Nursing is, by its very nature, an occupation subject to a high degree of stress. Every day a nurse confronts stark suffering, grief, and death as few other people do. Many tasks are mundane and unrewarding. Many are, by normal standards, distasteful, even disgusting, others are often degrading; some are simply frightening” (Hingey, P. 1984. The Humane Face of Nursing. Nursing Mirror, 159(21): 19-22).

What is the secret behind nurses who sustain high stress situations yet have low burnout rates?

Danny Lieberman, founder of Pathcare – the private social network for doctors and patients, tells the story of how Israeli nurses reduce stress and burnout and asked Dr. Jane Bluestein to prescribe some practical means for clinical care teams to deal with difficulty and stay cool.

Israeli nurses have low burnout rates – how do they do it and what can we learn?

Prof. Ayala Malach-Pines from Ben Gurion University in Israel uses an existential perspective to explain the phenomenon of low burnout in Israeli nurses.

Noting that life in Israel is very stressful, and that Israel has gone through five major wars and even during peace times that civilians live with the constant threat of terrorist activity, Malach-Pines proposes that the root cause of burnout lies in people’s need to believe that their lives are meaningful.

She asserts that the greatest sense of existential significance felt by people in the medical profession is because of their daily confrontation with life and death issues and her explanation for low burnout, not only in nurses, but also in teachers and managers, is due the fact that Israelis as less burned out, not despite, but because of the constant reminders to the threat to their existence.

Prof. Ayala Malach-Pines says that the more democratic style of interpersonal relationships, the traditional and clearly defined hierarchical relationships between nurses and physicians, and the larger and stronger support systems that are characteristic of the Israeli people act as buffers against burnout. See “Nurse burnout in a high stress health care environment: Prognosis better than expected? Elizabeth Hall

Dr. Jane says that this clearly demonstrates that empowered nurses are more likely to have increased autonomy, decreased job stress, increased job satisfaction, increased commitment, and lower burnout and goes on to prescribe 9 ways to sustain high stress and avoid burnout:

9 ways to deal with difficult people and stressful situations in the clinical care team

1. Don’t Take it Personally

Israelis are very direct but can also be very critical – if we all took things that our colleagues said – especially the surgeon professors to lowly nurses personally, it would be hard to get through the day.

Goethe said, “Misunderstandings and neglect occasion more mischief in the world than even malice and wickedness.”

You don’t need to rationalize hurtful behavior (or even understand it) and you can respond in the same self-caring ways regardless of the other person’s intent. For your own sanity, try to assume it’s not deliberate, even when it is.

2. Ask for What You Want

One thing we can learn from Israeli culture is it’s directness – I don’t need to know how my behavior makes you feel or what issues it brings up for you. Seriously. Just ask for what you want.

When something comes up, be direct. Many people dance around a problem, never getting close enough to actually resolve it. One of the most important skills in human interactions—if not the scarcest—is the ability to ask for what we want, and to do so without attacking or making anyone wrong.

Fear of anger (“He’ll have a fit.”) or disapproval (“She won’t like me.”) makes for some rather convoluted and dysfunctional interaction patterns. If you want me to continue my conversation away from your office, for example, ask me. Something as simple as “Could you guys go chat down the hall, please” can elicit consideration and cooperation, not just now but in the future as well.

On the other hand, sitting and stewing over what an inconsiderate person I am won’t get you what you want. (Even the most hypervigilant person probably isn’t as good a mind-reader as you’ll need in this situation.) Blowing up at me might get me to move, but even if it doesn’t bring out my defensiveness, justification or a counterattack, it’ll cost you down the line, if only in terms of my ability to trust you in the future. Likewise, telling me about it a week later, long after I can do anything about it, can also erode trust and respect.

3. Believe in Your Own Power

Many indirect approaches mask a belief system that excludes the perception that we actually have the ability to change things. Successful relationships require a belief in our power to influence our lives and interactions. (A “why-bother” approach is an adequate response only as long as you can live with the consequences of not bothering—quietly and happily.)

A more constructive alternative involves taking responsibility for meeting your own needs while considering the needs of the other person: “I think we have a problem. I signed up to use the room this afternoon. I won’t have another opportunity to run this meeting and we can’t really do this anywhere else. Is there some way we can work this out?” You identify the problem, giving your coworker additional information in a way that puts you both in a position to negotiate.

If the other person has any flexibility, especially if you have a history of cooperation and mutual respect with this individual, you’ll probably get the room (or arrive at an alternative solution you might not have otherwise considered). Even if you don’t get the resolution you like, you probably won’t burn any bridges either. A positive result is more likely when you believe in your ability to achieve it.

4. Do a reality check of your colleagues on the team

If a colleague approaches you in a state of emotional overload, his body is probably filled with stress hormones and locked into a fight-or-flight response which, neurologically, doesn’t allow easy access to the more rational parts of his brain. Your defensiveness or impulse to fight back, as natural as that may be given the situation, is likely to escalate his meltdown and make it even harder for him to see a more reasonable point of view, much less work toward a satisfying resolution.

But imagine if you counter his diatribe with compassion and understanding: “Well of course you’re upset about that!” Communicating agreement may be one of the most disarming and powerful strategies you can employ in a stressful situation. (This technique can be especially valuable in dealing with someone who is sent to you, for example, someone working with you who doesn’t want to be there.)

The better able you are to validate the reality of the other person’s experience—even if that reality is unreasonable or incomprehensible to you—the more quickly he can let go of his attachment to his hurt or angry feelings.

5. Set a Boundary

If you feel yourself getting upset or reactive, or if the other person’s behavior has escalated to a level of disrespect for which you are not prepared—here in particular, by the way, perception is everything—it is entirely appropriate to set a boundary to let that person know under what conditions he can continue this discussion: “I can see you’re upset about this. I want to hear what you have to say when you can talk to me without yelling. Let’s try this again in a few minutes.” And walk away.

6. Fine-tune Your Discernment Skills

If someone comes to you for help and you have the information, time and inclination, by all means share what you’ve got. But you’ve probably noticed that people are generally resistant to suggestions that require major changes in their belief systems or behaviors until they are either curious or dissatisfied enough to be receptive to this information.

These situations can exhaust your energy, intentions, and good will. It may be more effective, when people are resistant to change or can’t take in the information you’re giving them, to accept where they are in their process and validate their reality. Watch where you devote your time and energy. Healthy interdependence requires boundaries and self-care, and often the best way to help someone move forward is simply to move forward yourself.

7. Cut Your Losses

When our job becomes a stressful bundle of obstacles and conflicts, we may need to reevaluate if the payoffs and benefits are more need-fulfilling than the negative aspects of the work. We all grow and change, and there are times to let go of an unrewarding friendship, relationship, or job.

If you are unable to pack it in immediately, one of the most powerful behaviors you can engage in for your own self-protection is the conscious act of exploring your options.

Consciously choosing to stay in a situation in which you are well aware of the challenges, lack of support or other, more negative realities can eliminate constant disappointment and an exhausting sense of being victimized. Sometimes it can help to consider that you’re not trapped—you’re just not ready to make the move to a more satisfying alternative yet.

8. Believe in Your Own Deservingness

Self-care starts with a belief in its legitimacy. Of all the ingredients of healthy and positive relationships, this is perhaps the most important. Lacking an ability to take care of ourselves will inevitably compromise the quality of any relationship. Self-care reduces the chances that we will feel resentful, self-righteous or disempowered—feelings which often result from self-sacrifice—and enhances the quality of what we have to offer to others.

Until we believe we deserve to be treated with respect, for example, modeling self-respect and maintaining boundaries with others will certainly be quite difficult. And it’s equally challenging to effectively help others to make self-caring choices if we have a hard time appreciating what we see in the mirror or making constructive choices in our own behalf.

9. Give a Little

Finally, look for opportunities to support others.

As stressful as a hospital environment can be, you probably know very few people who complain about getting too much recognition or appreciation.

Even if you’re doing fantastic work in an unusually positive environment, it’s likely that you don’t get many strokes from your colleagues or supervisors (who, incidentally, probably need them just as badly).

It’s acceptable to ask for positive feedback, especially when you can be specific about the kinds of information that would be helpful to you. Whether or not you get the support you need, you certainly increase the odds by asking for what you want.

Never pass up a chance to let others know when they’ve done a good job.

Make a habit of recognizing and appreciating others; however, don’t take this route unless you can do so without an agenda or expectation of getting something in return.

Genuinely acknowledging a coworker’s skills or commenting on how effectively a colleague handled a difficult situation can not only make that person’s day, but also provide a badly-needed boost in the face of job stress and emotional fatigue.

Offering to give a colleague a bit of a break, or leaving an anonymous note or token of appreciation will add a great deal of positive energy to the culture of the workplace, and will probably leave you feeling pretty good at the same time.

Remember that good relationships don’t happen by accident, and even in a really stressful environment like a hospital, there are always things you can do to create your own little corner of safety and support.




Danny Lieberman is the authority in applying threat analysis to Governance, Risk, and Compliance (GRC) in healthcare. He is a sought-after speaker, prolific blogger on healthcare technology, and advisor on software security and privacy compliance issues to healthcare and medical device vendors. He is passionate about Pathcare: the private social network for a doctor and her patients. Danny is a solid-state physicist by training, professional programmer by vocation and avid amateur saxophonist and biker.

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