I believe there is more to say about the “nurse as patient,” a necessary shift in our thinking about the global crisis in nursing. Let me start by describing an article I use in one of my courses. This semester, I am the instructor of record for a PhD-level innovations in healthcare course. As I explain design thinking and how innovative approaches are distinct from typical problem solving, I ran across an article by Hagland (2022): “CFOs look at staffing shortage crisis – and its RCM and automation implications.” The intended audience is chief financial officers (CFOs), and Hagland (2022) takes the perspectives of those in the business of tracking the business of healthcare services. The paper was enlightening and dismaying. Based on the tone, the language/discourse, and recommended solutions, I can conclude that nursing has a public relations problem because the audience of this paper, CFOs, are seemingly oblivious as to the why nurses are leaving en masse, and the solutions proposed are disconnected to this reality. Through interviews, Hagland (2022) summarizes solutions put forth by CFOs and others, including automation for “resource planning,” using artificial intelligence and machine learning to “focus on the value of the work we’re doing to keep people well” (quote from Jennifer Marion, FHFMA, CPA, CGMA, senior vice president and CFO of Franciscan Alliance, Inc., p. 6). There you go. Nurses are seen as costs, the shortage a big inconvenience in healthcare business. This is not a new paradigm of thinking; but what is troubling is that this paradigm has outlived its usefulness and in the words of Kuhn (1970), normal science within this paradigm is no longer viable as anomalies become apparent and incommensurability abounds.
To introduce a new paradigm, my thesis is that the difficulties in nurses cannot be reduced to numbers or quantities: number of nurses, wages, AI, ML, and revenue cycles. If you want to consider solutions, there is the issue of quality to consider and not merely in the context of quality patient care, but the quality of nurses’ lives as they carry out the work of nursing. Nurses deal with the unspeakable (Herman, 1992; Georges, 2013) and when the unspeakable becomes overwhelming and traumatic, nurses choose to leave their jobs and the profession rather than be exposed again, and again, and again. Nurses saw and experienced many “unspeakable” things during the pandemic with some individuals still coping with posttraumatic stress. My own research testifies to this – as I interview nurses in recovery from substance use, their flat voices reflect their flat affect. They describe the unspeakable, which Georges (2013) describes:
The “unspeakable” has great power. It has the potential to create unequal power relations that result in violence and to render compassion impossible. In sum, it has the power to destroy nursing (p. 7)
Georges (2011) also asserts that the “unspeakable” creates a space where self-compassion and compassion for others is diminished or “nearly impossible” (p. 131). One nurse, a 20-year professional in the emergency department sadly stated, “In all my years, no one, no one, ever debriefed me after a bad episode.” So what are the choices given to nurses when faced with the unspeakable, when debriefing and seeing the nurse as patient who has endured trauma (Foli, 2022), the nurse as wounded healer (Conti-O’Hare, 2002) are ignored?
As I type this blog, approximately 15,000 nurses in Minnesota are on strike (Alltucker, 14 September, 2022). They list short staffing and underpayment as reasons – and they’re not alone. Several states have seen increasing union and collective bargaining strikes or near strikes by nurses. As traveling/agency nurses worked alongside organization-based nurses during the pandemic, salary comparisons were made with “travelers” making considerably more, tens of thousands more, than the organization-based nurses. Once that genie was out of the bottle, there was little turning back. Again, this genie was more than merely the dollar amount per hour; it was also about the nurses’ perceptions of fairness, loyalty, and equity.
There is another element of nurse suffering that alarms me. From three distinct data sources, I have learned of the practice of nurses attempting to normalize their alcohol intake. Nurses who responded to an open-ended question in a study I conducted during COVID (Foli, 2021), another in my current study of nurses in recovery, and a master’s student who described her ICU colleagues, statements such as these are reported: “I had a couple of bottles of wine last night. But you probably did too, right?” There is a need to check to see if the nurse is drinking the same amount as their colleagues, to validate they are not drinking in excess when compared with their peers.
The question of how we as nurses frame what we do has never been more critical, and subsequently, how do we influence those with the power to make financial decisions? When we discuss staffing, it’s not just about the tasks we perform, the IV insertions and pumps monitored, the sterile dressing changes, the food trays delivered…. It’s about our presence with the patient and the art of nursing; it’s about knowing ourselves and valuing our ontological selves as nurses; it’s about our ability to think and act ethically; feeling competent to provide quality care through empirical knowledge, and it’s about our emancipatory knowledge that fires us into thinking about issues surrounding social justice (Chinn & Kramer, 2021). If healthcare organizations are really interested in retention and tackling nurse burn-out, compassion fatigue, stress, and trauma, these ways of knowing, in balance, need to be appreciated and the unspeakable acknowledged. In this appreciation and acknowledgement, the organization can assume a trauma-informed culture, an overt awareness that healthcare is a business of frailty of the human body and soul. And about healing the nurse as well as the patient, as stated by Herman (1992):
Atrocities, however, refuse to be buried. Equally as powerful as the desire to deny atrocities is the conviction that denial does not work…Remembering and telling the truth about terrible events are prerequisites both for the restoration of the social order and for the healing of individual victims (p. 1).
Only by acknowledging and fully understanding the work of nursing will those in power understand that their old paradigm no longer explains reality. The paradigm and day-to-day normal science of categorizing nurses as costs, nurses as doing tasks, nurses as non-patients who are immune to trauma and the unspeakable contribute to the crisis; these views of reality are unable to reconcile the continuing surge of nurses who leave the profession, triggered by the unspeakable events of the COVID-19 pandemic. I sincerely hope that the profession I am part of, that I honor, can create a new paradigm that reflects the joy and hardships of nursing. In this way, nurses can heal so that they can, in turn, care for patients.
*This is a follow up to the blog posted on June 28, 2022. Since its posting, I was invited to present a webinar for Sigma Theta Tau on “Nurse as Patient: Individual and System Implications,” – thank you Liz Madigan! The recording of this webinar, attended by nurses from 11 countries, now resides in the Sigma repository, available to anyone, at https://sigma.nursingrepository.org/handle/10755/22788.
Also see Dr. Foli’s Middle Range Theory of Nurses’ Psychological Trauma
References
Alltucker, K. (14 September, 2022). Pay, staffing and fatigue: Minnesota nurses strike highlights worsening shortages across US. USA Today. https://www.usatoday.com/story/news/health/2022/09/14/nurses-strike-minnesota/10361103002/
Chinn, P., Kramer, M. & Sitzman, K. (2021). Knowledge development in nursing: Theory and process (11th ed.). Elsevier, Inc.
Conti-O’Hare, M. (2002). Nurse as the wounded healer: From trauma to transcendence. Jones and Bartlett Publishers.
Foli, K. J. (2022). A middle-range theory of nurses’ psychological trauma. Advances in Nursing Science, 45(1), 86-98. doi: 10.1097/ANS.0000000000000388
Foli, K. J., Forster, A., Cheng, C., Zhang, L., & Chiu, Y-C. (2021). Voices from the COVID-19 frontline: Nurses’ trauma and coping. Journal of Advanced Nursing, 77, 3853-3866. doi: 10.1111/jan.14988
Georges, J. M. (2011). Evidence of the unspeakable: Biopower, compassion, and nursing. Advances in Nursing Science, 34(2),130-5. doi: 10.1097/ANS.0b013e3182186cd8.
Georges, J. M. (2013). An emancipatory theory of compassion for nursing. Advances in Nursing Science, 36(1), 2-9. doi: 10.1097/ANS.0b013e31828077d2.
Herman, J. L. (1992). Trauma and recovery: The aftermath of violence. Basic Book.
Hagland, M. (2022). CFOs look at staffing shortage crisis – and its RCM and automation implications. Healthcare Innovation. https://www.hcinnovationgroup.com/finance-revenue-cycle/article/21268550/cfos-look-at-the-staffing-shortage-crisisand-its-rcm-and-automation-implications
Kuhn, T (1970; 2012). The structure of scientific revolutions. University of Chicago Press. (50th Anniversary Edition; Introductory Essay by Ian Hacking).
Thanks for this important and necessary reflection on the work of nurses!
We definitely need a new paradigm, not only for nurses but for all workers, many of whom are our patients. Nurses are seen as “costs” and CFOs propose “solutions” such as “resource planning” and artificial learning because our entire healthcare system is based in neoliberal economic theory.
Since the Reagan administration, our government has followed the principles of neoliberal economic theory as laid out by what is known as the “Chicago School of Economics” at the University of Chicago starting in the 1960’s. Neoliberal economic theory sees the role of government to be that of supporting the market and NOT providing support or social safety nets to its citizens.
The name of this theory is misleading because people tend to understand the term “liberal” in the context of political ideology. The name is related to liberal economic theory- such as that of Keynes- and has nothing to do with progressive, liberal thought on social issues. Every administration since Reagan has followed this economic theory and policy.
Neoliberal economic theory says that everything should be subject to marketization- goods and services like utilities (including water), housing, healthcare, education, transportation, social care, etc., should be provided by commercial interests with as little regulation as possible. Within this economic theory and framework, the government’s main function is to provide a framework for private enterprise.
Nursing has, from what I can glean from 38 years as a practicing NP and 22 years as a nursing professor, whole-heartedly embraced the Western metaphysics of individualism, competition, and consumerism driven by neoliberal economic theory. Within that neoliberal theory, we teach nursing students to produce informed “consumers” for whom “patient education” is the major, if not only, intervention to attempt to “educate” the structural violence of racism, poverty, trauma, and discrimination out of their bodies. I have had numerous doctoral students point out the contradiction in nursing between teaching students that healthcare is a human right and our role as healers and at the same time embracing neoliberal economic principles.
If we want to stop the hemorrhaging of nurses out of healthcare, we need to become activists working collaboratively with other healthcare providers, other workers, and our communities to disavow ourselves of Margaret Thatcher’s notion that “There is no alternative” to neoliberal economic theory. There are many alternatives and thousands of activists like me, from all different disciplines, are already working collaboratively on building those systems.
wonderful article. needs to be read by all. Amazing to read “unspeakable experiences and trauma! I’m looking for Nurse as Patient#1 as I somehow missed it