Nurse Retention and Burnout: Is it Rocket Science?
Over the last several years of my nursing career, I have endlessly heard discussions about burnout, directly experienced it, and read countless research studies on the issue. I have listened to managers and corporate leaders discuss the issue formally and informally. But it wasn’t until recently that my opinions of burnout and nurse retention shifted.
I casually ran a poll on my Nurse Abnormalities Instagram account, thinking the response would be like any other poll I have previously run. Meaning, I would have 25-50 replies and the replies would cease after a few hours. I asked two questions on my poll:
Would more pay increase your job satisfaction?
Would better nurse to patient ratios increase your job satisfaction?
Then I asked:
If you could only pick one of the two, which would it be?
And I requested for the responder to directly message me an answer.
While I realize this is the simplest form of research, roughly 6700 followers saw my first question and 88% replied that higher pay would increase their job satisfaction. Roughly 7300 followers saw my second question and 98% said better nurse to patient ratios would increase their job satisfaction. But, the direct messages I received were the most telling.
I had to take the post down because in less than 12 hours I had 253 direct messages. I logged them all on an Excel spreadsheet and typed up the answers. Seventy-four percent of nurses responded that they would choose better nurse to patient ratios over pay. Of the nurses who chose that they would like better pay, 51% sent me a message specifically stating they selected better pay because they lived in California where the ratios were mandated or worked in pediatrics or obstetrics with better ratios already.
But what really tore at my heartstrings were the comments accompanying the direct messages. As an ICU nurse who directly experienced burnout and felt like no one cared about my contributions to the job and as if the burnout was completely my fault, the comments made me teary-eyed at points. Here are just a few:
“Med-surg trauma nurse here, I would rest better at night knowing my patients were taken care of with better ratios, making a little more money does nothing for my conscience.”
“I choose better ratios because I just want to take better care of my patients.”
“I would take a pay cut to have better ratios. I am so burned out and feel like I am incapable of providing adequate care, that money really doesn’t matter.”
“I wish I could be the type of nurse I am on ‘overstaffed’ days every day.”
“I want to do everything I can to help patients, but ratios are so bad, even in the ICU. I have trouble utilizing my basic nursing skills like bathing, therapeutic communication, turning, and caring because I don’t have time. Then administration is constantly yelling at us for what we are doing wrong. When I leave at the end of the day, I feel like I have accomplished nothing.”
“I realize better pay isn’t realistic, I would take better ratios hands-down.”
“I feel like my talents are being wasted and that I am a failure. I had to move from an emergency department, which I loved, to an outpatient clinic because the pay wasn’t enough to balance being beaten up by patients and have 4-5 at a time, some of them being ICU status.”
“Being able to bathe, control pain, talk to, and spend time with my patients makes me satisfied because the patients are happy. Happy patients equals happy nurses. I can’t do that caring for 5-7 patients per shift.”
“The most frustrating part of being an RN is feeling like you are failing your patients. Management is yelling at you to do better, but you can’t because no single person could care for as many people as we do and no matter what you do to explain your job, no one understands, cares to understand, and no one truly trusts, experiences, or listens to your perspective. So then you just end up being quiet.”
As evidenced by just a few of the comments, the majority of nurses want their patients to be adequately cared for before anything else. Pay is either not important or secondary to better ratios. So many nurses embody the true definition of selflessness and they are reprimanded by the system for their natural way of being, thus they give up, because they have nothing left to give at all – that is the attitude contributing to burnout.
So here we are now, with countless research studies dictating the importance of better nurse to patient ratios and the effects on burnout, satisfaction, patient outcomes, and mortality. That’s right, better ratios have proven to decrease burnout, increase patient and nurse satisfaction, improve quality measures (decrease falls and pressure ulcers), and decrease mortality.
Just to be clear, a quick Google search, or in my case, a literature review in an academic library, revealed that there is a significant increase in patient mortality when hospitals have poor nurse to patient ratios. And “poor” nurse to patient ratios are the baseline for the majority of hospitals. As a patient, I would be asking how many other patients my nurse is caring for, because my chance of mortality will greatly increase if she or he is caring for over four patients, especially if I am a surgical patient.
Burnout and retention research has analyzed every last “nurse” characteristic in effort to solve the problem. High achievers are more likely to burn out, women are more likely to burn out, and in some cases ICU nurses are more likely to burn out. What has been done to compensate for this? Meditation rooms have been created that no one has time to go to, yoga classes are offered that no one has time to go to, gym memberships are free, but everyone is too tired to go to them, and finally the high achieving, perfectionistic, compassionate women who expertly care for patients are reprimanded for being high-achieving, perfectionistic, compassionate women who expertly care for patients.
Let’s talk about falls and pressure ulcers. I have experienced numerous corporate meetings discussing falls. Medicare does not reimburse hospitals for falls or hospital acquired pressure injuries because they are supposedly preventable – of course, everything comes down to money. What do we do to prevent falls? Academics have developed a tool to gauge how likely a patient is to fall and the nurses must chart the fall scale anywhere from 1-3 times per shift. We have “High Fall Risk” signage, yellow socks, and yellow blankets indicating the patient is more likely to fall. We have installed cameras in rooms and bed/chair alarms that must be activated by the nurse and if it is not activated (or does not work) and the patient falls, the nurse is reprimanded. Nurses have been told they need to answer the call light faster too. However, administration has failed to address, that there are not enough nurses to give the high-risk patients more attention, enough nurses to watch the installed cameras, or enough nurses to answer the call lights. But what is has done is given nurses yet another measure to chart distracting from patient care. The bottom line is, when a nurse is “watching” between 5-10 sick patients in separate rooms, it is not humanly possible to prevent a fall.
Pressure ulcers get just as much attention for the same reason. Administration gives us countless products – creams, dressings, lifts, etc., to prevent pressure ulcers. However, it’s hard to use any of those products when there are not enough nurses to help you turn your patients every two hours. Additionally, related to all of this, but can be discussed at length elsewhere, is the increased acuity of patients. Patients are sick. Meaning at minimum, they are more sedentary, stooling more, their nutrition is altered, and delirium is increased, putting them at an even higher risk for pressure ulcers and falls. Patients on med-surg floors are receiving blood products, regular labs, peritoneal dialysis, and IV medications and drips. Many of them are unable to feed and stool themselves. This indicates to me, that nurse to patient ratios need to be even lower than they are in already mandated states.
You may be wondering why I am referring so frequently to ICU and med-surg nurses in this post, even more so to med-surg nurses. In my experience, labor and delivery and pediatrics are some of the best-staffed places to work. I was unable to find any research as to why, but common sense would deduce that lawsuits are more detrimental in those areas of practice. When it comes to children, babies, and pregnant women, hospitals know that have to be safer because the stakes are higher. I might be wrong, but something in me doubts that I am.
While the secrecy and hindrance to providing the best patient care is most disheartening to me, a very close second is its implication on nursing as a profession. Many nurses would proclaim that we as a profession “have done this to ourselves” because we do not speak up and say no. I have even said this multiple times during my years as a nurse because 1) in some aspects of care there is some truth to it and 2) without thinking deeper and wider it is an easy default thought. However, I have developed a new perspective regarding this issue.
Nurses have a distinct personality when compared to others in healthcare. They are notoriously selfless. Anyone who has ever worked with a nurse might even deem them fearless. Much like other first responders, nurses will put themselves in the line of fire for the sake of another human without reason or warrant. They are skilled in overwhelming empathy, which is imperative to healing patients. It takes extensive understanding of the human condition to heal the human condition. Of note, neuroscientists suggest that when humans have decreased empathy, they have increased egocentrism. Egocentrism and nursing does not coincide well. Therefore, by encouraging a nurse to speak up and take a stand against a system regarding staffing (increasing egocentrism and unnatural for the nurse), might encourage a decrease in their ability to empathize. While I do agree nurses need to speak up regarding some issues, perhaps, it is the system and culture stealing the gifts and talents of the nurses and not the nurses themselves.
And for the record, it is impossible for the average Joe to realize how hard it is for a nurse to take a stand against a patient assignment. I personally have tried to say no to patient assignments. I have cared for three ICU patients simultaneously on multiple occasions throughout my career, sometimes with two of them on vasoactive medications and continuous dialysis or some other device. When faced with the choice of knowing that you have to take the patients or your nurse counterpart has to take the patients, you end up taking the patients because there is simply no one else. I have also been told my assignments were “easy.” For instance, I have been given three “easy” ICU patients. Of course, throughout my shift, one decompensated, the other two received no attention, I felt like a terrible nurse despite my efforts to keep people alive, my counterparts were equally as busy, and there was nothing I could do. There is just no such thing as a stable ICU patient.
Despite the push for change, the uniqueness of the nurse personality must exist in healthcare for the holistic healing of patients. And theoretically, it is the caring/empathizing personalities of the world that balance the egocentric/narcissistic personalities because each serves some sort of purpose in the grand scheme of life.
Therefore, the system should recognize our talents and protect them. The system should review the countless research studies proving the benefits of lower nurse to patient ratios, implement the change, and defend their patients and nurses. The culture should be preventative, and acting upstream to hire and staff more nurses instead of placing Band-Aids on a leaky dam. Nurses of this world are covered with wet Band-Aids.
But often times what should happen does not. Nice guys frequently finish last and our society is driven by money, technology, and often narcissism. So how do we fix it? Unions “fixed” California – kind of. Do we really need an agency to demand for patients to live? I guess so. What if patients knew? What if patients knew they had a higher risk of mortality in lesser-staffed hospitals – would they demand better care? Will it be the few, and the proud, nurses who fight for better ratios, or is there a way to band more than just a few together? Do we march in D.C.? I do not know the answer at this point beyond starting an open conversation.
What I do know is the beauty and necessity of this profession to healthcare and to society. I want it preserved and recognized. I want the system to stop giving nurses a machine-like amount of work and stop acting surprised and incriminating when patient care suffers. I have directly experienced better-staffed hospitals and know it is possible. I want the voice of a nurse to be trusted and respected even if not fully understood by corporate America. Without safe staffing and the opportunity to optimally perform our jobs, I worry that will not be possible. Sometimes, I even wonder if the damage done to the profession hinders our ability to get the “right” type of research to initiate a national change. This issue is rippling and cyclical, negatively impacting the nursing profession and shadowing our inherent talents on the broadest level – and that really breaks my heart. Now, I don’t believe changing ratios will fix every problem we have, but I definitely think it will help.
Finally, I also want to thank the nurse researchers who have devoted their lives and careers to this issue. Once I started reading, I just could not stop. For your reading pleasure, here are a few studies with open access to all. If you have access to a local university library, there is more current research available:
Hospital Nurse Staffing and Patient Mortality, Nurse Burnout, and Job Dissatisfaction
Nurse Burnout and Patient Satisfaction
The Effect of Nurse Staffing Patterns on Medical Errors and Nurse Burnout
Hospital staffing, organization, and quality of care: cross-national findings
Nurse–Patient Ratios as a Patient Safety Strategy: A Systematic Review
High nurse staffing ratios linked with reduced patient mortality: 3 study findings
I encourage you all to join your national and local nurse associations to get the conversation started on a local level. Here is a starting point for you:
As always, I am so proud to be included in the group of the best people I have ever known. You have no idea how unique and incredible you are – I know, I know, that is all part of being a nurse.
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