Long Time Coming

Identifying Systemic Sources of Stress in Healthcare

By Benjamin E. Ruark

Seated beneath every solution is a new set of problems. Thus, for every newly installed solution, there needs to be built-in contingencies. For instance, if asked, a majority of patients wouldn’t hesitate to ask this single burning question about healthcare: Despite the hubbub about its many cutting-edge fields, why are systemic stressors so widespread and allowed to thrive? Further, looking specifically at skilled nursing home care: Why aren’t management, the delivery system, and staff uniquely equipped to eradicate, minimize, or mitigate various systemic stressors, thereby preventing them from dampening the restorative effects of healthcare delivery?

As it stands now, if healthcare had a gold medallion awarded for superior service, it would mint with two heads, no tail. Its two heads would be ruefully symbolic of the industry’s two-faced nature. The front side’s motto would unsurprisingly tout we do no harm, while the reverse side would contritely amend apologies for systemic harm suffered. Skilled nursing care facilities, meanwhile, appear to be resting on their alleged laurels, presuming they’ve advanced considerably from the days of “human warehousing.” Yet a quick tour today would reveal their present operations have their fair share of systemic stressors: system-borne and maintained sources of stress thrust upon resident patients and staff alike, but mainly on patients.

It may be a long time coming, but what’s very much needed is a mechanism for identifying, by individual facility, specific systemic sources of patient stress. We might call this a Systemic-Stress EMM (SSEMM) audit. “EMM” denotes eradication, minimization, and mitigation. Depending on a source and its context, one of these three tactics will be more feasible than the other two.

The purpose, then, of an SSEMM audit is to identify actual stressor sources and their average stress degree or level for a patient population. These findings are then labeled “actual” and considered baseline. With collaborative input from a psychologist, social worker, and management, a set of EMM standards for all identified sources is next created and approved. These standards are labeled “desired.” The driving aim is to replace actual stressor levels with the desired, EMM-mediated changes facilitywide. This effectively closes the gap between the two conditions of actual and desired, which is why this type of audit is informally termed a gap analysis. After design changes are instituted and sufficient time has passed, an evaluation is performed to gauge the success in systematically closing the gap—thereby allowing a facility to declare that it is as acute-stress-free for patients as possible (emphasis on acute).

Oddly, research literature about healthcare worker stress is in copious supply. Yet little is said about patient stress, chronic or acute. It’s been fairly well documented, in general, that chronic stress is associated with many conditions and diseases:

  • Accelerated aging
  • Alzheimer’s disease
  • Appetite issues
  • Asthma
  • Autoimmune diseases
  • Behavioral problems
  • Depression and anxiety
  • Digestive complications
  • Emotional problems
  • Headaches
  • Heart disease
  • Pain (all kinds)
  • Physical complaints
  • Poor concentration
  • Reproductive issues
  • Skin problems
  • Sleep disturbance
  • Social withdrawal
  • Thinking and memory problems
  • Weight issues

Chronic stress promotes the growth and spread (metastasis) of some forms of cancer as well; it also worsens treatment outcomes. And while short-term or acute stress is touted as a performance enhancer, repeat instances of it, in general, are roughly as harmful as any diagnosed state of chronic stress. For example, within a narrow time frame, some patients experience multiple clashes with different stressors; likewise, also within a narrow time frame, some patients experience the same or similar stressors repeatedly. Both cases are borderline with chronic stress, and it’s unclear how sharp the dividing line is between acute and chronic.

So, if we factor in patient population instances of acute stress, that should have everyone in a skilled nursing facility doing a double take. By sheer membership alone, resident patients already cope with the usual ­internal personal stressors: mentally coping with institutionalized care; dealing with fear and anxiety about their prognosis; and reliving daily a near-complete loss of the many personal freedoms and rights enjoyed by seniors who are still living independently.

For external locus-of-control (LoC) patients, facility-based systemic stressors are thankfully a bit less harrowing. By nature, these patients are more or less accustomed to being cared for and having someone else controlling how their day unspools. Conversely, for internal-LoC residents, facility-based stressors likely exacerbate their current health problems. By their nature, these patients don’t like having their personal power usurped in any way, shape, or form. They’re therefore destined to experience more types and longer durations of stress brought on by the routine grind of healthcare personnel making demands upon them from every direction.

Regarding SSEMM audits, the following rough categorical breakdown of facility stressors is suggested:

  1. Activities unit/patient intake/physical therapy
  2. Administration
  3. Aides
  4. Facility cleaning crew/maintenance
  5. Mealtimes
  6. Medical treatment (minor to major procedures/interventions; also medication dispensing)
  7. Morning wake-up
  8. Patient physical/psychological health
  9. Resident rooms
  10. Staff conduct

Let’s dispel all notions of a smooth, orderly, punctual operation: On any given day, residents are subjected to a typically unsettling tableau of activities. Various staff are likely to commit human error by way of slips and memory lapses that result in things like the following:

  • Delayed delivery of in-room meals or delayed start of communal dining
  • In-room meals being delivered cold
  • Inadequate cleanup of shared restrooms
  • Unreasonable response times to patients’ call lights
  • Wake-up schedules that counterintuitively offer pain medication to sleeping patients
  • Unexpected intrusions on patient privacy from staff or outside agency representatives

To that last point, there are any number of unscheduled, unannounced intruders who may find their way into patient rooms: daily cleanup crew members, ombudsmen, social workers, dietary staff, physicians, laundry personnel, physical therapists, maintenance personnel, med techs or nurses dispensing medications, activities personnel, visiting volunteers, outside agency representatives, or mail deliverers. Completing the roundup are various aides either wanting something or delivering something, even in the wee hours when such visits could wake nearby sleeping residents.

Here’s a quick sampling of some other potential stressors:

  • Physically sore pressure points on a patient’s body
  • Incessant screaming for help of a patient suffering from dementia
  • Loud noise blaring 24/7 from a resident’s television
  • Excessive questioning, bordering on interrogation, from staff that exploit their sense of power
  • Bad attitude from certain aides or other personnel
  • Brusque demeanor from certain doctors or nurses
  • Restraints that keep the patient from falling out of bed
  • Lack of confidence in certain staff due to obvious incompetence

Such a list is much longer than most facility administrators would ever think to construct themselves.

Finally, a few words about work culture as a potential macro-stressor contributor. To what degree do staff check their street personality at the door and enter the facility intent on presenting a professional demeanor? To what degree do their language, behavior, and worldview spill over into their work persona and assigned roles? That considered, how many learned helplessness and toxic culture variables infect current work practices and add to, rather than subtract from, the stressors already identified?

So, we can conclude, we do no harm’s flip side—apologies for systemic harm suffered—is long overdue for a redress; otherwise, the gloomier option prevails. The healthcare world anxiously awaits seeing the notion of an SSEMM audit reified, its first formal how-to guide available soon on the market.

Ben Ruark is a former learning & development and continuous quality improvement professional. He now devotes his time to writing on important subjects for various industries, healthcare included.