Nursing is a calling. The average registered nurse spends 4 years after high school completing the grueling and competitive pre-nursing courses such as chemistry, biology, math, physiology, and human development just to jump into what has been described as the "most challenging" undergraduate degree. Then, and only then, are those that survive qualified to sit for a national exam (with an 85% pass rate) to proudly earn the title of Registered Nurse. Only a calling to serve those in need would motivate and inspire someone to work so hard. So why are so many nurses leaving the profession within 2 years of this immense achievement?

The Environment

The essence of the nursing role has never changed: provide care to enhance a patient's quality of life, partner with interdisciplinary professions to create and carry out the best plan of care, and advocate for the health and wellness of patients and the community. What has changed significantly in the past 20 years is the environment in which the nurse is expected to carry out his or her role. The Affordable Care Act has more patients accessing care, many for the first time in years. Additionally, states such as California took the opportunity to significantly changed the parameters to meet the low-income Medicaid threshold, which added thousands of patients to the already full healthcare rosters. This translates to not just an increase in volume, but patients with more co-morbidities such as obesity and diabetes.

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Work-Related Injuries

Nurses are constantly faced with the fear of being injured at work. Patients are 100% heavier than 30 years ago, which places the nurse at risk for patient-handling injuries such as neck or back strain. In spite of education and no-lift campaigns in the work unit, many nurses admit to moving patients alone due to the perception of time constraints. Due to costly patient-handling injuries, many healthcare systems and hospitals have established punitive consequences for nurses who handle patients alone and risk injury. While this may deter the behavior of lone-wolf nursing, the threat of disciplinary action for providing patient care adds to the overall tension of the job.

Workload

Nurses are expected to do more with fewer resources in an effort to find the sweet spot of the formula for productivity aligned with the actual number of nurses needed on a shift. The expectations from leadership as well as the patients and families boils down to tremendous stress for the nurse. Bedside nurses are working understaffing models that utilize a patient acuity system, such as GRASP, to calculate the needs and numbers of the patients in a unit to find the exact number of nurses to work for that shift. However, due to the complexity of these tools, it is not uncommon for the acuity system's numbers to be out of alignment with the true staffing needs of the unit. Challenges such as the geography of units or the nurses from the previous shift failing to accurately predict the care required for a patient can place the nurse in an assignment with an extreme workload, especially if the nurse has limited help from colleagues.

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Culture

Unfortunately, the phrase "nurses eat their young" is all too common in the profession. Nurses experience an almost rite-of-passage form of lateral violence in the workplace. As nurses who have gone through this cruel hazing often repeat the behaviors with new nurses under their charge, the culture is difficult to change. Nurses who have allies or friends in the department can rely on them to get through tough shifts and challenging assignments. Most nursing school programs expect a student nurse to care for only 3-4 patients at the most, whereas the first few months of being an actual nurse will more than double that assignment. Those nurses who could not or have not yet connected with fellow nurses compounds the additional feelings of isolation with not belonging to the group. Add that to a heavy workload and nurses can easily get overwhelmed with the physical and emotional demands of the role.

Emotional Strain

While nursing is a work of heart, it is too emotionally draining to connect deeply with all patients. Nurses must learn to balance and finesse the ability to connect on a personal level with patients and families without becoming entrenched into the personal lives of the patient. This is extremely difficult for some nurses based on personality traits as well as skill level. Nursing is a great occupation in the fact that there are nursing roles to fit individual personalities. For example, a nurse in the emergency department tends to have a more cut-and-dry personality than a nurse who works in oncology. Nurses who find a role that works best with their personality type will have an overall better career experience than those who are not able to work as their authentic self. It is a learned skill to provide compassionate care without becoming emotionally hijacked by every patient.

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Nurses leaving the profession within the first 5 years of their career is a significant symptom of the larger challenges in nursing. With alarming rates of up to 33% of new nurses leaving the workforce within the first two years, the (not so) great escape must be addressed overall by the profession. Foundations such as Robert Wood Johnson along with the American Association of Colleges of Nursing and other professional organizations are taking a multi-prong approach to address the root causes of the exodus. However, to truly stop the hemorrhaging, significant change needs to occur in the culture of the individual facilities, especially down to the unit level.

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