Nursing can sometimes be a difficult profession for many of the men and women who choose to give their lives to the service of others. However, many nurses bring additional challenges to their calling, such as physical and mental hurdles that extend beyond the nursing experience. Although physical disabilities can make nursing hard at times, mental roadblocks are just as common and essentially hidden from teachers, coworkers, and sometimes the nurses themselves.
The good news is, though, dealing with an invisible challenge isn’t insurmountable.
For example, attention deficit disorder (ADD) can cause difficulty focusing, brain fog, and trouble concentrating. Nursing school requires attention to detail and focused concentration. Yet, this is just one of the many challenges that nurses can overcome—and many have.
For instance, Carin Shollenberger, RN, CRNA, has had ADD since childhood. She wasn’t diagnosed until well into adulthood, and she could have let it hold her back.
“Not being diagnosed impacted my ability in succeeding to my highest potential in nursing school and anesthesia school,” Shollenberger says. “With ADD, the ability to focus on what you are told to focus on is nearly impossible.”
When nurses are drilled on how to use their senses to assess patients, those with ADD must marshal all of their will to get the job done. Success is doable, but it requires a strong effort and indefatigable motivation to overcome a brain that fights back.
It isn’t merely issues with focusing that can potentially stand in the way of a successful nursing career. Post-traumatic stress disorder, or PTSD, can make entering the nursing field complicated. Some of the tasks asked of nurses can trigger unwanted emotions and feelings.
Miranda Gallegos, RN, is one such nurse who has succeeded in nursing and even flourished while facing PTSD. Like most nurses—those who enter nursing with relatively few challenges and those who have to work harder to attain the same goals—she dedicated her life to making nursing work for her no matter what.
In fact, Gallegos states, “I found nursing school to be a welcome distraction and almost a period of remission. I had no interest in my peers so I could 100 percent focus on my studies. I did have a tendency to zone out or dissociate in times of stress.”
Gallegos, a hard worker, took refuge in the high attention to detail that nursing requires. In her case, her PTSD symptoms could help her to push through and succeed.
And this is the point: nurses who are faced with physical and mental challenges can become excellent nurses. Nursing may seem intimidating, especially to someone who is struggling. Nursing can sometimes seem impossible as a profession with a diagnosis of an attention disorder.
Yet these two women have shown what can happen with effort.
“My tip to prospective nurses would be to seek professional help sooner,” advises Shollenberger. “I would have told my past self that it was not normal to procrastinate nor was it normal to have the inability to focus on school work while most everyone else could. I didn’t know that I could be helped!”
Gallegos agrees: “I found that nursing school really empowered me to get help. Once I got help for my conditions my grades went from B’s to A’s. I didn’t know I had something wrong at the time until through school I learned about these disorders and realized I fit into a lot of these categories and symptoms.”
Surely, early detection is key. If you are having trouble with focusing or intense anxiety, these are symptoms worth checking out. Nursing is hard enough as it is, and no one should work with any hindrance that can put a patient in danger. Examine yourself. Know yourself. Discover what your needs are to make nursing a success.
Shollenberger found that both nursing school and anesthesia school could prove challenging before she knew about her ADD.
“In nursing school, I did not have a husband or kids. My friends in the dorm got a visit from me several times a day when it was time to study. In anesthesia school, it was even tougher with a family. I wish I would have been diagnosed and treated early on…it wouldn’t have been so stressful.”
Gallegos found that her PTSD actually helped her be a better student and a better nurse.
“PTSD has a known symptom of hyper vigilance and I use that to my advantage. I am able to quickly scan whole pictures and scenarios to develop my assessments and my priorities,” she explains.
These nurses have documented challenges they faced when they entered the profession. Both faced them head on and used their diagnoses to make their skills better than they may have been without them. Although they both walked a hard road at times, they have succeeded well in the profession.
What is it that helps them overcome what could be a daunting challenge? What should other nurses know about traveling down this road?
“My tips for other nurses is to just keep your head down, study, and do your work,” Gallegos explains. “Focus on lots of self-care, whatever that means for you. Don’t worry about what other people are doing.”
Nurses tend to compare themselves to others, trying to be the super nurse that doesn’t need any help. For someone facing additional challenges, this could be disastrous. Focus instead on introspection and using your unique skills to make yourself the best you can be.
Shollenberger sums up her positive nursing journey this way: “Before my diagnosis, I felt like a failure because even though I got good grades, my struggle to get them was real. I felt even more of a failure in anesthesia school because I couldn’t skate by the skin of my teeth anymore. Once I had the diagnosis, a lot of what happened in my life made sense, but I still had to work to overcome the adversity. Medication helped but knowing in my mind that I could overcome this was an even bigger push to succeed.”
You may have heard the term moral injury more frequently these days than ever before. Between the TEDx talks, the YouTube rants, and the LinkedIn articles, moral injury is being compared to post-traumatic stress disorder (PTSD) symptoms and is heading to replace one of our favorite words in the nursing world: burnout. However, there is a growing movement that believes that moral injury is the root-cause of burnout and PTSD. In other words, if burnout or emotional exhaustion is organ failure, moral injury is sepsis.
In the August 2018 issue of STAT News, Dr. Simon Talbot and Dr. Wendy Dean associated the term moral injury as the true cause of burnout; the cynicism, emotional or physical exhaustion, and diminished productivity that can be prevalent in many health care organizations. However, burnout implies that the clinician is not resilient enough to manage the components of the job, or perhaps is not participating in enough hot-yoga-self-care practice, whereas the actual root cause of the emotional discord is moral injury.
Historically, moral injury is associated with military personnel who have witnessed, participated in, or failed to prevent transgressions against humanity or acted contrary to “deeply held moral beliefs and expectations” according to a study published in 2009 in Clinical Psychology Review. While civilian clinicians in the U.S. are not necessarily bearing witness to the horrors of war, they are attempting to provide care, compassion, and healing in health systems that are broken and, oftentimes, focused on compensation rather than the patient or clinicians.
The slope of document-for-maximum-reimbursement vs. document-the-excellent-care-provided is slippery. The fact is, health care is a business. To take it one step further, given the publicly reported information on patient satisfaction scores, readmission rates, infection rates – not to mention social media – health care is a commodity and patients can trade their provider with the click of a mouse. Organizations simply must maximize revenues from the ever-changing world of insurance coverages to keep the doors open, let alone to fund strategic initiatives to make improvements or plan for growth.
Clinicians find themselves in the middle of the battle between care and compensation. For example, when a patient presents with a wound and, after they are seen and treated, the nurse knows the patient cannot afford the appropriate dressings, but the organization does not allow staff to offer long-term supplies (brown-bagging). Or a patient who needs an expensive biologic medicine that the clinician knows is the best on the market for the diagnosis yet is required to order the cheaper medication that is on formulary. These betrayals to the calling of medicine to provide excellent care in and of themselves are not impactful. But numerous and repeated injuries to the morality of health care takes a toll.
Cases of moral injury occur at all levels of the health care organization. While working as a Certified Nursing Assistant (CNA), Doug McGann experienced emotional exhaustion. “I felt very undervalued in my role as a nursing assistant. I knew that I worked hard and provided compassionate care, but the organization really didn’t do anything to recognize the role. In fact, when they removed tasks from the assistants, like measuring and recording vital signs, it felt insulting. We were providing less support to the team when most of us wanted to contribute more. Eventually, I left the role as it became too mundane and repetitive and went to nursing school.”
How do clinicians guard themselves against moral injury? What can organizations do to combat the insult? The answers are still being hypothesized and churned by many articles in the health care space. One answer could be to encourage clinicians to embrace nurturing practices such as meditation and other stress-relieving activities while acknowledging that self-care means something different to each person. But a “Code Lavender” approach to increasing stress is not always that simple, and once again puts the onus on the clinician to improve their coping mechanisms.
What needs to improve are the institutional patterns that perpetrate the moral injuries. Organizations need to reduce the competing demands on health care workers and strive to treat each discipline with the respect it deserves so that providers can practice at the top of their scope. Institutions should provide, advertise, and encourage employees to utilize employee health services that include a behavioral medicine practitioner for debriefing and centering. Also, there is strong data emerging related to the effects of supportive, competent, and empathetic leadership on reducing the effects of moral injury.
By changing the language and mindset of how we approach burnout to address the root of the issue, the business of health care can move away from moral injury and into a place of mutual respect, acknowledgement, and empowerment towards all levels of the medical team.
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.
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