Resilience in Nursing

Course Content

Author: Mallory Antico
Contact hours: 1 hour
Learning Objectives

  • Differentiate between resilience, burnout, and moral injury.
  • Describe systems-level, organizational, and individual issues that contribute to burnout.
  • Discuss strategies that systems, organizations, and individuals can use to improve resilience.
  • Describe how experiencing bias can contribute to burnout.

Introduction

The nursing profession is full of occupational stressors that can impact a nurse’s quality of life and the literature cites high levels of burnout in nurses (Dyrbye et al., 2020). Some stressors can be ameliorated by nurses learning healthy coping strategies, however, one cannot truly address resilience in the nursing workforce through the actions of individual nurses alone. There are widespread systemic issues in the healthcare system that make individual resilience very challenging. In this article, aspects of resilience, moral injury, and burnout will be examined and strategies to improve resilience at the individual, organizational, and systems level will be discussed.


What is Burnout?

The World Health Organization recognizes burnout in the International Classification of Diseases (ICD-11) as a syndrome exclusively related to one’s job that has three defining characteristics: being exhausted, experiencing a decreased efficacy in one’s work, and an increase in negative feelings about work. Resilience, or the ability to overcome challenges, can help reduce one’s risk of experiencing burnout (Gribben & Semple, 2021).

Nurses are expected to make difficult ethical decisions, and sometimes they cannot act on their own conscience. This phenomenon called moral injury, may lead to painful emotional wounds and experiences of sadness and guilt which lead to burnout. One example of a situation that can lead to moral injury is when nurses know what the patient needs but are unable to provide it due to circumstances outside of their control, leading to resentment, guilt, and regret (Cartolovni et al., 2021). These situations become more common as nurses are expected to do more with fewer resources, forcing them to act in ways that are contrary to their training and moral obligations (Hossain & Clatty, 2021). Terms used in the literature that describe how occupational stressors impact the quality of life of nurses are summarized in Table 1.


Table 1. Key Terms
Burnout
A state of physical and emotional exhaustion reduced efficiency, and negative thinking in response to stressors at work (Stewart & Arora, 2019; Gribben & Semple, 2021).
Moral InjuryMoral injury occurs when an individual either witnesses or performs an act that is contrary to what they believe is right and experiences feelings of guilt, shame, and disgust (Fitzpatrick, et al., 2022).
ResilienceThe ability to overcome adversity (Croke, 2020).
Work-Life BalanceHaving the resources needed to achieve an equilibrium in work and private life so that demands can be responded to effectively in both settings in a way that is satisfying to the individual (Gribben & Semple, 2021).

Consequences of Burnout

Consequences of burnout in the healthcare setting negatively impact nurses, patients, and the organization (Stewart & Arora, 2019). Burnout has detrimental effects on one’s personal life, well-being, relationships and work (Gribben & Semple, 2021). Burnout affects the mental health of clinicians, including conditions such as depression, substance use, suicidal ideation, and insomnia (Stewart & Arora, 2019). Physical symptoms of burnout may include musculoskeletal pain, weakened immune systems, and headaches (Croke, 2020).

Organizations have plenty of incentive to reduce burnout. Reduced patient satisfaction, increased medical errors and safety incidents, and unfavorable patient outcomes have been associated with high levels of staff burnout. It leads to increased staff turnover, poorer productivity, and absenteeism (Dyrbye et al., 2020). With value-based purchasing reimbursement in the United States healthcare system, nursing care plays an essential role in reimbursement for care, providing financial incentives for the organization to facilitate resilience (Wei, et al., 2019).


Factors that Affect Resilience

Occupational Stressors

Many occupational stressors can contribute to burnout in nursing. The physical demands of the job, such as long hours of standing, walking, and lifting and moving patients can take a toll and lead to physical exhaustion. The emotional labor that comes with caring for patients who are in pain, distress, or experiencing life-threatening situations can be mentally overwhelming. Exposure to death and dying frequently (Stewart & Arora, 2019) and the repeated witnessing of human suffering and grief (Gribben & Semple, 2021) further contribute to burnout. Nurses often develop strong connections with patients and their families but providing that comfort and support can be emotionally draining, especially when faced with difficult situations or patient outcomes. The chronic stress state that being a nurse creates may be a key contributor to burnout through an increase in the hypothalamic-pituitary-adrenal axis (Stewart & Arora, 2019).

The significant level of responsibility in patient care can add to the pressure and stress faced daily in nursing. The population is aging and as technology and medicine advance, nurses are constantly learning and adapting. They often work under-resourced, juggling multiple tasks simultaneously. Feelings of powerlessness can worsen burnout (Croke, 2020). Multiple studies show a relationship between burnout and increased workload. The experience of time pressures, particularly when the stakes are high, can contribute to burnout (Gribben & Semple, 2021). Issues such as inadequate staffing, increased patient acuity and availability of resources can magnify workload and increase time pressure (Stewart & Arora, 2019). Additionally, the literature cited high nurse-to-patient ratios, inadequate or absent break time during work hours, and insufficient time off to be associated with burnout (Gribben & Semple, 2021).

Leadership behaviors can directly contribute to staff burnout. Several studies have shown that nurses cite the leadership of their immediate supervisors to significantly impact job satisfaction and well-being. Nurses who perceived that their managers were supportive had less exhaustion, a key component of burnout (Dyrbye et al., 2020).

Difficult working conditions can harm work-life balance. Work-life balance can be defined as having the resources needed to achieve an equilibrium in work and private life so that demands can be responded to effectively in both settings in a way that is satisfying to the individual (Gribben & Semple, 2021). Nurses who come home emotionally and physically exhausted have little left for themselves and their loved ones.

Experiencing bias in the workplace can be detrimental to well-being and contribute to burnout. Some common biases that are seen in the workplace include gender, race, and age bias. Implicit bias refers to automatic, subconscious beliefs and attitudes that an individual holds about others that can influence their thoughts and behaviors. Unlike explicit bias, where the individual knowingly holds discriminatory beliefs, implicit bias occurs automatically and sometimes the person is unaware the thoughts are occurring. Nurses on the receiving end of interactions with others that are rooted in bias can have decreased engagement, job satisfaction, and productivity, which is known to contribute to burnout. Bias may occur between colleagues or between nurses and patients or their family members (Sabin, 2022).

Disruption in sleep patterns is thought to contribute to burnout, although more research is needed in this area to better understand the relationship. It is hypothesized that sleep disturbance contributes to burnout through the chronic depletion of energy. Clinicians often report hyperarousal and difficulty settling down for sleep due to work concerns. Providing nursing care is often a 24-hour job, thus many nurses are required to work various hours and long shifts, leading to inadequate sleep. They may try to make up for the lack of sleep by caffeine consumption which can further disrupt the circadian rhythm. The health effects of sleep deprivation are well documented, including changes in mood, irritability, difficulty concentrating, and fatigue and it can exacerbate health conditions (Stewart & Arora, 2019).


Individual Stressors

While burnout is defined as occupational, personal factors still play a role in resilience at work. Personal life stressors can significantly contribute to burnout at work. Struggles or conflicts within personal relationships, such as marital problems, family tensions, or difficulties with friends, can cause emotional strain and preoccupy the mind, making it challenging to focus and perform effectively at work (Aboagye, et al., 2019).

Financial stress, including debt, inability to meet financial obligations or concerns about job security, can create significant pressure. Financial instability and low income are significant stressors for individuals and families. The struggle to meet basic needs, such as housing, food, healthcare, and education, can create chronic stress and anxiety. Limited access to resources and opportunities can also contribute to feelings of insecurity and worry about the future. The constant worry about money can be distracting and make it difficult to concentrate and be productive in the workplace (Aboagye, et al., 2019).

Limited access to quality education and opportunities for personal and professional growth can create stress. Inadequate educational resources, unequal access to educational institutions, and limited job prospects can contribute to feelings of frustration, powerlessness, and a sense of being trapped in unfavorable circumstances. Living in poor-quality or unsafe housing environments, experiencing housing instability, or residing in high-crime neighborhoods can increase stress levels. Concerns about personal safety, lack of privacy, and limited access to essential amenities can contribute to chronic stress and anxiety (Aboagye, et al., 2019).

Personal health problems, either physical or mental, can be overwhelming and impact work performance. Chronic illnesses, pain, fatigue, or mental health conditions like anxiety or depression can drain energy and make it challenging to manage work responsibilities effectively. Limited access to affordable and quality healthcare services, including preventive care and mental health services, can contribute to stress. Concerns about healthcare costs, lack of health insurance, and difficulties in accessing timely and appropriate care can lead to heightened stress levels, especially when individuals or their loved ones face health issues (Aboagye, et al., 2019).

Experiencing discrimination, prejudice, and social inequality based on factors such as race, ethnicity, gender, sexual orientation, or disability can significantly contribute to chronic stress. Persistent exposure to discrimination and the resulting social, economic, and educational disparities can negatively impact mental health and well-being (Aboagye, et al., 2019).

Lack of social support systems and limited access to community resources can increase stress levels. Strong social networks, supportive relationships, and access to community services and resources can act as buffers against stress and provide individuals with the necessary support during challenging times. Balancing work with caregiving responsibilities for children, aging parents, or family members with disabilities can be demanding. Juggling multiple roles and responsibilities can lead to feelings of overwhelm and exhaustion, increasing the risk of burnout. Insufficient support systems in personal life, such as a lack of social support, emotional support, or a limited network of friends and family, can make it more challenging to cope with work-related stressors. Feeling isolated or unsupported can intensify burnout symptoms (Aboagye, et al., 2019).

Experiencing a significant personal loss, such as the death of a loved one, divorce, or a traumatic event, can have a profound impact on emotional well-being. Grief, sadness, and unresolved trauma can make it difficult to manage work-related stressors and maintain optimal job performance. Engaging in self-care practices, seeking support from friends, family, or professionals, setting boundaries, and practicing stress management techniques can help individuals cope with personal stressors and reduce the risk of burnout (Aboagye, et al., 2019).


Addressing Moral Injury and Burnout to Improve Resilience

The literature emphasizes the importance of a combined approach to addressing burnout that includes individual, institutional, and structural changes. There are many strategies that an individual can implement to help improve resilience. At the same time, organizations can make changes that make the workplace a healthier environment for nurses to practice in (Zhang et al., 2020).


Emotional Regulation

Emotional regulation is a significant factor in an individual’s response to occupational stressors. Nurses can enhance emotional self-care by identifying and expressing their emotions, seeking support from trusted colleagues or mentors, and engaging in activities that bring joy and relaxation. Regularly setting aside time for hobbies, journaling, or participating in creative outlets can help nurses process their emotions and alleviate stress (Riedel et al., 2021).

Mindfulness is a strategy that can be used to acknowledge feelings and thoughts while staying present. (Croke, 2020). Mindfulness is a type of meditation where a person focuses on their current feelings and sensations in their bodies without adding thoughts to them. Separating thoughts from feelings can help one remain calm in the moment. Deep breathing or guided imagery can be incorporated into mindfulness for an increased feeling of calm and clarity. These practices reduce stress hormones in the body and keep the brain from jumping into a fight or flight response to stress (Riedel et al., 2021).

Engaging in self-reflection allows nurses to identify areas of improvement, set boundaries, and make conscious decisions that align with their values and well-being. Self-reflection can be a powerful tool for managing stress at work. By taking the time to introspect and gain self-awareness, individuals can better understand their stress triggers, recognize patterns of behavior or thought that contribute to stress, and develop strategies for coping and self-care. There are several ways that self-reflection can be used to manage stress at work (Riedel et al., 2021).

Self-reflection is looking back on situations, tasks, or interactions that consistently cause stress and paying attention to the specific circumstances, behaviors, or thoughts that precede and accompany the stress response. Understanding one’s unique stress triggers can help to anticipate and prepare for them, or even find ways to mitigate their impact. Individuals can also reflect on how they currently cope with stress at work by asking themselves if their coping mechanisms are healthy and effective. Nurses should assess whether they engage in self-care practices, such as exercise, relaxation techniques, or hobbies, that help to recharge and manage stress. Reflection allows one to identify any unhealthy coping mechanisms, such as excessive caffeine or alcohol consumption, and consider healthier alternatives (Riedel et al., 2021).

Reflecting on thoughts and beliefs about work-related stress can help with perspective. Individuals should pay attention to self-critical or perfectionistic tendencies and consider adopting more realistic and compassionate perspectives. They should challenge negative thoughts and reframe them in a more positive and empowering light. They can think about whether work goals align with personal values and aspirations, clarify what truly matters, and make conscious choices about where to direct time and energy. Setting realistic goals and establishing clear priorities can help reduce stress and enhance a sense of accomplishment. They can consider reaching out to trusted colleagues, supervisors, or mentors to discuss work-related stress and seek their perspectives. Their insights and support can provide valuable guidance to help gain new perspectives on managing stress (Riedel et al., 2021).

Self-reflection is an ongoing process and may require regular check-ins to assess and adjust your strategies. Consider journaling, meditation, or therapy as tools to deepen your self-reflection practice. Ultimately, self-reflection empowers individuals to take ownership of their well-being, make conscious choices, and implement effective stress management strategies (Riedel et al., 2021).

While some emotional regulation strategies can be self-taught, others require care from a mental health professional. Treatments such as cognitive behavioral therapy (CBT), particularly cognitive processing therapy, eye movement desensitization reprocessing (EMDR) therapy, and emotional freedom techniques are some examples of interventions that mental health professionals can use to help patients process emotions (Hossain & Clatty, 2021; Riedel et al., 2021).

Organizations can facilitate emotional well-being by providing resources and making time for self-care during the work day. Interventions such as yoga, self-care workshops, stress management skills, communication skills, massage, and meditation have been used by some organizations to improve wellness. Structural interventions include workload or schedule rotations, stress management training programs, team building, and debriefing (Zhang et al., 2020).


Physical Activity

Nurses can prioritize activities that support physical health and vitality to improve resilience. Physical activity is a powerful tool for managing and reducing stress. Engaging in regular physical activity offers numerous benefits for both physical and mental well-being. Physical activity stimulates the production of endorphins, which are natural mood-boosting chemicals in the brain. These endorphins help to alleviate stress, reduce anxiety, and enhance feelings of well-being. Engaging in physical activity provides a healthy outlet for pent-up energy and helps to release tension and stress from the body (Croke, 2020).

Regular physical activity can promote better sleep quality. Quality sleep is crucial for managing stress as it allows the body and mind to rest and rejuvenate. By engaging in physical activity, you can enhance your sleep patterns, reduce insomnia, and wake up feeling more refreshed and energized. It also has a positive impact on mood. It can help combat feelings of depression, anxiety, and negative emotions associated with stress. The release of endorphins during exercise can create a sense of happiness and euphoria. Regular physical activity can improve overall mood and emotional well-being (Croke, 2020; Schultchen, 2019).

Participating in group physical activities, such as team sports or exercise classes, can provide opportunities for social interaction and support. Social connections and support networks are important for managing stress. Engaging in physical activity with others can foster a sense of community, belonging, and emotional support. Physical activity can help foster a stronger mind-body connection. Activities like yoga, tai chi, or mindful walking combine movement with mindfulness and can enhance self-awareness, relaxation, and stress reduction. These practices promote a sense of balance and harmony between the body and mind. Organizations can promote physical activity by providing free or discounted access to exercise equipment or workout classes (Croke, 2020).


Adequate Nutrition

Adequate nutrition plays a crucial role in managing and reducing stress. The food we eat provides the necessary nutrients for our body and brain to function optimally, including during times of stress. Consuming a balanced diet that includes complex carbohydrates, proteins, and healthy fats helps maintain stable blood sugar levels. Fluctuations in blood sugar can contribute to mood swings, irritability, and increased stress levels. By eating regular, balanced meals and snacks, blood sugar levels are stabilized, promoting a stable mood (Schultchen, 2019).

Certain nutrients are essential for the production and regulation of neurotransmitters, the chemical messengers in the brain that affect mood and emotions. For example, foods rich in omega-3 fatty acids, such as fatty fish, walnuts, and flaxseeds, support the production of neurotransmitters like serotonin, which is associated with feelings of well-being. Consuming a nutrient-rich diet helps support optimal neurotransmitter function and can positively influence mood and stress management (Schultchen, 2019).

Chronic stress can lead to dysregulation of stress hormones, such as cortisol. Nutrients like vitamin C, B vitamins, magnesium, and omega-3 fatty acids are involved in the regulation of stress hormones and can help modulate the body's stress response. Including foods rich in these nutrients, such as citrus fruits, leafy greens, nuts, seeds, and oily fish, can support the body's ability to cope with stress (Schultchen, 2019).

Stress can increase oxidative stress in the body, leading to the production of free radicals that can damage cells and contribute to inflammation. Antioxidants, found in abundance in fruits, vegetables, and whole grains, help counteract the harmful effects of oxidative stress and support overall health and well-being. Including a variety of colorful fruits and vegetables in your diet provides a wide range of antioxidants that can help protect against the negative impact of stress (Schultchen, 2019).

The gut and brain are interconnected through the gut-brain axis, and a healthy gut contributes to improved mental well-being. Adequate nutrition supports a healthy gut microbiome, the collection of beneficial bacteria in the digestive system. A balanced diet that includes fiber-rich foods, fermented foods, and prebiotic and probiotic-rich options promotes gut health, which in turn positively influences mood, stress response, and overall mental health (Schultchen, 2019).

Providing the body with the necessary nutrients and energy through a balanced diet ensures optimal physical and cognitive functioning. When we nourish our bodies properly, we have more energy, mental clarity, and focus to manage daily stressors effectively. It is important to prioritize a well-rounded diet that includes a variety of nutrient-dense foods, such as fruits, vegetables, whole grains, lean proteins, and healthy fats. Avoiding or minimizing excessive consumption of processed foods, sugary snacks, caffeine, and alcohol can also contribute to better stress management. Additionally, staying hydrated by drinking enough water throughout the day is essential for maintaining overall health and supporting the body's stress response. While nutrition alone cannot eliminate all sources of stress, adopting a healthy eating pattern can provide the foundation for better physical and mental well-being, making it easier to cope with stressors and maintain overall resilience (Schultchen, 2019).


Social Support

Social self-care emphasizes nurturing meaningful relationships and establishing a support network. Nurses can prioritize spending time with loved ones, maintaining friendships, and participating in social activities outside of work. Engaging in open and honest communication, both personally and professionally, can help nurses foster connections, share experiences, and receive support from others who understand the unique challenges of their profession (Wei, et al., 2019).


Sleep

Nurses can utilize good sleep practices to help reduce the chances of sleep deprivation. Adults should aim to get between seven to nine hours of sleep per night for adequate rest. They should not use technology including phones, tablets, computers, and television in bed. The room should be dark, quiet, relaxing, comfortable, and cool. It helps to only go to or stay in bed when feeling tired. Regular exercise, avoiding naps, and waking at the same time each day can also help improve sleep. Nurses should especially be aware of the dangers of drowsy driving and should seek treatment if there is a concern for a sleep disorder (Stewart & Arora, 2019).

At the systemic and institutional level, some interventions can improve the sleep of clinicians. Poor sleep habits can develop during education, so including healthy sleep initiatives in pre-licensure education can help students develop good habits early that can continue into their careers. Health professionals should understand that sleep is a part of overall health in both their patients and themselves (Stewart & Arora, 2019).

Organizations can impact sleep health by adjusting schedules, providing adequate coverage, keeping staff on consistent schedules, and avoiding contacting nurses outside of work, especially during their normal sleeping hours. Some organizations are implementing strategic rest breaks while on duty. The quality of rest of the staff members can be measured by tracking fatigue and burnout (Stewart & Arora, 2019).


Supportive Modalities

There are other modalities cited in the healthcare literature that require further research related to burnout but are worth noting as adjunctive interventions to support resilience. Pet therapy, art therapy, essential oils, music therapy, and the use of mobile applications can support self-care efforts. Pet, art, and music therapies have been shown in some studies to decrease stress levels but their study in healthcare workers specifically is limited. Mobile applications aimed at reducing stress and improving well-being are becoming increasingly popular and have been shown in some studies to be effective in self-care practices. While pet therapy is being seen more frequently in healthcare facilities for both staff and patients, the other discussed modalities are seldom used at the institutional level. They would need to be sought out by nurses on an individual basis (Stallter & Gustin, 2021).


Leadership Support

No amount of self-care can completely undo the effects of a hostile or unsafe working environment and it is important to note that the onus of preventing burnout and improving resilience is not only up to individual nurses. The organizational and departmental culture should be a collaborative and supportive environment that focuses on improving processes instead of blaming individuals. Ensuring appropriate scheduling and time off is essential to nurse wellness (Croke, 2020). Leadership can help facilitate social connections amongst staff, not only in individual units but facility-wide, to bolster morale and engagement (Wei et al., 2019).

Leadership behaviors that reduce stress in their team include setting clear expectations, offering guidance and support, and encouraging professional development. (Dyrbye et al., 2020). Nurse leaders should be excellent communicators and supportive role models to reduce the risk of burnout in their teams. Because powerlessness contributes to feelings of burnout, leaders need to involve team members in the decision-making process. Leaders should sincerely recognize team members for their accomplishments and demonstrate confidence in their skills and expertise (Croke, 2020). Education and career advancement can empower nurses. A comprehensive orientation for new nurses can help reduce burnout and intent to leave. Specialized training in dealing with emotional situations, managing stress, and self-care can also decrease burnout (Gribben & Semple, 2021).

Wellness benefits can help reduce burnout. Employee assistance programs that offer psychological counseling to employees at no charge (Croke, 2020). Employees might be offered discounted prices on gym memberships or for massages. Resilience-building activities can be implemented by leadership to support nurse self-care. The literature describes a wide variety of self-care activities, from expensive full-day workshops to small toolkits handed out to individual nurses that included lavender essential oil, deep breathing exercises, coloring pages, and instructions to download mindfulness apps (Andersen et al., 2021).

Nurses should be encouraged to seek support from their healthcare organization, supervisors, or employee assistance programs. These resources can provide counseling services, stress management techniques, and guidance on work-life balance. Creating a supportive work environment where nurses feel comfortable discussing their challenges and seeking assistance is crucial for promoting self-care. Nurses can then take steps to enhance job satisfaction and career growth by engaging in continuing education, attending conferences or workshops, and seeking opportunities for professional development. Setting realistic goals, maintaining a healthy work-life balance, and advocating for their needs can contribute to a sense of fulfillment and reduce feelings of overwhelm (Andersen et al., 2021).


Safety

Nurses often work in a hostile work environment, from peer-to-peer incivility to experiencing violence from patients or family members. Nurses' safety can be compromised in various ways within the healthcare setting. Acts of physical or verbal violence can lead to injuries and psychological trauma. Nurses may experience verbal abuse or harassment from patients, family members, or colleagues. This can include derogatory or offensive language, threats, or bullying behavior. Verbal abuse and harassment contribute to a hostile work environment, impact nurses' mental health, and can compromise patient care (Ausar, Lekhak, & Candela, 2021).

Addressing these safety concerns requires a comprehensive approach that includes implementing policies and procedures to prevent workplace violence, providing adequate staffing levels, offering training and resources, promoting a culture of respect and zero tolerance for harassment, and prioritizing nurses' mental health and well-being. Healthcare organizations must prioritize the safety of nurses and create a supportive work environment that enables them to deliver quality care while minimizing risks to their physical and mental well-being (Ausar, Lekhak, & Candela, 2021).


Spirituality

There is no universally agreed upon definition for spirituality, but in general, it can be defined as a journey to fulfillment and meaning in life which can be related to others and/or a higher power. Spiritual self-care will look different for each individual. For some it might be connecting with nature, for others I might be attending a religious service. Practices such as prayer, journaling, meditating, and spending time outdoors are all helpful in some individuals to improve resilience. Organizations can help facilitate spiritual self-care by connecting staff with the spiritual resources that patients have access to, such as a hospital chaplain, or attending a religious service during break time (Ausar, Lekhak, & Candela, 2021).


Conclusion

Nurses play a vital role in healthcare delivery, providing compassionate care and support to patients. However, the demanding nature of their profession often leads to physical, emotional, and psychological strain. To ensure their well-being and maintain high-quality care, nurses must engage in practices that improve resilience to prevent burnout.


Test Questions with Key

1. Which of the following terms is a state of physical and emotional exhaustion, reduced efficiency, and negative thinking in response to stressors at work?

a. Burnout
b. Moral injury.
c. Resilience.
d. Work-Life Balance.


Answer: A


Rationale:
Burnout
A state of physical and emotional exhaustion reduced efficiency, and negative thinking in response to stressors at work (Stewart & Arora, 2019; Gribben & Semple, 2021).
Moral InjuryMoral injury occurs when an individual either witnesses or performs an act that is contrary to what they believe is right and experiences feelings of guilt, shame, and disgust (Fitzpatrick, et al., 2022).
ResilienceThe ability to overcome adversity (Croke, 2020).
Work-Life Balance

Having the resources needed to achieve an equilibrium in work and private life so that demands can be responded to effectively in both settings in a way that is satisfying to the individual (Gribben & Semple, 2021).

Learning Objective: Differentiate between resilience, burnout, and moral injury.


Bloom’s Taxonomy: Knowledge


Reference: Page 3


2. Which of the following contributes to burnout in the nursing workforce? (Select all that apply).

a. Availability of resources.
b. Emotional exhaustion.
c. Inadequate staffing.
d. Implicit bias.
e. Time pressures.


Answer: A, B, C, D, E


Rationale: All answer choices are stressors for nurses in the workplace that contribute to burnout.


Learning Objective: Describe systems-level, organizational, and individual issues that contribute to burnout.


Bloom’s Taxonomy: Comprehension


Reference: Pages 4-5


3. Which of the following emotional regulation strategies is a type of meditation where a person focuses on their current feelings and sensations in their bodies without adding thoughts to them?

a. Journaling.
b. Mindfulness.
c. Self-reflection.
d. Therapy.


Answer: B.


Rationale: Mindfulness is a type of meditation where a person focuses on their current feelings and sensations in their bodies without adding thoughts to them. Separating thoughts from feelings can help one remain calm in the moment. Self-reflection is looking back on situations, tasks, or interactions that consistently cause stress and paying attention to the specific circumstances, behaviors, or thoughts that precede and accompany the stress response. Journaling is writing down thoughts, feelings, and reflection. Therapy is a broad term for treatment by a mental health professional.


Learning Objective: Discuss strategies that systems, organizations, and individuals can use to improve resilience.


Bloom’s Taxonomy: Knowledge


Reference: Pages 8-9


4. Which of the following are appropriate strategies for leadership to implement to improve nurse resilience? (Select all that apply).

a. Collaborative and supportive environment.
b. Ensuring appropriate scheduling and time off.
c. Keeping expectations vague to offer autonomy.
d. Involving staff in the decision-making process.


Answer: A, B, D, E


Rationale: No amount of self-care can completely undo the effects of a hostile or unsafe working environment and it is important to note that the onus of preventing burnout and improving resilience is not only up to individual nurses. The organizational and departmental culture should be a collaborative and supportive environment that focuses on improving processes instead of blaming individuals. Ensuring appropriate scheduling and time off is essential to nurse wellness. Leadership behaviors that reduce stress in their team also include setting clear expectations, offering guidance and support, and encouraging professional development. Nurses should be encouraged to seek support from their employers. These resources can provide counseling services, stress management techniques, and guidance on work-life balance. Creating a supportive work environment where nurses feel comfortable discussing their challenges and seeking assistance is crucial for promoting self-care.


Learning Objective: Discuss strategies that systems, organizations, and individuals can use to improve resilience.


Bloom’s Taxonomy: Comprehension


Reference: Pages 12-14


5. Which of the following organizational interventions can help improve nurse safety in the workplace? (Select all that apply).

a. Offering nursing staff training and resources.
b. Prioritizing patient satisfaction.
c. Promoting a culture of respect.
d. Providing adequate staffing levels.


Answer: A, C, D, E


Rationale: All of the interventions can help improve nurse safety except prioritizing patient satisfaction. While patient satisfaction is important, it does not improve nurse safety.


Learning Objective: Discuss strategies that systems, organizations, and individuals can use to improve resilience.


Bloom’s Taxonomy: Comprehension


Reference: Pages 14-17


6. Which of the following are caused by experiencing bias in the workplace and contribute to nurse burnout?

a. Better job satisfaction.
b. Decreased productivity.
c. Improved workload.
d. Increased engagement.


Answer: B


Rationale: Nurses on the receiving end of interactions with others that are rooted in bias can have decreased engagement, job satisfaction, and productivity, which is known to contribute to burnout.


Learning Objective: Describe how experiencing bias can contribute to burnout.


Bloom’s Taxonomy: Comprehension


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M. Antico DRAFT 10042023

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