Hey Nurses, How are You Doing?

Liz George PHN, BSN, RN

How We Can Use the Nursing Process to Help Ourselves Survive (and Thrive?) in these Tumultuous Times

As a working nurse, I know I don’t need to go into the details of what’s happening for nurses right now. For nearly every nurse the past few years have been a ****Storm of one public health emergency after another, or multiple public health emergencies at once. From floods to fires to pandemics and back again, it doesn’t matter if you work in a clinic, a hospital, home care, or public health; we have all been challenged to provide care for our clients in tumultuous times. Nurses have been leaving the profession in record numbers, twice as many in 2020 as 2010¹, a record 80,000 nurses gave up their careers. There may be many reasons for the nursing hemorrhage, but the consequences for healthcare are dire, according to, Business Standard², “The health of the nation’s nursing workforce is fundamental to our health care industry.” So how can we better understand this problem, improve working conditions for nurses, and stop the exodus? We can begin by learning more about the underlying issue and then applying the nursing process to the problem.

Secondary Traumatic Stress

Recently, a nurse co-worker sent me a Professional Quality of Life Scale (ProQOL)³ assessment. I was curious to see how I was faring based on this evidence-based assessment of compassion satisfaction, burnout, and secondary traumatic stress. The results surprised me. Like most nurses, I love my work and take pride every day in my ability to help others and make a difference in the world through nursing practice. The assessment clearly showed that for me, that is still true. I remain compassionately engaged in my work, I continue to love what I do, and I am not suffering from burnout. However, my score on the ProQOL scale did show that I am suffering from the effects of something called Secondary Traumatic Stress⁴.

Nurses are excellent listeners, our ability to provide therapeutic listening⁵ is part of what makes us good at our jobs and earns us the trust of our clients, (nurses continue to be the most trusted professionals⁶ in America, for the 18th year in a row). To remain engaged and empathic in the past few years has meant nurses are listening to more and more tragic stories, more stories without happy endings, or possibilities for positive outcomes, more stories that we cannot do anything to help other than listen. Hearing so many tragic stories of suffering takes a toll on healthcare practitioners. According to the AAP⁷, any healthcare provider may be at risk for Secondary Traumatic Stress.

“Secondary traumatic stress (STS) is a term used to describe the phenomenon whereby individuals become traumatized not by directly experiencing a traumatic event, but by hearing about a traumatic event experienced by someone else. Such indirect exposure to trauma may occur in the context of a familial, social, or professional relationship. The negative effects of secondary exposure to traumatic events are the same as those of primary exposure including intrusive imagery, avoidance of reminders and cues, hyperarousal, distressing emotions, and functional impairment”.⁸ (CR Figley (ED) Encyclopedia of Trauma, 2012.)

The Nursing Process

Like many nurses, when I am faced with something new (like a new client, or a new concept), I return to the Nursing Process⁹for support. The Nursing Process is the backbone of nursing care. Described by the American Nursing Association, the Nursing Process is “the essential core of practice for the registered nurse to deliver holistic, patient-focused care”. The process consists of five simple steps: Assessment, Nursing Diagnosis, Outcome Planning, Implementation, and Evaluation; always undertaken holistically and in partnership with the client, who just happens to be me today. As I would with any other client, I first assessed my strengths and risk factors, including paying special attention to how well I can care for myself physically (nutrition, exercise, and sleep). I made note of my support systems, my sense of well-being, self-esteem, and self-efficacy. From there I identified my risk factors, what needs a little extra attention, where are my challenges?

Assessment

A good nursing assessment reviews client strengths and risk factors:

Strengths

Spiritual framework
support system
ability to care for yourself
nutrition
sleep
alertness and memory
financial well-being
ability to relax (most of the time)
motivation
self-esteem
Internal locus of control
self-responsibility
positive self-efficacy

Risk Factors

Poor support system
No or little exercise
Poor nutrition
Learning challenges
Denial
Poor coping skills
Communication problems
Obesity
Fatigue
Memory issues
Hearing issues
Self-care issues
Negative self-efficacy
financial problems

What are your self-care strengths? What are areas that could use more support?

Nursing Diagnosis

Unlike medical diagnoses, Nursing Diagnoses¹⁰ take into account client strengths to create a picture of potential risks and readiness for health-enhancing behavioral changes. With a nice outline of my strengths and potential risk factors, and my understanding of how I am feeling at this moment about my potential for poor health outcomes related to Secondary Traumatic Stress, I was able to create a positive Nursing Diagnosis for myself: Risk for deteriorating well-being related to repeated secondary trauma, as evidenced by a high Secondary Traumatic Stress level on assessment, and readiness to prioritize healthy nutrition, exercise, and behavioral health to be better equipped to handle the emotional and physical challenges of nursing during public health emergencies.

Outcome Planning

Short-term interventions for me include: Improving my mental health with good nutrition¹¹ by making sure I eat at regular intervals, avoiding night eating, and developing an awareness of the effects of stress on my appetite. I will also make sure I have access to lots of fruits and vegetables during my work hours and I drink enough water every day. My medium-term plan includes making time for some fun with co-workers and enjoying laughter whenever possible. I will also be joining the nurse's Gratitude Project¹², a joint project of the American Nurses Foundation and the Greater Good Science Center at the University of California, Berkeley. The Gratitude Practice for Nurses is based on research that suggests gratitude improves physical health, mental health, and interpersonal relationships, and “is a valuable tool to respond to the stresses faced by nurses and other health professionals”. My long-term goal is to survive and learn to thrive, through the challenges of listening to the stories of clients who have experienced traumatic events.

Can Nurses Thrive Through Public Health Emergencies?

Climate change has created a greater need for Public Health and Emergency Response Nurses. The Covid-19 pandemic increased the need for nurses in the ICU, Emergency Room, Clinics, and Schools. To make sure we have enough nurses going forward we must regularly assess nurses for compassion fatigue, burnout, and secondary traumatic stress. The Implementation phase of my Nursing Process is just beginning. As with my clients, I am sure as I Re-Assess my plan, I will need to make some changes and refinements to my Outcomes Planning. However, thanks to the ProQOL assessment, and the Nursing Process, I have hope for the future resilience of my nursing practice no matter how tumultuous the times are. According to Beth Hudnall Stamm, Ph.D., one of the researchers and authors of the Professional Quality of Life project, “Professionals who have hope are far better at offering it to others!”

References

¹Nursing Shortage

²Nurses are leaving the profession, and replacing them won't be easy

³Professional Quality of Life: Elements, Theory, and Measurement

^4,7Tips for recognizing, managing secondary traumatic stress in yourself

⁵Therapeutic Communication: NCLEX-RN: Assessing Verbal and Nonverbal Client Communication Needs

⁶Nurses Continue to Rate Highest in Honesty, Ethics

⁸Secondary Traumatic Stress

⁹The Nursing Process

¹⁰Nursing Diagnosis Guide and List: All You Need to Know to Master Diagnosing

¹¹Food, Mood, and Brain Health: Implications for the Modern Clinician

¹²Gratitude Practice for Nurses