Tag Archives: reality shock in nursing

dealing with nurse-burnout, a simple trick

Back to normal

The election is over, and we can all take a bit of time to decompress. I was of course, happy with the outcome, but I also note that a few people dropped their subscription to this blog. Oh well, it’s a voluntary system, people come and people go. The readers are not my prisoners, though of course, it can be torturous to read my writing.

Though I’d share something I have found to be useful when dealing with stressful situations. When I wrote my book about volunteering rural Nepal, I included a reference to this little Jedi mind-trick. People told me that they started using it and it made things better. I did not invent it and I suppose we could discuss what the meaning of “better” might be.

Inner child

The thinking technique is one that derives from the work of Eric Berne, the founder of a movement in pop psychology known as Transactional Analysis. “T.A.,” as it was called, was a way to express complicated theories of personality and motivation in terms that were accessible to the general public, and I think it is the place where references to the “Inner Child” started to become popularized.

I won’t rehash the entire theory, I leave that up to you. we live in the age of the internets, go use them!

But, the short version is, when you anticipate a stressful or upsetting situation about to take place, you take a minute or two to perform this exercise, and it will lead to better execution of whatever things you need to do.  I suppose that some lay persons will respond by saying “hey, when the s^&t is about to go down, take your self away from that place, wherever it is!” – yeah, well, that’s true but it’s not an option if you want to be on the trauma team or if you wish to deal with people in any kind of crisis.

the long term issue is “secondary stress’ which I have written about before. a health professional takes on the stress of helping. entirely understandable.

so here it is:

You visualize your self as a five-year-old, presumably a happy innocent version of yourself, but vulnerable to upsetting things like ghosts stories or anger or abuse. picture that five-year-old version of yourself, the part that would cry if a bee stung you, or that would be amazed to see a butterfly; or that likes milk and cookies.

Then put on the voice of yourself as the all-knowing mom or dad. The all-knowing mom or dad says

“grownup things are about to happen now but you will not need to be part of this. I am going to tell you (the five year old) a story, give you a glass of milk, and put you to bed now, where you will be safe while the grownups do some work. when you wake up, we will laugh and sing. I love you”

You know it is working when your mind is cleared while you run through the ACLS or ATLS protocols.

Mister Spok

A similar technique has been called “going into Spok mode” based on the Star Trek character. Spok was the humanoid from planet Vulcan who had no emotion or nonscientific judgement, and was only able to deal in facts and logic. to go into Spok mode, you just make a decision to do two things: 1) only open your mouth to share something factual; and 2) not respond to anything that is not factual (or at least, evaluate everything that happens as to whether it is fact-based or not).

Christian coping?

and finally, a technique many Christians use. prayer.

the shortest prayer in the Bible. Matthew 14:30  which is of course, a direct plea from the Inner Child…. but also has its place :-)


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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

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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Especially for the older nursing student – it’s not about what you know

This is part of a series. click on the button at right, to subscribe to the blog.

Nowadays nursing is a popular choice for older students, whether it’s a person who already has a college degree (and is going for Master’s Entry into Nursing, or MEPN), or an LPN going back to get the degree, or somebody who needs to change careers.

Nursing school is a shock to the system

Regardless of how you got to nursing school, you find yourself back in college, back on the treadmill of studying, exams, seminars, group projects – everything. It’s a shock and a transition. For many, the shock is eased by the fact that you needed to take prerequisite courses before you finally got on the bus through nursing school, and this served to get you back into Study Mode. But it is still a shock as you learn what it is that nurses do.

through it all, there is something not to say.

“I already know everything I need to know, I am simply here to get the credential, sit for the NCLEX, and get a job. I don’t want to hear about all this theory. Just tell me what I need to do to pass the exam.”

(yes, I have heard actual students say those exact words.)

I would be the first to admit that getting a job is an okay motivation for choosing nursing, though it takes more cleverness right now than it did a year or two ago ( and yes, the job market will improve in a year or two, by the time you graduate). But if you repeat this statement in front of a faculty member, don’t be surprised if they raise an eyebrow… or two. Usually the response will be “Oh Really?” but that is not what the faculty member is thinking…….

What the faculty knows, that you don’t know

Here is why. Nurses are not paid for what they do, nurses are paid for how they think. This is such an important motto, it ought to be a tattoo (which is of course, the best way for The Youth of Today to study it).  Oh yes, we are teaching you how to insert a foley catheter, how to prepare a medication, how to start an IV, and a pile of other skills. But the skills in and of themselves do not compose the nurse. Don’t get me wrong – you need to be excellent at those skills and more. But, you need to learn how to think about patients in a wholistic manner, and also learn when not to do the skill, or when & how to change the way you do it to fit a given situation. this is the thinking part. Assessment-Plan-Intervene-Evaluate. A nurse is not a Junior Doctor; no matter how much we teach you about medicine that is only part of the nurse’s role.

for the older student

It’s possible that your faculty member may not be familiar with the term “Role Socialization” – but that doesn’t mean you can ignore this concept. Some people look at it and focus on the socialization part – thinking that maybe we mean you should be friends with your classmates. No, that is not even remotely what it means. Role socialization is the way a sociologist would describe the process of becoming a Nurse with a capital N.

Ask Yourself: How would a real nurse deal with whatever situation you are now facing?

The flip side of the coin

Here is a hint: if you ever want to impress your faculty member, ask them “How am I doing with role socialization?” and see what they say. They will most likely be impressed at the sophistication with which you are approaching the work.

If you are having difficulty getting it, the lack of role socialization will show up in your work. When you do patient care, you will miss things that you shouldn’t, and people will give you negative feedback about your “priority setting.” Or else, “lack of caring behavior” – which is of course, a dagger to your heart. A nurse’s number one job is to “care.” – we’ll go into that at some future date.

One solution? just do a websearch on the term.  You will find that there is a whole other universe out there among nursing scholars. The process of role socialization, and it’s success or failure, is a strong current in nursing education. Most of the links to it are to be found in scholarly journals. Looking for a research project?

One small Jedi mind-trick that real nurses use

Here is one tip: if a patient ever asks you a question, resist the urge to give them the answer. Always continue the dialogue by asking a followup question to clarify what ever they just said.

Boys vs Girls

I have two daughters. My wife and I, being children of the sixties, thought we would raise them in a gender-neutral way. Yes, we taught them to enjoy sports and boisterous play, such as throwing a football and go camping, and (later) to drive a stick. I built them a sandbox and got them a toy dump truck and a toy back hoe. But, even without our prompting, the two young ladies would spend time playing with dolls, doing hairplay with each other, and the like. To have kids is a fascinating experience in how girls learn to be girls and boys learn to be boys. Gender roles. the best example of socialization. Hey, I didn’t create the system, I simply bow to the fact that it exists.

Just for Men

Now, for the male student:

There are special challenges in role socialization for men who enter nursing. My best advice is to find the book “You Just Don’t Understand: Women and Men in Conversation” by Deb Tannen. Yes, it was published twenty years ago.  But it is still a classic. It’s a guide to clear communication when gender roles are different. It’s kind of book you can pick up and read from randomly yet you still will get something out of it. And on Amazon, you can get a copy for less than a dollar, plus shipping and handling.

Whenever I have a male student who is having trouble adjusting to nursing school, I lend them this book. Right now, I have no copies left…… hmmmmmm…..

Just one excerpt:


“For girls, talk is the glue that holds relationships together. Boys’ relationships are held together primarily by activities: doing things together, or talking about activities such as sports or, later, politics.” (pg. 85)

“Women and men are inclined to understand each other in terms of their own styles because we assume we all live in the same world. [A] young man in [Thomas Fox’ college] writing class noticed that his female peers refused to speak with authority. He imagined the reason to be that they feared being wrong. For him, the point was knowledge, a matter of individual ability. It did not occur to him that what they feared was not being wrong, but being offensive. For them, the point was connection: their relation to the group.” (pg. 179)

If that hasn’t whetted your appetite, I don’t know what will…… remember, it’s not about what you know, but how you think….

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student nurse job description – the unwritten rules for success

This one of a series of blog entries on the interface between nursing school and work. Every new grad needs to make the big leap. Past blogs have addressed issues of resumes, cover letters, etc.  Future blogs will address issues of how to make the transition to critical care. You are invited to subscribe. click on the button at the right!

Worked at McDonald’s, ever?

Nursing school admission is competitive these days, and you need to have a good GPA in order to get a seat in the class.  There is a difference between the nursing students from ten years ago, and the ones nowadays.  When studying is the main goal to the exclusion of everything else, it’s less likely that the student has had a part-time job outside of school in the past, not even at a McDonald’s. 

This means that when we teach beginner nursing students, we  also need to teach them about work behaviors. Oh, I believe in focusing on the illness the patient is experiencing, but the faculty would be missing something important unless we spent time saying what it means to have a job and be part of a team. Nursing is labor intensive and twenty-four hours a day seven days a week.

Unwritten rules for any job

The odd thing is that there is always a set of unwritten rules, things that are so common-sensical that a person who has been in the workforce takes them for granted. But when I have a kid who is just twenty years old and not had a time-clock type of job,  I go over “The Rules.”

Nursing is eclectic, and draws from a wide variety of sources for inspiration.  Don’t disrespect McDonald’s – it’s the entry-level job for many a sixteen-year-old around the USA – they teach people how to have a job.

 The Few, The Proud, the Brave

You may laugh, but there is another large organization in USA which has been around a long time, and which has gained a lot of experience giving responsibility to young people. They hire a lot of eighteen- to twenty-year olds every year, and teach them how to behave at their first job.  And so, I have borrowed the minimal job description from them. It’s – The United States Marines. Every Marine is required to memorize a set of Rules during boot camp.

Here is the Job Description for a sentry in the Marines:

“The Rules”

  • 1. Take charge of this post and all government property in view.
  • 2. Walk my post in a military manner, keeping always on the alert and observing everything that takes place within sight or hearing.
  • 3. Report all violations of orders I am instructed to enforce.
  •  4. To repeat all calls [from posts] more distant from the guardhouse than my own.
  • 5. Quit my post only when properly relieved.
  • 6. To receive, obey, and pass on to the sentry who relieves me, all orders from the Commanding Officer, Officer of the Day, Officers, and Non-Commissioned Officers of the guard only.
  • 7. Talk to no one except in the line of duty.
  • 8. Give the alarm in case of fire or disorder.
  • 9. To call the Corporal of the Guard in any case not covered by instructions.
  • 10. Salute all officers and all colors and standards not cased.
  • 11. Be especially watchful at night and during the time for challenging, to challenge all persons on or near my post, and to allow no one to pass without proper authority

Let’s break them down one by one and comment on what they mean when they are applied to a nursing unit.

1. Take charge of this post and all government property in view.

Be on time, and be very specific about which patients are yours and which tasks you will or will not do.  Introduce yourself to all other persons present and communicate.

2. Walk my post in a military manner, keeping always on the alert and observing everything that takes place within sight or hearing.

Don’t sit down on the job, make frequent rounds and check on things regularly. Don’t lose sight of the Big Picture.

3. Report all violations of orders I am instructed to enforce.

Learn what the orders are in the first place, and have a plan for every “order” whether you understand it or not. Know who to call when you need help.

 4. To repeat all calls [from posts] more distant from the guardhouse than my own.

Help the people around you as much as you can.

5. Quit my post only when properly relieved.

Don’t ever leave the floor without telling anybody. Don’t go to the rest room without telling anybody.  Don’t hand off a pateint without giving a report as to how your day went. Always share information.

6. To receive, obey, and pass on to the sentry who relieves me, all orders from the Commanding Officer, Officer of the Day, Officers, and Non-Commissioned Officers of the guard only.

see report, above. check in with your nurse frequently in case the “orders” change.

7. Talk to no one except in the line of duty.

don’t use FaceBook on the job. Turn off the mobile phone. Keep frivolous talk to a minimum.

8. Give the alarm in case of fire or disorder.

have a CPR card, get help when you need it.

9. To call the Corporal of the Guard in any case not covered by instructions.

This is about teamwork and communication. Ask questions when you don’t understand something.

10. Salute all officers and all colors and standards not cased.

Your faculty member, the staff, the housekeepers, every one else who works there – deserves your respect.  If somebody tells you anything, write it down and try to follow it. Yes, there is a pecking order, but that does not mean you should disrespect those who might be further down on the hierarchy. You can not do your job unless the housekeeping staff does theirs!

11. Be especially watchful at night and during the time for challenging, to challenge all persons on or near my post, and to allow no one to pass without proper authority

pay attention to the activities of the patient even if they do not involve you directly. who is seeing your patient and what are they contributing.

Read them, Learn them, live them

Sometimes I am met with incredulity when I talk about these rules with beginner students. They ask “how can this be? aren’t nurses independent professionals?”  They are surprised to learn that there may be any regimentation in nursing. The answer is, we need to have structure and a plan in order to accomnplish anything great.  An experienced nurses makes all his or her activities look like they just unfold naturally and there is a sense of  flow; but there is an underlying structure, always.

I suppose that discipline gets a bad rap when the indoctrination is mixed up with intimidation, such as the stereotype of a Marine Corps Drill Sargeant would present.  Nursing education is conducted with a lot more finesse than a USMC boot camp.

The fact is, we all need to work together as a team, and nobody will give you more responsibility unless you have shown that you can deal with the simple responsibilities. As Atul Gawande and others have described, sometimes excellence is a question of diligently working on the same thing every day and having good habits.

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