Introduction
Reaching Out . . . Without Being Pulled Down
Objectives of the Introduction
These mountains that you are carrying, you were only supposed to climb.
—Najwa Zebian
The end of the inner-city emergency department 12-hour shift approaches. Several staff gravitate to the lounge to gather themselves and to have a cup of coffee to fuel the drive home. Karen, an emergency room (ER) staff nurse and Kevin, a physician assistant share a small table. The COVID-19 pandemic has been raging for the past several weeks. To keep her husband and two young children safe, Karen convinced them to live with the in-laws until the crisis passes. In addition to working as an ER staff nurse, Karen is attending an online program to earn her master’s in nursing degree. The pace of work during the epidemic has taken its toll on her schoolwork, on relationships, on everything. Kevin completed his physician assistant program six months ago and never imagined this work intensity. He is living temporarily in a motel near the hospital to conserve his energy and protect his family. Jack, a veteran ER resident physician, enters the lounge, plops in a chair, and stares into space. “Mrs. Alverez just died. I just got off the phone with her family. They begged to visit, but the rule is the rule. It was gut wrenching for me to say ‘no.’”
Tears stream down Karen’s face, “I am just numb, pretty much running on automatic pilot, which is how I get through the shift. I do not remember half the patients that I care for or what I do for them. In one sense I am grateful that family cannot visit and that you are making those calls, and I feel so guilty about that but I cannot imagine the added pressure of dealing with family when so many patients are so critically ill and close to death. I love taking care of patients especially in the ER but never imagined this—like being at war.” Jack and Kevin nod in agreement. Kevin questions his career choice, “I did not sign on for war!” They sit in silence staring at the table.
This book is written for those who practice medicine (physicians and physician assistants) and those who practice nursing. There is no more compelling time for physicians, physician assistants, and nurses to examine the experience of secondary stress than on the heels of the COVID-19 pandemic. This second edition of Overcoming Secondary Stress in Medical and Nursing Practice is designed to alert those who practice medicine and nursing to the sources, acuity, and chronicity of secondary stress (the pressures experienced in reaching out to others) in the clinical environment; to the context in which secondary stressors are most likely to occur; to environmental conditions that provoke secondary stress; and to ways that strengthen the inner lives and overall health of those in the healing professions. This book is also written for leaders and administrators who can initiate the changes in health care systems needed to manage stress and prevent burnout among direct care clinicians. Overcoming secondary stress is a collective effort by individual practitioners and those who create the environmental conditions of health care delivery. In the modern health care setting, the information in this book is not simply desirable; it is essential for one’s personal and professional well-being.
The demands of modern health care on those who practice medicine and nursing are cumulatively extreme and include
• unreasonable or uncivil colleagues who catalyze hostile work environments.
• self-doubt and grief that often accompanies a review of ones’ decisions on behalf of patients.
If there is an apt proverb for the articulated and unspoken demands many people make of medical and nursing professionals today, it surely must be the Yiddish one: “Sleep faster. . . . We need the pillows!”
Christina Maslach, the social psychologist and noted authority on burnout, recounts her invitation by the government of Sweden to examine the effects of stress segments of the workforce. Government leaders were concerned with what they termed crises in workplaces leading to resignations and shortages in some fields. As Maslach1 recounts,
it turned out that there’s a social insurance system for everybody who works in Sweden. If you are going out on sick leave or some sort of disability, and you leave your job, they’ll pay your salary for up to a year and a half. They put you in treatment for whatever it is you need, and after the year and a half, you go back to your original job.
What they were seeing was this sharp increase in the number of people going out on sick leave from the healthcare field and from IT. They were particularly concerned because when they looked at the diagnosis, it was severe clinical depression work-related only. They’d say, “It sounds like burnout, that it’s depression but only work-related.” As my colleagues and I, looked at the data and we saw that “Well, actually, we think maybe burnout happened upstream, before this. You now have a problem with severe clinical depression, and that’s what you’ve got to treat, but there was probably a warning sign that people weren’t paying attention to, or didn’t know about, earlier on.”
Maslach’s insights and Sweden’s concerns ring true in different ways for all health care professionals today. Professional organizations such as the American Medical Association, the American Academy of Physician Assistants, and the American Nurses’ Association are addressing the same phenomenon observed in Sweden in 2019 by developing standards and programs that will contain the effects of secondary stress on their members. The American Medical Association features continuing education modules for physicians to prevent burnout and address well-being through its Stepsforward program.2 The Accreditation Review Commission on Education for the Physician Assistant has added a criterion to their national standards addressing work stress and self-care that all physician assistant programs must address in educational programs. Standard B2.20 for physician assistant programs is, “The curriculum must include instruction about provider personal wellness including prevention of: a) impairment and b) burnout.”3 The American Nurses Association is working to ensure Healthy Work Environments for nurses focusing on reasonable staffing, nurse health and safety, and prevention of nurse abuse including incivility, bullying, and violence.4 These professional organizations are working to change the culture of modern health care, which is, at least, partially responsible for secondary stress and burnout among direct care providers.
The Culture of Health Care
The COVID-19 pandemic has exposed many stress-inducing shortcomings of the health care system such as lack of preparedness, limited clinical capacity and protective equipment for clinical staff, and an ethic of doing more with less, highlighting the risks incurred in everyday practice. And there is more. Surveys of physicians, physician assistants, and nurses continue to highlight the negative impact of work culture and conditions on physical and mental health. The culture of health care is multileveled, including national trends such as the corporatization of health care, for-profit health care systems, the computerization of practice, and the maldistribution of services that lead to health disparities. There are also the cultures of specific work environments, framed by national trends, that create either healthy or toxic work environments. A 2015 Medscape survey5 of U.S. physicians reported that the top four leading causes of burnout were (a) too many bureaucratic tasks leading to loss of autonomy, (b) too many hours at work leading to extreme work life balance issues, (c) insufficient income related to declining reimbursements, and (d) an increasing computerization of health care leading to less facetime with patients, a phenomenon that Eiser6 terms “the silicon cage.”
Coplan et al.’s 2018 study of burnout, job satisfaction, and stress levels of physician assistants reported similar findings to the Medscape survey of physicians.7 The highest rated factors contributing to stress included (a) too many work hours, (b) income not high enough, (c) too many bureaucratic and administrative tasks, and (d) feeling like a cog in a wheel.
In 2013, the American Nurses Association launched a Health Risk Appraisal as part of its Healthy Nurse–Healthy Nation initiative.8 Three years of data from the survey reports of 13,500 registered nurses revealed that (a) 82 percent reported experiencing workplace stress including bullying and aggression particularly from peers rather than supervisors; (b) 25 percent had been physically attacked by patients or visitors; (c) more than 40 percent cited physical stressors such as lifting, prolonged standing, needlesticks, and exposure to blood borne pathogens; and (d) respondents also reported a drop in sleep hours and failure to eat a reasonably healthy diet.
The results of these surveys provide incontrovertible evidence that many health professionals are at risk. In their contact with patients, not only may healing professionals contract a physical disease, they are in even greater danger of being “infected” psychologically. Secondary stress, the pressure that results from reaching out to others in need, is a constant and continuous reality for physicians, physician assistants, and nurses. And, considering the culture of health care and disruptions such as the pandemic, it is a situation to be reckoned with in new ways.
Professionals, who have committed their lives to caring for others, are overwhelmed by frustrations and loss of perspective as stressors of the health care environment and its multiple cultures and demands bear down. Changes in practice driven by unreasonable quests for efficiency and profit, inequity that produces health disparities, societal and world instability as in pandemics, physical demands, and self-induced pressures fueled by unhealthy work environments make up only part of a psychological and physical combustible mixture. Therefore, not addressing these conditions is not only foolish; it is also dangerous to the well-being of talented, caring, and hitherto emotionally healthy persons working in the healing professions—the audience for whom this book is written.
This Book’s Framework
Overcoming Secondary Stress in Medical and Nursing Practice is a book designed to sit prominently on your desk for quick access. Randomly opening to any page in the book will convey the message that you are not alone and that you have and can reinvigorate internal resources to improve your situation or change your environment including moving on. This book distills current clinical papers and research; provides assessment tools and guidelines to pinpoint, avoid, and/or limit unnecessary distress and strengthen one’s inner life. It also offers recommendations for further exploration on the topic. If nothing else, its goal is to raise awareness that secondary stress is a danger. The denial and avoidance of dealing with the immense stress present in modern health care are alarming. Professionals seem so discouraged at times that they do not even consider—given the culture and their own personal resources—that there are possible practical approaches to deal with environmental and intrapersonal sources of stress in health care settings. Instead, unfortunately, they just sleepwalk, march on, or march out.
Time, of course, is especially precious for those in clinical practice. To keep afloat, they need to schedule their priorities and ensure that what is done is accomplished in the most effective way possible. And in this sorting process, oneself is often at the bottom of the priority list. Overcoming Secondary Stress in Medical and Nursing Practice is designed with these realities and practices in mind. Without a clear awareness of the challenges of professional health care and the simple, yet powerful, ways to remain a passionate, psychologically healthy physician, physician’s assistant, or nurse and appreciate the need to strengthen one’s “inner life,” one’s career may become derailed and one’s personal life unduly suffer.
This book is presented in a way that fosters an appreciation of the essential elements of the problem of secondary stress. It will help you to answer the question, “Why am I feeling so stressed or so numb?” Most of these elements will be obvious; some may prove quite surprising. This book will suggest guidelines for the development of a personally designed self-care protocol as well as information on maintaining perspective, reframing perceptions, and increasing self-knowledge as a way of learning and benefiting from, rather than just being pulled down by, stressful encounters. The authors have reviewed major portions of the stress-related research and clinical papers published over the past 10 years. The bibliography in this volume is extensive and includes both classical and recent major works on the topic and websites that might be helpful, including links to online videos of prominent clinicians and researchers working on issues of secondary stress and burnout. Beyond what is written in the five chapters and epilogue, all sources provide helpful follow-up reading for those wishing to do so.
Direct care providers realize that “for every poisoned worker there are a dozen with sub-clinical toxicity.”9 Using this as a metaphor for secondary stress, for every case of serious impairment, there are many nurses, physician assistants, and physicians who are beginning to manifest symptoms of chronic or acute secondary stress but may not even realize it until well after the fact and until well after they have made a decision to exit their current position or the profession. Consider the experience of a graduate nursing student who confided to her nursing instructor.
In a surprise phone call, three weeks before the end of the term, the nursing professor learned that one of her most outstanding graduate nursing students had decided to leave nursing. The instructor shared her surprise with the student but did not directly discourage her. Instead, she asked the student to share her reasons for this decision and her plans going forward. The student described her work environment, a fast-paced, clinical unit where she had hardly any time to spend with patients and families and where the nurse manager was more like an unforgiving “drill sergeant” barking orders and publicly calling out the staff. Most staff worked in fear and silence, but the stress was taking its toll—lack of sleep, ruminating thoughts, and hypersensitivity. “The only thing that has been holding me back is my tuition reimbursement benefit, but my decision is made, I am resigning and opening my own business.” The instructor listened supportively and encouraged the student to postpone her exit at least until she finished her coursework for this term. The student agreed to this plan, and the instructor gave the student the name of a counselor who might help her sort out her “options” in nursing or otherwise. “And if after careful consideration you decide to pursue that business,” the instructor offered, “let me know and I will be one of your first customers.”
As the academic year progressed, the instructor often thought of this student wondering if she had been lost to the nursing profession. Shortly before the end of the next academic year, there was another call from student to instructor. “I will see you at graduation,” the student exclaimed, “and I hope you will be there. I got into counseling and looked at my options. I have a new nursing position taking care of breast cancer patients. The staff and the setting are great. I cannot wait to get to work every day and I am so happy I made the decision to stay in nursing.”
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