We focus on our nation’s health care system from every possible perspective–political, legal, social, financial, emotional, and even global. Health care workers are immersed in, and care deeply about, this issue from all these perspectives, but they also have a much more intimate view. Nurses and every professional who interface with any aspect of a patient’s care experience daily not only the physical fatigue and stress from their long, busy shifts and staffing crunches, but also the emotional fatigue from everyone asking the following questions:
- “You LIVE this every day–what do YOU think about health care’s problems and proposed reforms?”
- “I hear about tired doctors and nurses making mistakes–how can you assure everything possible is being done for patients correctly every time?”
- “Does anyone care about the individual anymore? Hospitals seem to be only concerned about saving money and regulations.”
- “How do you DO it?”
Especially difficult dilemmas arise when health care decisions related to cost containment, pain management, and quality of life collide with end of life decisions for patients with poor prognoses. Recently I read David Bornstein’s New York Times editorial “Medicine’s Search for Meaning.” He begins by reminding us that “almost 50 percent of doctors report symptoms of burnout— emotional exhaustion, low sense of accomplishment, and detachment…Medicine is facing a crisis…not just about money, [but] about meaning.” He contends that physicians need to counteract the intense emotional toll that medical training exacts on their students and the subsequent “stuffing” of personal emotional responses modeled and observed whenever medical training comes across difficult patient situations. The current standard is to discourage physicians-in-training from reacting as caring humans to the tragic, painful, deeply sad patient and family events they participate in on a daily basis—sometimes even to the point of being told such behavior is highly unprofessional.
Featured in the article is one doctor’s unique solution, created as a response to having similar negative experiences during her residency. Dr. Rachel Naomi Remen has developed a unique course called “The Healer’s Art.” Although it began as a clandestine effort with just a handful of colleagues, it is now part a 15 hour course within the curriculum at half of all U.S. medical schools and at schools in 7 other countries. An essential belief of “The Healer’s Art” is that medicine draws its strength from its core values of “compassion, service, reverence for life and harmlessness” and that practitioners and medical students alike must recognize and “connect” to these values in order to “immunize themselves against the assaults of the medical curriculum and even the health care system itself.” Students and faculty gather in small groups, “participating side by side as equals. There are no experts, no hierarchies, no wrong answers; anyone may speak about his or her experiences or simply listen.”
“’What our students say loud and clear is this course helps to keep their spirits alive as they go through the training,’ explains Nancy Oriol, MD, Dean for Students at Harvard Medical School.” Professors of the course engage students in a variety of experiences–discussing the first time they realized that the needs of another living thing mattered to them; drawing pictures of the parts of their beings they feel they cannot bring into their work as a doctor; or thinking back to a time they experienced a loss, the feelings they experienced, and discussing what others may have done that was helpful or unhelpful.
This article and my years experience as a nurse made me wonder about a similar course or school of thought for nursing professionals and within nursing education. After all, similar burnout has been acknowledged within nursing. In fact, one survey reports that “turnover rates of [New Graduate Nurses is] roughly 30% in the first year of practice and as much as 57% in the second year.” Just as doctors don’t simply diagnose diseases, prescribe medications or perform operations, nurses don’t simply dress wounds, give medications, and educate patients. Both practitioners bring our “full spectrum of human capabilities”–depth of commitment, compassion and ethical vows – to each patient/family interaction. Since there is indeed a corollary within nursing education, I then wondered, what is nursing’s “Search for Meaning?”
I remember my first code as vividly as if it happened yesterday. Despite my initial panic, adrenaline and rote skills helped me handle the controlled chaos of drugs, lines, and procedures fairly well. But I will be eternally grateful to the charge nurse who quietly took me, visibly shaking, out of the room as soon as death was determined and told me, “You did well–now take a few minutes to cry in the ladies room before you cry with the family.” I needed that time to gather myself and remember what my professors and fellow students had discussed in many clinical post conferences–what to say and not say, should I cry or hold a hand, should I really listen and sit in silence (yes), or leave the room to manage my own feelings saying “I’ll leave you alone for a while (no).”
Often the struggle with emotions is intensified by sleep-deprivation, stress, fear of making mistakes, time management issues, and a perceived message that doubts or grief should be kept to oneself. As exemplified by “The Healer’s Art” courses, nurse educators can give students permission to not minimize or internalize their responses to the human suffering we encounter, and then help them learn how to come to terms with their own responses as well as those in their care, so they can develop a personal approach for compassionate care.
Such courses are not ends unto themselves; rather they are the impetus for each student to self-reflect and journey towards personalized, empathetic care. Our long history of nursing, founded upon the intuitive and insightful principles of Florence Nightingale, proves we can pass the torch handed to us and evolve, adapt, and grow in accordance with – and in spite of – the ever changing myriad of outside influences that shape health care policies while we maintain the tenets of our profession stated so well in the Nightingale Pledge.
I solemnly pledge myself before God and in the presence of this assembly, to pass my life in purity and to practice my profession faithfully. I will abstain from whatever is deleterious and mischievous, and will not take or knowingly administer any harmful drug. I will do all in my power to maintain and elevate the standard of my profession, and will hold in confidence all personal matters committed to my keeping and all family affairs coming to my knowledge in the practice of my calling. With loyalty will I endeavor to aid the physician in his work, and devote myself to the welfare of those committed to my care.
Or, to quote Dr. Remen, “Medicine offers you a front-row seat on life. Meaning is all around you. When you can see it, it gives you a sense of gratitude for the opportunity to do this work.” Even with all the challenges, nurses would agree.
