Abstract
For a workforce already strained to the breaking point by increasing demand for and expectations of health care, societal and technological changes more rapid than we have evolved to accommodate, and policies prioritizing shareholder profits and executive compensation over quality care for those we serve, the COVID-19 pandemic has been that breaking point. All caregivers have felt the strain, but nurses have been particularly subsumed in a blaming narrative that portrays workers ‘self-care and resilience as the way the U.S. health-care system will right itself.
This blaming narrative is one reason why our editorial board was very clear that articles mandating resilience and self-care as the solution to a problem will not appear here. Our articles do talk a lot about resilience and self-care – teaching about them to health-care professions students and to patients and their families, reforming systems to facilitate and enhance them, helping caregivers frame and integrate them, and sharing resources for individuals to practice them. Nowhere are there dose-related prescriptions for what we are dealing with. We know what we need. Our goal in this issue of Creative Nursing is to grant permission to take what we need, transforming a narrative of self-care as a strategy for maintaining systems into a narrative of systems that maintain self-care.
The U.S. health-care system, the costliest in the world, is facing an exodus of nurses and other workers. We are at a concerning juncture in which neither patients nor health professionals are satisfied with the operation and outcomes. The growth of corporate medicine has contributed to clinician stress and burnout and created conditions that have eroded autonomy. While there are sterling examples of extraordinary care, all too often patients experience fragmented care narrowly focused on a disease process rather than the whole person. Reform is needed to create cultures in which health-care providers have agency to make decisions that impact all aspects of patient care. Health workers who find joy, fulfillment, and meaning in their work can engage on a deeper level with their patients so that human connection is strengthened, health equity is achieved, and trust is restored.
Articles and Essays
The incidence of mental illness has continued to increase since the start of the COVID-19 pandemic. Mental health providers report inability to meet the demand, and increased wait times for access to care; more patients are seeking mental health care from their primary care providers. Integrative models of care are expanding into mental health care. Integrative Nursing is a strategy for improving the quality of care for patients with mental health diagnoses, as well as those with a goal of increasing mental health and wellbeing, and can serve as a framework for providing whole-person mental health care. Integrative interventions can serve as an important complement to enhance wellbeing and build resilience as individuals fluctuate on the continuum of mental health. Providing this upstream approach to care has the potential to prevent worsening of mental and physical health symptoms, reduce healthcare expenditures, and avoid escalating care to scarce specialty resources. A common misconception is that integrative approaches should be reserved for patients with the least severe mental health diagnoses. While it is crucial that integrative approaches be used in primary care to prevent escalation of symptoms and interventions, it is equally important to use integrative therapies for serious mental illnesses, in conjunction with necessary pharmacologic management. The article presents an Integrative Mental Health Clinical Pathway, based on an Integrative Nursing Principle that recommends using the full range of evidence-based interventions, beginning with the least intensive whenever possible. The Clinical Pathway begins with a comprehensive assessment based on Kreitzer's Wellness Model, leading to suggested interventions on four levels of increasing intensity. A clinical vignette demonstrates the assessment process and interventions in action.
The lives of nurses since the onset of the COVID-19 pandemic are characterized by high rates of anxiety, depression, and burnout, leading organizations to declare the nursing shortage a national emergency. Solutions cite work-life balance, but this term has no guiding definition. Experts in organizational psychology and personal development suggest another way to consider this dilemma, that of integration. The term integration suggests that composing a life in which there is synergy between work and home, family, friends, and volunteer pursuits is a more appropriate goal than balance. This article proposes using the concept of integration to focus on relationships with family and friends, work, and oneself, using the American Association of Critical-Care Nurses ‘standards for a healthy work environment to frame the benefits of an integrated life. Strategies to achieve an integrated life, one with meaning and purpose, are described to create more happiness and joy. An example of such a strategy is The Pause, a structured 45-second stopping when a patient has died. This simple act that shows compassion for the person and their family, and for fellow health-care team members, has caught the attention of hospitals worldwide.
Compassion is a precursor to caring for self and others, related to the ability to embody loving-kindness, and core to Caring Science. Compassion and caring are foundational concepts for the education of health professions students, yet many curricula prioritize skill-based learning and test-taking preparation, which limits opportunities for students to practice compassionately caring for themselves and others. Students who learn self-compassion and the importance of caring for themselves in balance with caring for others will be better positioned to contribute toward healing, health, and wholeness in health-care environments upon graduation. An elective wellness course in a health professions curriculum provided students with knowledge, understanding, and practice of self-compassion and caring as the foundation for holistically caring for others. The course's goal was to use ethics, values, and ontological competencies of self-compassion and Caritas literacy to awaken students to being, not just doing, and how it evolves throughout their professional careers. Narrative feedback from students demonstrated a deeper understanding of the necessity for compassion and caring for self to provide compassionate care to others.
Health systems need adequate personnel in order to function; improvements in health-care services delivery, and the enjoyment of standard health care as a right, depend on the availability, mixture, quality, and accessibility of the health-care workforce. This calls for deeper reflection on the choices of specialty that health science students make, the need for guidance in making those choices, and the impacts of policies and funding, with special consideration of current and future human needs.
Both guidance and policy making require empirical evidence about career choices and determining factors, obtained from reliable sources. This systematic review synthesized reliable evidence on determining factors among health science students ‘career choices; a search identified 27 studies from 16 countries, with a total of 45,832 respondents. The results showed that health science students ‘career choices do not reflect an adequate mix of healthcare team members to meet the needs of the world. Among medical students, the commonest choice was internal medicine. Public health and psychiatry were not preferred areas; this would be detrimental to global health and safety, considering the turbulent nature of the global environment and its health consequences. The four available studies of nursing students revealed preference for surgical, emergency, and intensive care specialties, to the detriment of others; geriatric and psychiatric nursing received less preference, while midwifery received none at all, despite the indispensability of this specialty. These studies of nursing students ‘career choices showed no evidence of formal career guidance. The determining factors of choice of specialty were in four themes: personal, socioeconomic, professional, and educational/policy. Barriers to choosing particular specialties included stigma, long working hours, and poor public recognition. Some studies reported lack of proper facilities, prolonged training periods, and lack of policy support as major deterrents, particularly in Low-Income Countries. An important hindrance to choosing a given specialty is low prestige among health- care professionals; any country with an interest in developing a formidable health-care team must take this issue into consideration.
Diversity, Equity, Inclusiveness, and Belonging
Inclusive organizational climates depend on the responsibility of their members to one another and the agreement to be respectful in communication behaviors. In academic settings, where future nurses are being taught how to engage with team members and patients, the behaviors observed in educators are often the behaviors students embrace and emulate. Therefore, effective communication in the academic setting is part of the educational process that contributes to optimal outcomes for the patients our students will encounter. The Promoting Empowered Approaches for Critical/Challenging Encounters (PEACE) program, developed at Duke University School of Nursing, is designed to navigate communication when there has been an exchange, either with actions, words, or behaviors, that does not align with the school's core values. The goal of this program is to provide resources that promote conflict resolution through conversation, as well as managing conflict at the organizational level.
A key component of the PEACE program is the facilitator role; these people are the first point of contact for individuals seeking assistance through the program to resolve a conflict. PEACE Peer Facilitators (PPFs) provide a safe environment in which to speak about a particular situation, strategies for one-to-one communications, and any additional resources the community member may need. Organizational policies that focus on workplace expectations often reflect zero tolerance for uncivil behaviors; therefore, the resulting actions for resolution are mostly punitive or are used to control or manage behavior. PPFs receive training in skills and knowledge designed to create a culture in which harm and conflict are less likely to occur or recur. This training is rooted in restorative justice, an approach that attempts to repair harm by providing an opportunity for those harmed to communicate and address their needs in the aftermath of an encounter. Those who cause harm have the opportunity to acknowledge how the harm affects the entire community. This insight is critical not only to resolving a problem, but to repairing relationships to encourage future engagement without fear of conflict.
Patient Safety
Communication is central to patient safety and colleague engagement. A hospital in the midwestern US has a robust nurse residency program that provides a pathway for new nurses to identify problems in the work setting and problem-solve their way through an issue to create a solution. A group of nurse residents identified unsafe communication, including lack of a formal handoff process, between “sitters” (staff members assigned to monitor patients identified as having safety concerns) and the nurses caring for those patients. Using the evidence-based format of Situation/Background/Assessment/Recommendation (SBAR), the nurse residents developed a Patient Safety Attendant (PSA) Handoff tool, which was made an official hospital form and implemented as a new standard of practice. A summary from 100 completed handoff forms identified the top reasons for needing a sitter were mental health and behavioral concerns. Analysis of the data showed more than 80 communication variables, which demonstrates how complex the patient story can be for someone requiring constant observation. In a post-implementation survey, most PSAs reported receiving adequate patient information during handoffs using the new form. The survey solicited PSA's suggestions for improving the form; the authors state, “To ensure the success of a process change, colleague input is critical, as these are the individuals who will be incorporating the change into their practice.”
Outcomes
Beginning nursing students may be familiar with the rigors of a college's general curriculum, but may not yet be adapted to the unique curriculum and demands of nursing courses. Nursing students report competitive and stressful learning environments related to high academic demands, and stressors in the clinical setting including fear of making mistakes, conflicts between professional beliefs and reality in practice, and providing care for patients in vulnerable situations. The COVID-19 pandemic accelerated these concerns as nursing students faced interruptions in their studies and uncertainties about their clinical preparation. Sophomore students in a baccalaureate nursing program participated in a Student Success Seminar with two interventions: a positive psychology curriculum of one-hour virtual group sessions emphasizing resilience, self-regulation, and self-efficacy, and a formal mentoring program led by senior- and junior-level nursing students. Participants ‘resilience was measured pre- and post-intervention using the Predictive 6-Factor Resilience Scale. Results showed statistically significant increases in the domains of Composure, Collaboration, Momentum, and Health.
The Student Voice
Information about substance use disorders (SUDs) is commonly taught in pre-licensure nursing programs. Nurses in all work settings will encounter clients who deal with SUDs; it is imperative that nurse educators prepare their students for the care of these clients. But what if the person experiencing SUDs is not a client, but a colleague? And do nurse educators prepare their students to consider the fact that they too may be at risk for SUDs simply because they are nurses? This article describes an innovative approach to teaching nursing students about SUDs that utilized a guest speaker who was a nurse in recovery from addiction. Student reflections showed that the learning activity increased their knowledge of addiction and helped them examine their own biases about people with addiction. This teaching strategy could be replicated by other nurse educators to ensure that future nurses are prepared to work alongside a colleague experiencing SUDs. A student said, “Now, I am more willing to assist someone with an addiction history, because of the nurse's statement, ‘No one dreams of becoming an addict.”'
Reflecting on Our History
Florence Nightingale's visionary work in the Crimean War resulted in data-based recommendations for using the environment to promote healing and wellness among sick and wounded British soldiers. She advocated for attention to environmental details, including ventilation, air, warmth, drainage, cleanliness, light, and noise levels. These important environmental concepts play a significant role in the delivery of nursing care of trauma patients in the contemporary emergency department. For example, interventions that highlight the relevance of Nightingale's concept of environmental warmth include monitoring core temperature, applying warm blankets, and pre-warming IV fluids and blood products. This article features an application of Nightingale's environmental concepts to a trauma patient case exemplar, and demonstrates the enduring impact of her work.
Media Review
Taking Charge of Your Health and Wellbeing: An Interactive Resource from the Earl E. Bakken Center for Spirituality & Healing at the University of Minnesota.
Reviewed by Susan Hayes Lane, PhD, MSN, RN, Associate Professor in the Department of Nursing, Beaver College of Health Sciences, at Appalachian State University in Boone, North Carolina, US. Taking Charge of Your Health & Wellbeing is an online interactive community resource with a focus on health and wellbeing, created by The University of Minnesota's Earl E. Bakken Center for Spirituality & Healing (
Upcoming Creative Nursing Issues
Vol. 29 Issue 2 – Challenging Long-Held Assumptions. Published mid-May 2023.
Vol. 29 Issue 3 - Revealing the Structures that Determine Health and Wellbeing. Published mid-August 2023
Vol. 29 Issue 4 - Understanding the Human and Financial Costs of Marginalization. Published mid-November 2023
Footnotes
Marty Lewis-Hunstiger, BSN, RN, MA, is a retired pediatric nurse and preceptor; Co-Editor-in-Chief of Creative Nursing; Developmental/Copy Editor of the Interdisciplinary Journal of Partnership Studies; and an Affiliate Faculty Member in the School of Nursing at the University of Minnesota.