Peggy Burke, Pamela A. Geller, Ph.D., Leah Sodowick, Chavis A. Patterson, Ph.D.

Providing care for preterm and ill babies while simultaneously offering support and guidance to the parents of these babies can be demanding and emotionally taxing. Overall nursing shortages, uncertainty, safety concerns, and shifting policy changes due to the COVID-19 pandemic have played a significant role in increasing stress levels for NICU front-line providers. This constant exposure to high levels of daily stress in the workplace can lead to burnout, and rates of burnout in providers have accelerated in the face of COVID-19. (1) Pre-pandemic, Profit, and colleagues (2014) (2) reported that an average of 26% of NICU providers experience burnout compared with up to about 20% of healthcare workers in general. (3)

Since the onset of the pandemic, Haidari and colleagues (2021) (4) have reported that, on average, 66% of NICU providers experience burnout compared with approximately 51% of healthcare workers in general. (5) This article will review how to recognize symptoms of burnout and provide practical individual and organizational level recommendations to help address burnout in NICU providers.

What is Burnout?

Burnout describes an occupational phenomenon when workplace stress becomes chronic and is not managed effectively. (6) Burnout is typically cumulative and develops gradually over time. The three dimensions of burnout include exhaustion, cynicism, and reduced professional efficacy. (7) Exhaustion, or emotional exhaustion, describes what is experienced when a worker’s resources to adaptively manage stress and challenges become depleted, leading to feeling drained and unable to support patients fully. (7) The second dimension, cynicism, involves mentally distancing oneself from work and negative attitudes towards work, patients, and families. General life dissatisfaction also can be evident. The third dimension, reduced professional efficacy, refers to feelings of incompetence and a lack of achievement and productivity. (7)

Serious work-related and personal consequences can result from burnout. De Hert (2020) (2) reported that burnout can lead to lowered effectiveness at work and impaired quality of care, factors that can contribute to increased risk to patient safety. High rates of burnout can be associated with increased “healthcare-associated infection,” decreased reporting of errors, increased patient mortality, and decreased patient-reported satisfaction. (8) NICU providers experiencing burnout also can have difficulties in their personal lives outside of the hospital. These effects may include elevated psychological symptomatology (e.g., depression, posttraumatic stress, anxiety), alcohol and drug abuse, and even gambling. (9) Providers also can experience increased physical health problems, such as sleeplessness, headaches, muscle tension, immune dysfunction, gastrointestinal and cardiovascular disturbances. (10) Difficulties in interpersonal functioning, such as withdrawing and distancing from loved ones and taking out frustrations on loved ones, also may result. (11)

Recognizing Signs of Burnout

Several symptoms can signal burnout. Because burnout is a gradual process, the signs and symptoms may be subtle at first but become worse over time. Physical symptoms often include fatigue and lack of energy, sleep disturbances, and deteriorating health sequelae or modifications such as frequent illness and appetite disturbance. (11,12) The emotional signs can include self-doubt, feelings of helplessness or hopelessness, and loss of motivation. (11) Often, there are feelings of dread about returning to work each day. Other signs involve feeling emotionally exhausted, incompetent in the workplace, and a decreased sense of satisfaction and accomplishment. (13) Finally, behavioral symptoms can include becoming distant and isolated, not only from family and friends but also withdrawing from patients and co-workers. (11) Workplace symptoms may involve taking out frustration on others, skipping work, consistently arriving late for work, or leaving early. (13)

Recognizing signs of burnout can help NICU providers prevent burnout symptoms from escalating. The earlier one can recognize signs of burnout in themselves, the sooner one can take action, practice self-care, and use practical tools to improve work motivation and quality of life.

Risk Factors for Burnout 

In the NICU, some factors can elevate rates of burnout more for NICU providers than for medical professionals in other settings. These factors include high workload, long hours, the need to deliver high-quality, compassionate care in a high-stakes, technical environment while simultaneously providing informational and emotional support to distressed family members of critically ill infants. (8) With a high NICU census, NICU nurses can have patients and families that they must check on frequently. This means that the provider needs to know all the facts, statistics, and tests occurring on each patient and in the NICU overall, and these change frequently. NICU providers must make decisions regarding life-sustaining measures and end-of-life care measures for their patients, which aids in the stress of the job each day. (14) Moreover, NICU providers work with babies receiving palliative care and experience the death of some patients, which further adds to job stress and increases the risk of burnout. 

Because the NICU serves medically ill and fragile babies, NICU providers are frequently confronted with life-or-death scenarios. (15) As such, a notable risk factor that has been associated with burnout in the NICU is moral distress. Moral distress is defined as the inability to act according to one’s core values and perceived obligations due to internal and external constraints. (16) For example, with increased advancements in medical technology, the age of viability has decreased, although the survival of infants born at earlier gestational ages may result in significant disabilities and poorer quality of life. NICU providers may decide to provide continued aggressive treatment to support families, even though this may conflict with the provider’s sense that reducing aggressive treatment and focusing on comfort care is the more appropriate decision. 

Other risks for burnout include administrative and bureaucratic challenges, such as the constant policy and procedure changes in the NICU and hospital-wide, especially in response to the COVID-19 pandemic. (17) Other challenges may include limited job resources and a sense of personal control, such as meaningful participation in decision-making and creating development opportunities. (18) Perceptions of unfairness and inequity in the workplace, insufficient rewards and recognition, and a mismatch between personal and organizational values are also risk factors for burnout. (19) 

Recommendations for Coping with Burnout 

Overall, burnout can be addressed in several ways and on multiple levels. There are internal and external factors in the development of burnout that need to be understood, as well as individual and organizational dynamics that can assist in lowering rates of burnout. (20) When it comes to internal factors, we must consider NICU providers’ individual resources and restore physical and emotional well-being. Primarily, NICU providers must prioritize their physical and mental health, even caring for sick babies and their family members. This is especially true at present when COVID-19 is surging across the world and is adding tremendous stress to the hospital system. Prioritizing one’s health involves maintaining a balanced diet, exercising consistently, and getting proper sleep each day. (2, 21) Even though it may conflict with other demands on their time, rest and downtime are essential restorative activities during non-work hours. Identifying and practicing self-care activities may also include partaking in enjoyable activities, cultivating specific personal interests, or obtaining professional counseling to resolve symptoms and help prioritize life values. (2) Stress-reducing activities can include breathing, meditation practices, yoga, and mindfulness exercises. (22) There are numerous free online resources to promote these activities. 

When a NICU provider is working long and strenuous hours in a high-demand setting, they must take time for themselves and prioritize social connections with others. While nurturing relationships with their partners, families, and friends outside of the NICU environment is critical, (21) meaningful interpersonal connections within the work setting are also essential. Talking to supervisors or co-workers experiencing similar situations can help decrease anxiety about NICU work. (23) Further, establishing personal relationships with work colleagues can help to limit burnout, as it allows opportunities to debrief informally and discuss the hardships and emotional aspects of their work. (2) Building relationships with colleagues can aid in more effective communication, limit setting, and increasing self-awareness in the workplace. (21) Because the NICU has such a specific way of working and treating patients, talking with colleagues allows the opportunity to vent to someone who understands, provides, receives social support, and exchanges ideas for managing various situations. (23) 

Professional growth and development activities can also decrease burnout. (21) Seeking continuing education, getting involved in professional organizations, and volunteering for altruistic and leadership activities can add meaning to the work that a NICU provider is doing each day and remind the person why they selected such a strenuous and challenging job in the first place. (21) 

Organizational Recommendations 

Because burnout symptoms are surging in these times of the COVID-19 pandemic, hospital and NICU leadership must acknowledge the added challenges their providers are experiencing and make tangible efforts to protect staff and reduce the incidence of burnout. The hospital can help by offering interventions that aim to empower NICU providers with knowledge about burnout and assist them in developing new skills to manage burnout. Additional hospital-level interventions that have been effective are aimed at improving communication, interpersonal relationships, and teamwork to offer more provider support. Aryankhesal (2019), (20) demonstrated that such interventions showed a 67% positive impact on nurse burnout and 50% positive impact on physician burnout. These findings evidence that rates of burnout can be reduced when providers are confident in their work, learn how to support one another, and learn how to manage stress. 

Cricco-Lizza (2014) (23) found that hospitals that offer psychosocial services in the NICU proved helpful to the NICU providers. Having a social worker or psychologist on-site for the NICU helped the families and created the opportunity to offer support to providers. NICU providers should have the opportunity to debrief cases and seek advice from a professional at any time during their shift. (23) Fawke and colleagues (2020) (24) found that debriefing was associated with improvements in the care process and a decrease in challenges in communication which can then decrease burnout. Mills and Cortezzo (2020) (14) also found that NICU workshops, debriefings, ethics training, and other debriefing practices, such as reflective writing, have also helped with burnout. These practices help providers examine the emotional impact of their stressful work situations and use these experiences as a way of coping and processing. (14) 

Providing staff education and social support to NICU providers is essential in aiding staff competence. First, educating providers about the emotional burden and psychosocial needs of NICU families is empowering. (25) Next, staff education should include properly taking care of oneself both inside and outside of the hospital, including self-care practices (e.g., taking adequate breaks) to minimize burnout. (10) To be most effective for each NICU, training should be delivered to the staff of all disciplines who have any interaction with NICU families. Ideally, staff education should occur at new staff orientations and periodically throughout each year. 

As noted in the 2022 Trends Report of the American Psychological Association Monitor on Psychology,(1) because “pandemic-related stressors likely won’t stop anytime soon, stress-reducing measures should be top of mind for employers and legislators alike.” In the article, Maslach is quoted as saying, “As demands increase, organizations need to focus on maintaining balance, taking things off the plate when they add something new. That is especially important in health care settings, where attrition rates are especially high”. (1) 

Conclusion 

The NICU is filled with constant stressors, physical and emotional strain, and difficult decisions to be made by NICU providers. The COVID-19 pandemic has only exacerbated the many factors that elevate the risk for burnout in NICU providers. Because burnout can lead to lowered effectiveness at work, impaired quality of care, and issues with patient safety and satisfaction, (2) it is imperative to address burnout among NICU staff to maintain adaptive functioning. Providers need to prioritize their self-care, and NICU and hospital leadership need to convey support and dedicate resources to allow NICU providers to recharge and maintain a sense of meaning and control in the work environment. Implementing strategies to reduce burnout may enhance NICU providers’ well-being and job satisfaction and thereby help NICU providers continue to serve their patients and families with high-quality care. 

References:

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Disclosure: The National Perinatal Association www.nationalperinatal.org is a 501c3 organization that provides education and advocacy around issues affecting the health of mothers, babies, and families.