Nurse leaders share methods that help nurses successfully combat burnout and maintain mental health and wellness.
Editor's note: This article appears in the November/December 2021 edition of HealthLeaders magazine.
Prior to the COVID-19 pandemic, nearly four out of 10 nurses reported they felt burned out because of long work hours, greater workloads, poor environments, and caring for significantly ill patients, according to the Well-Being Index. By January 2021, that figure had grown to 70%, according to a study by the International Council of Nurses.
During the second half of 2021, hospitals and health systems battled a tsunami of patients whose respiratory systems were attacked by the highly contagious and deadly delta variant. There's no telling where the burnout rate currently stands.
But nurse leaders are looking out for their nurses and providing ways to ease the overwhelming hardship wrought by the pandemic. Zen rooms, mindfulness activities, and pet therapy have found their way into many hospitals since the pandemic began.
Many providers started programs pre-pandemic, such as the Care for Caregivers program at SSM Health Cardinal Glennon Children's Hospital in Saint Louis, which provides peer-to-peer support to a colleague who is having a stressful reaction to an event or outcome, according to Michelle Romano, MSN, RN, NEA-BC, the hospital's vice president of patient care services and chief nursing officer over 800 nurses.
The program began when nurse leaders noticed high turnover and conflicts among staff and wanted to provide a way to help them care for themselves and each other, says Romano.
"It's grown to extend support for all members of our hospital," she says. "Providers, nonclinical staff, clinical staff—anybody who works within the walls of our facility."
"With this latest wave [of COVID-19], patients are young, they're for the most part unvaccinated, those who are extremely ill, and many of them to the end are not believing in the vaccine, and that is probably the most conflicted piece of the pandemic right now for staff," Fiore-Lopez says.
After three recent successive deaths of young people in the ICU, Fiore-Lopez asked the hospital's director of psychology to meet with the staff.
"I had met with them, but they needed someone who had that expertise," she says. "And so, that's the kind of episodic assistance we try to give our staff, as well."
HealthLeaders spoke with nurse leaders about three ways they've chosen to combat nurse burnout and how they've been successful.
1. Time management brings order to the COVID chaos
When COVID-19 brought chaos to nurse leaders at Allegheny Health Network (AHN)'s 14 hospitals, a time management course designed just for them helped them feel less overwhelmed about their day.
"They were saying, 'We work really hard all day, but we feel like we don't accomplish anything.' And that is a hit on their morale," says Claire Zangerle, DNP, MSN, MBA, RN, FAONL, NEA-BC, chief nurse executive for AHN, based in Pittsburgh. "They live in chaos all day, and the issue for them is, 'How do I control the chaos?' "
Nurse leaders indicated that they couldn't get enough time and engagement with their team because of other tasks such as staffing schedules, disciplinary actions, overseeing budgets, developing their team, and self-care, Zangerle says.
Claire Zangerle, DNP, MSN, MBA, RN, FAONL, NEA-BC, is the chief nurse executive for Allegheny Health Network in Pittsburgh. Photo credit: Photo by Justin Merriman.
Zangerle had recently taken an effective time management course and thought that might be a solution.
She worked with Carol Perlman, PhD, a cognitive behavioral therapist specializing in time management, who surveyed nurse leaders about their time management strategies and how they felt about how they managed their workday. From those responses, Perlman then created a word cloud chart, which is a clustered list of words mentioned by the nurse leaders, portrayed in different sizes. The bigger, bolder words are those that are mentioned the most.
"The biggest two words were 'busy' and 'chaotic,' " says Zangerle.
Perlman provided a customized time management course for the nurse leaders with the objectives of teaching them to create a daily schedule, helping them attain skills for centralizing a task list and prioritizing daily tasks, encouraging them to incorporate time for self-care, and creating a plan for engaging and developing their staff.
"The goal was to reduce their stress level and to help them feel that they were in more control of their day, which would lead to them being able to spend some time on themselves to eat right, plan their meals, take time for exercise, take time for meditation, or whatever would contribute to their health and well-being while in a chaotic environment," Zangerle says.
AHN provided the course for CNOs, nursing directors, and nurse managers at all the health system's hospitals.
Each participant was given an 18-month planner, customized with AHN's colors, along with a workbook. The 21-day course included daily self-paced work that generally took less than five minutes, plus weekly virtual sessions.
For one of those weeks, each individual discipline group—all CNOs, directors, and nurse managers—met with their peers to share information related to their leadership level, Zangerle says.
They also set up a Google classroom where the instructor posted lessons and participants could post their work, ask questions, and offer hacks, she says.
"Now, the nurse managers want their assistant nurse managers and supervisors to take the course," Zangerle says. "They recognized the need to cascade the same valuable information to this group of newer nurse leaders so they could also learn how to prioritize tasks, deal with the unexpected, and block out time appropriately."
For the 300-plus nurse leaders who have completed the time management course, "They feel that they're a lot more in control, and that contributes significantly to their wellness," says Zangerle.
The time management course resulted in collateral benefits as well, Zangerle says.
Allegheny Health Network CNOs pulled together directors from their hospitals and worked on lessons together, learning how to delegate and do succession planning, says Zangerle.
A post-course questionnaire revealed:
- 62% of nurse leaders rate their current time management strategies as "very good," as compared to 29.61% before the course.
- 76% felt they got many targeted tasks done by the end of the day, as compared to 35.9% before the course.
- 46% felt that time management affected their overall job performance "a lot," as compared to 32.45% before the course.
- 58% use a master list to organize their tasks every day, as compared to 26.2% before the course.
- 28% felt their ability to create and implement a leadership development plan for their staff was "extremely effective," as compared to 7.3% before the course; 54% felt their ability was "very effective" post-course, as compared to 28.7% before the course.
- 60% felt they used strategies to manage procrastination that interferes with their productivity "very well," as compared to 30.92% before the course.
- 78% can use a system to address unexpected demands "very well," as compared to 24.68% before the course.
A second word cloud created by Perlman after the course also revealed changes in how the nurse leaders felt about their day. Instead of "busy" and "chaotic," the biggest, boldest words in the post-course word cloud were "productive" and "good."
"The chaos is still there, but they feel like it's controlled chaos," she says. "We're going to have chaos for a while here, and the value is in de-escalating the chaos to control what you can, so that you can better manage the things you cannot."
2. Half-day haven hands nurses tools for mental health wellness
A half-day retreat that takes frontline nurses off the floor of UAMS Health at the University of Arkansas for Medical Sciences and to a serene riverside setting to learn about the importance of self-care seems to be working, says the CNO who engineered it all.
"Skeptical people go in saying, 'I don't know about this,' and they come out thanking us," says Trenda Ray, PhD, RN, NEA-BC, the Little Rock, Arkansas, health system's CNO and associate vice chancellor for patient care services.
The Caring for the Nurse Retreat originated from a survey about two years ago—before the COVID-19 pandemic—by a UAMS researcher who was focused on physician wellness and burnout. Inexplicably, he included nurses in the survey. The results were eye-opening.
"They were so surprised in that RNs led the way in burnout," Ray says. "Nurses surpassed residents, students, and attending physicians, and that became the signal for us that we needed to do something."
At a conference she was attending, Ray heard another organization speak about nurse retreats, and she took the idea back to UAMS with her.
"In October 2019, pre-pandemic, we had our first Caring for the Nurse Retreat and we modeled it based on what I had heard from another organization, but modified it a bit to fit our needs," she says.
Open to all frontline RNs, advanced practice RNs, and licensed practical nurses (LPN), the monthly half-day retreat is held off-site in a large, windowed conference room at the Department of Arkansas Heritage, which sits on the Arkansas River.
The hospital system's director of wellness and Ray's assistant facilitate each session, which is limited to 12–14 participants.
"Each session, I try to do the welcome. If I can't do it in person, they play a video where I explain the premise behind the retreat and why it's so important to us that we want healthy nurses not just at work, but we want our healthy nurses back at home with their families," she says.
Yoga is a large part of the retreat, so they start the day talking about the importance of movement, followed by a yoga session focused on mindfulness and gratitude, she says.
A healthy cooking demonstration from a UAMS culinary medicine faculty member shows the nurses healthy, easy foods they can cook for their families and bring for lunch. During a healthy lunch, participants also learn about journaling and how it can be an effective tool in managing mental health.
Evaluations from retreat attendees have consistently ranked high, Ray says.
"It's early and they're still looking at the data, but we have had a total of 14 retreats so far over the past year with a total of 149 participants. The average satisfaction score is 4.89 on a 5-point scale and, post-retreat, nurses reported significant improvements in self-care—nutrition, physical activity—and in management of stress," she says.
Feedback from nurses includes such statements as:
- "Thank you for valuing us and our time [nurses are paid for the four hours they spend in the retreat]."
- "Thank you for investing in our wellness and giving us tools to use in everyday life."
- "This was much needed, especially after the past year in the pandemic. I have become so focused on work and school that I've lost focus on what matters."
"And those are a few of the comments from just one session," Ray says.
'Focused on wellness'
The nurse retreats are sponsored by the Chancellor's Circle, the annual giving society for the entire UAMS system that provides funds to support key mission areas in healthcare education, research, and patient care.
"I didn't know how to get the financial backing, and when the Chancellor's Circle awards came through, we are so fortunate that our chancellor is focused on the wellness of our nurses and of our campus," she says.
Additionally, UAMS' foundation office has made the retreats part of its philanthropy efforts, and the Caring for the Nurse Retreat received more than $10,000 in donations in just a few weeks.
"Everyone has recognized this as something very special," Ray says.
Of the health system's roughly 2,000 nurses, nearly 150 have attended the retreat, which is why Ray plans to expand it to twice a month. And the retreat program that started out as a pilot is now being designed for other staff members across the medical center campus, she says.
How to get started
Nurse leaders interested in starting a nursing retreat at their hospital should first review what resources are available within their institution, Ray says.
"One of our nursing leaders was a yoga instructor, and we started with her," she says. "We're lucky that we have a wellness program here and someone who teaches mindfulness."
The retreat location at the Department of Arkansas Heritage is free because both are state institutions.
"The cost of this is low. We bought yoga mats and we buy food every time and a few other supplies here and there, but the cost is so low considering the benefit that we're seeing," Ray says. "I would suggest they look internally, that they talk to one another and ask who in their organization are experts around mindfulness or nutrition, and then find ways to partner."
3. Virtual reality transports frontline nurses from the COVID floor to paradise
A California hospital with a national reputation in virtual reality (VR) for pain, patient stress management, patient education, and maternal care has deployed that same technology to help its frontline nurses combat stress, anxiety, and burnout.
Nurses at Hoag Memorial Hospital Presbyterian in Newport Beach, California, who experience high levels of stress, particularly from treating COVID-19 patients, began finding relief in March through CenteredVR, a virtual reality–based mindfulness and stress management program developed especially for them by BehaVR.
"We have seen the power of virtual reality–enabled programming to support the mental health and well-being of our patients, so it was a natural fit for us to offer [this] tool to our nurses," says Dr. Robert Louis, chief of neurosurgery, under whose leadership Hoag has become a leader in healthcare VR.
"Mindfulness practices are shown to reduce chronic stress, and CenteredVR combines those principles with the neurological and psychological power of virtual reality, offering our nurses new resources to reduce stress and improve their overall health," Louis says.
CenteredVR was developed in collaboration with Johns Hopkins Medicine, says Kim Mullen, MSN, RN, Hoag's director nursing professional development, research and Magnet program director.
"It guides users into a soothing, immersive VR environment that helps alleviate stress through educational elements and mindfulness practices," she says.
Over the course of six 20-minute sessions, which can be done in the privacy and comfort of their homes, nurses learn to become less reactive and more resilient to stressors.
"You learn those mindfulness concepts by practicing and training your brain. You learn how to cope better and be more resilient versus go down that negative pathway in helping you cope with stress," Mullen says.
The VR kits are sent to each nurse's home. Including a headset, headphones, and remote control, each kit arrives in an appealing, scented box to conjure a relaxing, spa-like environment, Mullen says.
"It's all about the personal experience," Mullen says.
When Hoag introduced the CenteredVR program, nearly two-thirds of the nursing staff in the COVID-19 unit signed up to participate.
Crystal Watson, RN, initially was unsure about the VR technology.
"We've always had other ways of dealing with stress, but none that had a visual element, so I wasn't sure what to expect," she says.
But once she put on the goggles and plugged in her headphones, she was "floating high above the ocean like a bird," she says.
As Watson began to use CenteredVR regularly, her stress-induced headaches gradually subsided, she says.
Watson and other nurses can choose which session they want to experience based on the level of stress they are feeling, from options designed to target specific feelings of anxiousness, sadness, or hopelessness.
"I fell in love with the 'Body Scan' series," she says. "One minute I was on my couch stressing, the next minute I was watching a beautiful waterfall or meandering through a lush green forest."
Once she focused on the breathing exercises, tension in her neck and shoulders began to relax, she says.
Though many of Hoag's nurses use the technology to decompress, Watson often uses it before work to prepare her for the day ahead, so she can better handle the stressful challenges of a 12-hour shift, she says.
Early results on CenteredVR's impact on users' stress levels have been positive. Among the 70 nurses who have used the program to date, stress levels decreased, on average, by a reported 34%.
The hospital is also currently conducting a nursing research study to determine outcomes, Mullen says.
Further data has been gathered and submitted to the Institutional Review Board, Mullen says.
Nurse feedback has indicated that CenteredVR not only has decreased stress levels, but has helped dispel feelings of isolation and pain caused by stress and anxiety, Mullen says.
"They've said it's almost a getaway or escape, and you don't have to go anywhere," Mullen says.
Some, like Watson, say that VR has helped relieve chronic headaches, muscle tension, and anxiety.
"I always say, who wouldn't relax when you can lay and look at a beautiful waterfall and hear the sound, or walk through a beautiful, lush forest, or be at the beach?" Mullen says. "It's being able to travel when you can't."
“The chaos is still there, but [the nurse leaders] feel like it's controlled chaos. We're going to have chaos for a while … and the value is in de-escalating the chaos to control what you can, so that you can better manage the things you cannot.”
Claire Zangerle, DNP, MSN, MBA, RN, FAONL, NEA-BC, chief nurse executive, Allegheny Health Network
Carol Davis is the Nursing Editor at HealthLeaders, an HCPro brand.
With nurse burnout rates rising, nurse leaders are implementing mindfulness activities to boost nurses' mental health.
Partnering with experts has been an effective way for nurse leaders to provide supportive resources at their organizations to help avoid nurse burnout.
Virtual reality tools have proven to be effective in targeting and relieving feelings of anxiousness, sadness, and hopelessness in nurses.