Nurse Burnout, Reality Shock, Marlene Kramer

note: all words or phrases that are underlined lead to hyperlinks – be sure to click on them and see what happens ;-)

The B word?

In my recent blog about adrenaline junkies, I got a private message reply asking for advice: What if you were an adrenaline junkie now verging on burnout?

Well, naturally my first reaction is to tell that person to go to Amazon and buy my book about nursing in Nepal. One basic premise of the book is to explore what happens when you are a lifetime adrenaline junkie and you finally get to a problem so big, so overwhelming, that God can’t even deal with it. Yes, such problems exist, and yes, God has a special way to address them over the course of time. There is an answer – but you will have to read all the way to the end.

this book is about medical missionaries in Nepal. sure to become the number one beach read for summer 2014! go to Amazon and pre-order your copy at
http://www.amazon.com/Sacrament-Goddess-Joe-Niemczura/dp/1632100029/

you could also buy my second book. see picture of the cover at left.

Marlene Kramer,RN, PhD

I read a lot of papers written by nursing students on the topic of burnout when I teach the senior-level leadership, management and issues classes. I always check to see whether the person was diligent enough to find the book “Reality Shock: Why Nurses Leave nursing” by Marlene Kramer. This one is old by now – written waaay back in the 1970s – but it was such a classic that it still deserves to be studied and cited. (note: On Amazon there are only three used copies, and the minimum price is $199.50… go figure…). In fact, one Google source indicated that it has been cited 743 times in subsequent scholarly work. Dr. Kramer is now retired but had a long distinguished academic career. Her work on reality shock and burnout created a national dialog at the time which led to the work of Patricia Benner and others.

Kramer and Magnets

There were many who thought that Kramer portrayed nursing in a highly negative way, and this reaction produced a result that is still evolving today. The argument was “Okay, you have showed us what is wrong but why can’t we focus on the good things that are happening?”  Which is of course, what a reasonable person would ask.  Nursing advocacy, the heart and soul of what nurses do, is based on righteous indignation and the desire to make things better, and so Dr Kramer was firmly in the tradition started by Florence Nightingale herself.

Magnet Hospitals

The reaction to Dr Kramer caused the American Nurses Association to promote the studies about magnet hospitals – places where the new nurses were being nurtured and developed. and from there to the whole Magnet Nursing Service movement.  There is now an independent non-governmental agency which evaluates hospitals that voluntarily apply for Magnet Designation.  Can we agree that this is a good thing? We still have a long way to go, and the budget climate is not helping us, but an argument could be made for saying that Kramer gave the entire profession the wake up call that led to this work. She got the ball rolling. Every hospital should have a Magnet Nursing Service.

Return to wallowing in negativism

back to burnout. There are four phases.

the honeymoon. This is where the new nurse is still being oriented and everything is wonderful. The preceptor is so smart! The staff is amazing! The paycheck is HUGE! we all love to be around such a person and delight in the innocence of youth.

crash and burn. the onset of this is hard to predict, but usually about the six-month mark. Takes place when the nurse starts getting feedback from every direction, not all of it is easy to take because people are telling him or her that they are not perfect. The nurse is now saying “These people are jerks. This hospital has its priorities wrong. nobody is listening. Why did I ever want to be a nurse?”  This person can be angry and depressed.  Nothing is wonderful anymore. The road has a fork in it. One choice is to leave; the other choice is to stay.  When the nurse  leaves (regardless of where they go), it  causes the cycle to repeat with new nurses.  Turnover of this nature is expensive for all concerned. The National Council of State Boards of Nursing has recently recognized that up to 25% of staff nurses who do get a job, leave their first position within a year, which has caused the NCSBN to work on what they call “Transition to Practice” issues. In this way, we wonder if anything has changed since the 1970s……

recovery.  This is a phase of letting go of anger and depression, characterized by the return of a sense of humor. The preferred outcome of crash and burn.  The nurse wakes up and realizes that some things are good, some are bad and not everything is perfect. Or Burnout the nurse quits the job and goes to another job (to enjoy another honeymoon!) or maybe leaves bedside nursing altogether.

and resolution. where the nurse develops a sense of perspective and is able to contribute effectively.

The Care Plan for the Nurse?

The key is to assess yourself and those around you, and adopt some specific interventions.

the honeymoon? keep the new nurse grounded in reality. No, it’s not as perfect as you think

crash and burn? similar to above. No, it’s not as bad as you think. Hang in there and keep working at it!

recovery? find new ways to be productive now that the new nurse has been around the block.

and resolution? find joy and happiness in leading your life, with nursing being just a part of it…

Water over the dam

There’s been a lot of work on related topics since 1975. For example, the whole “codependence” thing came and went – the more codependent the nurse is, the more likely they are to experience burnout.  Closely related to this is the idea of OCD, and I gave my two cents on this in a prior blog. We have had periods of cost-cutting when a new wave of managers rejected efforts to nurture and  mentor new nurses through their role transition issues. Sometimes it feels like all the negative and positive trends are now stewing in the same pot…..

The Bottom Line

Probably the most important lesson is that you may go through these phases by yourself, but you are never alone. Use your peer-group resources. Each nurse has to start by assessing themselves as to where they lie on the four-phase continuum. Keep your sense of humor, and keep your self open to sharing with others.