Reflective Learning and Nursing Burnout

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Table of Contents

Introduction/Background
Critical Literature Review
References

Introduction/Background

The work pressures related to the daily Frontline role of staff nurses make them prone to stress and burnout. For this reason, reflective learning is increasingly becoming an effective intervention for enhancing resilience and understanding of professional practice for improved nurse and patient outcomes (Jack, 2017).

The purpose of this evidence-based project is to evaluate the impact of the adaptation of reflective learning on nursing burnout in managing cardiac patients in a coronary care unit of King Fahad Medical City (KFMC) in the Kingdom of Saudi Arabia. Anecdotal evidence based on the statements of student nurses undertaking a clinical placement at the unit formed the basis for this project. The student nurses often complained of stress and burnout during their placement at KFMC’s coronary care unit. High levels of stress and burnout can affect the students’ learning outcomes.

The genesis of nursing fatigue or burnout in nursing practice is ascribed to occupational stress, heavy workloads, low staffing ratios, and exposure to trauma/suffering (Khater, Akhu-Zaheya, & Shaban, 2014). Emotional/physical fatigue may arise due to heavy workloads. Burnout manifestations may be high in a coronary care unit because of the high exposure to trauma that causes emotional exhaustion (Khater et al., 2014). Therefore, the intensification of burnout among the student nurses in KFMC’s coronary unit may be related to adverse survival prognosis, exposure to patient pain/mortality, and age (Jack, 2017). Burnout manifestations among the student nurses included detachment and sadness.

It is crucial for student nurses and RNs to work in a positive clinical environment for their wellbeing and quality patient care delivery. A strong relationship has been established between nurse wellbeing and clinical outcomes (Romano, Trotta, & Rich, 2013).

This implies that occupational burnout or fatigue has adverse impacts not only for nurses but also for patients. Jenkins and Warren (2012) indicate that, in clinical settings, student nurses and staff nurses experience of trauma/suffering and heavy workloads reduce their performance and patient safety outcomes. Interventions that promote self-care have the potential of reducing nursing stress and burnout. Reflective learning, where nurses gain “new insights of the self and practice” from clinical experiences can ensure better preparation for similar situations (Henderson, Cooke, Creedy, & Walker, 2012, p. 302). As such, engagement in reflective learning could offer some protection to burnout, leading to improved nurse wellbeing and patient outcomes.

For student nurses, clinical experiences with cardiac patients; however, cardiovascular nursing can be demanding emotionally and physically. Reflective learning, i.e., meditating and analysing individual clinical experiences, can promote workplace resilience and professional development (Foureur, Besley, Burton, Yu, & Crisp, 2013). Nurses working with cardiac patients are exposed to trauma or distress on a daily basis related to poor survival prognoses. Further, in addition to attending to the patient’s clinical needs, they also provide family/patient emotional support – professional demands that often cause anxiety (Gomez-Urquiza et al., 2016).

Reflective learning is the key to better workplace resilience and coping with a stressful and intellectually demanding coronary care environment. In this paper, a critical review of relevant scholarly literature will be performed to establish the relationship between reflective learning and nursing burnout in a coronary care unit.

Critical Literature Review

Studies Worldwide

Nurses can improve their practice by engaging in reflective learning. A study by Crawley, Ditzel, and Walton (2012) involving American first-year nursing students found that reflective learning via storytelling builds confidence, awareness, and empathy in handling practice challenges. The authors conclude that the approach could be used to lower emotional exhaustion related to death or grief within critical care settings by enabling nurse students to construct “personal concepts around human experience” (Crawley et al., 2012, p. 49). Reflective learning through verbalised experiences/reflections allowed the student nurses to be sensitive and empathic to the practice complexities.

A disconnect exists between the pedagogical approaches for building the capacity to deal with stress/emotional fatigue and actual practice experiences. An integrative review by Dwyer and Hunter (2015) found that although reflection was a widely adopted instructional tool for improving the affective domain, the concept is rarely utilised in the American practice context. Thus, there is a need for interventions that support pedagogical and clinical preparation for demanding practice to build emotional and physical resilience in student nurses.

Analytical and critical thinking skills are emphasised in nursing practice. The compilation of a portfolio of evidence (PoE) based on clinical experiences is one way of enhancing reflective learning (Ticha & Fakude, 2015). A qualitative study examined the perceptions of student nurses in a South African medical university on reflective learning based on PoE compilation (Ticha & Fakude, 2015).

The results indicated that reflections captured in PoEs allowed the students to identify practice and classroom challenges and benefit from clinical learning experiences. In addition, through the reflective learning strategy, the subjects were able to develop the self-confidence and critical thinking skills required in nursing practice. Reflective practice also led to improved self-directed clinical learning. Therefore, the adaptation of reflective learning based on clinical experiences can motivate nurses to become critical thinkers and self-directed learners.

Besides critical thinking, self-care is considered to give adequate protection against stressors in practice contexts. Therefore, guiding nurses and learners through a journey towards self-care can enable them to manage nursing stress and burnout and enhance their efficacy. Blum (2014) evaluated a nursing program initiative that involved self-care activities taught to students in an American university.

The self-care practice activities involved mindfulness meditation and reflection in enabling the participants to learn from their experiences. The study found that self-care activities inspired and challenged students to deal with the stresses in their practices, be empathetic to others, and gain clarity on their professional goals (Blum, 2014). Further, through shared interactive experiences, the participants were able to identify self-care activities they can apply in practice.

Reflective practice is not self-criticism, but rather a source of psychological support for improved performance in the future. One way nurses can be motivated to engage in reflective practice is through clinical supervision groups. McAvey and Jones (2013) explored the views of clinical supervision groups in a London hospital on reflective learning as a tool for dealing with stressful and emotional issues in critical care environments. Participation in clinical supervision groups was shown to decrease burnout resulting from physical and emotional exhaustion. In addition, the groups provided a platform for nurses to compare practice with their peers, receive psychological support, and acquire practice skills required in critical care (McAvey & Jones, 2013).

Reflection is an important emotion-focused tool for reducing burnout to achieve improved wellbeing of nurses. Reducing nursing burnout contributes to improved patient care. Stewart and Terry (2014) explored educational interventions that could decrease nursing burnout in clinical environments through a systematic review. Their findings were consistent with those reported by McAvey and Jones (2013). Clinical supervision and training on stress management methods were found to contribute to lower burnout levels in nurses. Therefore, supportive relationships can enable staff nurses to deal with stress and burnout. In addition, professional/personal growth achieved through reflective learning can offer protection against burnout in critical care environments.

Studies in the Middle East

Studies carried out in Middle Eastern countries establish that engagement in reflective learning ameliorates stress and burnout by staff nurses. These findings are consistent with those of similar studies performed elsewhere in the globe. Baraz, Memarian, and Vanaki (2014) examined the reflective learning styles employed by Iranian student nurses in hospital settings. The qualitative study surveyed 15 baccalaureate student nurses in their clinical placements. The results indicated that the students utilised a variety of reflective learning methods in their practice with the main ones being “thoughtful observation, learning by thinking, and learning by doing” (Baraz et al., 2014, p. 529). The implication of these findings for practice is that classroom and clinical learning can be enhanced through reflective practice.

Reflective learning is particularly important during ICU placements due to the complex treatments involved. As such, the risk of stress and burnout for nurses and students is high. Vatansever and Akansel (2016) explored students’ views on ICU placements to determine student impact after the program at a Turkish university hospital. One of the key themes identified was the “comprehension of communication and empathy with ICU patients” (Vatansever & Akansel, 2016, p. 1043). Further, the analysis of the students’ views indicated that exposure to complex clinical procedures triggers reflective or experiential learning, which acts as a buffer against stress and burnout. However, the ICU can be a very stressful environment for students in their first placement.

A comparable study explored the clinical decision-making patterns of critical care nurses in a Jordanian hospital (Maharmeh, Alasad, Salami, Saleh, & Darawad, 2016). The study’s aim was to assess the use of reflective learning in routine patient care decisions. ICU cases require complex decisions that emotionally, intellectually, and physically draining. In this study, autonomy, collaborative decisions, and experience were found to reduce stress/fatigue in ICU environments. The ICU nurses exhibited great sensitivity and empathy to the patients under their care. Further, the authors concluded that reflective practice and experience increase the efficacy and confidence of ICU nurses in managing complex cases.

The risk of burnout and emotional fatigue is high in nursing practice. Social support systems that promote reflective learning can reduce the prevalence of fatigue/burnout among staff nurses. Ariapooran (2014) evaluated the prevalence of fatigue/burnout in 173 Iranian nurses and how they correlated with clinical support. The study found out that lack of social support contributes to compassion fatigue among nurses. In addition, a lack of engagement in support systems that promote reflective practice and collaboration increased the risk of nurse burnout. Thus, support systems that promote collaborative practice can help decrease the prevalence of burnout/fatigue in clinical settings.

Studies in Saudi Arabia

The prevalence of burnout in critical care and its impact on nurse outcomes has also been investigated in locally. Alharbi, Wilson, Woods, and Usher (2016) explored the impact of burnout/fatigue on job satisfaction among ICU nurses in a cross-sectional survey. The study found that burnout levels among Saudi nurses range between moderate to high in domains related to “emotional exhaustion and de-personalisation” (Alharbi et al., 2016, p. 715). Further, burnout was strongly correlated with low job satisfaction. Therefore, strategies, such as reflective learning, should be adopted in clinical settings to help nurses cope with stress and burnout.

On their part, Al-Sareari, Al-Khalidi, Mostafa, and Abdel-Fattah (2013) sought to determine the factors that contributed to fatigue among clinicians in Saudi healthcare centres. The qualitative survey found higher levels of emotional exhaustion among younger clinicians than older ones. This implies that experience and reflective learning can ameliorate the effect of stress in busy clinical settings. In addition, high levels of depersonalisation were seen in the younger nurse, implying that emotional intelligence develops with practice experience. Further, longer vacations were associated with low emotional exhaustion scores (Al-Sareari et al., 2013). Thus, vacations and experience can reduce the prevalence of job-related burnout among Saudi clinicians.

Job-related demands can adversely affect nurse performance. Al-Homayan, Shamsudin, Subramaniam, and Islam (2013) surveyed nurses working in busy Saudi public hospitals to identify the physical and emotional demands that cause poor performance. The main response to the heavy work demands was stress. The nurses also suffered from sleep deprivation due to the demanding nature of the public hospital environment.

The stress was ameliorated by organisational support for the nurses and care coordination. In addition, interpersonal support through staff motivation, consultation/collaboration, empathy, and share experiences was associated with reduced stress (Al-Homayan et al., 2013). This shows that collective reflections on shared experiences enhance resiliency among nurses working in a demanding clinical environment. Collective reflective learning also offers protection against emotional and physical stress inherent in critical care settings such as cardiac care units.

References

Alharbi, J., Wilson, R., Woods, C., & Usher, K. (2016). The factors influencing burnout and job satisfaction among critical care nurses: A study of Saudi critical care nurses. Journal of Nursing Management, 24(6), 708-717. Web.

Al-Homayan, M., Shamsudin, M., Subramaniam, C., & Islam, R. (2013). Impacts of job demands on nurses’ performance working in public hospitals. American Journal of Applied Sciences, 10(9), 1050-1060. Web.

Al-Sareari N., Al-Khalidi Y., Mostafa O., & Abdel-Fattah M. (2013). Magnitude and risk factors for burnout among primary health care physicians in Asir province, Saudi Arabia. Eastern Mediterranean Journal, 19(5), 426- 433. Web.

Ariapooran, S. (2014). Compassion fatigue and burnout in Iranian nurses: The role of perceived social support. Iranian Journal of Nursing and Midwifery Research, 19(3), 279-284. Web.

Baraz, S., Memarian, R., & Vanaki, Z. (2014). The diversity of Iranian nursing students’ clinical learning styles: A qualitative study. Nurse Education in Practice, 14(5), 525-531. Web.

Blum, C. (2014). Practicing self-care for nurses: A nursing program initiative. Online Journal of Issues in Nursing, 19(3), 120-129. Web.

Crawley, J., Ditzel, L., & Walton, S. (2012). Using children’s picture books for reflective learning in nurse education. Contemporary Nurse: A Journal for the Australian Nursing profession, 42(1), 45-52. Web.

Dwyer, P., & Hunter, R. (2015). Preparing students for the emotional challenges of nursing: An integrative review. Journal of Nursing Education, 54(1), 7-12. Web.

Foureur, M., Besley, K., Burton, G., Yu, N., & Crisp, J. (2013). Enhancing the resilience of nurses and midwives: Pilot of a mindfulness based program for increased health, sense of coherence and decreased depression, anxiety and stress. Contemporary Nurse, 45(1), 114-125. Web.

Gomez-Urquiza, J., Aneas-Lopez, B., Fuente-Solana, E., Albendin-Garcia, L., Diaz-Rodriguez, L., & Fuente, G. (2016). Prevalence, risk factors, and levels of burnout among oncology nurses: A systematic review. Oncology Nursing Forum, 43(3), 104-120. Web.

Henderson, A., Cooke, M., Creedy, D., & Walker, R. (2012). Nursing students’ perceptions of learning in practice environments: A review. Nurse Education Today, 32(3), 299-302. Web.

Jack, K. (2017). The meaning of compassion fatigue to student nurses: An interpretive phenomenological study. Journal of Compassionate Health Care, 4(2), 1-13. Web.

Jenkins, B., & Warren, N. (2012). Concept analysis: Compassion fatigue and effects upon critical care nurses. Critical Care Nursing Quarterly, 35(4), 388-395. Web.

Khater, W., Akhu-Zaheya, L., & Shaban, I. (2014). Sources of stress and coping behaviours in clinical practice among Baccalaureate nursing students. International Journal of Humanities and Social Science, 4(6), 194-205. Web.

Maharmeh, M., Alasad, J., Salami, I., Saleh, Z., & Darawad, M. (2016). Clinical decision-making among critical care nurses: A qualitative study. Health, 8, 1807-1819. Web.

McAvey, J., & Jones, T. (2012). Assessing the value of facilitated reflective practice groups. Cancer Nursing Practice, 11(8), 32-38. Web.

Romano, J., Trotta, R., & Rich, L. (2013). Combating compassion fatigue: An exemplar of an approach to nursing renewal. Nursing Administration Quarterly, 37(4), 333-336. Web.

Ticha, V., & Fakude, L. (2015). Reflections on clinical practice whilst developing a portfolio of evidence: Perceptions of undergraduate nursing students in the Western Cape, South Africa. Curationis, 38(2), 1502-1510. Web.

Stewart, W., & Terry, L. (2014). Reducing burnout in nurses and care workers in secure settings. Nursing Standard, 28(34), 37-45. Web.

Vatansever, V., & Akansel, N. (2016). Intensive care unit experience of nursing students during their clinical placements: A qualitative study.International Journal of Caring, 9(3), 1040-1049. Web.

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