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

This episode of the NLN Nursing EDge Unscripted Surface track is part 1 of 2 featuring guest Cynda Rushton.

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Transcript

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[Music][Music] Welcome to this episode of the NLN podcast Nursing EDge Unscripted the Surface track  and thank you for joining us. This episode is entitled Fostering Well-being in the  

Nursing Community: 0:46

Finding our Voice to Ask for Support, where we will discuss the current state  of well-being in nurses and nurse educators on the heels of a pandemic, nursing strike, debates  on staff and ratios and many other topics that impact how we perceive our role and  state of wellness within these roles. With that, we will also discuss the stigma associated with  mental health and the importance of finding our voices to advocate for help when needed.  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  

Moral Resilience: 1:51

Transforming Moral Suffering in Healthcare. Welcome Cynda, thank you for joining us.  Well I would like to get us started just talking about the words we use because  as we've mentioned sometimes the vocabulary can get conflated and it's important that we  recognize that the words we use matter and they 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  

of ourselves: 3:08

our physical, our psychological, our spiritual, our moral well-being, how we can be whole  people in a way that reflects who we really are and how we want to be in the world.  The other topic of course the word that is used a lot and we certainly are using it is resilience, which has many meanings. There's not one unifying definition of resilience,  but there's a way in which certain parts of those definitions have been sort of  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.