After seeing a crispy, burned-out, brûléed emergency nurse say goodbye to emergency nursing on Twitter, I thought about the many emergency nurses who also left over the years.
Physicians are stuck with (or at least attached to) a particular field. Emergency physicians could pivot to urgent care, but a cardiologist can't scope colons. A nursing degree, though, allows you to work in any part of health care. An ED or ICU may not hire nurses fresh out of nursing school, but nurses can have different careers in various specialties.
You can't teach excellence in emergency nursing any more than you can teach excellence in emergency medicine. Excellence is knowledge plus experience, and that can only be earned with time. What is so hard when good nurses leave emergency nursing is that they take their Spidey sense with them.
I put out a call on Twitter for nurses to talk to me, and talk they did. Fifteen emergency nurses told me about their experiences. I also researched whether nurses are really leaving the profession or if this was just a natural progression for some nurses to move to another career.
We don't have large datasets on nursing attitudes during or post-COVID, but I can tell you it wasn't great for them pre-COVID. Survey data from nearly four million nurses in 2018 showed similar concerns to those of physicians, especially burnout. (JAMA Netw Open. 2021;4:e2036469; https://bit.ly/3n5qzDX.)
Three percent of nurses had left their jobs, and an incredible 17 percent were considering leaving. (I wonder what EPs' “considering” percentage would be.) Most said burnout was why they were leaving their jobs. Can you guess in which fields the rates of leaving from burnout were highest? Yep, hospital (RR 2.1) and skilled nursing facility (RR 2.3) jobs, increasing for the number of hours worked each week. Nurses said burnout was caused mostly by a stressful work environment, inadequate staffing, and poor management. The rate of nurses leaving their profession entirely has accelerated over the past five years, which only worsened our already serious nursing shortage.
Love the ED
The nurses I spoke with expressed similar themes, and all of them loved the ED. They had an average of 14 years of ED experience, and said the main issues for them were feeling supported in their job (not overworked), having good management and leadership, and spending time with their coworkers.
Not a single one mentioned pay. Many did say they could have had an easier nursing life outside of the ED (and many moved to other departments), but they loved and missed the ED job. They preferred emergency nursing because of the pace of the ED, having patients move through the system (as opposed to caring for the same patients for days on the floor), and feeling like a critical part of a team.
One nurse I spoke with left the ED because of the inability to provide the care she wanted to provide and that she felt her patients deserved: “There wasn't one big incident that made me leave [but a combination] of many small ones. There was one shift where I was working triage and I had an elderly lady ... with a broken hip, and I knew she had to pee. I just couldn't get down there to assist her; there were too many things happening. By the time I was able to go see her, she'd been incontinent.
“She was a well person aside from her broken hip, well dressed, still independent at home, and she was so embarrassed that she cried, and I cried with her. I felt so awful. I knew the care she needed, and I had been constrained from being able to give her that. I know it sounds like a small thing and just a bit of pee ... but it was a big deal for her, having her feel undignified and forgotten.”
Another nurse said she left because the culture of the hospital system changed, not for the better. “Our system was bought out by a bigger system, and we all hoped that it would get better. However, we felt more and more neglected as nurses. Administration was telling us that we were important and needed, but they weren't doing it in their actions. We went through four directors in five years, which led to a lot of changes.
“Staff wasn't consulted or even told beforehand. We just showed up at work and had new rules. The inability to include nursing in decision-making and issues with the department, despite their statements about shared governance, was very hard for me and my fellow nurses. I became disillusioned with nursing, realizing that I didn't have the control over my career that I wanted.”
One nurse talked about the camaraderie in the ED: “The relationship with the providers is a huge source of satisfaction for me. They are my friends, and I have always felt that they care about the nursing staff, that they are working with everyone as a team, that nurses are integral to their success. This is huge. I really cannot overstate it. Without the mutual respect and the autonomy that they foster with nursing, I very much doubt I would have put up with this place for this long.”
Cost of Burnout
What can we do about this? Is this just a normal part of emergency nursing? Not everyone—even the best nurses I've ever worked with—can tough it out. I don't think that's what we want our standard to be for emergency medicine or emergency nursing. We want the best and brightest to work among us and help our patients, and we shouldn't lose them to easier jobs.
As one nurse put it: “The hospitals spend so much time and money on recruitment and training, and then don't consider the impact of burnout and mental health and wellness on staff retention. And that doesn't even account for the additional costs and impacts of burnout to me and the individuals who are my friends and work family.”
Are we shooting ourselves in the foot, paying for travel nurses when we could just treat our current ones better? Even I know that Costco saves more money than Sam's Club because they pay their workers better and provide better benefits, which yields employee retention and saves money on recruitment and training.
One nurse shared an idea that helped her ED: cross-training for similar departments (like the ED and ICU) so nurses could work in both. This also bred collegiality and better partnership between the departments. “There are also benefits to both units,” she said. “The ED gets more critical care hands, and the ICU gets ED specialty in large team resuscitation and staff who can just figure things out and make it happen.” She said she was the happiest professionally while enjoying challenges in both units.
I've barely mentioned COVID in this article, which has burned us all to a crispy thin wafer, but we know it is taking a toll. (Becker's Hospital Review. April 6, 2021; https://bit.ly/3tyEo0h.) How many more nurses will our field lose, taking their expertise with them?
Dr. Walkeris an emergency physician at Kaiser San Francisco. He is the developer and co-creator of MDCalc (www.mdcalc.com), a medical calculator for clinical scores, equations, and risk stratifications, which also has an app (http://apps.mdcalc.com/), and The NNT (www.thennt.com), a number-needed-to-treat tool to communicate benefit and harm. Follow him on Twitter@grahamwalker, and read his past columns athttp://bit.ly/EMN-Emergentology.