The Silent Struggle

Photo: Julia Lehman-McTigue

By David Pavlak

The scene in a busy Philadelphia hospital is enough to send anyone into a state of panic. Sirens blare from the tops of ambulances as paramedic crews rush in new patients. Heart monitors beep with each rise of the chest. Hospital staff in their off-white shoes scurry across the sterile tile floors. Keyboards click, equipment is transported with a rumble, and quiet, huddled conversations are held.

Doctors and nurses move about the crowded rooms—talking, listening, prescribing, and hopefully, releasing each person they come in contact with. Some may not be so lucky.

Nursing-related stress is on the rise, but it’s a problem rarely talked about, hardly studied, and difficult to understand. Though mental health issues are receiving more awareness, occupational stress still seems to be sort of an outlier. Students enroll in colleges across the United States and abroad with aspirations to enter a specific field. Yet, some have difficulty coping with its numerous rigors. Nurses are in the room as a new life enters the world, but also stand diligently bedside as another one leaves. The emotional element leaves scars.

“Most of the time, the stressors come from the ratio of nurses to patients, the acuity levels, the amount of hours you have to work, and then, in addition, you have that human factor with how you’re dealing with individuals that are so sick and not getting better,” said Dr. Mary Wombwell, Professor & Coordinator of the RN-BSN Program in Holy Family University’s School of Nursing and Allied Health Professions.

Wombwell is well accustomed to the struggles new nurses face. She has worked at the now-closed St. Agnes Medical Center in South Philadelphia, Frankford Hospital (now Jefferson Frankford Hospital), Episcopal Hospital (now Temple University Hospital - Episcopal Campus), and Holy Redeemer Hospital in perioperative services, home care, and in the community health sector for 15 years.

Photo: Julia Lehman-McTigue

“When I first graduated, you had eight to 10 patients to deal with and you didn’t have the confidence as a new graduate to say, ‘No, this isn’t safe; I can’t do this.’ You went along with it. There were individuals that stood up, and lots of times they got fired because they identified something that was not safe. You’re not seeing that as much, and a lot of that has to do with educational advancement, accreditation, satisfaction rates that hospitals get back from patients, and nursing retention rates.”

Nursing burnout rates are on the rise and the stress has led to increases in leaving the hospital setting, leaving the profession altogether, and suicide rates. A study by the Office for National Studies in the United Kingdom found that from 2011-2015, “the risk of suicide among health professionals was 24% higher than the national average. This finding is largely explained by the higher risk of suicide among nurses, which was 23% above the national average.”

In-depth research on nursing suicide rates are difficult to find. Data on nursing burnout rates are more prevalent. There is also an abundance of articles, op-eds, and blogs by current and former nurses calling for more attention to this silent problem.

Photo: Julia Lehman-McTigue

“People are dealing with a number of things and if they don’t have some balance in their life, that suicide rate is going to increase,” Wombwell said. “Sometimes you can just go on automatic pilot and that’s what happens when one patient dies and you go into the next patient’s room. It’s still there though. When will you deal with it? That part is really hard. You try and bury it almost so people or other patients can’t see that you’re sad. We know its ok to show people that you’re sad. It just really comes down to making sure you’re attending to your own self-care.”

Today, most hospitals implement a nursing residency program, designed to give new nurses a mentor, receive the support and guidance needed to refine skills, and increase confidence.

“Hospitals that have nurse residency programs retain 96% of new graduates that they hire. It’s not uncommon for a new graduate to last a year or less in those hospitals that do not have nurse residency programs, and say ‘I can’t do this.’”

Photo: Julia Lehman-McTigue

Being proactive, the School of Nursing and Allied Health Professions requires a class for senior students: Transition to Professional Role, a course designed to discuss a variety of issues new nurses face as they prepare to enter practice.

“Transition to Professional Role provides discussions, role play, and simulations related to safe practice issues, incivility, and caring. As students explore issues, they discover the tools for safe practice and are better prepared for nursing practice.”

The training has proved beneficial. Kelly Hardiman, a 2018 graduate who is completing her first year as a Medical-Surgery and Telemetry Nurse at St. Mary’s Medical Center has used tactics from the class to speak up and help close gaps in the care patients receive.

“Sometimes it’s best to just think of it as ‘What can I do to produce better patient outcomes?’” Hardiman said. “Maybe it’s splitting a heavy assignment or advocating for a patient’s family when they are upset a physician has not spoken with them. Just always remember to be professional and take issues to the right person.”

Wombwell admits that a lot of new students experience self-doubt early in the process, overwhelmed with the coursework, materials to study, clinical and laboratory experiences, and the at-times hectic schedule.

“Lots of times, students will come and say ‘I tried it. I don’t like it. I’m out. I want to change my major.’ That’s a hard decision to come to. You’re disappointing yourself, you think you’re disappointing your family. I usually say to them have you talked about this to anybody. It’s that ability to talk whether you’re a student or a practicing nurse to share this is what happened and this is how I feel. Sometimes practicing nurses don’t have that time.”

Hardiman used her experience during her undergraduate years to make the transition to her full-time profession more seamless.

“I was nervous my first day on my unit, but I was paired with an amazing preceptor who had me shadow her so I got a feel for the unit,” Hardiman said. “I would say the most stressful transition was being alone my first day on the unit. I remember not being able to sleep the night before my first shift thinking I was all alone and what if I couldn’t juggle multiple patients at once. However, you’re never actually alone in the hospital.”

Wombwell and her colleagues have also created a Mindfulness course that has been offered during the University’s August Weekend Intensive in 2014 and 2018. The course examines theories related to stress, the outcomes of stress, and the response of the body physically, mentally, and emotionally. In addition to the theory, students also participate in yoga, tai-chi, and various breathing and meditating exercises that they can use in the field.

“Stress levels increase cortisol and adrenaline levels, the fight-or-flight hormone,” Wombwell said. “When released at high levels, these chemicals effect metabolic balance, visual acuity, and problem-solving abilities. Quality of care and safety are at risk. Professional nursing practice requires you to be in the moment, to be mindful, and to critically think to support safe and healthy outcomes.”

The stress in high-performing occupations is a lot, including those new to the profession and seasoned veterans. However, the advice to overcome these difficult situations tends to be the same.

“Breathe,” Hardiman said. “Everyone has been a new graduate at some point. You will make a mistake, it’s ok. You will have a physician talk down to you, it’s ok. You will need help, it’s ok. Just remember why you are there: to take care of your patients. Some days will be stressful. Some days you will barely get a lunch, but you will be coordinating care for so many people and it’s a rewarding job. Practice to the best of your knowledge, ask questions, and practice with heart.”