Recognizing and Combatting Director of Nursing (DON) Burnout

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Recognizing and Combatting Director of Nursing (DON) Burnout

Burnout is a widespread stress-related phenomenon that impacts personal quality of life and professional success. It is particularly prevalent in healthcare workers, and according to some research, has been shown to impact approximately two-thirds of nurses. The World Health Organization defines burnout as a syndrome caused by chronic workplace stress. Stressors can include long hours, unpredictable schedules, and administrative burden, all of which are characteristic of careers in nursing

Nurses suffering from burnout experience ongoing emotional exhaustion, depersonalization, and a diminished sense of personal accomplishment, which lead to frustration and hindered productivity. Burnout has also been correlated with diminished job satisfaction and poor retention in both nurses and physicians.

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Identifying and addressing nurse burnout is crucial, as it significantly impacts the nurse’s health and quality of life, the quality of patient care they provide, and the success of their organization. Directors of Nursing (DONs), in particular, demonstrate high levels of burnout due to the demanding nature of their positions. DONs must oversee all nursing personnel and patient care and ensure that documentation and protocols are appropriately maintained.

Primary Factors Impacting DON Burnout

Ensuring compliance with state and federal regulations is a critical responsibility of DONs, and burnout can lead to oversight and noncompliance violations, which impact facility success and cause further DON stress and burnout. Properly supporting DONs and maintaining a well-informed team is critical to combatting burnout.

Although burnout symptoms may be mitigated by employing self-care practices and improving workplace communication, eradicating the problem requires organizational commitment and adjustments to healthcare practices. This includes improving mental health resources and emotional education, improving work hours and work-life balance, and reducing administrative burden. 

Reducing nurse migration is also critical to preventing DON burnout, as
staffing shortages diminish facility efficiency and force nursing leaders to the frontlines of patient care. One valuable way to address DON burnout is by ensuring that nurses have adequate staff support. This helps avoid major stressors by reducing the risk of poor patient outcomes, state survey violations, and litigation. Staffing an adequate number of certified wound care nurses is also critical to the skilled nursing facility environment.

Vohra Physicians Work to Alleviate DON Burnout through Improved Wound Outcomes

When nursing facilities partner with Vohra Wound Physicians, the nation’s most trusted wound care solution, they are able to significantly improve patient healing times, decrease re-hospitalization rates, and avoid costly survey violations and wound care litigation. Vohra works with nearly 3,000 Skilled Nursing Facilities across 28 states and helps facilities become Centers of Excellence for Wound Management

Vohra physicians conduct weekly visits to nursing facilities to implement essential treatment protocol and educate nurses on wound care, improving outcomes and regulation compliance. This can decrease DON burnout and improve nurse retention and patient success. Nursing facilities considering partnering with Vohra are invited to contact us

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Identifying DON Burnout

A survey found that approximately 50% of nurses are considering leaving the field for reasons including a demanding workload, exorbitant paperwork, and lack of professional enjoyment, all of which are symptoms of burnout. Nursing staff shortages is another key factor in burnout, as it has led to increased workloads on both nurses and DONs and necessitates an investment in hiring and training new staff. Particularly as we face a global nurse shortage, it is more important than ever to ensure DON job satisfaction and provide DONs with the resources they need to succeed. 

What causes DON burnout?

The most pressing factors contributing to DON burnout are professional responsibility and lack of work-life balance. Although burnout can affect any profession, it is notably experienced by those who do “people-work” such as human services and medicine. This is due to the significant investment required to enter these fields and the often high-stress and emotionally demanding nature of practicing. 

Nurses work long hours, have unpredictable schedules, and provide regular patient care. Nurses must also be continuously prepared for high-stress or emergency situations. 

DONs have a particularly high level of workplace stress due to their immense responsibilities: they oversee all of the nurses and patients within their facility, ensure documentation and compliance with regulations, monitor infection control, and serve as a contact point for nurses, physicians, facility management, patients and families.

Long hours at work also impact DON work-life balance, which can prove damaging to relationships with family and friends. Frustration with personal relationships can perpetuate burnout symptoms and contribute to professional dissatisfaction.

The stigma associated with seeking help for mental health can prevent DONs from receiving the support they need, which further contributes to burnout.
Layoffs in healthcare and nursing shortages are additional stressors.

Is DON burnout increasing?

As nursing facilities face nurse shortages and staffing challenges, DONs are shouldering increased responsibility and facing higher instances of burnout. This is particularly notable during the COVID-19 pandemic. DONs are at the frontlines as nursing facilities implement new restrictions and battle infection control in hopes of avoiding virus spread and preventing compliance violations. Without significant change to the healthcare system and improvement of DON support systems, it is unlikely that burnout rates will decrease.

What does DON Burnout look like?

DON burnout primarily manifests as emotional disruption causing fatigue, frustration, cynicism, and detachment. This can lead to diminished motivation, absenteeism, and feelings of self-doubt and career dissatisfaction. DON burnout symptoms present in both personal and professional settings and lead to impaired relationships and professional performance errors. 


Nurse burnout is associated with increased patient hospitalization rates and poor patient engagement, which negatively impacts patient outcomes and organizational success. The stress associated with burnout can also lead to decreased quality of sleep, which is correlated with impaired critical thinking and poor decision-making. When determining whether a DON is experiencing burnout, notable symptoms are fatigue, altered bedside manner, irritability, and increased desire to be alone.

How is DON burnout measured?

DON burnout is often self-reported, but the most accurate way to determine the presence and severity of burnout is by using a well-being assessment tool such as the Maslach Burnout Inventory or the Nurse Well-Being Index. Some organizations choose to develop their own well-being assessments in order to better calibrate them to the specific needs and challenges of their workforce. 


These assessments determine burnout by asking targeted questions about emotional status, professional satisfaction, and sense of engagement and accomplishment. 

Is burnout a medical condition?

No, burnout is not considered a medical condition. However, it is classified in the World Health Organization’s International Classification of Diseases (ICD-11), the global standard for health assessment. The ICD-11 describes burnout as a syndrome caused by work-related stress and breaks it down into three core components: exhaustion, mental detachment or cynicism, and diminished efficiency. This classification enables mental health physicians to cite burnout as a reason that patients are seeking medical care and/or as a factor contributing to mental health disruption.  It is important to note that although you cannot be diagnosed with burnout, it can lead to other diagnosable mental health disorders such as anxiety or depression. Instances of depression in nurses are twice that of the general population. Identifying and mitigating burnout in nurses and DONs is critical to improving mental health, job satisfaction, and organization and patient success.

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The Impacts of DON Burnout

DON burnout leads to diminished quality of life and higher likelihood of mental health disruptions. For nursing facilities, the costliest effect of DON burnout is impaired patient care and regulation compliance. Burnout has been correlated with decreased patient quality of care and increased risk of medical error. 

Burnout also impacts organization and productivity, which can disrupt documentation and lead to noncompliance with state and federal regulations. Since DONs oversee many aspects of their facilities, when they experience burnout it can have a trickle-down effect that impacts nurses, patients, and the organization as a whole.

The retention of DONs and nurses significantly affects burnout. DONs experiencing burnout are more likely to migrate facilities, and DONs working within a facility with high levels of nurse turnover are more likely to have increased burnout. When DONs are experiencing burnout, they can contribute to nurse burnout within their facility. Nurse burnout leads to instances of medication and charting errors, poor judgement, and failure to communicate.

Nurse migration is also costly: it takes approximately three months and nearly $60,000 to replace one bedside nurse. Maintaining DON health and productivity is a critical factor in preventing nurse burnout and maintaining facility health and success. Nurse and DON burnout is particularly prevalent during the COVID-19 pandemic as health care providers work longer hours, face equipment shortages, and risk their lives each day. 

How can DON burnout impact healthcare facilities?

One critical responsibility of DONs that is impacted by burnout is maintaining compliance with state and federal regulations during CMS State Surveys. CMS compliance ensures patient insurance coverage and prevents costly citations.

When DONs experience burnout, they are more likely to make patient care and documentation mistakes and commit administrative oversight. This can cause facilities to receive federal tags (F-Tags), which are indications of regulation violations. F-Tags impact the overall health rating of a facility, impact facility reputation, and increase the risk of litigation. 

One of the most common F-Tags that nursing facilities receive is F-686, which addresses the prevention of pressure ulcers. F-686 violations can be prevented by careful documentation and physician advocacy. When nursing facilities work with wound physicians, they can reduce the risk of F-Tags and mitigate the risk and impact of DON burnout. Delegating appropriately to nurses with advanced certifications and training can also shift appropriate responsibilities to nursing staff, thus lightening the burden of responsibility for the DON.

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How can physicians aid DON burnout?

Physicians can aid DON burnout by improving patient outcomes and advocating for nursing facilities during state surveys, as these are two significant DON stressors. Specialized wound physicians for example are able to improve patient healing times and instances of rehospitalization, which decreases the likelihood of litigation and reduces DON stress and burnout. These physicians are also able to advocate for nursing facilities during annual state surveys, which helps prevent F-Tag violations and associated penalties.


When nursing facilities partner with Vohra physicians, they see significant increases in patient outcomes and decreases in re-hospitalizations. Vohra physicians also serve as in-house advocates prepared to discuss patient treatment and outcomes with state auditors.


Vohra physicians address patient needs on the day of admission to identify potential causes for citations and visit facilities as often as needed to provide patient care and ensure treatment plans are being implemented. Vohra physicians alleviate DON burnout by preventing citations and providing an outcomes-focused, physician-led approach to wound care.

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Addressing DON Burnout

DON burnout is a widespread healthcare problem that merits significant attention. It impacts DONs as well as their nurses, patients, and healthcare organizations, and can lead to costly oversights and errors. Improving identification and treatment of burnout is a critical step in mitigating these risks and optimizing patient care and organizational success.

How can burnout be prevented?

Medical professionals believe that comprehensive burnout prevention requires significant change within the healthcare system and alignment between care providers and top-level management. Resulting changes can include alterations to schedules, adjustments to electronic documentation procedures, and widespread implementation of emotional resiliency programs and mental health support. DONs can contribute to burnout prevention by seeking change within their healthcare organizations and addressing factors that may lead them to experience burnout.


Individually, DONs can seek to prevent burnout by implementing self-care practices. This can include following a healthy diet and exercise routine, making time for friends and family, and engaging in regular self-reflection. Communicating with superiors and seeking support when needed are valuable ways to address workplace stressors before they lead to burnout.

How can burnout be addressed?

When a DON is experiencing burnout, there are several ways that symptoms may be addressed. Here are a few tactics that DONs may employ:

  • Building emotional resilience. Emotional education and stress management practices have been shown to promote wellness and provide “immunity” to burnout. Emotional resiliency practices can include yoga, meditation, or therapy.

  • Remembering their goals. DONs typically pursue careers in nursing because they have a desire to help people. Focusing on this mission and remembering the meaning in their work can mitigate the frustration of repetitive or bureaucratic tasks. Encouraging other staff to do the same is also valuable since DON burnout can cause burnout in other care providers.

  • Practicing self-care. Taking time to care for themselves. This may be through exercise, quality time with family and friends, time alone, or reflective practices such as journaling. Prioritizing yourself and mindfully practicing gratitude have been shown to improve symptoms of stress.

  • Seeking organizational support. Many workplace stressors can be mitigated through organizational support. For DONs, this may include asking for an adjusted schedule, increasing task delegation, or seeking further physician support in order to diminish the risk of poor patient outcomes and survey violations. Partnering with talented care providers such as Vohra Wound Physicians can lead to improved patient outcomes, decreased violations, and reduced instances of burnout. Contact us to bring Vohra into your facility here.

How can DON burnout be improved moving forward?

Improving DON burnout rates requires health care systems to grow more adept at recognizing and addressing chronic workplace stress. This can involve regular well-being assessments, stress management training, and easily accessible mental health support. In the meantime, DONs can prevent or mitigate burnout by making individual lifestyle adjustments and seeking supportive organizational changes.


Working with Vohra is a valuable way to prevent or mitigate DON burnout, by improving patient outcomes and decreasing the risk of survey violations. Effective patient care requires a dedicated group of qualified physicians and nurses, and building the right team is critical to avoiding nurse turnover and costly medical errors. By partnering with Vohra, nursing facilities can improve DON burnout, which in turn improves the success of the entire facility and its patients.

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Author: Janet S. Mackenzie, MD, ABPS, CWSP, AAGP

Janet S Mackenzie MD, ABPS, CWSP, AAGP is the Chief Medical Officer at Vohra Wound Physicians. She has been with the company since 2013 and has almost 30 years of wound care experience as both a plastic surgeon and a wound care specialist. After obtaining a Master’s degree in Education, she obtained her Medical Degree from the University of Pennsylvania Perelman School of Medicine. She trained in general surgery at Dartmouth Hitchcock Medical Center and plastic surgery at McGill University. She is board certified by the American Board of Plastic Surgery, the American Board of Wound Management, and the American Board of General Medicine, and is a Certified Wound Specialist Physician (CWSP).

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