It's the start of a new year. The time when New Year's resolutions are made; when people think about what they might do differently in the year to come—be more giving, eat healthier foods, or exercise more. We generally think about things we will do. Often, if we do them, these activities help us better deal with life's stressors. Nurses and other health care professionals, in particular, live with high levels of stress.
The work of nurses and other health care providers is hard. Working with patients who are suffering, sometimes in treatment/health care environments that are not supportive, is stressful. Occupational stress can be from workplace violence (WPV). RNs and other health care providers experience WPV four times more often than those in all other U.S. private industries (Occupational Safety and Health Administration [OSHA], 2015); much of this is accounted for by nurses in high-risk areas, such as psychiatric mental health and substance misuse treatment or other behavioral health settings, and by nurses in emergency departments and geriatric settings (Dvorak, 2017; OSHA, 2015). Psychiatric technicians and aides have the highest rate of violent injuries among all health care workers (Bureau of Labor Statistics, 2015).
High occupational stress is linked to poor overall health behaviors (Kim et al., 2016), less physical activity (Gerber, Jonsdottir, Lindwall, & Ahlborg, 2014), weight gain (Geiker et al., 2018), and cognitive problems, such as reduced attention, concentration, and decision making ability (Raab, 2014). Chronic stress not only negatively affects health care providers, but has implications for patients as well, including suboptimal patient care and medical errors (Duarte, Pinto-Gouveia, & Cruz, 2016), negative patient satisfaction, and longer patient recovery times (Raab, 2014).
Professional organizations try to help. The American Nurses Association (2017) named 2017 as the Year of the Healthy Nurse, and the American Psychiatric Nurses Association (n.d.) has a tip sheet for self-care, which leads with “Whole health begins with mental health. Let it begin with you!” As we know, stress will always be present, so we must enhance our ability to handle it, and be more resilient and better with our patients. Adaptive coping and positive emotions help (Gloria & Steinhardt, 2016), along with empathy (Mercer et al., 2016), mindfulness, and self-compassion (Cavanaugh & Rose, 2017; Duarte et al., 2016; Raab, 2014).
Empathy and Compassion
Empathy and compassion are core skills needed to manage the emotionally intense nature of providing quality care (Pucino, 2014; Raab, 2014). Ironically, although empathy and compassion are associated with positive patient outcomes, such as reducing anxiety in individuals with breast cancer (Duarte et al., 2016) and improving end-of-life care for Veterans (Williams, Bailey, Goode, & Burgio, 2016), empathy and compassion can put providers at risk for burnout (Duarte et al., 2016) and compassion fatigue (Raab, 2014; Sorenson, Bolick, Wright, & Hamilton, 2016) if they are unable to regulate their empathetic feelings (Duarte et al., 2016). Compassion fatigue is “a state of reduced capacity for compassion as a consequence of being exhausted from dealing with the suffering of others” (Duarte et al., 2016, p. 3) and is associated with burnout because it is a form of secondary traumatic stress (Raab, 2014).
In recent years, a growing body of research has demonstrated that mindfulness, and in particular mindful self-compassion, may serve as a protective factor against stress, emotional exhaustion, and burnout (Duarte et al., 2016; Raab, 2014; Rao & Kemper, 2017). Whereas compassion is defined as “a deep awareness of others' suffering and the wish to alleviate it” (Raab, 2014, p. 97), self-compassion is “compassion directed inward, relating to oneself as the object of care and concern when faced with the experience of suffering” (Duarte et al., 2016, p. 3).
Based on the work of pioneering researcher Kristin Neff (2003), self-compassion includes three interrelated components: self-kindness, common humanity, and mindfulness (Raab, 2014).
Self-kindness reduces self-criticism, self-condemnation, blaming, and rumination, which are common notions of depression. Common humanity is the realization that as individuals, we are part of a greater human community that experiences similar emotions, reducing self-isolation and increasing general well-being. Mindfulness counters over-identification, reducing excessive fixations on negative thoughts (Raab, 2014).
Research consistently suggests that self-compassion strengthens one's psychological profile, as it helps build resilience against depression and anxiety and increases life satisfaction, optimism, social connectedness, and happiness (Raab, 2014), as well as improves emotional intelligence, wisdom, and well-being (Duarte et al., 2016). Additional evidence suggests that self-compassion and mindfulness can also enhance patient outcomes and patient satisfaction by improving interpersonal interactions (He et al., 2015), reducing anxiety in individuals with breast cancer (Duarte et al., 2016), and providing better metabolic control and fewer metabolic complications in individuals with diabetes (Seppala, Hutcherson, Nguyen, Doty, & Gross, 2014).
For a more experiential understanding of the concept of self-compassion, try this: bring to mind a dear friend who has recently gone through a difficult time. Take a few moments to reflect on how you showed up/treated this person during his/her time of need. Perhaps it's helpful to recall the quality of your listening, the things you said, and, more importantly, how you communicated (i.e., with tenderness, concern, empathy), and maybe even if you provided a hug or a shoulder to cry on. Now, bring to mind a recent time in your life when you have gone through a somewhat difficult experience. Without judgment, bring this same kind of reflection to your own experience. How did you treat yourself? What did you say (to yourself)? Did you ignore your needs with a “stiff upper lip” mentality? As you compare the two scenarios, do you notice a difference? If you answered yes, take a breath and extend a kind gesture to yourself (e.g., place your hand on your heart). Notice in this moment any feelings of judgment, and allow your feelings to be present. As you continue to breathe, repeat a kind phrase to yourself (e.g., “May I be kind to myself in this moment”), and acknowledge that pain and suffering are part of a common human experience, and that you should not feel alone or isolated in your situation.
What you just experienced is the practice of self-compassion. Imagine for a moment, what it would be like if the next time you made a mistake, overreacted, or felt challenged beyond your limits, you practiced self-compassion instead of automatically reacting in self-criticism. How would doing so change the way the rest of your day unfolded, from that moment forward? How would it affect your levels of stress or ability to focus on the tasks at hand and interact with those around you?
Nurses and other health care professionals think of others first. It is in our nature, but we must stop and also care for ourselves. Practicing self-compassion is one practice that might help (see Shattell & Johnson, 2017, for others). Self-care is essential. Our patients depend on it.
Mona Shattell, PhD, RN, FAAN
Angela Johnson, Dipl OM, MSTOM,
Assistant Professor and Practitioner of
Rush University Medical Center
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