Hey Nurses, How are You Doing?

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The Nation is suffering from a loss of nursing staff as we move through one public health emergency after another and nurses, suffering from secondary trauma, leave the profession. Can we find a way to survive, and even thrive, through the Nursing Process?

Specializes in Maternal Child Health Public Health Nursing. Has 11 years experience.

Can nurses thrive through public health emergencies?

Hey Nurses, How are You Doing?

How We Can Use the Nursing Process to Help Ourselves Survive (and Thrive?) in these Tumultuous Times

As a working nurse, I know I don’t need to go into the details of what’s happening for nurses right now.  For nearly every nurse the past few years have been a ****Storm of one public health emergency after another, or multiple public health emergencies at once. From floods to fires to pandemics and back again, it doesn’t matter if you work in a clinic, a hospital, home care, or public health; we have all been challenged to provide care for our clients in tumultuous times. Nurses have been leaving the profession in record numbers, twice as many in 2020 as 20101, a record 80,000 nurses gave up their careers. There may be many reasons for the nursing hemorrhage, but the consequences for healthcare are dire, according to, Business Standard2, “The health of the nation’s nursing workforce is fundamental to our health care industry.” So how can we better understand this problem, improve working conditions for nurses, and stop the exodus?  We can begin by learning more about the underlying issue and then applying the nursing process to the problem.

Secondary Traumatic Stress

Recently, a nurse co-worker sent me a Professional Quality of Life Scale (ProQOL)3 assessment. I was curious to see how I was faring based on this evidence-based assessment of compassion satisfaction, burnout, and secondary traumatic stress. The results surprised me.  Like most nurses, I love my work and take pride every day in my ability to help others and make a difference in the world through nursing practice.  The assessment clearly showed that for me, that is still true. I remain compassionately engaged in my work, I continue to love what I do, and I am not suffering from burnout. However, my score on the ProQOL scale did show that I am suffering from the effects of something called Secondary Traumatic Stress4.

Nurses are excellent listeners, our ability to provide therapeutic listening5 is part of what makes us good at our jobs and earns us the trust of our clients, (nurses continue to be the most trusted professionals6 in America, for the 18th year in a row).  To remain engaged and empathic in the past few years has meant nurses are listening to more and more tragic stories, more stories without happy endings, or possibilities for positive outcomes, more stories that we cannot do anything to help other than listen.  Hearing so many tragic stories of suffering takes a toll on healthcare practitioners. According to the AAP7, any healthcare provider may be at risk for Secondary Traumatic Stress.

“Secondary traumatic stress (STS) is a term used to describe the phenomenon whereby individuals become traumatized not by directly experiencing a traumatic event, but by hearing about a traumatic event experienced by someone else. Such indirect exposure to trauma may occur in the context of a familial, social, or professional relationship. The negative effects of secondary exposure to traumatic events are the same as those of primary exposure including intrusive imagery, avoidance of reminders and cues, hyperarousal, distressing emotions, and functional impairment”.8 (CR Figley (ED) Encyclopedia of Trauma, 2012.)

The Nursing Process

Like many nurses, when I am faced with something new (like a new client, or a new concept), I return to the Nursing Process9 for support. The Nursing Process is the backbone of nursing care. Described by the American Nursing Association, the Nursing Process is “the essential core of practice for the registered nurse to deliver holistic, patient-focused care”. The process consists of five simple steps: Assessment, Nursing Diagnosis, Outcome Planning, Implementation, and Evaluation; always undertaken holistically and in partnership with the client, who just happens to be me today. As I would with any other client, I first assessed my strengths and risk factors, including paying special attention to how well I can care for myself physically (nutrition, exercise, and sleep). I made note of my support systems, my sense of well-being, self-esteem, and self-efficacy.  From there I identified my risk factors, what needs a little extra attention, where are my challenges?

Assessment

A good nursing assessment reviews client strengths and risk factors:

Strengths

  • Spiritual framework
  • support system
  • ability to care for yourself
  • nutrition
  • sleep
  • alertness and memory
  • financial well-being
  • ability to relax (most of the time)
  • motivation
  • self-esteem
  • Internal locus of control
  • self-responsibility
  • positive self-efficacy

Risk Factors

  • Poor support system
  • No or little exercise
  • Poor nutrition
  • Learning challenges
  • Denial
  • Poor coping skills
  • Communication problems
  • Obesity
  • Fatigue
  • Memory issues
  • Hearing issues
  • Self-care issues
  • Negative self-efficacy
  • financial problems

What are your self-care strengths? What are areas that could use more support?

Nursing Diagnosis

Unlike medical diagnoses, Nursing Diagnoses10 take into account client strengths to create a picture of potential risks and readiness for health-enhancing behavioral changes. With a nice outline of my strengths and potential risk factors, and my understanding of how I am feeling at this moment about my potential for poor health outcomes related to Secondary Traumatic Stress, I was able to create a positive Nursing Diagnosis for myself: Risk for deteriorating well-being related to repeated secondary trauma, as evidenced by a high Secondary Traumatic Stress level on assessment, and readiness to prioritize healthy nutrition, exercise, and behavioral health to be better equipped to handle the emotional and physical challenges of nursing during public health emergencies.

Outcome Planning

Short-term interventions for me include: Improving my mental health with good nutrition11 by making sure I eat at regular intervals, avoiding night eating, and developing an awareness of the effects of stress on my appetite. I will also make sure I have access to lots of fruits and vegetables during my work hours and I drink enough water every day.  My medium-term plan includes making time for some fun with co-workers and enjoying laughter whenever possible. I will also be joining the nurse's Gratitude Project12, a joint project of the American Nurses Foundation and the Greater Good Science Center at the University of California, Berkeley. The Gratitude Practice for Nurses is based on research that suggests gratitude improves physical health, mental health, and interpersonal relationships, and “is a valuable tool to respond to the stresses faced by nurses and other health professionals”. My long-term goal is to survive and learn to thrive, through the challenges of listening to the stories of clients who have experienced traumatic events.

Can Nurses Thrive Through Public Health Emergencies?

Climate change has created a greater need for Public Health and Emergency Response Nurses.  The Covid-19 pandemic increased the need for nurses in the ICU, Emergency Room, Clinics, and Schools. To make sure we have enough nurses going forward we must regularly assess nurses for compassion fatigue, burnout, and secondary traumatic stress. The Implementation phase of my Nursing Process is just beginning.  As with my clients, I am sure as I Re-Assess my plan, I will need to make some changes and refinements to my Outcomes Planning.  However, thanks to the ProQOL assessment, and the Nursing Process, I have hope for the future resilience of my nursing practice no matter how tumultuous the times are. According to Beth Hudnall Stamm, Ph.D., one of the researchers and authors of the Professional Quality of Life project, “Professionals who have hope are far better at offering it to others!”


References

1Nursing Shortage

2Nurses are leaving the profession, and replacing them won't be easy

3Professional Quality of Life: Elements, Theory, and Measurement

4,7Tips for recognizing, managing secondary traumatic stress in yourself

5Therapeutic Communication: NCLEX-RN: Assessing Verbal and Nonverbal Client Communication Needs

6Nurses Continue to Rate Highest in Honesty, Ethics

8Secondary Traumatic Stress

9The Nursing Process

10Nursing Diagnosis Guide and List: All You Need to Know to Master Diagnosing

11Food, Mood, and Brain Health: Implications for the Modern Clinician

12Gratitude Practice for Nurses

Liz George has been practicing holistic public health nursing for 11 years, through floods, fires, and a pandemic. She continues to love nursing, to feel empathy and compassion for every one of her clients, and for every one of her fellow nurses.

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19 Comment(s)

SmilingBluEyes

Specializes in Specializes in L/D, newborn, GYN, LTC, Dialysis. Has 24 years experience.

Thank you for an excellent article that highlights those needs we should keep at the forefront of our practice. It's always said "you can't pour from an empty cup" and this is so true.

Liz George PHN, BSN, RN

Specializes in Maternal Child Health Public Health Nursing. Has 11 years experience.

I appreciate that insight! Thank you for reading the article.😊

 

The workforce is slim pickings in all areas of employment.  Employers cannot hire trained help and expect them to do the work of three people. This is why they are quitting. Workers have to feel a sense of pride in their work and they can not achieve this with multiple responsibilities in different areas. No amount of money or praise will stop the burnout. The cure is enough willing support staff to pick up the slack.  This does not happen because it is more economical to work what you have into the ground.  

Liz George PHN, BSN, RN

Specializes in Maternal Child Health Public Health Nursing. Has 11 years experience.

So true!

hppygr8ful, ASN, RN, EMT-I

Specializes in Psych, Addictions, SOL (Student of Life). Has 19 years experience.

As I write this I am sitting at home waiting for the results of a Covid test. We haven't had a positive patient in a while which I attribute to the high vaccination rates in our local area, But we had two in my building that I had no direct contact with. I hope the results come back before Thursday as I was hoping to host a small family gathering for Thanksgiving.  I have four days off for the holiday and plan to work in my greenhouse (Installing a heater). Map out my veggie garden for Springe and sleep a lot.

Hppy 

Liz George PHN, BSN, RN

Specializes in Maternal Child Health Public Health Nursing. Has 11 years experience.

That sounds like excellent self care! Sorry to hear about the potential exposure. I had a miserable breakthrough infection in September. Wouldn’t wish it on anyone, but it did make me feel bulletproof for a bit after I recovered. I hope your test is clear and you enjoy your holiday! All the Best, -Liz

Congrats on the unscheduled vacation!  Think about this..... How many SAR's, Flu in all its variations, flesh eating bacteria, MRSA, and spectrums of other communicable things that you did not get due to your good practices. (I would never bring this line of thinking up to those who make decisions).  Follow those good practices and have your family over, or not.  

 

hppygr8ful, ASN, RN, EMT-I

Specializes in Psych, Addictions, SOL (Student of Life). Has 19 years experience.

4 hours ago, Liz George PHN said:

That sounds like excellent self care! Sorry to hear about the potential exposure. I had a miserable breakthrough infection in September. Wouldn’t wish it on anyone, but it did make me feel bulletproof for a bit after I recovered. I hope your test is clear and you enjoy your holiday! All the Best, -Liz

Here is a new bloom. I purchased the seedling two years ago and this is it's first bloom. My husband jokes that with all the time, money and effort that went into it, It's like watching your kid graduate from college. 

 

IMG_1146.JPG

Liz George PHN, BSN, RN

Specializes in Maternal Child Health Public Health Nursing. Has 11 years experience.

Beautiful!

Granuaile, ADN, RN

Specializes in hospice, medsurg/tele, ED, corrections. Has 12 years experience.

On 11/20/2021 at 2:04 AM, lever said:

 

The workforce is slim pickings in all areas of employment.  Employers cannot hire trained help and expect them to do the work of three people. This is why they are quitting. Workers have to feel a sense of pride in their work and they can not achieve this with multiple responsibilities in different areas. No amount of money or praise will stop the burnout. The cure is enough willing support staff to pick up the slack.  This does not happen because it is more economical to work what you have into the ground.  

I agree with this fully. I do feel that in addition to the factors discussed by the OP, that nursing burnout is ultimately a problem that originates at the top. Or at least, that this is where change needs to start.

Even though there are lots of research papers, news articles, and blogs written on nurse burnout, it still feels like a topic that nurses are reluctant to talk about or take a stand on. And who can blame us? Nurses voices are not heard or valued when we do speak out, and in fact many nurses face a real fear of retaliation if they do, not only from management, but from their peers; it's as though nurses are set up to do what they need to do to survive, because that's all we have time for, and we are not supported to go beyond that.

https://jamanetwork.com/journals/jamanetworkopen/fullarticle/2775923

https://www.nbcnews.com/news/us-news/nurse-burnout-remains-serious-problem-putting-patients-danger-experts-say-n1266513

https://pubmed.ncbi.nlm.nih.gov/33764561/

https://www.nytimes.com/2021/08/12/opinion/nurses-understaffing-covid.html

https://www.mckinsey.com/industries/healthcare-systems-and-services/our-insights/nursing-in-2021-retaining-the-healthcare-workforce-when-we-need-it-most

Nobody would work that hard with that much responsibility for money!