Nowhere is the degree of concern more intense than in the mind of a nurse practitioner. "What patient is next? What must I do next? Did I remember everything? Is there something I forgot? Did I document adequately? Was that the best medicine? Did I do enough for that person?" It's an internal tape that plays inside your head, taunts you with self-doubt - and it will follow you out the doors of your practice setting and right on home if you let it.
"NPs' minds are always set to go, go, go; we live out our lives as professional multitaskers under the pressure of limited time," said Kate Sheppard, PhD, RN, FNP, PMHNP-BP, FAANP, a clinical associate professor who is coordinator of the psychiatric mental health nurse practitioner program at the University of Arizona College of Nursing in Tucson.
That internal voice is "busy, distracting and frenetic," Sheppard said. And sometimes it needs to be silenced.
But leaving work at work can be tricky business. Healthcare providers are no longer protected by the physical shell of a practice. With connectivity, the practice of medicine has expanded and pushed its way into every conceivable corner of life.
"You can practice medicine from anywhere," said Nancy Brook, NP, MSN, RN, who practices at Stanford Hospital and Clinics in Redwood City, Calif. And "anywhere" most assuredly includes home sweet home. What's more, it may even include a phone call during your child's soccer game, emails on the beach or a text during a holiday dinner.
Brook said it's especially hard for new NPs to pull the proverbial cord - or escape Wi-Fi - because lack of experience invites an understandable tendency to second-guess decisions and rethink assessments from the previous day. "We all want to be hard-working and motivated, and most especially we want to be effective in treating patients and securing positive outcomes."
A Need for Boundaries
It is not enough to acknowledge the fact that work too often comes home; it is essential to understand why it is imperative to put a limit on work creep.
"Sometimes the work we do as NPs can run from thought provoking to disturbing to downright draining," Brook said. "When we take these emotions home with us, how can we be truly present with family and friends?"
The boundaries between professional life and home life easily become blurred, to the detriment of significant relationships. And going a step further, when home life is disturbed, it often has a negative impact on professional performance.
Theresse (Terry) Douglass, PhD, ARNP, a mental health/psychiatric nurse practitioner in Bainbridge Island, Wash., said it can be a tough balancing act. "I am in solo practice and that means I am 'on call' all the time," she explained. However, she makes it clear to her patients that they are only to call her during off-duty hours if it is urgent. "By that I mean it cannot wait until morning, you feel your life is in danger, and this is certainly not about a refill or an appointment,'' she said. Most patients catch on quickly and respect her need for private life and sleep.
Douglass said it wasn't always that way. She recalled a time 5 years ago when the needs and demands of patients - and her responses to them - put her on physical and mental overload. "One evening I was with friends, and suddenly my body took over. My hearing just stopped - I couldn't understand the conversation. I believe my body just took me out of commission when I was overtaxed. That is my own conclusion. I can tell you with certainty that we are at much greater risk for any problem when we are sleep deprived, not eating well, anxiety-ridden and under-the-gun."
We Already Know What to Do
Are these salient points "news" to most NPs? Probably not. "This is not a knowledge deficit. Nurses already know this stuff," said Patricia Cunningham, DNSc, APRN-BC, president of the American Psychiatric Nurses Association and an associate professor of nursing at the University of Memphis. "What gets in our way of being self-serving so that we can do what we want in multiple roles in our life? What is in our patterns and our habits that prevents us from doing those things that we know are self-sustaining? Certainly we know that when we do take care of ourselves, we can be better nurses, spouses, parents, teachers - you name it."
Cunningham believes one problem is that NPs allow themselves too many choices. In fact, she said data confirm that too many options in performance is counterproductive. In practical terms, this means that when it's time to stop working, the correct choice is to stop.
"Do not get into the 'one more' syndrome - 'I can take one more patient,' 'I can make one more phone call,' 'I can check on one more prescription,'" Cunningham said. "The choice that you have to make is to understand that there is way more need than there is 'you.' Accept that everything does not have to be now, now, now. Corner yourself to the behavior you are after. If you want to stop working at 5 p.m., stop thinking about it and just stop working. Period."
While she agreed that true emergencies are another matter, Cunningham said NPs have to examine the reality of what can be accomplished in 24 hours and step off the professional treadmill. "Even saying, 'I'll work something out' implies more work. Use the right language for yourself. If you say. 'It's lunchtime,' mean it. Don't check your email, text or multitask throughout 'lunchtime.' Eat lunch, people."
Cunningham also suggested that NPs get rid of the "squatters" in their brains - phrases like "should have," "could have" and "would have." She said it's best to avoid dealing in hypotheticals. If you identify a problem in your professional performance, fix it. Then the "should haves" will no longer be necessary.
Cunningham suggested that NPs log everything they do for 4 weeks. She said the understanding that comes from it can be meaningful. You may see that you are never taking a break fully, never recharging your own batteries. "Who fuels your tank?" she asked. "You do. If you take work home, you are going to be running on empty."
Sheppard said there are strategies to help NPs get beyond the compassion fatigue of work and the tendency to live with it round the clock.
"It is better to slow down a little at the end of the day and give yourself 30 minutes for reflection. Take the time to review your calendar, your patient schedule, and to think about everything you did," she advised. "Review it in quiet, and ask yourself if you have done everything that was needed. Once you have completed the thought process, go out and shut the door. Leave the work there; it is time to go home."
She also advised that once home, it is a good idea to practice visualization as a means to keep work where it belongs. "Imagine the front door of your home as a protective gate that work cannot infiltrate," she said. "And if a work thought does sneak into your mind, encapsulate it in an imaginary bubble and send it off into space. Visualization can be so powerful."
Brook said that "being mindful" also can help you break the work-to-home overlap. "Be mindful of who you are - you are not just a healthcare provider. Maintain your identity as an individual - as a spouse, parent, baker, runner, singer, tennis player, animal lover - whatever the case may be. Keep up with your hobbies and interests, and make the time allotted for those things just as important as the time for work."
She has advised students and colleagues to turn off pagers, cell phones, texts and emails during family time, and to maintain contact with people outside of healthcare to keep conversations and activities diverse. She also believes that mindful thinking about the limits of work can help solve the problem of "homework."
"Symbolism with intentions around them can define the parameters of work," she said. "It can be something as simple as taking off your white coat and hanging it up at the end of the day. This signals that work is finished. These simple actions draw a line and create a division between work and home." It must become a sacred, non-negotiable division. "You can't care-take 24/7," Brook said. "You must replenish yourself and regroup."
Cunningham agreed. "I would argue that we learn this big caring side of things, but we never learn to manage our own capacity. We need skills around the way we talk to ourselves and manage our expectations. Truly successful people examine their mistakes, learn from them and move on. Taking care of yourself is not selfish; it's the only way you will be cognitively, emotionally and physically sharp enough to really help others."
Valerie Neff Newitt is a staff writer. Contact: firstname.lastname@example.org