Occupational Hazard is a series about how different jobs affect workers' mental health.
Nurses do the work that neither hospitals nor patients could live without, which comes at an ever-increasing physical and emotional cost, as they are expected to aid sicker patients for longer hours with less support.
Otherwise, nursing could easily be the best job in the United States—the Bureau of Labor Statistics estimates more than 400,000 new jobs will be created by 2024. In five states, the average pay clears $85,000, with nursing jobs in California crossing into six figures.
Those numbers are no surprise to those who are aware of how much older the nation’s old are, and how much sicker they are, too: By 2030, there will be 70 million people over the age of 65, of which an estimated 14 million will have Alzheimer’s and more than 50 million will have at least two chronic health conditions.
But just as the need for nurses is increasing, so too is the price for devoting one’s life to the direct care of strangers. Nearly a quarter of hospital and nursing home nurses aren’t satisfied with their jobs, according to one study, and more than a third feel burned out. “Burnout is an occupational hazard in nursing,” says Jeanne Geiger-Brown, dean at Stevenson University's School of Nursing and Health Professions. “It is hard to generate a lot of caring about other people, because you are so depleted yourself.”
Burnout, of course, is caused by overwork, but what causes overwork is more complicated and reveals how the cost-cutting priorities of hospitals force their nurses to pay an emotional tax.
“What’s causing the overwork is the increased acuity of patients,” says Susan Letvak, a professor at the University of North Carolina at Greensboro School of Nursing. “You are only in a hospital if you are so acutely sick that you can barely move. The minute you can move, you are kicked out the door.”
"The push is to get everybody out of the hospital as fast as we can,” echoes Bernadette Melnyk, dean of the College of Nursing at the Ohio State University and the university's Chief Wellness Officer. Melnyk and her colleagues recently published a paper that shows depression among nurses is associated with both burnout and medical errors.
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Getting people out of the hospital “quicker and sicker,” as a few Harvard health policy researchers explain, is a response, in part, to Medicare’s prospective payment system, which pays a fixed amount for a diagnosis no matter the length of stay, and the need for open hospital beds. If that formula seems designed to create higher rates of readmission, well…yeah. Even so, there’s also a financial incentive to avoid having people readmitted.
How does the quicker and sicker approach add up for nurses? Physically, it means the shifts themselves are much harder, especially since shifts are often twelve hours to begin with, which itself is a risk factor for burnout and mistakes in a place where patient alarms are constantly sounding. “It’s not healthy for the nurses, it's not safe for the patients,” Melnyk says.
Emotionally, the quicker and sicker model means the long hours are engineered to be less fulfilling. “It’s not very satisfying to just put bandaids on people who are really quite ill,” Geiger-Brown says.
When the hospital is successful at turfing patients to home or anywhere else, you might expect nurses to benefit somewhat: Fewer patients on a given day could mean a slower shift and a chance for a break. But that’s not how it often plays out.
“Minimum is maximum staffing,” Letvak says. “We don’t have any easy days anymore. If the [patient load] is low, which happens all the time, they send the nurses home, instead of them having a light afternoon. How few do we need? That’s all that you’re getting. Every time you are at work, it is a bad day. There really isn’t a chance of having a lighter day anymore.”
Yet nurses should have the lightest days possible—like air traffic controllers, they do a job in which we accept no room for mistakes. Suppose you know that the ideal number of patients for a nurse is four—would you want to be number five?
While it may seem like a water is wet revelation to say nurses should care for fewer patients rather than get sent home, take a look at the work of Linda Aiken and her colleagues at the University of Pennsylvania. They have shown just how many lives are on the line when nurses are overworked. Give a nurse just one patient beyond four and the chances of that patient dying shoot up 7 percent and the chances of that nurse getting burned out climbs an astonishing 23 percent.
Overworking nurses extinguishes their lifesaving impact. Aiken and her team have shown elsewhere that every ten percent increase in the proportion of nurses with bachelor’s degrees lowers the risk of death for patients by five percent. A study by a different group found that a 10 percent increase in registered nursing staff saves five lives for every 1,000 people discharged. (If five saved lives doesn’t sound like a lot, try replacing “five” with five names of your loved ones.)
And while nurses care for a sicker and older population in an environment that is a burnout and depression generator, they may avoid mental health care for themselves, fearing that a hospital concerned first-and-foremost with the bottom line will use a mental health diagnosis against them.
“Think about the legalities,” says Letvak, who teaches on law and policy. “If a nurse made an error and something were to come out that they had depression, and then you can see the research that links depression and errors, that nurse just exposed herself to potential liability.”
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