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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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 nurses 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.

It is possible that the nurses who care the most might bear the highest risk. Researchers report that some types of personalities are more susceptible to stress and compassion fatigue, such as people who are overly conscientious, perfectionistic, and self-giving. And nurses are already highly empathizing people. “We are programmed to be able to do it all; we give our life and soul to the profession,” said a Florida psychiatric nurse. “Sometimes, if you feel you can’t help an individual, you feel you have failed.”

Compassion fatigue may have increased in recent years because of the demands of managed care. Because doctors and nurses have more time pressures to see more patients and complete more paperwork, they have less time to enjoy, for example, “the connection that many family physicians shared with their patients, [which] was replenishing, which helped them cope with the stressors of practicing medicine,” Indiana University School of Medicine researchers observed.

Nurses are also vulnerable to post-traumatic stress syndrome (PTSD), a psychiatric disorder experienced by 8 to 10 percent of the general public. University of Colorado researchers found that 22 percent of surveyed nurses exhibited PTSD symptoms. All of them had observed a traumatic event such as a patient death, massive bleeding, open surgical wounds, or trauma-related injuries, or they had performed futile care on critically or terminally ill patients. Other events that could lead to PTSD include helping with end-of-life care; handling postmortem care; dealing with combative patients; taking verbal abuse from patients, family members, doctors, or other staff members; performing CPR; experiencing stress because of unsafe nurse-patient ratios; and failing to save specific patients.

ICU nurses are subjected to many of these events on a daily basis. An Emory University study discovered that ICU nurses experience PTSD at a rate similar to female Vietnam veterans. Among ICU nurses, 24 to 29 percent exhibited PTSD symptoms, compared to 14 percent of general nurses. (Outpatient nurses are less likely to develop PTSD than inpatient nurses.)

A PACU nurse in Washington State said she suffered from PTSD for several months after caring for a coding post–heart attack critical care patient who died on her shift. The hospital offered no resources to help her cope. “There was nothing available to me. I still cry thinking about the situation and how I was supposed to give 150 percent to this patient who was basically already dead,” she said. This trauma came on top of the usual nurse stresses. “Often, I feel it’s an impossible job. [Some of us] go home feeling we were unable to give the care we wanted because we were so overworked by patient numbers, acuity, and needing to be everything to everyone: nurse, friend, coworker, empathetic listener, computer specialist.”

Second victim syndrome

In 2010, Kimberly Hiatt, a veteran pediatric critical care nurse at Seattle Children’s Hospital, accidentally gave an eight-month-old critically ill infant 1.4 grams of calcium chloride instead of the correct 140-milligram dose. The infant died days after the mistake. Hiatt was fired, even though it was not clear that the miscalculation directly caused the death of the infant, who had heart problems. A ten-fold overdose of calcium chloride, which is given to support circulation and prevent heart and neurological problems from low blood calcium, would not necessarily be fatal.

Hiatt, who told staff about her error as soon as she realized it, officially reported it herself. “I messed up,” she wrote on the hospital’s electronic feedback system. “I’ve been giving CaCI for years. I was talking to someone while drawing it up. Miscalculated in my head the correct mls according to the mg/ml. First med error in 25 yrs. of working here. I am simply sick about it. Will be more careful in the future.”

Hiatt reportedly was stunned that the hospital fired her for making one significant medical mistake in her entire career. Administrators had given her glowing reviews; two weeks before the incident, her evaluation awarded her a 4 out of 5 and called her a “leading performer.”

To keep her nursing license, the state nursing board required Hiatt to pay a fine and agree to a four-year probationary period during which she would be supervised when dispensing medication. But Hiatt had difficulty finding a new job, even though she aced an advanced cardiac life support certification exam, qualifying her for a flight nurse position. Seven months after her mistake, depressed and isolated, Hiatt, at age 50, committed suicide.

Hiatt apparently suffered from “second victim syndrome.” According to the Institute for Safe Medication Practices, “Second victims suffer a medical emergency equivalent to post-traumatic stress disorder. The instant patient harm occurs, the involved practitioner also becomes a patient of the organization [because he/she needs medical help]—a patient who will often be neglected.” A 2011 survey found that surgeons who thought they made a medical error were more than three times as likely to have considered suicide as those who did not.

Humans are going to make mistakes. Washington University researchers found that 92 percent of doctors surveyed had perpetrated a near miss or actual mistake and 57 percent confessed to a serious error. Retired anesthesiologist F. Norman Hamilton wrote in a Seattle Times letter to the editor following Hiatt’s death, “If we fire every person in medicine who makes an error, we will soon have no providers. We all make errors. It is only by the grace of God that most of them do not result in great harm or death.”

While second victims usually require immediate emotional support, healthcare organizations largely don’t help employees through “the deeply personal, social, spiritual, and professional crisis,” the ISMP reported. “Although the first victims of medical errors are the patients who are harmed and their families, the second victims are the caregivers and staff who sustain complex psychological harm when they have been involved in errors that harm patients while caring for them. . . . But, too often, we remain silent and abandon the second victims of errors—our wounded healers—in their time of greatest need.”

That’s what Seattle Children’s administrators did to Hiatt. Instead of easing her out of second victim syndrome, they arguably threw her under the bus, appearing to blame her for the fatality. Paradoxically, then– hospital CEO Tom Hansen wrote an internal memo in which he said, “Of course, we will also support our staff members during this difficult time.” Hansen went on to write, “It is important to me that all staff and faculty feel it is safe to report when mistakes are made, and that everyone is confident that we recognize the difference between an honest mistake and reckless behavior.”

In direct contradiction, Seattle Children’s fired the staff member who seemed to need a great deal of support, damaging the career of a nurse who apparently thought it was safe to report that she made an honest mistake. After Hiatt’s case hit the news, a Washington State Nurses Association survey found that half of nurse respondents believed “their mistakes are held against them.” Even more worrisome, a third said they would hesitate to report an error or patient safety concern because they were “afraid of retaliation or being disciplined” and more than a quarter would hesitate to report those concerns because they were afraid they would lose their job.

Following the incident, the hospital changed policies, including instating a rule that only pharmacists and anesthesiologists could prepare doses of calcium chloride in nonemergencies. Also of note: In 2003 and 2009, Seattle Children’s staff allegedly had made two other fatal medication errors. After the 2009 death, Seattle Children’s medical director Dr. David Fisher said in a statement, “This was not the fault of any one individual.” It appears the hospital’s problem was much larger than the single nurse it pushed forward as the scapegoat when her error occurred in 2010.

Instead of firing a nurse who reportedly had made a single notable error in a quarter-century of service, the hospital could have tapped her to help devise a system that would have caught her error in time, thereby both improving the hospital and allowing Hiatt to contribute to her own healing process. Firing her helped no one. As University of Missouri Health Care patient safety director Susan Scott told msnbc.com, “If my mom got an insulin overdose from a nurse in a hospital, I would want that nurse to give her that insulin tomorrow.” That nurse would probably be the least likely to make that mistake again.

What hospitals aren’t doing

Hospitals aren’t adequately addressing nurses’ work-related health issues, but are they legally liable for causing them? In 2013, Ohio nurse Beth Jasper, a 38-year-old mother of two, died in a car accident while driving home from a twelve-hour shift. Her widower filed a wrongful death lawsuit against Jewish Hospital, claiming that administrators knew that Jasper was “worked to death.” Jim Jasper alleged that the understaffed hospital regularly forced nurses to take extra shifts and go without breaks. The case was dismissed because the judge determined that the hospital could not be responsible for a death that occurred after work hours.

Certainly, hospitals aren’t doing enough to prevent these problems. In Massachusetts, when a newborn died minutes after an emergency caesarean section, a veteran nurse told The Boston Globe that she “came very close to losing it psychologically” because of grief, but hospital administrators did not want her to see an independent psychologist in case he could be called to testify in a malpractice lawsuit. (The Globe article gave no indication that the death was attributable to human error.) “The hospital is more worried about lawsuits than they are about the effects the incident has on the staff,” the nurse told the Globe. How can nurses best address the health of their patients when they are expected to shove their own health issues under the rug?

Lara’s debriefing room idea is an effective low-cost solution. As a hospice nurse told me, at times nurses need to go somewhere to “have a little cry.” Other small concessions that hospitals could provide are opportunities for nurses to eat, take a break or a short walk, and check in with loved ones outside of work. Nurses also could use easy access to support groups and trained counselors. Some nurses said that even when their hospitals hold debriefing sessions, administrators refuse to offer coverage for nurses who want to attend. They neglect staff members who truly might need these sessions to understand, reflect on, and share feelings about what they have seen.

So many of these problems could be solved by hiring more nurses, which would reduce patient load and nurse mistakes, give nurses more time to do their jobs well, decrease stress, and provide coverage. An analysis by health economists found that, by a conservative estimate, hospitals can recoup more than 99 percent of an average nurse’s salary (70 percent of salary plus benefits) from reduced medical costs and improved productivity alone. It should be stated that staffing for hospitals is not a zero-sum game: “Registered nurses are a revenue center rather than a cost center,” said ANA senior policy fellow Peter McMenamin. A strong nursing staff can generate revenue for hospitals not only in improved productivity but also in retaining top physicians.

In the time it takes for hospitals to make this happen, however, nurses themselves could do a better job of focusing on self-care. Nurses sacrifice their own health to attend to ours. They are so accustomed to working nonstop to take care of other people that they often forget to nurture themselves. It isn’t uncommon for nurses to donate blood or bone marrow to specific patients. “People will just about kill themselves to give care to others without taking care of themselves,” Canadian health services officer Norma Wood has said. “It can get into a martyr situation where patients matter more than we do.” Researchers recommend that nurses take self-care measures, including changing work assignments or shifts, taking time off or reducing overtime hours, getting involved in a project of interest, and focusing on work-life balance.

It can also be helpful for nurses to talk about their feelings. “I believe most nurses don’t seek counseling or support outside of friends and families. We need to do a better job of permitting ourselves to seek support,” a longtime Michigan nursing school professor said.

Some hospitals do have programs, counselors, chaplains, on-call coping liaisons, or debriefing sessions. Barnes-Jewish Hospital in St. Louis recently launched a successful program to help staff cope with these issues. The hospital offers a compassion fatigue course, stress-reduction workshops, support groups, meditation, and discussions about difficult cases. Three-quarters of the staff members who have taken the formal class have been nurses, said Patricia Potter, director of research for patient-care services at Barnes-Jewish. Particularly in the medical ICU, where the head nurse has championed the program, nurses have seen a noticeable difference in their relationships with each other and their ability to communicate effectively as a team. Program graduates “tell me that they are recognizing more when they feel stress, and that the skills we’ve taught them have been very helpful to reduce the perception of that stress,” Potter said.

Many nurses have shared that, with experience, they have learned to view patients medically rather than emotionally, and to separate their work experiences from the rest of their lives. They learn how they react to various situations and they develop coping mechanisms to prepare themselves accordingly. University of Akron professors found that registered nurses younger than 30 are more likely to burn out, experience “significantly higher rates of the most intense levels of frustration, anger, and irritation” than older nurses, and are less likely to find ways to cope with these emotions. As a result, the researchers suggested that experienced nurses could serve as emotional mentors to younger nurses to help them navigate the profession’s demands.

A young Maryland medical/surgical nurse said that a nursing school mentor was instrumental in preparing her for the emotional side of nursing. “She let me know it’s all right to let things affect you and that doesn’t make you any less of a nurse. She taught me how to handle bad days. She was very open with me about her own experiences starting out and how they shaped her, which I draw on a lot now,” the nurse said. “Mostly, she demonstrated how to stay calm in intense and emotionally charged situations, and let me know that nursing is not always as ideal as people make it out to be and everyone feels that at some point or another.”

Why it’s worth investing in nurses’ mental health

“The greatest common risk to patients is the understaffing of nurses,” Minnesota ER doctor Gary Brandeland, who has written about medical mistakes, told The New York Times. “A nurse may make a critical mistake, and a patient might die. She has to live with the error, but the real culprit, the root cause often is that she or he was understaffed and overworked and a mistake was made. The hospital doesn’t pay for it on a personal level. They just get a new nurse.”