Self Care for Nurses: Small Doses for Wellness 9781646481019, 9781646481996, 9781646481026, 9781646481033, 9781646481040, 1646481011

Table of contents :
Front Cover
Back Cover
Title Page
Table of Contents
Small Doses for Your Happiness and Health
It’s Not What You Think
Burnout: Sound Familiar?
Rewire Your Brain for Resilience
What's Your Mindset? Case Studies in Neuroplasticity
Be a Flashlight
Pay Attention
Cultivate Your Appreciative Practices
Tend Your Emotional Garden
Choose Joy and Positivity
Reframe
Exercise Gratitude
Change Your Question, Change Your Mind
Use Your Vision to Change Your Fate
Go to Your Safe and Happy Place
Cultivate Your Wisdom
Rest
Nourish Your Body and Hydrate
Evaluate Your Alcohol Consumption
Breathe Deeply
Move Your Body
Integrate a Life That Works With a Life That Counts
Make It a Good Place to Work
Take Care of Each Other
The Pause: When a Patient Dies
Mattering Matters
Put an End to Bullying and Incivility
Advocate for Yourself and Others
Lead From Where You Are
Endnotes
About the Authors
Acknowledgments
Copyright Page
Additional Resources

Citation preview

T

he term resilience often gets a bad rap, but the ability to take care of yourself during stressors remains key to creating a work environment where you can thrive. Grounded in research and rich in expertise gleaned from fellow nurses and other practitioners across the healthcare spectrum, Self Care for Nurses offers proven self-care strategies in small doses that can positively transform your relationship with work. The authors filled this book with practical exercises that will fit easily into your lifestyle and might just keep you from the brink of burnout. Contents include: • Over 30 science-based wellness practices that tend to your mind and body • Bite-sized exercises that apply the latest in self-care research • Relatable stories and helpful guidance from nurses and wellness experts that offer inspiration, camaraderie, and support for your challenging-yet-rewarding work as a nurse Authentic self-care practice is best for you, for your patients, and for your colleagues. Integrating these purposefully simple and easy-to-adopt strategies into your life can help you flourish in good times and grow in difficult ones. NATALIE B. MAY, PhD, is a self-care and resilience researcher and Associate Professor at the University of Virginia School of Nursing.

DORRIE K. FONTAINE, PhD, RN, FAAN, is the Dean Emerita at the University of Virginia School of Nursing and founder of UVA’s Compassionate Care Initiative.

May | Cunningham | Fontaine

TIM CUNNINGHAM, DrPH, MSN, RN, FAAN, is the Co-Chief Well-Being Officer for the Woodruff Health Sciences Center at Emory University.

Self Care for Nurses Small Doses for Wellness

US $24.95

Self Care Nurses for

Small Doses for

Wellness

Natalie B. May she/her

Tim Cunningham he/him

Dorrie K. Fontaine she/her

SigmaMarketplace.org/Books

SelfCareGift_Cover.indd 1

3/3/23 10:18 AM

Self Care Nurses for

Small Doses for

Wellness

Natalie B. May she/her

Tim Cunningham he/him

Dorrie K. Fontaine she/her

To all nurses: May you care for yourselves and each other with the same fierceness that you care for your patients and their families.

Table of Contents Small Doses for Your Happiness and Health. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6 It’s Not What You Think . . . . . . . . . . . . . . . . . . 15 Burnout: Sound Familiar?. . . . . . . . . . . . . . . . . 23 Rewire Your Brain for Resilience. . . . . . . . 33 What’s Your Mindset? . . . . . . . . . . . . . . . . . . . . 39 Be a Flashlight. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 45 Pay Attention. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 49 Cultivate Your Appreciative Practices. . . . 59 Tend Your Emotional Garden. . . . . . . . . . . . . 71 Choose Joy and Positivity. . . . . . . . . . . . . . . . . 79 Reframe. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 85 Exercise Gratitude. . . . . . . . . . . . . . . . . . . . . . . . 91 Change Your Question, Change Your Mind. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 97 Use Your Vision to Change Your Fate. . . . 105 Go to Your Safe and Happy Place. . . . . . . . 113

Cultivate Your Wisdom. . . . . . . . . . . . . . . . . . 119 Rest. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 127 NourishYour Body and Hydrate . . . . . . . . . 133 Evaluate Your Alcohol Consumption. . . . 139 Breathe Deeply. . . . . . . . . . . . . . . . . . . . . . . . . . . 143 Move Your Body. . . . . . . . . . . . . . . . . . . . . . . . . . 147 Integrate a Life That Works With a Life That Counts . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 155 Make It a Good Place to Work . . . . . . . . . . . 163 Take Care of Each Other. . . . . . . . . . . . . . . . . 167 The Pause: When a Patient Dies. . . . . . . . . 171 Mattering Matters. . . . . . . . . . . . . . . . . . . . . . . . 175 Put an End to Bullying and Incivility. . . . . 185 Advocate for Yourself and Others. . . . . . . 191 Lead From Where You Are . . . . . . . . . . . . . . 200

I have met myself and I am going to care for her fiercely. –Glennon Doyle

Small Doses for Your Happiness and Health The terms resilience and self care may carry some baggage for nurses. Did we just see an eye roll? But we firmly believe the ability to take care of yourself in the midst of stressors is the core of creating a work environment where you can be well. We’re not here though to suggest you must adopt the contemplation practices of a monk and exhibit the compassion of Mother Teresa, all while eating organic foods and taking a daily bubble bath. The version of self care we present in this book—one backed by research—is something you can fit seamlessly into your life at doses appropriate to your circumstances. (And sure, maybe that results in a new meditative practice!) When you’re empowered to take deliberate steps toward your own well-being and that of others, everyone flourishes. If your workplace isn’t prioritizing your well-being, that’s all the more reason for you to ferociously guard your health and to advocate for the change you and your patients deserve.

Small Doses for Your Happiness and Health

7

Since publishing our previous book, Self-Care for New and Student Nurses (2021), we’ve heard a lot from nurses. Some of it has been delightful to hear: “This book is great.” “I keep it on my desk as a resource.” “I wish I could give this book to every nurse.”

But from some nurses who are facing increasing challenges in their work, their comments have been hard to hear: “Don’t talk to me about self care when I can’t even get time off for a doctor’s appointment.” “If one more person tells me to breathe, I’m going to scream.” “Self care is basically just telling the drowning person to save themself.” “I hate it that anyone has to be resilient.”

So what are three passionate teachers, researchers, nurses, and writers who care deeply about the well-being of our colleagues to do? One path is to keep listening, teaching, and writing. Another is to delve even deeper into advocacy for our nurses and every one of us who works in healthcare. A third approach is to shout from the rooftops that self care still does matter! We choose to do all three. If approached with openness, self-compassion, and a little science, self care can bring us joy and foster better connections with those around us. In fact, it may be our most powerful tool in delivering fiercely compassionate care and creating meaningful change. And frankly, if we don’t care for ourselves, who will?

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Self Care for Nurses

This goes without saying, but we’ll say it anyway: We need all the gifts you bring to the nursing profession. Your patients need you. Your colleagues need you, and especially new nurses need you as they enter the profession. There are a lot of people at stake in your becoming the best nurse you can possibly be. Nursing affords you routine interactions that change the lives of your patients, strengthens the resolve of your colleagues, and ripples beyond your immediate circle to surprising places. Your gifts are beyond measure. We know there is more to your life than nursing. You also have commitments to family, friends, and others and passions outside of your work that are worthy of your most joyful and best self. This isn’t a book about self care “just” to make you a better or more resilient nurse. We approach self care in a holistic way to foster your well-being in all aspects of your life. If you can bring awareness and mindful responses to a difficult patient encounter, then you can use those same skills to create greater connection to your family and friends.

What do we mean by self care? A standard definition of self care is elusive in part because of the breadth of the topic and the individual nature of self-care practices. As you’ll learn in this book, one size definitely doesn’t fit all. If you’re lucky, you may have learned some self-care practices in nursing school. Or maybe you’ve learned some from the school of life, books, or podcasts. There are so many terrific resources out there today. Nursing researchers Pam Ashcraft and

Small Doses for Your Happiness and Health

9

Susan Gatto1 offer that self care is “deliberate decisions made and actions taken by individuals to address their own health and well-being.” We appreciate their emphasis on deliberate decisions and the recognition that we’re all empowered to manage our behaviors and resulting health and well-being. We think this is an excellent starting point. Here are some more truths about self care: Self care generates the energy and wisdom that you will draw upon when the going gets rough. Self care is a collection of personally and culturally appropriate practices that provide you with skills to be with their stress, to experience growth during difficult times, and to provide compassionate care always. Self care takes time, effort, and reflection. Self care is a conscious decision to be aware of your thoughts and feelings and to be curious about them. Self care is gentle and self-compassionate. It follows then that self care isn’t judgmental or harsh. It’s not a failed diet or New Year’s resolution—you should never feel guilt or shame for struggling periodically or even frequently.

We’ve found that the diversity of self-care definitions mirrors the diversity of the nursing workforce—there are countless meaningful self-care practices. We’d be remiss to say there is only one definition that is “right,” that there is only one correct way to do self care. Use this book and every resource at your disposal to find the practices

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that resonate with you, that make your heart leap a bit and cause you to think, Yes, that sounds like a good fit for me! Your self-care practice should complement, even enhance, who you are and what you’re already doing. Your self-care practice will evolve as you grow and as your life circumstances change. We hope you’ll find what fits for you now and that you will store away ideas for future use. Exploration and practice are the guiding principles of this text. Self care is not a magical elixir. It alone will not fix the problems that create stress in your life as a new or veteran nurse; however, a self-care practice can help you to develop the necessary tools to find creative solutions to problems, to enjoy and rely on the camaraderie of your team, and ultimately to flourish in a meaningful and exciting career.

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11

About us We—Dorrie, Tim, and Natalie—have had the great fortune to be colleagues for many years, despite our diverse roles, responsibilities, and backgrounds. What we share is a passion to help our nursing colleagues find joy and fulfillment in their work. For 11 years, Dorrie served as Dean of the UVA School of Nursing, where she was recognized for her role as student, faculty, and staff advocate and her commitment to healthy work environments. Someone once called her “the nicest person in healthcare.” She may be nice, but she is fierce when it comes to ensuring that we all can flourish in our work roles, however that may look for each of us. Tim started his career as a clown working in war zones with Clowns Without Borders. But don’t be fooled by his good humor and ability to juggle whatever he finds on your desk or work station. He takes self care and clinician well-being as seriously as anyone we know. Tim brought this passion to bear in his role as an emergency trauma nurse, and he brings it now in his current role as Co-Chief Well-Being Officer for the Woodruff Health Sciences Center, Emory University. Natalie is a researcher whose interest in self care and resilience was born in a personal health crisis—a breast cancer diagnosis in 2008. The realization that her thoughts about her illness and treatment informed her feelings about them—well, this insight was profound.

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Self Care for Nurses

In the intervening years, she has studied and sought out teachers and researchers who explore this connection between thoughts, feelings, behaviors, and outcomes.

About this book Everything in this book is grounded in research and the expertise of psychologists, therapists, social workers, physicians, and other smart people, especially your fellow nurses. As your guides on this journey, we know a lot, but we don’t know everything. We do, however, know a great idea when we hear it, and we’ve listened to nurses share their ideas about what is helpful and their experiences with making many of these ideas work for them. We have participated in resilience retreats with our nursing colleagues Jonathan Bartels, Esther Golda Lozano Otis, and Hannah Crosby, and we love their approach: They offer their students a “menu” of options, let them experience each one, and send them on their way. They trust that each student will connect with the practices that resonate or fit into their lifestyle. They also understand full well that your needs evolve over time. What works for you today may not work for you in three years. Your self-care journey will take some effort on your part, and this book aspires to guide you along the way.

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13

We designed this book with the real-life nurses we know and love in mind. We asked ourselves, When and where will a nurse have time to read this? Will it fit in a backpack? We’ve written the entire book in small, bitesized chunks. Read a few pages on the bus or during a break. You don’t even have to start at the beginning. We welcome you on this journey, and we hope you’re excited by the opportunity to explore the concept of self care, what it means, what works best for you, and how it can help you flourish in good times and help you grow in difficult ones. We’re especially grateful and humbled that we can do it with you. Fondly, Natalie, Tim, Dorrie

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Self care is giving the world the best of you, instead of what’s left of you. –Katie Reed

It’s Not What

You Think

D

oes caring for yourself sound selfish? Do you think of a good night’s sleep, a nutritious meal, or a workout at the gym? Or maybe that mindfulness workshop your boss kept encouraging you to take (in your spare time)? Perhaps self care is that thing you’ll do “someday” when you’re not so stressed at work. We’d like to rethink some of these notions. Let’s examine the top six common misconceptions about self care in nursing.

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1

It’s selfish. In nursing, self care gets a bad rap as selfish care. As a profession, we’re recognized for our empathy, compassion, and—to a fault—for giving so much of ourselves to our patients that we suffer exhaustion, moral distress, and burnout. Some call this pathological altruism—caring so much for others that we become mentally or physically ill.2 Not surprisingly, your burnout can lead to poorer job performance like decreased patient safety, increased errors, and other adverse events.3 It’s an easy argument to make. Self care is far from selfish: Physically and mentally healthy nurses lead to healthier patients.

2

I’m a nurse—of course I take care of myself. Your health is vital. Period. Your overall safety and resilience depend on the strength and resilience of your body. Ironically, you probably do a terrific job teaching your patients about self care, but do you have the same regard for your own health? There’s a statistical chance you don’t. Compared to physicians and the general population, nurses have poorer lifestyle behaviors, higher prevalence of depression, and poorer health outcomes.4, 5 Working night and evening shifts? Well, night shift workers show increased mortality from cardiovascular disease, diabetes, Alzheimer’s disease, and dementia.6, 7 We explore a few aspects of physical health in this book—sleep, exercise, and nutrition—but our primary focus is on your mind and how you think. Your work as a nurse is as challenging as it is important, and we hope you fully grasp the power of your mind to keep you physically safe, resilient, and well.

It’s Not What You Think

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3

You just need a workshop. Do people around you assume wellness is something you can learn simply by taking a workshop or a class? This notion has arisen alongside the increase in wellbeing, stress management, and resilience programs offered in many health systems today. They’re wellintentioned, and most provide exposure to effective strategies for well-being, but a class or lecture won’t build the mental strength and cognitive changes that will serve you best during the challenges of work and in life. A self-care practice must be ongoing and practiced to be effective. Some effective and accessible activities include gratitude, mindfulness, narrative reflection, spirituality, and more. They’re fruitful because they foster ongoing practices that change the neural connections in your brain . . . much more on this later.

4

There is simply no time. We hope to convince you that waiting until you’re in the middle of a crisis is too late, that there is no better time to begin a self-care practice than right now. Begin to strengthen your resilience and wellbeing muscles as soon as possible. Yes, you do have well-being muscles. It took resilience to get to where you are today.

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5

Nursing is so meaningful—you must be coldhearted if you struggle with your work. You’ve heard the proposed solution for health workers suffering from burnout: “Just re-connect with the meaning of your work.” The Mayo Clinic8 published a national study on the state of well-being among healthcare workers in 2021: 82 percent of the 28,796 nurses surveyed agreed their work was meaningful to them. Yet nurses had the highest level of burnout (63.7%) of all health professionals except for pharmacy workers (65.9%). Apparently, a meaningful job is not a mitigator against burnout and emotional exhaustion. If it were, we wouldn’t be having this discussion, right?

6

Your employer has you covered. Unfortunately, healthcare systems themselves often abuse the concept of self care. Organizations that offer mindfulness classes but don’t address staffing shortages or equipment failures can’t be let off the hook. Self care as the industry presents it—as a workshop or a pamphlet—is not a panacea for the well-being of you or others who care for patients. However, we’re pleased to see increasingly vocal calls for systemic approaches to clinician well-being in recent years.9

It’s Not What You Think

19

Instead, we propose that . . . We hope, of course, that you come to see yourself as part of the solution, contributing to much-needed changes in our health systems. Use your voice and experience to advocate for yourself and others when you see abuse of nurses. But the burden is not all on you. The practices in this book stem from the work of psychologists and positive psychology researchers. Don’t let your organization say, “You, not we, are responsible for your own well-being.” As Davis writes in his book The Happiness Industry, there is an injustice contributing to the misery you might experience, and the system cannot and should not try to blame you for that.10 So, we’d like to push back on these all-too-common assumptions about well-being. Instead, we propose:

Self care is not selfish. Exercising authentic, regular self care doesn’t require more time in the day, simply intention as you go about your daily routine.

Your flourishing is found in a lifelong practice of self care.

Nursing is an extremely meaningful profession, but meaning does not mitigate burnout.

Wellness practices for your mind help keep the body physically well. Individual self-care practices do not let organizations off the hook.

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You’re not starting at square one Maya Angelou11 declared, “I do not trust people who don’t love themselves and yet tell me, ‘I love you.’ There is an African saying which is: Be careful when a naked person offers you a shirt.” When it comes to caring for others, nurses are too often the naked person offering someone else their shirt. We can’t—and shouldn’t—give something to our patients (and colleagues, families, and friends) that we don’t have ourselves. We now know beyond any doubt that workplace stress has a powerful impact on our mental and physical health. A key goal in this book is to help you develop an awareness of your in-the-moment risk for the effects of stress and build on the self-care practices that you have most likely begun to develop. If you read that last sentence and said, “Wait. I don’t have a self-care practice. I barely have time to pee, and I haven’t gotten a day off to take care of my own health for over two years,” then we’re certainly glad you found this book. But we would also offer that you already have a budding self-care practice. You know when you’re feeling exhausted. You’ve probably said to yourself or others, “I just need to take a break and clear my head.” Or you know when you need a nap or to go for a run or to call a friend. And we suspect you’re self-aware enough to feel how the nap, run, or conversation with your friend refreshed you. This basic level of self-awareness is a great first step in caring for yourself. The goal is to not wait until you’re running on empty to take care of your own needs. Don’t be the naked person offering someone your shirt.

It’s Not What You Think

REFLECT Your Self-Care Inventory You already engage in self-care practices. Over the past few years, how have you cared for yourself when you felt stressed, anxious, or overwhelmed? Gone for a run? Called a friend? Meditated? Read? Knit? Knocked back a few beers? Did some online shopping? Write down all the activities you turn to when you need to care for yourself. Put a plus sign next to the activities you think are helpful and want to keep in your selfcare toolkit. Put a minus sign next to those you want to eliminate or modify, such as self-medicating with food or drink. Finally, what self-care activities do you aspire to that you haven’t tried or found time for?

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Burnout is not a badge of honor. –Greg McKeown

Burnout:

Sound Familiar?

W

e’re all up-close-and-personal acquaintances with stress. You couldn’t possibly be where you are today without regular encounters with it, both the good and bad kind. This means you’ve also learned how to manage your stress, to some degree, to get where you are today. But unchecked stress that carries on for a long time, keeping your body and mind in overdrive, is a recipe for burnout and the whole point of this book. There are few professions that report higher levels of occupational stress than nursing,12 so pour yourself a cup of tea because the list of stressors in nursing is long.

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From stress to burnout Stress is anything that causes a sudden physical or psychological reaction—a sports competition, an exam, a first date, a bear sighting, physical danger, or traumatic events. Your body gives you a jolt of energy and awareness to respond effectively to these situations. This fight-orflight response is a great gift when you’re swerving to miss an oncoming car or running from a burning building, but if you’re continually bombarded by stressors and you stay in that heightened state, it causes serious health effects. So what’s burnout? It’s not the result of a one-time stressor—a difficult shift or an especially challenging patient. Burnout is your response to excessive workrelated stress that goes unchecked for a long time. It stems from one or more prolonged “mismatches” between you and your work, characterized in three dimensions:13 • Emotional exhaustion, feelings of loss of energy, or exhaustion; feeling emotionally drained • Depersonalization, feelings of mental distance from one’s job, or feelings of negativity or cynicism related to one’s job; loss of idealism • Reduced sense of personal accomplishment, efficacy, or competence Any of these relatable? The first two often go hand in hand: When you’re emotionally exhausted, you readily lose a sense of human connection with your patients. You might even believe they brought their bad fortune upon themselves.14 Addressing burnout in nursing is critically important to ensure high-quality, compassionate care.

Burnout: Sound Familiar?

25

General causes Do you recognize the stressors you face, perhaps every day, in your workplace? Let’s begin with general workplace stressors, the ones you find not just in hospitals and healthcare environments, but anywhere. Several Stanford researchers conducted a meta-analysis of 228 studies on workplace stressors, and they looked at self-rated physical and mental illness, doctor-reported illness, and mortality rates to determine the significance of workplace stress on health.15 In the study, the following were found to have a significantly negative impact on employees’ mental health, physical health, and mortality:

Low autonomy at work Absence of health insurance Low social support

Work-family conflict Lack of perceived fairness in an organization and low organizational justice Shift work, long hours, and overtime

Job insecurity

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Nursing-specific causes Whether you work in a small clinic, a large hospital, or anywhere in between, you work in a demanding environment, facing a daunting list of unique workplace stressors in your role caring for others. Research consistently finds that these adverse job characteristics are associated with nursing burnout:16, 17 • High workload • Low staffing levels • Long shifts • Low control • Low schedule flexibility • Time pressure • High job and psychological demands • Low task variety • Role conflict • Low autonomy

• Negative nurse-physician relationship • Poor supervisor/ leader support • Poor leadership • Negative team relationship • Job insecurity • Lifting/ repositioning of significantly heavy objects

• Physical assault by a patient or patient’s family member • Physical safety • Musculoskeletal pain • Coming in early, staying late, and working through breaks to accomplish workload • Bullying • Working 10 hours or longer daily

None of this even touches the fact that you’re “routinely confronted with human suffering, patient morbidity and mortality, complex ethical decision-making, and difficult conversations with patients and their families.”18

Be Honest: Are You Burned Out? Impacts of Burnout

27

The harm caused by these repeated stressors has ripple effects on your life and your surroundings. On your career • Job dissatisfaction • Intention and decision to leave your job

On your patients • Less time with health workers • Suboptimal quality of care

• Career regret and the desire to leave the profession entirely

• Racial bias toward patients

• Decline in job performance • Occupational injury

• Errors and mistakes; reduced patient safety

• Problematic alcohol use

• Unprofessional behavior by nurses

• Suicide risk • Suboptimal professional development • Decline in general health • Decline in mental health

• Increased patient mortality ratios

• Poor communication between nurses and patients • Missed care • Higher infection rates • Patient dissatisfaction • Patient falls • Family complaints

On community and society19 • Erosion of trust • Worsening health outcomes • Increased health disparities • Lack of preparedness for public health crises

On healthcare organizations • High nursing turnover and staffing shortages • Absenteeism • Limited services available • Lower willingness to lead • Lower inpatient satisfaction ratings • More healthcareassociated infections • Increased malpractice claims • Presenteeism (working while sick) • Increased costs

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The world isn’t helping Four major societal trends have an influence on the nursing workforce and will likely affect our abilities to thrive in coming decades.20 We will need energy and creative solutions to address them.

1 The aging of millions of baby boomers. We will see

an increase in the demand, intensity, and complexity of healthcare.

2 The increasing shortage and uneven distribution

of physicians. Nurses who practice in rural areas, in particular, will be asked to carry more of the healthcare burden for their populations.

3 Nurses of the baby boomer generation have begun

to retire in extremely high numbers. Since 2012, 60,000 nurses have retired each year, and this number is expected to increase.21, 22

4 The persistent uncertainties of healthcare reform. The increasingly political and unpredictable nature of health policy has implications for patients’ health and the care nurses provide.

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And still you deliver compassionate care Given your intimate position with patients, it’s your responsibility to offer compassionate care under all work conditions. When faced with a bad supervisor or clunky technology that doesn’t always work, you can’t just dial back the quality of care you provide. The nature of your work as a nurse magnifies your stressors because they impact the well-being of others. It’s a cycle of stress, and this may be the most important reason a self-care practice is so vital. You chose nursing for a reason, and your decision reflects your desire to help others. Although you chose a noble profession, you also chose one of the most difficult. You face challenges big and small—a problematic coworker, the death of a favorite patient, or a global pandemic. There might be days or weeks when you ask yourself why you didn’t choose a less demanding path. When you experience exhaustion, frustration, and grief, you balance not only nursing responsibilities but also commitments to family and community. On those days when you question your career choice, a voice inside you may whisper, “I am a nurse.” We hope you never have to betray that voice. No matter what comes your way, we wish you the strength, skills, and resilience to keep moving forward. But let us be clear: We don’t want you to move forward at the expense of yourself or your well-being. We want you to move forward with wisdom and clarity of purpose, using every resource you can muster. We hope what is contained in this book will become a valuable resource throughout your career.

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Change Your Mind, Not Your Circumstances Psychologist Amishi Jha wrote the book Peak Mind: Find Your Focus, Own Your Attention, Invest 12 Minutes a Day. In it, she helps her readers unleash the power of brain neuroplasticity and mindfulness meditation to build resilience and well-being. She tells the story about a time she hit a wall. She and her husband were working full tilt, raising a 3-year-old and renovating an old house, and she suffered a stress reaction, suddenly losing the ability to feel her teeth. She writes: When you’re faced with a crisis like the one I was in, the natural approach might be to figure out how to change your life so you can cope better—switch jobs, drop responsibilities, and so on. Yet to me, nothing was particularly negotiable. I was already on the right path, doing what I loved. There wasn’t anything I was wanting to change—except for the way I was feeling in the midst of it all.23 She didn’t change her career. In fact, she became even more productive, conducting groundbreaking research on attention and the brain. She didn’t reduce her commitment to her family. Instead, she learned how to change her brain so she could respond more effectively to stress and prevent burnout. Jha’s method was mindfulness meditation, as well as many of the tools you will read about in this book.

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REFLECT Assess Your Level of Burnout At this point, you may be asking, “Am I burned out?” Here’s a simple assessment using a tool developed for primary care health workers.24 Overall, based on your definition of burnout, how would you rate your level of burnout?

1 I enjoy my work; I have no symptoms of burnout. 2 Occasionally I am under stress and I don’t always have as much energy as I once did, but I don’t feel burned out.

3 I am definitely burning out and have one or more

symptoms of burnout, such as physical and emotional exhaustion.

4 The symptoms of burnout that I am experiencing won’t go away. I think about frustration at work a lot.

5 I feel completely burned out and often wonder if I can

go on. I am at a point where I may need some changes or may need to seek some sort of help.

Are you burned out? If you selected responses 1 or 2, you’re hanging in there just fine. If you selected one of the other three responses, keep reading this book. And please consider taking advantage of any resources your workplace (Employee Assistance Programs) or health insurance provide.

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For if the brain is the cause of suffering, it can also be its cure. –Rick Hanson

Rewire

Your Brain for Resilience

Y

our self-care activities—going for a run, getting a massage, spending time with friends—have benefit beyond the moment when you’re doing them. Sure, these are pleasurable experiences, but more importantly, they benefit your future self in powerful ways. They change your brain and lead to resilience.

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It’s all about changing your brain Your brain literally rewires based on your experiences. It’s called the science of neuroplasticity, your nervous system’s ability to form new neural pathways. Those self-care activities you’re doing change your neural pathways, and the result is resilience. Maybe you’ve learned that traumatic events can change victims’ brains in negative ways. Similarly, positive neuroplasticity explains why fostering your own well-being today has a powerful influence on your well-being months or even years from now when you face adversity. What do we mean by the word resilience? Clinical psychologist Rick Hanson translates the complex neuroscience of resilience into effective, simple behaviors that anyone can practice: Mental resources like determination, self-worth, and kindness are what make us resilient: able to cope with adversity and push through challenges in pursuit of opportunities. While resilience helps us recover from loss and trauma, it offers much more than that. True resilience fosters well-being, an underlying sense of happiness, love, and peace. Remarkably, as you internalize experiences of well-being, that builds inner strengths which in turn make you more resilient. Well-being and resilience promote each other in an upward spiral.25 By watching a funny movie or snuggling with your canine or feline companion, you’re on your way to building new positive pathways in your brain, turning “passing experiences into lasting inner resources built into your brain.”26

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Savor the good things How can you make sure your self care has lasting change? The most important method of fostering resilience is to internalize experiences of well-being. Be present and pay attention to those experiences that fill you with positive emotions. It’s not enough simply to focus on it; you must truly sit with an experience or feeling long enough (and often enough) to enable that experience to rewire your neural pathways. You must be intentional about creating positive change. In other words, for neuroplasticity to take hold, you must savor experiences. You can practice savoring all day long: • How do you feel in your cozy bed in the morning? What sounds do you hear? • Truly taste that first cup of coffee or tea. • What do you see on your way to work? Don’t travel in a trance. Absorb the sights, sounds, and smells around you. • When a patient or family member says, “Thank you. You made such a difference,” do you rush off to the next task, or do you take a moment to appreciate the connection that exists between you? This is simply the beginning of an infinite list of moments to savor throughout any given day. Every moment of your day presents an opportunity to create lasting changes in your brain. For example, do you have a beloved pet? When that fur ball curls up in your lap, don’t always be texting or watching Netflix. For just a few moments, notice the cat purring and how happy that makes you feel. Notice how much the dog’s snoring makes you smile, and feel grateful that you have a pet.

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Next time you sit down to a meal, savor the sights, sounds, flavors, and feelings the meal evokes. Is the food delicious? Does it remind you of your childhood? Does it stir gratitude because someone cooked it for you? If you love music, don’t allow the music to fade into the background. Take time to not only listen intently but pay attention to how it makes you feel. Does the song make you feel powerful and energized? Does the symphony send you on a whole range of emotions or bring you to tears? Live concerts are the greatest opportunities to absorb the sights, sounds, and energy of music. These experiences and so many others are fuel for positive neuroplasticity. Your goal is to strengthen the circuits in your brain, specifically the circuits you want to strengthen, such as those that foster positive emotions. Seek these positive emotions, and when they present, really double down on appreciating them. This takes practice. Your 3-pound brain has 1.1 trillion cells and 100 billion neurons, and each neuron fires 5 to 50 times each second.27 This presents nearly an infinite number of opportunities to strengthen your resilience and fortify your well-being.

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This practice can sound like a lot to do, and to pay attention to, especially if you feel like you live a very busy life. But what about considering doing these practices—all about paying attention—in short spurts? Even if your day is totally booked, you still can take a minute to enjoy your furry friend or a few seconds to gaze up at the clouds. Take a few breaths, smell your tea or coffee, and then get back into the mix of things. Some people consider this micro-dosing wellbeing, and so do we. It’s the little stuff, done regularly over time, that helps us positively change our brains. Imagine that your brain is a forest full of many paths. When you savor things that bring you joy, envision that you are forging new paths while letting the old paths that don’t serve you grow over with brush and grass.

REFLECT Savor the Day For one day, be intentional about savoring the sights, smells, and sounds around you. Savor moments of peace, awe, or gratitude. Really taste your lunch or piece of fruit. Pay attention to sounds of laughter or the voices of colleagues. Give your brain something new to focus on—drive a new route to work or walk a different way to the cafeteria.

Changing the way we see the world in turn changes the way we feel and the way we act, which changes the world itself. –Douglas Abrams

What’s

Your Mindset?

Case Studies in Neuroplasticity

L

et’s meet two early-career nurses, Nate and Pat. Both are in their mid-20s, and both have faced difficult circumstances in their lives. The ways they respond to their circumstances teach us something about neuroplasticity. Do you see parts of yourself in Nate or Pat?

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Nate Nate’s parents announced their divorce when he was 14 years old after years of fighting and two separations. He felt anger and sadness over the divorce but never developed the resilience needed to help him flourish as an adult. When something goes wrong—a failed test, a broken friendship, a missed opportunity—Nate tends to blame others and dwell for long periods on the disappointment of the moment. Nate is often the first to point out that something isn’t fair or that someone else has made a mistake. He seems to be looking for the world to validate his belief that life is hard, even futile. The result is that Nate has difficulty dealing with daily annoyances and learning from his mistakes. In truth, he doesn’t easily attract others in friendships or even casual relationships. It becomes a self-fulfilling cycle of hardship: Nate believes the world is harsh, and when he experiences disappointment, that disappointment reinforces his belief that the world is harsh.

Pat Pat’s mother was diagnosed with cancer 10 years ago and was in and out of hospitals for nearly two years. Her mother recovered and is doing well. When Pat’s mother was ill, Pat remembers her mom expressed a lot of gratitude for her doctors, nurses, relatives, and friends who cared for her and her family. Throughout the experience, Pat noticed the kindness of people who brought the family meals, sent them cards of encouragement, and invited Pat and her siblings on outings so her mom could rest. Several times, Pat went to the clinic to keep her mom company during her treatments. As a young girl, Pat was enthralled by the

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nurses who efficiently and kindly tended to her mother. They were expert at the needles and machines, and they seemed approachable too. They laughed a lot and joked with Pat that someday she might grow up to be a nurse. Pat’s mother never said, “Why me?” at least not in front of her children. In large part because of her mother’s attitude, Pat’s brain was wired to look for silver linings during her family’s health crisis. Instead of instilling fear or dread, the clinic inspired awe for the nurses, doctors, and medical technology. Rather than turning her mental eye continually toward her mom’s hair loss, hospitalizations, and the disruptions in her own life, Pat learned to see kindness and even delight in some parts of their family’s journey. Pat certainly experienced the fear and frustration that any child would in this situation, and some days were terribly hard. But overall, the experience taught her many lessons about resilience, and perhaps most importantly, it led her to a career in nursing. As a nurse, Pat has many friends who turn to her for compassion and wisdom. She’s fun to be around, in part because she can find the good or goofy in most situations. She attracts like-minded friends, and she has earned the respect of her work colleagues. It wasn’t all a walk in the park. Nursing school wasn’t easy for her. Classes were harder than she expected, and she had a terrible experience with a roommate, just to name two of her struggles. But she came through it all because she had built a network of support, and she had some experience in not letting adversity overwhelm her.

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How do you respond? You probably already have an idea of how you respond to the bad days, or weeks, in nursing. Think about a time in your life when you experienced adversity. Perhaps like Nate, you went through your parents’ divorce, or you have endured the death of a loved one. Hopefully, you have been spared life’s worst tragedies, but your adversities can be less extreme and still pack a wallop. Have you ever failed to get a promotion? Lost a best friend? Perhaps you didn’t get into your first-choice college, or you didn’t make a sports team. How you responded in those situations provides insight into your default strategies for moving through adversity, whether you are more like Pat or more like Nate. The good news is that thanks to the neuroplasticity of your brain, you have the capacity to build your own reservoir of resilience.

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REFLECT Choose a Response What’s your default response to daily stressors? When you’re cut off in traffic, a patient is rude, or a partner annoys you, how do you react? For many of us, we respond with irritation, dismay, or worse. What does this have to do with self care and resilience? Instead of allowing your default responses to prevail, you can practice responding to daily stressors in more mindful ways. You can focus on what you want more of. You can learn new ways to engage with others. Notice your default responses to daily stressors. When you’re irritated or angry, pause and take a deep breath. Give a name to those feelings in your mind, or write them down. See them for what they are: simply passing feelings. Then ask yourself, Is there another way I could respond? Practice this exercise with daily annoyances—slow checkout lanes at the grocery store, traffic jams, a misplaced set of keys— to help you form and strengthen new neural pathways that will ultimately make you more resilient.

Remember to focus on the here and now. Living in the moment is a gift. That’s why they call it a “present,” y’all. –Ted Lasso

es, be a flashlight and shine on the things you want more of in your life. Amishi Jha calls your focus—your ability to pay attention—your own mental “flashlight.” Imagine walking outside on a dark night with only a flashlight to guide you. What the light shines on is all you can see, and the rest falls away from your attention. Jha’s studies show, as have others, that when we focus our attention on something, that something grows and becomes more visible to us.28 (Jha, 2020).

Be a

Flashlight

Y

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Self Care for Nurses

If you want to experience awe, then focus on awe. (And there is excellent new research on the ability of awe to leverage well-being.)29 When you want to experience compassion, then look for examples of compassion. Your focus is your fate. If you’re like Nate, it’ll be easy to find people and experiences around you that reinforce your belief that life is filled with negativity. But it’s possible, no matter what your past experiences, to foster a mindset more like Pat’s that will ultimately bring you joy, connection, and satisfaction. Have you ever wondered why walking on the beach, visiting a new city, or hiking a mountain trail brings joy? It makes you feel good in large part because you must pay attention in these situations. Not paying attention on a mountain trail could mean stumbling and tripping into a ravine. You pay more attention, or shine that metaphorical flashlight, when you’re in new environments. Your mind is less likely to wander to a challenging patient or an upcoming meeting when you’re trying not to get lost in the woods. Not only are you focusing your attention on the task at hand (enjoying the scenery, not falling off a cliff, finding your way home), you’re also enjoying yourself. You feel better because you’re staying in the moment and because you’re having fun. This focus leads to long-term positivity in the face of stressors. Why does this work? Back to neuroplasticity—your brain changes based on your experiences, whether they’re good ones or bad ones. This makes sense, especially when you think about children whose brains are especially primed for building neural structures that will form their unique personalities, likes and dislikes, and more. Negative

Be a Flashlight

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experiences, due to something called the negativity bias, tend to have more power over your brain development. For example, children must learn not to touch a hot stove for their safety and survival, so the negative experience of touching the stove is a powerful teachable moment. With intentionality and self-compassion, you can build your own resilience by allowing positive experiences to have the same power as negative ones in terms of your personal neural rewiring. And that’s why not falling off a mountain can bring joy.

REFLECT Be a Flashlight It’s time to begin a mindfulness practice, but we’ve been to this rodeo before and know not everyone chooses meditation as a way to practice mindfulness. For now, try a small bite and simply develop an awareness of your attention. Practice being a flashlight, shining your attention on the sounds on your hospital unit or really noticing that tree outside your window. No worries if your mind wanders; that’s what minds do.

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Nothing is more precious than being in the present moment. Fully alive, fully aware. –Thich Nhat Hanh

Be Honest: Are You Burned Out?

Pay

Attention P

aying attention pulls you into the moment and is the foundation of well-being. Much of this book explores ways to check in with yourself and the myriad responses to what you can learn about your physical and mental state.

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Use your senses Check in with yourself right now. Notice feelings in your body, such as aches, throbbing, or tingles. Do you feel tension anywhere? Shoulders tight? Relax them. Notice how much better that feels. Be curious about your emotional state. Do you feel anxious or relaxed, stressed or at ease, or bored or engaged? If you feel a negative emotion like anger or impatience, gently ask, “What’s up with that?” and explore how it feels and what the source may be. Get in the habit of checking in with yourself as frequently as possible throughout the day and then responding appropriately. Loosen a clenched jaw. Quench your thirst with a drink of water. Acknowledge feelings of frustration and let them go. Savor feelings of joy or awe. Notice new things. What have you habitually overlooked during your daily routine? Try taking a new route to the grocery store or sitting in a different seat at the dining table. Change your perspective simply by looking up or out toward the horizon. Take a moment and focus your attention on one item. Try to study it with your senses, not only with your mind.

“

Check in with yourself right now. Be curious about your emotional state. Get in the habit of checking in with yourself as frequently as possible throughout the day and then responding appropriately. Notice new things.

”

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Check in with yourself (and others) It’s one of your most important superpowers because you can’t fix something if you don’t know is broken. We know a nurse whose neck and shoulders were in excruciating pain after every shift. She’d load up on ibuprofen and bribe her kids to massage her shoulders. When she began the practice of checking in with her body throughout the day, she discovered she constantly kept her shoulders scrunched up near her ears—ouch! Checking in allowed her to relax those muscles, and over time, her end-ofshift pain often disappeared completely. It took practice, but it was a great first step in learning physical and emotional self-awareness. Think about it this way: If you check in on a patient and she says her legs hurt, you assess the cause (such as decreased circulation, neurological pain, or mobility needs), and then you might try several different things to help her feel better. You might recall something you tried with a patient last month that worked. You might ask a colleague for advice. You might get discouraged, but you’ll try again. You might discover exactly what she needs, and you advocate for her to get it. When you do something to reduce her pain, you’re actually practicing the definition of compassion. You’re being compassionate to her while you do your job. This is a similar process to developing a continual and effective self-care practice—self-compassion. If you check in with yourself and find you’re feeling irritated, for example, you have to try a few things to calm yourself and not let the irritation overtake you. You might need to remove the source of irritation by advocating for change or asking for help.

Sam the Firefighter: An Example of Awareness The simple practice of paying attention to your own needs builds the skill of self-awareness for the bigger things too . . . like your career path. A colleague of ours, Sam, shared the story of her career path. We affectionately call her “the firefighter” because she was a firefighter with her father before she was old enough to drive. She served two military tours as a nurse in Iraq and Afghanistan before returning to the States to work in a busy emergency department. Just like in her firefighter days, she thrived on the pace and the challenge of a war zone and an ED. But reflecting on why she eventually had to leave the ED, she said, “It was so easy to be present [with patients and families] and just be available, but at the same time, that all comes at a price, right? Because every time you’re a part of those intense experiences, a little piece of you goes out into the world, your light, and your energy. And if you are not working hard to restore that, which I wasn’t, it starts to dim.” Sam knew she was no longer able to provide the kind of care her patients deserved, and she found a job she loves in interventional cardiology at the same hospital. Her continual practice of checking in on her own well-being allows her to care for herself in the big decisions. 0n her new unit, she provides compassionate care without such a high personal cost.

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A wandering mind is an unhappy mind Are you paying attention to the present moment or is your mind wandering? In one clever study,30 researchers gave smartphones to 2,250 adults and pinged them randomly throughout the day. They asked their subjects three questions: What are you doing? How happy are you? Is your mind wandering? They discovered the most significant contributor to happiness was paying attention. In other words, someone who was doing housework but paying attention could be happier than someone in a fivestar restaurant who was looking at their phone during the meal. They concluded that a wandering mind is an unhappy mind. When you check in with yourself, ask, “Am I paying attention? Am I focused on this moment or stressing about the future? Am I upset about something that happened in the past?” If your mind has wandered away from the here and now, gently invite yourself back to this moment. Practice paying attention as you move through the mundane tasks in your day, such as waiting for the elevator, walking to your car after work, and straightening a patient’s room. Remember, you are fine-tuning your resilience skills. It will become more natural over time.

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REFLECT Check in With Yourself How do you feel when you’re walking to work? Excited? Wellrested? Are you tense or anxious? Is there any discomfort in your stomach or bowels? A tightness in your neck or shoulders? What are you thinking that makes you feel this way? Could you think differently about the upcoming shift, and would that new way of thinking change the way you feel? Can you intentionally release the tension in your shoulders? This begins the process of checking in and noticing, making a choice in the moment about how to proceed, and compassionately caring for yourself by switching to a new thought or behavior.

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an essay

Self Care for Nurses

An Inner Energy Gauge –by Anna DeLong A long journey’s success will be impacted by how well you refuel along the way. In our culture, it’s generally accepted mechanical wisdom that if you want to drive across the country in your car, there is no way to do this successfully without pausing to pull over and refuel. Monitoring the gas gauge and refueling accordingly is essential. Neglect refueling and you end up stuck on the side of the road. Although one might at times challenge this mechanical wisdom to explore the distance a vehicle can travel on vapors, the wisdom is not questioned. A car requires refueling or recharging to sustain progress on the journey. Can you imagine how your life might be different if you applied this same wisdom to your body? Imagine having an Inner Energy Gauge that monitors not just your physical energy level but also your emotional energy and your cognitive energy. How might your life be different if you vowed to never go below a quarter tank without refueling? If you were to check your own Inner Energy Gauge right now, what would you discover? Are you running low? Do you know how to refuel? Do you know what nourishes and restores you most effectively? Do you know your own early warning signs? Over the past three decades, I asked these questions of thousands of dedicated, hard-working healthcare providers. Not only did they indicate they were on empty more often than not, but many also reported they didn’t know how to refuel or couldn’t remember how they used to do so. I don’t believe this is a coincidence. Instead of self-monitoring and honoring one’s own needs, it’s common in our culture to

click into high gear and stay there intending justOut? “push 57 Be Honest: Are You to Burned through” in order to bring a mission to fruition. We often walk around with this unconscious assumption that we’ll somehow automatically just get what we need for ourselves even as we attend to everyone else. This is a problematic and errant assumption. It’s imperative that we intentionally and consciously plan to attend to our own needs along the way. One of the most debilitating symptoms of depletion is the loss of perspective. Diminished frustration tolerance, lack of empathy, foggy thinking, poor memory, and difficulty problem solving are also signs of a depleted energy tank. If you find yourself in this brain state, remember this isn’t an indication of inadequacy. Rather, this is a sign of a person low on energy. An optimal response is one that assesses the Inner Energy Gauge and potential refueling needs with grace and self-compassion. If the goal is to live and work in a healthy and sustainable way, learning not only to recognize signs you are running low on energy but also to respond in ways that effectively nourish and restore you is essential. Rather than just assume or hope you’ll get what you need, it is wise to strategize. Look over your calendar to schedule and protect time for refueling at strategic intervals depending on the pace and amount of energy you’re expending. This will benefit you as well as those for whom you care.

About ANNA DELONG, LCSW, CEAP, MSW, BA, is a therapist and mindfulness teacher with more than 30 years of experience as a psychotherapist. Anna is a voracious student of neuropsychology and stays on top of evidence-based strategies to promote wellness and healthy relationships.

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What you think, you become. What you feel, you attract. What you imagine, you create. –Gautama Buddha

Be Honest: Are You Burned Out?

Cultivate

Your

Appreciative

Practices

A

ppreciative practices are your bundle of tools for well-being that promote a positive mindset in your workplace culture and interactions. These practices are rooted in the understanding that you have the power to use your thoughts to shape your feelings and behaviors. You can do appreciative practices anywhere— with family or friends, at work, or in the checkout line at Trader Joe’s. They provide a lift to your work as a nurse on good days and bad. By practicing them frequently and in multiple situations, they’re more likely to be hardwired when you need them.

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Appreciative practices are how you energize your healthcare team If you and your coworkers want to feel energized, eager to come to work, and less burned out, you’ll all need to commit to a culture change.31 How can you accomplish this? Through team dedication to appreciative practices. Here are a few appreciative practice actions to take:32

Foster positive emotion Assume positive intent

Reframe

Imagine the best of what is

Practice gratitude

Practice curiosity

The rest of this section illustrates your appreciative practices in action.

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Create that positive culture You can invite all members of your team to become your best selves, together. With traditional problem-solving, you might ask, “What’s wrong and how can it be fixed?” This method often involves blame and finger-pointing. In contrast, the term appreciative practices is born out of Appreciative Inquiry (AI), a culture-change methodology that asks an organization or team, “Who are you when you’re at your best, and how do you get more of that?”33 You delve deeply into your strengths—what it looks like when everyone is firing on all cylinders. You dream with your team members about what would be possible if you could maximize these strengths. Then you plot a path to get from where you are today to where you dream to be. As you know, however, even the best-laid plans don’t always come to fruition. That’s because hospital staff also needs to alter the way they interact with one another. You and all of the other nurses, along with physicians, technicians, social workers, chaplains, and anyone involved in your team, need to tweak your behaviors to foster an environment conducive to positive change. Those behavior tweaks are your appreciative practices, and they pave the way for an environment that’s positive and energizing.

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A (Very) Brief Introduction to Appreciative Inquiry AI began with a professor at the Case Western Reserve School of Business, David Cooperrider. His wife, an artist, asked (so the story goes) David why he and his colleagues always focused on what’s wrong with an organization. She told him that in the art world, there is something known as the “appreciative eye,” that artists see beauty in every piece of art, in everything. She wondered why business school students didn’t study organizations with an appreciative eye.34 She posited that there is beauty in everything; it simply depends on how you look at it. It’s like when you visit a friend’s house and see children’s artwork fastened to the refrigerator door. Any objective art critic would deem the artwork simplistic, certainly childish, and perhaps even ugly, but your friend sees great beauty and even finds joy in the masterpiece given by the child. It’s because the artwork is seen through the eyes of love. David Cooperrider and his colleagues learned that whatever you look for, you will find. In their studies, they began looking for what they called an organization’s “positive core.” They flipped organizational study on its head and asked a revolutionary set of new questions. Instead of asking what was wrong or what was broken, they asked what was working well. They began searching for the best in organizations and the people who inhabit them. This approach unleashed energy, optimism, and creativity that could be harnessed to solve the most challenging organizational problems. Since that time, AI has been used by countless businesses and corporations, nonprofits, cities, health systems, educational institutions, and even the United Nations.35

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Appreciative Inquiry in practice With an AI approach, you ask unconditionally positive questions, such as, “When have I succeeded in the past, and how can I replicate that success now?” It’s a strengthsbased approach to problem-solving using what is called a 4-D process—after defining the topic, you move through the steps of Discovery, Dream, Design, and Destiny (or Do). DEFINE DISCOVERY DESTINY

DREAM DESIGN



The Appreciative Inquiry 4-D Cycle36

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The following example illustrates this process in action. Imagine you have a patient with diabetes who needs to increase his activity level, cut back on processed foods, and be more consistent in taking his medications. A traditional approach might see all these goals as problems to be fixed, and your head will swim with the following thoughts: • The patient has never been good at managing his diabetes. • I’m not an effective nurse, at least not with this patient. • He must not care about his well-being. • Why can’t he just try harder? • He faces too many socioeconomic barriers to effectively manage these difficult issues. If you’ve ever had this experience, you know this kind of selftalk only takes you (and thus the patient) further down the road of discouragement with no significant improvement in health outcomes. It’s hard to get on track together if this patient is somehow “broken” and in need of “fixing.” The 4-D cycle and an appreciative mindset can offer a new way to proceed.

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1

Discovery: begin a process of uncovering. Identify the patient’s strengths, abilities, and the circumstances under which he is likely to succeed. Uncover all the factors that contributed to past success and carry them forward into his present and future. With this approach, questions arise about when the patient was successful in the past and how those strengths could be brought to bear now. What was happening? What was he doing? How did others contribute? What are his strengths? This line of questions would potentially reveal statements such as the following: • He walks his granddaughter to her school bus stop every morning. (Perhaps he could walk around the block after she’s boarded her bus.) • He uses handwritten notes to remember important dates, such as birthdays and doctor’s appointments. (Maybe he could use notes to remember his medications.) • He has a strong supporter in his adult daughter. (Perhaps they could brainstorm some healthy eating strategies together.) • He loves watching cooking shows on TV. (Maybe he could step up his cooking game.) This second set of responses is energizing, hopeful, and likely to produce more successful results. The statements reveal behaviors the patient already knows how to do or has an interest in learning. There is no need for him to learn new behaviors—just a need to remember these keys to success, dust them off, and apply them to his diabetes management.

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2

Dream: build on stories of success by imagining an ideal future. Ponder, “What would it look like if we grew the very best of ourselves, our patients, and our teams?” You and the patient could paint a picture of his success. What is his goal? It could be seeing his granddaughter graduate from high school (or from nursing school!) or feeling well enough to do an activity he’s always dreamed of. What does it look like when you succeed? How does it feel? In AI, it’s very important to visualize this success in as much detail as possible.

3

Design: create the strategy for success. Make a plan. Your patient walks his granddaughter to the bus every morning. He is dressed and out of the house, so the plan could be to simply walk to the end of the block each day for the first week. The second week, he could walk around the block, the third week even farther. His self-care plan could involve promising methods for remembering medications and eating healthier based on his past experiences and strengths.

4

Destiny: just do it! Implement the plan. At his next visit, you’ll see what successes can be celebrated and which parts of his plan need to be tweaked, restarting the process with discovery. Remind him to keep that detailed dream vision in his head at all times. As needed, you’ll start over again with step 1.

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REFLECT Recall Times of Well-Being Everyone’s definition or experience of well-being is uniquely their own. Think back to a time in your life when your sense of well-being was high. You flourished. You brought your best self to everything you did. It could have been last week, last year, or as far back as your childhood. Describe how you felt. What specifically were you doing in your life that supported this sense of well-being? What were others around you doing? Explore this time in as much rich detail as possible. What lessons can you carry forward with you in support of your own well-being?

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a little thought

Your Focus Is Your Fate Appreciative practices build on something known as the “poetic principle,” which harks back to Nancy Cooperrider’s “appreciative eye”37—this notion that there is beauty in everything, depending on how you choose to look. What is most important is that we have the power to choose. A rainy day can be depressing, or it can bring life and freshness to the world around us. It can be an opportunity to sleep in or splash in puddles. A long walk to work from your parking spot can be an indicator of your low status in the health system, or it can be an opportunity to get fresh air and exercise or to listen to music or podcasts. What we choose to focus on becomes our fate.38 If we look for problems, we will find problems. If we look for beauty, we will find beauty. Often the first thing we hear from people when we teach the poetic principle is that it sounds a lot like we’re wearing rose-colored glasses. Does this mean that in looking for the things we want more of we are ignoring the bad and ugly in the world? No, it definitely doesn’t mean that. By learning how to foster an appreciative mindset and an open, curious stance in the world, we’re better equipped to encounter life’s challenges in creative and meaningful ways.

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The fatefulness of your focus can transform a negative circumstance into a positive consequence. There’s a commercial we love as an example: Imagine a young boy, about 10 years old, alone in the batter’s box of an empty baseball diamond. He enthusiastically shouts, “I’m the greatest batter in the world!” Then he tosses the ball up in the air, swings, and misses. He repeats, “I’m the greatest batter in the world!” tosses up the ball, swings, and misses again. For a third time, he boasts that he’s the greatest batter, tosses the ball, swings, and misses. Three strikes and he’s out. But suddenly his face brightens, and the background music blares, and he shouts, “I’m the greatest pitcher in the world!” That is the essence of seeking out something positive in a bad situation, or reframing.

A little test in awareness Have you ever bought something that you thought was unique, say a red suitcase, but suddenly you started seeing red suitcases everywhere? This is an example of something called the frequency illusion, in which you are seeing something more simply because you are noticing it more. Travelers aren’t suddenly buying more red suitcases; you are just aware of that specific color suitcase because you just got so excited about buying one for yourself.

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Imagine that your mind is a garden. You can tend to it in three ways: observe it, pull weeds, and plant flowers. –Rick Hanson

Be Honest: Are You Burned Out?

Tend Your Emotional

Garden I

magine your mind as a garden. Would you prefer it full of weeds or brimming with flowers and vegetables? As humans, and certainly as healthcare professionals, we’re prone to negativity bias, or being more strongly influenced by the negative aspects of our environment than the positive,39 figuratively filling our mind– gardens with weeds. It makes sense from a survival lens—it’s more imperative to notice the hungry predator than the lovely sunset—but it negatively affects our behaviors in numerous realms, including learning, attention, and how we make sense of the world.40

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Mimic naturally happy people The negativity bias leads you to focus on what needs to be fixed, but in the last section, we asked you to develop an appreciative mindset, another tool for fostering well-being and successful outcomes. An appreciative mindset allows you to focus on more of what you want in yourself and those around you while growing (back to that garden!) the thoughts, feelings, and behaviors that support well-being and happiness. In other words, we’re not all naturally happy people, but mimicking what happy people do can benefit us all. We love The Book of Joy, the bestselling conversation between His Holiness the Dalai Lama and Archbishop Desmond Tutu, which says the same: In fact, survey after survey has shown that it is unhappy people who tend to be most self-focused and are socially withdrawn, brooding, and even antagonistic. Happy people, in contrast, are generally found to be more sociable, flexible, and creative, and are able to tolerate life’s daily frustrations more easily than unhappy people. And, most important, they are found to be more loving and forgiving than unhappy people.41 You see the difference between happy and unhappy people every day in your work. You see the differences in resilience among them. You also see how happy patients, even in their difficult times, attract others to them in meaningful connections, a cycle that further fosters their resilience.

Be Honest: Are You Burned Out?

Angry Man in the Airport Once when co-author Natalie traveled through the Atlanta airport, walking between concourses, she came upon a group of people waiting for the tram. A man was angrily shouting at a pilot, who was minding his own business as he also waited for the tram. People quickly moved away from the loud, angry, hostile man (and Natalie was glad she had chosen to walk to her gate instead of taking the tram). She was sure he would be traveling alone at his end of the tram car when he boarded. Later that night when she arrived in her hometown, she chatted with her Uber driver. She asked him how he dealt with difficult passengers. He said, “I’ve learned I don’t know what they’re going through, and I tell myself that maybe they got in a fight with their spouse or they just got bad news.” His compassion, humility, and wisdom embodied the characteristics of a happy person. Natalie and the driver talked for the 30-minute ride, establishing a much-needed human connection after a long day. She walked away with a new mantra: “In a world of angry air travelers, be an Uber driver.”

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Reap holistic benefits The simple, positive act of mindfully mimicking happy people supports your overall health and success. By shifting your focus to what you want more of—beauty, joy, kindness, and compassion—you most assuredly will create more of it, and creating more will benefit not only yourself, but also those around you, including your patients: • A positive mindset benefits our immune systems and cardiovascular health.42, 43 • Positive emotions foster creativity, improve cognition, reduce depression, and increase our abilities to cope with stress.44, 45 • Those who write about gratitude daily are more likely to offer emotional support to others.46 • A physician’s emotions affect their decision-making and ultimately patient safety.47, 48 The key is that this requires some degree of mindfulness on your part. By mindfulness, we mean a nonjudgmental awareness of the present moment, or the ability to stop yourself in mid-thought or mid-sentence and ask, “Hmm . . . I wonder what’s up with that? How am I feeling? What other way could I think about this situation?” Pay attention. Be curious.

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REFLECT Are Positive People Really Happier? At this point, you may be thinking this is too much Pollyanna and rose-colored glasses for your taste. We get that. We’ve tried to provide science to back us up, but do your own science for the next few days. Make a written or mental list of the people you’re attracted to, the ones who pull you in and make you glad to be in their presence. Think about the colleagues you enjoy sharing shifts with and the patients and families you most enjoy caring for. What is it about them that draws you toward them? Is it their wicked sense of humor, positive attitude, or helpfulness? Perhaps their lives are complicated or their jobs are hard, but you still look forward to being with them. What’s their secret sauce, do you think? Would you say they are happy? Why or why not?

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a conversation

Difficult Feelings Have a Purpose –with Hannah White Hannah cares a lot about boundaries, specifically about how she uses attention to her feelings and her body to know when a boundary has been crossed for her. Perhaps a colleague interrupts her while she’s concentrating on a patient’s needs. When she notices her irritation, or even anger, she is learning how to use those feelings in a way that serves herself and others. The feeling, she says, “has a purpose and a place. It’s not something to be pushed aside. I can explore it without fear. And the more I become curious about why is this happening? Where is this coming from? And what do I need? The faster I am able to move toward a place where I can engage with another person and potentially have a hard conversation.” Hannah adds that she knows it’s important for her also to remain aware that the other person has needs and circumstances. Hannah appreciates that “everybody has experiences outside of this moment that inform who they are and how they respond and what their feelings and emotions are about this. I can’t control any of that.” She continues, “But I can look into myself and this feeling that

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I’m experiencing and use it as an anchor, as a valuable tool to inform where I need to show up for myself or for that other person.”

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Hannah is also a superstar when it comes to what she calls “micro-self cares,” and she’s especially good at finding and creating small doses of joy throughout the day. She keeps a photo of her family on her desk. “They’re the reason I show up for work every day,” she says. She has an affirmation in her planner that she moves forward each week. She carries a lunchbox with a smiling piece of toast on it. “It probably looks a little juvenile for a 35-year-old, but I think it’s hilarious.” She makes time for “tea breaks” every day and encourages her colleagues to care for themselves as well. She has one more touch point at the end of the day. As she’s walking to her car, she touches the flowers and plantings in front of the hospital, a connection to the natural world which is so important to her. “I take the first few fingers and my thumb, just kind of feel the pressure of that. And there’s something in that rhythmic movement that just moves the day away and resets. I’m headed home.”

About HANNAH WHITE, BSN, RN, is a second-career pediatric orthopedic nurse in an outpatient clinic at the University of Virginia. We met Hannah in a nurse residency program session on self care.

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Choosing to laugh doesn’t undermine the serious work we have to do. It enables us to do it. –Colleen Patrick-Goudreau

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Choose Joy and

Positivity T

im loves to tell the story of when he listened to His Holiness the 14th Dalai Lama give a speech. Two things stuck out: First, the Dalai Lama laughed frequently and spoke with a sense of levity. And second, when an audience member asked him, “What is the secret to a good life?” the Dalai Lama laughed so hard that his body shook. “I don’t know,” he said. Then he laughed again and said, “I think if you had to choose one thing that you could do to have a good life, it would be to make sure you get enough sleep!” The crowd roared with applause and laughter. Laughter and sleep. Sounds simple. But as we know, it’s not always that easy.

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Harness the power of positive emotion As cliché as it sounds, laughter, if not the best medicine, is certainly a good one. Please, watch those funny TV shows, movies, and YouTube and TikTok videos because they have a positive psychological and even physical effect on your well-being. Enjoyable experiences reduce stress hormones, strengthen your immune system, and help you come back to “normal” after you’ve been angry or upset.49 What positive emotions should you go chasing? The 10 most frequently experienced positive emotions are:50

Joy

Serenity

Hope Inspiration

Gratitude

Love

Awe

Interest

Pride

Amusement

These are correlated with happiness and well-being, and we can foster them in ourselves and others. Your goal is to build a reservoir of positive emotions that you can draw upon when faced with daily or intermittent stressors by savoring the positive emotion you’re focused on.

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Let your joy compound itself Positivity begets positive results. It’s a well-studied focus of neuropsychologists as a powerful force linked to:51, 52, 53 • Flexibility • Healthy behaviors and overall health • Creative problemsolving • Reduced burnout • Longevity • Improved clinical judgment

• Recovery from stressful situations • Business and academic success • Resilience • Improved cognitive functioning • Reduced depression • Healthy social relationships

Broaden and Build Barbara Frederickson and her colleagues were the first to establish the “broaden and build” theory of positive emotions. It suggests that positive emotions spark, or broaden, your in-the-moment menu of responses to daily encounters, unlike negative emotions, which tend to shut you down and limit your possible reactions to situations or stressors.54 This means when you feel joy, you’re more inclined to play. When you feel love, you’re more likely to extend kindness to others. Seek these positive feelings because they can be a springboard into positive action.

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Seek social opportunities to create joy Similarly, positivity results in social bonding that feeds your well-being. Think about a committee or team you’ll never forget because you accomplished something important. We’re willing to bet you had many other positive emotions associated with that experience. You looked forward to going to the meetings and you left them feeling better than you did when you arrived. Appreciative Inquiry thought leaders write that “large amounts of positive affect and social bonding—hope, inspiration, and sheer joy in creating with one another” help create positive cultural change and well-being.55 This means you’re more creative, better able to solve problems, and more open to learning and to new ideas when you’re experiencing positive emotions. While a positive emotion may be fleeting, it has power beyond the moment and strengthens your capacity to cope with stress. Not only do positive emotions spark positive “thought-action repertoires” (that menu of responses from Broaden and Build), they also, in turn, allow you to build and expand your personal physical, intellectual, social, and psychological resources.

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Find joy in healthcare For now, let’s focus on joy. Have you found it at work? Patient safety leader Don Berwick writes: In our work in health care, joy is not just humane; it’s instrumental. As my colleague Maureen Bisognano has reminded us, “You cannot give what you do not have.” The gifts of hope, confidence, and safety that health care should offer patients and families can only come from a workforce that feels hopeful, confident, and safe. Joy in work is an essential resource for the enterprise of healing.56 If joy is necessary for healthcare, how can you get more of it? How can you train your flashlight to seek out joy so that you’ll see more joy simply by looking for it?

REFLECT Look for Joy at Work Where do you find joy at work? Make a list. Is it when you connect with a patient or family and feel like you’ve made a difference? Is it when your team comes together in a crisis and gets the job done? Is it in quiet moments? Are there any common themes in this list? Think of at least one way you can be intentional about creating more joy at work, for yourself and others. Consider asking a colleague to do this same exercise and then compare notes. What surprises you? What excites you?

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Reframing your perspective is a powerful move. When you feel stuck or resistant, pause and look for the upside. Shifting your thinking from “I have to do this” to “I get to do this” engages curiosity. This turns every experience into a chance for growth, wisdom, and understanding. –Cory Allen @HeyCoryAllen

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Reframe

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he act of reframing—or “positive reappraisal,” as it’s been called in the nursing world57—opens possibilities that may have been hidden from you. It’s your ability to purposefully explore and choose new ways of seeing in order to experience the best of what’s possible.58 Through a new lens, you can learn to view individuals and situations with curiosity, creativity, and an openness to new possibilities and ways of understanding the world.

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Every situation presents an opportunity for reframing—of asking, “What is possible? What do I really want?”

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As with anything, it requires practice. But the result can be transformative. You’re more likely to succeed in your endeavors, big and small, if you view stressors and setbacks as challenges, not failures.59 For example, we work with a palliative care colleague who uses his long walk every day as an opportunity to pray for the patients he’ll see that day. A patient who may be perceived as difficult is now perceived as in desperate need of compassionate care. Every situation presents an opportunity for reframing—of asking, “What is possible? What do I really want?”60 Here are a few more examples: • Being stuck in traffic is an opportunity to practice deep breathing. • Exercise is a celebration of what my body can do, not a punishment for what I ate. • My chores such as cooking dinner or cleaning house are an act of caring for myself and others rather than a burden. • A long walk from my parking space is an opportunity for exercise and a chance to decompress from my day. Anything can be reframed, and how you think about something determines how you feel about it. After a week of rainy days, an art therapist colleague was walking to work, grumbling to herself about the weather. She noticed an extraordinary growth of mushrooms near the sidewalk. She got out her camera, knelt down to the ground, and snapped photos. People stopped to see what she was doing and then to admire the mushrooms. She said it turned into a refreshingly social moment, and she realized that without all the rain, she wouldn’t have experienced the awe and connection to others.

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Glennon’s “Drab” Kitchen In 2014, writer Glennon Doyle posted a photo of herself in her kitchen on social media. Almost immediately, followers sent her “helpful” suggestions about how she could tackle some home improvement projects to make her kitchen look better. Glennon says she had always loved her kitchen, but suddenly, through her followers’ eyes, it seemed drab. Then she remembered a passage from Thoreau’s Walden: “I say, beware of all enterprises that require new clothes, and not rather a new wearer of clothes.” She looked at her kitchen with “fresh perspectacles” and saw an appliance that keeps her Diet Coke cold, a faucet that provides clean, running water, and a magical machine that makes coffee “Every morning. On a timer.”61 And the kitchen floor that provides space for her children to dance. In the conclusion, she captures the heart of reframing and appreciative practices—that with a curious and willing mindset, we generate energy that can be turned toward the challenges we face: Today I shall keep my perspectacles super-glued to my face and feel insanely GRATEFUL instead of LACKING and I will look at my home and my people and my body and say: THANK YOU. THANK YOU, THANK YOU, THANK YOU. THIS IS ALL MORE THAN GOOD ENOUGH, ALL OF IT. Now. Let us turn our focus onward and outward. There is WORK TO BE DONE and JOY TO BE HAD.62

Reframe

REFLECT Become a Skilled Reframer We encourage you to make reframing a regular practice. Sometimes it’s as simple as a change in language (e.g., box wine to “cardbordeaux” or procrastinator to “deadline oriented”). As situations arise, try your hand at seeing things in a different way. Tap into your curiosity and creativity. Notice how a shift in perspective, or a reframe, affects how you feel. Sometimes reframing is challenging, and if you feel stuck, ask yourself, “What do I want to see or experience more of?” Inevitably, your reframing practice will encounter tragic events such as grief, natural disasters, and global pandemics. But just as inevitably, communities learn from these events, rally around each other, and develop creative solutions, alternatives, or preventatives.

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Gratitude is the magical marvelous transformative energy that draws people and good things to us. –Anne Lamott

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Exercise Gratitude

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hen you’re intentionally grateful, your long-term health is better for it.63 Leading gratitude researchers call gratitude a form of “cognitive appraisal,” meaning you get to judge or determine the value of your experiences, whether it be something done for you or simply an awareness of nature, art, and circumstances. That means you get to choose to see positive value. Studies in which participants wrote daily gratitude lists exhibited higher measures of wellbeing than those who made lists of “hassles” or neutral life events. Gratitude list makers were also more likely to offer emotional support to others.

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Notice the good things. Savor them. Express thankfulness. In numerous studies, gratitude practices are shown to improve mental and physical well-being.64, 65 In one study, 228 healthcare workers who faced high rates of stress tested a well-validated exercise called Three Good Things as an intervention to reduce burnout.66 These workers showed significant improvement in emotional exhaustion, symptoms of depression, happiness, and work-life balance for up to 12 months.

The Book of Delights The poet Ross Gay wrote an essay a day for a year about things that delighted him, a practice similar to a gratitude practice. The Book of Delights is a luminous collection of joy—joy for the woman on the plane who carried tomatoes with her, for handmade infinity scarves, and for weeds. In an interview with Krista Tippett, he said, “one of the things that surprised me was how quickly the study of delight made delight more evident.”67 Your focus becomes your fate.

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REFLECT Three Good Things Commit to taking time at the end of each day to write down three good things that happened to you that day (in a small notebook, on your phone, or even on social media). These can be exciting events such as winning the lottery or getting a promotion, but most likely, they’ll be more humble moments. You might appreciate a delicious meal, an unexpected connection with a friend, a nap, or a sunny day. The most important thing is to do it regularly for at least 10 days. You will begin to notice that throughout the day, your attention and thoughts will be drawn toward those good things around you and away from those things that produce negative feelings. Take this exercise a step further: Pick one good thing each day and reflect on the people and events that made that good thing possible. For example, if a patient has a good outcome, consider all the people who contributed along the way—medical and nursing school faculty, supportive family, janitorial staff, manufacturers of vital equipment, and more.

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an essay

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A Silver Lining During COVID —by Maggie Beyer 2020 is the year of the nurse, they said, but who knew what that actually meant.  There was nothing that could prepare you in your career for what we actually witnessed. The heartbreak, the despair, and working tirelessly around the clock. What were we doing? I didn’t feel like I was able to take care of my patients like usual. I couldn’t get them cleaned and looking nice for family or make sure the room was organized with plenty of supplies. We were always working with limited supplies and machines.  We were the patient’s family. No visitors were allowed during this time, but the patients were never alone. We didn’t even realize how strong we were, how brave we were, and how resilient we really were as nurses.  I have been a pediatric ICU nurse for six years and have no experience with adult patients. At the time, the virus wasn’t affecting kids like it was the adult population. So it wasn’t really a question in my mind—I knew I had to help them. That’s what nurses do; we help each other. We help each other bathe patients who have just passed, we help each other hang IV bags that are about to run out, and we help each other get through each moment.  A silver lining seemed to be rare in these days of the coronavirus. However, I was able to find one. My cousin is an experienced adult nurse who had recently taken a job in the same pediatric unit as me, working nights.

Nurses who had adult experience wereAre asked if theyOut? would go Be Honest: You Burned 95 over to take assignments with adults. Of course, he accepted right away.  Throughout Long Island Jewish Hospital, there were multiple ICUs filled with COVID-19 patients—multiple units even converted into a makeshift ICU. One night at shift change, I saw my cousin walking into the unit I was on, and sure enough he was taking over my patient assignment for the night.  Growing up we didn’t see each other all that much, but working together through this experience brought us closer than ever. I am so grateful for him. He would listen to the hard days I had, and he understood exactly what I was going through. Most times you couldn’t even find words to describe the scene you witnessed. But Peter knew. He knew the words I was trying to say but couldn’t quite form. I was terrified to work in the new, adult population against this new virus everyone was still learning about. But knowing I had Peter by my side made things seem a little bit easier.  The nursing bond is a strong one, but a family nursing bond is even stronger. Indeed, we will forever remember this time in history as the year of the nurse.  Reprinted with permission from the American Association of Critical-Care Nurses.68

About MAGGIE BEYER, MSN, RN, CCRN, is a pediatric ICU nurse, and her cousin, Peter Castellano, is a nurse in the same unit at Cohen Children’s Hospital in Queens, New York, affiliated with Long Island Jewish Hospital. During the first surge of the COVID-19 pandemic in New York, together they cared for adult ICU patients with COVID-19.

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The ability to ask beautiful questions—often in very un-beautiful moments—is one of the great disciplines of a human life. And a beautiful question starts to shape your identity as much by asking it as it does by having it answered. –David Whyte (On Being episode)

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Change Your Question,

Change Your Mind

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he way you ask your questions can be fateful, inextricably linked to change.69 In something called the simultaneity principle, in the moment you ask a question, your psyche notices the tone and the intention behind it. Glennon Doyle showed you how to use this principle in a powerful way in the “Reframe” section. She had a choice between asking herself: “What’s wrong with my kitchen?” versus “What amazing features can be found in my kitchen?” Your questions—the ones you think in your head and the ones you speak aloud—are a powerful tool available to shape your life and experiences.

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“

Asking your questions with openness and positivity provides a path toward curiosity and resilience. It points you in the direction of creative solutions and new possibilities.

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Asking your questions with openness and positivity provides a path toward curiosity and resilience. It points you in the direction of creative solutions and new possibilities. The ability to approach situations and others with a stance of curiosity not only expands your options but also has the power to help you develop more trusting and collaborative relationships with others.70 Curiosity helps you overcome the trap of confirmation bias, or only noticing evidence that confirms your beliefs rather than exploring information that may contradict them. Curiosity lessens your defensiveness when you’re stressed out and moderates aggressive reactions when you’re provoked.71 It’s good for you and for others! Curiosity begins in the form of a question and helps you find creative solutions to difficult problems. In writing about design thinking, a problem-solving methodology being used in healthcare, Professor Jeanne Liedtka72 writes, “Defining problems in obvious, conventional ways, not surprisingly, often leads to obvious, conventional solutions. Asking a more interesting question can help teams discover more-original ideas.” In other words, you can explore novel ways of moving through the world simply by asking better questions. Faced with a challenge, you could ask yourself, “What can I learn from this?” instead of, “Why did this happen to me?” Curiosity is one of the most valuable tools in your toolkit. Unlocking its power simply takes a moment of awareness to remember that you can choose your questions, and then it requires continued vigilance to keep the guiding question front and center in your mind.

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Harness the Power of Positive Questions in Your Daily Life The following table shows some of our favorite examples. Instead of asking

Try

What is wrong?

What is possible?

What are you most worried about?

What are you looking forward to?

Why did this happen?

What can we learn from this?

Why isn’t there enough?

What do you want more of?

How will I survive?

How will I find meaning? OR What surprises me about the situation?

Why am I failing?

What can I do to move forward?

What is wrong with this patient?

What are this patient’s greatest strengths?

What do I have to do today?

What do I get to do today?

Change Your Question, Change Your Mind

REFLECT Reframe Your Questions Ask your questions in a way that illuminates more of what you want. Find ways to turn your questions into opportunities. A great example is nutritious eating. Instead of asking, “What can’t I eat today?” you can ask yourself, “What do I get to eat today?”

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a little thought

When Things Go Wrong: Posttraumatic Growth We all know someone who has faced extreme adversity but who somehow transformed their tragedy or trauma into something meaningful. These may be individuals in your personal life, your patients or colleagues, or maybe they’re people you’ve read about. We experience so much progress in healthcare because someone experienced illness or loss but managed to find growth, even meaning, in their pain. I AM ALS, the Lorna Breen Heroes Foundation, the Susan G. Komen Foundation, and the Schwartz Center for Compassionate Care—these are just four advocacy groups formed in the wake of pain and trauma. You’ve probably studied the condition called posttraumatic stress disorder (PTSD). Posttraumatic stress is essentially the emotional and psychological fallout from traumatic events such as a natural disaster, loss of a loved one, or surviving an act of violence.73 PTSD can be caused by a single event or a series of events and exposures to trauma, including systemic racism and discrimination. We love the work of Richard G. Tedeschi and Lawrence G. Calhoun, two researchers who developed a different psychological construct for trauma survivors: posttraumatic

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growth (PTG). As you might guess, it refers to a process when individuals experience trauma but change in a positive way. The growth after trauma typically occurs in one or more of five domains:74 1. Greater appreciation for life and changed sense of priorities 2. Warmer, more intimate relationships with others 3. Recognition of new possibilities or paths for one’s life 4. Greater sense of personal strength 5. Spiritual or existential development In our careers, we meet patients facing grave health crises who find new meaning and purpose in their lives. We encounter others who, through illness, are surprised to learn how much inner strength they have. Some reconnect with family, friends, or faith communities as they renew their appreciation for these relationships. It’s a privilege to share in these growth experiences with our patients. We offer PTG as yet another way to think about self care and resilience. Tedeschi and Calhoun gave us a new way to understand adversity and its opportunity to build meaning, connection, and purpose in unlikely circumstances. Just as we seek to understand how we can help individuals build resilience, it’s also important for us to know that we can help others and ourselves foster growth in the wake of trauma.

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Without leaps of imagination, or dreaming, we lose the excitement of possibilities. Dreaming, after all, is a form of planning. –Gloria Steinem

Be Honest: Are You Burned Out?

Use Your

Vision to Change Your Fate

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hat does your vision board look like for your future—the collage of goals and desires you have for your life? You move toward the image of the future that you hold in your imagination. The more positive that picture, the more positive your future.

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You have to smell it and hear it Think like a world-class athlete. Elite golfers Arnold Palmer and Tiger Woods and tennis great Billie Jean King all used visualization techniques for decades. Athletes use imagery in nearly every sport, from swimming to ping pong, to help them improve their coordination, focus, strength, and flexibility.75 Olympic athletes use imagery to mentally simulate an approaching competition. Team psychologists encourage competitors to create mental images of every aspect of their event, from speaking at news conferences to riding on the bus to every twist and turn of the race. The imagery must engage all the senses to be effective. Emily Cook, an Olympic freestyle aerialist, says, “You have to smell it. You have to hear it. You have to feel it, everything.”76 Again, imagery must be positive. Golfers don’t visualize their tee shots going into the rough, and tennis players don’t imagine their serves landing in the net. Imagery is a powerful tool for the rest of us as well. Your mental imagery mimics the same brain functions as your physical actions: motor control, attention, planning, and memory spark from the same place in your brain, meaning that positive visualization enhances your confidence, self-efficacy, and motivation.77 Your brain and your imagination are powerful tools that you should harness whenever possible.

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The picture of health There is great power in visualization and your beliefs about the future, and this has been proven with medical studies. Research on healthy aging reveals that those who believe that they’ll age well are less likely to be hospitalized and to experience cardiovascular events and Alzheimer’s disease and more likely to recover quickly from a disability.78, 79 What do you picture about your health as a nurse, and how can you improve that image?

Take it to the floor We love rehab nurses. They have told us that when they first admit a patient to the rehab hospital, they “see the patients as they will be, not as they are now.” Visualization at its best. Work with your colleagues to visualize the future of your work. Researchers have found that visualizing the plan is even more powerful than imagining the outcome.80 For this to work, you must imagine the process with vivid detail. How do things look? How do you feel? What are people doing? Are they smiling, laughing, celebrating? Once you have created this ideal image, what steps will you take to achieve it?

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Ryan Speedo Green: From Juvenile Detention to the Metropolitan Opera A remarkable story about the power of visualization comes from opera singer Ryan Speedo Green. Green, the subject of the biography Sing for Your Life, was a young man living in the Tidewater region of Virginia. At one time, he was placed in a juvenile correction facility, in solitary confinement. Later, as a student at the Governor’s School for the Arts, he went on a class trip to New York’s Metropolitan Opera House to see his first opera, and in that one evening, everything changed. In an interview with Terri Gross,81 he recalled that while in the audience that night, he decided that he, too, was going to sing at the Metropolitan Opera. After the performance, he shared his plan with his teacher, Mr. Brown. Mr. Brown gently explained that Ryan would need to learn to read music, learn to memorize lines, learn a foreign language, go to college, attend a young artist program, and actually get some work singing. If he did all those things, Mr. Brown told him, he might someday be able to audition at the Met. Green concluded the story: “And then kind of in my mind, I think, I took it all down and made a list. And nine years later, I sang at the Met.” It is certainly astonishing that Green made his way from solitary confinement to the Metropolitan Opera, but we’re certain it wouldn’t have happened if he hadn’t held onto a compelling vision of himself performing on that stage. Green’s vision had the power to guide his in-themoment actions, to learn a particular skill, to accept help from a teacher or mentor, and to study with focus and determination.

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REFLECT Visualize Your Goals and Future Start small Try a simple visualization before you get out of bed each morning. Select one or two things you’d like to accomplish that day and imagine those activities unfold. Create as much rich detail as you can muster—outline the steps you’ll take, describe how it looks and feels—and replay these details in your mind. The most important thing is generating positive, rich details about the activity or end result. Work your way up Use visualization to achieve larger goals. Focus on a question (“What will I do when I earn my next degree?”) or a goal (“I’d like to find a life partner”) and create a one-hour block of uninterrupted time in a quiet, comfortable space. On a piece of paper, make a detailed list. The magic is in the details. If you’re thinking about your life after retirement, imagine a day in retirement. Write down every single detail, from the moment you wake up until you go to bed. Where are you sleeping? What are you wearing? What do you eat for breakfast? Who do you spend your time with? Let your mind flow; don’t edit your list. The list of questions (and answers) in this visualization exercise is infinite, but your map will come from the seemingly least consequential details. Engage all five senses, paying attention to sights, sounds, smells, tastes, and touch. The details generated by this kind of quiet reflection will create a vivid picture of your future that you may begin to move toward in the present moment.

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an essay

Self Care for Nurses

Stand on Solid Ground By Joy Miller

During the most stressful situations, through signaling by your amygdala and hypothalamus, you’re naturally activated. Your sympathetic nervous system is a gas pedal that throws you into overdrive. You might exhibit physical symptoms, such as getting flushed, heart racing, sweating, shaking, or all of the above. It can feel paralyzing, and it can negatively affect your judgment and inhibit important cognitive processing. When this happens chronically, there are long-term tolls on your body including physical damage to blood vessels and arteries, increased blood pressure, and an increased risk of heart attack or stroke, as well as elevated cortisol levels that contribute to the buildup of fat tissue. You need to find the brake pedal, and that’s where your parasympathetic nervous system kicks in to help you de-escalate and temper that “fight or flight” response. Although this is a natural phenomenon, you can choose how activated you become through a grounding practice, right then and there in the moment of your activation. It’s helpful to identify this “activation” state early, pause, and then engage in a mindful practice to down-regulate this arousal.82 I regularly practice down-regulation with the process of grounding. I tune into the feeling of my feet on the ground, whether I’m sitting or standing. I focus totally on this sensation, and I instantly feel supported by my feet on the floor. I will move my feet back and forth in my shoes to reset my stance, all in an effort to stimulate the feeling of support.

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I ground myself in every chaotic moment that comes my way, and I move from a state of activation to calm. I may have to do this dozens of times in that moment, but the practice of grounding is something I can call upon anytime, anywhere. This applies to all types of stressful situations. With practice, this will become more natural, and you’ll be able to ground yourself in the moment of stressful arousal and experience even more down-regulation benefits.

About JOY MILLER, BS, MSN, RN, CPNP-PC, CPN, is a pediatric nurse practitioner on the Pediatric Palliative Care team at University of Virginia Children’s Hospital. She is a Wisdom, Wellbeing, and Peer Support representative in her unit.

REFLECT Practice Grounding When you notice a stressor taking hold, practice grounding. It’s a technique developed by Elaine Miller-Karas83 to help communities in the wake of traumatic events. Grounding quickly settles your nervous system, brings your attention to the present, and provides a shortcut to a sense of safety. First, find a quiet place and give yourself a moment to stand (or sit). Turn your awareness to your feet on the ground, or the chair supporting your thighs and bottom. Then try it during your day when your gas pedal throws you into overdrive to bring yourself back to a place of calm.

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Only by making sure we have as much energy coming in as we have going out can we all stay committed to the people, work, and ideas we love. .

–Emily Nagoski

Be Honest: Are You Burned Out?

Go to Your

Safe and

Happy

Place

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e’ve been urging you to “pay attention” and “stay in the moment,” but when your mind is racing or you are overwhelmed by chaos or stress, sometimes you might just need to “check out.”

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Think of something that protects, nurtures, or uplifts you. It could be a person, place, memory, or activity. When you feel stressed or overwhelmed, go to your happy place. Plan a vacation or a party. Mentally hike in the mountains or run a marathon. Remember baking cookies with your grandmother. Plan your fantasy football picks. Design an embroidery or knitting project.

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. . . Discovering vocation does not mean scrambling toward some prize just beyond my reach but accepting the treasure of true self I already possess. Vocation does not come from a voice “out there” calling me to become something I am not. It comes from a voice “in here” calling me to be the person I was born to be, to fulfill the original selfhood given me at birth. –Parker J. Palmer

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A Call to Remember: Nursing Origin Stories –by Robin C. Brown-Haithco Through an intentional exploration of my own life narrative, I have come to know myself in ways I would never have imagined. As I have reflected on my personal story, I have been invited to “recall” and “remember” life experiences that are only now leading to transformation. In my work with healthcare staff, I always begin with their story. As they lean into my invitation to share their story with me, often there is an aha! moment; their face will light up, and they will say something like, “That’s where that comes from—that’s why I do what I do.” Twice a year I’m invited to lead a training on resilience in the workplace for new graduate nurses. As I begin the training, I invite the new nurses to recall the event, moment, or story when they knew this vocation of nursing summoned them and the moment when they accepted that call in all its uncertainty and joy. As they recall and remember, I invite them to hold on to that memory, that point of connection with their spirit that will sustain them when the moments of suffering are overwhelming, when their own grief in the midst of suffering might lead them to question their vocation. My own personal experience has provided wisdom for my own vocation of staff support. There have been moments in my vocational life when I have wondered, “Can I keep doing this

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work?” There have been moments when I have known that if I didn’t find ways to nurture myself physically, emotionally, spiritually, and mentally, then this work of caring for others would deplete me and steal my joy. One such moment was when my mom died. In the days following her funeral, my grief was so great I found it difficult to get up each day and go to work, knowing that in my day I would have to encounter more death and dying, suffering, and pain. My daily walks in the park meditating, and my time in therapy doing my grief work, helped to call me back to a place of resilience and well-being, a place of hope. When I stop in those moments of questioning to remind myself why I chose this vocation, and why it chose me, I realize that this work I am engaged in is something I can’t not do. It is in the fabric of my being. It is who I was created to be. It is that to which I was called to at birth by the One who created me. Could I do something else? Yes, absolutely. But would that something else nurture my spirit? Probably not. It is my belief that at certain points in our lives, this work of remembering is key to health and wholeness because it calls us back to our true selves, to those places within that often we cannot explain to ourselves or others. But what we do know is that it in that place of soul and spirit, gratitude, joy, and hope is what allows us to live with freedom and flexibility in the vocations to which we have been called.

About ROBIN C. BROWN-HAITHCO, M.DIV., is a hospital chaplain, educator, and ordained Baptist minister. She has served as the Director of Spiritual Health and Staff Support at Emory University Hospital for over 16 years.

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REFLECT Recall and Remember Accept Robin Brown-Haithco’s invitation to recall and remember when the vocation of nursing summoned you. Hold that memory and its connection to your spirit. Maybe write yourself a note naming the power that comes from that connection. One source of burnout, especially for new nurses, is the disconnect between expectations about being a nurse and the reality of day-to-day nursing. How has nursing failed to meet your expectations? How has nursing exceeded them?

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Someone who has experienced trauma also has gifts to offer all of us—in their depth, their knowledge of our universal vulnerability, and their experience of the power of compassion. –Sharon Salzburg

Be Honest: Are You Burned Out?

Cultivate

Your

Wisdom W

e’ve worked with countless wise nurses throughout the years. Wise nurses navigate the uncertainties and challenges of their jobs with intelligence, reflection, and compassion. They see situations from multiple perspectives. Wise nurses reflect on their own thoughts and feelings before reacting in the moment. They know how to use their skills in the right way, at the right time, for the right reasons,85 and sometimes this may even mean bending the rules a bit.

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Transformative experiences We look to healthcare professionals who have grown after trauma and allowed themselves to be transformed by suffering. In an interview study of physicians who had been involved in a serious medical error, we learned that some were too devastated by the experience to remain in medicine.86 Others self-medicated, become overly cautious in their medical practice, or withdrew emotionally. There were others, however, who moved through the trauma of making a mistake by eventually becoming better physicians, teachers, and even parents and spouses. They drew purpose from the trauma of harming a patient. Some became open about sharing their experience of the error so others could learn from their mistake. Others adopted the role of patient safety expert or advocate in order to ensure similar errors would be prevented in the future. And many grew more compassionate and less judgmental, having themselves experienced shame, the harsh judgment of others, and even legal proceedings.87 Consider how you can react with grace to the experiences in your life and work and allow them to transform your way of being and doing.

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The path to wisdom The authors of that study identified something that looked a lot like wisdom. Although the concept of wisdom is age-old (think Socrates, Job, and Buddha), it has only in the past few decades been studied as a psychological construct. One researcher identifies those qualities we typically think of as embodied by “wise” persons:88 • The ability to deal with uncertainty and ambiguity • Seeing the deeper meaning of things • An awareness of self and others • The ability to learn from mistakes • Compassion and concern for the greater good Many believe you can only gain wisdom through the experience of adversity, that life’s challenges force you to find creative coping skills and draw you closer to others who are suffering.89 Yet we hope to attain growth and wisdom in the context of all circumstances, as this leaning into wisdom will serve us as another form of resilience.

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Wise nurses A wise nurse is able to demonstrate compassion toward others, transcend self-centeredness, and make decisions with the greater good in mind. This compassionate wisdom manifests in the creative ways nurses have found to support their patients who are suffering, in their caring for each other and themselves, and in their willingness to advocate for their patients, health systems, and communities.

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A wise nurse is able to demonstrate compassion toward others, transcend self-centeredness, and make decisions with the greater good in mind.

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REFLECT The Gift of Crisis Glennon Doyle has written: You have been offered “the gift of crisis.” As Kathleen Norris reminds us, the Greek root of the word crisis is “to sift,”’ as in, to shake out the excesses and leave only what’s important. That’s what crises do. They shake things up until we’re forced to hold on to only what matters most. The rest falls away.90 Think back to a time when you faced a difficult challenge. It could be a crisis at work or in your personal life. In this situation, what was the “gift of crisis” that you received? What lessons, wisdom, or meaning do you wish to actively remember as you move forward in your career?

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a little thought

The Power to Choose When you’re in the throes of daily stressors or a traumatic event, you still have agency. No one can take that away, even in the worst circumstances. You can choose to pay attention, to stay present, to reframe, and even to be grateful. You can choose to breathe deeply and move forward with grace. It’s never easy, but by practicing even a few of the techniques described here, it gets easier. You can gradually fine-tune your default responses, shifting to ones that serve you and those around you. Your compassion for yourself and others will grow. It’s a lifelong process, but the practices described here open a path to flourishing in your life and work.

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You may not control all the events that happen to you, but you can decide not to be reduced by them. –Maya Angelou

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Let’s begin by taking a smallish nap or two. –A. A. Milne (Winnie the Pooh)

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Rest S

o far, you’ve focused on ways to use your thoughts and attention to foster your emotional well-being amidst the challenging work you do, conveying that the way you think about things determines how you feel about them, and the way you feel determines how you behave and ultimately the results you end up with. We now offer you a couple of bite-sized practices you can integrate into your life that attend to your physical well-being. No one is alike, and no selfcare practice is one-size-fits-all, but first one that we all need—sleep!

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Sleep, plain and simple Do you feel like you get enough of it? We can say we often wish we could get more of it. If that’s you too, we’re not alone. In developed nations worldwide, twothirds of adults don’t get the recommended eight hours of sleep each night.91 Inadequate sleep (less than six or seven hours per night) can wreak havoc on your immune system; shorten your life expectancy; make you more susceptible to Alzheimer’s disease, cancer, heart disease, diabetes, memory impairment, depression, anxiety, and suicidality; and stimulate your body’s hunger hormones and increase your weight.92 You can’t perform as well at work when you’re tired, and you’re less likely to exercise or eat well when you’re struggling with exhaustion. This is just the tip of the why-we-need-sleep iceberg. As Matthew Walker writes in his book Why We Sleep, there are no biological functions “that do not benefit from a good night’s sleep.”93

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Develop sleep hygiene Physiologically, we know that regular sleep cycles are key to health and self care; however, in the nursing profession, especially with shifts that might rotate from days to nights, that kind of regularity of sleeping hours isn’t always possible. Whether you have regular sleep cycles or not, there are actions you can take to support your sleep hygiene:94 • Be consistent. Go to bed at the same time each night and get up at the same time each morning, including on the weekends. • Make sure your bedroom is quiet, dark, relaxing, and at a comfortable temperature. • Remove electronic devices, such as TVs, computers, and smart phones, from the bedroom. • Avoid large meals, caffeine, and alcohol before bedtime. • Get some exercise. Being physically active during the day can help you fall asleep more easily at night. Good sleep hygiene is important especially for nurses. Work stress, hectic schedules, and night shifts are just a few of the sleep disruptors you might typically face. The nature of your work requires that you be alert and able to concentrate. You need to safely operate equipment, including a vehicle if you drive one home.

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Hannah White, the pediatric orthopedic nurse who practices micro-self cares (see the earlier “Difficult Feelings Have a Purpose” essay), says that sleep and regular meals are nonnegotiable. “They are macro, not micro!” She says the key to her sleep hygiene is having a consistent bedtime (and for her children to have a consistent bedtime too). She has honed her techniques over the years, and now what works for her is creating a routine that cues to her body it’s time to rest: I’ll usually brush my teeth and get my water, get settled down in bed. My dog usually is in there snuggling for a little bit, and then my husband will take her and put her to bed. I’ll turn my audiobook on, and that is the cue the day is ending. I’ll set it on a timer so that it turns off. I find that an audiobook is engaging because I tend to be pretty wound up. It takes me a minute to come down and really settle in to be able to go to sleep. And so it bridges that gap so I’m not just going 60 to zero, I’m just kind of coming down a little slower.

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GIVE IT A GO Sleep Challenge Do you get enough sleep each night? If not, then are you ready for a challenge? For 30 consecutive days, try to get adequate sleep—at least seven hours. This is a commitment, and you probably won’t be perfect, but we’re certain you’ll notice benefits with any amount of intentional improvement. To help you with your sleep challenge, create a list of the activities you want to include in your sleep hygiene toolkit.

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Don’t forget to drink water and get some sun. You’re basically a houseplant with more complicated emotions. –Unknown

Be Honest: Are You Burned Out?

Nourish

Your Body

and Hydrate

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ou’re knowledgeable about the health benefits of sleep and exercise, and you have an intellectual understanding of the importance of good nutrition, but you probably face many barriers to healthy behaviors. These include long work hours and exhaustion, making it difficult to prepare healthy meals and to adequately hydrate. Nurses often work in unhealthy food cultures where baked goods and vending machines are plentiful but healthy options are not.

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Listen to your body We hope that eating a nutritious diet is important to you, but how will you figure out what works best for you? Books, podcasts, social media, websites, and blogs—like us, maybe you’re overwhelmed by information about nutrition and diet. Many diets and ways of eating claim to be based on scientific evidence; some are, and some are not. We hear from experts and enthusiasts about the benefits of high-carb diets, low-carb diets, high-fat and low-fat diets, vegan and vegetarian diets, whole food diets, locale diets (e.g., Mediterranean, Sonoma), keto diets, and paleo diets. Others weigh in on the timing of meals, the harms and benefits of snacking, and intermittent fasting. There are special diets for people at risk for heart disease, diabetes, and allergies and food sensitivities. You can probably name a few more. These diets may work for some people, but not for everyone.95 So how will you create your own eating and nutrition guidelines?

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Begin by paying attention to your body. How do you feel after eating certain foods? What does hunger feel like for you on a scale of 1 to 10? At what point while eating do you feel too full, and how does that make you feel? What aspects of nutritious eating stress you out the most? Consider the approach of mindful eating, when you’re intentional about your nutritional intake.96 For example, if you’re hungry, take care of yourself and eat a little bit. Snacks can be very beneficial when you’re on the move, have a full patient load, and you know your lunch break might not happen. A medical student who had just finished her clinical rotations said the best lesson she learned was to keep hard-boiled eggs in her white coat pocket. She said she could sneak into a restroom and eat one quickly to keep herself going (which we think is an unfortunate reality, but a good adaptable practice). If you’re fasting for a religious practice, such as for the Muslim holy month of Ramadan, or you have given something up in your diet for the Christian practice of Lent, reconnect to the meaning in these practices, and maybe notice an increase in your ability to focus and home in on your intentions as a caregiver and a nurse.

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Stay hydrated This is a key element of good nutrition, so be sure to drink ample water. In addition to the obvious physiological importance of hydration, electrolytes and water have other restorative properties. What many people don’t realize is that when you feel hungry or tired, often a serious drink of water (or sparkling water) will help you regain solid footing. Fatigue and hunger are signals that your body might be dehydrated.97 Find a “water transport system” that works best for you. Slap a sticker on a bottle that makes you smile. Keep your bottle full and the temperature to your liking. And don’t forget to actually drink it!

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GIVE IT A GO Just One Goal You likely have an idea of a nutritional practice you wish you were implementing. Pick one achievable thing—it doesn’t have to be a total overhaul—and implement it until it’s a habit. This could be the goal of finishing your water bottle by the end of the shift (and we won’t tell anyone if you’re chugging it on the way to the car). It could mean you come armed with one healthy snack every shift (like that hardboiled egg) and commit to pausing for a moment to eat it. Or maybe you decide you’ve eaten your very last bag of stale potato chips from the vending machine.

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Observing desire without acting on it enlarges our freedom to choose how we live. —Tara Brach

Be Honest: Are You Burned Out?

Evaluate Your Alcohol Consumption

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e’d be remiss not to say something about the pros and cons of alcoholic beverages as a form of self care. Having a drink with friends can be a great way to relax and unwind. However, alcohol, especially near bedtime, can disrupt your sleep,98 and alcohol certainly isn’t abundant with nutrients. Alcohol can lead to even more dangerous consequences, especially if you’re at high risk of addiction.

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Know yourself A glass of wine at the end of a shift can be a form of self care for some people. Pay attention to your drinking behaviors and how you feel before and after you drink. If that nightly glass of wine becomes multiple glasses or even a nightly bottle of wine, try a Kaizen approach (a Japanese term meaning continuous improvement). Maybe you only drink one glass a day, then work down to weekends only, and then perhaps to just on special occasions. Notice if reducing your alcohol intake improves how you feel. If you still crave alcohol or can’t cut back, then please consider talking with a trusted physician or nurse practitioner. Signs of alcohol dependence include:99 • An ongoing need to drink more to obtain an optimal level of intoxication

• A desire to drink less or change drinking habits or the inability to do so

• Drinking to manage a hangover or feelings of alcohol withdrawal

• Giving up important social or occupational activities so that you can drink

And it follows that alcohol abuse could look like:100 • Ongoing use of alcohol despite the failure to accomplish academic, occupational, and social responsibilities

• Using alcohol regularly during situations when it is physically dangerous (such as driving or operating heavy machinery)

• Ongoing alcohol use in spite of social disruptions

• Legal actions taken against you while you were under the influence of alcohol

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Avail yourself of resources There are many resources available both online and in your community. The AUDIT (Alcohol Use Disorders Identification Test) can be self-administered online (https://www.drugabuse.gov/sites/default/files/audit. pdf). If you work in a hospital, you should have access to an Employee Assistance Program, or you can call your insurance provider for a referral to a therapist or substance use disorder program. One of the most wellknown organizations in the US that has shown very good results for many of its participants is Alcoholics Anonymous (AA).101 There are AA chapters in most cities and towns across the US, so if you would like to learn more about them, you can seek your local chapter at www.aa.org.

GIVE IT A GO Consider How or if Alcohol Fits Into Your Life At first, simply take notice. Then you can use your great wisdom and discernment as a nurse whether there’s a further step you should take.

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Almost everything will work again if you unplug it for a few minutes, including yourself. —Anne Lamott

Be Honest: Are You Burned Out?

Breathe

Deeply T

ake a deep, restorative breath. Or two or three. Restorative breathing is free and can be done anywhere at any time, involves no pharmaceuticals or calories, has no addictive properties, and it works. Deep breaths can effectively lower your respiratory rate and cortisol levels, improve blood pressure, increase concentration and focus, and reduce anxiety and depression. It’s the fastest and least obtrusive way to calm yourself.

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Restore homeostasis When your “accelerator” is pressed, or your body is revved up in the sympathetic nervous system with a rise in heart rate, respiratory rate, and muscle tension, then a voluntary and controlled change in breathing patterns can reduce your stress.102 It’s like pushing the brakes to bring your body back into homeostasis. You might be surprised by how often you hold your breath, especially when concentrating, working through a problem, or exerting physical energy. Try to bring awareness to when your breath “catches” and resume normal breathing patterns or take a moment for box breathing.

Implement a breathing technique There are many deep breathing practices, including the SKY breath meditation that has shown good results with college students,103 but one we especially like is the box breathing technique. Box breathing is a simple four-part technique that you can do every morning and throughout the day as needed. SEALFIT founder and Navy Seal Mark Divine developed the technique, claiming it allowed him to remain calm and focused during the chaos of battle.104 If it can work for a Navy Seal in the middle of combat, we’re thinking it can work for a nurse in an ICU, or wherever and whenever you need a bit of calm.

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Box Breathing Start: Begin by expelling all the air from your chest. Step 1: Keep your lungs empty for four counts. Step 2: Inhale through your nose for four counts. Step 3: Hold the air in your lungs for four counts. Don’t get tense. Step 4: Release and exhale smoothly through your nose for four counts. Repeat. Divine recommends repeating the cycle five times to get the full effect. This is an excellent technique to share with your patients, too.

GIVE IT A GO Breathe. You’ve Got This! Your “breathing practice” doesn’t have to be difficult or complicated. Sure, try box breathing if that Navy seal thing sounds good to you, or if you like counting to four. But honestly, a deep, restorative breath or two is sometimes all you need to calm yourself. We encourage you to simply try a few deep breaths any time you feel stressed. You’ll feel better—we promise.

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When I want to be bold about my movement . . . I for sure do not call it exercise! —Mary Anne Radmacher

Be Honest: Are You Burned Out?

Move Your

Body W

hen our ancestors saw a sabertoothed tiger, they ran, and it was healthy. Your body doesn’t know what high patient acuity or high patient volume means (in some ways similar to that tiger), so authors Emily and Amelia Nagoski encourage you to tell your physical self that the stress has passed in a language your body understands— body language, or movement. In their widely read book, Burnout: The Secret to Unlocking the Stress Cycle (2019), they explain that stress creates physical and emotional chaos in your body and brain if you don’t tell your body that the stressor has abated.105

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The Nagoskis don’t say you need to run, although that works, but you can also dance, swim, do Zumba, or simply take big inhales and exhales. You could stand up from your chair, clench all your muscles for 20 seconds, and then relax. That’s movement, too. Harvard researcher Alia Crum led a fascinating study around the question of exercise and the placebo effect. She and her research team studied 84 female hotel housekeepers. They told the intervention group that their work cleaning rooms and making beds met the Surgeon General’s recommendations for a healthy lifestyle. Compared to the control group of housekeepers who were not told this information, the intervention group not only believed they exercised more, they also had measurably better health outcomes such as reductions in weight and blood pressure. The results suggest that exercise “affects health in part or in whole via the placebo effect.”106 What did this study suggest to us? The housekeepers who were told that their work was “doing exercise” improved on certain scores, though nothing had changed but their mindsets. We see in this work that intention or belief can be a powerful tool for health.

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GIVE IT A GO Stretch! This self-care practice focuses on moving your body in different ways than you normally might. Take a few seconds or a few minutes during your shift to stretch your arms, legs, shoulders, and neck. This helps increase blood flow and potentially relieves some stress. You can move your body while standing, sitting in a chair, or even while relaxing in the break room. If you participate in a practice such as yoga, you may be familiar with some specific stretches and poses, but any simple stretch will do. You just might inspire your colleagues to join you.

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an essay

Six Practices to Foster the Perfect Workday –by Esther Golda Lozano Otis There is almost no way to make the “perfect” workday in healthcare. The reality of nursing is that you don’t know what you’re walking into, and depending on where you work, it may feel like you’re going into battle. Though you can’t create a “perfect” workday, you can create an optimal workday. When considering wellness opportunities in your workday, it can be helpful to go back to the basics and keep it simple. However you choose to explore these, do it with kindness and compassion toward yourself. Your shift really starts with the night or day before. 1

Sleep. Getting enough sleep is essential for you to sustain that long 12-hour shift that many nurses endure. It’s better to be prepared to stay beyond your scheduled hours, as this can often happen. 

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Prep nourishing meals. Prepare your meals the day or night before. Bringing prepared food from home can be essential when considering your workflow reality because you may not know when you’re going to have time to eat a meal.​​There is not always time to run to the cafeteria or order food online. Having nourishing meals can make or break your day or evening. “Hanger” (hunger plus anger) is a real thing. 

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Be intentional with time. Don’t rush before your shift. As you know, nursing can often be one big catch-up game. Try waking up just a few minutes earlier to relish in the calm. However, on the days that you need more rest, give yourself some grace. Establishing healthy habits is easier said than done. Before starting your shift or workday, consider taking a few minutes to sit quietly. Even if you only have two minutes, that is enough. Set a timer if you want. Those two minutes can be to simply clear your mind or perhaps set an intention and focus your thoughts or energy. As nurses, it’s important to remind ourselves of the greater purpose of this work. This can be done anywhere, such as a quiet place in your home or in the car before you head in.

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Be open to the outcome. One of the most humbling things you can do is to stay open to the outcome. The truth is, once you walk through the doors and into your shift, you don’t know what your shift may turn into. This constantly changing landscape can be very unsettling, and you can choose to be upset by it or open to the unknown. This shift in mindset is not necessarily easy but can offer a greater sense of freedom and ease. Remember, this is a skill that takes time to build, so go easy on yourself if you feel challenged by this.

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Take brain breaks. Try to take short brain breaks during your workday. Beyond an OSHA work standard, a brain break is a short mental break in your day (think two to five minutes). You may use a brain break by taking a short walk off your unit or maybe grabbing a tea or coffee. This may feel impossible depending on where you work, but taking those breaks can be key for shortand long-term mental health.

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Uphold your team. Beyond your patients, your coworkers also need your support. Having your team’s back is vital to a smooth and safe shift. It can be helpful to acknowledge that your teammates come from different backgrounds, work histories, work styles, and ethics. These differences are what make a strong team. This same sentiment can be extended to your own team that helps support you while you’re working.

We’re all human, and we all handle adversity in different ways. Consider these six practices a framework for wellness at work. As you begin to develop wellness practices in your life, there will be days when these may not seem feasible. When striving to create the “perfect” workday, always remember to be compassionate toward yourself and others. 

About ESTHER GOLDA LOZANO OTIS, BSN, RN, IBCLC is the Staff Resiliency Coordinator at Sentara Martha Jefferson Hospital in Charlottesville, Virginia. She leads wellness retreats for staff and students.

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What is it you plan to do with your one wild and precious life? –Mary Oliver

Be Honest: Are You Burned Out?

Integrate a Life That Works

With a Life That Counts

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ou’ve heard the term work-life balance, that precarious seesaw where your happiness is somehow defined by an exquisite but unattainable feat of balance. We think the idea suggests you must view work and life in opposition to each other. “Are we not alive at work?” asks organizational design and training expert Peter Block.107

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Achieves harmony and integration Differing views about balancing home and work are common. Your coworker may proudly say, “I leave work at work,” while your view might be, “I wake up at night and can’t stop thinking about my patient.” Frequent rumination on a long commute home over what could have gone better is a hallmark of the nursing profession. If balance is not the best goal, what is a better, more realistic alternative? Perhaps harmony and integration are the better words, concepts that are much more attainable than the notion of balance. This view can offer multiple ways to achieve success, as Haley Schlottmann, DNP, FNP-BC, expresses (personal communication, 2020): I like the word integration much better than work-life balance because that assumes they each operate in a silo . . . Balance implies you have it or you don’t, where synergy/integration means there is a give and take, a reciprocity . . . increasing demands in one domain can lead to a reprioritization in the other domain and that is OK . . . I achieve synergy by setting boundaries—when work demands feel too high, intentionally limiting time spent doing work at home, or when home life feels too stressful, intentionally working on ways to improve my professional self. Good friends and a mentor help more than anything!

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Integrating life and work is a self-care strategy with multiple well-being benefits to you and those around you. Integration requires that you compose a life in which there is synergy between work and home, family, friends, and volunteer pursuits and hobbies. It might entail professional autonomy, schedule flexibility and predictability, paid leave, and respect for the boundaries between work and nonwork time.108 For example, we know a nurse who, upon passing the difficult CCRN exam, was celebrated by her entire unit. They supported and encouraged her while she studied, and their support allowed her to be authentic during the challenging times and the success.

Reflects the authentic self It’s less stressful to be who you really are, and an integrated life makes that possible. It reflects your authentic self by fostering clarity, meaning, and purpose. Being yourself at work and allowing others to see you as you really are invites connections and belonging. You don’t necessarily need to overshare, but giving colleagues insight into your family, outside interests, and maybe even some of your worries makes you human and humble. Think of a colleague who shares their baking gifts with the team on special occasions, or the nurse manager who proudly mentions a child’s recent accomplishment, or the new nurse on your team who shares stories of her home country. These nurses all authentically share aspects of who they are beyond the workplace. By connecting with colleagues this way, you experience self care, community care, and meaningful, holistic connections.

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Builds a culture of friendship Nurses who value collegiality at work go out of their way to learn about team members—not in a gossipy way but in a way that says, “I want to know more about you as a person, not just as a nurse.” For example, nurses on a unit we worked with once struggled to know each other across the many shifts. “I don’t know these new nurses from a loaf of bread,” one of the managers said. The manager became very intentional about asking new nurses about not only their nursing experience and expertise but also their nonwork lives. She made a point of introducing new nurses to others and introducing them often. The unit created a bulletin board with pictures of the team—longtime members and new ones—with brief biographies to help everyone get to know each other. Your unit can foster a stronger culture of friendship by communicating in ways that are supportive and positive. You can warmly celebrate achievements and acknowledge milestones. Having a close friend or a trusting relationship at work has become increasingly desirable in fostering safety, innovation, and joy at work.109 It’s harder to resign from a hospital unit or work setting when the staff are your valuable colleagues and friends.

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Offers multiple ways to achieve success With an integrated approach to your work and nonwork life, you’re not “grading” yourself only on how you perform as a clinical nurse, friend or partner, parent, or whatever other roles you embody. You have multiple ways to view success and achievement. When life in one area is trending downward, like friends moving away or a relationship changing, you may be energized at work by being given challenging assignments, a promotion up the clinical ladder, or attending a motivating conference. Integration leads to many ways to chart progress toward your own varied goals. Being upset by disappointment in any role is normal, but it can be temporary and offset by the other aspects of life that bring solace, perspective, and enjoyment.

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Fosters well-being and happiness An integrated life can foster joy when, after a challenging day at work, you come home to your cheerful dog, a child who reports being chosen for the team, or maybe a surprise note from a friend expressing gratitude for you. Integration reduces the unrealistic expectation that your life should somehow be “balanced.” It allows you to savor and appreciate those aspects of your life that bring you joy, meaning, and fulfillment, no matter where they appear. An integrated life does not mean you design a life with neat, tidy compartments. Instead, you look to see how life synergizes across your roles. Experiencing compassion and gratitude at work is a gift you can bring home to family and friends. An integrated life creates harmony that can improve and sustain your well-being, foster more joy at work and home, and enhance meaning and purpose in life.

REFLECT What Can You Do? The following chart shows evidence-based strategies for creating your integrated life. Strategies

Implementation Ideas

Know yourself

Self-reflect. Make time for a mindfulness practice via a class, app, or even a retreat. Know what you’re good at and claim your space.

Seek support

Develop connections with others by being a good friend and colleague. Professional organizations are a good source of knowledge and support.

Offer support to others

Everyone should feel they matter. Offer support to colleagues, family, and friends; affirm them and reassure them.

Offer gratitude to yourself and others

Start a gratitude practice, writing down three things every day you’re thankful for. Each day, consider writing one thing about your colleagues that you are grateful for.

Use kindness as your default response

Pay attention and notice others. Be fully present to see when kindness is needed. Consider His Holiness the Dalai Lama’s comment: “My religion is kindness.”

Develop a spiritual discipline

For some people this is religion, and others call it spirituality. What’s important is that you stay in touch with your values and core beliefs. What are your nonnegotiables?

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I’m in a good place. Not emotionally . . . just that I’m at a taco stand. —@createthelove

Be Honest: Are You Burned Out?

Make It

a Good

Place to Work

Y

our workplace might not be as joyinducing as a taco stand, but it should be a good place to spend so many hours of your life—literally 100,000 hours in a typical career.110 You might spend more time with coworkers than you do with your children, partners, and friends,111 so where you spend this time should be a place that is worthy of you and your unique passion and dedication.

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The essentials How can your workplace support the health of you and your colleagues? There are a few qualities that have defined healthy work environments for the last 15 years. Your workplace should:112, 113, 114, 115, 116 • • Be a place where you can grow and develop, using all • your skills and interests • Have colleagues and • mentors whom you respect • across disciplines • Recognize you formally and • informally for your hard work and contributions

Protect you from harm Provide connection and community Uphold work-life harmony Make you know you matter Be an opportunity for growth

We suspect these essential ideas sound familiar. The evidence is clear that meeting healthy work environment standards benefits everyone, especially patients and nurses.117

Six standards for a healthy work environment In 2005, at the time of a serious nursing shortage and increasing reports of rising medical errors, poor workplace communication, staffing inadequacies, and rising moral distress among nurses, the American Association of Critical-Care Nurses released the AACN Standards for Establishing and Sustaining Healthy Work Environments.118 A second edition came out in 2016. You can look to these six standards for helping to create a quality environment that’s both an excellent place to work and be a patient.

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AACN Standards for Establishing and Sustaining Healthy Work Environments119

1 2 3

Skilled communication

Be as proficient in communication skills as you are in clinical skills.

True collaboration 

Be relentless in pursuing and fostering true collaboration.

Effective decision-making

Be committed partners in making policy, directing and evaluating clinical care, and leading organizational operations.

4 5 6

Appropriate staffing

Staffing must ensure the effective match between patient needs and nurse competencies.

Meaningful recognition

Be recognized and recognize others for the value each brings to the work of the organization.

Authentic leadership

Fully embrace the imperative of a healthy work environment, authentically live it, and engage others in its achievement.

REFLECT What Can You Do? See the standards in the previous list and ask yourself if you experience these in your current work setting. Are there steps you can take to uphold or create them?

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In the absence of community care, self care is insufficient. –Cheryl Grills

Be Honest: Are You Burned Out?

Take Care of

Each Other N

urses are rock stars when it comes to taking care of others—patients, families, and friends. What if you used this strength to care for all the members of your team? If one of your colleagues fell to the floor clutching their arm or chest, you would know exactly what to do. But what if they suddenly become withdrawn or tell you they’re quitting nursing? Depending on your relationship, you might make a pretty good attempt to keep them from leaving. Knowing that you cared enough to counsel your colleague would probably make a difference in their life.

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Tip of the iceberg in culture change The rest of the book focuses on some tried-and-true methods for helping your colleagues and yourself move through your work lives with better well-being, stronger connections to one another, and hopefully with more confidence to help each other flourish. But these aren’t the only ways to care for your colleagues in the workplace. It’s truly the tip of the iceberg. We hope these ideas and the real-life stories we share will inspire you to pay attention to the many ways you and your colleagues can foster each other’s well-being. We all want to work in cultures of respect, care, and joy, but sometimes creating culture change at work seems like a very heavy lift. In our experience, it’s overwhelmingly apparent that small steps matter. Each small positive change begets another. And another. We encourage you to be creative and persistent in this work.

Institutional responsibility Don’t forget though that leadership and institutions bear responsibility for the well-being of their workers, and this is especially true in healthcare. You’re not in this alone, nor should you be. In the remaining sections, in addition to actions you may want to try, we add steps that your leaders can take to foster the well-being of nurses and others. Feel free to leave this book with dog-eared pages and highlighted sections in places your leaders might find them.

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REFLECT Caring for Each Other Author and orchestra conductor Amelia Nagoski says, “The cure for burnout is not self care; it’s all of us caring for each other.”120 A social worker colleague of ours, Eboni Bugg, calls this “community care.” Think about a time when others cared for you when you needed it most. What was the situation, and what did they do to care for you? Do you agree that it’s not about self care but rather caring for each other?

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Rarely, if ever, are any of us healed in isolation. Healing is an act of communion. —bell hooks

Be Honest: Are You Burned Out?

The Pause:

When a Patient

Dies

I

n 2014, an emergency department (ED) nurse created a transformative moment after a patient died. They paused.

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It looked something like this: A patient was wheeled into the ED, and the EMS crew was performing CPR. After almost an hour of resuscitative efforts, the patient died. When the physician leading the code called the time of death, the ED RN, Jon Bartels, said: Let’s pause. Let’s pause here to honor the life in front of us that just ended. We don’t know this person, but we know that they loved and that they were loved. We know that they were a part of a family. Let’s pause to honor them and also let’s pause to honor everyone on our team that did all we could to help this person.121 Then the team stood in silence for about 45 seconds and went back to work. This pause started an international movement that is now being practiced all over the world in EDs, ICUs, oncology centers, and in board rooms.122 The pause has been shown to increase your ability to feel present and connect with other people.123 You can “micro-dose” pausing throughout the day. It doesn’t take long at all, but it can create space for compassion—for those around you and for yourself.

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REFLECT What Can You Do? Before you go into a patient’s room, pause at the pump, and as you gel in, take a deep breath and reflect on how you may do something to improve the life of your patient. At the end of a shift, close your eyes for 10 seconds and pause to wish all your patients and colleagues well. At the end of a huddle or meeting, say: “Let’s pause for a few seconds in silence to honor the wisdom and experience that everyone here brings to our work. Let’s reflect in silence on how we can use what we have learned and know together to support our patients, our team, and our community.”

What Can Your Leaders Do? Ask your leaders to design inservices and just-in-time training on the pause. Ask them to make it OK for team members to take small pauses throughout the day to reflect and rejuvenate. Encourage them to lead by example: Implement the pause as a regular part of leadership meetings.

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Every one of us is looking for the same thing—we want to know we matter. –Oprah Winfrey

Be Honest: Are You Burned Out?

Mattering

Matters W

hen was the last time you told someone they mattered to you? When was the last time you knew you mattered to someone else? How do you know what you are doing as a nurse matters?

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How to measure mattering To rephrase the question, how do you know your work is important or significant? It could be measured by discrete outcomes, like “my patient isn’t getting bedsores because I turned him appropriately,” or “my patient is getting better because I safely administered her medications and attended to her condition.” Or perhaps it could be that your patient is less nervous because you explained what would happen in the procedure that they are about to have done, or your patient’s family was at peace when he died because the team provided time and information that allowed them to have closure. For you, the answer to this question likely reflects the aspects of the job that you find most satisfying and significant. But is it enough simply knowing you have done something meaningful, or will it be important for you to receive validation from others?

Add value and be valued There are many personal connections and circumstances that contribute to your sense of mattering as a nurse. In our research, we’ve learned that something as simple as a coworker remembering your favorite menu item at a nearby restaurant can create a sense of mattering. Personal connections in which you feel seen as more than “just a nurse” create a sense of mattering. When someone checks in with you after an especially difficult shift or slips a protein bar into your pocket with the words “I know you haven’t had time to eat today,” these acts of kindness foster a felt sense of mattering.

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Meaningful acknowledgment for contributing to the team creates a sense of mattering. Blast emails do not convey mattering, but a personal email or handwritten note that says, “Thank you for what you did today” conveys mattering. The more specific you are in the note, the more meaning it will have to the person receiving it. There’s a lot your employer can be doing too. Meaningful acknowledgment includes adequate and equitable pay. It includes flexible hours so you can tend to yourself and your family. During Covid, a hospital social worker told us she knew she mattered because her employer provided “family care” benefits that she didn’t even know she had until the pandemic hit and she needed them to care for her father.

For your well-being It’s not surprising to find that when you feel like you matter, it impacts your well-being. Early work in healthcare mattering research indicates that a sense of mattering may mitigate against burnout.124 Researchers in the social sciences have linked mattering to a number of essential elements of well-being such as self-efficacy, personal growth, relatedness, social belonging, and life satisfaction.125 When you feel like you matter, you lead a richer and more connected life. There are many easy, inexpensive things we can all do. Try it out and help someone else know that they matter.

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REFLECT What Can You Do? There are many things you can do to make colleagues feel as though they matter. None of them are rocket science, but they require a degree of intention. First, learn and remember people’s names. If you’re in an academic medical center, this is especially important in the care and feeding of students who rotate on your unit. Try to learn a little bit about coworkers or staff who are new or with whom you interact less frequently. Everyone wants to be seen and appreciated for the complex people that they are. And here’s a bonus: Research shows that the best way to remember someone’s name is to learn a little bit about them.126 Check in with a colleague who may be going through a difficult time. A simple text message that says, “I’m thinking about you and hope you’re OK” tells the recipient that their well-being matters to you.

What Can Your Leaders Do? Encourage your leaders to be vulnerable. When appropriate, they should acknowledge that a particular situation is new territory for them, or that they’re learning, too, and would appreciate others’ patience and input. Vulnerability creates a safe space for others to be honest about their own vulnerabilities or discomfort with a situation.

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Prompt your leaders to be transparent. If a survey or other form of feedback indicates that the team needs change of any kind, make sure leaders explain the organization’s response or lack of response. Silence indicates that health workers’ opinions and needs don’t matter. A direct and transparent conversation when a leader says, “We have heard your concerns, and we are taking steps X, Y, and Z to fix them” helps to set clear expectations. If no immediate change is forthcoming, ask your leaders to explain. This should go without saying, but equitable pay tells others they matter to the organization. Seeing a supervisor or manager advocate for the team sends a powerful message about mattering. Free T-shirts, cupcakes, and balloons for a job well done may not convey a personal sense of mattering to frontline workers. Instead, your leaders could ask what recognition would be meaningful for those they wish to acknowledge. It will most certainly be different for different groups. Even the act of inquiry conveys a sense of mattering. As an example, DAISY Awards are a form of meaningful recognition because they are for a specific act of extraordinary compassion, and because each nurse is nominated by someone who has observed them up close and personal.

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an essay

Transhealth: A Success Story Rooted in Peer Support and Authenticity –by Dallas Ducar Transhealth, rooted in Western Massachusetts, has created a responsive, reflective, and trauma-informed organization. The organization’s values, based on liberation and authenticity, are consistently discussed and modeled in the spirit of creating a home for patients and each other. There are no dress codes. We call each other “team” to decenter any one profession. We practice at the top of our licenses. We also understand the scope of each other’s licenses, so we have realistic expectations of each person’s professional practice.

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Every week, everyone in the organization meets to discuss gaps in care and works together to solve issues. Once a month we hold a “Startup Day” and extend this meeting block to four hours to roll up our sleeves and work together. It’s about professional practice, and it’s about finances too. We keep our budget transparent, and departments are empowered to direct their budgetary needs. Our teams are invited weekly to anonymously report on how they’re doing so that we can better support those needing resources and hold leadership accountable. When reporting our own stress levels, we use a modified version of the “Stress First Aid scale” to de-pathologize talking about stress and instead speak to whether we are in the “green, yellow, orange, or red” zone. We do all this with a steady dose of humor, compassion, and peer support. I will never forget the first day of onboarding when a new clinician said, “I’ve been working in healthcare for years, and I’ve never worked at a place where the organization cares as much about me as they do the patients.” That same day another new clinician remarked, “I’ve never worked at a place where I am actually excited for the team parties!” We’ve been predominantly excluded from the table, uninvited from the party, not counted in surveys—leading to a loss of our own voice and ability to change the system. Transhealth seeks to change this.

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As a team of trans, gender-diverse, and queer folks, we know what it feels like to face a world that actively seeks to harm you. So many of us have arrived at Transhealth with remnants of distrust and trauma and seek to build a collaborative and empowering home together. We know that the victories that lie ahead will not just be for gender-affirming healthcare, but all healthcare. The first lesson is simple. When people can show up to work and be their authentic selves, they will undoubtedly be able to show up fully for themselves and others. This creates a work environment that is rooted in liberation and authenticity—and consistently discussed and modeled—in the spirit of creating a home. In this home, everyone has the opportunity to be themselves and therefore demonstrate authentic leadership. This inspires open dialogue and trust and creates a space where colleagues can support each other in meaningful and hopeful ways, and even love being at work with others. We, therefore, have a duty to foster a moral vision of the future. We live in a time with tremendous resources and the power for entire systems to heal. To do this, we must disassemble the system, reexamine its values, and ensure that the institution reflects both the values of the organization and, more importantly, the authentic humanity of the people who work within it.

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When we can truly show up and be ourselves, we foster an environment where everyone can care for themselves, their patients, and each other. Being authentic takes a tremendous amount of trust, and that can only be possible by co-creating a home—a place where you can be you, whether you’re a patient, client, or team member.

About DALLAS DUCAR, MSN, RN, PMHNP-BC, CNL, NREMT-B, NP (she/her/hers), is CEO of Transhealth in Northampton, MA.

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It’s important to make sure that we’re talking with each other in a way that heals, not in a way that wounds. –Barack Obama

Be Honest: Are You Burned Out?

Put an End to

Bullying and Incivility

I

ncivility takes various forms, but you definitely know it when you see it. Toxic behavior in the workplace—anything on the continuum from rude behaviors such as eye-rolling and disrespect to more serious instances of intimidation and even physical aggression127—leads to as much as an eight-fold increase in burnout symptoms.128

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One of our students, Tom, chose to work in a busy emergency department in a large teaching hospital for his first job. For the most part, he enjoyed the pace, his preceptor, and the teamwork of his colleagues. What he wasn’t prepared for was the backbiting and gossip from the nursing staff. He said he would enter the break room and hear them talking about other new graduates in derogatory terms. “Don’t they teach them anything in nursing school?” these nurses lamented behind closed doors. He wondered if they talked about him that way as well. It made him wonder if he had made the right choice choosing to work in this department. Nearly half of all direct care nurses are planning to leave their current positions because they no longer wish to endure bullying and incivility.129 In addition to its impact on staffing turnover, there’s a steep emotional cost of incivility. Nurses are at risk of depression and burnout, and it’s not just the individual nurse alone who suffers, but patients and families as well. Consider this: A study of teams in a neonatal intensive care unit demonstrated that rudeness alone in this intense clinical environment can negatively influence diagnostic and procedural performance, leaving fragile premature infants at risk.130 While being nice to others may be considered a “soft skill,” it truly can be hard unless practiced repeatedly, in an authentic way. It’s easier to be kind in work cultures that support kind behavior. Kindness cannot be overrated, and we agree with Sharon Salzberg that kindness is compassion in action.131

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REFLECT What Can You Do?

Be an upstander. In these situations, you have the responsibility to speak up. Monitor your own behavior. Cynthia Clark, a frequent author on civility in the academic setting, notes that the keys to stopping incivility include reflecting before acting, speaking, or sending an email that could easily be misinterpreted.132

What Can Your Leaders Do? Encourage your leaders to rely on nurse managers. Nurse managers are essential to de-escalating the drama at work. Once a leader sees a pattern of abusive behaviors among staff, they have a mandate to stop it early. An effective nurse manager will seek multiple viewpoints to a story, stay realitybased, provide coaching to the nurses causing drama, and establish new behavioral expectations and norms.133 Leaders must hire the right people and build a strong team. As savvy nurses figure out, hospital units have reputations, and the units that have a reputation for unkind behaviors are the ones to avoid. It’s no surprise that these units often have trouble retaining good nurses while other units with reputations for supportiveness and positivity often have waiting lists of nurses wanting to join their team. It’s a virtuous cycle— turnover is reduced with a healthy work environment, thereby reducing the need to hire nurses with less desirable behaviors.

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a conversation

Get the Team Together, Get the Team Outdoors –with Samantha Henry When we’re about to take off on a flight, we’re told to put the oxygen on ourselves before assisting someone else with theirs. In our active shooter training, we’re taught to save ourselves first in order to be in a position to help someone else in the future. As nurses and healthcare providers, we’re so accustomed to taking care of others, we often take ourselves for granted. Sometimes, we don’t even notice that we need to come up for air. This is a critical component to burnout and compassion fatigue. As the unit director, I’m now responsible for my staff. Wellness is very important to me, and I’m mindful about putting on my own oxygen. By doing so, I’m able to better focus on my team. I coordinate the monthly outings so that my team doesn’t have to plan or figure it out. They just have to sign up and go. My outings are primarily outdoors during spring, summer, and fall. During the winter, activities are indoors. It’s my opinion that nature heals.

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Taking in the beauty of the trees and the streams shifts focus. The sun warms the spirit, and the breeze provides a breath of fresh air. The best part is that it’s free for everyone. I don’t have to tell anyone this is why we plan our outings— they feel if for themselves. Every single time. I coordinate activities that appeal to various levels of fitness and interests. Not all activities are outdoors. I recognize that being outside doesn’t appeal to everyone. Some prefer indoor social activities or events that bring out the artist in all of us. True, some are better artists than others, but the sense of relaxation and accomplishment is the same—sense of wellness and well-being. Each year I’m able to get more and more participants. Today, I even get recommendations of different outings staff would like to see. My hope is that exposure to my monthly outings will not only wake up their own personal desire to maintain their wellness but also help them to begin to manage the maintenance of their own oxygen.

About SAMANTHA HENRY, MBA, BSN, RN, is the director of a transplant unit at Emory Healthcare.

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True optimism involves seeing the world as it is, yet still believing—and more importantly, behaving—in ways that create better outcomes for all of us. –Karen Reivich

Be Honest: Are You Burned Out?

Advocate for Yourself

and Others

T

he many definitions of burnout all point in the same direction: Burnout is caused by workplace stressors. It’s important, then, that you focus your well-being efforts on the workplace if you want to reduce or eradicate burnout.134 Practicing self care away from work is important, and as you can see from this book, we fully support self care everywhere and anywhere. But when a leader, boss, manager, or director ignores the workplace stressors and tells you to just go practice self care on your own time, that’s when you should consider looking for another job.

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The three things Researchers at Stanford University have spent years trying to determine what keeps teams well. They identified three straightforward things that you can do to support yourself and your teammates: nutrition, rest, and mindfulness. Here’s a checklist from their findings, with basic steps to make them available to you and your team.

1. Eat. A randomized trial has shown that when health workers have adequate nutrition, their risk of causing patient harm goes down, and their quality scores go up. People with adequate nutrition can think better and more clearly, and they essentially make better patient care decisions.135

REFLECT What Can You Do?

Advocate for meal times for your teams. Keep pushing your manager or director to make sure that there is float coverage so that another nurse can come in and cover all your patients while you eat. Some units have created “lunch buddy” programs to help with meal coverage. Share evidence in your unit practice council that taking breaks does matter, and advocate for 45-minute or even hour-long breaks.

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If you like to cook, consider making nutritious meals every now and then for your teams to come together and build community at work. Small steps can have a positive ripple effect. Others may follow your lead. We love a team in a rehab hospital that instituted monthly potlucks; staff were invited to bring dishes from their country of origin to share with their coworkers. They even invited the nutrition services staff to join the fun, but they weren’t allowed to cook!

What Can Your Leaders Do? Tell your managers that you want them to push for healthy food options in your hospital’s cafeterias. There are many hospitals that have instituted healthy food option programs, offering more nutritious food and displaying calorie counts or colored health labels, to name a few. Remind them that when we eat well, we think well, act well, and live well. Encourage your leaders to support a culture of shared governance. Whether it’s called shared governance or professional governance or you collaborate with a union— the language doesn’t matter. What does matter is that leadership supports structured ways for the nurses they serve (like you) to have a meaningful voice. With a meaningful voice, you can advocate for lunch breaks, rest breaks, and psychologically safe spaces to refresh.

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2. Take micro-breaks. We talked earlier in the book about the importance of sleep, but what about physical and mental rest during the workday? We know, it feels like an act of resistance, and in many ways, it is. Yet research (and common sense) shows that by taking small breaks during the workday, people can feel more vitality in their work, less fatigue, and more positive emotions.136 Try a quick walk, watch a fun video, have a snack, or take a power nap. The key is to do something you enjoy and something not related to work. Checking your email doesn’t count.

“

We think rest matters because you matter. You are not here to be ‘productive.’ You are here to be you, to engage with your Something Larger, to move through the world with confidence and joy.

And to do that, you require rest.  –Emily Nagoski,  Burnout: The Secret to Unlocking the Stress Cycle137

”

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REFLECT What Can You Do?

Encourage your team members to take short breaks, even for short amounts of time during the working day. Hannah White, the pediatric orthopedic nurse we met earlier, takes a brief afternoon tea break nearly every day without fail. Her colleagues have begun to ask her, “Is it teatime yet?” and are slowly adopting the ritual of an afternoon break themselves. Get creative with your manager to think about ways to allow short, 10-minute breaks during shifts. Support a culture of teamwork and trust where you can cover for other nurses to let them relax. Prioritize rest by turning off screens when you are on your breaks, prop up your feet, take a few deep breaths, and maybe even close your eyes. (Don’t forget to set an alarm!) Print or copy the quote on the previous page and post it in your workspace. It may seem trivial, but for the often-glacial culture change to occur, we need to nudge it along with small acts of kindness and compassion.

What Can Your Leaders Do? Leaders should talk with their colleagues in human resources to ensure that there are policies written in support of rest for teammates. Make it OK for someone to take a power nap during their unpaid lunch or dinner breaks. Leaders should think about ways to create spaces where you work that are away from patient view and where it is safe to close your eyes for a few minutes. Power naps increase your power!

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3. Be mindful. Many people talk about mindfulness, and there are countless smartphone apps that encourage us to practice mindfulness meditation. Some of them are very helpful, but be wary. For one thing, looking at your phone can actually make you less mindful and more stressed because phones are so distracting and often contain stressful content. (Think global news. Election results. You know what we mean.) Try this instead: Look up. Really, just look up and notice the clouds, the trees, your real surroundings. Then take a deep breath and get back to it. That is a way to microdose self care. Mindfulness is a practice, and it’s how we practice paying attention—how we pay attention to other people, our colleagues, our patients, and of course, ourselves.

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REFLECT What Can You Do? When you’re walking between patient rooms, focus on what it feels like to simply walk. When you’re listening to a patient or a colleague, focus on what it feels like to simply breathe in and out while you listen. When you perform hand hygiene, try focusing simply on what it feels like for your hands to touch each other, the texture of the gel or soap, and the feeling of the water as you rinse. Keep mindfulness simple, and simply notice.

What Can Your Leaders Do? Encourage your managers or directors to carve out a few seconds at the beginning or end of huddles and meetings to remind everyone to take a few breaths together. They can use this time to remind everyone to feel their feet on the floor or their backs against a chair. They can remind your teams to practice being present for just a few short seconds.

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an essay

Self Care for Nurses

Research Mentorship for Social Justice and Well-Being –by Roxana Chicas When I entered the nursing PhD program at Emory University, I had so much anxiety. I worried I wasn’t as well prepared as my peers. I’m a first-generation Latina college student. Most of my peers came from college-educated families. They were well traveled and knew so much about research. I came to the United States at the age of 4, literally on my mom’s shoulders as we crossed the Rio Grande. I was undocumented until the age of 18, when I obtained Temporary Protected Status. Somehow, I got into a PhD program at an R01 institution that values NIH funding. As a TPS holder, I was ineligible to submit for NIH grant support. My anxiety was further exacerbated when I was notified that the Dean of the Nursing School, Linda McCauley, would be my advisor. Surely it is a mistake, I thought. Nonetheless, she was in fact my advisor. I purchased a new outfit to wear to my first meeting with her. I dressed to impress since I would probably not impress her with my intellect, as I did not have a specific research question. One of the first things the Dean told me at our first meeting was that she didn’t expect me to have a research question. She said this to me even before I revealed that I didn’t have a research question. It was as if she intuitively

Honest: Youstatement, Burned Out? my199 knew exactly what to say to me. Be With thatAre one anxiety reduced drastically. I trusted and believed her. Later, she told me I would apply for small grants from various nonprofit organizations to support my dissertation study. I realized my immigration status and the fact that I couldn’t apply for NIH funding had not dissuaded her from taking me on as her student. She didn’t see my immigration status as a burden! This to me exemplified that as a leader she lived by the values of excellence and social responsibility—that there was space for all of us under her leadership. I felt a sense of belonging and happiness. I felt accepted and supported. I felt wellness. 

As our relationship progressed, I realized that for my advisor to give me the guidance I needed, I had to be willing to be honest and speak up about my needs and challenges with her. There were several instances when I had to tell her I didn’t know how to do something, that I needed her guidance. Every time, I felt nervous and embarrassed. And every time, she met me where I was and gave me the guidance I needed without judgment.  Dean McCauley’s mentorship is an example of effective allyship and action that has transformed my life and advanced racial justice. She used her privilege to ensure that I had resources as a student. She was and continues to be committed to ensuring that power is equitably shared. This transformative leadership and healthy workplace have profoundly contributed to my professional and personal wellness.

About ROXANA CHICAS, PHD, RN, is an Assistant Professor in the Nell Hodgson Woodruff School of Nursing at Emory University.

I keep telling them, “You don’t have to set yourself on fire to keep other people warm.” Healthcare can’t just be about making patients well. We have to care for the healers, too. –Mona Masood

Lead From Where You Are We invite you to become a leader in self care and community care in whatever way that means to you. This leadership may take a rich variety of forms: practicing it, learning about it from others, encouraging your teammates, teaching it to your patients, and advocating for policies and practices with your leaders. The way that you lead can reflect your own passions, skills, and creativity. We hope that you are energized to explore the possibilities.

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The letters after your name and your official role in your organization don’t matter when it comes to caring for yourself and those around you. To lead in self care, simply remain connected to the profoundly beautiful meaning of your work as a nurse. We are healers. We all experience suffering during our lives, leading us all on a journey toward healing ourselves while we heal others. Our fire—the fire fueled by compassion, excellence, and determination—can keep us and those around us warm. We can lead self care by living it; and by living it, we lead. Be well, friends.

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126. Willingham, D. T. (2021, August 22). Remembering names can be tricky. Lots of strategies flop, but one actually helps. Washington Post. https://www. washingtonpost.com/health/tricks-for-remembering-names/2021/08/20/e889bedaf566-11eb-9738-8395ec2a44e7_story.html 127. Clark, C. M. (2020). The imperative of civility in uncertain times. Nurse Educator, 45(4), 173. https:// doi.org/10.1097/NNE.0000000000000874 128. Brassey, J., Coe, E., Dewhurst, M., Enomoto, K., Giarola, R., Herbig, B., & Jeffery, B. (2022, May 27). Addressing employee burnout: Are you solving the right problem? McKinsey Health Institute. https://www.mckinsey.com/mhi/our-insights/ addressing-employee-burnout-are-you-solving-the-right-problem 129. American Nurses Foundation. (2022, August 2). Pulse on the Nation’s Nurses Survey Series: 2022 Workplace Survey. https://www.nursingworld.org/~4a209f/ globalassets/covid19/anf-2022-workforce-written-report-final.pdf 130. Riskin, A., Erez, A., Foulk, T. A., Kugelman, A., Gover, A., Shoris, I., Riskin, K. S., & Bamberger, P. A. (2015). The impact of rudeness on medical team performance: A randomized trial. Pediatrics, 136(3), 487–495. https://doi.org/10.1542/peds.20151385 131. Salzberg, S. (2005). The force of kindness: Change your life with love and compassion. Sounds True. 132. See Endnote 127. 133. Sherman, R. O. (2020). Dialing down drama at work. American Nurse Journal, 15(6), 24–26. 134. Cunningham, T., & Pfeiffer, K. (2022). Posttraumatic growth as a model to measure and guide implementation of Covid-19 recovery and resiliency. Nursing Administration Quarterly, 46(1), 81–87. doi:10.1097/NAQ.0000000000000509 135. Makowski, M. S., Trockel, M. T., Menon, N. K., Wang, H., Katznelson, L., & Shanafelt, T. D. (2022). Performance nutrition for physician trainees working overnight shifts: A randomized controlled trial. Academic Medicine, 97(3), 426–435. https://doi.org/10.1097/ACM.0000000000004509 136. Albulescu, P., Macsinga, I., Rusu, A., Sulea, C., Bodnaru, A., & Tulbure, B. T. (2022). “Give me a break!” A systematic review and meta-analysis on the efficacy of micro-breaks for increasing well-being and performance. PLoS ONE, 17(8), e0272460. https://doi.org/10.1371/journal.pone.0272460 137. See Endnote 105, p. 184.

About the authors Natalie B. May, PhD, transitioned to the University of Virginia (UVA) School of Nursing after 30 years as Associate Professor of Research in the Division of General Medicine in the UVA School of Medicine. She is a founding member of the UVA Center for Appreciative Practice. Certified as an Appreciative Inquiry facilitator and lead author of Appreciative Inquiry in Healthcare, she enjoys developing appreciative inquiry projects and teaching appreciative practice workshops at her home institution and beyond. She is an experienced qualitative researcher, and her current work focuses on mattering in medicine and the wisdom of nurse managers. She is co-author of Choosing Wisdom: The Path Through Adversity, and co-producer of a PBS film, Choosing Wisdom. She is now the project manager for an HRSA-funded training grant, Wisdom and Wellbeing Peer Support Training, for healthcare workers and first responders at UVA and in Central Virginia. She earned a BA in economics and urban studies from Wellesley College, an MA in creative writing from Boston University, and her PhD in educational research from the University of Virginia Curry School of Education. May lives in Richmond, Virginia, with her husband, Jim. Her most consistent and effective self-care practices are modern quilting and walking near water, especially the James River and the Outer Banks of North Carolina.

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Tim Cunningham, DrPH, MSN, RN, FAAN, began his professional career as a performing artist and clown. As a clown, he worked for two organizations that changed his life. The first, the Big Apple Circus, employed him to perform as a clown doctor at Boston Children’s Hospital, Yale New Haven Children’s Hospital, and Hasbro Children’s Hospital. Concurrently, he volunteered for Clowns Without Borders (CWB), performing in various refugee camps, war zones, and other global zones of crisis. He later served as Executive Director of CWB. It was in pediatric hospitals and refugee camps where he witnessed and began to learn about the true meaning of resilience and self care. This performance work inspired him to pursue a career in nursing, and so Cunningham completed a second-degree nursing program at the University of Virginia. He became an emergency trauma nurse and worked clinically in Charlottesville, Virginia; Washington, DC; and New York City. It was during his time in New York City that he completed his doctoral degree in public health at the Mailman School of Public Health at Columbia University. Cunningham is the former Director of the Compassionate Care Initiative at the University of Virginia, where he had the opportunity to work closely with Drs. Fontaine and May as this book came to fruition. He currently lives in Atlanta, Georgia, and serves as the Co-Chief Well-Being Officer for the Woodruff Health Sciences Center at Emory University. He also holds a joint appointment as an Adjunct Associate Professor at the Nell Hodgson Woodruff School of Nursing at Emory University. Cunningham began his academic journey receiving his BA in English from the College of William and Mary in 2000. For self care, he is an avid runner and wanna-be gardener. He loves any chance he can get to swim in the ocean or meditate as the sun rises.

About the Authors

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Dorrie K. Fontaine, PhD, RN, FAAN, is the Dean Emerita at the University of Virginia (UVA) School of Nursing, where she served as dean for 11 years until 2019. A champion of creating healthy work environments in clinical and academic settings, she is a Past-President of the American Association of Critical-Care Nurses. In 2009 she created the Compassionate Care Initiative at UVA, which has grown to be a guiding force in transforming the culture of the school with a focus on fostering human flourishing and resilience for students, faculty, and staff. A noted author of critical care texts, a leadership book, and multiple papers and presentations on creating healthy work environments through compassionate care, Fontaine credits a retreat at Upaya Zen Center in Santa Fe in spring 2009 with the Abbot, Roshi Joan Halifax, for setting her on the path of mindfulness, meditation, and a renewed focus on self care. She attended Villanova University and the University of Maryland and received her PhD from The Catholic University of America. Her four-decade career of teaching and academic leadership includes positions at the University of Maryland, Georgetown University, and the University of California, San Francisco. Fontaine lives in Washington, DC, and the Blue Ridge Mountains of Virginia with her husband, Barry.

Acknowledgments We thank our students and colleagues, especially the nurses we are so fortunate to know and work with. We also thank our always gentle and supportive creative team at Sigma who launched this book with their vision of “small doses” for our nurses: Alexandra Andrzejewski, Carla Hall, Emily Hatch, Becky Batchelor, Todd Lothery, and Dustin Sullivan.

Copyright © 2023 by Sigma Theta Tau International Honor Society of Nursing All rights reserved. This book is protected by copyright. No part of it may be reproduced, stored in a retrieval system, or transmitted in any form or by any means, electronic, mechanical, photocopying, recording, or otherwise, without written permission from the publisher. Any trademarks, service marks, design rights, or similar rights that are mentioned, used, or cited in this book are the property of their respective owners. Their use here does not imply that you may use them for a similar or any other purpose. This book is not intended to be a substitute for the medical advice of a licensed medical professional. The author and publisher have made every effort to ensure the accuracy of the information contained within at the time of its publication and shall have no liability or responsibility to any person or entity regarding any loss or damage incurred, or alleged to have incurred, directly or indirectly, by the information contained in this book. The author and publisher make no warranties, express or implied, with respect to its content, and no warranties may be created or extended by sales representatives or written sales materials. The author and publisher have no responsibility for the consistency or accuracy of URLs and content of third-party websites referenced in this book. Sigma Theta Tau International Honor Society of Nursing (Sigma) is a nonprofit organization whose mission is developing nurse leaders anywhere to improve healthcare everywhere. Founded in 1922, Sigma has more than 135,000 active members in over 100 countries and territories. Members include practicing nurses, instructors, researchers, policymakers, entrepreneurs, and others. Sigma’s more than 540 chapters are located at more than 700 institutions of higher education throughout Armenia, Australia, Botswana, Brazil, Canada, Colombia, Croatia, England, Eswatini, Ghana, Hong Kong, Ireland, Israel, Italy, Jamaica, Japan, Jordan, Kenya, Lebanon, Malawi, Mexico, the Netherlands, Nigeria, Pakistan, Philippines, Portugal, Puerto Rico, Scotland, Singapore, South Africa, South Korea, Sweden, Taiwan, Tanzania, Thailand, the United States, and Wales. Learn more at www.sigmanursing.org. Sigma Theta Tau International 550 West North Street Indianapolis, IN, USA 46202 To request a review copy for course adoption, order additional books, buy in bulk, or purchase for corporate use, contact Sigma Marketplace at 888.654.4968 (US/Canada toll-free), +1.317.687.2256 (International), or [email protected]. To request author information, or for speaker or other media requests, contact Sigma Marketing at 888.634.7575 (US/Canada tollfree) or +1.317.634.8171 (International). ISBN: HARDCOVER ISBN: EPUB ISBN: PDF ISBN: MOBI ISBN:

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___________________________________________________________________ Library of Congress Control Number: 2023003551 ___________________________________________________________________

First Printing, 2023 Publisher: Dustin Sullivan Acquisitions Editor: Emily Hatch Development Editor: Alexandra Andrzejewski Project Editor: Alexandra Andrzejewski Interior Design/Page Layout: Rebecca Batchelor

Managing Editor: Carla Hall Publications Specialist: Todd Lothery Cover Designer: Rebecca Batchelor Copy Editor: Todd Lothery Proofreader: Todd Lothery

Additional resources available for Self Care for Nurses: Small Doses for Wellness Follow the QR code or link below for a book sample and additional free resources for Self Care for Nurses: Small Doses for Wellness.

http://hdl.handle.net/10755/23013

Other Sigma self care books for nurses from Natalie, Tim, and Dorrie: Self-Care for New and Student Nurses

https://www.sigmamarketplace.org/ self-care-for-new-and-student-nurses

The following instructional materials are available as free downloads from the Sigma Repository (use QR codes for Repository downloads) and available as for-purchase print books from your preferred online retailer. Simply search for the title and purchase the workbook or instructor guide from any online retailer. Instructor Guide for Self-Care for New and Student Nurses Workbook for Self-Care for New and Student Nurses