Evidence-Based Nursing Research Project Paper

"Do differing stress factors cause an increased nurse burnout in critical care units rather
than medical-surgical units?"
Group #10
Gloria Juarez, Mary Kate Dustin, Molly Webb, Rachel Fletcher, Abby Floyd, and Emily Wallace

Synthesis
Summary of Studies
The majority of our studies with the exception of one, had a level of evidence of a six.
This type of intervention study involves both a qualitative and descriptive component. The
qualitative study gathers data on human behavior in order to understand why and how decisions
are made (Ebling Library, 2015). Whereas the descriptive study provides information on the
background, such as the what, where, and when (Ebling Library, 2015). One study analyzed the
burnout rates, occupational satisfaction, and workplace mental health of new graduate nurses in
their first year of employment (Laschinger et al, 2014). The study included 907 graduate nurses.
The conclusion was that as levels of burnout continued to increase so did job dissatisfaction
(Laschinger et al, 2014). Since the study focused on new graduate nurses during their first year
of employment, this could have had skew the results. As new nurses, there is already the stress of
adapting to a new routine and environment, being independent, and working alone with patients.
If we add the ICU component, then the stress increases because these nurses will care for the
more ill individuals and witness deaths more frequently. Therefore burnout rates will be higher
for new graduate nurses to begin with. This will be an inconsistency among our studies and we
should base our focus on a specific population of nurses within ICU and medical-surgical units.
Another study looked at the relationship between hospital nurses shift lengths and burnout rates,
job dissatisfaction, and intention to leave the job (Stimpfel et al, 2012). This study included
22,275 registered nurses, where we found that increased shift lengths contribute to nurse burnout
and job dissatisfaction (Stimpfel et al, 2012). There was also a higher possibility of nurses
wanting to leave their job. This study was also cross-sectional, making it difficult to conclude the
effects of nurse shift length on patient or nurse outcomes (Stimpfel et al, 2012). The sample of
this study also only represented 25% of the US population and was collected from four states

(Stimpfel et al, 2012). This could affect our results because every state has their own individual
nursing regulations and policies. The study was also conducted through a survey, therefore the
hospitals that were included were voluntary and not a representation of all hospitals. This could
lead to outliers or a bias from certain hospitals.
A 2015 study was conducted by Kashani et al. on 58 critical care personnel to assess the
levels of burnout, perceived stress, and quality of life, as well as the impact of a brief stress
management training on these outcomes; through the use of a 90 minute stress management
intervention and instruments such as the Satisfaction With Life Scale (SWLS) and the Perceived
Stress Scale (PSS-14). It was found that burnout rates were substantially higher among
graduating fellows versus new and transitioning fellows and that the burnout was not
significantly improved with interventions but stress was reduced through these interventions.
Limitations to this study include: a small sample size with a singular study setting, a lack of
comparison due to an absent control group, and an inability to measure certain factors such as
social support and an inability to determine if the participants were fully disclosing information
without reservation (Kashani et al., 2015). A 2013 cross-sectional study conducted by Ayala and
Carnero in Peru examined the association between sociodemographic and occupational factors
with elements of burnout in 93 critical care personnel. The Maslach Burnout Inventory (MBI)
was utilized to find that the association between elements of burnout and the socioeconomic and
occupational factors were dissimilar. It was concluded that screening and preventative
interventions should focus on nurses who are new/have less experience, are single, have children,
or those who work in the most acute critical care units. Limitations to this study include: an
inability to use a foreign reference score such as MBI with Peruvian nurses, a limited sample

size, and the setting and characteristics of the nursing population may create generalizability of
study findings (Ayala & Carnero, 2013).
Another case study found focused specifically on one ICU nurse throughout her career. It
explores unresolved issues of ICU nurses due to immense exposure to death and illness. It
explores how these unresolved issues build up leading to leaving the profession and burnout. The
overall theme of the article is that this ICU nurse experienced an extreme amount of unresolved
trauma. She had to have counseling and resolve these death experiences before she could
continue as an ICU nurse. She realizes the importance of having activities one enjoys outside of
ICU nursing. The article gives a detailed depiction of the life of an ICU nurse (Couden, 2002).
This article was used to compare to other testimonies of med-surg nurses. The quality of the
evidence is high, however it cannot be generalized to all ICU nurses because it was only one
subject. Every nurse is different in terms of his or her perceptions and coping abilities. This may
affect overall conclusions made in the article. Another limitation is the fact that, the article was
written in 2002 so information may not be completely applicable to nursing today. However,
overall, the article contains currently relevant information.
Documents such as evidenced-based guideline recommendations were also examined.
One guideline in particular focused on implementing compassion fatigue reduction therapy for
nurses in pediatric critical care units. The purpose of this study was to express guidelines for
PICU nurses and their administrators regarding the effectiveness of compassion fatigue training
in decreasing compassion fatigue levels in these nurses. The interventions involved training
being given to PICU nurses regarding compassion fatigue. This included self-care preventative
techniques as well as information regarding compassion fatigue itself to promote awareness. The
study resulted in the recommendation that nurses should receive compassion fatigue training.

This should include compassion fatigue awareness, coping strategies, stress management,
relaxation techniques and self-care interventions (Cincinnati Childrens Hospital, 2013). The
training has been shown to reduce the level of compassion fatigue in ICU nurses. We used this
article to understand the nature of ICU nurse compassion fatigue. Knowing what alleviates
burnout for ICU nurses helped us understand the factors that contribute to burnout. These factors
were compared to Medical-Surgical nurse burnout factors. The quality of evidence is very high.
It was developed by a quality organization, the Cincinnati Childrens Hospital Medical Center,
and was officially published as a best practice guideline. A rating scheme for the strength of the
evidence was used. Systematic review was used to analyze data. The study has been examined
and approved by Cincinnati Children's Hospital Medical Center (CCHMC) Evidence
Collaboration. Two independent reviewers from this organization examined the study by making
sure it passed certain quality requirements. Limitations include the fact that the study focused on
Pediatric ICU instead of generalized intensive care. Therefore, this study cannot be generalized
to all ICU nurses.
In attempts to identify determinants of burnout syndrome (BOS) in critical care nurses,
one study created a questionnaire that was sent to multiple hospitals with intensive care units
(Poncet, 2007). 2,392 ICU nursing staff members completed the questionnaire and returned it,
creating the sample for the study. It was determined from the information collected that one-third
of nurses who work in intensive care units have severe BOS (Poncet, 2007). Suffering from
severe BOS was due to multiple stress factors found within the units. A limitation in this study
was the way the data was collected. When using a survey for data collection, you are relying on
others to complete it which can create a limit on the study's sample size because not all who
qualify will do so. This limitation applied to another study that was conducted to examine the

association between medical-surgical nurses working long shifts and burnout, job dissatisfaction,
dissatisfaction with work schedule flexibility and intention to leave their current jobs (Dall'Ora,
2015). All registered nurses who were delivering direct care to patients from 30 hospitals, which
had a minimum of two medical-surgical nursing units per hospital, were asked to participate in
the survey. Data was collected from the 31,627 nurses who completed the survey, and the results
showed that nurses working shifts of greater than 12 hours were more likely to experience
burnout than nurses who only worked eight hour shifts. This trend was also evident in the results
for job dissatisfaction, dissatisfaction with work schedule flexibility, and intention to leave their
job due to dissatisfaction.
Another study looked to see the stress levels of critical care nurses. This study included
114 registered nurses. The nurses were asked to rate their physical, emotional, and spiritual
wellbeing (with one being the lowest score and ten being the highest score). Meanswere6.6
(SD,1.8)foradultcriticalcare,6.5(SD,1.8)forneonatal/pediatriccriticalcare,and6.7(SD,
1.9)formedical/surgical/oncology.Thisstudyshowedthehighstresslevelandlevelofburnout
thatcriticalcarenursesexperienceintheireverydayjobs.Alimitationinthestudywasthesmall
samplesize.Only114registerednursesarespeakingforallregisterednursesworkingincritical
careunits(Rushtonetal.,2015).Thelimitationofasmallsamplesizeappliedtoanotherstudy
thatonlyhadasamplesizeof50nurses.Thisstudy'sgoalwastoexaminetheleveland
frequencyofmoraldistressinstaffnurses.TheRevisedMoralDistress(MDS)Scalewasused.
Overall,thenursesreportedlowlevelsofmoraldistress.Doctorsreportedmuchhigherlevelsof
moraldistress(Wilsonetal.,2013).
Study commonalities

There were many studies that analyzed similar components of nursing such as burnout
rates, job dissatisfaction, intention to leave the job, and mental health. Many emphasized that
nurse burnout is a critical issue. All are reputable sources published within the last 10 years, with
the exception of a still relevant case study.
Many studies analyzed different components of nursing that could lead to nurse burnout.
Most studies used similar populations of nurses such as those who work in medical-surgical and
ICU units. However, there were studies that were more specific therefore giving us different
results. One study looked at recent graduate nurses in an ICU floor, which skewed our results
one way, concluding that there was a definite increase in burnout rates. Another study took into
account lengths of hospital shifts and their influence on burnout rates. Each study also had a
different sample size, ranging from 1 to 31,627. The higher the sample size the less the
possibility of there being any outliers that could skew the results.
We were unable to find many articles regarding the specific burnout rates of medicalsurgical nurses. The ICU burnout articles greatly outnumbered the medical-surgical burnout
articles. We may not have gotten the full picture of medical surgical nurse burnout due to the lack
of articles.
Recommendations for Practice
According to our research, it is evident that all nurses should be offered access, by their
workplace, to some form of fatigue and burnout training and counseling. The training should be
given for preventative measures, potentially stopping burnout from happening in the first place.
Hiring more healthcare personnel can also reduce burnout. It is strenuous to take care of twelve
patients at one time and aside from the nurse experiencing burnout, the patient outcome can also

severely decline. It is important to take into account that burnout is not just a matter of
exhaustion, but it also correlates with inefficiency and cynicism. With more healthcare personnel
on the unit at a given time, we can provide better patient outcomes with nurses who are more
thorough and less stressed. If we encourage socialization in the workplace with extended or more
frequent breaks, the work environment will not be associated with stress and hostility and can
drastically improve performance as well as patient care.

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