Bailouts, Bankruptcies, and Unemployment

In 2008, our nation faced an economic challenge. Although not at the level of the Great Depression, it was serious enough that the financial system teetered on the brink of disaster. The banking and mortgage industries had engaged in making loans to citizens who believed home ownership was the gold standard for success (Office of the Press Secretary, 2002). The problem was a very large number of these loans were made to individuals who would subsequently face adjustable interest rates that would balloon to two or three times the original payment (referred to as adjustable-rate mortgages [ARMs]). The housing market was in a boom, but when these ARMs came due, many families were not able to make their payments and defaulted on their loans. When a tipping point was reached in the market, banks, some of which were thought to be the strongest in the country, began to clamor for a federal infusion of funds to stay solvent (Levitin & Wachter, 2011). Not only did banks want bailouts, but the automotive industry also sought relief from the federal government. This led to one of the largest bailouts in our nation’s history, with Congress passing the Troubled Asset Relief Program (TARP) and authorizing up to $700 billion to stop the financial crisis, although the full $700 billion was never completely tapped (The New York Times, 2010).

Health Care Reform

Simultaneously, health care reform once again took center stage. Campaigning on a platform that basic health care is a right not a privilege, President Obama moved forward with this reform, which was met with pushback from Congress and also began what is now a quagmire of bills, state lawsuits, and monikers for health care rationing from those who did not want health care for all. All industrialized nations, except for the United States, have health care for all citizens in some form or another.

Meanwhile, stocks crashed and middle class Americans saw retirement accounts, accumulated after decades of hard work, vanish or become severely diminished. People stopped buying goods and services, leading to more layoffs in manufacturing and other industries. This ripple effect caused unemployment rates to rise to new levels, at one time reaching 10% (Bureau of Labor Statistics, 2012). As the unemployment rate climbed, the economy continued to face monumental challenges in recovery. Faced with chronic unemployment, many filed for bankruptcy, further exacerbating the financial crisis, moving it from industry to a more personal issue and generating more uncertainty. In 2010, bankruptcies were at a high of 1,593,081 business and nonbusiness filings (American Bankruptcy Institute, 2011).

Although the health care industry remains one of the strongest in our country, it too has been met with severe challenges in decreased reimbursements and uncertainty about how health care reform will affect all aspects of daily operations and budgets. It is as if the industry is frozen in time, waiting to see what will happen next before it is willing to make significant moves in one direction or another. As other countries around the world enter what has been called austerity measures, so too has the United States and the health care industry, without naming it as such.

Nurse Employment During the Last Four Years

Once thought of as a recession-proof profession, nursing has also experienced a roller coaster ride in employment. As more partners and spouses lost their jobs, scores of nurses, who were working either part-time or not at all, reentered the workforce, pushing aside those who were new to the profession. As recently as 2011, Peter Buerhaus and colleagues published a paper in Health Affairs indicating that the nursing shortage may be over for now (Auerbach et al., 2011). However, for decades there has been a push for more nurses from a wide range of key stakeholders, which includes but is not limited to the following:

Central to the common message is that a sufficient number of nurses, the linchpin of the industry, must be ready to meet the impending demand when baby boomers (over 77 million strong) will reach the age at which they will consume the greatest amount of health care goods and services in their lifetime.

There is a significant movement for a more humane approach to managing and leading people in nursing through these difficult times. One such way is for Healthy Work Environment (HWE) standards to be put in place in health care organizations (American Association of Critical Care Nurses [AACN], 2005). In addition, since the Institute of Medicine’s Future of Nursing report was published (Institute of Medicine [IOM], 2010), 48 Action Coalitions have been launched to improve the state of nursing and the health care industry by utilizing nurses and their skills more wisely (Robert Wood Johnson Foundation [RWJF], 2011).

The Link to Stress and Time Management

It is clear that uncertainty is the status quo in health care. Managers trying to lead staff nurses to deliver quality care when constantly being pressured to “do more with less” can cause great professional and personal stress on even the strongest leader. Staff nurses are also facing the daily consequences of doing more with less at a time when cost of living raises have all but disappeared, support staff have been cut, jobs are fewer, and even staffing levels fluctuate widely. These issues are facing not only the industry but also the largest group of providers in the country—registered nurses. At the same time, more people are becoming uninsured, which causes them to wait to seek care until they are far sicker than if they had been able to get proper care. Emergency departments are becoming destinations for these uninsured, as they use this far more expensive portal of entry, given they have no other way to access care. What staff nurses see every day are what has been characterized as the “sicker quicker” syndrome, meaning that people who might typically have met the criteria for a critical care bed in the past, are now on a general floor where the nurse-to-patient ratio is far greater than a critical care ratio. This day-to-day grind makes it extremely difficult to feel good about nursing or encourage others to become nurses, and may even cause roots of hostility to form toward the system that seems to constantly be letting nurses down.

Although challenging, these stressors are transient and cyclical. With sound tools prepared to use, nurses and their work environment can stay healthy when these issues recycle.

Stress As We Live It

With all the uncertainty in the nation and world today, it comes as no surprise that stress levels are high. A recent report found that 39% of Americans reported that their stress levels had increased over the past year, whereas only 17% reported decreasing levels (American Psychological Association [APA], 2012). Because stress can be a negative emotional experience that has measurable biological manifestations, stress management techniques must target both aspects.

The most frequency cited sources of stress for Americans today are money, the economy, and work (APA, 2012). Nursing’s work is often particularly stressful. In addition to long hours, nurses have the added emotional burden of dealing with human illness and suffering, life-and-death situations, making critical judgments, and balancing work and family (McNeely, 2005). People may be aware when they are stressed but are often unable to determine what coping strategies will help. Only 29% of adults reported that they do an “excellent” or “very good” job at managing stress (APA, 2012). Fortunately, it is possible to learn good stress management techniques.

Personal Management of Stress

One of the most important parts of stress management is self-care. Though everyone needs to spend time on themselves, those in caring professions such as nursing often put the needs of others ahead of their own (Fischer & Keenan, 2010). However, it is difficult to care for patients or families if the nurse is not caring for himself/herself. What constitutes self-care is unique to each person, and each will have to find what works best for him/her. However, the following tips are a good starting point (Fischer & Keenan, 2010):

Another important step in managing stress in daily life is creating healthy boundaries. A boundary in its most basic sense is a limit, and it can be physical, emotional, or mental (Katherine, 2000). One of the causes of too much stress is that people do not set or enforce their own personal boundaries. Rather than being able to set a limit on how they spend their time, they feel the need to please other people, often at the expense of themselves. In order to change this, nurses need to be aware of what their boundaries are and how to enforce them with other people. Boundaries on your time allow you to know when to alter commitments, say no when favors are asked by others, and attend to your own needs (Katherine, 2000). Often, people do not give themselves permission to say no and find that all their personal time is spent on other people. This is not to say that boundaries cannot be flexible at times. In fact, it is also unhealthy to have too rigid of boundaries and to never make an exception. However, in general, it is important to maintain consistency with personal boundaries and to not overaccommodate others at the expense of personal mental and physical health (Gionta, 2009).

Because stress is not only emotional, but also physical, it is important to learn to relax the body. There are many relaxation techniques that can be effective in calming the body, such as imagining a peaceful scene or event or breathing deeply (Mind Tools, 2010). By calming the body’s physiological response to stress, a person will be able to think more clearly about what needs to be accomplished. One example of a relaxation exercise is known as the relaxation response, and it includes the following steps: (1) sit quietly and comfortably; (2) close your eyes; (3) relax all your muscles, beginning with your feet and moving up the body; and (4) breathe deeply through your nose, concentrating on the breathing. It is recommended that a person continue this exercise for 10 to 20 minutes, once or twice a day (Benson & Klipper, 1976). However, this can still be a beneficial exercise in shorter time periods.

If the person is still feeling stressed but unsure about what is causing it, keeping a stress journal can help the person to focus. In the journal, record times when you felt stressed, the causes, the levels of stress, and your reaction to it. Once collected, this information can show how you best manage stress and highlight areas where you need to improve (Mind Tools, 2010).

Moral Distress

Nurses work within health care systems that are dynamic and complex, with a myriad of regulations, technical advances, and uncertainty. The unpredictable nature of the work, along with its complexity, can be contrasted with the essence of caring, where nurses establish patient/family relationships by synergistically framing meaning and knowledge (Fairchild, 2010). Confronting and resolving the conflicts experienced when caring for patients is intimately tied to the nurse-patient meaningful relationship. Unresolved ethical issues add emotional fracture to the already stressful work within complex systems. This may lead to moral distress, burnout, and intent to leave either the current position or the profession (Redman & Fry, 2000).

Moral distress occurs when clinicians know what ethical action should be taken, but they are prevented from doing so by either internal or external obstacles (Rushton, 2006). Internal obstacles include such personal characteristics as fear or lack of resolve, whereas external ones are more typically a lack of resources or a hierarchy preventing the nurse from taking the desired action (McCarthy & Deady, 2011). The American Association of Critical Care Nurses (AACN) has taken the position that moral distress is very serious problem in nursing today. It is a significant cause of emotional suffering and is a contributing cause to nurses leaving the workplace and the profession (AACN, 2008). In response to this important issue, the AACN has released a paper describing how nurses can deal with moral distress.

The AACN’s (2004) The 4 A’s to Rise Above Moral Distress details the response to moral distress as a change process, consisting of a four-part cycle: ask, affirm, assess, and act. In the first stage (ask), nurses must become aware of their moral distress. The nurse is to ask himself/herself if what he/she is feeling is moral distress. Only by first becoming aware of internal distress, can the nurse then begin to address it.

The next step is to affirm the distress by validating feelings and making a commitment to take care of oneself. At this time, commitment to addressing moral distress as part of professional responsibility to oneself is suggested.

Assessing involves identifying the sources of the distress. Take time to understand when and under what circumstances this moral distress is occurring. For instance, it might be related to a particular patient or situation, or it might be a more broad issue with a unit practice. Next assess the severity by rating your distress on a scale of 0 (not distressed) to 5 (very distressed). Use this same scale to assess your readiness to act by determining how important the issue is to you and how strongly you feel about making a change. If you are having difficulty determining if you want to address the issue, it may be helpful to list the benefits and risks of taking a particular action.

The final stage of the cycle involves acting. Here the strategy is to address internal and external barriers. When preparing to act, first develop a plan and find sources of support. These support systems can be co-workers, supervisors, or outside resources, such the ANA Code of Ethics or a literature search for relevant information. Finally the plan is put into action. This will start the cycle again, so it is important to monitor the change to see that it has succeeded in eliminating or reducing moral distress.