Critical care nurses experience high levels of workplace stress, which can lead to burnout. Many medical centers have begun offering wellness programs to address burnout in their nursing staff; however, most of these programs focus on reducing negative states such as stress, depression, and anxiety. A growing body of evidence highlights the unique, independent role of positive emotion in promoting adaptive coping in the face of stress. This article describes a novel approach for preventing burnout in critical care nurses: an intervention that explicitly aims to increase positive emotion by teaching individuals empirically supported skills. This positive emotion skills intervention has been used successfully in other populations and can be tailored for critical care nurses. Also discussed are recommendations for addressing burnout in intensive care unit nurses at both the individual and organizational levels.
The intensive care unit (ICU) is a busy, complex, and demanding work environment in which nurses, physicians, and other health care staff members are routinely confronted with human suffering, patient morbidity and mortality, complex ethical decision-making, and difficult conversations with patients and their families. Prolonged exposure to the heavy workload, patient acuity, complex decision-making, and challenging communication that characterize working in the ICU may contribute to the high rates of stress, burnout, and compassion fatigue that have been documented among critical care nurses.1-3
A variety of factors contribute to the experience of high workplace stress for ICU nurses. Some of these factors affect the nursing profession in general, such as long hours, low autonomy, complex care delivery, conflict with physicians and other staff members, ineffective management, difficult interactions with patients and their family members, and integration of new technology.4-7 Other factors are specific to working in the ICU, such as issues related to end-of-life care, morally distressing situations, intense pace of work, and increased exposure to life-threatening conditions.8-13 Nurses working in such high-stakes and high-stress environments may be particularly vulnerable to developing low morale, dissatisfaction with their jobs, compassion fatigue, and burnout.1-3
Burnout is an individual’s response to prolonged exposure to high levels of job-related stress; it is typically characterized by 3 dimensions: a lack of personal accomplishment (eg, losing one’s “joy in practice”), emotional exhaustion (eg, a state of lost energy), and depersonalization (eg, a lost sense of caring).14-16 A 2019 report on clinician burnout from the National Academies of Science, Engineering, and Medicine indicated that rates of burnout among nurses in the United States tend to range from 35% to 45%.17,18 Burnout rates tend to be especially high among nurses and health care professionals working in the ICU.3,17,19-22 Nurse burnout has been linked with a host of negative consequences for the nurse’s personal well-being and for patient care, including perceived medical errors.17 Moreover, nurse burnout has been linked with greater absenteeism and intentions to leave the profession.17,18,23 One survey of 2323 critical care nurses showed that 17% of nurses reported intending to leave their current job within the next year.24 In turn, the resulting missed nursing care and reduced productivity have been linked with adverse patient outcomes and reduced quality of care provided, as well as compassion fatigue.4,17,25,26
As professional caregivers, nurses are in a constant state of self-giving in order to provide support and healing to patients. Although caring and compassion are central tenets of the nursing profession, the high levels of stress and the continued exposure to suffering in ICU nursing can make it especially challenging for nurses to sustain a sense of compassion for patients over time.27 Ultimately, the continued strain of self-giving can lead nurses to experience compassion fatigue,28,29 which arises as a result of “prolonged, continuous, and intense contact with patients, self-utilization, and exposure to multidimensional stress leading to discomfort that exceeds nurses’ endurance levels.”30(p237) Compassion fatigue is characterized by the inability to nurture others, manifesting as intrusive thinking, sleep disturbances, and depression. Compassion fatigue can lead to burnout and reduced quality of patient care.27
Adaptive Role of Positive Emotion in Coping With Stress
Many medical centers have begun offering wellness programs to address burnout and compassion fatigue among their nursing staff.31-37 Most of the current programs to address wellness (eg, mindfulness-based stress reduction, cognitive behavioral stress management) focus on reducing negative states such as stress, depression, and anxiety.31-37 Emerging evidence suggests that positive emotion has a unique, independent role in the coping process.38-42 Research in populations coping with major life stress (eg, bereavement, caregiving for a partner with a chronic health condition, receiving a diagnosis of a life-limiting illness) has demonstrated the important role of positive emotion for adaptive coping.38-43 Positive emotion has been found to be an independent predictor of health, well-being, and longevity, even after adjusting for the effects of negative emotion and other potential con- founders such as exercise, smoking, and other sociodemographic characteristics.44-50 Positive emotion has also been linked with greater creativity, better social relationships, and superior job performance.50-53 Finally, positive emotion has been associated with increased humanistic motivation in physicians and greater job satisfaction and well-being in nurses.54-57 Taken together, this research suggests that positive emotion may be a promising avenue to target for interventions addressing burnout in nurses.
Positive Emotion Skills Intervention for Coping With Stress
This article highlights a novel approach for preventing burnout in critical care nurses: an intervention that explicitly aims to increase positive emotion. Our team has developed a theory-based intervention that teaches individuals 8 empirically supported skills for increasing the frequency of positive emotion experienced in daily life.58-64 The original skills taught in the intervention are (1) noticing positive events, (2) savoring or capitalizing on positive emotion, (3) gratitude, (4) positive reappraisal, (5) mindfulness, (6) personal strengths, (7) setting and working toward attainable goals, and (8) acts of kindness. We have tested this intervention in several populations and have found evidence supporting its feasibility, acceptability, and preliminary efficacy for promoting psychological adjustment in people coping with health- related stress.58-61,64 This positive emotion skills intervention can be tailored for various populations, including critical care nurses.
Case Study: Tailoring the Intervention for Medical Students
Although our positive emotion skills intervention was originally developed and tested in populations coping with health- related stress, we recently tailored this program to help medical students cope more effectively with the stress of medical training (Cheung et al, unpublished data).We conducted an extensive modification process to adapt the intervention content, exercises, and skills to optimize acceptability and relevance for medical trainees. A similar process could be used to tailor the intervention to address burnout and compassion fatigue in critical care nurses.
To adapt our positive emotion skills intervention to address burnout in medical students, we first conducted a focus group with medical students at Northwestern University’s Feinberg School of Medicine. The focus group allowed us to obtain qualitative data to inform the tailoring of the intervention for medical students. The medical students were asked to review the existing intervention content (ie, lessons, home practice exercises) that was previously delivered to populations coping with health-related stress. We solicited feedback from the medical students about how the intervention could be tailored to be maximally relevant and acceptable for them. The feedback we received from the focus group helped determine which positive emotion skills we included in the intervention for medical students as well as the specific examples of medical student stressors and experiences that we incorporated into the intervention content and exercises. For instance, we added the skill of self-compassion because the medical students in our focus group indicated that self-compassion is often lacking in medicine, which has a culture that promotes self-criticism, competitiveness, and perfectionism. In addition, we modified the skill of “acts of kindness” to discuss compassion toward others in medicine and incorporated content from empathy-training interventions65 and compassion-meditation interventions into our program.66,67
We also asked the medical students in our focus group to provide specific examples of relevant stressors they had experienced during medical school that we could use to inform the lesson content and home practice, as well as suggestions for how the skills could be integrated into their work and life (eg, incorporating mindful moments as one washes one’s hands throughout the day). We used the specific stressors and suggestions provided by the medical students as examples and activities throughout the intervention.
The tailored program is called LAVENDER, which stands for Leveraging Affect and Valuing Empathy for Nurturing Doctors’ Emotional Resilience. We recently conducted a single-arm pilot trial of the LAVENDER intervention delivered to a cohort of 157 medical students in their clerkship (third) year at the Albert Einstein College of Medicine (Cheung et al, unpublished data). In this pilot trial, a facilitator delivered the intervention content to the students in a group format in 4 hour-long sessions during the fall term, with the program integrated into the mandatory medical curriculum. We also provided students with an online, mobile-friendly website that included medical student-specific tutorials, practice exercises, and additional resources. The findings from the pilot study indicated that LAVENDER showed good feasibility and acceptability (Cheung et al, unpublished data). Medical students demonstrated understanding of the intervention content and enjoyment of the program: 76% of the participants agreed that they found the skills they learned in the program to be useful, and 72% agreed that they would recommend the program to others.
The success of the positive emotion skills program in medical students indicates that it may help critical care nurses as well. Specifically, the intervention may help nurses cope more effectively with their workplace stress and sustain a sense of meaning and engagement in their work. Ultimately, a positive emotion skills intervention adapted for critical care nurses may help protect against burnout and compassion fatigue in nursing.
Tailoring the Intervention for Critical Care Nurses
Several factors must be taken into consideration when designing an intervention for critical care nurses, including these nurses’ limited time and energy, the importance of translating the skills to practical exercises that can be integrated into nurses’ everyday practice, and the inherently social and team-based aspects of the nursing profession.
First, the significant demands of critical care nursing can leave nurses with limited time and energy to participate in activities focused on preserving their psychological well-being.68,69 Traditional psychological interventions often require a significant time commitment that may not be feasible in the context of the ICU. We sought to address this potential barrier to nurses’ uptake of the intervention by providing examples of brief and practical applications of the positive emotion skills that require a minimal time commitment (less than 5 minutes), are easy and enjoyable to do, and can be easily integrated into everyday workplace activities (eg, in team huddles, when administering medications). For instance, nurses can perform quick (1- to 2-minute) mindful breathing exercises as they wash their hands throughout the day or spend 5 minutes each evening reflecting on 3 good things that happened to them that day.
Second, nursing is an inherently social profession. Working as a nurse requires continuous interactions with patients and their families, physicians, nurse managers, colleagues, and other health care staff. Many workplace stressors for nurses involve interpersonal strain (eg, conflict with colleagues, low levels of support from nurse managers and other staff members, difficult interactions with patients and their families). As a result, we sought to include specific examples that focused on how the skills could be used to address interpersonal stressors in particular, as well as examples of exercises that could be practiced socially in a team setting (eg, during team huddles). We hoped that these team-based exercises would promote enhanced coping across the health care team while also building collegial support and stronger relationships.27
Third, workplace well-being interventions tend to be most effective when they are clearly supported by leadership and the skills are modeled from the top down. Nurse managers play an important role in promoting wellness in the workplace by cultivating positive work environments,70 fostering collegial relationships, and readily offering debriefings and support after stressful situations such as the death of a patient.70,71 Thus, we took care to highlight specific examples of how nurse managers could integrate the skills into exchanges with their nursing team (eg, acknowledging each nurse’s unique personal strengths during their evaluations), how they could role-model specific skills, and how they could create opportunities for their teams to practice the skills in their everyday work.
The skills taught in the positive emotion skills intervention are outlined below. Table 1 provides specific applications of each of the skills to the nursing profession and offers practical suggestions for how each skill could be practiced individually and as part of the health care team.
Noticing Positive Events
Even in the midst of severe stress, people can and frequently do experience small positive moments (eg, a beautiful sunset, a good cup of coffee or tea, playing with a pet). When people notice these everyday positive events and take time to savor them, they can experience increases in positive emotion, which may help them cope more adaptively with stress.72 Nurses can practice noticing small positive moments and taking time to pause, appreciate, and celebrate these events throughout their days. A nurse could practice this skill individually by, for example, taking a moment to celebrate a patient’s reaching a milestone in his or her recovery or to appreciate a meaningful interaction with a patient’s family member. At the team level, nurses could modify team huddles by incorporating noticing 3 good things that happened that day. Over time, the practice of noticing and appreciating these small positive moments may help nurses sustain joy in their practice and a sense of fulfillment in their work.
When people experience positive events, they can amplify the accompanying positive emotion by capitalizing on the positive event. Capitalizing is an expressive response to positive events that can involve sharing the experience with others (eg, telling a friend about it, sharing it on social media, writing about it in a journal, actively remembering it again later on, or marking the occurrence in some way with a token or picture). Capitalizing is closely related to the construct of savoring and has similar benefits. Capitalizing can enhance the positive emotional experience by strengthening the association between positive events and positive emotion.73,74 It allows the individual to extend and maximize the experience of positive emotion associated with an event by allowing him or her to relive the positive emotional experience over time without necessarily creating new positive events. Nurses can practice capitalizing on positive events by sharing positive experiences with someone else on their unit or with a loved one at home. Teams can practice capitalizing on positive events by documenting positive events and successes on a bulletin board or in weekly emails or newsletters.
Gratitude is a feeling of thankfulness and appreciation that people can feel toward other people, experiences, nature, or things. A wealth of research has documented the importance of gratitude for physical and psychological adjustment.75 Nurses can practice the skill of gratitude by keeping a daily gratitude journal to log the things they are grateful for each day or writing a letter to express gratitude toward a colleague or loved one. Teams can encourage the expression of gratitude through activities such as “gratitude popcorn.” In this activity, a charge nurse or nurse manager starts each team huddle by identifying something he or she is grateful for. That individual then selects another nurse to “pass it on” to. That nurse then identifies something he or she is grateful for and selects another nurse to pass it on to (and so on).
Positive reappraisal is a coping strategy that involves reinterpreting or reframing the significance of a negative or stressful event in a more positive way. This strategy may involve benefit finding, “seeing the silver lining” in a situation, identifying aspects of the situation that are meaningful, or finding opportunities for learning and growth in difficult situations. Positive reappraisal can be applied to everyday stressors and can be used to dispute excessively negative interpretations of an event.38,76 Nurses can practice the skill of positive reappraisal individually by keeping a journal in which they write down alternative ways to interpret or frame a situation to find the positive aspects. Teams can practice the skill of positive reappraisal by playing the “Lemons to Lemonade” game, in which individuals or teams compete to generate the greatest number of positive reappraisals of common daily hassles.
Mindfulness is a specific way of paying attention, on purpose, in the present moment, in a nonjudgmental fashion. Mindfulness is associated with higher levels of positive emotion and lower levels of negative emotion, and interventions to increase mindfulness have been shown to increase positive emotion.77,78 Nurses can practice mindfulness individually by engaging in formal guided meditation practices or by incorporating informal mindfulness into everyday workplace activities (eg, taking a mindful moment when administering medications or as they wash their hands). Teams can encourage mindfulness by creating quiet mindful spaces in the hospital (eg, designating a “quiet zone” in certain parts of the medication room) or by incorporating guided meditation into team huddles or breaks.
Recognizing and appreciating one’s unique personal strengths is a form of self-affirmation. Self-affirmation is associated with more adaptive responses to failure and better physical and psychological adjustment.79-83 Nurses can practice taking note of the unique set of strengths, skills, and talents they bring each day to work (eg, being especially skilled at starting an intravenous infusion or calming down anxious patients). Moreover, nurse managers and teams can acknowledge and affirm personal strengths in evaluations and during huddles or rounds. Nurses can also acknowledge personal strengths during patient handoffs (eg, the outgoing nurse can verbally convey a personal strength of the incoming nurse to the patient).
Goal setting is common in health promotion and education interventions. The act of setting and pursuing attainable goals (versus more global distant goals) has been associated with greater well-being, increased life satisfaction, and higher levels of positive emotion.84-88 Setting SMART (Specific, Measurable, Attainable, Realistic, and Time-bound) goals can help give nurses a greater sense of control in an otherwise hectic, busy, and unpredictable work environment. Nurses can practice the skill individually by setting a SMART goal each week and tracking their progress daily. Teams can practice setting and working toward attainable goals by setting goals for the team that can help improve workflow.
Self-compassion is the tendency to be kind and understanding toward oneself in instances of pain and failure, to perceive one’s experiences as part of the larger human experience, and to hold painful thoughts and feelings in balanced awareness.89,90 Although nurses tend to show a great deal of kindness, compassion, and generosity toward their patients, they often have difficulty directing the same kindness and compassion toward themselves. Nurses can practice self-compassion individually through exercises such as writing a letter to oneself from the perspective of a compassionate friend. Teams can practice encouraging a culture of self-compassion by hosting “war story” panels in which nurses share their own personal experiences of failure and inadequacy in nursing. These war stories can help create a culture in which nurses understand that mistakes and feelings of inadequacy are common and that they are not alone in these experiences.
Compassion Toward Others
Growing research indicates that helping others is good for the person giving the support. Compassionate behaviors are associated with better physical health and even a longer life.91 Clinicians who are able to maintain emotional engagement with their patients are able to derive greater meaning and fulfillment from their work.54,55,92-94 The practice of nursing requires a certain level of compassion toward others and constant teamwork based on give and take. Nurses can practice engaging in small compassionate acts by finding ways to step in and help other nurses on their team (eg, a nurse answering a call light from a patient not assigned to him or her and assisting with the patient’s needs). Nurse managers can build a culture of collaboration and support by modeling the importance of team support from the top down. This may include helping out members of their staff who may be having a bad day, finding ways to make a new staff member feel welcome, celebrating positive life events (eg, birthdays, engagement, new baby), and providing support for difficult life events (eg, divorce, family illnesses). These small kind gestures can make a big difference in creating a workplace culture of support, collaboration, and community.
In addition, such acts of kindness can personalize and humanize the exchange between nurses, which may lead to greater generosity toward each other in the future.
How the Intervention May Help Address Burnout in Nurses
As shown in our conceptual model (see Figure), the positive emotion skills taught in this program may help address burnout in nurses through differentially targeting the 3 dimensions of burnout: lack of personal accomplishment, emotional exhaustion, and depersonalization. Specifically, the skills of noticing positive events, capitalizing on positive emotion, and gratitude can increase nurses’ sense of personal accomplishment (“more enthusiasm”) by training nurses to direct their attention toward the small, positive moments in nursing that can help them sustain a sense of meaning, engagement, and satisfaction in their work. In addition, the skills of positive reappraisal, mindfulness, and attainable goals can lead to less emotional exhaustion (“more energy”) by helping them cope more effectively with daily hassles and stressors, which can free up “bandwidth” to tackle larger goals and challenges. Finally, the skills of personal strengths, self-compassion, and compassion toward others can lead to less depersonalization in themselves and others (“more caring”) by helping nurses recognize their unique personal strengths during moments of stress or failure, respond to these moments with compassion rather than self-criticism and perfectionism, and maintain a sense of understanding and connectedness with others.
Recognizing the Need for Organizational Change
Although the positive emotion skills intervention described in this article can help nurses cope with their daily workplace stressors more adaptively and sustain a sense of meaning and purpose in their work, nurse managers and leadership must recognize that addressing burnout at the individual level is not enough. Burnout does not result solely from a lack of resiliency in the individual; rather, an individual’s symptoms of burnout tend to reflect broader problems in the workplace. When hospitals and medical centers focus solely on providing individual-level solutions to the problem (eg, mindfulness training, psychological coping interventions), these efforts are often met with skepticism and disillusionment among health care professionals, who may perceive them as evidence that the organization is “blaming the victim” or putting a “bandage” over the real problems and inefficiencies at the organizational level that are contributing to burnout.
Burnout can be conceptualized as a breakdown in the relationship between an individual and his or her work. Both personal and organizational factors contribute to this breakdown (Table 2). Thus, organizational solutions to burnout in nurses may include initiatives focused on workflow redesign to reduce administrative burden or strategies to enhance interprofessional teamwork.
To address burnout in nursing, organizational change is necessary. However, such change takes time, resources, and effort to implement. In the meantime, individual-level interventions, such as this positive emotion skills program, can help to address burnout and compassion fatigue in critical care nurses. If nurse managers and leaders are serious about addressing burnout in nursing staff, they must understand the many factors, both personal and organizational, that are contributing to the problem. Then they can offer solutions at both levels concurrently to address these factors and improve the situation.
The positive emotion skills intervention described in this article holds promise for addressing burnout in critical care nurses. These quick, convenient, and relatively inexpensive strategies can be easily integrated into the busy lives of ICU nurses. Future research should further tailor the intervention for critical care nurses and test the feasibility, acceptability, and efficacy of the intervention in helping nurses cope more effectively with the stress of working in the ICU and sustain a sense of joy in their practice and professional fulfillment. Ultimately, if shown to be efficacious, the intervention can be included in comprehensive training programs to address burnout in nursing.
The authors declare no conflicts of interest.