Nursing has a hierarchy of power and experience like any other profession; it also has a hierarchy that sometimes feels akin to the laws of survival on the savanna or in the jungle – the herd mentality at work.
Have you ever observed that the less experienced and more vulnerable nurses frequently get left on the outside, often falling prey to bullies and “predators”? This is the herd mentality at its worst, and many novice nurses are taken down by bullies and power-hungry colleagues who eat them alive when they’re demonstrating the slightest weakness.
Protection and Predation
Out on the African savanna, herds of gazelles keep watch for lions, one of their most fierce predators; the culling of the pack is a natural phenomenon, and lions need to eat just like anyone else. However, some naturalists notice that the sicker, older gazelles are left outside the herd, vulnerable to predation and outside of the safety of the circle. Young gazelles are naturally kept on the inside, their parents and elders protecting them and keeping them close, with the innate understanding that they are the carriers of the gene pool which need to survive into adulthood so that the species can thrive in the future.
In the healthcare environment, we often see a herd mentality; in this scenario, the experienced nurses make up the bones of the innermost circle of safety, and survival of the fittest is frequently the name of the game. But what about the newer nurses? Where are they in the hierarchy?
A Med/Surg Herd
Let’s consider a large Med/Surg unit where we find a mix of older, highly experienced nurses, some nurses two to five years into their careers, and several fresh-faced novice nurses in their first year.
Now let’s imagine a bully in the mix; she’s a nurse with 25 years of experience, a toxic personality, and a stranglehold on the unit culture. The administration is afraid of her, the nurse manager turns a blind eye to her egregious behavior, and most nurses keep their heads down and hope she doesn’t pick on or single them out.
The older, more experienced nurses may be relatively safe from the bully; they’ve known her a while, put up with her toxicity, humor her, or perhaps ignore her as much as they can to not call attention to themselves. Their silence is essentially complicity, and some may play into the bullying and tacitly empower her aberrant behavior. A bully can sometimes be a younger nurse who bullies older nurses, too; this power dynamic can work in both generational directions.
The New Nurse: Falling Prey to the Lion
Meanwhile, the newer nurses are fresh blood for the bully/lion/predator; they are unsure of themselves, need to ask questions, and are vulnerable to being singled out and stalked by the bully and her minions.
If the members of the nursing herd try to stay out of the bully’s way – or support her in being the bully – what does that mean for the newer nurses? It generally means they are kept outside the circle of protection and safety, left to fend for themselves against the nurse predator.
If you think of the nurses on the unit as a herd, the young are left outside to fend for themselves. The elders are primarily held in the center, cushioned against the attacks of the predator/bully; however, an elder nurse can also be deemed weak by the “herd” and thus ostracized to the fringes.
The calculus of this situation is untenable and unhealthy, with certain nurses receiving the short end of the stick; vulnerable novice nurses need nurturing and support, not the feeling of being thrown to the lion(s).
Extending the Circle of Safety
To counteract a situation that lends itself to the burnout and attrition of newer nurses (as well as those seasoned nurses who are vulnerable to bullies), the circle of safety needs to extend its protection to everyone. Rather than leaving more vulnerable colleagues to be picked off the edge by predators and bullies, the circle closes around those needing its reassuring sanctuary, whether older, younger, or somewhere in between.
Dr. Renee Thompson, one of the world’s foremost experts on nurse bullying and incivility in the healthcare workplace, has documented and communicated the subtleties and vicissitudes of this scourge through books, blog posts, articles, podcasts, keynote speeches, videos, social media, and the powerful work of the faculty of her Healthy Workforce Institute. As Dr. Thompson informs us, we must learn to speak up in the face of bullying and to protect those members of our team who are susceptible to a form of professional predation that sends many a nurse running for the exit, often leaving the profession altogether.
We must reject the adage that nurses eat our young; we can create and embrace a new paradigm where nurses nurture and empower their young instead.
This isn’t rocket science, but we nurses need to learn the skills that will help us to bully-proof ourselves, speak up in the face of bullying, end nurse predation, and enclose our colleagues in a circle of safety that keeps the lions on the outside and the vulnerable protected from harm.
We can make different choices, and it’s our daily decision regarding our path. I implore you to extend the circle of safety, protect the vulnerable, and bring a sense of community, safety, and symbiotic togetherness to your corner of the nursing world.
Minority Nurse is thrilled to feature Keith Carlson, “Nurse Keith,” a well-known nurse career coach and podcaster of The Nurse Keith Show as a guest columnist. Check back every other Thursday for Keith’s column.
Nurses—especially in the last year during the pandemic—have been experiencing burnout. Often, articles focus on what they can do to make themselves feel better. But what can their workplaces do?
Anne Dabrow Woods, DNP, RN, CRNP, ANP-BC, AGACNP-BC, FAAN, Chief Nurse of Wolters Kluwer, Health Learning, Research & Practice, a Critical Care Nurse Practitioner at Penn Medicine Chester County Hospital, and a Clinical Adjunct Faculty member at Drexel University. She’s also authored and presented on many clinical and professional topics including a recently published eBook, COVID-19: Transforming the Nursing Workforce in the New Paradigm of Care.
She took time to answer our questions about what hospital leadership can do to prevent nurse burnout.
From a hospital leadership standpoint, what are some of the steps they can take to help prevent nurses from burning out?
Health care systems need to recognize that their most valuable commodity is their workforce. For years, health care systems have focused on patient well-being, but now many of those institutions are beginning to see the importance of focusing on workforce well-being too. Hospitals need to provide a safe environment for their workers, recognizing when they’re exhausted, burnt out and/or experiencing moral distress on the job. Safe environments should include the assurance of personal as well as patient safety and having adequate personal protective equipment, clinical decision support resources, and adequate staff to appropriately care for patients.
Staffing needs must be based on clinical acuity and severity of illness, not just on the number of patients. And having an agile workforce that can work in a variety of units as well as be shifted to other units when and where they are needed the most, is also a new essential, thanks to COVID. What we want, and need, are multispecialty nurses who can work across multiple units, not just single-specialty nurses working only with one patient population. Cross-training and upskilling staff to care for patients in a variety of units with a variety of care needs brings flexibility and efficacy to the workforce so managers will not need to overwork staff and can provide necessary time off.
Health care systems need to recognize when a member of their workforce is experiencing burnout and moral distress by having leadership and those trained in recognizing emotional distress available and on the unit to assess for it. Social workers and mental health workers are excellent resources to utilize for this kind of assessment. Taking the time to debrief and discuss what went right and what could have gone better in emergencies is a great opportunity to decompress after stressful situations. Many hospitals have instituted a moment of silence after a death where everyone in the room stops to acknowledge the life that was just lost.
Employee assistance programs (EAP) are good, but only if they can be easily accessed by those who need them. Too often EAP programs are difficult to find on the health care system website, and once they are found, the paperwork and or searching for an available care provider is incredibly challenging. EAP programs need to be made readily accessible and usable.
What should they do first?
The most important first step is to recognize that there is a problem with burnout. If staff are quitting, retiring early, or are becoming less engaged, there is a real problem. Be present! The leaders within the organization must be up on the units to experience what is going on firsthand. You need to find out if staff able to take breaks and leave the unit to have a meal. Are they able to sit down or are they constantly moving and up on their feet? Are they working as a team or as individuals? Health care is a team activity. It takes an interdisciplinary approach to provide the highest quality care and facilitate the best outcomes. If patient outcomes are not where they need to be, the first place to look is at your caregivers to see if they are exhausted, burned out, or experiencing moral distress.
What action steps should leaders recommend that nurses take? How can they get this information to them?
The question should not be what steps leaders should recommend to nurses to combat burnout, but how can health care organizations facilitate workforce well-being and prevent burnout? It is the obligation of leaders to assess the situation, make a plan, implement it, and then evaluate if the plan and interventions are working.
Start meeting with the staff, watch and listen to what they have to say, and start implementing these 10 steps:
Assess if the staff are burned out or experiencing moral distress.
Make employee assistance programs easy to access and utilize.
Adequately staff the patient care units with the right staff for the right patient populations.
Cross-train the workforce so they are more agile and can go when and where they are needed.
Provide adequate support systems, unit coordinators, unlicensed assistive personnel, and transporters.
Make sure the workforce takes their breaks and mealtimes.
Offer healthy food. Get a cart and take healthy options to the unit if the staff is too busy to get to the cafeteria at mealtime.
Give the staff time to debrief and collect themselves after a challenging situation.
Decrease documentation burden and make sure nurses have input on what is added to required documentation in the electronic health record.
Offer continuing professional development activities and career ladders to meet the staff’s professional needs.
Remember, nurses have family and financial concerns; offer care alternatives and financial counseling if and when it’s needed.
If nurses are already experiencing burnout, what should hospital leaders do? How can they help? And how can they let nurses know that their jobs aren’t in jeopardy if they need to take time off for their mental health because of burnout?
Take the time to see, hear, and experience what nurses are experiencing. You can’t do that from an office, so get up on the patient care units and look around. If the workforce doesn’t feel valued by the organization, they will leave, and there will be fewer caregivers left to care for the patients. Develop a “care without judgement model,” meaning that to whomever is in need of care—a patient, a nurse, or another employee—care will be delivered, without judgment. No one’s job should be at risk if they need to take time to step away and focus on self-care. You cannot be a good clinician unless you care for yourself first. Again, make it easy to access employee assistance and mental and physical health resources.
What should hospital leaders absolutely *not do when trying to prevent their nurses from burning out? What are the biggest mistakes they can make?
The biggest mistake health care leaders make is not recognizing that the health care workers are the most important commodity within their organization. Patient outcomes are optimized only if the staff feels valued, have adequate resources, are properly trained, and feel safe in their work environment—both physically and emotionally. Everyone on the health care team needs time to be able to take a moment to step away and recharge.
During COVID-19, what have been the biggest challenges that nurses are facing in terms of burnout? Is there anything that hospital leadership can do to help?
The biggest challenges have been fear and uncertainty. Fear that we initially didn’t know enough about the COVID-19 virus, and we might bring it home to our families or become infected ourselves, and fear that the death we experienced day after day wouldn’t stop. And uncertainty that we wouldn’t be strong enough to keep delivering care to our patients as we fought this seemingly unending pandemic. Yet we did. We looked fear and uncertainty in the face and said—”we will not be daunted!” That’s who we are—we are nurses, and our passion is to care for those in need.
Health care systems need to invest in workforce well-being, retaining the talent they have and recruiting new nurses to take the place of those who have left the profession. Care begins with those in our family. In health care, the workforce is our extended family.
Anything else?
The vaccine is a game-changer for nurses. The more shots in arms, the lower the number of patients we will see fighting for their lives because of COVID-19. Let’s trust in the science and use the evidence to educate people about COVID-19 and how to prevent it.
And finally, nurses need to invest in their own well-being so they can invest in caring for others.
Are you like most nurses, filling your days with taking care of everyone else but yourself? That may seem heroic, but putting yourself last ultimately leads to a dip in on-the-job productivity and career burnout. But when you take care of your own needs first, not only do you benefit, and so do your coworkers and patients.
Is there a secret formula to boosting your health and happiness? Fortunately, there is no secret. It’s simple, though not easy, to make yourself a priority in your own life.
By attending to your own self-care, you’re more likely to head off the symptoms of overload which can cut your nursing career short. But where do you start, when there are so many components of a happy, healthy life?
Self-care is easier to establish if you know what’s most important to you at this particular point in time. You may want to focus on a major life activity—eating, exercise, sleep, or relationships—because they seem like obvious drivers of well-being. Improvements in any of those important areas can certainly yield major benefits, but they’re usually tough to crack.
Even if you highly prioritize self-care, it’s difficult to say “No” to that big slice of cheesecake, fit in workouts, or turn in for bed on-time. Especially when your schedule is already jam-packed, your shifts are long, or you work nights.
Why not try another tactic? Consider setting a self-care habit in motion by starting with baby steps toward your ultimate goals. Improvements don’t have to start in your “hot zones” either. Like dominoes, a shift in one habit or routine will cascade down to every other area of your life.
Here are two powerful ideas to spark your thinking:
1. You Need a Budget.
Who even uses a budget anymore? It sounds so old-school, like playing music on 8-track tapes and paying with paper checks at the supermarket. But sitting down to crunch the numbers, and getting a grip on your income and outgo, can be an effective stress-reliever. Your financial situation may remain the same, but seeing the actual facts can stop the free-floating anxiety that’s fueled by imagination.
Your budgeting system doesn’t have to be fancy, either—just use a notebook and pencil to note and track your household expenses and income. Some people like to allocate cash to specific purchases, using an envelope system popularized by Dave Ramsey. One envelope for cafeteria lunch money, another for…
And don’t forget to plan for seasonal outlays (holiday gifts or taxes) and emergencies. That way if you need to replace a dental crown, you’ll have a buffer fund to cover it, and won’t panic as much.
There are also many apps out there for budgeting, including the grand-daddy, You Need a Budget (YNAB).
2. Do a Digital Detox.
Are you always texting, Skyping, Tweeting, Facebooking, or otherwise deep in your digital stream? That’s the case for many “social media natives” and even for their oldest colleagues.
Even if you’re following social media guidelines for nurses in your workplace, you may find that digital is a distraction, always in the back of your mind, ringing, buzzing, or vibrating to get your attention. You could get relief from all sorts of social media ills, from text neck to FOMO, by choosing a set time to disable it, for hours or days.
Some people like to set aside long weekends to go away on formal retreats, like the ones offered by Digital Detox while others simply reduce everyday use. Digital refers to all smartphones and computers (sometimes TV’s too), so resolving to stay away from electronics and screens after 8:00pm could be enough to calm your down, and make it easier to get to sleep at a decent hour.
Oh, but wait, what if you ditched your alarm clock? There are all kinds of new devices for improving your sleep hygiene that you may want to check out. One example is the Philips Wake-Up Light Alarm Clock with Sunrise Simulation, which costs less than $50. The light on this clock slowly gets brighter over a 30-minute span, to gently awaken and welcome you to the new day.
It’s important for you (and your patients) that you engage in self-care every single day. So resolve to take a baby step toward making yourself a priority in your own life.
Why not start today?
Compassion Fatigue and Burnout in Nursing
In this second edition of her seminal text, Dr. Todaro-Franceschi offers new insights on professional quality of life, incorporating current practice, research literature, and examples to show how contentment and happiness of the nursing workforce is related to quality of care. The book provides practical strategies for dealing with a myriad of issues, including compassion fatigue, burnout, moral distress, caring for the dying, PTSD, and workplace violence.
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