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Nurses’ work is often demanding and exhausting. Nurses face physical, mental, emotional, moral, and ethical challenges everyday. These challenges can poorly affect nurses’ health and well-being, resulting in a burnt out workforce and decreased quality of care.
Nurses’ health and well-being must be supported so they can effectively care for patients, advance health equity, and improve the health of the nation. In this episode, we hear from frontline nurses and other health experts on how nurses are impacted when they experience challenges like burnout, racism, or are reluctant to report bad situations; and focus on what strategies should be taken to better support nurses and whose responsibility it is to do so.
The United States has some of the poorest health outcomes. Health disparities run deep, leaving many people without equal opportunity or access to care. As long-time advocates for health equity, nurses are in unique positions to address the root causes of poor health, reduce health disparities, and improve the health and well-being of the nation.
In this 8-part series from the National Academy of Medicine, we explore practical strategies for the nursing profession to advance health equity. We’ll hear stories and experiences of frontline nurses and other health experts from a wide range of settings. These strategies reflect the recommendations from the report The Future of Nursing 2020-2030: Charting a Path to Achieve Health Equity.
If you’re a nurse, involved in any health sector, or want to know how to create a better future for all Americans through improved health outcomes, this podcast is for you.
Dr. Charmaine Lawson (00:16):
Nurses are committed to meeting the diverse and often complex needs of people every day. For many nurses, their careers include caring for the needs of people and communities with knowledge, care, and compassion. While nurses may be motivated by a deep sense of service and purpose, the work can be, and often is, demanding and exhausting. Nurses encounter physical, mental, and emotional, moral, and ethical challenges every day. These challenges shift depending on the nurse's role and work setting. They can include managing and supporting the complex needs of multiple people, risk of infection, physical or verbal assault, having emotional conversations with families, confronting social and ethical issues or encountering health inequities such as food insecurity. As nurses have encountered these challenges, it's very clear that nurse's health and wellbeing are affected by both the demands of their work and the inadequate systems in which they care for people.
Marcus Henderson (01:21):
I think in cases where I have have not felt supported or a colleague of mine has felt supported, I mean, it really does damage to you as a person, as an individual and as a nurse, because it makes you feel as though that, well, what is my role here? What is my purpose in being here?
Dr. Charmaine Lawson (01:38):
If the stresses and demands of nursing poorly impact a nurse's wellbeing, well this in turn affects the quality and safety of care they're delivering to patients.
Dr. Marshall Chen (01:48):
The more fundamental problem is that many nurses are not feeling well because of systems issues like understaffing, taking care of too many patients at the same time or feeling that they don't have power, that they don't have a voice in how the systems are organized and how cures delivered or nurses and other providers feeling that they can't deliver the best possible care because what they're supported for doing isn't the best possible system for caring for patients.
Dr. Charmaine Lawson (02:19):
If the health and wellbeing of nurses suffer, the health of the nation and suffers.
Dr. Charmaine Lawson (02:41):
This is the Future of Nursing, a series from the National Academy of Medicine, based on the recently published report, The Future of Nursing 2020-2030, Charting a Path to Achieve Health Equity. I'm Dr. Charmaine Lawson and I'm a nurse practitioner, and I'll be taking you through the stories of nurses confronting health disparities, and together we'll learn how nurses can use their unique skills, knowledge, and dedication to address health inequities and overall improve the health and wellbeing of the nation. There are many stressors that can impact nurses health and wellbeing. In this episode, we are going to focus on three: burnout, racism and the reluctance to report when things go wrong. We're going to learn what it's like for nurses to encounter these issues and what should be done to better support them.
Dr. Charmaine Lawson (03:43):
Burnout for nurses is not new, but the COVID 19 pandemic especially exacerbated the severity of existing burnout, compassion fatigue, and mental health stressors experienced by nurses. Burnout is characterized by one or all three of the following characteristics: emotional exhaustion, apathy, and/or a low sense of accomplishment at work.
Marcus Henderson (04:09):
Burnout can take many different forms.
Dr. Charmaine Lawson (04:12):
That's Marcus Henderson. Marcus is a practicing psychiatric mental health nurse and was a member of the Future of Nursing 2020-2030 Consensus Study Committee. Unfortunately, Marcus has been all too acquainted with burnout.
Marcus Henderson (04:27):
One example of how burnout has surfaced in my clinical practice experience has been when I work from seven to seven and there oftentimes not being a nurse coming to relieve me. Now I'm tired, I'm exhausted. And I have to come back in here the next day, and I'm tired and exhausted and I might make an error. I might have poor judgment. But you're relying on me to fix your problems when you're not thinking about how all of this is impacting me. And there's a lot of evidence out there about how long work hours and shift work impacts nurses' health and wellbeing negatively.
Dr. Charmaine Lawson (05:06):
Marcus's burnout was attributed to many things. The main factor being that his health system was understaffed. As a result Marcus was overworked. Not only did Marcus feel exhausted from being overworked, but he began questioning whether the health system, he worked under truly prioritized his wellbeing.
Marcus Henderson (05:27):
I know many nurses that that's how burnout has festered in their careers, is that the system use you as expendable. Well, if you can't do it, then I'll just replace you. But while you're here, I'm going to suck out as much as I can.
Dr. Charmaine Lawson (05:41):
As nurses experience the consequences of working with little support in an understaffed system, it can lead them to question their value.
Marcus Henderson (05:51):
When we talk about the lack of support, do I feel valued by the system? Do I feel as though my contributions are recognized? Do I feel as though that I have the resources to provide patient care?
Dr. Charmaine Lawson (06:04):
There are several factors that can create an environment in which nurses feel the strain that leads to burnout. These factors can include high workloads, staff shortages, extended shifts, and the burden of clinical documentation. Dr. Kenya beard, who we heard from in previous episodes has witnessed how these factors have placed an unrealistic and unsustainable expectation on nurses.
Dr. Kenya Beard (06:30):
When we talk about nurses who are under-supported, first with COVID, we've seen some pretty unrealistic demands placed on nurses across the board, which has impacted patient outcomes. But high workloads, the high workload demands, they are not new to nursing.
Dr. Charmaine Lawson (06:49):
Burnout creates a big risk, and that is, it puts the nurses' mental health in danger. And this must be acknowledged in the workplace.
Dr. Kenya Beard (07:00):
When I get evaluated as a nurse, I should be asked, first of all, do you feel supported? We have seen that nurses are at a higher risk for suicide than the general population.
Dr. Charmaine Lawson (07:11):
Even before the pandemic began, suicide risk was twice as high among female nurses compared with American women as a whole.
Dr. Kenya Beard (07:25):
How are you protecting your mental health and your wellbeing and what is it that I can do to help support your wellbeing? I think institutions need to recognize that when we talk about wellbeing, it has to be operationalized in a way that wellbeing becomes a core value. And when we talk about core values, we know that hospitals are actually demonstrating that it's important.
Dr. Charmaine Lawson (07:56):
There are several things that institutions can do to prioritize nurse wellbeing and monitor for burnout. It starts with leadership choosing to routinely check in on their nursing staff.
Dr. Feedo Linda Lim (08:07):
Just sensing something from a staff member, having that extra feeling that, Gee, one of my staff maybe is not feeling well today, or maybe this is something unique or a new experience that he needs to to process.
Dr. Charmaine Lawson (08:23):
That's [Dr. Feedo Linda Lim. 00:08:25]. Dr. Lim has worked in nursing for 33 years, both in critical care and as faculty in nursing education. Throughout his career, Dr. Lim has seen why it's critical for nurse managers to consistently check in on their staff.
Dr. Feedo Linda Lim (08:41):
So it's a personal commitment by the nurse manager on a given day. You know, suddenly a stress environment or a crisis comes in, you're trying to balance your staffing. That random check-in huddle with your staff, I think is vital in showing your support.
Dr. Charmaine Lawson (09:02):
One of Dr Li's former students is a practicing frontline nurse. Frank Boz is a nurse in the cardiothoracic intensive care unit. During the height of the COVID 19 pandemic, he personally experienced how the right kind of support from hospital leadership can make a world of difference in difficult times.
Frank Boz (09:21):
During the COVID 19 pandemic, it was a very stressful situation. We were overwhelmed with the amount of patients and admissions and the amount of work and the leadership, the institution I work, they were rounding on the staff and holding staff meetings and also having town halls where the staff was able to come in and ask questions so that they can have their concerns answered and that everyone can be kept in the loop. And that we all had a sense of what was going on and where we were standing at the time. And that sense of transparency, that communication from leadership, from management to the staff, really provided me with the support that I didn't expect, especially when during this time we were all overwhelmed with the amount of work. We were overwhelmed with the amount of patients we had to take care of as staffing was also an issue.
Frank Boz (10:21):
And just to have the managers, the leadership, round on you on your busiest days, on your busiest moments, meant really a lot. It provide a sense of ease to myself and to my colleagues as well. And I think that idea of having open communication and transparency between leaderships and nursing staff and healthcare workers meant a lot for a lot of us.
Dr. Charmaine Lawson (10:44):
Open communication and transparency between leadership and nursing staff can help create an environment where nurses not only feel cared for, but they also feel safe to request support. Therefore it's so important that hospital leadership commit to personally supporting each member of their staff. When it comes to situations that cause burnout, the responsibility to support nurses doesn't just fall on nursing leadership. It's the responsibility of the health system overall. But according to Dr Beard, our health system has not been known to fully support nurses.
Dr. Kenya Beard (11:24):
It's difficult because we have inherited systems that have not always been kind to nurses or really appreciated the role of a nurse. And I use the example, if I was a surgeon and I was in the middle of surgery, no one would interrupt that surgery to ask me to come out and address an issue with one of my patients who had surgery, who might have an infection now, and they might need something. There would be someone else to deal with that. And that's how the system is designed to support surgeons. But where is that support for nurses?
Dr. Charmaine Lawson (12:10):
When nurses are under supported, it's not just their wellbeing that suffers.
Dr. Kenya Beard (12:17):
So when nurses cannot keep up with external demands and they feel that they are under supported, everyone suffers. Hospitals suffer because when nurses leave prematurely, it costs hospitals millions of dollars. And we cannot simply replace nurses without thinking about the collateral damage that a nurse's departure has on an institution. When a nurse leaves, they leave with knowledge and besides the hospital suffering, patients end up suffering because the quality of care is jeopardized.
Dr. Charmaine Lawson (12:53):
When nurses suffer from burnout, the entire health system suffers. Patients may not receive the best quality of care. Hospitals may experience high turnover rates and costs of care may increase as well. Costs of nurse turnover are high. Hospitals can end up spending between $3.6 to $6.1 million a year, just on turnover alone. To prevent this structures in the health system need to change.
Dr. Marshall Chen (13:27):
The bigger solution is redesigning our systems of care so that nurses don't get burned out. That nurses should not be in this position where they're under difficult work circumstances that cause the poor wellbeing or the burnout.
Dr. Charmaine Lawson (13:46):
That's Dr. Marshall Chen. Dr. Chen is a general internist and health equity researcher at the University of Chicago and was also a member of the Future of Nursing 2020-2030 Committee. Both Dr. Chen and Dr. Beard recognize that to redesign systems of care, we need to figure out exactly what in the health system has contributed to nursing burnout.
Dr. Kenya Beard (14:09):
We have to recognize and own up to the ways in which some of our policies and practices have historically undermined the wellbeing of nurses. For example, when we arbitrarily assign a nurse to X number of patients, what are we saying? That the needs of the patients, the experience level of the nurse, the situation, or the dynamics of the institution, those things don't matter? To say that a everyone can take care of X number of patients is faulty reasoning and contributes to burnout. Secondly, since wellbeing is so critical to the role of nursing, it has to be an integral component of evaluations. Nurses should be asked what they're doing, what they need and what the institution can do to better support wellbeing.
Dr. Charmaine Lawson (14:57):
To better support others, nurses must be fully supported by the health system. Throughout his research Dr. Marshall Chen has observed that health systems need to adopt a more holistic approach. One that acknowledges the needs of both the nurse's wellbeing and the individuals they care for.
Dr. Marshall Chen (15:17):
Nurses are the health providers. They would love systems where they have the time to comprehensively address the medical and social needs of patients. Right now, they're not supported for that. Specialist social needs really is an afterthought because even though everyone knows it's important, the systems don't pay for spending a lot of time with patients to address social needs. So that's an example, a very concrete example of how we need to have the two-prong approach, both supporting the nurses who does not have wellbeing at the same time, creating the best possible systems of care to address patients medical and social needs. That will also enable nurses and other health professionals to have a better wellbeing.
Dr. Charmaine Lawson (16:06):
We have to acknowledge however, another major issue that impacts nurses health and wellbeing, and one that can also contribute to burnout: structural and cultural racism and discrimination. These issues have always been present, but are now receiving the widespread recognition it has long deserved. Historically nurses have encountered racism and discrimination from employers, colleagues, and patients. These racist and discriminatory actions can be made against themselves or against their colleagues. Marcus Henderson, the frontline nurse, who we heard from earlier experienced a moment like this during the summer of 2020,
Marcus Henderson (16:52):
I was taking care of a patient, a white patient, a white child, from a suburb of the city and I deal every day with anxious parents or guardians who are worried about their child being in the hospital and trying to kind of ease their anxiety, talk to them about the experience. But this child's parent was particularly challenging. And at this time their was no hospital visitation. So no parents could come in and see their child. They could only speak with them over the phone and if we had Zoom capabilities which was only during the week. And this mother drove up to the hospital and came to the lobby and requested to speak with the nurse.
Marcus Henderson (17:28):
So I do my job as I would with any patient. I walked up to the front lobby, the mother is there, anxious, and I begin talking with her about what's going on, what to expect, call on Monday morning, ask to speak with your social worker and ask these questions. Kind of like helping her to advocate for herself and her son. And the woman looks at my colleague sitting at the front desk, a black woman. She turns her back to the woman sitting at the front desk and looks at me and says, "Is it those kind of people that work [inaudible 00:18:00] here? Because my son isn't exposed to those people."
Marcus Henderson (18:04):
I was in shock. I never said anything about race. I just said, "Your son is doing well in the unit. He's interacting with all of the children. He's playing appropriately. He's excited. He has a bright affect. He's very engaged in groups and in therapy. So your son has not identified any issues with his interactions with other patients on the unit and our staff on the unit."
Dr. Charmaine Lawson (18:33):
Marcus found himself in a dilemma. He had to address the patient's family member, but he also didn't quite know how to immediately address their racist behavior.
Marcus Henderson (18:45):
Most of the patients that I work with are children of color and the staff that I work with, most of them are people of color. And I remember reflecting on that experience of was I wrong to not call out her acts of racism in that moment? I think that I had the appropriate response. I didn't feed into the prejudices and the racism that she was giving off.
Dr. Charmaine Lawson (19:07):
Marcus was also unsure of how to handle this situation because of his own identity and lived experience.
Marcus Henderson (19:15):
I'm biracial, I'm African American and white. Most people don't recognize that, but I think what just struck me the most was that she just had the audacity and she felt comfortable enough to look at me, say, okay, this is is a white man. So I'm going to ask him about the black staff here. That really was like this pivotal moment in my life that I was like, no, I can stand up for my colleagues. I can stand up for my family and people in my community that experience racism and discrimination because I lived experiences living in both worlds.
Dr. Charmaine Lawson (19:50):
Marcus decided he could stand up for his colleagues and his community that have frequently experienced racist and discriminatory behavior. But even when nurses choose to stand against racism, racist actions still impact their wellbeing and their ability to provide high quality of care.
Marcus Henderson (20:12):
That happens all the time where patients say, "Can I get a new nurse?" I've heard where patients would request a new nurse because they didn't want the black nurse that was caring for them. I think it's really hard because clearly it can evoke a very emotional reaction when someone's speaking to you and using racist language that's directed towards yourself or your colleagues. I mean that evokes a really emotional response. So it's really hard sometimes to kind of keep those emotions in, to maintain professionalism and go about your day in providing the services and the care that you're there to provide.
Dr. Charmaine Lawson (20:54):
Nurses are still human. It's difficult for nurses to contain their emotions and maintain professionalism if a patient is hostile because of a nurse's race or appearance. Some times a patient rejects their nurse or a nurse experiences discrimination because of their nationality, sexual orientation or disability. Nurse managers must acknowledge that this puts nurses, especially nurses of color, in a situation that can negatively affect their wellbeing. And they must be willing to support and protect the dignity of their staff through it.
Marcus Henderson (21:32):
I think many nurses like myself sometimes are uncomfortable with addressing that head-on themselves. So I think it really is important for leadership, your immediate supervisor, your nurse manager, whomever is supporting you at that moment in time, who comes in and kind of reiterates the kind of environment that the workplace is. This is an anti-racist work environment. We're about inclusivity, excellence, diversity, and we pride ourselves in providing high quality care, regardless of who the individual that's providing your care or the who the patient is. I think it's important that the institution acknowledges when those things occur, holds themselves accountable, whether it's a patient that's committing the act, whether it's a peer, a colleague, whomever, that there's, there's acknowledgement that it exists. There's accountability and actions taken when it happens.
Dr. Charmaine Lawson (22:24):
So what can institutions do to support nurses when they're imp impacted by racism and discrimination?
Marcus Henderson (22:32):
I think first and foremost, institutions need to take a zero tolerance stance on any form of violence, of racism, discrimination, bullying, incivility, within the workplace. I think first and foremost, it's a zero tolerance stance that if any of these things occur, it's unacceptable. And we are going to do something about it.
Dr. Charmaine Lawson (22:57):
After making it clear that racism and discrimination from anyone is not tolerated. Health systems must examine why these biases exist in healthcare in the first place.
Dr. Marshall Chen (23:10):
We need to have that hard look inwards within the health professions of why is there bias and structural racism within healthcare generally, or the nursing profession. What can we do to recruit more nurses of color into the profession? What can we do to support them when they're in the profession so there aren't these both outright explicit structural biases, as well as implicit biases that people have in all. We can do much better within healthcare. Nurses in basically all of healthcare would do much better regarding addressing the issues of structural racism within our professions.
Dr. Charmaine Lawson (23:53):
Health systems may not be able to stop patients from speaking or committing racist acts, but health systems can support their nurses and fully back them should a nurse encounter racism. Health systems may not be able to stop harassment or discrimination, but health systems can examine the biases that perpetuate it.
Frank Boz (24:13):
I believe that institutions should have guidelines and standards against discriminations. They should reinforce, monitor and follow that these guidelines are being met just to make sure no one is feeling discriminated against. They should also have channels for nurses to be able to express themselves if they're being discriminated against. They should make nurses aware that if they feel a certain way, they can speak up.
Dr. Charmaine Lawson (24:44):
Hospitals can and should set up a clear system where nurses can safely report incidents of racism, incidents of bullying from peers or incidents of workplace violence. The problem with this is that many nurses are hesitant to report these issues.
Marcus Henderson (25:01):
Many nurses and other individuals are afraid to report incidents of violence, experience of racism, discrimination, being bullied by peers, because when they report, it is again the nurse is blamed or there's retaliation against the nurse for reporting such an incident.
Dr. Charmaine Lawson (25:22):
Dr. Regina Cunningham, who we heard from in our last episode is a CEO at the hospital at the University of Pennsylvania, and was a member of the Future of nursing 2020-2030 Committee. Throughout her career she's also witnessed why nurses feel so discouraged to report problematic situations.
Dr. Regina Cunningham (25:41):
They should make sure that reporting issues is not something nurses are penalized for. I mean, sometimes nurses are afraid to report issues within an organization because they're afraid that they'll somehow be penalized for it.
Dr. Charmaine Lawson (25:53):
Unfortunately, what Marcus and other frontline nurses have observed is that when nurses report certain incidents, employers don't always prioritize supporting them in return.
Marcus Henderson (26:04):
The frame is not, I'm so sorry this is happened to you. Let's work to ensure it doesn't happen again. It seems as though that employers and institutions are trying to maintain the status quo or protect themselves rather than protecting the people that work there.
Dr. Charmaine Lawson (26:21):
There's no point to a reporting system if the employer doesn't take the nurse seriously, and if the employer doesn't take the nurses concern seriously, the nurses will never be fully supported. A reliable reporting system must be thorough. And employers must take several steps to find the root causes behind workplace incidents.
Marcus Henderson (26:47):
But if we have a system of reporting where an individual reports an incidence of violence or racism, discrimination, bullying, and then that triggers a process of let's get to the root cause of what happened. Let's really take in all the facts and information. Let's examine how the system itself, how the institution itself, through its policies, procedures, structures and practices, might have contributed to this issue occurring. What prevention strategies do we have in place already that failed to protect the individual from experiencing this issue? And then taking that at, and actually developing solutions to the problem and ensuring that it doesn't happen again. So it's taking that more proactive approach with reporting rather than a retaliatory and reactive approach to reporting, I think is very, very important.
Dr. Charmaine Lawson (27:39):
Like we mentioned before, employers can't always control the actions of others. They can't stop a patient from making a racist statement. They can't control if one nurse decides to bully their colleagues and they may not be able to immediately stop a patient's attempt to physically or verbally assault nursing staff, but they can control how they respond to these situations. And they can and should respond by not tolerating poor behavior, listening to the nurse, investigating the situation, providing resources and support to that nurse, and then taking the next step by looking at what root causes lay behind the situation. Nurse leaders can shape the day to day work life of nurses. They have the power to set the culture and tone of the workplace. They can develop and enforce policies and they can serve as exemplars of wellbeing.
Dr. Charmaine Lawson (28:43):
When it comes to supporting nurses, it's the responsibility of policymakers, employers, nursing schools, professional associations, and nurses themselves. Nurses must consistently check in with themselves and monitor if they are supporting their own wellbeing. Are they getting enough sleep? Are they incorporating physical activity and a healthy diet into their lifestyle? How is their mental health? And if they notice that their wellbeing is struggling, they must then ask themselves why? As nurses support their own health and wellbeing, employers must do everything possible to create safe work environments that alleviate the natural stressors and demands of the nursing profession. And to do this, health systems must be willing to invest their resources into supporting nurses.
Dr. Regina Cunningham (29:35):
There's always a finite amount of resources. So when you say something's a priority, it often means that you are going to invest resources in getting it done. So organizations need to prioritize. They need to take a long view here because we know that by supporting nurses to do this work, we know that environments that support nurses actually have improved outcomes. I mean, there's decades of empirical evidence about this, about the importance of supporting nurses in the work environment and how that connects to better outcomes for patients.
Dr. Kenya Beard (30:09):
That's how we begin to right the ship. And we could take a lesson from the airline industry and create a culture where it is expected that nurses put the oxygen mask on themselves first. And when there's turbulence, there's an audible, flight attendants, take your seats. However, it's my belief that nurses tend to put the mask on others at their own expense.
Dr. Charmaine Lawson (30:34):
Nurses are taking on more responsibilities to address health equity, but we can't expect them to care for patients, advance health equity, and improve the health of the nation until health systems implement structures that support and protect nurses health and wellbeing. In our next episode, we're going to look at the barriers that stand in the way of nurses practicing to the full extent of their education and training. And we're also going to explore how nurses contributions can be valued more until then, if you want to learn more about this topic and what your organization can do to fully support nurses, check out the Future of Nursing 2020-2030 report. You can visit the report homepage at nap.edu/nursing 2030. As always, thanks for listening.