Episode 10: Burnout vs. Moral Injury

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Cara Lunsford

Oh, hey, nurses. Welcome to the Nurse Dot podcast. Giving nurses validation resources and hope. One episode at a time. Oh, Today on Nurse Dot podcast.

Rola Aamar

Being in an environment that creates a sense of belonging, that allows you to be fully human, bring your authentic self. Those are the environment you actually be able to practice your coping strategies. Having someone go in and cover you for 30 minutes so you can process, you can cope. That happens in these environments where belonging and psychological safety are prioritized.

Cara Lunsford

Dr. Rola Amar is one of my wicked smart colleagues who holds a Ph.D. in behavioral health. In recent years, Rola has turned her focus to the moral injury that is affecting nurses across the country and beyond, and how it differs from burnout. I'm your host, Kara Lunsford, registered nurse and VP of community at Nurse.

So we can start with a good old fashioned introduction to Rola Amar. So, Rola, you have your PhD? I do. You're Dr. Rola Amar. I will call you. And you have a focus on behavioral health.

Rola Aamar

I do? Yes. That is my background. So I'm trained as a clinician, as a marriage and family therapist, something that I love down to my core. And I got to work in a lot of really unique settings. So everything from that traditional therapist setting that you think of when you think of therapy to schools, clinics, community centers, even doing outreach in whether it's people's homes or going out to farms where they're migrant farm workers and then cancer units in hospitals, women and children's hospitals.

I'm going to do a little bit of everything, and that has been a really fulfilling clinical experience. But around 2017, 2018, I decided to make the transition out of the health care system, which I'm sure we'll talk a little bit about today, because the topic is burnout and moral injury. And that was really an instigating factor for me in why I needed to leave that health care space that I love so much.

Thankfully, I found a role that allows me to use my expertise and my health care knowledge and still be connected to the work that I'm so passionate about. I just get to do it from a space that is better for my emotional well-being. So I came to Elias in 2018. I joined as a clinical effectiveness consultant and my role was to work with behavioral health organizations and other organizations around data management and consult on things like quality improvement initiatives, you know, using the data to improve the outcomes of their patients.

So again, really meaningful work. My role at REALIZE has grown over the past five years, and now I get to do a lot of thought leadership and research around topics that are really impacting the health care workforce right now. So things like moral injury and burnout or diversity, equity and inclusion and how it ties into who makes up our workforce and how we care for our patients.

You know, another topic that I'm super passionate about right now is psychological safety and how that impacting workforce retention and what organizations can do. So we talk a lot about burnout or moral injury or, you know, this turnover that's happening. But what about the flipside of that? What can organizations do to keep their staff feeling happy and safe and feeling like they belong?

And so my career has transformed, but I'm really thankful that I get to stay in this health care space. And do you know what I was originally trained in? Right. All the work around behavioral health care.

Cara Lunsford

Sometimes it's really hard when you leave the bedside per say, okay, so we'll call it like direct patient care.

Rola Aamar

Yes.

Cara Lunsford

And when you leave and you kind of start working on the periphery and you start to pull yourself out so that you can kind of see the forest for the trees. Right. And you want to be able to help all the people who are there at the bedside. Because when you start to realize, okay, I need to do something that can help my colleagues to be able to do the work that they want to do, that is soul fulfilling and feels safe and supported and use all this knowledge that I have, use all this education that I went to school for all of this experience, this personal experience that I now have, and how can

I then apply that And then hopefully change the lives of people who are working in this industry for the better? And I think that that's exactly what you have done because you were able to have these experiences yourself. You experienced burnout, you experienced moral injury, probably experienced feeling psychologically unsafe.

Rola Aamar

Yes. Yeah.

Cara Lunsford

And through those experiences, you were able to then drill down on those things so that you can start to communicate that with people. So can you tell me a little bit more about even just defining that psychological safety and stuff like that?

Rola Aamar

Sure. So when I talk to organizations about psychological safety, what I'm encouraging them to strive for is an environment where staff feel like they belong and where staff feel like they can be their true, authentic selves. Something that, you know, I'm sure you're familiar with in the health care spaces, health care providers, we will consistently prioritize our staff above ourselves.

And there is this piece of bringing this professional self in and leaving the rest of it at the door. But that's just not possible when you're in the health care space because you know you're sitting with people on some of the worst days of their lives. You're helping people through some of the most challenging experiences or helping them get better or learn new things about themselves.

In order to be able to do that work, you need to be able to be authentic. You need to not feel like you're compartmentalizing all these different parts of yourself. And so psychological safety is about being allowed to bring in those different parts of yourself and have a space where you still feel like you belong, where you can just be honest about your experiences.

And so I think if I had to define it in one word, it would be about belonging.

Cara Lunsford

Psychological safety is really that sense of belonging and, you know, really wouldn't be a podcast if I didn't bring up Brené Brown.

Rola Aamar

Love her, as do all therapists.

Cara Lunsford

As do all therapists. And Cara, I'm not a therapist, but oh, God, do I love Brené Brown?

Rola Aamar

Her work really connects with with so many people because goes back to authenticity. Belonging. Yeah. So you're saying.

Cara Lunsford

I really think that remembering that we are emotional human beings who get triggered and that just because you go in as a professional does not mean that you are not going to get triggered by something that you see here, smell any one of your senses can get triggered. That sense of psychological safety. It really does center around knowing that your colleagues, your administrators, whoever it is, is not going to shame you for being a human being with feelings and emotions and that somehow you are not less of a care provider just because you might need some space or you might need some counseling.

This is not a bad thing. Do I need to crawl in the bed with my patient and be in the fetal position crying? No. Does the parent of a sick child need to be consoling me more than consoling their loved one? No. Do I need to have good coping mechanisms? For sure.

Rola Aamar

That's such a good point about having those good coping mechanisms. We know that there is a line, right? There's a boundary getting in the fetal position in your patient's bed. That's not appropriate, Right? That's a crossing a boundary. And having good coping strategies is a major part of that. Now, being in an environment that creates a sense of belonging, that allows you to be human, fully human being, your authentic self, those are the environments you actually be able to practice your coping strategies so that you don't end up in a ball on the floor, which, by the way, I've seen happen to health care providers before where they just the environment was just too much.

Something triggered that. They ended up in a ball on the floor sobbing. Right. But environments that allow you to be authentic, to be your full self, those are environments where coping strategies can actually be practiced, right? So an environment where if you encounter a patient where maybe it just hits a little too close to home and you just need to walk away for a minute and be able to gather yourself and process your feelings.

Having someone being able to share that with with a colleague or with a supervisor and having someone go in and cover you for 30 minutes so you can process, you can cope. That happens in these environments where belonging and psychological safety are prioritized. In our webinar last fall. One of the things that you had mentioned was someone will come in and do her like regulatory reviews or and they'll see a water bottle at the nurse's station say, Well, you have that out here and it's that like straw that broke the camel's back, essentially.

I mean, I can't even get away for 20 seconds to get a sip of water. You want me to not have it right next to me? It just having those opportunities to recharge, to just feel like you're allowed to be human. I mean, humans get thirsty, right? I mean, how are you going to get access to it? It's just again, it's about creating those opportunities for recharging.

That I think makes an ultimate difference. The little stuff, the little things along the way.

Cara Lunsford

That's absolutely right. And that all feeds into that psychological safety that you can ask for the things that are basic human needs and not feel gaslit or crazy for asking for like the basics. Okay. And then I think that that Segways in really nicely to talking about what happens when an environment does not support you from a basic standpoint.

So like you showed me a picture or you you painted a picture for me, it's so weird because I feel like I have this image of you showing me a picture, but you probably didn't. You probably just painted the picture for me in my head of a candle trying to stay lit in a hurricane.

Rola Aamar

And I will say our amazing graphics team actually did find an image like that for us because I was like, it's just so core to understanding the difference between burn out and moral injury. So shout out to our graphics team for finding that, taking this like, yeah, this metaphor and being able to visualize it for us. But yes, so when comparing the two, when we think about something like burnout, burnout implies that that wick of that candle either isn't long enough to withstand the challenges of a job or that something in the person is a deficit, right.

And the wick is burning out too quickly or it's not long enough or whatever the case may be. That's why burnout is happening and moral injury says, Well, hold up. No, it's not about this person. This candle not being able to withstand it or not being strong enough. Rather, it's about this person's like a candle in a hurricane.

You have this candle sitting out in a hurricane and you expect the wick to stay lit. That's not going to happen. I mean, think about, you know, the rain's pouring down. The wind is going like 55 miles an hour and you want that candle to seal it. It's not going to happen. It's the same thing when we look at nurses.

I mean, particularly we understand the struggle with nurses, but health care providers as a whole are experiencing it. But with nurses really being I think all health care professionals would agree that nurses kind of the backbone of our health care system and a lot is placed on them. Right. And then they have all of this stuff happening around them that is really tied to the system or tied to operations or, you know, remember Grossman or the list goes on and on, and they're asked to take on a little bit more and a little bit more and a little bit more.

Now they have to manage not just the expectations of patient care, but they have to manage the 500 other things that don't necessarily fit into their job role and they don't have the time to do it, but they also sort of have to find the time. And so now they are this candle sitting in the hurricane with all of these things swirling around them, 55 miles per hour, and everyone's going, Oh, well, why are they so burnt out?

Or, you know, why are they leaving in droves? What is it about more pay? And that I can't think of another word other than it cheapens the conversation to say, well, it's this one factor that is causing this burnout or this workforce turnover that we're experiencing with the nurses right now. That's not the case, right? It's all of these super complicated factors that are well beyond the nurses ability to control.

Cara Lunsford

Exactly. It was so validating for me when I heard you first provide this description in this explanation of the difference, I was like, How is this ever going to be sustainable for me as a nurse if there's all these things that keep getting added to my plate, you know, Oh, there's a new e, R, there's this new policy, there's this new thing, and we'll just keep adding it.

Oh, and not only are we going to do that, but we're going to start taking away things, things that were making your life easier. We're going to start taking away those things. Oh, you know, we used to have LV ends, now we don't use LV ends anymore. We take LV NS away from the system. Right? You get slow boiled after a while is what happens.

And that's what some people don't realize. They're like, well, you know, if this was happening, like, why didn't she say something? You know that? No, because it's like that saying of if you just dropped a frog into boiling water, they'd jump right out. But, you know, if you just kind of slow boil them, they'll just you know.

Rola Aamar

It's a perfect analogy because that's what happened. And that's typically what happens to a lot of health care workers. Right. Is, you know, you kind of go in and you start out and your role is pretty well-defined and then you get more comfortable in the system and things start to add up. And so, you know, with what's happening in nursing, I think it's just a perfect analogy.

Cara Lunsford

To coming up in our next segment.

Rola Aamar

It's not about another pizza party. It's not about lunch being available in the break room every Thursday because if people can't get away from the bedside to go get lunch, it's not a helpful policy.

Cara Lunsford

So welcome to a segment we call the Dart Spot, where you will hear more of your voice in a little less of mine. You can visit Nurse dot com forward slash podcast to share stories, feedback and requests as a valued listener, you will also receive discounts on nurse dot com courses and C use by using code nurse dot at the checkout.

Oh. Oh. I've done a couple podcasts and I've been talking to a few different people and one of the things that keeps coming up is there are ways that we can personally avoid burnout because maybe that's a lack of professional boundaries.

Rola Aamar

Yes. So it's both end right? So yes, there are absolutely coping strategies that are there to help you, you know, remembering to take walks, remembering to take BYO breaks, eating a meal, prioritizing spending time with family and having hobbies. Those are all really important and effective coping strategies and they become protective factors in times of extreme duress. And it's also on the system to recognize when they're asking too much of their staff.

You know, one thing that I didn't really get to experience in the health care system because there weren't that many of us, is I didn't have someone who said how much vacation time have you taken? Or holidays are coming up. Are you going to take a little bit of time to get away and spend time with family? Those are questions that were asked of me when I was in health care systems.

Yep, because there just aren't enough people to do the job. Coming into this role, I was really shocked that my managers were asking me, Hey, do you plan to take any time off or, you know, you've only taken about ten days. Maybe you should take some more before the end of the year so you can recharge. That was so odd to me and internalized it at first as if I doing something wrong, like is it coming across that I'm stressed when that wasn't the case at all, just someone was there to say, Hey, the expectation is that you look out for you too, that you take time for you.

And that isn't the norm in health care systems, particularly with nurses, particularly with the staffing shortage we're experiencing right now. If that happened, who's going to take care of the patients? The ironic thing is now that it's not happening, we're also confronted with who's going to take care of the patients because we have such high turnover rates, because humans cannot withstand this constant barrage of stress and lack of boundaries.

Yeah, both intensely. Your question, you're absolutely right.

Cara Lunsford

It's a two part deal, right? Each side has to practice being uncomfortable because it's uncomfortable for the health care system to remind their nurses or their health care workers to take time off to prioritize themselves when they are in a staffing crisis. So it's uncomfortable. I don't think any health care administration, I don't think they're just evil. I don't think that they're just like, oh, we you know, let them just grind down to the bare knuckles and like try to, you know, get blood out of a turnip kind of thing.

I don't think that that is the case. I think that they are desperate and the health care workers are also desperate. And when you have two entities or two individual organisms that are in fight or flight, very, very difficult to get each one of them to see the other's point of view.

Rola Aamar

I think a way to bridge this gap, like you're saying, between this, you know, having this fight or flight response and then, you know, moving from that bridging the gap to creating an environment where safety is prioritized, not just physical safety, but emotional safety is there are ways to create policies around that. And I think about, yes, it's very important that people have adequate time off, be able to get away from the job, that sort of thing.

But when I also think about what we were just talking about, about creating these boundaries and coping skills, it's a lot about what happens on the job to write about having policies in place. So that people can walk away. One of the things one of my colleagues at Realize Vince Fire talks about a lot is about the staffing ratios.

And I think you mentioned this a lot to Cara about having adequate staffing ratios so that people can actually even just take a break. So having policies in place, one of the issues that you mentioned was the policy around like messy hair, but.

Cara Lunsford

Oh, yes, you know, like, are you creating ridiculous policies like where you're spending your time? Right.

Rola Aamar

So when I think about it, I'm like, if someone was it was around and thought, hey, we need to have this policy about messy hair buns. But they have just shifted their attention to maybe use that 10 minutes to say, Hey, maybe we should have a policy about mandatory bio breaks and having someone cover a five minute firebreak every hour or every 2 hours for people, whatever it is, right.

Something that starts that little change. And I'll tell you as a therapist, I mean, systems work working with families, people who don't see eye to eye in certain situations. My bread and butter. Right. That's what I was trained in. And when you want to create change in systems, especially systems that may have become contentious, it is crucial to make these little changes that are going to help the system do the bigger changes over time.

Right. If you can sustain those little changes are going to be a lot more successful about the big ones later. There are a lot of policies in place about handwashing and getting, you know, these physical safety measures. I think it's time for health care systems to look at it and go, okay, we've got a set of safety measures in place to make sure that people are physically safe.

What are we going to do to to mirror that and create that psychological safety, too?

Cara Lunsford

Yeah. For every single policy that you create, you have to create an equal one that is like if it's like whatever it is, it's like, okay, well, if you want to create a policy, you also have to create a policy that addresses one of these major issues around retention. I really think that if our administrations understand, truly understand the problems, that they are very bright individuals.

These are smart people. I trust that if they really take the time to understand the real issues that they're workforce is facing, that they will create policies that are solutions. Yes, to those problems.

Rola Aamar

I think the reason that we're having these conversations right now is I feel like health care systems are primed for it right now. I find myself hearing from a lot of systems that are asking, what do we do? Right? They realize they're kind of in this spot that they didn't expect to be in. I think COVID brought a lot of it to the surface.

And so a lot of health care organizations are now saying, okay, we see that there is an issue, we want to do something about it. What? And so I think that health care systems are really primed for it. I think they are asking for it and interested. I think it's important to acknowledge it's a lot of work. Right.

And there is no easy button for this. It takes multiple lovers, whatever additional, you know, metaphors you want to throw out there for this. It takes work and it takes intentionality on the part of senior leadership to say, okay, we're going to make this a priority and we're going to believe it and back it up. And then bringing that message down to directors and managers, supervisors who are going to just as equally prioritize it from there, figuring out the what comes back to listening to your staff, listening to the employees that are most affected by this, and making sure that when you put in a place or things that are actually important to them, right.

It's not about another pizza party. It's not about lunch being available in the break room every Thursday. Because if people can't get away from the bedside to go get lunch, it's not a helpful.

Cara Lunsford

Policy, right? There was a strike in New York and 7000 nurses were on strike. And, you know, some people were focusing on the fact that they were out there striking because they want safe patient staffing. They want safety. And then there was, you know, people that were focusing on the fact that, like, these people just want more money.

How can they just ask for more money? It's like first of all, they deserve more money. But at the same time, it's like if you are someone who keeps asking for change and you ask for it and you ask for it and you ask for it and you keep saying over and over and over again, This isn't safe.

This isn't safe. I can't work like this. The level of risk and liability that I'm taking every single day, you know, and what that does to me, what that does to my soul, you know, if you're not going to make a change, I'm going to hit you where it hurts. I'm going to hit you in the pocketbook until you decide to make the changes that I'm asking for.

At some point, they're going to say, if you cannot make these changes, then you better believe you're going to pay me to take the level of risk and liability that I am taking every single day because this is killing me physically, mentally, morally, ethically. And so you better believe you're going to pay me big if this is the kind of environment that you're going to put me in.

Rola Aamar

You know, one thing that I remind folks, any time I do a webinar presentation, anything of that nature is those of us who go into the health care field, we're not going into it for the money, right? When you think about the amount of training we have, schooling, the hours that we put in, none of us are doing this for the money.

And so again, when the conversation happens and it's, oh well, they want more money, we can't pay more reimbursement rates, blah, blah, blah. Well, that is it's very dismissive of everything that's happening around those health care workers. Rob the nurses. And so, you know, like you said, it's about the acknowledgment that if someone can't feel fulfilled, if someone can't feel safe in their role, then it is going to come back to a question of am I getting anything in return for all of the risk that I'm taking on, just like you said.

And so the economics of relationships, I mean, we we talk about it a lot in therapy spaces, too, is at some point you have to figure out what's going to be worth it for you, Right? Where are you going to see the reward that makes living through what you're living through worth it?

Cara Lunsford

I think that people are like, Oh, but this is your calling. Almost like a nun. Like, if you were just called to be you, should you be paid for like, No, no, no. This may be our calling. We may be compassionate. You know, we may be hardwired to do this type of work. And it really does fill our souls.

It's very soul fulfilling work. When you feel like the work that you're doing has an effect and that it actually is changing lives and that you are able to get the fruits of your labor out of seeing a patient heal from a surgery or from a disease, and you're able to be a part of that process and you're you're able to help that person get back to health that fills you up inside.

And when you're able to do that, that economic exchange that you are getting is a combination of financial and also just that filling you up.

Rola Aamar

Mm hmm.

Cara Lunsford

Making you feel like the work you do matters. And the combination of those two things is oftentimes enough. It's enough for somebody who's in health care.

Rola Aamar

Well, then it's about being connected to purpose. During the pandemic, we saw a lot of coverage around, especially millennials and Gen Z, who are going to start making up more and more of the workforce that the things that they're prioritizing in their jobs aren't necessarily about money. Right? It is about that connection to purpose. And that is what the majority of health care providers go into the field for.

Right. Is that connection to purpose. And so when we look at kind of that desire to help, that needing it to feed your soul, like you said, and then looking at what the makeup of the workforce is going to be over the next decade, this becomes such an important part of the conversation because now it's not only about understanding that there really isn't going to be an amount of money that's kind of enough to keep people in a job If there's no purpose to it.

But now you're also going to have a workforce that's going to look at some of these conditions and go, No, thanks. And so when we look at what the future of the workforce is going to look like, this conversation about being connected to purpose, understanding that proper compensation is important, but it's not going to be the only thing that keeps your workforce kind of in their seats.

It needs to be on the minds of every health care leader that's running an organization to say, What are we doing to create environments where people want to stay? Compensation Totally important. Please pay nurses more. We've got like a million amazing nurses stories, but creating environments where they're safe, where they're valued is just as important.

Cara Lunsford

Yeah, you cannot have one without the other. They're not going to just be able to work off of purpose alone because we live in an environment where we have bills to pay. We have to live in a society that runs off of money, you know, So that's just, you know, the truth of the matter. So we can't live off of purpose alone, but we also cannot, especially health care workers, because this is not how they're wired.

So they cannot live off of money alone. It cannot only be a financial incentive because that is a aid. They might think that that's something that they're willing to accept for the short term, but 100% it won't last. Then they'll take maybe an assignment, maybe they'll take like a 13 week assignment. Go. You know what? I'm just going to put a nest egg away.

I'm going to put some money away for my kid's college fund, and I'm just going to go. And who cares? I'm going to make the big bucks for 13 weeks and put it aside. It's not sustainable. At some point, they're still going to be looking for what fills them up inside. And that purpose?

Rola Aamar

Well, it brings up an important point about the implications of something like that happening. Let's say that you can, you know, recycle. You've got this churn every 13 weeks of nurses coming in or out. But what does that do to some of this big picture stuff that we're moving towards in health care, right, when we're thinking about things like value based payments.

Right. Some of these big performance improvement initiatives that we are hearing so much about that are being prioritized by CMS and the current administration, some of these really big initiatives that we want to do in health care, they cannot happen if we've just got this constant churn of health care providers that are paid really well for a while and then they piece out and take care of themselves and, you know, do what they want to do to to fill their cups.

Those things can't happen when you've got lots of churn, right, because you don't have the staff that has the long term knowledge of the organization of the patient population. You know, in order to make those types of initiatives successful, you not only need people who are competent in their roles, but people who have the content to make these programs happen.

Cara Lunsford

Yeah, and we are a team industry. We like to historically work in teams and we like to know our colleagues and we like those relationships of people we've worked with for the last ten or 15 years. We really, truly love those relationships and it is exhausting to constantly have to learn a new system, learn a new environment. Also, if you are a staff nurse and you're having to constantly train new people that are coming in and leaving and coming in and leaving, that's not sustainable either.

So it's like we could talk about this all day because you and I are very, very, very passionate about, you know, moral injury and burnout in general. And I think that the thing is, is that the major takeaway here, right. Is that we really, truly have to look at these environments, these environments have got to be environments that are not just survivable, okay, Like we need to aim higher than survivable.

They need to be a place where we can truly thrive. If you want patients to have excellent outcomes, then you have got to create environments where your health care workforce can thrive. And I have a feeling that you and I are going to be doing a few podcasts about moral injury.

Rola Aamar

Well, well, I would love to. And I just I want to share one more thought because when you said thrive, it made me think about another big thing that clinical teams that religious are working on, and that's growth addressing burnout and moral injury. It's not just about keeping people in their seats, it's about also offering people the opportunity to grow as professionals, as individuals.

And that is something that I truly believe we can get to in the health care space. But again, it's just going to take that effort and it's going to take prioritizing, like you said, prioritizing, helping our people thrive, helping our people grow. And so I'd be happy to talk more about this. I love getting to chat with you about this topic.

It's one that I'm so incredibly passionate about and one that I'm really grateful that we're finally being able to have this interconnectedness of, you know, the medical and behavioral health worlds. We've seen it a lot on the patient level, and now I'm excited that we get to bring some of that to the provider level as well.

Cara Lunsford

Absolutely. Rola As always, I am massively grateful to have you as a colleague and a friend and one of the guests on this podcast. And I just want to thank you again for being here with me and for helping to shed a little light on something that is so important for health care workers to understand in today's world.

Rola Aamar

Yeah, Thank you so much for having me. This was great and can't wait to connect with you again soon.

Cara Lunsford

Thanks, Rola. If you are a nurse who enjoyed this episode and you have an idea for future episodes, you can connect with me by downloading the nurse dot com app. See you there.