Nurses Say Stress Interferes With Caring For Their Patients

This article was republished with permission from SCRUBS Magazine.

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Jordin Purcell-Riess has worked as a registered nurse at the emergency department at St. Francis Hospital in Hartford, Conn., for three years. She describes her workplace as phones going off, voices everywhere, every room full. “You look around and the hallways are full of patients on stretchers; you walk out to the waiting room and you can see on our board that there’s 15 people signing in,” she says. “The second you can get your ICU patient upstairs, there’s another one waiting for you.”

She typically doesn’t get a chance to eat or drink or go to the bathroom during her 12-hour shift, Purcell-Riess says. And she’s not alone. Her nursing manager points out that a 2007 study in the American Journal of Respiratory and Critical Care Medicine found that 24 percent of ICU nurses and 14 percent of general nurses tested positive for symptoms of post-traumatic stress disorder.

Nursing has long been considered one of the most stressful professions, according to a review of research by the National Institute for Occupational Safety and Health at the Centers for Disease Control and Prevention in 2012. Nurses and researchers say it comes down to organizational problems in hospitals worldwide. That includes cuts in staffing; some California nurses struck last month for a week over low staffing and wages.

But some researchers say that just hiring more people won’t fix things. Other proposed solutions include restructuring hospitals so that administrators pay more attention to what nurses have to say about patient care and work flow, and training programs to help nurses relieve their stress and deal with ethical dilemmas.

Theresa Brown is a clinical nurse in Pittsburgh who has written two books about what it’s like to be a nurse. She says nurses are often stretched to the limit.

“A friend said when she started working as a nurse, when she would drive, she would vomit on the way in to work just because of the incredible level of stress,” Brown says.

“One of the senior nurses said there is no place we can go to just be alone and be in a quiet room for five or 10 minutes, except for the bathroom … you could have a patient get really really sick, you could have a patient die, and there’s no break,” she says.

She adds that whenever hospitals start adding new forms of documentation or electronic health records, that work is often given to the nurses so their workload just gets larger. “It shouldn’t be this way, but the patient demands are the ones that can get put off.”

It’s not just a problem in the U.S., either. A recent study in Hong Kong found nurses to be at much higher risk for stress, depression and anxiety compared to the general population. The Guardian reported last January that the number of nurses in the U.K. taking time off due to stress has soared — 1 in 29 are off because of stress. The problem is that most hospitals aren’t organized to support nurses, or even doctors, says Linda Aiken. She is a professor of nursing and sociology at the University of Pennsylvania. “They’re highly bureaucratic, they’re very top-down organizations, they don’t really seek out clinicians’ solutions for solving problems in patient care,” Aiken says. “Therefore the problems exist over decades, and they’re basically not solvable by any individual nurse.”

If the work environment at a particular hospital is bad, just adding more nurses won’t address the problem, Aiken says. As an example of what hospitals can do, she points to magnet hospitals, a form of voluntary accreditation from a subsidiary of the American Nurses Association that looks at nursing culture, training and work practices, including issues such as not having a nurse lift patients alone, a significant cause of disability for nurses. There are about 400 certified magnet hospitals in the U.S.

Aiken says to get magnet status, hospitals need to give the nurses and doctors who are treating the patients a greater say in what resources are used for those patients, make decisions based on evidence, be well-staffed, and invest in educating their doctors and nurses. “That’s not the conventional way that hospitals are managed now,” she says.

Magnet hospitals with at least one nurse per bed are less likely to send patients to the ICU or have patients die, according to a study that Aiken co-authored that was published in January in JAMA Surgery. The improved results didn’t cost the hospitals more; some actually saved money. St. Francis Hospital, where Jordin Purcell-Riess works, follows the magnet principles though it is not accredited.

Linda Aiken says she’s worried that hospitals think of nurses as a cost to be cut and not as a revenue stream. Cynda Rushton, a professor of nursing and bioethics at the Johns Hopkins Berman Institute of Bioethics and School of Nursing, agrees. “There is a mindset among some administrators that nurses are easily replaceable commodities — a nurse is a nurse is a nurse,” she says.

Almost 20 percent of newly registered nurses leave a hospital within the first year for the same job elsewhere, or a different job in a different organization, according to a 2014 study. Rushton says to her, that means health care organizations aren’t investing enough in their nursing staff.

Nurse burnout also is linked to moral distress, Rushton says, from situations where nurses know what they should do for their patients but can’t act on it. For example, nurses might have to give a patient at the end of life a treatment that causes suffering without any medical benefit. She just started a program called the Mindful Ethical Practice and Resilience Academy to try to help new nurses deal with moral distress.

It’s a series of in-person workshops, some of which involve nurses using simulations to practice how to make their ethical concerns heard at work. One scenario includes a patient with a complex medical condition and a nurse has been caring for him and talking to him for days following the recommended treatment.

If the nurse sees that the medicine isn’t working, she could say that she’s assessed the patient’s pain, it’s a 10 out of 10, Rushton says. She could say she’s concerned about the treatment because “in my role as a nurse, one of my primary goals is to relieve my patient’s suffering and I’m not able to do that, so I’d like to talk about how we can figure out a way to more fully address this patient’s pain and their suffering.”

The goal is to help nurses better communicate with other staff members, Rushton says, as well as take care of themselves through mindfulness, reflection and other practices.

Nurses around the world are struggling with how to fulfill their ethical obligations, Rushton says. “In one sense, it could be considered a public health crisis, because if we don’t have sufficient nurses to meet the needs of people in need of health care,” the entire health care system could crumble. “I think that it’s time that nurses are recognized as a scarce resource that needs to be invested in, supported and respected.”

Share your thoughts on this important topic in the comments section below.


This article was republished with permission from SCRUBS Magazine.

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4 COMMENTS

  1. Hospital practices have changed dramatically over the past 45 years that I started working as an RN. Then the hospital systems were smaller and my hospital administrators actually took time to round and get to know ALL of the hospital staff. We worked on overcrowded units, but worked in teams, which helped improve patient care. Nurses were available to round with their patients physician, provide care updates and offer suggestions for continuity. Today, nurses are unrecognized for their abilities, knowledge, and the ability to practice their profession. Nurses are given high patient assignments, without support staff, are expected to fully assess, provide medications, do bedside care and procedures, and do the EMR charting in current time on all of their patients. Stress is the #1 factor that new nurses change jobs frequently or leave the profession, and why experienced nurses get frustrated, injured, and retire early.
    Did I mention that from day one, nurses do not get a pension when they retire? Nurses care for all people, and deserve the recognition for their ethics, caring, and compassion. Administration needs to start asking seasoned nursing staff and personnel for input in how to have the hospital be more efficient, and put the CARE, HEAL, & DO NO HARM, back into hospitals!

  2. There have to be changes in how nurses are treated if the healthcare system is to survive. After 30 plus years I am burned out and just will not do it much longer. The nurses in the above stories are right there is no break for twelve hours none. I have already had two surgeries because of this and will probably have one more in a year or so. It just has to stop. We are not machines.

  3. I agree that nurses are generally very stressed out. I have been a Registered Nurse for 34 years. I worked as a staff hospital nurse for 11 years and a Care Manger for the remainder of time. Nurses are stretched to the limit in terms of what they are expected to do and the work often involves overtime. It is also physically and mentally demanding. I also had a spinal fusion due to the demands of the job, despite using proper body mechanics, and it has negatively impacted my quality of life because I like to be an active person such as riding horses, exercising, etc. It does have its rewards, knowing that you are helping people, but it comes with a high price.

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