case study 4 1 a crisis in nursing

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The Truth Behind the Nursing Crisis

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The Real Issues Driving the Nursing Crisis

Our analysis of nurses’ employer reviews reveals the true source of burnout and why nurses are leaving the field. Here’s how health care leaders can improve nurse job satisfaction to fight a looming nursing shortage.

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Health care leaders face a daunting set of challenges — rising costs, the transition to digital health, and shifting payment models, to name just a few. But according to a recent survey from the American College of Healthcare Executives, the No. 1 problem hospital CEOs face is staff shortages and burnout. 1 Ninety percent of the CEOs surveyed cited nursing shortages as a particularly acute pain point.

In 2021, the total number of registered nurses working in the U.S. dropped by the largest amount in 40 years, with younger nurses leading the exodus. 2 By 2025, the U.S. health care system could suffer a shortfall of up to 450,000 nurses, or 20% fewer than the nursing workforce required for patient care. 3

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High levels of job dissatisfaction and burnout are driving nurses from the profession. The COVID-19 pandemic placed tremendous pressure on all health care workers, but dissatisfaction and burnout among nurses have not improved since the pandemic ended. And by some measures, it might be getting worse: In 2021, nearly two-thirds of registered nurses would have encouraged others to become a nurse, but only half said they would recommend nursing as a profession two years later. 4

One of the richest sources of insight on dissatisfaction among nurses is how they describe their job, in their own words, on employment sites like Indeed and Glassdoor. This information is voluminous but difficult to synthesize because most of it takes the form of unstructured free text. To understand the challenges nurses face, we analyzed how 150,000 of them had described their employers in Glassdoor reviews since the beginning of the pandemic. (See “The Research.”) In this article, we share key insights from that analysis and offer advice to health care leaders about how they can address nurses’ most pressing issues.

Health Care Leaders Are Out of Touch

Nurses view their managers as out of touch with the daily realities of patient care. We categorized their comments about managers into nearly 50 leadership traits. The second most frequently cited trait described managers as being unaware of the challenges that nurses struggle with in the workplace. When nurses discussed how managers understood life at the bedside, their comments were negative 9 times out of 10.

Nurses are particularly critical of members of the senior executive team for their disconnectedness. The top team was 10 times more likely than front-line supervisors and middle managers to be criticized for being out of touch. Our results reinforce a separate survey in which nearly half of hospital nurses said they believe management does not listen to their concerns. 5

To address dissatisfaction and burnout, health care leaders must first understand what’s happening at the bedside. This can be challenging, particularly in large health care systems with thousands of nurses working across multiple sites and specialties.

Historically, leaders have struggled to systematically analyze the gold mine of insights into nurses’ frustrations that can be gleaned from their comments in employee surveys or external reviews. Reading, understanding, and analyzing huge volumes of unstructured textual data has simply not been practical. However, recent advances in artificial intelligence make it possible to identify deep patterns in large bodies of text and understand feedback at scale. Leaders can now mine free text to gain a nuanced understanding of the issues driving dissatisfaction and burnout among nurses and use that insight to improve life at work for their nursing staffs. (See “Getting Started With Text Analytics.”)

Identify Relative Strengths and Opportunities Through Benchmarking

Nursing satisfaction varies widely across employers. We identified 200 of the largest health care employers in the United States, including hospitals and health care systems, home health care providers, operators of senior living facilities, and staffing agencies. For each employer, we calculated how highly nurses rated the organization and senior leadership on Glassdoor from the beginning of the COVID-19 pandemic through June 2023. 6

Among large employers, nurses’ Glassdoor ratings ran the gamut from poor (2.6) to nearly perfect (4.9) on a 5-point scale. Nurses’ assessments of how well senior leadership has performed during and after the pandemic were even more varied, ranging from 2.1 to 4.9 on the same 5-point scale. The wide variance in Glassdoor ratings is consistent with a separate survey in which the percentage of dissatisfied nurses ranged from 2% to 48% across 60 U.S. hospitals. 7

Employees of the 200 large health care organizations can use our interactive tool to see how their organization ranks against others. The index is sortable by nurses’ overall ratings, their assessments of the top leadership, and the four most powerful predictors of nurses’ satisfaction: compensation, workload, organizational support, and toxic culture.

Nurses who work for staffing agencies (who are sometimes referred to as travel nurses) are, on average, much more satisfied than other nurses. The five highest-ranked employers in our sample (and six of the top 10) are staffing agencies.

Higher compensation, of course, accounts for part of this difference, but not all of it. We compared how positively nurses working with staffing agencies spoke about 200 topics compared with their counterparts employed by hospitals and health care systems. (See “Staffing Agencies Rate Better on Many Key Factors.”) While compensation was viewed more favorably by agency nurses, issues around solving nurses’ problems and open, honest communication had a larger sentiment gap between the two groups. By focusing on nurses as clients, staffing agencies excel at practices that improve satisfaction beyond simply paying higher wages. Other health care leaders can learn from their example, and we’ll make some concrete recommendations below.

Prioritize Drivers of Job Satisfaction

To understand the drivers of job satisfaction among nurses, we analyzed the free text of all reviews that had been written by the nurses in our sample since the beginning of the COVID-19 pandemic and classified the text into nearly 200 topics. 8 We then clustered topics into two dozen broader themes and used those themes to predict nurses’ overall ratings of their employers. We then compared each theme’s relative importance in predicting ratings. (See “Top and Bottom Predictors of Nurses’ Job Satisfaction.”)

Compensation was the top predictor of satisfaction among nurses reviewing their current employer, which is not surprising, given that inflation eroded the purchasing power of take-home pay during the period we analyzed. The importance of workload, the second-most-important driver, jibes with findings from a separate large-scale survey that found insufficient staffing was the strongest predictor of nurses’ job dissatisfaction, burnout, and intent to quit. 9

Workload and compensation are root causes of the nursing crisis that must be addressed, but they are not the only factors influencing nurses’ job satisfaction. Our analysis surfaced other aspects of the work environment, including toxic culture, organizational support, work schedules, communication, and learning and development opportunities, that leaders can focus on to improve nurses’ work lives.

This analysis also highlights areas that are unlikely to move the needle in improving the workplace experience for nurses. Perks are nice, but they will not compensate for a punishing workload or wages that fail to keep pace with inflation. Highlighting the corporate mission to promote patient health won’t help much either. Nurses already know that their job serves a higher purpose; that’s why most of them became nurses in the first place.

Mine Free Text for Actionable Insights

Many health care organizations rely on annual employee surveys, with dozens of items rated on a 5-point scale and a few open-ended questions tacked on as an afterthought. Faced with a long list of multiple-choice questions, employees are prone to switching to autopilot and assigning similar scores to very different items. The choice of questions constrains what employees can discuss, and there is seldom room to expand on why they chose a particular numeric response.

Open-ended, free-text feedback provides a rich source of nuanced and actionable insights. When nurses can decide which topics to write about, they use their freedom to discuss what matters most to them. Open-ended questions provide nurses with the space to expand on their concerns in their own words, offer crucial context, and propose concrete and actionable fixes to the problems they face. Individual free-text responses can be aggregated into broader themes to prioritize where leaders could focus their attention and limited resources to achieve the largest improvements in nurses’ satisfaction.

While organizational averages are useful, it is important to remember that distinctive subcultures can coexist within the same organization. This is particularly true among large health care systems that have grown through mergers and acquisitions. One national hospital chain, for example, has ratings that range from 1.9 to 3.9 across nearly 50 sites. Rather than relying on organizational averages alone, health care leaders must measure and analyze differences across locations, departments, functions, teams, and individual leaders.

Women, underrepresented minorities, and older employees can also experience organizational culture very differently from other employees. 10 It’s crucial to understand the drivers of job satisfaction and burnout across diverse employee populations.

It’s crucial to understand the drivers of job satisfaction and burnout across diverse employee populations.

Leaders can mine the free text for detailed insights about the most critical pain points for specific groups and tailor their interventions accordingly. Schedules, for example, have a significant impact on nurses’ job satisfaction, but which aspects of scheduling matter most will depend on the specific position. Flexibility in scheduling shifts and the ability to take uninterrupted work breaks is very important for nurses in hospitals and primary care practices, while home health care nurses place a premium on predictable schedules. 11

Nurses’ comments provide a treasure trove of practical suggestions to improve the workplace and patient care. The Glassdoor reviews we studied, for example, include dozens of actionable suggestions for how employers can improve scheduling. Some are easy-to-implement actions, such as using an app to make it easier to pick up or swap shifts, or paying a $20 to $50 bonus to nurses who pick up shifts at the last minute. Others are more systemic changes, like including nurses on a committee established to set schedules or ensuring that employees who receive tuition assistance are able to schedule work around their classes.

Listen to Nurses Who Leave Your Organization

Most organizations limit their surveys to current employees. Exit interviews are administered haphazardly, if at all, and the feedback from former employees is too often dismissed as the rantings of malcontents. But ignoring feedback from former employees is a big mistake.

Interviewing or surveying former employees can surface the reasons for their departure and pinpoint the most effective actions to retain talent. Free of the threat of retaliation, nurses who are leaving (or have left) an organization are more likely to provide candid feedback, even about taboo issues that current employees are reluctant to discuss. By collecting feedback from those who have left, organizations can uncover potential blind spots.

More than one-third of the Glassdoor reviews in our sample were written by former employees and provide insights on what mattered most to nurses who voted with their feet. 12 The bars on the left side of the figure “Top and Bottom Predictors of Nurses’ Job Satisfaction” rank the factors that predict how nurses who quit rank their former employers, and it sheds light on a critical reason nurses might head for the exits.

In an earlier article , we argued that five behavioral attributes — disrespectful, noninclusive, unethical, cutthroat, and abusive — mark an organizational culture as toxic. 13 Among nurses who quit, toxic culture is more than twice as predictive of their overall satisfaction than compensation or workload. The importance of toxic workplaces among nurses who quit is consistent with earlier research that found toxicity to be the strongest predictor of industry-adjusted attrition during the first six months of the Great Resignation. 14

Toxic culture has become more important for nurses in the post-pandemic era. When we compared which factors best predict how nurses rated their employer before and after the pandemic, toxic culture experienced the largest gain in relative importance post-COVID-19 (followed by workload, well-being, and compensation). If your organization suffers from cultural toxicity, another article of ours, “ How to Fix a Toxic Culture ,” presents several evidence-based interventions health care leaders can use to detox their own organization.

Learn From Staffing Agency Practices

As the figure “Staffing Agencies Rate Better on Many Key Factors” shows, nurses are very positive about the processes staffing agencies have in place to resolve problems quickly and efficiently. Of nurses who mentioned the efficiency of staffing agencies’ processes, 75% were positive, compared with 23% expressing positive sentiment for health care systems. For travel nurses, common process issues include onboarding, obtaining required credentials and licenses, contract negotiation, and reimbursement. The best staffing agencies listen to feedback, develop a deep understanding of the typical problems travel nurses face, and optimize their work processes to address these issues.

Many of the pain points encountered by staff nurses will differ from those of agency nurses. Health care systems, home health agencies, and long-term care providers could, however, adopt a similar approach to capture and analyze nurses’ feedback, prioritize the most common and frustrating challenges they face, and work with staff members to address these issues.

Consistently listening to and acting on feedback can also build trust with the nursing staff. Staffing agency nurses are more positive about having the psychological safety to speak up about difficult issues and be heard than are nurses working in hospitals and health care systems.

The benefits of psychological safety are blunted, however, if management is slow to respond to issues that nurses raise. Nurses speak highly of how quickly staffing agencies respond to their questions and concerns. In contrast, nurses frequently complain that other types of employers are slow to respond to emails raising issues, if they get a reply at all. Nurses also place a high value on having multiple channels of communication with their supervisors, including text, email, Facebook, Jabber, and a 24/7 hotline.

Another insight from our research is that nurses value honesty and transparency. They understand the challenges health care faces as well as anyone, and they expect honest communication about what is happening in the organization, how it affects them, and why decisions were made. Triage, a staffing agency and the fourth most highly rated large employer we studied, places honest communication at the center of its value proposition: “We tell it like it is so you won’t be surprised by how it goes.” 15

Health care systems can learn from staffing agencies, but they can also leverage their own distinctive advantages to attract and retain nurses. Nurses in full-time staff positions rate hospitals and health care systems higher than staffing agencies on three important aspects of organizational life: learning and development (including promotion opportunities and reimbursement for training), benefits, and colleagues. Those three factors are among the top 10 predictors of how nurses rate their employers. Health care systems should invest in their comparative advantages and emphasize them when communicating their value proposition to potential and current employees.

Health care systems can learn from staffing agencies, but they can also leverage their own distinctive advantages to attract and retain nurses.

Translate Feedback Into Action to Build Trust

It’s one thing to collect employee feedback, but it’s another to consistently act on those insights. Employees are less likely to surface issues or propose potential solutions if they believe that managers will not act. 16 Worse yet, employees are more likely to quit if they believe that management lacks the power, resources, or interest to make changes based on their suggestions. 17 Nearly half of nurses believe that management will not fix problems that clinical staff members bring to their attention. 18

Organizations need to put in place structures to consistently act on employee feedback. One well-known example is Kaiser Permanente’s unit-based teams (UBTs), which consist of clinical staff members and managers who regularly work together in a specific unit or department. 19 The teams, which meet at least once per month, are responsible for their unit’s performance and are co-led by a manager, a labor representative, and, typically, a clinical staff member.

The UBTs identify opportunities to improve along four dimensions: quality (including patient outcomes), patient service, affordability, and employee experience. The teams use employee feedback to identify and prioritize improvement opportunities. Next, the teams develop and test solutions using best practices and evidence-based methods. Once a solution has been deemed effective, it is implemented across the unit, department, or, in some cases, the entire organization. The UBTs then monitor the impact of these changes in terms of patient outcomes, employee satisfaction, and cost reduction.

Our study of 150,000 reviews written by U.S. nurses since the onset of COVID-19 reveals wide variation in how nurses rate their employers as a whole, and specifically in terms of compensation, workload, toxic culture, and organizational support — the four factors that most shape nurses’ job satisfaction. In our view, this variation offers a message of hope. Despite the structural challenges that all health care organizations face, it is possible to provide an environment where nurses look forward to going to work every day.

Many organizations, including some of the largest employers of nurses, have significant room for improvement. These rankings are not designed to “name and shame” but rather to make health care leaders aware of the magnitude of the gap between their organization’s performance and what is possible when it comes to providing a healthy workplace for nurses. We also hope that the objective data on how health care organizations rank on factors that matter most to nurses can provide their leaders with the impetus to make improvements and the evidence to convince all stakeholders of the urgent need for change.

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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. Leaders who continue business as usual should not be surprised when staff members quit, workers unionize, and state and federal legislators dictate regulations to protect the interests of nurses.

To improve the work lives of nurses, and indeed all health care workers, leaders must collect and act on their feedback, recognizing that different parts of the organization and different populations will face distinctive challenges and issues. Listening to nurses demonstrates that there are meaningful steps health care leaders can take to fix the nursing crisis. The single most important step is to listen to them in the first place.

About the Authors

Donald Sull ( @culturexinsight ) is a senior lecturer at the MIT Sloan School of Management and a cofounder of CultureX. Charles Sull is a cofounder of CultureX.

1. “ Survey: Workforce Challenges Cited by CEOs as Top Issue Confronting Hospitals in 2022 ,” American College of Healthcare Executives, Feb. 13, 2023, www.ache.org.

2. D.I. Auerbach, P.I. Buerhaus, K. Donelan, et al., “ A Worrisome Drop in the Number of Young Nurses ,” Health Affairs Forefront, April 13, 2022, www.healthaffairs.org.

3. B. Martin, N. Kaminski-Ozturk, C. O’Hara, et al., “ Examining the Impact of the COVID-19 Pandemic on Burnout and Stress Among U.S. Nurses ,” Journal of Nursing Regulation 14, no. 1 (April 2023): 4-12; and G. Berlin, M. Lapointe, M. Murphy, et al., “ Assessing the Lingering Impact of COVID-19 on the Nursing Workforce ,” McKinsey & Co., May 11, 2022, www.mckinsey.com.

4. R.A. Smiley, R.L. Allgeyer, Y. Shobo, et al., “ The 2022 National Nursing Workforce Survey ,” Journal of Nursing Regulation 14, no. 1, sup. 2 (April 2023): S1-S90.

5. L.H. Aiken, K.B. Lasater, D.M. Sloane, et al., “ Physician and Nurse Well-Being and Preferred Interventions to Address Burnout in Hospital Practice: Factors Associated With Turnover, Outcomes, and Patient Safety ,” JAMA Health Forum 4, no. 7 (July 2023): table 2.

6. We selected the largest 200 employers based on the number of U.S. Glassdoor ratings by nurses from April 1, 2020, through June 30, 2023.

7. Aiken et al., “Physician and Nurse Well-Being,” table 1.

8. This methodology is similar to that employed by M. Jura, J. Spetz, and D.-M. Liou in “ Assessing the Job Satisfaction of Registered Nurses Using Sentiment Analysis and Clustering Analysis ,” Medical Care Research and Review 79, no. 4 (August 2022): 585-593.

9. Aiken et al., “Physician and Nurse Well-Being,” table 3.

10. M.A. McCord, D.L. Joseph, L.Y. Dhanani, et al., “ A Meta-Analysis of Sex and Race Differences in Perceived Workplace Mistreatment ,” Journal of Applied Psychology 103, no. 2 (February 2018): 137-163; and K. Aquino and S. Thau, “ Workplace Victimization: Aggression From the Target’s Perspective ,” Annual Review of Psychology 60 (February 2009): 717-741.

11. A. Bergman, H. Song, G. David, et al., “ The Role of Schedule Volatility in Home Health Nursing Turnover ,” Medical Care Research and Review 79, no. 3 (June 2022): 382-393.

12. Nurses quitting (versus being fired) accounted for 96% of all separations from hospitals in 2021. See “ 2021 NSI National Health Care Retention & RN Staffing Report ” (East Petersburg, Pennsylvania: NSI Nursing Solutions, March 2021): 3.

13. D. Sull, C. Sull, W. Cipolli, et al., “ Why Every Leader Needs to Worry About Toxic Culture ,” MIT Sloan Management Review, March 16, 2022, https://sloanreview.mit.edu.

14. D. Sull, C. Sull, and B. Zweig, “ Toxic Culture Is Driving the Great Resignation ,” MIT Sloan Management Review, Jan. 11, 2022, https://sloanreview.mit.edu.

15. “We Tell It Like It Is So You Won’t Be Surprised by How It Goes,” Triage, accessed April 24, 2023, https://triagestaff.com.

16. E.W. Morrison, “ Employee Voice and Silence ,” Annual Review of Organizational Psychology and Organizational Behavior 1 (March 16, 2014): 173-197.

17. E.J. McClean, E.R. Burris, and J.R. Detert, “ When Does Voice Lead to Exit? It Depends on Leadership ,” Academy of Management Journal 56, no. 2 (April 2013): 525-548.

18. Aiken et al., “Physician and Nurse Well-Being,” table 2.

19. “ Unit-Based Team Overview ” and “ UBT Roles ,” Labor Management Partnership, accessed Aug. 30, 2023, www.lmpartnership.org.

i. We ran models for the pre- and post-COVID-19 samples by current employees, former employees, and all employees for a total of six models. The average out-of-sample adjusted R2 across a tenfold validation ranged between 0.29 and 0.39 for all models. A model using structural attributes of employers, including ownership, type of organization (health care system, nursing home, or specialty hospital), and location, however, together explained less than 5% of the variance in how nurses rated their employers. Our analysis of structural attributes included seven ownership types, 17 organizational types, and 50 U.S. states. For the structural model, the average out-of-sample adjusted R2 across a tenfold cross-validation was 4.2%.

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3.5 Crisis and Crisis Intervention

If you were asked to describe someone in crisis, what would come to your mind? Many of us might draw on traditional images of someone anxiously wringing their hands, pacing the halls, having a verbal outburst, or acting erratically. Health care professionals should be aware that crisis can be reflected in these types of behaviors, but it can also be demonstrated in various verbal and nonverbal signs. There are many potential causes of crisis, and there are four phases an individual progresses through to crisis. Nurses and other health care professionals are often the frontline care providers when an individual faces a crisis, so it is important to recognize signs of crisis, know what to assess, intervene appropriately, and evaluate crisis resolution.

Definition of Crisis

A crisis can be broadly defined as the inability to cope or adapt to a stressor. Historically, the first examination of crisis and development of formal crisis intervention models occurred among psychologists in the 1960s and 1970s. Although definitions of crisis have evolved, there are central tenets related to an individual’s stress management.

Consider the historical context of crisis as first formally defined in the literature by Gerald Caplan. Crisis was defined as a situation that produces psychological disequilibrium in an individual and constitutes an important problem in which they can’t escape or solve with their customary problem-solving resources. [1] This definition emphasized the imbalance created by situation stressors.

Albert Roberts updated the concept of crisis management in more recent years to include a reflection on the level of an individual’s dysfunction. He defined crisis as an acute disruption of psychological homeostasis in which one’s usual coping mechanisms fail with evidence of distress and functional impairment. [2] A person’s subjective reaction to a stressful life experience compromises their ability (or inability) to cope or function.

Causes of Crisis

A crisis can emerge for individuals due to a variety of events. It is also important to note that events may be managed differently by different individuals. For example, a stressful stimulus occurring for Patient A may not induce the same crisis response as it does for Patient B. Therefore, nurses must remain vigilant and carefully monitor each patient for signs of emerging crisis.

A crisis commonly occurs when individuals experience some sort of significant life event. These events may be unanticipated, but that is not always the case. An example of anticipated life events that may cause a crisis include the birth of a baby. For example, the birth (although expected) can result in a crisis for some individuals as they struggle to cope with and adapt to this major life change. Predictable, routine schedules from before the child was born are often completely upended. Priorities shift to an unyielding focus on the needs of the new baby. Although many individuals welcome this change and cope effectively with the associated life changes, it can induce crises in those who are unprepared for such a change.

Crisis situations are more commonly associated with unexpected life events. Individuals who experience a newly diagnosed critical or life-altering illness are at risk for experiencing a crisis. For example, a client experiencing a life-threatening myocardial infarction or receiving a new diagnosis of cancer may experience a crisis. Additionally, the crisis may be experienced by family and loved ones of the patient as well. Nurses should be aware that crisis intervention and the need for additional support may occur in these types of situations and often extend beyond the needs of the individual patient.

Other events that may result in crisis development include stressors such as the loss of a job, loss of one’s home, divorce, or death of a loved one. It is important to be aware that clustering of multiple events can also cause stress to build sequentially so that individuals can no longer successfully manage and adapt, resulting in crisis.

Categories of Crises

Due to a variety of stimuli that can cause the emergence of a crisis, crises can be categorized to help nurses and health care providers understand the crisis experience and the resources that may be most beneficial for assisting the client and their family members. Crises can be characterized into one of three categories: maturational, situational, or social crisis. Table 3.5a explains characteristics of the different categories of crises and provides examples of stressors associated with that category.

Table 3.5a Categories of Crises

Phases of Crisis

The process of crisis development can be described as four distinct phases. The phases progress from initial exposure to the stressor, to tension escalation, to an eventual breaking point. These phases reflect a sequential progression in which resource utilization and intervention are critical for assisting a client in crisis. Table 3.5b describes the various phases of crisis, their defining characteristics, and associated signs and symptoms that individuals may experience as they progress through each phase.

Table 3.5b Crisis Phases [3] , [4]

Crisis Assessment

Nurses must be aware of the potential impact of stressors for their clients and the ways in which they may manifest in a crisis. The first step in assessing for crisis occurs with the basic establishment of a therapeutic nurse-patient relationship. Understanding who your patient is, what is occurring in their life, what resources are available to them, and their individual beliefs, supports, and general demeanor can help a nurse determine if a patient is at risk for ineffective coping and possible progression to crisis.

Crisis symptoms can manifest in various ways. Nurses should carefully monitor for signs of the progression through the phases of crisis such as the following:

• Escalating anxiety
• Confusion or disordered thinking
• Anger and hostility
• Helplessness and withdrawal
• Inefficiency
• Hopelessness and depression
• Steps toward resolution and reorganization

When a nurse identifies these signs in a patient or their family members, it is important to carefully explore the symptoms exhibited and the potential stressors. Collecting information regarding the severity of the stress response, the individual’s or family’s resources, and the crisis phase can help guide the nurse and health care team toward appropriate intervention.

Crisis Interventions

Crisis intervention is an important role for the nurse and health care team to assist patients and families toward crisis resolution. Resources are employed, and interventions are implemented to therapeutically assist the individual in whatever phase of crisis they are experiencing. Depending on the stage of the crisis, various strategies and resources are used.

The goals of crisis intervention are the following:

• Identify, assess, and intervene
• Return the individual to a prior level of functioning as quickly as possible
• Lessen negative impact on future mental health

During the crisis intervention process, new skills and coping strategies are acquired, resulting in change. A crisis state is time-limited, usually lasting several days but no longer than four to six weeks.

Various factors can influence an individual’s ability to resolve a crisis and return to equilibrium, such as realistic perception of an event, adequate situational support, and adequate coping strategies to respond to a problem. Nurses can implement strategies to reinforce these factors.

Strategies for Crisis Phase 1 and 2

Table 3.5c describes strategies and techniques for early phases of a crisis that can help guide the individual toward crisis resolution.

Table 3.5c Phase 1 & 2 Early Crisis Intervention Strategies [5]

Strategies for Crisis Phase 3

If an individual continues to progress in severity to higher levels of crisis, the previously identified verbal and nonverbal interventions for Phase 1 and Phase 2 may be received with a variability of success. For example, for a receptive individual who is still in relative control of their emotions, the verbal and nonverbal interventions may still be well-received. However, if an individual has progressed to Phase 3 with emotional lability, the nurse must recognize this escalation and take additional measures to protect oneself. If an individual demonstrates loss of problem-solving ability or the loss of control, the nurse must take measures to ensure safety for themselves and others in all interactions with the patient. This can be accomplished by calling security or other staff to assist when engaging with the patient. It is important to always note the location of exits in the patient’s room and ensure the patient is never between the nurse and the exit. Rapid response devices may be worn, and nurses should feel comfortable using them if a situation begins to escalate.

Verbal cues can still hold significant power even in a late phase of crisis. The nurse should provide direct cues to an escalating patient such as, “Mr. Andrews, please sit down and take a few deep breaths. I understand you are angry. You need to gain control of your emotions, or I will have to call security for assistance.” This strategy is an example of limit-setting that can be helpful for de-escalating the situation and defusing tension. Setting limits is important for providing behavioral guidance to a patient who is escalating, but it is very different from making threats. Limit-setting describes the desired behavior whereas making threats is nontherapeutic. See additional examples contrasting limit-setting and making threats in the following box. [6]

Examples of Limit-Setting Versus Making Threats [7]

• Threat: “If you don’t stop, I’m going to call security!”
• Limit-Setting: “Please sit down. I will have to call for assistance if you can’t control your emotions.”
• Threat: “If you keep pushing the call button over and over like that, I won’t help you.”
• Limit-Setting: “Ms. Ferris, I will come as soon as I am able when you need assistance, but please give me a chance to get to your room.”
• Threat: “That type of behavior won’t be tolerated!”
• Limit-Setting: “Mr. Barron, please stop yelling and screaming at me. I am here to help you.”

Strategies for Crisis Phase 4

A person who is experiencing an elevated phase of crisis is not likely to be in control of their emotions, cognitive processes, or behavior. It is important to give them space so they don’t feel trapped. Many times these individuals are not responsive to verbal intervention and are solely focused on their own fear, anger, frustration, or despair. Don’t try to argue or reason with them. Individuals in Phase 4 of crisis often experience physical manifestations such as rapid heart rate, rapid breathing, and pacing.

If you can’t successfully de-escalate an individual who is becoming increasingly more agitated, seek assistance. If you don’t believe there is an immediate danger, call a psychiatrist, psychiatric-mental health nurse specialist, therapist, case manager, social worker, or family physician who is familiar with the person’s history. The professional can assess the situation and provide guidance, such as scheduling an appointment or admitting the person to the hospital. If you can’t reach someone and the situation continues to escalate, consider calling your county mental health crisis unit, crisis response team, or other similar contacts. If the situation is life-threatening or if serious property damage is occurring, call 911 and ask for immediate assistance. When you call 911, tell them someone is experiencing a mental health crisis and explain the nature of the emergency, your relationship to the person in crisis, and whether there are weapons involved. Ask the 911 operator to send someone trained to work with people with mental illnesses such as a Crisis Intervention Training (CIT) officer. [8]

A nurse who assesses a patient in this phase should observe the patient’s behaviors and take measures to ensure the patient and others remain safe. A person who is out of control may require physical or chemical restraints to be safe. Nurses must be aware of organizational policies and procedures, as well as documentation required for implementing restraints, if the patient’s or others’ safety is in jeopardy.

Review guidelines for safe implementation of restraints in the “ Restraints ” section of Open RN Nursing Fundamentals .

Crisis Resources

Depending on the type of stressors and the severity of the crisis experienced, there are a variety of resources that can be offered to patients and their loved ones. Nurses should be aware of community and organizational resources that are available in their practice settings. Support groups, hotlines, shelters, counseling services, and other community resources like the Red Cross may be helpful. Read more about potential national and local resources in the following box.

Mental Health Crisis Resources

NAMI: National Alliance on Mental Health ADRC of Central Wisconsin Wisconsin County Crisis Lines Wisconsin Suicide & Crisis Hotlines

Mental Health Crisis

When an individual is diagnosed with a mental health disorder, the potential for crisis is always present. Risk of suicide is always a priority concern for people with mental health conditions in crisis. Any talk of suicide should always be taken seriously. Most people who attempt suicide have given some warning. If someone has attempted suicide before, the risk is even greater. Read more about assessing suicide risk in the “ Establishing Safety ” section of Chapter 1. Encouraging someone who is having suicidal thoughts to get help is a safety priority.

Common signs that a mental health crisis is developing are as follows:

• Inability to perform daily tasks like bathing, brushing teeth, brushing hair, or changing clothes
• Rapid mood swings, increased energy level, inability to stay still, pacing, suddenly depressed or withdrawn, or suddenly happy or calm after period of depression
• Increased agitation with verbal threats; violent, out-of-control behavior or destruction of property
• Abusive behavior to self and others, including substance misuse or self-harm (cutting)
• Isolation from school, work, family, or friends
• Loss of touch with reality (psychosis) – unable to recognize family or friends, confused, doesn’t understand what people are saying, hearing voices, or seeing things that aren’t there

Clients with mental illness and their loved ones need information for what to do if they are experiencing a crisis. Navigating a Mental Health Crisis: A NAMI Resource Guide for Those Experiencing a Mental Health Emergency provides important, potentially life-saving information for people experiencing mental health crises and their loved ones. It outlines what can contribute to a crisis, warning signs that a crisis is emerging, strategies to help de-escalate a crisis, and available resources.

Read NAMI’s Navigating a Mental Health Crisis: A NAMI Resource Guide for Those Experiencing a Mental Health Emergency .

• Caplan, G. (1964). Principles of preventive psychiatry. Basic Books. ↵
• Roberts, A. R. (2005). Bridging the past and present to the future of crisis intervention and crisis management. In A. R. Roberts (Ed.), Crisis intervention handbook: Assessment, treatment, and research (3rd ed.). Oxford University Press. pp. 3-34. ↵
• Centers for Disease Control and Prevention. (2018, May 25). The National Institute for Occupational Health and Safety. https://www.cdc.gov/niosh/ ↵
• Brister, T. (2018). Navigating a mental health crisis: A NAMI resource guide for those experiencing a mental health emergency. National Alliance on Mental Illness. https://www.nami.org/Support-Education/Publications-Reports/Guides/Navigating-a-Mental-Health-Crisis/Navigating-A-Mental-Health-Crisis?utm_source=website&utm_medium=cta&utm_campaign=crisisguide ↵

The inability to cope or adapt to a stressor.

Nursing: Mental Health and Community Concepts Copyright © 2022 by Chippewa Valley Technical College is licensed under a Creative Commons Attribution 4.0 International License , except where otherwise noted.

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Regulating During Crisis: A Qualitative Comparative Case Study of Nursing Regulatory Responses to the COVID-19 Pandemic

• Kathleen Leslie, PhD, JD, RN Kathleen Leslie Contact Affiliations An Assistant Professor, Faculty of Health Disciplines, Athabasca University, Athabasca, Alberta, Canada, and the Governance and Regulation theme lead for the Canadian Health Workforce Network. Search for articles by this author
• Sophia Myles, PhD Sophia Myles Affiliations A postdoctoral fellow, Institute of Health Policy, Management and Evaluation, University of Toronto , Toronto, Canada, and a research assistant at Athabasca University. Search for articles by this author
• Sarah Stahlke, PhD Sarah Stahlke Affiliations An Adjunct Professor, Department of Sociology, University of Alberta, and an instructor and research associate at Athabasca University. Search for articles by this author
• Catharine J. Schiller, PhD, JD, RN Catharine J. Schiller Affiliations An Assistant Professor and Coordinator of Undergraduate Nursing Programs, School of Nursing, University of Northern British Columbia, Prince George, British Columbia, Canada. Search for articles by this author
• Jacob J. Shelley, SJD Jacob J. Shelley Affiliations An Associate Professor, Faculty of Law and School of Health Studies, Faculty of Health Sciences, Western University, and the Director of the Health Ethics, Law & Policy (HELP) Lab. Search for articles by this author
• Karen Cook, PhD, MSc (A), BSN Karen Cook Affiliations An Associate Professor, Faculty of Health Disciplines, Athabasca University. Search for articles by this author
• Jennifer Stephens, MA, PhD, RN, OCN, CCNE Jennifer Stephens Affiliations An Assistant Professor and Associate Dean of Undergraduate Programs in the Faculty of Health Disciplines, Athabasca University. Search for articles by this author
• Sioban Nelson, PhD, RN, FAAN, FCAHS Sioban Nelson Affiliations A Professor in the Faculty of Nursing, University of Toronto. Search for articles by this author
• Regulation nursing COVID-19 pandemic licensure qualitative case study legislation
• Canadian Institute for Health Information
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• Smiley R.A.
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• Reneau K.A.
• Silvestre J.H.
• Alexander M.
• Full Text PDF
• Scopus (211)
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• Frogner B.K.
• Armstrong D.
• Buerhaus P.I.
• Scopus (83)
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Federation of State Medical Boards. (2020). U.S. healthcare licensing and regulatory organizations issue joint statement on COVID-19 pandemic. Retrieved August 27, 2022, from https://www.fsmb.org/advocacy/news-releases/u.s.-healthcare-licensing-and-regulatory-organizations-issue-joint-statement-on-covid-19-pandemic/

National Council of State Boards of Nursing. (2020, April 9). NCSBN offers free fast-track nurse license verification for state and federal emergency response organizations [News release] . https://www.prnewswire.com/news-releases/ncsbn-offers-free-fast-track-nurse-license-verification-for-state-and-federal-emergency-response-organizations-301038342.html

• Benton D.C.
• Wannamaker K.

Professional Standards Authority for Health and Social Care. (2021, April 15). Learning from Covid-19: A case-study review. https://www.professionalstandards.org.uk/publications/detail/learning-from-covid-19-a-case-study-review

• van Stralen A.C.
• Carvalho C.L.
• Girardi S.N.
• Massote A.W.
• Cherchiglia M.L.

Study Design

• Scopus (101)

Data Collection

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Data Analysis

• Hayfield N.
• Merriam S.B.

Ethical Considerations

• 1. Risk-based responses to reduce regulatory burden
• 2. Agility and flexibility in regulatory pandemic responses
• 3. Working with stakeholders for a systems-based approach
• 4. Valuing consistency in regulatory approaches across jurisdictions
• 5. The pandemic as a catalyst for innovation.

Theme 1: Risk-Based Responses to Reduce Regulatory Burden

Theme 2: agility and flexibility in regulatory responses, theme 3: working with stakeholders for a systems-based approach, theme 4: valuing consistency in regulatory approaches across jurisdictions, theme five: the pandemic as a catalyst for innovation.

• Scopus (12)
• National Council of State Boards of Nursing
• Scopus (16)
• Laverdière M.
• Steinecke R.
• Sweatman L.
• McDonald F.
• Hatefimoadab N.
• Mohammadi N.
• Nasrabadi A.N.

Limitations

Health Statutes Amendment Act, SA 2020, c. 27 (2020). http://canlii.ca/t/b2w5

• Steering Committee on Modernization of Health Professional Regulation

Future Research

• Wenghofer E.F.
• Kaminski-Ozturk N.

APPENDIX. Sample Interview Guide

• 1. Introduction: Introduce research team members, review written consent form, provide overview of study, answer questions, and begin recording.
• 3. Concluding question: Is there anything else you would like us to know about how your nursing regulatory body has been regulating in the public interest during the crisis?
• 4. Wrap up: Thank you to participant(s) and description of next steps for research team.

British Columbia College of Nurses and Midwives. (n.d.-a). Frequently asked questions: Duty to provide care. Retrieved March 16, 2021, from https://www.bccnm.ca/LPN/Covid_19/Pages/faq.aspx

British Columbia College of Nurses and Midwives. (n.d.-b). Temporary emergency registration. Retrieved March 16, 2021, from https://www.bccnm.ca/LPN/Covid_19/Pages/temp_registration.aspx

College of Licensed Practical Nurses of Alberta, College and Association of Registered Nurses of Alberta, and College of Registered Psychiatric Nurses of Alberta. (2021, March). Social media and e-professionalism: Guidelines for nurses. Retrieved May 20, 2021, from https://www.clpna.com/wp-content/uploads/2020/03/doc_Social_Media_E-Professionalism_Nurses.pdf

College and Association of Registered Nurses of Alberta. (2020, April 3). Effects of COVID-19 pandemic on professional conduct processes. Retrieved May 20, 2021, from https://nurses.ab.ca/protect-the-public/effects-of-covid-19-pandemic-on-professional-conduct-processes

College and Association of Registered Nurses of Alberta. (2021). Courtesy applicants. Retrieved May 20, 2021, from https://connect.nurses.ab.ca/home/%2Fcourtesy-applicants%2F

College of Nurses of Ontario. (2021, April 23). Important update: New provincial orders – Change to scope of practice in hospitals. Retrieved April 28, 2021, from https://www.cno.org/en/news/2021/april-2021/important-update-new-provincial-orders--change-to-scope-of-practice-in-hospitals

College of Nurses of Ontario. (2020a). COVID-19: Practice resources: Reassignment/redeployment to other roles or duties. Retrieved January 10, 2021, from https://www.cno.org/en/covid-19/covid-19-practice-resources/

College of Nurses of Ontario. (2020b). COVID-19: Practice resources: Refusing assignments or discontinuing nursing services during COVID-19. Retrieved January 10, 2021, from https://www.cno.org/en/covid-19/covid-19-practice-resources/

• College of Nurses of Ontario

College of Nurses of Ontario. (2020d). Standards & guidelines: Standard of care and nurses’ accountabilities. Retrieved January 10, 2021, from https://www.cno.org/en/learn-about-standards-guidelines/standards-and-guidelines/

Minnesota Board of Nursing. (2020a). Nursing rule variance. Retrieved February 12, 2021, from https://ncsbn.org/MN_Program_Variance:Procedure_4_2020.pdf

Minnesota Board of Nursing. (2020b). Policy brief: U.S. nursing leadership supports practice/academic partnerships to assist the nursing workforce during the COVID-19 crisis. Retrieved February 12, 2021 from https://mn.gov/boards/assets/Policy_Brief_US_Nsg_Leadership-COVID19_tcm21-425457.pdf .

State of Minnesota Executive Department. (2020, March 27). Emergency executive order 20-23: Authorizing Minnesota health-related licensing boards to modify requirements during the COVID-19 peacetime emergency. Retrieved February 12, 2021, from https://mn.gov/governor/assets/EO%2020-23%20FINAL_tcm1055-425466.pdf

Vermont Secretary of State Office of Professional Regulation. (n.d.). Policy for continuing education and impacts of COVID-19. Retrieved May 15, 2021, from https://cms.sec.state.vt.us:8443/share/s/AkPaa4uFQTuBzkySr5EyQg

Vermont Secretary of State Office of Professional Regulation. (2020a). Emergency administrative rules for remote hearings . Retrieved May 15, 2021, from https://sos.vermont.gov/media/njpcgbof/emergency-administrative-rules-for-remote-hearings-filing.pdf

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Vermont Secretary of State Office of Professional Regulation. (2021). Telehealth, out-of-state & expired license registration. Retrieved May 15, 2021, from https://sos.vermont.gov/opr/about-opr/covid-19-response/telehealth-out-of-state-expired-license-registration/

Washington State Department of Health. (n.d.-a). COVID-19 nurse licensing waiver information. Retrieved June 1, 2021, from https://doh.wa.gov/newsroom/covid-19-nurse-licensing-waiver-information?udt_33417_param_id=31043

Washington State Department of Health. (n.d.-b). Telemedicine training requirement. Retrieved June 1, 2021, from https://doh.wa.gov/newsroom/telemedicine-training-requirement?udt_33417_param_id=61404

• Washington State Department of Health

Article info

This study was supported by a grant from the NCSBN’s Center for Regulatory Excellence. We also wish to thank Aleah McCormick for her research assistance and the interview participants for generously sharing their time and insights during this challenging time.

Identification

DOI: https://doi.org/10.1016/S2155-8256(23)00066-2

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Tackling the workforce crisis in district nursing: can the Dutch Buurtzorg model offer a solution and a better patient experience? A mixed methods case study

Affiliations.

• 1 Centre for Health and Social Care Research, Kingston University Faculty of Health Social Care and Education, London, UK.
• 2 QUEST Community Health Care Consultancy, London, UK.
• 3 Independent health economist, London, UK.
• PMID: 29880574
• PMCID: PMC6009560
• DOI: 10.1136/bmjopen-2018-021931

Despite policy intentions for more healthcare out of hospital, district nursing services face multiple funding and staffing challenges, which compromise the care delivered and policy objectives.

Objectives: What is the impact of the adapted Buurtzorg model on feasibility, acceptability and effective outcomes in an English district nursing service?

Design: Mixed methods case study.

Setting: Primary care.

Participants: Neighbourhood nursing team (Buurtzorg model), patients and carers, general practitioners (GPs), other health professionals, managers and conventional district nurses.

Results: The adapted Buurtzorg model of community nursing demonstrated feasibility and acceptability to patients, carers, GPs and other health professionals. For many patients, it was preferable to previous experiences of district nursing in terms of continuity in care, improved support of multiple long-term conditions (encompassing physical, mental and social factors) and proactive care. For the neighbourhood nurses, the ability to make operational and clinical decisions at team level meant adopting practices that made the service more responsive, accessible and efficient and offered a more attractive working environment. Challenges were reported by nurses and managers in relation to the recognition and support of the concept of self-managing teams within a large bureaucratic healthcare organisation. While there were some reports of clinical effectiveness and efficiency, this was not possible to quantify, cost or compare with the standard district nursing service.

Conclusions: The adapted Buurtzorg model of neighbourhood nursing holds potential for addressing issues of concern to patients, carers and staff in the community. The two interacting innovations, that is, a renewed focus on patient and carer-centred care and the self-managing team, were implemented in ways that patients, carers, other health professionals and nurses could identify difference for both the nursing care and also the nurses' working lives. It now requires longer term investigation to understand both the mechanism for change and also the sustainability.

Keywords: human resource management; organisation of health services; primary care; quality in health care.

© Article author(s) (or their employer(s) unless otherwise stated in the text of the article) 2018. All rights reserved. No commercial use is permitted unless otherwise expressly granted.

Publication types

• Research Support, Non-U.S. Gov't
• Aged, 80 and over
• Clinical Nursing Research
• Community Health Services / organization & administration*
• Cooperative Behavior
• Health Workforce / organization & administration*
• Middle Aged
• Models, Nursing*
• Nursing Care / organization & administration*
• Organizational Innovation
• Young Adult