Build resilient teams to tackle nursing burnout

Author(s): Teresa M. Stephens, PhD, MSN, RN, CNE

Use purpose, priorities, perspective, and personal responsibility to create culture-changing teams.

Takeaways:

  • Burnout has been identified as a public health crisis, negatively affecting individuals, organizations, patients, and communities.
  • Enhanced personal resilience should be simultaneously combined with efforts to build resilient teams to effectively address the root causes of burnout.
  • Resilient teams are necessary radically transform the culture of nursing.

Taking Action Against Clinician Burnout: A Systems Approach to Professional Well-Being, the 2019 consensus report by the National Academies of Sciences, Engineering, and Medicine (National Academies), details the latest evidence on burnout and calls for an immediate response. This work follows other recent recommendations for addressing burnout and recognizing it as a public health crisis due to its devastating effects on individuals, organizations, patients, and communities. (Read more about the report in “Leading the way to professional well-being” in the February issue of American Nurse Journal.)

Personal resilience (using personal protective factors to cope with stress and adverse events to enhance well-being and the ability to face future challenges) can help individuals mediate the negative effects of workplace stress and adversity, but we can’t expect individuals armed only with personal resilience to single-handedly tackle the larger systems and cultural issues that lead to widespread burnout, especially in the presence of fear and intimidation. The National Academies recommends a systems approach that includes radical positive disruption and creative problem-solving. This approach requires the commitment and courage of a resilient team, composed of resilient individuals, dedicated to collaboratively promoting change.

Teamwork

The Agency for Healthcare Research and Quality in partnership with the Department of Defense developed the TeamSTEPPS curricula to improve teamwork within healthcare organizations. This important (and free) program is based on the evidence that teams (whether they work effectively or ineffectively) are directly related to the quality and safety of patient care.

In my previous article, “Building personal resilience”, I introduced the 4Ps of resilience: purpose, priorities, perspective, and personal responsibility. The 4Ps also can be applied to developing resilient teams that collectively harness their energy, knowledge, skills, and attitudes to transform systems.

Building resilient teams

To fully grasp the relevance and importance of building resilient teams, we should begin by clarifying two key terms. First, what is a “team”? The TeamSTEPPS curriculum provides a definition that can be applied to both practice and academic settings: “A team consists of two or more people who interact dynamically, interdependently, and adaptively toward a common and valued goal, have specific roles or functions, and have a time-limited membership.” Next, let’s apply the definition of resilience to teams. Resilient teams can be described as those that use intentional strategies to cope with challenges, adversity, and stressors to successfully achieve goals and objectives and to enhance their ability to face future challenges.

Think about a successful team that you’ve been a part of or have observed. You may even think of fictional teams, such as those depicted in books or movies. One characteristic most of these teams have in common is the uniqueness of the individual team members; they each bring their own knowledge, skills, and attitudes (diversity) to the team to enhance its ability to meet the desired outcomes. The intentional design of a team is critical to its success. If you have the luxury of building a team from the ground up, the design process will be easier than if you already have a team in place. However, a team using the 4Ps can become resilient with intention, commitment, and the essential competencies (knowledge, skills, attitudes) of resilience. Keep in mind that this isn’t a strictly linear process. I encourage you to revisit each of the 4Ps for reflection and revision.

Purpose

When discussing personal resilience, I usually begin with priorities as the first P, but a team must first establish its purpose before moving through the other domains. Your team’s purpose is your why: Why does this team exist? Why are we here? These questions may seem simple, but many teams have members with different thoughts about the purpose. To avoid confusion, frustration, and conflict, establish a shared mental model of your team’s “why” before beginning or moving forward with its work. This first step requires consensus and commitment from every team member. Begin by identifying the problem or issue you want to address. For instance, if you’re a member of a search committee, you may decide to focus on recruitment and/or retention.

Purpose

  • Why are we here?
  • Why does this team exist?

Priorities

Our priorities consist of our organizational and individual values, professional ethics, and desired outcomes. In other words, they’re the goals we want to accomplish, how we want to accomplish them, and how we want to be known or evaluated (our image). Begin by listing your organization’s values (if you’re unsure, check your organization’s website, where they should be readily available) and use them as a foundation for your team priorities. Acknowledge individual values and recognize that generational and cultural differences may exist. After identifying the core team values, determine the team’s desired outcomes and goals; develop them in sync with the team’s purpose.

Ensure that everyone has a clear understanding of expected behaviors. Consensus is best achieved when a high level of trust exists among team members. Daniel Venables, who works with schools to build professional learning communities, recommends establishing team norms (common patterns of participation that promote a shared understanding of individual expectations of each team member). Venables has developed a free tool for developing team norms (access the tool here). You also may want to consider developing a team charter or code of conduct to further establish team norms, especially if you’re addressing a sensitive topic. (See Code of conduct.)

Priorities

  • What matters to us? Why does it matter?
  • What are our organization’s values? Individual team members’ values?
  • What are the essential elements of our professional code of ethics?
  • What are our goals/objectives? (List two or three SMART [specific, measurable, achievable, relevant, and time bound] goals.)
  • How do we want to be known (our reputation within the organization)?
  • What behaviors will not be tolerated (incivility, rankism, “abuse of power,” etc.)?
Code of Conduct

Use this sample resilient team code of conduct to develop one for your team.

As members of this team, we agree to commit to the following code of conduct in all team interactions.

1 I commit to the development of a psychologically safe team environment where everyone has a shared voice and all issues and concerns can be openly discussed without fear of reprisal. This includes my personal responsibility to demonstrate humility, courage, compassion, a growth mindset, mutual respect, integrity, accountability, and trustworthy behavior.

2 Each team member has an equal voice in all interactions and decisions, without deference to rank, title, or tenure (years of service).

3 I agree with the established purpose and priorities for this team. If Ifind myself in conflict with them, I will share my concerns in a timely manner with the entire team.

4 I agree that every member of this team brings value to our purpose and priorities. Therefore, each individual may assume leadership when his or her specific knowledge and skills are needed for guidance. I commit to recognizing my own areas of expertise as well as my own limitations, and I am willing to listen and consider evidence that is contrary to my personal opinions.

5 I agree that our team will pursue our goals and objectives through the review of best evidence and practices, which may be contrary to our current policies, processes, and personal opinions.

Date: ________________

Team member signatures: ___________________________________

Perspective

A resilient team needs an informed perspective where behaviors and decisions are guided by facts (evidence) rather than personal opinions, cultural norms, and/or precedent. Teams serve to fulfill needs that can’t be fulfilled through an individual’s own knowledge, skills, and strengths.

To be effective, a team must have the right people in the right seats, and this requires diversity. Think about the most successful sports teams or musical groups. Each member brings unique skills to perform a specific function required for success. However, no team member works in isolation. Each individual performs his or her roles and responsibilities in sync with other team members and key stakeholders.

An informed team perspective begins with a foundation of respect and trust. Members should be chosen based on their “fit” with the team’s purpose and priorities, including their abilities and willingness to share and receive information. They shouldn’t be chosen to simply fulfill the requirements of having a committee without having real roles and responsibilities in decision-making. Many organizations use the shared governance model to effectively empower and ensure diverse perspectives are heard and valued.

Develop your team’s informed perspective and determine the knowledge and skills it needs by identifying what’s known and not known about the problem or issue you’re tackling, including a review of the evidence to identify trends and best practices, as well as any discrepancies in current practice. When possible, seek information from interprofessional colleagues from within and outside your organization.

Perspective

  • What do we know about this issue? What have we already tried?
  • What policies/processes are we using to guide our practice(s)? How do they compare to national trends and/or best practices?
  • Why haven’t we succeeded in addressing this issue? What are the bottlenecks, biases, or blind spots?
  • What are the key elements of this issue? For example, if you’re developing a team to address retention, you’ll want to choose team members with expertise in the issues (work environment, leadership, workload, culture, salary/benefits, etc.) known to affect it. (Note: This will require a literature search to identify current evidence.)
  • Who in our organization is an expert on any of these key elements?
  • Who outside our organization is an expert on any of these key elements?
  • Do any professional organizations provide toolkits, white papers, or position statements on this issue?
  • Who has already successfully addressed this issue? What are they doing differently from us?
  • Who needs to be on this team to provide an informed perspective to see the bigger picture?
  • Who no longer needs to be on this team?

Personal responsibility

Our personal responsibility as a member of a resilient team is centered on our commitment to the previous 3Ps: purpose, priorities, and perspective. We must be willing to let go of our own personal agendas and egos to fulfill our obligations to the team’s purpose and priorities. At times, we may have to make decisions that are difficult, even risky. This is especially true when dealing with culture change. We may need to demonstrate moral courage in speaking out against behaviors and practices that have led to unhealthy work environments or broken systems that contribute to nurse burnout. We need to avoid getting caught up in the emotions of these situations and not approach them from a position of anger or judgment. Then, with compassionate courage, we can boldly speak the truth without personal attacks or actions that harm individuals.

Personal responsibility

  • Who is influenced/affected by my behaviors, actions, and/or decisions? (Consider colleagues, supervisors, subordinates, and yourself.)
  • How am I held accountable for my behaviors, actions, and/or decisions? (This is especially important for leaders.)
  • When was the last time I openly changed my mind when presented with evidence contrary to my personal opinion?
  • When did I last seek advice or wisdom from someone with expertise on the subject before I made a decision?
  • What are my personal biases and/or blind spots? What would others say are my biases and/or blind spots?
  • How do I avoid rankism when working within a hierarchical system?
  • How do I encourage others to openly discuss their concerns or areas of disagreement with me?
  • How would others describe my strengths and weaknesses? How have I responded to this feedback in the past?
  • Do I value people over policies and processes? Do I value relationships over rules and regulations?
  • How do I promote a psychologically safe work environment?
  • How do I want to be known? Is this consistent with the feedback I receive from evaluations? If not, what are the discrepancies?
  • What can I do to improve others’ perceptions of me?

Moving forward safely

When facing a problem or issue that’s contributing to moral distress or burnout within an organization, carefully assess your own behaviors, potential biases, blind spots, and motives. Then find someone you can trust in the organization who shares your desire to improve the workplace culture. Review this article together and brainstorm how you can begin building a resilient team. If you don’t have someone within the organization you trust, seek the counsel of an outside mentor or colleague.

You may recall learning about Maslow’s hierarchy of needs and the importance of feeling safe before we can move to higher levels of self-actualization. The concept of “psychological safety in the workplace” is the focus of Amy Edmondson’s book, The Fearless Organization, which describes the results of her research into effective team dynamics. Edmondson—a leadership, teaming, and organizational learning expert—describes team psychological safety as a shared belief that the team is safe for risk-taking. Psychological safety in nursing is critically important to promote engagement and reduce what Edmondson calls the “epidemic of silence” (not speaking out even when we believe we have something important to say). Psychological safety is critical to building resilient teams.

Make a commitment to building resilient teams in an environment that provides psychological safety. Creating these teams has the potential to radically transform nursing and address burnout.

Teresa M. Stephens is an associate professor at Medical University of South Carolina in Charleston.

References

Brigham T, Barden C, Legreid Dopp A, et al. A journey to construct an all-encompassing conceptual model of factors affecting clinician well-being and resilience. National Academy of Medicine. January 29, 2018. nam.edu/journey-construct-encompassing-conceptual-model-factors-affecting-clinician-well-resilience/

De Clercq D, Pereira R. Resilient employees are creative employees, when the workplace forces them to be. Creativity and Innovation Management. 2019;28(3):329-42.

Dyrbye LN, Shanafelt TD, Sinsky CA, et al. Burnout among health care professionals: A call to explore and address this underrecognized threat to safe, high-quality care. July 5, 2017. National Academy of Medicine. nam.edu/burnout-among-health-care-professionals-a-call-to-explore-and-address-this-underrecognized-threat-to-safe-high-quality-care

Edmondson A. Creating psychological safety at work in a knowledge economy. July 6, 2018. youtube.com/watch?v=KUo1QwVcCv0&feature=youtu.be

Edmondson AC. The Fearless Organization: Creating Psychological Safety in the Workplace for Learning, Innovation, and Growth. Hoboken, NJ: John Wiley & Sons; 2019.

Edmondson A. Psychological safety and learning behavior in work teams. Adm Sci Q. 1999;44:250-82. journals.sagepub.com/doi/pdf/10.2307/2666999

Joseph ML, Bogue RJ. A theory-based approach to nursing shared governance. Nurs Outlook. 2016;64(4):339-51.

Jha JK, Pandey J. Spreading the light of knowledge: Nexus of job satisfaction, psychological safety and trust. Int J Knowledge Manag. 2016;12(3):30-47.

Maner JK. Dominance and prestige: A tale of two hierarchies. Curr Direct Psychol Sci. 2017;26(6):526-31.

McAndrew NS, Leske J, Schroeter K. Moral distress in critical care nursing: The state of the science. Nurs Ethics. 2018;25(5):552-70.

National Academies of Sciences, Engineering, Medicine. Taking Action Against Clinician Burnout: A Systems Approach to Professional Well-Being. Washington, DC: The National Academies Press; 2019.

Savel RH, Munro CL. Moral distress, moral courage. Am J Crit Care. 2015;24(4):276-8.

Shanafelt T, Swensen SJ, Woody J, Levin J, Lillie J. Physician and nurse well-being: Seven things hospital boards should know. J Healthc Manag. 2018;63(6):363-9.

Sherman RO. Finding your true north. Nurse Lead. 2017;15(6):370-1.

Stephens TM. Nursing student resilience: A concept clarification. Nurs Forum. 2013;48(2):125-33.

Stephens TM. Building personal resilience. Am Nurs Today. 2019;14(8):10-5.

Stephens TM, Smith P, Cherry C. Promoting resilience in new perioperative nurses. AORN J. 2017;105(3):276-84.

Ulrich CM, Grady C. Moral distress and moral strength among clinicians in health care systems: A call for research. National Academy of Medicine. September 23, 2019. nam.edu/moral-distress-and-moral-strength-among-clinicians-in-health-care-systems

Venables DR. The Practices of Authentic PLCs: A Guide to Effective Teacher Teams. Thousand Oaks, CA: Corwin; 2011.

Weberg DR, Fuller RM. Toxic leadership: Three lessons from complexity science to identify and stop toxic teams. Nurse Lead. 2019;17(1):22-6.

White EM, Aiken LH, McHugh MD. Registered nurse burnout, job dissatisfaction, and missed care in nursing homes. J Am Geriatr Soc. 2019;67(10):2065-71.

 

LEAVE A REPLY

Please enter your comment!
Please enter your name here