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13 Articles in Volume 18, Issue #3
Anger Expression & Chronic Pain
Ask the Expert: Should reliance on gabapentin/pregabalin be limited?
Chronic Pain in Children
Considering Comorbidities When Selecting Medications for Chronic Pain Management (Part 1)
Dousing the Physician Burnout Epidemic: An AMA Perspective
Harnessing the Power of Words
Inside ASRA with David Provenzano, MD
Management of Intrathecal Therapies by Interprofessional Teams
Nurse Burnout in Pediatric Pain Management: A Model and Pilot Intervention
Physician Burnout: An Oldtimer’s View
Reporting Metrics, Media Coverage...Letters from the Minds of Peers and Patients
The Case for Slow-Release Anesthetics
The Impact of Pain Practice

Nurse Burnout in Pediatric Pain Management: A Model and Pilot Intervention

The authors summarize their recent assessment and development of a model intervention aimed at relieving nurse burnout as a result of caring for a pediatric population with chronic pain.

Editor's Note: In spring 2019, the WHO added "burnout" as an official medical diagnosis to the International Classification of Diseases (ICD-11), defining the condition as: feelings of energy depletion/exhaustion; increased mental distance from one's job or feelings of negativism/cynicism related to one's job; and reduced professional efficacy. PPM has covered this subject from the healthcare provider perspective starting with nurse burnout below. See also: The Impact of Pain Practice and the AMA's view.


Burnout consists of physical, emotional, and mental exhaustion that occurs as a reaction to demanding working conditions over an extended period of time.1 Burnout may include a combination of emotional exhaustion, depersonalization (eg, cynicism and lack of empathy), and a decreased sense of personal accomplishment.2 Burnout in healthcare workers may lead to negative attitudes, diminished quality of care and patient safety, and reduced productivity.3 Institutionally, burnout may be costly, as it may lead to tardiness, absenteeism, and difficulty in retaining current and recruiting new staff.4

Nurses working with inpatient youth with chronic pain may be particularly prone to burnout. Nursing this population consists of a number of duties, including educating the patient and family about the condition, symptoms, and coping techniques; providing support and assurance that the experience is common and can possibly be outgrown; and managing a complicated treatment program.5 Compounding the situation, pharmacological interventions do not always provide adequate pain relief.6 Thus, identifying and targeting contributors of nurse burnout is crucial. However, the little work that has been done in this area used samples that combined nurses working across a range of settings and services.

In the authors’ study,7 qualitative focus groups and quantitative questionnaires were held to thoroughly examine nurse burnout within a unit that included pediatric patients with chronic pain. The mixed-methods assessment provided the foundation for a targeted nurse burnout intervention, which is summarized herein.

Assessment of Nurse Burnout

Full details of the assessment are provided in the studies.7,8 In brief, the authors conducted focus groups to discuss burnout among all nurses (n = 33) in the unit. Audiotapes were transcribed, coded, and analyzed. Four internal, person-specific themes (ie, negative beliefs about chronic pain, fear of losing compassion, moral distress, self-efficacy) and four external, environmental themes (ie, barriers to optimal pain management, time in unit, coworker social support, negative views of the hospital environment) emerged. Based on these themes, the nurses completed a battery of questionnaires. Taking into account both qualitative and quantitative findings, the authors proposed a visual representation of nurse burnout related to working with pediatric patients with chronic pain (see Figure 1).

Figure 1. Nurse Burnout Model in the context of chronic pediatric pain (reprinted with author permission7). ^ = relation to burnout supported only qualitatively. * = relation to emotion exhaustion supported by both qualitative and quantitative results. ↑↓ = indicate the direction of the relations with the outcome.


Treatment of Nurse Burnout

Based on the assessment, the authors developed a four-module nurse burnout intervention provided in 90-minute groups with eight to nine nurses per group. A manual detailed talking points and role-play scenarios for each module. A more comprehensive description of the intervention is detailed in the pilot program publication.8 The four modules were self-titled: Pain Reframe, Expert Collaborator, Magic Ratio, and Self-Nursing, each summarized below.

Pain Reframe

The Pain Reframe module included skills nurses could use with their patients to (a) broaden the definition and meaning of pain, and (b) shift the focus from pain to functioning. First, the authors discussed the Gate Control Theory,9,10 highlighting how thoughts, emotions, and behaviors may enhance or diminish pain, and encouraged nurses to appreciate that pain reports might reflect fear, anxiety, and physical sensation. Further, nurses were asked to shift their own definitions of patient success from “pain relief” to “functioning.” Along these lines, each time the children were asked for a 0 to 10 pain rating, the nurses were asked to also prompt children for 0 to 10 rating of success on a non-pain domain (eg, friendship, completing homework).

Expert Collaborator

The Expert Collaborator module emphasized problem-solving and reflective listening. Collaboration among healthcare professionals and between professionals and patients is recommended to encourage patient safety, satisfaction, and healthcare workers’ job satisfaction.11 As a shorthand for remembering the advice, the authors asked nurses to use “RAA”—standing for: “Reflect what is said, Acknowledge the emotion, and Ask for possible solutions.” A key objective was for the patient to increase his/her own responsibility for handling difficulties. This method also helped to shift the nurses’ perceived role from “fixer” to “collaborator,” which the authors hypothesized may minimize the pressure nurses endured when asked to solve difficult or impossible situations (eg, elimination of long-standing pain).

The Magic Ratio

The third module, Magic Ratio, encouraged nurses to minimize complaining or co-ruminating with each other about patients and related challenges. Instead, the authors asked that nurses attempt to focus on positive aspects and gains with patients. Thus, nurses were challenged to state at least two positive qualities about a patient any time that they complained about the patient to a colleague. This intervention was grounded in a strong literature highlighting negative to positive perspectives within marriages, families and parenting, and other interpersonal relationships.


Lastly, the literature has shown that self-care is crucial for reducing the likelihood of burnout.12 The key message from numerous studies is that self-care is effective for reducing emotional exhaustion and increasing patient care. In keeping with these findings as well as the data from focus groups, the Self-Nursing component of the pilot intervention involved educating the nurses about the need to take care of themselves. In addition, each nurse identified and committed to engaging in relaxing or enjoyable activities during the workday (eg, walk-in hospital garden) as well as in their personal lives (eg, massages, bubble baths). Participants identified coworker partners to prompt, check-in, and provide accountability for these self-care goals.

Discussion and Conclusions

In summary, the author’s mixed-methods assessment guided the development of a tailored pilot intervention for burnout in nurses working with pediatric inpatients living with chronic pain conditions. Data suggested that the intervention was feasible and acceptable to the staff. In addition, pilot findings suggested that the intervention might contribute to improvements in some targeted behaviors, such as self-compassion, general health, and burnout in nurses. In contrast, the data indicated little to no improvement in negative chronic pain beliefs, talking to patients about functioning, or discussing positive qualities about patients with coworkers.

These results were not deemed surprising, given the brief intervention, but the authors believe that, with some modifications to improve long-term uptake, more significant change may be possible. For example, the authors recommend including nurse champions, booster follow-up sessions, or other avenues to enhance adherence and maintain enthusiasm for treatment.

Additionally, the study was limited to targeting the nursing staff for intervention as opposed to targeting the institution (eg, staffing based on acuity, reducing patient caseload). The mixed-methods results and available literature indicate that comprehensive interventions should target the individual, unit (eg, clinic), medical institution, related healthcare systems (eg, insurance, accreditation organizations), and national policies.

Finally, while nursing burnout is an important primary target, the authors are optimistic that improvements on this variable may have a host of downstream positive effects on patients, other medical staff, and the system at large. In conducting the mixed-methods analysis and pilot intervention, the authors hope to have spotlighted nurse burnout related to pediatric chronic pain. Overall, these interlinked projects provided an example of how mixed-methodology may guide individualized treatment development in a targeted population.

Last updated on: May 29, 2019
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