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.”
In times of budget cuts and healthcare changes, hospitals may be reluctant to alleviate understaffing and/or to provide resources to help nurses deal with burnout, compassion fatigue, PTSD, second victim syndrome, and other assaults on their mental health. But administrators must openly acknowledge that their nurses’ health is worth the investment. Burnout and compassion fatigue have been linked to decreased productivity, more sick days, and increased turnover among nurses, which are correlated with higher patient mortality rates, lower patient satisfaction, and compromised patient care. Nurses suffering from these issues are more prone to make mistakes. The ISMP has reported that fatigue alone can cause reduced accuracy, inability to deal with the unexpected, slower recall, and reduced hand-eye coordination, all of which could greatly impact patient care.
Researchers have also found that nurse burnout is linked to hospital-acquired infections, which kill approximately 100,000 patients a year. The researchers theorized that burnt-out nurses might be less vigilant about washing hands (and reminding visitors and other clinicians to do so) and other infection control procedures. They calculated that in hospitals that reduced nurse burnout by 30 percent, the number of urinary and surgical site infections dropped by 6,239, which saved $68 million a year. Washing hands matters: When the Michigan Health and Hospital Association implemented a checklist to remind staff to clean their hands and keep the field sterile, within three months the median rate of infection in central line catheters had fallen to zero.