Heart of the Matter

Several weeks ago, I got a call from one of the first new-to-practice nurses I ever trained. She did very well then, and experienced meteoric success in the years that followed. She often attributes (blames!) her success to me but, it’s her talent, drive and compassion that make her who she is! She’s now a clinical director of nursing with responsibilities that include three ICUs and the Emergency Department. The critical care units were placed under her charge a year and a half ago; she’s been the ED director for three years.

We “talk” often, primarily by social media, but catch up on bigger things via phone. The purpose of her call — advice. This isn’t unusual; she often taps into my past experience as a nurse manager and corporate director.  Now, though, she’s looking for my current front line experience at the bedside. Specifically, am I satisfied being a bedside nurse? What keeps me coming back to work? What is my relationship like with peers, patients, physicians, bosses etc.?

I say to her, “It sounds like you’ve just gone through a nursing satisfaction survey” and, indeed, she has. She is now left holding the distinction of managing the most dissatisfied nurses amongst her peer group. Her only consolation is that general satisfaction is significantly worse throughout her hospital when compared to the last survey three years ago. As she tells me more, the story sounds familiar; it echoes some of the themes of my post, Why God? — Burnout, Vicarious Trauma and Moral Distress

One thing that confirms my suspicions comes when I ask her about nursing salaries. She says, “That’s the crazy thing! Satisfaction with pay reached an all-time high. It completely contradicts the rest of the survey!”  I guess, and she confirms that many of the newer nurses ( <5 years experience) show greater satisfaction than more seasoned nurses. Nurses beyond five years, but less than 12 years experience, are dropping like flies; turnover and sick-time utilization is highest in this group. The mix is 50/50 with those at the upper levels of experience. She approximates that 50% feel the “golden handcuffs” of being stuck in their job — the negatives of starting over at this point is personally too great; they include loss of salary, seniority, influence, etc.. The other half of senior staff remain engaged, interact well with others, take on practice issues and orient new staff.

I respond to her, “You’ve got yourself some cardiac problems. Your nurses have lost their love for nursing!”

“Let’s start with your biggest group”, I say as I  “diagnose” her mid-career nurses — they’re like patients with hypertrophic cardiomyopathy — all muscle, no squeeze! Knowledge, experience and time inflow to produce great potential with this group — just like the stretching of the right heart during diastole (preload). The cardiomyopathic heart fails to give to its potential which leads to compromised oxygen delivery, ensuing ischemia and resultant shock. Similarly, failure of nurses to engage in the work at hand (the delivery of effective nursing care) results in professional dissatisfaction, bad patient outcomes and career collapse. Without intervention, whether we’re talking nurses or patients, the end result is death.

I continue with my heart analogy. Her “golden handcuff” group is the one with an outflow problem – they have nothing to give — Diagnosis: dilated cardiomyopathy. They’ve grown larger but not stronger. They’re just kind of blobbing around waiting for the end to come. There’s little to give, not a lot of action and they’re killing everything connected to them.

Her newer to practice nurses also possess potential “cardiac” risk factors despite their seeming good health. I save this group for last because the other two “diseased” groups may be this one’s biggest threat. Why? Because cardiac disease is progressive. Strong, healthy relationships build bonds that create effective teamwork. Likewise with the heart, it is the coordination of electrical and muscular properties that lead to effective cardiovascular function. Atrioventricular dissociation is its opposite — the atria become isolated from the ventricles, which works for a bit, but is ultimately doomed to fail. Nurses “growing up” in hostile work environments don’t fair any better.

My friend likes my take on this but then asks, “What’s the cure”. I, like any good consultant, respond, “That’s the million dollar question!” The problem to a solution is threefold!

  1.  These problems take time to develop and thus, time to fix
  2. There are options (think medical vs. surgical) to try but sequelae to each.
  3. Failure to intervene results in greater illness.

So we assessed some of the problems and now planning is the next step in the nursing process! I’ve given her food for thought and make a deal with her to follow-up on next steps. She wants to digest this a bit and agrees to call me back.


And this is where I turn to you, help me help her. I’m a good emergency nurse which means I’m good at figuring out problems — problems I identify then send out the door for others to fix! Let’s get a dialogue going in the comments section. Please identify your area of practice and years of experience in answering the following questions:

  1. What are your top three satisfiers/disastisfiers in bedside nursing?
  2. When it comes to the future of bedside nursing, is the glass half-empty or half-full? Why?
  3. What relationship would improve your satisfaction if it was most improved? Peer, Patient, Physicians, Boss (or one not listed)?

Answer any or all, I’d love to hear from you!

As always, thanks for reading A Patient Nurse! See you soon in your local Emergency Department!

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8 thoughts on “Heart of the Matter

  1. Adam I feel her pain being a formal manager of several ED’s my biggest obstacle was staff dissatisatisfaction was with hospital administration and by default then me as part of that administration. Getting staff involved in the solution was key as you know. Giving them a voice in the solution process is key not that you can guarantee results but engagement is key. Once they feel they have a voice then they once again feel valued and produce better and more engaged staff both individually and as a group. But it starts with administration being willing to allow that process to happen. Each unit is unique in their needs and as such no one solution will work for everyone. They must remember that any changes to flow or policy must not have a negative impact on patient care as that must remain the first priority. Shared governence models help but are not the only tool available.

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  2. well my good friend – i believe they may have Takotsubo cardiomyopathy (broken heart syndrome) which is – as you know- the ‘muscle’ of the heart weakens as a result of stress (emotional and physical). After 24 years of nursing, and now being on the ‘other side’, I witness the very things we do to our frontline staff. Change this, do that, add this, remove that, and i wonder what on earth did we expect would happen? I remember all too well the days of ‘get out of my way and let me do my job’. How do we lead and stay out of their way? A recent report came out of the Advisory Board describing how to engage your frontline nurses. Interestingly, we have nurses that will stay in the profession, but have lost their ‘heart’ colliding with a new generation of nurses who want to be challenged, want feedback and nurturing, and are not afraid to go get what they want – and that may be they leave the job. Lastly, we measure our ‘success’ on patient satisfaction surveys during what is probably the worst time of their life – and spin out of control trying to figure out a fix. Yikes – quite the conundrum. We need to take a bold stand – set the tone – stop the status quo – invest in our workforce – and breathe. The good news is Takotsubo is reversible!!! Thank you for your posts!

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    1. Beautifully said (so funny that I just ordered some Advisory Board material on the subject) I feel as bad for front line staff as I do managers caught amidst this maelstrom. This is reversible and all involved need to be engaged in its solution!

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  3. Adam,
    First, I think we should clone you-you’re engaged, pushing the front lines forward, an arm around your coworkers, egging them on to be the best they can be. Since cloning’s not possible, the way I found keeping tired, frustrated, even complacent nurses engaged is to give them a pupose and engage them in the process as part of their workday. Taking care of patients, though satisfying to help others, is grueling , exhausting work, day after day. To have a project they choose and own, something which the unit may identify is needed gives staff a sense of ownership and satisfaction, thus engaging them.
    And attitudes and atmosphere one works in comes from the top down. If managers are seen as doers and nurturers, willing to take a case on periodically or assist with a tough admission, teach the staff, it makes a big difference to all of the staff. Ask staff what’s missing on the unit, what would they be interested in taking on and owning? It can be a long or short term project. Staff will always complain when they think someone should fix”it”. Allow the staff to have an open voice and not just suggest solutions but actively work on them. I’ve watched nurses over many years come to expect and feel entitled about what is “their due”. When they stop being the frustrated end of a process tossed at them by administration to implement, it’s often because they were engaged in the solution, a part of it that they made work. If they just see the senior nurse who’s now a “white coat” going from meeting to meeting with other managers, they will often no longer see someone who cares about the front line burning out nurse, but someone who moved up and “out”. As a nurse who left clinical nursing in my early 50s, I was fortunate to move to a very supportive environment with autonomy and respect and yet I never worked harder in my entire career- it was left to me to complete everything, no one to come in on the next shift to finish. I made the decisions, designed the program and had great guidance and support all around me. That made it the best job and when I left it, it was left in the hands of an engaged, energetic, forward thinking individual who benefits from the most supportive team and managers possible. It makes all the difference to work in an inclusive, engaged, supportive nenvironment!

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