Surface – Fostering Well-being in the Nursing Community: Finding our voice to ask for support – Part 1

To help us today we have a very special guest, Dr.  Cynda Rushton. Dr. Ruston is an Ann and George L.   Bunting professor of clinical ethics at the  Johns Hopkins Berman Institute of Bioethics   and School of Nursing and co-chairs John Hopkins  Hospital Ethics Committee and consultation service.  

Dr. Ruston has a rich and extensive experience  that includes co-leading and co-chairing several   national initiatives to transform moral distress  into moral resilience and contributes to expert   panels to initiate cultures of ethical  practice. She is the editor and author of  

have implications that we may not recognize. So   Cynda, do you mind starting us off with unpacking  for us a little bit about the lexicon around   well-being and mental health and mental illness? 

That's a great question and I would add one more   to that list, which is the issue around resilience  because these are all terms that are part of our   narrative right now and they are words that  have strict meanings that somehow have,   in many instances, been corrupted in one way or  another and have kind of drifted far from their   original meaning. So to me, the well-being umbrella  is a is an umbrella that encompasses all parts  

created as memes. The idea of  resilience is about bouncing back but actually   that is only one small dimension of what it means  to be resilient. It means our ability to meet   challenges in ways that are healthy, that allow  us to create meaning and learn from them and to   grow as opposed to be overwhelmed and degraded 

by them. So if you think about that word   sometimes they can become weaponized where there's this this sort of narrative of   don't tell me to be resilient because  that puts all of the responsibility on me as an   individual. In fact, nurses are already resilient  and they wouldn't be nurses if they weren't.  

I mean just surviving birth is a resilient  process so I think it really matters how we sort   of set up this conversation the dichotomy of  on the one hand we say either you're burned   out or you're resilient and what we know is  that those are actually two distinct concepts   that the absence of resilience is not necessarily  burnout and the converse is also true that if   you are burned out doesn't mean that you are not 

resilient. It may well mean that the circumstances   have exceeded your capacities to meet those  challenges, not because you're deficient or   lacking but because they're exceeding anyone's  abilities to sort of stay healthy and whole.   Then we sort of drill down even further on  the mental health / mental illness continuum.  

One of the things we often see is we conflate  our biases, our understanding of mental illness   with the concept of mental health and when we  do that there's an opportunity where there's a   lot of projection of stigma and assumptions  about what it means to be mentally healthy.  

The mental illness frame I think leads us  down a path where it can really reinforce some of   our biases about being able to be honest about  our limitations about where we're struggling,   where we might need support in a more  proactive way versus the diagnosis   that requires a different kind of  intervention. It is   being really specific about where we're  locating ourselves in the conversation.  

I really appreciate that and two things that are  running for me as I'm hearing all that one is that   being burned out and being resilient are not  mutually exclusive and I also hear in that is that   an individual can in terms of their mental health  can be unhealthy   but they're not it's not a mental  illness, correct? Exactly and I think   being able to sort of see that  continuum can help us shift from this  

stigma that goes along with the whole idea. I mean,  as a as a culture we have so much bias about how   we think about mental illness even within nursing.  If you can't see that you have an injury   or an illness then there's all  these questions that come up about well,   why don't you just take care of that? Can't you 

just control that or can't you fix that? Instead of   applying the very same compassion and  curiosity that we would for a person who had   heart failure or cancer to a person who may  be struggling with mental challenges   of depression or anxiety or in our workforce  right now, PTSD. I think it's a real opportunity   especially right now in our profession that  we really pay attention to those distinctions. 

It's so important and Michelle, I  was curious to hear Cynda's thoughts on   putting our lens on the the nursing workforce  in terms of well-being. You think we should   transition to that? Absolutely. Excellent. So  I'm wondering, I'd like us to put our lens of   this conversation on the nursing workforce right  now in terms of well-being and resilience.   I think there are a lot of factors at play  both for academia and practice that can really  

impact resilience and overall well-being. I think  about the pandemic. I think about this increased   spotlight on litigation for medical errors  and the impact it has on systems thinking.   I think about the nursing staff shortage and both  on academic faculty shortage and bedside practice.   All of these factors I see having a significant  impact on well-being and resilience and so I'm   curious to hear your perspective on what is the  state of our well-being as a profession both in  

academia and in clinical practice? Well, it's not  great. Let's just sort of tell the truth here.    It's not as if these are new problems. They have  been present for as long as I've been a nurse. The   the pandemic has really intensified them though in  ways that I've not seen in my profession.  

It's like we know from lots of  data that nurses are experiencing   high degrees of depression and  anxiety, PTSD, we're seeing more   of an uptick in suicide among nurses, which is  a very extreme response to a sustained   and often unrelenting stress that nurses are  experiencing along with the general public.   In my work we've seen you know evidence that  alongside all of these things the levels   of burnout are very high. Before the pandemic 

they were hovering around 40, 42 percent. We've   heard of levels of 60 or 80 percent of  nurses demonstrating symptoms of burnout   and a moral injury and moral distress. In one of  our studies four in ten nurses in our sample had   clinically significant symptoms of moral injury.  That tells you that there are extreme stressors   everywhere and it's not just in nurses who are 

delivering direct care. It's in leaders, but it's   also in faculty and students who are in this  milieu of trying to respond to this   overwhelming and unrelenting pandemic that we've  been in. I think that it is important for us   to pause and to say, you know, probably about  half of us have symptoms of depression. That   we are anxious and that it's not a moral  failing that we are experiencing these   kinds of responses to a situation that  really has exceeded all of our capacities.  

Some of us look like we're doing okay  but truth is none of us have been through this   experience unscathed. There's  I think an invitation for us to to step back   and to ask ourselves what's missing from 

our repertoire? I do believe that it is   on the one hand the lack of resources that  individuals have themselves to meet these   challenges but that is not sufficient to actually  address the system contributions that create the   conditions where this extreme stress and  distress and moral injury is occurring. So this is really important. I'm hearing really 

two levels of a concern. There's probably more in   there that I may not be picking up right away, but  there's sort of this individual moral distress or   experience of moral injury that I also feel like  is quite, I'm going to use the word contagious for   a lack of better words, but if you're experiencing  moral injury or or moral distress you're going   to be sharing that unconsciously or consciously 

with other people. So when I think about faculty,   if we're experiencing this kind of distress,  it's going to be projected and shared   and leaked out maybe even without 

our intention, in the classroom, in clinical. If   we're feeling anxiety it tends to and I just even  think about that personally as a mother, if I'm   feeling some stress at work and I walk in the door  and I don't clear that space I mean everybody's   gonna get some of that whether it's  just snapping or being short-tempered...  

And if you think about a nurse feeling  that in the context of patient care, how   serious that can be for one another from the morale of the unit and then for the patient care   and family care directly? So that's concerning  to me just the ripple effect and then I also   heard you mention systemic, right, systemically  if we're not addressing some of the systemic   barriers or challenges then it's just all  going to continue to be experienced.  

I think that's a really good point. The  sort of moral suffering that people experience   often is related to the gap between what they  think they ought to do and what they are actually   doing and I think this is also a time when  we again, back to your point about language,   the reason that we're distressed  about staffing is because   not having the resources to provide care that we  know we could under other circumstances creates   this dissonance and distress that somehow 

I'm not fulfilling my ethical obligations   to my patients or to my students. That  is a kind of moral residue that stays with   us and it begins to accumulate and we begin to...  our integrity begins to be degraded and it has   physical and psychological consequences.  And what you're talking about Michelle I   think if you think about it from our nervous  system, we resonate with each other's energy   and our nervous system is oriented toward threat. 

So when we come in with negative energy we're   more likely to start resonating, everybody else  is going to start resonating with that as well   and you know you put on top of that if you think  about the features of burnout, emotional, exhaustion   cynicism, lack of personal accomplishment, one of  the things that's happening and an unconsciously   the spread of this negative narrative  is that our cynicism about our work has been   fueled again and again and again by repeating the 

negative disempowering narrative about burnout.   So we're we're inadvertently reinforcing in  our nervous system this fight or flight freeze   kind of responses that don't actually help us to  be able to connect to each other to connect to   ourselves and to connect to the resources that  we might need to help us to navigate through  

this particularly challenging time. I think  what's interesting too is the probably people's   I don't want to say lack ,almost lack  of skill or awareness to talk about   moral distress and discomfort and so when  I'm experiencing this nervous system   disturbance, we'll just call it a fight  or flight, or this elevation,   it's felt by others and then people don't know  how to respond to it so people will then either shut down or they may even say, are you okay? 

I'm usually...I'll be honest. I'll say I'm fine.   I'm fine because I'm just trying to like keep  it together or keep it down. I've learned to say   to stop when I get that kind of input to stop  and check myself. Am I feeling fine? Where am I not   feeling fine? Why am I not feeling fine? But that  took some time and intention and a long history of   experiencing burnout and distress to navigate  that space. But if we don't have the language, if we don't have the 

skills, we're not going to connect. We're just   going to separate and I think I've experienced  that many times personally, but I'm worried more   again about the profession at this separation  that we're experiencing and seeing  

and that's concerning. Yeah. If you think  about one of the consequences of the pandemic is   in part because everybody was in PPE,  we're masked up, we are not in our usual   settings that many people in the midst of  feeling challenged emotionally and physically   they're also socially challenged of isolation.  And one of the consequences is we begin to   question - do I belong here? Do I belong in this  profession? Do I belong in this organization?  

It's part of that cascade of how  when these kinds of experiences accumulate that if   we're not able to notice, as you said Michelle, , am I really okay? And how do they   then ask for and receive support and resources?  I feel like this is one of the big issues in  

nursing right now. One is who are we now and the  other one is how do we create an environment   where asking for and receiving support is a norm  that we all uphold and honor and how we then can   create systems that make it easier for us to  do that so that the the kind of stigma that   we often associate with mental health and that  overlap I'm mentally ill now because I'm   feeling so sad today, that I'm depressed or I'm 

so anxious I can't focus. The labeling of those   experiences as somehow bad or wrong I think  is something we have to really pay attention   to in nursing because we've got a culture where it's the survival of the fittest and we do not have a lot of tolerance if you  seem to be struggling. We're like, well, that's not how to be in our  profession and so I think that's that's a   place where we we need to spend some time  examining how we're all contributing to that.

As I hear this and I think about this it  makes me think about who I consider might be   our most vulnerable in the nursing profession  and I think about our new grads those who are   transitioning to practice whether they're  transitioning to practice at entry level   or transitioning to practice an advanced  practice level and we know the rates of  

retention. We know the risk to leave the profession especially in the first one   to two years and then you layer on that all of  these other stressors and factors and it makes   me wonder are we doing enough on the academic  side when we talk about readiness to practice,   our lenses usually do they have the knowledge the  skills abilities to be safe and competent nurses? 

Add to that, are we really doing enough to help  prepare them with the language, the reframe, the   skill set to be able to take on these stressors  and build resilience and focus on well-being?   My gut intuition is thinking I don't think  we're doing enough, no, I don't think we are and   you know it's interesting if you  think about all of our DEI efforts   this is another area where there is a lot of  diversity but also a lot of stigma and bias  

that goes along with it. If we were to think  about how we create an environment of inclusion   we have to also think about this issue - how stigma's perceived - that a   person who's struggling is somehow irrational  or not real, not reliable, and I've learned so   much about this from my colleague Elena Bergman  who's a doctoral student here at Hopkins and Katie   Boston Leary who has done a lot of work in 

this area of of stigma. So how we even   explore that and from those biases how we  internalize the message that I should be   able to you know pull myself up by my bootstraps  and meet this challenge. I think inadvertently   we may be in academia giving the message  that if you you can't make it here   and follow the the path that we've set  out for you probably don't belong here.  

Then you add on to it the anticipated  stigma - what are people going to think about me if I ask for help and and then how do leaders  and faculty members respond when students say   I'm really struggling. Do we accommodate, to  what extent, how do we really   respond to that. Then the the last part is really sort of enacted stigma   it's what happens and what the experience is  when you actually take the risk to ask for help.   Do people gossip? Do they respond with compassion? 

Do they label certain individuals in a way   that is really unjust and and potentially  disrespectful? I think in academia it is   for one thing we have to look at ourselves and  how we are showing up in the classroom and in   our own work, how we are with each other. Students  are watching. They're watching how we are together   and I think until we do that work   there's a risk that our engagement  with students can sound kind of hollow.

I think we have to really pay attention to  how we approach those issues together and in our   schools but also then how do we prepare them? How  do we incorporate content like this into an over-   stuffed curriculum already. Everybody's like, I  don't have time. We don't have time. And so then   we end up doing these sort of superficial things  that don't have a lot of impact and I think these   are the kinds of behavioral tools and skills  that need experiential learning. We need to have a  

place to practice the skills. Michelle mentioned  we've been implementing this resilient nurses   initiative R3 in in Maryland and one of the  things that we did we've created first 28 modules   that address various aspects of resilience and  ethical practice. Then we collaborated with   our nurse residency collaborative, which is  36 hospitals, so this new nurse transition piece   and we asked them where the gaps were based on  what we'd already developed. One of them was  

around asking for and receiving support. So we've developed a module for new nurses   and arguably for students about how to work  with noticing their own limitations   and symptoms that require attention and how  do they bring those concerns to faculty or to   their nurse manager if they're in a practice 

environment. We included in that a script   for how they could be sure that they're  having a psychologically safe conversation   before they talk about their concern because  there is a risk that when you... have the courage to bring that up that the person 

receiving it may not be skillful. We don't want   to create unsafe situations for students...or new nurses for that matter but   this is where I think practice in advance  of normalizing this is something you're going   to need to have some skills in and dedicating  time to practice so that it's not a new idea. We want to be conscious of our time boundaries.  This conversation could go on and it will. We   will pick up with our conversation with  Dr. Cynda Rushton on the next episode.

Thank you for joining us on this episode  of NLN Nursing EDge Unscripted Surface.   We hope you join us next time. Until then,  remember, whether your water is calm or choppy,   stay connected, get vulnerable and  dare to go beneath the surface.