Are we experiencing mass burnout in healthcare?

[SheaTab]

This was written in response to a thread where a nurse experienced lateral violence at the hands of her preceptor. I thought it would be an appropriate discussion to start in this area. Thoughts?

And so it goes in the world of nursing that we eat our young and also each other. This is known as lateral violence and until the world of nursing stands up and says, "No More!," we will be challenged to put this abuse of each other to rest. I am so saddened by your story because I know it happens all too often. I hope that your organization offers the option to give feedback on your orientation experience and process.

The problem is so convoluted that there is not one simple solution. This lateral violence that is prevalent in all nursing practice areas is a symptom of what I believe is a much bigger problem. Burnout. Nursing is under attack, now more than ever, and we are constantly challenged to perform at a higher level, take care of increasingly complex patients, and fill out an enormous amount of paperwork to meet the demands imposed upon us by our facilities. Many of the "unfunded mandates" are passed on to us as a result of health insurance companies requiring herculean efforts by hospitals to attain maximum reimbursement. In order to sustain a profit, healthcare organizations must jump through an amazing number of hoops and pinch every penny. Unfortunately, this doesn't translate into effective and safe levels of nurse staffing. Many organizations haven't embraced the concept that in order to have lofty goals, they also must be willing to devote the necessary resources to achieve those goals. They have turned to manufacturing process improvement methodologies in the effort to remove all possible waste, and this has had the unfortunate result, in many cases, of leaning us to death.

Most of us, with a few exceptions, graduate from nursing school with the overwhelming desire to take expert nursing care of our patients only to find that we will never have enough time in a given shift to do all that we'd like. We are haggard! Many of us have felt that we have been set up to fail in a system that should have safe and quality healthcare as the principle driver to all decisions made in the organization. I have worked in a number of organizations and also teach nursing students. I have seen some horrific nursing care given in all the areas I've worked. I do not blame the nurses; however, I blame the system. My mother spent 11 days on an oncology floor this month and only one time did a nurse assess her lungs and bowel sounds! This translates into falsifying shift assessment documentation on at least 21 occasions. I refuse to believe that she just happened to get a few bad nurses. This is a system problem. We are burned out to the point that our patients are suffering and the only safe place to vent our frustrations with the system is by taking it out on each other. Read up on "failure to rescue" if you want some sobering statistics on the state of our healthcare system. Our patients are suffering tremendously as a result of our deficiencies in care and because we are failing to recognize their subtle signs of decompensation before they ultimately succumb to cardiac and/or respiratory arrest.

Burnout starts as idealistic new nurses first hit the floor. We have incorporated teaching about "reality shock" in many nursing programs because we know that the "real world" of nursing is nothing like what we learned in school and we hope that preparing students will slow the inevitable course of disillusionment. When we hit the floors, we realize we can barely tread water much less give the care we were all taught was so important. Some of the more feisty among us fight the system with the hopes that we can change it; however, fighting can be career suicide (i.e. you will get fired)! Others realize that the system is not changing and is in fact, getting worse. Some of those nurses choose to leave nursing altogether. Those who choose to stay will eventually become resentful of their employer. This resentment comes out sideways at each other and also our patients. The end result is varying levels of apathy which further erode our ability to provide safe and quality patient care. This apathy is a function of self-preservation! It is prevalent in all areas of healthcare and has not been lost on doctors. If you don't become apathetic to a certain degree, you will eventually become exhausted and our reflexive primal instinct is to avoid exhaustion at all costs in an effort to survive. Check out the statistics. Nurses have higher rates of depression, suicide, and substance abuse than the general population. This is true of physicians and many other helping professions as well. The research also supports that burnout is contagious. In other words, we pass this legacy on to new nurses as soon as they hit the floor. We teach them that this is the appropriate way to behave.

I am one nurse in America who is looking for answers and would love to generate a thoughtful discussion to that end. There are pockets of us who are willing to stand up and fight; however, many are just too tired which is completely understandable. While working in an emergency department last night, I had an elderly patient with a significantly elevated potassium. I was discussing her care with another nurse who suggested that I wait until she was about to go to the floor to give her dose of Kaexalate. I know what this nurse was thinking. We are terribly busy in the ED and the last thing we have time to do is to manage a patient with limited mobility and severe diarrhea. However, what happened to this nurse that he/she would suggest that I put this patient at risk of developing a fatal cardiac arrhythmia to avoid inconveniencing myself? At the start of my horribly busy shift, I tried to call report to a floor nurse who asked about the patient's IV access. I looked at my paperwork and realized that the patient (who had been in the ED for 8 hours) did not have a line. Her hostile response to me was, "I am going to have to call the house supervisor and ask why you think it is okay to send me a patient without an IV line." Here's the deal, I placed the line and sent the patient up, but I was actually really hurt by the interaction. We are all busting our proverbial orifices, why can't we at least be kind to each other. There are enough folks standing in line ready to take a jab at us; why must we also do it to each other? What happened to the professionalism of nursing practice? My students wonder aloud all the time why they are required to thoroughly assess their patients when it is rare to see anyone else doing it, doctors included. How many times do you see docs fly through the unit placing their stethoscope on the front of a patient's chest when they know full well that early pulmonary edema can usually only be heard on the posterior chest? Are they waiting for it to become severe enough that the patient requires intubation and significant diuresis? Shouldn't we all be focused on prevention, early identification and treatment? Come on, what has happened to us? I believe we have all run of time and also of the energy required to do the right thing every time for our patients. We are so busy making sure that all of our paperwork is filled out so that we meet our hospitals documentation requirements that we have lost sight of the most important thing a nurse does and that is, assessment. How in the world can we justify any intervention when we haven't adequately performed the one thing that our interventions are supposed to be based upon?

Nurses of America, what are your thoughts? Does anyone else feel a similar sense of urgency to reclaim the ability to safely care for our patients?

I am so sorry you have had this experience with your preceptor, but I am afraid that it happens across our country more often than it should.

Warmest Regards,

Tabitha

[ukstudent]

That was well written and so very very true. However, part of the problem with burnout is the fact that nursing is powerless to change any of the causes of burnout. Lateral violence is a symptom, not a cause in my mind.

Adequate staffing, adequate supplies, adequate time with patients are all controlled by upper management.

[travel50]

I have just quit my job of 10 yrs., and it was b/c of the harrassment from my immediate boss at the corporate level. If I can do so, I may never work as a nurse again. For 26 yrs., I've been the best nurse I knew how to be, and I am just tired of it all.

[SheaTab]

That was well written and so very very true. However, part of the problem with burnout is the fact that nursing is powerless to change any of the causes of burnout. Lateral violence is a symptom, not a cause in my mind.

Adequate staffing, adequate supplies, adequate time with patients are all controlled by upper management.

UKStudent:

Being that we are the largest collective group of healthcare workers in the nation, is it really true that we are powerless or have we been led to believe that this is so?

Let me tell you a story. Once upon a time while I was working with a group of students, we noticed a physician going from isolation room to isolation room wearing the same personal protective gown. He would walk up to the nursing station in the gown and stand there while writing orders. He would then head off to the next patient's room. So much for preventing the spread of infection! Infections, our little gifts to our patients, result in untold numbers of deaths in our country every day and that we would do even one to cause harm to a patient is unforgivable. Having the expertise and and yet still making the wrong choice is egregious. One nurse asked the house supervisor if she was going to say something to him. Her response was, "No way." This is one of many examples I could give of the perceived powerless of nurses even to the extent that it affects our ability to effectively advocate for the safety of our patients. Certainly I'm not arguing that nurses do not feel powerless, but I am concerned that we aren't fighting harder (collectively) to change this which is not to suggest that I know the right solution.

Do you have any thoughts around how we, as a profession, could make a more dramatic statement or impact?

I definitely agree that lateral violence is a symptom of the larger problem which I wholeheartedly believe to be burnout. I hold that everyone has the right to a satisfying and rewarding career path and am concerned that, over time, our current system has taken away this right.

I'd love to hear more of your thoughts.

Another thought, has the cost of caring grown so enormous in terms of the disease complexity of our patients, paucity of insurance reimbursement, increased supply costs, and other factors, exceeded our ability to sustain a significant profit in healthcare? Are administrators fighting a losing battle in trying to sustain and increase their bottom-line with the most concerning result being staff burnout and patient injuries?

There are many interventions that we perform as nurses which are impossible to bill for and also difficult to quantify in terms of time. For example, I was once told that a good ED triage nurse can finish his or her assessment in 10 minutes or less. This is true in many cases; however, but this does not account for the fact that our patients are getting older and sicker and it has taken me at least this long to accurately transcribe the med list of many patients not to mention their heath, social, and surgical history! If I don't copy the med list down accurately, I risk the safety of my patient and also the wrath of my employer because most hospitals are hyperfocused on the Medication Reconciliation process which must start at the point in which the patient hits the door. However, I also risk condemnation for taking too much time to do what is asked of me and for the the sake of the patient. In theory, Medication Reconciliation is of critical importance because so many harmful errors have occurred as a result of mistakes in the reconciliation process. However, giving us another paper to fill out and not allowing us additional time is the way of healthcare and things aren't looking up. As it becomes more difficult to turn a buck and sustain a profit, look for mass-casualties among the nursing staff.

Is it possible that administrators believe nurses to be lazy individuals who without constant oversight and PUSH, would choose to read magazines and surf the net? While I have seen more than my fair share of nurses doing more socializing than patient care, my hope is that this is the exception and not the rule. As for myself, I have so little time to do what I love that I am highly motivated with the small amount of time I'm allowed. Again, the case of the "lazy nurse" is what I believe to be a yet another symptom of a much more concerning plague, and that is, burnout. "If we can't effectively do the job we'd like to do, then why bother?" becomes the theme and mantra for some. Frustration breeds anger. Anger breeds resentment. Resentment breeds apathy (some may mistaken this for laziness).

As always, these are just my thoughts and I could certainly be wrong. I'd love to hear the insights of the rest of the community.

Best!

[meandragonbrett]

we are a necessary evil that the hospital has no choice in having. We are a line on an expense report and that is reflected in the current state of the profession.

[SheaTab]

I have just quit my job of 10 yrs., and it was b/c of the harrassment from my immediate boss at the corporate level. If I can do so, I may never work as a nurse again. For 26 yrs., I've been the best nurse I knew how to be, and I am just tired of it all.

Travel50:

I am so sorry to hear that you are considering leaving the profession. I am of the firm persuasion that in life, "things" never change; however, people do. We cannot create peace by starting a war. Starving yourself will not solve world hunger. If we are to bring about the dramatic changes that are needed in nursing, enough folks are going to have to change their thinking and also their tolerance for the poor treatment. We will never fix healthcare by giving up or becoming apathetic. I hope you'll allow me to give you a couple of examples.

Consider the history of both the suffrage and enslavement of African Americans in the United States. The first twenty or so enslaved black Africans sailed aboard a Dutch slave ship to the new world colonies around 1619. After years of disenfranchisement and unspeakable suffering, African American men were given the legal right to vote in the 15th amendment to the U.S. Constitution in 1869, a full 250 years after setting foot on the shoreline of Jamestown. While outside the scope of this discussion, most would agree that even after the aforementioned Constitutional amendment, the Jim Crow laws of the south made it nearly impossible for African American men to actively engage in the democratic process. The fact that Martin Luther King Jr. delivered his infamous “I Have a Dream” speech ninety-four years later (August 28, 1963) in Washington, D.C., tells us all that we need to know about the relative ineffectiveness of the 15th amendment to universally impact the civil rights of African Americans. Even a civil war wasn't enough to change "things." It wasn't until enough "people" changed their level of tolerance for the atrocities of inequality that real change was affected and sustained.

In 1607, English settlers first arrived in Jamestown among whom were women. These were desperate times, in fact, within a few months only fifty-three of the original 104 colonists remained. Their survival came at an unimaginable cost though, as one historical account tells the story of a man who partook of a personal feeding frenzy that “clean devoured” all parts of his wife, “saving her head.” Was the head inedible or did he save it for another reason? We may never know. Many would be surprised to find that women of all colors and ethnicities were not given the right to vote until August of 1920, when the 19th amendment to the U.S. Constitution was ratified. The profundity of the point must be underscored that over three centuries had passed since the arrival of women to the Jamestown Colony. Certainly, as a woman myself, I am able to appreciate the progress we have made as a country in terms of gender equality. Be that as it may, I am sorely disappointed that the journey was so arduously protracted and also that it lingers even today to some degree. Women did not earn the right to vote in our country until enough people changed their level of tolerance for this social injustice.

Consider another example that will hit close to home for nurses. In the 19th century, both Florence Nightingale and Joseph Lister suggested that infection might be prevented by hand hygiene. Many of you know that there is a massive campaign in 21st century healthcare to encourage patients to ask us if we have washed our hands. Sadly, left to our own devices, nearly 200 years have passed and we still can’t get it right.

Of all the forms of inequality, injustice in health care is the most shocking and inhumane.

— Martin Luther King Jr.

Things don't change, People do.

Best,

Tabitha

[SheaTab]

we are a necessary evil that the hospital has no choice in having. We are a line on an expense report and that is reflected in the current state of the profession.

MeanDragonBrett:

How can nurses be considered a "necessary evil?" Have we really digressed so far as an industry that, for the most part, success is defined by our bottom-line? Is it because more of the budget dedicated to staffing is devoted to nurses than any other professional? If that is true, why is it that we don't have more of a voice in the decisions that affect our work environment, nurse-to-patient ratios, and benefits? It would seem that since so much of the budget is devoted to nurse salaries and also that the lion's share of FTE's is devoted to nurses, that we would have found our center eons ago.

Why is it that in many cases, the hospital Chief Nursing Officer is often compensated less than other chief administrators?

Thoughts?

[meandragonbrett]

MeanDragonBrett:

How can nurses be considered a "necessary evil?" Have we really digressed so far as an industry that, for the most part, success is defined by our bottom-line?

Bottom line....hospitals are businesses and the bottom line is what matters.

[ccr53]

You are right on target with the burnout and lateral violence. I am a preceptor and have been at my current company for 6 years. Each new employee that comes to me I am so hopeful and positive they will stay. I do my best but the company is so difficult that they all leave after a few months of being out of orientation. Orientation is 13 weeks and by the time they finish they see first hand how poorly staff is treated by management. They all leave. I am now frustrated and feel I spend all this time training nurses and they will never stay. I am the preceptor for the unit so they all come to me. This is an acute dialysis unit and can be very stressful. Management has us budgeted for 6 nurses, but we are working mandatory overtime every week and the days are long. Starting 5:30am and often not finishing until 8pm or later. On call 8-10 days a month. I am finally getting burned out and am seeking a job with more stable hours. I love dialysis as do many of the nurses who leave us but the treatment is poor by management. And as always the bonus management receives does not shrink. I tell staff we have to stand up and improve things but management at this company does not care if everyone resigns. Their response was we will just get travelers until we train nurses. I talk to nurses in the hospital and they are upset computers and paperwork are compromising patient care. What can we do as a group?

Ceil

[inshallamiami]

Union Union Union

If nothing else, it annoys the hell out of management.

[arelle68]

That was well written and so very very true. However, part of the problem with burnout is the fact that nursing is powerless to change any of the causes of burnout. Lateral violence is a symptom, not a cause in my mind.

Adequate staffing, adequate supplies, adequate time with patients are all controlled by upper management.

We are powerless ONLY because we are not united. We think that we can't do anything about any of this because the corporations have all the resources. Nurses have forgotten that we ARE the resource. If nurses would unite, we would have safe ratios, better benefits, higher wages, and less abuse to put up with, and our patients would only benefit.

[SheaTab]

We are powerless ONLY because we are not united. We think that we can't do anything about any of this because the corporations have all the resources. Nurses have forgotten that we ARE the resource. If nurses would unite, we would have safe ratios, better benefits, higher wages, and less abuse to put up with, and our patients would only benefit.

My best friend, who happens to be a medical malpractice attorney, said it best when she said that she didn't know if she would personally be willing to stand up for her patients rights if it meant that she would not be able to put food on the table. With that in mind, how would you propose uniting a middle-class profession?