Victoria University researcher Dr Helen Rook’s recently completed PhD research found Kiwi nurses felt conflicted and anxious at being unable to deliver care true to their nursing values because of pressures on the ward to discharge patients quickly, keep-up the paper work and keep costs down.

She said the nurses’ response– sometimes conscious and sometimes not – was to focus on essential duties like documentation and nursing tasks as a coping strategy. Sometimes this also lead to nurses cutting short patient conversations, ignoring call bells and in other ways withdrawing from their patients to protect themselves emotionally.

Rook’s PhD research  – prompted in the wake of the inquiry into patient neglect in Mid-Staffordshire – involved spending 300 hours observing nurses on medical wards in three district health boards, multiple interviews, checking nurse sensitive indicator statistics (like falls and pressure injuries), and measuring burnout levels. She concluded that the conflict that the nurses felt – between their personal and professional values and how they actually were able to practice nursing because of the constraints of modern healthcare – caused anxiety, exhaustion, cynicism and burnout.

Building and supporting nursing leadership at the ward level upwards was one recommendation by Rook to help nurses speak up and act on their concerns. Another was for district health board and other healthcare providers to put in place strategies to help mitigate the organisational dysfunction and financial constraints that lead to nurses feeling unable to consistently deliver compassionate, clinically competent care.

Withdrawing from patients a coping strategy for conflicted nurses

“In all of the wards the nurses said they were practising team nursing and yet there was very little evidence of that,” said Rook.  Instead they were observed to be mostly focussed on tasks and “getting things done”.  “They are very skilful at that,’ said Rook. “In order to protect themselves they use defensive strategies to protect themselves from anxiety.”

She said the conflicted nurses also used the coping strategy of withdrawing a little bit from the patients they were caring for.  So they tried not get caught in conversations with patients by using strategies like giving a quick smile.  “Or say ‘I’ll be with you in a minute’ and then pull themselves away as they know they have all this other stuff they need to get done.”

Rook said she also observed more overt withdrawal by busy nurses. “I watched nurses walking past patients who were calling out for help, and call bells that were unanswered, not because nurses were uncaring but because they had so many other things to do, to comply with.”

When she spoke to nurses about the organisational values at their DHBs – and the DHB’s strategies for improving patients care – she said a number expressed cynicism that while DHBs talked about focusing on partnership and respect most improvement projects were actually about discharging patients quicker, balancing the budget and ensuring the required documentation was done.  She said there was also a sense that the DHB’s emphasis on economics and managerialism was becoming more prevalent not less.

But she added that for her Phd she drew on the iconic nursing research carried out in a London hospital in the late 1950s by Isabel Menzies, who wrote about how nurses de-personalised patients to protect themselves from the anxiety of their work.

“That’s a long time ago – we’re 2017 now – but a lot of things that she found in that research I also found in my research.  Not a lot has changed in healthcare in the intervening years really…”

Be consciously present not emotionally numb

“Nurses go into the profession with an assumption that they will be caring for people who are sick, taking a moment to talk with them and build caring relationships,” said Rook.

But said the current culture didn’t allow for that and DHB’s managerial imperatives to get patients out of hospital quickly, combined with financial constraints, meant that it just wasn’t possible.  So nurses often responded by focussing on doing the essential nursing tasks.

“I think there is a bit of guilt in that we focus on tasks,” said Rook.  “I don’t think it’s such a bad thing if we do. Because that is what the public expect – they expect us to be able to do things for them.”

Rook said if the reality was that nurses’ coping strategy for pressured workloads was to focus on tasks, then nurses should take ownership of this new reality.  They needed to be vocal about the type of nursing care they were able to deliver, and why, and then deliver the task excellently.

“We need to be very clear that ‘okay we are going to focus on a task but we are going to be excellent in that task and in our interactions with people….even if is only a minute or two.”

She said nurses need to aim to be fully present with their patient even if “just doing a task” as that would be much more beneficial therapeutically.

“We need to be consciously present rather than emotionally numb in our patient interactions.”

But in the long-term she said it was imperative that nurses on the frontline were supported to build leadership skills and find their voice so the culture was changed and they could provide the nursing care that matched their personal and professional values. Also organisations had to introduce strategies that removed the constraints currently preventing nurses from delivering that care.

Rook, who is currently the Programme Director at the Graduate School of Nursing, Midwifery and Health at Victoria University of Wellington, graduates next week with her PhD in nursing.

She has a background in critical care nursing in the United Kingdom, Ireland and New Zealand, and has worked as a nursing academic in New Zealand and Ireland delivering undergraduate and post-graduate education.