Tag Archives: nurse burnout

Ten experiences every nurse needs before graduating from nursing school

Ten experiences each student nurses needs to have before getting out of nursing school

There are two trends in nursing school today that bother me. I know that I am an opinionated curmudgeon at times, but I need to say these out loud, just in case the act of putting it out there makes them go away like magic. In reality, I know that we can’t wave a magic wand and get what we want, but – work with me on this!

The first is a nationwide trend. Every nursing school is full to the max with students and it is harder to get optimal clinical experience. We are substituting simulated experiences for the real thing. We focus on “the standard patient” as if all patients are standard when they are not.

The second is, we are losing the old “what is nursing” battle. By that I mean, there is increased emphasis on medical content. Physiology, pharmacology, surgery, etc. less emphasis on psychosocial implications. This goes hand in hand with the lack of “role socialization” in nursing.

Tip: the NCLEX tests nursing, not medicine. Every question on the NCLEX is either an Assessment, Planning, Implementation or Evaluation question. The Nurse Practice Acts define nursing according to APIE and nursing diagnosis; the “junior doctor” parts are limited to the section on Delegation. Every nursing faculty needs to ask themselves about whether they are teaching nursing or medicine, and to have a clear handle on the difference. If your school is having problems with NCLEX pass rates, it’s probably because the faculty are confused about this specific principle.

Let’s explore the above, shall we?

To begin with, I first taught on a nursing faculty fulltime in 1990. I taught maternity and pediatrics, and took students to a hospital for OBGYN that did about 1200 deliveries a year. That meant an average of one baby born per shift. Sometimes more, sometimes less. In those days I made a pact with the students. If they would be flexible about their hours the day they were in Labor and Delivery, so would I. the goal was to help them have the experience of seeing a baby born. In the three years that I supervised students in L & D clinical, every one of them did see a delivery. One time I hung around until 9 PM. That specific student got the idea of how long it actually takes to deliver a baby. the idea was to get a first hand look at the way all the theoretical stuff translates into what is done in real life.

When we try to simulate every experience, there is a tendency to only present scenarios where the ideal is portrayed, and to sanitize everything somehow.

On a related note, on day one of maternity orientation, I always asked the nurses to save me a fresh placenta or two. We would all don gloves, look at the membranes, the cotelydons, the shiny and dirty side, etc and marvel at it. I always viewed this as an important experience to have. It desensitized the student to the appearance of body tissue, helped them to visualize what we were talking about ( so much of prenatal care is designed to help grow a healthy placenta) and removed some mystery.

Nowadays, I am sure there are people who would look on horror and say “Om My God, it’s exposure to body fluids!” – well – no – not when PPE is applied. even in those days we wore gloves.

Ten. maybe more

There are ten clinical experiences you should have. I sincerely hope that every nurse gets these while still in nursing school, but if you don’t you still need to find them at some point. The advantage of having them in nursing school is, an experienced person can interpret the experience for you. Guidance from a guru is critical to draw the proper conclusions. By proper I mean, conclusion which reflect the role socialization appropriate to nursing.  without the proper guidance any of these can do a number on your head.

1) Coaching a woman through labor and seeing a baby born.
2) Giving a shot to a 2-year-old. Getting a 2-year-old to do anything!
3) Being with a person who is dying from cancer. Two parts: talking to them before hand; and being present at time of death.
4) Seeing surgery
5) Smelling cautery. Or any one of about a dozen distinctive olfactory stimuli peculiar to health care.
6) Having a conversation with a person suffering from delusions or psychosis.
7) Talking with family members of a person having a serious illness, whether it’s acute or home-based.
8) Doing CPR
9) Dealing with a drunk person.
10) Helping a person who is a member of an oppressed minority, whether it is a racial or ethnic group, a group subject to bullying, or perhaps a homeless person.
11) Giving nursing care to a person who is seriously ill but who is your own mirror image in terms of age, social level, education, family etc.

The key to each of the above is, it’s not about the actual experience per se. it’s about incorporating the interpersonal flexibility required to actually be of use to the person receiving the care, and about dealing with your own feelings and reactions. There is only one way to do CPR ( the Heart Association protocols) but it is inevitable that you will have personal thoughts go through your mind when you are doing compressions, and these need to be considered “by hand.”

special note about autopsies

I was once asked by a student how come viewing an autopsy is not something we can arrange, or why we don’t include it or promote it. At the time I thought the student ( a male of course) didn’t quite “get it” and had a sort of voyeuristic quality to his request. “What is the goal?” I asked. Let me emphasize that simply getting these experiences checked off is not the purpose.  The purpose is to develop an overall professional approach that can be generalized to all such experiences that have any aspect of threat to the self-image of the student.

If I had to name a single concept that everyone needs to grasp, it’s “this is not a game, not just a well-paying job, but a critical service offered to society by members of this profession.”  Often by being the one  person in the room who is maintaining composure during a stressful event.  You could look at the above list in that way.

For each of the things listed above, there are certain professional expectations as to how a successful nurse conducts themselves. I could write a blog on each one to detail these, but hey – that is what textbooks are for!

hint: we can develop a simulated experience to go with each of the above, but it will never substitute for the doing of the actual thing for a real person. Not ever. just about every negative experience can be reframed into something positive with proper guidance. (for example, cleaning human fecal incontinence can be viewed as distasteful because it involves feces, or else we can reframe it into helping the person feel better and clean while retaining dignity).

Nursing Diagnosis sayonara

As to the “junior doctor vs actual nurse” argument – I worry. There is a trend by which nursing schools are quietly getting away from the teaching of nursing diagnosis. What does your school do?

I have heard all kinds of rationales – “practicing nurses don’t use it” being the main one. My answer is, “practicing nursing surely do use nursing diagnosis!” though maybe they call it something else. Maybe they have it down so well they it is less obvious, but I guarantee you that no hospital can have a functioning customer service program unless somebody in the nursing service uses psychosocially-based problem-solving. Caring is a learned behavior, and nursing diagnosis is the vehicle by which we teach people how to care. You need more than just warm positive regard for the person you are serving. It’s too hit or miss otherwise.

Hold hands before crossing the street – the lost art of curriculum design

Nowadays in the shortage of nursing faculty, we are pressing into service anybody with a Master’s Degree, including nurses that took a Nurse Practitioner course and never took even one course in pedagogy, test construction, curriculum design, or anything. Such a new faculty person needs guidance in how to be a teacher.

Curriculum Implications

When ever there is a transition from one curriculum to another, or whenever you are designing a comprehensive course of study, it’s useful to think of a “crosswalk.” In the parlance of educational design, a crosswalk is a comparison of two lists. The first is the “old curriculum” and the seconds is the new. Where does a theme of nursing school appear in any given course of study? If it was there before and you are changing your curriculum, where is it now? It is a useful exercise to make a list of things the student is expected to know (we call them “outcomes”) and to actually place them somewhere along the line, in a rational sequence. For example, if a student nurse has never dealt with a normal person having a crisis, why would a curriculum expose that same student to concepts of mental illness first? The crosswalk needs to be analyzed according to how to teach psychosocial needs in a logical sequence. This is simply lost when the coursework focuses on a tour of body systems or medical diagnoses.

Bottom line

To become a fully actuated professional nurse is a lifelong process. When a nursing school teaches you how to care, they are teaching you “how to be a human” – which sounds easy. It’s something we need to think about….. If we only present the “standard case” we are focusing too much on the basic medical care, and not enough on the psychosocial.

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nobody wants to teach nursing

received a provocative link from a colleague.

see below

http://www.insidehighered.com/news/2013/07/22/nursing-schools-face-faculty-shortages#ixzz2ZnV1RCGX

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Nurse Burnout, adrenaline junkies, and secondary stress, part deux

Q: What kind of bird are – you?

note; the underlined words or phrases are hyperlinks to related background material. be sure to to click on these.  especially the one related to my book about Nepal.

Burnout happens.

Got a lot of responses to my last blog posting about Burnout, Marlene Kramer and stress. It got mentioned in the AJN blogroll of nursing blogs which is titled “Off the Charts. At that location, they keep a list of blogs by nurses. Some are quite good.

The editor there called me “peripatetic” –  not a word I use every day. Moi? Come to think of it, I don’t spend a lot of  time trying to describe myself.  The words that come to mind are handsome, witty, charming, emotionally available, and compassionate.   :-)   and of course, humble!

Urban Dictionary

so naturally I went to the Urban Dictionary. For those of you in search of eternal youth, this is a terrific site. I would have never learned the meaning of “4-20 friendly” for example, if I had not used that resource. And of course, the place includes current commentary on issues of the day, such as this gem.  (Like the vast majority of Americans I don’t think we should elect male legislators who think they are the only ones qualified to tell women what to do with their bodies. I have spent too much time with too many crime victims to laugh at their expense.)

1) The act of, relating to, or given to walking about;
2) Moving or traveling from place to place to freekin place;
3) Snooking around touching every damned thing around;
4) Cant sit still or settle down; and
5) Constantly, without rest, surveying, reconing, and otherwise annoying the hell out of everyone by any of the above actions.
Okay, well – I don’t have just one theme for this blog. I get up and think new thoughts every day. Or try to.
Today’s thought about Burnout, Secondary Stress, OCD in nursing, codependence in nursing,  and self-care in nursing
In the past blog, I reviewed Marlene Kramer’s four stages of burnout, and I focused on assessment of yourself and others. I didn’t really get into detail about some of the other things I think can help you if you are having problems with this.
Riding the Dragon is a book by Bob Wicks, a professor at Loyola College in Maryland.  It’s about developing resilience in every day life despite uncertainty. Pretty simple wording that you could use to meditate upon, I suppose.  My two cents? when you are health care professional, sometimes your work calls you to deal with a darned big dragon!
He’s written a bunch of other books.  I met him and heard him speak when he visited the Catholic Campus Center of the University of Hawaii.  I had the opportunity to speak with him afterwards, and was delighted to receive a copy of one of his other books in the mail two weeks later. This one was titled Overcoming Secondary Stress in Medical and Nursing Practice: A Guide to Professional Resilience and Personal Well-Being.
My review of this book:
In my experience as a critical care nurse and also as a hospital manager and  teacher of nursing, I have dealt with issues of secondary stress for many years
and I have seen many victims of this problem. And so, I stay abreast of this issue.On Page 5 of the book, the author says:”it’s a ‘one-sitting book’ designed to distill current clinical papers and research; provide proper guidelines to avoid and/or limit unnecessary distress; strengthen
the inner life of physicians, nurses and allied health personnel; and offer recommendations for further reading on the topic. If nothing else, its goal is
to raise awareness that secondary stress is a danger..”and I think this nifty little tome fills every one of these these goals and more. In a survey  book, Dr. Wicks has managed to distill the best suggestions, on a very practical level, into something that’s readable and deceptively simple. I say deceptive, because he has a way of describing the profound thoughts of stress, death,
burnout, and spirituality into an engaging style.It is readable and has many anecdotes to which a clinician will relate. He makes excellent use of summarized bullet points, and checklist style formats to present ideas. I found myself thinking of all the people who need this as a christmas present.

in short: highly recommended!

There are gradations of burnout.
I gave my copy of the secondary stress book to one of my best students, who is a perfectionist and highly “driven.”
The phrase “burnout” gets thrown around a lot and can lose it’s meaning. Sometimes a person simply needs to talk with a coworker for a couple of hours away from work; other times they need a two-week vacation; but in extreme cases the person gets a glimpse of the horror that life can be for some of the people we meet, and goes into a state of full existential angst.  we can all benefit by creating a work environment that sorts through these issues.
Perfectionism as a related problem or symptom
I do think there are nurses who bring an insidious type of emotional baggage with them, who are more at risk of the total-despair variety of burnout. These are the ones who are needy about proving their worth by being excellent caregivers, but they get it mixed in with caretaking. Also known as co-dependent, experiencing co-dependency. Manifested also by perfectionism and OCD on the job.  For these persons there are a couple of really good books. One is an oldy-but-goodie “I’m dying to Take Care of You: Nurses and CoDependence.  The other is Codependent No More: How to Stop Controlling Others and Start Caring for Yourself.
Work Environment
a final point: the books above mainly deal with how to identify stress and burnout within yourself but do not really go into the management skills and sensitivity needed to create a supportive work environment.  If you have a manager who tries to suppress the staff’s ability to deal with stress collectively, you need a new manager. Honesty is a key to effective problemsolving.
Let’s be realistic: if you deal with trauma and sadness all day at work, you need help from those around you. period. If  the team is one which gives you the message that you are on your own or that somehow it’s your fault,  your stress will be magnified.

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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/

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 movementThere 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.

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How to avoid the Nursing Work Culture From Hell

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Culture at the workplace?

A workplace becomes a surrogate family for the people who spend time there. When people spend so much time together, the personalities come out. A group will adopt a set of informal rules that guide each day. This becomes “workplace culture.”

If you have been a nurse for any length of time, you develop a sixth sense for this. The minute you walk on to the patient care area, you get a vibe of what it’s like there.  It may be calm and peaceful, it may be chaos, it can be happy or tense. It can be this way independently of how much nursing care the patients require. When you interview for a nursing job, be advised: the best managers know about workplace culture, and they are looking to add staff who will value it and honor it. A theme of this blog has been to encourage new nurses to live up to their caring potential, and it includes caring for those around them as well as for the patients.

Urban Community Hospital – a “war story”

My first nursing job was not a place for teamwork. It was an “urban community hospital”  and chronically understaffed. Each shift was a contest to see whether you could get through all the work yourself, and the assignment was heavy. It was a trauma ward, lots of gunshot wounds and stabbings and victims of beatings, along with a population of heroin addicts and homeless persons. Lots of crime victims. The staff consisted of a head nurse who had worked there since the dawn of time, and each spring there was a fresh crop of new graduate RNs. The hospital would hire a batch of new grads all at once, they would stay a year, then leave once they got “the golden year” of hospital experience. Or at least they were planning to leave then; most left my particular unit before hand, chewed up by the system of unsupportive coworkers. The crew of nurses aides were all older than the young RNs.

Walking Rounds

We did “walking rounds” there, change-of-shift report consisted of a procession of sorts, all the nurses in a group  following the kardex from bed to bed like it was the Bible at the beginning of Mass. The circus was led by the head nurse, same age as my mother. She generally arrived each morning with an attitude, and would heavily criticise the night nurse, pouncing on any inconsistency she found between the way the patient looked and what was written in the kardex; or how the story was presented.  Very theatrical. As report was read, she would examine each patient (“you said the IV was NS w 40 of K, why is it I see a bag of LR hanging?”) This included getting on her hands and knees to look under the bed, on occasion, as well as barbed sarcasm. Every day.  One day she chased a rat out of the ward, to the cheers of the rest of us…. but that is a whole nother story ( it was a very large and well fed rat). Yes, she was teaching us how to have standards and to follow them; but nowadays we would call her approach “horizontal violence’ or “verbal abuse” or “eating the young.”  That was the way it was in that time and place.

These days there is a national movement toward something called “Magnet Culture” – hopefully to eradicate that sort of approach. UPDATE: a former student emailed me after reading this, to alert me to some excellent work published by Sigma Theta Tau about Bullying in the Nursing Workplace.

New RN working nights

I was on eight-hour shifts, a day night rotation and soon found myself working nights about eighty percent of the time – the only time I was on days was on the head nurse’s weekend off.  The day I passed my Boards I was Charge RN whenever I showed up from then on. That was how I spent my first year as an RN. Since I was on nights so much, it meant that I got to be the person going through the gauntlet every morning. And yes, I did well at it – better than the others. In those days I could be just as sarcastic and unforgiving as others. I would spit it right back at the head nurse, to the astonishment of other first-year RNs on the crew.

I no longer treat others that way.

The usual night staffing was two RNs for up to thirty patients, and even then, I went out of my way to help the other RN be ready, which was appreciated. I promised myself I would never be the kind of nurse manager  that I was now working for, and that if I ever had anything to do with it, I would be kind and respectful.

In other words, it was the Work Culture from Hell. Got the picture? I can go on and on – you got me started, but like a bad dream, I need to wake up and remember that this degree of dysfunction is not the way to go through life. Let’s focus on positive ways to interact, here.

Teaching workgroup culture. learn it and live it.

What I do now is to incorporate healthy work behaviors into nursing school. Nursing school is not simply to learn about patient care; it’s to learn the way a professional person acts and thinks. Sometimes in the Fundamentals lab, a student acts as though the only thing they are there to accomplish  is to learn how to perform a specific skill according to the checklist. They don’t care whether others also learn, and don’t help their classmates or spend time coaching somebody slower to grasp the concept. Somehow there is a subset of students who think it’s okay to be a jerk to those around them while they focus on their own learning needs. This may work for Jack Sparrow, but will not lead to success in a hospital workplace.

This tells me that such a student has a learning opportunity.  Focusing on yourself is not the way to go through life. You are missing a major part of the ride.

(Note: a few years back I developed a one-page handout for how to act in the nursing school lab which I will send to anybody who emails me and asks for it)

How to Succeed as a team

Want to develop the habits of a helpful work group culture? here are some ideas. They are not a “Code” – more like Guidelines.

In both lab and clinical: Your work is not finished until the work of everybody is finished. Nobody sits down until everybody is able to sit down. If one person is getting swamped, we pitch in and help them. In the lab, it’s the students and faculty together, who tidy up and make the lab ready for the next group of students. Don’t rely on somebody else to clean up after you.

In the clinical setting: learn about  each other’s patients. Depending on how morning report is handled, this can be a challenge. If it’s a group report that’s easy; but if it is nurse-to-nurse report, you have to go out of your way to do this.  Find a way to check in with the other staff nurses (or the other students) after an hour or so.

Nobody lifts or transfers any patient by themselves.  There is a strong evidence-base out there regarding nurses and prevention of back injuries, so we have an important reason for this. Some wards have many “heavy” patients, and this attitude makes a big difference. But it’s also a chance to create and strengthen relationships among the staff.

say thank you. this goes a long way. there’s an old saying that “People may forget what you did or said but they won’t forget how you made them feel.” think about it.

use names. there is a parade of people through every hospital area every day. Learn who they are, and use their name in conversation.  You don’t have to go to Happy Hour with them or learn their kids’ names, but why not humanize the workplace? this includes housekeeping, the docs – everyone.

name tags. Ever been in a college class where the professor never learned your name, even by the end of the semester?  At my nursing school, we teach the same course to a different cohort each semester, there are fiftysix or sixty new names to learn. On the first day I always set up a system of using name tags, keeping them at the lab. The students collect at the end of each session. We call each of the students by name. They are not allowed to melt into the woodwork, which is often a surprise for the students.

just like a basketball team
Huddle. this picture was taken in Nepal, but any of my students will recognize this gesture. When I wave my hand at waist  level, they know that I want them to approach. I never have to raise my voice when calling them over. (and yes, they know i will not bite…) At lab and clinical practice,  I call a huddle every now and again. soon the students learn to call their own huddles without me.  Communication is a big part of teamwork. We use the time to share and to plan out our work and get ideas.

The Bottom Line about workgroups

The fact is, we all have a choice to create a healthy work culture, or not. which will you choose?

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