Selected Podcast
Promoting Mental Health & Wellbeing in Critical Care Nurses: An Urgent Call
Critical care nurses report high levels of anxiety and depression. Nurses in worse mental & physical health report more medical errors than nurses in better mental & physical health. When nurses perceive high levels of wellness support from their organization, they are more than twice as likely to have better health than nurses who report not having worksite support. Hospital and healthcare system leaders need to create and sustain cultures of wellness to improve overall health and well-being.
Featuring:
Bernadette Melnyk, PhD, APRN-CNP, FNAP, FAAN
Bernadette Melnyk, PhD is VP Health Promotion, University Chief Wellness Officer, Dean and Professor. Transcription:
Bill Klaproth (Host): Promoting mental health and wellbeing in critical care nurses is of utmost importance. So, how do you know if you are burned out and suffering from that? What happens as a result of being burned out? And what are some strategies you can take to combat burnout and promote your own health and wellness?
So let's find out with Bernadette Melnyk, Vice President of Health Promotion, University Chief Wellness Officer and Dean and Professor at the Ohio State University.
This is Today in Nursing Leadership, a podcast from the American Organization for Nursing Leadership. I'm Bill Klaproth. Bernadette, thank you so much. It is a pleasure and an honor to talk with you. Thank you so much for your time. So when it comes to promoting mental health and wellbeing in critical care nurses, let's start with this. Can you explain to us what EBP plus clinician wellbeing and how that equals the quadruple AIM in healthcare? Let's start with that.
Bernadette Melnyk, PhD, APRN-CNP, FNAP, FAAN (Guest): So, the triple AIM was advanced about five to six years ago. And there were three goals to the triple AIM. Enhancing the patient experience. That includes health care quality and safety, improving population health outcomes, and decreasing costs. But then several years later, after the triple AIM was talked about, there was a landmark paper that said we're missing one important AIM. And that is improving the work life and wellbeing of clinicians. Because if we don't, mentally and physically healthy clinicians it's not only going to affect population health but it's gonna adversely affect healthcare quality and safety. So we've got to aim for all of those four AIMS.
Host: Absolutely. And those are tied together, right? Clinician wellbeing and healthy outcomes. They are kind of linked together. Is that right?
Dr. Melnyk: Yes.
Host: Right. Well, and the problem is, is that it's very stressful being a clinician, and there's a lot of stressors out there. So, let's dig into those a little bit and try to identify those. So can you tell us what the terrible toos are and why it's important for us to understand those?
Dr. Melnyk: So I call the terrible toos, too much stress, too much work. Too many tasks. And too time for self care. Burn out in nurses, physicians, other clinicians has so many adverse consequences. For clinicians, as well as for learners, we look at the risk of depression and suicide when somebody is burnt out. Occupational injury, problematic alcohol use.
But on the healthcare side of things, burnout leads to lower morale and productivity, presenteeism. That means people show up for work. They are physically there. But they're often not mentaly engaged. So burnout leads to fewer staff because of absenteeism and turnover. Our country spends 4.6 billion dollars a year because of burnout.
That's incredible. So lot of negative consequences. And most important, it impacts quality of healthcare as well as safety. About 250,000 people die every year in the United States due to preventable medical errors sadly from well-meaning clinicians who are burned out.
Host: Those are amazing stats. And that really frames the issue at hand and I love how you talk about the terrible toos. That's an interesting way to put it, too much stress, too much work, too many tasks, too little time for self care. So the terrible toos really are terrible. So you talked about people coming to work. They're physically there, but mentally, not really. So how can someone judge their own level of burnout? How do we recognize this in ourselves?
Dr. Melnyk: There's a lot of signs of burnout and I'll just share a few. Feeling helpless. Self-doubt, feeling like you're a failure, beginning to detach from your work, loss of motivation. A real lack of energy. And a lot of people who are burning out, tend to get negative, even cynical and there is decreased satisfaction and a sense of accomplishment.
So again, the important thing is to be self-aware. To ask yourself, no matter what your definition of burnout is, how burned out do you feel today? Recognizing that we're burning out is a strength. It's not a weakness. And it's not selfish to stop and say, I need to take better self-care. But I will tell you, it's not just a lack of self-care that leads to burnout. We. We have so many broken systems in our health care environments that lead toclinician. Burnout. Our C suites, across the country, have to recognize the toll that burnout takes on our clinicians, our healthcare quality, safety and patient outcomes.
Host: Again, you've really painted a picture for us of the problems of burnout and being self-aware, understanding it in yourself. You said the feeling of being helpless, having the feelings of self-doubt, feeling like you're a failure, beginning to detach your work, loss of motivation. It's very important to understand those things. That's for sure. And I'm sure COVID not help any of this at all. Is that right, Bernadette? This just really compacted and compounded everything.
Dr. Melnyk: Absolutely. I just published a national study of travel nurses actually. They had tremendously high rates of burnout about two-thirds, high rates of depression and anxiety. How people though are attempting to cope with these symptoms and with COVID is often with unhealthy behaviors.
So, in this sample, mainly travel nurses, people were coping with unhealthy eating, increases in the alcohol use and declines in physical activity. And we're gonna see again, adverse outcomes of people engaged in these unhealthy behaviors 2 3, 5 years down the road with the increases in high blood pressure, diabetes, and other types of chronic disease. In addition to the serious mental health effects of this pandemic.
Host: So true. Absolutely that stress and burnout, certainly is going to manifest in these unhealthy lifestyle, behavioral choices, like you just mentioned. So how do we get out of this, Bernadette? How do we create a culture of wellness now that we've recognized that, hey, I might be having burnout right now. How do we get out of this?
Dr. Melnyk: Yes. So first I want to emphasize important system focused intervention strategies, effectivenss of what we do in our hospitals, in our healthcare systems increase when individual and organizational interventions are combined. So the C-suites across the country must focus on fixing broken systems that we know cause burnout. For instance, patient nurse staffing ratio. There are a lot of places that have nurses taking care of 10 to 12 patients at a time. So short staffing, long hours, my research has consistently shown 12-hour shifts are not healthy for nurses. And not good for patient's safety. We've got to stop 12-hour shifts even though nurses traditionally will say we love them. But they're so burned out after they work three 12-hour shifts, that they don't then give quality time at home due to burn out. So you've got to fix system problems. And at the same time, build wellness cultures and make it easy for people to seek mental health help if they need it. Make it easy for them to engage in healthy lifestyle behaviors.
Culture eats strategy for breakfast, lunch, and dinner. But it takes time to change culture. The culture is so critical. You can have really great cultures of wellness. You can be resource rich, like we are with the evidence-based resiliency programs at Ohio State. But again, if you've got a lot of broken systems, people aren't going to be able to engage in what you would have to offer.
Host: Yeah, that makes sense. As you put it system focused intervention strategies, and it's really up to the C-suite across the country. They must focus on fixing broken systems, as you say that we know cause burnout. So that's so true. I wanted to ask you about the Mind Body Strong Program. What is that? Is that something we can use as a strategy to help decrease burnout?
Dr. Melnyk: Yeah. So, over two decades ago, I in my research hat of what I do; I wanted to manualize cognitive behavioral therapy. Because CBT is gold standard first line evidence based treatment for depression and anxiety. So I first started to develop the CBT based program for adolescents. And then I spun off a version for children, for young adults and about 20 studies really show that this cope program really does decrease depression, anxiety, suicidal ideation and improves healthy lifestyle behaviors.
Well, a few years ago, I adapted it for nurses, physicians and other clinicians. And one of my PhD students, Marlene Samson, tested as part of her PhD, her dissertation. So we did a randomized controlled trial. She integrated this program. It's seven, weekly about 40 minute sessions into the residency program.
And we looked at was it effective on depression, anxiety, stress and job satisfaction and we found wonderful differences between the nurses who went through this CBT program and those that Got an attention control program. So this CBT based evidence based program is really starting to scale to hospitals and healthcare systems throughout the country to really build mental resiliency in our clinicians.
Host: And speaking of mental resiliency, you talk about having negative thoughts. How can we catch negative thinking and what can we do to reverse that?
Dr. Melnyk: Think about this. The majority of cases of depression, anxiety and stress are caused by negative patterns of thinking or unhelpful patterns of thinking. For instance, catastrophizing. We do that a lot. Right. Oh, I flubbed up at work. I flubbed up on a test. I am going to get a poor performance evaluation. I'm gonna lose my job and eventually I'll be homeless. We have a lot of these negative automatic thoughts. So here's the key. When you feel stressed, anxious, or depressed, for the next 30 days I encourage people to stop and say to themselves what was just going through my mind. Is the thought really true?
Is this type of thinking helpful? And do I have the evidence to back it up? Chances are the answer's gonna be no to those questions. So the key is to catch those thoughts. Chuck them with those questions. And turn those negative or unhelpful thoughts around to positive because how we think impacts, how we feel. And how we behave.
Host: That is really helpful. So when you feel stressed, anxious, or depressed stop and say to yourself, what was just going through my mind? Is this type of thinking helpful? Do I have the evidence to back it up? Ask yourself, those questions when those negative thoughts come up and it's very helpful, Bernadette, thank you for that. And you've got another great saying, I love this. We all need to take our doses of vitamin G. What is vitamin G?
Dr. Melnyk: Vitamin G stands for gratitude. We have so much research to show that if we just practice gratitude every morning, and every night before we go to bed, by thinking about two or three things or people who we are thankful for and actually name them, or create a gratitude board in your clinical unit. So when people come on for their shifts, they write down one personal thing they're grateful for that day. We have so much research to show a daily does a vitamin G practiced every single day, improves mood, cardiovascular health, optimism, sleep, and blood pressure. It's one of the simplest evidence-based practices that if we put it into practice every day, we're going to feel so much better emotionally and physically.
Host: Again, so good. So we need to take our dose of vitamin G every morning and, and every night we go to bed and you just explained it, so many positive benefits by being grateful and having an attitude of gratitude, if you will. So you've really kind of laid this out for us. Recognizing that you are burned out right. Trying to enact change in your organization, starting at the C-suite to build that culture of wellness. You've taught us how to avoid negative thoughts. You've talked about vitamin G as well. And if we do that and practice, healthy lifestyle behaviors, all of that should help us moving forward. Is that right?
Dr. Melnyk: Absolutely. We have to remember 80%, of chronic disease is totally prevrentable with healthy behavior like physical activity, healthy eating, not smoking, limiting alcohol intake to just one drink a day but then everybody asked me Bern, how big can that drink be? And I tell them not the size of the alcoholic beverages we get in Vegas, but if we put on top of that, seven hours. Yes. Seven hours of sleep a night and then regularly engaging in a stress reduction practice every single day. Think about it, we could almost wipe out chronic disease, including mental health problems in our society.
Host: That is amazing. And so true, 80% of chronic diseases, as you say, totally preventable, by choosing healthy lifestyle behaviors, practicing gratitude, and getting away from those negative thoughts. Just amazing. So, Bernadette, thank you so much for your time. We really appreciate this. You also talked about what we should shoot for in the next two to five years. What should our goals be? Help us kind of formulate our thoughts moving forward.
Dr. Melnyk: We need to shift our current paradigm. In the United States, we are still way too focused on sick care. We need to switch that paradigm more to a wellness focus and prevention. We spend more money on healthcare then any Western world country, yet we rank in the bottom for health outcomes. We only invest about 8% of our healthcare spending in prevention and wellness. An ounce of prevention is worth a pound of cure. We've got to flip that paradigm.
Host: Yeah. As you said, we are too focused on sick care. We need to switch that paradigm more to a wellness focused, that's for sure. Bernadette, you're such a wealth of information and knowledge. If you could wrap this up for us, is there anything else you'd like to share with us?
Dr. Melnyk: I want to encourage everybody who is listening to just take a little bit better self-care. We cannot continue to pour from an empty cup. Self-care is not an extra add on. It needs to be built in to end to our daily practices as we cannot continue to pour from an empty cup and we cannot take great care of other people unless we take good self-care.
Host: Another great visual that really sums it up. You cannot continue to pour from an empty cup. That's so simple when you think about it. We do need to take better care of ourselves and keep that cup full. Right?
Dr. Melnyk: Absolutely.
Host: Bernadette, this has really been fantastic. I really enjoyed talking with you and thank you for sharing all this great wisdom and knowledge with us. We really appreciate it. Thanks again.
Dr. Melnyk: Thank you. Stay well.
Host: And once again, that is Bernadette Melnyk. A lot of fun talking with her, a lot of great wisdom for you. And thank you so much for listening to this podcast today from AONL. For more information, you can visit aonl.org. And if you found this podcast helpful, please share it on your social channels. And check out the full podcast library for topics of interest to you. This is Today in Nursing Leadership. Thanks for listening.
Bill Klaproth (Host): Promoting mental health and wellbeing in critical care nurses is of utmost importance. So, how do you know if you are burned out and suffering from that? What happens as a result of being burned out? And what are some strategies you can take to combat burnout and promote your own health and wellness?
So let's find out with Bernadette Melnyk, Vice President of Health Promotion, University Chief Wellness Officer and Dean and Professor at the Ohio State University.
This is Today in Nursing Leadership, a podcast from the American Organization for Nursing Leadership. I'm Bill Klaproth. Bernadette, thank you so much. It is a pleasure and an honor to talk with you. Thank you so much for your time. So when it comes to promoting mental health and wellbeing in critical care nurses, let's start with this. Can you explain to us what EBP plus clinician wellbeing and how that equals the quadruple AIM in healthcare? Let's start with that.
Bernadette Melnyk, PhD, APRN-CNP, FNAP, FAAN (Guest): So, the triple AIM was advanced about five to six years ago. And there were three goals to the triple AIM. Enhancing the patient experience. That includes health care quality and safety, improving population health outcomes, and decreasing costs. But then several years later, after the triple AIM was talked about, there was a landmark paper that said we're missing one important AIM. And that is improving the work life and wellbeing of clinicians. Because if we don't, mentally and physically healthy clinicians it's not only going to affect population health but it's gonna adversely affect healthcare quality and safety. So we've got to aim for all of those four AIMS.
Host: Absolutely. And those are tied together, right? Clinician wellbeing and healthy outcomes. They are kind of linked together. Is that right?
Dr. Melnyk: Yes.
Host: Right. Well, and the problem is, is that it's very stressful being a clinician, and there's a lot of stressors out there. So, let's dig into those a little bit and try to identify those. So can you tell us what the terrible toos are and why it's important for us to understand those?
Dr. Melnyk: So I call the terrible toos, too much stress, too much work. Too many tasks. And too time for self care. Burn out in nurses, physicians, other clinicians has so many adverse consequences. For clinicians, as well as for learners, we look at the risk of depression and suicide when somebody is burnt out. Occupational injury, problematic alcohol use.
But on the healthcare side of things, burnout leads to lower morale and productivity, presenteeism. That means people show up for work. They are physically there. But they're often not mentaly engaged. So burnout leads to fewer staff because of absenteeism and turnover. Our country spends 4.6 billion dollars a year because of burnout.
That's incredible. So lot of negative consequences. And most important, it impacts quality of healthcare as well as safety. About 250,000 people die every year in the United States due to preventable medical errors sadly from well-meaning clinicians who are burned out.
Host: Those are amazing stats. And that really frames the issue at hand and I love how you talk about the terrible toos. That's an interesting way to put it, too much stress, too much work, too many tasks, too little time for self care. So the terrible toos really are terrible. So you talked about people coming to work. They're physically there, but mentally, not really. So how can someone judge their own level of burnout? How do we recognize this in ourselves?
Dr. Melnyk: There's a lot of signs of burnout and I'll just share a few. Feeling helpless. Self-doubt, feeling like you're a failure, beginning to detach from your work, loss of motivation. A real lack of energy. And a lot of people who are burning out, tend to get negative, even cynical and there is decreased satisfaction and a sense of accomplishment.
So again, the important thing is to be self-aware. To ask yourself, no matter what your definition of burnout is, how burned out do you feel today? Recognizing that we're burning out is a strength. It's not a weakness. And it's not selfish to stop and say, I need to take better self-care. But I will tell you, it's not just a lack of self-care that leads to burnout. We. We have so many broken systems in our health care environments that lead toclinician. Burnout. Our C suites, across the country, have to recognize the toll that burnout takes on our clinicians, our healthcare quality, safety and patient outcomes.
Host: Again, you've really painted a picture for us of the problems of burnout and being self-aware, understanding it in yourself. You said the feeling of being helpless, having the feelings of self-doubt, feeling like you're a failure, beginning to detach your work, loss of motivation. It's very important to understand those things. That's for sure. And I'm sure COVID not help any of this at all. Is that right, Bernadette? This just really compacted and compounded everything.
Dr. Melnyk: Absolutely. I just published a national study of travel nurses actually. They had tremendously high rates of burnout about two-thirds, high rates of depression and anxiety. How people though are attempting to cope with these symptoms and with COVID is often with unhealthy behaviors.
So, in this sample, mainly travel nurses, people were coping with unhealthy eating, increases in the alcohol use and declines in physical activity. And we're gonna see again, adverse outcomes of people engaged in these unhealthy behaviors 2 3, 5 years down the road with the increases in high blood pressure, diabetes, and other types of chronic disease. In addition to the serious mental health effects of this pandemic.
Host: So true. Absolutely that stress and burnout, certainly is going to manifest in these unhealthy lifestyle, behavioral choices, like you just mentioned. So how do we get out of this, Bernadette? How do we create a culture of wellness now that we've recognized that, hey, I might be having burnout right now. How do we get out of this?
Dr. Melnyk: Yes. So first I want to emphasize important system focused intervention strategies, effectivenss of what we do in our hospitals, in our healthcare systems increase when individual and organizational interventions are combined. So the C-suites across the country must focus on fixing broken systems that we know cause burnout. For instance, patient nurse staffing ratio. There are a lot of places that have nurses taking care of 10 to 12 patients at a time. So short staffing, long hours, my research has consistently shown 12-hour shifts are not healthy for nurses. And not good for patient's safety. We've got to stop 12-hour shifts even though nurses traditionally will say we love them. But they're so burned out after they work three 12-hour shifts, that they don't then give quality time at home due to burn out. So you've got to fix system problems. And at the same time, build wellness cultures and make it easy for people to seek mental health help if they need it. Make it easy for them to engage in healthy lifestyle behaviors.
Culture eats strategy for breakfast, lunch, and dinner. But it takes time to change culture. The culture is so critical. You can have really great cultures of wellness. You can be resource rich, like we are with the evidence-based resiliency programs at Ohio State. But again, if you've got a lot of broken systems, people aren't going to be able to engage in what you would have to offer.
Host: Yeah, that makes sense. As you put it system focused intervention strategies, and it's really up to the C-suite across the country. They must focus on fixing broken systems, as you say that we know cause burnout. So that's so true. I wanted to ask you about the Mind Body Strong Program. What is that? Is that something we can use as a strategy to help decrease burnout?
Dr. Melnyk: Yeah. So, over two decades ago, I in my research hat of what I do; I wanted to manualize cognitive behavioral therapy. Because CBT is gold standard first line evidence based treatment for depression and anxiety. So I first started to develop the CBT based program for adolescents. And then I spun off a version for children, for young adults and about 20 studies really show that this cope program really does decrease depression, anxiety, suicidal ideation and improves healthy lifestyle behaviors.
Well, a few years ago, I adapted it for nurses, physicians and other clinicians. And one of my PhD students, Marlene Samson, tested as part of her PhD, her dissertation. So we did a randomized controlled trial. She integrated this program. It's seven, weekly about 40 minute sessions into the residency program.
And we looked at was it effective on depression, anxiety, stress and job satisfaction and we found wonderful differences between the nurses who went through this CBT program and those that Got an attention control program. So this CBT based evidence based program is really starting to scale to hospitals and healthcare systems throughout the country to really build mental resiliency in our clinicians.
Host: And speaking of mental resiliency, you talk about having negative thoughts. How can we catch negative thinking and what can we do to reverse that?
Dr. Melnyk: Think about this. The majority of cases of depression, anxiety and stress are caused by negative patterns of thinking or unhelpful patterns of thinking. For instance, catastrophizing. We do that a lot. Right. Oh, I flubbed up at work. I flubbed up on a test. I am going to get a poor performance evaluation. I'm gonna lose my job and eventually I'll be homeless. We have a lot of these negative automatic thoughts. So here's the key. When you feel stressed, anxious, or depressed, for the next 30 days I encourage people to stop and say to themselves what was just going through my mind. Is the thought really true?
Is this type of thinking helpful? And do I have the evidence to back it up? Chances are the answer's gonna be no to those questions. So the key is to catch those thoughts. Chuck them with those questions. And turn those negative or unhelpful thoughts around to positive because how we think impacts, how we feel. And how we behave.
Host: That is really helpful. So when you feel stressed, anxious, or depressed stop and say to yourself, what was just going through my mind? Is this type of thinking helpful? Do I have the evidence to back it up? Ask yourself, those questions when those negative thoughts come up and it's very helpful, Bernadette, thank you for that. And you've got another great saying, I love this. We all need to take our doses of vitamin G. What is vitamin G?
Dr. Melnyk: Vitamin G stands for gratitude. We have so much research to show that if we just practice gratitude every morning, and every night before we go to bed, by thinking about two or three things or people who we are thankful for and actually name them, or create a gratitude board in your clinical unit. So when people come on for their shifts, they write down one personal thing they're grateful for that day. We have so much research to show a daily does a vitamin G practiced every single day, improves mood, cardiovascular health, optimism, sleep, and blood pressure. It's one of the simplest evidence-based practices that if we put it into practice every day, we're going to feel so much better emotionally and physically.
Host: Again, so good. So we need to take our dose of vitamin G every morning and, and every night we go to bed and you just explained it, so many positive benefits by being grateful and having an attitude of gratitude, if you will. So you've really kind of laid this out for us. Recognizing that you are burned out right. Trying to enact change in your organization, starting at the C-suite to build that culture of wellness. You've taught us how to avoid negative thoughts. You've talked about vitamin G as well. And if we do that and practice, healthy lifestyle behaviors, all of that should help us moving forward. Is that right?
Dr. Melnyk: Absolutely. We have to remember 80%, of chronic disease is totally prevrentable with healthy behavior like physical activity, healthy eating, not smoking, limiting alcohol intake to just one drink a day but then everybody asked me Bern, how big can that drink be? And I tell them not the size of the alcoholic beverages we get in Vegas, but if we put on top of that, seven hours. Yes. Seven hours of sleep a night and then regularly engaging in a stress reduction practice every single day. Think about it, we could almost wipe out chronic disease, including mental health problems in our society.
Host: That is amazing. And so true, 80% of chronic diseases, as you say, totally preventable, by choosing healthy lifestyle behaviors, practicing gratitude, and getting away from those negative thoughts. Just amazing. So, Bernadette, thank you so much for your time. We really appreciate this. You also talked about what we should shoot for in the next two to five years. What should our goals be? Help us kind of formulate our thoughts moving forward.
Dr. Melnyk: We need to shift our current paradigm. In the United States, we are still way too focused on sick care. We need to switch that paradigm more to a wellness focus and prevention. We spend more money on healthcare then any Western world country, yet we rank in the bottom for health outcomes. We only invest about 8% of our healthcare spending in prevention and wellness. An ounce of prevention is worth a pound of cure. We've got to flip that paradigm.
Host: Yeah. As you said, we are too focused on sick care. We need to switch that paradigm more to a wellness focused, that's for sure. Bernadette, you're such a wealth of information and knowledge. If you could wrap this up for us, is there anything else you'd like to share with us?
Dr. Melnyk: I want to encourage everybody who is listening to just take a little bit better self-care. We cannot continue to pour from an empty cup. Self-care is not an extra add on. It needs to be built in to end to our daily practices as we cannot continue to pour from an empty cup and we cannot take great care of other people unless we take good self-care.
Host: Another great visual that really sums it up. You cannot continue to pour from an empty cup. That's so simple when you think about it. We do need to take better care of ourselves and keep that cup full. Right?
Dr. Melnyk: Absolutely.
Host: Bernadette, this has really been fantastic. I really enjoyed talking with you and thank you for sharing all this great wisdom and knowledge with us. We really appreciate it. Thanks again.
Dr. Melnyk: Thank you. Stay well.
Host: And once again, that is Bernadette Melnyk. A lot of fun talking with her, a lot of great wisdom for you. And thank you so much for listening to this podcast today from AONL. For more information, you can visit aonl.org. And if you found this podcast helpful, please share it on your social channels. And check out the full podcast library for topics of interest to you. This is Today in Nursing Leadership. Thanks for listening.