Resiliency rising!

Author(s): Cynthia Clark, PhD, RN, ANEF, FAAN

Ten just-in-time self-care strategies.

Takeaways

  • Experiencing stress and anxiety during the pandemic is a normal response to an abnormal situation.
  • The combination of work, family, and life pressures—intensified by pandemic-related stressors—collide to create fertile ground for uncertainty and anxiety to take root.
  • This article describes 10 just-in-time self-care strategies to help nurses take a mini-recess from life’s hectic and stressful situations and to reset with a renewed sense of strength and purpose.

Editor’s note: This is an early release, web exclusive article that will appear in the upcoming January 2021 issue of the American Nurse Journal. 

“Life is a dance. Mindfulness is witnessing that dance.”—Amit Ray

Self-care is how you take your power back.”Lalah Delia

As this article goes to press, the Centers for Disease Control and Prevention reports over 11.3 million people in the United States have tested positive for COVID-19 and more than 247,000 have died, of which 1,700 were healthcare workers. As nurses work tirelessly to meet the challenges of the pandemic, many have shared their stories of stress and burnout. The following statements represent three individual perspectives during this challenging time. 

Abigail*: Assistant nurse manager, intensive care unit (10 years of experience)

Our team is burned out, and moral distress is a daily—if not hourly—occurrence. Dealing with COVID-19 positive patients has everyone staying busier than usual and worried about the future as the virus is expected to surge during the fall and winter months. Guidelines and protocols shift rapidly, and it’s a challenge to keep current. Several spouses are working from home, and some have lost their jobs. We’re homeschooling children while trying to have some semblance of family life. We feel guilty hanging out with friends even when we’re doing it responsibly. It’s all so complicated. 

Talia: Associate clinical professor, BSN program (5 years of experience)

It’s been very stressful teaching nursing classes during the COVID-19 era, especially teaching clinical in a virtual environment. Last spring, we made an abrupt and immediate pivot from teaching in-person to teaching online. I must admit, the changes left me feeling stressed, exhausted, and wondering if I could learn, much less master, the skills needed to help students care safely for patients using technologies I’ve never used before. I work hard every day to ensure that students are learning and that my courses are relevant and applicable in today’s healthcare settings. I guess time will tell.

Carlos: Third-year nursing student, BSN program

I can hardly keep up with the competing demands of school, work, and home. I keep getting confused about what I’m supposed to do, when I’m supposed to do it, and where I’m supposed to be. My days are filled with completing course assignments on time, parenting and homeschooling my children, caring for aging parents, and working part time as a certified nursing assistant in a care facility. I’ve always wanted to be a nurse, but I’m not sure it’s going to happen. There is just too much going on, and at times the stress is overwhelming.

The stress of COVID-19 and beyond

The stress expressed in these real-life accounts is unsettling and far too common. Practice-based nurses, faculty, and students face daily challenges as they respond to competing family, work, and educational demands while navigating a new reality for nursing and nursing education. Providing quality patient care while simultaneously experiencing new ways of working, teaching, and learning—frequently intensified by pandemic-related physical, emotional, and moral distress—collide to create fertile soil for uncertainty and anxiety to take root.

Nurses in all settings and representing all specialties are modeling and leading the way as they individually and collectively respond to the pandemic and its myriad consequences. At the same time, nurses are concerned about their own health as well as the health of loved ones, and they frequently find themselves balancing these concerns with the ethical obligations of providing care during staff shortages and limited personal protective equipment. In addition, some community members may perceive nurses as a health threat because of their work with infected patients

Protecting nurses’ well-being

Given the enormity and widespread effects of COVID-19 and other associated stressors on nurses’ mental health, the need for a multilayered approach to support self-care, build resilience, and effectively manage stress is evident. (See Resilience in action.) This support must include helping nurses prioritize their own health and wellness as much as possible, extending and receiving peer support as nurses look after one another, team member and manager help, and an intentional systematic organizational response.

Resilience in action

Resilience is the capacity to successfully meet life’s various challenges, to adapt well in the face of adversity and stress, and to recover from demanding situations. Building resilience also enhances your ability to face future challenges.

One power-packed way to build resilience is to practice mindfulness activities. Mindfulness is the state of paying attention and being fully present and alert to your surroundings and environment. It means focusing your attention on the present moment, becoming aware of what’s happening in the here-and-now, and being cognizant of your internal and external world without judgment. Practicing and honing self-care techniques before you need them can help mitigate stressful situations.

Although a multilayered approach is essential, this article provides immediate, just-in-time strategies for self-care and stress reduction that can be used in the moment and in a variety of situations and settings. They cost nothing, can be performed anywhere, are easily mastered, and may provide stress relief in less than a minute.

Just-in-time self-care strategies

Nurses know they need to attend to their physical health—drinking plenty of water to stay hydrated, getting adequate rest, eating healthy foods, and exercising. Fulfilling these needs during a global pandemic creates challenges, but self-care is more important than ever. The following strategies are designed to help nurses take a mini-recess from life’s hectic and stressful situations—to reset and re-engage with a renewed sense of strength and purpose.

Mindful breathing

Deep, mindful breathing creates a sense of calm and a deeper connection to your body, which helps quiet the mind and ease stressful thoughts. Because breathing is living, it can be done anywhere at any time.

To practice mindful breathing throughout the day, pause for a moment and take a slow, deep, calming breath in through your nose; then slowly exhale through your mouth as you imagine stress leaving your body. Focus on your breathing and notice the sensations of your lungs filling and your rib cage falling. Relax as you continue to breathe and visualize exhaling stress and anxiety and inhaling peace and calm.

Cognitive behavioral therapy (CBT)

CBT is an effective, evidence-based approach for dealing with stress, anxiety, and mild-to-moderate depressive symptoms. CBT is based on the theory that our thoughts influence our feelings, our feelings influence our behaviors, and our behaviors influence our thoughts. To use CBT to reduce stress, think about stopping or turning off negative or intrusive thoughts with an image such as the off position on a light switch, the power-off button on a TV remote, a stop sign, a red light, or the undo button on your computer. Use the image to interrupt or turn off negative, intrusive, or harmful thoughts; then take one or two deep cleansing breaths and replace the negative thoughts with a positive image. The positive image you visualize is personal to you—it might be a vision of your child or grandchild, ascending the summit of a mountain peak, feeling the sun on your face as you relax on a sandy beach, or imagining a beautiful mountain meadow burgeoning with stunning wildflowers.

Reframing thoughts

Reframing is a cognitive technique used to look at a situation differently by changing its meaning and viewing it from a different perspective or point of view. As humans, we construct mental models from prior experiences, life events, successes, and conditioned ways of thinking. Sometimes we become entrenched in our thinking, which narrows our view of the world. During the pandemic, you may feel isolated, lonely, or negative. Reframing begins with identifying and acknowledging what you’re experiencing and restating the experience in a more positive way. Here are examples that Carlos and Talia might use during the COVID-19 pandemic.

Statement: “Teaching online and being physically distanced from my students is joyless and overwhelming.”

Reframing the statement: “Teaching online isn’t my favorite way of interacting with students, but technology provides a way to stay involved and connected.” 

Statement: “This pandemic will never end—life will never be the same.”

Reframing the statement: “This pandemic won’t last forever, and we’ll emerge from this experience more creative, nimble, innovative, and resilient.”

Power of positive affirmations

Similar to reframing, using positive affirmations in stressful times can help create a sense of personal control and inner strength. If you’re prone to thinking and speaking negatively or pessimistically, it may take time and practice to change your internal dialogue and replace negative self-talk with positive affirmations. Crafting positive affirmations, writing them down, and practicing them daily can shift your attitude and improve your outlook on life. Here are two examples to get you started.

  • We’re creating new best practices that will revolutionize nursing practice and education.
  • Today will surely bring new challenges and unexpected wins, and I’m ready for both.

Notice five things

When you find yourself getting caught up in your thoughts and feelings, pause for a moment and use all your senses to soak in your surroundings. As you look around, notice five things you can see, hear, feel, or smell. For example, before a major exam, Carlos can breathe deeply and absorb and notice his environment. What does he see, hear, feel, and smell? Perhaps he sees the breeze blowing through the trees out his window, hears birds chirping, and smells the lingering spices from a recent meal. This simple, yet potent, exercise helps us refocus and reconnect with our environment.

Mindful handwashing

Handwashing is an impressive mindfulness activity that can be used now and in the future. It’s an uncomplicated endeavor to practice alone, with children, and certainly in patient care areas. For example, as Abigail washes her hands she’s mindful of the water, feels the friction of her fingers rubbing against each other, observes her hands moving along her wrists and forearms, and notices the suds washing away as she rinses. She does all of this while breathing deeply.

Susan Bauer-Wu, PhD, RN, president of the Mind & Life Institute, developed the WORTH method for mindful handwashing:

Wash your hands with awareness, feel the warm water, and watch the soap lather and rinse away.

Open the door, notice the experience of walking into the room, and observe the patient and family as you enter.

Remember that you’re caring for a person who has a full life and is much more than a disease or a procedure.

Take a couple of slow full breaths and tune in before saying or doing anything.

Handle the patients (and families) with calm, clarity, and presence.

He Gu (large intestine 4) acupressure

The Chinese translation for large intestine 4 (LI4) is He Gu, which means union or converging valley. The LI4 acupressure point is located on the web of the hand between the thumb and index finger (the depression where the index finger and thumb bones part. He Gu acupressure is used to relieve stress, headaches, and neck pain. To use this technique, locate the He Gu point in the web of the hand. Then breathe fully as you apply deep, firm pressure to massage and stimulate the area for 4 to 5 seconds. This traditional Chinese acupressure technique can be self-administered or with assistance from a colleague or friend. This technique is used widely, but it may induce labor and is contraindicated during pregnancy.

Aromatherapy with essential oils

Aromatherapy, a form of complementary and alternative medicine, is an easy-to-use, fast-acting, low-cost, low-risk intervention to help decrease stress and anxiety. It’s considered a natural remedy to create calmness and improve well-being. Essential oils such as lavender, sandalwood, lemongrass, rose, peppermint, chamomile, and jasmine may be applied topically or inhaled via a diffuser or personal nasal inhaler. We can also add personal nasal inhaler to calm the mind and body and reduce feelings of stress and anxiety. A certified clinical aromatherapists can suggest the best essential oil treatment options.

Scalp massage

A scalp or head massage is an effective stress reliever. Applying pressure to the head and neck increases blood circulation and can help you relax and reduce anxiety. Self-massage also helps boost energy throughout the day and increase concentration.

Talia, Abigail, and Carlos can benefit from a self-administered head massage to ease headaches and tension. They can start by using their fingertips to apply gentle pressure and rub the temples. Next, they can apply firm pressure and small circular motions as they gradually move their fingers along the hairline to massage their entire forehead and then slowly inch along to massage the entire scalp.

Express gratitude

Expressing gratitude and appreciation for the people, places, creatures, and things around you can help decrease your stress level and put life into perspective. Expressing gratitude also helps boost happiness levels. Each day or when feeling stressed or overwhelmed, think about a person, experience, event, or something you’re grateful for and reflect upon them for several seconds or record your thoughts in a journal. Conveying gratitude trains our brain to see the positive and may be one of the most effective strategies for achieving and maintaining a contented life.

Perhaps Abigail is grateful for her teammates and their esprit d’ corps, Talia may be thankful for her time at home and not needing to commute to campus for classes, and Carlos might appreciate his family and their time together.

Make a commitment to yourself

The stress and anxiety experienced during this unstable time is a normal response to an abnormal situation. Times of uncertainty test our patience and grit and can contribute to heightened levels of stress. Give yourself and others the gift of grace as we navigate these uncertainties together and seek calm and restoration through mindfulness and other resilience-building activities. The emotional impact of COVID-19 is undeniable. Integrating self-care and wellness activities into our daily lives is essential to our overall health and well-being. Today, let’s recommit to taking better care of ourselves as we care for others.

Cynthia Clark is professor emeritus at Boise State University and Founder of Civility Matters® based in Boise, Idaho.

*Names are fictitious. 

References

Chowdhury MR. The neuroscience of gratitude and how it affects anxiety and grief. January 9, 2020. positivepsychology.com/neuroscience-of-gratitude

Hazlett-Stevens H. Mindfulness-based stress reduction for health care staff: Expanding holistic nursing paradigms to the whole system. Holist Nurs Pract. 2020;34(5):301-5.

Hedderman E, O’Doherty V, O’Connor S. Mindfulness moments for clinicians in the midst of a pandemic. Ir J Psychol Med. 2020:1-4. ncbi.nlm.nih.gov/pmc/articles/PMC7276502

Maben J, Bridges J. Covid‐19: Supporting nurses’ psychological and mental health. J Clin Nurs. 2020;29(15-16):2742-50.

National Academies of Sciences, Engineering, and Medicine. Taking Action Against Clinician Burnout: A Systems Approach to Professional Well-being. Washington, DC: The National Academies Press; 2019.

Stephens TM. Building personal resilience: Develop skills to overcome daily challenges and prepare for the future. American Nurse Today. 2019;14(8):10-5.

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