With still about half his shift left, Michael Odell, RN, a critical care nurse at Stanford University, told his supervisor he needed to retrieve something from his car. He did not return.
It was about 4 a.m. on Jan. 18, 2021, and friends and volunteers searched for two days before police divers found his body in the waters off Dumbarton Bridge in Fremont, CA. His car was found nearby, as he apparently walked into the water rather than jumping from the bridge. The case is a presumptive suicide; Odell attempted to take his own life the year prior. Afterward, he went into therapy and was treated for depression. Odell apparently had rebounded after once talking of all the patients he had seen die of COVID-19.1
The report of the popular Odell’s death resonated and disturbed the nursing community in the Bay Area and beyond. Sarah Warren, RN, a nurse in Florida was motivated to become involved despite no connection to the case. Warren talked to Odell’s grieving roommate, and they were determined to act. The result was the creation of Don’t Clock Out, a nonprofit nursing support group.
“The expectation of resilience and the reliance on the resilience of healthcare workers is part of the reason we are in this crisis,” said Warren, co-founder of the organization. “There is only so much resilience you can build within your environment. If the environment does not change, there is really not much you can do to feel supported or support yourself.”2
Warren spoke during a podcast with another nurse support pioneer, Shannon McPeek, RN. McPeek founded Operation Happy Nurse in 2019.
A neonatal ICU nurse for six years, McPeek experienced occupational anxiety and suffered in silence. “When I started nursing in the NICU, I didn’t feel I was adequately prepared for the pressure that you are under,” she said. “I didn’t feel like I was given adequate resources to cope with a patient death or even to cope when your patient starts going downhill. Some of the things that we were expected to deal with and not show emotion — it’s just wild when you go back and think about it.”
McPeek worked on strengthening her mental health, finding she was not alone in this problem. “It was actually a large issue in the nursing profession — and this was back in 2017 [to] 2018,” McPeek said. “A lot of people have this idea that COVID caused this mental health crisis, which is not the case. It has always been there. Luckily, with our two organizations we are able to address that.”
The two organizations are partnering in joint ventures under the umbrella title The Self Care Unit. Together, they are breaking the stony silence that held so long in healthcare.
“When I looked around, everybody else seemed fine — but thinking back on it, I seemed fine to them, too,” McPeek said. “I didn’t tell anybody about it. There was such a silence around this. Now that we are able to talk about it, we can acknowledge that yes, nursing is hard. Healthcare is hard.”
To that end, Happy Nurse offers a three-month experience where 30 nurses work together in such areas as stress management, yoga and meditation, discussion boards, and more. There also is lighter fare, such as a book club, social events, and a playlist of the month on the website.
The pandemic is at some brief respite, and we step outside and take a ragged breath like survivors of a hurricane. We know all too well some new variant of COVID-19 could be a gathering storm somewhere in the world, but as of March 23, consider these average daily numbers for SARS-CoV-2 per 100,000 people in the United States: seven hospitalizations, deaths at less than one.3
The pandemic has slowed to a still point. Employee health professionals and healthcare workers reflect on the damage done and the work that remains. A few bold voices are saying the only way out is up — that this is the time to reclaim your work with a purpose that may lead to finding some actual “joy” in helping.
“At this point, you might be asking yourself, ‘Is this really even possible?’” Heather Gilmartin, PhD, NP, CIC, a research scientist for the VA health system, noted during a recent webinar. “The organizational and societal challenges can seem overwhelming. Every day, you wake up to something new in the paper and think, ‘How do we start? But the answer is ‘yes,’ there is joy to be found in [healthcare].”
Gilmartin is the lead author of a recently published paper that addresses the elusive nature of joy and the intentionality necessary to manifest it.4
“Why are joy and happiness so elusive?” Gilmartin and co-author asked. “Multiple authors have tried to answer this question. [One of them concludes] that ‘joy isn’t something we just find. It’s something we can make, for ourselves and for those around us.’”
Gilmartin emphasized simple practices, such as “framing, gratitude, and kindness to remedy the effects of burnout and help us find more joy in our daily work.” Framing in this situation is more accurately “re-framing,” putting a problem in a different light or context or finding another path to approach it from a less negative perspective.
The old philosophical adage “the obstacle is the opportunity” emphasizes one may feel positive about achieving a task that might be too daunting if it is perceived negatively. “Be aware that humans tend to focus and frame experiences with a negative bias due to the evolutionary, survival advantage,” Gilmartin and co-author noted. “Evolutionarily speaking, the person with a negativity bias was the one who tended to survive.”
Regarding gratitude, Gilmartin and co-author noted these moments can be kept in a personal journal or extended to a team with gratitude breaks periodically as a tonic against despair. The simple act of kindness can be challenging in times rife with anger and division, but “studies have shown that when people are kind, they have lower levels of stress hormones and feel less depressed, less lonely, and happier.”
Crediting the Institute for Healthcare Improvement (IHI) for pioneering much of joy-work in medicine, Gilmartin said she originally was met with some skepticism from clinical colleagues.
“They were like, ‘Are you kidding me?’” Gilmartin recalled during the webinar. “‘This is squishy stuff. What do you want us to do, hug it out?’ I was [thinking], yeah, hugging it out. That would be awesome. [Writer] Shel Silverstein used to talk about a ‘hug’ of war.”
Certainly, there is a lot of cynicism afoot in these hard-bitten times, but why should joy be such a far-fetched idea in healthcare?
“In healthcare, caring and healing are naturally joyful activities, in addition to being intellectually, physically, and emotionally demanding,” Gilmartin said. “Most of us have chosen healthcare because it brings us meaning, right? We could go work in a cubicle; we could do numbers. We don’t have to interact with humans, but we’ve chosen to.”
Although much of this healing is individual, there should be no confusion that burnout in its various expressions is evidence of a systems problem.
“Burnout is not caused by broken people,” Gilmartin emphasized. “We’re not weak. It is not that we just can’t hack it. It’s caused by broken systems. Yes, there are things that individuals and teams can do to address their own burnout, but we need leaders across the industry to take on the bigger challenges.”
Healthcare administrators need to give healthcare workers flexible schedules to accommodate work-life balance, Gilmartin recommended. Give healthcare workers opportunities to identify and solve workplace problems while maintaining adequate staffing and reasonable workloads.
“Burnout is not unique to healthcare, but it’s really concerning for the people who lead our world, because healthcare is a giving place. If we have nothing left to give, that’s a problem,” Gilmartin said.
IHI and other researchers have found that expenditures to address these issues improve staff retention and reduce adverse patient outcomes.5
For healthcare workers, barriers to joy in work are rote paperwork or EHR demands on time. Barriers and daily irritants can be addressed proactively through team meetings and emails in a process Gilmartin called “pebbles in the shoes.”
Here, we pause to caution against airing petty grievances — particularly if they involve patients — on social media. A hospital in Georgia fired four labor and delivery nurses after they posted a TikTok video filmed at work that mocked patients they found annoying.6
The exercise Gilmartin described involves asking colleagues to write or speak aloud these little irksome things that cloud their job experience. “Make a list of these ‘pebbles’ in the meeting, prioritize them, and brainstorm,” she said. “Then, organize a little plan-do-check cycle to address each pebble.”
A timeless path to joy and gratitude is a mainstay in all manner of mental health approaches and wisdom teachings. It can range from the appreciation for a simple gesture to a deep, almost spiritual expression of thanks.
“It requires us to see how we’ve been supported and appreciated by others,” Gilmartin said. “Hundreds — and I mean hundreds — of studies have documented the social, physical, and psychological benefits of gratitude.”
It comes more naturally to some than others, but gratitude is a skill that can be developed, a muscle that can be strengthened. “There is a lot of unspoken gratitude in healthcare that many feel, but we don’t express it out loud,” Gilmartin said. “Give staff an opportunity to verbalize gratitude. You can end a daily huddle or a meeting with a moment for everyone to say something they felt grateful for. You can ask, ‘Does anyone have any gratitude they want to share?’ Then you can give an example yourself.”
A corollary practice is the “three good things” method of writing down positive incidents or feelings daily for a week.7 “The science behind this is: After seven days of identifying three good things that happened every day, you actually see a positive increase in your outlook in life,” Gilmartin noted.
Do not isolate yourself. Indeed, try to positively connect with colleagues, although this does not mean your “best friend” has to be a co-worker, Gilmartin said, anticipating the pushback she often encounters on this recommendation.
“We know that developing respect for the work of others and creating positive connections with our colleagues creates joy at work,” Gilmartin said. “We also know that high-quality work relationships are energizing. They increase the team’s ability to cope with stress, and they are a source of well-being.”
REFERENCES
- Chatterjee R. A nurse’s death raises the alarm about the profession’s mental health crisis. NPR. March 31, 2022.
- The Self Care Unit. The nurse nonprofits behind The Self Care Unit. March 7, 2023.
- The New York Times. Coronavirus in the U.S.: Latest map and case count. Updated March 23, 2023.
- Gilmartin HM, Saint S. Finding joy in medicine: A remedy for challenging times. NEJM Catal Innov Care Deliv 2022; Sept 1. doi: 10.1056/CAT.22.0215.
- Perlo J, Balik B, Swensen S, et al. IHI Framework for Improving Joy in Work. 2017.
- Freeman G. Nurses fired after posting TikTok video disparaging patients. Healthcare Risk Management. Feb. 1, 2023.
- Greater Good Science Center. Three good things. 2023.
Support groups help nurses with occupational anxiety, strengthening mental health and offering ways to manage stress.
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