Background

Professional burnout is a widespread phenomenon in health care. The health of patients and organizations begins with the well-being of health care professionals. Identifying and understanding self-care strategies that professionals perceive to be helpful is crucial to combat burnout.

Objective

To determine perceptions of self-care strategies to combat professional burnout among nurses and physicians in pediatric critical care settings.

Methods

This was a qualitative descriptive study with a phenomenological overtone. The study was conducted in a 20-bed pediatric intensive care unit and an 8-bed intermediate care unit of a children’s hospital in the United States. Information flyers and emails were used to introduce the study. A combination of convenience and purposive sampling methods was used to recruit participants who were full-time nurses and physicians in the 2 units. Information saturation was used to regulate sample sizes, resulting in 20 participants. Data were collected through a onetime face-to-face interview with each participant. A qualitative descriptive approach was used to analyze the data. The first author was the primary coder and discussed the codes with the coauthors throughout the coding process.

Results

Six major self-care strategies were identified: finding meaning in work, connecting with an energy source, nurturing interpersonal connections, developing an attitude of positivity, performing emotional hygiene, and recognizing one’s uniqueness and contributions at work.

Conclusions

Developing effective self-care strategies helps promote health care professionals’ physical and psychological well-being and reduce burnout. It is vital for health care professionals to care for themselves so that they can best care for others.

Professional burnout is a widespread phenomenon in health care. Burnout is a psychological state resulting from a persistent negative reaction to work-related stress.1  The symptoms of burnout have been categorized into 3 dimensions: emotional exhaustion, feelings of cynicism, and a sense of inefficacy.2,3  When individuals experience burnout, they feel overwhelmed by their work, have a sense of depersonalization, and do not feel efficient at work.

Burnout is common in nurses and physicians. In a recent study of 6586 actively practicing physicians, more than half (54.3%) of participants reported symptoms of burnout, one-third (32.8%) experienced excessive fatigue, and 6.5% indicated recent suicidal ideation.4  In a 2018 national survey of physicians representing 29 specialties, those working in critical care reported the highest rate of burnout.5  About half of pediatric critical care physicians demonstrate symptoms of burnout.6  Nurses also experience high burnout rates. About 60% of nurses working in pediatric and adult critical care units report symptoms of burnout.7,8 

The growing prevalence of nurse and physician burnout has been recognized as a potential hazard to health care quality and patient safety. Research shows that physicians who report signs and symptoms of burnout are more concerned about making medical errors.4  A study of 53 846 nurses from 6 countries showed that higher levels of nurse burnout were correlated with lower ratings of patient care quality.9  When experiencing burnout symptoms, health care professionals may develop a sense of detachment from work, both physically and psychologically.2,3  A 2018 report on national health care retention and registered nurse staffing published by Nursing Solutions, Inc, indicated an average hospital turnover rate for 2017 of 18.2%, setting a new high record for the decade.10 

Moreover, hospitals’ financial viability is profoundly affected by organizations’ workforce stability and patient care quality. The current value-based purchasing system has interwoven health care organizations’ reimbursement with patient care quality. The high staff turnover rate adds an immense economic strain to hospitals that are already experiencing a shrinking financial margin. Therefore, reducing health care professionals’ burnout is key to increasing the stability of the workforce and thus promoting patient care quality and organizations’ financial viability.

Because of the importance of health care professionals’ welfare, a popular framework for health care delivery has been modified from the “Triple Aim” to the “Quadruple Aim.”11  In addition to the components of the Triple Aim—enhancing the patient experience, improving population health, and reducing health care costs—the Quadruple Aim includes improving the work life of health care providers. Various critical care organizations have issued calls to promote health professionals’ well-being and thereby reduce burnout.12,13 

Reducing health care professionals’ burnout requires actions on different levels: organizational, unit, and personal.7,1417  A meta-analysis by Panagioti et al14  indicated that organization-directed interventions such as reducing physician workload and making schedule changes play an important role in decreasing physician burnout. A literature review on nurse work environments showed that the unit-level work environment affects nurse well-being.16  Nurse leaders are indispensable in fostering a resilient nurse workforce.15,16  Although organization- and unit-level factors play significant roles in the establishment of suitable policies and work environments, self-care is rudimentary for health care professionals to combat burnout.17 

Reducing health care professionals’ burnout requires actions on different levels: organizational, unit, and personal.

The well-being of all entities involved in health care—patients, health care providers, and health care organizations—begins with the well-being of health care professionals themselves.12,13  Identifying and understanding the self-care strategies that health care professionals perceive to be helpful is a pivotal step in combating burnout and promoting optimal well-being for all health care entities. Therefore, this study was conducted to determine perceptions of self-care strategies to combat professional burnout among nurses and physicians in pediatric critical care settings.

Methods

Study Design

This was a qualitative descriptive study with a phenomenological overtone.18  This research design emphasizes participants’ subjective feelings and experiences. Physicians’ and nurses’ thoughts and feelings about self-care are portrayed in everyday language instead of in terminology characteristic of a conceptual, philosophical, or highly abstract framework.

Setting and Sample

The study was approved by the institutional review board of East Carolina University. The study was conducted in a pediatric intensive care unit (PICU) and an intermediate care unit of a children’s hospital in the United States. The PICU is a 20-bed unit, with about 70 full-time nurses and 15 full-time physicians caring for about 900 children with life-threatening conditions per year. The pediatric intermediate care unit is an 8-bed unit caring for children with a step-down status from the PICU with a 3:1 patient-nurse ratio.

This study was carried out between November 2017 and April 2018. A combination of convenience and purposive sampling methods was used to recruit participants, which allows participants to self-select or be purposively recruited to ensure a representation of physicians and nurses. Inclusion in the study required the participant to be a full-time nurse or physician in the PICU or the intermediate care unit and to have worked in either unit for at least 1 year. Providers who did not want to share their self-care strategies were excluded from the study. Information saturation19  was used to regulate the sample size, resulting in 20 participants.

The questions asked during the interview focused on the participant’s experiences working with children with critical conditions and strategies for self-care.

We used flyers and emails to introduce the study. Nurses and physicians interested in the study contacted the first author (H.W.), who set up a time to meet with the potential participant. When a provider agreed to join the study, his or her written informed consent to participate was obtained and a onetime face-to-face interview was scheduled.

Data Collection

Data for this study were collected using a demographic survey and an individual face-to-face in-depth interview with each participant. The demographic information consisted of the participant’s age, sex, ethnicity, profession, and years of experience. The first author (H.W.) conducted the interviews while taking field notes. Each interview lasted from 45 to 75 minutes and was audio-recorded and transcribed.

The questions asked during the interview focused on the participant’s experiences working with children with critical conditions and strategies for self-care, such as the following: “Could you please tell me what self-care means to you?” “What do you usually do when you feel stressed?” “What brings you to work every day?” “How do you maintain your self-care practice?” “What kind of self-care strategy is most important to you?” More detailed information was elicited using probing questions such as the following: “Could you explain how that makes you feel?” “Would you please give me an example of … ?”

Data Analysis

Data were analyzed by means of a qualitative descriptive approach,18  which was considered best suited for the purpose of the study. This approach effectively guided us to discover and describe nurses’ and physicians’ strategies for self-care. We developed codes on the basis of participants’ interview transcripts and the field notes taken during the interviews. We used NVivo (QSR International), a qualitative data analysis computer software package, to facilitate data analysis.

The first author (H.W.) was the primary coder of the study. The codes and supporting quotations were discussed with and reviewed by the entire research team. During the coding process, if questions arose about a certain code, we referred to participants’ transcripts to find supporting quotations and clarify. In accordance with the recommendations of Sandelowski,18  we took the following specific steps to analyze the data: (1) reading the interview transcripts thoroughly to gain knowledge of participants’ overall experiences; (2) recognizing passages in which participants described their self-care strategies to cope or prevent burnout; (3) using memoranda to reflect on insights into participants’ strategies; (4) identifying common themes for classifying participants’ self-care actions; and (5) coding passages to fit one of the themes.

Study Rigor

To ensure study rigor, we followed the suggestions of Sandelowski20  for achieving credibility, fittingness, auditability, and confirmability. To warrant the credibility of the findings, we made sure that the codes selected were true to participants’ descriptions. Fittingness was ensured by selecting participants working in acute care settings, in which professional stress and burnout are evident, according to the literature. To uphold auditability, we maintained a clear audit trail during the research process.

Results

Participants

A total of 20 nurses and physicians participated in the study: 13 (65%) nurses and 7 (35%) physicians. These participants were diverse in age, ethnicity, and work experiences, representing the demographics of the units. The demographic characteristics of the participants are shown in Table 1.

Perceptions of Self-care

Six major self-care strategies were identified: finding meaning in work, connecting with an energy source, nurturing interpersonal connections, developing an attitude of positivity, performing emotional hygiene, and recognizing one’s uniqueness. The strategies are described below in the order of their frequency of mention by the participants, from most to least. Further details on the self-care strategies and their frequency of mention are shown in Table 2.

Finding Meaning in Work

Finding meaning in work was referred to as an inner compass guiding individuals’ actions and reminding them of their purpose. Remembering one’s initial sense of purpose may renew individuals and motivate them to do what they have a passion for and love. Finding meaning in work was the most frequently mentioned approach to implement this strategy among the physicians and nurses in the study (n = 18; 90%).

Being able to care for others made nurses and physicians feel that their work was purposeful and meaningful. One nurse said, “Caring, for me, is the heart. Doing things out of our heart adds meanings and values to what we do.” Another nurse confirmed, “I love being a nurse because I have the privilege to come in and care for someone’s child, mother, brother, or sister and touch people’s lives.” A nurse added, “Taking care of others makes me feel that I am doing something meaningful. I am involving myself in something for the greater good.” A physician affirmed, “What brings me to work is knowing that I am a part of a bigger picture and entity. We are all here for the same goal, which is to provide great care for the betterment of patients and families.”

These expressions showed that a person’s sense of purpose determined the degree of his or her engagement and dedication. Finding meaning in work could help nurses and physicians remember their initial passion for becoming a health care professional and value what they do every day. Finding ways to remember one’s sense of purpose might help refresh or renew one’s commitment to caring and overcome exhaustion.

Connecting With an Energy Source

Connecting with an energy source meant finding ways to tap into one’s resources for support. An energy source could be one’s initial inspiration for becoming a health care professional, family support, social connections, or spiritual beliefs. Three-quarters (n = 15; 75%) of the nurses and physicians interviewed expressed the need to find ways to recharge physically and emotionally.

Half of these participants stated that patients’ positive progress was an uplifting energy source for them. One nurse said, “Patients are the center of our care. It motivates me at work that I am able to help patients and families feel better.” Another nurse added, “I want to feel that I did the best that I could to patients and families at work… . When I do, I feel happy and energized.” Although half of the participants stated that providing high-quality care made them feel motivated and energized, other participants referred to family and spiritual support as their energy source. A physician said, “My family is my buffer and energy source.” Relying on a spiritual source was another way to connect to an energy source. One participant said, “As a health care provider, I feel that I work for a higher being. My spiritual belief and value give me energy.”

These health care professionals considered being able to provide high-quality patient care as a source of energy. Helping patients and families feel better became the driving force for some of the physicians and nurses to come to work. Their motivation and contentment largely depended on the positive progression of patients’ conditions and the quality of the care that they could provide. Although these examples showed the dedication of nurses and physicians, they also revealed a vulnerable side. If health care professionals tie their happiness to patients’ positive progression, they could be at high risk for burnout.

Nurturing Interpersonal Connections

In addition to connecting to one’s energy source, nurturing interpersonal connections was perceived to be vital for nurses and physicians to enjoy their work. Developing trusting and enjoyable work relationships was perceived to be fundamental to creating a caring and healing environment and reducing work-related stress. Collaborating with supportive coworkers and leadership teams was an important motive for coming to work. A caring and healing work environment was considered essential to limiting work-related stress.

Fourteen (70%) participants conveyed the importance of workplace relationships and leadership teams in constructing a nurturing work environment. A physician said that a caring work atmosphere was key to providing high-quality patient care. A nurse expressed, “I love the people I work with. We help one another. My coworkers make work fun.” Another nurse admitted, “I like to help. I feel it’s easier to offer help than to receive it. But, I also think that it’s important to both give and receive help.” One nurse specifically mentioned nurse leadership rounds, which she thought were very effective in building nurse-leader relationships. The nurse said, “Nurse managers’ willingness to reach out makes a difference on a unit. Their availability on the unit created the bonding between nurses and nurse leaders.” A couple of physicians also expressed their gratitude when senior physicians provided opportunities for them to take breaks, which made them feel valued.

Participants’ comments conveyed the importance of both giving and receiving help. Health care professionals felt the need to shift their mindset to reflect that it was acceptable and often necessary to receive others’ help. Caring interpersonal relationships made individuals feel visible and valued at work. Such relationships included support and encouragement from leadership teams. Participants expressed their gratitude for being able to trust and rely on team members’ and leadership teams’ support.

Developing an Attitude of Positivity

Developing an attitude of positivity was a critical tactic to care for oneself from within. It was referred to as a process in which nurses and physicians learned to focus on the positive side of circumstances instead of the negative aspects. As nurses and physicians faced challenges and stressors at work every day, developing and maintaining an optimistic outlook was instrumental to keeping them physically and emotionally healthy.

Twelve (60%) of the participants shared that they developed a practice to help them face difficult situations. These participants expressed that they used to have a tendency to focus on unfavorable outcomes at work such as death and dying or the things that they did not do well, which made them feel tired and stressed. They then shifted their thoughts. One nurse shared, “I started to focus on the bright side of my work. Doing so helped me relieve my stress and boost my energy.” A physician stated, “Being open-minded is helpful to relieve my stress.” A nurse explained, “While some days were demanding and emotionally distressing, I found a way to position myself to face the challenges by seeing the good in the overall picture. I keep a gratitude journal to count my blessings.” A physician said, “Recognizing my contributions to the lives of others and having a positive attitude help me face the high demand of my job.”

These examples show that developing a positive attitude helped participants reframe adverse events and prepared them to face adversities with an optimistic approach. Cognitive reframing, being open-minded, and keeping a gratitude journal were some ways to cultivate positivity. Nurse and physician leaders needed to find ways to help other nurses and physicians develop a positive attitude.

Performing Emotional Hygiene

Performing emotional hygiene could be one way to help nurses and physicians develop a positive attitude in dealing with adverse situations and achieve psychological well-being. Maintaining one’s psychological well-being was as important as maintaining one’s physical well-being. The strategies mentioned by participants to promote emotional hygiene included self-reflecting, praying, spending time with family and friends, setting boundaries between home and work, and getting adequate sleep and moderate exercise.

Helping patients and families feel better became the driving force for some of the physicians and nurses to come to work.

Eleven (55%) of the participants in the study talked about their strategies for maintaining emotional well-being. A nurse said, “We all know the importance to perform physical and personal hygiene, but tend to ignore our emotional hygiene. We need to know how to be emotionally strong when bad things happen.” A physician concurred, “What I do to recover emotionally is to set boundaries and maintain a work-life balance. I try to separate myself from work when I am home. When I leave work, I don’t look at work emails.” A couple of participants mentioned that relaxation techniques such as mindful breathing and meditation as well as yoga and exercise helped them relax and reduce stress. One physician said, “Practicing mindfulness helps me reduce stress.” Another physician stated that he liked to sit on his deck and enjoy the forest without doing anything, which was his way to relax his mind. All of the participants reported that methods of promoting physical health such as getting moderate exercise and adequate sleep also helped them feel better psychologically.

Performing emotional hygiene was essential for nurses and physicians to maintain their psychological well-being in order to care for themselves and provide high-quality patient care. Participants tested various strategies to help them relieve their stress. Practicing mindfulness was an especially effective strategy that helped participants take a mental break from their busy work lives. Performing emotional hygiene was vital to sustaining psychological well-being.

Recognizing One’s Uniqueness

Recognizing one’s uniqueness was described as awareness and appreciation of one’s own strengths and contributions to a team. An individual’s uniqueness resided within his or her inner self. The recognition of one’s unique self helped the individual find his or her inner strength and power during difficult times. Participants pointed out that health care was like a team sport, in which the entire team was needed to provide high-quality care to patients and families.

Eleven (55%) nurses and physicians interviewed pointed out the importance of recognizing one’s uniqueness on a team. One nurse said, “Each of us is a unique contributor to saving children’s lives and making differences in patients and families.” Although recognizing one’s own uniqueness was crucial, it was also important to acknowledge the strengths of others and the significance of interprofessional collaboration and teamwork. A physician asserted, “Health care is like a team sport in which each one of us has a unique position [to play]. I may have mastered ventilator settings and hemodynamics, but I’m not an expert in all fields. We rely on one another to care.” Another physician affirmed, “Teamwork starts with the recognition of the expertise and limitations of each team member. It takes a whole team to win a game, which in health care is patient safety and quality care.” This notion of recognizing one’s uniqueness was especially important to new nurses and physicians, who often felt overwhelmed. A new nurse appreciated the nurturing learning environment of the unit. She said, “Even though I am a new nurse, my coworkers make me feel that I am an important member of the team, which helped me build confidence in myself.”

Performing emotional hygiene could be one way to help nurses develop a positive attitude in dealing with adverse situations and achieve psychological well-being.

Participants articulated that it was critical for team members to recognize their own as well as others’ expertise and focus on each individual’s strengths. This practice would create a nurturing environment that fostered individuals’ growth and ability to provide high-quality patient care. Thus, strengths-based self-care could be an effective strategy for collaborating in a team environment and fighting symptoms of burnout.

Discussion

This study revealed the self-care strategies that nurses and physicians perceive to be helpful in combating professional burnout. These strategies include finding meaning in what they do, connecting with an energy source to feel renewed, building social connections with colleagues and trusting relationships with leadership teams, cultivating a positive mentality, performing emotional hygiene, and recognizing one’s uniqueness and special strengths at work. These self-care strategies align closely with the mechanisms of building resilience.21,22 

Resilience plays a significant role in combating burnout and promoting health care professionals’ well-being. Biologically, acute and uncontrolled stressors can profoundly affect the brain’s cognitive functioning. Chronic and sustained stressors can cause lasting damage to the neurons of the prefrontal cortex and the hypothalamic-pituitary-adrenal axis, affecting logical thinking and judgment and leading to a series of physiological compromises due to hormonal alterations.23,24  The self-care strategies of shifting focus, developing a positive mentality, expressing gratitude, seeking social support, and practicing mindfulness can not only reduce stress and burnout symptoms but also help improve brain functions such as working memory, emotion regulation, and active coping.2325 

According to the anecdotes of the participants in this study, a rudimentary element of self-care is finding meaning in one’s professional experiences and incorporating it into one’s personal identity. In doing this, nurses and physicians can develop a healthy perspective on work, which in turn can help them care for patients and families with deeper empathy and less strain. An accepted norm among health care professionals is being “selfless,” placing others’ needs before one’s own.3  However, evidence from the literature supports the findings of this study that without adequate self-care strategies, health care professionals are at risk for secondary trauma, burnout, and compassion fatigue.15,26  Having a loving and caring heart and being compassionate toward one-self is key to being able to care effectively for others.

Many participants in this study committed themselves to the field of health care because they wanted to make positive contributions and help others. What has helped them live up to that commitment is team spirit and positive interpersonal relationships at work. Participants reported that respect, support, availability, and encouragement from colleagues and leadership teams play a crucial role in creating a positive culture at work, which in turn helps them combat their burnout symptoms. Nurturing interpersonal relationships can provide opportunities to improve collaboration, decrease stress, and promote health professionals’ well-being.27  Positive social relationships and support are well known to benefit individuals’ physical and psychological well-being.

The culture and environment of a workplace have a major impact on health care professionals’ vulnerability to burnout,28  quality of interpersonal relationships at work, and physical and psychological well-being.16  A strong predictor of a healthy work environment is authentic leadership.28  The results of the current study suggest that nurse leaders and senior physicians play an important role in promoting a healthy work environment and reducing nurse and physician burnout. Qualities of an authentic leader include reliability, compassion, and trustworthiness, attributes that are essential to establishing a healthy work environment and reducing professional burnout.28  Meaningful recognition from leaders and peers can be a powerful source of energy, helping to revitalize professionals’ empathy and kindness.

Developing a positive mentality, a strategy based on positive psychology,29  involves intentionally looking for the good and positive aspects of a situation.29  Although it is not possible to eliminate all of the negative features of a workplace, developing a positive mentality may increase the ratio of positivity to negativity30  and promote a healthy and positive work environment.16,31  A healthy work environment can improve the well-being of health care professionals, reducing their symptoms of burnout and thus improving patient care.

Recognizing one’s own strengths as well as those of others on a team is an effective method of promoting team members’ self-esteem and sense of engagement and satisfaction.29  Research has shown that recognizing and acknowledging employees’ strengths can result in increased employee job satisfaction and work productivity.32  The results of the current study indicate that recognizing each individual’s unique expertise and contributions may promote feelings of self-fulfillment and enhanced team collaboration, leading to reduced symptoms of burnout and higher-quality patient care.

Nurses and physicians in pediatric critical care settings are the anchors for parents and children with critical and life-limiting illnesses. Following admission to the PICU, children and their parents are at high risk for symptoms of posttraumatic stress.33  Parents of children with life-limiting illnesses such as congenital heart disease have described their hospitalization as like riding an emotional roller coaster of fear and uncertainty.34  Nurses and physicians working in pediatric care must attend not only to the critically ill children but also to their parents, who experience immense stress and grief during this time.35  These parents depend on health care providers’ guidance and support to cope with their emotional distress and provide care and support for their child.36,37  Thus, effective self-care is especially important for pediatric critical care professionals so that they can meet the challenges of caring for critically ill children and their families.

Developing inner strength and resilience, connecting with an energy source, finding a sense of purpose, building trusting relationships, and maintaining a positive attitude can all be effective self-care strategies.

Limitations and Future Research

As a qualitative investigation with a small sample size, this study was not intended to yield findings that could be generalized to all nurses and physicians working in pediatric critical care settings. Rather, it was meant to determine and describe perceptions of self-care among physicians and nurses at the study sites. The study yielded valuable information about nurses’ and physicians’ experiences of self-caring while providing care and treatment to children with critical illnesses.

Despite efforts to balance the number of participants from the PICU and the intermediate care unit, more nurses in the intermediate care unit responded to the call to participate in the study. However, because of a close relationship between these 2 units, nurses often float between them in accordance with patient census and acuity. Although the imbalance remains a limitation of the study, the findings still provide useful insights into self-care strategies among pediatric critical care professionals.

Clearly, most nurses and physicians who participated in this study do not have a consistent, systematic method of performing self-care. They are constantly learning and experimenting with their own ways to maintain their well-being and work-life balance. Future research is needed to investigate evidence-based self-care strategies that are tailored to the population of pediatric critical care professionals.

Conclusion

Health care is known to be a challenging and stressful work environment. With the growing crisis of human capital in the health care field, self-care among health care professionals is becoming an urgent concern. Self-care (ie, finding ways to replenish, recharge, and invigorate oneself) is an important approach to combating professional burnout. Developing inner strength and resilience, connecting with an energy source, finding a sense of purpose, building trusting interpersonal relationships, and maintaining a positive attitude can all be effective self-care strategies for nurses and physicians. It is vital for health care professionals to care for themselves so that they can best care for others.

Acknowledgments

The authors thank all the participants in the study for their time and cooperation.

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Footnotes

To purchase electronic or print reprints, contact the American Association of Critical-Care Nurses, 27071 Aliso Creek Rd, Aliso Viejo, CA 92656. Phone, (800) 899-1712 or (949) 362-2050 (ext 532); fax, (949) 362-2049; email, reprints@aacn.org.

 

Financial Disclosures

This study was supported in part by a seed grant from the College of Nursing at East Carolina University.

 

See also

To learn more about burnout among critical care nurses, read “Joy in Work and Reducing Nurse Burnout: From Triple Aim to Quadruple Aim” by Fitzpatrick et al in AACN Advanced Critical Care, 2019;30(2):185-188. Available at www.aacnacconline.org.