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The emotional cost

Caring for others can mean nurses neglect to manage their own feelings. Here’s how to improve your wellbeing. 

Graduate nurse Laurie Bickhoff knew her career would be punctuated with emotional distress when she was assigned to care for a patient at the end stages of treatment for cancer soon after her mother had been diagnosed with terminal cancer.

“Going through that situation and caring for a patient like that when I knew my mother was going to be in that same situation, that was a really big struggle,” she says. “Seeing what the patient’s family was going through just really touched me personally and was one of the hardest things I’ve had to deal with.”

Bickhoff says she didn’t feel adequately prepared for the emotional demands of nursing before starting full-time work.

“At uni, we always talked about dealing with aggressive patients, the violence that’s found in health or horizontal bullying and that cultural side of it, but we never really discussed the emotional side of it,” she says. “I first came in contact with the emotional side of nursing in my third year of my nursing degree [on placement] and I’d had no nursing experience prior to starting my degree. I didn’t expect the emotional side to be so hard at all.”

For the first time, Bickhoff witnessed cardiac arrest and a full resuscitation attempt, the deaths of palliative patients and unexpected deaths in the emergency room.

Now in her second year of full-time work, Bickhoff deals with challenging emotional situations during most shifts. “I’ve been there when patients have come into the emergency department and the doctors are having that conversation with the family about how incubation and CPR won’t work for their family member,” she says. “I see little babies and their families getting told they have cancer. It’s often the reaction of the families that gets me the most.”

Whilst there’s no doubt that sustaining a successful nursing career is hugely rewarding, taking responsibility for the sick and injured can come at the expense of one’s emotional wellbeing. But through a combination of education, self-care and workplace management programs, nurses can manage stress and promote good health outcomes – for patients as well as themselves.

An emotional reaction

John Hurley, an associate professor for nursing at Southern Cross University, says there is increasing evidence that the physical and mental health of nurses in Australia is poor . “As to whether that’s in a way because of spending so much time caring for others – perhaps as professionals nurses haven’t stood back and cared for themselves as a priority – is an important thing for the profession to consider.”

According to new research by Southern Cross, Australian nurses rate the overall health of their colleagues between poor and average. More than 6000 nurses responded to the survey, with many reporting stress-induced chronic illness that resulted in time off work.

“Not surprisingly, many nurses feel they are unhealthy, with stress identified as the biggest contributing factor to obesity, hypertension, respiratory disease, musculoskeletal problems, risk of developing type 2 diabetes and ‘not looking after myself properly’,” says Kay Ross, a researcher from the Southern Cross school of health and human services. “You are dealing with people at their most vulnerable and you need to be at your best every day that you go in to work, even if you don’t feel 100 per cent. Often a nurse’s own health and wellbeing are put on the backburner.”

So who is responsible for the emotional wellbeing of nurses? Hurley says training varies amongst universities, from little acknowledgement of the issue, to voluntary education programs and embedding the development of emotional resilience into undergraduate curriculum.

On the job, it depends on the organisational culture of the hospital or health provider. “Because there are a wide variety of workplaces, each organisation is going to have a different working culture and working climate,” he says. “We know that there are some very good examples of work culture and climate and there are poor examples of work culture and climate, particularly where workplace bullying is prevalent.”

Bernadette Twomey, executive director of nursing services at The Royal Children’s Hospital Melbourne (RCHM), says a good employer recognises the emotional challenges of nursing work and has an appropriate structure for support in place.

“Nursing is a physically and emotionally challenging job,” Twomey says. “We spend a lot of time supporting nurses’ induction and orientation to the organisation and that’s about ensuring we have a competency framework. We’ve got a robust way of supporting nurses and ensuring that they’re confident and comfortable and have the right knowledge, skills, attributes and abilities to care for the patients, so they feel supported in the care they provide.”

Twomey says RCHM offers regular sessions led by the nurse unit manager, where nurses get together and talk about their experiences on the ward. For extra support, new staff work alongside experienced nurses for a period at the beginning of their employment.

“Another important way that we support people, particularly through the competency support framework, is we have regular stages where people sit down and talk with their nurse unit manager and their education person about how they’re experiencing the ward environment, how they’re travelling and what extra things they need to support them,” Twomey says.

Dealing with feelings

Whilst Bickhoff has received “you get used to it” responses from colleagues after enquiring about the best way to deal with emotional situations, Twomey and Hurley agree that suppressing emotions won’t lead to improved wellbeing.

In fact, research shows that nurses who easily identify specific emotions during stressful situations spend less time dealing with their emotional reactions. Nurses with high emotional intelligence – the ability to feel, use, communicate, recognise and manage emotions – are likely to have a superior ability to adapt to stressful situations at work, better overall health and greater life satisfaction.

Bickhoff is now a member of the Australian College of Nursing Emerging Nurse Leader Program, a three-year course of personal and professional development. She recommends taking advantage of voluntary clinical supervision, which helps nurses respond to the demands of their work. “If your workplace offers clinical supervision or mentors, they’re often volunteer programs, instead of compulsory, but I think it’s essential to sign up for those, especially for new nurses,” she says. “In my [case], it involved a more experienced nurse outside of the area we were working in who we could meet to have an informal debrief. Basically, they’re there to see what problems you’re having. With mine, we discussed caring for palliative patients – I found that really difficult – and dealing with emotional family members.

“They’re there to talk through it. They give you reflective questions like, ‘What did you think you did well in that situation?’, ‘What do you think you could’ve done better?’ and, ‘What can you improve next time?’. They get you to take a step back from the situation. They can also put you in touch with employee assistance programs for further help.”

At RCHM, Twomey says, managers have a responsibility to understand what’s going on with staff and provide support – so nurses should look to their employer for support. “Staff need to feel safe about flagging on a daily basis that they’re feeling confident with their allocation,” she says. “If they’re feeling particularly challenged about an area of practice, it’s important that they have someone on the team they can talk to about that and have appropriate supports put in place. That’s our job, to support our nurses [in providing] care therapeutically for our patients.”

Me time

At an independent level, Bickhoff says she receives strongest support from her nursing colleagues and friends. “It’s essential for me to have a really tight knit group of nursing friends and colleagues, where I know I can pick up the phone or meet for coffee and talk it through, and they know exactly what I’m going through,” she says. “Family and friends might ask how work is going and you just brush it off because you don’t want to bring up personal events with people who don’t understand it.” She also recommends keeping a journal detailing difficult experiences at work.

Research published in the Journal of Clinical Nursing found successful strategies to enhance wellbeing among nurses include making healthy lifestyle choices, debriefing, self-validation, assertiveness and emotional support. A nurse with positive emotional wellbeing will feel a sense of balance.

Hurley says self-care and developing emotional self-awareness are crucial aspects of managing the emotional effects of nursing. “We have to be able not just to access our emotions but also to make sure we’re expressing emotions that are in the right place, right context and right intensity to what we’ve experienced,” he says. “We need to be able to verbalise our emotions to those around us, and we need to be able to exercise degrees of emotional self-control and self-management.”

Exercise is also important. The link between physical and mental health is well established, and Hurley says evidence shows two or three sessions of moderate-intensity exercise a week provide the same neurochemical benefits as taking half an antidepressant tablet after about six to eight weeks. Exercise improves mood by releasing feel-good brain chemicals, reducing immune system chemicals and increasing body temperature. Organised activities such running, playing basketball or going to the gym, as well as everyday activities like gardening and washing the car, get the body moving and help to improve mood.

Above all, Hurley says, nurses should be kind to themselves. “Nurses are very good at giving others compassion but they’re not particularly good at giving themselves compassion. To psychologically give self-compassion is a very important way to emotionally manage ourselves,” he says.

For her part, Bickhoff tries to have one day each week for herself, where she doesn’t work or study. “I just reconnect with my family and friends, which makes me realise how much my work means to other people.”

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