Running Head: BURNOUT PREVENTION THROUGH WALKING

Burnout is a significant problem in the nursing profession, contributing to psychological distress, job dissatisfaction, employee turnover, reduced quality of care, and increased healthcare costs. Nursing students are exposed to many of the same stressors that are associated with burnout in practicing nurses. The objective of this paper is to synthesize existing literature regarding the influence of a walking program on burnout in nursing students. A literature search was conducted using PubMed, CINAHL, The Cochrane Database of Systematic Reviews, Scopus, and Google Scholar. The following MeSH terms were included in the search: “Burnout, professional,” “walking,” “personnel turnover,” “nurses,” and “costs and cost analysis.” Studies provided evidence that a walking program could promote positive coping among nursing students, reducing the likelihood of burnout. Further research is necessary to determine a walking program’s specific effects on burnout in nursing students. BURNOUT PREVENTION THROUGH WALKING 3 Burnout in Nursing Students Professional burnout is an unfortunate situation experienced by many workers, and nurses are no exception. Whether through personal experience or that of a colleague, most nurses are familiar with burnout and its negative effects. Professional burnout, often simply referred to as burnout, is defined as exhaustion due to interpersonal stressors in professional relationships at the organizational level (Maslach, Schaufeli, & Leiter, 2001). While burnout can affect nurses of all specialties and experience levels, novice nurses are particularly vulnerable. The strain of learning in the field while lacking confidence in clinical knowledge and abilities has led some nursing students to exhibit signs of professional burnout while still in training. Identification of the Topic Burnout among nurses has been well documented in the literature, while burnout among nursing students has been studied to a lesser extent. As with any problem solving process, information about what is known and what has yet to be identified is essential at the outset. An overview of the history, definitions, contributing factors, and current management related to burnout in the nursing profession, and more specifically, in nursing students, is summarized in the proceeding paragraphs. Historical Context. Staff burnout was initially described in the 1970s, when burnout was observed to be associated with somatic symptoms, such as illness and poor sleep, as well as behavioral symptoms, such as rigidity and negativity (Freudenberger, 1975). The topic of burnout gained further attention in the 1980s with the advent of the Maslach Burnout Inventory. A tool for assessing burnout among “people-workers”, the Maslach Burnout Inventory was originally tested on nurses, social workers, physicians, police, and various other human service professionals. It was found that working in a direct patient care role was associated with higher BURNOUT PREVENTION THROUGH WALKING 4 levels of emotional exhaustion (Maslach & Jackson, 1981). Two decades later, a landmark study brought serious attention to the problem of nursing burnout, highlighting its role in increased patient mortality and increased costs to hospitals (Aitken, Clarke, Sloane, Sochalski, & Silber, 2002). Soon thereafter, a longitudinal study involving nursing students demonstrated that certain personality characteristics were significantly associated with components of burnout (Deary, Watson, & Hogston, 2003). Although several studies have been done in the last decade on burnout in nursing students, many questions remain unanswered. Definitions. Several terms relevant to the discussion of professional burnout may be unfamiliar to the reader. Clarification of these terms will promote better understanding of the subject matter. The definitions of terms related to professional burnout are listed below. • Professional burnout. To reiterate, burnout is exhaustion due to interpersonal stressors in professional relationships at the organizational level (Maslach, Schaufeli, & Leiter, 2001). Burnout consists of three components: Emotional exhaustion, depersonalization, and personal achievement (Maslach & Jackson, 1981). Throughout this paper, the terms “professional burnout” and “burnout” are used interchangeably. • Emotional exhaustion. One component of burnout, emotional exhaustion (EE) is a measure of how one's work may lend to feelings of being emotionally overextended due to depletion of personal resources (Maslach & Jackson, 1981, Michalec et al., 2013). • Depersonalization. A second component of burnout, depersonalization (DP) is a measure of the tendency to see recipients of one's care as objects instead of humans (Maslach & Jackson, 1981, Michalec et al., 2013). BURNOUT PREVENTION THROUGH WALKING 5 • Personal achievement. Personal achievement (PA) refers to feelings of competence, achievement, and productivity in one's work with people, and is another component of burnout (Michalec et al., 2013). Measurement of burnout. Burnout can be measured using the Maslach Burnout Inventory (MBI). The MBI measures the three components of burnout: EE, DP, and PA. Higher scores on the EE and DP subscales correspond with higher degrees of burnout (Maslach & Jackson, 1981). Conversely, lower scores on the PA subscale are associated with burnout (Maslach & Jackson, 1981). The MBI has served as a reliable tool for the measurement of burnout for over 30 years, and has demonstrated high reliability and validity (Maslach & Jackson, 1981). Causes of burnout and factors contributing to burnout. There are many reasons why nurses are predisposed to burnout. The caring nature of the nursing profession naturally lends itself to potential for EE (Aycock & Boyle, 2009). The nurse-patient relationship often revolves around the patient’s problems, and solutions for such problems are not always easily obtained (Maslach & Jackson, 1981). Repeatedly being involved in situations where patients are suffering, dying, or dealing with loss of functional capacity can take its toll on nurses over time. Especially in certain areas of nursing, frustration and despair can frequently permeate the nursepatient relationship, leaving the nurse feeling “used up” at the end of the day. These types of situations can lead to EE, one of the key components of burnout. Once a nurse is emotionally exhausted, a sense of negativity can develop. With personal resources depleted, the nurse may begin to display a cynical attitude. Often, this translates to DP, the nurse’s failure to recognize and appreciate the patient’s humanness (Maslach & Jackson, 1981). A constant sense of negativity can cause nurses to feel unhappy about themselves and BURNOUT PREVENTION THROUGH WALKING 6 their job role. They may fall into a thought pattern of rating themselves poorly, and experience a lack of pride in their work (Maslach & Jackson, 1981). This describes the PA aspect of the burnout triad. Additional factors can play a role in the development of nurse burnout. Work environment is one potential factor, as the demands of certain specialties may expose nurses to repeated opportunities for EE (McHugh, Kutney-Lee, Cimiotti, Sloane, & Aiken, 2011). Another potential factor in nursing burnout is workload, as each additional patient per nurse is associated with a 23% increased risk of burnout (Aitken et al., 2002). Other factors include poor support and resources, rapidly changing circumstances, difficult patients and their families, relationships with physicians, low institutional commitment to nursing, and the delivery of poor quality care (Chang, Hancock, Johnson, Daly, & Jackson, 2005). Unfortunately, the prevalence of nurse bullying in some work environments continues to erode the sense of camaraderie that nurses need to do their best work and avoid burnout (Hakojarvi, Salminen, & Suhonen, 2012). Research has shown that novice nurses, with little experience to drawn upon, are at even higher risk for burnout than experienced nurses. During the first three years of their career, roughly one fifth of all nurses will find themselves “burned out” (Rudman & Gustavsson, 2011). Stressors for nursing students. Nursing students must cope with some of the same stressors as practicing nurses, and they have additional stressors as well. Fundamental to success in nursing school is the commitment to long hours of study and an associated lack of free time, which many students find stressful (Jones & Johnston, 1997). Nursing students report that the engulfing demands of their nursing programs are physically debilitating, emotionally exhausting, and an impediment to their personal relationships (Beck, 1995). Additionally, nursing students often endure separation from home, financial worries, regular clinical and educational BURNOUT PREVENTION THROUGH WALKING 7 assessment, and frequently changing clinical environments (Deary et al., 2003). Most nursing students experience insecurity about their developing clinical skills, as well as their perceived lack of practical skills that are so essential in the nursing field (Hamill, 1995). The increase in nontraditional student enrollment ushers in more concerns about burnout, as students with dependents frequently report disproportionate levels of stress (Gibbons, Dempster, & Moutray, 2008; Pryjmachuk & Richards, 2007). For a whole host of reasons, nursing students are prone to burnout during their nursing programs. Current management of burnout. Existing efforts to curb burnout in the nursing profession are few. Addressing nurse workload, the state of California enacted a law that mandated a 1:5 nurse to patient ratio for medical surgical units over a decade ago (Aitken et al., 2002). Another strategy to reduce burnout in nurses is increased clinical supervision, which has proven effective at lowering psychological distress (Hyrkas, 2005). Promotion of Problem Based Learning has been shown to be effective at enhancing student empowerment and selfefficacy (Dunlap, 2005), which may be helpful in reducing burnout among the nursing student population. Mindfulness meditation has proven effective at reducing stress in nursing students, but encounters practicality issues as an intervention due to the need for professional training and guidance to learn the practice (Kang, Choi, & Ryu, 2009; Shirey, 2007). Other suggestions to reduce nurses’ stress include increasing support staff and providing more opportunities for formal debriefing (LeSergent & Hanley, 2005). There is much room for improvement in the current management of nursing burnout, as large scale attempts to tackle the problem have yet to