Nurse burnout: Maitre d' or Sentinel?

“The hospital doesn’t have Splenda.” was a response on a Patient-satisfaction survey. “This somehow became the fault of the nurse and ended up being placed in her personnel file.”
That happened.

Surveys used to assess nurses also ask questions like, “During this hospital stay, after you pressed the call button, how often did you get help as soon as you wanted it?” 

Hospitals with high patient-satisfaction scores get more money, so nurses are under pressure to do everything they can to make patients happy.


Also in the news: “Forty-nine percent of registered nurses under 30 and 40 percent of registered nurses over 30 experience burnout, according to one study — a sobering statistic for healthcare providers who want to improve patient care.”

These two things are related.

“Nurses are not waitresses or waiters,” says Nurse Smith, who has been a floor nurse and is now a nurse educator. “I see nurses as sentinels. A sentinel stands guard and is constantly on alert.

 “When a nurse walks into a patient’s room, there are a hundred things going through their mind. They are looking at monitors, carefully selecting which ones are important given the patient’s disease and treatment. They need to understand not just the physiology but the pathophysiology of the disease so that they can assess the patient and monitor their progress or decline.

“If an elderly demented patient starts to act a little wonky, is it just the waxing and waning of their dementia? Could it be some form of a hypoxia, perhaps a stroke? They need to have the assessment abilities to know if this could be a serious issue, when to call in the doctor and which tests could help clarify what is happening with the patient.

“They also need to assess when patients need more time. And it is not always the loudest patient. It may be the very ill patient whose blood pressure is dropping and a good nurse needs to attend to them.”

 The name of the game is not patient satisfaction - it’s patient safety.

So, surveys asking patients if the nurse came when they were called are completely inappropriate. The nurse must be given the clinical respect to make decisions about which patient needs attending to urgently and which patient can wait. What matters is did the patient get better? Did that nurse monitor and save lives of the very ill first? Even if some patients had to wait for ice chips. 

Nurse Jonathon - a nurse with over a decade of experience in the emergency room, critical care and in management - explains that numerous issues contribute to burnout in nurses.

“There are often too few nurses per patient and that is not safe,” says Nurse Jonathon. He points out that in an emergency room there could be a number of patients that should be admitted to the ICU but are waiting for a bed. These patients require constant care but there may be six to 9 other patients, or more, that the nurse needs to watch over and care for.

‘We are the ones who monitor patients,” says Nurse Jonathan, “No one else but your nurse monitors you 24/7. Everything from heart rates to breathing to blood pressure. We constantly assess patients.

“Most nurses have a passion for excellence and we want to get everything right. If something happens to our patient, we can’t stop. We must move on and take care of the next patient. We can’t stop for a second. These are peoples’ lives.

“Hospitals don't help staff to cope with these feelings. A debriefing would help. To understand what happened.”

Nurse Smith explains, “As the patient goes through their journey in hospital, it’s the goal of the nurse to help them advance every shift - to get home or at least get better. At the change of shift, it’s like a relay race - you pass the baton to the next nurse who continues the journey.”

Handing off your patients and doing so safely is one thing. But what if you are handing over too many patients for the next nurse to handle? Worry. Because all good sentinels watch and keep those they stand guard over safe. 

Many surveys demand nurses do a job that has no resemblance to the job they were trained to do. Nurses feel the pressure to do certain things to get good scores on these surveys. Ultimately though, nurses want to do their real job. The one they were trained to do. They want to keep watch over patients to keep them safe, to intervene when they need to and to have enough time to do this job well. They were trained as no one else is to do their job.

Letting nurses do their job, having enough nurses to do the work safely and having an opportunity to debrief from stress would go a long way to reducing burnout. Oh, and holding the Splenda comments.

Note: The real names of the nurses were not used. Both practice in the United States.

Part 1: Physician Burn Out and Suicide– The Road they Travel.

by Mary Fernando

When the fall meets winter, before the snow is thick enough to obscure the road, the black tarmac can beguile you into driving on it. For those of us who have watched as winter makes it’s entrance, we know that the most dangerous driving is on those clear roads, topped with black ice, that can send your car careening off course.

Research shows us that one out of every two doctors are burnt-out and that doctors have the highest rate of suicide of any profession. Beware of suggestions that the problem will go away when doctors develop more resilience, take personal time or do yoga: these are just putting a coating of black ice on the problem- it looks safe but can send us careening dangerously off course.

To show you the road on which one doctor travels, let me introduce you to Dr. Johns, a Canadian family physician. Before we look at the road he is now traveling, let’s take a peek at the road he took to get to where he is. In his late teens and twenties, he worked hard, often around a hundred hours per week, with his nose in a book and caring for patients. Car accidents, severed arms, the agony of multiple illnesses coupled with old age, cancer in children – all the most devastating human conditions, sent him to study more, work harder, learn what he needed to to care for these patients. Many say medicine is a calling but it is built on a foundation of tenacity to help patients, coupled with the grit and determination to do so. Dr. Johns accumulated debt while others were earning, spent his nights by bedsides of the ailing while others were out having a drink with friends and eventually became a doctor. Resilience? He had that in spades.

Let’s zoom forward to the road Dr. Johns walks on today. Fifteen years after his training, he now has well over a thousand patients in his care.

“I carry these patients with me. The ones that are suffering, worry me. We are the ultimate patient advocate. We are responsible for their care, their well-being and ultimately their lives. Their care is my responsibility.”

Is he burnt out?

“I see it as a cumulative moral injury that I carry.”

Moral injury? Let’s break that down by looking at some of his patients, like the ones with knee or back injuries. The first problem is getting the tests needed for diagnosis - sometimes with wait times of one to two years. When the tests are finished and surgery is needed, add another year or two of waiting, at least. During that time, Dr. Johns explains, his patients are less mobile, maybe unable to work or adequately care for their children or aging parents. They are plagued with chronic pain, with each step eventually bringing agony. Dr. Johns works longer hours seeing these patients and calling hospitals and surgeons to try to get them better care.

“I work harder than ever before but I have so much more guilt about the patients I can’t help. It is enforced mediocracy.”

So what can Dr. Johns do? He worries about treating the pain with painkillers and risking drug dependence. He worries about their financial precariousness and their loss of independence and dignity. He worries about the patients who have multiple illnesses and are increasingly isolated form their community by their lack of mobility. He worries about the development, often inevitable, of depression secondary to chronic pain and the loss of the ability to work and care for those who need them, because mental healthcare is simply another wait of years.

Many of these factors Dr. Johns cannot change, because “the decisions about the availability of diagnostic tests, access to surgery or mental health services are decided by administrators who manage the system but are not accountable: they never sit with the patient and hear their stories. They never feel responsible for their care.”

In Canada, these administrators decide what services are available and in the United States, they decide access in different ways. But all administrators forge the care patients receive, without having any responsibility for each patient impacted.

So, moral injury? Dr. Johns argues that the care that he trained so diligently to provide is not the care his patients get and he is powerless to change that. It is, for him, a deep moral injury. This is the evisceration of doctors.

Dr. Phillips, who works as a hospitalist, points out another serious gutting of doctors: doctors in hospitals are discouraged from bringing to the attention of the media the lack of beds, equipment and access to operating room times. Many are threatened with loss of privileges or loss of their jobs if they speak to reporters directly. So, how do you fix a problem that is out of your control when you cannot speak about it?

Recently, the NRA told doctors to stay out of the gun control debate, by asking them to stay in their lane. Responses from doctors on twitter told stories of gun violence with the sassy hashtag #ThisIsOurLane. However, despite speaking out, patients with gunshot wounds are still flooding into hospitals because doctors have no control over policy, but are responsible for saving the lives impacted by policy.

This is just a small glimpse into the road that doctors travel. If we let administrators and policy makers have control over patients’ lives but never have even one patient under their care, if we muzzle doctors from speaking out or ignore them when they do speak for patients, then we have the conditions for burnout. If you coat that road with thin ice of words like ‘resilience’ and suggestions like ‘lunchtime yoga’, there is a good chance that you are creating black ice that will drive any change dangerously off course. Worse, much worse, it is patients who drive that road with their doctors and often careen off into the ditch of increased disability, pain and suffering.

Doctors suffer in a system they cannot change for the better — they burnout and they die — because when they are crushed by the moral injury caused by the weight of the thousands of patients who they cannot help.

Losing the Edge

Lately I've been reading a lot of mysteries by James W. Hall. His series protagonist lives in the Florida Keys and enjoys, among other things, tying fishing lures. In Hall's fifth novel, Buzz Cut, the hobby has become sort of a business venture, and the lures don't seem to work anymore. They won't catch fish. Here's an excerpt:

His flies had lost their allure. He had always tied them for himself. Sold his extras. The compulsion behind each one was the simple desire to snag his own bonefish. To concoct his own bait so appetizing it would guarantee the thudding strikes and wrenching excitement he had relied on for more than thirty years. But he'd lost something, tying them exclusively for others. His fingers committing the same act, tweezers and scissors, Mylar and feathers, hackle and ribbing. Everything exactly the same. Identical to the eye. But now they were duds. Failures on some level so subtle, so subatomic that only the fish could see it.

That got me to thinking. Can that kind of unconscious burnout happen in other creative endeavors as well? Can it happen in writing?

Sure it can.

The Over the Hill Gang


How often do you find that certain authors whose work you've been reading for years suddenly don't seem to write as well or as compellingly as they used to? I won't call any names here, but I can think of at least half a dozen bigtime novelists whose latest work doesn't seem to be able to deliver the same punch that their earlier (and sometimes earliest) books did. The style and voice are the same, but the stories themselves just aren't as entertaining. They don't pull you in and hold you the way they once did.

If that's true--and I believe it is--then it's certainly a contradiction. One would expect a craftsman of any kind to get better the longer he or she practices that craft. So the question is, what could cause a writer to lose some of his or her appeal, and effectiveness?

Part of it could be the fact that doing something--anything--day after day, year after year, can grow boring for the person doing it. The old saying "familiarity breeds contempt" was probably meant to apply to relationships, but it could also apply to fields of endeavor. The quality of the product can be directly proportional to the level of enthusiasm of its creator. I recall reading someplace that the cars that go through the assembly line on Monday usually don't turn out as well as those assembled later in the week.

Or maybe, as in the case of the fly-tying fisherman, the artisan starts doing things more for the end user than for himself or herself. I realize we should all try to "write with the reader in mind," but we must also write in a way that pleases ourselves. I've said that even if I knew I would never publish another word of fiction, I would continue to write it anyway because spinning these tales is so much fun to do. For me it's therapy as well as recreation. The process itself is enjoyable and satisfying and relaxing.

But what if you're writing under a tough deadline? I once heard a well-known novelist tell a group of beginning writers that "your first novel will probably be the only one that's really fun to write--and might be the only one that you're ever completely satisfied with." The reasoning is that if that first novel is successful, your agent and publisher will probably want another book from you every year. Maybe more. And when that happens, what started out as play can quickly become work. All of a sudden you have responsibilities, your audience and your publisher have expectations, your hobby has become gainful employment, and your merry romp in the fictional clover is now a real job.


(By the way, when I say "first novel," I'm referring to published work. All of us have stories and novels that never saw the light of day, and for good reason. I suspect that many famous authors have a few unpublished books--truly first novels--stuffed underneath their beds or in the back of their closets.)

The Top of the Hill Gang

I can think of several ways that writers might prevent or recover from "losing their edge." Intentionally or not, some authors seem to have extended their popularity--and probably their careers--by writing in different genres (Larry McMurtry, Nora Roberts, Evan Hunter), writing both series and standalone novels (Harlan Coben, Elmore Leonard, Robert Crais), creating more than one series (James Lee Burke, Robert B. Parker, John Sandford), writing both novels and shorts stories (Lawrence Block, Stephen King, Jeffery Deaver), and collaborating with other writers (James Patterson, Tom Clancy, Janet Evanovich). It might also be said that authors like Thomas Harris and John Irving stay at the top of their game by going more than a year--sometimes several years--between novels. However effective these kinds of things are, I suspect that they are done more for personal reasons than commercial reasons. Maybe they ward off the boredom we talked about earlier.

In closing, let me mention that some authors seem to have kept their ability to thrill and entertain throughout their careers. Lee Child, Carl Hiaasen, Greg Iles, and Dennis Lehane come to mind, and I think some of Michael Crichton's later books were as strong as some of his early ones.
As for Stephen King, his novel The Stand remains one of my favorites, but his 11/22/63, published 33 years and thirty novels later, was just as good, and possibly better. That's comforting news to me, in more ways than one: King and I are the same age--well, he's two months older--so maybe if he can still think clearly, so can I.

Hey, I'll take inspiration wherever I can get it.