Addressing Nurse Burnout with Stress First Aid



While career burnout among healthcare workers is not a new concept, nurses were faced with extraordinary new challenges due to the COVID-19 pandemic. As the healthcare professionals who coordinate patient care, nurse case managers encountered a sharp increase in patients and more complex cases, while navigating ever-changing protocols and fewer resources in which to serve those patients.

The World Health Organization’s definition of burnout is a syndrome 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; and reduced professional efficacy (World Health Organization, 2019). However, Dr. Richard Westphal, PhD, RN, PMHCNS-BC, PMHNP-BC, FAAN, professor of nursing at the University of Virginia and creator of the Stress First Aid model, offers an important distinction. “Burnout is not the failure of an individual to cope; it is an expected reaction to unbalanced demands and resources.”

In a December 2022 Pulse on the Nation’s Nurses Survey from the American Nurses Foundation (the Foundation), 46% of case managers who responded to the survey indicated they were experiencing some level of burnout, including 5% who are “completely burned out, and may be in need of help.” Forty-seven percent of case managers are planning to or are considering leaving their position in the next 6 months. Of those, 40% indicated the reason was because work was negatively impacting their health or well-being, and a quarter of respondents said there were “not enough staff to adequately do my job.” Despite burnout, nurses point to time spent with colleagues as something that strengthens their well-being.

Last year, the Foundation launched a new program to address the occupational phenomenon of burnout and the role peers play in supporting other nurses. The Stress and Burnout Prevention Pilot, made possible by generous support from the United Health Foundation, is a three-year, $3.1 million grant to address well-being and burnout among nurses. It will seek to achieve this goal by increasing nurses’ ability, both individually and in teams, to confront the reality of sustained and excessive stress in the work environment.

The program is based on the Stress First Aid Model, which was originally developed for the military and has since been deployed in other high-stress professions. At its core, Stress First Aid is a framework of peer support and self-care designed to improve recovery from stress and avoid future harm. The model, being adapted through the pilot “for nurses by nurses,” offers a burnout prevention model to normalize nurses’ ability to assess their own well-being and that of their peers, and to utilize mental health resources earlier and more effectively.

“This pilot program goes beyond identification of burnout to intervention by helping nurses speak about their stress and burnout, normalize talking about it, and provide support to their peers so they can return to wellness over time,” said American Nurses Foundation Executive Director Kate Judge.

A central component is a color-coded Stress Continuum that provides nurses with a common language to use regarding stress reactions, which in turn reduces stigma. It utilizes a universal color system that most people can easily recognize—green, yellow, orange and red. Stress responses lie along a spectrum of severity and type, with a green response representing optimal function and wellness and a red response indicating severe distress.

The initiative expands beyond Stress First Aid by implementing three key components with the goal of reaching thousands of nurses across the nation. The first component is infusing a nursing lens into content, imagery and examples to ensure nurses can see themselves represented. The interactive portion of the training, for example, includes vignettes based on real-life situations that nurses face in their daily lives. The second component is engaging four diverse organizations across the country. Nurses from the pilot sites and nationwide are grappling with extraordinary stress, leading to burnout and staffing shortages. To address this, the third component will build national awareness within nursing.

The first cohort of 12 nurse champions at the pilot sites have now been trained and are leading workshops for their peers. These champions have shared early reflections, including how the training has helped them become more aware of their own stress reactions, burnout and personal coping mechanisms. They are also acutely aware of the potential it has for their peers and see the program as a way to help them retain their inspirational spark and passion for nursing. Nurses in the units that received training have shared feedback that “it’s not just another training, but instead is helping us strengthen our team.” Surveys to assess program implementation progress will measure the impact on nurse burnout and turnover between units participating, nurses who are aware of Stress First Aid, and those who are not.

Woven across these components will be a focus on millennial and Generation Z nurses and nurses of color who, according to multiple studies, have been the most negatively impacted by stress and burnout. The December 2022 Pulse on the Nation’s Nurses Survey found that while the entire nursing profession has been impacted by the pandemic, nurses under 35 and nurses of color indicate higher levels of stress, as well as lower states of optimism and emotional health. The program will ensure younger nurses and nurses of color are represented in surveys, focus groups, pilot sites and in the national awareness campaign.

Instead of addressing burnout at the individual nurse level, the program addresses burnout at the system level by transforming organizational culture. “Within the piloting organizations, the program is being built at a unit level because we want teams to work closely with this content, give feedback, and build slow sustainable culture change that can expand across the organization over time,” said Judge.

Addressing burnout is essential to the nursing workforce and directly impacts the level of support and quality of care case managers provide to patients. “Learning from the pilot sites and their experience will enable us to adapt and improve content, making it more relatable to the American nurse while incorporating the goals of reaching younger nurses and nurses of color,” Judge added. By the end of the pilot, the materials and resources will be accessible for free through the Foundation’s website.

Burn-out an “occupational phenomenon”: International Classification of Diseases. (2019, May 28). World Health Organization.

Erin Gilfenbaum is a Program Manager for the American Nurses Foundation Well-Being Initiative, which supports the mental health and resilience of all nurses. She manages the day-to-day operations of the Stress and Burnout Prevention Pilot Program. With over 15 years of non-profit project management and grants administration experience, Erin enjoys building strong relationships with a broad range of stakeholders to bring initiatives from conception to implementation. She has a master’s degree in communication from Johns Hopkins University.



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