Kyana Brathwaite, founder and CEO of KB CALS- Caring Advocacy & Liaison Services, worked as a critical care nurse when she hurt her shoulder during a patient transfer.
“Our patient population is getting heavier [and] it is not always realistic to pull colleagues from different areas/departments to help. My true issue was not with the injury—although unfortunate, they do happen—my issue was with how my particular situation was handled after the injury by both management and the entity I worked for,” she explains.
For these reasons, the pain of her injury and the lack of support by management, Brathwaite chose not to stay at the bedside. Would she have stayed had circumstances been different?“Prior to the injury, I was considering staying at the bedside for at least five more years to give me time to plan the direction in which I wanted to take my nursing career.”Although she did plan to continue her career eventually, she would have given solid years to suffering bedside nursing specialties.
In fact, many nurses run from the bedside as soon as possible because conditions are so deplorable. They look for jobs in advanced practice, teaching, and other non-bedside related areas of nursing, while the number of nurses taking care of the most critical patients continues to dwindle.
Here are four reasons nurses leave the bedside and some ideas as to how to make them stay.
1. New Grad Education
New grads can go into a bedside job and not know exactly what they are in for. In nursing school, clinicals usually don’t go beyond two to three patients per student so they are not exactly exposed to the real-life rigors and stresses that come with the life of a bedside life—and cultural shock is a very real phenomenon.
“Nursing students are constantly told by faculty, peers, mentors, and experienced nurses what bedside nursing is ‘really like,’ says Greg Eagerton, DNP, RN, an associate professor at the University of Alabama at Birmingham School of Nursing. “However, it is like the first time we ride the bike by ourselves…The same is true for new nurses; their hands are held throughout their training and then the day comes when they are ‘alone’ and it’s a little frightening. They now have the sole responsibility for their patient’s care, their patient’s life—and that can be daunting. It’s also the reason we always encourage team support from their mentors, their more experienced peers, and from all members of the health care team, including physicians, therapists, support staff, etc.”
Although this is true, new grads often express intense dislike of their new role as a bedside nurse, and they immediately want to move to another branch of the profession. Is it that the nurse is not prepared or that the job is simply too difficult? It certainly sounds like management is trying to accommodate new nurses, but a quick search of internet nurse boards will reveal new nurses in despair. Perhaps more intensive job shadowing will allow new grads to see what bedside nurses do. Perhaps more realistic teaching would also go a long way toward helping them. Whatever the answer, new grads are a special population that needs attention—though it already gets quite a bit—to keep them safe and happy at the bedside.
2. Staffing Ratios
Another issue that chases nurses from the bedside is poor staffing ratios. It can be overwhelming for one nurse to have eight to ten patients to themselves. Not only is it unsafe, it is also stressful, and many nurses would rather find a new job than to put their licenses and their mental health on the line like that. For this reason, staffing ratios are important to consider when examining the loss of bedside nurses.
“I do not feel staffing ratios is the main driving factor,” argues Ken Shanahan, MSN, RN, CCRN-K, clinical nursing director at Tufts Medical Center. “One of the main reasons I feel this way is because the only state with staffing ratios is California and yet they have the most nurse strikes. These strikes are actually increasing dramatically and are something we will need to address as a profession. The work environment is the most important factor and number of nurses or ratios is only a component of the working environment. There are many other components that we are not hitting the mark on that would help create a healthy work environment.”
Although a large portion of nurses would disagree with Shanahan’s opinion on the importance of staffing ratios, he does have a point: they are not all that is involved here. Getting the floors better staffed is only one part of the puzzle, but addressing pressing issues such as horizontal violence is needed, too. Everyone knows about staffing ratios, but few realize they are only one prop to hold up a very large house meant to keep nurses at the bedside.
3. Compassion Fatigue and Burnout
Compassion fatigue and burnout are the psychological components that keep nurses from staying at the bedside. The two are closely related but are not the same. Burnout, in short, is frustration with the situation and is typified by anger. Compassion fatigue is an exhaustion of the ability to extend oneself emotionally anymore and is typified by depression. Please note, these are very simple definitions and they are not exhaustive. Both of these conditions can occur together, and neither is pleasant. Nurses have had their lives broken over these issues, and no one wants to go through that. How, then, do we solve this problem?
“Burnout and compassion fatigue are concerns for direct care providers in all professions,” explains Eagerton. He suggests the following measures to help support staff:
- Leaders should be visible and approachable.
- Work schedules should allow adequate time off between shifts.
- Adequate breaks should be provided during the work shift so that staff have down time.
- Schedule time for staff to have discussions about what stressors they are experiencing that may lead to burnout and fatigue.
- Create opportunities for staff to be involved in activities that allow them to do things that are not direct patient care but have meaning to them, such as committee membership, attending professional conferences, and so on.
- Have resources available for nursing staff in addition to their managers to discuss their stressors, such as chaplains, mental health professionals, and counselors.
- Have dedicated space(s) on or near the units where they work where they can have some quiet time or time to eat their meal or have their break without interruption.
With these ideas in place, nurses can have a better shot at overcoming compassion fatigue and burnout. When these are not a factor or are a mitigated factor, the more a nurse can feel happier staying at the bedside.
Nursing is definitely a contact sport, as stories like Brathwaite’s prove. Transferring patients is getting more and more difficult with increased body weights. In addition, various specialties are more susceptible to transfer related injury. For instance, operating room nurses are at great risk because they must move patients who are unconscious and essentially dead weight. However, that doesn’t make your typical bedside nurse any less at risk. Moving and lifting are just as much a part of the job, and mechanical equipment is usually not available to help.
“There is only one of you, [and] there will always be more patients,” says Nick Angelis, CRNA, MSN, author of How to Succeed in Anesthesia School (And RN, PA, or Med School) and cofounder of BEHAVE Wellness.“If no one is available to perform a task safely with you, don’t do it. Hospitals always push putting the patients first, but you’re a danger to patients if you give and give until your weekly schedule must also include time for massage and chiropractor appointments. Flu vaccines, unsafe equipment, dangerous staff ratios, risk of physical harm from unruly patients because hospital security resembles nursing home patients—these all require putting yourself first.”
It really does come down to this: Nurses need to learn how to put themselves first. If you can’t lift that 300-pound patient, then don’t even try, no matter how much it needs to be done. Similarly, hospitals need to make allowances for nurse injuries. Providing mechanical lifts, better security, and education about safety could go a long way towards protecting nurses and keeping them at the bedside.
In the end, the question of keeping nurses at the bedside is definitely multifactorial—and controversial. Patients have been cared for all this time with the methods we’ve been using, so why change? The reason to change is that the nursing shortage is real, and it isn’t what you think. It isn’t a lack of trained nurses. It is a lack of trained nurses willing to work. If we can make the bedside more appealing to these nurses who have run for cover, perhaps the nursing shortage wouldn’t really exist at all.
Health care quality and patient safety are not dependent upon a singular factor. Rather than addressing the system and its processes in a methodical, incremental fashion, the current model focuses improvement in a single area, rather than addressing the system as a whole—this is where the industry is failing. Organizations are seeing functions such as patient safety, provider safety, patient experience and satisfaction, utilization and others, rather than an intricate web with the patient and direct care providers at the center.
In health care, quality improvement is seen as the domain of clinical staff. Look at the profiles of people in quality improvement roles, and you will see most are RNs, MDs, or DOs, thus sending the message that the onus of quality improvement is on the clinical staff alone. This prevailing attitude is sabotaging the ongoing efforts to improve quality and ultimately impacting patient safety and experience.
What the typical health care approach to quality improvement (QI) fails to consider is that health care is a system made of disparate processes. Processes that feed into multiple areas and functions, far beyond direct patient care. It is an intricate web, that gets results. Whether good or bad, systems will always have the result that they are intended to and confining quality to the domain of clinical staff and their leaders is a huge failing that many organizations are still perpetuating.
The rigidity of roles in health care have created siloed efforts of improvement. Yes, there are state and regulatory compliance issues around licensure and scope of practice, but some of the restrictions in improvement work has been self-imposed by outdated attitudes and practices that no longer reflect the quickly changing field of health care. This impacts communication and can result in harm to our patients.
As health care continues to adapt Lean and Six Sigma into its QI practices, the industry is falling into the trap of only using Lean tools, but not following the spirit of a Lean culture. A Lean culture empowers everyone to work across departments and functions, make changes to improve quality, and add value to our patients. Risk is inherent with change, but with Lean, blame is never assigned—mistakes are seen as learning opportunities. Whether or not an organization uses this methodology, the mind shifts that must occur are imperative to improving care and having a true culture around continuous improvement. Thirty years ago, the New England Journal of Medicine ran a piece called “Sounding Board.” In it, the author describes two cultures: one that is punitive toward mistakes (Bad Apples), and the other is collaborative, with management acting as coaches who encourages honest dialogue about errors, with staff feeling supported to learn from them. The second was far more effective than the first. Why, after thirty years, is health care is still struggling to adapt continuous improvement?
Today marks Post Traumatic Stress Disorder (PTSD) Awareness Day to educate the public about a condition that can strike anyone. PTSD, an often-misunderstood ailment, is treatable but can have lasting impacts if people don’t recognize it in themselves or in others.
Nick Benas QMHC and Michelle Hart LICSW are authors of Mental Health Emergencies, a book that examines how anyone, but particularly medical and emergency professionals or those in roles such as teaching or human resources, can respond to a mental health crisis including post traumatic stress disorder. Providing the proper response and supports can open up the patient to a wide range of effective and needed treatment without the stigma they often feel in their daily lives.
Michelle Hart answered a few questions from Minority Nurse to help promote understanding of this condition, its causes, its treatments, and the sensitivity needed to help people who have it.
Please tell me how PTSD develops. Does it impact all ages?
PTSD develops after an exposure to real or perceived threat and/or witnessing or experiencing a traumatic event. Vicarious trauma can occur by listening to another’s detailed account of a traumatic event. It can impact all ages and babies have been born with high levels of cortisol, which is an indication of PTSD, after having a parent while in utero experience PTSD. The level of a person’s resiliency is a factor whether or not the effect of a trauma will eventually lead to PTSD.
Is there effective treatment for PTSD?
The most effective researched based therapeutic approach to PTSD is Dialectical Behavioral Therapy, DBT. However, many aspects of Cognitive Behavioral Therapy (CBT) have been proven to reduce symptomology.
How can nurses recognize signs of PTSD in patients or in those close to them?
One of the most common signs of PTSD is derealization or depersonalization. Examples of this include the following:
- The inability to experience a range of natural occurring emotions
- Lagging mind/body connection
- A person who is injured who does not experience pain in accordance with the level of injury
- A flat affect of emotions, not able to cry or laugh when situationally appropriate
- A person who stares off into space when discussing an event or appears to be re-experiencing the event when telling story
- Heightened awareness or hyper-vigilance in a safe environment
- Sleep disturbance, either not able to sleep or frequent nightmares, is a common occurrence with individuals experiencing PTSD
Finally, if a person actually states they feel traumatized they should be acknowledged in any event. It is usually not a major event that happens, but it can be small events over a period of time as well. Listen to a person when they are reporting the above stated symptoms.
How can nurses help someone with PTSD? In an emergency? In a non-emergency?
Being self aware is the major point of helping someone in an emergency with PTSD. Other important ways to help include the following and this all holds true for emergency and non-emergency situations. :
- Move with intention and do not make sudden movements.
- Explain and paraphrase what is happening during the emergency.
- Listen to an individual and do not argue.
- Allow a person to speak without interruption.
- Do not ask for details that do not matter.
- It is not effective to relive or retell the event as a matter of helping someone.
- Keep your voice calm and do not become over animated.
- Ask the person what they might need to feel safe for that moment.
- Keep the person safe and do not allow them to be alone in the midst of a panic attack associated with PTSD.
What are some common misconceptions about PTSD?
The biggest misconception of PTSD is that you have to be involved with something major. PTSD is individualized and can be compounded by many factors. The event which leads to the PTSD diagnosis might not be the overall cause. Bear in mind that negative childhood experiences can factor into a person who experiences PTSD. Certainly we hear about the large scale events which cause a person to experience PTSD, but never rule out a person experiencing PTSD based upon ones own thoughts of how traumatic an event was for them.
What gives those with PTSD hope?
PTSD is a treatable ailment. Most clinics have a variety of specialists who can help with PTSD. Help a person understand that the emotions and the things they are experiencing are real for them. Allow them to understand they are not alone and help them give a name to what they are experiencing. There are effective treatments available to help with the treatment and lessen the symptoms of PTSD. Have local resources available to give to patients and/or help them get in contact with assistance.
How can nurses spread that message?
The best way to help everyone is to DESTIGMATIZE PTSD. It is not an us-or-them diagnosis. Everyone in their lifetime will experience an event that could possibly cause PTSD. Allow others to have their own experiences without personal bias. We are not here to judge, just allow others to heal.
When it comes to having surgery, many people will think mostly about the operation itself more than the postoperative recovery period. As a nursing professional, you will know that this is actually only half the battle! The surgery itself can be the easier part, as it is done in a very controlled environment and within a set timescale.
Postoperative recovery on the other hand is not so simple. There can be a whole range of issues that crop up for your patients, which can cause them discomfort or even result in the surgery being a failure. With this in mind, it is vital to find ways to care for your patients in a way that makes any post-op period a success.
This is an area within nursing that has seen many changes over the years in how it is approached. This has affected not just the patients themselves, but also you as the nursing staff who look after them.
What exactly has changed in postoperative care?
- Rehab has become more essential – for your patients, the essential role that rehab plays in recovery from surgery has grown over the years. The importance of not only accessing the right kind of rehab but also taking advantage of it is very important to your patients. This has been made easier over the years, as more hospitals make rehab exercises and sessions open for your patients to engage with. This will not only get them moving around but also give them specific exercises to help recover faster.
- Diet is key – healthy eating has seen a much-improved profile in recent years and this has also been seen in postoperative recovery. For patients, it is key that they remember to eat the right foods and follow a diet rich in the right minerals to help their body heal. Of course, this has also affected hospitals, where healthy food is now expected to be served to patients.
- Education – when it comes to changes in how nursing care is done post-op, patient education is a key factor. Now, more than ever, you would talk to the patient after the op to inform them of what they can do to help speed up their recovery. This not only allows you to provide a better level of care for them, but also helps make the surgery an overall success.
- Increased postoperative pain awareness – when it comes to being a nurse, one of the big challenges that you will face is helping the patient to deal with any post-surgery pain. There have been many advances in this area, from closer monitoring of post-op patients’ pain levels to finding alternative ways of helping patients to manage pain.
- Advice around too much sun for patients – while you will be aware that some vitamin D and fresh air is good for recovery, it has been found that too much sun is not great for post-op wounds. An excess of UV rays can actually harm the tissue around surgical scars, and damage the area. With this in mind, it is much better to enjoy any trips outside for patients in moderation and to consider advising the use of sunscreen to help protect the relevant areas of the skin.
One area within postoperative pain relief for the nursing and medical profession that is seeing change is the move away from opioid-based pain relief. As noted above, patients are now far more likely to be advised by medical staff to rely more on alternative therapies or less addictive painkillers to help them recover in the long term. Advances made by Dr. Erol Onel in this area have seen effective pharmaceutical options to help patients experience less risk when managing post-op pain.
Naturally, the way that you care for your patients and the way they themselves interact with the recovery process has seen considerable change. As time goes on, innovations such as the development of non-opioid pain relief could bring even more change, which will lead to you being able to provide a much better level of care to any patients in your charge.
One of the toughest things nurses face is caring for themselves, and eating for optimal nutrition at work is especially problematic. Filling up on whatever is around can actually zap your energy and lead to longer-term health problems. And a recent study proves the grab-and-go in the break room is challenging for everyone.
A recently published study by the American Society for Nutrition shows that relying on food in the workplace might actually hurt your health. In a time crunch, buying quick take out in the cafeteria, granola bars or candy bars at a vending machine in the hall, or a juice or soda for a pick-me-up can wreak havoc on everything from your blood pressure to your weight.
Even if you resolve to spend nothing on food at work, you aren’t out of the woods. The candy dish that remains filled with tiny pieces of chocolate, the birthday cake for a coworker’s big day, and the party leftovers that appear in the kitchen or break room all add unexpected calories to your daily or weekly total.
The study’s author, Stephen Onufrak noted in his presentation abstract the dietary quality of foods obtained in the average work setting of the study provided less nutrition and a higher ratio of sodium and fats than healthy guidelines recommend.
Even worse, you often aren’t even aware of what you’re eating. A few small cookies barely make a dent in your hunger, but easily pack a lot of fat and calories to your day with little nutritional value. And because nurses work a physically demanding job, eating on the run is pretty common. Sometimes you think it must be better to grab a slice of coffee cake than nothing, and sometimes it is better to do that. But planning ahead and having a yogurt that’s just as fast to eat, string cheese, whole-grain crackers, or a handful of dried fruit and nuts that provides fiber, protein, and a few vitamins to boot is a better choice and provides longer lasting energy.
If it’s the social aspect of workplace eating that appeals to you, just be aware of your intake. Allocate what you are willing to splurge on and what you won’t really miss. Advocate for healthier choices when food is supplied for meetings, lunches, or celebrations. Also be your own cheering section. Take the time to stash your favorite snacks in your bag so you can feel social, but still fuel your body with healthy foods. As with any behavior change, it helps to enlist support. Find a buddy who can help you resist the urge to nosh on whatever is closest at hand.
With healthier eating comes many benefits, but feeling better is one of the biggest benefits of all.
Every workplace has its challenges. But, on the flip side, each has its advantages as well. We asked Beverly A. Ely, APRN, FNP-C, who works as a Family Nurse Practitioner in Harrogate, Tennessee, about what it’s like to see patients in a rural area.
Beverly A. Ely, APRN, FNP-C
What kind of work do you do?
I currently am a Family Nurse Practitioner and work with Lincoln Memorial University/DeBusk College of Osteopathic Medicine. We have 2 clinic locations that serve the University and the public. In the clinic, I see patients of all age groups from newborns to the elderly.
Working in a rural area is quite different from what most nurses do. Have you worked in a more urban or suburban area before this? If so, how does working in a rural area differ from those places?
My career spans over many decades and regions. I began a career in nursing in the late ‘80s. I graduated from Lincoln Memorial University with a degree as an Associate Nurse. I chose to begin my nursing career in Knoxville, TN and commute back and forth. Working in a suburban area, I encountered larger volumes of patients in which needs were very different than those in an urban location.
The urban area is different than the area where I first began my career. Coming back to it was a different experience, but one that has proven to be the most rewarding. I help them meet the simplest of everyday needs and assist them with coping skills to understand a diagnosis—this is rewarding. That is what I cherish about rural health and the people of the Appalachian area. I can now say that I can give back and serve the people that have given me so much.
Why did you choose to work in a rural setting? What kinds of patients do you tend to see? How are they different from those you saw in a more urban setting?
I chose to work and serve in the rural area of Appalachia because the needs are so great. I completed 29 years as a suburban nurse and saw many different classes for people. The common denominator for both is survival.
What have you learned from working as a nurse in a rural area?
I have learned to be patient and compassionate. I have learned that there is very little that we truly need in order to survive.
What are the biggest challenges of working in a rural setting?
The biggest challenge is compliance and understanding of their illness.
What are the greatest rewards?
Seeing people feel better and the smiles on their faces.
What would you say to someone considering moving to work in a rural area? What do they need to be willing to do or deal with?
I would voice that rural health is the most rewarding field that you can chose. It requires you to have compassion and patience.
Is there anything else about working in a rural area that is important for people to know?
Yes. Do I plan to continue here? The answer would be YES. It is the most rewarding of my 30 years as a nurse that I could have ever imagined. I’m compassionate and love the people of Appalachian and desire to see them live life to the fullest.