F.A. Davis Building Resilience in Nursing Students

Building Resilience in Nursing Students

Susan Sportsman, PhD, RN, ANEF, FAAN Managing Director Collaborative Momentum Consulting

The Problem As a faculty member in a nursing program, you are always glad to hear from former students. Today, however, you get a call from a past student who graduated from your nursing program two years ago and she sounds very distressed. Her voice trembles as she says, “I don’t think I can do this job much longer. The stress is just too great! Patients and other team members yell at me, and I feel like I fall short providing the kind of care I should be giving—that I was taught to give. Although I try my best to manage all the demands, I leave work every day feeling like a failure. I am not sleeping well, which makes me feel awful. There has to be something else I can do that won’t leave me mentally and physically exhausted!” Such conversations are not what faculty want to hear from past graduates; however, increasingly, nurses of varying ages and experience levels are sharing with friends, family, and colleagues the same sort of stories.

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The Impact of the Most Recent Nursing Shortage 1. Problems associated with nursing shortages are not new. With some exceptions, the United States has experienced a chronic nursing shortage for the last half a century. Yet, there is something different about the current acute shortage. Driven by a worldwide pandemic in addition to the complexity of the healthcare system in general, this shortage has huge consequences. Approximately 100,000 Registered Nurses and 34,000 Licensed Practical/Vocational Nurses have left the workforce in the last two years as a result of stress, burnout, and retirement. These findings from the 2022 National Nursing Workforce Survey are quite alarming. However, additional findings paint an even more disturbing picture. Another 610,388 nurses reported an “intent to leave” the workforce by 2027. An additional 188,962 RNs younger than forty reported similar intentions to leave nursing. Altogether, approximately one-fifth of RNs nationally are projected to leave the workforce by 2027 (Smiley, Allgeyer, 2023). Moving forward, we may think that nurses’ workload will improve as COVID-19 wanes. Yet, the healthcare delivery system is likely to remain chaotic for the foreseeable future. In addition, data from research reported by Joi (2022) suggests that the annual probability of extreme epidemics occurring could increase threefold in the coming decades. The probability of a pandemic similar to COVID-19 is about 2% in any given year. Since much of the world is still reeling from the shock of the pandemic, additional extreme medical conditions that further tax healthcare workers must be considered possible. The researchers in Joi’s (2022) report emphasized the urgency to develop plans for rapid response to disease outbreaks, building capacity for pandemic surveillance, strengthening health systems, and increasing research to understand why large outbreaks are becoming more common. The crisis of the current nursing shortage is being addressed by numerous groups. For example, (Beal, 2022), Beckers Hospital Review reports on the recommendations of a 2022 Nursing Staffing Think Tank, sponsored by the American Association of Critical Care Nurses, the American Nurses Association, the American Organization of Nurse Leaders, Healthcare Financial Managers Association, and Institute for Healthcare Improvement. The recommendations included six priorities for hospitals to address the shortage: 1. Promoting a healthy workplace. 2. Fostering diversity, equity and inclusion. 3. Offering work schedule flexibility. 4. Addressing the stress injury continuum. 5. Implementing innovative care delivery models. 6. Providing comprehensive compensation packages, including paid time off for self-care. (Beal, 2022) In addition, there have been widespread recommendations for federal, state, and local policy changes, such as financial assistance to increase the number of nurse educators available to teach more students. In the midst of all these approaches designed to address the problems brought about by a chaotic healthcare environment, what can nurse educators do to prepare students? Developing nursing students who have sufficient resilience to move through challenging times without significant burnout is a responsibility that nurse educators are in a position to assume. Healthcare is unlikely to be significantly less stressful for health professionals going forward. However, developing resiliency can be an antidote to negative stress. The American Psychology Association defines resilience as the process and outcome of successfully adapting to difficult or challenging life experiences, especially through mental, emotional, and behavioral flexibility and adjustment to external and internal demand. The ways in which individuals view and engage with the world, the availability and quality of social resources, and the ability to apply specific coping solutions increases the individual’s resiliency to stress and burnout. Psychological research has demonstrated that developing resilience can be cultivated and practiced (https://www.apa.org/topics/resilience).

In these turbulent times, all of us—direct care nurses, students, and even nurse faculty—are subject to burnout and must pay attention to our own well-being. As previously noted, findings from the 2022 National Nursing Workforce Survey describe the significant loss of RNs younger than 40 who plan to leave the work force which confirms this susceptibility. While nurse faculty cannot change the turbulence within the healthcare system, they can provide learning opportunities to increase student resilience while they are in the nursing program. Here are some recommendations that nurse educators can integrate into the curriculum and other school experiences to boost student resilience: 1. Understanding Burnout and Compassion Fatigue: Students must understand their potential for burnout and compassion fatigue, both during their education and in their future roles as healthcare professionals. Understanding the symptoms and the environmental factors that may be contributing to them is key to being resilient. The table below presents definitions and symptoms that provide clues to the potential danger to the individual. Students should be presented with this information early in their course of study, so they will be prepared for the high expectations of the nursing program and later in their professional roles. Table A outlines important information to understand burnout and compassion fatigue. Table A: Burnout and Compassion Fatigue

CONDITION

DEFINITIONS

SYMPTOMS

Burnout

§ A syndrome resulting from chronic workplace stress that has not been successfully managed § Characterized by three dimensions: • Feelings of energy depletion or exhaustion • Increased mental distance from one’s job, or feelings of negativism or cynicism related to one’s job • Reduced professional efficacy § The onset of burnout is more progressive than compassion fatigue Maunder, Heeney, (2021) § A combination of physical, emotional, and spiritual depletion associated with caring for patients in significant emotional pain and physical distress (Lombardo, Eyre, 2011). § Compassion fatigue is more acute than burnout; however, having burnout can increase the likelihood of developing compassion fatigue.

§ Emotional exhaustion

(feeling drained & fatigued)

§ Becoming indifferent or emotionally withdrawn § Decreased sense of professionalism § Depression

§ Thoughts of suicide § Poor physical health Maunder, Heeney, (2021)

Compassion Fatigue

§ Avoidance/dread of working with certain patients § Reduced ability to feel empathy towards patients § Frequent use of sick days § Headaches, digestive problems: diarrhea, constipation, upset stomach § Muscle tension § Sleep disturbances: inability to sleep, insomnia, too much sleep § Fatigue § Cardiac symptoms: chest pain/pressure, palpitations, tachycardia § Mood swings § Restlessness § Irritability § Oversensitivity § Anxiety § Excessive use of substances: nicotine, alcohol, illicit drugs § Depression § Anger and resentment § Loss of objectivity § Memory issues § Poor concentration, focus, and judgment

2. Talking about one’s concerns and feelings with an appropriate person or group can relieve stress. Discussing with an instructor or advisor, or informally with colleagues over a cup of coffee, provides surprising relief from stress. Nursing programs provide a number of activities which allow students to talk about feelings and concerns (e.g., discussions in class, post-clinical conferences, study sessions). Helping students realize that these experiences relieve stress emphasizes the importance for students to find such groups after they graduate. 3. Building strong, supportive relationships can be an antidote for burnout and compassion fatigue. Nursing programs provide many opportunities for developing professional/personal relationships, through course work, clinical groups, student organizations, and informal gatherings. Encourage these groups to work together and provide them with opportunities to practice appropriate communication in a variety of situations involving possible conflict. 4. Fostering student engagement and the application of content. A lack of confidence over time can be a precursor to burnout and compassion fatigue. While a lack of confidence is to be expected while a student is learning and is also common in a novice nurse, a primary goal for nursing faculty is developing evidence-based teaching and learning activities that build confidence. Preparing students for the NGN NCLEX® using the Clinical Judgment Measurement Model is also helpful in increasing the confidence of students and new graduates. 5. Providing students opportunities to reflect on specific situations they encounter and their performance in those situations is key. Students should have regular opportunities to practice reflection in both didactic and clinical courses. Developing the skill of reflection begins with students using one or more of the reflection models considered best practice. To ensure that reflection is effectively integrated into classes and clinical experiences, it’s helpful to have course objectives that require reflection. Additionally, all clinical evaluation instruments should assess students’ ability to reflect on their own performance as they progress through the program. 6. Maintaining self-care. Self-care can mean different things to different people. Self-care might include exercise, yoga, massage, sports, or other personal preferences. Many nursing schools have found it beneficial to offer a required or elective course or module on stress management at the beginning of the program. Recommendations such as maintaining life balance, getting adequate sleep, ensuring proper nutrition and hydration, and prioritizing fresh, whole foods over processed alternatives should be emphasized. 7. Setting boundaries between personal life and school life. While it can be challenging to establish boundaries when feeling overwhelmed, spending time doing schoolwork during personal activities can prevent us from receiving the advantages of being away. The author can be accused of grading nursing students’ papers while attending her children’s athletic events. However, a child “dripping” on students’ papers at a swim meet doesn’t exactly scream “Setting Boundaries!” Still, it remains crucial to continually strive for a healthy work-life balance throughout one’s career.

Maintaining resilience when the workload results in ongoing fatigue

How can resilience be maintained when the workload results in ongoing fatigue, such as during a crisis or when the work exceeds your capacity to complete satisfactorily? Sometimes, the workload, whether in a clinical setting or school, becomes overwhelming and may feel impossible to complete satisfactorily. Fatigue is often marked by a profound lack of energy, sensations of muscle weakness, and slowed movements or central nervous system responses. Additionally, fatigue can lead to significant mental exhaustion, manifesting as a lack of mental clarity, difficulty concentrating, and in some cases, memory lapses. What strategies can be implemented to cope with fatigue? On the following page are some examples of helpful interventions which faculty can share with students either in a formal class or informal discussion.

Managing Fatigue 3. § Prioritize sleep by decreasing off-work/school obligations as much as possible until feeling fully rested. § Use relaxation apps or techniques to aid in sleep onset if you have trouble falling asleep (longer than 15-25 minutes). § Create a bedtime routine and keep your sleeping environment comfortable, dark, cool, and quiet. § Avoid alcohol, spicy foods, and nicotine for at least 2-3 hours prior to sleep time. § Avoid caffeine at least 5 hours before bedtime (longer if sensitive to caffeine). § Avoid sunlight/bright lights 1.5 hours prior to sleep, as it can stimulate your circadian system to promote wakefulness. § Use strategically timed naps to decrease fatigue. Short naps (15-30 minutes) can help to decrease fatigue during work hours. Longer naps (1.5 hours) can help prevent fatigue before working a night shift. § Find a colleague to be a buddy for checking in on how each of you are coping. § If students are working as unlicensed assistive personnel in a healthcare setting, inform them that extended shifts (greater than 12 hours) increase the risk of fatigue-related incidents. Having one full day of rest for every seven days of clinical work is necessary for adequate sleep and recovery. § Watch for signs and symptoms of fatigue in yourself and coworkers. These may include yawning, concentrating, emotional instability, flawed logic, and poor communication. (Hittle, Wong, 2020). Early career nurses are leaving the nursing profession at rates similar to those who are reaching retirement age. Nursing faculty must prepare future nurses to manage the stress, burnout, and compassion fatigue that may be inherent in being a nurse. Providing opportunities to develop a high level of resilience while in school will do much to protect individual students as they transition into the workforce as well as support the future of the nursing profession.

References AHRQ (2023) Burnout in primary care. Assessing and addressing it in your practice. Agency for Healthcare Research and Quality. https://www.ahrq.gov/sites/default/files/wysiwyg/evidencenow/tools-and-materials/burnout-in- primary-care.pdf. Accessed 2023. ANA (2023) Healthy Workplace and Practice and Advocacy. American Nurses Association. https://www. nursingworld.org/practice-policy/work-environment/. Accessed 2023. APA. (2023) Resilience. American Psychological Association. https://www.apa.org/topics/resilience. Accessed 2023. Beal, N. (2022) 6 Strategies to address nursing shortages in the next eighteen months. Beckers’ Hospital Review. May. https://www.beckershospitalreview.com/workforce/6-strategies-to-address-nursing-shortages-in-the-next-18- months.html. Accessed 2023. Hittle, B., Wong, I., Caruso, C. (2020) Managing fatigue during times of Crisis: Guidance for Nurses, Managers, and other Healthcare workers. NOSH Science Blog, Centers for Disease Control and Prevention. https://blogs.cdc.gov/ niosh-science-blog/2020/04/02/fatigue-crisis-hcw/?deliveryName=USCDC_170-DM24834. Accessed 2023. Joi, P. (2022) New Study Suggests Risk of Extreme pandemics like COVID-19. Gavi, Vaccines Work. September 5th. https://www.gavi.org/vaccineswork/new-study-suggests-risk-extreme-pandemics-covid-19-could-increase- threefold-coming. Accessed 2023. Lombardo, B., Eyre, C. (2011) Compassion Fatigue: A nurse’s primer. Online Journal of Nursing (OJIN) 16 (3). https://pubmed.ncbi.nlm.nih.gov/21800934/. Accessed 2023. Maunder, R., Henney, N., Struckwick, G., Shin, H., O’Neill, B., Young, N., Jeffs, L., Barrett, K., Barrett, K., Bodmer. L., Born, B., Hopkins, J., Juno, P., Perkhim, A., Price, P., Razak, F., Mushquash, C. Mah, L., (2021) Burnout in Hospital- Based Healthcare Workers during COVID-19. On Behalf of the Ontario, COVID-19 Science Advisory Table. October. https://covid19-sciencetable.ca/wp-content/uploads/2021/10/Burnout-in-Hospital-Based-Healthcare-Workers- during-COVID-19_published_20211007.pdf. Accessed 2023. NCSBN (2023) NCSBN Projects Significant Nursing Workforce Shortages. National Council of State Boards of Nursing Research Project. Press Release. 4/13. https://www.ncsbn.org/news/ncsbn-research-projects-significant-nursing- workforce-shortages-and-crisis. Accessed 2023. About the author Susan Sportsman, PhD, RN, ANEF, FAAN , is a nationally recognized speaker and consultant with over 10 years of consulting experience, providing program development and other consultation services to nursing and health professions programs throughout the United States and Canada. Previously, she served as Dean of the College of Health Sciences and Human Services at Midwestern State University in Wichita Falls, Texas.

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