A diary of distress: heavy workloads, high stress and staff shortages are a dangerous combination. A high-performing nurse and respected NZNO delegate chronicles her slide into work burnout and underlines the importance of NZNO's current fair pay and safe staffing campaigns.

THIS STORY is not about gaining sympathy because I am feeling enough sympathy for myself. My hope is that by sharing my thoughts about what has been happening to and for me, some of the myths about stress and burnout can be dispelled. I hope those who are feeling under stress right now will organise leave. For those not affected, I hope you will recognise the need to take holidays regularly. For managers, I hope you care enough about your staff to learn the lessons herein and apply them.

I am a high profile, high performing nurse and midwife, who not only works well under enormous pressure, but who actually enjoys doing so. The speed and drama of intensive care has been my motivation since 1980, and I can't imagine not working in a critical care area. Working in neonatal intensive care, as I have for 15 years, has always been very rewarding.

I have always been pretty good about taking regular leave. If you're also a high profile NZNO delegate, you have to practise what you preach, after all! I've been in the public hospital system for so long now, I have nearly eight weeks' leave every year, so I take two weeks' leave every three or four months. This is not excessive, given I work up to 60 hours in a week, around 20 hours unpaid, advocating for nurses and midwives, and teaching neonatal resuscitation.

Neonatal resuscitation has long been a passion of mine. I established, and now oversee, a network in our region to ensure everyone who needs to, can have regular updates. I spearheaded a process to ensure national standards would be available, as they are for adults, children and infants. I had negotiated the time to do this--at least a month a year--into my role. But when somebody left the neonatal unit, that time was taken from me, temporarily I thought. But that time was never reinstated, despite repeated requests.

I also carry a huge NZNO workload as the workplace convenor.

I am also passionate about nursing and midwifery. I spend hours every week, preparing submissions to Parliament, Nursing Council and others. I spend hours on the phone talking to sad, angry, savaged, and troubled nurses. I spend hours in sometimes pointless meetings with various managers, listening to often unenlightened opinions on what nurses actually need. I bang my head on the corporate wall, sometimes with positive results, often not.

Last year, I was part of the laborious process of negotiating the Northern Districts Multi-Employer Collective Agreement (MECA), eventually ratified after 18 months' negotiations. Negotiations took two days every second week, out of an already busy schedule. Did I also mention I am a single mum? The time in negotiations was meant to be instead of some of the days that made up my 40 hours' paid work per week, but invariably ended up being as well as. I did get paid for this. In fact, I've been paid for 50 hours per week in the last financial year. But money doesn't compensate for all endeavour. I can't tell you how mind-bendingly petty, important and tedious the negotiations were. There were some positives, eg the friends and networks I made. But I digress. I am setting the scene, dear reader.

Looking back at last year's diary, I only took planned annual leave for a maximum of three days in a row. The MECA negotiations, distressed nurses/midwives, the at most constant bed occupancy of 127 percent in the neonatal unit, ensured that. I also felt pressure "to do some work", as well as "fluffing about with union stuff". In retropect, I think, this pressure was mostly self imposed.

I didn't like to miss out on MECA negotiations, as it was really difficult to get back into the minutiae of them. True, but this is one of the first signs of developing burnout, isn't it?

I can never say "no" to someone who rings wanting help, as I'm aware other delegates in the hospital have as big a load as me. I've always found that when the pressure is getting a bit much, apply more pressure. It makes me lift my game and there I go, managing better than ever! It always worked before. I know "one day" it won't work, but that won't be today.

So, to the nitty gritty, dear reader. Other signs? My memory got worse. I've always been a bit absent minded (the mark of a genius, I always say), but it got to the stage where I had to write everything down or it wouldn't get done. I missed meetings, sometimes really important ones, despite the dates and times being in my diary. Impatience with colleagues was another sign.

Then I, who have always prided myself on being one of New Zealand's best intensive care nurses, found myself unable to multi-task one night duty. I had to ask the nurses to line up and present their patients' problems, one at a time, in order to prioritise and solve them. At this time I was thinking: "Yes, I know I'm a bit stressed, I'm a nurse, for goodness sake! But I've got some leave booked for after the MECA mediation and I'm actually going to take it this time, so I'll be fine."

I've always had ectopics (heartbeats not pregnancies!) when really tired. "They're normal" I said to myself, "and will go away when I've had a holiday, which is soon, okay?"

I was not sleeping terribly well, but I'd never been a big sleeper, especially on night duty, which I did two weeks out of every seven week roster. What do you expect? I'm a nurse, for goodness sake!

During this time the list of "things to do" was enormous. I delegated where I could, which was not very often. I knew that was another sign of impending burnout, but I was taking leave soon and then everything would be all right. I could put some of the list onto the following day--it didn't all have to be done today--and prioritise. I could do that. I'm a nurse, for goodness' sake! But the next day, there were so many people at me, that the lists just grew and grew and I was at work late each day, fixing the lists before I went home. I couldn't leave any of the work undone--it was critically important and the world could not manage without this completed work. I knew that was another sign, but I still thought I could manage and last until my holiday. I'm a senior nurse and virtually indestructible, for goodness' sake!

I was now sleeping, because I was so exhausted. Even when on night duty, I slept up to six hours a day, which was unprecedented. I was managing nicely. The old "apply more pressure" theory had come through for me again. But I was having disturbed sleeps, like when I was kid and afraid of earthquakes. I kept waking with a feeling of impending doom but I seemed to be worrying about things that didn't actually exist, so I'd have a cup of tea, read for an hour and go back to sleep. Always thinking: "It's mediation next week, and then a holiday--right? It's stress, I know, but I can get to the end of this, have my holiday and then I'll be all right."

I thought I might even take some sick leave and extend my time off. But I was determined to maintain my composure. All the pressure would go away when I'd had that holiday. I have to finish this, for myself as well as my colleagues. I'm a nurse, for goodness' sake!

To add to my problems, I'd booked for a couple of conferences. I was going to present papers, which I thought would be fun and refreshing after the MECA negotiations. There were the usual hassles about air tickets and getting reimbursed for things I'd already paid for, but I was dealing with these problems more firmly than before and was feeling pretty good about things. Then I failed a neonatal resuscitation instructors course. I couldn't believe it. I knew I was tired, jangled and nervous but I'd been an instructor since 1983 and knew the information backwards.

The final straw

The final straw, dear reader, was not recognisable as such. But from my perspective, it looked like a bloody great log off the back of a very large truck. I turned on my cellphone to call the kids and tell them MECA mediation would be going on for yet another day. I was now on my promised leave and this was the second leave day I had been in mediation. There was a message on my cellphone to contact a clinical nurse leader (CNL) who was dealing with a distressed nurse. I needed to contact her immediately. That was the final straw. I called the CNL and spat the dummy--"I can't possibly manage this," I shrieked. "I'm in mediation while I'm on annual leave, yet again." I told the CNL it was now sick leave--I'd just put myself on stress leave. I told her I'd organised another delegate to look after this nurse. "Here is her number. For God's sake, where do you people get off? Do you know how much actual work I do--in my bloody leave time?"

That poor CNL probably needed a tympanoplasty after my tirade.

Help forthcoming

So, now I am at home, recovering from stress. I received a call from a senior manager: "Are you all right? Is a month long enough? Do you want some counselling? When you get back, we'll sit down and put into place the things you need to allow you to perform your role without all the extra time you have to spend at it." If I'd realised such help was forthcoming, I'd have spat the dummy six months ago! So why didn't I get the help when I needed it? I know the answer--I'm a nurse, for goodness' sake!

The ectopics went in the first few days, though sitting down quietly, I realised there were more than I'd ever had before. The dreams were gone in a week and I'm sleeping now. But it's true about stress keeping you going. Now I have this paralysing inertia. I cannot get out of bed in the mornings. Only the kids' needs keep me going.

There are still all these things that need doing, and, although I'm happy to put them on hold, I cannot avoid them forever. And I cannot stay like this. As yet, I cannot see an end to this feeling of total disability. I cannot yet see myself as a vibrant, useful, strong and dynamic member of anybody's team. That's pretty scary. I might end up like Miss Haversham, with my dreams, yellowed with age and disuse, in a box in a cupboard, waiting for the return of the strength that has abandoned me forever, like her love did.

Time heals--how much time? I cannot afford to be on sick leave forever, the money is not good enough, for a start! All that penal and overtime does have its uses. To add to the stress, we've had to face a family crisis. Discussions with the children about the meaning of life and ways of coping with life's challenges have replaced night duties, MECA negotiations and advocacy. In some ways it will be a welcome contrast to get back to work as a break from the effort of supporting the boys through this crisis. Stress--whether at home or at work--is a normal part of life. But sometimes it can change its shape and form and become overwhelming.

EPILOGUE ...

JANET BLACK returned to work in October last year, with little enthusiasm and continuing lethargy. After two or so months, during which she often felt "tired and grumpy", director of nursing Jan Adams suggested some further time away from work. Black was scheduled to return to work again on April 5.

There will be no further shift work for some time, rather Monday to Friday work. At first Black will devote time to her particular passion, neonatal resuscitation. "One of the few bright lights in the last few months has been the publication of national newborn resuscitation standards, something I've worked towards for a long time."

She will then be involved in some projects with the DON. "She has been very supportive. We're lucky to have her at Waikato Hospital."

But Black remains "cross" at the organisation. "A nurse is put on stress leave and the stress then becomes her responsibility. I'm not the only nurse on stress leave within the organisation, so clearly there are issues the organisation has to take responsibility for, to deal with stress among its staff. NZNO's nurse: patient ratio campaign is absolutely critical as a way of addressing the stress nurses are suffering."

Black's NZNO workload has been shared, with the role of convenor now divided, with Black responsible for just the women's hospital. "I don't want to walk away from my NZNO work. I've learnt a lot of skills. What I want is recognition for my work outside my nursing role and I'm getting that now."

A desire to share her nursing and midwifery skills is one of the main reasons she has returned to work. "I've learnt so much from other nurses and midwives and patients sharing their knowledge and experiences with me. I want to give back some of that."

Black has been pondering how to better care for those nurses who are working in an advanced neonatal practice role. "I've developed some ideas around shift work that I'd like to see explored further."

On the eve of her return to work this month, Black said she was not feeling all that enthusiastic about nursing. But she does not feel trapped and wants to try and develop ways of working that will enable her to care for herself and her patients in the best way possible. "I want to be able to work on my terms. And I feel strong enough to deal with what that will entail."

If that proves impossible, Black is clear she will leave nursing. Writing beckons, an interest rekindled during her time away from nursing.

--Janet Black, RGON, RM, is back teaching neonatal resuscitation at Waikato Hospital and is involved in some project work.