Transforming Nurses' Stress and Anger Steps Toward Healing Second Edition SandraP.Thomas,PhD,RN,FAAN,isPro- fessor and Director of the PhD Program inNursingattheUniversityofTennessee, Knoxville. Her initialnursing preparation was at St. Mary’s Hospital School of Nurs- ing, and she worked as a hospital staff nurse for 10 years before pursuing new challenges as a nurse educator and re- searcher. She holds bachelor’s, master’s, and doctoral degrees in education as well as a master’s in nursing, with clinical spe- cialization in community mental health. Dr. Thomas is editor of Issues in Mental Health Nursing, and serves as a reviewerformanyotherprofessionaljournals.SheservesontheBoard of Directors of the International Council on Women’s Health Issues. SheisachartermemberoftheSouthernNursingResearchSocietyand alsoholdsmembershipsintheAmericanPsychologicalAssociation,the American Nurses Association, Sigma Theta Tau International, and the SocietyofBehavioralMedicine.In1996shewasnamedaFellowofthe American Academy of Nursing, and in 1999 she became a Fellow of theSocietyofBehavioralMedicine.Herresearchhasfocusedonstress, anger, and depression. She has presented her research at numerous national and international conferences and published over 90 journal articles and book chapters. Her previous books are Women and Anger (SpringerPublishing,1993);UseYourAnger:AWoman’sGuidetoEmpow- erment,withcoauthorCherylJefferson(1996);TransformingNurses’Anger and Pain (Springer, 1998); and Listening to Patients: A Phenomenological ApproachtoNursingResearchandPractice,withcoauthorHowardR.Pollio (Springer, 2002). Listening to Patients received both a Choice Magazine Award as an “Outstanding Academic Title” and an American Journal of Nursing “Book of the Year” Award. Transforming Nurses' Stress and Anger Steps Toward Healing Second Edition Sandra P. Thomas, PhD, RN, FAAN Copyright©2004bySpringerPublishingCompany,Inc. Allrightsreserved Nopartofthispublicationmaybereproduced,storedinaretrieval system, or transmitted in any form or by any means, electronic, mechanical, photocopying, recording, or otherwise, without the priorpermissionofSpringerPublishingCompany,Inc. SpringerPublishingCompany,Inc. 536Broadway NewYork,NY10012-3955 AcquisitionsEditor:RuthChasek ProductionEditor:JeanneW.Libby CoverdesignbyJoanneE.Honigman 0405060708/54321 CIPtocome Printed inthe UnitedStates of Americaby IntegratedBook Tech- nology. Contents Preface vii Introduction xi Part I: Uncovering the Layers of Nurses’ Stress and Anger 1 Chapter 1: TellingOurStories:WhatAreNursesStressedand 3 Angry About? Chapter 2: ExposingtheConsequencesofMismanagedAnger 29 Chapter 3: Differentiating Between Rational and 70 Irrational Anger Chapter 4: Modifying Nonproductive Anger Styles 91 Part II: Connecting With Others 113 Chapter 5: Improving Interactions With Colleagues 115 Chapter 6: Forging Alliances With Patients 159 Part III: Healing Ourselves 181 Chapter 7: ExaminingWhatWeLearnedAboutAngerWhile 183 Growing Up Chapter 8: Overcoming the Legacy of a Painful or 197 Abusive Past Chapter 9: Managing Stress and Caring for the Self 215 Part IV: Claiming Our Power and Using It 233 Chapter 10: TakingaNewStanceTowardtheConceptofPower 235 Chapter 11: Solving Problems 249 Chapter 12: Dreaming the Future of Nursing 267 Conclusion 274 Epilogue 277 References 282 Index 312 v This page intentionally left blank Preface IhavebeentoScutari,tothatimmenseandformidablehospitalwhere Florence Nightingale cared for thousands of British soldiers wounded in the Crimea. Prior to my visit, I had read all about what happened there, but the written accounts of Nightingale’s wartime experiences did not adequately prepare me for the emotional impact of being in this place. As I walked through the long dark corridors, the anguished criesofthesickanddyingmenstillrose,reverberatingagainstunfeeling stone. I could see them piled like so many bloody discarded rags, thrashingandmoaning.WhatconsternationNightingalemusthavefelt uponfinding3,000mencrammedintotheSelimiyeArmyBarracksthat served as the hospital. Four miles of beds, tightly crushed together, held the mutilated bodies awaiting Miss Nightingale’s ministrations. The“hospital”hadnokitchens,nolaboratory,nooperatingtable,and no bed linens. It is hard to imagine the conditions at Scutari. Therewerenobasins,notowels,nosoap,nobrooms,nomops,notrays,noplates...no knives or forks or spoons. The supply of fuel was constantly deficient. The cooking arrangements were preposterously inadequate, and the laundry was a farce. As for purelymedicalmaterials,thetalewasnobetter.Stretchers,splints,bandages—allwere lacking;andsowerethemostordinarydrugs....Theverybuildingitselfwasradically defective.Hugesewersunderlayit,andcesspoolsloadedwithfilthwaftedtheirpoison intotheupperrooms...thewallswerethickwithdirt;incrediblemultitudesofvermin swarmedeverywhere.(Strachey,1918/1996,pp.16–17) Have any of us in modern nursing ever faced such appalling condi- tions? So daunting a task? Probably not, unless we have nursed during primitive wartime conditions. Yet all of us can readily empathize with the enormity of Nightingale’s workload. So many patients, so many urgent needs. Compounding the difficulties presented by the sheer volume of work at Scutari was the scathing hostility of the men in authority. The intrusion of Nightingale and her small band of nurses intotheall-malemilitaryenvironmentwasgreetedwithderision.Obsta- cleafterobstaclewasplacedbeforeherbytheunyieldingarmybureau- cracy. Even today, we can identify with such obstacles. We decry “the vii viii Preface system” that prevents us from giving the kind of care we long to give. Nightingale also had to deal with conflict and dissension within her own staff—a destructive phenomenon still common among nurses. At one point, Florence began to believe that none of her colleagues had theproperdedicationtothework.Fromthisplaceoffilth,horror,and death,adiscouragedNightingalewroteinanearlyletterhome:“There should be a sign: ‘Abandon Hope, All Ye Who Enter Here’” (Isler, 1970). But you know the rest of the story. She did not abandon hope. Enshrinedintheloreofnursinghistoryaretheincredibleachievements of Nightingale at Scutari. With energy, vision, and astute management of peopleand resources,the mortalityrate ofthe soldiers wasreduced from 42% to 2% in 6 months. Scutari was transformed into a place of caring, order, and cleanliness. For these remarkable achievements Nightingale was accorded the attributes of near-sainthood. An ideal image of nurse entered the psyche of the British people: the gentle “lady with the lamp.” Less well known is the force of Nightingale’s anger. Late at night in herlittleroomintheNorthwestTowerofSelimiyeBarracks,shevented that anger in a torrent of letters that document its extent and force. She minced no words as she described the privations of Scutari to the people back home in England: “No sufficient preparations have been madeforpropercareofthewounded.Notonlyaretherenotsufficient surgeons...not only are there no dressers and nurses...there is not evenlinen tomake bandages...thecommonest appliancesof awork- house sick-ward are wanting” (Woodham-Smith, 1951, p. 85). Nightin- galepassionatelyadvocatedforbettersanitation,nutrition,andmedical care for the British soldiers. Her missives were successful in capturing theattentionofthepublicandkindlingtheirrageaswell.ForNightin- gale, anger was a powerful tool: “I do well to be angry,” she said (Stra- chey, 1918/1996, p. 31). These words could easily be ours, as we look down the corridors of ourownScutariintheearly21stcentury.Again,nursesarefacingchaos, vast human need, lack of resources to give proper care, unresponsive bureaucracy, and a highly stressful environment. Today’s nurses feel embattled, assaulted, and literally on the firing line. Notes Wanda Hooper,“Workplaceviolencewasallbutnon-existent25ormoreyears ago, but it is a very real part of the environment today. It takes many forms, and nurses have been injured, even killed, while practicing” (2003,p.4).Forthe6-yearperiod1993–1999,therewere429,100violent Preface ix crimesagainstnursesonduty(U.S.DepartmentofJustice,2001).Nurses experiencedworkplacecrimeatarate72%higherthanmedicaltechni- cians and at twice the rate of other health care workers. Other safety issueshaveproducedmountingconcern.Inthecourseofaday’swork, therecouldbeaneedlestickinjury,abackinjury,orexposuretovirulent infectious diseases. And all too often we leave the workplace bone- tired and soul-weary, trying to shake off the sticky residue of moral distress—thatawfulrealizationthatwecouldnotgivepatientsthecare they deserved. Itisnotsurprisingthathighscoresonburnoutwerefoundinastudy of more than 43,000 nurses from 700 hospitals in the U.S. and four other countries (Aiken, Clarke, Sloane, & Sochalski, 2001). In fact, 2 in 10 U.S. nurses told the researchers they planned to quit their jobs within the year. Among nurses younger than 30, 1 in 3 intended to leave.Whentheyleave,analreadycriticalnursingshortagewillintensify, severely impacting the quality of patient care. Simply producing more graduatesisnottheanswer.Dispiritedrecentgraduatesareleavingthe professionatratesevenfasterthantheirpredecessors(Sochalski,2002). Theycitethestressfulworkenvironmentasthecause.Unquestionably, stress in the work environment has escalated because of the acute nursing shortage. The nurses remainingon the job must do more and more with less and less. Their job satisfaction soon plummets. Nurses in hospitals with the highest patient workloads are twice as likely to be dissatisfied with their jobs and more than twice as likely to experience burnout, compared with nurses in better-staffed hospitals (Aiken, Clarke,Sloane,Sochalski,&Silber,2002).AsBarbaraBrownhaspointed out, “stress is a result as well as a cause of the shortage” (2003, p. 47). Thus we have a disturbing situation that calls for innovative ideas andconstructiveactions.Nurses’angeraboutthissituationisjustifiable. Wefeelunsafeandunsupported.Ouranger,however,isnotchanneled into constructive actions. It eats away at us inside and takes its toll in fatigue, physical health problems, depression, and substance abuse. It spills over to our own peers, corroding relationships. Like Nightingale, can we do well to be angry? Can we transform our anger into something positive? I think we can. Nightingale’s words challenge us to “do the thing that is good, whether it is ‘suitable for a woman’ or not” (Nightingale, 1859/1992). She decried the societal characterization of nurses as self-sacrificing and subservient: “No man, notevenadoctor,evergivesanyotherdefinitionofwhatanurseshould be than this—‘devoted and obedient.’ This definition would do just as wellforaporter.Itmightevendoforahorse”(Woodham-Smith,1951).