The Nurses: A Year of Secrets, Drama, and Miracles with the Heroes of the Hospital (26 page)

Nurses can also become emotionally attached to their patients, some of whom die in front of them. “The patients become part of our family. It’s a whirlwind relationship because you meet someone, and the next thing you know, you’re looking at their naked body and listening to their innermost anxieties. In return, you listen, try to help, and share parts of your own life,” said a Maryland hematology nurse. “If they die, it’s very hard; you have lost someone you became close to very quickly, someone you were cheering to beat the odds. As a nurse, you can’t dwell on your loss. You have other patients who need you. One might think that you would build a tough exterior that doesn’t let the hurt in, but to truly be effective, you can’t. You share your grief with work friends because people at home can’t understand the connection that you share with patients.”

For all of these reasons, nurses are the hospital employees most likely to develop work-related psychological disorders. Eighty-seven percent of surveyed nurses at one university hospital exhibited symptoms of anxiety, depression, PTSD, or what researchers call burnout syndrome. Nurses have relatively high rates of suicide, depression, and anxiety relating to job stress. University of Kentucky researchers found that 35 percent of surveyed nurses are mild to moderately depressed, compared to 12 percent of the general population and 12 percent of emergency medicine residents. Occupational reasons for this depression include not enough time to provide emotional support to patients or to complete their nursing tasks, too much time spent on non-nursing tasks like clerical work, and not enough staff for proper patient care, all of which could be alleviated if hospitals increased nurse staffing.

Nurses’ schedules can leave them little time to recuperate from arduous patient care. They might stress about missing family birthdays, recitals, sports games, and holidays. They are not necessarily paid commensurate to their sacrifices. Nurses told me about sleepless nights during which they were so worried about patients that they called the unit to check on them, and days off that they spent doing something for a patient instead of for their family. And it is difficult to explain the letdowns of the job to people who aren’t nurses. “People don’t know how hard it is to compartmentalize your life when you have a bad day at work, like when a patient dies or declines, and then you have to come home and act like nothing is wrong,” a Maryland OR nurse said. “Your husband and children have a difficult time understanding and it’s impossible to explain. They don’t teach that in nurses’ training.”

Workplace stressors are affecting nurses’ mental health across the world. In Quebec, where the local nursing union has asked the government to end sixteen-hour shifts because understaffed nurses are “overworked and exhausted,” five nurses killed themselves in an eighteen-month span. At least one of them left a suicide note in which she blamed her hospital’s working conditions. When the woman’s sister-in-law contacted the hospital, she was allegedly told, “She’s not the first to commit suicide and she won’t be the last.”

In 2013, the U.K.’s Royal College of Nursing announced that 82 percent of nurses go to work while sick because they worry that understaffing would harm patient care. Reporting that stressed nurses are “forced to choose between the health of patients and their own,” the RCN revealed that staff shortages and increased workloads caused more than half of surveyed nurses to become ill. In a separate report, South African nurses conveyed similar issues, in addition to poor security, lack of government support, and unhygienic hospitals.

Experts estimate that approximately 30 percent of nurses are burnt out, which has been defined as a “loss of caring.” Burnout symptoms include irritability, difficulty concentrating, low energy, and sustained thoughts of quitting. Many nurses also experience a related but lesser known condition that is often confused with burnout. “Compassion fatigue,” also called secondary traumatic stress disorder, can occur when empathetic nurses unconsciously absorb their patients’ traumatic stress. They experience the traumas emotionally, sometimes mirroring the patients’ anxiety. As they pour their energy and compassion into caring for their patients, many of whom do not improve, they fail to care properly for themselves and/or their own families. The resulting sense of helplessness has been called “a combination of physical, emotional, and spiritual depletion” and “a state of psychic exhaustion.”

This can happen to nurses who treat children the same age as their own or to nurses who have nothing in common with their patients. A St. Louis oncology nurse quoted Holocaust survivor and psychiatrist Viktor Frankl to States News Service in 2012: “ ‘What is to give light must endure burning.’ I think people who care for others understand. Caregiving is painful.”

The ANA lists compassion fatigue symptoms including anxiety, depression, disrupted sleep, memory problems, fatigue, headaches, upset stomach, chest pain, and poor concentration. Nurses suffering from compassion fatigue might be less able to feel empathy toward patients or their families and more likely to abuse drugs or alcohol; they might avoid or dread working with certain patients.

Distinguishing characteristics of burnout versus compassion fatigue vary by the expert, but there seems to be a general consensus that burnout is caused by stress related to the job (understaffing, lack of support) while compassion fatigue is caused by stress related to the patients (connections with patients or families, caring for the suffering or dying). Burnout can lead to emotional exhaustion, but compassion fatigue causes heavy- heartedness. Michigan nurse and staff educator Shari Simpson explained at an Association of Pediatric Hematology/Oncology Nurses annual conference, “Compassion fatigue does not mean one is no longer capable of feeling compassion. It’s the feeling of compassion weigh[ing] so heavily on you that the way you experience life is affected.”

Both conditions, author Deborah Boyle wrote, “are associated with a sense of depletion within the nurse, a ‘running on empty’ feeling.” And nurses can experience burnout and compassion fatigue at the same time. A trauma nurse in North Carolina was hit by this double whammy. “Doctors are demanding, patients are demanding, management is demanding. If the doctor orders a wrong medication, and the nurse gives it to the patient, whose fault is it? It’s your fault for giving it. If a drunk patient gets out of bed and falls, it’s your fault for not being there to stop him, but the doctor won’t give you an order for restraints. Everything in hospital healthcare comes down to the nurse. Every second of every shift, you are giving, doing, running, caring—it’s draining,” she said.

For this nurse, the combination of compassion fatigue and burnout contributed to a depression that bordered on suicidal. “I have had days where I would have rather crashed my car than go into work. I was getting sucked dry. The neediness of everyone! It’s like a never-ending rendition of ‘If you give a mouse a cookie’ and as nurses we don’t like to fail. It’s not allowed,” she said. “As a nurse I am completely in tune with my patients, their needs, and the needs of their family. I really can lose track of myself. If it comes down to helping a patient to the bathroom or being able to empty my own bladder after eight hours, it’s going to be the patient every time. It’s not totally healthy. But I can’t imagine doing anything else.”

On a particularly bad day, she arrived at a preshift meeting in which supervisors scolded the nurses. “What I heard was, ‘Customer service is really lacking in the Emergency Department. It doesn’t matter what’s going on in your personal life. We don’t care. It is always all about the patients,’ ” she remembered. “And this whole time, I had been thinking of killing myself. In my head, I kept putting a gun in my mouth and pulling the trigger; it was like I was watching a movie over and over again.” Eventually, the nurse confided in a psychiatric resident and her husband, who helped her to pull through. Today she is a stable, healthy nurse who continues to love her work.

Employees in any helping profession can be afflicted with compassion fatigue, including social workers, counselors, chaplains, and humane workers. But nurses are particularly vulnerable, Boyle wrote, because “they often enter the lives of others at very critical junctures and become partners, rather than observers, in patients’ healthcare journeys. Acute care nurses in particular often develop empathic engagement with patients and families. This, coupled with their experience of cumulative grief, positions them at the epicenter of an environment often characterized by sadness and loss.” Simpson calculated that if an inpatient nurse sees an average of even just four patients during a twelve-hour shift, in twenty years she will care for more than 11,000 patients and families. A clinic nurse who sees ten patients per shift will care for nearly 43,000 patients. Those numbers require an extraordinary amount of compassion.

It is possible that the nurses who care the most might bear the highest risk. Researchers report that some types of personalities are more susceptible to stress and compassion fatigue, such as people who are overly conscientious, perfectionistic, and self-giving. And nurses are already highly empathizing people. “We are programmed to be able to do it all; we give our life and soul to the profession,” said a Florida psychiatric nurse. “Sometimes, if you feel you can’t help an individual, you feel you have failed.”

Compassion fatigue may have increased in recent years because of the demands of managed care. Because doctors and nurses have more time pressures to see more patients and complete more paperwork, they have less time to enjoy, for example, “the connection that many family physicians shared with their patients, [which] was replenishing, which helped them cope with the stressors of practicing medicine,” Indiana University School of Medicine researchers observed.

Nurses are also vulnerable to post-traumatic stress syndrome (PTSD), a psychiatric disorder experienced by 8 to 10 percent of the general public. University of Colorado researchers found that 22 percent of surveyed nurses exhibited PTSD symptoms. All of them had observed a traumatic event such as a patient death, massive bleeding, open surgical wounds, or trauma-related injuries, or they had performed futile care on critically or terminally ill patients. Other events that could lead to PTSD include helping with end-of-life care; handling postmortem care; dealing with combative patients; taking verbal abuse from patients, family members, doctors, or other staff members; performing CPR; experiencing stress because of unsafe nurse-patient ratios; and failing to save specific patients.

ICU nurses are subjected to many of these events on a daily basis. An Emory University study discovered that ICU nurses experience PTSD at a rate similar to female Vietnam veterans. Among ICU nurses, 24 to 29 percent exhibited PTSD symptoms, compared to 14 percent of general nurses. (Outpatient nurses are less likely to develop PTSD than inpatient nurses.)

A PACU nurse in Washington State said she suffered from PTSD for several months after caring for a coding post–heart attack critical care patient who died on her shift. The hospital offered no resources to help her cope. “There was nothing available to me. I still cry thinking about the situation and how I was supposed to give 150 percent to this patient who was basically already dead,” she said. This trauma came on top of the usual nurse stresses. “Often, I feel it’s an impossible job. [Some of us] go home feeling we were unable to give the care we wanted because we were so overworked by patient numbers, acuity, and needing to be everything to everyone: nurse, friend, coworker, empathetic listener, computer specialist.”

In 2010, Kimberly Hiatt, a veteran pediatric critical care nurse at Seattle Children’s Hospital, accidentally gave an eight-month-old critically ill infant 1.4 grams of calcium chloride instead of the correct 140-milligram dose. The infant died days after the mistake. Hiatt was fired, even though it was not clear that the miscalculation directly caused the death of the infant, who had heart problems. A ten-fold overdose of calcium chloride, which is given to support circulation and prevent heart and neurological problems from low blood calcium, would not necessarily be fatal.

Hiatt, who told staff about her error as soon as she realized it, officially reported it herself. “I messed up,” she wrote on the hospital’s electronic feedback system. “I’ve been giving CaCI for years. I was talking to someone while drawing it up. Miscalculated in my head the correct mls according to the mg/ml. First med error in 25 yrs. of working here. I am simply sick about it. Will be more careful in the future.”

Hiatt reportedly was stunned that the hospital fired her for making one significant medical mistake in her entire career. Administrators had given her glowing reviews; two weeks before the incident, her evaluation awarded her a 4 out of 5 and called her a “leading performer.”

To keep her nursing license, the state nursing board required Hiatt to pay a fine and agree to a four-year probationary period during which she would be supervised when dispensing medication. But Hiatt had difficulty finding a new job, even though she aced an advanced cardiac life support certification exam, qualifying her for a flight nurse position. Seven months after her mistake, depressed and isolated, Hiatt, at age 50, committed suicide.

Hiatt apparently suffered from “second victim syndrome.” According to the Institute for Safe Medication Practices, “Second victims suffer a medical emergency equivalent to post-traumatic stress disorder. The instant patient harm occurs, the involved practitioner also becomes a patient of the organization [because he/she needs medical help]—a patient who will often be neglected.” A 2011 survey found that surgeons who thought they made a medical error were more than three times as likely to have considered suicide as those who did not.

Humans are going to make mistakes. Washington University researchers found that 92 percent of doctors surveyed had perpetrated a near miss or actual mistake and 57 percent confessed to a serious error. Retired anesthesiologist F. Norman Hamilton wrote in a
Seattle Times
letter to the editor following Hiatt’s death, “If we fire every person in medicine who makes an error, we will soon have no providers. We all make errors. It is only by the grace of God that most of them do not result in great harm or death.”