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.”
Second victim syndrome
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.”
While second victims usually require immediate emotional support, healthcare organizations largely don’t help employees through “the deeply personal, social, spiritual, and professional crisis,” the ISMP reported. “Although the first victims of medical errors are the patients who are harmed and their families, the second victims are the caregivers and staff who sustain complex psychological harm when they have been involved in errors that harm patients while caring for them. . . . But, too often, we remain silent and abandon the second victims of errors—our wounded healers—in their time of greatest need.”
That’s what Seattle Children’s administrators did to Hiatt. Instead of easing her out of second victim syndrome, they arguably threw her under the bus, appearing to blame her for the fatality. Paradoxically, then- hospital CEO Tom Hansen wrote an internal memo in which he said, “Of course, we will also support our staff members during this difficult time.” Hansen went on to write, “It is important to me that all staff and faculty feel it is safe to report when mistakes are made, and that everyone is confident that we recognize the difference between an honest mistake and reckless behavior.”
In direct contradiction, Seattle Children’s fired the staff member who seemed to need a great deal of support, damaging the career of a nurse who apparently thought it was safe to report that she made an honest mistake. After Hiatt’s case hit the news, a Washington State Nurses Association survey found that half of nurse respondents believed “their mistakes are held against them.” Even more worrisome, a third said they would hesitate to report an error or patient safety concern because they were “afraid of retaliation or being disciplined” and more than a quarter would hesitate to report those concerns because they were afraid they would lose their job.
Following the incident, the hospital changed policies, including instating a rule that only pharmacists and anesthesiologists could prepare doses of calcium chloride in nonemergencies. Also of note: In 2003 and 2009, Seattle Children’s staff allegedly had made two other fatal medication errors. After the 2009 death, Seattle Children’s medical director Dr. David Fisher said in a statement, “This was not the fault of any one individual.” It appears the hospital’s problem was much larger than the single nurse it pushed forward as the scapegoat when her error occurred in 2010.
Instead of firing a nurse who reportedly had made a single notable error in a quarter-century of service, the hospital could have tapped her to help devise a system that would have caught her error in time, thereby both improving the hospital and allowing Hiatt to contribute to her own healing process. Firing her helped no one. As University of Missouri Health Care patient safety director Sus
an Scott told msnbc.com, “If my mom got an insulin overdose from a nurse in a hospital, I would want that nurse to give her that insulin tomorrow.” That nurse would probably be the least likely to make that mistake again.
What hospitals aren’t doing
Hospitals aren’t adequately addressing nurses’ work-related health issues, but are they legally liable for causing them? In 2013, Ohio nurse Beth Jasper, a 38-year-old mother of two, died in a car accident while driving home from a twelve-hour shift. Her widower filed a wrongful death lawsuit against Jewish Hospital, claiming that administrators knew that Jasper was “worked to death.” Jim Jasper alleged that the understaffed hospital regularly forced nurses to take extra shifts and go without breaks. The case was dismissed because the judge determined that the hospital could not be responsible for a death that occurred after work hours.
Certainly, hospitals aren’t doing enough to prevent these problems. In Massachusetts, when a newborn died minutes after an emergency caesarean section, a veteran nurse told The Boston Globe that she “came very close to losing it psychologically” because of grief, but hospital administrators did not want her to see an independent psychologist in case he could be called to testify in a malpractice lawsuit. (The Globe article gave no indication that the death was attributable to human error.) “The hospital is more worried about lawsuits than they are about the effects the incident has on the staff,” the nurse told the Globe. How can nurses best address the health of their patients when they are expected to shove their own health issues under the rug?
Lara’s debriefing room idea is an effective low-cost solution. As a hospice nurse told me, at times nurses need to go somewhere to “have a little cry.” Other small concessions that hospitals could provide are opportunities for nurses to eat, take a break or a short walk, and check in with loved ones outside of work. Nurses also could use easy access to support groups and trained counselors. Some nurses said that even when their hospitals hold debriefing sessions, administrators refuse to offer coverage for nurses who want to attend. They neglect staff members who truly might need these sessions to understand, reflect on, and share feelings about what they have seen.
So many of these problems could be solved by hiring more nurses, which would reduce patient load and nurse mistakes, give nurses more time to do their jobs well, decrease stress, and provide coverage. An analysis by health economists found that, by a conservative estimate, hospitals can recoup more than 99 percent of an average nurse’s salary (70 percent of salary plus benefits) from reduced medical costs and improved productivity alone. It should be stated that staffing for hospitals is not a zero-sum game: “Registered nurses are a revenue center rather than a cost center,” said ANA senior policy fellow Peter McMenamin. A strong nursing staff can generate revenue for hospitals not only in improved productivity but also in retaining top physicians.
In the time it takes for hospitals to make this happen, however, nurses themselves could do a better job of focusing on self-care. Nurses sacrifice their own health to attend to ours. They are so accustomed to working nonstop to take care of other people that they often forget to nurture themselves. It isn’t uncommon for nurses to donate blood or bone marrow to specific patients. “People will just about kill themselves to give care to others without taking care of themselves,” Canadian health services officer Norma Wood has said. “It can get into a martyr situation where patients matter more than we do.” Researchers recommend that nurses take self-care measures, including changing work assignments or shifts, taking time off or reducing overtime hours, getting involved in a project of interest, and focusing on work-life balance.
It can also be helpful for nurses to talk about their feelings. “I believe most nurses don’t seek counseling or support outside of friends and families. We need to do a better job of permitting ourselves to seek support,” a longtime Michigan nursing school professor said.
Some hospitals do have programs, counselors, chaplains, on-call coping liaisons, or debriefing sessions. Barnes-Jewish Hospital in St. Louis recently launched a successful program to help staff cope with these issues. The hospital offers a compassion fatigue course, stress-reduction workshops, support groups, meditation, and discussions about difficult cases. Three-quarters of the staff members who have taken the formal class have been nurses, said Patricia Potter, director of research for patient-care services at Barnes-Jewish. Particularly in the medical ICU, where the head nurse has championed the program, nurses have seen a noticeable difference in their relationships with each other and their ability to communicate effectively as a team. Program graduates “tell me that they are recognizing more when they feel stress, and that the skills we’ve taught them have been very helpful to reduce the perception of that stress,” Potter said.
Many nurses have shared that, with experience, they have learned to view patients medically rather than emotionally, and to separate their work experiences from the rest of their lives. They learn how they react to various situations and they develop coping mechanisms to prepare themselves accordingly. University of Akron professors found that registered nurses younger than 30 are more likely to burn out, experience “significantly higher rates of the most intense levels of frustration, anger, and irritation” than older nurses, and are less likely to find ways to cope with these emotions. As a result, the researchers suggested that experienced nurses could serve as emotional mentors to younger nurses to help them navigate the profession’s demands.
A young Maryland medical/surgical nurse said that a nursing school mentor was instrumental in preparing her for the emotional side of nursing. “She let me know it’s all right to let things affect you and that doesn’t make you any less of a nurse. She taught me how to handle bad days. She was very open with me about her own experiences starting out and how they shaped her, which I draw on a lot now,” the nurse said. “Mostly, she demonstrated how to stay calm in intense and emotionally charged situations, and let me know that nursing is not always as ideal as people make it out to be and everyone feels that at some point or another.”
Why it’s worth investing in nurses’ mental health
“The greatest common risk to patients is the understaffing of nurses,” Minnesota ER doctor Gary Brandeland, who has written about medical mistakes, told The New York Times. “A nurse may make a critical mistake, and a patient might die. She has to live with the error, but the real culprit, the root cause often is that she or he was understaffed and overworked and a mistake was made. The hospital doesn’t pay for it on a personal level. They just get a new nurse.”
In times of budget cuts and healthcare changes, hospitals may be reluctant to alleviate understaffing and/or to provide resources to help nurses deal with burnout, compassion fatigue, PTSD, second victim syndrome, and other assaults on their mental health. But administrators must openly acknowledge that their nurses’ health is worth the investment. Burnout and compassion fatigue have been linked to decreased productivity, more sick days, and increased turnover among nurses, which are correlated with higher patient mortality rates, lower patient satisfaction, and compromised patient care. Nurses suffering from these issues are more prone to make mistakes. The ISMP has reported that fatigue alone can cause reduced accuracy, inability to deal with the unexpected, slower recall, and reduced hand-eye coordination, all of which could greatly impact patient care.
Researchers have also found that nurse burnout is linked to hospital-acquired infections, which kill approximately 100,000 patients a year. The researchers theorized that burnt-out nurses might be less vigilant about washing hands (and reminding visitors and other clinicians to do so) and other infection control procedures. They calculated that in hospitals that reduced nurse burnout by 30 percent, the number of urinary and surgical site infections dropped by 6,239, which saved $68 million a year. Washing hands matters: When the Michigan Health and Hospital Association implemented a checklist to remind staff to clean their hands and keep the field sterile, within th
ree months the median rate of infection in central line catheters had fallen to zero.
It would also behoove administrators to decrease staff turnover, and not only because hospitals must expend resources to train and hire new employees. Inadequate nursing staffing has been called a national emergency. When nurses resign from a hospital, they create a cycle in which the remaining nurses are left short-staffed and more stressed. A Drexel University study found that when nurse turnover rates increase, so do the odds of nurse injury and patients’ risk for pulmonary embolism/deep vein thrombosis.
Meanwhile, it is up to nurses to bolster each other, and to appreciate when hospitals get the system right. Nurses at a midwestern NICU rely on a particularly effective chaplain and each other’s strong support. After a tragedy, the team discusses the case to talk about the plan of care and what could have been done differently. They often follow up with parents whose children died in the hospital.
“One of the worst parts of coping with traumas and tragedies is when the family is present,” said a pediatric ICU nurse in New York. Parents might watch CPR breaking their child’s ribs, alarming bedside procedures, the monitor numbers dropping, or their children in an altered mental state. “Believe me, it’s shocking what we do to these children; the brutality of a [cardiac] arrest can be very intense. We are trained to be the eye in the storm, to stay calm. But in the periphery of the storm, that’s where some of the worst damage can be done; parents suffer PTSD, they have nightmares. So do we, though.”
Recently, as the New York nurse gave compressions to a baby in cardiac arrest, the child’s parents were on their knees sobbing and praying in the corner of the room. After the team had lost the pulse twice more, a doctor escorted the parents out of the room so they would not be present for emergency surgery. “The surgeon got there and the baby’s chest was opened at the bedside so he could do manual heart massage and his fellow could rewire the pacer wires. The child ended up being fine. That is the miracle of medicine,” the nurse said. “This baby left three weeks later in his parents’ arms with a Superman cape tied around his little neck. No residual neurological damage, no cracked ribs. Nothing. That’s what you have to remind yourself of the next time a kid codes and things don’t go so well.”
The Nurses: A Year of Secrets, Drama, and Miracles with the Heroes of the Hospital Page 21