SARAH: This is At the Core of Care, a podcast where people share their stories about nurses and their creative efforts to better meet the health and healthcare needs of patients, families and communities.
I'm Sarah Hexem Hubbard, Executive Director of the Pennsylvania Action Coalition and the National Nurse-led Care Consortium.
As part of our special COVID-19 pandemic coverage, we’re going to spend this episode and the next one hearing several different nursing views on the impact of burnout and what we can do about it.
Dr. Ali Tayyeb is our guest for this episode, and he doesn’t even use the word “burnout” anymore.
ALI: At this point, I've changed the word for myself anyway, to burndown. Because it is very much systemic, and not an individual thing.
Based in California, Ali is a registered nurse and a United States Navy veteran who specialized in combat trauma. He’s currently an assistant professor at California State University Los Angeles, where he teaches a range of courses, including nursing leadership, nursing research, informatics and ambulatory care. Ali is also the host of a podcast called RN Mentor and enjoys making art in his free time as we’ll hear later.
SARAH: The word burnout, or as Ali calls it, burndown has become increasingly synonymous with the health care professions. And many of us connected to this sector have experienced its impact personally or secondhand, or sometimes both ways.
We asked Ali to share his reflections with us on how we even got to this point in the first place.
ALI: I think it's something that's been with the profession and the healthcare profession period, along with other professions. It's something that is a realistic fact for us. And you can only mitigate it so much with your own personal actions. And I think that's important to note. We promote a healthy, pre-pandemic, promoted healthy lifestyles, healthy eating healthy, you know, exercise, yoga, meditation, mental health awareness kind of campaigns and things like that, but most facilities are wore at the time, probably lucky if they had one, sort of the Employee Assistance person who tends to be a licensed family social worker, or something like that, that helps with when staff have any kind of issues. It was private. It was free services. And they tend to be, you know, in the basement of the hospital somewhere in the back corner, the little tiny office. So that was really the whole intervention that you know, most organizations have in place to help, and this was pre-pandemic, right.
I see the word burnout a lot. And for me, burnout always feels like something that I did that caused it. The reason I say it's systemic is because if you look at, like, for example, staffing, which is a huge issue, which became more apparent during the pandemic, healthcare systems, we staff to the minimum, right? What is the minimum requirement that we need to have on hand in order to take care of the patients? And it's a business model. It's a money thing. Healthcare systems are businesses. And I think we need to be realistic about that, that healthcare systems in the United States are a business. Even the nonprofits are still a business? They still have to pay salaries and retirements and all that stuff. So they still have to make money. So it's run like a business, and that's why usually have the upper echelons tend to have like an MBA somewhere in their alphabet soup, right. So for that reason, I think we need to be aware of how hospitals and healthcare systems run. And by saying that we staff to the minimum, that means we have minimum number of people that are available. And when one or two of those people all of a sudden are out of that system, the system really feels it. So the California we’re luckier than most other states, we have ratios. We have patient nurse ratios. But when California did that, a lot of hospitals, again, with the business model in mind took away a lot of resources when the ratios came into place. So the idea around the ratios was that we do ratios, but we keep the resources. But when the ratios came into place, a lot of hospitals took away those resources. So it helped. But n other ways, it hurt us.
And I know there's other places in the US that those ratios don't even exist. So the whole model from perspective is a bit broken. So when you deal with these things from a business in a systemic. When you look at it from a systemic perspective, staffing is a huge issue. Pay discrepancies is a huge issue. And benefits are a huge issue, right. So whether you're unionized or not unionized. If you have advocacy for the work that you're doing. When you look at the sort of a hierarchial system that exists within healthcare, healthcare systems where physicians are put on top, and nurses, you know, are the ones that are taking orders from the physicians, instead of that collegial environment. Some systems do a beautiful job at having that collegial environment, most places are not there yet. So you have this top down mentality, where it doesn't work. And it creates friction between the different professions within the healthcare system. And also it creates these silos. So you don't feel you're part of a team, but you're more of a worker within a system and you're paid your salary, and you're supposed to do your job type of thing. So all of those things contribute, and then you add on to everything, your 12-hour shifts, and working sometimes four or five days being called in on your days off. And again, that’s paid time, but all of those things that are in place add to those stressors, and when you add those stressors up it causes that burn out. And I call it burn down because it's systemic. So the systemic is actually the system is burning you down from forcing you into these situations where you are under such stress.
SARAH: And all those issues Ali just laid out for us are further compounded by the nature of the work, as we’re about to hear.
ALI: In the healthcare field, we deal with a lot. We deal with people who are not feeling their best, sometimes we end up being the outlet of their frustrations and their anger of what's happening to them. Especially with nurses, I know, physical abuse by patients is a realistic fact for us, which shouldn't be tolerated.
We tend to deal more with the patients, with their families. We’re usually the first person that they see and the last person that they see, and sort of in between 24/7, especially in the acute care area. So I think, just for those reasons, we tend to have be an easier target. Especially we, a lot of times, we establish more of a relationship with those individuals. So when things go wrong, or things don't go the way they expect, it's a more personal let down with them with that nurse, rather than then something that they can, at the time, objectively kind of quantify in their own mind. So I think for that reason, just for us being around, and we're usually the ones that are more accessible to them.
Overall, I think the entire system was not built to deal with what's happening now. We deal with a lot, and we can't just shut all of that out, we take some of that in. So that's why there's issues, for example, with nurse suicide, which goes back to how we are taking care of the professionals in the health care field. And by professionals, I mean, anybody who's working in the healthcare field, all the way from the physicians that tend to run most organizations, to the EVS workers that are doing the very necessary job of making sure everything's clean and everything is tidy, so there's reduction of infections and things like that. So I think when I say professionals, just want to clarify, it's everybody that is working in that arena.
SARAH: And once the pandemic hit, Ali says the ripple effect of everything he just described, on top of the current nursing shortage and increased demand for critical care nurses for example, has only amplified these stressors.
ALI: Now with how the system is completely strained, everybody is kind of working to the max. In addition to that what the system did because it created this shortage of nurses, now we see systems who are I want to say on the higher tier of like they care. Think of the whatever big hospital in your system that has lots of money. Now those hospitals are now offering somewhere around seven to $10,000 a week for travelers. Now I we've seen this happen to L.A. where they've gone from a community hospital which is serving the community, a lot of Medicare/Medi-Cal that those types of patients, which doesn't have those kinds of funds lose nurses to a travel agency, and they have gone cross town to one of the bigger hospitals working for $7,000 to $10,000 a week. So they take like a three month assignment for $130,000. I can't really blame them because of the working conditions. Working conditions really are not the best across the board. So a lot of the people that I've talked to, they're like, well, if I'm going to be in a system where I'm not necessarily being taken care of, and being paid what I'm being paid, I might as well go into a system, again, not being taken care of, but at least I'm getting paid more. Because again, at the end of the day, some nurses are going to go where the money is.
And we're also causing an international effect, because now we're recruiting internationally. And we have these third world countries where they don't have the funds, but they have nurses, but those nurses are being recruited into the U.S. system making ridiculous amounts of money. But then we're leaving these countries shorthanded. So we're causing this international drain of qualified nurses. And it's not just any nurse, especially critical care nurses, not everybody comes out of nursing school as a critical care nurse. That is with its own specialty. If somebody went into a critical care area, it will take anywhere between six months to a year for them to become an independent critical care nurse. And they're not growing on trees, so that within itself, because of the pandemic and all the ICU and critical care patients cause even a bigger drain in that arena. So it's not ideal. It's not the best situation. But what the pandemic did do is significantly show how there is a nursing shortage.
SARAH: As nurses and other health care providers continue to promote vaccine confidence, they’re increasingly providing critical care for unvaccinated COVID-19 patients.
And in some cases this is leading to more burnout as colleagues fall ill to COVID and staffing shortages persist.
From what we’ve heard at the National Nurse Led Care Consortium from providers around the country, this dynamic has been challenging. We asked Ali to share his perspective.
ALI: I mean, at the beginning of the pandemic, I think, just everybody in the healthcare field was super motivated to help the people even though we were losing a lot of people. They were still very motivated to help the people that were coming in the door because there was no mitigating factor such as vaccines that we know are effective. But now, it's a sort of a punch in the gut. And I think that's when you see people that have the ability to be vaccinated and reduce the chances of not only themselves being infected, but infecting others. And I think that's the big misinformation that exists out there, that by not being vaccinated, you're only impacting yourself. Well, that's not true. Let's hypothetically say you are the only one being impacted, you're still going to probably get sick. You're probably going to be hospitalized. And you're taking the place of somebody who was having, for example, a heart attack or a stroke, or some other chronic condition that they need hospitalization for. Or even acute. You could be in a car accident, right, and need hospitalization to go to the ICU. But now the ICU is filled with a bunch of people that are just unvaccinated. They chose not to be vaccinated, and now they're in the ICU as COVID patients. So you're impacting those people that way. So that's frustrating in itself.
But now let's take the fact that these unvaccinated people also can be infectious even though they could be asymptomatic. They still can be infectious and impact those individuals that have multiple health conditions and have comorbidities. And now you're putting them at risk. We're putting at risk the children that are not vaccinated, right. So now you're impacting them. You're impacting elderly people, you're impacting people who are immunocompromised. Because being immunocompromised also puts you at risk for higher chances of being infected and being hospitalized. So I think the frustration and the anger that you may see coming from the healthcare field is two years ago, they were being clapped for. They were banging pots and pans together. There were heroes signs everywhere, which is a whole other issue that I'm not going to talk about, but we had all these signs everywhere, and everybody was for the health care system.
But now the people that we're seeing coming through the door are the anti-vaxxers, anti-maskers. And with that comes the mentality of being resistant to the healthcare system, the nurses and physician that are trying to help you. And it just doesn't make sense, for us, it doesn't make sense. We're still going to take care of them from a healthcare perspective, because that's what we do. But we wish it wasn't because of their own neglect And part of it is because this whole thing has become political. And I'm not going to get into the political component of this. But a lot of this has become political, and a lot of misinformation out there, like in some media areas. A lot in social media. And it's unfortunate, because those social media, and the TV, cable, whatever it is that those individuals are listening to, and what they're being fed is very much hampering the system and it’s not allowing it to recover. And really, for us to be able to take care of the people that really need to be taken care of if everybody was vaccinated. We would still have some people that are going to be hospitalized. But the severity would be less, and we will still be able to have the surgeries and not cancel any. We still will be able to take care of everybody else we need to take care of because of all the other health conditions that exist in the world and all the accidents that happen in the world that put people into hospitals.
SARAH: Given everything Ali has shared so far, we’re left wondering what can be done at a systems level to mitigate burnout. And for Ali, he sees an opportunity here to reframe what resilience means.
ALI: Again, this is a word I dislike is resilience training. I know a lot of health care organizations have turned into like they've drank the Kool-Aid on resilience training. It's sort of like giving somebody a fire extinguisher when their house is completely engulfed in fire. It's like that fire extinguisher is not going to do a whole lot. I'm all for resilience training. But maybe, maybe in school at the beginning of school, like we give them some tools, you know, this is how you decrease stress, this is how you take care of yourself. But then we have to have other things in place like proper staffing, proper pay, proper resources. Those things still need to be in place. I have nurses right now that are working five, six days a week, 12 hours a day. They're getting paid for it. But that's not it's not helping the fact that you're going to be burning them down along the way. Right. That's not a sustainable workforce. We're seeing nurses leave the bedside altogether and go do other things. Because this is not a sustainable model.
And part of it has to do again with the fact that we're not staffed properly. We don’t have the right people in place. And now and for the last two years, we've seen hospital systems shut out schools of nursing, that need to be in clinicals to graduate to go to work, but we're seeing hospital systems shut out schools of nursing and say, sorry, you can't come because of the pandemic. I'm like, You're short nurses. But you're putting this barrier for nurses to be able to get through schools, graduate and go into new grad programs also kind of disappear in some organizations, like you don't have the systems in place to support a workforce push into the hospital systems. And again it's a business model that the healthcare system has had for forever, and it doesn't work. We need to really look at this and say, We need to significantly grow our nursing force. We need to remove scope or barrier practices. And I think that's really what's going to help the system in the long run. I think right now it's too late. Because there's no way we're going to make enough critical care nurses to take care of what we need without. So can support systems be in place? Yes, to a degree, but again, I don't think it's going to make a lot of it's really, it takes time, it takes money, and we're behind the eight ball already.
So I appreciate resilience training. But it's like resilience training, but you're going back into a hostile environment still. And some people I know they've compared it to like combat or being in the military. And to a degree it is because, some of the same PTSD and things like that exists with our nurses, because every day they're going back into this hostile environment and the administrations for many organizations have, you know, like their intervention has been, ‘oh, take a resilience training class.’ And for me, that would be more of a stressor, like you're going to make me take a class on resilience, that and then I'm going to go back into the same environment that is hostile, Short staff, don't have the resources, don't have enough nurses or LVNs or CNAs. And so I think the whole system we're behind the eight ball and we're not doing what we need to do to catch up.
SARAH: On a personal level, we asked Ali to share how he’s dealt with stress throughout the pandemic and the creative outlets he’s cultivated to support colleagues and others in the health professions.
ALI: I feel for my colleagues who are at bedside. I wish I could do more. I have. I had some of those things in place already. Just because of my own life experiences. I have PTSD from my military days. So I picked up some healthy habits along the way. I've been an artist, and it feels weird calling myself an artist. I'm a person who likes to do art. [LAUGHS] So I mean, art has been an outlet for me a couple of years ago when the pandemic happened, and I used art as an outlet for me to get information out about the nurses that we were losing, the health care professionals we were losing. The lack of PPE in the system and things like that. So I use art as a way to get information out as to what's going on within the system.
One of the first things I did because I was not at the bedside. But I was seeing through social media, and I was getting texts from my former students and things like that of what's going on? And I can't tell you how many phone calls I got from people that I knew. And there were just conversations that had to be had, because when I saw them there, they weren't doing well. So I'd give them a call or text them say, ‘Hey, what's going on? Do you need to talk?’ A moral support type of thing. And all of a sudden, I realized very early on that people didn't know what this necessarily was and what they need to do and how they're supposed to get everything they need. And I started looking at the headlines. So I ended up something that I've never done before. I started working on sort of this sculpture, and the sculpture is called The Healthcare Professionals. It started out as the Health Care Professionals Memorial Art project because we saw so many health care professionals dying right off the bat, and that was very impactful for us because we have never seen healthcare professionals die in these numbers. And that was very jarring for a lot of us.
So the Healthcare Professionals Memorial Art Project really came about in a way where I did this 3D sculpture. I had actually 14 Incredible nurses from across the country actually donated their stethoscopes for the project and a sculpture which has a figure of a healthcare professional in the middle. It's a huge paper mache. It's seven feet by nine feet, three panels, and it is covered with the 14 stethoscopes and the 14 stethoscopes each have a plexiglass in front of them. And that was really symbolic of the Plexiglas world we've kind of transitioned into. And the figure itself and the panels themselves are all covered with the news headlines that was happening between early 2020 all the way till I finished it in fall of 2020.
So about 400 hours or so went into making this and it was really therapeutic for me. It was a way for me o understand and grasp what was going on in the world. But it was also a way for me to try to share that. And that piece ended up actually getting picked up by several newspapers across California. The American Journal of Nursing actually published it in May of 2021. It's just a way for me to sort of not only de-stress but try to comprehend what was going on. So the art piece really had to do with that. And I've used several of the doodles that I've done over time as a way for me to get information out as to what's going on in the world, with the pandemic. And I use it for other stuff too. But it was a creative outlet for me where it helps me deal with what's going on and things that we're dealing with.
SARAH: Besides making art, Ali has spent a lot of time hiking with his wife. And early on in the pandemic, he also started a podcast called RN Mentor.
ALI: I have a project in my nursing leadership class, that I put my students in groups, and they reached out to people who I said are at sort of at the peak of the profession, right? Like the people who are running nursing organizations, people who are doing research in academia, that are doing great work. And I gave them a list of different places they could look and these groups would find these individuals, email them, talk to them, get in contact, look at their CVs. So they can see the profession of nursing as just not only bedside but the impact that we have internationally, in policy, in academia, in research. We’re everywhere. So getting them to see what the scope of the profession is. So when the pandemic happened, people stopped returning emails and phone calls, because everybody was overwhelmed. So I said, You know what, I know a couple of people, I can record them and share it with my class. And after I did that first recording, I said, you know what, I actually am going to give my wife credit for this. She said, why don't you do a podcast? So that's how the podcast came to be. And you know, now we just kicked off season five of the podcast. I've had the honor of meeting some incredible incredible, not some, all of them are incredible nurses and nurse advocates that are doing incredible work, and I'm so privileged to have had the opportunity to talk with them and share their stories. But it really is. It’s their nursing journey. It's how they got to where they are and the incredible work that they're doing now.
So I think it's important for nurses to take a step back, take a look at what they need to do to take care of themselves. And whether that's to take a few days off, they need to take a few days off. If they need to get out of town, they need to get out of town. If they want to pick up a hobby, pick up a hobby. Like some of the things they used to do that they don't do anymore. That was a healthy outlet for them, go back to doing those and taking care of themselves. Because I think what a lot of nurses have done is put those things aside because of what's going on now. And I know it feels sometimes it feels, not sometimes, it always feels selfish when I say this, that I need to take care of myself in order for me to be there for my students, my family and all that stuff. But that's an opportunity for me to make sure that I'm healthy, and I can provide a healthy environment for the people around me. So if there is one advice that I would say are good outlets or good ways to, for us to go back into the mindset where we know we're going to go back into these environments that may be hostile, or may be difficult for us.
But we need to go back to what was making us happy and healthy, and try to replenish. We're never going to be replenished. Like we were prior to the pandemic until this, whatever this is, subsides and life sort of goes back to normal. But I think we need to go back to the healthy habits that we had. Or if we didn't have any, we need to build some of those healthy habits.
CREDITS:
SARAH: Next time on At the Core of Care, we’ll talk with another nurse leader about mitigating burnout at a systems-level.
Support for our special COVID-19 pandemic coverage comes from the Centers for Disease Control and Prevention.
You can find our most current and past episodes of At the Core of Care wherever you get your podcasts or at paactioncoalition.org.
For more information about related upcoming webinars and where to find COVID-19 resources, log on to nurseledcare.org. And you can stay up to date with us on social media @NurseLedCare.
At the Core of Care is produced by Stephanie Marudas of Kouvenda Media and mixed by Brad Linder.
I'm Sarah Hexem Hubbard of the Pennsylvania Action Coalition. Thanks for joining us.
