Do nurses pay a "well-being" tax?

"substance use disorder" free ai image from www.craiyon.com

According to Choflet et al.(2022), the academic literature for nurses describes symptoms that articulate and define a nurse's traits and behaviors with an impassioned nonverbal declaration of drudgery, lack of energy, despair, and pessimism as what is commonly known as "burnout." In addition, the literature suggests that secondary causes of the feelings associated with the work involved in caring for society's most ill patients adversely affect the mental health of nurses.

Along with that, literature abounds on the mental health of leaders' wellbeing, with a broad definition that defines three components of health: the individual's mental wellness, their physical or biological personal wellness, and the overall wellness of their interpersonal support systems (Oc & Chintakananda, 2025). How do nurses take care of themselves?

"Burnout" or "compassion fatigue" is a common term found in the healthcare literature, but hearing about it, speaking about it, or talking openly about it is somewhat taboo. Nurses are not alone in experiencing burnout at work. It is common among physicians, who may also describe feelings of patient and provider withdrawal, isolation from other healthcare team members, a loss of purpose in helping and caring for others, and a disconnect from one's calling (Longo, 2018).

Other authors acknowledge drug use and dependency in nurses and forecast chilling insights for those of us who have professional caring careers. Gabele et al. (2023) signal an alarming statistic that roughly just under 20% of practicing nurses in the U.S. have a dysfunctional relationship with alcohol and other substances.

To the extent that nurses choose coping mechanisms of alcohol and other substances to manage symptoms of nurse-patient tensions and worry, nervousness and agitation, sadness, melancholy, and, unfortunately, the temptation to take one's own life (Choflet et al., 2022) how can those charged with stewarding others help, support and empower nurses and other members of the healthcare team to promote wellbeing and seeking help? Awareness conversations and measures to reduce stigma are needed.

Psychological Safety

Academics have written extensively in the healthcare literature regarding workplace environments where speaking up without fear of being embarrassed, humiliated, or accused of expressing how one feels about any given situation at work is what is known as a psychologically safe workplace. In other words, Camilleri et al. (2023) explain the type of workplace climate where all staff can discuss topics of misunderstanding, miscalculations, and clarification seeking without again being ridiculed. Often, psychologically safe environments are touted as best practice for staff to speak up, for instance, in preventing medication errors (Camilleri et al., 2023) for patient safety.

How do workplaces morph to follow a psychologically safe workplace where topics, as mentioned before, for mental health and alcohol and/or drug dependency, can be brought up ethically and morally in appropriate manners to help those suffering ultimately? Again, it begins with awareness, education, assessment, and knowing when to intervene.

Recognize and Empathize

Nurse leaders can take an assessment of staff behaviors and share with others attitudes that could red flag a potential staffer who is struggling, such as tardiness, increased absenteeism, tired and fatigued work habits, as well as the most apparent signs as anyone demonstrating characteristics of being under the influence of mood-altering substance would present such as altered alertness and speech variations, increased irritability at work, avoidance behaviors, and out of the regular personal behavior shift disappearances (Gabele et al., 2023).

In addition, since nurses are the frontline administrators and dispensers of patient medication, mainly controlled substances, and have medication dispensing equipment user access, nurse leaders and colleagues can be watchful and attentive to medication distribution processes.

Pharmacy equipment, syringes, hypodermic needles, and intravenous access kits, such as tourniquets, alcohol swabs, and gauze sponges, in conjunction with empty used medication vials, empty medication packaging, and other paraphernalia surrounding the work environment, such as oral and intravenous narcotics and benzodiazepines, that are left unattended in areas where they are atypical should raise caution (Gabele et al., 2023). Examples include restroom trash, coffee and soda lounges, and areas for break time and workstations.

Gabele et al. (2023) also caution the new nurse leader and the seasoned nurse manager to pay attention to instances where medication variances are increasing, such as documented narcotic administrations in the EMR but diminished waste documentation in medication dispensing reservoirs. These highlight unaccounted-for discrepancies and variances indicating potential medication diversion activity.

Courageous Support

Understanding that each organization has its policy and procedures for dealing with situations such as an altered employee or when it is discovered that drug diversion is suspected and confirmed, corrective measures must be followed according to institutional policy. Although never an easy encounter, Gabele et al. (2023) remind the nurse leader to help the staff individual be dismissed and immediately help them seek professional help through intervention, counseling, and recovery sources.

Supporting a psychologically safe work environment that fosters a speak-up culture in support of nurse wellbeing is one of those elements that leaders can promote through staff engagement, especially during the post-pandemic period when nurses are listed as at risk for self-harm resulting in death due to alcohol dependence and recreational and pharmaceutical dependency on drugs adversely affecting there physical and psychological health (Choflet et al., 2022). 

Engagement huddles and conversational rounding regarding delicate, intricate, and high-risk conversations about alcohol and substance use in the workplace are hard to navigate. However, with visibility, open access to leadership, and intentional listening (Camirelli et al., 2023), leaders can help support those who may need it most during their most demanding and vulnerable time.

References:

Camilleri, M. A., Allegra, M., & Kearney, J. (2023). Answering the wake-up call to nurse leaders: Five practices to restore psychological safety after the Vaught case. Nurse Leader, 21(2), 213–217. https://doi.org/10.1016/j.mnl.2022.12.020

Choflet, A., Barnes, A., Zisook, S., Lee, K. C., Ayers, C., Koivula, D., Ye, G., & Davidson, J. (2022). The nurse leader's role in nurse substance use, mental health, and suicide in a peripandemic world. Nursing Administration Quarterly, 46(1), 19–28. https://doi.org/10.1097/naq.0000000000000510

Gabele, D., Keels, K. M., & Blake, N. (2023). Out of the Shadows and into the Light: Destigmatization of substance use disorder in Nursing. Nurse Leader, 21(4). https://doi.org/10.1016/j.mnl.2023.04.003

Longo, Dan L. (2018). Approach to the patient with cancer. In J. Larry Jameson & Anthony S. Fauci & Dennis L. Kasper & Stephen L. Hauser & Dan L. Longo & Joseph Loscalzo (20th Eds., Vol. 1), Harrison's principles of internal medicine (pp. 435-443). McGraw-Hill Education.

Oc, B., & Chintakananda, K. (2025). Wellbeing of formal leaders: A critical and interdisciplinary review of predictors shaping leader wellbeing. The Leadership Quarterly, 36(1), 101842. https://doi.org/10.1016/j.leaqua.2024.101842

Code Blue Cath Lab

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I hunched over at my desk, again trying to keep up with the incessant flow of emails in my inbox. I was staring at my coffee, now lukewarm, and I could see the creamer curdling on the inner rim of the paper cup next to my phone as another sick call came in from the staff, informing me that another person would not be there to fulfill staffing needs in our department.

My ergonomic work example will never make it to the safety messages where we are reminded to sit up straight, keep feet flat on the ground in good posture, and ensure the computer screen is at eye level to reduce strain on the neck and back from sitting. Most days, I sit at my desk with the hips of my chair low enough to spring, leapfrog up, and dash out of the office quickly. Realistically, I sit in a way that makes it look like I am about to dive right into my screen.

Email management, somedays, is like breaching a damn, and unfortunately, the spillway of messages from separate departments comes continuously, some needing immediate responses; some emails don't make a bit of sense and are often written in a way that assumes you know what the sender is communicating, email etiquette as it is is an art, and some have not learned the skill.

It is difficult to sit at my desk and find time to peal away and round; however, it is an automatic one that raises and lowers, and to my left, a space heater that is on a medium setting every day, excluding weekends because the average temperature in the office is around 55 degrees, cold enough for me, to keep a heater running. The department is usually cold, sterile, and uncomforting, typical of an operating room environment; you never want to stay there any longer than you need to, which is the feeling you get. Most hospitals are set up that way. However, we make the office more comforting, welcoming, and warm by adding personal touches with pictures, plaques, and, most importantly, snacks, coffee, and sodas.

During the day, oftentimes, the staff drop by to say hello or get a snack from the repurposed file cabinet in the office; I do not think it has ever had an office file of paperwork with dividers in it. Instead, it became the snack shop file cabinet, and the staff prefers salty, crunchy, and fatty foods during the day to break up the routines of procedures. Feel-good foods like fatty chips, sugary candies, and caffeine are the ingredients that keep staff up and running in a cardiac procedure environment. We know we should consume the types of foods and snacks sparingly, but in a stressful, oftentimes spur-of-the-moment, ever-changing environment, how harmful can it be to staff for peace of mind and tranquility?

Typically, chips and crackers fill the cabinet with a few chocolate bars, the small ones like bite-sized, or they come by to get a coffee from the abused, worn-down Keurig. The staff also comes by to drop in for a schedule adjustment, review a pay discrepancy, or escalate a ticket for some repair needed either with the hospital building itself or with the numerous technical equipment native to the cath lab. Most of the time, they come by to get coffee and snacks and seek an opportunity to talk, share, and check in. I like it when they visit us in the office. I pause, pull my face and eyes away from the computer screen, and gaze in their direction, looking for nonverbal cues to engage and see how they are doing. Sometimes, the staff visits, and they have an agenda or a need and are obliging and ready for me to assist; I get after addressing any issues with no delays.

The ticket repair requests on an average day can be countless. However, we can often solve this immediately and get our computers, monitors, imaging equipment like X-rays, and picture-taking gear back online with a simple reboot. We continue our procedures sometimes, though we have to escalate and request a ticket to higher echelon support from industry experts and technological skills field experts to get our equipment back online when the usual restart techniques that the staff know how to do are insufficient. I always ask myself what astronauts do on the Space Station when they have computer glitches. Do they call and put a ticket into IT like we do?

Days like this are typical, familiar, and routine in the work we do in our service area, and believe it or not, code blues are also typical, familiar, and routine in our area where we treat heart problems. One day, however, was not so usual for me.

On the day that we had anesthesia available, those were the doctors who helped our patients sleep and manage their pain while we did our heart procedures. It was a standard case where we performed our aortic valve implant cases during the middle of the week. The technology to help patients is cutting-edge and innovative. It gives older adults who typically have difficulty catching their breath better ability to get dressed, brush their teeth, or give themselves a bath or shower. They need assistance with better breathing and heart function because they have leaky valves as they age. Not being able to breathe affects their ability to go to the grocery store, pick up basic needs, and do activities that a younger middle-aged person takes for granted. Again, these types of procedures are typical for the staff.

Sitting at my desk, jumping into emails, toggling back and forth between Google Chrome and Microsoft Edge, and performing administrative tasks, the overhead paging system, loud and audible, the voice booms and explodes from the speakers above, from the organization's operator, whose voice is very distinctive and articulative when she speaks, "Code blue, third-floor cath lab, code blue third-floor cath lab."

The sound of operating room doors opening more rapidly down the hallway, footsteps outside 

my office pacing a little more frantically, and an overall sense of hurry, rush, and scramble is par for the course. I get up from my desk, take a deep breath, put my pen in the v-neck collar of my thin scrub top, adjust my eyeglasses, put my paper-printed daily schedule in the left pocket of my scrubs with my iPhone, and head into the surgery procedures suites pass the warning red lines on the floor to the operating procedure area to discover which out of the five labs in our department is the code blue occurring.

I know that out of the five of our rooms, one of them is performing the aortic valve repair. As I gathered my bearings and took another deep breath in, because after 22 years of taking care of sick heart patients, although not as close as before since my new role, I thought to myself, which never gets easier, please, God, let the aortic valve patient be okay, not that the other patients are any less important or those cases any less critical or essential. Still, in my heart and mind, I could sense that my thoughts and prayers might have been silent as I saw the crowd of necessary staff, providers, and emergency professionals heading in the direction nervously and eagerly with equipment, additional supplies, and resources for life-saving, to the room and place that I feared most—the aortic valve repair. 

Teamwork 2.0

images from www.lmpartnership.org/tools/leading-change-together

Can we ask those we lead, "Are you willing to take ownership of your actions, decisions, and attitudes in the workplace?" Or should leaders hold employees accountable for their actions, decisions, and attitudes? Let us examine two viewpoints.

Accountability or Ownership

According to an article in Nursing Management, the authors suggest that workplace cultures emphasizing accountability rather than ownership are socially dissatisfying in three distinct ways (Tye et al., 2022). First, people associate the vocabulary word accountable as antagonistic. Secondly, accountability is always and ultimately personified and rarely objectified to a place or thing as being responsible for the outcome of an action, either intentionally or inadvertently; ultimately, a person is involved. Lastly, using accountability as a metric for performance promotes low expectations (Tye et al., 2022). The onus to empower others to take ownership of their actions, decisions, and attitudes and to make them congruent with their values and beliefs continues to be an area needing more attention.

Compare what Stephen Covey addresses in his book, The Speed of Trust (Covey, 2018, p. 210), accountability is associated with the trust of direct reports in any workplace where the employees know, believe, and understand that those who diverge from the workplace norms will be held responsible to their actions, decisions, and attitudes. Most people will agree that there is a fine line between the two ideas discussed. However, at least in the literature, it is worth noting that two different viewpoints exist to compare the accountability concept regarding workplace culture.

Policies and Procedures

According to Marquis & Huston (2021), organizations have policies and procedures in place to ensure that, first and foremost, a written set of goals, mission statements, and the aim of an institution are recorded, albeit in a condensed format, to guide its employees to align with the institution's directives.

Furthermore, as healthcare leadership academics, the authors indicate that policies and procedures are in place to guide healthcare practitioners in their practice according to accreditation and licensing standards for all providers. Marquis & Huston (2021) further explain that processes are written down for healthcare providers, or procedural steps available for reflection on how to do a particular task, function, or procedure in delivering healthcare services.

An organization's attendance policy is an example of a policy for professional conduct. In contrast, the written rubric or steps and processes for removing intravenous sheaths to prevent bleeding and obtain hemostasis are examples of procedural documents to guide the how-to of specific skills, operations, and actions. Both are developed to control organization and individual professionalism, organizational citizenship, and best practice models and interventions.

Policies and procedures are the guidelines that promote organizational congruency and ensure continuity of practice (Marquis & Huston, 2021). They should be evidence-based and based on best practices, ultimately providing the backbone and means for leadership to maintain a reference point for the superintendency of its employees.

Labor-Management Partnership

Can superintendency be shared in the workplace between leadership and staff? Scholars and others who have written and published extensively from experts in business relations and management strategies believe so.

Consider what Cohen et al. (2010) report when discussing the theoretical concepts of teams that work together in a unit or, otherwise known as the unit-based team approach to solving and working together to accomplish organization goals when addressing patients' ability to get access to the hospital, the patient's perception of the type and quality of care and their perceptions when receiving medical services, affordability, and medical waste reduction as well as cultural indexes of staff satisfaction in the workplace.

Most pointedly and worth noting is the correlation between the quality of the care given to patients in departments where the staff and providers have an antagonistic relationship (Cohen et al., 2010). The functionality of the teams working together ideally involves a physician stakeholder, although not always the case, staff participation, union representatives, and managers collectively to address the goals above. The literature demonstrates empirical evidence of the connection between teamwork and quality of patient care.

In summary, workplace cultures can aim for an environment where a mixture of accountability and examples of trust in all individuals in a department team are lived out and tempered to a construct of individual and team ownership. In addition, organizations have specific policies and procedures that provide the framework, structure, and guidance for organizational mission, align with industry standards and benchmarks for the patient's benefit, and provide internal control for situations where deviance and variance arise. Furthermore, recognizing the valued importance of teams in the healthcare sector improves patients' experiences. As recalled by Cohen et al. (2010), teamwork reduces the time spent waiting for patients to receive appointments and care. When organizations strive to make the workplace safe for patients and employees, contributing to lowering reported injuries, teams can positively impact safe practices.

Although these details and determinates in the scope of healthcare delivery require initiative, contributive sharing and collaboration, and appropriate resources and knowledge utilization for the best outcomes and organizational success, a reminder is that the patient is ultimately at the center of everything healthcare institutions do.

References:

Cohen, P. M., Ptaskiewicz, M., & Mipos, D. (2010). The case for unit-based teams: A model for front-line engagement and Performance Improvement. The Permanente Journal, 14(2), 70–75. https://doi.org/10.7812/tpp/09-126

Covey, S. M. R., & Merrill, R. R. (2018). The speed of trust: The One thing that changes everything. Free Press.

Marquis, B. L., & Huston, C. J. (2021). Leadership roles and management functions in nursing: Theory and application (10th ed.). Wolters Kluwer Health.

Tye, J., Hanrahan, K., Edmonds, S., Hyatt, D., & Tye, A. (2022). Courageous leadership for a culture of emotional safety. Nursing Management, 53(11), 16–23. https://doi.org/10.1097/01.numa.0000891468.54597.90