System-Driven Stress in Acute Care Nursing: The True Cause of Burnout

As a follow-up to my first article on chronic stress among nurses, I originally thought I would go deeper into the physiology, addressing the HPA axis, the HPG axis, and all the internal pathways we’ve come to know so well. But the truth is, there is already plenty of content on this topic, and quite a bit of it is well done. Check the links I provide below.

So, I had to stop and ask myself: What would I really be contributing?

As a practitioner, when I sit with someone who is clearly under a great deal of stress, I don’t begin with pathways or hormones. I begin by acknowledging what is right in front of me. And then, gently, I begin to ask: What is causing this?

In my first article, I named what so many nurses are experiencing: chronic stress.
But naming something is only the beginning. Now, I want to take a deeper look at the causes, with a focus on hospital-based nurses.

The literature has quite a lot to say about this.
And yet… I noticed something strange in the way stress was being addressed in this context. When I looked at several studies from outside the United States, the language is direct, clear, and unapologetic. Researchers use terms like stress and occupational stress without hesitation. But when I turned to studies from within the U.S., something seemed to shift.
What nurses are experiencing is no longer called stress. It’s called burnout.

Both sets of articles were addressing the same experiences that we all know too well:
* Challenging working conditions with insufficient staffing ratios, nurse shortages, physical exhaustion, and even the risk of violence.
* An organizational climate that too often results in incivility and bullying, as well as ageism and other forms of discrimination.
* Moral distress and emotional exhaustion from the daily exposure to suffering, death, and how these are managed.

So why is there a difference in the language we use to describe the same experiences?
Is there a difference between stress and burnout? Or are they the same?

Let’s dive a little deeper – and spoiler alert, they are NOT the same! Let’s look at the evidence.

The International Classification of Diseases (ICD) is an international coding system for the classification of diseases. It’s created by the World Health Organization (WHO). In 2018, an 11^th edition was released, becoming effective in 2022. As of 2025, more than 60 countries have adopted it (WHO, n.d.).

This is NOT the same ICD coding structure that is currently used in the US, expressly for the billing of health services, although the ICD-11 is under review (Feinstein et al., 2023). However, countries such as Norway, Canada, the Netherlands, Finland, and Thailand are leading adopters in using it not only for public health reporting but also for clinical reimbursement.

The ICD-11 helps us to better understand the difference between stress and burnout. It defines burnout as “a syndrome conceptualized as resulting from chronic workplace stress that has not been successfully managed” (WHO, May 28, 2019).

And there it is! Chronic stress in the workplace is a CAUSE of burnout. These two words are very different.

The ICD-11 goes on to describe the symptoms of burnout as being 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.

Understanding this difference now leads to the next question:

Why has burnout become the language we focus on in the US, while many other countries directly address its cause?

Perhaps the answer lies in the fact that burnout describes what the nurse is experiencing internally. It’s very personal. Chronic workplace stress, on the other hand, describes the conditions in the work setting that lead to burnout. The ICD-11 defines burnout not as a disease, but as an occupational hazard caused by a system that creates a stressful environment. If the focus is placed on this environment, it becomes the system’s responsibility to address it.

It comes down to the difference between personal and institutional responsibility. The US has a very complex health care system that focuses on outcomes, so it makes sense that burnout, as an outcome, is its immediate concern. This is especially relevant since the research points to burnout as directly impacting patient outcomes (Li et al., 2024). An additional benefit to the institution when focusing on burnout is to then shift the responsibility for managing it to the nurse.

Words have meaning. Meaning develops into beliefs. Beliefs shape behavior and actions. Putting the focus on burnout leads to the belief that nurses need to address this personal issue. They are encouraged to become more resilient. Perhaps they need to seek help, counseling. There is movement now to encourage self-care among nurses. The American Nurses Association has a free, ongoing initiative to support nurses’ well-being called Healthy Nurses, Healthy Nation (HNHN, n.d.). It’s organized around six domains: physical activity, rest, nutrition, quality of life, safety, and mental health. This is a wonderful endeavor, but these are health-promoting practices that benefit everyone!

So why do nurses need to be especially targeted? To mitigate burnout.

This underscores again that the responsibility lies largely with the nurse and not the institution where she/he works. In their 2025 report for this initiative, I found very little that addressed the workplace environment that creates chronic stress leading to burnout. The only hint can be found in these two sentences: “Advocate for healthy work environments. Collaborate with colleagues to identify and suggest improvements and speak up for policies that support well-being” (ANA, 2025). But even this does not address systemic factors creating chronic stress and leading to burnout. Meanwhile, the system keeps functioning with the same factors that created nurse burnout.

Let’s be clear. The primary cause of chronic stress experienced by hospital-based nurses is not their inability to cope or poor life-work balance. Chronic stress is caused by a work environment that invests time in quickly improving outcomes, while lacking a true understanding and appreciation for the root causes of burnout. This is amplified by a culture outside the institution that urges increasing financial and material gain at the expense of individual well-being.

Now that I’ve shared my views on the real causes of chronic stress and burnout among acute care nurses, I will add that none of this is entirely new. I had my first job in 1974 in a 45-bed male ward in New York City. Check out this and my other acute care nursing stories here.

RESOURCES
The following are some very helpful videos that are easy to understand and will help get you up to speed in understanding the stress response.

2-Minute Neuroscience: HPA Axis
These are created by a professor at Penn State who clearly loves his work . He has other well-done videos as well, so check them out!

Hypothalamic Pituitary Ovarian Axis | Female Reproductive System
These videos are created by Dr. Matt and Dr. Mike – two award-winning university professors who cover a whole range of topics in physiology and pathophysiology in very easy-to-understand ways. A great resource!
If this piece spoke to you, and you’d like to support my work, you can buy me a coffee. Thank you for being here.

REFERENCES
ANA (2025). Healthy Nurses, Healthy Nation. 2025 Report. https://www.healthynursehealthynation.org/globalassets/2025-hnhn-report.pdf

Feinstein, J. A., Gill, P. J., & Anderson, B. R. (2023). Preparing for the International Classification of Diseases, 11th Revision (ICD-11) in the US Health Care System. JAMA Health Forum, 4(7), e232253. https://doi.org/10.1001/jamahealthforum.2023.2253

HNHN (n.d.) Healthy Nurse, Healthy Nation. https://www.healthynursehealthynation.org/

Li, L. Z., Yang, P., Singer, S. J., Pfeffer, J., Mathur, M. B., & Shanafelt, T. (2024). Nurse burnout and patient safety, satisfaction, and quality of care: A systematic review and meta-analysis. JAMA Network Open, 7(11), e2443059. https://doi.org/10.1001/jamanetworkopen.2024.43059

WHO (n.d.). International classification of diseases and related health problems. https://www.who.int/standards/classifications/classification-of-diseases

WHO (May 28, 2019). Burn-out an “occupational phenomenon”: International Classification of Diseases. https://www.who.int/news/item/28-05-2019-burn-out-an-occupational-phenomenon-international-classification-of-diseases