Through research and practice, nurses advocate for themselves and each other
By Jenny Price
Katie Pavek ’08, PhD’21, was six months into her nurse residency at UW Health University Hospital when she hit a wall. She felt burned out and started to question her career choice.
Pavek eventually learned she wasn’t the only one who felt that way, and that research confirmed nurses often struggle at this pivotal point in their transition to practice. “Nobody was really talking about it,” says Pavek, who recalls thinking, “Why are we all suffering in silence?”
When she started in 2015 as a full-time clinical instructor in the School of Nursing, this memory came roaring back as Pavek witnessed the same stress and anxiety in her students and began to fear they were ill-prepared in some ways for the transition to their chosen profession. “I was counseling them more through that than I was through the actual course content,” she says. “That was my ‘a-ha’ moment.”
Burnout is one of the leading causes for nurses to leave the profession, which contributes to the national workforce shortage. The pressures of the pandemic, which made nurses more visible than ever, are expected to make it worse. But nurses in the field and scholars in the School of Nursing are pushing for policy reforms, researching the root causes and effects of the critical issues facing the profession, and implementing new evidence-based tools to improve working conditions and patient outcomes. Silence is not an option. Neither is suffering.
“Advocacy is a pillar of our profession, whether we are advocating for the patient or we’re advocating for the profession. Without that, we actually lose a vital part of our practice.” — Dean Linda Scott
“Advocacy is a pillar of our profession, whether we are advocating for the patient or we’re advocating for the profession,” says School of Nursing Dean Linda Scott, PhD, RN, NEA-BC, FNAP, FAAN. “Without that, we actually lose a vital part of our practice.”
Last fall, Scott was among a group of 11 nursing school deans from around the country who pushed for action to address well-being, resilience, and suicide prevention among students. The American Association of Colleges of Nursing (AACN) adopted their resolution, encouraging academic leaders to offer programs, screenings, and support for nursing students, faculty, and the campus community to help manage mental health and prevent suicide and burnout.
Prior to the pandemic, nurse suicide rates were higher than the general population, and Scott says attention to the issue is even more critical as the crisis lingers. “You can imagine what those statistics might be now after having been in a pandemic more than a year and knowing that we’re still not out of this,” she says. “No matter how resilient you are, there will still be moments where individuals are at risk.”
It has been about 20 years since Scott began studying nurse fatigue to understand the relationship between errors and nurses regularly working long shifts and overtime, a body of work that showed the need for increased nurse staffing and better fatigue management. Research remains a critical piece of advocacy, Scott says. “To make informed decisions, you need the evidence,” she says. “What research does is generate that new knowledge and provide evidence to help truly advocate for policy change.”
Research Meets Practice
Hospital-based nurses experience the highest rates of turnover in the profession, but the existing methods for measuring their occupational stress are decades old, Pavek says. So, she is digging into whether those tools reflect current nursing practice and are still valid and reliable. She is also trying to identify profiles of nurses who have high levels of stress and coping abilities in order to compare their characteristics with nurses who also have high stress but low coping abilities.
“If we can identify these kinds of profiles of nurses, we may be better positioned to identify them upstream and help them navigate occupational stress or stress in general by developing more appropriate coping strategies based upon their profile rather than a one-size-fits-all approach,” she says.
For some nurses, a mindful breath before entering a patient’s room may be helpful, but for others it may not. Pavek sees that as the next phase of her research: how to build more tailored interventions for stress management.
There is a wide spectrum of how nurses experience stress, says Élise Arsenault-Knudsen, MS’10, PhD’19, who works as a clinical nurse specialist at UW Health. “Some people can bounce back in five minutes; some people take five hours; some people might need a week off,” she says. “But right now, we don’t have great processes to accommodate that level of individualization.”
Arsenault-Knudsen recalls a conversation with a nurse manager who recounted the reality of nursing care — that when a patient codes and dies, whether expected or unexpected, the process nurses follow immediately afterward doesn’t change. “You do postmortem care, you take care of what needs to get done, that room gets cleaned, and that nurse has another patient to take care of,” she says. “There’s not often really time for recovery and processing those emotions.”
One of the ideas that the pandemic has reinforced is the image of the “super nurse,” says Arsenault-Knudsen, which speaks to how nurses in our society are held up as heroes; but that can work against them exercising self-care and advocating for workplace changes that promote well-being. The construct, outlined in a 2015 paper by School of Nursing Professor Linsey Steege, PhD, and Jessica Rainbow, PhD’18, now an assistant professor at the University of Arizona, is a major barrier to addressing fatigue.
“In my opinion, this image of nursing should be challenged; we don’t need to be perpetuating this,” Arsenault-Knudsen says. “If you think that you are supposed to — as a new nurse — aspire to be the superhuman, then that’s a tall order.”
In her role at UW Health, Arsenault-Knudsen helps nurses conduct and use research to bolster their practice. In her role, she oversees a UW Health committee for nursing practice guidelines; one guideline that was adopted even before the pandemic provides a set of recommended strategies to prevent and mitigate nurse fatigue. During her graduate studies, she did research on nurse fatigue with Steege, and says she learned the importance of systems-level changes to decrease fatigue and burnout among nurses.
“You could have a perfectly well-rested, well-hydrated, well-fed nurse who’s done all of their mindfulness and resiliency training,” Arsenault-Knudsen says. “[But] if nurses, no matter where they are, show up to an environment where there’s a number of things that cause them to have to work unnecessarily harder, either in a given day or over time, you really start to see that wear on an individual nurse, but also on a nursing workforce more broadly.”
In the last several months, she’s seen the visible exhaustion on faces of nurses she’s known for years who are typically upbeat, bright-eyed, and optimistic. For her, that adds to the urgency to accelerate research and findings to make sure that systems can take up new practices to improve outcomes for nurses and patients. “I think one of the neat things about working at UW Health is the Academic Practice Partnership that we have with the School of Nursing and the ability to go across the street to one another and say, ‘Okay, well, what do you know? And what do we need?’”
Arsenault-Knudsen co-authored a study with Steege and fellow PhD candidates Hyeonmi Cho, PhDx’22, and Sarah Brzozowski, PhDx’21, that found the number of patients a hospital nurse or unit discharges in a 12-hour shift was a significant predictor of fatigue by the end. This kind of work can help predict fatigue levels among nurses and develop systems to proactively monitor and manage it, but much more research is needed, Arsenault-Knudsen says.
“We don’t have a robust body of evidence to go from to say, ‘If you do these five things, you will have decreased fatigue,’” she says. “One of the fundamental reasons for that is because we’re still humans caring for humans, and so there are so many different variables to consider.”
Brzozowski, a PhD candidate in the School of Nursing who has also studied fatigue, is the daughter of a nurse who told her not to follow in her footsteps. She didn’t listen.
She has devoted her research to creating systems that better support nurses. “At the center of that is the patient,” she says. “If you can do that, it only increases the quality and the outcomes for the patient.”
After studying Spanish and business as an undergraduate, Brzozowski returned for a nursing degree, inspired in part by the nurses she met while volunteering at the hospital where her mom worked. “One thing that stood out to me was how humble nurses were,” she says. In her current professional role as director of Magnet® and Nursing Excellence at UW Health, her job is to recognize nurses for their work. “It’s the most amazing job ever,” she says. “You talk to a nurse and they’ll say, ‘Well, that’s just what I do.’”
Brzozowski’s dissertation is focused on professional nursing practice, leadership, and job satisfaction in primary care across the country. And because leadership models have not been tested in primary care settings, she’s also looking to understand what practices can — or can’t — be translated and transferred from one setting to the next so leaders and nurses have what they need to be successful and patients have great outcomes.
Brzozowski, who also has an MBA and is fascinated by organizational culture, conducted a study where she interviewed direct care nurses throughout the region about what they do and what tools they need to be successful, as well as their perspectives on their work environment and leadership. “If nurses share their voices to help us better understand their needs, we can build off of that,” she says. “This allows leaders to better understand how nurses are perceiving a situation or feeling about things, and what actions need to be taken to remedy them.”
Give Voice to Advocacy
Scott embarked on her research into nurse fatigue after the Institute of Medicine released its 1999 report — called “To Err is Human” — that revealed there were almost 100,000 deaths associated with preventable errors. The path of Scott and the nurse scholars that have come after her show how research can fuel advocacy by building a case for changing both organizational and legislative policy.
When Scott began, there was only anecdotal evidence about the connection between errors and how many hours nurses worked, but her research documented the relationship. “The more hours they worked, the greater the risk for error,” Scott says. “In order to really truly advocate for policy change, having that type of data really helps to move those changes forward.”
And Scott also says the biggest change she witnessed over time is how nurses have found more ways to advocate beyond the patient’s bedside. That includes efforts by some School of Nursing faculty members to push for changes to Wisconsin law to allow advanced practice registered nurses to offer care to the full extent of their education, training, and experience. In the 20 counties where there is not a practicing psychiatrist, a change to full practice authority for nurses would provide patients with much-needed options for mental health care.
“We have always been rated the most trusted profession among the public, but yet nurses don’t tend to be at the decision-making table — whether it’s in the boardroom or in the political arena,” Scott says.
Scott says School of Nursing students begin building that mindset through participation in events where they can influence policy, such as Nurses Day at the state Capitol. The event typically draws 1,000 RNs, APRNs, student nurses, and nursing faculty who receive training to prepare for group meetings with legislators. DNP students learn how to write policy briefs and how to advocate at that level, she says.
“You’ve got two minutes for that elevator speech — how are you going to grab the attention of a legislator and hopefully sell your case?” she says. “It’s making sure that we use our voice in that way.”
Advocacy in the Age of COVID-19
Researchers document the toll
A new study from School of Nursing researchers reported for the first time on the poor sleep, elevated fatigue, and psychological problems of hospital nurses during the COVID-19 pandemic in the U.S. “The levels of post-traumatic stress, depression, and anxiety are worrisome,” according to the study released in November. Nursing staff experienced poor sleep, fatigue, and multiple psychological problems during the COVID-19 pandemic, researchers reported. Staff who were involved in the care of coronavirus patients, worked more than 40 hours per week, and skipped 30-minute breaks showed generally worse self-reported outcomes. The researchers, including Professor Linsey Steege, PhD, and PhD candidate Hyeonmi Cho, recommended that nursing administrators:
- Monitor for fatigue and distress on nursing units
- Revisit current scheduling practices
- Reinforce rest breaks
- Provide access to mental health and sleep wellness resources with additional support for their frontline nursing groups
No One’s Punching Bag
Katie Pavek ’08, PhD’21, sometimes bore the brunt of frustrations from depleted families and patients when she worked as a nurse in general medicine and geriatrics. “I’ve been called about anything you can think of,” says Pavek, now a clinical instructor in the School of Nursing.
Pavek was grateful for more experienced mentors on her unit who set an example for how to set boundaries. “In no other profession would you walk into somebody’s office or workplace and chew them out or swear at them or call them names, and it would be OK,” she says.
“Ninety-nine point nine percent of the time, I would politely excuse myself in the situation and give them time to calm down and come back, and there’d be an apology the minute I walked in the room.”
In a new study Pavek co-authored with Hyeonmi Cho, PhDx’22, and Professor Linsey Steege, PhD, on workplace verbal abuse experienced by nurses, 80 percent of participants reported experiencing verbal abuse from patients or their families. The authors note that nurses are viewed by patients and families as people who will “listen to anything.”
Nurses in their 20s reported more verbal abuse from physicians than their counterparts in older age groups, and those who experienced verbal abuse from physicians or other employees were less likely to feel comfortable reporting safety problems. The study recommends more interventions and education, especially for early-career nurses, and more efforts by nursing leaders to monitor instances of abuse and resolve them.
Pavek says she works to help nursing students understand that “we’re not punching bags,” while also having the compassion to recognize when people are struggling to find the balance between taking it in stride and sticking up for themselves. “As long as your patient is safe, you can always walk away,” she says.