Michele Hoole, an operating room nurse for a major Lehigh Valley Health Network, is an 18-year veteran of the profession. She has seen and experienced firsthand the physical and emotional toll the demanding career can take.
“It affects you,” she said. “You are sometimes the only person with a patient when they die. Even if you are only with that person for 12 hours, you become their family. The last person they see is you. Yet when someone dies, you have to leave it at the door, because you have other patients who are still depending on you.”
Nurses like Hoole often make the commitment to “battle on,” never taking a moment for themselves, for the good of their patients. But this culture of staying strong in the face of countless stressors may have a downside.
New research from The Robert Wood Johnson Foundation for Interdisciplinary Nursing Quality Research Initiative, a national public health and research organization based in New Jersey, reports that nurses experience clinical depression at twice the rate of the general public.
“Anyone who says that it doesn’t affect you isn’t being truthful,” Hoole said. “A lot of nurses are afraid to speak up about how they are feeling. They are afraid to upset managers and other staff.”
Jeanne, a telephone-support nurse for a New Jersey-based health insurance company who did not want her last name used, has her own mechanisms for coping with the emotional drain of working with patients who are often having their “worst possible day.”
“I’ve learned to work at it,” she says. “I have a therapist. I take an anti-depressant and I have an anti-anxiety medication that I can take if I really need it.”
Jeanne is also familiar with a strategy many nurses employ that she calls, “crying in the car on the way home.”
“You come home and don’t want to burden your family,” she said. “You don’t want to spread that sadness around, so you stick it in a compartment and keep going, and don’t deal with it.”
Despite the mental and emotional fatigue, Jeanne and Hoole say nursing is a labor of love.
“You have to love what you do and the people you work with to be in this career,” Hoole said.
More support needed
Hoole believes more mental health support, higher pay and more appreciation from management could go a long way to prevent depression among the nursing workforce. More nurse aides to help with the growing workload would also help, she said.
“The pay is not enough for the workload,” she said, noting that nurses feel a constant pressure to continue their education. “I have two masters degrees, and my pay is not much different than a new grad. Anyone who goes to school for nursing for money needs a reality check. Be in it for the patients and the love of nursing.”
For now, Hoole uses exercise to manage the stress. She’s a better nurse when she feels healthy and fit. She also leans on a close circle of friends for support.
Like Hoole, Jeanne says dealing with death has an effect on a person. When added to the struggle to balance more patients, wages that don’t match the workload and a shortage of nurses aides, and avoiding depression is a challenge, she said.
She knew a fellow nurse who didn’t survive and died by suicide. “She showed no signs. No one suspected that she might do something like that.”
To avoid tragedies like that one, Jeanne recommends employers do mental health check ins with their nurses. Sometimes, she said, just asking how someone is doing can lead them to seek help.
“There isn’t a lot of discussion of burnout in nursing school,” she said. “Employers and schools need to address the mental health of their nurses more.”
Still far to go
Dr. Renee Koval, director of the psychiatric mental health nurse practitioner program at DeSales University in Center Valley, tries to prepare student nurses for the psychological demands they will face. At DeSales, undergrads are offered psychology courses that teach the signs and symptoms of depression. The problem, she says, is that nurses tend to downplay their own symptoms to others, finding it easier to help patients than themselves.
“How do we teach nurses to say, ‘I need help?,” she said “There is such a pressure to be stoic and strong. If someone has a broken arm, we tell them to get treated right away, and they will, but mental illness still isn’t completely that way. People are definitely waking up to it, but there is still so far to go.”
Women between 18 and 25, a cohort that makes up the majority of nursing grads, have a higher rate of depression, Koval said. So, when this population, already at risk for depression, is exposed to the stressors of nursing, the risk rises higher.
“All nurses experience some upsetting things,” Koval said. “They are taking care of patients who have been physically abused, sexually abused. Patients are aggressive to them. And then there are the physical stressors, not eating, night shift nurses are not sleeping well…You have to keep water in the break room, how often does a nurse have time to go to the break room? This all adds up.”
To Koval, having a mental health team available for consultation during and after work hours, could be a proactive solution to the problem.
“I know a 24-year-old nurse who was attacked by a patient in the IU,” she said. “She was physically ok, but no one asked if she wanted to take some time, or if she wanted to go home. There should be a mental health team available for consultation, to say, ‘We are here for you. We want to hear about your experience.’”
Rachel Moore, director of media relations for the Hospital and Healthsystem Association of Pennsylvania, said that the organization is working to promote addressing the mental health needs of hospital employees in the state.
“Pennsylvania is home to a diverse hospital landscape and while there are no one-size-fits-all solutions,” said Moore, “hospitals across the state have adopted different models to work with their care teams to foster a healthy and safe work environment.”
Employee wellness and safety are two key focus areas for HAP’s advocacy, she said. HAP currently is convening a Health Care Talent Task Force, which is addressing, among other issues, employee wellness and burnout.
Kelly Stephens, director of professional development for the Pennsylvania State Nursing Association, an advocacy group, agrees that more should be done to support the mental health of nurses.
Currently, her organization is focusing on safety in nursing, whether that be depression risks, workplace violence, work-life balance, or safe staffing.
“And with depression and suicide on the rise in nursing,” said Stephens, “it might be time to push for employers to give staff time during the day to take a walk, listen to music or meditate.”
That push for more breaks during the day is just one step of many. All the nurses that Lehigh Valley Business spoke with argued that speaking up is the real first step to creating change. Whether speaking up for more education, more time off, higher pay, or more mental health counseling, change doesn’t happen without a voice that is calling out to be heard.
“We need to be our own best advocate,” says Hoole, the operating room nurse and 18 year veteran of the industry. “We need to help ourselves first before we can help others.”