At the start of a committee meeting, Lara presented her idea. “I was thinking we should have a debriefing room, a place where we can gather our thoughts after something awful happens. Everyone from the nurses who worked on the patient to the janitor who mopped the blood off the floor could take five minutes to think, talk, or pray.” Lara thought this strategy could ease the tensions that were typically high for hours after a tragedy.
“That’s a great idea,” said a tech. “We need a place to go and sit for a minute.”
“Which room should we use?” Lara asked.
“We could use part of the lunchroom,” said a unit secretary.
“Then we’d be focusing on eating instead of catching our breath,” a floor nurse said.
“Why don’t we use this room right here?” asked another nurse. “It’s only used for meetings sometimes anyway.”
The group became animated as they came up with low-cost ways to make the room more serene. “We could put in one of those little waterfall-on-the-rocks things!”
“And a white noise machine with peaceful sounds.”
“I have the perfect picture I can bring in to put on the wall.”
“I could bring in some lavender, that’s a therapeutic smell.”
“Ooh, I have a cool plant I can donate.”
Lara was so excited that once the committee settled on colors for the room, she volunteered to purchase the paint out of her own pocket.
• • •
Two weeks before Christmas, Lara went to her mother’s house one last time to finish clearing it out before it went on the market. She posted on Twitter that she was having a sad day. In the middle of the night, Lara opened her laptop and scrolled through dozens of replies about her mother and the house, which had been the neighborhood hangout. The uplifting messages made her smile.
Then she read the next post on her Twitter feed: John had tweeted to a woman with a half-naked photo, one of those porn star models that hundreds of men posted to daily, “Alabama, you’re so hot. I want to put this picture on my truck.”
Lara knew that John had cheated on her in the past, she knew about his gambling addiction, she knew about his sex addiction. But to post something like this where all of their friends and family members could see it, right after Lara’s tweet about mourning her last day at her childhood home? No. Lara was done. People had told her that the last straw before a divorce often was relatively insignificant compared to past transgressions. She understood that now.
Lara turned on the light in the bedroom. “Hey, John, when you tweet to another female, like your friend Alabama, everybody sees it,” she said. “So now everyone we know is looking at your conversation with the porn star.”
John jumped out of bed, looking panicked. He ran to his computer and started deleting tweets. Lara took a deep breath and whispered a quick, quiet prayer: “Please give me the strength to do this.”
“John, I cannot do this anymore,” she said, her voice steady. “I’m going to move out. You have health insurance. Get help for this sexual addiction. You need to make an appointment.”
“Stop playing this bullshit game,” he said.
Lara had thought for sure that he would beg her to stay, but he didn’t. “I’m not going to your family’s holiday party tomorrow,” she said.
He didn’t believe her. The next morning, he loaded the car while Lara finished feeding the kids breakfast. “Just get your suitcase and come on,” he said.
“I’m not going,” she said.
“Get your goddamn suitcase. You know you’re going to go.”
“No, I’m not,” she said.
He looked momentarily surprised, then began to usher the kids out the door. Lara kissed her children good-bye and told them that she had to go to work. As soon as the door shut behind them, Lara burst into tears. She was proud of herself for finally standing up to him, but wondered, still, whether she was giving up too soon.
Why Nurses Crack
After twenty years of working as a cardiac nurse in Washington State, Elena Uhls became so stressed that she sank into a major depression. The combination of the unit director increasing her patient load to twelve at a time, the nurse manager asking her to perform tech duties on top of her own, and patients and techs treating her disrespectfully had broken her spirit to the point where she grew suicidal. “I was crisp,” she said, using nurse slang for “burnt out.” “I felt worthless. I made errors, forgot things.” She considered switching careers, but she couldn’t imagine herself in any other job. “I was so paralyzed. I knew it was possible that I’d accidentally kill somebody if I didn’t take time off. Every day as I drove home, I slowly plotted my death. Depression is painful; suicide felt like the only way out.”
Once she found a helpful doctor and took antidepressants, Uhls recovered her basic mental health, but she isn’t the same nurse she used to be. A traveler, she floats among hospitals, avoiding the workplace where “every day was a nightmare.” She said, “I know in my heart I’m not that loving nurse I once was. If I can make a difference, I try, but what can I do in a few hours? I [used to] try to be their coach, their cheerleader, their educator, whatever it took, but not now. I still care, but not with the same light heart. It’s more businesslike. Maybe it’s better that way.”
We rely on nurses to be our healers, our heroes, to comfort us, to soothe our hurts and salve our psyches. But how often do we pause to wonder who takes care of the nurses?
Nationwide, nurses’ top health and safety concern is the effects of stress and overwork, according to the ANA Nursing World Health and Safety Survey. More nurses are worried about this issue now than in 2001, when the average shift length was shorter and patient loads were lighter. Their second biggest concern is that they will suffer a disabling musculoskeletal injury because of their constant heavy lifting; throughout an eight-hour shift, a nurse lifts an average of approximately 1.8 tons.
Injuries are a major stressor for nurses, who must lift and move patients in addition to working on their feet most of the day. The number of nurses reporting work injuries has increased in the last decade. The ANA found that “Nearly all nurses still indicate that they have worked despite experiencing musculoskeletal pain, including eight in ten who say it is a frequent occurrence.” Other common nurse injuries include needle sticks, strains, sprains, bruises, cuts, head injuries, broken bones, or dislocated joints. A Virginia women’s health nurse added, “Many nurses have bladder issues by age fifty. ‘We don’t pee so you can!’ How’s that for a women’s health nurse motto?”
A number of nurses interviewed for this book reported feeling overworked, overwhelmed, and underappreciated for several reasons. For twelve to fourteen hours at a time, they must demonstrate physical and emotional stamina, alert intelligence, and mental composure, even if they are berated by patients or bullied by doctors and other coworkers. Many healthcare employers don’t engage nurses in decision making, although nurses are at the forefront of patient care. Nurses are under pressure to work quickly and correctly, taking sometimes contradictory orders from professionals who will blame them if something goes wrong. They are stressed because, an Oregon nurse manager said, they are responsible “not only for the patient but also the family, the team of support specialists, hospitalists, physical therapy, occupational therapy, social work, hospice if needed, meals, medications, teaching, spiritual support, keeping the patient clean and comfortable and documenting, documenting, documenting.”
Nurses must constantly face traumas, tragedies, and patients who will die on their watch, no matter what they do. A New York City pediatric ICU nurse recalled, “The other day, one of my coworkers said, ‘I’m taking care of a brain-dead baby today and I just can’t take it.’ When there’s no hope left, that’s when it gets really sad.” Nurses are expected to care for the dying, to save the degenerating, and to minister to all manner of injury. And they are
expected to do it without breaking their composure. “Some nurses are exposed to repeated horror on a regular basis, things that a regular Joe couldn’t handle,” said a Virginia NICU nurse. “The worst thing you could ever imagine seeing, we see at work. My hospital doesn’t have anything in place to help. If you can’t deal with it, you leave.”
While doctors and other hospital personnel are also exposed to death and suffering, nurses may be more susceptible to the lasting emotional impact. Nurses spend the most time with patients individually and have a hand in every level of their care. “Nurses are not only ‘first responders,’ but are also ‘sustained responders,’ ” author and clinical nurse specialist Deborah Boyle has observed. “Nurses become part of a mosaic of caring within a family framework that may be fraught with anticipatory loss, tension, disbelief, and physical disfigurement. In the acute care setting they are responsible 24/7 for the patient’s care and the family’s response to the illness trajectory. Often, they cannot leave the situation after bad news is shared or a death has occurred. It is this extended time and the placement of the nurse at the center of the interchange that makes nursing’s role unique.”
Nurses can also become emotionally attached to their patients, some of whom die in front of them. “The patients become part of our family. It’s a whirlwind relationship because you meet someone, and the next thing you know, you’re looking at their naked body and listening to their innermost anxieties. In return, you listen, try to help, and share parts of your own life,” said a Maryland hematology nurse. “If they die, it’s very hard; you have lost someone you became close to very quickly, someone you were cheering to beat the odds. As a nurse, you can’t dwell on your loss. You have other patients who need you. One might think that you would build a tough exterior that doesn’t let the hurt in, but to truly be effective, you can’t. You share your grief with work friends because people at home can’t understand the connection that you share with patients.”
For all of these reasons, nurses are the hospital employees most likely to develop work-related psychological disorders. Eighty-seven percent of surveyed nurses at one university hospital exhibited symptoms of anxiety, depression, PTSD, or what researchers call burnout syndrome. Nurses have relatively high rates of suicide, depression, and anxiety relating to job stress. University of Kentucky researchers found that 35 percent of surveyed nurses are mild to moderately depressed, compared to 12 percent of the general population and 12 percent of emergency medicine residents. Occupational reasons for this depression include not enough time to provide emotional support to patients or to complete their nursing tasks, too much time spent on non-nursing tasks like clerical work, and not enough staff for proper patient care, all of which could be alleviated if hospitals increased nurse staffing.
Nurses’ schedules can leave them little time to recuperate from arduous patient care. They might stress about missing family birthdays, recitals, sports games, and holidays. They are not necessarily paid commensurate to their sacrifices. Nurses told me about sleepless nights during which they were so worried about patients that they called the unit to check on them, and days off that they spent doing something for a patient instead of for their family. And it is difficult to explain the letdowns of the job to people who aren’t nurses. “People don’t know how hard it is to compartmentalize your life when you have a bad day at work, like when a patient dies or declines, and then you have to come home and act like nothing is wrong,” a Maryland OR nurse said. “Your husband and children have a difficult time understanding and it’s impossible to explain. They don’t teach that in nurses’ training.”
Workplace stressors are affecting nurses’ mental health across the world. In Quebec, where the local nursing union has asked the government to end sixteen-hour shifts because understaffed nurses are “overworked and exhausted,” five nurses killed themselves in an eighteen-month span. At least one of them left a suicide note in which she blamed her hospital’s working conditions. When the woman’s sister-in-law contacted the hospital, she was allegedly told, “She’s not the first to commit suicide and she won’t be the last.”
In 2013, the U.K.’s Royal College of Nursing announced that 82 percent of nurses go to work while sick because they worry that understaffing would harm patient care. Reporting that stressed nurses are “forced to choose between the health of patients and their own,” the RCN revealed that staff shortages and increased workloads caused more than half of surveyed nurses to become ill. In a separate report, South African nurses conveyed similar issues, in addition to poor security, lack of government support, and unhygienic hospitals.
Burnout, compassion fatigue, and PTSD
Experts estimate that approximately 30 percent of nurses are burnt out, which has been defined as a “loss of caring.” Burnout symptoms include irritability, difficulty concentrating, low energy, and sustained thoughts of quitting. Many nurses also experience a related but lesser known condition that is often confused with burnout. “Compassion fatigue,” also called secondary traumatic stress disorder, can occur when empathetic nurses unconsciously absorb their patients’ traumatic stress. They experience the traumas emotionally, sometimes mirroring the patients’ anxiety. As they pour their energy and compassion into caring for their patients, many of whom do not improve, they fail to care properly for themselves and/or their own families. The resulting sense of helplessness has been called “a combination of physical, emotional, and spiritual depletion” and “a state of psychic exhaustion.”
This can happen to nurses who treat children the same age as their own or to nurses who have nothing in common with their patients. A St. Louis oncology nurse quoted Holocaust survivor and psychiatrist Viktor Frankl to States News Service in 2012: “ ‘What is to give light must endure burning.’ I think people who care for others understand. Caregiving is painful.”
The ANA lists compassion fatigue symptoms including anxiety, depression, disrupted sleep, memory problems, fatigue, headaches, upset stomach, chest pain, and poor concentration. Nurses suffering from compassion fatigue might be less able to feel empathy toward patients or their families and more likely to abuse drugs or alcohol; they might avoid or dread working with certain patients.
Distinguishing characteristics of burnout versus compassion fatigue vary by the expert, but there seems to be a general consensus that burnout is caused by stress related to the job (understaffing, lack of support) while compassion fatigue is caused by stress related to the patients (connections with patients or families, caring for the suffering or dying). Burnout can lead to emotional exhaustion, but compassion fatigue causes heavy- heartedness. Michigan nurse and staff educator Shari Simpson explained at an Association of Pediatric Hematology/Oncology Nurses annual conference, “Compassion fatigue does not mean one is no longer capable of feeling compassion. It’s the feeling of compassion weigh[ing] so heavily on you that the way you experience life is affected.”
Both conditions, author Deborah Boyle wrote, “are associated with a sense of depletion within the nurse, a ‘running on empty’ feeling.” And nurses can experience burnout and compassion fatigue at the same time. A trauma nurse in North Carolina was hit by this double whammy. “Doctors are demanding, patients are demanding, management is demanding. If the doctor orders a wrong medication, and the nurse gives it to the patient, whose fault is it? It’s your fault for giving it. If a drunk patient gets out of bed and falls, it’s your fault for not being there to stop him, but the doctor won’t give you an order for restraints. Everything in hospital healthcare comes down to the nurse. Every second of every shift, you are giving, doing, running, caring—it’s draining,” she said.
For this nurse, the combination of compassion fatigue and burnout contributed to a depression that bordered on suicidal. “I have had days where I would have rather crashed my car than go into work. I was getting sucked dry. The neediness of everyone! It’s like a never-ending rendition of ‘If you give a mouse a cookie’ and as nurse
s we don’t like to fail. It’s not allowed,” she said. “As a nurse I am completely in tune with my patients, their needs, and the needs of their family. I really can lose track of myself. If it comes down to helping a patient to the bathroom or being able to empty my own bladder after eight hours, it’s going to be the patient every time. It’s not totally healthy. But I can’t imagine doing anything else.”
On a particularly bad day, she arrived at a preshift meeting in which supervisors scolded the nurses. “What I heard was, ‘Customer service is really lacking in the Emergency Department. It doesn’t matter what’s going on in your personal life. We don’t care. It is always all about the patients,’ ” she remembered. “And this whole time, I had been thinking of killing myself. In my head, I kept putting a gun in my mouth and pulling the trigger; it was like I was watching a movie over and over again.” Eventually, the nurse confided in a psychiatric resident and her husband, who helped her to pull through. Today she is a stable, healthy nurse who continues to love her work.
Employees in any helping profession can be afflicted with compassion fatigue, including social workers, counselors, chaplains, and humane workers. But nurses are particularly vulnerable, Boyle wrote, because “they often enter the lives of others at very critical junctures and become partners, rather than observers, in patients’ healthcare journeys. Acute care nurses in particular often develop empathic engagement with patients and families. This, coupled with their experience of cumulative grief, positions them at the epicenter of an environment often characterized by sadness and loss.” Simpson calculated that if an inpatient nurse sees an average of even just four patients during a twelve-hour shift, in twenty years she will care for more than 11,000 patients and families. A clinic nurse who sees ten patients per shift will care for nearly 43,000 patients. Those numbers require an extraordinary amount of compassion.
The Nurses: A Year of Secrets, Drama, and Miracles with the Heroes of the Hospital Page 20
