Hospitals are filled with sick people. Unfortunately, many of them aren't patients, and most don't admit that they are ill.
Charlotte was a nurse manager at a neonatal nursing unit in a major medical center.
This meant that she, along with 25 other nurses and two other nurse managers, took care of the smallest patients in the hospital. Three-pound neonates lived, often for months, in warmed "beds" - actually small incubators, relying on Charlotte and her staff for life support. These tiny creatures, fetuses really, were carefully observed 24 hours a day as they clawed at the air, writhed, gasped, contorted their little faces, cried, and then, like angels, slept. Charlotte's nurses watched every move and recorded all procedures, medicines, foods, liquids, temperatures, and environmental indicators, all the while offering comfort to worried parents. When the babies were out of danger, the nurses relished holding them, cuddling their small charges, as the babies relied more on human warmth than technical forms of life support. This phase was bittersweet for the nurses, since it signaled the impending end of their time with "their" babies.
"Most babies get better when they are with us," Charlotte said with pride. Her reddish round face beamed as she spoke, although her massive body barely moved. Then her mood darkened.
"The work is stressful enough. One mistake and these babies can go into crisis. We almost lost one last week, but we pulled through."
I asked how the nurses deal with the stress.
"This stress - here on the unit?" she inquired. "Or the stress at home? Most of the girls go home to a second shift."
I then learned the story of these nurses. As "all caregivers, all the time," many had untreated alcoholic family members, were single mothers, or had primary responsibility for their children, as well as the "breadwinner" role. Many also cared for elder or sick parents, each chosen among siblings as the one who could handle the job when family members were in need.
Somehow, these women precariously met the tense demands for their time and attention. The national nursing shortage's impact on their hospital also created a demand for more shifts from fewer nurses. Most already worked 50-60 hours per week, and they were begged to work more by pleading scheduling nurses. Overtime pay was used by the nurses to pay for babysitters for the nurses' children, who missed their mothers but felt unable to ask for more time when the women were out saving lives.
Their spouses lived parallel lives, finding ways to depend on them less. Consequently, many of the nurses' marriages failed. Only two of the nurses over age 35 were still married in Charlotte's unit.
Ironically, care for the most needy had resulted in the neglect of the caregivers. Neglect is an insidious, often ignored condition, until symptoms emerge.
When I interviewed the nurses, at Charlotte's request, about how they handled their stress, the response was uniform: "Chocolate!" they cheered in chorus.
In fact, the women, so utterly careful about the care and feeding of their tiny charges, were not at all concerned with filling the nursing station (and their mouths) with high-fat, high-sugar donuts, cookies, cake, high-cholesterol egg bagels, and candy. When the unit won the hospital's "top care unit" award, it asked for chocolate milk in the vending machines as a reward.
"If the administration gives us chocolate, we know they love us!" said one unit member.
On average, each nurse had gained between 18 and 20 pounds within two years of joining the unit. The weight gain was a sad, although acknowledged joke on the ward, as women ordered successively larger-sized scrubs. Most had been able to handle stresses at home without significant health effects. The added work stress, however, had created an epidemic of obesity.
According to the National Institute of Health (NIH), more than 60 percent of Americans 20 years and older are overweight, with about a quarter of adult Americans also being obese - putting them at significantly greater risk for heart disease, diabetes, strokes, osteoarthritis, high blood pressure, high cholesterol, gallbladder disease, and even certain forms of cancer. The NIH has stated: "Obesity is more than a cosmetic problem: it is a health hazard. Approximately 280,000 deaths in the U.S. each year are related to obesity." Does this mean that untreated work stress, leading to obesity, can be fatal?
Charlotte didn't think that work would kill her nurses, but she did know that she wasn't handling the stresses well, and she felt increasingly unable to support her staff. She needed help, had heard I might be able to help, and called. Now, after interviewing the staff, she wanted to hear my assessment and suggestions. She kindly offered me cookies and hot chocolate as we sat down in her office.
Refusing the food, I shared the results. She was right. All but one of her nurses had experienced a significant reduction in health since working in the unit, and all but one had gained a lot of weight. Of those who had gained weight, three quarters were developing or already had secondary symptoms of obesity, such as an elevation in blood pressure or cholesterol significant enough that treatment was needed. This was causing a physical and financial strain, since some of the medical care and medicines required copayments above what the nurses' health insurance covered. We agreed that interventions would be useful to stop the cycle of neglect that had resulted in overeating and obesity.
I suggested three steps, to be taken simultaneously. The first was dietary. Charlotte and I constructed a "healthy" selection of foods - less sweet and much lower in fat - for the nurses' station. This was accompanied by support from the hospital's dietary department, which supported a "healthy take-out" program. At shift changes, healthy take-out meals were available to the working moms, who ate them while working and often also brought them home. Charlotte also joined the local Weight Watchers group, and arranged for a meeting once a week at the hospital for nurses who wanted to lose weight.
We then instituted an exercise competition. Those who wanted, received "step monitors" and were encouraged to walk 1,000 extra steps per week. Climbing the stairs or walking uphill counted double. Rigorous exercise counted triple. Monthly highs were recorded and rewarded.
And finally, Charlotte changed. She learned to take care of herself and gradually changed her approach to her staff. Rather than providing for them or rewarding them with sweets for their selfless work, she learned to reward them for self-care in addition to caring for others. This is a lesson for us all.
Caregivers from all walks of life, and all types of institutions, face the challenge of finding ways to support others while remaining healthy. Stay tuned to my next article for a deeper examination of how this worked well in a health care institution.
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