Running head: Caregivers and Despair

Professional Caregiver Despair: A Concept Analysis

Thomas Cox

Doctoral Student in Nursing

Virginia Commonwealth University

School of Nursing

April 2. 2002

The Leaden Echo and the Golden Echo
(Maidens' song from St. Winefred's Well)

THE LEADEN ECHO

HOW to kéep -- is there ány any, is there none such, nowhere known some, bow or brooch or braid or brace, láce, latch or catch or key to keep
Back beauty, keep it, beauty, beauty, beauty, ... from vanishing away?
Ó is there no frowning of these wrinkles, rankéd wrinkles deep,
Dówn? no waving off of these most mournful messengers, still messengers, sad and stealing messengers of grey?
No there 's none, there 's none, O no there 's none,
Nor can you long be, what you now are, called fair,
Do what you may do, what, do what you may,
And wisdom is early to despair:
Be beginning; since, no, nothing can be done
To keep at bay
Age and age's evils, hoar hair,
Ruck and wrinkle, drooping, dying, death's worst, winding sheets, tombs and worms and tumbling to decay;
So be beginning, be beginning to despair.
O there 's none; no no no there 's none:
Be beginning to despair, to despair,
Despair, despair, despair, despair.

Gerard Hopkins, Poems (1918) - Section 10
Professional Caregiver Despair: A Concept Analysis

Disaffection, disaffiliation, and alienation of professional caregivers (PCs) is a critically important, poorly understood, and largely neglected phenomenon in the health care system, affecting providers, consumers, and healthcare organizations. PCs who are dissatisfied with their professional roles and activities represent a great loss in replacement costs, sub-optimal use of human resources, and most of all because of the personal losses it represents in the form of interrupted careers and altered lives. As well, disaffected and disaffiliated healthcare professionals may act in ways that are dangerous to themselves, other healthcare workers, and clients.

Background, Significance, and Relevance

Nurses, as do other healthcare professionals (Boisaubin, 2001; Weinberg, 2000) , experience high levels of stress and dysphoria related to their work. Exposure to patients that are seriously ill (Molassiotis, 1996), that become more ill during caregiving, and the inevitable impact of death (Payne, 2001), family distress and feelings of frustration with self and others during caregiving activities all contribute to stressful work experiences. As well, changes in healthcare environments, financial and otherwise (Blythe, Baumann & Giovannetti, 2001; Poissonnet, & Veron, 2000), contribute to job dissatisfaction and work related stress. Nurses, like physicians, have relatively easy access to drugs (Blazer, 1990; Boisaubin, 2001), and incorporate medical model assumptions that include labeling their experiences in terms of illness. The labeling and treatment of the effects of responses to work related events often takes on the form of diagnoses of depression and anxiety, with attendant treatment in the form of medication to alleviate symptoms (Spence Laschinger, H. K. P., 1997; Weinberg, 2000). An alternate conceptualization of these experiences, as non-medical, non-illness experiences may be more helpful.

The concept of professional caregiver despair (PCD) is unexplored in the professional literature. Rather, professional literature may describe these experiences as: illness events; stress; burnout, deviant professional conduct; poor adjustment to environmental change; poor role performance; or departure from practice (Valentino, 2002). Understanding PCD is critically important. Current events suggest that a crisis in healthcare looms ahead as the demand for nurses exceeds the supply of nurses. This is assumed to be likely to worsen over the next few years. As well, mandatory double shifts, routine requirements for overtime, and short staffing of health care facilities add to the burdens currently faced by nurses (Valentino, 2002). All these dimensions of the problem are likely to be further exacerbated by, and for, PCs who experience PCD. An alternative, relatively unvoiced view is that there is no nursing shortage but rather, a shortage of economic, personal, and professional incentives to enter or remain in the field (Cox 2002). It is unlikely that any nurse makes the decision to enter nursing or to leave nursing for few or simple reasons. Understanding why nurses depart the field or consider leaving the field, and why many nurses work part time rather than full time may add valuable new insights to the discourse on the ‘nursing shortage’ and suggest new ways of addressing contemporary events.

Orienting Definitions

The Oxford online dictionary defines “professional” as a person:

“That is trained and skilled in the theoretic or scientific parts of a trade or occupation, as distinct from its merely mechanical parts; that raises his trade to the dignity of a learned profession.”

The Oxford online dictionary defines “despair” as

“The action or condition of despairing or losing hope; a state of mind in which there is entire want of hope; hopelessness.”

As well, synonyms for despair include: ‘desperation’; ‘despondency’; and ‘hopelessness’. It may also be defined as: ‘to give up, as beyond any reasonable hope or expectation of fulfillment’.

Interestingly, the International edition of Bartlett’s Quotations defines Despair by using the following synonymous terms: Desperation, Sadness and Wretchedness.

The Oxford Dictionary does not provide a definition for caregiver but this author is inclined toward the following definition of a PC:

A person who has special training to help people with health problems, such as a nurse, physician, chiropractor; is engaged in remunerated employment, qualifies for licensing, as appropriate, and is capable of performing such duties, tasks, and procedures as may be required in the normal course of delivering care; which include meeting client’s physical needs such as feeding, bathing, medications, toileting, comfort, and support, supporting client’s physical, intellectual, social, and emotional needs, dealing with emergencies as a routine part of their paid employment.

PCD is complex, involves the actor or actress in particular, contextualized, settings, and the experience of PCD among PCs may be fundamentally different than their experience of ‘being in the world’ in other settings.

Toward a Synthesis of Meaning

Having defined PC, the crux of our task is the construction of the concept of PCD as it may exist, in a moment in time, subject to changing perceptions. It is not meant to be universal, timeless, or static. Changes will be introduced and the concept is expected to evolve when used by different persons, in different settings, and at different times. PCD is situated in the professional experiences of PCs, performing as providers of care in settings appropriate to their professional activity. PCD does not refer to how PCs feel when they are at home, although such information may be important in determining whether the concept applies to a particular individual.

Despair

Erikson (1950) suggested that the last stage of human life, from the age of 65 until death, was marked by the developmental crisis of “Integrity versus. Despair”. In 1950 this would have been a relatively brief period and most people would never even have reached it. In this ‘stage model’ it seems that one either achieves integrity during the life review by focusing on satisfactions and successes or dwells in despair by focusing on disappointments and failures. However, Erikson’s stages are not really linear. Rather, life review, reassessment of one’s actions, achievements and failures, is likely to be a cyclical process throughout the lifespan. In fact, not only is it likely to be a cyclical process, but it is likely to have outcomes that vary with what is being reviewed, the setting of the events reviewed, and the setting in which the review takes place. In particular, self-reflective professional practice is likely to involve ongoing review. This is critically important for the concept of PCD because it is likely that PCs experience varying qualities and amounts of despair, at different points in their career, and for differing reasons. Even within a day, it is highly likely that PCs will experience moments of despair, hope, optimism, interest, disinterest, joy, and sadness. While despair may be a theme in the PC’s life, it is not likely to be the only theme. Although Erikson assumes a static outcome and one that is deferred until old age, people feel old and young in the same day. People see themselves as bounded and closed as well as unbounded and open, coincidentally. Hence when we assert that we are focused on PCD, it is with the recognition that the phenomena is very contextualized, fluid, inexact, subject to change, non-replicable, transient, and ephemeral. This is not, however, to suggest that it is not meaningful merely because it may be transient. PCs make decisions, act in the world, and withdraw from the profession. Knowledge about the experience of despair may have implications for addressing issues in nursing that continue to create turmoil in the nursing profession, interrupt careers, and create difficulties for healthcare employers.

Issues of Temporality and Location

Carboni (1990) in her study of homelessness among senior citizens, living in a nursing home, brings attention to the paradoxical nature of homelessness. As an example, a ‘homeless’ person living on the street may have a connection with their environment that makes the alleys, storefronts, bushes, and parks that provide their day to day living environment with the sense of ‘home’ (For a further elaboration of how this might happen see Appendix A.) Paradoxically, a person in a nursing home may be clothed, fed, bathed, and sheltered, and yet feel adrift, purposeless, that their life has lost meaning and they may pine for the past, and dwell in their memories of a lost ‘home’, thus embracing despair as well as a sense of homelessness. They may feel they have no private space, that the environment is foreign to them. Carboni’s (1990) characterization of elderly nursing home residents as ‘homeless’ paves the way for essential features of the paradox of PCD. PCs that experience despair need not experience all life, or even all their professional life, as despair. Where the world of definitions is usually conceived as static, fixed, and bounded, PCD as other concepts, is fluid, dynamic, and context-sensitive. Few caregivers are likely to dwell in despair constantly. By its very nature one cannot imagine ever-present despair as possible. Rather, as Carboni (1990) suggests about homelessness, we must appreciate that despair exists precisely because the notion of the antithesis of despair exists. Without hope, hopelessness is an unexpected phenomenon. Without an image of a distant, fragmented, perhaps inaccessible ‘home’, ‘homelessness’ is impossible. The jarring disparity between what could be and what is is critical for PCD.

Professional Caregiver Despair

PCD is not clinical depression. That doesn’t mean that a PC who is depressed does not experience despair. Depression is a medical interpretation of individual experience and manifestations of ‘being in the world’. The role of medicine is the classification, diagnosis, and treatment of disease. Pressure within and about medicine, is directed to making medicine more responsive to individual experience. Nursing, on the other hand, is primarily interested in the phenomena of the unique, contextualized, client (Cowling, WR, 2000; Cowling, WR 2001). Two patients with heart disease may both be diagnosed with coronary artery disease (CAD) and both will be scheduled for bypass surgery. The conditions under which an appropriate diagnosis of CAD is to be made and the conditions under which bypass surgery are appropriate, as well as how the surgery will be done are part of the rationalized part of medical care as described by Gadamer (1996). This system of care is well developed, extraordinarily useful, and often needed.

On the other hand, the two patients have different worlds in which they reside. The worlds are constructed from the individual raw experiences over the course of a lifetime, their different standing in the world, the ways they view the world, and their ‘being’ in it, and what they see as possible and not possible. Part of that unique world of the individual patient is the unique configuration of responses on the part of healthcare professionals and the system as a whole, to their experiences and the unique configuration of all the other actors and actresses, technology and resources that are available and unavailable to them, the knowledge of that availability or even the knowledge or lack thereof about what is available to them.

So where traditional medical intervention focuses on prevention and treatment of disease, nursing activity is generally concerned with a larger and hazier domain. The distinction that may be drawn between PCD and PC depression is also phenomenological. Some of the unique experiences of PCD will support a diagnosis of depression. The distinction is that the phenomenological world of the PC may not change dramatically as a consequence of treatment for depression. As well, a diagnosis of depression may not be appropriate to the experience of PCD. The social relationships, material resources, environmental constraints and opportunities, the worldview, and the gestalt in which the PC perceives themselves to be embedded, will generally not change merely from treatment with an anti-depressant or mood elevator. The work of the PC experiencing despair toward the recognition and integrality of their wholeness and unity remains to be done, even after conventional medical intervention.

Table 1 (See Appendix B) offers details on some of the conceptual distinctions between depression and despair. It also functions as an elaboration of the concept of despair, the implications, and how despair may be approached from the standpoint of an intervention. As suggested in the comparison table, socio-therapy, rather than psychotherapy may be the appropriate ‘intervention’. Change, rather than adaptation may be the imperative. This table is used to highlight differences between PC depression and PC despair that may be unclear in the three narratives (See Appendix C). PCD is also not existential despair, the complete absence of meaning, sense of purposeless, angst, existential dread that may accompany the recognition of the meaninglessness of life. PCD, on the contrary, is suggested as a way in which PCs shape the meaning of their experiences and it represents the world they have constructed about which they despair. There are reasons for their hopelessness; it is not just a response to biological inadequacy, of deficiency of medication. There are unmet expectations, unfulfilled hopes and dreams, opportunities lost, challenges too formidable to meet, futures that seem harsh and uninviting, and perhaps a past that seemingly cannot be replicated or resurrected. The PC experiencing despair has not withdrawn from the world, they are perhaps, trapped in it, making sense of their experience, blending art, science, perception, feeling, and intuition into an organic and meaningful whole that represents their reconstruction of the world. Despair is not simply unhappiness either. Despair is a deep misgiving, a sense that something is fundamentally awry with the world. A feeling perhaps that one experiences in an auto accident or when running into a plate glass window. That instantaneous sense that we don’t understand what has happened but we know at a deep, guttural, mind wrenching, and bone jarring level that something is not right. As happens when we run into a wall, we know that things are out of kilter, we should be moving forward but we are not. Neither do we belong where we are.

Recapitualization of the Narrative Cases

Four cases put forth representations of an exemplar of despair, a contrary case, a borderline case, and a case of professional caregiver depression. John is clearly absent of PCD. Ann may be headed toward PCD in the future but is not clearly there at the moment. Sally seems firmly embedded in PCD, a pervasive sense of hopelessness about her professional setting and practice, and a sense that the future looms ahead in an unfavorable manner. Joan suffers from chronic, untreated and perhaps untreatable depression. It affects her at home as well as at work. It flavors her every experience, leaving her drained, tired and with little energy for life. Theoretically, it may be possible that a new wonder drug will turn this all around. None have worked as yet. What is the characteristic nature of the differences between these four PCs? After all, they all work the same shift, in the same hospital, and they often care for the same patients, interact with the same medical, housekeeping, and allied health teams. In each case we have a characteristic story, or narrative, that our caregivers have woven about their lives. The stories aren’t about an objective reality – this is obvious because the stories are so different. The stories hold together though. We can imagine these people, we work beside them, and maybe, in some measure, we see ourselves in these stories.

It is, of course, possible that Sally suffers from a problem with regard to reuptake of serotonin. It may be appropriate for Sally to start taking Prozac. But even if the Prozac therapy is effective, it is unlikely that all the features of Sally’s ‘being in the world’ will change. She will still have financial concerns, the patient acuity issues will remain, and the disparity between what her role used to be and what it has become will remain. Her coworkers John and Ann simply will never understand the way healthcare has changed in the same way that she does.

Each of our nurses has a story about their lives, their professional roles, their professional setting that is an organized whole, an ensemble of experiences, personal and cultural introjects, subjective interpretations, a different interpretation of time, different visions of the future, and of the past. Where John imagines a future of unlimited possibility, Ann sees uncertainty, and Sally sees disadvantage and ruin. These visions are partly socially mediated – Ann is still young and attractive, looking to marry a doctor – though no longer the one she thought she would marry. Sally carries the pain and loneliness of distant divorce, increasing age, and weight gain. She feels unattractive, disinterested, and is unlikely to marry again. She avoids romantic entanglements, refuses to date people she meets at work, despite the fact that she works 50 – 60 hours a week and has limited other opportunities for meeting new and unattached people. Ann, on the other hand is trying her best to be attractive to male physicians, is hopeful and intent on marrying a doctor. John has dated several physicians and systems analysts, and has no plans to ‘partner’ before he finishes a master’s degree.

Conclusion

Four vignettes demonstrate an exemplar, contrary, borderline and an analogous case of professional caregiver depression. PCD is phenomenologically different than depression. It is not about biology, nor is it about particularizing acceptable and unacceptable parts of the self. It is about a gestalt in the way people are in the world. It is about wholeness, meaning making and the rich experience of life.

References

Blazer, L. K. (1990). A comparison of substance use rates among female nurses, clerical workers and blue-collar workers. Journal of Advanced Nursing, 21, 305-313.

Blythe, J., Baumann, A., Giovannetti, P. (2001). Nurses' Experiences of Restructuring in Three Ontario Hospitals. Journal of Nursing Scholarship, 33, 61-68.

Boisaubin, E. V. (2001). Identifying and Assisting the Impaired Physician. American Journal of the Medical Sciences, 322, 31-36.

Cox, T. (2001). "Risk theory, reinsurance and capitation." Issues in Interdisciplinary Care, 3(3): 213-218.

Cox, T. (2002). Editor's Corner - The Bear's Lair. Rogerian Nursing Science News Online 1(2).

Cowling, W. R. (2000). Healing as Appreciating Wholeness. Advances in Nursing

Science. 22(3):16-32.

Cowling, W. R. (2001). Unitary Appreciative Inquiry. Advances in Nursing Science. 23(4):32-48.

Erikson, E. (1950). Childhood and Society. New York: W W Norton & Company.

Gadamer, H-G (1996). The Enigma of Health: The Art of Healing in a Scientific Age. Translated by Nicholas Walker and Jason Gaiger. Stanford: Stanford University Press.

Molassiotis, A. (1996). Evaluation of burnout and job satisfaction in marrow transplant nurses. Cancer Nursing, 19, 360-367.

Payne, N. (2001). Occupational stressors and coping as determinants of burnout in female hospice nurses. Journal of Advanced Nursing, 33, 396-405.

Poissonnet, C. M. & Veron, M. (2000). Health effects of work schedules in healthcare professions. Journal of Clinical Nursing, 9, 13-23.

Spence Laschinger, H. K. P. (1997). The Effect of Workplace Empowerment on Staff Nurses' Occupational Mental Health and Work Effectiveness. Journal of Nursing Administration, 27, 42-50.

Valentino, L. M. (2002). Future Employment Trends in Nursing: The nursing shortage has struck just about everywhere in the United States and there’s no relief in sight—but its effects vary by region and specialty. American Journal of Nursing, Volume Supplement 1 pp 24-28.

Weinberg, A. (2000). Stress and psychiatric disorder in healthcare professionals and hospital staff. Lancet, 355, 533-537.

Appendix A

The Paradox of being homeless and having a home

A ‘homeless’ person living on the street may have a connection with their environment that makes the alleys, storefronts, bushes, and parks that provide their day to day living environment with the sense of ‘home’. There may be a complex set of rules, held to be true by the homeless person that reinforces this notion. For example, the homeless person may choose to view a storefront as his or her nighttime residence, refusing entry to anyone else. However, as part of their rule construct, their entitlement to the storefront may end at 7 AM when the shopkeeper arrives. Absent conflict with the shopkeeper, the legal status of the homeless person’s claim to entitlement may never be challenged. Unlike Carboni’s example of the elderly person who feels that their room is not theirs because staff can enter at will, the ‘homeless’ person is navigating their world by accommodation and establishing a private system of rules and entitlements that rationalize their confrontations with an otherwise jarring reality.

At 7 AM the ‘homeless’ person may shift the ground of their ‘home’ to the park, or perhaps a fast food restaurant, where they will attempt to secure coffee and a breakfast sandwich from a trash bin or departing customers. They may have a preferred trash bin, corner, or restaurant entrance that they consider to be theirs. At 9 AM the ‘homeless; person may make their ‘home’ at a park, library, mall, or subway station depending on weather conditions and local environmental characteristics. As long as nobody challenges the rules, the ‘homeless’ person may feel they have a ‘home’. Where Carboni’s elderly may feel they have no privacy, the homeless person may view the bush they use to cover them while they defecate and urinate as their private space for such intimate functions, despite the fact that they have to be ever watchful for passersby who may be unaware of their entitlement to their private bathroom.

Appendix B

Appendix C – Narratives of Cases

Exemplar Case

Sally has been a nurse for 22 years. She works in a medical-surgical environment, caring for people before and after surgery. During the course of her career, patient acuity has risen, staff has been reduced, and patients are released before they have recovered sufficiently to go home and take care of themselves. Today, she prepared the paperwork to discharge an 85-year-old woman who lives alone. The woman will leave the hospital with an IV, wounds that require cleaning and new dressings, and a clear inability to do these things. Sally cried as she processed the paperwork. She thinks to herself: “It didn’t used to be like this.”

While Sally’s salary has risen during the last 22 years, it has risen nowhere near as fast as the salaries for top administrators in the hospital, nor has it kept pace with salaries in other fields. Even teachers with similar lengths of service, who work on 10-month contracts, get better pay. Sally often regrets not having become a teacher. But she couldn’t do that; she couldn’t afford to go to college. The level of detail in her work and the technology with which she works has destroyed her life. She spends more time writing documentation and trying to learn how to use new equipment than she spends with her patients. As she looks around she sees new graduate nurses earning 90% of her current salary with no experience at all. She thinks John, a new nurse, is incompetent, uncaring and cannot understand why he won’t help her use the computer. She feels that he ought to be asking her how to be a better nurse and is embarrassed and dismayed that instead, she has to ask him for help.

She feels thwarted professionally by the lack of a career ladder that incorporates the expertise she believes she has acquired. A graduate of a diploma nursing program, she sees opportunities drying up every day as one facility after another moves to require a BSN as the minimal entry level education. She has never even been to college let alone earned a four-year degree, and some days she wonders whether it is really true that the kind of training she had in nursing is so deficient. Most days Sally does not enjoy being at work. She worries that her clients are not receiving the kind of care she entered nursing to provide.

At the same time that she has experienced very marginal increases in salary, she is aware that the value of her tiny portfolio of stocks in the corporation that runs the hospital has risen 300% in the last year. She believes that stockholders, who do not provide any care at all, are the primary beneficiaries of her expertise, labors and commitment to others. She has been able to invest very little in employer matched stock purchases because her small raises in the last 10 years have actually fallen short of increases in the cost of living. She lives in an apartment she rented after her divorce and cannot imagine ever owning her own home again. She often thinks about leaving nursing because she sees no future, cannot imagine how she will successfully retire when her expenses continue to rise relative to her income. She consistently rates her satisfaction with her current job as ‘very low’. When she leaves work, she often dwells on her concerns about her patients and even her own safety. She knows that she should use more precautions, but there is so little time that she often forgets to use the latex gloves. As well, her hands always start itching whenever she does use them. Years of exposure to latex may be taking their toll where the younger nurses aren’t having problems yet. She fears blood borne illness and longs for simpler times when she feels she was really able to care for people. She remembers that shortly after two nurses became infected with hepatitis C, the hospital changed the health insurance plans available from an excellent plan to an HMO. The financial benefits for employees that changed over were so good that almost everyone made the change. But when one of the nurses became sick she found that she could not get the kind of care she needed. Sally is worried that the HMO will treat her as badly if she gets sick.

When she is not at work it is like a new person emerges. Once she sheds her work clothes, showers and dresses, life is very different. She volunteers at the local art museum, takes dancing lessons, and is a regular in the church choir. Outside of work she is able to forget the pain she experiences each day, she can ignore the economic plight she is in, and she is surrounded by friends and people who think well of her and of whom she thinks well. Most of the time when she is not at the hospital she doesn’t understand why it gets to her so much. Vacations are even better, and next month Sally is going to take a month long trip to Costa Rica to visit a shaman in the Rain Forest.

Contradictory Case

John is a relatively new graduate nurse. In school he trained with the very latest technologies for bedside care. He has no prior experience working in healthcare. He went through a community college program in nursing because it was the shortest and least expensive path to a good paying job among the alternatives available. He fully expects to advance fast enough so that his associate degree in nursing will not become a problem. He enjoys using the computerized management information system, spends more time with the computer than with his clients, and imagines a future career working on MIS design and programming. Next semester he plans to enroll in some computer classes at the local university with the ultimate objective of training in nursing informatics. He sees a rosy future in a higher paying field in which a couple of years of experience in bedside nursing will pay great dividends in opportunity and salary. He figures that a RN license, a BS in computer science and a master’s degree in nursing informatics is a quick path to a very nice lifestyle.

He has never really enjoyed patient contact, tends to see his patients as increasingly and inappropriately dependent as they recover from their surgeries. He does not wish to foster that dependence and spends less time responding to patients as they recover. He has a pretty carefully mapped out idea of which patients need what kind of help and he doesn’t intrude beyond providing what is needed. He is glad that Sally is finally taking steps to discharge the old lady in room 410. If she had still been his patient he would have pushed her discharge yesterday.

He enjoys interacting with the medical staff, the janitors and allied health personnel, plays on the hospital softball and bowling teams, and meets with a ‘male only’ steering group that serves as an ‘informal’ employee advisory council for the hospital CEO. Both the CEO and the CFO play on his softball team though they often can’t make it. They are both, however, frequent attendees at the post game celebrations at a local bar and often pick up several rounds of drinks on their expense accounts for the team members and friends.

He sees his career as virtually unlimited, offering many opportunities to leave the bedside, earn more, and live comfortably in a profession in which few of his peers focus on career advancement. As a result of the new contract, John received a healthy increase in pay after only two months on the job – he doesn’t understand why Sally is complaining about her pay. He has not been eligible for the employee stock purchase plan but started investing in the corporate stock when he decided to accept his job 6 months ago. His original investment in corporate stock has tripled and he checks the performance of his portfolio several times during each shift. He invests primarily in health stocks, high tech companies, and insurance companies. His expenses are low and he made the decision years ago that he wanted to invest 50% of his earnings. He has been doing that and with the new raise he will be able to move that figure to 60%. He figures if he suffers any losses he is young enough to make up for it later. However, he rarely picks stocks on which he loses money.

As far as he can see, Sally is slow to grasp new opportunities, has deficient skills, and seems to spend entirely too much time chattering away at her patients, writing up paperwork, complaining about the way things are, and reminiscing about the way things used to be. He wonders how different it could be – hasn’t it always been pretty much the way it is now? Most of his case notes require nothing more than a few mouse clicks on the automated documentation system. Computers make his job much easier than when he was a student and had to write up complete SOAPER notes. He rates his satisfaction with his current job as very high, but his focus is clearly on the future. He thinks Ann is attractive but it is obvious that Ann’s objective is to marry a doctor and he doesn’t feel like dealing with her coming sense of loss.

Borderline Case

Ann has been a nurse for three years. Due to the most recently negotiated contract she has received a very attractive increase in pay. While her technological skills have begun to weaken, she is still relatively comfortable with the introduction of new equipment that has recently occurred. She is beginning to question some corporate policies that influence the quality of life on the floor but the recent salary increase has convinced her that the new management is doing a good job. She has been investing the maximum amount in matched employee stock options and even more. In the last year her sizable investment has increased 300% and she will soon have enough to buy a house. She would like to spend more time actually caring for her patients but has been inundated with the increased paperwork since the management team instituted the new quality improvement program and the new computer system. She doesn’t quite understand why the paperwork is needed but everyone else seems to accept that it is necessary. She has to enter information in the computer and then works with Sally on writing up reports, a practice initiated when Sally was Ann’s mentor. She is a little jealous of John. She doesn’t feel comfortable with the computer system and he seems so adept. She really doesn’t understand why John doesn’t spend as much time on paperwork as she does. Sally says it is because John doesn’t do his job but that makes less and less sense the longer he is here. In fact, she admires John’s abilities with high tech equipment though she wishes he were a little more sensitive.

When Ann started nursing she was living with a medical student. He didn’t invite her to come with him to his residency 1,000 miles away and recently told her that he had started dating again. She is beginning to wonder about her future and is having doubts about some of the choices she has made. Maybe she will go back to school and become a nurse practitioner – but not now.

At the moment, Sally feels somewhat adrift, but a lot of things are working to her advantage. If she wants to, she can go back to school and her tuition will be paid by the hospital. She has excellent benefits, the HMO plan is cheap and she likes her doctors and the NP, but then, she hasn’t been sick a day in her life.

Professional Caregiver Depression

Joan, a nurse on the same unit, has been struggling with depression for 20 years. She carries with her a pervasive sadness, at home, at work, in virtually all her activities. She is constantly on the verge of tears. There are events in her life that are very sad, that would make anyone cry, but her feelings about these events are little different than her feelings about events that would make most people gleeful. She had the same basic response to the wedding of her daughter that she has when she loses a patient. There is something not quite there about Joan. It is although she is a walk-on in a movie scene, not completely off camera but hardly noticeable even when the camera focuses on her. She seems to be in the background in almost every setting. She has been on every anti-depressant available and none of them have ever done more than stem the tidal wave of bad feeling that comes and goes against the everyday experience of life as ‘blue’. She is partnered with an incredibly sensitive, aware, compassionate and generous human being but she often treats her partner as though they didn’t exist. While there are many days when the depression is so deep that it results in her calling in sick, the most general experience is of a morbid sense of impending doom and loss. She often contemplates suicide and has attempted it twice. She feels invaded by her dysphoria and wants to get rid of it. She sees her dysphoria as foreign and as an enemy with which she is engaged in mortal conflict. In interactions with peers, which she keeps to a minimum, she is negative, evasive, eats lunch by herself, and rarely asks for or offers help.