Burnout - From the ER and Beyond, Healthcare Workers at Risk

With a rising awareness real mental health, one of its aspects seems to lack practical application in the workplace. Nursing, and healthcare professionals, know that their job is fast-paced, sometimes at break neck speed, role that demands significant focus and investment in all ways. That includes mental and physical weight that can have adverse effects if nothing seriously. We have seen many healthcare professionals, not the least of which are nurses, have to take long extended leave, or worst, leaving the profession entirely because of burnout. The question for discussion is this: How does your workplace treat burnout? The startling reality is that burnout happens, and you need to take care of yourself. However, workplaces seem to ignore this reality and do not have adequate mechanisms in place to help their employees. The culture of overworking is one that's leaving unhealthy nurses in its wake. Are there programs in your workplace that are helping? What have you seen work? What do you do for yourself to ensure holistic health?


Mental Health Awareness and Care for Nurses

It's mental health awareness month in the US, and mental health awareness in Canada.

There's a noticeable increase in mental health awareness. For example, it's helpful when celebrities step up and share their struggles. It normalizes what has largely been either hidden or stigmatized.

Mental health is something many health practitioners know intimately. Both in what they see on the job, but also what they what they have to deal with themselves.

If, as a health practitioner, and especially a nurse, you don't take care of your own health, you're going to suffer. Faced with acute issues normal in a healthcare setting, like a hospital, increases the likelihood of mental illness.

High stress environments are a normal part of the job. However, the consequences of that environment need to be treated as normal too. Often, the results of losing work time and employees to issues such as anxiety impact the healthcare delivery system as a whole. What's both disappointing and incredulous (if you're the healthcare practitioner) is how little management acknowledges the problems.

From management, to corporations, to insurance providers, to workplace safety, mental illness still has a ways to go before it is recognized as in need of both proactive treatment (self-care), and space for healing (when illness emerges).

How many nurses, for example, suffer from mental illness yet can't claim that as a viable health concern to receive time off and insurance coverage for that time? How many are wondering if they're they only person who suffers from workplace anxiety because the issue is simply not addressed by management. How many are faced with management or environments that simply assume you work until you burn out and then are replaced?

The holistic care for employees in the healthcare, especially doctors and nurses, is lacking. We need to use the increase in mental health awareness to raise the prominence of adequate services and policies to protect workers as they continuously provide services in areas with a high degree of impact on one's own mental health.

What are do you do for self care? Share your insights.

What do you receive or see happening in your workplace both positive and negative?


Nurses: You are Intrepid Pioneers

The knowledge and skills of nursing are portable and reflect versatility. Nurses are scientific critical thinkers who see their vocation as a calling to improve the health care of citizens through compassionate healing. Nurses’ ability to evaluate and think on their feet in a variety of situations is found in all locations of health care from the operating room to patient homes.

The history of nursing reflects innovation. Since May is the month we find nursing week this article will take a look at one aspect of the future of nursing. Nursing’s bird’s eye view of health care gives nurses opportunity to see how health care delivery can be improved through new inventions of equipment and services. There are many examples in the past of nurses who have filled voids in the health care system by pioneering health care innovation. They have been mentioned in this space already, such as Frontier Nurse Services or the Visiting Nurse Services of New York and the Henry Street Settlement.

Some nurses have extended the entrepreneurial spirit to create businesses of their own. This article will give several examples of present nursing businesses and possibilities in the future.


The Horror Stories of Clinical - Student Nurses Share Their Experiences

All nurses have them. At first, it was a shock, but if you stuck with it, you realized it was going to be a routine affair. We're talking about the chaos of humanity you can only find in healthcare.

Although not specific to the ER, sharing stories about your time in clinical (especially if you're in the midst of it now) is a good cathartic release for what can be heavy stuff. Here are two anecdotes to share. If you have an experience from your time in clinical or internship, (hopefully with levity) add it to the comment section below.


Work Abuse on Nurses: Seven Mondays in a Week: The Consequences of Society’s Decline in Civility

Would you look forward to work each day if you knew there was a possibility you would be verbally or physically abused?

Emergency departments are experiencing an increase in use by the public. Hospitals are unable to keep up. An analysis of this use points to one unintended consequence of a non universal private health care system. The emergency department of a hospital is the only location in an overburdened health care system where any patient who shows up must be treated regardless of ability to pay. With state facilities and programs for mentally ill citizens, and those suffering drug addiction being eliminated these patients often end up in emergency wards. Visits to emergency departments(ED) for alcohol or drug related incidents are on the rise.

Emergency departments are often overcrowded. Overcrowding is defined as all beds in use and the waiting room full for more than 6 hours a day, patients placed in halls, and seriously ill patients having to wait more than 1 hour to see a doctor. (1)
Long waits are more then rule than the exception. Add sickness, trauma, mental illness and drug use to the lack of privacy, and a less than ideal situation is created for patients to appropriately cope with stress.

Nurses who execute care and spend the most time in triage and treatment suffer the brunt of patient and family frustration. They are subject to verbal and physical abuse at unacceptable rates. Studies have shown that health care workers are the most likely to suffer workplace violence after prison guards and police officers. In a profession where healing and mercy are requirements it is disturbing that nurses are subject to these assaults.

Nurses are abused verbally by been sworn or yelled at, or called names. Physical violence includes being spat upon, scratched, hit, slapped, kicked, or stabbed. Injuries can range from the not visible to months taken off work for severe injuries.

The Emergency Nurses Association believes that violent incidents are underreported according to a recent survey. Nurses often don’t report incidents. They fear it will reflect badly on them as being less than competent. Or they believe that the administration will not take them seriously or be indifferent. They do have some basis to believe that as up to 75% of medical centers do not respond to reported workplace violence. Also many institutions do not have workplace violence policies or prevention programs. Nurses also believe that abuse by patients and families are part of the job. In some cases they can empathize with the scenario that created the violence. Often they believe if they press charges that the perpetrator will escape conviction because they were mentally ill or high on drugs.

 Nurses associations are advocating to end violence against nurses. The Pennsylvania Association of Staff Nurses and Allied Professionals had a conference in early November, Massachusetts Nursing Association is one that has done a lot of work in raising awareness. The Occupational Safety and Health Administration office has issued guidelines for medical centers to address this challenge. However, these guidelines should become enforceable standards. The survey shows that hospitals with a zero tolerance workplace violence program have less than half the number of incidents of other medical centers that have no policy.

In Massachusetts, a House representative and a senator have introduced an act requiring Health Care Employers to Develop and Implement Programs to Prevent Workplace Violence. 26 states now have more strict penalties for assaults on nurses. New York very recently made assaulting a nurse a felony same as assaulting a police officer, firefighter, or EMS personnel. In contrast, 2 states that were going to move these assaults from misdemeanor to felony killed the proposal. Another state deferred the decision. Even in hospitals where severe assaults have disabled staff, the administration has only struck committees yet have failed to disclose when the committee would meet or the results of the meeting.

Prevention and being proactive are the keys to meeting this challenge. If administration is committed to training all staff and encourages reporting of incidents there would be progress towards prevention. Administration must also be committed to having adequate staffing levels at all times in the ED. Several bodies such as the American College of Emergency Physicians and the International Association for Healthcare Security and Safety, have made recommendations such as yearly risk assessments especially if the hospital is located in an area where there is high crime or gang activity. If it means having metal detectors and visitor sign-in those should be put in place as one hospital in Detroit did. Why would anyone need to bring a gun or a knife into the ED?

In the Institute of Medicine’s(IOM) report in 2007 on emergency care in the US they commented that that crowding, boarding, and ambulance diversion were the total opposite of high quality medical care. The Joint Commission for Accreditation of Hospitals had tried in 2004 to institute strong measures to counteract these now common practices but pressure from hospitals caused the measures to be watered down. In no uncertain terms the IOM’s report recommends that these measures be reinstated. Decreasing crowding, boarding and ambulance diversion would go a long way to dealing with ED violence and allow high quality emergency care. The violence is only a symptom; the root caused must be addressed.

One interesting fact is that less than half of ED patients require urgent care. To reduce wait times hospitals are considering NPs to treat non urgent patients.

The Ed puts a microscope on societal attitudes to nurses, health care, and especially violence. The examination is not pretty. Why do patients feel they need to act out their frustrations on someone that will ultimately help them get better? Why aren’t hospital executives proactively seeking to prevent violent incidents? The IOM notes that hospitals have no financial incentives to reduce ED crowding.  Are numbers and dollars more important than patients and staff safety and well being? Has society become so desensitized to assaults that it is seen as an inevitable part of life? How can anyone tolerate that a nurse can be abused on the job? Acceptance of the unacceptable says a lot about the people that have the power to change it.



The Preparation of Nurses to Enter Complex Practice

The unprecedented need for more nurses has led to an examination of the state of nursing education in the nation. This article will present several recent views that discuss both the need for a greater number of nurses and increasing the quality and relevance of nursing education.

A number of factors are preventing nursing education from reaching its full potential.  Nursing education has not changed significantly in the last half century. Clinical training availability is of paramount concern. RNs typically have little financial incentive to leave clinical nursing to become instructors. Half of all present faculty will retire within this decade. They are not being replaced at the same rate and yet there will be a need for even more instructors quite soon.

It has been suggested that the many ways to enter nursing does not encourage enough graduates to continue on past the ADN or BSN therefore missing the opportunity to become instructors.  Without faculty, potential applicants will not become nurses. Unfortunately, many thousands of applicants are turned away yearly.  How to correct this situation?

In Educating Nurses A Call for Radical Transformation Patricia Benner set out to investigate present nursing education with this question: Are nurses graduates adequately prepared to practice to their maximum potential? The answer she found was no. There were strong points in present nursing education but areas where changes could be made. This is not entirely because of any shortfall of nursing education. There are pressures, challenges, and issues that place unprecedented demand on the nursing profession. Many of them originate outside of the nursing profession.

The first challenge is the state of professions in general. The author mentions that one hallmark that distinguishes professions from other career paths is it’s sense of social responsibility. Professions must advance society’s good. Yet in recent decades society and therefore the professions have placed more of an emphasis on technical knowledge and adherence to the business model. Health care professions and nursing have not been immune to this philosophical shift in the professions. Nurses must often feel caught between their core values and fulfilling the bottom line, especially given that much of health care in the nation is private and for profit.

The turmoil in the health care system does not create the ideal environment for nurses to be adequately prepared on graduation. Turmoil and change can often result in philosophies that deal with crises in a short term way, often sacrificing long term vision as a result. For example the enormous need for more nurses puts pressure on educational institutions to lower admission requirements and to fast track students to achieve the numbers over quality. That urgency will only increase this decade, so nursing education needs to transform as Benner stated.

What does this transformation look like? She emphasizes the importance of integration of the 3 foundations of nursing education.

All three foundations must be integrated and not taught in isolation. The first foundation is nursing knowledge and science. Yet the acquisition of knowledge is not the end goal. Learning must be experiential, situated coaching in a community of practice. She stresses clinical reasoning and teaching for a sense of salience which she describes as gauging what is important to know and do for a patient and his/ her particular situation. It is knowing how to use the knowledge the student has acquired. Health care is unpredictable and open ended so the student must be able to evaluate what is the best course of action. She cites 2 examples of this from her interviews with instructors:

The student didn’t realize that 7 days was too long for a patient with an appendectomy to be in hospital. So they examined the patient and took a better history. Although they looked at the report it wasn’t as thorough as it could be; it did not provide any clues. Through investigation they discovered gangrene in his colon; that was why he was there so long.

In her second example a supposedly stable patient was deteriorating rapidly. Yet the staff nurse responsible for the patient did not think the changes warranted action. The instructor insisted the patient should go to ICU. She engaged the student by asking her What one test could we do to prove the deterioration? They decided on the blood gasses test which was done immediately. The test showed the patient needed to go to ICU.

 The last pillar is ethical formation and ‘comportment’. Formation involves looking beyond technical skill of the profession to the moral content eg obligations and demands which involves character formation. For instance when students see less than ideal practice that involves nurses treating patients badly how does one deal with that as a nurse?  How does a nurse help peers look at their practice to make positive change? Is that possible when in the beginning one doesn’t have institutional authority? Can a nurse help make changes in the professionalism of their peers? What about when a patient refuses a simple life prolonging intervention?

At present only around 20% of ADN graduates go on to the BSN. This is in part due to the time it can take to get any degree, which is time taken away from work and family. The goal of articulated programs is to streamline the process from ADN to BSN and beyond.  Regional innovations in nursing education are addressing this challenge. One of them is the Oregon Consortium of Nursing Education. Schools in Oregon have partnered to first of all envision the type of nurse that the population would need. Building on this vision they created a common curriculum and share resources. The consortium is committed to ongoing faculty development. City University of New York has received a Robert Wood Johnson Foundation grant for their program.

Because nursing practices in the space between medical diagnosis /treatment and the patients experience of wellness and illness a nurse requires both technical knowledge and expert relational skills. The education of nurses must prepare them to be lifelong clinical learners.

As one student said: “I have the honor of being present with and learning from patients in intimate, vulnerable, scary situations. I get to regularly advocate for the underserved in the hospital setting. I have access to environments I would otherwise never been exposed to, I have learned, grown and broadened my world perspective. I better understand how our system works and hope some day this knowledge will help me make changes in the system.”

Health care systems and society must recognize that improving education of nurses is a high priority. But nurses must take the initiative if they do not.

Educating Nurses: A Call For Radical Transformation. P Benner et al. The Carnegie Foundation for the Advancement of Teaching 2010 Jossey Bass


The Nursing Village around the World: How the US is Influencing Nurse Migration

Every nurse would agree that sharing skills, knowledge, experience, and technology to improve lives of patients worldwide is indisputably necessary. What is the role of US nursing in this unfolding phenomenon?

With the effects of increased globalization the world is becoming a global village. How is the migration of nurses to the US affecting worldwide health care?

A starting point for this discussion would be to evaluate the experiences of internationally educated nurses in the US. What has been their journey?

Internationally educated nurses comprise a growing percentage of newly licensed RNs in the US, a trend that will continue. 68% of these nurses have at least a bachelor’s degree in nursing compared to 50% of US educated nurses.(1) The most common ways nurses find work are through either the placement model where nurses work for the medical center. Integration and wages are more likely to be equal to US educated nurses in the placement model. In the staffing model nurses work for the agency which charges the health care organization and pays nurses a percentage of the hourly charge. Nurses are bound by an 18-36 month contract to work for the same employer. In the staffing model there is a  penalty to break the contract in the form of an expensive fee. Curiously Canadian nurses are not under contract in this manner. Wage differentials not based on training, threats of withholding of documents or immigration status, forced overtime, and lack of training were reported by internationally educated nurses working in nursing homes. In this study internationally educated nurses were reluctant to participate in focus groups, a reticence in part based of fear of possible reprisal from recruiting agencies.

A study conducted by M.M. Jose was based on interviews of internationally educated nurses. It is one of the few studies on the experiences of these nurses conducted in the US. From the interviews 6 themes were evident: Internationally educated nurses came to the US with dreams of a better life, then encountered the beginning of a difficult journey, a shocking reality of adjusting to life in a new country.  They rose above the challenges of work: One nurse explained that she overcame her inexperience which her peers sometimes interpreted as incompetence. These nurses next stage in their new life was feeling and doing better, and finally through their experiences became ready to help others on their own journeys. It is the last that is the key for the US role in advancing nursing globally. Internationally educated nurses’ migration to the US can have vast influence and benefit in the rest of the world. How is that happening?

How does migration affect the countries where nurses migrate from? Nurses working in the US do send money back to their home country, which are called remittances. Remittances can comprise a significant benefit to the receiving countries. Remittances also positively affect the social factors such as poverty and access to education that can provide opportunity for better health care. Yet if internationally educated nurses are actively recruited from countries with severe nurse shortages this has and will have an adverse affect on health care delivery in general. If the medical workers who remain in a home country suffer more difficult working conditions due to understaffing, patients are affected and staff turnover increases a negative feedback situation that is hard to correct.

But migration can also elevate the status of nursing in the countries that provide nurses. This is the case in India where migrating nurses have influenced more students to enter nursing.

Easier and less expensive travel, and the ease of communication via the internet has resulted in globalization. Thus migration may no longer be one way and permanent.  Migrating nurses create and maintain multiple ties between countries is more the reality for many. A study on nurse migration in 2002 found that up to 50% of nurses return to their country of origin usually within 5 years of departure.

So what are some ways that US nursing is sharing its vast resources to improve health care delivery in developing countries? Many of the initiatives are a result of collaboration and partnerships between organizations, be they private companies, educational institutions, medical centers, or non government organizations.

The International Centre for Nurse Migration is a partnership between the International Council of Nurses and the CGFNS. Its vision is to establish effective migration policy and practice that ‘facilitates safe patient care and positive practice environments for migrant nurses.’ It is a resource for research and policy discussion, and has been in existence since 2005.

Some recruiting companies are creating programs either in countries where nurse migration occurs, or in the US. For example, nurses who plan to migrate may be required to work in their home country for a period of a few years acquiring experience, before working in the US. The recruiting companies then assist the source hospitals in planning for the resulting vacancies. US educators also have initiated exchange programs with source countries’ educational institutions to train both faculty and staff.  Hospitals have also participated in sister programs where relationships are established to share technology and information. Some companies create training programs in source countries for their recruits that are also open to all staff. The internet has made diaspora networks a means to share vital knowledge with nations who want to improve their health care delivery. Even if migrating nurses never return to their original country they now have the means to stay connected and contribute to innovation through technological channels even if they are not physically present.

Patients’ right to effective health care must be balanced with nurses’ right to migrate. An examination and discussion of international migration begins with more research and data collection. Because of globalization, migration will continue. Its nature is dynamic, and it is now easier for nurses who wish to migrate to be able to access the information necessary to make it a successful journey.

International migration that is a positive experience for all parties will establish the global significance of nursing. The internationally educated nurses who work in the US contribute to health care delivery in both the US, for example by enhancing culturally sensitive care, and in their home country, by the sharing of knowledge. Continued collaboration, and coordination through the many modes of communication will ensure that patients in the US and abroad have access to excellent health care, and advance nursing everywhere in the world.

(2) http://intlnursemigration.org (Return Migration of Nurses Fact Sheet)

US based Recruitment of Foreign Educated Nurses American Journal of Nursing June 2010 Vol. 110 No 6 pp 38-48

Lived Experiences of Internationally Educated Nurses in Hospitals in the United States of America International Nursing Review 2011 Vol. 58 pp 123-129