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Dr. Turck:
Emergency departments are demanding, causing ER nurses to experience high levels of work-related stress, and they're at a higher risk of burnout now more than ever before. Welcome to Clinician's Roundtable on ReachMD. I'm your host, Dr. Charles Turk, and joining me to talk about her research on stress in the emergency department, or ED, is Dr. Allison Norful. She's an adult nurse practitioner and Assistant Professor of Nursing at Columbia School of Nursing. Dr. Norful, thanks for joining me today.

Dr. Norful:
Great. Thanks for having me.

Dr. Turck:
Before jumping into your research, Dr. Norful, would you tell us about the unique stressors of nurses in the ED that can lead to burnout?

Dr. Norful:
I think the factors leading to burnout are multifaceted. There's really no concrete one or two things that we know if we fix this, then burnout will disappear. A couple of years ago, pre-pandemic, the National Academy of Medicine put forth this big action collaborative for clinician well-being. And for the first time, they published a really exhaustive conceptual model for clinician well-being that demonstrated how many factors can contribute to burnout. They were subdivided into organizational and then individual factors. So it's kind of this ongoing interplay between how a unique individual interacts with their environment.

You know, on the organizational side is, what kind of team compositions are there and what kind of culture the environment is. We had a colleague, Dr. Jin June, that published a paper several years ago that talked about the unique impact of unit-based culture. So nurses I think tend to gravitate toward a service line that they feel most comfortable with.

I think some of the unique stressors that have really come out of probably five or six of the past studies that we've done, both pre-COVID and since then, ethical challenges is a big one. You know, nurses know what they need to take care of patients. They know what resources they need. They know the time that it takes to perform tasks. And if they don't have those resources, they don't have enough staffing, and they don't have the physical supplies that they need to effectively deliver patient care to the highest quality that they know how, that can create an ethical dilemma. And then in turn, what we're starting to see are things like not only burnout, but moral distress and injury and compassion fatigue. And we're trying to now understand, does that eventually yield to more severe mental health conditions, things like depression, anxiety, and even suicide?

I think the second unique stressor is kind of this need and desire for autonomy. Nurses want to be able to deliver care in the way in which they were trained. Right? And of course, this has to abide by the missions and policies of their organization, but sometimes those policies don't align with preferences or workforce capacity.

Dr. Turck:
Now turning to your study about burnout, would you tell us how it was designed?

Dr. Norful:
Sure. So for this particular study, I really worked with a strong study team on this, and the conceptualization of the study idea came from my colleague, Dr Jessica Kastner, who has been really an advocate and leader in emergency nursing for many, many years. But we really came together with the commonality that we all wanted to understand not only causes and factors specific to emergency nurses, but also what were some of the reasons why these nurses were leaving their positions, and this whole study idea again was pre-COVID. So burnout rates were already going up to alarming rates. So one of the things that we did first is we identified what was available to us and what the current evidence was; we knew we had rising burnout rates. We were able to identify licensure information and workforce supply data, but we really did not have real-time turnover data. So we decided to leverage the national sample survey of registered nurses. This survey was first implemented back in the 1970s. And I think to date, it's the longest running kind of effort to survey nurses nationally.

But it's a fantastic, detailed survey that captures professional and work environment characteristics. And we're able to isolate nurses by where they work. What's even greater is that they ask very specific questions. Like, have you left your primary position in the last year? What are the reasons why you left that job? So this is a sub-sample of the greater nursing workforce population in the US. But it gives us a lot of really unique information that we can then isolate some of the factors that are causing turnover because otherwise, if we can't reach these nurses, if we can't reach out to them, and if we can't get the data from organizations about turnover rates, we know far little.

Dr. Turck:
And how did you decide which nurses to include as part of your study?

Dr. Norful:
Well, the first thing that we had to do was we had to look at the entire sample within the dataset. So this was a secondary data analysis of existing survey data that's publicly available. And the first thing that we did was we isolated those nurses that identified as working in the emergency department and then we grouped other nurses in other departments, inpatient units, and primary care, and we kind of divided them into two groups, so they were aggregated.

For our analysis, I think our weighted sample size was upward of 3 million. So we thought that would be a really nice representation of the national nursing workforce. So we used the entire sample, but because we aggregated them, we were able to really isolate and hypothesize our different research questions to really try to isolate some of the factors that were specific to emergency nursing, while at the same time, able to compare them to nurses working in other settings.

Dr. Turck:
For those just tuning in, you're listening to Clinician's Roundtable on ReachMD. I'm Dr. Charles Turck, and I'm speaking with Dr. Allison Norful about her research on emergency department nurse burnout. So with all that information in mind, Dr. Norful, what did your study show with regard to high turnover, burnout, and the rate at which nurses are leaving the profession?

Dr. Norful:
Couple of interesting things that we did not anticipate finding, and that's kind of the joy of working with a large dataset that's representative of a national nursing workforce. First, we found that there was no significant difference between those that identified as emergency nurses and all other nurses. So that tells us that burnout is kind of this universal experience in the nursing workforce.

But we took it a step further and we wanted to really understand, well, there's no difference in burnout, but then why are emergency nurses leaving their positions? And we found some significant factors that put emergency nurses at a higher risk compared to other nursing colleagues. There were actually seven factors, and the two organizational factors were things like insufficient staffing and the patient population that one takes care of. And then there was also some individual factors, such as the physical job demands.

You know, this is a big thing. Nurses are trying to protect their health for a long time. We've had nurses with low back pain and knee pain, and that's just kind of physical ailments. That doesn't even capture the mental health ailments of the job demand. Other individual factors included things like length of commute, relocation outside of the region or outside of the area, better pay elsewhere, and career advancement. So there's some really personal factors that are putting emergency nurses at a higher risk for burnout. And I think this really speaks to the importance of work-life balance. It was really interesting that we found this finding pre-pandemic, and I would argue that in some of our other research, we're finding more and more that nurses are prioritizing their health.

Dr. Turck:
That's absolutely a good thing. What are some strategies we could implement to combat burnout and attrition in the profession?

Dr. Norful:
I think first and foremost we can start by ensuring that nurses have an organizational-level voice. We have to ensure that more and more nurses are being invited to contribute to interprofessional committees and councils. There's a plethora of nursing councils across different settings, but a lot of times, you know, it's great if nurses are being able to vent, plan, or conduct quality assurance projects and quality improvement. But it's another thing if you have different professions in the same room and bringing different perspectives that also need to be aligned with organizational goals and fiscal budgets. So nurses need to be at the table more.

I think the second thing is that by giving nurses the voice, that actually promotes a higher sense of value for nursing-specific contributions to patient and organizational outcomes. And people might say, okay, well, that's really broad. Like, how do you promote a sense of value?

But, you know, that goes back to some of the common factors, how autonomous are nurses? How much say do they have in their everyday practice? You know, what is actually hindering their decision making? So involving nurses in high-level corporate decision-making I think is of the utmost importance.

The other thing I think we can do better is organizations, hospitals, primary care, and outpatient settings as well need to invest in more research infrastructure. Now one might say, “Oh, there's no way. I definitely don't have the fiscal capacity to do this.” But in reality, we're actually seeing more and more academic research and clinical partnerships where clinical organizations are partnering with universities and academic medical centers where it's a win-win because they can leverage the expertise of statisticians, nurse scientists, and economists. And then we're able to leverage the data, you know, we collect so much data in healthcare. And data speaks volumes. So I think in order to really influence policy and practice change, we have to leverage the data to illuminate the impact of organizational-specific resources and finances and the whole interaction between workforce, patient, and nursing outcomes.

Dr. Turck:
Before we close, Dr Norful, are there any additional thoughts or key findings you wanted to leave with our audience today?

Dr. Norful:
Yeah, I think overall it's really critical to understand that even in the same organization, even in the same health care system, the solution may work in one setting, but not the other; it may work for one person or not the other. So we have to really appreciate how individualized well-being is among clinicians and what everyone's needs are. Now we can't solve every problem for everyone, but we can really try to take this individualized approach, and I've been calling it precision wellness; you know, offer resources to your employees to be able to implement interventions that they know will work for them rather than doing group-level interventions. Let them pick and choose what support they need. And then, again, I think by doing so, you're able to really individualize burnout mitigation, and by giving them more of a voice and involving more nurses, we will get closer and closer to understanding those isolated factors that are putting emergency nurses at risk for not only burnout and not only turnover, but more substantial long-term physical and mental health risk as well.

Dr. Turck:
Well, this is such an important topic, and it's clear there's still considerable work to be done to address nursing burnout in the emergency department. And I want to thank my guest, Dr. Allison Norful, for sharing her research and insights with us today. Dr. Norful, it was a pleasure speaking with you.

Dr. Norful:
Thanks so much, Dr. Turck.

Dr. Turck:
For ReachMD, I'm Dr. Charles Turck. To access this and other episodes in our series, visit reachmd.com/cliniciansroundtable, where you can Be Part of the Knowledge. Thanks for listening.