Stress and Burnout in Nurse Anesthesia

This study was designed to determine the current American Association of Nurse Anesthetists, Wanda level of stress and its physical manifestations in Cer- Wilson, CRNA, PhD, distributed a link to this survey tified Registered Nurse Anesthetists (CRNAs) and in 2 electronic requests to approximately 28,000 nurse student registered nurse anesthetists, it also looked anesthesia providers. The response rate was 26.9% (N at coping mechanisms individuals commonly employ = 7,537). Based on responses and comments, recomto combat the effects of stress. The study used data mendations can be made for future Wellness intervencollected between February and May 2008 using a tions for the Association and for individuals. Stress and Burnout Survey on an online survey tool (SurveyMonkey). The fiscal year 2008 president of the Keywords: Burnout, stress, Stressors, symptoms.

The American Association of Nurse Anesthetists (AANA) estahlished its Wellness Program in 2004 with the objective of developing and implementing functional strategies of health promotion and the elements of Wellness, balance, and self-care into the lives of nurse anesthetists. Prior to the push by the AANA for Wellness, the professions for the last 25 years had heen served hy a group of dedicated peer advisors who attempted to enlighten members about the dangers of stress and substance abuse. Unfortunately, many nurse anesthetists still envision the concept of Wellness in our profession as peer assistance activities such as being ahle to avoid or deal with the consequences of substance abuse. Wellness goes much further than peer assistance; it involves a balance within us, including our mental, emotional, spiritual, and physical well-being. It means caring for ourselves as much as we care for our patients, I often, Certified Registered Nurse Anesthetists (CRNAs) do not recognize that the same stress response we count on and acknowledge in our patients is also at work in our own bodies hecause of stress both on the joh and in our personal lives. Stress is the body’s way of reacting to different situations, hoth good and bad. Chances are that if we are feeling stress at work we are likely to experience stress in other aspects of our lives.

Background
Stressors, or events that evoke stress in an individual, vary among all of us. What may provoke stress in one individual may not in another; furthermore, we each have different built-in abilities to adapt to stress. The knowledge, skills, and administration of anesthesia are learned and practiced in a stressful environment. In the classroom, students are homharded with lectures, skill challenges, and the emotional experience of being no longer the expert in the nursing unit but a novice in a new environment. In the surgical setting, the actions that we take or those that result from the actions others take can cause changes in our patient that ultimately lead to increased stress in ourselves. Our ancestors used the responses of “fight or flight” to cope with the daily pressures of survival.

Unfortunately, nurse anesthetists cannot adopt these same responses to cope with school, their jobs, or everyday life. Fighting or fleeing is not an option. Coping, negotiating, acquiescing, and reconciling are the more frequent and demanding choices. Stress is unavoidable but is not all had. Too litde stress leads to sleep and boredom, whereas too much stress gives us a sense of panic and tension. Acute stress is the most common form of stress. It comes from demands and pressures of the recent past and anticipated demands and pressures of the near future, such as our joh of providing anesthetics or attending nurse anesthesia school. Fortunately, most people recognize acute stress symptoms. Because it is short term, acute stress does not www.aana.com/aanajournalonline.

All anesthesia providers know the effects of the surgical stress response on patiients. This response protects the patient and leads to increased heart rate, blood glucose levels, blood pressure, aiid metabolism, while suppressing vital functions such as immune responses. These are normal biological and psychological functions mediated by hormones released by activation of the hypothalamicpituitary-adrenal (HPA) axis to help cope with challenging physical events.’ According to Sandra Tunajek, CRNA, DNP, and former executive director of the Council for Public Interest in Anesthesia, “Nurse Anesthetists spend endless hours dedicated to the workplace, where they are constantly exposed to a variety of Stressors. Sttadies note that protracted stress has significant physical and mental consequences for healthcare professionals that can affect health, sometimes to the point of disability, and may even affect patient care. Stress can result in disruption in relationships, fatigue, headaches, gastrointestinal disturbances, weight loss or gain, insomnia, depression, even addictive behavior.”^ 122 AANA Journal • April 2011 • Vol. 79, No.

have enough! time to do the extensive damage associated with long-tei’m stress. The most eommon symptoms of acute stress include the following; emotional distress, manifested as anger, irritahility, or depression; muscular problems, including tension headache, hack pain, and jaw pain; stomach, gut, and howel problems; and physical symptoms such as elevated hlood pressure, rapid heartbeat, sweaty palms, heart palpitations, dizziness, migraine headaches, cold hands or feet, shortness of breath, and chest pain.” Chronic stress is insidious and ultimately more devastating than acute stress. This type of stress does not let up. Our ¡bodies are continually bathed in the “stress hormones” from the HPA axis.^ These stress hormones affect us on a daily basis and may ultimately destroy minds, bodies, and lives. As we get used to chronic or long-term stress, we tend to forget it is there because it is not new. Chronic stress does not get our attention until its damage is done. Personal resources, both mental and physical, become depleted, leading to illnesses such as obesity, hypertension, heart attack and stroke, ulcers, violence, depression, substance abuse, and decreased ability to concentrate and learn.

These physical, mental, and emotional reactions result in exhaustion—when a person’s individual threshold is breached. The complex causes of chronic stress may include factors from work or home. These Stressors may stem from financial pressures; interpersonal relationships, including anger management issues; or a nonsupportive environment, emotional or physical. Any or all of these may lead to a lack of selfcare. All too often, self-care becomes the lowest priority in our already demanding lives. One of the unfortunate consequences of chronic personal and professional stress is burnout. Burnout is a state of physical, emotional, and mental exhaustion caused by long-term exposure to demanding work situations, or the cumulative result of stress. Cordes and Doutherty,”* in their study of healthcare employees, found that workers who have Ifrequent intense or emotionally charged interactions with others are more susceptible to burnout. You may be more prone to burnout if*:

• You identify so strongly with work that you lack a reasonable balance between work and your personal life. • You try to be everything to everyone. • Your job is monotonous. The first 2 are characteristic of the typical alpha individual drawn to our profession. As nurses we are engaged, empathetic, and attached to our patients. As nurse anesthetists, our overachiever personality drives us to excel, to be in control in not only the classroom but also in the operating room and in our personal lives. Over time, our fast-paced cases may eventually give way to automatic pilot and boredom. Our focused lives become complicated with children, mortgages, aging parents, and frustrations with coworkers and administration. As the stressful routine becomes the norm, burnout becomes a www.aana.com/aanajournalonline.aspx

likely consequence. When there is no “me” time, balance is upset. When catastrophic events such as cancer, divorce, litigation, and bankruptcy occur, it is no longer possible to be everything to everybody. Given the highly charged and stressful nature of our profession, how susceptible are we to stress, how do we cope, and what are the costs? This study was designed to determine the current level of stress and its physical manifestations in CRNAs and student registered nurse anesthetists (SRNAs). It also looked at coping mechanisms, of these individuals reported as commonly employed to combat the effects of stress. Based on responses and comments, strategies may be developed and recommendations can be made for future Wellness initiatives, for individuals and for the profession.

Methods
After approval by the institutional review board of the Medical University of South Carolina, a multifactorial questionnaire'”^ was undertaken using a survey (www. SurveyMonkey.com). An electronic invitation to participate in the survey was distributed by Wanda Wilson, CRNA, PhD, president of the American Association of Nurse Anesthetists (AANA). The invitation was sent to approximately 28,000 CRNAs and SRNAs who had email addresses on file with the AANA. Data were collected between February and May 2008. There were 7,537 respondents, or 26.9% of all eligible anesthesia providers.

The survey was a self-assessment that contained: • Demographic questions that included age, gender, employment descriptions, years in anesthesia practice, ethnicity, and marital status. • Manifestations of stress, including symptoms, life changes in the last year, self-assessment of stress levels, satisfaction with work and life, stress coping assessment, and, at the request of the AANA Foundation, an assessment of chronic illnesses. • Suggestions for how the AANA Wellness Program, managed by the Council for Public Interest in Anesthesia, can help decrease stress and promote Wellness of the AANA members. This survey was the work of the authors, with input from Sandra Tunajek, CRNA, DNP, and past executive director of the Council for Public Interest in Anesthesia, and Lorraine Jordan, CRNA, PhD, executive director, AANA Foundation.