1. Schwarz, Thomas RN

Article Content

Three incidents in two years led to my departure from clinical nursing. The first occurred in the ED while I awaited the arrival of a man who had crashed his motorcycle. Images of the mangled cyclist filled my head. A cold sweat broke out on my forehead, and then the world drained of color-a trick of the mind I had first encountered a year earlier when a motorcyclist died after striking my car.


The second incident occurred later, after the unsuccessful resuscitation of a hunter who had been shot accidentally. While I was performing postmortem care, a patient care representative quietly asked whether I would like to speak to someone? "Someone?" I asked. "An employee assistance counselor," she said. A psychiatrist, my mind heard. Other nurses didn't seek counseling after such tragedies; why would I?


The third incident came before one of my last midnight shifts. I stopped the car on my way to work and, in the early spring darkness, my heart pounding, prayed, "Please, God, don't send any patients tonight!! I can't do this anymore!!" I was burned out.


It is my belief that primary and secondary (vicarious) posttraumatic stress disorder (PTSD) play a role in the exodus of nurses from our profession. They sure did in mine. Many researchers have sought to determine reasons for the nursing shortage. One often cited is burnout, a state of emotional and physical depletion that I consider a subspecies of PTSD, which is often accompanied by an aversion to work and is caused by repeated and unrelieved workplace stress. Or as a friend of mine puts it: "How much can you take?" Apparently, some of us have limits.


I have attended many nursing conferences in my six years at AJN. I frequently ask attendees, "Were you taught anything in school about burnout or PTSD among nurses? Have you ever been offered counseling after a traumatic incident at work?" Universally, the answer to my questions is no.

FIGURE. Apparently, ... - Click to enlarge in new windowFIGURE. Apparently, some of us have limits.

A nurse's seeking help when experiencing PTSD should not be viewed as personal weakness, nor should it be seen as dangerous to one's career. Some nurses become quickly overwhelmed by distress and leave their jobs, while others stay for decades, seemingly emotionally undaunted. But most nurses' responses to the stresses of their work fall in the middle of a bell curve. Burned out but functional, they're unaware of-or deny-the cause of their headaches, gastrointestinal troubles, insomnia, eating disorders, smoking, addictions, and ragged emotions displaced onto partners, colleagues, and patients.


When I began nursing in 1979, I was inured to patients' pain. Over the years my sensitivity grew-for several reasons, some of which I don't fully understand-until I couldn't take another shift. Whenever a nurse quits her job, everyone pays: units are left shorthanded, patients suffer higher rates of medical errors, and the ex-nurses haven't addressed the roots of their angst.


But at the 2004 Emergency Nurses Association annual meeting, Jane Metzger, DNSc, RN, senior vice president and chief nursing officer at Rhode Island Hospital in Providence, and other nurses discussed their emotional responses to caring for more than 60 people who were critically burned in a nightclub fire two years ago. Metzger and the hospital got it right, providing critical incident stress debriefing-provided by teams of mental health care professionals to minimize job stress after a crisis-within 48 hours to all nurses who worked the night of the fire.


Too often, health care professionals suffer in silence together. In order to stanch the flow of nurses from the profession, nursing schools must put more emphasis on burnout prevention. Hospitals, nursing homes, and visiting nurse services must provide confidential and effective counseling to all employees. Research should attempt to determine the optimal interventions and establish why some nurses seem not to experience PTSD. Most important, nurses must acknowledge the burdens they bear and the emotional and physical tolls those take. They might just be adding to the crisis in nursing.