< Previous8 American Nurse Journal Volume 15, Number 7 MyAmericanNurse.com families to let go of mealtime traditions. Interventions are based on the patient’s ill- ness stage and care goals. If the patient has a serious illness and is continuing to receive curative treatment, gastrostomy-tube feeding or total parenteral nutrition may be ordered until the patient can eat on their own. Families of patients with an end-stage dis- ease may worry about “starving the patient” and encourage them to eat, causing distress for everyone. Nurses can help by explaining that the body is beginning to “shut down” and can’t process the same amounts of food and fluid as before. Artificial hydration and nutri- tion aren’t recommended at end of life be- cause the body can’t absorb the fluid or nutri- ents, resulting in pulmonary edema, aspiration pneumonia, or diarrhea. Some medications can improve appetite, but their effects vary and are short acting. Before these medications are prescribed, a thorough assessment should be performed to ensure the loss of appetite isn’t caused by delayed gastric emptying or constipation. Steroids, such as dex- amethasone, frequently are ordered because they increase appetite. Tricyclic antidepressants (such as mirtazapine) also may be prescribed as appetite enhancers. Many patients use cannabi- noids, such as dronabinol and medical marijua- na, for nausea and appetite enhancement. Constipation Many patients with serious and end-stage ill- nesses experience constipation caused by a bowel abnormality or obstruction, fecal im- paction, dehydration, limited mobility, or opi- oids prescribed for pain management. Best practices in hospice and palliative care recom- mend that patients taking opioids must have a prophylactic bowel regimen. If constipation isn’t treated, it can lead to obstipation and in- crease the risk for peritonitis. Bulk-forming agents, such as psyllium, should not be used to treat constipation in pa- tients who are seriously ill or dying; these agents absorb water and can cause dehydra- tion, exacerbating constipation. Oral laxatives and stool softeners, such as docusate sodium, magnesium citrate, and polyethylene glycol are recommended instead. If a patient hasn’t had a bowel movement after 3 days of oral laxatives, a rectal suppository may be ordered. If the pa- tient still doesn’t have a bowel movement, per- form a digital rectal exam to check for fecal im- paction. Impactions should be removed; if no impaction is found, an enema may be given. Delirium Delirium can be hyperactive, hypoactive, or a combination. It can manifest as hallucinations, delusions, paranoia, agitation, lethargy, apa- thy, and slowed speech and thought. First assess the patient to rule out reversible causes, such as drugs and uncontrolled pain. If the patient is at end of life and all reversible causes have been ruled out, they likely have terminal delirium. Terminal delirium is part of the dying process and manifests as emotional and phys- ical restlessness. It can’t be reversed, but it may come and go. Sometimes, the patient may calmly talk to people who died long ago, and no intervention is necessary. At other times, the patient may be agitated and unsafe. Agitation treatment includes medications such as haloperidol and quetiapine. Haloperidol is the most effective treatment, but it can’t be given to patients with Parkinson’s disease be- cause it lowers the seizure threshold. In these patients, quetiapine is recommended. Anxiety All patients with serious or end-stage illnesses should be assessed for anxiety. Pharmacologic treatment typically includes a short-acting benzodiazepine. Do opioids hasten the dying process or cause addiction? No evidence exists that opioids, when used according to established dosing guidelines, hasten the dying process. In fact, treating pain effectively has been shown to increase lifes- pan and quality of life. Legally and ethically, providers have a duty to provide opioids for symptom relief at the end of life, and a provider’s fear of death as a consequence doesn’t justify withholding these medications. Patients and their families may fear opioid addiction. However, the rate of addiction is extremely low in patients who are seriously ill or dying. The more common issue is pseudo - addiction, which refers to drug-seeking behav- ior caused by inadequate pain management. As patients becomes tolerant to a certain dose, or the pain worsens, reassess their pain regi- men and advocate for dosing that manages pain adequately. MyAmericanNurse.com July 2020 American Nurse Journal 9 What nonpharmacologic measures can be used for symptom relief? As nurses, our scope of practice includes facil- itating a healing environment for patients and families. In addition to administering medica- tion, we should consider nonpharmacologic comfort measures, including creating a calm- ing environment, positioning patients com- fortably, and facilitating frequent oral hygiene. (See Comfort measures.) What is the role of the interprofessional team? An interprofessional care team for patients with serious and end-stage illnesses typically includes physicians, physician assistants, nurses, nurse practitioners, social workers, case managers, chaplains, physical therapist, dietitians, and aides. In many cases, nurses serve as case man- agers or liaisons, coordinating care among the different disciplines. The team takes a holistic care approach, ad- dressing the patient’s medical, nursing, psychoso- cial, and spiritual needs. In addition to helping the patient and family, this approach provides support and a range of expertise to ensure the team provides optimal care. Working on a team also helps ensure everyone is on the same page. What are the stages of death? Signs and symptoms of dying will vary among individuals; however, with many end-stage ill- nesses, they typically fall within three stages: declining, transitioning, and actively dying. Decline doesn’t have a definite time frame but typically starts a few months before death. Patients may be unable to complete activities of daily living, and they frequently feel much more fatigued than at baseline. Transitioning occurs weeks to a month be- fore death. At this stage, patients’ food and fluid intake decreases (they begin taking only bites of food and sips of fluid), they spend more time sleeping, and they may exhibit signs of delirium (for example, confusion, ag- itation, and talking to people who have died). Actively dying starts hours to days before death. Common signs are decreased conscious- ness, breathing pattern changes, dark urine, and terminal delirium. How can I tell if someone is dying imminently? Signs of imminent death vary among patients, but some hallmark signs are common. Breathing changes Respiratory changes frequently occur at end of life. Patients may have an irregular breath- ing pattern (Cheyne-Stokes respirations) in which the respiratory rate becomes progres- sively faster and deeper, then decreases, end- ing with a period of apnea. “Guppy breath- ing,” also seen at end of life, consists of shallow, rapid, agonal breaths. Dyspnea is Keeping patients and their families comfortable during a serious or end-stage illness is a primary nursing goal. Consider these suggestions for achieving that goal. • Keep the patient’s environment calm, cool, and quiet with low lighting. • Apply heat, ice, compression, and/or elevation to help alleviate pain. • Place the patient in a comfortable position (for example, tripod, Fowler, semi-Fowler). • Play soothing music or the patient’s favorite music. • Use guided imagery, reiki, or massage to reduce pain or dyspnea. • Speak to the patient in a calm and reassuring manner. • Listen to patients and family members. • Provide culturally sensitive care. • Facilitate frequent oral hygiene and keep fluids fresh. • Determine the patient’s food and beverage preferences. • Advise smaller, more frequent meals to help reduce gastric distress. • Reorient patients having delusions if possible, but don’t argue with them. • Include the family in the patient’s care plan. • Encourage family members to talk to the patient, even if he or she is unconscious. • Provide adequate education and frequent check-ins with patients and families about treatments, prognosis, symptom management, and medication regimens. Comfort measures10 American Nurse Journal Volume 15, Number 7 MyAmericanNurse.com common, even when patients are unrespon- sive, and it should be managed with sublin- gual or injectable morphine. Audible congestion (“death rattle”) At end of life, the muscles of the jaw relax, the patient may swallow infrequently, and the mouth may hang open, resulting in oropharyngeal secretions collecting at the back of throat. The fluid vibrates during breathing and “rattles.” This isn’t uncomfort- able for the patient, but it may be distress- ing for the family. Rather than suctioning the patient, which will increase secretions, reposition them and elevate the head of the bed. Medications such as scopolamine, gly- copyrrolate, and hyo scya mine (sublingual or injectable) may be ordered to help dry secretions. Decreased level of consciousness and terminal delirium As the patient gets closer to death, mental status changes are common. Patients may withdraw socially, sleep most of the day, and become more unresponsive. They may experience ter- minal delirium, a state where they become more restless, agitated, and/or hallucinate. Ter- minal delirium can be managed with medica- tion and environmental changes. Extremity cooling, pallor, and mottling Closer to death, blood is shunted away from the extremities to core body organs (heart, brain, lungs). When this happens, the extrem- ities will cool, pulses will weaken, and the skin will become pale and mottled. These signs aren’t seen with every patient, but they can indicate that death is imminent. Decrease in food and fluid intake As the body starts to shut down, patients de- crease food and fluid intake. Family members may think the patient is being starved. Talk to them about the dying process so they under- stand that this is normal. Offer the patient food and fluids for comfort. Use mouth swabs to moisten the mouth, and provide oral care. Consider dipping swabs into the patient’s fa- vorite foods (in liquid, soup, or puree form), so that they can enjoy the flavor even though unable to eat. Decreased fluid intake will reduce urine out- put, which will be dark in color. This natural dehydration may cause a fever. Use cool com- presses on the forehead, axilla, and groin to keep the patient comfortable, and administer acetaminophen orally or rectally if tolerated. Urinary and fecal incontinence While imminently dying or upon death, urethral and anal sphincter relaxation occurs, which can cause urinary and fecal incontinence. How can I best support family? Nurses play a major role in providing sup- port and reassurance to the family and care- givers, both in home and long-term care set- tings. Family members who want to do more for their loved one may feel helpless and alone. Education is key to helping them feel supported and part of the care plan. Teach family members and caregivers about the disease process, the stages of dying, and what to expect. Provide detailed instructions and reasons for any treatments or medica- tions they need to give. Also, teach them to assess and treat the patient for signs of dis- comfort. Death is overwhelming, so provide ongo- ing family and caregiver education; they may not grasp everything the first, second, or even third time they hear it. Provide reassurance that they’re doing a good job caring for the patient. Friends and family may be afraid to talk to dying patients. Let them know that they can continue to talk with the patient as they normally would, even if they aren’t conscious. Encourage them to be open and honest about how they feel. Easing distress Death is a process that’s frequently hidden away in our culture. Watching someone die can be stressful and scary to family and friends. As nurses, we can help patients and families cope with the dying process. We can help them establish a “new normal” and en- sure that loved ones understand when the pa- tient is comfortable. This can provide a great source of relief. AN Kaveri M. Roy is an assistant professor of nursing at MGH Institute of Health Professions in Boston, Massachusetts, and a hospice nurse educator at Care Dimensions in Danvers, Massachusetts. Visit myamericannurse.com/?p=66918 for a list of references and a mnemonic for the reversible causes of delirium.MyAmericanNurse.com July 2020 American Nurse Journal 11 Please mark the correct answer online. 1. Sam Jones*, a 45-year-old man dy- ing of spinal cancer, states he is having severe pain. Which of the following would be an appropriate pharmacolog- ic choice? a. Lorazepam b. Acetaminophen c. A nonsteroidal anti-inflammatory drug (NSAID) d. An opioid agent 2. An appropriate adjuvant to help manage neurologic pain is a. hydromorphone/hydrocodone. b. ibuprofen. c. gabapentin. d. high-dose methadone. 3. Which statement about the use of fentanyl patches to treat pain in pa- tients with end-stage disease is cor- rect? a. They are used for short-acting pain management. b. They are used for long-acting pain management. c. They can be used in patients of any size. d. They are easily titrated. 4. Mr. Jones is experiencing break- through pain. Which of the following might help control it? a. Hydrocodone and hydromorphone b. A tricyclic antidepressant c. High-dose methadone d. An NSAID 5. A patient with end-stage disease develops chronic heart failure (CHF). Which drug will help reduce cardiac preload and afterload? a. Nitroglycerin b. Lorazepam c. Furosemide d. Acetaminophen 6. Mr. Jones reports frequent episodes of nausea and vomiting, which his provider suspects is related to constipa- tion. Which of the following would be an appropriate drug? a. Haloperidol b. Ondansetron c. Octreotide d. Metoclopramide 7. Which of the following statements about treating Mr. Jones’s constipation is correct? a. An enema is the first-line treatment for constipation. b. Bulk-forming agents, such as psylli- um, should not be used. c. Stool softeners, such as docusate sodium, should be avoided. d. A rectal suppository may be or- dered after 24 hours of oral laxa- tives. 8. Mr. Jones’s vomiting becomes in- tractable when he develops a bowel obstruction. If surgery isn’t possible, his provider may order a. haloperidol. b. ondansetron. c. octreotide. d. metoclopramide. 9. Mr. Jones starts taking only sips of fluid. He also becomes confused and periodically talks to his father, who died 10 years ago. Mr. Jones is consid- ered to be in what stage of death? a. Decline b. Transitioning c. Active dying d. Stable 10. All of the following indicate that Mr. Jones is actively dying, except : a. tightening of jaw muscles. b. cool, mottled skin. c. dark urine. d. fecal incontinence. 11. Mr. Jones is actively dying, and oropharyngeal secretions are collecting in the back of his throat. Which of the following is an appropriate action for you to take? a. Elevate the head of the bed and give hyoscyamine as ordered. b. Put the bed flat and administer scopolamine as prescribed. c. Suction Mr. Jones every hour and more often as needed. d. Suction Mr. Jones every 2 hours and give glycopyrrolate as ordered. 12. You have cared for Mr. Jones for several weeks and want to keep him as comfortable as possible. Take 5 min- utes and think about what strategies you could use to ease his discomfort. Consider the types of symptoms he might have and the nonpharmacologic comfort measures that you could im- plement. 13. Mr. Jones is married with a 16-year- old son and a 22-year-old daughter. Take 5 minutes and reflect on how you can best support them. What emotions might they be feeling? What education would they need? How would you de- termine communication preferences? *Name is fictitious. POST-TEST • Frequently asked questions about palliative care Provider accreditation The American Nurses Association is accredited as a provider of nursing continuing professional development by the American Nurses Credentialing Center’s Commission on Accreditation. Contact hours: 1.5 ANA is approved by the California Board of Registered Nursing, Provider Number CEP17219. Post-test passing score is 80%. Expiration: 7/1/23 CNE: 1.5 contact hours CNE12 American Nurse Journal Volume 15, Number 7 MyAmericanNurse.com V IVIAN M ARTIN ,* a 72-year-old woman, arrives in the emergency department (ED) saying she has a headache, feels light-headed, and that her heart is “pounding.” Ms. Martin has mild arthritis but is otherwise healthy. She’s afebrile with a heart rate (HR) of 122 beats per minute (bpm), respiratory rate (RR) 26 breaths per minute, and blood pressure (BP) 188/118 mmHg. The ED provider diagnoses Ms. Martin with uncontrolled hypertension and starts her on an I.V. infusion of clevidipine. An hour later, her BP is 125/80 mmHg. Ms. Martin is started on lisinopril, the clevidipine is discontinued, and she’s transferred to the progressive care unit. Assessment An hour after Ms. Martin is admitted to the unit, you start your shift and conduct a neuro- logic exam. Your exam reveals a droopy right eye, uneven smile, right arm drift, and slurred speech. You realize your findings align with the acronym FAST (Face, Arm, Speech, Time to call 911), which details the most common signs of stroke. You activate the stroke proto- col, start 2 liters of oxygen via nasal cannula, and obtain Ms. Martin’s vital signs: BP 210/120 mmHg, HR 95 bpm, and RR 20 breaths per minute. Ms. Martin’s oxygen saturation is 92%, and she remains afebrile. You realize that she’s in a hypertensive crisis and is likely having a stroke. You complete the National Institutes of Health (NIH) stroke scale, which provides a numeric score based on assessment results. Ms. Martin’s score is 6, indicating a moder- ate stroke. (Access the scale at emedicine.med scape.com/article/2172609-overview .) Taking action Ms. Martin’s provider restarts the clevidipine infusion, with a goal of lowering the BP to 185/110 mmHg. As part of the stroke alert, you ensure Ms. Martin has two patent I.V.s and arrange for transport to radiology for a computed tomography (CT) scan. You also notify the neurologist of her condition and the pending scan. The CT scan shows no evidence of bleed- ing or head trauma, and Ms. Martin is diag- nosed with stroke. The time from Ms. Martin’s initial signs of stoke when you evaluated her to diagnosis is 2.5 hours, well within the time window for antithrombolytic therapy with al- teplase—4.5 hours after stroke symptoms start. She meets other inclusion criteria as well. Her BP is now 176/108 mmHg. Although her initial uncontrolled hypertension would have excluded her from alteplase, now that it’s controlled with clevidipine, she can re- ceive this therapy as ordered by the provider. The nurse who admitted Ms. Martin to the unit had obtained her weight, so you can ver- ify that the alteplase dosage is correct. After administering the drug, you transfer her to the intensive care unit (ICU) for close monitoring. Outcome In the ICU, the goal is to keep Ms. Martin’s BP at 180/105 mmHg or lower for 24 hours after alteplase administration. Excessively lowering the BP can reduce cerebral perfusion pressure and exacerbate stroke symptoms. ICU staff monitor Ms. Martin for any signs of bleeding, such as change in level of consciousness, and use the NIH stroke scale for assessments. She doesn’t experience any complications and is transferred to a medical/surgical unit 24 hours after alteplase administration. She has minimal right arm weakness and some speech slurring, but her BP is controlled and she’s looking for- ward to returning home. Follow up Ms. Martin will need long-term BP control, with a goal of 140/90 mmHg. She’ll also need evaluation for deficits related to her stroke; physical therapy, occupational therapy, or speech therapy may be required after dis- charge. Fortunately, your quick action ensured that her deficits aren’t more serious. AN To view a list of references, visit myamericannurse.com/ ?p=67082. * Name is fictitious. Alysia D. Adams is the director of emergency and trauma services at Owensboro Health in Owensboro, Kentucky. Stroke: Act FAST Quick action ensures timely therapy. By Alysia D. Adams, DNP, APRN, AGACNP-BC, CCRN, NE-BC STRICTLY CLINICAL Rapid Response 14 American Nurse Journal Volume 15, Number 7 MyAmericanNurse.com Year of the Nurse The world recognizes our crucial role. From your ANA President W E ’ RE now 7 months into the Year of the Nurse, the worldwide initiative designed to honor and recognize the significant contributions nurses make every day. And although most “celebratory” plans have been put on hold, nurses’ contributions to patient care and pub- lic health efforts over these past few months have been widely recognized. The media have reported countless stories about frontline nurses providing critical care under extreme circumstances and others vol- unteering to help in any way they can. Across the nation, people have shown their appreci- ation for nurses and other healthcare workers by standing outside their doors and cheering at designated times, displaying thank-you signs in the windows of homes and businesses, and driving past healthcare facilities in mini-cara- vans. Even folks like basketball Hall of Famer Kareem Abdul-Jabbar, singer Jennifer Lopez, professional golfer Rory McIlroy, and talk show host Jimmy Fallon have voiced their gratitude and support. Although the public will never know every- thing we do and the varied roles we have, they understand that nurses are crucial to safe, quality care. And they are now witnessing our care, commitment, and compassion on a glob- al stage. As I write this, circumstances around COVID- 19 continue to evolve, but I want to take this time to recognize all nurses in every setting and role and at every experience level during this Year of the Nurse. I’m talking about those directly providing care to COVID-19 pa- tients, engaging in testing and contact tracing, innovating efficient and safe care processes, and addressing food insecurity and access to care among populations made even more vul- nerable. Also vital to healthcare are nurses’ ongoing roles as educators, researchers, and clinicians in labor and delivery, the operating room, and mental health services, to name a few. Thousands of new nurses have found themselves battling a pandemic while simulta- neously trying to master new skills and pro - cesses, and thousands of retired nurses have answered the call to help support staff and embody the saying, “Once a nurse, always a nurse.” The list goes on. I also want to speak to our universal role as advocates. During these past several months, the American Nurses Association (ANA), specialty organizations, and individual nurses have relentlessly advocated for sufficient pro- tective equipment and other infection control and prevention measures to keep patients, communities, and themselves safe. You can read about ANA’s activities at nursingworld.org/ coronavirus , but one effort that I want to point out is our ongoing outreach to the Trump ad- ministration. We specifically asked for a key nursing role with the Coronavirus Task Force. We believe having nursing’s perspective and knowledge is critical now and as our nation moves forward. We must take what we learn from this pandemic, combine it with our nurs- ing expertise, and advocate for a healthcare system that’s safe, equitable, and better pre- pared for emergent issues. Additionally, we must advocate for our profession, so it contin- ues to be one that many want to join and view as a lasting career. It’s not the Year of the Nurse we envi- sioned, but nurses’ voices are being heard and the world is listening. We always rise to chal- lenges and are critical to the health of our na- tion every day, every year. I encourage you to share your stories at anayearofthenurse.org and keep our collective advocacy going at RNAction.org . Ernest J. Grant, PhD, RN, FAAN President, American Nurses Association PRACTICE MATTERS We believe having nursing’s perspective and knowledge is critical now and as our nation moves forward.MyAmericanNurse.com July 2020 American Nurse Journal 15 LEADING THE WAY Leadership challenge: Learning to let go Holding on to the past can sabotage your future. By Rose O. Sherman, EdD, RN, NEA-BC, FAAN, and Tanya M. Cohn, PhD, MEd, RN K ELSEY worked for years as director of profes- sional practice in her organization. The hos- pital achieved Magnet® designation twice dur- ing her tenure. A recent merger with a bigger health system eliminated her position when the functions of the professional practice de- partment merged with that of the larger health system. Kelsey was offered no other role and left the organization. Kelsey is still stunned by this turn of events, and she’s having trouble letting go of what happened and making plans for the future. Kelsey’s reaction to her job loss is under- standable. Losing a role that you’ve held for years can shake your confidence. Job loss can lead to grief associated with a sudden loss of role identity, professional colleagues, and work routine. Few leaders don’t at some point experience a crisis in their job, health, or family. Learning to let go of our expecta- tions and the demands that we place on our- selves can be challenging. Clinical psychologist Henry Cloud, PhD, has noted that life is a delicate balance of holding on and letting go. Learning to let go is difficult but frequently essential. Continuing to ruminate about what’s happened doesn’t fix anything, nor does wishing that things were different. What Kelsey may not realize is that holding on to the past will wreak havoc in her life. If she lets go, she can free herself from the sources of pain and suffering that are holding her back. But letting go isn’t easy. Why letting go is so hard Our desire to work hard and challenge our- selves can make letting go difficult. And we may have a compelling inner voice that tells us not to be a quitter. However, letting go and quitting aren’t the same. Letting go is a process of accepting change as a positive next step in life that will result in profession- al maturity. Many of us fear starting something new. A new job creates anxiety that subsides as we become more familiar and comfortable with the organization and our new colleagues. We develop new personal and professional net-16 American Nurse Journal Volume 15, Number 7 MyAmericanNurse.com works, and we grow professionally through projects and promotions. These roots are im- portant because they establish our mutual commitment, but they also make it hard to let go. We have to remind ourselves that starting something new may be stressful, but the re- wards of professional growth will outweigh that. Letting go also requires us to forgive. When an abrupt change, such as Kelsey’s, occurs, we can get so absorbed in being up- set that a path to forgiveness seems impossi- ble. We would rather believe that things shouldn’t be this way or that those making the decision don’t understand our value to the organization. However, we can’t truly let go and move on unless we can forgive and create a sense of acceptance, release, and peace that allows us to move forward with a positive outlook. For Kelsey, the process of letting go is fur- ther compounded by the fact that her posi- tion was eliminated. This can create a feeling of devaluation, which is entirely understand- able; however, Kelsey must maintain her dig- nity and not sabotage her career by speaking negatively about the organization. She must remember that a department merger isn’t a personal attack on her or a negative reflec- tion on all the hard work she devoted to the organization. If Kelsey can do that, she can transition to a new organization and position more positively than she is currently. Part of transition is accepting what we can control and what we can’t. The illusion of control We frequently believe we have control over all things that happen in a situation when, in fact, we don’t, which leaves us feeling frus- trated or angry. Even worse, we might blame ourselves. What we’re feeling is a sense of powerlessness, which may lead us to think that if only we could go back in time we could do or say something to change the out- come. But we must remember that we can’t control others’ decisions or actions. We can control only our actions and reactions. We must stay present and manage our emotions. For Kelsey, this means identifying where the illusion of control is interfering in her sit- uation. She might believe that her position and leadership success warrant her control over the organization’s direction. Or she might blame herself for her position’s elimi- nation. Neither is correct. The decision to merge departments and eliminate Kelsey’s position is the direct result of the organiza- tion’s strategic change. In the end, Kelsey must accept that she didn’t have control over the changes, but she does have control over her actions and reactions. If she lets go of her previous position and the events that sur- rounded the change, Kelsey can embrace creating a positive professional outlook for a new position and organization, allowing her to make plans for the future. Strategies for letting go As Kelsey has learned, losing a job is hard. It impacts our self-esteem and self-confidence. Moving on professionally means letting go of what happened. Failing to do so can lead to future career derailment. Kelsey can use these five strategies to help her let go. 1. Express gratitude. When confronted with a crisis, think about what’s good in your life to help you stay calm and centered. Reflect on things you’re grateful for and thank those who support you. Expressing gratitude reminds you that you need to let go of only a part of your life. 2. Stay in the present. When facing uncertainty, you easily can be- come anxious about the future. You might look for reassurance that your life will get back on track quickly, but you can’t live in the future today. This is a lesson that people with alcohol misuse who go through the Al- coholics Anonymous 12-step program quick- ly learn—take one day at a time. 3. Admit you need help. Kelsey’s career success means she probably was a go-to person for others who were hav- ing problems. She may find admitting that she needs help challenging; ultimately, though, she may find it liberating. Relying on trusted friends and family is essential now. They will remind her what a great person she is. As nurses and leaders, we frequently believe we should be able to solve our own problems and don’t ask for help. A trusted circle can provide sound advice on the next steps in a job search and hold you accountable if you demonstrate anger and resentment. MyAmericanNurse.com July 2020 American Nurse Journal 17 4. Change your vantage point. When you’re in the midst of a struggle, see- ing the bigger picture can be difficult. Get- ting some distance from your crises and changing your perspective can help you emerge wiser and more thoughtful. Usually, when you let go of one thing, other doors open that you might not consider walking through if you stay in your comfort zone. 5. Decide to let it go. Things don’t disappear on their own; you have to commit to letting them go. If you don’t make this conscious choice up front, you might sabotage any effort to move on from this hurt. Making the conscious decision to let it go also means accepting you have a choice to let it go. Kelsey can stop reliving the past pain and ruminating about the organizational deci- sion to eliminate her position. Realizing this can be empowering. The choice is yours: Hold on to the pain or live a future without it. Wise advice As we gain more life experience, we contin- ue to learn that things don’t always go as planned. The psychiatrist Carl Jung once said, “I am not what happened to me. I am what I choose to become.” This is wise ad- vice for all of us, even when the rejection feels very personal. Letting go is ultimately a decision to take control of the rest of your life. AN Rose O. Sherman is adjunct professor at the Marian K. Shaugh- nessy Nurse Leadership Academy, Case Western Reserve Universi- ty in Cleveland, Ohio, and author of the book The Nurse Leader Coach: Become the Boss No One Wants to Leave. You can read her blog at emergingrnleader.com. Tanya M. Cohn is an associate professor of practice and consulting nurse scientist at Simmons University in Boston, Massachusetts. References Cloud H. Necessary Endings: The Employees, Businesses, and Relationships That All of Us Have to Give Up in Or- der to Move Forward. New York: Harper-Business; 2010. Cushatt M. Undone: A Story of Making Peace with an Unexpected Life. Grand Rapids, MI: Zondervan Press; 2015. TRENDING on myamericannurse.com American Nurses Association/American Nurses Credentialing Center ANA Nurse Focus ............................................................................ IBC ANA’s Principles for Nurse Staffing ................................................... 35 Healthy Nurse Healthy Nation ......................................................... IFC See You Now Podcast ......................................................................... 5 Berkshire Hathaway Specialty Insurance ............................................... BC Calmoseptine, Inc . ................................................................................ 13 A D I NDEX For advertising and partnership information please contact John J. Travaline. 215-489-7000 • jtravaline@healthcommedia.com Popular on social media PPE access still a concern among nurses Results of an ANA survey of U.S. nurses working on the frontlines of COVID-19 include concerns about PPE, staffing, and training shortages. bit.ly/3fZ5AhJ Nurse influencers COVID and racism: Tipping points for change in 2020 Nursing is the most trusted pro- fession and it’s a recognition that we can use to truly enact change. bit.ly/2CwUu4X Featured content Dialing down drama at work Learn to spot workplace drama and take steps to eradicate it. bit.ly/37T5CEVNext >