Unbearably Unhappy

Any experienced nurse can walk in to any particular unit and tell almost immediately if it’s a happy place to work. There’s something about the body language, maybe, or the lack of laughter, or how the nurses present themselves. Like pornography or good art, you can’t exactly put you finger on defining it, but nevertheless, you know it when you see it. I like to think (for all of my moaning and biting) my own little corner of nursedom is a fairly happy place to work, or at least, it’s far, far better than most of the places I’ve worked.

My father has a chronic condition which requires fairly regular if infrequent visits to a particular Toronto-area hospital for consultation. So today I spent the day with him and his wife at this hospital while he was getting treatment. While my father was in the procedure room, I remarked to his wife (who incidentally is a retired nurse, and a pretty sharp observer, to boot) that the nurses working in the short stay unit seemed particularly unhappy.

“Oh yes,” she replied. “I’ve talked to a few of them and they’ve all said it isn’t a pleasant place to work.” She lowered he voice. “In fact, I’ve seen the manager come on the floor and ream out a few of them here in front of patients and families. Totally, totally inappropriate.”

At that moment the manager came out. She was short and pale, and looked like she ate nursing licences for breakfast. Hell, she scared even me. There was an immediate stiffening amongst the nurses, and a couple of them, I noticed, surreptitiously left the unit through a back exit. Definitely an authoritarian, then. I felt sorry for this gem’s staff.

If I were a manager, and my staff were avoiding me like the Ebola virus, I might think I may have a problem. She probably thinks she’s doing a good job, and has mastered the voo-doo arts of human resources management.

I emphatically would not work that particular unit, nor would I work in a hospital that supports that management style. It’s bad nursing and bad for nursing.

I wondered though: in choosing between a happy work place and an unhappy one, wouldn’t you choose the former and eschew the latter as being unfavourable for morale and a quality nursing work-life environment, and therefore poor inducement for retention and recruitment, and more importantly, an indicator for poor patient outcomes?

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  1. #1 by Diana on Monday 23 August 2010 - 2057

    That unit sounds a lot like mine. I’ve only been there 2 1/2 years, and morale seems to be at an all time low. Weekends are the least stressful as our manager isn’t present to micromanage the trivial while ignoring the relevant. Something’s got to give. I’ve definitely been thinking of what I’ll do when my initial contract is up. For now I’m simply encouraging our unit nurses to utilize existing councils to exercise autonomy in the day-to-day running of our unit. We’re up for magnet re-certification next year. Now’s the time to force administration to take the councils seriously.

  2. #2 by Wade on Tuesday 24 August 2010 - 0657

    I’d say it’s more than an “indicator of poor patient outcomes” … it’s a direct cause.

    It’s fascinating, in a morbid way, that a unit with a leak in the ceiling and wet floor would be cited by JCAHO as a patient risk, but a unit with a manager who clearly damages the psychological-safety and open feedback teamwork required to catch errors and deliver safe care is allowed to continue without comment.

    So stick a red flag and GPS-location-transmitter on that problem and let’s group think about how to do something more powerful than notice it, complain, and dismiss it. This is a clear and present danger to patient’s lives, and should be a clear duty to address, but in some more effective way than whistleblow-and-be-fired-for-life.

    Pondering. As W. Edwards Deming noted, management is generally not interested in hearing about the fact that management IS the problem. Retaliation for even THINKING such a think seems common. So, the direct approach of presenting credible peer-reviewed studies and evidence is off the table.

    Similarly, going over management’s head outside the chain of command has a pretty dismal track-record of success.

    So, for this effort, to fix a hazard to patient care, is going to need to come from higher, such as JCAHO or better CMS – now that Don Berwick is in charge, bringing IHI’s focus on quality. HE certainly understands the direct cause-effect relationships here.

    So, assembing the fragments of thought here, it would seem that (1) nurses (or anyone) could substantially improve patient care if they could take effective action that would remove rattlesnakes, wet floors, and dangerous managers from the system.
    (2) For anyone to try this alone, unaided, by pushing UPWARDS is a proven no-win approach.
    (3) Don Berwick is the right guy to lead an effort to put teeth in a move to deal with such managers, and CMS certainly has the clout to threaten to cut off all medicare funding for a hospital that refuses to listen. So that part is in place, finally.
    (4) So how can individual nurses contribute to this nascent action coming to fruition. Probably, that’s what professional organizations are about and for.

    Conclusion — it’s within nurse’s professional duty to lean on and assist their collective professional organizations to put pressure on Berwick to “do the right thing”, and to rally other nurses to join them in this move to improve patient care AND, as a side effect, to improve working conditions, retention, cost-effective care, hospital survival, etc.

    Is that logic solid?

  3. #3 by Anonymous on Tuesday 24 August 2010 - 0733

    It’s fascinating, isn’t it, that something so straightforward as improving a system by getting rid of bad middle-managers, can be so difficult?

    They (middle-managers) seem to dig into the system, kind of like Tuberculosis, surrounding themselves with protective layers of deflection of blame and distortion of reality, so that top management and the Board can’t see clearly what is going on (“My employees are idiots! It’s their fault!”), patients are so far out of the loop they can’t trace the root-cause of hospital errors to bad middle managers, and nurses are deep within the jaws of said managers, so that whistleblowing will often result in immediate termination.

    Top managers would win by having far more cost-efficient hospitals with far better patient outcomes. Nurses would win, patients would win, society would win.

    Yet this sludge of TB-like illness remains intractable, infecting our health care system.

    This requires brighter lights and more attention on what, exactly, is preventing the “obvious” solution from working.

  4. #4 by Eleanor Cramer on Tuesday 24 August 2010 - 1016

    I worked in an office with such a manager, except that we didn’t have the luxury of looking for a new contract — my co-workers and I had been there 10 – 20 years before this manager was put in place, and we were heavily invested in pensions, benefits etc, so leaving wasn’t really an option.

    He had been in place for only 18 months when the first staff member suffered a nervous breakdown. Before 24 months, two more had gone the same way. All three went on sick leave and two of them were still not able to work 7 years later. Finally our toxic manager was forced to retire. Yes, it took three breakdowns before upper management (who had been approached for at least a year before the crisis) to take some sort of lame action about this “personality conflict.”

    What was the final cost to the company, including sick leave/disability, retirement payouts, loss of productivity, retraining costs, HR seminars and lost morale among the survivors? My off the cuff guess is not less than $1M.

    These kinds of managers are hugely expensive. They would actually be less damaging if they came in every day and put arsenic in the coffeemaker. At least then, staff would have nice clear complexions.

  5. #5 by Jenn Jilks on Tuesday 24 August 2010 - 1538

    I often thought that school principals could be evaluated by the number of transfer requests in any given year. Easy to figure out their principles! Good post.

  6. #6 by Cartoon Character on Wednesday 25 August 2010 - 1318

    I interviewed at 3 different hospitals when I first moved to the lower mainland. Luckily, in our nursing “community” within our province – word travels fast. You don’t even have to visit the hospital….everyone *knows* which places you don’t want to work. Lucky for us also…we can “port” our seniority, sick time, and pension anywhere within our province so we aren’t “stuck”……..

  7. #7 by Mary on Friday 27 August 2010 - 0443

    This is very unhealthy not just for the nurses but also the patients.
    A stressed nurse in this way, would have a hard time doing his/her job and that’s bad for the patients.

  8. #8 by Sue N Clark, RN, MS on Friday 27 August 2010 - 0910

    You are so right . . . and we must vote with our feet. Speak our truth politely and respectfully, for our own good, i.e., the knowledge that we’ve spoken and not suffered in silence before slinking away, and then seek out healthy work environments. Not to do this would be hypocritical; we are about health promotion, and need to live and practice what we teach.

    It is important to recognize that nurses are not responsible for sick environments and cannot “fix” the negative energy around them. We can speak, and offer to be part of the solution, but there are those who would turn the problem back on the victims, and many nurses, ever eager to help and to be team players, might embrace a problem that is not rightly theirs. A manager who exudes negative energy, and a toxic work setting, are that way for a reason, which others may or may not ever understand. But what it sure is that they are not as they are solely for want of our magic fixes, and we are not likely to save the day with heroic efforts to “help” the leopard change its spots.

    Walk, my colleagues! You and your patients deserve better!

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