13 January 2019

Nurse burnout: Maitre d' or Sentinel?

“The hospital doesn’t have Splenda.” was a response on a Patient-satisfaction survey. “This somehow became the fault of the nurse and ended up being placed in her personnel file.”
That happened.

Surveys used to assess nurses also ask questions like, “During this hospital stay, after you pressed the call button, how often did you get help as soon as you wanted it?” 

Hospitals with high patient-satisfaction scores get more money, so nurses are under pressure to do everything they can to make patients happy.

Also in the news: “Forty-nine percent of registered nurses under 30 and 40 percent of registered nurses over 30 experience burnout, according to one study — a sobering statistic for healthcare providers who want to improve patient care.”

These two things are related.

“Nurses are not waitresses or waiters,” says Nurse Smith, who has been a floor nurse and is now a nurse educator. “I see nurses as sentinels. A sentinel stands guard and is constantly on alert.

 “When a nurse walks into a patient’s room, there are a hundred things going through their mind. They are looking at monitors, carefully selecting which ones are important given the patient’s disease and treatment. They need to understand not just the physiology but the pathophysiology of the disease so that they can assess the patient and monitor their progress or decline.

“If an elderly demented patient starts to act a little wonky, is it just the waxing and waning of their dementia? Could it be some form of a hypoxia, perhaps a stroke? They need to have the assessment abilities to know if this could be a serious issue, when to call in the doctor and which tests could help clarify what is happening with the patient.

“They also need to assess when patients need more time. And it is not always the loudest patient. It may be the very ill patient whose blood pressure is dropping and a good nurse needs to attend to them.”

 The name of the game is not patient satisfaction - it’s patient safety.

So, surveys asking patients if the nurse came when they were called are completely inappropriate. The nurse must be given the clinical respect to make decisions about which patient needs attending to urgently and which patient can wait. What matters is did the patient get better? Did that nurse monitor and save lives of the very ill first? Even if some patients had to wait for ice chips. 

Nurse Jonathon - a nurse with over a decade of experience in the emergency room, critical care and in management - explains that numerous issues contribute to burnout in nurses.

“There are often too few nurses per patient and that is not safe,” says Nurse Jonathon. He points out that in an emergency room there could be a number of patients that should be admitted to the ICU but are waiting for a bed. These patients require constant care but there may be six to 9 other patients, or more, that the nurse needs to watch over and care for.

‘We are the ones who monitor patients,” says Nurse Jonathan, “No one else but your nurse monitors you 24/7. Everything from heart rates to breathing to blood pressure. We constantly assess patients.

“Most nurses have a passion for excellence and we want to get everything right. If something happens to our patient, we can’t stop. We must move on and take care of the next patient. We can’t stop for a second. These are peoples’ lives.

“Hospitals don't help staff to cope with these feelings. A debriefing would help. To understand what happened.”

Nurse Smith explains, “As the patient goes through their journey in hospital, it’s the goal of the nurse to help them advance every shift - to get home or at least get better. At the change of shift, it’s like a relay race - you pass the baton to the next nurse who continues the journey.”

Handing off your patients and doing so safely is one thing. But what if you are handing over too many patients for the next nurse to handle? Worry. Because all good sentinels watch and keep those they stand guard over safe. 

Many surveys demand nurses do a job that has no resemblance to the job they were trained to do. Nurses feel the pressure to do certain things to get good scores on these surveys. Ultimately though, nurses want to do their real job. The one they were trained to do. They want to keep watch over patients to keep them safe, to intervene when they need to and to have enough time to do this job well. They were trained as no one else is to do their job.

Letting nurses do their job, having enough nurses to do the work safely and having an opportunity to debrief from stress would go a long way to reducing burnout. Oh, and holding the Splenda comments.

Note: The real names of the nurses were not used. Both practice in the United States.


  1. Good points. From my experiences in hospitals, the nurses, registered and practical, are the ones who really get patients well.

  2. Absolutely Janice. And the misperception of nurses as those who fluff pillow does them little justice. Further, as nurse to patient ratios fall, unless we understand their real role we will never understand how dangerous this is for patients.

  3. The nurses who nursed me through my bypass surgery and beyond are so good and I praise them when I can. My daughter-in-law is an RN and nurses us as well (intelligent advice mostly).

    As for complaints, as a retired police officer I had many against me (most were trivial matters). I became an internal affairs investigator near the end of my career and legitimate complaints are serious business. The petty complaints bent on taking away an officer's livelihood is also handled seriously. Here in Louisiana, it is a crime to file a false police report and a crime to file a false complaint against a law enforcement officer. As for the petty complaints, well, we don't prosecute even though we sometimes found the complaint was a lie. One complainant said an officer had cursed him during a traffic stop, not realizing we wear body cameras recording video and audio. "Would you like to see how you cursed out the officer, instead of the other way around?"

  4. Mary, I always learn from your posts, & I'll say that when I arrived at the hospital in labor & labored 20 more hours giving birth to my daughter, it was the nurses who saw me through. My doctor was fantastic but he wasn't the one who stayed with me in the room the entire time.

    It isn't the nurse's fault, but the hospital really should have Splenda!

  5. O'Neil - An interesting perspective on petty complaints. Yes. They impact many professions.
    Elizabeth - thank you. Yes, nurses are so important. And they should be judged on the care they provide not Splenda - though lol! on your comment.

  6. Totally agree that all care providers are being asked to do more with less and that there are huge systemic contributors to stress and burnout. I would argue though that it’s not patient safety over patient satisfaction. In an ideal world it should be both, as pieces of the constellation of high quality care. Good, safe care should also feel good to the patient and be respectful and inclusive. We can’t provide care that is safe at the expense of any of the other dimensions of quality and feel good about our care. Ultimately staff safety (feeling good about our jobs and ourselves) results in safe care. I don’t believe we need to set ourselves “against” patients but should all be working towards a better system for everyone.

  7. Naturally patients are going to be miserable, scared, whiny and fussy, but I'm annoyed me no end by the attitude a hospital's employees are one's servants to be bossed around and lashed if they do wrong. Sadly, the person I know who's worst in this regard has a family full of medical professionals– physicians, RNs, pharmacists, an an├Žsthetist and an an├Žsthesiologist. She terrorizes young LPNs with threats of reporting them to the powers that be. It didn't occur to me until this moment that perhaps those fancy suites with pink pastel wallpaper, fresh flowers, and 'concierge service' encourage such an attitude.

    My belief is to give the crew every possible consideration. Not only do they hold lives and comforts in their hands, but if you really, really insist upon something, a positive attitude goes a long way toward having your request granted. Give the ladies a break and the favour will be returned.


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