It’s 4:30pm, and my alarm is sounding. As my children are settling in for the evening, my workday is actually just getting started. Driving to work, I have a renewed sense of excitement. I am looking forward to what the shift will bring and serving my staff. I am a nurse manager; my job is to care for the caregivers. In the last three years, my perspective has shifted. I used to arrive at my unit and see smiling faces. These were my people, and our bond was special. We had cried together, laughed together, and were exhausted together. Today, as I arrive at my unit, I am surrounded by mostly strangers. The excitement I felt is replaced with a knot in my stomach, a sense of dread. Not because I don’t want to serve, but because I no longer know how to serve. Since the start of the pandemic, my team of nurses has dwindled. Over time, I have watched the light go out of their eyes, and it was not the patients I was watching die, but the spirits of my nurses, my team.
The above perspective is from a nurse manager, and I would imagine that some version of that story has run through your mind if you are in nursing leadership. The American Nurses Foundation published that over half of all nurses report they feel exhausted, 43% report they are overwhelmed, and close to 30% want to leave the workforce. Nurses and their leaders are feeling defeated and powerless. I am currently reading a book by Isabel Wilkerson called Caste: The Origins of Our Discontents. In the introduction of her book, she compares the structural racism in the US to an old home where the foundation needs to be rebuilt. Her story resonated with me because I see the US healthcare system the same way. Our current healthcare structure is the home where I am to practice. I did not build the house, and many people have lived here much longer than me. There is a foundational issue with the home, and it needs major repairs. Unlike an actual home undergoing remodeling, we (healthcare professionals) can’t move out while it’s renovated. We have to learn to rebuild the foundation and repair the cracks and chipped paint while still living inside the home. Patient care cannot stop because the system is broken. What can leaders do to make the daily conditions of our home livable so nurses and other healthcare workers will stay?
One of the crucial first steps that leaders can take is studying and understanding why our workforce is dwindling. Many of us attribute it to burnout and the data supports that assumption. But do we, as nurse leaders, really know what “burnout” means? The term “burnout” was coined in the 1960’s by psychologist Hebert Freudenbreger. It was how he described the emotional and physical exhaustion he saw in healthcare workers in the acute care setting. The official definition for burnout is: a state of emotional exhaustion where the individual feels overwhelmed by work to the point of feeling fatigued, unable to face the demands of the job, and unable to engage with others. Decades later, Christina Maslach enters the equation and develops an actual tool quantifying burnout. The Maslach Burnout Inventory measures burnout using three variables: detachment, inefficacy, and mental and physical exhaustion. Let’s take a closer look at each variable.
- Detachment occurs when nurses and other care staff no longer connect with patients or residents on a human level. They start to see patients as tasks that are to be checked off their long list of “to-dos.” They are unfeeling and impersonal to patients.
- Inefficacy measures lack of competence and success one feels in their daily work. Like the nurse manager in the introduction, who once drove into work feeling excited about the impact she will make, this excitement transitioned into dread because she started to believe she was incapable of positively impacting her nurses.
- And finally, there is mental and physical exhaustion. Nurses and their leaders are mentally and physically exhausted. The thought of change makes our head hurt or even frustrates us. We are tired and looking for reprieve.
Signs and Symptoms
Burnout is insidious, and affects every area in healthcare. It doesn’t matter what your position is within the hospital system. All levels of nursing feel the effects of burnout and perpetuate it, from the bedside nurse to the CNO. A nurse manager experiencing burnout feels indifferent towards the nurses on their unit and no longer can provide support. Similarly, a bedside nurse feels indifferent towards their patient and spends less time interacting with them.
Some physical manifestations could be that your staff appear tired even when they’ve been off work for a few days or even are theoretically getting enough sleep. You may also notice an increased number of call-outs and absenteeism. One study found that nurses with higher rates of burnout were more likely to be absent 1 or more days from work each month.
Detached nurses and care staff are not as engaged with new policies and procedures. Maybe in the past, introducing a unique process that makes their daily jobs easier was welcomed, but now they resist change. Many nurse managers have reported decreased compliance with hourly rounding; they see fewer names and numbers on the whiteboards in inpatient rooms. In the past, this lack of engagement happened on busy shifts and wasn’t the norm because none of us “get it right” 100% of the time. One nurse manager told me, “what I see now is consistent disengagement with rounds and less time with patients.” Or, on a more personal note, maybe you’ve provided lunch or dinner out of your own pocket without even receiving a thank you, which is out of character for your team.
So, what is the solution? Unfortunately, there is not a single fix to the problem. It will likely be years and interations of tearing down the structure and rebuilding. Does that mean we work in a home that is unstable? Absolutely not. There are numerous programs and interventions being practiced by healthcare systems all over the country, but instead of giving you a list of items for your organization to implement, I want to highlight a crucial first step.
Recently, I’ve had numerous conversations with nurse leaders ranging from supervisors, managers, directors, and CNOs, and one intervention they are all leaning on is conversation. It’s that simple, and it’s free. Ensuring that there is an avenue for staff members to provide feedback, voice concerns, or simply vent in a safe environment creates a sense of safety for nurses and promotes trust.
Many leaders are increasing the number of town halls or starting programs called “Walk Your Hall” which are designed to provide staff an avenue to speak their truth and bring to light the imperfections of the system. Both programs intentionally put leaders in the trenches to learn what the front lines are experiencing day-to-day. They are asking questions and listening to understand.
Sometimes as leaders, we are afraid to allow our teams to talk and ask questions because we don’t always have the answers. What if they ask me a question and I can’t respond? Many of the problems plaguing nurses and other healthcare workers are out of our control. We don’t have a solution. The issues are foundational problems within our home, and we need expert assistance. It is ok to not have the answers. There is power in listening. When I’m hurting, the people who are willing to sit with me and say nothing reassure me that while they can’t understand my unique experience, I am not alone. These are the leaders that make it possible for me to do my job and fulfill my calling.
Other organizations are implementing acute stress response programs like “Code Lavender.” These programs are designed to surround the bedside nurse and other care staff with real-time support. Maybe a patient died or coded or maybe the staff member had an argument with a loved one before they got to work. Stress response programs provide nurses the autonomy to raise their hand for themselves or another team member and say, “we need help right now.” Once activated, a chaplain, another nurse leader, or social worker arrive on the unit and tend to the staff member. This real-time support not only reassures the nurse they are not alone, but it allows them to re-center their mind so they can do their job - provide great care for patients.
Nurse author Theresa Brown was featured in a Fresh Air interview with Terri Gross in 2015. I remember many details about that interview, but one statement really resonated with me. Theresa said:
There’s a sense that you can stretch a nurse just like an elastic band… and the problem is that people do not stretch like rubber bands, and even rubber bands will break if you stretch them too far.
To me, the breaking point of the rubber band is the pinnacle of burnout. And breaking for a nurse doesn’t have to look like a mental breakdown or a dramatic outburst. Nurses break all the time and continue to work. Think about that same metaphor. It’s like continuing to use a rubber band to hold something together after it’s broken. It can’t function as it was intended to - and nurses are the same way. We are continuously being used even after we give out, and we can’t entirely function the way we were educated and trained. Let’s start a discussion on how nurse leaders can help bring the light back into our nurses’ eyes and help them practice and provide care the way they intended.
If you'd like to be part of the conversation, feel free to reach out to me at firstname.lastname@example.org