Nurse Up!

I recently read an article written by Debra Wood, RN, a contributor to Nursezone (dot)com. (you can read it here) The topic was a study that reported an alarming percentage of registered nurses who are suffering from depression. I believe she referenced 18% of nurses polled in a study reported symptoms of depression—in comparison to 9% of U.S. adults who have reported having depression. She posed a reasonable question: Why is this happening? Many of us who have worked at the bedside recently or are currently practicing at the bedside can recite at least ten or more reasons easily. My number one response is: the evolution of Corporate Nursing. I’ve blogged about this “new” specialty of nursing that has been developing over the course of years as the healthcare system has become more complex.

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Before I discuss Corporate Nursing further, I’d like to offer my own take on the depression issue. My hunch tells me that the rate of depression in nurses is significantly higher than reported. Although the study itself included a little over a thousand nurses I think of two things: the stigma associated with depression and other mental health disorders is such that people are ashamed to report symptoms or to approach their primary care providers for help. “That” goes in your medical record, and if for some reason your medical record is accessed down the road other people will know about your diagnosis. If you think that your electronic medical records are safe because you see physicians or go to clinics within your healthcare institution—think again. Those records are privy to the inspection of risk management, employee health, and the information “magically” makes it to your unit managers. (Of course they will feign “shock” at even the suggestion that they get this type of information on their staff) From there you can be considered a liability to patient care. This does happen, and I was advised of this by an attorney who says it is a common “under the table practice.”***I’ve said it many times before—practice defensive corporate nursing!**** If you need to get help, get it “outside” of the healthcare providers associated with your workplace!!

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The other reason I think nurses are depressed is the perception of being “stuck.” I read some research in recent days that discussed reasons many new graduates are leaving the nursing profession so soon after graduation— it’s the shock they encounter when they actually get out there and do the real stuff nursing is about. Students are not taught what they will actually be a part of after they graduate—the pressure, the workplace politics, the moral distress, the higher acuity of the patients, and the impossible expectations from management to “get the patient satisfaction scores up.” Those are just a few of the burdens we face as bedside nurses. Other nurses feel stuck because they did not go back to school and increase their marketability so that there would be greater career possibilities, as a result they are pinned down at the bedside and remain there for years—a perfect recipe for burnout. There was a statement in the article about how “being depressed” leads to all the problems interacting with coworkers, patients, and providers. I’d like to pose the theory that its those very interactions that can be the “cause” of the depression. Nurses don’t just get depressed out of the blue and start taking it out on everyone around them, its an accumulation of negative or emotional interactions with others that is a very big contributor. We could ask that well known question—”What came first, the chicken or the egg?” My bet is that the depression comes from the workplace first and initiates a cascade of interactions or issues much like the clotting cascade. When something goes awry….it can rapidly deteriorate to DIC. We could also utilize the Renin Angiotensin Aldosterone feedback loop as a comparison.

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Generational differences in the workplace are also a problem. The time honored conflict of the “older generations of nurses versus the newer generations of nurses.” Most of the “veteran or baby boomer” nurses are in management positions and have a very different view of the workplace, how they communicate, and how they behave in comparison with the newer X and Y generations of nurses. Many of these management figures never went back to get a higher degree or to learn the leadership skills that are so essential to run a successful unit with good patient care outcomes, effective teamwork, and happy nurses. Research has shown the greatest conflicts exist between the Generation X nurses and the Veterans/Baby boomers. The caustic relationship these two generations have with one another is where the phrase “nurses eating their young” came from. Certainly, that can contribute to depression over time. I don’t think I need to go into the emotional and physical effects of nurse bullying on a nurse—whether it be in the workplace or in cyberspace. There are plenty of books on the subject, and I am going to make a safe assumption that it’s a pretty big contributor to depression in nurses.

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Corporate Nursing has evolved into something reminiscent of assembly lines in a factory. We discharge three patients and right away we get three new ones. There is paperwork to complete, orders to process, phone calls to make, and charting to do. Today’s nurses don’t even have the time to go over the patient’s history in the computer or do care plans because of the fast paced environment, impossible nurse to patient ratios and the higher acuity of the patients. The patients need more, and more, and more. Nursing theory? What’s that? Nursing diagnoses? There is no time for such luxuries. I can tell you that many days I went off shift swearing that I knew nothing about my patients except that they were alert, oriented, pink, warm, dry, had their meds, had good blood pressures, decent rhythms, and that my charting was done. That isn’t what I went into nursing for.

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As I was growing up I didn’t dream of being a nurse so I could just process people in and out of a hospital as fast as possible before I felt they were even safe to discharge. I didn’t work hard to make it through nursing school with my daughter just so I could go perform a bunch of tasks over and over that really add up to nothing but “tasks” at the end of the day. I went to school to become a nurse because I wanted to get to know my patients, to help them make decent recoveries, to take the time to teach them and listen to them and support them. I went to school because I wanted to help “people.” I went to school with the idea that nursing was about my allegiance to “the patient.” I graduated with that understanding too. My nursing professor constantly stressed the importance of balancing “hi tech nursing with hi touch.” Unfortunately that isn’t what nurses “do” or who nurses “are” in hospitals today. The definition of nursing as we are taught by our professors is not the same definition a hospital has for our profession. Personally I have a problem with the art and science of nursing being manipulated and refashioned into something I don’t even recognize—all in the interests of the mission, values, and goals of an institution.

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To be successful nurses, Corporate Nurses must have allegiance to the institution FIRST. They are required to be who the hospital wants them to be, look like the hospital wants them to look; they are to believe what the hospital wants them to believe, and they are to follow the status quo without questions. One’s sense of ethics, values, beliefs are to be set aside because they have no place in the Corporation. Over time, it can be very easy to lose one’s self in all of that. One day you wake up and wonder who the hell you are and why you are there…you wonder how long it’s been since you really knew what you stood for in the world or in the profession. Today’s Corporate Nurses know they cannot speak up in the interests of their patients without retaliation, so they feel forced into silence and stuck between a Corporation and their patient, between their job and the lives of their patients. It can’t be a fun feeling to have at the end of the day when you try and sleep, or when you get off of a three shift run and have four days to think about the patient you knew was in danger but were forced to turn away from. Certainly enough of these scenarios can really tax a nurse’s emotional and physical health over time.

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At the end of horrific days during which none of the nurses on a unit got the chance to eat, use the bathroom, or get a moment away to attend to their own psyche– it’s unrealistic to expect that these same nurses are going to bounce on out the hospital doors focused on heading straight to the gym for a cardio session or adding up their calories and fat grams for the day. They go home, say hi to their families, and crash—hard. Then, it’s time to do it all over again even though they feel they could still sleep another whole day before being ready to go back to “that.” I dare suggest that for a majority of nurses preventive health is one of the last things on their mind because they are too busy and stressed trying to “survive” moment by moment, hour by hour, day by day. Their brains are too full, their shoulders too burdened to think of themselves and living out the “ideal healthy life.” As it is they barely get enough sleep or rest.

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Look, I could go on and on and continue to list reason after reason for why nurses are depressed more than the general population. The Nursezone article offered some strategies to reduce depression in nurses that, in my opinion, aren’t going to happen anytime soon. After all, they would require the “ok” of the Corporation and the investment of more money into what hospitals already recognize as the biggest expense they have—Nurses. One suggestion I found completely unrealistic in today’s politically charged, toxic work environments involved having managers bring up an open discussion on depression during staff meetings. I can’t see any nurse wanting to pipe up during that “talk” and take the chance of possibly being “looked at closer” by management. Some suggestions in the study she cited included: “Advocating for policies that support good mental health and treatment for those with problems, promoting supportive work environments and making reasonable accommodations for nurses whose depression is negatively affecting their work performance.” Again, a supportive work environment means what a Corporation wants it to mean, not what nurses want, desire, or need it to mean. The word “advocating” and Corporations just don’t go together. Furthermore, Corporations don’t make “accommodations” for those who present a potential liability to their bottom line, they just find ways to discipline the liabilities until they can terminate them—it’s cheaper and less messy.

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When you think about it–It all goes together, why nurses are depressed more than other people. When your body is under a great deal of stress your stress hormones and metabolism go out of whack. The fight or flight response is always “on.” When you’re busy you don’t think of eating, or eating the way you should. Some people utilize food to self- medicate for stress. When you aren’t getting good sleep your metabolism is greatly affected and your weight can increase as a result of that. If you aren’t happy with your job to begin with and you aren’t sleeping, eating right, exercising, and are gaining weight it could be hypothesized that a nurse would likely begin to feel like everything is out of his/her control—especially if all of these things are affecting the home life as well. Loss of control depresses our patients, we are not exempt from that.

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Balance is the key word here, but it is hard for nurses to maintain balance in their lives when one of the biggest parts of their life is so unbalanced. This toxicity spills over into all other areas of their lives, through no fault of their own, and I believe that. If we want healthier, more balanced nursing professionals who will remain in our profession changes have to start at the Corporate level. Corporations have to buy into the theory that investing in the health and well- being of their nurses will pay off for them in the long run. They must be convinced that they will get a return on their investment. Remember that Nurse Managers cannot advocate for bedside nurses when their loyalty is to the upper management that they must answer to and support. Corporations have to view nurses as a valuable resource and act accordingly. They have plenty of money to expand and buy more properties and equipment…I have a hard time believing that these same Corporations can’t invest in a high tech fitness center/trainers for its staff members, massage therapy, communications courses, support groups for nurses, a partnership with companies like Weight Watchers to help people learn how to eat better on the run, or financial incentives to promote healthier BMI’s and pounds lost. Certainly there is room in the budget (we all know there is) to invest in lift equipment for every patient room, more patient care assistants to help the nursing staff, and a work schedule option that would allow nurses to choose 8, 10, or 12 hour shifts.

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Let’s recall the RWJF’s initiative “Transforming Care At the Bedside.” If you want happy, satisfied patients and good patient outcomes, you must must must invest in the happiness, satisfaction, and health of the nurses first–as well as the cohesiveness and well being of the nursing team. (Its purpose is also to enhance positive multidisciplinary interactions but I am focusing on nurses for sake of discussion) Until Corporations stop putting the cart before the horse (skipping over the nurse and focusing on competition, profits, and patient satisfaction) the number of nurses with mental health ailments like depression is going to continue to rise and they will keep leaving our profession as fast as we get them in.

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We cannot heal others until we heal ourselves FIRST. We can’t give to others what we don’t have to give to ourselves.

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