When Helping Hurts
Unable to deliver the kind of care they feel patients deserve, nurses often are plagued with guilt long after their shift ends

By Donna Hemmila
October 24, 2002


With a nurse for a mom, Richard Clapp, RN, knew what he was getting into when he graduated from college in the spring and started working a night shift in a hospital med/surg unit.

One thing he wasn't prepared for was the nagging guilt that follows him home at the end of his shift.

There are days when he goes home feeling he didn't do enough. That's not a good feeling, said Clapp, who works at Sarah Bush Lincoln Health Center in Mattoon, Ill.

"It's impossible to give nine patients the care they deserve," Clapp said. "You hop from one to one to the next. It's hard. I don't think I realized how often I would feel like this."

The kind of guilt Clapp experiences is not unique to the latest crop of nursing rookies. Many veteran nurses tell tales of chronic guilt and the emotional drain it wreaks on their psyches. As patient acuity levels rise and staffing levels sink, the cycle of guilt keeps on spinning.

More and more nurses are finding it difficult to reconcile their self-expectations with their work environment. When that happens, many nurses start looking for a way out of the profession.

Guilt has always been part of the emotional landscape for nurses, many veterans say. Candy Montalvo, RN, recalls feeling bad about her hospital work 15 to 20 years ago. Even back then, nurses felt rushed and complained about not having enough time to spend with individual patients.

Montalvo left hospital and clinic work 10 years ago to practice as a parish nurse. In that role, she visits patients in San Francisco Bay Area hospitals and sees that the conditions that used to fuel her guilt have grown worse.

"It looks like there's just not enough staff," Montalvo said. "The staff looks harried, like they're pulled in six directions."

It's common that no one answers a patient call bell, and when she goes out into the halls searching for a nurse to help one of her parish members, sometimes it's tough to track down the right caregiver. Her clients complain about things like needing to go to the bathroom in the night and waiting for someone to assist them. A nurse can do only so much in a day, Montalvo said, but knowing that doesn't make it any easier to shake those guilty feelings.

"We see the problems, and we want to do better," she said. "We know we can do better. We were trained to do better."

Bad connection

A study by the Joint Commission on the Accreditation of Healthcare Organizations released Aug. 8 found a startling connection between nurse shortages and patient outcomes.

In the last five years, 24 percent of unanticipated hospital deaths, injuries and permanent loss of function were tied to a shortage of nurses. Such research findings can add to a nurse's guilt, Montalvo said, but they also can help bolster the professionarguments that they need more staff. Any nurse knows rates of infection and patient falls are related to staffing shortages. Having research to back up the stories can help nurses prove to administrators how badly they need better staffing, Montalvo said.

Nurses find little support for their idealism, said Dorothea Hover-Kramer, Ed.D., RN, a clinical psychologist whose San Diego counseling practice caters to nurses and other health care professionals.

"There's such a hiatus between the ideals we're taught in university and the real situation, which is very exploitive and detrimental to nurses," she said.

Students are taught active listening skills and other caring techniques, but when they get into the trenches, they find little time to practice them.

They must struggle not only with their own expectations, but with a public that expects nurses to walk on water, Hover-Kramer said. People's expectations for nurses are way beyond what nurses can accomplish, she said.

When Hover-Kramer counsels RNs, she reminds them that overly high expectations can lead to frustration. It's OK to lower expectations sometimes, she said, and to acknowledge the difference between your work setting and what you hold up as the ideal.

One way to conquer guilt is to set firm boundaries between work and home and start practicing better self-care.

"Nurses are depleted," said Karilee Halo Shames, Ph.D., RN, a certified holistic nurse. "Many nurses are not as healthy as they need to be."

Shames, a clinical specialist in psychiatric nursing and a holistic healing proponent, wrote Energetic Approaches to Emotional Healing with Hover-Kramer. The book explores ways for nurses to practice the art of self-care. Shames' newest book, Thyroid Power: 10 Steps to Total Health, expands on the holistic healing themes she advocates as essential for nurses to do their jobs well.

Shames paints a dismal setting for hospital nurses-10- to 12-hour shifts, unhealthy cafeteria food, poor ventilation and lighting and little opportunity for quiet and relaxation.

"The staffing shortage is costing lives, and it's costing nursing lives with high divorce rates, high addiction rates," Shames said. "The more beaten down nurses get, the less energy we have to meet the challenges."

Shames, founder of Nurse Empowerment Workshops and Services, is passionate about the need for nurses to start taking better care of themselves. Nurses can't say no, so they end up taking on more than they can handle. Then they go home feeling lousy because they couldn't do the job well enough, she said.

Unfortunately, more and more nurses are saying no by leaving the profession. Shames believes more would return to nursing if they were honored for the work they do.

"We have to be able to define boundaries; we have to be able to say, 'These conditions are unsatisfactory and killing my spirit,' " Shames said.

To some extent, nurses-with a natural inclination for compassion-are more vulnerable to guilt feelings. But much of that guilt could be erased if health care administrators rewarded nurses with more money and more control over their own practices, said Joan Hrubetz, Ph.D., DSc (honorary), dean of Saint Louis University School of Nursing.

Hrubetz received her nursing diploma in 1956 and has witnessed more than 40 years of nursing practice. Our health care system can't work without nurses, she said, and nurses themselves need to make people realize that.

"I think guilt is the most useless of emotions unless it motivates one to act," Hrubetz said.

If nurses are going home every day feeling bad, that should tell them they need to do something about it. "Nurses need to take more responsibility," she said. "Instead of being Pitiful Pearls, they need to let administrators know their needs."

Contact Donna Hemmila at dhemmila@prodigy.net