When it hurts to care-Nurses’ Journey from burnout to resilience

From personal protective equipment (PPE) to personal protective factors (PPF)

Nurses often are said to have the strangest of personalities.  Covered in unrecognizable bodily fluids, faced with a life-or-death procedure, yelled at by inter- departmental staff members, they last 8–12hour days without a break, holding a full bladder, dealing with a patient that abuses the call light, faced with distraught family members, and they can still be on their top game.    But what happens, when the passion begins to fade?  Or a mountain of self-doubt creeps in? 

Burnout- The term has always been constantly used while describing nurses.  But what happens when nurses are required to constantly jump from one crisis to another, without resolving the emotional stresses that follow a traumatic event?

Let’s talk about Nurse A, who wishes to remain anonymous; the symptoms of burnout seemed to appear gradually. It started with fading empathy and rising cynicism. On the outside, everything seemed great: she was a successful nurse in a moderately staffed behavioral health facility. Extremely passionate in her job, resilient, ‘I can do anything, handle any patient, highest acuity, I can be the heart, the mind and the muscle if need be, all at the same time” kind of a nurse, ended up  dreading waking up to go to work each morning.  Increasing violence, the constant fights over masks and isolation precautions, the frustration, anger and resulting violence has turned this gunslinging tomboy into an emotional wreck. 

“My colleagues and I were burned out just not too long ago.  I don’t think I can deal with another outbreak with the new variants.  We saw more deaths this year than an average man would ever see in his lifetime.  I don’t want more of this” says Matt, an ICU nurse from New York.

“I saw the outpatient clinic psychiatrist get stabbed in his stomach for gently refusing to prescribe narcotics.  I saw the blood, the intestines rolling out, the pain and the shock in his eyes….” says Nurse C, as she describes the incident that led to her leaving the profession altogether.  “I still have nightmares of the event, chronic insomnia and am quick to startle at the tiniest sounds.  Added to the physical symptoms are the negative thoughts, “Could I have done anything to stop that from happening?  Could I have been quick enough to raise alarm, to call for help, to start a code?  Am I reliable enough?”  Soon the negative thoughts translated into somatic symptoms, ‘Headaches, gastric disturbances and lethargy were my constant companions now.  I never realized how and when I began calling out sick more often” she ruminates

“COVID-19 is just the tip of the iceberg.   There is little being done about the larger pandemic within this one-The mental health crisis, with the rising mortality rates, the opioid addictions are soaring, the suicide rates are skyrocketing…. more children and teens are getting diagnosed with depression and severe anxiety; while the public is arguing over the mask mandates and the vaccines, we are dying, both physically and mentally” She sadly continues.  

These were just a few of the examples.  However, no nursing discipline is immune to burnout or even PTSD.  Sadly, the heavy costs of burnout aren’t limited to the organization alone, but find their way into nurses’ personal lives, resulting in increased incidences of depression, substance abuse, and even suicidal ideations. 

How do you know if you are experiencing burnout?

• You wake up feeling physically and psychologically exhausted
• Dread going to work
• Negative thoughts, frequently questioning yourself and your skills, self-blame.
• Feeling helpless, hopeless or powerless
• Increased irritability, angry and a feeling of detachment
• Detachment from friends and family and hobbies that previously held your interest
• Ruminating about the events at work and how things could have worked differently
• A decreased sense of personal and professional accomplishment
• Physical symptoms, including sleep and appetite disturbances, headaches and body aches, nausea and dizziness
• Hyper vigilance and emotional avoidance
• Reduced feelings of sympathy or empathy
• Behavioral disturbances like insomnia, overeating, skipping meals, addictive behavior, self-medicating, isolating oneself, depression, anxiety and even suicidal ideations.

Factors leading to burnout

A survey conducted among a group of nursing colleagues across the United States revealed the most probable factors that led to their feelings of burnout:

• Poor staffing ratios
• Being over extended/mandatory overtime
• An overwhelming set of responsibilities that forces nurses to bounce from traumatic experiences to other care activities with no time to recover
• Perceived lack of organizational support
• Negative perceptions of patient care
• The rise of violence and point-of-care safety threats in health care settings
• Feelings of helplessness and hopelessness in the face of pandemic
• Ethical dilemmas over mandatory mask and vaccine requirements
• Fear of future trauma

COVID-19 has changed the way we look at healthcare, as with everything else.  “Not sure how much longer I can continue working in Covidland.   The skills that worked fine just a few months ago seem insufficient now with increased turnover and mandatory floating to unfamiliar work zones. It seems like a never ending tunnel with no silver lining in sight” says a nurse working at a remote ER.

If you have been reading this, I know you relate to this at some level.  Know that you are not alone.  The entire nursing fraternity stands alongside you. If you have been experiencing any of these signs of burnout, know that it is time to tune in to your personal protective factors.  PPE alone will not protect you; you need the PPF too.

What are personal protective factors?

Personal protective factors are individual or environmental charectistics, conditions or behaviors that reduce the effects of stressful life events.  In short, they are coping skills that we can use as our defense against stress.  Interestingly, as I browsed through the Code of Ethics for Nurses recently, I found that it said that the nurse owes the same duties to self as to others, including the responsibility to promote health and safety, preserve wholeness of character and integrity, maintain competence, and continue personal and professional growth. 

What does self-care look like when you are a nurse?  

Self-care is all about setting priorities.  It is choosing to make a positive choice.  A choice to heal.  A choice to reach out. 

• You may not have the energy to go for a jog; take a relaxing walk instead.
• You may not have a trusted friend to vent to; start a journal instead
• Make an intentional choice to adopt healthy behaviors like a balanced  diet, prioritize sleep and exercise
• Most of all, know that not all your feelings are facts.  Your stress might be the cause of your heightened emotions.

Instead of ruminating over your burnout and stress, ask yourself how you can improve your current situation?

• Will speaking up and voicing your opinions improve your current situation at work?
• Whom can I reach out to for support and understanding?

Tip: Get social- How often can you trust others to provide support for you? • Are you close to your family or have a best friend/buddy? • Do you have a strong and positive social support network beyond your family? Who/what do you consult before making decisions?

• How can I develop positive thinking? 

Tip 1:  “No matter how the patient’s outcome, I know I did my part to bring about an improvement in that person’s life. It’s not up to me to understand the “whys” to circumstances, but to know I did something right.”

Tip 2: Instead of saying, “I might get the COVID-19 virus and get really sick” change it to “I will stay healthy by taking good self-care and practicing good infection control practices”.

Is this my cue to make an ‘exit’ from my current job? 

One of the best things about being a nurse is that there’s a variety of nursing roles within the profession, and it’s important that every nurse knows that if they feel like they can’t do it anymore, there are other options and other roles that might be a better fit for them at that point in their lives. Never believe that  you’re stuck in your career and there are no options available. Because when you’re in the role of taking care of other people, if you’re not doing well, it is going to reflect on how you take care of your patients.  So, ask yourself this: Where should I go looking for my next job? Who can benefit from my experiences or what I love to do? How can I use my talents and skills to help someone else?

Tip 1:  How flexible are you when it comes to change?  What does your dream job look like? Are you adaptable to change? • How do you respond when someone asks you to do something extra or change your plans? • Are you able to adapt to changes in your expectations, even when they’re important to you?

Tip 2:  Quitting is not a sign of weakness.  Making the right decision to quit at the right time is self-preservation.  You owe it to yourself, to your mental health.

What are some of the creative ways to relieve stress at work?

  Tip:  Use your moments of hand hygiene to practice deep breathing; to recite your favorite verse or hum into your favorite tune. 

Tip:  Apps like headspace can be life savers during a routine lunch break to unwind during a stressful shift.

What are some of the coping skills you can try today?

Tips:  Try brain dumping:   Set a timer and write about the events that stress you the most.  Stop writing when the timer goes off and tear off what you have written.

• Put aside cell phone and other devices between 6 and 9 PM each evening.  Be it mindfulness, yoga or music, experiment to find what nourishes you.

On a concluding note, when you find yourself feeling overextended or overwhelmed; pause, take a step back and grab a drink.   As you sip, use the time to breathe slowly and let your body relax.   Then start prioritizing what needs to be done, is there a way to delegate things, or talk to someone who can help. On your days off, pick a hobby to help you relax. Keep your work phone on silent or flight mode or turn it off altogether.  Ease on picking extra shifts or volunteering for overtime unless absolutely necessary.  Go visit places, spend some quality time with your family or just take the time to chill and relax.