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.
