Work-Related Stress
Preventing Burnout, Compassion Fatigue, and Vicarious Trauma

LEARNING OUTCOME AND OBJECTIVES:  Upon completion of this course, you will be able to identify the causes, symptoms, stages, management, and prevention of work-related stress and components of a healthy workplace. Specific learning objectives to address potential knowledge gaps include:

• Define “stress.”
• Describe the potential health impacts of stress.
• Differentiate between burnout, compassion fatigue, and vicarious trauma as work-related stressors.
• Discuss individual and organizational strategies to minimize the effects of work-related stress.
• Explain how stress contributes to suicidal ideation.

INTRODUCTION

As healthcare professionals care for patients, they are challenged by a variety of stressors on a daily basis. These work-related stresses can take a toll on the mind and body of these professionals, which in turn may affect the quality of patient care and outcomes. Work-related stress may also impact job satisfaction, workforce stability, and safety in the healthcare environment (AHRQ, 2022).

Many healthcare professionals work in demanding situations, hold high expectations for themselves, and believe they should be able to handle anything no matter what the challenge. But burnout, compassion fatigue, and vicarious trauma are common risks they may face in their stressful work environment. Fortunately, work-related stress is both “treatable” and preventable. Professionals can learn to cope with different forms of stress by gaining an understanding of stress and stressors, recognizing their signs and symptoms, acquiring skills to manage the destructive effects of stress, and preventing or reducing its impact in the future.

In recent years, healthcare workers have faced the many stresses of dealing with the COVID-19 pandemic, which has exposed them to circumstances that threaten their health, well-being, and ability to work. The pandemic has also greatly stressed healthcare systems throughout the world, and its effects continue to be felt. Although the acute phase of the pandemic has ended, the virus is mutating and still poses a significant threat to life, especially in older adults, infants, and people with pre-existing medical conditions. COVID-19 ranked as the 10th most common cause of death in the United States for 2023 even though this is a decrease from previous years (Manchia et al., 2022; WHO, 2022; CDC, 2024b). (See also “Aftereffects of COVID-19” below.)

UNDERSTANDING STRESS

The alleviation of work-related stress is the responsibility of all healthcare professionals and the institutions where they work. Unless it is managed effectively, stress will continue to have adverse effects on staff as well as patients and visitors.

What Is Stress?

Stress is the body’s response to pressure. It is the feeling of being overwhelmed or unable to deal with physical or mental pressure. It is a state of worry or emotional tension caused by a challenging situation. Everyone deals with stress in different ways. The ability to respond effectively to stress depends on genetics, childhood events, personality, traumatic life experiences, and social and economic circumstances (MHF, 2023; WHO, 2023).

The National Institute for Occupational Safety and Health defines work-related stress (job stress) as the “harmful physical and emotional responses that occur when the requirements of a job do not match the capabilities, resources, or needs of the worker.” Job stress can lead to poor health and even injury (NIOSH, 2024).

Work-related stress is often unavoidable in the healthcare field due to the demands of the work environment. In fact, some work demands may be perceived as acceptable since they may keep healthcare workers alert and motivated. However, when these demands lead to excessive or unmanageable stress, the results can be devastating. It is estimated that healthcare workers experience high stress and burnout at rates up to 70% and that such stress and burnout adversely affect patient care, including increased medical errors, hospital-acquired infections, and length of stay (Rink et al., 2023).

Causes of Work-Related Stress in Healthcare

Healthcare environments are busy and complex. Meeting the needs of patients, some of whom are critically ill or injured, can become overwhelming. Some of the causes of stress in the healthcare profession include:

• Long work hours. Many healthcare professionals work long, 10- or 12-hour shifts and often put in overtime. Additionally, it is frequently hard to leave work on time when shifts end. Shift rotation as well as planned and unplanned overtime can increase job-related stress by triggering such problems as fatigue and inability to plan for activities outside the workplace (e.g., family obligations, pursuit of academic education).
• Workforce instability. Workforce instability refers to unpredictable or unstable availability and retention of staff in healthcare facilities. Instability is caused by a number of issues such as a shortage of skilled workers, burnout, and high turnover.
• Risk of harm. Healthcare workers are at risk from injuries because of the physical work and patient handling. There is also ongoing risk for hazardous exposures to transmissible disease pathogens.
• Putting others first. Many healthcare professionals feel compelled to put the needs of others before their own needs. This can be characterized by a drive to take care of others. Combining this drive with family obligations and, for some, the pursuit of academic education can increase the risk of stress.
• Busy, high-stress environments. Thanks to technology advances, improvements in diagnosis and treatment, patient acuity, and ongoing pursuit of academic or continuing education to increase their knowledge, healthcare professionals’ responsibilities in the workplace have increased significantly over the past several decades. The fast-paced, complex workplace can cause them to feel overwhelmed and stressed.
• Coping with sickness and death. Daily exposure to illness and death, as well as to the emotional toll illness and death takes on patients and families, can be overwhelming and physically and emotionally exhausting. Healthcare professionals may not have time to decompress or grieve over taxing workplace situations.
• Additive effects of stress. Research has established that the cumulative effects of stress impact both family functioning and job performance. Job conditions associated with work-to-family conflict may have broad impacts across the workforce.
• Lack of control. Feeling unable to influence decisions that affect job performance, assignments, work load, and so forth can contribute to burnout.
• Unclear job expectations. Being uncertain of what is expected regarding one’s job performance contributes to burnout.
• Dysfunctional workplace dynamics. For example, if a workplace is affected by bullying, the risk for stress increases.
• Lack of social support. Feelings of isolation at work or at home add to stress.
• Conflict with work colleagues. Poor work relationships with supervisors, peers, or subordinates can lead to job-related stress.
  (CDC, 2024a; ShiftMed Team, 2023; Mayo Clinic, 2023a)

AFTEREFFECTS OF COVID-19

Research shows that the COVID-19 pandemic exacerbated the problems of fatigue, strain, stress, loss, and grief experienced by healthcare workers and continues to do so. Some healthcare workers report symptoms representative of posttraumatic stress disorder (PTSD) as the result of the pandemic (CDC, 2024a). For example, research shows that healthcare workers in Massachusetts experienced high levels of burnout, with nearly 40% of workers reporting that they are planning to leave healthcare within five years and one third of workers under the age of 35 planning to leave within two years (Boston University, 2023; Burrowes et al., 2023).

Research also indicates a 25% increase in the prevalence of anxiety and depression in the worldwide population that was triggered by the COVID-19 pandemic. This increased prevalence of mental health problems coincides with “severe disruptions to mental health services, leaving huge gaps in care for those who need it most” (WHO, 2022).

Necessary support and mental health services must be provided to healthcare workers. Healthcare professionals need these types of support and services to provide the best possible patient care. In addition to necessities such as adequate supplies, updated equipment, and administrative support, adequate and appropriate staffing levels must be met if healthcare professionals are to provide high-quality and compassionate patient care (Burrowes et al., 2023).

STRESS AMONG MANAGERS

It is not only front-line healthcare professionals who deal with stress. Managers face these issues, too. Managers have one of the most demanding jobs in the healthcare setting. They are pushed to increase productivity while simultaneously holding down costs, supporting their staff members, and ensuring the delivery of quality patient care. Recruitment and retention problems have been cited as one of the major reasons that lead to manager burnout. Other frequently mentioned stressors that challenge managers include:

• The need to achieve organizational goals
• The expectation that managers must always show strength, calmness, and confidence at all times
• The need to work tremendously long hours (For example, the average hospital administrator works a 12.5-hour day and additional hours on weekends.)
• Lack of job security, with the average hospital administrator remaining on the job for an average of only 18 months
• Feeling isolated and having no support
  (Green, 2022; Vital Work-Life, 2024)

STRESS AND VIOLENCE

The threat of violence adds to the stress found in the healthcare setting. Workplace violence is defined as violent acts, including physical assaults and verbal threats, that are directed toward people at work or on duty. Healthcare workers are five times more likely to experience a workplace violence injury than other professionals, and the actual incidence of workplace violence is likely higher than reported because violent acts often go unreported (Jones et al., 2023; Menendez et al., 2024).

Risk factors for workplace violence in healthcare settings include:

• Unpredictable behaviors of patients and families
• Organizational and systems factors (e.g., high-stress work environments, staff shortages, and lack of organizational policies)

Horizontal violence, defined as the aggressive and harmful behaviors directed toward coworkers, affects all healthcare professions, especially nurses. These behaviors include actions, words, or behaviors such as bullying, incivility, or hazing. It is estimated that 22%–44% of nurses experience bullying at some point in their professional careers (Jones et al., 2023).

Effective 2022, the Joint Commission published updated standards for the prevention of workplace violence in hospitals. These standards mandate that hospitals manage safety and security risks by:

• Establishing processes for the continuous monitoring, reporting, and investigating incidents related to workplace violence
• Requiring that staff engage in ongoing continuing education and training pertaining to workplace violence
• Creating a culture of safety, including addressing horizontal violence in the workplace
  (Jones et al., 2023; Joint Commission, 2022)

Impacts of Stress

In early research into stress, published in 1946, Hans Selye observed that stress caused patients to suffer physical effects not caused directly by a disease or medical condition. Selye found that stressors may be physical (such as infection, injury, and pain) or psychological (such as fear, anger, and sadness) and that stress also has both physical and mental impacts. Selye described what he called a general adaptation syndrome, whereby the body seeks to maintain homeostasis, or balance. He divided his general adaptation syndrome into three stages (see box below) (APA, 2022; Fishman, 2023; Selye, 1956).

Stress can have a major impact on the physical functioning of the human body. It raises the levels of adrenaline and corticosterone, which in turn increases the heart rate, respiration, and blood pressure, and puts more physical stress on bodily organs. In the short term, this allows a person to perform at levels beyond their normal limits (Chu et al., 2024; Office on Women’s Health, 2019).

Stressors may, at times, lead to a useful response such as helping people to address and move on from fear, disappointment, pain, and emotional distress. Stress may also help individuals deal with challenging situations, such as speaking in public. In these types of cases, stress hormones quickly return to normal as the stress dissipates (Chu et al., 2024).

Too much stress, however, can have a significant physical and mental impact. It can leave the body in a permanent state of “flight or fight,” which leads to feelings of being overwhelmed or unable to cope not only with stress but with activities of daily living (Chu et al., 2024; MHF, 2023).

IMPACTS OF STRESS ON PHYSICAL HEALTH

Stress can have significant negative health impacts on the human body. The impact of stress on cardiovascular status has been well documented. Studies show that workplace stress is a significant risk factor for cardiovascular disease. Stress is linked to obesity, elevated cholesterol, hypertension, heart attack, tachycardia, and stroke (APA, 2022; Corporate Wellness Magazine, n.d.).

Stress causes the muscles to tense, which can lead to headaches, migraines, and generalized body aches and pains. Tension-type headaches are common in women.

Stress is also linked to gastrointestinal problems. Short-term stress can cause nausea, vomiting, or diarrhea. Long-term stress can trigger the development of irritable bowel syndrome (IBS), which is twice as common in women as in men. Additionally, stress can exacerbate IBS symptoms such as flatulence and bloating.

Stress increases the amount of the hormone cortisol, which can lead to overeating. In turn, this causes the body to store fat and can lead to obesity, which is linked to a large number of health issues such as heart disease and cancer (Office on Women’s Health, 2021).

Stress may cause sleep disturbances, such as sleeping more or less than usual. People dealing with stress may feel more tired than usual. They may also clench their jaws or grind their teeth while asleep (Marks & King, 2024).

The respiratory system is also negatively impacted by stress. Stress can cause hyperventilation and shortness of breath, which exacerbates conditions such as asthma and chronic obstructive pulmonary disease (COPD) (APA, 2022).

Stress can also affect reproductive functioning, including a loss of sexual desire and sexual dysfunction. Women who experience chronic or long-term stress are vulnerable to more severe premenstrual syndrome (PMS) symptoms or irregular menstrual cycles. Stress can interfere with the ability of a woman to become pregnant and may also decrease the sex drive. Additionally, women dealing with stress may take longer to become aroused during sexual activity (Marks & King, 2024; Office on Women’s Health, 2021).

Stress may also cause infertility problems in men. Studies have confirmed a link between stress and sperm concentration, appearance, and mobility in semen. It is hypothesized that the release of steroid hormone during periods of stress can decrease both testosterone levels and sperm production (Phoenix Sperm Bank, 2022).

IMPACTS OF STRESS ON MENTAL AND BEHAVIORAL HEALTH

Long-term stress increases the risk for depression and anxiety. In the workplace, in addition to the risk for anxiety and depression, the risk of burnout increases. In an effort to cope with stress, people may turn to substance use to alleviate its effects. Employees who are stressed at the workplace are more likely to take part in unhealthy behaviors such as smoking cigarettes, vaping, alcohol and drug abuse, and poor dietary intake (Corporate Wellness Magazine, 2021; Marks & King, 2024).

Stress can lead to a number of signs and symptoms of mental and behavioral health impacts. Cognitive symptoms may include:

• Problems concentrating or thinking
• Lack of motivation
• Feeling less commitment to work, family, and other responsibilities
• Memory problems
• Lack of self-confidence
• Negative self-perception
• Ongoing anxiety and worrying
• Difficulty making decisions

Emotional symptoms may include:

• Moodiness or feeling more emotional than usual (e.g., grumpy, tearful)
• Feeling overwhelmed and nervous
• Depression
• Restlessness
• Anxiety
• Low morale
• Irritability
• Agitation
• Feelings of hopelessness
• Feelings of helplessness
• Feelings of unhappiness
• Feelings of guilt
• Being unable to relax

Behavioral symptoms may include:

• Changes in appetite and eating patterns
• Exercising less frequently
• Changes in sleeping patterns
• Nervous habits (e.g., biting nails, grinding teeth, tapping one’s foot)
• Increase in use of caffeine, cigarettes, alcohol, or other drugs
• Neglect of family
• Neglect of work responsibilities
• Decline in productivity
• Avoiding friends and family

(APA, 2022; CAMH, n.d.; Marks & King, 2024)

COMMON STRESS-RELATED CONDITIONS

Work-related stress in the healthcare profession commonly manifests in one of several distinct, identifiable conditions. These include:

• Burnout: A syndrome that results from unmanaged chronic workplace stress (WHO, n.d.). Burnout has been defined as “a state of emotional, mental, and often physical exhaustion brought on by prolonged or repeated stress” and is most often caused by work-related problems (Psychology Today, n.d.-a).
• Compassion fatigue: Occurs when healthcare professionals take on the burdens and suffering of patients, leading to ongoing worries and concerns about patients both on the job and at home. Professionals can become so overwhelmed or overempathetic that they go “numb” to patients’ sufferings and experience significant exhaustion both mentally and physically (Videbeck, 2023; Clay, 2022; Psychology Today, n.d.-b).
• Vicarious trauma: Defined as “an ongoing process of change over time that is due to witnessing or hearing about the pain and suffering of other people.” Vicarious trauma occurs when healthcare professionals identify with the pain of others who have dealt with traumatic events and bring their patients’ grief, fear, anger, and despair into their own consciousness and experience (Jefferson Center, n.d.).

Within both healthcare literature and common usage, these terms are sometimes used interchangeably. In general conversation, this may not be an issue, especially if the intent is to share personal experiences or to express concern or empathy. But healthcare providers are more likely to be seeking to understand their reactions or to formulate personal care or prevention plans. In this case, understanding the similarities and differences between these different stress reactions is important.

Burnout

The World Health Organization describes burnout as an occupational phenomenon and defines it as “a syndrome conceptualized as resulting from chronic workplace stress that has not been successfully managed” and “characterized by three dimensions”:

• Feelings of energy depletion or exhaustion
• Increased mental distance from one’s job or feelings of negativism or cynicism related to one’s job
• Reduced professional efficacy

It is important to note that the term burn-out is used specifically in the occupational context and is typically not applied to describe experiences in other areas of life (WHO, 2019).

STAGES OF BURNOUT

Burnout has been described as having five stages:

1. Honeymoon phase
2. Onset of stress
3. Chronic stress
4. Burnout
5. Habitual burnout
   (Hanley-Dafoe, 2024; Integris Health, 2021)

Stage 1: Honeymoon Phase

This phase is characterized by high job satisfaction, energy, and optimism. The employee is committed to the job, energetic, and creative. Although employees may believe that this stage will last indefinitely, job stress is inevitable. Employees should anticipate eventual job stress during the honeymoon phase. Coping strategies should be established in order to support personal and professional well-being.

Characteristics of this phase include:

• Job satisfaction
• Happily accepting responsibility
• High energy levels
• Optimism
• Commitment to the job
• Desire to prove oneself
• Creativity
• High productivity
  (Hanley-Dafoe, 2024; Integris Health, 2021)

Stage 2: Onset of Stress

The second stage of burnout is characterized by an awareness that there are difficult days at work. The effects of the honeymoon phase decrease. Optimism starts to wane, and symptoms of stress begin to appear, including:

• Irritability
• Sleep disturbances
• Trouble focusing
• Reduced social interaction
• Anxiety
• Headaches
• Heart palpitations
• Short-term blood pressure spikes
• Fatigue
• Changes in appetite
• Forgetfulness
• Inability to enjoy activities outside of work
  (Hanley-Dafoe, 2024; Mayo Clinic, 2022; Integris Health, 2021)

Stage 3: Chronic Stress

In the third stage of burnout, chronic stress develops. Symptoms from stage two become more intense, and additional symptoms develop, including:

• Persistent fatigue
• Missed work deadlines
• Procrastination at work as well as at home
• Resentfulness
• Physical illness
• Social withdrawal
• Anger
• Apathy
• Cynicism
• Decreased libido
• Feeling out of control
• Increased alcohol, drug, or caffeine intake
• Feeling powerless
• Withdrawing from family and friends
  (Hanley-Dafoe, 2024; Integris Health, 2021)

Stage 4: Burnout

Stage four is actual burnout. Symptoms become critical, and one’s ability to cope is crumbling. It is harder to deal with the responsibilities of work and life, leading to overwhelming physical, emotional, and mental exhaustion. Professional mental health counseling is essential at this stage. People in stage four may exhibit:

• Obsession over problems at work or in life
• Self-doubt
• Physical symptoms increasing in intensity
• Social isolation
• Chronic headaches
• Chronic gastrointestinal problems
• Neglect of personal needs
• Desire to move away from work or friends and family
• Desire to escape from society
• Cynicism
  (Hanley-Dafoe, 2024; Integris Health, 2021)

Stage 5: Habitual Burnout

The final stage, habitual burnout, is characterized by the ongoing mental or physical problems described above. Feelings of chronic mental and physical fatigue may prevent someone from working, which can place their job in jeopardy. Additional symptoms may include:

• Chronic sadness
• Depression
• Chronic mental and physical fatigue
  (Hanley-Dafoe, 2024; Integris Health, 2021)

RISK FACTORS FOR BURNOUT

Job burnout is caused by many interactive factors; some are due to the personality and lifestyle of the individual and others due to the work environment.

Individual Risk Factors

Individual risk factors for burnout mirror many of the individual risk factors noted in other sections of this course. Work-related risk factors for burnout include:

• Lacking control over one’s schedule, assignments, and workload
• Having unclear expectations about one’s job
• Working long hours (e.g., 12-hour shifts, overtime, being called in when staffing is short, finding it difficult to leave work when the shift is over, being on call)
• Working in busy, high-stress environments
• Lacking the skills needed to do the job
• Lacking social support (isolation)
• Having a work-life imbalance
  (Cleveland Clinic, 2021; Mayo Clinic, 2023a)

Individual personality traits can affect the stress response, which, in turn, can influence the risk for burnout. Many organizations use the Five Factor Model of personality to evaluate job candidates and predictors of burnout. Findings from the majority of studies suggest that the factors of neuroticism, extroversion, openness, agreeableness, and conscientiousness are personality traits that may partially determine stress response and vulnerability to burnout (Lovering, 2022).

• Neuroticism: Neuroticism is defined as a tendency toward anxiety, depression, self-doubt, and other negative feelings. Emotional stability is low. Neuroticism is linked to increased vulnerability to stress (Psychology Today, n.d.-d.).
• Extroversion: Extroversion is a measure of how sociable, outgoing, and energetic someone is. It is typically associated with someone who seeks out excitement and social interactions. Extroverts may be more likely to seek social support when dealing with stress compared to those who are introverted. Extroversion is associated with lower self-reported stress in response to initial stress exposure (Criteria, 2023; Lovering, 2022; O’Riordan et al., 2023).
• Openness: Openness is described as being creative, imaginative, and looking for new experiences. Openness is typically associated with lower stress, while being “closed” is linked to vulnerability to stress (Criteria, 2023; Lovering, 2022).
• Agreeableness: Agreeableness is a reflection of how well people get along with others and how they might interact with team members. It is associated with a lower tendency for self-reported stress, depression, and anxiety (Criteria, 2023; Lovering, 2022).
• Conscientiousness: Conscientiousness is a measure of how careful, deliberate, self-disciplined, and organized someone is. Conscientious people are planners and meet their responsibilities. Although conscientiousness is generally associated with ability to cope with stress, people who are overly conscientiousness (e.g., sacrificing time with friends and family to focus on work) may experience more stress (Criteria, 2023; Lovering, 2022; Psychology Today, n.d.-c.).

Organizational Risk Factors

Increasing attention is being paid to the organizational environment and the development of burnout. Researchers have identified the following organizational risk factors for burnout among healthcare professionals:

• Work process inefficiencies (e.g., computerized order entry and documentation)
• Excessive workloads/caseloads
• Inadequate staffing
• High turnover rates
• Long working hours
• Bullying
• Shift rotation
• Unrealistic goals for employees
• Being assigned tasks outside competency level
• Dysfunctional workplace dynamics
• Unclear job expectations
• Organizational climates characterized by high levels of role overload (when an individual is called upon to fulfill multiple roles simultaneously but does not have the resources to do so) and role conflict
• Lack of opportunities for professional growth
  (Davis, 2024; Pistoia, 2022; Mayo Clinic, 2023a)

Compassion Fatigue / Empathy Distress Fatigue

The ability to feel what someone else is experiencing or to “put oneself in another person’s shoes” is generally considered to be an essential characteristic of healthcare professionals. However, the ability to relate to and care for others has its limits. Surpassing these limits can result in negative emotions and compassion fatigue or empathy distress fatigue (Cleveland Clinic, 2021).

Compassion fatigue is a term used to describe a state of deep emotional exhaustion resulting from repeated exposures to traumatic situations, hearing about the traumatic experiences of others, or providing care to patients who have had to deal with traumatic situations. This type of exhaustion reduces the healthcare professional’s ability to feel empathy for their patients, family, and coworkers. Compassion fatigue occurs when dealing with these traumatic patient situations start to affect thoughts, moods, and well-being outside of work (WebMD, 2022).

In healthcare, empathy distress fatigue is another term for the emotional and physical exhaustion that occurs when healthcare professionals care for people day after day under extremely stressful conditions (Cleveland Clinic, 2021).

RISK FACTORS FOR COMPASSION FATIGUE

Both individual and organizational issues contribute to compassion fatigue. Some of these overlap with the risk factors for burnout described earlier in this course.

Individual Risk Factors for Compassion Fatigue

Healthcare professionals at greater risk for compassion fatigue include those who:

• Are in situations where they fear for their safety or the safety of their patients
• Have a lack of or are separated from personal support systems
• Perform physically difficult or exhausting tasks
• Face long-term exposure to overwhelming job demands
• Have a heavy workload
• Do not get enough sleep
• Have substance use issues
• Are exposed to anger or lack of gratitude
• Have excessive empathy
• Feel helpless to deal with work circumstances
  (Thomas, 2022; Cleveland Clinic, 2021)

Others at high risk for compassion fatigue are healthcare professionals who form close, personal relationships with patients or families, especially when personal boundaries are crossed. Sometimes, in an effort to be supportive and empathetic, healthcare professionals begin to slowly cross professional boundaries without actually being aware of what they are doing. Every relationship between a patient and a healthcare professional must be based on the premise of professional behavior.

Organizational Risk Factors for Compassion Fatigue

Anyone who works in a difficult work environment is at risk for stress-related conditions, including compassion fatigue. Organizational factors that contribute to a difficult work environment include:

• Lack of managerial support
• Failure to be recognized for contributions to the workplace (e.g., patient-care outcomes)
• Rotating shifts
• High turnover rates
• Changing job assignments
• Long working hours
• Asking employees to do more with less
  (Davis, 2024; Thomas, 2022)

SIGNS AND SYMPTOMS OF COMPASSION FATIGUE

Symptoms associated with compassion fatigue include:

• Feeling bored with work
• Feeling exhausted most of the time
• Self-medicating with drugs or alcohol
• Feeling detached and distant from patients and colleagues
• Conflicts in interpersonal relationships
• Being irritable and short-tempered
• Difficulty sleeping
• When off duty, worrying about things that may have been forgotten at work or thinking about disturbing events that took place at work
• Mental and physical exhaustion
• Headaches or backaches
• Nausea, especially when going to work
• Substance abuse
• Loss of self-confidence
• Mood swings
• Cognitive impairment (e.g., memory issues, difficulty focusing)
  (Davis, 2024; Cleveland Clinic, 2021)

Vicarious Trauma

Vicarious trauma occurs when healthcare professionals experience secondary traumatic stress reactions triggered by helping, or wanting to help, traumatized patients and families. It is a process of change due to empathetic engagement with survivors of trauma. Anyone who behaves empathetically with survivors of traumatic incidents is at risk for vicarious trauma. Vicarious trauma refers to negative changes in the healthcare professional’s view of self, others, and the world that occur as a result of repeated empathetic involvement with patients’ traumas. Vicarious trauma tends to make it difficult to focus and perform duties as assigned (BMA, 2024).

RISK FACTORS FOR VICARIOUS TRAUMA

Individual Risk Factors

Vicarious trauma is influenced by individuals’ personal experiences with traumatic events that have impacted them, their family members, or close friends. Such personal experiences can make someone more vulnerable to vicarious trauma. People are also at risk for vicarious trauma if others who work with them are experiencing the phenomenon, thereby becoming a negative influence on those around them. That is, vicarious trauma can “spread” from one person to another (BMA, 2024; Kane, n.d.).

Persons who work in helping professions are especially vulnerable to vicarious trauma as well as compassion fatigue. Factors that place an individual at high risk for developing either vicarious trauma or compassion fatigue include:

• Personal history of trauma
• Caring for patients who have suffered trauma
• Repeated exposure to patients’ narratives of trauma
• Preoccupation with the traumatic stories of the people they care for and work with
• Displaying emotional symptoms of anger, grief, mood swings, anxiety, or depression (which may also indicate that the person is already experiencing vicarious trauma)
• Experiencing physical issues related to stress (e.g., headaches, fatigue, gastrointestinal problems) (which may indicate that the person is already experiencing vicarious trauma)
• Having difficulty maintaining professional boundaries
• Overidentification with the patient
• Becoming emotionally involved with the patient
• Experiencing bystander guilt, shame, or feelings of self-doubt
• Experiencing feelings of powerlessness, hopelessness, and disillusionment
  (BMA, 2024; Kane, n.d.)

Organizational Risk Factors

A workplace that fails to support its employees increases the risk for vicarious trauma. Specific organizational factors that increase the risk of vicarious trauma in the workplace include:

• Failing to acknowledge the problem and develop a strategy for reducing it
• Failing to provide support services (e.g., mental health resources) to staff who are experiencing patient/family trauma
• Failing to create an environment where persons experiencing vicarious trauma can acknowledge it without fear of ridicule or job compromise
• Failing to know what vicarious trauma is, what strategies can prevent it, and what actions are needed to help those experiencing it
• Failing to acknowledge that managers and supervisors also experience vicarious trauma and require appropriate support
• Failing to provide adequate staffing, equipment, and communication with management
• Failing to recognize the symptoms of vicarious trauma
  (BMA, 2024; Sutton et al., 2022)

SIGNS AND SYMPTOMS OF VICARIOUS TRAUMA

Among the physical manifestations of vicarious trauma are anorexia and direct gastrointestinal (GI) symptoms such as nausea, stomach pain, and diarrhea. If the person reacts to this GI upset by not eating or eating less than usual, fatigue and reduced energy can result. Paradoxically, both insomnia and hyperactivity are also possible. Headache and chest pain may present (Joyful Heart Foundation, 2022).

Psychological signs may present as exaggerated forms of a person’s usual behavior or as reactions not usually seen, at least in the workplace. As the situation continues, these responses may become more frequent, stronger, or require less and less to trigger them.

Among the common presentations of vicarious trauma are the following:

• Irritability, anger, resentment, or cynicism
• Feeling that no matter how much one tries or gives, it is never enough
• Feelings of hopelessness and helplessness
• Feeling disconnected from emotions
• Difficulty in seeing multiple points of view or new solutions to problems
• Having intrusive thoughts or images related to the traumatic events seen or heard about
• Absenteeism from work
• Isolating from family and friends
• Avoidance of work, responsibilities, or engaging in interpersonal relationships
• Dread of activities that used to be positive
• Lacking a personal life outside of work
• Using food, alcohol, or drugs to respond to the trauma
• Extreme concern about the safety of loved ones
  (BMA, 2024; Joyful Heart Foundation, 2022)

CREATING A HEALTHY WORK ENVIRONMENT

The causes and prevention of stress are interrelated, involving both workers who suffer burnout and the environment in which they work. To prevent stress, employers must identify and address workplace factors that cause stress while individuals similarly must identify and resolve stress-producing issues in themselves. When healthcare professionals and their organizations both address these matters then both benefit. Individuals experience less stress, and organizations maintain a staff that provides patients with the highest quality care.

What Organizations Can Do to Improve the Work Environment

Decreasing stress and the trauma it causes is an organizational challenge and requires consistent effort on the part of those in leadership positions. This is not an easy task, and some members of leadership may resist recommended strategies. However, organizations must recognize the threat of healthcare stress and burnout and their consequences. When employees suffer from stress and become cynical, detached, and exhausted, productivity is reduced, standards are compromised, and the reputation of the organization is diminished. This is particularly true of service industries such as those that provide healthcare.

Providing assistance and effective interventions to protect healthcare professionals from the effects of workplace stress are of prime importance in addressing this stress on an organizational level. The Patient Safety Network (PSNET) has identified the need for strategies addressing individual, work unit, organizational, and national factors across seven domains:

• Workload and job demands
• Efficiency and resources
• Meaning in work
• Culture and values
• Control and flexibility
• Social support and community at work
• Work-life integration
  (Yellowlees & Rea, 2022)

Leadership must be aware of these domains and incorporate them as a foundation for their policies and practices regarding stress and burnout.

RECOGNIZING STRESS

Positive organizational climates are characterized by ensuring that employees have the necessary support (e.g., staffing, equipment, orientation) to provide safe patient care. In order to establish such a climate, organizations must address the factors that lead to stress and burnout. It is important that an organization’s senior leaders:

• Know the different forms of workplace stress, including burnout, compassion fatigue, and vicarious trauma
• Understand the impacts of stress on both the organization and employees, how to recognize stress, and how to prevent it
• Ensure that mental health services are available to employees, since mental health interventions can help alleviate workplace stress
• Evaluate the working climate of the organization on a regular basis, soliciting input from all employees
• Initiate education and training on the topics of burnout, vicarious trauma, and compassion fatigue
  (BMA, 2024; Thomas, 2022; NCADV, 2018)

The American Heart Association (2023) surveyed working adults to identify best practices to combat burnout and promote employee mental health. Nine employer practices were identified:

• Assess alignment between skillset and job tasks.
• Establish clear roles and responsibilities.
• Regularly assess workloads.
• Design job roles with employee input.
• Establish a training path to develop employee skills.
• Assess whether employees feel supported to lead a healthy life.
• Promote overall employee well-being.
• Discourage work-related technology use after hours.
• Promote employee support (resource) groups.

IDENTIFYING INSTITUTIONAL ISSUES

To prevent burnout in employees, managers in organizations also work to identify the specific institutional issues that create stress and then take measures to alleviate them, namely:

• Unclear job descriptions
• Unreasonable job expectations
• Ambiguous chain of command
• Scant recognition and rewards
• Chaotic or high-pressure environments
• Destructive interpersonal dynamics
• Mismatch of employee strengths with work assignments
• Dubious ethical practices regarding honesty, integrity, kindness, respect, and confidentiality
  (CDC, 2024a; NCADV, 2018; Office for Victims of Crime, n.d.)

Management is recommended to ask—and act upon—the following questions as a strategy to prevent caregiver burnout:

• Workload. Are job expectations reasonable? If not, how can they be changed to match the need? Are job descriptions current, clear, and accurate? Is there a mismatch between employee strengths and work assignments? Is the work environment chaotic or high-pressured? If so, how can it be moderated to reduce worker stress?
• Control. Is the chain of command clear and understandable? Does it foster efficiency, collegiality, and fulfillment of the organization’s mission? Is it being followed? If not, why not?
• Rewards and recognition. Are performance standards clearly stated and known by employees? Are workers recognized and rewarded for meeting their performance standards? What else can the organization do to support and encourage employees?
• Social community. Is there a positive, collegial work environment? If not, what is hampering its development? What can the organization do to foster a cooperative, supportive environment?
• Fairness. Do workers feel they are treated with respect and fairness? Are work schedules flexible enough to get the job done yet meet the needs of staff members? Is there a fair wage for every category of worker? How do wages compare to other similar organizations?
• Values. Is the institution known for its integrity? Are the ethical principles of honesty, respect for human dignity, benevolence, autonomy, and justice encouraged and rewarded?
  (ANA, 2024; Mayo Clinic, 2023a)

PROVIDING EDUCATION AND TRAINING

All employees require adequate education and training to achieve and maintain competency at work. Formal and informal training can prepare workers to face the unique stressors involved in working in the healthcare profession. Ongoing education and training about stress and how to deal with it are essential, and the benefits may include:

• Improving patient care
• Enhancing professional growth
• Enhancing personal growth
• Keeping knowledge up to date
  (NHA, 2024)

Leaders as well as staff members should attend education classes on workplace stress and other conditions such as burnout, compassion fatigue, and vicarious trauma.

ADDRESSING BURNOUT AMONG MANAGERS

Burnout, exhaustion, and frustration with reimbursement have been identified as reasons why nurse managers consider leaving their managerial jobs. Additional reasons that nurse managers give for burnout among those in leadership roles include:

• Ongoing staffing shortages
• Financial constraints
• Spending 60%–80% of their time on recruitment, staffing, and scheduling
• Increasing patient and family complaints
• Seeing nurses struggle with mental health issues
• Lack of work-life balance
• Guilt in knowing not enough is being done to help staff nurses cope with job stress
• Struggling to project a positive image
• Increasing patient volumes
  (Sherman, 2022)

Survey results have identified several best practices in helping nurse managers fight burnout. These include:

• Interacting with other leaders to share best practices
• Receiving chief nursing officer (CNO) commitment to help nurse managers set boundaries (e.g., not reading emails when off duty, reducing required meeting attendance)
• Establishing manager mentor programs
• Developing the role of assistant managers who are not in the staffing count
• Establishing weekly nurse manager support groups
• Using interim managers when nurse managers are on vacation
• Developing nurse leader strategies to deal with a changing workforce that consists of multiple generations
• Establishing nurse leader appreciation days
  (Sherman, 2022)

Many of these recommendations are also appropriate to other types of healthcare professionals.

What Individuals Can Do to Improve the Work Environment

A positive work environment is linked to better patient outcomes and job satisfaction for healthcare professionals. Walden University (n.d.) offers the following suggestions for ways in which individuals can help improve the work environment.

• Communicate effectively. Be assertive, not aggressive or combative.
• Encourage collaboration. Collaboration with colleagues promotes job satisfaction and reduces turnover.
• Use good decision-making techniques. Become part of clinical and operational decisions.
• Support recruitment and retention efforts.
• Encourage recognition for a job well-done. Recognition can come from colleagues as well as management.
• Improve the environment by example. Colleagues can learn from one another. This is especially true when healthcare professionals exemplify positive work-related behaviors.

INDIVIDUAL ACTIONS TO ADDRESS AND RECOVER FROM WORK-RELATED STRESS

Strategies to address work-related stress include the following:

• Applying prevention strategies in the workplace
• Employing problem-solving strategies
• Practicing assertiveness
• Practicing self-care
• Taking a break and getting help
• Identifying and grieving for losses
• Confronting denial and cynicism
• Acknowledging one’s limitations
• Establishing personal boundaries
• Talking openly about how job stress affects well-being and job performance
• Identifying and accepting things that are out of one’s control
• Employing healthy living strategies (e.g., regular exercise, eating healthy, not smoking)
  (CDC, 2024a; Mayo Clinic, 2023a)

Applying Stress-Prevention Strategies in the Workplace

It is vitally important for healthcare workers to be active in taking good care of themselves while on the job. The following are recommendations to help reduce or prevent stress in the workplace:

• Make a list of work demands/responsibilities, prioritize them, and determine the time needed to complete them.
• Look for opportunities to acquire new skills and participate in continuing education.
• Take breaks and meal times in order to relax and refresh one’s ability to go back to work.
• Get outdoors in the sunlight or take a short walk to improve energy and focus.
• Connect with coworkers, even if it is just a greeting at the beginning and end of one’s shift.
• Pace oneself and monitor for excessive fatigue, irritability, poor focus, or anxiety.
• Take time to breathe slowly before entering a patient room or a work area, since slow breathing is calming and helps the body cope with symptoms of stress.
• Reframe anxiety-provoking statements (e.g., say, “A great many people get sick and recover” instead of “I might get sick and die”).
  (BMA, 2024; CDC, 2024a; Workplace Strategies for Mental Health, n.d.)

Employing Problem-Solving Strategies

Problem-solving is especially difficult for individuals who are stressed because they are emotionally and physically exhausted. Nonetheless, when individuals employ such strategies, they can help prevent the negative impacts of stress. Four common steps in problem-solving are as follows:

1. Define the problem. Ask, “What work-related area is causing me stress?” If there are several problem areas, prioritize the list and address the one most amenable to solution. The goal is to identify the problem, not the symptoms of the problem.
2. Generate alternative solutions. Consider multiple alternatives. Do not become focused on only one way to solve a problem.
3. Evaluate and select an alternative. Choose an alternative that will solve the problem without causing other problems, will be accepted by the individuals involved, can likely be implemented, and fits within organizational goals and constraints.
4. Implement and follow up on the solution. Establish a process to evaluate and measure the effectiveness of the alternative chosen.
   (ASQ, n.d.)

Practicing Assertiveness

Many individuals who experience burnout cite working conditions such as inadequate staffing or lack of manager or collegial support. In order to deal with these types of difficult situations, it is important to be able to communicate concerns clearly without becoming angry and accusatory.

If the problem is with staffing, for example, do not start by blaming the manager. Always come prepared with recommendations for helping to defuse the problem (Mayo Clinic, 2024). Do not, for example, simply demand that more staff be hired. There may be budgetary constraints or lack of qualified candidates. What actions could the staff take, working as a team, to resolve these issues? How should communication take place?

Make sure not to engage in negativity or complaining about managers or colleagues. Negativity spreads rapidly, may cause people to become aggressive and have hurt feelings, and generally does nothing to help the situation. Consider that it is important to:

• Avoid complaining. It may be tempting to vent frustrations at work, but one’s comments will be spread among colleagues and probably exaggerated. Complaining may also result in receiving some of the blame for current work-related difficulties and lead to a reputation as a complainer. Vent frustrations and concerns to trusted friends or family members outside of the workplace.
• Follow the chain of command. Most, if not all, organizations have a chain of command for expressing concerns and proposing solutions. This usually means starting with one’s immediate supervisor. It is important not to bypass the immediate supervisor and go to the next person in the chain of command unless one has already followed the organization’s policies and procedures for problem resolution. In cases where one may think, “But the supervisor never listens to anything I have to say,” it can be useful to analyze the way one is approaching the supervisor: Do you ask in advance to have a particular topic addressed during a staff meeting, or do you surprise the manager with unexpected complaints? Are you aggressive instead of assertive in your communication (see box below)?
• Promote a healthy work environment. Voice your concerns skillfully to your manager and cooperate with your coworkers on addressing areas for improvement.
• Analyze your communication style. Aim to come across as confident and assertive, not angry and aggressive. Before you walk into a staff meeting, consider constructive ways to contribute. For instance, if staffing issues are on the agenda, begin by making recommendations to deal with current shortages.
  (Mayo Clinic, 2024)

It may be challenging to maintain assertiveness. Assertiveness training can help enhance confidence, improve problem-solving skills, and increase one’s ability to improve the workplace environment.

DIFFERENTIATING BETWEEN ASSERTIVENESS AND AGGRESSION

Assertive	Aggressive
(Perry, 2024; Arocho, 2021)
Stating opinions while being respectful of others	Attacking or ignoring others’ opinions
Speaking in a calm tone of voice and actively listening to the opinions and concerns of others	Interrupting and talking over others, often in loud, even shouting, ways
Making good eye contact	Frowning and staring at others in an attempt to make them uncomfortable and/or intimidate them
Having a relaxed posture and respecting others’ personal space	Displaying a rigid posture, crossing the arms, and invading the personal space of others
Remaining calm	Shouting and losing one’s temper
Listening respectfully to what others have to say	Ignoring others or discounting what others say
Adopting a problem-solving approach so that all parties involved in conflict or problem resolution come to an agreement that benefits, as much as possible, everyone involved	Wanting to “win”; seeing only one’s own point of view and wanting to achieve it without caring if others are hurt in the process; not looking at the whole picture to benefit everyone

Practicing Self-Care

Self-care means caring for oneself. When people who are burned out finally stop and get help, they are beginning to nurture themselves. Self-care is a conscious awareness of personal needs, with the focus on taking responsibility for oneself.

Ultimately, such self-nurturance is a measure of maturity. It means taking care of one’s own basic needs for survival, safety and security, belonging and affection, respect and self-respect, and self-actualization. Practically speaking, self-care means creating a healthy lifestyle, finding a good work-life balance, and engaging in self-actualizing activities. Strategies include:

• Making a life beyond work by engaging in nonwork activities and developing interpersonal relationships outside of the workplace
• Maintaining a healthy diet and participating in regular exercise (e.g., biking or walking to work if possible)
• Avoiding alcohol, drugs, and excessive amounts of caffeine
• Getting an adequate amount of sleep
• Keeping up connections with friends and family, since meaningful interactions with loved ones is important for well-being
• Asking for help from a support network of friends, families, and colleagues in order to problem-solve together
• Evaluating other career options
• Seeking out services from a mental health professional when needed
  (BMA, 2024; Mayo Clinic, 2024; Cleveland Clinic, 2021)

Taking a Break and Asking for Help

Stressed individuals may find that they have used up their emotional and physical reserves. When people acknowledge they are stressed, they need to take a break and get help. It is important that healthcare professionals realize that taking care of themselves is the most important step for them to continue to care for others.

It is normal to feel anxious when needing help from a supervisor or colleague, because one may fear receiving unwanted advice, shaming, or rejection. All relationships benefit when people admit they are struggling and express their needs. This allows others to do the same. It is important for healthcare professionals to acknowledge when they are hurting and to return support and caring to colleagues as well as patients (Mayo Clinic, 2023a).

Identifying and Grieving for Loss

As burned-out individuals scrutinize each part of their story, it is not unusual to find that one or more of the pieces is a jagged, unhealed, unresolved loss. That loss may be their reputation, a cherished loved one, a prized possession, their health, an opportunity, or some other treasured thing.

When unresolved bereavement is a factor in burnout, it is important to engage in what some call grief work. This is an emotional process through which bereaved individuals re-experience their loss, loosen the ties to it, and gradually adjust to life without the cherished person, item, or situation. To facilitate the grieving process, individuals set aside a time to grieve during which they allow themselves to re-experience the loss. At the end of the allotted time, they “close the book,” dry their tears, and return to activities of daily living. They do this repeatedly and over time. Such grief work facilitates a separation from what has been lost (Joyful Heart Foundation, 2022).

Confronting Denial and Cynicism

When individuals are in positions of high stress and overwhelming anxiety, they may not realize just how stressed they have become. They may insist they can “handle it,” whatever “it” may be. Over time, they become distraught, distrustful, and skeptical of the goodwill of others. They may attempt to protect themselves with a defense of cynicism and denial. This does not work because denial is a lie they tell themselves.

When people confront the truth and admit their exhaustion, cynicism, and vulnerability, they open the door to health and healing. In fact, truth does set people free. As soon as they accept themselves just as they are, honestly admitting their frailty, failures, and fatigue, they are relieved of the burden of being perfect and are able to replace denial, cynicism, and fear with acceptance, joy, and hope (Thomas, 2022; Mayo Clinic, 2023a).

Acknowledging Limitations

Often, individuals who are burned out have been trying to be “super-beings.” They have been strong and accommodating, worked diligently, and persevered no matter what was asked of them. Things are different now. When people reach the end-stage of burnout, they must admit that they are not super-beings; they are human beings and have limits. These limits may be different from other people, but they are real for that individual. As with denial, when people admit they are less than perfect, they are wonderfully liberated. In the future, they will be better equipped to heed the signs and symptoms of emotional and physical exhaustion (Mayo Clinic, 2023a).

Establishing Personal Boundaries

Setting personal boundaries means knowing who you are, where you begin and where you end, and when to say, “This is my responsibility and that is yours.” Typically, healthcare professionals are empathetic, understanding, and nurturing. When individuals fail to maintain personal boundaries, they may exercise inappropriate control over others and become unwittingly codependent (Mayo Clinic, 2023a; NCSNB, 2018).

STRESS AND SUICIDAL IDEATION IN HEALTHCARE PROFESSIONALS

Suicide rates among healthcare professionals have reached staggering levels. Therefore, experts are warning healthcare systems to focus more on emotional support programs designed to reduce stress, burnout, and compassion and empathy distress fatigue (Chard, 2021).

Compared with non-healthcare workers, suicide rates are significantly higher for healthcare workers overall. These findings correlate with research findings that show healthcare workers are at increased risk compared with non-healthcare workers for mental health problems such as mood disorders (Olfson et al., 2023).

Findings have not identified specific healthcare work-related occupational exposures that add to suicidal ideation. For instance, burnout has been associated with suicidal ideation in some, but not all, research studies. Work and home stress have been found to be related with increased suicide risk, while social integration was associated with reduced risk (Olfson et al., 2023).

A study conducted by the University of Michigan determined that the incidence of death by suicide between 2017–2018 (per 100,000) was:

• Nurses: 17.1 (women), 31.1 (men)
• Physicians: 10.1 (women), 31.5 (men)
• General population: 8.6 (women), 32.6 (men)
  (Davis et al., 2021)

Risk Factors for Suicidal Ideation

The risk factors for suicidal ideation can be subdivided into the categories of workplace stressors, home-life stressors, and individual risk factors.

Workplace stressors:

• Shift work/working hours
• Management issues
• Lateral violence (horizontal violence)
• Bullying
• Workplace conflict
• Inadequate preparation for role

Home life stressors:

• Financial stressors
• Relationship stressors
• Drug or alcohol use by self, family, or significant others
• Being the primary caregiver for children or parents
• Lack of an adequate support system
• Violent relationships
• Social relationships
• Family history of death by suicide

Individual risk factors:

• Previous suicide attempt(s)
• History of depression and other mental illnesses
• Chronic illness
• Substance use/abuse
• History of child abuse
• Financial problems
• Legal/criminal problems
• Easy access to firearms and other means of death by suicide
• Feelings of hopelessness
  (CDC, 2024c)

Warning Signs of Suicidal Ideation

The American Foundation for Suicide Prevention has published the following list of warning signs for suicide attempts:

WARNING SIGNS FOR SUICIDAL IDEATION

(AFSP, n.d.)
Verbal comments (topics an individual talks about)	Killing or hurting oneself Feeling hopeless Having no reason to live Feelings about being a burden to others Feeling trapped Having unbearable pain
Behaviors	Increased drug and alcohol use Investigating how to die by suicide Withdrawing from social activities Isolating from family and friends Sleep disturbances Communicating with people to say goodbye Giving away prized possessions Aggression Fatigue
Moods	Depression Anxiety Irritability Humiliation Shame Agitation Anger

It is also important to take note if a coworker has a sudden improvement in mood and behaviors. This may indicate that the person has made the decision to die by suicide and is relieved about the decision.

What to Do When Someone Is Suicidal

Healthcare professionals begin an assessment for potential suicide by asking the individual direct questions about suicidal thoughts or feelings. Asking direct questions will not prompt someone to do something that is self-destructive. On the contrary, it may help the healthcare professional to identify persons at risk for death by suicide. Examples of questions to ask include:

• Are you thinking about hurting yourself?
• Have you ever thought about suicide?
• Are you thinking about dying?
• Do you have a plan to harm yourself?
• Do you have access to weapons or things that can be used to harm yourself?
  (Mayo Clinic, 2023b)

It is also important to be alert to warning signs described previously. If someone is on the verge of death by suicide, immediate help is needed.

• Do not leave the person alone.
• Call 911. The person needs emergency intervention.
• Assess whether the person is under the influence of drugs or alcohol or has taken an overdose.

If someone talks about suicide and suicide is a possibility, help should be obtained from a trained professional as quickly as possible. The person may need hospitalization until the suicidal crisis has resolved. The person is also encouraged to call a suicide hotline number (see “Resources” at the end of this course) (Mayo Clinic, 2023b).

CONCLUSION

Stress and burnout can significantly affect individual healthcare professionals, the organizations for which they work, and the people to whom they give care. Healthcare professionals are at an increased risk for workplace stress because of the demanding nature of the job. By understanding and addressing its causes, job-related stress can be reduced. Both individual and institutional strategies can be employed to address and prevent workplace stress, thereby creating a healthier environment for both healthcare professionals and their patients.