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Preventing Burnout in Nursing - Bredenberg & Manion

Ingrid Bredenberg
Ingrid Bredenberg, M.A. is an organizational development "coach" and wellness specialist. Her work is designed to unleash and direct the inherent creativity and ability in people to produce outstanding results in their personal and professional lives as well as in their relationships.

As a former Director of Corporate and Community Wellness at a large Florida teaching hospital, Ingrid understands the pressures and stressors in the healthcare environment. She is an ingenious facilitator and innovator who brings fresh, viable approaches to creating more balance, joy and resourcefulness in people's lives.

She received her B.A. from Florida Presbyterian College, St. Petersburg, FL., M.A. - Industrial/Organizational Psychology from University of New Haven, CT, and Certifications in: inscape publishing assessment and learning resources: Kirton Adaptive Innovation assessments.

Ingrid Bredenberg
Human Resource Innovations
PO Box 128 * Montague * MA 01351
Tel:(413)367-2204 * Fax: (413)367-2206
innovate@crocker.com * www.lifeshaping.com











Kernan Manion
Kernan Manion, MD is the director of Work/Life Design, a novel coaching and consultancy service devoted exclusively to assisting individuals and organizations in identifying and resolving the matrix of issues which contribute to disabling occupational stress, compassion fatigue and burnout, and to helping to craft pathways toward enduring individual and organizational well-being.

Dr. Manion attended LSU Medical School in New Orleans and trained in Adult Psychiatry at Tufts New England Medical Center after completing an internal medicine internship and a subsequent interim year of emergency medicine practice. He has been in practice in Massachusetts since 1983 and has served on a rich diversity of hospital and clinic medical staffs. He took a particularly avid interest in understanding and addressing professional burnout in 1995 upon recognizing its emergence both in the lives of colleagues as well as in his own.

He became familiar with quality systems paradigms as they apply to healthcare and was invited to become an examiner for the Massachusetts Quality Award (which follows the Malcolm Baldridge Award criteria). He began to apply various creative problem-solving tools to his work with physicians grappling with occupational stress. He had the fortunate opportunity to receive training at the Harvard School of Public Health Program in Health Care Negotiation and Conflict Resolution and is pleased to serve as head of its alumni association. He has incorporated many of the program's effective communication and conflict resolution strategies into the Work/Life Design approach.

Work / Life Design
Helping You Achieve Wellbeing Through Personal, Career and Organizational Health
"Collaboratively Crafting Transformational Change"
Kernan Manion, MD Director
1620 Sudbury Road, #5 Concord, MA 01742
978-369-0368
kmanion@pol.net



Question 1 - Hello Ingrid and Kernan, Seems like with all the stresses taking place in healthcare, it would be very difficult for leaders and managers to be proactive on this issue. What would you recommend to leaders and managers, who are under a great amount of stress themselves , for creating a proactive environment in decreasing nursing pressures within their organizations? I think our leaders and managers can have a huge impact on nurses and their stresses. Do you know any leaders and managers who are making a difference in the nursing culture of their organizations? by tammy on June 12, 2000

Answer 1 - Hi Tammy, You're right - it IS difficult for leaders and managers to be proactive on occupational stress and burnout in nursing. In states of turmoil, which I think it's pretty fair to say healthcare is in, it's difficult for anybody to be proactive on anything but survival.

But when we're in turmoil, we have to be at our sharpest. We need to be able to sort through the turmoil and understand the ongoing vortex of forces at work.

The ironic thing is that it's precisely in environments of crisis and turmoil that we need to be communicating with each other - MORE SO than in times of predictable calm. (We haven't seen those times in quite a while, and all indications are that we're not going to be seeing any smooth sailing for quite a while).

Imagine an army for a moment. You're fighting on five fronts, and if any of them goes down, you're sunk. You have to stay in touch with each battalion, you have to ensure that it's holding its territory and you have to be thinking about how each is going to safely advance. The lines of communication have to stay open for the group as a whole to survive.

Tense environments tend to make people not only hunker down, but also retreat into isolation. Yes, administrators and managers and nurses and doctors and line staff are all under great stress - there are so many forces acting on healthcare concurrently that it's difficult to tease them apart and to know how best to respond to them. It is a veritable whirlwind. But we do know this about stressful times - "we can either hang together, or we'll hang separately!"

The operation of any team endeavor - be it sports, entertainment, military, commercial or family - calls for ongoing communication. To work together as a team, you've got to be proactive - in envisioning, clarifying, strategizing and acting. And to do all of these, you need to be proactive in making opportunities to talk with each other about what it is that you're trying to do.

Case in point: I was on staff at a medical rehabilitation hospital and nursing was understaffed and under stress (could there be any relationship?). There was an incident in which a paralyzed patient, in a private room, nearly aspirated and was not able to use the specially rigged call button. Administration took their usual stance about "no more money for staffing"; nursing felt very overwhelmed and unsupported. What needed to take place? A number of things - all having to do with very proactive communication:
- an examination of the workplace environment that contributed to the error (and this was in fact an error).
- a stat discussion with all participants about how this could better be handled in the future.
- establishment of immediate corrective measures with input from key participants.
- exploration of the stresses that staff is/was going through to see if this is an isolated example or indicative of a high stress (and therefore unsafe) environment.
- Debriefing of the affected staff.

Now, if you think that's a lot of dialog for one measly incident, let me assure you, a) it is; b) the incident, like so many in the life-or-death work that we do is NOT measly; c) if you think that's a lot of dialog, think about how much dialog goes on in a deposition and d) if you think that's a lot of effort, think about how much effort it's going to take to recruit, train and "enculture" a new nurse for the unit after s/he's burned out from the chronic stress!

We just don't have any choice about being proactive in communication in these times. And I think most administrators and managers and clinicians would all agree. "Yeah, yeah, yeah" - but how? It appears that the organizational structures/processes that many facilities have in place are inadequate for the task. If we're committed to communication, we're going to have to put into place the means by which we can promptly, effectively, and truthfully communicate. And if we haven't devised those yet, then we need to get some focused help in doing that.

Speaking of truthful communication, a nursing group here in the northeast recently favorably resolved a very courageous strike they undertook because of this very issue of overwork and under-staffing. Their primary issue was that of mandatory overtime, but they made it clear that they were quite concerned about the impact that understaffing has on quality of care.

Some of the questions that healthcare participants need to be asking themselves are: Are we communicating in the optimal way given the situations that we face? How are each of us holding up in this embattled environment? Are we ensuring that we're getting input from as many front-line staff as we can? What are we doing about communication strains within and between departments? How are we communicating our support to front-line staff? How might we go about this differently? Could we benefit from some focused consultation around optimizing communication? Around conflict resolution? Around creative problem-solving for our system's structure/process improvement? by Kernan Manion on June 13, 2000
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Question 2 - Do you think the quality programs in hospitals and other facilities are providing a way for nurses and other clinicians identify and get help with clinical and other quality problems?

If not, why? by kmack on June 12, 2000

Answer 2 - Kathleen, Your question regarding "quality" programs is a provocative one.

In short, "quality programs" like CQI (Continuous Quality Improvement) and TQM (Total Quality Management), envisioned in the 70's and 80's, were imported into service industries from the manufacturing industry. The automobile industry imported them from the Japanese who were then leading the US in their exports of energy efficient AND less expensive AND more reliable cars. The Japanese had discovered that if you look at the system as a whole - from customer request, through design, production, alliance with suppliers, inventory, delivery and feedback from all components, including that of the end-user - the buyer - you could create a system which a) was efficient; b) capable of self-correcting; and c) always strove for further improvement. You would also have comprehensive ways of analyzing systems problems, using a variety of tools - fishbone diagrams, affinity diagrams, cause & effect (interrelationship) digraphs, process mapping etc.

Ah, the vision of a system which is geared toward quality AND which is efficient and self-correcting! It was a vision which is still most desirable. Alas, it's the deployment which has failed miserably.

Most hospital and clinic staffs that I've been on have received the TQM/CQI vision as a mandate for more paperwork, which, if you don't do, you lose funding or are in some other way penalized.

Because it involves only a few of the organization's members at a time, and because it is seen as another bureaucratic hassle, it is most often performed perfunctorily.

As a reviewer, you'd get a stack of charts and look for documentation of this or that - whatever we were looking for (e.g. substantiation of admission diagnosis). You'd find a certain error rate, there would be a passing announcement at a medical staff meeting about how important it was to substantiate the evidence for the admission diagnosis, and that would be it. Tah-dah - continuous quality improvement in action.

Now, why was this occurring in this faulty way? For one, the issue of TQM/CQI got so watered down that there really wasn't "buy in" from the participants. It has to be in the organization's blood, it has to be a clear commitment. Unfortunately, the way it got handed to the medical establishment is via bureaucratic mandate. Another reason has been that you're imposing on people whose plates are already overloaded and you're often asking/telling them to do this on their own time.

Now, in the manufacturing world, what do you think the response would be if you asked workers to focus on quality issues "on their own time"? It's hypocritical!

If you want to invest in quality systems, in process analysis, in error correction, in burnout prevention, the reality is - you're going to have to put in the necessary resources to do that! And that includes: taking time to instruct everyone on the importance of what you're doing; making time and space available for the activities; and providing the necessary funding for it to take place.

You're absolutely right, Kathleen - if we did have true quality management systems in place, we'd be capable of addressing nursing burnout, performing error analysis and correction, and optimizing work systems. But the "pro forma" way these are currently executed, the bureaucratic mandate behind them, and the current survival mentality in healthcare (combined with "change-weariness" and cynicism) make deployment of the diversity of quality management tools difficult.

Kernan Manion, MD
by Kernan Manion on June 13, 2000
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Question 3 - Building on Kathleen's question, What kind of return on investment does implenting a good burnout program provide an organization? Although I would like to think organizations would provide because the problem exists and they should, we all know that dollars are so short in healthcare and everything has to be measured in dollars and cents. by yvette on June 14, 2000

Answer 3 - Hi Yvette, Let me be sort of "tongue in cheek" here and reverse the question - "What kind of return on investment does staff burnout provide an organization?" If we really need to think in terms of dollars and cents, i.e. the "bottom line", what's it costing your organization to NOT have burnout prevention and coping resources for your staff? Resources such as Communication Skills, Managing Work/Life Balance, Conflict Resolution, Leadership Training, Team Building, Creative Problem Solving, "Open Space"…. All of these are known to contribute to employee satisfaction, enhanced quality of worklife, as well as increased productivity and employee retention.

We know that stress-related claims are one of the fastest growing (read 'troubling') trends for the insurance industry. People are grappling with how to identify, prioritize and best manage stress in their lives. Why? Because we've got a lot of it, and today's healthcare environment is particularly stressful as it goes through the turmoil of redefinition. Fatigue from work overload or over-exposure (what's it like to have chronically increased exposure to high-intensity illness with high risk outcomes?), unresolved anger or sadness, anxiety about layoffs, cynicism, pessimism, apathy… Do these take a toll? You bet!

And yet, still, many organizations stick their heads in the mud hoping it'll just go away. Are they afraid of putting into place very low cost/high return programs? (What's there to be afraid of? It's a no-brainer.) Maybe "opening Pandora's box"? If the organization is a powder keg of anger, a Pandora's box of resentment, it's programs like these that ENABLE people to do problem identification and resolution and actually address the anger. At talks that I give on "Occupational Stress and Burnout - Achieving Balance and Wellbeing", people are begging for the opportunity to talk with each other, to collaboratively problem solve, to support each other. (The presentation actually becomes very interactive and people invariably say "thanks for the opportunity to be heard and validated….").

Now, getting down to hard dollar figures - I have not seen any study which can state in black and white - "chronic dis-stress leads to burnout which leads to absenteeism, increased medical and disability claims of $$$ as well as a lowered productivity cost of $$$ per affected employee." There just isn't that kind of data available.

But a consulting group newsletter revealed the following, of significant interest:

Without even considering the medical and disability and absentee costs, look at the following costs of employee turnover:

Outplacement counseling/exit interviews for departing employee
Recruitment (print ads, head hunters, HR interviews - per employee)
Retraining the new employee in the unit's practices
Lost productivity / quality of work of the previous employee during her/his last 4 weeks (at least)
Lost productivity / quality of work of the entire team (especially if the lost employee was a manager!)
Lost productivity / quality of work in the interim of losing the old employee and integrating the new hire

These various costs - again not even considering the health- and disability-related costs, not even considering the impact on personal and family wellbeing or even on adverse patient outcomes - are estimated to be in a range of $6,000 - $12,000 - PER EMPLOYEE!

Now, I can already hear some managerial/administrative skeptics "well, she's got sick days, let her use those…"; "everybody else seems to be doing okay…."; "we keep a close eye on quality and it's never been affected"; and perhaps the most malignant one (seldom overtly stated) "there's more where s/he came from…and besides s/he just wasn't pulling her weight." (Workers need to realize they're in a very toxic Stalinist environment when they hear that one! This is an organization that chews up its workers and spits them out; head for the hills!). (A variant of the Stalinist theme is "we were going to downsize anyway…." That's like a parent saying, after the death of a child "we really wanted a smaller family anyway"! Yikes, what would it be like to be in THEIR family?!)

Some organizations think that if they give their employees better "customer service" training (like how to greet people with a smile, and polite ways to respond to a customer's demanding request etc.) this will be sufficient. Sure, these address "service" and "customer retention" and "branding" and all the other commercial buzz words, but they simply don't address the issue of real occupational stress and burnout - in fact, they ignore it, they further pathologize it by implying "if you still don't know how to work on this unit - after this fine customer service training program, you're a defective/undesirable employee….". And the stress and burnout continues to wreak its havoc - on the individual, the team, the unit, the organization, the patient, and the employee's family and friends.

It occurred to me that maybe the idea of addressing occupational stress and burnout is just too big. So, perhaps it would make sense to break it down here into a single "stress area" and a "skill training" resonse. Nurse, who worked a double yesterday, incidentally at the pleading of the nurse manager, is back on the job this morning. Difficult rounds/report. Clarifying a possible med error. Angry, demanding docs in earlier, blasting out lots of stat orders. Now dispensing meds, interrupted again by call buzzer. Angry demanding patient (different from the earlier docs only in the fact that this one has a funny gown on obscenely exposing the bum) yells at her about the lousy service. She proceeds to "lose it". (Imagine anything here). Then goes back to the nurses' "lounge"/report room and breaks down in tears.

Fair to call this stress? Fair to say it has implications for patient care? For team work - with other nurses, with docs? Would anything help here? Are there any techniques she can readily call upon to help her manage this situation? Well, fresh from a Conflict Resolution in-service, or a "Dealing With Angry Patients" training, or even a more personal "Stress & Coping" workshop, she would. And might avoid the erosive impact of the tremendously high stress she's just encountered. She might have been able to a) speak to the demanding docs in a more boundary-defining and assertive way; b) subordinate dealing with one of the pressing issues; c) employed "defusing", "venting" and other conflict resolution techniques; and d) taken a "mini-centering" exercise to "re-group. (Maybe she might have even been able to be assertive enough to say "no, I better not do a double - I get so fried, and it's a bad scene for everybody when I'm fried, even though we need the money and it'll give me priority scheduling….").

But, what happens now if she hasn't had these resources, these mini-trainings, made available to her? She's done damage to the hospital's reputation, and the old codger with the funny gown insists on seeing the VPs of Nursing and of Patient Services and invariably gets more immediate (and supportive!) contact with the administration than she does; and the docs file a complaint, saying she's surly; and she feels powerless and angry and gets progressively more disinvested in her job; and she starts to show signs of depression, or she pulls her back out; and she goes on leave and starts to wonder whether this job is for her, or whether she made the wrong career choice…. Costs?

Needless to say, Yvette, I could go on and on. The key points are that:
Stress is real, and chronic stress has real, documented adverse effects on people's minds and bodies;
Occupational stress is real and has the very same adverse effects;
There are ways (and very cost-effective ones!) for individuals and organizations to address and dismantle stress before it leads to burnout (and increase patient as well as staff satisfaction in the process!);
Burnout leads to loss of productivity, loss of job satisfaction, employee turnover, absenteeism, and increased medical and disability expenses;
The direct and indirect costs of NOT doing stress management and burnout prevention are massive compared to the small cost to the organization of doing them.

Thanks for your question,
Kernan Manion, MD
Work/Life Design
Concord, MA
kmanion@pol.net
by Kernan Manion on June 14, 2000

Answer 3 - Dear Yvette, Dr. Manion has done a great job in answering your question. I'll just come at this from a slightly different perspective. The new economy is requiring that people think entreprenuerally. In other words, everyone is their own business. While it certainly makes sense for an organization to invest in their employees' wellbeing, it also makes sense for individuals to take responsibility for their own mental, physical and spiritual health. Proactively utilizing EAP programs, requesting trainings, attending personal growth and relationship seminars can go a long way toward contributing to an individual's wellbeing and personal effectiveness.

Sincerely,
Ingrid Bredenberg
innovate@crocker.com
by Ingrid Bredenberg on June 16, 2000
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Question 4 - Nursing is a difficult place to be, especially acute care nursing. The stress of taking care of more patients with less staff when your employer, usually a hospital, has not made the investment in information systems, operational change and training to help you do your job more efficiently (lack of good leadership in health care). How nurses must struggle with wanting to do a good job and spend more time at the patient's bedside while doing all of the little distracting administrative things that simply keep them out of lawsuits. by cstipe on June 16, 2000

Answer 4 - Dear Chris, You make some very good points about the dilemmas that healthcare providers are in as they attempt to provide high quality, personal patient care, while complying with all the necessary paperwork, guidelines, timeframes and other limitations placed on them.

While you aren’t posing a specific question about this, I’ll offer my own perspective about the situation. It may help to recognize that certain aspects of this dilemma that are “gravity” issues, meaning that like gravity, they are always with us and probably won’t go away anytime soon, if ever, i.e. compliance issues, more acute patient needs, limited time to attend to patients’ personal needs.
As Dr. Manion has pointed out in other responses, stress and burnout are caused when we feel out of control, lacking success or completion with projects, and/or when we are physically, mentally or spiritually fatigued. While we may not be able to directly address some of the “gravity” issues, we can seek ways to increase flexibility, identify even small successes, celebrate completions and restore ourselves physically, mentally and spiritually.

I have learned to use a very powerful “clearing” technique that allows me to reflect on my day or week, release frustrations and disappointments, address incompletions, and celebrate successes. This is a dialogue process that is best done with a friend, partner or colleague who is willing to be a committed listener. The process itself may take as little as ten minutes....or longer, if there is a lot of “stuff” to clear. The result is a clearer mind, relaxed body, and restored spirit. I have introduced this process to nurses and other clients as a way for them to empower themselves in a high-stress environment. I would be willing to send you an outline of this very simple, yet powerful process if you or anyone else is interested.
Bottom line - the more resourceful individuals can become within themselves, the better they can deal with stressors and the more satisfaction they can feel within themselves. Programs, classes and coaching which help individuals expand their resource toolkit of communication, assertiveness, and relationship skills are a good investment by an organization. Nurturing, supportive relationships both at work and at home also increases a person’s resiliency and self-esteem.

In an ideal world organizations would understand the value of investing in their “human capital” by helping them develop emotional intelligence, relationship, leadership and communication skills as well as build in systems which foster high level wellness. In the current reality, those people who take charge of their own lives and seek ways to fully empower themselves will be rewarded with more satisfaction in themselves, their work and their relationships,

Sincerely,
Ingrid Bredenberg
Innovate@crocker.com
by Ingrid Bredenberg on June 16, 2000

Answer 4 - I completely concur with Ingrid's thoughts.

So what does have to happen, Chris, to support nurses in the current climate? Change takes place from multiple levels. As Ingrid pointed out, we must avail ourselves of the resources we each individually need to take care of ourselves. We must seek lives of balance and self-replenishment. No matter what an organization may or may not do, we are still responsible to ourselves and the significant others in our lives to strive toward wellbeing and balance. This includes regularly checking in with ourselves about our stress level and the healthiness of our coping.

We need to examine our worklives and determine how we can make them best work for us, while achieving the goals of the organization.

Our professional peer group can be a great source of support and change. Sometimes, organizations actually do change from the "bottom up". One, or better several, members of an organization effectively "lobby" for the proposed change (even if it may simply mean setting up a dialog with administration/management).

And the organization needs to continuously examine what it can do to make the work more "doable" and "rewarding". And this is not just a "one-stop" effort ("oh, yeah, we did that - four years ago…"). It's a continuous loop - that of a learning organization, willing to re-visit work structures and processes and alter them with active worker input for improvement.

This sort of collaborative "worklife optimization" effort requires effort from all participants - it requires ongoing open communication. Not only does the organization need to be active in this effort - the workers themselves need to find ways to continually engage decision-makers in dialog. One of the key skills that workers need to effect organizational change is "organizational savvy" (in some studies of burnout, it's been found that actually teaching people the decision-making process and how to "work the system" have been immensely helpful both in empowering people as well as effecting vital change - thereby preventing burnout). The worker needs to understand how to get the system to pay attention to his/her needs and get buy-in.

One thing to be certain of - avoid useless "bitch" sessions, where everybody complains and lives in an ongoing tantrum. Be an active part of the change process.

Good luck!
Kernan Manion, MD
Work/Life Design
Kmanion@pol.net
by Kernan Manion on June 16, 2000
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Question 5 - There's a difference between a job, which pays the mortgage and bills, and work, which satisfies you no matter what. I think nursing, especially, is more in the line of "work". You have to be internally motivated to work in such a high stress field. Management has failed to realize this in many cases. What can nurses and other healthcare practitioners do to make work
"real" and rewarding? Remember what drove you through school--was it the idea of making money or the idea that you could make a wonderful difference in someone's life? Maybe even save a life? Focus on those things--the internal rewards, and set up structure in your workplace to help alleviate some of the workplace stresses. Get management on the ball, and working with you on this. If you work as a team, there's no telling what you can accomplish. Don't make a committee on it, to study it--get out there and do it. Fix the little things that drive everyone batty. Focus on the larger picture, on WORK instead of JOB. In any field, that can make the difference between hating to get up in the morning and really enjoying what you do every day. by annemarie on June 16, 2000

Answer 5 - Dear Anne Marie, Amen! I appreciate your proactive suggestions. Many individuals choose a "victim" or "entitlement" approach about work. Your distinction between work and a job is useful. I also like the term "vocation" or calling. I imagine that most healthcare workers entered the field as a calling. Changes in healthcare, the economy and our society in general will create missed expectations. As I've mentioned in some of my other responses, a person can have most effect on their wellbeing by coming from a place of personal empowerment. While it is wonderful when organizations offer programs that develop skills for personal empowerment, it is up to the individual to design their own life and work in a way that is both fulfilling and creative. If the "job" doesn't provide the right environment or intrinsic rewards, it's time to re-design your life. It's a good idea to do that every now and again. While it is not always easy, it sure beats suffering in an unsatisfactory job. Thanks so much for your comments.

Ingrid Bredenberg
innovate@crocker.com
by Ingrid Bredenberg on June 16, 2000

Answer 5 - I agree with you, Anne Marie. Most people went into healthcare, not as just another "job" but as their life's work, their calling, their vocation, if you will. And as a calling, our life's work, we need to be able to find sustenance in it in order to continue it.

Unfortunately, even exceedingly well-motivated people can be worn down by the relentless stress, the lack of validation, the lack of opportunity to "re-group" and replenish one's soul.

To ensure that the work you've chosen does in fact continue to satisfy you, both you and the organization need to be in a collaborative dialog about how can both best work together. The organization needs to continually be checking in with its workers about how things are going, seeking their input regularly on ways to optimize work processes and maintain quality. (And, even though it really shouldn't have to be explicitly stated - an organization simply can't maintain quality if it doesn't look after the quality of the employees' worklife, the "wholesomeness" of the job, the balance and wellbeing of the worker. When you have stressed/burned out employees who are wiped out, angry, cynical or indifferent - you simply won't have a quality product or service.)

Let me create a fictional example to make my point. Take a new nurse - fresh out of school and eager to enter into the "real world". S/he gets hired by a hospital which is understaffed. S/he's made to feel that it's her/his duty put in the extra effort. Add to this picture high intensity illness - perhaps pediatric burns. Add to this a particularly challenging period in this unit's census, say some really high intensity cases and grieving parents. And add to this the fact that the hospital is undergoing a general staffing alteration - say the director of nursing - because of a merger…

The typical organizational response to this scenario is - nada. So, what's the impact on the new nurse? Singed. Baked. Early on. Like putting a 20 amp fuse in a 100 amp outlet.

But what will the organization see? She's "holding up okay, given the circumstances". "It looks like people are managing pretty well under adverse circumstances". And s/he, and they, are probably overall doing "okay".

But what's going on inside the new nurse's head - what's the internal dialog and the emotional response?:
"I'm wiped out"…"This is high intensity stuff"…."I feel so inadequate"… "Maybe I'm not cut out for this work"…. Some may argue - "well, that's just part of being a new nurse. And - PART of it may be. But we've got to realize - all of this is exacting a severe toll, and - it may not be able to be measured right now. If this new nurse continues to feel awful, overwhelmed, saddened, angry, powerless, unsupported, unprepared for a variety of encounters - what happens? Eventually, s/he leaves. S/he says "I got an offer at ….". May not look like frank burnout. But it has all the rudiments of it.

And this same scenario applies to every nurse (and every person) who does clinical care. The bottom line is this - if you allow a harsh environment to incessantly and adversely impact people - without continuously trying to make changes to make it more tolerable, more workable - you contribute to people's burnout. We need to be aggressive in this harsher new world of healthcare delivery in our pursuit of supporting our staffs - hearing them out, attending to their needs, validating their work, seeking their input for making improvements, offering opportunities for ongoing life skills training (leadership, team development, communication, maintaining balance, coping & stress, time mastery….), offering mentoring, offering a means of professionally advancing, ensuring protection from involuntary overload, offering critical incident debriefing and select critical skills training (e.g. communicating with a grieving family member; defusing a hostile patient….).

Only by continuously attending to the environment of our worklives are we going to be able to sustain our life's work, our vocations. Without that, without that aggressive attention to the worklife setting, good people will find themselves in situations that are physically or emotionally unsustainable, and they will wither, like un-fed branches of a tree.

Kernan Manion, MD
Work/Life Design
Kmanion@pol.net
by Kernan Manion on June 16, 2000

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