Текст книги "The Nurses: A Year of Secrets, Drama, and Miracles with the Heroes of the Hospital"

Автор книги: Alexandra Robbins

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Текущая страница: 13 (всего у книги 33 страниц)

This theory could help to explain why bullying is so rampant among healthcare professionals. Not many workplaces are as tense and simultaneously as emotionally and spiritually draining as a hospital. It is evident how the cycle might perpetuate: Multiple studies have found that bullied nurses have much higher levels of burnout than their peers. If these victims, now burnt out, need an outlet themselves, they might be more likely to engage in the same bullying behavior.

Does hazing make nurses stronger?

There may be a reason why nurse bullying commonly targets young, inexperienced, or newly transitioned nurses. It’s arguable that there is a difference between the kinds of workplace bullying that are universal across professions and the type that qualifies as nurses “eating their young.”

Nurses told me that colleagues want a new nurse to prove herself before they accept her as part of the team. “There is a sort of test new nurses need to pass to become part of the nursing clique,” said a California nurse practitioner. Because of the nature of the job, nurses hold one another accountable to strict standards. “Due to the broad base of knowledge we must have, and many of us being ‘Type AAA’ perfectionist personalities, we have very high expectations of our peers,” a Missouri public health nurse said.

As a result, some nurses are short on patience and stingy about sharing knowledge, in order to toughen up new nurses. “Eating their young” refers to “the fact that a new nurse has to earn the right to work in the unit. No one gets any slack for being new,” said a Pennsylvania OR nurse. “You have to jump right in and be able to care for the most difficult patients as if you’ve been doing it a hundred years. Even when I moved to a new facility and had been doing the same job previously, there was this feeling of being tested to see if I would measure up and fit in.”

This philosophy leads some nurses to assign new nurses the most difficult or highest number of patients without assisting them, or to give them a hard time when they don’t know what to do. “Nurses put their own on steep learning curves to test their mettle. It’s sick and often counterproductive,” said a Virginia labor-and-delivery nurse. “Older or very insecure nurses often push the younger ones by giving them too many tasks to complete and not enough support.”

But making someone feel worse about her skills is not the same as making her a better nurse. And sometimes the “testing” goes too far. As I interviewed nurses for this book, many stories sounded similar to those of the college girls I interviewed for Pledged, a book investigating sororities. Like sorority sisters, nurses told me about overbearing cliques, governance by administrators more focused on money and image than on people and substance, arbitrary standards regarding their looks, and, most relevant to this section, a long tradition of hazing and questionable rites of passage.

Nurses eating their young is a form of hazing, different from other types of workplace bullying both within and outside of the nurse profession. It is as if nurses, like sorority members, have to endure a pledge period during which they must prove themselves worthy of a group that has already admitted them. A Texas nursing school professor referred to nurses eating their young as “sorority initiation.” Nurses in other states told me about rituals such as an OR’s tradition of initiating new nurses (most often the young, pretty ones) into the department by dunking them into the scrub sink with the water running.

Even American Nurses Association (ANA) literature called nurse bullying “a type of initiation to determine if the new nurse is tough enough to survive in nursing.” (The ANA added, “But the problem extends beyond the new nurse to include nurses at all levels as potential victims.”) A Florida psychiatric nurse told me, “Older nurses being harsh to newer nurses is almost like a ritual. I think sometimes it’s done subconsciously. We can be harsh to new nurses to make them strong for the many challenges they will face in this profession.”

When a North Carolina nurse started out in the ER, she said the old guard “punished” her for being young and attractive. If every other nurse had zero patients and she had four, her colleagues would assign her a fifth. “The existing nurses had been there for eons and felt they owned the place. They treated new staff however they pleased. I cried on the drive home every day for my first six months,” she said. “I was in the Marine Corps before this, I survived boot camp. [I thought] surely I could take all of the mean, snarky, underhanded hazing. But I wasn’t at that hospital longer than a year because of it.”

An Idaho murse said he was hazed a few years ago partly because he was a new graduate, but mostly because he is male. “I was treated like an idiot for the first several months. They made snide remarks or didn’t value my opinion. Also, as a man, I was expected to act differently in crisis. Starting as a new nurse was terrifying. When someone is actively dying in front of you or having a psychotic episode, it takes some getting used to, regardless of gender,” he said. “When I was giving report, it was as if I were being interrogated by the Gestapo. I’d be asked questions I didn’t know and treated like an idiot for not knowing the answers. I had to earn every ounce of respect that I got. ‘Eating their young’ comes from the need to weed out nurses who don’t belong, but there must be a better way to go about it. My experience was awful.”

Researchers have described how experienced nurses use lateral aggression to keep younger nurses and students in their place. By making the less experienced nurses doubt their ability, they create a perceived hierarchy tiered by seniority. This is not unlike sororities grinding pledges down to rebuild them in the preferred mold. “Here, a select group of senior nurses take any opportunity to tear a nurse down. Entering an ICU, I thought I’d have a great preceptor to teach me everything I’d ever need to know. But I really felt like I was set up for failure,” said a cardiovascular nurse who was hazed repeatedly. “New nurses are inevitably going to make mistakes, but senior nurses feed off it and make it worse. I understand that you need to know your stuff, but those nurses are there to teach you.”

When an inexperienced coworker was assigned to a case that was out of her depth and she was afraid she couldn’t properly serve the patient’s needs, she asked her preceptor and the charge nurse for help. “They left her to drown,” the cardiovascular nurse said. “She broke down in tears in the middle of morning doctor rounds. Unfortunately, I think this will continue, because when new nurses bring this up as bullying or harassment, it gets pushed aside or sounds like tattling.”

Significant numbers of Greek alumni believe their college sorority is more cohesive because they suffered through hazing together; and that because they participated in the hazing tradition, so should every group that follows. Similarly, Boston Medical Center’s Martha Griffin has observed, “Tolerance for some forms of nursing practice lateral violence is seen historically in the context of a rite of passage or expressed in the thought ‘this is how people were to me, when I was learning.’”

Australian researchers report that nurse bullies “are usually themselves past or current victims and most are convinced that their experiences have strengthened them for their nursing role.” Under the guise of teaching younger nurses to be strong, these nurses appear not only to prefer to see new colleagues fail than succeed, but also to help them along in the process of failing. “Why do we tear each other down so much?” a Texas ER nurse wondered. “[They act like] they earned their stripes the hard way, the ‘old fashioned way,’ so they don’t want to make it any easier for the new nurse learning the ropes. It’s like the parent saying, ‘When I was your age, I got beaten with a log, so you should be thankful when I do it to you.’ Right, it was terrible the things you had to go through to get to where you are now. Shouldn’t you then want to make it easier for someone else, so they don’t have to experience that kind of heartache?”

Much like sorority members, the nurses I interviewed were split on whether nurse hazing is ultimately beneficial or detrimental to the profession. At first, Emma, a Mid-Atlantic surgical nurse, was furious when an older nurse hazed her at the Pyxis by “making me feel stupid, when my main goal was to get my patients their medications as efficiently as possible. [I felt] this sort of hazing was totally unnecessary and counterproductive,” Emma said.

Now that she has been on the job for a few years, however, Emma finds herself defending the practice. “Older nurses feel a need to set a high standard and not baby new nurses. Sometimes this comes off as very harsh and unnecessary, but in retrospect, I really appreciate being challenged to be diligent early on, even if it meant being called out on my failings in front of others. This sort of corrective hazing that a few older nurses are known for might not be the most delicate way to help someone see their errors, but it certainly is effective. I was fortunate that the nurses on our unit generally don’t ‘eat their young’ just for the sake of it, but rather to guide and provide the opportunity for new nurses to prove themselves.”

In recent years, as workplace bullying generally has become an increasing part of the national dialogue, some nurses worry that supervisors are abandoning a no-nonsense teaching style because new graduates might consider it bullying. “We’ve coddled these new young nurses. There is way too much hand-holding,” said a Virginia Neonatal Intensive Care Unit (NICU) nurse. “If a new nurse screws up or doesn’t have her stuff together, she needs to know. We have to hold ourselves and each other accountable for our patients’ care. Nurses should eat their young to get rid of the weak. If you can’t deal with an older nurse correcting you and watching out for your practice, how are you going to handle resuscitating a dead patient solo, or dealing with an alcoholic sex offender who is making disgusting comments to you?”

Even some younger nurses are willing to let the practice continue if it prepares new graduates by whipping them into shape, like a nursing boot camp. “Nurses take an immense amount of pride in what they know, what they’ve seen, what they’ve experienced. And unless you know what they know, seen what they’ve seen, or experienced what they have (and you won’t, especially when you’re a new grad and new to a unit), you don’t know jack until you prove yourself otherwise. So suck it up, earn your place,” said a New York pediatric ICU nurse who graduated two years ago.

A nurse in Lebanon argued that bullying among nurses is “good because it is part of the learning process. It helps you sharpen your communication skills. We learn how to face our bully, act with knowledge, and continue doing what we do best for the sake of the patients.” Similarly, the New Zealand study found that a small number of nurse bullying victims viewed the situation positively because it enabled them to stand up for themselves and to “feel stronger.” A Washington, DC, pediatric oncology nurse remembered when older nurses drilled her relentlessly about various patients and diseases. “One nurse was so intimidating that I was crying as I tried to give report to the next nurse. But you do certainly learn things quickly that way.”

Another similarity to sorority hazing: Nurses eating their young continues because nurses often don’t report it. Researchers say that nurses tend to keep quiet because they are afraid of retaliation, they don’t think reporting the behavior will penalize the bully or result in change, or the perpetrator is a manager. Like patient assault, lateral aggression has become so ingrained in the culture of the profession that many nurses don’t report the behavior because they—both victims and perpetrators—don’t realize that it is unacceptable. In one study, when nurses confronted their aggressors, three-quarters were “shocked that the victims felt that way.”

Some older nurses said that they don’t mean to treat new nurses harshly; their language or tone can reflect the tension of an urgent moment. An Arizona pediatric oncology research nurse tries to give students as many appropriate nursing tasks as possible. One day, however, this nurse’s young patient was declining and she needed help from seasoned nurses, residents, and respiratory therapists. As the nurse was attempting to contact the child’s parents, a student approached her to ask, “What should I do?” The nurse recalled, “It seems like an innocent enough question, but I had fifteen people I was listening to and giving information to. The last thing I needed was some clingy, high-strung student asking what she should do. I said, ‘Stand in the corner. Watch, and don’t say a word!’ I knew the minute it came out of my mouth that I had just eaten my young. I simply was not nice. But if a student doesn’t have the wherewithal to know she’s in the midst of a tremendous learning situation just by observing, I certainly don’t have the time to explain it to her at that moment.”

In Washington State, a day surgery nurse explained that although she enjoys precepting on occasion, “It all depends on where my head is on any given day. I’m very Type A and if I’m in a ‘gotta get it done’ mode, then mentoring can drive me nuts, because obviously a new employee (especially new grads) takes lots of time getting stuff done that I know I could be doing so much faster. And sometimes I feel I must jump in and do part of the job. That is not good mentoring,” she said.

Because so many departments are short-staffed and turnover is frequent, some inexperienced nurses are automatically expected to take on massive responsibility and pressured to work on critical patients whether or not they are ready. A nurse in Singapore said that nurses eat their young because they expect new nurses “to be as skillful as if you were already thirty years into the job. And if you are not up to their standards, you may be given a tongue-lashing, taken off the learning curve, or banished indefinitely to the Siberia of nursing chores to clear bedpans and clean backsides,” a repercussion reminiscent of the 1909 New York Times article.

When these new nurses get overwhelmed, complain that they have too many assignments, or don’t have the experience to handle their tasks properly, older nurses can get frustrated; they might have little sympathy because they are or were in the same boat. “We work hard, come to work on time, prepared, focused, and ready to jump into the trenches,” said a twenty-year veteran of a Midwestern NICU. “We have had years of terrible hours, schedules, and holidays—obviously tons of shitty, unfair assignments—and we just did it, trusting that the seasoned nurses had a plan with the assignment choices.”

At the same time, if inexperienced nurses are too casual, older nurses might think they don’t take their work seriously. The generational divide is severe. In the United States, the average nurse is 47, and many nurses are delaying retirement through their late sixties, according to a 2014 Health Affairs study. “The younger nurses have good skills and, with our guidance, demonstrate excellent skills over time. The issue is that they lack respect and can be rude and arrogant. You lose patience with nurses who can’t wait their turn, won’t shut up and listen, can’t stay off their phones, argue with policy, or show their butt-cracks. They whine about their assignments, take chances when asking for help would be safer, take long lunches, interrupt, and bad-mouth other nurses within earshot. They come to work rushed and on the phone, eating, and often not in scrubs; ignore parents of sick children while they are charting; and often surf the Internet,” the Midwestern nurse said. “There is a pecking order and a prejudice against the younger nurses because they are hard to work with. When my generation of nurses started, we were so intimidated as new nurses that we came in early, took notes, and focused on the task at hand. We have years of experience and skills that can’t be matched.”

While “kids-these-days” gripes are predictable and inescapable in any profession, they are louder in nursing because the workforce skews older. Widening the generational divide, nursing degree programs have changed since older nurses began working. Until the late 1970s, nurses attended school in the hospital setting, where they learned both in classes and in the wards, explained Canadian nurse and author Donna Yates-Adelman. “Today, baccalaureate degree nurses graduate with very little hands-on clinical experience and are left to catch up after they graduate,” she said. “This has created a rift between the new graduates and the working nurses (many who are hospital-trained), who see it as having to help finish the new nurses’ education.”

Indeed, a Florida Atlantic University study revealed that the young nurses most affected by nurses eating their young “were those with university education; they felt they were resented for learning too much theory and not enough practical training.” Canadian researchers found that “older, diploma-prepared nurses expressed resentment for new baccalaureate degree graduate nurses. These older nurses would relax at the desk and watch their new colleagues flounder. Young baccalaureate nurses . . . concealed their educational background to prevent ridicule and resistance.”

The quandary leaves new nurses feeling stuck. To earn respect from their coworkers, they need the experience gained from what amounts to on-the-job training. But some coworkers aren’t necessarily willing to give them that training because they don’t respect the new nurses. When a Kansas nurse’s colleague grumbled, “I hate nursing students,” the nurse said, “I told her, ‘This from someone who was once a nursing student.’ How quickly we forget where we came from.”

Younger nurses say they feel like they can’t win: If they are too timid, coworkers push them to toughen them up; if they are too confident, coworkers try to take them down a notch. “In my ER, new nurses are lumped into the same boat: know-it-alls who know nothing who are trying to steal the thunder of the older nurses around them. Which is hysterical,” said a Texas nurse who has been at her job for less than a year. “These experienced nurses have years of wisdom they could share to help a younger nurse. But when they do, it’s to assert dominance. They hold it over your head: ‘Remember that time I saved your ass?’ And they use it and use it and use it against you.”

No matter the cause, lateral aggression, like doctor–nurse bullying, is a problem that goes beyond hurt feelings. It can be just as psychologically damaging as physical abuse, and the effects can last for years. Nurse victims can suffer from symptoms of depression, anxiety, fear, shame, self-blame, guilt, post-traumatic stress disorder, and eroded self-esteem.

Furthermore, multiple studies have found that bullying can have substantial economic consequences for healthcare institutions. Researchers found that higher rates of workplace bullying are associated with higher rates of nurses quitting or intending to quit. This turnover can cost workplaces between $40,000 and $100,000 per nurse, and the sick days nurses take to cope with or avoid incidents can cost additional hundreds of thousands of dollars.

Nurse bullying also has been proven to increase medical errors and accidents and decrease productivity. Besides the distraction of dealing with the behavior and the effects of the emotional fallout, Griffin observed that “lateral violence stops newly licensed nurses from asking questions, seeking validation of known knowledge, and feeling like they fit in, and stops them from acquiring the tacit knowledge-build necessary in clinical practice.” When nurses are afraid to ask questions, they are less likely to be able to provide safe care.

From sorority to sisterhood

Nurses are a sisterhood, a sisterhood that can be empowering, invigorating, edifying, spirit-raising, the stuff of the “secret club” about which a nurse rhapsodized in the introduction to this book. But this sisterhood (males included) could be so much stronger if nurses weren’t divided by perceived hostilities, misdirected anger, and vast generational rifts.

Beginning in nursing school, nurses learn to be advocates for patients, but not necessarily to be advocates for each other. As new graduates during a time of vulnerability, some nurses are trampled by the same coworkers they need to support them through their transition to practice. Strong mentors can dramatically help both to change this atmosphere and to help new nurses thrive despite it. A New Jersey nurse practitioner who said it’s her “goal to change the attitude of ‘nurses eat their young’ ” advised mentors to “engage in teachable moments, put your ego away, learn something from the mentored, and take pride in the work you do. If you love your work, you will impart that passion to others.”

That impression during a nurse’s formative years can last for an entire career. Several nurses told me that they chose their specialty because of a particularly impassioned instructor or that they have returned to a cherished mentor for guidance repeatedly throughout their careers. More than a decade after working with her, an Arkansas CRNA is still in contact with a mentor who was “like a big sister to me. She taught me to be a patient advocate, to stand up to doctors, and voice my opinion if I felt like something would affect the patient negatively or if I had an idea that might benefit the patient. She also taught me to say no if asked to do something I wasn’t comfortable with. She gave me a confidence in my professional abilities that has allowed me to achieve my ultimate career goal.”

The mentor/mentored relationship can benefit both parties. A Washington State PACU nurse precepted two new graduate nurses who remained at her hospital and now work as her peers. “I love the feeling of supporting them and knowing that I provide a safe space for asking questions and sharing stories. And I got a couple of great friends out of it!” the nurse said.

Nurses representing all generations want to strengthen the sisterhood. “We may be fat, old, and wrinkled, but we pitch in and help each other even when it is not our patient. If the youngsters would just lay low and learn instead of being competitive, then they would flourish,” said an Ohio NICU nurse. “When something cool is going on, I try and snatch a new nurse to share with her. We have had the occasional nurse who is excited about learning but also cautious. She is easy to tuck under your wing and share everything you know with her, [while] often learning from her newer views at the same time.”

Young nurses said they want the same thing. Experienced nurses “are the foundation of hospital care, and their strength and giving nature inspires me to want to learn more and succeed as a nursing student,” said a Massachusetts first-year student. “One nurse I work with has a great skill of being able to explain complex body functions in ways students are able to understand. After becoming a nurse, I hope I can be as influential to students as the nurses are to me.”

When a nursing team is able to build an ideal sisterhood, the result is glorious. A Florida high-risk OB nurse said that the camaraderie among her nursing team is “unparalleled.” At and outside of work, these nurses grew to know and to respect each other. “When we finish our individual nursing assignments, we check on one another to see that everyone has completed their nursing responsibilities and assist them if they haven’t. Working holidays is part of the deal, so we plan dinners to celebrate at work since we can’t celebrate with our families. Our job creates a place of comfort, happiness, support, and sisterly love. I know I could depend on these nurse sisters for anything I may need. It’s just the way it is with nurses.”

It is the way it could be.