Support for Staff: Building Resilience in Nurses

Abstract

Technology is having a significant impact in neonatal and children’s palliative care. Babies are surviving both extreme prematurity and life-limiting conditions for extended periods of time, albeit with complex morbidity and invasive technological interventions. Simultaneously, the domains of private and professional are no longer so clearly defined, with access to information, the means to share it and social media, all rapidly advancing. Certainty about best practice is debated, and decision-making in intricate cases is complex. Nurses working in neonatal palliative care must assimilate technological advances in clinical and non-clinical domains and also understand and work with the impact of the technologies upon the babies and families they support. Simultaneously, a national shortage of registered nurses and ongoing austerity measures in the UK may present another set of difficulties. Salary, benefits and working conditions can all present a range of challenges to the nurse at the cotside. Each of these issues may be seen as a risk to the well-being of the neonatal palliative care nurse, putting them in danger of stress, moral distress and burnout. When such symptoms present, they potentially impact not only on the individual nurse but also on the care we deliver. However, an alternative outcome of exposure to adversity is that the nurse develops resilience.

Appendices

Appendix 1: Resilience Engine Exercises

Please complete the following exercises and use a reflective log to capture any areas you would like to explore or develop further for yourself.

Think about two beliefs written below and their importance to you. Please take time to identify how much they influence the way you lead your life. You can use the scale 1–5 to help you think about how great this is, 1 being little influence and 5 being profound influence.

Belief	Influence
I have a belief for my purpose in life—I know I have a purpose and what it is
I believe in my own judgement: judgement of other people and judgement of things and situations

Appendix 2: Seven Attitudes

Please read through the following and rate your current attitude as honestly as you can; 1 is low and 5 is high. Complete this exercise at 3-month intervals. You can continue for as long as you wish.

Attitude	Initial rating date	Follow-up rating date	Final rating date
1. I take full responsibility for myself, my own action and reactions
2. I don’t dwell, I forgive when necessary, I move on
3. I don’t take myself too seriously. I have humility, and I have a self-deprecating sense of humour
4. I am optimistic
5. I am grounded with my feet on the ground and am pragmatic
6. I have a high level of independence and independent judgement
7. I value others and their opinions

Appendix 3: How Is Your Self-Confidence?

Use the following table to note the things that irritate you (your triggers, your blind spots), others may already have told you about some of these and the things you know you have as strengths. These may be the things that the closest people in your life know about you and are willing to invite them to tell you.

Strengths	Triggers	Blind spots
.
.
.
.
.

1.1 Pacing Cycle

1.1.1 How Is Your Capacity to Adapt to Your Pace?

Please answer the following three questions as honestly as you can. Take time to consider any areas you wish to explore further in your learning log.

Adaptive capacity	Never	Sometimes	Frequently	Always
How often are you able to step back from a situation in order to better see and understand?
How often do you consider yourself and support yourself to ensure you are continually refreshed?
How often do you consider you maintain a steady pace and have a steady use of energy rather than experiencing peaks and troughs?

Appendix 4

1.1 Compassion Satisfaction and Compassion Fatigue (PROQOL) Version 5 (2009)

PROFESSIONAL QUALITY OF LIFE SCALE (PROQOL)

When you help people, you have direct contact with their lives. As you may have found, your compassion for those you help can affect you in positive and negative ways. Below are some questions about you and your current work situation. Select the number that honestly reflects how frequently you experienced these things in the last 30 days.

1 = Never

2 = Rarely

3 = Sometimes

4 = Often

5 = Very Often

• 1. I am happy.

• 2. I am preoccupied with more than one person to help.

• 3. I get satisfaction from being able to help people.

• 4. I feel connected to others.

• 5. I jump or am startled by unexpected sounds.

• 6. I feel invigorated after working with those I help

• 7. I find it difficult to separate my personal life from my life as a helper.

• 8. I am not as productive at work because I am losing sleep over traumatic experiences of a person I help.

• 9. I think that I might have been affected by the traumatic stress of those I help.

• 10. I feel trapped by my job as helper.

• 11. Because of my helping, I have felt “on edge” about various things.

• 12. I like my work as a helper.

• 13. I feel depressed because of the traumatic experiences of the people I help.

• 14. I feel as though I am experiencing the trauma of someone I have helped.

• 15. I have beliefs that sustain me.

• 16. I am pleased with how I am able to keep up with helping techniques and protocols.

• 17. I am the person I always wanted to be.

• 18. My work makes me feel satisfied.

• 19. I feel worn out because of my work as a helper.

• 20. I have happy thoughts and feelings about those I help and how I could help them.

• 21. I feel overwhelmed because my case work load seems endless.

• 22. I believe I can make a difference through my work.

• 23. I avoid certain activities or situations because they remind me of frightening experiences of the people I help.

• 24. I am so proud of what I can do to help.

• 25. As a result of my helping, I have intrusive, frightening thoughts.

WHAT IS MY SCORE AND WHAT DOES IT MEAN?

In this section, you will score your test, so that you understand the interpretation for you. To find your score of each section, total the questions listed on the left and then find your score in the table on the right of the section.

1.2 Compassion Satisfaction Scale

Copy your rate on each of these questions on to this table and add them up. When you have added them up, you can find your score on the table to the right
3
6
12
16
18
20
22
24
27
30
Total

The sum of my compassion satisfaction questions is	So my score equals	And my compassion satisfaction level is
22 or less	43 or less	Low
Between 23 and 41	Around 50	Average
42 or more	57 or more	High

1.3 Burnout Scale

On the burnout scale you will need to take an extra step. Starred items are “reverse scored”. If you scored the item 1, write a 5 beside it. The reason we ask you to reverse the score is because scientifically the measure works better when these questions are asked in a positive way though they can tell us more about their negative form. For example, question 1. “I am happy” tells us more about the effects of helping when you are not happy so you reverse the score.

Burnout score totals
*1
*4
8
10
*15
*17
19
21
26
*29
Total

The sum of my burnout question is	So my score equals	And my burnout level is
22 or less	43 or less	Low
Between 23 and 41	Around 50	Average
42 or more	57 or more	High

1.4 Secondary Traumatic Stress Scale

Just like you did on Compassion Satisfaction, copy your rating on each of these questions on to this table and add them up. When you have added them up, you can find your score on the table to the right.

Secondary trauma totals
2
5
7
9
11
13
14
23
25
28
Total

The sum of my secondary trauma questions is	So my score equals	And my secondary traumatic stress level is
22 or less	43 or less	Low
Between 23 and 41	Around 50	Average
42 or more	57 or more	High

Based on your responses, place your personal scores below. If you have any concerns, you should discuss them with a physical or mental healthcare professional.

Compassion Satisfaction ________________

Compassion satisfaction is about the pleasure you derive from being able to do your work well. For example, you may feel like it is a pleasure to help others through your work. You may feel positively about your colleagues or your ability to contribute to the work setting or even the greater good of society. Higher scores on this scale represent a greater satisfaction related to your ability to be an effective caregiver in your job.

The average score is 50 (SD 10; alpha scale reliability 0.88). About 25% of people score higher than 57 and about 25% of people score below 43. If you are in the higher range, you probably derive a good deal of professional satisfaction from your position. If your scores are below 40, you may either find problems with your job, or there may be some other reason—for example, you might derive your satisfaction from activities other than your job.

Burnout ________________

Most people have an intuitive idea of what burnout is. From the research perspective, burnout is one of the elements of compassion fatigue (CF). It is associated with a very high workload or a non-supportive work environment. Higher scores on this scale mean that you are at higher risk for burnout.

The average score on the burnout scale is 50 (SD 10; alpha scale reliability 0.75). About 25% of people score above 57 and about 25% of people score below 43. If your score is below 43, this probably reflects positive feelings about your ability to be effective in your work. If you score above 57, you may wish to think about what at work makes you feel like you are not effective in your position. Your score may reflect your mood; perhaps you were having a “bad day” or are in need of some time off. If the high score persists or if it is reflective of other worries, it may be a cause for concern.

Secondary Traumatic Stress _____________

The second component of compassion fatigue (CF) is secondary traumatic stress (STS) . It is about your work-related, secondary exposure to extremely or traumatically stressful events. Developing problems due to exposure to other’s trauma is somewhat rare but does happen to many people who care for those who have experienced extremely or traumatically stressful events. For example, you may repeatedly hear stores about the traumatic things that happen to other people, commonly called vicarious traumatisation (Dunckley and Whelan 2006). If your work puts you directly in the path of danger, for example field work in a war or area of civil violence, this is not secondary exposure; your exposure is primary. However, if you are exposed to other’s traumatic events as a result of your work, for example as a therapist or in an emergency worker, this is secondary exposure. The symptoms of STS are usually rapid in onset and associated with a particular event. They may include being afraid, having difficulty sleeping, having images of the upsetting even pop into your mind, or avoiding things that remind you of the event.

The average score on this scale is 50 (SD 10; alpha scale reliability 0.81). About 25% of people score below 43 and about 25% of people score above 57. If your score is above 57, you may want to take some time to think about what at work may be frightening to you or if there is some other reason for the elevated score. While higher scores do not mean that you do have a problem, they are an indication that you may want to examine how you feel about your work and your work environment. You may wish to discuss this with your supervisor, or a healthcare professional.

© B. Hudnall Stamm, 2009–2012. Professional Quality of Life: Compassion Satisfaction and Fatigue Version 5 (ProQOL). www.proqol.org . This test may be freely copied as long as (a) author is credited, (b) no changes are made, and (c) it is not sold. Those interested in using the test should visit www.proqol.org to verify that the copy they are using is the most current version of the test.

Appendix 5: The Six Keys to Personal Resilience

(Saltbox.org)

Resilience involves a set of key skills or capabilities which, if present, enable you to manage whatever is thrown at you and continue to move forward towards achieving what you and others want. This tool can assist nurses to identify areas that challenge them and inhibit or promote resilience.

1.1 Key 1. A Sense of Purpose

This is the foundation for all of the other keys. Not everyone is clear about their purpose, and it is frequently something that you will need to re-define as you move through life. The stronger your sense of purpose, the better equipped you are to handle challenges and setbacks and to recover from them. Are you clear about your direction and goals? Do you understand the purpose of all the activities you engage in? Do you remain true to your goals and values?

What does a “sense of purpose” mean to you?

What can you do to ensure that you have a clear sense of purpose?

1.2 Key 2. Positive Mental Attitude

This component is something of a balancing act, between being able to think positively about situations and events while being realistic about what can be achieved. It is not about naive false optimism but involves being able to generate positive thoughts and feelings about situations. Do you have the ability to see the positive side of things without creating unreasonable expectations and subsequent disappointment?

What does a “positive mental attitude” mean to you?

What can you do to ensure that you have a positive mental attitude?

1.3 Key 3. Connecting with Others

People matter to all of us, so building supportive and caring relationships is essential. Your interpersonal communication and skills can be an important element of your ability to be resilient, based on how you can handle difficult situations or times. It is also essential to be able to offer appropriate help and support to others and ask for it, when needed.

What does “connecting with others” mean to you?

What can you do to ensure that you connect with others?

1.4 Key 4. Determination

How good are you at seeing things through? When faced with challenges do you deal with them by having a “can do” approach, being proactive and taking action? How well do you finish tasks and things which you have started? Are you able to keep going in the face of adversity rather than giving up? How adaptable and open-minded are you to provide yourself with a greater range of choices, dealing with different situations?

What does “determination” mean to you?

What can you do to ensure that you stay determined?

1.5 Key 5. Taking Control

Control comes from how you think and react. It is about understanding your inner self—how you think, feel and react—and controlling this so that you develop positive patterns in the way you deal with different situations and challenges. Do you take responsibility for yourself and your actions? Are you able to recognise what challenges or situations are beyond your control and to let go of these in order to focus on the things that you can actually do something about? Knowing something and doing it are two different things—do you do what you need to do rather than just talking about it?

What does “taking control” mean to you?

What can you do to ensure that you take control?

1.6 Key 6. Looking After Yourself

Looking after yourself, physically, mentally and emotionally, are essential in order to deal with stress, which has a big impact on your resilience. Do you lead a healthy lifestyle? Do you have strategies and tools to help you deal instantly with difficult or stressful situations? Are you able to relax your body and mind so that you can see problems or difficult scenarios in a calm and clear way? Make sure you learn some simple techniques to help you do this.

What does “looking after yourself” mean to you?

What can you do to ensure you look after yourself?

Neonatal Nursing Panel Points for Practice

What I learnt from this chapter which I view as essential in informing my practice

• From personal experience, resilience within the work place often correlates with adapting to challenging environments and adjusting our working strategies. A systematic working routine, with good organisation, pre-empting situations and forward planning can assist when managing unpredictable and ever-changing external stressors.

• Self-resilience is derived from a combination of both internal personal qualities and external opportunities. Utilising external opportunities such as training and education assist with creating a sense of control, competence and self-efficacy. Utilising additional knowledge and skills, underpinned by evidence-based practice, can alleviate moral distress.

• Comparing our internal perspective with other external perceptions is never going to be a fair comparison. Utilise a friend or a trusted peer to gain the much sought-after external perspective. Often this will positively impact our worth and subsequent resilience.

• Think small but effective. Often organisational limitations inhibiting our sense of accomplishment result in burnout. Do not become complacent with the huge accomplishments we achieve on a daily basis with families, parents and infants. Rearrange our perspective.

• Regardless of external confidence portrayed by others, identifying limitations in knowledge or skills is a positive learning tool. Self-compassion and accepting we are not perfect, nor will ever be, spurs us on to improve ourselves and our practice.

Frances Dullaghan,

Southern Health and Social Care Trust (NI),Portadown, UK