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Nursing perspective: Cognitive overload and burnout in healthcare

My husband first noticed the symptoms. 

I was a new nurse practitioner working for a busy surgical practice. The learning curve was a vertical line. I would come home from each shift and sit on the couch in a vegetative state. The mere thought of deciding what to have for dinner was overwhelming, and I responded to any question with a simple “yes” or “no” answer. I’d crawl into bed exhausted but would lie awake with visions of patients dancing through my brain. Did I remember to chart that critical lab result? What happened to the patient with appendicitis in the ED?

One day, my husband said, “Honey, I think you’re burnt out.” While devastated, recognition was relief as I acknowledged the fact that I was so cognitively and emotionally overloaded that I’d lost my ability to function outside the hospital.

A community in crisis

I turned to my support group of nurses on social media and asked them one question: What symptoms do you experience when you have cognitive overload at work? I received 141 responses. A travel nurse said, “I was losing my humanity” following a year in different ICUs full of COVID-19. Another said, “My focus and concentration have been shot for months. I’m exhausted all the time.” She said it had become hard to make decisions or start new tasks. 

Several pointed out they had to leave nursing altogether due to severe symptoms. One nurse said, “I just needed to stop experiencing the brain fog and the agitation in my life, because I don’t want to keep spreading it to my loved ones when I know that’s not the person I truly am.” Another nurse, who left to go into outpatient administration said, “My squirrel brain is on OT right now. If I don’t write what I’m thinking of down immediately, I forget almost instantly. It doesn’t take much to make me upset, and I was getting bad headaches.” 

And then there were some stories that just broke my heart.  One nurse wrote: “When I leave work each day and get in my car, I just close the door and listen to the silence. Then I come home and drag myself out of the car and go in. Sleep for three hours. Do what I need to do to get ready for another day of work, shower, go to bed, and sleep till the alarm goes off at 4 a.m. No life. Too exhausted. I’m about done.” She’s 26.

What is burnout?

By definition, burnout is a long-term stress reaction marked by emotional exhaustion, depersonalization, and a lack of sense of personal accomplishment. Research on the mental health implications among healthcare workers during the COVID-19 response is still emerging. Yet, risk factors for burnout have been magnified by extremely high demands, lack of control, resource scarcity, and possible ethical dilemmas.

What is cognitive load theory?

Cognitive load theory delves into how our working memory functions. There is a fixed intrinsic cognitive load, which is the ‘weight’ of the data or task as determined by how complex it is for us to process. Then there’s the extraneous cognitive load, which is the mental load imposed by the organization of information. As you’d guess, poorly organized information is harder for us to process.

When considering cognitive load in a real-world setting, think about the EHR and the volumes of data it contains. A Mayo Clinic study found only 60 pieces of information among tens of thousands of datapoints truly mattered for patient care. That’s about 0.1% of the data. This means we need to continue to find ways to find and communicate only the information that really supports treatment decisions.

Epidemic within the pandemic 

Nurse burnout isn’t new, although COVID-19 certainly has made things worse. Prior to the pandemic, Megha K. Shah, MD, MSc, of the Department of Family and Preventive Medicine at the Emory School of Medicine, found that burnout was the reason nearly a third of nurses left their jobs in 2018.

Fast forward to 2021, and ANA Enterprise’s Year One COVID Impact Assessment of more than 22,000 U.S. nurses found that 18% intend to leave their jobs in the next six months, and 21% are undecided about leaving. Forty-seven percent state their decision to leave is due to their work negatively affecting their health/well-being. Similarly, another study shows new levels of nurse burnout in the forms of trauma and PTSD. Of the 12,596 nurses who completed the survey, 13.3% reported trauma and 39.3% experienced post-traumatic symptoms.

Unfortunately, the ongoing nursing shortage is also expected to intensify in the coming years, with a deficit of 510,394 RNs by 2030. Part of this situation is due to the fact that of the roughly 4 million registered nurses (RNs) in the U.S., 500,000 are expected to retire by 2022.

How do we solve burnout in nursing?

If we look back to Maslow’s Hierarchy of Needs, we’re reminded that basic requirements such as rest and security must be met before a person can move on to addressing psychological, relationship, and esteem needs, and ultimately self-fulfillment. When nurses are exhausted, feel their work has depersonalized them, and struggle with cognitive overload for extended periods of time, it’s no wonder the situation is so dire, and many are leaving their jobs. Their basic needs aren’t even being met.

Ultimately, hospitals need to make it far easier for nurses and other clinicians to work on a daily basis. Implementing an intuitive clinical communication platform that makes it easy to find care team members and pull actionable information from the EHR is one step toward removing stress and simplifying information-driven workflows. Even before the pandemic, Mayo Clinic began using ambient intelligence to combat ICU information overload. This helped deliver critical patient data from the EHR to clinicians by sorting through thousands of unnecessary data points to get to those 60 or so details that truly inform care.

Nursing resilience in the face of difficulty

As more healthcare administrators begin to understand the challenges nurses across the country are facing, I’m confident we’ll start to see changes. In the meantime, there are well-being tools and resources that can help. We nurses are resilient, and I hope that highlighting the issue at hand will increase the level of support this community so desperately needs.  As for me, I left clinical practice for several years then went back to another high-stress environment.  Ultimately, I found my calling in medical software, but I still volunteer at a free clinic to make sure I never lose sight of why I became a nurse in the first place.