Reduction of Nurse Burnout Through Group Therapy

Topics: Burnout, Therapy Words: 4156 Pages: 6

Summary

High burnout rates are detrimental to the United States healthcare system, causing major losses in both finances and lives. The most suitable approach to their reduction can play a critical part in uplifting the quality of care to the desired standards, especially considering the current increase in pressure on nursing personnel. Whether or not a team-based approach is more suitable for burnout reduction, this issue poses a looming threat to the integrity of society.

Purpose

This evidence-based project will present the data that aims to evaluate the efficiency of team-based anti-stress therapy sessions and compare it with standard self-care practices in a hospital setting.

Relevance

Burnout rates among nursing personnel across the healthcare settings do not only cause higher expenditures but also the loss of life. High levels of stress among healthcare workers are the reason for a significant reduction in the quality of provided care (De Oliveira et al., 2019). Approximately 74% of all nurses in the United States exhibit symptoms of chronic stress stemming from burnout (Thomas et al., 2019). With the COVID-19 pandemic, this issue has grown into a life-threatening crisis as isolation and depersonalization become even more apparent. Nonetheless, the selection of solutions varies greatly from one organization to another, while their efficiency is rarely taken into account.

The focus during such a selection must lie on the resolution of the majority of issues. The most common reasons for burnout in hospital nurses are the fear of loss of patients, unappreciation for performed work, and the loss of personal life/work balance (Thomas et al., 2019). These factors tend to cause mental health issues, such as low self-esteem, the rise of cynicism, depression, and anxiety, among others (Thomas et al., 2019). Many studies regarding the impact of each type of intervention reveal the positive effects of both individual and organizational solutions to the issue (Aryankhesal et al., 2019). However, these discussions rarely compare the differences in the outcomes for each approach in an attempt to promote either type or synthesize a hybrid approach to achieve the highest efficiency.

At the same time, such a comparison might bring up critical differences that could make benefits more apparent and develop new functions for organization-level stress-related policies. Group therapy sessions enable organizations to adjust strategies on the fly by introducing new measures, such as appreciation events or assistance from a psychiatrist (DeCaporale-Ryan et al., 2020). It is also vital to consider the secondary effects of both self-care and team-based approaches and their indirect impact on stress levels. Aryankhesal et al. (2019) state that “training and improving communication skills” are considered to be the most efficient ways to reduce burnout rates (p. 7). Lighter workload, which is one of the individual-oriented solutions to stress-related issues, does not resolve disengagement from organizational goals (Montgomery et al., 2019). Self-care might be less optimal, as some individual coping strategies can be deemed inefficient without proper training.

Group therapy sessions give coping strategies a different role in a hospital setting. The emotional struggles of each team are unique to their facility and unit, making such sessions especially efficient in resolving stress from the lack of understanding (DeCaporale-Ryan et al., 2020). Instead of merely growing personal resilience to the environmental factors that induce stress, workers can change their work environment to become less pressuring.

Potential Outcomes

Team-based solutions might present just the right approach that also has a multitude of benefits aside from stress reduction. There are two distinct outcomes that are expected to occur with the widespread implementation of team-based therapy sessions aimed to reduce stress. By accepting a team-based approach as a default solution for high burnout rates, organizations can assist groups of employees through empathetic and reassuring discussions that will cover the most common reasons for burnout. Their lift people’s moods and give them an outlet for expression that is otherwise might be misunderstood by others, thus increasing nurses’ overall well-being (De Oliveira et al., 2019). In the long term, this approach has the potential to integrate social support generated during therapeutic sessions into a workplace environment, boosting teamwork and improving attitudes towards cooperation. Therefore, group sessions can decrease turnover rates not only for the teams that visit them but for all staff members.

This format of communal training gives employees a chance to build closer relationships. Thankful events, group psychiatric sessions, and regular meetings for sharing experiences provide an opportunity for work teams to bond with each other, improving their cooperation and mutual support at a workplace (Aryankhesal et al., 2019; Montgomery et al., 2019). There is evidence that such an approach increases interoperability among teams within the same hospital, stemming from a less competitive and more friendly work environment (Montgomery et al., 2019). Loneliness, which is one of the primary outcomes of the busy hospital units, such as acute care, can be completely negated by a supportive team.

Clinical Question

In hospital nursing personnel, what is the effectiveness of group therapy sessions compared with self-care practices, such as meditation and schedule self-management, on the burnout rates reduction?

Review of Literature and Synthesis of Evidence

The PICO question ” in hospital nursing personnel, what is the effectiveness of group therapy sessions compared with self-care practices, such as meditation and schedule self-management, on the burnout rates reduction?” was reviewed with the help of several peer-reviewed articles found through online databases. Keywords that led to the articles used in this paper were “burnout self-care,” “burnout interventions comparison,” “burnout prevention strategies,” “stress coping,” and “burnout team-based therapy.” The following databases were searched: ScienceDirect, PubMed Central, Wiley Online Library, Multidisciplinary Digital Publishing Institute, and APA PsycINFO. Additional criteria for the articles were peer-reviewed, posted in 2018 or earlier, written in English, with mandatory inclusion of the “nursing” keyword in all papers. Eight out of eleven relevant articles consisting of meta-analyses, scoping reviews, systematic reviews, and two case studies were selected to be utilized for this paper. Their levels of evidence were analyzed in accordance with Melnyk’s hierarchy of evidence (Melnyk & Fineout-Overholt, 2015). Four level one articles were utilized, followed by three papers of level five and one level four.

Common Themes in Literature

The majority of the articles discussed the impact of nurses’ burnout on the quality of healthcare and presented a collection of common factors contributing to this phenomenon in a hospital setting. Some of the articles have focused on either self-care or organizational interventions that aim to alleviate the issue. However, many systematic reviews have taken into account both individual resilience training and group mindfulness sessions, although without their direct comparison.

Definition and impact of nurses’ burnout. The articles clearly outline the adverse effects of the decreased mental status of healthcare personnel. Several papers present data regarding the quality of care and its apparent decrease due to a high-stress work environment. Burnout in nurses can be summarized as a state of mental and physical exhaustion stemming from work-related conditions (De Oliveira et al., 2019; Sultana et al., 2020). Articles often describe how this impediment affects nurses’ workplaces, leading to adverse outcomes among patients (Aryankhesal et al., 2019; Barrientos-Trigo et al., 2018; Sultana et al., 2020). The reduction of this impact is the primary objective for intended interventions.
Primary psychological stressors in hospitals. The factors that are essential to alleviate in order to improve nurses’ working conditions are common in focus. The key sources of stress are identified as the following: depersonalization, accomplishments perceived as unsatisfactory, emotional exhaustion, high demand for positive outcomes, low control over job tasks, insecurity of career, and irregular work hours (De Oliveira et al., 2019; Gray et al., 2019; Thomas et al., 2019). Many interventions focus on either one or several stress factors by utilizing various wellness techniques from psychology (Prudenzi et al., 2021; Thomas et al., 2019).
Group-based stress reduction interventions. The application of organization-wide interventions is a primary topic for the two case studies that are selected for the paper, as well as the discussed option in reviews. Group therapy is defined as an intervention that focuses on teams from the same setting and has shared work-related stress sources (Montgomery et al., 2019; Prudenzi et al., 2021; Sultana et al., 2020). Several articles focus specifically on this topic to present a valid point for changes in the role a healthcare facility in the wellbeing of its employees (Montgomery et al., 2019; Prudenzi et al.).
The role of self-care in burnout prevention. The topic of self-care is widely covered within the presented articles, giving a clear picture of how healthcare personnel can benefit from such techniques (Barrientos-Trigo et al., 2018; De Oliveira et al., 2019). Articles do present evidence that nurses can build individual resilience without any external support. Such papers suggest that these interventions increase the feeling of control in employees (Barrientos-Trigo et al., 2018; Gray et al., 2019). Nonetheless, focusing on a single individual may be disruptive for an organization.

Identified Gaps in Knowledge

The following gaps were identified: the lack of comparison between anti-stress methods, no standardized measure for different approaches, and no clear statements regarding the necessary changes in an organizational culture. Despite presenting an overwhelming amount of data regarding the usefulness of each technique, many studies did not get deep into the comparison of different interventions. As a result, there are implications for the necessity of further research on this topic. There are different scales for measuring burnout rates, which are not compatible with each other, requiring further development of a standard method for burnout measurement.

Strategies presented in the articles are not equally represented in the sample healthcare facilities, implying the need to observe the outcomes on a larger scale. The impact of each method on the organizational culture is not clearly outlined, which may present a critical factor in the decision-making process for each hospital. There are disputes regarding the most suitable approach, as many authors mention that there are factors that prevent the generalization of their findings (Barrientos-Trigo et al., 2018; Gray et al., 2019). Additional trial interventions may assist with resolving these gaps, and systematic reviews that put self-care and communal therapy up for comparison would assist with achieving the highest level of evidence regarding the topic.

Findings

The majority of the articles have determined that most, if not all, types of stress reduction interventions successfully decrease stress in nurses. Moreover, they reveal the inconsistencies in the outcomes for each type of anti-stress approach, making their insight highly valuable for resolving the issue presented in this paper. It is clearly outlined within the papers that there are significant improvements to both stress levels and organizational cohesion that followed the implementation of group-based therapies. Their basis can be utilized as the foundation for the PICO question.

PICO Question: in hospital nursing personnel, what is the effectiveness of group therapy sessions compared with self-care practices, such as meditation and schedule self-management, on burnout rates reduction?
Databases Searched: ScienceDirect, PubMed Central, APA PsycINFO, Wiley Online Library, Multidisciplinary Digital Publishing Institute.

Table 1. Summary of Reviewed Evidence.

Author(s) and Date of Publication ONLY	Sample/Setting/ Design	Data Collection Tools	Findings/Results	Appraisal of Evidence: Worth to Practice include Strengths, Weaknesses and Conclusions	Level of Evidence (LOE)
Aryankhesal, A., et al. (2019)	Design: A systematic review of articles on randomized clinical trials (RCTs) and case studies. Setting: Healthcare providers in hospitals from the Netherlands, the United States, and England. Sample: 12 RCTs and six case-control studies.	Search through databases for articles related to the issue, excluding the articles focusing on settings other than hospitals. The only employees who were focused on were nurses and physicians. The quality of each article was analyzed through the Critical Appraisal Skills Programme.	The paper reveals a positive improvement in burnout reduction for nurses, with slightly less successful outcomes for physicians. 7 different methods, including four individual and three group-based therapies, were tested, all showing positive outcomes.	Strengths: Different interventions have been analyzed, presenting characteristics that were improved through each one. Weaknesses: No comparison between methods and study results was conducted in the article. The findings cannot be generalized due to unique working conditions. Conclusions: Both scopes of intervention show a meaningful positive impact, yet further analysis is needed to improve generalization.	LOE: Level 5
Barrientos-Trigo, S., et al. (2018)	Design: A scoping review. Setting: Hospital care personnel only, studies from the United States and Europe. Sample: 21 peer-reviewed articles.	Database and grey literature search for keywords within the scope of the study.	Interventions for meso-, macro-, and micro-management levels were identified and assessed. Macro- and micro-management techniques were identified as more favorable. The list of proposed interventions was created by the authors.	Strengths: A positive correlation between implemented methods and outcomes is documented for each article. Weaknesses: The lack of long-term influence analysis of the proposed interventions. Conclusions: The article presents a wide variety of possible solutions, although short-term outcomes may be overrepresented.	LOE: N/A
De Oliveira, S. M., et al. (2019)	Design: A literature review. Setting: Primarily hospitals from different regions. Sample: 30 peer-reviewed RCT articles.	The RCT articles were selected based on their types of interventions and the quality of evidence.	A positive correlation between prevention interventions and the reduction of stress is noted in 80% of articles, and the importance of mental assessment is well-documented.	Strengths: The article contains a qualitative assessment of different anti-stress methods. Weaknesses: Techniques in the article discuss only alleviation of burnout and not its prevention. Conclusions: Some interventions were identified as more efficient than others.	LOE: Level 6
Gray, P., et al. (2019)	Design: A systematic review Setting: Different healthcare settings (primarily hospitals) from various regions. Sample: 46 out of 1290 articles were selected for analysis.	Articles that had a measure of nurses’ mental health were selected via database search.	Common themes among intervention techniques were noted, and short-term improvements are shown through a comprehensive discussion.	Strengths: The article provides recommendations suitable for both individuals and groups. Weaknesses: The generalizability of the article’s contents is arguable, as low- and middle-income countries present different factors for mental health deterioration. Conclusions: A strong positive correlation between short-term stress measurements can indicate which factors are easier or more beneficial to focus.	LOE: Level 5
Montgomery, A., et al. (2019)	Design: Meta-analysis. Setting: Hospitals. Sample: Forty-five articles and official guidelines from healthcare organizations.	The collection of strategies from various peer-reviewed or governmental sources is utilized, yet no data on its origin is provided.	Different strategies for improvement are synthesized and presented for the readers, with the prevalence of team-oriented approaches noted.	Strengths: Environmental factors are taken into consideration throughout the article. Weaknesses: The methods for study selection are not clearly outlined in the article. Conclusions: Assessments of organization-wide levels of stress present solid evidence for anti-stress methods selection.	LOE: Level 4
Prudenzi, A., et al. (2021)	Design: A systematic review. Setting: Different healthcare organizations. Sample: 10 RCTs, 12 pre-post design studies, two ACT meta-analyses.	Studies that focused on healthcare providers were selected from four databases.	The Acceptance and Commitment Therapy (ACT) is the primary focus of this article that is shown to be an efficient tool for reducing stress.	Strengths: Evidence in favor of ACT presents a strong therapy method against stress through study analysis. Weaknesses: The authors note that the methodological quality of studies was insufficient and disallows generalizability. Conclusions: Different types of distress can be analyzed individually yet targeted simultaneously via ACT.	LOE: Level 4
Sultana, A., et al. (2020)	Design: A literature review. Setting: Different healthcare facilities in various regions. Sample: Sixteen studies among 632 nurses.	The articles that address COVID-19 and its related spikes in stress levels among nurses are included.	Evidence-based approaches that worked in the pandemic are analyzed to give a mean score for each intervention’s potential.	Strengths: Reduction in burnout scores in a high-stress situation with the identified methods is supported by evidence for both group and individual scopes. Weaknesses: COVID-19 severely increased the stress levels among nursing personnel, making some statistics oversaturated. Conclusions: The improvement of one’s work environment appears to have the highest impact on performance.	LOE: Level 5
Thomas, C. M., Bantz, D. L., & McIntosh, C. E. (2019)	Design: A case study supported by a literature review. Setting: Nursing faculty. Sample: Sixteen peer-reviewed articles and one nurse for the case study.	An interview with a nurse from an undisclosed nursing educational facility is included alongside an extensive literature review.	Leadership in nursing personnel is shown to take a critical role in organization-wide stress levels.	Strengths: The study includes the discussion of many symptoms of burnout, giving an opportunity to define the necessary organizational changes. Weaknesses: The case presents the work-life balance for a nurse in an educational facility. Conclusions: Recognition of burnout requires the implementation of prevention techniques at different levels of management.	LOE: Level 6

Plan for Implementation

Alas, the current situation at the Advocate Christ Hospital puts its nursing personnel under a high amount of stress, leading to high turnover rates and rampant absenteeism cases. With no burnout prevention strategies in place, this intervention will benefit the hospital despite whether group therapy sessions will be more beneficial or not. Both individual and group therapy will be attempted as a possible mediator for the chronic stress among the local nursing personnel that currently consists of 32 nurses.

Implementation of this project is expected to take a significant amount of time since the reduction of stress levels is not a rapid process. Moreover, nurses will yet remain in a highly stressful work environment that negates a portion of the progress due to the circumstances out of their control. At the core of the successful realization of this project lies the Promoting Action on Implementation Research in Health Services (PARIHS) framework. This concept presents the idea that three primary elements are responsible for a project’s future: evidence, context, and facilitation (Harvey & Kitson, 2020). These parts rely on the proper assessment of involved variables. They include the involved individuals (nurses) and their receptiveness for changes, the support for a project from the facility managerial staff, and the strength of the presented evidence that addresses the need for intervention (Harvey & Kitson, 2020). The specifics of the work environment in the Advocate Christ Hospital must be taken into consideration, especially due to the lack of proper anti-stress practices at this moment. Facilitation will depend severely on the input from both nurses and hospital administration.

Stakeholders

The active stakeholders in the implementation of this project are the nurses of the Advocate Christ Hospital. However, the managerial personnel who will be set onto analyzing and determining the best outcome and working on implementing meaningful changes in the nurses’ anti-stress practices will count as passive stakeholders. The finance department and the human resources department take a significant part in some of the project’s steps, making them passive stakeholders as well.

However, both departments must be presented with sufficient evidence for the project approval first. Aside from the hospital administration, there will be the need to convince nurses to cooperate with each other on the resolution of any disputes that might have arisen during their work that prevent their efficient communication. They will be notified regarding the implementation of this project after its initial approval, as there might be necessary adjustments depending on the resources that the hospital will be willing to provide. The ten charge nurses will be given the necessary explanation of the intervention’s details to convince them of the necessity of this project.

The hospital’s human resources (HR) department can gain a significant benefit from being introduced to the evidence and the outcomes of this program. In case of a successful intervention, group therapy sessions can become a new norm for future nurses who face similar challenges at the workplace, and the HR team can work on its further integration. Furthermore, the positive outcomes of this intervention would decrease turnover rates, giving the HR department more freedom in terms of nurse training programs.

Organizational Fit

This evidence-based project aims to assist the nursing personnel of the Advocate Christ Hospital with establishing the most efficient anti-stress policy. This project aligns perfectly with the mission of the hospital and the unit participating in it. The hospital’s goal is to satisfy the health needs of people, which does not exclude its own personnel from this statement (“Mission, values & philosophy,” n.d.). As the hospital values compassion and cooperation, this project will be a perfect addition to the facility’s policies. Healing is the focus of all the presented sources, which lie at the basis of the hospital’s philosophy (“Mission, values & philosophy,” n.d.). It will alleviate the burden of healthcare personnel and improve the quality of care, which is the final goal of this intervention. At this moment, there are no similar activities that have been performed within the facility. This notion has led many nurses to quit their jobs already, with many more struggling significantly with the high levels of stress.

Barriers to EBP Implementation

There are several barriers to the implementation of a new approach, which lie primarily in the work environment and the hospital’s organizational culture. Currently, there are no measures taken against burnout, leading to a wide array of issues within nursing teams. This notion may lead to an initial lack of confidence in the proposed measures, which need to be reassured via an educational course and promotional materials. Another barrier is the potential unwillingness of nurses to communicate with each other for a prolonged period. Since the Advocate Christ Hospital presents a highly stressful work environment, some nurses may be unwilling to participate in communal therapy and choose to partake in self-care instead. There will be the need to select nurses for each therapy at random to ensure more statistically meaningful results.

Facilitation Strategies for EBP Implementation

It will be critical to conduct measurements of the progress to link the evidence on both individual and group anti-stress techniques and adjust the strategy on the fly. The Maslach Burnout Inventory questionnaire, the Professional Quality of Life Scale questionnaire, and similar tools must be employed during the sessions for continuous assessment of stress levels among personnel (Suleiman‐Martos et al., 2020). Practice change may require significant structural changes, as the current state of the hospital’s work environment leaves nursing personnel in a vulnerable state. Feedback from the participants shall be used by a psychotherapist involved in the process, as well as the HR team, to assess the need for adjustments in the nurses’ schedules.

Resources Needed

There will be the need to provide nurses with the necessary financial resources in order to conduct this intervention successfully. First of all, it is vital to provide a short course with a psychotherapist for training self-care techniques to the self-care group. Another part of the financial expenses is the space and educational resources for group therapy sessions. Meetings among nurses must be conducted within an environment that would promote friendly, assuring conversations and activities. The average length of such interventions takes approximately nine months to produce meaningful results, such as the reduced rates of chronic depression and emotional exhaustion (Aryankhesal et al., 2019). These meetings may be performed on-site, although there might be the need to rent a community space for nurses to feel less stressed by the environmental factors.

Another critical issue that needs to be resolved prior to the implementation of this project is the working hours of nursing personnel that need to be adjusted in order to fit the following intervention. In this hospital, there is a significant deficit of free time among nurses, as there is a constant shortage of personnel. For a team, educational resources must be available for constant checking of the most successful practices. In order to secure these resources, initial proposals must present sufficient evidence at an appropriate scale for this hospital.

Table 2. Estimated Timetable Blueprint for Implementation.

Task	Estimated Date of Start	Estimated Date of Completion	Person Responsible
Reach for the hospital’s administration and present the evidence on burnout effects.	3/1/22 (2 weeks)	3/15/22	– Nursing administration – Student – Clinical nurse specialist – HR department
Gain financial support from the finances department.	3/1/22 (2 weeks)	3/15/22	– Finances Department – Student – HR department
Find a suitable person for the position of a psychotherapist. Select promotional and educational materials for each type of technique.	3/16/22 (2 weeks)	4/4/22	– Off-site psychoterapist – Clinical advisor – HR department
Educate nurses on the importance of anti-stress practices and present them the evidence behind both self-care and communal therapy.	4/5/22 (3 weeks)	4/26/22	– Off-site psychoterapist – Clinical advisor
Conduct a standardized measure of an average stress level using the selected stress scale.	4/19/22 (1 week)	4/26/22	– Off-site psychoterapist – Clinical advisor – HR department
Begin the enrollment in the program.	4/27/22	5/2/22	– Charge nurses – Off-site psychoterapist – Clinical advisor – HR department
Conduct meetings two times a week for nurses who were selected for group therapy sessions Begin self-care therapy among nurses who were taught about self-care techniques.	5/2/22 (24 weeks)	11/2/22	– Charge nurses – Off-site psychoterapist – Unit personnel
Take mid-way measurements on the impact of the proposed stress mediation techniques.	8/2/22 (1 week)	8/8/22	– Charge nurses – Off-site psychoterapist
Make any necessary adjustments in the project.	8/8/22 (3 weeks)	9/1/22	– Charge nurses – Off-site psychoterapist – Unit personnel
Prepare a final report regarding the outcomes of the intervention, including measurements of burnout rates according to the selected scale of stress.	11/3/22 (2 weeks)	11/17/22	– HR department – Student – Chare nurses – Clinical nurse specialist

References

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Barrientos-Trigo, S., Vega-Vázquez, L., De Diego-Cordero, R., Badanta-Romero, B., & Porcel-Gálvez, A. M. (2018). Interventions to improve working conditions of nursing staff in acute care hospitals: Scoping review. Journal of Nursing Management, 26(2), 94-107. Web.

De Oliveira, S. M., De Alcantara Sousa, L. V., Vieira Gadelha, M. D., & Do Nascimento, V. B. (2019). Prevention actions of burnout syndrome in nurses: An integrating literature review. Clinical Practice & Epidemiology in Mental Health, 15(1), 64-73. Web.

DeCaporale-Ryan, L., Goodman, J., Simning, A., Press-Ellingham, L., Williams, L., & Hasselberg, M. (2020). Addressing skilled nursing facilities’ COVID-19 psychosocial needs via staff training and a process group intervention. The American Journal of Geriatric Psychiatry, 28(8), 894-895. Web.

Gray, P., Senabe, S., Naicker, N., Kgalamono, S., Yassi, A., & Spiegel, J. M. (2019). Workplace-based organizational interventions promoting mental health and happiness among healthcare workers: A realist review. International Journal of Environmental Research and Public Health, 16(22), 4396. Web.

Harvey, G., & Kitson, A. (2020). Promoting action on research implementation in health services: The integrated-PARIHS framework. In P. Nilsen & S. A. Birken (Eds.), Handbook on implementation science (pp. 114-143). Edward Elgar Publishing.

Melnyk, B. M., & Fineout-Overholt, E. (2015). Evidence-based practice in nursing and healthcare: A guide to best practice (3rd ed.). Wolters Kluwer Health.

Mission, values & philosophy. (n.d.). Advocate Health Care. Web.

Montgomery, A., Panagopoulou, E., Esmail, A., Richards, T., & Maslach, C. (2019). Burnout in healthcare: The case for organisational change. BMJ, l4774. Web.

Prudenzi, A., Graham, C. D., Clancy, F., Hill, D., O’Driscoll, R., Day, F., & O’Connor, D. B. (2021). Group-based acceptance and commitment therapy interventions for improving general distress and work-related distress in healthcare professionals: A systematic review and meta-analysis. Journal of Affective Disorders, 295, 192-202. Web.

Suleiman‐Martos, N., Gomez‐Urquiza, J. L., Aguayo‐Estremera, R., Cañadas‐De La Fuente, G. A., De La Fuente‐Solana, E. I., & Albendín‐García, L. (2020). The effect of mindfulness training on burnout syndrome in nursing: A systematic review and meta‐analysis. Journal of Advanced Nursing, 76(5), 1124-1140. Web.

Sultana, A., Sharma, R., Hossain, M. M., Bhattacharya, S., & Purohit, N. (2020). Burnout among healthcare providers during COVID-19: Challenges and evidence-based interventions. Indian Journal of Medical Ethics, 05(04), 308-311. Web.

Thomas, C. M., Bantz, D. L., & McIntosh, C. E. (2019). Nurse faculty burnout and strategies to avoid it. Teaching and Learning in Nursing, 14(2), 111-116. Web.