The Joint Commission Tackles Nurse Burnout

The accreditation agency calls on healthcare organizations to support nurses by addressing the causes of burnout.

By John Palmer

Editor's note: This article originally appeared on PSQH.

Realizing the growing impact that stress and burnout take on the health of nurses and their ability to do their job properly, The Joint Commission is stepping in to help battle the problem.

In July 2019, the accreditation agency released Quick Safety Issue 50: Developing Resilience to Combat Nurse Burnout, to help healthcare facilities with the process of personal protection from burnout for nurses and other frontline staff.

According to The Joint Commission, of the 2,000 healthcare providers who participated in an April 2019 national nursing engagement survey, more than 15% of all nurses reported feelings of burnout, with emergency department nurses at a higher risk. The second survey in 2019 found that burnout is among the leading patient safety and quality concerns in healthcare organizations.

Only about 5% of respondents surveyed said their organization was highly effective at helping staff deal with feelings of burnout. Only about 39% said their organization was "slightly effective" at dealing with burnout, and 56% said their facility was either slightly or highly ineffective at it.

"As the frontline caregivers in healthcare today, nurses accomplish a myriad of tasks and responsibilities, but often at high personal cost," according to The Joint Commission publication. "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."

Burnout: A longstanding issue

It's not a new problem. According to a 2016 study from the Mayo Clinic, at least 15%–20% of adults in the U.S. report high levels of stress. The study, published in the Journal of Occupational and Environmental Medicine, concluded that stress and burnout in the healthcare industry is a major problem that leads to negative health behaviors. It recommended that companies look to integrate and enroll employees into wellness programs to help cut down on stress and fatigue.

A high correlation was found between the stress levels of an employee and what was called the four domains of quality of life: physical health, mental health, nutritional habits, and perceived overall health. Higher stress correlated to lower levels of all four domains.

The study found that employees who reported high-stress levels and perceived poor quality of life also reported the lowest usage of wellness programs.

What leads to stress and burnout?

Perhaps most important than recognizing the presence of stress in healthcare is knowing why it occurs. A 2017 Joint Commission study of more than 3,000 nurses worldwide found that the most common factors related to burnout are exclusion from the decision-making process, the need for greater autonomy, security risks, and staffing issues.

"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," The Joint Commission said. "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."

The Quick Safety report identified several areas that healthcare facilities should work on to help battle the problem of burnout, including the following goals:

• Educate nurses, preceptors, and nurse leaders on how to identify behaviors caused by burnout and compassion fatigue, and to become aware of their individual stress triggers, participate in self-care activities, and discuss resiliency
• Improve clinician well-being by measuring it, developing and implementing interventions, and then remeasuring
• Offer nurses opportunities to reflect on and learn from their practice and from other practitioners
• Work with internal teams to assess whether current EHR systems may be customized to better support nursing workflow
• Conduct regular staff meetings that include discussions about new organizational policies, processes, and outcomes from leadership meetings—making sure to engage nurses in these meetings

Occupational stress, defined by the National Institute for Occupational Safety and Health (NIOSH) as "the harmful physical and emotional responses that occur when the requirements of the job do not match the capabilities, resources, or needs of the worker," is nothing new in the healthcare workplace, and up until recently was regarded by many to be part of the job.

But as more attention is paid to the adverse effects of stress and burnout on patient safety, and with resultant costs to healthcare in the forms of lawsuits, financial losses, and reputation consequences, the need to be proactive becomes more paramount.

"Studies indicate that health care workers have higher rates of substance abuse and suicide than other professions and elevated rates of depression and anxiety linked to job stress," according to NIOSH. "In addition to psychological distress, other outcomes of job stress include burnout, absenteeism, employee intent to leave, reduced patient satisfaction, and diagnosis and treatment errors."

Among nurses specifically, NIOSH found certain factors, including the following, to be linked with higher stress:

• Work overload and time pressures
• Lack of social support at work (especially from supervisors, head nurses, and higher management)
• Exposure to infectious diseases and needlestick injuries
• Exposure to work-related violence or threats
• Sleep deprivation
• Role ambiguity and conflict
• Understaffing
• Career development issues
• Dealing with difficult or seriously ill patients

"As a general rule, actions to reduce job stress should give top priority to organizational changes that improve working conditions," according to NIOSH literature. "But even the most conscientious efforts to improve working conditions are unlikely to eliminate stress completely for all workers. For this reason, a combination of organizational change and stress management is often the most successful approach for reducing stress at work."

Creating a healthy work environment

What exactly are those organizational changes? According to the Quick Safety report, there are several steps that leaders at healthcare organizations can take to help develop and foster a more resilient environment, including informing leaders in the organization about the professional factors that foster resilience, such as the following:

• Feeling valued professionally
• Colleague support
• Use of mentors/role models
• A feeling of making a difference
• Team support and organizational support
• Use of debriefings
• Feeling competent to meet the needs of the job
• Positive reappraisal, empowerment, and sense of accomplishment

In addition, the report recommends that healthcare organizations develop and practice leadership empowering behaviors (LEB), which enhance the meaningfulness of work, foster opportunities to participate in decision-making, express confidence in high performance, facilitate the attainment of organizational goals, and provide autonomy and freedom from bureaucratic restrictions. These LEBs can be developed and practiced by doing the following:

• Create a safe and positive work environment. Security concerns have been identified as a risk factor for the development of staff burnout, so it's important to engage with staff around their perceived environmental threats and develop action plans to address concerns.
   
• Enable employees to participate in decisions related to their work. The Joint Commission says that shared decision-making strengthens the voice of clinical nurses as they collaborate with leaders around optimal staffing plans.
   
• Express confidence in employees' ability to perform at a high level and help them attain goals.
   
• 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 dialogues help provide nursing leaders with a forum to foster best practices, find workable solutions for departmental issues, and teach leadership skills through mentoring sessions.

John Palmer is a freelance writer who has covered healthcare safety for numerous publications. Palmer can be reached at johnpalmer@palmereditorial.com.