Delaware - June 2022

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Page 6 • DNA Reporter June, July, August 2022 Pediatric Nurse Well-Being: Concerns of the Past and Meaning in the Present Catherine Haut, DNP, CPNP, CCRN, FAANP, FAAN Christina Russell, BSN, RN, HTCP, HNB-BC, RYT-200 Catherine Haut earned her BSN at Notre Dame of Maryland University and her MS and DNP at the University of Maryland School of Nursing. She is the Director of Nursing Research and Evidence Based Practice at Nemours, Children’s Hospital in Wilmington Delaware. Catherine is also board certified as a pediatric nurse practitioner in both primary and acute care. Her role at Nemours includes leading and participating in research activities and supporting nursing staff in designing and completing research and quality improvement projects. Catherine has over 35 years of pediatric experience as a nurse, educator, and practitioner and has held leadership positions in several national nursing organizations, currently serving as the President of the Foundation Board for the National Association of Pediatric Nurse Practitioners. She has Catherine Haut presented nationally on a variety of clinical and leadership topics, authored many journal articles and was the co-editor of two textbooks for pediatric nurse practitioners. Cathy can be reached at: Catherine.haut@nemours.org or phone: 302-651-5161. Christina Russell earned her BSN from Wilmington University, is currently pursuing her MS in Complementary and Integrative Therapies at Drexel University, and is due to graduate December 2023. Christina has been a pediatric nurse for over 20 years. Prior to becoming a nurse, she was a Hospital Corpsman in the U.S. Navy and then worked as a nurse’s aide while attending nursing school. During her career, she has worked in a variety of roles including medical/surgical, infusion/sedation, and nurse manager. In 2015, she achieved her national Healing Touch Certified Practitioner (HTCP) status, completed her 200-hr Yoga Teacher Training in March 2018, and became a Board-Certified Holistic Nurse (HNB-BC) in 2019. She transitioned to the Department of Integrative Medicine in 2018 and is currently the Healing Touch Program Coordinator at Nemours Children’s Hospital-Delaware. Christina can be reached by email at crussell@nemours.org or by phone at (302) 651-4325. Christina Russell Nursing has been rated the most trusted profession, earning high scores for honesty and ethics, important characteristics of the largest group of health care providers. Nurses are devoted clinicians who provide education, lead research, engage in evidence-based practice, offer holistic care, and advance policy at all levels. Portrayed as a “glamorous” profession and cited as “heroes,” nurses historically work in stressful and highly emotional environments. They experience the effects of working long hours around the clock and face obstacles to providing high-level patient care. Increasing patient complexity, rapidly changing clinical environments, staffing shortages, and concern for illness exposure, escalated through the Covid-19 pandemic, remain challenges. Nurses are doing more with less, and workplace expectations have heightened, without consistent opportunities for support. The American Nurses Association (ANA), “Healthy Nurse/Healthy Nation (HNHN),” an interactive initiative targeting healthy lifestyles for nurses, portrayed the overall health of nurses as poor, and initial HNHN survey results indicated stress, workplace violence, lack of work breaks and insufficient nutrition and exercise as health and safety hazards identified by nurse respondents (Gould et al., 2022). Over the past several decades, terms including traumatic stress, fatigue, moral distress, burnout, and compassion fatigue have been described but not completely addressed relating to the psychological effects of nursing practice. Nurse burnout is documented to increase with a pandemic and the past two years of Covid-19 are no exception (Sullivan et al., 2022). Nurses experienced an environment of limited resources for a new illness, caring for critically ill and dying patients with worry for passing illness to other patients, themselves, and their families (Sullivan et al., 2022). In a recent American Association of Critical Care Nurses (AACN) survey, 92% of 6500 critical care nurses believe the pandemic has “depleted nurses,” with 66% of respondents considering leaving their nursing career (Munro and Hope, 2022). ANA data indicate that younger nurses have more distress with nurses less than age 35 reporting anxiety and depression at much higher rates than other age groups (Sherman, 2022). The complexities of nursing increase the importance of maintaining self-care and well-being, recognized and never more relevant to the care of patients and viability of health care systems (Munro and Hope, 2022). Historically, attempts to support well-being, including the AACN Healthy Work Environment in 2001, identified six standards for successful nursing care that continue to be inherently important (Munro and Hope, 2022). The ANA HNHN initiative offers nurses online health guidance and opportunities to make lifestyle changes. To maintain the reputation and engage the profession, nurses must be supported and their well-being a concern of every health care organization. The definition of well-being includes health and happiness, simple terms, but extremely meaningful for the nursing profession. Well-being is a life balance that takes into consideration aspects of physical and mental health, relationships, and economic and spiritual constructs. Pediatric nurses have faced a roller-coaster of activity over the past two years, with Children’s hospitals experiencing decreased volume in the initial months of the pandemic but rebounding with high census and acuity. More patients to care for, higher than usual admission rates for children with mental health problems, and nursing turnover and shortages then ensued. Nemours Children’s Hospital in Wilmington, Delaware, and their extended health system continued to provide high-quality care for children, but like other organizations, experienced staffing challenges. However, regard for pediatric nurses‘ well-being remained a high priority. Dr. Maureen “Mo” Leffler is the Nemours enterprise, Chief Well-Being Officer, a physician charged with the mission of maintaining well-being throughout the healthcare system. In addition to speaking to nurses at various virtual meetings, Dr. Leffler provides routine updates regarding vaccination, CDC guidelines and the health status of Nemours employees. Through a program called “Your Health,” employees are engaged in a holistic approach to health, wellness, and fitness. Nurses at Nemours are offered opportunities for peer or professional counseling, and events that focus on healthy lifestyles, including fitness challenges and nutrition coaching. There is an employee gym in the hospital and online programs that address exercise, sleep, ergonomics, and financial well-being. “Kudos,” a program encouraging institution-wide peer recognition, encourages nurses to be recognized for actions above and beyond. Recognition is one area outlined by the AACN as important to a healthy environment for nurses. The Department of Integrative Medicine offers therapies for patients, families, and employees, which include massage, Healing Touch, yoga, aromatherapy, and guided meditation. Christina Russell, BSN, RN, HTCP, HNB-BC, co-author of this article, is a holistic certified nurse who holds certifications in Healing Touch and Yoga. She regularly provides individually based sessions for patients with the goal of teaching self-care strategies and relaxation. During these sessions, she reviews breathing techniques and uses guided meditation, but these services are not only for patients. Christina facilitates virtual guided meditation for nurses and other employees each week and offers Healing Touch opportunities. Prior to pandemic restrictions, nurses week included a “Day of Caring” which offered Healing Touch and massage for nurses. Hopefully, the future will allow this inperson activity to occur again, but until then, virtual options are available. Links for videos facilitated by Christina including yoga sessions, meditation, and selfcare Healing Touch techniques are offered. Most recently, she created a virtual wellness program that includes mindfulness strategies and yoga for anyone across the hospital system. A program evaluation research project, approved by the Institutional Review Board will include data collection to determine if these offerings influence nurse and employee well-being. This wellness program is set to begin in early May. Unit-based and individually crafted opportunities for nursing wellness at Nemours include the Neonatal Intensive Care Unit (NICU) “garden” events, an escape to an outside area where nurses can talk, enjoy food, and/or socialize outside the walls of the busy NICU. Maria Gaudino-Smith, BSN, RN, CCRN and Ashley Wilhelm, BSN, RN, CCRN, nurses working in the Pediatric Intensive Care Unit created a respite room offering staff time to regroup, unwind and de-stress when high acuity and stressful situations present. Mindfulness and meditation activities are available in this room. A study completed by the Nursing Research Council, led by Virginia Conte, MSN, RN, CPN, focused on the well-being of pediatric nurses during the pandemic and explored activities nurses engaged in for well-being. Increased awareness of life challenges, especially during the pandemic, assists in addressing self-care, reminding nurses of life outside of work. “JAVA” with Jane and friends is a monthly event for night shift staff to meet with the chief nurse and the leadership team who visit with cookies and coffee. Dr. Jane Mericle, Executive Vice President and Chief Nurse Executive completed a project to identify stressors for nurse managers and determine opportunities for increasing well-being among these leaders. She acknowledges that leadership well-being is especially important in supporting nurses, the largest workforce in the hospital. Pediatric nurses have unique skills, requiring specialized training to care for children and support families. Caring for pediatric patients has great rewards, but also presents ongoing challenges putting nurses at risk of compassion fatigue and burnout, areas not well studied (Forsyth, et al. 2022). Pediatric nurses represent a small percentage of the total population of nurses, but concern remains for the well-being of all nurses and the decision to stay in the profession. Focus on nurse well-being and creative methods of support along with research on these topics should be on the agenda of every health care organization. References Forsyth, L. A., Lopez, S., & Lewis, K. A. (2022). Caring for sick kids: An integrative review of \ the evidence about the prevalence of compassion fatigue and effects on pediatric nurse retention. Journal of pediatric nursing, 63, 9–19. https://doi.org/10.1016/j.pedn.2021.12.010 Gould, L., Carpenter, H., Farmer, D. R., Holland, D., & Dawson, J. M. (2019). Healthy Nurse, Healthy Nation (HNHN): Background and first year results. Applied nursing research: ANR, 49, 64–69. https://doi.org/10.1016/j.apnr.2019.04.001 Munro, C. L., & Hope, A. A. (2022). Improving nurse well-being: The need is urgent and the time Is now. American journal of critical care: American Association of Critical- Care Nurses, 31(1), 4–6. https://doi.org/10.4037/ajcc2022603 Sherman R.O. (2022). Focus on nurse well being. Nurse Leader. DOI: https://doi. org/10/1016/j.mnl.2022.03.001 Sullivan, D., Sullivan, V., Weatherspoon, D., & Frazer, C. (2022). Comparison of nurse burnout, before and during the COVID-19 pandemic. The Nursing Clinics of North America, 57(1), 79–99. https://doi.org/10.1016/j.cnur.2021.11.006
June, July, August 2022 DNA Reporter • Page 7 From Burnout to Resilience: The Journey of the Walking Wounded Karen Avino, EdD, RN, MSN, AHN-BC, HWNC-BC Karen Avino earned a BSN, MSN, and EdD from the University of Delaware. Karen taught Holistic Nursing and Integrative Health for 20 years in online and on campus classes at the University of Delaware where she received the Faculty Senate Excellence in Academic Advising and Mentoring Award. Karen received the Delaware Excellence in Nursing Practice Award as Nurse Educator. She is Karen Avino currently the Executive Director of Education for the Integrative Nurse Coach Academy and the International Nurse Coach Association providing online and onsite continuing education programs for nurses. As a consultant, she helps healthcare organizations create optimal healing environments and integrate Holistic Nursing and Nurse Coaching as a professional practice model of care. She has 40+ years of experience in Maternal-Child Health, Administration, Holistic Nursing, and Nurse Coach practice, and as a COO and Director of Specialty Programs in Community Health. Karen is a Reiki Master, Stress Management Instructor, HeartMath, and Clinical Meditation and Imagery Practitioner. Karen served as a Director-At-Large board member of the American Holistic Nurses Association and a founding leader of the Delaware Chapter. She is an author and editor of Holistic Nursing: A Handbook for Practice (2016, 2022) and Core Curriculum for Holistic Nursing (2014). Karen is a Peer Reviewer for the Journal of Nursing Scholarship and Holistic Nursing Practice journals. She is an international and national speaker on holistic and integrative topics. Karen can be reached by email at kavino@inursecoach.com. With healthcare organizations scrambling to fill vacant nursing positions, and nurses unhappy with their present jobs, it is time to seriously examine how to support the healing process of our wounded nurses. Conti-O’Hare (2002) used the term the Walking Wounded, originally from Greek mythology, to describe the process or journey needed to develop resilience. Self-Development is the journey required to heal the pain and suffering and emerge as a Wounded Healer. Resilience is defined as the ability to face adverse situations, remain focused, and continue to be optimistic about the future (Kester & Wei, 2018). The journey to resilience includes recognizing, transforming, and transcending the traumatic pain experienced or anger, emotional problems, substance abuse, job dissatisfaction, and burnout will occur. The work environment will be spoken of as a negative experience. Going through the Self-Development process for ourselves allows the Wounded Healer to be able to empathetically sit with the suffering of others and therapeutically use self as an instrument of healing. We use the term burnout to describe the Walking Wounded nurses that are depleted in body, mind, and spirit. What the nurse may be experiencing and calling burnout may be attributed to grief and loss as witnessed especially during the pandemic. With grief and loss, or burnout, comes attitudes of negativity towards the organizations they work for and a lack of interest in being engaged in new ideas and opportunities for positive change. Of course, this also extends into a nurse’s everyday life. One nurse stated, “I told my manager that I thought I was experiencing burnout, and she told me to go practice self-care and get a manicure.” It is apparent that the concept of self-care is not well understood. Self-Care is one component of the Self-Development process that includes: Self- Assessment, Self-Reflection, Self-Evaluation, and Self-Care. The key is understanding that it is an integral process, a journey that should begin early in life, reinforced during nursing school, and supported by employers. Self-Development is a lifelong journey encompassing phases of woundedness, healing, and seeking to find meaning to wholeness through personal growth experiences. This directly relates to the nurse’s ability to offer a healing presence, hold the sacred space, and reflect with clients to allow inner wisdom and solutions to unfold. The diagram below outlines resilience development through the Self- Development process. The Integrative Nurse Coach Academy’s Integrative Health & Wellness Assessment tool considers eight dimensions of wholeness: Life Satisfaction, Relationships, Spiritual, Mental, Emotional, Physical (Nutrition, Exercise, Weight), Environmental, and Health Responsibility. Jung and Hull (1980) said the layers closest to our awareness become known; those farthest away operate autonomously. The assessment brings awareness of all the dimensions and increases active participation in decision-making about our daily choices. Without self-development and bringing “together aspects of the body-mind-emotion-spiritenvironment at deeper levels of knowing towards integration and balance” …. healing cannot occur (McElligott, 2015 as cited in Dossey et al., 2015, p. 407). Healing involves the processes of recovery, repair, renewal, and transformation that increase wholeness, order, and coherence (Southard et al., 2021). Ultimately, discovering meaning, healing, and balance through Self- Development is possible. So how can we reenergize nursing practice and create a transformational process to support selfdevelopment? Overall well-being requires nurses to take a deep dive into their own wholeness. A program such as The Integrative Nurse Coach Certificate Program, guides the journey into Self- Development and provides coaching communication skills. Over a six-month period, nurses are supported to envision a higher level of lifestyle health and wellness, develop coping skills, and envision a happier and healthier life for themselves and others. Frey and Ratliff (2018) reported on the Integrative Nurse Coach Certificate Program graduates’ personal and professional experiences. Through interviews, four common themes were identified: (1) development of self, (2) enriched self-care, (3) a call to action for facilitating the health care paradigm shift, and (4) incorporating Integrative Nurse Coaching skills into practice. Examples of comments included: 1) “it gave me a renewed awareness of what I lost as a nurse with a new focus of practicing prevention, wellness and wellbeing”, 2) “It’s raised my awareness about how much nurses want and need this” and, 3) “It’s energized my perspective of healthcare.” This transformational process has reenergized nursing practice with first a focus on mind, body, and spirit for self, and how it can be applied to others. Nurse coaches promote health and well-being and facilitate the growth and healing of the whole person by using coaching principles and integrative healing therapies that integrate bodymind-emotion-spirit-culture and environment into practice. Nurse Coaching is the framework for caring communication skills and relationship-based care that is missing in current healthcare settings. Relationshipbased care improves the culture of health care by focusing on three key relationships: relationships with self, colleagues, and with patients/families. Having reenergized nurses that can live, role-model, and walk the talk of the philosophy of relationship-based care as Wounded Healers is an essential component of a healed healthcare system. Qingqing and Zheng (2021) examined nurses’ stress levels when caring for COVID-19 patients in an intensive care unit and found depression, anxiety, and sleep disturbances. Solutions were suggested to include: • Freedom to feel your feelings • Intentional adoption of a coping strategy***** • Regular check-ins with nurses • Breaks from news and social media • Recall and strengthen the importance and meaning of nurses’ work. ***** *****Bringing new energy into the nurse’s work and intentional Self-Development work are essential solutions. Integrative Nurse Coaching has become a professional practice model for healthcare organizations. Introducing concepts of Integrative Nurse Coaching in orientation, having board-certified nurse coaches on the hospital floors as preceptors and managers will allow for mentoring to integrate nurse coach skills into practice and, also encourage self-development of the nurse to improve nurse satisfaction, reduce attrition (especially at the 24-month mark) and improve patient outcomes. The key elements of a professional practice model are a theoretical foundation, such as The Theory of Integrative Nurse Coaching, and six common components: leadership; nurses’ independent and collaborative practice; environment; nurse development and reward; research/ innovation; and patient outcomes (Slatyer et al., 2016). Integrative Nurse Coaching supports the Magnet journey, the ANCC Practice Transition Accreditation Program with new nurse residencies and the RN & APRN Fellowships to transition experienced nurses to master new clinical skills programs. Aligning Integrative Nurse Coach practice will create a shared purpose and vision for health & wellness promotion across the organization and heal our nursing profession. References Conti-O’Hare, M. (2002). The theory of the nurse as a wounded healer: From trauma to transcendence. Sudbury, MA: Jones and Bartlett Publishers. Frey, L., & Ratliff, J. (2018). The personal and professional experiences of integrative nurse coach certificate program graduates. Journal of Holistic Nursing, 26(2),134–144. McElligott, D. (2015). Nurse Coach Self- Development. In B. Dossey, S. Luck, B. & Schaub. Nurse Coaching: Integrative Approaches for Health & Well-being. International Nurse Coach Association. North Miami, Fla: www.inursecoach.com Jung, C., & Hull, R.F.C. (1980). The archetypes and the collective unconscious. Princeton, N.J.: Princeton University Press. Kester, K., Wei, H. (2018, June). Building nurse resilience. Nursing Management, 49(6), 42-45 doi: 10.1097/01. NUMA.0000533768.28005.36 Slatyer, S., Coventry, L.L., Twigg, D., & Davis, S. (2016). Professional practice models for nursing: A review of the literature and synthesis of key components. Journal of Nursing Management, 24(2):139-50. doi: 10.1111/ jonm.12309. Southard, ME., Dossey, B., Bark, L., & Schaub, B. The art & science of nurse coaching: The provider’s guide to coaching scope & competencies. Silver Spring, MD: American Nurses Association. Qingqing L. & Zheng, Y. (2021). Nurses’ emotional stress levels when caring for COVID-19 patients in an intensive care unit. Alternative Therapies, 27(5), 46- 50.
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