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This post is part seven in a nine part continuing education series on Surviving Nursing. 

Part one - "I Hate Being a Nurse." I get it, and it doesn't have to be this way.

Part two - Surviving Nursing Part 1: Why Self-Care Is Not Enough

Part three - Surviving Nursing Part 2: The Financial Path

Part four - Money and the Nursing Exodus Part 1: Everyone’s Missing the Point 

Part five - Leap From Career Misery To Financial Clarity, Confidence, Space & Ease w/ Maureen, ARNP

Part six - Money And The Nursing Exodus Part 2: Finances In A Burnout Role

Introduction: Toxic Nursing Culture

Allow me to be direct and maybe a little bit dramatic for a moment. The nursing profession (and American and Canadian healthcare culture more broadly) is locked in a death spiral of toxicity that’s hurting everyone involved. 

An article in MIT Sloan Management Review about the issues driving the nursing crisis identified toxic workplaces as having five behavioral attributes:

• disrespectful
• noninclusive
• unethical
• cutthroat, and
• abusive

You’re nodding your head, right? While this doesn’t describe all workplaces, these characteristics describe much of the modern nursing experience. Enough of healthcare culture is like this that it doesn’t seem controversial to describe the modern nursing experience as a toxic death spiral.

In the modern healthcare environment, a complex set of problems have put unprecedented pressure on a system that was already dysfunctional and failing. Interventions that have been put in place to manage the pressure have made the situation worse. There doesn’t seem to be a clear end in sight.

The unprecedented pressure, of course, came from the impact of the pandemic. However, the reason it pushed the system to the brink is that COVID-19 hit a system with existing chronic problems, which was already sitting on the edge of crisis. 

The longstanding nursing shortage was one pre-existing issue, but so was the demographic problem. When I went to nursing school 25 years ago, nursing professors warned us about what was going to be happening right about now – the aging workforce retiring and a significant surge in the demand for nurses, primarily driven by the needs of the vast Baby Boomer population. Boomers are the biggest generation alive (well, they were until Millenials recently surpassed them). They are leaving the nursing workforce at the same time as needing an increased amount of healthcare. 

No expert could have known that a pandemic would hit when it did, but people have been talking about the most important challenges in the American healthcare system for decades. 

• Disorganization as a function of our decentralized private system. 
• Dissatisfaction among the workforce. 
• A general shortage of staff. 
• Social issues leading to distrust of the healthcare industry. 
• Increase in workplace violence against healthcare workers. 
• The pace of change and the difficulty for systems to integrate new technology. 
• Rising costs, administrative waste, and failures for patients.

None of these things are new, and we’ve had the data for years. I studied this back when I was getting my Masters in public health in the late 2000s and nothing has changed much since. 

The American healthcare system is unhealthy, expensive, and achieves poor results. Our country has the lowest life expectancy at birth of any comparable economy in the world and the highest healthcare costs. It’s an oversimplification, but it’s safe to say that we’re paying more than other countries and getting worse health outcomes. 

The pandemic crashing into an already stressed system has created a nightmare scenario for healthcare workers on the front lines, leading to a crisis of departures from the nursing workforce driven by burnout and trauma – I wrote more about it in this article. 

It’s not just RNs and NPs who are recognizing this. According to a poll of hospital leaders, staff nurse retention and burnout is the number one problem organizations face. 

“Ninety percent of the CEOs surveyed cited nursing shortages as a particularly acute pain point.” 

I wonder if any of them talked about the fact that there are a million qualified nurses who have decided not to work due to poor workplace conditions?

Despite leadership recognition of some aspects of the problems, many organizations have responded to the nursing shortage with interventions that have made the situation worse. It’s a familiar dynamic. 

• Floors are short of staff, so managers decline PTO and push people to mandatory overtime. 
• Staff start to burn out so managers provide them with self-care skills to try to maximize the amount of suffering they can endure. 
• Managers hire contract workers at a much higher cost to regular staff willingly creating inequitable workplace conditions where nurses working in the same area with the same number of years experience, doing the same job receive dramatically disparate pay. 
• Costs (predictably) go up so administrators fight against requests for raises or other increased compensation, despite the fact that workload and stress have increased dramatically for frontline staff. 
• Union activity increases, and hospitals go into union busting mode. 
• The relationship between staff and administration gets (more) toxic. 
• Nurses get fed up and eventually quit, making the situation on the floor even more difficult.

The death spiral continues.

It’s the toxicity, stupid.

When you work on the front lines, you can get the impression that administrators think that all of this is going to work out somehow. Keeping staff pay down and hours up, and pushing nurses towards the idea that this will all be okay if they just get more efficient and better at self-care. 

The fact is though, all of this ultimately makes nurses perform more poorly and eventually quit. Increased workload, insufficient staffing, poor communication, and lack of support leads to mistakes, apathy and frustration. As this article by Hegazy et al. put it, it’s a well-researched dynamic that “inadequate work environment and negative perceptions are counterproductive to providing high-quality and safe health care.”

In other words, academic research supports the idea that happy and safe nurses are better at their jobs and more productive.

I can practically hear the collective groan when you read the word “productivity.” But stick with me.

Academic research suggests that the pursuit of productivity at all costs actually leads to a long term decrease in productivity, because burnt out and unhappy workers produce less. 

In nursing, because our business is life and death, “decreased productivity” means very complicated moral problems. Reduced productivity among nurses means more suffering for patients. As this study states, “Among the outcomes of burnout, we found reduced job performance, poor quality of care, poor patient safety, adverse events, patient negative experience, medication errors, infections, patient falls, and intention to leave.”

Nursing salaries are increasing in the midst of all of this mess. That is a good thing, and is probably leading nurses to stick around in their jobs a bit longer. However, survival is not just about pay.

During the pandemic nurses knew they were in crisis mode, so they tolerated unacceptable conditions. However, conditions didn’t improve after the pandemic. Emergency stopgap measures were extended into what seem like unacceptable permanent policies, and it’s pushed a lot of us over the edge.

We leave the stress and physical demands of our job, then go home to other stressors and more caregiving. It’s too much. 

We’re in a phase where short-term thinking is creating long-term problems, causing active harm to both staff and patients, and undermining the future of healthcare. 

What do non-toxic nursing environments look like?

What can be done about all of this? The good news is, a lot!

While it’s true that poor patient outcomes are associated with toxic cultures in healthcare, the opposite is also true. Workplaces where nurses are satisfied and happy tend are safer and have better patient outcomes.  

Factors that contribute to nurse satisfaction and retention are clear: healthy organizational culture, leadership support, adequate compensation, and manageable workload. 

Other research extrapolates out a bit. The review by Hegazy et al. cited a sense of autonomy, environmental control, healthy relationships between doctors and nurses, and organizational support. The same study also cites safe-staffing levels, competent managers, good communication in the workplace, responsive administrators and engagement with decision making in the workplace, as well as meaningful recognition of authentic leadership. 

Factors outside of work also contribute to nurse satisfaction and retention. Healthcare workers are happier when they experience feelings of altruism, and the chance to help others at work. They’re better off participating in recreational activities, taking vacations and breaks, spending quality time with their friends and family, and getting good quality sleep. 

(Side note: if you’re a frontline nurse, you might be asking yourself if these conditions actually exist anywhere for healthcare workers. Sort of. Some workplaces do much better than others. Have a look at this interesting comparison chart.)

If you put all of this together, it’s easy enough to get a picture of what healthcare organizations should do if they want to improve patient care and staff satisfaction. When it comes to nurses, organizations should: 

• keep their wages up and their hours down, 
• enact safe-staffing ratios, 
• minimize the amount of suffering nurses have to endure on the job, 
• increase their autonomy and 
• find avenues for meaningful input into decisions that affect them. 

Organizations should work on building relationships between leaders and nurses/APRNs that are supportive rather than adversarial. 

They should consider interventions like: 

• Increasing PTO 
• Increasing opportunities for nurses to lower their FTE if they need to 
• Providing wages that are commensurate with other comparable professions 
• Minimizing the pay gap between health care administrators and front line workers

What should organizations NOT do? As the Sloan MIT Management Review concluded, “What leaders should not do is ask nurses to work harder and endure more frustration and stress while failing to understand and address the organizational factors that make life miserable for many of them.”

What can nurses do now?

As I talked about in the last post, front-line nursing is not a career that’s sustainable for 40 years. And this is true for all nurses: NPs, CRNAs, bedside nurses, LPNs. All nurses. Pressure is going to continue increasing for leaders to create environments that facilitate career longevity.

But what about when change is slow to come? As nurses stuck inside these toxic environments, we need solutions now.

It's not our job to solve these problems. Administrators and even colleagues may make you think you are responsible for resolving these system problems yourself, but you are NOT. 

However, I want you to walk away from this episode knowing that, while all that political and organizational work gets ironed out, you do have a meaningful action to take–one that you’re fully in control of. 

And that’s making sure to build your own safety net. 

As we talked about in this article about Surviving Nursing, building your own safety net means taking the steps you need to become financially literate and develop your money skills so that you can: 

• Decrease your financial stress, 
• End your dependence on working for a paycheck to cover bills, 
• End your reliance on your employer,
• And prepare to leave or retire early when you need to… with or without your employer’s help. 

By the way, it is possible to get your organization’s support on this right now. If your employer provides leave and/or pay for continuing education or professional development, you can use that to learn financial skills and build your safety net so you can escape toxicity and entrapment! 

If you’re inside the toxic nursing spiral and ready to start learning how to work when you want, take my free training to start seeing how you can set up a future where

• You work part-time or not at all
• You say no to that dangerous assignment and take unpaid time if needed
• When your PTO is declined you take it anyway, paying yourself if you need to
• You refuse to bend to pressure to work more to fill staffing gaps
• You speak up for patient safety without fear of retaliation

Breaking this cycle is what Nurses Investing for Wealth is all about. So you can do the things that mean the most to you now…and stop putting them on hold

• Pursue your creative goals
• Pivot in your career
• Work because you want to, not because you have to
• Invest in yourself and upskill without taking on extra debt
• Start your own business
• Travel and explore as much as you want
• Prioritize your family

Click the link below or to get started setting up your financial independence plan. 

I’ll see you over in the next article, where we’ll be discussing how nurses and APRNs are using the resources they have to respond to the toxic nursing culture… and finding ways to use financial literacy to make their nursing career sustainable.

I’ll see you there or in the free training…maybe both!

I’m glad you’re here. Together, we’re turning one nurse's financial independence into another nurse's power. 

Studies and articles cited in this post

Anderson, M. (2023) “More healthcare workers are looking to unionize post-pandemic,” Healthcare Brew. Available at: https://www.healthcare-brew.com/stories/2023/05/18/healthcare-workers-looking-to-unionize (Accessed: 14 March 2024).

Aya M. Hegazy; Manal M. Ibrahim; Wafaa A. Shokry; Hayam A. El Shrief. "Work Environment Factors in Nursing Practice". Menoufia Nursing Journal, 6, 2, 2021, 65-73. doi: 10.21608/menj.2021.206247

Black, Lisa M. PhD, RN, CNE. Original Research: Tragedy into Policy: A Quantitative Study of Nurses' Attitudes Toward Patient Advocacy Activities. AJN, American Journal of Nursing 111(6):p 26-35, June 2011. | DOI: 10.1097/01.NAJ.0000398537.06542.c0 

Boyce, H. (2023) “Registered nurses’ pay projected to increase $13 an hour by 2033,” Atlanta Journal-Constitution. Available at: https://www.ajc.com/pulse/registered-nurses-pay-projected-to-increase-13-an-hour-by-2033/LYEIE2ST5FADNEYMRGJVPTTHTU/ (Accessed: 14 March 2024).

Dall’Ora, C., Ball, J., Reinius, M. et al. Burnout in nursing: a theoretical review. Hum Resour Health 18, 41 (2020). https://doi.org/10.1186/s12960-020-00469-9

Fraga, B. et al. (2023) “Large Catholic health care system engaged in union busting, union claims,” National Catholic Reporter. Available at: https://www.ncronline.org/news/large-catholic-health-care-system-engaged-union-busting-union-claims (Accessed: 14 March 2024).

Greiner AC, Knebel E, editors. Health Professions Education: A Bridge to Quality. Washington (DC): Institute of Medicine (US) Committee on the Health Professions Education Summit; National Academies Press (US); 2003. Chapter 2, Challenges Facing the Health System and Implications for Educational Reform. Available from: https://www.ncbi.nlm.nih.gov/books/NBK221522/

Hut, N. (2023) “Healthcare Labor Union activity gains steam: The consequences for hospitals and Health Systems,” HFMA. Available at: https://www.hfma.org/finance-and-business-strategy/healthcare-business-trends/healthcare-labor-union-activity-gains-steam-the-consequences-for-hospitals-and-health-systems/ (Accessed: 14 March 2024).

Isham, A., Mair, S., Jackson, T., “Worker wellbeing and productivity in advanced economies: Re-examining the link,” Ecological Economics, Volume 184, 2021, 106989, ISSN 0921-8009, https://doi.org/10.1016/j.ecolecon.2021.106989. (https://www.sciencedirect.com/science/article/pii/S0921800921000471)

Janes, Gillian PhD∗; Mills, Thomas PhD∗; Budworth, Luke PhD†; Johnson, Judith PhD∗; Lawton, Rebecca PhD∗. The Association Between Health Care Staff Engagement and Patient Safety Outcomes: A Systematic Review and Meta-Analysis. Journal of Patient Safety 17(3):p 207-216, April 2021. | DOI: 10.1097/PTS.0000000000000807

Lee, J. (2022) “Travel nurses’ gold rush is over. now, some are joining other nurses in leaving the profession altogether.,” NBCNews.com. Available at: https://www.nbcnews.com/health/health-news/travel-nurses-gold-rush-now-are-joining-nurses-leaving-profession-alto-rcna45363 (Accessed: 14 March 2024).

Muthuri, R.N.D.K., Senkubuge, F. & Hongoro, C. “Determinants of happiness among healthcare professionals between 2009 and 2019: a systematic review.” Humanit Soc Sci Commun 7, 98 (2020). https://doi.org/10.1057/s41599-020-00592-x

Neal, A. and Bombardieri, M. (2022) “How to ease the nursing shortage in America,” Center for American Progress. Available at: https://www.americanprogress.org/article/how-to-ease-the-nursing-shortage-in-america/ (Accessed: 14 March 2024).

NNU: High and rising rates of workplace violence and employer failure to implement effective prevention strategies is contributing to the staffing crisis." Contify Life Science News, 22 Jan. 2024, p. NA. Gale OneFile: Health and Medicine, link.gale.com/apps/doc/A780156224/HRCA?u=anon~d99cce47&sid=sitemap&xid=2a05f142. Accessed 13 Mar. 2024.

Nsiah, Comfort et al. “Barriers to practicing patient advocacy in healthcare setting.” Nursing open vol. 7,2 650-659. 19 Dec. 2019, doi:10.1002/nop2.436

OECD (2024), Life expectancy at birth (indicator). doi: 10.1787/27e0fc9d-en (Accessed on 25 March 2024.) https://data.oecd.org/healthstat/life-expectancy-at-birth.htm 

“The Role Of Administrative Waste In Excess US Health Spending, " Health Affairs Research Brief, October 6, 2022. DOI: 10.1377/hpb20220909.830296

Sharpnack, P.A., (May 31, 2022) "Overview and Summary: Nurses’ Impact on Advocacy and Policy" OJIN: The Online Journal of Issues in Nursing Vol. 27, No. 2, Overview and Summary.

Sull, D. and Sull, C. (2023) “The real issues driving the nursing crisis,” MIT Sloan Management Review. Available at: https://sloanreview.mit.edu/article/how-solve-nursing-crisis/ (Accessed: 14 March 2024).

Sull, D. and Sull, C. (2023a) “Explore how nurses rate their employers,” MIT Sloan Management Review. Available at: https://sloanreview.mit.edu/article/nursing-satisfaction-index/?utm_source=release (Accessed: 14 March 2024). 

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