When Nurses Need Nursing

Friday, March 13, 2015

In the last post, (read it here) I mentioned that this post would cover the topic of “When Nurses Need Nursing.”

Nurses in general are the people that patients deal with most often in a health-care-delivery situation, especially when in the hospital. They are expected to be calm, collected, and stoically professional at all times. Smile in the face of all situations. Don’t cry. Don’t show negative emotions at all – hey – it’s unprofessional.


Anecdotally, I’ve heard that many a nurse has been “written up” for unprofessional behavior – for crying in a location where a patient may see them.

Our expectations are incredibly high on this profession as a whole, overall. Should they be? Yes of course, but we also need to understand that the nurse is someone’s sister or brother, daughter or son; wife or husband. In other words, they are human, and therefore bound by the same limitations as the rest of us.

Let’s walk in their shoes before judging.

“Emotional Labor”

One of the studies we’re looking at today claims that the nurse’s identity is the “outward persona of competent and composed professionalism.”

This study explores the concept of “emotional labor.” Other related terms for this include burnout, compassion fatigue, job stress, or that one nasty word – stress.


Let’s look at “compassion fatigue” and “emotional labor” as the two base phrases today.

I found an article to cite about the topic, called “When Nurses Need Nursing: The Toll of Emotional Labor.” It was written by Laura A. Stokowski, RM, MS., and published by Medscape on May 13, 2014 (http://www.medscape.com/viewarticle/824689).

Ms. Stokowski is an experienced nurse, and focused her article on nursing in a Neonatal Intensive Care Unit (NICU) at a Level 4 NICU in a children’s hospital. She cites extensively from a research study performed by Roberta Cricco-Lizza, a University of Pennsylvania researcher. Cricco-Lizza performed what’s called “ethnographic research” at this NICU. This type of study means that she became embedded into the daily lives and routines of these nurses (114 of them) over a period of 14 months.

Ethnographic research – continuous observation for long periods of time

This type of research uses many tools for a project of this type, including observation sessions, informal interviews, and formal interviews with 18 “key informants.” The behaviors and approach of the nursing staff with patients, parents, and other staff members, and were studied and documented over a significant period of time, as you can see.

In other words, this was a long-term project in an attempt to get to the root of the subject area rather than just be a one-time (or repeated) “snapshot-in-time” survey. Quite a contrast in approach. This type of study is designed to provide deeper insights as well as somewhat more objective observations of the researcher. What may not be thought of, or come up during the time a nurse fills out a survey, may appear in the long-term observational study.

In a nutshell, the ethnographic approach allows the researcher to study the deeper nuances of a situation. It also helps to divine the sheer level of impact that topic has on the subject(s) being observed. These deeper data points are discovered due to the fact that trust naturally builds over the significant amount of time researchers and the subjects spend together.

Cricco-Lizza wanted to gain a better understanding of the challenges of working in a busy NICU, as well as how that work environment affects the nurses’ private lives.

“Stressful work environment”

One of the early statements both authors make is, simply put, “the NICU is a stressful work environment.” On the face of that, it seems both obvious and at the same time, counter-intuitive. Obviously it is stressful because the babies in the NICU are in distress. Bluntly, some will not make it home – and that is very hard to accept for some nurses.

They are human after all.

But it’s counter-intuitive too. This is because for those children that thrive and go home in the face of all that adversity – well – let’s say that the positive impact those nurses had on the lives of that child and it’s parents is profound indeed. It has to be incredibly rewarding to see a struggling small one gain strength and thrive over time.

And therein lies the issue.

Nurses in general cannot show their emotions when challenging things happen, and yet  they need to be able to celebrate with the parents when they get to take their child home, finally.

Think about that for a moment – in your daily life – if you see “bad things” at work, you are expected to either fix them, or at least speak with others in your organization (or your customer’s /supplier’s organization) to the point whereby the issue is resolved. You are respected for your professionalism as well, of course – you identified a problem, and you fixed it. But if you make a mistake, more than likely, and depending entirely on your profession, a defenseless little one doesn’t die. So yes, we all have stress, but for most of us, it’s not “life or death” type stress.

Yes, the nurses have chosen this life, but that doesn’t mean that stress is now non-existent for them. Let’s admit that, and find a way to reduce it.

Three disparate causes for stress

Cricco-Lizza found that there are three main sources of stress in the lives of a NICU nurse:

Caring for the babies – many nurses (quite naturally) become very attached to the babies and their families. And when they do well (or not), at some point, that relationship comes to an end. As we know, there is little room for any type of error when dealing with challenged patients, and much need for constant vigilance, regardless of how tired or stressed the nurse is feeling on that particular shift.


Employer demands – there are many and varied sources of stress from the employer perspective. Constant change in rules and regulations, new technology – both medical and computer system-wise, training new staff members (due to a fairly high turnover rate), short staffing, rotating shifts; even something as simple as answering the phone “promptly.” That last one seems minor to most people in most professions, but many times a phone call interrupts the care procedure they may be giving at that particular moment. Now add that to the demand that no mistakes are made when delivering care, and you can see the conflicting issue here, which in turn causes stress.

Personal life – many NICU nurses are also mothers, and therefore can project the issues their patients are suffering onto their own children. Expectant mothers can suffer anxiety about their unborn child as a result of what they see on a daily basis. Also, today’s reality is, many “experienced” nurses are at an age whereby they are also caring for an elderly parent at home, perhaps. This can be stressful also, and does not then provide for an escape from the work pressures, even at home. Many nurses also report that because of the privacy expectations we have of them, their profession does not allow them to speak with friends and family members about their cases, and so the burden is carried alone.

So where do they learn how to handle it?

The study by Cricco-Lizza points out the fact that there is no class on handling stress during the nurses’ educational experience and formal training periods.

Most hospitals and doctor’s offices do not have workshops for the nurses in any of the departments on how to deal with job stress. In fact, most health-care organizations will not even admit that high levels of stress (or emotional labor) even exists, much less have methods for handling it well.

Again, it boils down to the powerful stigma that our nation holds towards people that suffer emotional or mental challenges. If a legal professional were to find out that a nurse has been “acting out” due to high stress, and one of the babies under her care were to pass, there would be justification for legal action against the nurse and the health-care organization that employs him or her. Whether or not it’s deserved –  or even related to the care that NICU nurse provided – a diligent attorney will find a way to make it a cornerstone of his or her case against the hospital – and probably win that case when presented to a jury of his/her peers.

If, societally, we’d be OK with heading off stress prior to it’s building up that far, perhaps the issue may not have happened in the first place. Perhaps that baby would have gotten a different level of care. Perhaps that nurse (or doctor) would not have subsequently committed suicide.

Let’s be honest with ourselves here. We all have our mental issues (at some level or another) simply because we are all human. We all have some sort of mental challenge we’re working on, or a stressful situation we are dealing with. An addiction we’re trying to overcome – be it substance abuse or even just a guilty pleasure of too much reality tv. Some people handle stress better (longer?) than others, but at some point, we all have our breaking point. It’s called the “end of our rope” in some circles.

So, even though I’m not a “bible-banging” person as a rule, I do have two “Christian” rules from my upbringing that keep coming to mind as I study this topic:
1) Judge not lest ye be judge
2) Let he who is without sin stand in the circle and cast the first stone

If you’d like the exact biblical reference for either of these, please leave me a message in the comments section, below.

Maybe we’d all be better served if we were to allow medical professionals unfettered access to the counseling, seminars, stress-reduction workshops that they need, to avoid more stress buildup.

Healthier doctors and nurses mean healthier patients. Healthier patients means lower health-care costs overall.


Next post: Thoughts and research on why people commit suicide


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