Permission to Care for Ourselves

In Creative Nursing 2022, Thinking Like a Nurse, we learned that Caring Science must be our foundation; our caring must match the needs and characteristics of those we serve; we need to know how to teach people to think like a nurse; and we must always be mindful that our caring takes place within a context: Family and Society. This first issue of Creative Nursing 2023 is being published open access on the web site of the Earl E. Bakken Center for Spirituality & Healing at the University of Minnesota. The Center's Director, Dr. Mary Jo Kreitzer, is our Guest Editor for this journal issue, and the Center is hosting the virtual launch event celebrating its publication. The Bakken Center is the ideal place for this journal issue to live and from which to go out into the world; our theme is Inspiring, Recruiting, and Retaining the Health-Care Workforce, and the healing that is needed as a part of this call to action is their calling.

For a workforce that was already strained, sometimes to the breaking point, by increasing demand for and expectations of health care, societal and technological changes more rapid than our brains have evolved to accommodate, and policies that prioritize shareholder profits and executive compensation over quality care for those we serve, the continuing COVID-19 pandemic has been that breaking point. All healthcare professionals 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. At the beginning of the pandemic, people banged pots at 7p.m. (even though those on 12-hour nights were long since at work, and those on 12-hour days would be still be reporting and charting for hours), and hospitals said, “Just hold on, we know this is terrible. We'll get through this together.” Now, in city after city, nurses facing staffing ratios beyond unsafe are told, “This is the new normal. Get used to it. Be resilient. Do self-care.”

This blaming narrative is one reason why, in assembling this issue, our editorial board was very clear that articles mandating resilience and self-care as the solution to a problem will not appear here. Nowhere are there dose-related prescriptions for resilience and self-care as a treatment 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.

Our articles do talk a lot about elements of resilience and self-care, though: teaching health-care professions students and patients and families about them, reforming systems to facilitate and enhance them, helping caregivers frame and integrate them, and sharing resources for individuals to practice them. Other articles acknowledge the imperative to support our co-workers who have been targets of incivility and those dealing with substance use disorder, and to develop tools that help us practice safely by communicating vital patient information to each other. Still others, from the wider world, acknowledge the personal and professional needs of individual health science students who choose specific specialties, and detail the influence of Florence Nightingale's knowledge on contemporary trauma care worldwide.

Dr. Kreitzer addresses head-on this issue's theme about inspiring, recruiting, and retaining, and asks, what will it take? The U.S. health-care system, the costliest in the world, is facing an exodus of nurses and other workers. We are at a time in which neither patients nor health professionals are satisfied with processes and outcomes. Corporate medicine has contributed to clinician stress and burnout and has eroded autonomy. Too often, care is fragmented, narrowly focused on a disease process rather than the whole person. Her article calls for reform in which nurses and other healthcare providers have agency to make decisions that impact their practice and 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” (Kreitzer, p. 2).

Practicing and Teaching Self-Care

Dr. Kreitzer and colleagues Megan Voss of the Bakken Center, and Laura Sandquist and Kate Otremba of the Penny George Institute for Health and Healing at Allina Health in Minneapolis, Minnesota, present one modality to address this fragmentation of care for patients with mental health issues: Integrative nursing. This evidence-based framework, which emphasizes that human beings are whole systems with an innate capacity for healing and well-being, is becoming mainstream, and not a moment too soon. Integrative nursing uses the full range of conventional and integrative approaches; it focuses on the health and wellbeing of caregivers as well as those they serve. “Integrative interventions can serve as an important complement to manage secondary symptoms, enhance wellbeing, and build resilience as individuals fluctuate on the continuum of mental health” (Voss et al., 2023, p. 2). This upstream approach to care has the potential to prevent worsening of symptoms, reduce expenditures, and avoid escalating care to scarce specialty resources. Their article presents an Integrative Mental Health Clinical Pathway that begins with a comprehensive assessment leading to suggested interventions on four levels of increasing intensity. A clinical vignette demonstrates the assessment process and interventions in action.

Susan Hayes Lane of the Beaver College of Health Sciences at Appalachian State University in Boone, North Carolina, reviews Taking Charge of Your Health and Wellbeing, an interactive resource on the Bakken Center web site. Taking Charge is a comprehensive tool to “assess one's own health, discover more about different health conditions, consider a variety of holistic practices, and set health-related goals through developing holistic approaches and skills” (Lane, 2023, p. 1). The review presents an overview of the resources provided by the Taking Charge site, evaluates its understandability and actionability using the Patient Education Materials Assessment Tool for Audio-Visual Materials, and recommends areas for improvement.

Dorrie Fontaine, Dean Emerita at the University of Virginia School of Nursing and coauthor of Self-Care for New and Student Nurses, writes that literature about healthcare workers ‘increasing rates of anxiety, depression, and burnout cite work-life balance as a solution, but this term has no guiding definition. She proposes another lens: integration, which 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” (Fontaine, 2023, p. 2). She advocates for 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.

Two related articles discuss curricula incorporating self-care principles. Erica Hooper and Sara Horton-Deutsch of the University of San Francisco School of Nursing and Health Professions describe a wellness course that incorporated the concepts of Caring Science into a curriculum for health professions students, providing them with knowledge, understanding, and practice of self-compassion and caring as the foundation for holistically caring for others. “Students who learn self-compassion and the importance of caring for themselves in balance with caring for others while in the formative years of their education will be better positioned to contribute toward healing, health, and wholeness in health-care environments upon graduation” (Hooper & Horton-Deutsch, 2023, p. 9). And Susan Huehn, MaryBeth Kuehn, Jenny Ortiz, and Rafa Al-Helal of St. Olaf College in Northfield, Minnesota, report on a Student Success Seminar for beginning nursing students that had two interventions: a positive psychology curriculum of group sessions emphasizing resilience, self-regulation, and self-efficacy, and peer mentoring by junior- and senior-level students. Measures of students ‘resilience showed statistically significant increases post-intervention. Both articles present cost-effective, replicable ways to share knowledge about self-care; “Nurse educators have the potential to provide sustainable curricular practices to promote student well-being through targeted interventions” (Huehn et al., 2023, p. 14).

Helping Colleagues in Need

Sometimes self-care is not enough – we need to care for each other, from moment to moment but especially in adverse circumstances. Brigit Carter and Crystal Arthur report on a program called Promoting Empowered Approaches to Critical/Challenging Encounters (PEACE), implemented at Duke University School of Nursing, to navigate communication when there has been an exchange with actions, words, or behaviors that does not align with the school's core values. They state, “Respectful communication behaviors are key in any setting, but are critical in an academic setting, where faculty and staff are role models for undergraduate and graduate nursing students” (Carter & Arthur, 2023, p. 2). The goal of this program is to provide resources that promote conflict resolution through conversation, as well as managing conflict at the organizational level. Policies that focus on workplace expectations often generate actions for resolution that are punitive or are used to manage behavior; the PEACE program 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, an insight critical to repairing relationships, encouraging future engagement without fear of conflict.

Nurses in all work settings will encounter clients who deal with substance use disorders (SUDs); it is imperative that nurse educators prepare their students for the care of these clients. But what if the person experiencing an SUD 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? Jacqueline DeBrew of Elon University in Elon, North Carolina 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; one student said, “Now, I am more willing to assist someone with an addiction history, because of [the nurses'] statement, ‘No one dreams of becoming an addict” ‘(DeBrew, 2023, p. 4-5).

With the increasing acuity of patients hospitalized on medical/surgical units, the use of “sitters” (staff members assigned to be constantly physically present with patients identified as having safety concerns) is becoming widespread. Paige Hawley and Rachel Holst, new graduates in a nurse residency program at a hospital in Iowa, identified unsafe communication, including lack of a formal handoff process, between “sitters” and the nurses caring for those patients. They were supported by Jennifer Bredlow, coordinator of the residency program, and Tara Nichols, Director of the RN-BSN Program at Waldorf University in Forest City, Iowa, in reporting to us about their response: A Patient Safety Attendant Handoff tool, using the evidence-based format of Situation/Background/Assessment/Recommendation (SBAR), which was made an official hospital form and implemented as a new standard of practice. This form serves as a template for systematically sharing vital information about the patient in real time, and a tool for gathering and aggregating data. Analysis of data from 100 completed handoff forms showed more than 80 communication variables, “which demonstrates how complex the patient story can be for someone requiring constant observation” (Hawley et al., 2023, p. 9).

Students ‘Career Choices Impact Global Health

Health systems need adequate personnel in order to function, and depend on the availability, mixture, quality, and accessibility of the health-care workforce to meet current and future human needs. The choices of specialty that health science students make, the lack of guidance they receive in making those choices, and the consequences of policies and funding, all impact the adequate mix of health-care team members to meet the needs of the world. Njaka Stanley, doctoral student in the School of Health Sciences at Universiti Sains, and colleagues Raishan Shafini Binti Bakar, Kueh Yee Cheng, and Intan Idiana Binti Hassan of Universiti Sains, and Aaron Beryl Nwedu of Ebonyi State University in Abakaliki, Nigeria, conducted a systematic review of literature about health science students ‘career intentions that encompassed 27 studies from 16 countries, with a total of 45,832 respondents. Their results showed that health science students ‘career choices do not reflect an adequate mix of health-care 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. The four available studies of nursing students revealed preference for surgical, emergency, and intensive care specialties; geriatric and psychiatric nursing received less preference, and “midwifery none at all, despite the indispensability of this specialty” (Njaka et al., 2023, p. 14). Barriers to choosing particular specialties included stigma, long working hours, poor public recognition, lack of proper facilities, prolonged training periods, and lack of policy support. “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” (p. 16).

Reflecting on Our History

The University of Alabama at Birmingham School of Nursing possesses an extensive archive of literature by and about Florence Nightingale. In a valuable reminder of the foundations of our profession, our colleagues there, Lynn Stover Nichols, Michael Hyde, Michael Mosley, and Melanie Gibbons Hallman write about the connections between Nightingale's insights into environmental details gained from her work in the Crimean War, including ventilation, air, warmth, drainage, cleanliness, light, and noise levels, and aspects of trauma care today that facilitate healing for patients and, in many cases, lead to a healthier, calmer milieu for health-care workers as well. The article features an application of Nightingale's environmental concepts to a trauma patient case exemplar. The authors remind us of her impact on interprofessional relationships: “She supported the integration of nurses into the hospital staff during a time when physicians did not value nurses as colleagues” (Nichols et al., 2023, p. 2).

Looking Ahead

Creative Nursing has a new publisher. Sage Publishing Inc. will incorporate this issue into our new web site in the next few months, along with our upcoming issues: Issue #2, Challenging Long-Held Assumptions; Issue #3, Revealing the Structures that Determine Health and Wellbeing, and Issue #4, Understanding the Human and Financial Costs of Marginalization. Stay with us as we begin this exciting new chapter in our journal's history.

Cite this article

Lewis-Hunstiger, M. (2023). Permission to care for ourselves. Creative Nursing 29(1), Article 2.