Collective Bargaining or Collective Grieving?

While I may have hung up my stethoscope almost six years ago to work more on the preventative side of the health equation, I am fortunate enough to remain in close contact with a myriad of healthcare professionals through friendships, networking and via my coaching services. Of late there has been an alarming and increasing prevalence of healthcare professionals reaching out for coaching not only for assistance in alleviating self-described symptoms of burnout and chronic stress but, lately, more often than not, to engage a partner to help navigate the decision to pursue an entirely different career path altogether.

This trend is not surprising considering the fact that according to a recent report by the oldest and largest management consultancy agency ?McKinsey & Company, nearly one third of registered nurses are contemplating leaving the field. Anecdotally, it is no better in other provider arenas such as with our physicians, nurse practitioners and physical therapists.

??So, what could be happening?

?I can only speak to what I have witnessed in my practice, what I have been told firsthand during those beloved coffee catch ups with old colleagues, and in the authentic feedback you will see highlighted in this piece when solicited via social media.

?What I have noticed is that the descriptions and experiences of these providers sounds eerily similar to those expressed by caregivers during my time as a registered nurse… in hospice. Yes, hospice. These healthcare professionals, especially post COVID-19, describe secondary trauma, helplessness and loss. Not just for patient life but for the healthcare institution itself. During the most heartfelt exchanges I can’t help but compare what they are describing to the process of grieving.

?Most of us are familiar with the five stages of grief: denial, anger, bargaining, depression and acceptance. But how can this be relevant to our current healthcare crisis and the profound shortage of the people we need to provide us with the most vital care during our most?vulnerable times of life?

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One thing I know for certain is that healing professionals, the great ones, enter the field out of a deep and fundamental desire to be an intimate and instrumental part of a system that eases human suffering. If the working conditions and environment make it almost impossible to offer this healing, how could there not be grief?

What might be seen as some of the external signs of grief being played out?

?Anger can easily be seen during walkouts, strikes, and demonstrations. Bargaining and negotiating for desperately needed change seemingly never ends at various organizational and governmental levels. Physicians, nurses and their allies express intense emotions of sadness, overwhelm, fear and of course frustration and anger. We witness division between colleagues, interhospital politics and disputes on the front pages of our news feeds.

?One health professional worded her denial and bargaining attempts as so: “I made a lot of compromises while believing wholeheartedly if I tried hard enough and gave enough of myself, I could make it better. I know I did for the patients I served directly, and for those whose care I influenced in my roles in education and staff development. But the big change I wanted to see, the cultural improvement I believed healthcare organizations to be capable of, was frustratingly out of grasp no matter how much I angled for better outcomes. My burnout didn’t come from the long hours, the thankless efforts, the lack of title, the disrespect, or disregard for my capabilities and professional autonomy. My burnout ultimately stems from chronic disappointment.”

?Many clinical staff members I have spoken to express another symptom of grief, guilt, because they no longer believe necessary change is even possible and an apathetic stance has prevailed in an effort to self-protect. Many share the familiar phrase of just “needing to get through the shift,” a depressive, gloomy shadow now blanketing their work life. What was once sacred now has become something to endure with gritted teeth and a coat of armor.

?One occupational therapist responded, “If I were ever to need to do that for financial reasons, I certainly would not invest so deeply of myself as I have in the past. I would have to maintain a transactional mindset, because ultimately that’s what it is for pretty much any major organization. The staff are cogs in a machine, to be broken and replaced with no remorse.”

Providers often describe high acuity, increasingly complex and sick patients, an exponential growth of burdensome paperwork, technology issues, chronic understaffing and insurance regulations that impede best practice and outcomes. Time spent not offering care but dealing with an almost incapacitating number of extraneous tasks. These stories offer a tangible sense of providing care in a constrained space that perhaps does no harm, but in their eyes, doesn’t do much good either. The proverbial band aid application until the next shift or the next patient.

A simple loss in job satisfaction? I think not. Because if you ask these people who they are at their core, almost all of them will use some version of the word healer. Now they are left grieving not only for the career they hoped to have, but for many, their very identity.

I remain but one humble observer, but I often search for answers and inspiration from the experts who have long studied not only human behavior but human flourishing—the potential for purpose and meaning in not just in our personal lives but what in how we earn our living.

The theory of self-determination comes to mind as a possible source of insight towards solutions because it not only applies to our internal motivation, but it also examines our desire to persist when challenges and difficulties arise. In healthcare I think we all can agree that grit is a necessary component for what lies ahead.

Self-determination’s three central tenets are offered below and accompany provider sentiments on how system barriers currently impede these three fundamental core needs from being met. While this is but the tip of the ice burg, the heartfelt input from those who have already left the field offers plenty of a valid discussion points and perhaps, with contemplation, some ideas towards resolution.

?Autonomy

?Fundamentally, are workers able to make choices and choose actions that are in accordance with their training AND values?

?In my past position in home health, wound care treatment choices were sadly not solely based on what would heal the wound in an expedient and safe way but how expensive the dressing care was to the organization.

Recovery and care choices are directly hampered by a lessor payor reimbursement.

Sadly, these types of factors are common provider complaints. Best practice autonomy thwarted due to financial pie charts and mathematical reimbursement equations.

Another example is expressed by this healthcare professional: “Lack of autonomy: being provided parameters around how many visits could be made for a particular type of diagnosis and having to make calls to a supervisor and justify recommendations outside of that range and gain their approval” even though in this case, as in many, healthcare supervisors area of expertise was business and non-clinical.

?Some questions leadership may consider are:

?Can workers utilize professional knowledge and experience to contribute to clients’ plans of care?

?Are fundamental changes to staffing and protocols subjected to open forum and discussion with all members of the department including night shift?

Just as important, is leadership acknowledging and implementing on the ground staff member suggestions for beneficial workflow changes within clinical settings??One former nurse manager stated that although asked for input, ultimately, “The leadership just couldn’t relinquish control to those who should be entrusted with it.”?

??As basic as it may seem, breaks, cafeteria choices, and flex schedule options are a great source of autonomy for staff. One difficult sticking point is in the consideration of how holidays are scheduled. The best system I experienced in over two decades of nursing had the staff rank holiday requests off in order of highest priority and tried to meet those needs rather than first come first choice or on a solely seniority basis.

?A looming block to provider autonomy is expectations of productivity based on number of patients seen and treated versus patient outcome. Can providers spend more time with higher-acuity patients or do examination and treatment times based on one size fits all? Complexity of patient needs is increasingly becoming… well, more complex.

?This can bleed into the next area of consideration, that of competence. The enduring time constraint restrictions in regard to everything from physician well check visits to complex surgical procedures. Commonly mentioned by RN’s is an inability to have a voice in assignments on hospital units, finding themselves chronically tasked to care for six to eight very sick patients and finding it impossible to meet their needs sufficiently.

?Competence?

Do the workers have a sense of mastery over their environments? Do they feel they are equipped with the knowledge, the training, the equipment and tools needed to do the best job? Is confidence boosted through professional experience and leadership opportunities or is the environment chaotic and crowded with poorly oriented staff? A common complaint is a glaring lack of training and stories of being “thrown onto the floor with cursory uncompleted checklists and left to sink or swim.”

?A former team leading occupational therapist offered some of the most profound words contained in this article “My team was responsible for new staff orientation and current staff education but routinely got pulled from those duties (by someone else) to cover patients - meaning new staff went undertrained and existing staff went unsupported…...turnover remains very high... observing others being openly shamed for things they had insufficient education or experience with. No one should be shamed for ignorance. That is why we teach, listen, support, build confidence."

Are workers able to leave with a sense of accomplishment or is the end of the day or shift marked with the feeling of leaving vital tasks undone? Healthcare is different than many other industries and very little can be safely or realistically carried over to the next day’s work.

?In an attempt to create a sense of competence many staff work uncompensated outside their normal shifts at home. One homecare professional described this endeavor as so; “Unrealistic to impossible scheduling/productivity expectations, resulting in always having extra work to do after hours or early in the morning, at all levels of the agency.” ?Another said, “I felt incompetent, pressured by paperwork deadlines constantly that I couldn’t keep up with the literal face to face care they needed in the real world.”

?Another consideration is the question of feedback from superiors. Is it offered in a way that highlights effective contributions or is it only for the purpose of spotlighting areas where growth is needed??

?A frightening hindrance to competency in many aspects of healthcare is reported sleep deprivation, especially in high-risk face paced arenas. One surgical nurse stated. “I know a huge portion of my staff are leaving because we are exhausted. We work 5-8’s and take call as well. We are expected to work post call which is incredibly unsafe based on sleep deprivation studies. At my previous employer we were guaranteed the day off post call. It makes a huge difference. My ability to think clearly and work competently is definitely hindered if I've gotten a few hours or no sleep. And I believe this is not an uncommon problem in surgical units in smaller hospitals.?“

?A major contributor to staff not feeling competent to deliver care is exacerbated greatly by staff shortages. One professional stated “constant promises of ‘it will get better,’ meanwhile a decade later you’re still trying to recruit and sling staff members in the field to cover the attrition outpacing hiring and training…? nothing gets better. Large organization leadership [is] totally out of touch with what’s happening on the ground, despite theoretical efforts to connect with ‘the people.’ Their allegiance was always to those above or lateral to them as far as I could tell… being asked for feedback only to be told over and over again nothing could be done about it. Then why take my feedback? No real focus on retention, all efforts on recruitment, chasing behind a problem rather than working on solving it and preventing employee attrition to begin with.”

??Too often floors are not only staffed but supervised by travel nurses who, while a vital piece of the current crisis situation, do not confer the benefit of having a long-standing cohesive unit. This affects not only the staff’s sense of competency but the next factor, one of relatedness.

??Relatedness

?Relatedness is often described as “the need to experience a sense of belonging and attachment to other people.”

Dysfunction in high stress environments can be common but yet the work needs to be viewed as a cooperative effort moving towards a defined mission statement with an altruistic purpose.

Do the staff feel connected to each other? Is there division between shifts? Is there discouragement from socialization and common bonding?

?In my decades of being surrounded by a wide variety of healthcare professionals, I have come to fundamentally believe that the need for relatedness is the most vital component of self-determination in healthcare settings. Again, these workers as a whole deeply value attachment and doing service for the greater good. They commonly express the need to practice in a deep and meaningful way or they lose the motivation and joy in work that they once had, even if that work was consistently challenging and difficult.

?Their values must be aligned and congruent in the acts they carry out day after day. One worker lost her motivation to continue in her nursing career and said she felt this was at the heart of the issue: “Focus on the almighty dollar rather than compassionate care, dignity and respect of people.”

Another RN similarly expressed, “Healthcare changed when care managers took the place of nurse department heads. This happened in the 90s. All the care managers I knew were non-clinicians from the private business sector. Decisions being made changed from patient focused to budget focused. Sadly, the bottom line was more important than patient care. I felt less fulfilled in my nursing career when that shift took place. I thought the department head nurses did a much better job running their departments than the business managers who were brought in to replace them. Every decision had to go through the care manager to determine if it was fiscally sound……it seemed no longer based on the nursing process we were all taught. I retired from nursing much earlier than I had planned for oh so many reasons.”

?A physical therapist added “little annoyances became glaringly obvious violations of my personal values. As I reflect on my career, every job I left was a result of misaligned values.”

?Staff shortages are leading to greater wait times, a decrease in quality of care and the frightening evolution of patients becoming frustrated, unseen and unfortunately acting out, changing the entire milieu of healing. It doesn’t take long to validate the disturbing trend of physical and nonphysical violence being perpetrated against health care workers and dramatically altering the trust and intimate care required for therapeutic spaces.

?As a matter of relatedness, staff also need to feel their unique contributions truly matter and are not easily and quickly replaceable.

?A telling and poignant response from a former physical therapist: “I feel like the burnout is the ultimate ‘umbrella’ reason that I left. A billion little things led to me being burnt out though. The overall feeling that what I was doing was just turning a cog in the machine, and not actually making a positive difference in anyone's lives. That was the biggest reason I burnt out. I got into the field because I wanted to help people. And once I started working in it, I realized the system was working against us, I realized I couldn't help the way people really needed me to. I decided that the relatedness/relationships with people mattered to me more, so I left the field for more holistic applications (yoga, massage therapy, reflexology, reiki) and I haven't looked back. I'm realizing I still feel a version of complex PTSD from the experience though.”

?Ethical questions are faced multiple times during healthcare shifts. All manner of providers facing the choice of forgoing their own needs to meet the patients like choosing to take a break knowing that a patient may wait longer in pain, with an IV running dry or lying in a soiled bed. Also understanding your colleague may have to work harder the next shift to make up for what you were unable to complete.

?After endless sources of moral injuries and dilemmas have piled on top of one another, the final disconnect is often verbalized then demonstrated when hope is lost in the caregiver’s mind—not only in their ability to provide healing, compassionate care but in their fear of losing their very humanity.

?Now to circle back around to the last stage of grief, acceptance. According to Nursing Solutions, Inc., nurse turnover skyrocketed to the current annual rate of 27% in acute care environments, and the use of travel and agency nurses to supplement core team staffing has become routine.

?Sadly, no matter the self-care, meditation, diet and exercise practices,?healthcare workers are unhappy, sad and grieving.

?I am here to voice my concern that the real possibility exists that the results of acceptance may just look vastly different than what is in our collective best interests.

?As I alluded in the beginning of this piece, watching healthcare workers reach the acceptance phase of the grieving process looks increasingly like them choosing to save their souls.... and leaving.

?A former healthcare leader encapsulates this sentiment: “I’ve decided the only way to live a life truly in accordance with my own values is to work for myself. I made that transition nearly two years ago, and while I certainly don’t make the same money, my freedom of time, autonomy and conscience has far outweighed the financial ramifications. I would need to be suffering far more than I am now to return to corporate healthcare.“

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The US healthcare system accounts for 18.3 percent of our Gross Domestic Product. Last year it accounted for 9.3 percent of our employment. As we become older and sicker it continues to grow and has become an increasingly complex and disjointed labyrinth.

?Big things move slowly.

I can’t help but feel we are rapidly running out of time.

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