Nurses continually do terrific things for other people; we strive to improve the lives of our patients and their families every day. We often read and share feel-good stories, but what about stories that do not feel so good? As we near the year’s end, I have reflected on some nursing issues that captured my attention and my heart. These studies cover a range of interrelated topics, such as unhealthy work environments, violence in the workplace, unhealthy nurses, and nurse suicide. Although these issues are disconcerting, action on the individual and collective levels can improve outcomes.
Acute and critical care nursing is a high-stress profession. Nurses work incredibly hard under very difficult circumstances. Our patients have become increasingly acute, technology and the health care system have become more complex, and change is constant in our environment. Additionally, we may experience external factors that weigh on our minds. Healthy work environments (HWEs) are associated with less emotional strain and burnout,1 suggesting that unhealthy work environments take their toll on our personal well-being. In a 2013 survey of 8080 American Association of Critical-Care Nurses (AACN) members, Ulrich et al2 reported an improvement in critical care nurse work environments. However, opportunities for improving these work environments still exist; major challenges include inappropriate staffing and issues related to physical and mental well-being.
According to Ulrich et al,2 implementation of the AACN Healthy Work Environment Standards was associated with an increase in critical elements of the Healthy Work Environment Scale (skilled communication, incorporating patients and families into decision-making, true collaboration, and effective decision-making), yet more than half of the nurses surveyed indicated intent to leave their current position within the next 3 years.2 Dissatisfiers related to intent to leave included perceived lack of respect from administration and supervisors. Within a 12-month period, more than 198 000 incidences of physical and verbal abuse, discrimination, and sexual harassment occurred; most abuse incidents were caused by patients and families.2 Physical and verbal violence against health care workers is a prominent, unacceptable, and underreported issue that has recently been designated as a sentinel event by The Joint Commission.3 The aim of the Sentinel Event Alert is to increase awareness and organizational acknowledgment and to educate health care workers on prevention techniques such as deescalation and crisis intervention.3
Workplace violence also includes bullying and incivility by coworkers or supervisors. Workplace violence may negatively affect patient care (quality and outcomes), reduce job satisfaction, and promote the development of psychological conditions.4 Barriers to reporting violence include a culture that believes workplace violence is part of the job, a belief that verbal harassment is not a type of violence, fear of retaliation or blame, lack of leadership and peer support, and unfamiliarity with the reporting system.4 Today, only 9 states have formal reporting systems in place for workplace violence, whereas national reporting systems exist in the United Kingdom and Aus-tralia.4,5 The American Nurses Association (ANA) has several resources to help end workplace violence, including “A Nurses Call to Action: I Will Protect My Own Life So I Can Protect My Patients.”4 The ANA supports zero-tolerance policies for violence against nurses; to support nurses, sign up at www.EndNurseAbuse.org.6 You can also text “pledge” to 52886 to support nurses and other health care workers.6
When I reflect on nurse-to-nurse incivility and bullying, I think about the phrase “nurses eat their young.” I first heard this phrase as a new graduate nurse, and I am dumbfounded that this issue still persists some 35 years later. Do some nurses direct work-related stress to their colleagues? This type of activity must stop. Our nursing colleagues require mentoring in a safe environment to become expert clinicians and remain healthy over time.7 Healthy nurses are necessary for personal well-being and as role models and caregivers to our patients, family, and friends. However, nurses are reported to have higher stress levels, be more overweight, and sleep less than the average American.8
Suicide has become the 10th leading cause of death in the United States.9 In a secondary analysis of a Centers for Disease Control and Prevention database, Davidson et al9 found that the 2014 incidence rate of nurse suicide in females and males was greater than the suicide rate in the general population when analyzed by sex. Nurses who committed suicide were found to have higher levels of mental health problems than the average population.9 Risk factors for nurse suicide include depression, access to means, knowledge about lethal doses, personal and work-related stress, smoking, and substance abuse.10
Davidson et al11 reported that nurse suicide has not been openly discussed because of stigma and other factors. I agree with Davidson and colleagues that it is time to break the silence. Suicide is very real to me; I lost someone in my personal life as well as 2 colleagues in my professional life to suicide. Like the findings of Davidson et al, my former intensive care unit nursing colleagues abused pharmaceuticals, specifically benzodiazepines and opioids, which ultimately played a role in their suicide. Their drug abuse was unknown to colleagues, but some of us had identified unusual behaviors that we reported to our manager and discussed with the nurses involved. In my experience, people at risk for suicide can disguise their suffering and make plausible excuses for unusual behavior that in hindsight becomes remarkably clear. Following the death of my colleagues, I was fortunate to participate in a critical incident stress debriefing. We may not have had the knowledge and skills to save these individuals, but moving forward we may be able to help save others who experience suicidal ideations.
Become aware of the warning signs for suicide and reach out to anyone you suspect may need assistance.12 A San Diego program, Healer Education Assessment and Referral, counsels employees who feel overwhelmed; the program has counseled more than 500 health care workers during the past 10 years.13 Hopefully, future mental health programs across the country will be modeled after this successful program.
Contributing to a Positive Workplace
With increased awareness, we should focus on what can be done to improve our mental and physical health, safety, and workplace environment. I am not referring to New Year’s resolutions and a plan that is not sustainable over time; I am referring to small wins, such as being good to yourself and good to those who you work with. Seek balance in life with work, family, friends, school, and what is meaningful to you. Create a positive work environment. If we do not engage in improving our own work environment, who will? We should seize opportunities to be involved in shaping the environment in which we live and work, at least the aspects that are within our control.
We also need to treat our ourselves and our colleagues with respect—no exceptions. The ANA advocates for a culture of “respect that is free of incivility, bullying, and workplace violence.”4 A free toolkit to assist with mitigating violence in the workplace includes 5 criteria for a successful workplace violence prevention program.12 The toolkit also includes an environmental self-assessment for violence (lateral, patient, and family), educational materials, how to develop a zero-tolerance policy, and a violence prevention plan.15 The ANA promotes reporting all workplace violence incidents (including bullying and incivility). Resources can also be accessed on Twitter at #EndNurseAbuse. Resources include educational materials, the ANA Issues Brief on Reporting Incidents of Violence, a podcast, a pledge for action, and a legislator contact form.
The ANA sends a clear message for individuals on the receiving end of workplace violence, stating that “abuse is never your fault.”6 An educational program developed for student nurses may provide skills to prevent and mitigate bullying by future nursing colleagues.16 Additionally, an HWE self-screening tool from AACN can be used to assess your workplace.17 One unit that implemented the HWE standards reported a 17% decrease in nurse turnover, a 6% increase in nurse satisfaction, and a 3% increase in teamwork and staff recognition over a 4-year period.18 Healthy work environments are associated with greater psychological health, job satisfaction, and retention.1
Contributing to a Positive Self
The ANA declared 2017 as the Year of the Healthy Nurse.19,20 Numerous resources are available on the ANA website to promote wellness; topics include healthy sleep, combating stress, happiness, recovering work-life balance, mental health wellness, healthy eating, and workplace wellness. The ANA campaign is active, and resources are available at #healthynurse and by texting “healthynurse” to 52886.8 Join an online community to promote healthy living and honor nurses.
For those who are well enough, I believe we also have a responsibility to recharge our own batteries. Let us work together to foster an environment in which we support and encourage each other to be the best that we can be. As nurses, we focus intently on positive patient outcomes; I challenge you to also focus on your positive personal outcomes. When was the last time you had 7 to 8 hours of sleep? Down time of your choice? Exercise? I hope that you will not only embrace self-care but make it a priority. Model self-care to be a good role model for your patients and their families, but more importantly, do it for you!
All the best for the holiday season and the New Year! Be well!
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