses working in the ICU include the need to establish boundaries in their work, taking the time to recharge, learning to relax, and talking to a supervisor on any issues of concern that affect their productivity in the workplace. It is apparent that several best practices can be implemented in the Neuro-ICU department to reduce fatigue and burnout for nurses which affects the nursing retention. It would be necessary to have effective strategies designed to have positive outcomes in reducing the high nurse turnover rates in the ICU department.       

Evidence Summary

The need to address the nursing shortage by increasing the supply of competent registered nurses is a contributing factor to improved performance and increased motivation among nursing staff.

Cowen and Moorhead (2014) published a book published that presents the challenges that nurse’s face in today’s healthcare arena and provided a forum for knowledgeable debate on the important issues that nurse face today such as fatigue and burnout resulting in a nursing shortage. It sums up the issues by suggesting, therefore, the need for a collaborative effort should be adopted among nursing leaders in practice and education, government and care executives so as to ensure the adequate supply of nurses (Cowen & Moorhead, 2014).  Nursing schools can also form strategic partnerships and seek private support to assist in increasing the capacity of nurses.

A study published in 2014 has shown that effective communication and collaborative efforts are paramount in minimizing emotional distress as well as exhaustion that may be contributing to high nurse turnover (Vertino, 2014). Formal staff training in communication and conflict resolution skills can pay a crucial role in assisting ICU nurses in coping with issues in their work. The integration of team workshops and staff education assists ICU providers to cope with moral distress and fatigue.

An article published in 2014 provides a review of an evidence-based research and comprehensive survey of the organization and function of intensive care units. It discusses ethical issues related to providing critical care in regions with scarce resources. This article is crucial for researchers seeking to understand the process and personnel important to the intensive care unit. The use of a daily goals worksheet to enhance communication concerning patient care has also been shown to enhance ICU clinician satisfaction (Scale & Rubenfeld, 2014)

An article published in 2016 emphasizes on proper training and continuous training sessions as crucial in assisting the nursing workforce deal with emerging issues affecting their profession as well as teaching proper time management (Aiken, Marshall & Chaboyer, 2016). The integration of counseling sessions that assist nurses as well as encourage them to undertake individual assessments is critical in enhancing their well-being and reducing fatigue and burnout symptoms.

An article published in 2012 explains that, when work stress becomes chronic, it can be overwhelming and harmful to both physical and emotional health (APA, 2012). Unfortunately, such long-term stress is all too common. The outlined steps were identified in the study as effective strategies. They include: tracking stressors, developing healthy responses, establishing boundaries, taking the time to recharge, learning to relax, talking to a supervisor, and getting some psychological support. The article concluded that individuals can always avoid the tensions that occur on the job and can take steps to manage the work-related stress.

An article by Saunders, Krugman and Schloffman (2013) challenges the nursing executives to take leadership roles in creating a healthy work environment for nurses and all disciplines. It states that engaging in partnerships and empowering clinical nurses to construct the solutions to the existing challenges in meeting the goal of a satisfied and healthy workforce are important strategies toward success (Saunders, Krugman & Schloffman, 2013). This publication reviewed how this strategy works in evaluating projects that a 3-time Magnet-designated academic hospital has implemented, working with shared leadership councils, to meet the standards for a healthy work environment. It concluded that a highly engaged, well-educated, and committed nursing workforce, nurtured by a strong leadership team, has created a positive work environment characterized by low turnover and high retention. 

The study by Boynton (2015) focuses on the successful nurse communication safe care for a healthy workplace and rewarding careers. The authors explain on the need to develop the skills and techniques required in communicating effectively with patients, families, and colleagues in the examination of the critical role played by communication in assuring the safe and ethical practice of nursing. The ability to communicate successfully has a positive impact on the nurse-client, nurse-family, and colleague-colleague relationships and makes the work environment less stressful and manageable for the personal challenges.

In another study, the issues, trends, and management of the contemporary nursing aspects were analyzed and focused on the relevant issues that affect the day to day nursing practices (Cherry & Jacob, 2015). The authors focused on the evolution of nursing, the role of the nurse today, the safe and effective decision-making, collaboration and communication, as well as leadership and the issues that affect healthcare and nursing practice. The study offers relevant information on the factors that affect job satisfaction and among them is fatigue and burnout as experienced by the ICU nurses.   

A qualitative study by Foglia, Grassley, and Zeigler (2010) was conducted to identify the factors that influence pediatric intensive care unit nurses to leave their jobs. The researchers sought to discover the reasons for ten nurses to voluntarily leave the pediatric intensive care unit (PICU) at a big hospital in the Southwest. From the study findings, it was found out that there exists an inescapable and unavoidable tension between human factors and the PICU work environment. The nurses reported unrelieved job stress as the major reason for leaving work. Other factors that contributed to leaving work include the interactive environmental characteristics of the nature of the job, inadequate resources, and negative perceptions of team leaders. The authors recommended the need to focus on the interventions in the areas of nursing practice, education, and research as required in reducing the possibility of losing more PICU nurses.

 A study by Le Gall, Azoulay, Embriaco, Poncet and Pochard (2011) focused on the burnout syndrome among the critical care workers and identifies burnout syndrome (BOS) as a condition that results from extended exposure to job stressors. The authors identify that intensive care units are characterized by a high level of work-related stress. Several of the studies reviewed revealed that burnout syndrome is found in half of all the critical care physicians and one-third of nurses in those settings. The determinants of burnout syndrome vary between groups of caregivers. The intensity of burnout syndrome tends to be high for those with many working hours for the night shift. The severe burnout syndrome for the ICU nurses has a relationship to the facility organization and the end-of-life care policy. The preventive measures discussed include working in groups, enhanced communication during the end-of-life care as well as prevention and management of ICU conflicts.

The article by Houser and Oman (2010) provided an evidence-based practice guideline for the implementation of guidelines in health care organizations. The authors identify that effective clinical practice has a basis in the best possible rigorous evidence. The past decade has seen various advances in information technology that makes research and other types of evidence available to health care practitioners. The triad of evidence-based practice entails the best scientific evidence, the clinical experiences, and the patient preferences. All the health care practitioners ought to use evidence-based research data in their practice to ensure that they solve the existing clinical problems and make decisions on the appropriate interventions. As such, the problem of fatigue and burnout in the ICU should be addressed by using evidence-based research studies that have been conducted on the topic and implemented.            

Recommended Practice Change, Quality Improvement, or Innovation

The nurse administrators and managers in the medical institutions ought to identify solutions in the recruitment of nurses of their medical organizations and also be knowledgeable on how to support and retain nurses after employment. The daily schedule of nurses involves dealing with tragedy, suffering and human distress as they assist patients in overcoming health challenges. Appropriate policies must be developed to balance the demand-and-supply equation of the nursing workforce. The two primary policies that can be developed include increasing the supply of nurses in the department and decreasing nursing turnover rates. There is need to hire many nurses, both young and experienced, to ensure that there are adequate nurses to serve the patients and increase the supply of nurses. This policy is appropriate in achieving both long-term and short-term organizational goals in an institution. The measure will solve the issue of the nursing shortage, thus reduced workloads and consequently reduced burnout and fatigue. Decreasing nursing turnover rates can be achieved by enhancing the working conditions and professional’s requirements of the nurses (Chlan, 2013). Effective communication approaches should also be adopted so as to prevent fatigue and job dissatisfaction among the nursing workforce (Aitken, Marshall & Chaboyer, 2016). Leaves for Neuro nurses should also be included in the program especially for nurses who have served in the hospital for over a year. Nurses who may experience burnout symptoms may require job enrichment so that their employment can be exciting as before. All non-nursing duties should be eliminated for Neuro ICU nurses so as to reduce work pressure.

Successful treatments of Neuro-ICU nurses can also assist in curbing the problem of increased turnover. Successful treatment process commences with the integration of a strategic plan. Innovation may need substantial personnel education and implementation support so as to ensure that all the stakeholders especially the Neuro ICU nurses understand what gets required to attain success. Training and learning in nursing today, are no longer a benefit but an expectation. The nursing workforce expects more than just technical competence. The nurses have to get educated through continuous training that assists in their professional development. There is a need for promotion of awareness, teamwork, effective communication and collaboration along with adopting strategies along with adopting techniques to enhance a healthy work environment. It assists in supporting Neuro-ICU nurses and values their commitment to offering patient and family-centered compassionate care. 

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