If you follow my practice, read my blog, have joined any of my educational programs, or even follow me on social media, then you're aware I worked myself into complete burn out, from which I am still working to recover. I was always, even through my childhood, the one who did it all and did it well, until I couldn't. Many nurses have a bit of a co-dependent personality, even poor boundaries, and too readily make ourselves the sacrificial lamb. More often than not, nurses come from an abusive family so we've learned we must sacrifice ourselves for others to be safe.
Today I teach Professional Roles for Advanced Practice Nurses in two different family nurse practitioner programs, one on either side of the country. This past week was dedicated to ethics, particularly human rights, compassion fatigue, patient autonomy, dehumanizing behaviors, gender inequality, and moral fatigue. Students talked about putting their lives in danger through the #pandemic because they lacked sufficient personal protective gear and the overwhelming burden of having to choose who, of their patients, would get life-saving care when resources were few. They talked about violating their patient's rights, abandoning them in their time of need, and being forced to immunize themselves, with an unproven vaccine, after all they had sacrificed.
Compassionate Fatigue
Compassion fatigue is what pushed me into #midwifery. It was incredibly difficult witnessing women's rights and requests be violated in their most vulnerable times. Why was it that being mindful of their birthing experience and having hopes for their outcomes, even committing themselves to their experience and then putting that in written form so they can clearly communicate with their care providers, meant they would be labeled, dismissed, ridiculed, and abandoned? Every day, when I worked in a large Indianapolis maternity unit, I would come home to my husband and vent about the atrocities that I was sure no one else was experiencing or witnessing because this was just too heinous to be the norm; in fact, it was the norm, and remains the norm. And I wasn't even seeing the worst of it.
Compassion fatigue is experienced when caregivers unconsciously absorb the distress, anxiety, fears, and #trauma from those they provide care. It plays a significant role in burnout which is a prolonged response to physical or emotional stress resulting in feelings of exhaustion, being overwhelmed, self-doubt, anxiety, bitterness, cynicism, and ineffectiveness (Henry, 2014).
Imagine working in oncology for example, not only do you have to be part of informing the client they have cancer and now need life-saving treatment that is so rough the treatment in itself may kill them, but if your client is a woman, many times you also get to hold her hand through this barbaric treatment because she'll be all alone. Her partner most often leaves in her time of need. Nurses are trained for this. In fact, they often prepare their patients for divorce after cancer diagnosis. Add to this any injustice the nurses witnesses from the healthcare industry itself towards their vulnerable patient, and their inability to really protect them from the pain and trauma is sometimes insurmountable particularly when shifts are short staffed and you haven't the resources to properly perform your duties, or in the case of a nurse practitioner, you are reminded that as much as you do, as much responsibility as you carry, you are still the only #clinician on the team that doesn't measure up. You are just a #midlevel provider.
Burnout can Look Different Among Nurses
Burnout was first coined by Freudenberger in 1974 when he witnessed caregivers detach and have less commitment to those they served within a mental healthcare facility. Maslach created an instrument to objectively measure burnout and he proposed burnout as a mismatch between ourselves and a six different variables. When we perceive we have an excessive workload and demands so that we can't recover, then burnout is a likely outcome. As employees, when we don't feel we have the resources needed to accomplish our responsibilities, or that we don't have any control in acquiring these resources, burnout is also likely. Unfairness in the workplace, particularly with inequity of workload and pay, or when there isn't connection and community, is high risk for burnout. When employees are forced to act against their own values and their aspirations and when they lack adequate reward for the job done well, then again, burnout can be profound (Dall'Ora et al., 2020).
Burnout may look like detachment, apathy, cynicism, and even dehumanization towards those they care for, or it may look like anger and resentment. Often I was saying to myself that I just felt so exhausted, that I was just so overwhelmed, but I always had hope that around the corner things would completely change, because I was self-employed and felt I could create the necessary change. However, I didn't have control over the resources I needed for my clients, like respectful collaboration or third party reimbursement so I could charge a fee that actually covered the services being rendered while also providing myself and my team a reasonable salary. Burnout can also look like a growing abdomen, central obesity, because in spite of your commitment to a client diet and regular exercise, your chronic fight-or-flight response is sending your blood sugars and cortisol through the roof. If you look at your local midwife, if she's been in practice a while, she is likely built the same.
Workplace Aggression
Any behaviors, whether within or outside of an organization, that is intended to physically or psychologically harm a worker and occurs in a work-related context is defined as workplace aggression. This may be physical; it may be a physician stabbing a curved suture into the palm of a nurse's hand because she offered him an instrument out of line or it may be a colleague kicking, pinching, biting, pushing, or slapping another. It can also be verbal. Like domestic violence, abuse doesn't just harm when the bruises are on the outside. Verbal abuse is like a punch to the brain, and quite literally, even the heart. Verbal aggression is when a colleague insults you. When they try to intimidate you. When they swear at you and use derogatory language (Rippon, 2000; Vincent-Hoper et al., 2020). Nurses, have any of you not witnessed or experienced this? It has always been my experience, for almost three decades.
Now, I ask you: if an advanced practice nurse, in half the states in this country, can not work to the full scope of their training for no other reason than the American Medical Association having effectively lobbied better than the nursing organizations in their state, is this not tolerated #oppression? If the clinical outcomes for advanced practice nurses demonstrate that not only do consumers more often choose them as their primary care provider when given opportunity (Leach et al, 2018), but they have similar if not better outcomes and are more cost effective then isn't calling them, and only them, the mid-level provider an attempt to intimidate and insult? If nurse practitioners and nurse-midwives have earned their doctorate degrees and in every other profession this means they have earned the right to use that title, as it respects their terminal degree, not their profession then why is this disallowed for nurses and nursing doctors shamed, even reprimanded? Is this not, by definition, abusive?
Physical and verbal aggression from patients, their families, and visitors is a pervasive problem in our profession and in all of our healthcare settings. Nursing is the occupation at most risk of experiencing aggression and #violence (Vincent-Hoper et al., 2020). Thirty-six percent of nurses report having suffered physical violence (Liu et al., 2019), and when they are punched and stabbed and kicked, and even when it causes bodily injury or disability, police refuse to take a report arguing this is part of the nurse's role and responsibility. We have case law of nurses who have tried to file civil claims against those who caused their disability and the judge determined this was part of her role; however, hit a cop and your consequence is even greater than hitting your wife or child.
Sixty-seven percent of nurses have reported being verbally assaulted (Liu et al, 2019). A study in Germany found that 80 percent of their nurses had experienced aggression in the workplace within the last 12 months, with 94 percent having experienced verbal abuse and 70 percent having experienced physical aggression (Schablon et al., 2018). Although the exact percentages differ to some degree across studies, it is quite clear that the prevalence rates of abuse towards nurses is astronomical. This reality has significant impact on nurses and ultimately, healthcare in our country.
Why is it that physicians who pursue APRNs do not suffer ramifications from hospital regulatory boards or even the Labor Board, or the prosecutor? This is school yard behavior; it should not be tolerated in our State Houses or our healthcare system. Why is it that nurses had to reuse personal protective gear if even they had any in the first place, during a pandemic, risking their own lives and the lives of their family, but when riots were occurring, police officers were provided military warfare to ward off their own citizens? If nurses can't be protected by abuse under the law and police get even greater protection than our own citizens, then might this be an issue of gender discrimination?
Post-Traumatic Stress Disorder
Workplace aggression and violence severely impairs healthcare workers. Burn-out is certainly evident, but so is depression and post-traumatic stress disorder. Although I have yet to verify this claim, I was speaking with a large group of midwives and someone stated the professional career for a nurse-midwife is on average only 7 years because of overwhelm, exhaustion, and burnout. When midwives leave the profession, they quite often suffer post-traumatic stress disorder.
Emotional exhaustion is the energetic component of burnout and refers to feelings of being overextended and depleted of emotional and physical resources, while depersonalization is more the development of cynical attitudes and feelings about those in our care. We start to detach, to disassociate and become numb, so we detach, become callous, and even become dehumanizing towards others (Vincent-Hoper, 2020).
Negative Work Environments
The nursing turnover and nursing shortages are increasingly common problems found throughout the United States and both are often the result of nurses having the perception their work environments are hostile and unsafe. The opposite though is also true. When nurses perceive their work environments to be positive, they have improved professional commitment and engagement. The latter is unfortunately, not the norm (Adams, 2019).
Overwhelmingly, nurses perceive their roles and work responsibilities to be physically and emotionally demanding. Nurses are short-staffed and expected to work beyond their job description. Leadership is often uninvolved and nurses are not invited to circles making the decisions. Burn out has become the reaction to prolonged work-related stress, evident even prior to the pandemic. Nurses are hopeless, apathetic, and underperforming. They are suffering physically, mentally, and emotionally (Adams, 2019).
There are studies that identify creating cultural change through a "kudos" board and suggestion boxes in nursing units reduces turn over (Adams, 2019), and while these interventions may offer temporary support, certainly, and even hope, if nurses continue to be overworked, exploited, and under appreciated, even dehumanized, then a mere thank you from a peer is not going to demonstrate long term success. This effort will be offensive in time if the underlying issues are ignored.
There is also evidence that although primary prevention for avoiding workplace aggression should always be the priority, because organizations will not be able to prevent all incidences of aggression and violence against nurses (and clearly it is quite likely to occur), interventions for reducing the strain and stress within their reactions after experiencing assault should be given more attention (Vincent-Hoper, 2020). Debriefing and counseling for example, are considered effective strategies for minimizing potentially negative emotional and mental impacts but interestingly, this has demonstrated more effective for physical violence and not nearly as much for verbal abuse. The tendency to view verbal abuse as more benign is a misnomer (Vincent-Hoper, 2020).
Pandemic has Exacerbated this Tragedy
Nursing shortages have already been very apparent, even before the pandemic, as well as poor working conditions, but the pandemic certainly exacerbated this situation and the consequence has been a higher rate of suicides among nurses. Teena M. McGuiness PhD, PMHNP-BC, FAANP, FAAN stated in her 2021 article, Suicide: A Dark Cloud Over Nursing, that "at no other time in the history of nursing have we faced such prolonged, cumulative trauma and stress" (para 2).
The pandemic resulted in more deaths from nursing staff than any other healthcare professional, with 1,140 nurses in just the first year. One of my classmates, from my Nurse Practitioner program died of COVID. This doesn't even account for the lived trauma nurses experienced, and continue to today. As a culture, we tend to avoid hard conversations, uncomfortable truths, and dialogues that focus on trauma and mental health; however, nurses mitigate trauma and distress and death on a daily basis. Add to this the conditions of the pandemic on top of the stigma associated with seeking help for mental health disorders, and we have a perfect storm for suicide (McGuinness, 2021).
Here's a key point though that I think goes completely ignored. Suicide is the tenth leading cause of death overall in the United States, but maybe you knew that. Maybe you're even aware that suicide has increased by 30 percent since 2007 and maybe even still you were aware that nurses have a higher rate of suicide than physicians, or even the public, but did you consider that the nursing profession is predominantly women and men are four times more likely to commit suicide than women? If you do then math then, becoming a nurse means you are 8 times more likely to die of suicide because of the abuse and violence you'll suffer (McGuinness, 2021). Here's the thing too, this is also true of men who practice as nurses; becoming a nurse increases your risk of early demise (Patrician et al., 2020).
What the research largely, or almost exclusively evaluates are interventions to improve this scenario, but in my mind, this is little more than platitude. Start a conversation with a colleague? Know your resources? And of course, teach grounding? Yeah, I am a fan of that too, but isn't this like giving your neighbor your garden hose when their house is on fire?
Now let's talk about what we're not suppose to talk about because things will get super uncomfortable... these required practice restrictions and the fact that because most states in the United States require them, nurse practitioners and nurse-midwives are put into vulnerable positions in spite of their doing nothing more but lining the pockets of physicians and limiting access to care. The collaborating provider can drop the APRN at any moment, putting their entire clientele at risk or not even tell them at all, and put their license at risk. They can also put the practitioner in a position to have to tolerate poor behavior, sexual advances, and even turn a blind eye when their collaborator is working below the standard of care. While I do want to highlight a few important interventions, what really needs to happen is a complete overhaul in the healthcare infrastructure. We need the patriarchy within healthcare to be eliminated and for nurses to garnish the respect they deserve, and those that violate those tenants receive actual punishment. The proverbial short white skirt and white hat still remains.
Moving Forward
There are a lot of ideas here, and I am going to start with potentially the most controversial simply because it isn't spoke of and it is considered taboo to even consider. Nursing is so often thought of as a service, even a ministry, a right of consumers and so not a profession that should really profit from that. However, nurse practitioners haven't advanced their own salaries as have the rest of the healthcare professions, to the point that often, nurses working at the bedside are often making more money than advanced practice nurses.
When I was a new graduate, a hospital in Idaho flew me out there to interview. They paid for my family to join me for the week, wined and dined us, then after requesting 24/7 coverage to cover both a birth center and hospital practice shared with two other midwives, they offered me $20K less than what I was already making as a labor & delivery nurse working weekends. The dichotomy was profound, in that to be available 24/7, my husband would have to be available for the children at all times so we would be living on a single income but making less than either of us did alone. The physicians however, interviewing me, were the backup for the midwives so we were the first ones called and therefore attended the bulk of the births and committed the bulk of the time, but made a fraction of the money, less even than the staff nurses.
Consider too that physicians are often given bonuses when they hit and exceed minimum productivity requirements, but nurse practitioners are often compensated at a proportional level. Many institutions around the country are giving premium pay incentives to Registered Nurses, so they too are receiving a higher salary than nurse practitioners. Not to say this isn't appropriate for staff nurses, because yeah! They too deserve an excellent salary; their responsibility is great and their personal investment is significant. Salary should reflect that. Either way, when compared with pay incentives and retention bonuses Registered Nurses receive, the salaries of nurse practitioners have failed to keep pace and certified nurse-midwives are even worse off in spite of worse hours and greater liability. As the demands on nurse practitioners increase, an equitable system needs to be created to address that responsibility.
Another point I have to argue, again controversial, is that APRNs have been challenged to advance the profession, to earn a terminal degree similar to other clinicians such as dentists, podiatrists, audiologists, optometrists, and veterinarians but we aren't respected as such, or even compensated for the additional effort. Why assume more student loan debt and still be paid less than an RN after all salary and incentives are totaled?
Interestingly, for the first time since 2001, enrollment in master's programs has decreased by 3.8 percent, which translates to 5,766 fewer students enrolled in 2021 than in the previous year. As the shortage of NPs grows, those who remain become more dissatisfied. Without enough physicians, who will meet the need? As a potential fix, nurse practitioners need to be given financial incentives commensurate with the professionals we are, as well as respect for those earned titles. I earned my title just as any other professional with the same academic degree and deserve to use that title, and while I do have that title on my home page, I also make clear I am a nurse practitioner and nurse-midwife. I am proud of those professions and have no desire to be perceived otherwise, but just as your local dentist or veterinarian's office doesn't clarify their profession after every use of the title doctor because it is cumbersome and unnecessary, neither should the nurse practitioner be required. How many times have consumers been confused and expected a pap smear during their eye exam because the receptionist answered the phone "Dr. Smith's office." As a college professor I am referred to as a doctor, but I catch grief doing so in the clinical setting and if I were in California, I could be charged with fraud.
The research talks a bit about employee assistance programs with intention of mitigating nursing burn out, (Henry, 2014) but can these talk sessions really overcome barriers to practice? There is also research that supports sessions on #compassion fatigue resilience (Potter et al.). My prior midwifery practice was quite busy and because there is a lot of trauma associated not only with challenging births, but also in the stigma associated with practicing in a birthing environment not always recognized as professional by our colleagues, we did host retreats. We also asked our staff to participate in debriefings after a transfer, and we offered EMDR to our staff. This support did prove beneficial in our practice, and improved retention; however, it simply doesn't even compete with the emotional exhaustion that comes with the restrictions on our practice. It's not just a restriction on trade, but it is demeaning and oppressive.
Historically, institutions have had difficulty in utilizing nurse practitioner roles appropriately. We are often worked far below the thresholds of our scope of practice. For a month I worked in a practice that had turned over three previous nurse practitioners in just two days, to no surprise. The practice owner, a chiropractor, would use the nurse practitioner as a scribe but of course, the visit would be filed to insurance on the nurse practitioner's license and the nurse practitioner would be used to provide referrals for ancillary services throughout his practice, lining his pocket even further, all off the back of the NP. They can use the title doctor though, and its incredibly controversial for an NP to do so.
Physicians have extended collaborative agreements for high fees, imposed further restrictions, or placed demands on us such as covering their clients during off hours, providing home visits for their clients, and I was once told I would need to utilize part of my home for transitional housing for recovering addicts for collaboration. We won't talk about all the hugs and pats that come along with trying to gain favor with a physician when you are desperate for such just to practice. This factor is profound when it comes to feeling exhausted, completely burnt out, even broken and dirty. Employment though, where collaboration is provided for you isn't always better because when titles are stripped and the work for the APRNs are front line, but there is no voice and the compensation isn't consistent with the responsibility of the role, ultimately we recognize we are being exploited. Nurse practitioners are leaving the profession and returning to the bedside, or leaving healthcare altogether.
There really does need to be greater definition of the nurse practitioner role, and better understanding of how advanced practice nurses can be utilized when the power of their oppressors is stripped away. Institutions can better utilize nurse practitioners in meeting the needs of consumers, but they must be willing to ruffle a few feathers because the power has been out of balance for so long; physicians have long dominated the narrative. We are complementary practitioners with different expertise, one no better than the other, and both enhanced by the other.
Empowering Nurses Negates Burn Out
Interventions among nursing teams that prioritize self-care, relaxation, and creating balance in work and family relationships are quite effective (Cohen-Katz et al,. 2005). The concern though is that this creates a challenge for employers, as nurses are no longer available for their exploitation. One can't promote self-care and then understaff regularly or require sick nurses to come in because there is no replacement, or file charges of abandonment when an emergency room physician takes a sick day to care for themselves. When we start to empower nurses, and nurses have a voice, they hold their employers accountable; most employers just aren't willing to make the necessary changes for improvement. This would mean hospital CEOs reevaluating their personal salaries and cutting some of the administrative fat. It would even mean making some tough calls because truly balancing the power among he clinical team power risks upsetting high dollar players.
What Does This All Mean Then?
A recent study entitled, Results of a National Survey: Ongoing Barriers to APRN Practice in the United States was fairly recently published in February of 2022. Nurse practitioners identified a number of barriers to practice, all of which contribute to burn out. Licensure issues are significant and the need for physician signatures to practice what we have already been trained is restrictive without improving outcomes. Administrative barriers along with a lack of collegiality makes the practice environment tense. Add to that uneven reimbursement, therapy restrictions, physician-only procedures or clients, and tele-health issues and the challenges really cause nurse practitioners to pause and ask what are we really doing here?
My thoughts are to share your stories. Add them here in the comments. Share them with your administrative staff, your legislative leaders, your community journalists. Let your voice be heard. There really is no better time for nurses to speak their truth, after the world watched us put our lives on the line to save those in need. We deserve better. We deserve better compensation. Consumers deserve our barriers to be removed. We deserve roles that truly show who we are, and we deserve benefits equal to our knowledge, contribution, expertise, and impact on consumers. Don't tolerate insults, threats, or intimidation in the work place any longer, even if this has been the cultural norm. It's time people feel a little uncomfortable. Change is way over due.
References
Adams, A., Hollingsworth, A., & Osman, A. (2019). The implementation of a cultural change toolkit to reduce nursing burnout and mitigate nurse turnover in the emergency department. Journal of Emergency Nursing, 45, 452-456. doi.org/10.1016.j.jen.2019.03.004
Cohen-Katz, J., Wiley, S., Capuano, T., Baker, D. M., Deitrick, L., & Shapiro, S. (2005). The effects of mindfulness-based stress reduction on nurse stress and burnout a qualitative and quantitative study, part III. Holistic Nursing Practice, 19, 78-86.
Dall'Ora, C., Ball, J., Reinius, M. & Griffiths, P. (2020). Burnout in nursing: a theoretical review. Human Resources for Health, 18(41). doi.org/10.1186/s12960-020-00469-9
Henry, B. (2014). Nursing burnout interventions: What is being done? Clinical Journal of Oncology Nursing, 18(2), 211-214
Leach, B., Gradison, M., Morgan, P., Everett, C., Dill, M. J., & de Oliveira, J. S. (2018). Patient preference in primary care provider type. Healthc (Amst), 6(1), 13-16. doi: 10.1016/j.hjdsi.2017.01.001
Liu, J., Zheng, J., Liu, K., Liu, X., Wu, Y., Wang, J., & You, L. (2019). Workplace violence nurses, job satisfaction, burnout, and patient safety in Chinese hospitals. Nurs. Outlook, 67, 558-566.
Patrician, P. A., Peterson, C., & McGuinness, T. M. (2020). Suicide among RNs: An analysis of 2015 data from the national violent reporting system. American Journal of Nursing, 120(10), 24-28. doi: 10.1097/01.NAJ.0000718624.25806.3f.
Potter, P., Deshields, T., Berger, J. A., Clarke, M., Olsen, S., & Chen, L. (2013). Evaluation of a compassion fatigue resilience program for oncology nurses. Oncology Nursing Forum, 40, 180-187. doi: 10.1188/13.ONF.180-187.
Rippon, T. J. (2000). Aggression and violence in healthcare professions. Journal of Advanced Nursing, 31, 452-460.
Schablon, A., Wendeler, D., Kozak, A., Nienhaus, A., & Steinke. S. (2018). Prevalence and consequences of aggression and violence towards nursing and care staff in Germany: A survey. International Journal of Environ. Res. Public Health, 15, 1274.
Vincent-Hoper, S., Stein, M., Nienhaus, A., & Schablon, A. (2020). Workplace aggression and burnout in nursing: The moderating role of follow-up counseling. International Journal of Environmental Research and Public Health, 17(3152). doi:10:3390/ijerph17093152