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THE BULLETINBrought to you by the Indiana Nurses Foundation (INF) and the Indiana State Nurses Association (ISNA) whose

dues paying members make it possible to advocate for nurses and nursing at the state and federal level.Quarterly publication direct mailed to approximately 2,300 RNs and electronically via email to 65,000+ RNs licensed in Indiana.

Volume 46 • Number 3May, June, July 2020

INSIDECertification Corner

Page 2

CEO Note

Page 3

Policy Primer

Pages 4-5

2020 Indiana State NursesAssociation Awards

1

Independent Study:Compassion Fatigue: You Are Not Alone

Page 12

MESSAGE from the PRESIDENTEmily B. Sego

DNP, RN, NEA-BC

When the World Health Organization and International Council of Nurses announced 2020 as the “Year of the Nurse and Midwife,” little did they know a few months later a worldwide pandemic would strike putting nurses on center stage. As I reflect on all that has happened since the first case was confirmed in Indiana on March 6, 2020, there is one thing that remains forefront in my mind and that is how our nurses have responded to the call for action in their communities.

You might recall seeing information from the American Nurses Association recently that brought awareness to some concerns around new CDC guidelines for personal protective equipment. Despite these concerns, I have been humbled with emails, texts and calls from nurses across Indiana who have continued to treat patients, work in capacities they are unfamiliar with, and sign up for extra shifts.

The world is watching us and today more than ever is our time to shine and we most certainly are. A particular segment from the Nightingale Pledge says, “I shall be loyal to my work and devoted towards the welfare of those committed to my care.” In a time of great fear and worry, I encourage all of us to stay the course and continue to deliver on our promise to those in need of our care.

In weeks to come, our profession will be challenged in ways that we cannot even begin to fathom. The emotional and mental impact this pandemic will have on our nurses will require us to decompress even more often. Take time to check in on your co-workers and see how they are doing. I urge all nursing leaders to continuously monitor their workforce for signs of fatigue and develop strategies and plans to ensure adequate time to refresh and refuel. Well-being plans should include virtual access to counseling, chaplaincy services, and behavioral health support as needed.

This is a historical time and I am confident that the innovative approaches to care that are being developed by nurses throughout this pandemic will be catalysts for moving healthcare forward in the future. On behalf of the Indiana State Nurses Association, thank you for your devotion and for maintaining resilience in these times of uncertainty and disruption.

Indiana Nurses FoundationLuncheon Postponed

Original Date: April 17thFuture Date: To Be Determined

At this time, the Foundation will proceed with awarding INF Grants as applicable. Please stay tuned as we plan for our future luncheon. Connect with us

@IndianaStateNursesAssociation for updates!

Justin Hicks, Indiana Public Broadcasting

The Centers for Disease Control and Prevention this week eased its guidance on face masks for health care workers treating patients with coronavirus. The change has some Indiana nurses worried about their own health.

Up until March 10, the CDC advised health care workers to use masks which filter out 95 percent of airborne particles. But, due to a shortage, it’s now saying nurses can use simple surgical masks. The American Nurses Association says the decision was made with more consideration for supply chain than safety.

Emily Sego is the president of the Indiana State Nurses Association. She says Indiana’s healthcare workers continue to treat patients despite those concerns.

“Despite any fear, panic [or] risk that they may incur while working, they’ve been signing up for extra shifts and are doing whatever they can to make sure that our community is served,” she says.

She says nurses are also concerned about a lack of affordable childcare while they work as some Indiana schools switch to online learning during the coronavirus outbreak.

Contact Justin at [email protected] or follow him on Twitter at @Hicks_JustinM.

This is a rapidly evolving story, and we are working hard to bring you the most up-to-date information. However, we recommend checking the websites of the Centers for Disease Control and Prevention or the Indiana State Department of Health for the most recent numbers of COVID-19 cases.

Hoosier Nurses Working Hard Amid Protection Concerns

The CDC recommended that nurses use a N95 particulate respirator prior to March 10.

CREDIT BANEJ / WIKIMEDIA COMMONS

The Bulletin May, June, July 20202

Published by:Arthur L. Davis

Publishing Agency, Inc.

www.indiananurses.org

An official publication of the Indiana Nurses Foundation and the Indiana State Nurses Association, 2915 North High School Road, Indianapolis, IN 46224-2969. Tel: 317/299-4575. Fax: 317/297-3525. E-mail: [email protected]. Web site: www.indiananurses.org

Materials may not be reproduced without written permission from the Editor. Views stated may not necessarily represent those of the Indiana Nurses Foundation or the Indiana State Nurses Association.

ISNA StaffKatherine Feley, DNP, RN, NE-BC, CPPS, CEO

Blayne Miley, JD, Director of Policy and Advocacy

ISNA Board of DirectorsEmily Sego, President; Beth Townsend, Vice President; Barbara Kelly, Treasurer; Angela Mamat, Secretary; Directors: Shalini Alim, Brian Atwood, Jolynn Kuehr, Susan Waltz and Recent Graduate Director, Andrea Jacobs

ISNA Mission StatementISNA works through its members to promote and influence quality nursing and health care.

ISNA accomplishes its mission through unity, advocacy, professionalism, and leadership.

ISNA is a multi-purpose professional association serving registered nurses since 1903.

ISNA is a constituent member of the American Nurses Association.

Address ChangeThe INF Bulletin obtains its mailing list from the Indiana Board of Nursing. Send your address changes to the Indiana Board of Nursing at Professional Licensing Agency, 402 W. Washington Street, Rm W072, Indianapolis, IN 46204 or call 317-234-2043.

Bulletin Copy Deadline DatesAll ISNA members are encouraged to submit material for publication that is of interest to nurses. The material will be reviewed and may be edited for publication. To submit an article mail to The Bulletin, 2915 North High School Road, Indianapolis, IN. 46224-2969 or E-mail to [email protected].

The Bulletin is published quarterly every February, May, August and November. Copy deadline is December 15 for publication in the February/March/April The Bulletin; March 15 for May/June/July publication; June 15 for August/September/October, and September 15 for November/December/January.

If you wish additional information or have questions, please contact ISNA headquarters.

For advertising rates and information, please contact Arthur L. Davis Publishing Agency, Inc., 517 Washington Street, PO Box 216, Cedar Falls, Iowa 50613, (800) 626-4081, [email protected]. ISNA and the Arthur L. Davis Publishing Agency, Inc. reserve the right to reject any advertisement. Responsibility for errors in advertising is limited to corrections in the next issue or refund of price of advertisement.

Acceptance of advertising does not imply endorsement or approval by the Indiana Nurses Foundation of products advertised, the advertisers, or the claims made. Rejection of an advertisement does not imply a product offered for advertising is without merit, or that the manufacturer lacks integrity, or that this association disapproves of the product or its use. ISNA and the Arthur L. Davis Publishing Agency, Inc. shall not be held liable for any consequences resulting from purchase or use of an advertiser’s product. Articles appearing in this publication express the opinions of the authors; they do not necessarily reflect views of the staff, board, or membership of ISNA or those of the national or local associations.

THE BULLETINCERTIFICATION CORNERSue Johnson

Matthew S. Howard, DNP, RN, CEN, CPEN, CPN is a leader in a professional organization as Director of Scholarship Resources with a clinical background in emergency nursing. His certification journey will inspire anyone who has thought about certification and hesitated to pursue it. Certification is more than a credential. As Matthew says certification is a confidence-builder that leads the way to future success. Here’s Matthew’s story in his own words.

What certification(s) do you have?• Certified Emergency Nurse • Certified Pediatric Emergency Nurse• Certified Pediatric Nurse

Why did you decide to take the certification exam? My path toward certification took quite a while. I was

very fortunate and blessed to have some amazing nurse mentors while I was in nursing school and my first few years as a nurse in Western Kentucky. These nurses took me under their wing and showed me how professional emergency nursing is done, but also helped me to understand why we do what we do in nursing. Among the many things they taught me was to be certified in your area of nursing. Being certified shows your patients, your hospital, and your colleagues that you know and have the skills to do your job above and beyond minimum requirements. Nearly all of my nurse mentors were certified in emergency nursing, and of course, I wanted to be like my mentors. I saw what they offered their patients, the hospital and each other. I knew I wanted to be a part of that.

How did you prepare for the exam? What did you study? What resources did you use?

I feel that I have extreme test anxiety, so I used many resources to prepare for the examinations. I know that

people learn and study differently, but I find that I study best by listening to information, so I used audio and video review courses that I could listen to while going to and from work. That and review questions worked the best for me. I would review a question or two using flashcards while returning to the department after taking a patient to the floor, or when running on the treadmill. I found that anywhere I could focus for small amounts of time on a question or two really helped me retain the information.

How do you use your certification in your practice?I feel the certifications do provide me with a level of

confidence in my knowledge and skills that I did not have prior. I think it helps me when working with physicians and colleagues that see my credentials and know they can trust my knowledge and judgment.

How has being certified made you a better nurse and leader?

I personally like learning and expanding the horizons of what nurses can do. Becoming board certified has increased my confidence and provided career advancement that I was not even expecting. I have been asked to assist with programs and initiatives at my hospitals because of my experiences and certifications in emergency nursing. It has allowed me to become a leader.

What advice would you give to others seeking the same certification?

Just do it. Remember, procrastination is your enemy, not the exam. Do not let your anxiety be your crutch. We often learn more from our mistakes than our successes. Also, use multiple modalities to study including reading, audio, video, etc.

Thanks, Matthew, for sharing your story with us and for serving as a role model for certification for other nurse leaders.

Do you want to share your certification story with your colleagues? It may encourage them to join you! Please contact me at [email protected] to share your experiences!

2020 Indiana State Nurses Association Convention Request for Abstracts

ISNA is issuing a call for abstracts for podium presentations for our 2020 Indiana State Nurses Convention in Indianapolis, currently scheduled for Friday September 18th. We are requesting proposals that relate to the promotion and recognition of the Year of the Nurse 2020: Excel, Lead, Innovate theme….Please submit this completed form to [email protected] by JUNE 1ST.

Podium or Poster:

Presentation title:

Learner Objective – Upon completion of this session, the learner will:

Summary:

How will this presentation help attendees?

Name/credentials of presenter(s): Degree(s) & Certification(s): Agency/school/organization:

Position/title:

Phone:

Email:

ISNA Member Yes/No?:

May, June, July 2020 The Bulletin 3

CEO NOTEShine Bright Like a

DiamondKatherine Feley, DNP, RN

I see you shining. Yes, you! You’re sparkling from head to toe.

I witnessed our unified glow as we came hundreds strong to stand up for our title, advocating this past legislative session when our profession and patients needed it the most. Our light continues to reflect during this extraordinary time of uncertainty and fear. Nurses, among other working heroes, are the light source that will guide us through this pandemic, and I couldn’t be more proud of our profession. Yes, you. Whether you are helping your elderly neighbors gather necessary supplies, sharing the importance of social distancing on your social media platforms, providing care through telehealth, or shining on the front lines (as you always have); we see you. Thank you for carrying the light.

We are strong, brilliant, and resilient and together we will overcome. Like diamonds, our strength comes from within. We are unified in a bond made of compassion, commitment, and collaboration that not only fortifies internally, but also provides strength to those who need it the most around us. We have always done well under pressure and today is no different.

I have witnessed strength in unity through various platforms, from national nursing organizations to nurses at the bedside. We will continue to spread our glow, advocating for each other and our patients. Nothing can dim the light that shines from within (Maya Angelou). Shine on!

Self-Regulation and MindfulnessAmid a Pandemic

Jennifer L. Embree, DNP, RN, NE-BC,CCNS, FAAN

Reflecting back on personal disaster experiences and defining moments helps nurses build their own resilience. I continue to think about the quote that you are getting exactly what you asked for and you are prepared for it, as I contemplate our current pandemic. Every disaster that I have experienced, read about, or heard about all bring me back to how we as nurses self-regulate through mindfulness. I recall being voluntold to be the Safety Officer on a military base where nursing students and collaborative healthcare professionals were having mass casualty incident field simulations. (How hard could it be, I thought to myself). After taking an exam and nearly having a nervous come apart, I assumed my duties. We were in a closed hospital that was full of dust bunnies, peeling paint, and many safety hazards. I survived the day with only one minor injury reported.

As nurses, we have the ability to be mindful and alert, observing, appraising, fortifying, and adapting as we continually shift our priorities, actions, and responses (Holtz, Heinze & Rushton, 2017). This ability to be mindful is key in our self-regulation and is a resilience strategy (ANA, 2017).

Our fellow health care and ancillary staff help us assure that we are caring for ourselves, amid the challenges that we face on a daily basis as well as during a pandemic. How are they supporting our physical, emotional, spiritual, and social well-being? How often do we get a quick text, an email, a call, an emoji that makes us smile, takes us away to a beach scene, or a walk in the woods, or visit with a happy puppy?

How do you maintain your balance and keep your bucket full of energy, solace and faith? Working remotely, I reach out to people. I text people funny pictures of puppies, positive messages, or just do a check in. As I reach out to others, it is sometimes to fill my own empty bucket. I use my ANA Healthy Nurse Healthy Nation Strategies to keep me moving (as well as a puppy nudge “I want to go out”). My passion about a civil work environment fills my bucket, but can drain me, so sometimes I have to say “no.” Because if you say yes all of the time, how are you spending your time?

I try to be on the lookout to recognize others when I see the greatness in the work that they do every day. We all need support and encouragement. Have you smiled, reached out, or checked on someone today? I try to be self-aware as well as aware of how others are feeling. I have a plan to support my own well-being and build my moral resilience. One great opportunity is to engage with students who are also worried about supporting nurse resilience. A recent study comes to mind to help increase nurse resilience through pet therapy. While peripheral and supportive to the study, one unanticipated consequence of the study was that ICU nurses called for pet therapy more for their patients (Cinbat, 2019).

Another strategy to increasing resilience is improving and practicing communication, being mindful and focused, resolving conflict and collaborating interprofessionally. Working lately with a hospital chaplain and a nun brought different flavors to my experience and to my day. Divine intervention comes in a variety of ways.

This is a call to action to identify and use your personal resources-people, your organization, or your community. How can you virtually connect to continue to get the socialization that you need to keep your resilience bucket full so that you can be the best nurse possible as well as helping support others? How can you be more aware of what you and others need?

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POLICY PRIMERBlayne Miley, JD

ISNA Director of Policy & [email protected]

The 2020 Indiana General Assembly session concluded in mid-March. At iga.in.gov, you can lookup full details of all the bills and video recordings of all the legislative hearings. With the support of our lobbyists Glenna Shelby and Rebecca Eberhart of LegisGroup Public Affairs, ISNA monitored all healthcare-related bills, and here are some examples of the active advocacy by ISNA this session:

• Stopped an amendment to Senate Bill 427 that would have legitimized a veterinary nursing degree as a pathway to a veterinary technician license. This was aided by nearly 100 nurses that made calls and sent emails on short notice to the Chair of the House Committee on Employment, Labor and Pensions after an action alert sent to ISNA members.

• Improved Senate Bill 146 detailing new procedures for victims of sexual assaults to ensure the language did not unduly interfere with sexual assault nurse examiners or have negative collateral consequences of restricting access to care. Very early in the legislative process ISNA connected the bill’s author with Angie Morris, the Coordinator of the Indiana SANE Training Project run by the Southwest Indiana Area Health Education Center (AHEC). This enabled the bill’s author to receive additional expert input to better accomplish the goals of the legislation and avoid negative collateral consequences (SB 146).

• Worked with the Professional Licensing Agency to allow recently retired nurses to serve on the Indiana State Board of Nursing and to modify a requirement for APRN representation on the Board to reduce the risk the requirement would create Board vacancies. Supported the bill, which also allows APRNs to sign death certificates (House Bill 1392).

• Joined the Indiana Organization for Nursing Leadership in voicing concerns on an amendment to House Bill 1004 that would have reduced hospital system reimbursement in a manner jeopardizing the viability of off-site locations of the hospital system.

2020 Indiana General Assembly Bills Signed Into Law

SB 1 Tobacco and e-cigarette age to 21Raises the minimum age to purchase or possess

tobacco and e-cigarettes to 21. Increases fines to retailers for selling to underage individuals.

SB 5 Health care pricing disclosureProhibits health care provider contracts from

prohibiting the disclosure of the pricing of health care services.

SB 19 Allows Contacts and Glasses to be Prescribed via Telemedicine

Sets forth requirements for the prescriber.

SB 21 Requires Pharmacists to Honor Prescriptions Written by APRNs & PAs Licensed in Other States

Effective immediately.

SB 61 EMS Interstate CompactImplements the interstate licensure compact for

emergency medical services personnel. Eighteen other states have joined.

SB 146 Sexual assault victim rightsEstablishes rights for a sexual assault victim

regarding forensic medical exams and law enforcement interviews. This includes the availability of a sexual assault counselor. Special thanks to Angie Morris, Indiana’s SANE Training Project Coordinator, for her advocacy and expertise on this subject.

SB 239 Coverage for breast prosthesisRequires insurers that cover mastectomies to cover

breast prosthesis.

SB 241 Pharmacy benefit managersRequires pharmacy benefit managers to be

licensed.

SB 246 School mental health servicesRequires schools to partner with community health

centers or providers for mental health and addiction services before applying for a grant from the Indiana secured school fund.

SB 255 Access to insulinRepeals a provision that requires a prescription to

purchase insulin.

SB 288 Hunting license organ donationAllows for anatomical donor designations on

hunting licenses.

SB 299 Fetal remainsRequires abortion providers to offer cremation/

internment of fetal remains.

SB 427 Provisional licensesEntitles individuals licensed in other states that

establish residency in Indiana to receive a provisional license upon submitting to a national criminal background check and paying a fee.

HB 1003 Teacher requirementsModifies requirements for teacher licenses.

Changes oversight of teacher CPR requirements from the Department of Education to the Board of Education.

HB 1004 Out of network billing & hospital reimbursement

Prohibits a provider from billing a patient for greater than the in network amount, unless they notify the patient with a good faith estimate. Requires certain providers to provide a good faith estimate of the price of nonemergency services beginning in 2021.

HB 1067 Dental hygenist scope of practice

Expands services a dental hygenist can provide without a dentist present at the facility. Restricts the administration of nitrous oxide to dental hygenists, dentists, and physicians.

HB 1077 PLA updateUpdates regulations on the Professional Licensing

Agency. Allows a state DEA registration to be revoked if disciplinary action is taken by the DEA on the individual’s federal registration.

HB 1129 Require Infants to be Screened for Adrenoleukodystrophy (ALD)

Becomes effective July 1, 2021.

HB 1182 HIV terminology, health care provider exposure to communicable diseases, & Suicide/OD Review Committees

Updates state regulations on HIV and state mandated information to be shared to be consistent

Mailto:[email protected]


POLICY PRIMERwith current medical information. Requires a physician or their representative to advise a patient of certain information before ordering an HIV test. Allows for the creation of county and regional suicide and overdose fatality review committees. Their charge is to analyze trends in an effort to improve community resources to prevent suicide and overdose fatalities. Provides health care providers the same ability as law enforcement and first responders to request a blood sample through a court if they have been exposed during treatment of a patient.

HB 1199 Palliative careAllows patients that are not eligible for hospice to

receive community based palliative care services from certified providers.

HB 1207 Requires Pharmacists to Honor Prescriptions Written by APRNs & PAs Licensed in Other States

Also allows for easier transfer of prescriptions between pharmacies. Also allows pharmacists to dispense auto-injectable epinephrine.

HB 1209 Reimbursement for EMS services

Requires health insurers, including Medicaid, to reimburse for emergency medical services provided by certified EMS providers.

HB 1210 ISDH omnibusAllows for criminal prosecution and civil penalties

for interfering with an ISDH investigation into a home health agency or for retaliating against someone that reports a violation. Allows the department to use the immunization data registry to store and release nonimmunization personal health information, specifically blood lead screening and newborn screening information. Updates regulations on food handling.

HB 1243 Genetic counselorsAllows genetic counselors more flexibility to

determine the appropriate genetic test for a patient without a specific order from a physician. Updates licensure laws for genetic counselors.

HB 1326 Community Mental Health Centers

Overhauls the regulation of community mental health centers. For purposes of Indiana Medicaid, grants APRNs working in community mental health centers the same supervisory rights and responsibilities as physicians, including prior authorization.

HB 1392 APRN & PA sign death certificates and changes Board of Nursing eligibility

Allows APRNs and PAs to sign death certificates and submit death records to the appropriate regulatory entities. Allows recently retired nurses to serve on the Board of Nursing. They must have worked within the last five years from their initial appointment. Requires the Board to have one APRN member, who must have had prescriptive authority. The bill was amended from has prescriptive authority to has had prescriptive authority at ISNA’s suggestion, to ensure recently retired nurses can fill the APRN slot on the Board.

Focus Shifts to 2021With the 2020 legislative session behind us,

attention turns to 2021. The Indiana General Assembly is expected to announce the topics selected for interim study committee hearings later in May. The committees will hold public hearings on the selected topics typically from July to October. Over the summer is a great time to contact your two state legislators about APRN prescriptive authority, nursing workforce needs, and any other topic of interest. Has the COVID-19 pandemic exposed shortcomings in our healthcare regulations? Share your expertise with your legislators! I am here as a resource to provide any assistance I can in your advocacy, so do not hesitate to contact me at [email protected].

The annual ISNA Policy Conference continues to grow in attendance and bring relevant presentations on policy current events. This year, our event was on January 29th with 120 attendees. It included presentations on:

• Indiana State Health Department initiatives on smoking/vaping reduction, OB navigation, and sepsis by State Health Commissioner Dr. Kristina Box and Pamela Pontones, Deputy Health Commissioner & State Epidemiologist

• Healthcare challenges in the aging community by Jean Ross, KayBee Nurse Care Coordinator, and Russ Evans, COO of Care Revolution

• Medical cannabis policy by Cpt. Jason Straw of Indiana NORML

• Legislative session report by ISNA lobbyists Glenna Shelby and Rebecca Eberhart of LegisGroup Public Affairs, along with Blayne Miley, ISNA Director of Policy & Advocacy

We were also fortunate enough to receive visits from Representative Ethan Manning and Senator Vaneta Becker, each of whom stopped by to talk about the ongoing session. Every year at this event we are able to connect nurses and nursing students with policymakers to discuss healthcare issues. By holding the conference during the legislative session, our content consists of actionable advocacy matters.

A big thank you goes out to the ISNA Political Action Committee, who helped plan and run the event. ISNA PAC members are Emily Sego, Jean Ross, Deborah Spoerner, Terry Moore, Heather Anderson,

Kimber Nagy, and Kate Cerbin. Another thank you to ISNA Board of Directors members Beth Townsend and Jennifer Embree for helping with the registration table. We would also like to thank our exhibitors; Purdue University Northwest Nursing school, American College of Education, and the IU School of Nursing at IUPUI.

If you have suggestions for topics or speakers for the 2021 ISNA Policy Conference, send them to [email protected].

2020 ISNA Policy Conference

Photo L to R: Blayne Miley, Rep. Ethan Manning, Rebecca Eberhart, and Glenna Shelby.

Call for ISNA Policy Platform ResolutionsThe Indiana State Nurses Association maintains a

policy platform that contains position statements on policy topics. It is viewable at www.indiananurses.org by clicking the Policy heading. Every year at our annual convention, the policy platform is up for revision through the introduction of resolutions. Any member of ISNA may introduce a resolution. Submitted resolutions will be published in the August edition of the Bulletin. The format of the

resolution is to have two sections (1) a WHEREAS section that spells out the reasoning for the policy statement, and (2) a BE IT RESOLVED section that contains the specific wording change proposed for the ISNA platform. Anyone interested in submitting a resolution is welcome to email Blayne Miley, [email protected], for assistance with formatting. We ask that resolutions be submitted to that email by June 16th.


Transitioning from Nursing Student to New Graduate Nurse

and BeyondAndrea Jacobs, BSN, RN

Three years ago, when I was in my last semester of nursing school, I found myself in the tunnel of transition. The idea was to keep moving forward, although I was not exactly certain which direction the tunnel was leading me. I would not consider where I was as “lost,” but more or less in the position of change. One of the most critical points of senior year is the last semester where one completes their “capstone.” During my capstone, I was blessed to have been placed in such supportive hands. This place was exactly where I needed to be in order to give me direction.

In my capstone, I was taken under the wing of my current supervisor. He was not my preceptor, but he made sure I was looked after by his own staff. He was (and still is) this amazing, almost superhero figure who guided me into his office at the very end of my capstone rotation to ask me if I would be interested in staying after passing the NCLEX. I was thrilled, but also struck with a pit of nervousness; this was the moment I had been waiting for since the day I told my academic advisor I wanted to declare my major in nursing.

Through this conversation, the one thing that stuck out to me was his demeanor. He already knew that I was in this transition period, and he empathized with me. From day one, he encouraged me and supported me. I still remember what he told me on that day I was nervously sitting in his office, ready to face my first workweek as a new nurse. He said, “Always have a 2-year plan, 5-year plan, and 10-year plan.” I took it to heart.

From then on, I told myself the first two years of nursing would be dedicated to getting my feet underneath me – to learn and keep learning until I felt confident in myself. Then, I told myself I would be ready for the start of the 5-year plan – engage, get involved, and start furthering my education. Today, I finally feel that chapter of my 2-year plan closing and the next chapter opening. I am a board director for the ISNA, a volunteer registered nurse at a free health care clinic, a member of several nursing organizations, and actively pursuing my dream of becoming a family nurse practitioner. I can see the different paths in the tunnel, and I am so happy to have had my supervisor through it all.

In that last semester going into the “real” world, you will experience many overwhelming emotions due to change. Change is inevitable, but having someone there to mentor you through the process is a very important part. Leadership is about more than making tough decisions; it means giving others the means to become leaders themselves. By really taking this to heart, I learned how I can take control and establish goals for myself and my discipline. I recommend doing the same for those out there reading this.

Lastly, I want to express my condolences during this very uncertain time for many nursing students. With many nursing programs coming to a halt, clinicals up-in-the-air, and endless possibilities regarding graduation, I want to let all of you know that now is the time to take what you have learned and put it into practice. Remember that social support is not just for your patients; you have to care for yourself in order to care for others. One of the best ways is to find these mentors and stay in contact with them. Lean on them for continued growth and support during these challenging times. I can guarantee that you will find the light to stay on track in your own tunnel. Additionally, take these hurdles and spin it into something positive. You will be able to say you did your part during the COVID-19 pandemic and you will be an invaluable resource for our future generation of nurses hereafter.

ISNA would like to recognize healthcare organizations that are making a commitment to safeguard clinician’s well-being and creating a positive practice environment for our nurses. With 25 Magnet and 10 Pathway designated sites across Indiana, #IndianaNurses are practicing in a state in which promotes excellence in care delivery, in addition to safe and healthy environments in which we are providing care. Please join me in celebrating newly (within the last 12 months) designated Magnet and Pathway sites, and those that continue striving for excellence with Magnet Redesignation.

The Pathway to Excellence Program® – the premier designation for healthy work environments – recognizes health care organizations that demonstrate a commitment to establishing the foundation of a healthy workplace for staff. Pathway Standards impact a range of factors that influence bottom-line results, such as employee turnover, job satisfaction and engagement, productivity and teamwork, nursing-sensitive quality indicators, errors and safety events, and patient satisfaction.

Hancock Regional Hospital 2019

Indiana University Health Blackford Hospital 2020

Indiana University Health Frankfort Hospital 2020

Indiana University Health Saxony Hospital 2020

Indiana University Health White Memorial Hospital 2020

The Magnet Recognition Program designates organizations worldwide where nursing leaders successfully align their nursing strategic goals to improve the organization’s patient outcomes. The Magnet Recognition Program provides a roadmap to nursing excellence, which benefits the whole of an organization. To nurses, Magnet Recognition means education and development through every career stage, which leads to greater autonomy at the bedside. To patients, it means the very best care, delivered by nurses who are supported to be the very best that they can be.

Riley Hospital for Children at Indiana University Health 2019

Union Hospital, Inc. 2020

Magnet Redesignation

Goshen Hospital 2019 (2004)

Hendricks Regional Health 2019 (2010)

Indiana University Health West 2019 (2014)

Thank you to all of Indiana’s 35 designated sites. From greater nurse satisfaction to improved patient outcomes, discover the ways that ANCC’s Magnet and Pathway programs can help drive your organization to succeed, and for a detailed list of designated sites, please visit nursingworld.org/organizational-programs/.

http://www.fortis.edu

http://www.fortis.edu


American Nurses Association Recognizes Travel Health Nursing

as New Specialty Nursing Practice

SILVER SPRING, MD - The American Nurses Association (ANA), representing the interests of the nation’s four million registered nurses, announces the formal recognition of travel health nursing as a nursing specialty.

Travel health nursing is an evidence-based practice that advances the well-being of all travelers both domestic and international, and the communities to which they travel and return. It has evolved as a distinct and increasingly complex specialty over the past three decades and draws upon the knowledge of nursing, pharmacology, epidemiology, tropical medicine, primary care, and behavioral psychology.

“ANA is pleased to recognize the specialty status of this essential area of nursing practice,” said ANA President Ernest Grant, PhD, RN, FAAN. “It’s a privilege to play such a vital role protecting the public and ensuring nursing practice maintains the highest and relevant clinical, research and educational domains. Granting this specialty recognition underscores the importance of nursing’s contribution to the global impact of travelers’ health and safety.”

“ATHNA is thrilled and honored by ANA’s recognition of our specialty scope and standards,” said the American Travel Health Nurses Association (ATHNA) Interim President Sandy Weinberg, RN, BSN, MA, FATHNA, CTH®. “This recognition is a milestone for our specialty. It highlights and acknowledges the more than 25,000 nurses who provide travel health services to travelers of every age who make any journey.”

Travel health nurses are specially educated and trained to promote the health and safety of travelers through comprehensive risk analysis, assessment, immunizations, health education, and therapeutic interventions. Nurses in this specialty provide services in three different clinical encounters: pre-travel, during travel (“in-transit”), and post travel in a variety of settings that include college health, occupational health, public health, the military, primary care, and nurse-managed travel health clinics, among others. Travel Health Nursing: Scope and Standards of Practice (2020), an important professional resource, is in production and will be available at nursingworld.org/nurses-books in the near future.

ANA is the neutral reviewing body of specialty nursing scope of practice statements and standards of practice, requests for specialty recognition, and more recently affirmation of focused practice competencies.

About the American Travel Health Nurses Association (ATHNA)

The American Travel Health Nurses Association (ATHNA) is the professional organization that represents more than 2,000 members from every U.S. state, many Canadian provinces, and several countries. ATHNA members practice in a multitude of clinical settings to provide care to travelers during all stages of trips to destinations both international and domestic. Currently, ATHNA offers free membership to any professional nurse who wishes to join. ATHNA advocates for nurses in this specialty and promotes professional development and the provision of standardized, quality travel health care. ATHNA provides its members with a number of special benefits including an annual Networking Education and Development Day (NED) and TravelBytes, its peer-reviewed blog. Learn more at www.athna.org.

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HOW TO CELEBRATESuggestions for Celebrating & Elevating Nursing

Your future starts now, so make the Year of the Nurse your year to inspire, grow, and celebrate! Throughout the year, we encourage you to seek opportunities and engage in activities to promote nursing excellence, infuse leadership, and foster innovation. Below are suggestions for how you can excel, lead, and innovate.

EXCELGo beyond the ordinary in 2020 and make

this the year you focus on your professional and personal development.

• Find a mentor. Is there a colleague, nurse friend, or former instructor who has useful insights to share or inspires you to be your best? Having a mentor who can help you navigate your career and offer advice could be the motivation you need to excel and advance your nursing career. ANA also offers its members a Mentorship program. Enrollment for 2020-2021 will open in the summer.

• Take your nursing to the next level. Do you want to build your leadership ability or improve your nursing practice? Webinars and online courses can help enhance your knowledge and give you skills you need to succeed. Sign up for the free webinars Ten Steps to Becoming a Successful Nursing Manager or What’s Happening in Nurse Staffing?

• Knowledge is power. Make 2020 your year for professional development. Whether you are looking to achieve your first certification, explore new ones, or renew a certification, the American Nurses Certification Program lets you demonstrate your specialized knowledge and continuing competence.

• Make self-care a priority. Join the Healthy Nurse, Healthy Nation™ Grand Challenge, an initiative to connect and engage nurses, employers, and organizations around improving health in five areas: physical activity, nutrition, rest, quality of life, and safety. If you’re looking for an inspiring way to focus on your well-being in 2020, join the monthly challenges.

• Give back to your community. Help promote the value of nursing by supporting a special health screening event in your community or volunteering at a health clinic. Consider joining a local organization that supports something you are passionate about and could benefit from your insight as a health care professional.

LEADAs a nurse you inspire, influence, and innovate – all leadership qualities. In

this Year of the Nurse, commit to elevating your voice to show the influence you have as the backbone of health care.

• Inspire the next generation. Your outreach this year is critical to engaging with the next generation of nurses and increasing workforce diversity. Visit elementary and middle schools, career fairs, community centers, and youth

clubs to talk about your path to nursing and inspire future nurses.

• Exercise leadership skills. Make this the year you learn about how you can serve on a board of directors. Start by visiting Nurses on Boards for resources and updates on nationwide board opportunities. If you are already contributing to board leadership, inspire others to serve on boards by sharing your “bedside to boardroom” story.

• Impact political change. In this critical election year, make a commitment to engage in political advocacy. Visit RNAction to learn how you can ensure nurses’ voices are heard by politicians. Learn more about candidates, priority issues, voter registration, and ways to volunteer on campaigns. Share what you learn with your friends, family, and colleagues. If you want to engage more in political advocacy, participate in your state or constituent nurses association’s Legislative Day and ANA’s Hill Day in June. These annual events provide the opportunity for you to share your perspective as a nursing professional and gain elected officials support for crucial legislation.

• Raise your voice with the media. Share your perspective about the value of nursing and nursing leadership with your local media. Reach out to a reporter in your city who covers health issues to recommend they do a story about the Year of the Nurse, submit an editorial to your local newspaper, or send a letter to the editor commenting on recent coverage that would have benefited from the nursing perspective.

• Elevate your profession. Introduce yourself to patients, colleagues, and members of the community as “Nurse (Last Name).” Include your RN credential on Business cards, checks, credit cards, email signatures, and more. Take every opportunity to educate others about nursing and show pride in your profession.

• Get social. Share a week of posts on your life as a nurse. Give your social media followers a glimpse into all you do with highlights about your activities, colleagues, and nursing moments where you make a difference. When making work-related posts, be attentive to ANA’s Social Networking Principles. Use #YON2020 or #yearofthenurse in your posts.

• Inspire colleagues. Words of encouragement and random acts of kindness can make all the difference in a person’s day, especially for nurses. Share inspirational messages or a handwritten “words from a nurse” letter to give the support, encouragement, and motivation we all appreciate and occasionally need to brighten our day.

• Celebrate the power of great nursing. Honor a nurse mentor, celebrate a nurse colleague, or thank a special caregiver, nurse friend, or family member with a contribution to the American Nurses Foundation in their name. Your donation will support innovations to make care more patient-centered, financial aid to students in need, and programs that help nurses achieve better health.

INNOVATENurses are natural problem solvers and innovators.

Innovations occur at all levels of health care, nurses can and should be at the forefront, just like Florence Nightingale, the first nurse innovator.

• Initiate an innovation program. Nearly 70 hospitals and health systems across the U.S. are recognized for their innovation programs. If your organization has an innovation program, are there opportunities for you and your nurse colleagues to support it? If your organization does not have an innovation program, how can you start one that improves workflow, efficiency, and patient care?

• Join or host a hackathon. Champion nurse-led innovation by participating in or organizing a platform that encourages nurses to bring their ideas to life. Live-action events such as pitch competitions or hackathons are fun ways to learn about innovation, design thinking, and even failure. Check for corporate-sponsored events, or competitions at local nursing schools or your state nurses association.

• Share your experience. Are you a nurse innovator or aspiring visionary who wants to help build a culture of innovation? Consider sharing your ideas, thoughts, and advice in a blog post or writing an article for a nursing, health care industry, or nursing school publication.

• Launch your idea. Do you have a nursing-led innovation you want to see through from concept to reality? Consider launching your idea at NursePitch, a live interactive event for nurses to compete for a chance to turn their innovation dreams into reality. There is no time like now to start planning for the 2021 competition.

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Awards to be given this year at the 2020 ISNA Convention uses our four pillars as a guide: Unity, Advocacy, Professionalism, and Leadership and combine the National ANA award categories.

To nominate a nurse for any award, submit information on the nominee, including curriculum vitae, if available. Document the nominee’s involvement in each area listed in the award’s criteria. Information on the nominator should also be submitted including name, position, employer, address, and phone number. Include information on your relationship with the nominee and how you became aware of his/her practice/leadership excellence. Complete Nominating form below and e-mail to [email protected]; or mail to ISNA, 2915 N. High School Road, Indianapolis, IN 46224. You may also submit on line at www.IndianaNurses.org.

I. UnityPresident’s Award

• To recognize distinguished service or valuable assistance to the Indiana State Nurses Association and, thus, to the profession of nursing.

• Criteria: This award is selected by the current ISNA President and presented to an individual(s) who can be a registered nurse or a non-nurse, who has given distinguished service or assistance to the Indiana State Nurses Association. If the nominee is a nurse, the individual must be a current member of ISNA and have held membership in ISNA for at least four (4) years. Selection shall not be made posthumously.

The first President’s Awards were presented at the 1989 Awards Banquet by Doris R. Blaney. The nominee(s) approved by the ISNA Board of Directors will be invited to attend the ISNA Convention for the presentation of the Award. If due to extenuating circumstances the nominee cannot be present, the presentation will be made in absentia. Names of individuals not receiving honorary recognition may be resubmitted for consideration at another time.

II. AdvocacyPublic Policy and Advocacy Award

• To recognize outstanding contributions to the development and implementation of health related policy at the local, state, and/or national level.

• Criteria: A member of the Indiana State Nurses Association, who has significantly influenced policy and legislation that positively affects the health and well-being of the citizens of Indiana and the practice of professional nursing.

In June 1999, the ISNA Board of Directors established the Georgia B. Nyland Award in her honor and memory. Georgia was devoted to the advancement of the nursing profession and to excellent health care. For many years, she used her tireless energy and talents to influence legislators and others in the health policy arena to evoke positive changes that have benefited many. She took great pride in her membership in ISNA. She was a good friend and mentor.

III. ProfessionalismNursing Professionalism and Practice Award

• To recognize outstanding professional contributions and excellence in the practice of the science and art of nursing.

• Criteria: A member of ISNA, and who has demonstrated excellence in Nursing practice in Nursing education, clinical practice, innovation and contribution in Nursing research, is a clinical role model and inspires other nurses to improve the health of patients, families or communities.

An example of Nursing Professionalism Award is the Psychiatric Nursing Professionalism Award which honored Ruth Stanley and Beverly S. Richards who made significant contributions and lasting legacies in psychiatric nursing practice and advocacy. These award recipients demonstrated excellence in psychiatric practice through working directly with clients, families, or groups, and serves as a clinical role model who inspires other nurses to improve client care.

IV. LeadershipDistinguished Nurse Leadership Award

• To recognize excellence in the areas of national and local nursing leadership, academic leadership (nurse education/research), community leadership, innovation, or entrepreneurship.

• Criteria: A member of ISNA who has demonstrated excellence in leading, motivating, mentoring, and promoting the professional advancement of nurses and exemplary nursing practice.

2020 Indiana State Nurses Association Awards

Student Nurse Leadership Award• To recognize excellence, volunteer work, and leadership in the areas of

national and local nursing leadership, academic leadership (nurse education/research), community leadership, innovation, or entrepreneurship.

• Criteria: A member of the Student Nurse Association who has demonstrated excellence in motivating, mentoring, and promoting the student nurses’ role in exemplary nursing practice.

Nominations will be accepted through July 31, 2020.

Award Nomination for: (Check one)

Unity _____ Advocacy _____ Professionalism _____ Leadership _____

Name of Member ____________________________________________________

Employer ___________________________________________________________

Position ____________________________________________________________

Member Address ____________________________________________________

___________________________________________________________________

Member Phone number_______________________________________________

Nominator __________________________________________________________

Nominator Phone Number ____________________________________________

Your Relationship with Nominee _______________________________________

How has the member met the award criteria? ____________________________

___________________________________________________________________

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INDEPENDENT STUDY

ISNA is going even greener; the time has come to move to electronic CEs. Please note this is our last printable continuing education opportunity. We are reviewing electronic platforms, focusing on availability, cost and pertinent courses with you in

mind. Until we are up and running, we recommend the following:• https://www.nursingworld.org/continuing-education/• https://www.ce4nurses.org/ • https://www.nursingce.com/

Please contact [email protected] with comments, concerns, and for assistance with finding the right CE platform to match your needs. Thank you for your patience and understanding as we continue this transition.

Compassion Fatigue: You Are Not AloneLearner Outcome: The learner will demonstrate

sufficient understanding of compassion fatigue and burnout by achieving a score of 70% or better on a post-test.

Disclosures1 Contact Hour will be awarded with successful

completion.

Criteria for Successful Completion: Read entire study, complete evaluation questions and achieve post-test of 70% or more

Expiration: 9/30/2021

There is no conflict of interest among anyone with the ability to control content of this activity.

The Ohio Nurses Association is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center’s Commission on Accreditation. (OBN-001-91)

This independent study was written by Jessica Dzubak, MSN, RN

This is not intended as legal or professional advice. If you or someone you know needs help, please contact a licensed mental health professional.

Jessica Dzubak, MSN, RN

Compassion fatigue. Burnout. Secondary stress. We have heard the terms in the break-rooms or in the locker room, and we read about them in the literature. Sometimes it is very easy for us to identify it in others. We have all seen that colleague who snaps at their patients or has lost their spark.

But are we just as good at identifying it in ourselves?

Compassion fatigue continues to be a growing concern among healthcare professionals, including nurses at all levels of care. However, healthcare workers are not the only ones prone to compassion fatigue. The literature suggests it primarily affects

“the helping professions,” such as psychotherapy, social work, veterinary medicine, law enforcement and education (Abcug, 2017; Hunt, 2017; Turgoose, Glover, Barker & Maddox, 2017). Research found that approximately 50% of people, across professions, are burned out (Seppälä & King, 2017). Many professional associations have pages dedicated to compassion fatigue, such as the American Bar Association and the American Veterinary Medicine Association.

You don’t have to be a professional to experience compassion fatigue, secondary trauma or burnout. One rural health department identified the risk of these adverse effects in the lay people in the community who receive naloxone kits and are trained to administer in the event of an overdose emergency (Aguilar-Amaya & Gutierrez, 2019). With Ohio ranking second for highest rate of drug overdose deaths involving opioids in 2017, the public dispensing of naloxone kits in the community is becoming commonplace (National Institute on Drug Abuse, 2019). In addition to members of the community being affected, first responders are being hit exceptionally hard. A fire chief in West Virginia, in an area hard-hit by drug overdoses, has begun implementing measures to increase resiliency and prevent compassion fatigue for her first-responder staff, including on-site massage therapy, mindfulness training, and the hiring of a mental health counselor (Bloomberg Cities, 2018).

The effects and consequences of compassion fatigue and burnout can be so profound that even the patients suffer, including decreased satisfaction with their care and an increase in errors made by health professionals (Valentine Upton, 2018; Lachman, 2016). Nurses and healthcare providers must be aware of the concepts of compassion fatigue and burnout in order to recognize the signs in themselves and in their colleagues. Nurses have an ethical responsibility to self just as much as to others (American Nurses Association, 2015, p. 19). The ANA Code of Ethics (2015) pushes nurses to concern themselves with their own health, wellness, and safety. It has long been established that mental health is equally important as physical health, and nurses must remain diligent in tending to their own mental wellness.

What is Compassion and Why is it Important: “…a multidimensional process comprised of

four key components: (1) an awareness of suffering (cognitive/empathic awareness), 2) sympathetic concern related to being emotionally moved by suffering (affective component), (3) a wish to see the relief of that suffering (intention), and (4) a responsiveness or readiness to help relieve that suffering (motivational)” (Jazaieri, et al., 2012)

“to suffer together” “the feeling that arises when you are confronted with another’s suffering and feel motivated to relieve that suffering” (Greater Good Magazine, 2019, para. 1).

“Nursing’s most precious asset” (Valentine Upton, 2018, p. 2)

Research shows us that humans are “wired to empathize” (Keltner, 2012, para. 7). The same parts of our brains that light up when we experience pain are also activated when we witness other people in pain (Keltner, 2012). Compassion takes us beyond empathy and into the realm of wanting to help. It can be incredibly stressful when a nurse is witnessing a negative situation or the suffering of his/her patient, yet he/she cannot do anything to help. Sometimes, every effort can be made to save the patient, remedy the situation, or fix the problem – yet a negative outcome occurs anyway.

Nurses go into the profession because of their inherent desire to help and support others, regardless of circumstance, socioeconomic status or culture (American Nurses Association, 2015). In order to provide this level of care, nurses must display a certain degree of compassion and empathy.

Nursing is unique in that it touches people in all walks of life, from newborn babies to criminals imprisoned for life. Each and every patient we touch deserves the same level of compassion and respect. This constant demand to remain calm, respectful and compassionate can become overwhelming if the nurses are not taking the time to treat themselves with the same level of kindness and care.

Nursing is stressful, and life is stressful. We must learn to manage ourselves before we can even begin to manage others. We must also learn to recognize when things start to change. A decrease in job satisfaction or increased difficulty in managing “difficult” patients require attention. Giving these troublesome things a bit of attention does not mean you are self-indulgent, selfish or weak. It means you are human and are taking the steps to manage issues that could worsen and impact your career and well-being.

Compassion fatigue vs. BurnoutCompassion fatigue and burnout, are they the

same?Per the American Institute of Stress (AIS), there is a

“clear difference.” The AIS explains the key difference

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May, June, July 2020 The Bulletin 13being that compassion fatigue has a “more rapid onset” and burnout is something that develops and “emerges over time.” Additionally, compassion fatigue is thought to have a faster recovery, but only if it is recognized and managed early (American Institute of Stress, 2018).

Burnout: Jenaro, Flores and Arias (2007) explain burnout as ‘a syndrome composed of emotional exhaustion, depersonalization, and reduction of personal accomplishments and is displayed as feelings of hopelessness, difficulties in dealing with work, and poor work performance’ (Jenaro, Flores, & Arias, 2007). These emotional components result in difficulties carrying out job duties, hopelessness in improving the situation, and a decrease in effectiveness in the workplace (Stamm , 2010).

In the latest version of the International Classification of Diseases, ICD-11, the World Health Organization (WHO) has added burnout as an “occupational phenomenon” (World Health Organization, 2019). Burnout is not to be confused with a medical condition.

Compassion Fatigue: Compassion fatigue can be described as either a preoccupation or a re-experiencing of a patient’s or client’s traumatic event(s), which can decrease the caregiver’s aptitude or interest in bearing the suffering of other people (Mathias & Wentzel, 2017). Compassion fatigue can also be described as “a state of detachment and isolation experienced when healthcare providers repeatedly engage with patients in distress” (Lee, McCarthy Veach, MacFarlane, & LeRoy, 2015, para. 1). Another respected definition, stated by Dr. Frank M. Ochberg, is “basically … a low-level, chronic clouding of caring and concern for others in your life – whether you work in or outside the home. Over time, your ability to feel and care for others becomes eroded through overuse of your skills of compassion” (Ochberg, n.d.., para 3).

Often, the term secondary stress or secondary trauma stress can be used instead of compassion fatigue. Secondary stress is defined as: “the emotional duress that results when an individual hears about the firsthand trauma experiences of another” (The National Child Traumatic Stress Network, n.d., para 1). Nurses and many others in the ‘helping professions’ both hear and witness other people’s stress and trauma on a sometimes daily basis. Therefore it is understandable to see how this stress can become overwhelming.

When discussing compassion fatigue, it is important to recognize compassion satisfaction, or “gratification obtained when doing one’s work to the best of one’s ability” (Mathias & Wentzel, 2017, para. 16). Another definition is “…the feeling of pleasure that results from ably executing one’s duties.” (Mathias & Wentzel, 2017). Compassion satisfaction is what we want to feel every day when we walk out of a shift. We want to feel like we did good, treated our patient’s to the best of our ability, and like we made a difference. We want that pleasure and gratification, not because we are self-involved but because it makes the negative aspects worth it, and because it reminds us of why we do this work. So what makes it so hard to do this?

Compassion fatigue, secondary stress, and burnout, while often reduced to simplistic definitions, are not simple concepts. In fact, they are complex and multifaceted. Both affect the nurse’s ability to function effectively, both personally and professionally. The quality of the care provided is decreased in both situations (Mathias & Wentzel, 2017). Regardless of the combination of symptoms, any of them can decrease one’s ability to provide top-quality care. In some cases, symptoms can be so detrimental that even the safety of the care is compromised.

The “cumulative stress” those in the caring professions face can ultimately lead to these physical, emotional, social and spiritual effects (Sinclair, Raffin-Bouchal, Venturato, Mijovic-Kondejewski, & Smith-MacDonald, 2017).

Common Symptoms:Boredom Increased blood pressureCynicism Loss of compassionAnxiety FatigueDiscouragement ApathyIntrusive Thoughts IrritabilityAvoidance NumbnessPersistent arousal DepressionSleep disturbances Detachment

Other Effects:• More sick days• Higher turnover rate• Decreased productivity• Patient dissatisfaction• Increase in errors(Valentine Upton, 2018; Sheppard, 2015)

The American Bar Association (2017) provides another comprehensive list of detailed symptoms and behaviors linked to compassion fatigue:

• Perceiving the resources and support available for work as chronically outweighed by the demands

• Having client/work demands regularly encroach on personal time

• Feeling overwhelmed and physically and emotionally exhausted

• Having disturbing images from cases intrude into thoughts and dreams

• Becoming pessimistic, cynical, irritable, and prone to anger

• Viewing the world as inherently dangerous, and becoming increasingly vigilant about personal and family safety

• Becoming emotionally detached and numb in professional and personal life; experiencing increased problems in personal relationships

• Withdrawing socially and becoming emotionally disconnected from others

• Becoming demoralized and questioning one’s professional competence and effectiveness

• Secretive self-medication/addiction (alcohol, drugs, work, sex, food, gambling, etc.)

• Becoming less productive and effective professionally and personally

Prevalence and Statistics: • Burnout is among the leading patient safety and

quality concerns (The Joint Commission, 2019)• Up to 85% of healthcare workers experience

compassion fatigue• Higher levels of compassion fatigue in younger

nurses and/or those with fewer years of experience

• 6% of all nurses reported feelings of burnout (emergency department nurses = higher risk)(The Joint Commission, 2019)

• “Very new” nurses to the acute care setting = high levels (Valentine Upton, 2018)

• Female nurses have a higher incidence• Age: 40-49 year old nurses had “significantly

lower compassion satisfaction” and higher rates of burnout (Sacco, Ciurzynski, Harvey, & Ingersoll, 2015).

Why does compassion fatigue hit nursing so hard? One study points out that interviewees in the study reported the feeling of being “undervalued” and “being taken for granted by patients who have unrealistic expectations of the nursing role” (Valentine Upton, 2018). “It is important to look at these personal growth benefits without judgment and be honest with yourself regarding what you hope your job will provide as these personal benefits because it is when your work doesn’t provide us this gain, you become vulnerable to emotional injuries which are often experienced as secondary trauma and compassion fatigue” (Tobey, 2019, p. 7).

Reflection: Have you experienced caring for a patient(s) who have “unrealistic expectations” of your role as the nurse? What were these expectations? How did you handle the situation?

With an increased emphasis on patient satisfaction scores, nurses are being stretched thin to accomplish their nursing tasks safely and meet all of other patient’s needs (Bachman, 2016). Most nurses will tell you they truly enjoy this part of their job, making a patient feel more comfortable during a stressful time or even just providing a shoulder to cry on. But over time, this willingness to help can cause problems if stress and emotions aren’t managed properly.

As nurses, we become so focused on alleviating our patient’s stress and pain that we fail to address our own.

Organizational Compassion Fatigue Compassion fatigue doesn’t just affect individuals.

It can spread and begin to affect an organization as a whole. The Compassion Fatigue Awareness Project (2017) describes the following as organizational symptoms of compassion fatigue:

• high absenteeism• constant changes in co-worker relationships• inability for teams to work well together• desire among staff to break company rule• outbreaks of aggressive staff behavior• inability of staff to meet deadlines and complete

tasks• lack of flexibility• negativism toward management• reluctance towards change• inability to believe in improvement A combination of these factors can lead to a less-

than-desirable work environment. With the steady prevalence of workplace bullying, lateral violence, and workplace violence, healthcare workers should be looking at the correlation between compassion fatigue, burnout and violence. The literature shows that there is a connection between healthcare workplace bullying and burnout (Bambi, Foa, De Felippis, Lucchini, & Rasero, 2018; Giorgi, et al., 2015). Workplace and social support have been linked with lower levels of burnout and greater satisfaction and productivity (Seppälä & King, 2017).

Students:While educators must be careful not to scare

or discourage students about nursing, an honest discussion about the demands of the job is warranted. Students should be aware of resources they have as well as learn coping skills and stress management skills early on. Studies show that students even

Independent Study continued on page 14

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The Bulletin May, June, July 202014Independent Study continued from page 13

experience compassion fatigue during their nursing school experience (Jack, 2017).

The study goes on to say “At times it seemed that the students cared more for the patients than they did for themselves, as they became more and more involved in the challenging situations which led them to place high expectations on themselves” (Jack, 2017, para. 23).

The reality of nursing can be overwhelming, and educators are in a challenging position. They need to disseminate crucial information while also preparing nursing students for the “real world.” Educators must teach the clinical information as well as the practical. In order to do this, educators must find innovative ways to communicate with their students and foster a culture of safety. One way to do this is to regularly have opportunities for debriefing.

The importance of debriefing cannot be understated (Schmidt & Haglund, 2017; Wanninger, Riley, Hofer, & Swift, 2019; McCorkle, 2016). Debriefing allows students to talk about experiences, whether positive or negative, review events in a non-judgmental way, and learn from the opportunity. It also encourages the student nurse to continue this as they transition to professional practice. Talking with a colleague, manager or mentor after a stressful incident can alleviate some of the stress and anxiety, and resources can be obtained if necessary.

We must instill in our nursing students that while stressful things may occur, feeling compassion fatigue and burnout are not “just part of the job.” A 2016 study found that nursing students experience a high-level of stress, but the majority of them (92%) do not typically or frequently make time to personally debrief or unwind after a stressful situation (Homan, 2016).

Debriefing is also critical for seasoned, established nurses and others in the helping professions. Research supports debriefing, showing that it has a positive relationship to compassion fatigue and burnout (Miller, 2016). Additionally, debriefing may increase the perceived level of support in an organization or among coworkers, providing another resource to combat compassion fatigue.

A 2017 study examined whether or not a “sacred pause” at the time of a patient’s death impacted resilience and levels of closure (Kapoor, Morgan, & Siddique, 2018). While the study was not large enough to conclude that this ritual actually prevents or lowers rates of burnout, it did find that participants reported more closure, less cumulative grief and distress, increased resiliency and professional satisfaction among the healthcare team (Kapoor, et.al., 2018).

Training and Treatment at Work• De-briefing sessions• Bereavement interventions• On-site counseling• Education• Create a culture of support among leadership• Encourage discussions on stressors, critical

incidents, and staff experiences• Support groups(Boyle, 2011; Lachman, 2016)

The Joint Commission released the following strategies to promote nurse resiliency and identify burnout or compassion fatigue (The Joint Commission, 2019).

• Provide education for nurses, preceptors and nurse leaders to:- Identify behaviors caused by burnout and

compassion fatigue- Become aware of their personal stressors and

triggers.- Take part in self-care activities/techniques

(such as sleep, fitness and eating habits).- Discuss resiliency.

• Improve clinician well-being by measuring it, developing and implementing interventions, and then re-measuring it.

• Provide nurses with opportunities to reflect on and learn from practice and other practitioners (e.g., positive role models).

• Develop or utilize current tools for staff to use to anticipate opportunities and problems.

Compassion Fatigue: You Are Not AlonePost-Test and Evaluation Form

DIRECTIONS: Please complete the post-test and evaluation form. There is only one answer per question. The evaluation questions must be completed and returned with the post-test to receive a certificate.

Name: ______________________________________________________________________________ Date: ___________________________ Final Score: _______________

Please circle or otherwise indicate the correct answer.

1. Which of the following best describes the difference between compassion fatigue and burnout?a. Burnout is a medical condition; compassion

fatigue is notb. There is not a differencec. Burnout is a syndrome of exhaustion,

hopelessness and inefficiency at work while compassion fatigue describes a rapid on-set set of emotions that occurs when you repeatedly encounter people in distress.

d. Compassion fatigue is more serious than burnout

2. True or false: Burnout remains one of the leading patient safety and quality concerns of healthcare organizations.

3. True or false: Compassion fatigue only affects professionals working in healthcare.

4. Which of the following are symptoms of organizational compassion fatigue? Select all that apply.a. Higher turnover ratesb. Negativity towards managementc. Longer ER wait timesd. Difficulty for staff to work in teams

5. Which of the following is a benefit of debriefing?a. It is a chance to reprimand errors. b. It provides a non-judgmental opportunity to

discuss incidents and eventsc. It encourages staff to report their colleague’s

errors after an incidentd. It is only beneficial for students

6. Which of the following is recommended if you are experiencing feelings of burnout? Select all that apply.a. Change jobsb. Reflective journaling c. Practice mindfulnessd. Increase your caffeine intake

7. True or false: Compassion fatigue encompasses physical, emotional, spiritual and social effects.

8. The gratification obtained when doing your work to the best of your ability best describes: a. Compassion fatigueb. Burnoutc. Altruismd. Compassion satisfaction

9. True or False: Practicing mindfulness can help nurses and other professionals cope with symptoms of mindfulness and burnout.

10. Compassion fatigue differs from empathy because: a. Empathy is putting yourself in someone

else’s shoes, while compassion fatigue is the cumulative stress from repeatedly feeling the desire to act on empathy

b. There is no differencec. Empathy is an emotion while compassion

fatigue is a medical conditiond. Empathy is an abnormal response to stress

• Work with your internal team to assess if your current electronic health record (EHR) system may be customized so that it optimally supports nursing workflow.

• Hold regular staff meetings. Include discussions regarding new organizational policies, processes and outcomes from higher leadership meetings. Engage nursing input in staff meetings by posting an agenda and asking for additional items the nurses would like to discuss or present.

• Cultivate a health professional culture that is based on altruism, setting a good example, mentoring, leading, coaching and motivating others.

• Recognize nurses in a meaningful way. Since individuals interpret recognition differently, find out from nursing staff how your organization can best demonstrate that it is invested and interested in recognizing nursing staff for the work that they do.

The Joint Commission (2019)

That sounds like me. Does this mean I am a bad nurse?

No. Suffering from compassion fatigue and/or burnout does not mean you are a bad nurse or that you should start searching for a new career. When you have a fight with a loved one, you don’t immediately give up on the relationship – you search for a solution or compromise. The same concept applies; except the person we are fighting with is ourselves. In some ways, this can make it even harder to solve. Humans have difficulty showing themselves the same level of kindness and compassion that we show others. Those in the healthcare field are unfortunately accustomed to abuse, disrespect, and undesirable working conditions. Yet, despite all of that, we expect ourselves to ultimately become immune to the stressors yet still keep the same level of enthusiasm on the job.

We have all heard the old adage; you can’t pour from an empty cup.

I think I’m burned out. What do I do now? • Write• Talk with a mentor• Change directions• Visit a counselor• Volunteer• Practice mindfulness• Make time for exercise and quality sleep• Resiliency training• Take a vacation(Duarte & Pinto-Gouveia, 2016; American Institute

of Stress, 2018) References available upon request.

Registration Form

Name: _____________________________________(please print clearly)

Address: ___________________________________

___________________________________________

Day phone number: __________________________

Email address: ______________________________

Please return:- Completed Post-test - Evaluation Form- Registration Form- $20 Check

TO: Indiana State Nurses Assocation 2915 N. High School Road Indianapolis, IN 46224


Mindfulness – A Self-Care StrategyKaren Avino, EdD, RN,

MSN, AHN-BC, HWNC-BC

Reprinted with permission from DNA Reporter February 2020 issue

Karen Avino earned her BSN, MSN, and EdD at the University of Delaware. She is a board certified Advanced Holistic Nurse and a Health & Wellness Nurse Coach. Karen is an experienced educator and clinician with over 20 years’ experience teaching Holistic Nursing and Integrative Health at the University of Delaware. She is a founding leader of the Delaware Chapter and is a Director At-Large of the American Holistic Nurse Association. Karen is an author and editor of Holistic Nursing: A Handbook for Practice (2016, 2020). She is a partner and Director of Education of the Integrative Nurse Coach Academy providing onsite and online continuing education courses and the International Nurse Coach Association as a consultant to organizations. She has a private Integrative Nurse Coach practice at the Birth Center: Holistic Women’s Healthcare providing Coaching, HeartMath Stress Management, Reiki and The Institute for Functional Medicine Food Plans such as Elimination, Detox and Cardiometabolic. Karen can be reached at [email protected].

Mindfulness is no longer an uncommon term. It is often heard in daily language as well as in research reports identifying the benefits of mindfulness. Mindfulness is suggested as a self-care practice as well as a treatment method for conditions. The overarching benefit of mindfulness is the ability to learn to live in the present moment without continued worry about the past or the future which can help to decrease symptoms of depression and anxiety. While Mindfulness practices originated from Buddhist traditions, Jon Kabat- Zinn was influential in creating awareness of the use in healthcare by researching the benefits of mindfulness in patients with pain and demonstrated significant improvements in pain levels, mood, and psychiatric symptoms (Kabat-Zinn, Lipworth, & Burney, 1985; Kabat-Zinn, 1994). This prompted other studies to examine the effect on variety of diseases, the effect on stress levels, and the immune function (Goyal et al., 2014; Kabat-Zinn et al., 1985). The National Center for Complementary and Integrative Health webpage discusses the positive effects mediation that it can have in many other conditions such as hypertension, irritable bowel syndrome, ulcerative colitis, and anxiety (see https://nccih.nih.gov/health/meditation/overview.htm#hed3).

Mindfulness has also been found useful as a complementary treatment for people with opioid use disorder and chronic pain in methadone maintenance therapy (Robinson, Mathews, & Witek-Janusek, 2003). In fact, the U.S. Department of Veterans Affairs has implemented a Whole Health for Life person centered approach to care and advocates for the use of mindfulness for Post-Traumatic Stress Disorder (Garland et al., 2019; Hempe, 2014) (See https://www.va.gov/PATIENTCENTEREDCARE/Veteran-handouts/Introduction_to_Mindful_Awareness.asp).

Currently, mindfulness is a recommended practice for everyone including older adults (King et al., 2013). Today’s busy world with technology overload does not allow for downtime or body homeostasis adjustments to rebalance. Nurses live in a state of heightened chronic stress levels. It is well known that the nursing profession is a stressful career.

Implementing mindful self-care strategies by organizations employing nurses will benefit by reduced attrition of nurses and improved quality of care. The American Nurses Foundation suggested Five Simple Ways to Feel and be Better; 1) Stop, take a Breath and Observe, 2) Do a Body Scan, 3) Breathe, 4) Stretch, and 5) Eat and Drink Often (Geiger et al., 2016). These are all the tenets of Mindfulness. Mindfulness enhances areas of the brain that are responsible for attention and executive function and modulates the amygdala or emotional brain, which improves focused attention, develops intention skills for actions taken, and decreases reactivity without reflection that leads to decreased judgement and improved acceptance of differences. Therefore, mindfulness improves communication abilities that lead to improved patient outcomes, patient satisfaction, and nurse satisfaction. Increasing around the country, Healing Circle programs are being offered by holistic nurses to nurses in healthcare settings. The program develops a community of peer to peer support and an opportunity to practice mindful skills in a safe environment. The American Holistic Nurse Association provides mindfulness tools and information entitled Holistic Stress Management Is Based on Self-Reflection and Self-Care (see https://www.ahna.org/Home/Resources/Stress-Management).

Mindful Practices Mindfulness practices are about increasing awareness of bodily sensations,

especially the breath, and using mindful movement practices to increase the awareness of connection. There are many types of meditations each with a different twist on the technique including: Buddhist, Hindu, Chinese, Christian, Sufi, and the common practice of guided mediations. Some techniques are relaxing, some create awareness, and some claim deeper transformation and/or spiritual development. Experimenting with a variety to find the one that works best for your unique needs and personality is best. The idea is to practice on a daily basis so you can call on it in times of need. Once you have become comfortable with this daily practice, the techniques can then be applied to patient care.

In Integrative Nurse Coaching, using awareness practice techniques in practice provides a time for reflection and help for patients to reach their inner wisdom to come up with solutions or answers on their own. This awareness creates an openness to new possibilities and motivation or engagement to aspects of the experience, without judgement or attachment. There are a variety of guided awareness scenarios that can be used for particular situations in patient care based on the need. These are learned through the self-development process and practice of Integrative Nurse Coaching.

The Basic Technique• The goal is that awareness of thoughts, feelings, emotions, sounds, and smells are

acknowledged but then let go as your awareness is returned to the breath in the center of the chest. These techniques require continued practice in letting go.

• Most techniques suggest starting in a seated comfortable position to maintain awareness. The point is not to fall asleep during the experience. Your eyes can be closed or have a downward gaze.

• As you move your awareness to the center of your chest, experience the centering as the breath enters and exits. As thoughts or sounds enter your mind or awareness, acknowledge without judging, let go, and return your awareness to the breath in the center of your chest. Continue this centering, acknowledging, let go, and return as many times as needed in the timeframe you are practicing.

• It is not uncommon to hear “this doesn’t work for me.” Awareness practices are a learned experience, the more you practice, the easier is the return, and the outcome of living life with awareness of the present moment, feeling balanced with increased clarity is gratifying. Find what time of day, or length of time works for you. Most use a 10-15 minute timeframe daily for practice. The following are quality websites that provide free access to guided mediations for self-care and patient use.

Quality Free Mindful Practice WebsitesMindful.orghttps://www.mindful.org/audio-resources-for-mindfulness-meditation/UCLA Mindful Awareness Research Center https://www.uclahealth.org/marc/body.

cfm?id=22&iirf_redirect=1UC San Diego Center for Mindfulness https://medschool.ucsd.edu/som/fmph/research/

mindfulness/programs/mindfulness-programs/MBSR-programs/Pages/audio.aspxThe Center for Contemplative Mind in Society http://www.contemplativemind.org/practices/

recordingsInsight Meditation Society, Inc. https://www.dharma.org/resources/audio/#guided

ReferencesGarland, E.L., Hanley, A.W., Kline, A., Cooperman, N.A. (August 5, 2019, Epub).

Mindfulness-oriented recovery enhancement reduces opioid craving among individuals with opioid use disorder and chronic pain in medication assisted treatment: Ecological momentary assessments from a stage 1 randomized controlled trial. Drug and Alcohol Dependence. Retrieved from https://nccih.nih.gov/research/results/spotlight/more-may-reduce-opioid-cravings-and-chronic-pain

Geiger, P.J., Boggero, I.A., Brake, C.A., Caldera, C.A., Combs, H. L., Peters, J. R., Baer, R. A. (2016). Mindfulness-based interventions for older adults: A review of the effects on physical and emotional well-being. Mindfulness,7(2):296-307. doi:10.1007/s12671-015-0444-1.

Goyal, M., Singh, S., Sibinga, E.M.S., Gould, N.F., Rowland-Seymour, A., Sharma, R. … Haythorn, J. (2014). Meditation programs for psychological stress and well-being: A systematic review and meta-analysis. JAMA Intern Med, 174(3), 357-368. doi:10.1001/jamainternmed.2013.13018

Hempe,l S., Taylor, S.L., Marshall, N.J., Miake-Lye, I. M., Beroes, J.M., Shanman, R., … Shekelle, P. G. (2014). Evidence map of mindfulness. VA evidence-based synthesis program reports. Washington (DC): Department of Veterans Affairs (US). Retrieved from https://www.ncbi.nlm.nih.gov/pubmed/25577939

Kabat-Zinn, J. (1994). Wherever you go, there you are: Mindfulness meditation in everyday life. New York: Hyperion.

Kabat-Zinn, J., Lipworth, L. & Burney, R. (1985). The clinical use of mindfulness meditation for the self-regulation of chronic pain. Journal of Behavioral Medicine, 8, 163-190.

King, A.P., Erickson, T.M., Giardino, N.D., Favorite, T., Rauch, S.A., Robinson, E. … Liberzon, I. (2013). A pilot study of group mindfulness-based cognitive therapy (MBCT) for combat veterans with posttraumatic stress disorder (PTSD). Depress Anxiety, 30(7), 638-645. doi: 10.1002/da.22104. Epub 2013/04/19.

Meditation: In Depth (2016, April). National Center for Complementary and Integrative Health. Retrieved from https://nccih.nih.gov/health/meditation/overview.htm#hed3

Robinson, F. P., Mathews, H. L., & Witek-Janusek, L. (2003). Psycho-endocrine-immune response to mindfulness-based stress reduction in individuals infected with Human Immunodeficiency Virus: A quasi-experimental study. The Journal of Alternative and Complementary Medicine, 9, 683–694.

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What Would Florence & Her Colleagues Do?Sue Johnson, PhD, RN, NPD-BC, NE-BC, FAAN

Excerpted from an article pending publication; used with permission of the author

In May 2020 Florence Nightingale will be 200 years old. In this Year of the Nurse and Midwife and the COVID-19 pandemic, we should ask how our nursing history can help us navigate the current troubled waters. Hospitals and health care providers have not experienced this in our known past, but let’s seek lessons we can use today.

Before Ignaz Semmelweis, a Hungarian obstetrician, became chief resident in the maternity clinic of Vienna General Hospital in March 1847, no physician or health provider considered hand washing, even between patients with open wounds. He annoyed his colleagues by making them disinfect their hands with a chlorinated lime solution. Semmelweis was ridiculed, but his action reduced maternal deaths from childbed fever from 18.27 to 1.27 percent in his division. Unfortunately, his belief that clean hands would save lives wasn’t widely accepted until after his death in 1865 (Trueman, 2019). Today, Semmelweis is revered as the Father of Infection Control.

In 1851 a 31-year old well-bred Englishwoman arrived in Germany at a place named Kaiserswerth to begin her study of nursing. Her name was Florence Nightingale and she had struggled to pursue nursing because her mother did not consider nursing as proper for a gentlewoman. As Nightingale said later “It was as if I wanted to be a kitchen-maid” (Cook, 1913a, p. 60). After several years of trying, she convinced her mother to let her study for three months. Florence’s observations are pertinent: “There was no neglect. The food was poor. No luxury; but cleanliness” (Cook, 1913a, p. 113).

In February 1853, Nightingale gained her mother’s permission to visit and study hospitals in Paris. This opportunity enabled her to develop statistical and analytical skills that would serve her, nursing, and healthcare well throughout her lifetime. Her emphasis on call bells, precursor of today’s call lights, and lifts to move supplies that evolved into dumbwaiters were far ahead of her era. In July she returned to England, and by August she was in charge of nursing at Number 1 Harley Street in London where she hired a dispenser (pharmacist) to reduce drug costs and facilitated discharges for patients no longer requiring hospitalization (Cook, 1913a).

In October 1854, England went to war with Russia in the Crimea and Nightingale was asked to organize and command a group of 38 nurses for Scutari under the direction of the Chief Medical Officer of the hospital there. Female nurses had never served with the British army or in war zones and some officers placed obstacles in their path. The hospital at Scutari was filthy and rat-infested nothing like today’s modern hospitals and healthcare systems. The hospital buildings were above open sewers, overcrowded with desperately ill and wounded soldiers, and without even basic items like sheets and bedding. Cholera, typhus, and dysentery were rampant. Nightingale and her nurses found men lying on matting on the floor for mattresses in lines 18 inches apart for four miles within the hospital! No basins, towels, soap, or brooms were available. According to Mr. Macdonald of the Times Fund in Scutari, “The first improvements took place after Miss Nightingale’s arrival—greater cleanliness and greater order. I recollect one of the first things she asked me to supply was 200 hard scrubbers and sacking for washing the floors, for which no means existed at that time” (Cook, 1913a, p. 195). Canvas sheets were washed in cold water when they were washed at all. Finding such sheets filled with vermin after washing, Nightingale had soldiers’ wives wash bedding in hot water by supplying a house with boilers at her own expense so the men would have clean linen. Finding that cooking only occurred at one end of the long building and required 3-4 hours to serve every man a dinner, Nightingale opened two extra diet kitchens at other parts of the building by having extra boilers placed there to heat meals. Her attention to cleanliness and nutrition positively impacted the soldiers, but she discovered that these basics were not enough.

Medical and surgical supplies were nonexistent. When Nightingale’s nurses arrived, even screens were not available to put between patients when one was having a limb amputated! The British Army had a Purveyor who was supposed to provide essential

supplies. However, supplies weren’t available to address soldiers’ needs. When Army leaders couldn’t or wouldn’t address these needs, Nightingale became the Purveyor-Auxiliary for the soldiers. In her own words “I am a kind of General Dealer in socks, shirts, knives and forks, wooden spoons, tin baths, tables and forms, cabbage and carrots, operating tables, towels and soap, small tooth combs, precipitate for destroying lice, scissors, bedpans and stump pillows” (Cook, 1913a, p. 200). Medical officers began to requisition supplies from her which she obtained from her own stores, with the assistance of Mr. Macdonald of the Times Fund in purchasing additional supplies. She also monitored the stock in the Purveyor’s store because often supplies had arrived and were not filled without an additional requisition from the medical officers. No records were kept of supply requisitions that weren’t filled previously. The Purveyor also didn’t provide any clothing, and if soldiers didn’t have their supply kits, their clothing was not fit for use. At the same time, Lord Stratford, the Ambassador to Turkey, declared that the Army needed nothing and the Times Fund should focus on building an English church at Pera. Nightingale determined that clothes for the soldiers was more important than altar-cloths for the new church, so she went ahead and provided them (Cook, 1913a).

Nightingale also mustered the power of the press and her connections to powerful people in the British Empire, including Queen Victoria, who sent comfort items to the wounded soldiers for Florence to distribute. Mr. Macdonald’s dispatches spoke glowingly of her and the soldiers sang her praises. The British people began contributing to a Nightingale Fund that eventually resulted in the first school for training nurses in England. Nightingale had the distinct advantage of being a member of the upper class in England whose dispatches were listened to and in many cases acted upon by leaders back home.

She strived to make the soldiers’ lives better within the context of her time. However, death rates in The British Army for the period from 1854-1856 were 22.7%, most of which were due to preventable diseases. In the winter of 1854-1855, the French death rate was 11% and the British death rate was 23%. However, by the winter of 1855-1856, the French death rate was 20% while the British death rate fell to 2.5%. Credit for this drastic reduction was not solely the efforts of Nightingale’s nurses to provide nutrition, cleanliness, and orderlies to care for hospitalized soldiers. These were factors that the French Army was unable to provide consistently in the second year. The Barrack Hospital at Scutari where Nightingale was responsible for nursing had a death rate during the two years of 11.9%, only exceeded by Koulli at 25.9% under the Irish Sisters of Mercy. Both hospitals had the worst cases and serious sanitation issues (MacDonald, 2014).

When three Sanitary Commissioners were appointed in February 1855 to examine the conditions of the hospitals at Scutari, Nightingale learned the importance of sanitation and used this knowledge and her passion for statistics to advocate for sanitary reforms for the rest of her life throughout England, Europe and India (Cook, 1913a & b). One of these Commissioners, Dr. John Sutherland, became a valued friend and colleague of Nightingale in promoting Army, India, and Poor Law reform over many years. The Commission set to work implementing hospital improvements, including removing dead animals, opening and cleaning sewers, disinfecting/closing/sealing up open privies, evacuating wards over stables, disinfecting the graveyard, and establishing new rules for burials. After these improvements, mortality was less than 0.1 from the beginning rate within six weeks (MacDonald, 2014).

Nightingale became famous and revered after her service in the Crimea, but her actual influence intensified across the globe in her nursing disciples who took Nightingale’s basic tools and precepts and advanced the profession and positive patient outcomes. One of these individuals was Clara Barton who came to nursing after working as a teacher and Patent clerk. When the Civil War began, she found her passion in nursing soldiers on the battlefields with the following statement: “I may be compelled to face danger, but never fear it and while our soldiers can stand and fight, I can stand and feed and nurse them” ( Brown-Pryor, 1987, p.80). For the next four years Barton bought (or begged for) and delivered

relief supplies to the troops that weren’t supplied by Army quartermasters. She cooked, cleaned, assisted with surgeries, and boosted the morale of sick and wounded soldiers (Brown-Pryor, 1987). Like Nightingale, Clara Barton’s major achievement was beyond the battlefields. In 1881 with the permission of the International Red Cross, she started the first branch of the American Red Cross, which has grown to provide relief in multiple national disasters, including the current pandemic.

Lillian Wald loved nursing, but was frustrated by rules and regulations that limited her effectiveness in caring for patients in 1891. She began studying medicine in New York, but wasn’t satisfied with that role either. One day in 1892 she taught a nursing class on Henry Street and found her true calling. A young girl ran into the room asking for someone to help her sick mother. Wald followed the child to a tenement apartment and a crowded, dirty room where a woman was bleeding after childbirth. She cared for the mother, cleaned her and the room, and never returned to medical school. Soon, she and another nurse named Mary Brewster met with a local philanthropist who contributed $60 a month for the two nurses to live in the neighborhood as well as providing funds for supplies, medicines, medical fees, and food for the sick (Williams, 1948). They focused on cleanliness while providing care and overcame suspicions of immigrants by living among them. At night, both nurses maintained detailed records of sickness and unsanitary conditions. Wald met with the President of the Board of Health to begin the first Visiting Nurse Service. She also continued to document reports of sickness and unsanitary conditions. Among her numerous accomplishments were the first school nurses, special education classes, public playgrounds, and establishment of a children’s bureau by the Federal government in 1912. Her Henry Street Settlement promoted these and other public health causes for forty years (Block, 1969). Lillian Wald was truly the mother of community nursing and the skills she fostered will be needed now and in the future.

Mary Breckinridge was from a distinguished Kentucky family and her love of children encouraged her to pursue a nursing career. Volunteering in Europe after World War I, she focused her efforts on feeding children under six and pregnant and nursing mothers. Her goat fund encouraged influential friends and political leaders to supply funds to buy goats so these individuals could have milk (Breckinridge, 1952). Breckinridge became convinced that becoming a nurse midwife was the best way to meet the needs of children from before birth to age six. She studied in London under Rosalind Paget, founder of the Midwives Institute and the first Queen’s Nurse. Paget had studied under Nightingale and helped Breckinridge develop her skills. Then, she went to the Highland and Islands Medical Service in Scotland for ideas about how to set up a successful nursing service in Kentucky. Finally, Breckinridge met with supporters in 1925 to review annual statistics that showed nearly 20,000 mothers and 200,000 infants died at birth or within one month of delivery. American death rate in childbirth was the highest in the world and data showed that maternal death rates exceeded deaths in all wars fought by Americans until that time. Comprehensive data would be vital to determine the new service’s effectiveness., including annual audits, accurate records, free transportation for medical care, legal and professional status of nurse-midwives, provision for medical consultation, and location of services (Wilkie & Moseley, 1969; Breckinridge, 1952).

The Frontier Nursing Service brought nursing services to remote parts of Kentucky and Breckinridge kept detailed records as she trained nurse-midwives and public health nurses to see their clients via horseback. The Depression impacted the Frontier Nursing Service with staffing reduction, some nurses taking a one-third pay cut, and some volunteering who could afford to do that. Subscribers continued and the majority of nurses stayed because they believed in their mission (Breckinridge, 1952). Metropolitan Life Insurance Company helped by tabulating maternity cases and supporting a health insurance plan where services for hospital and home care were available at $1.00 per year with free services if patients couldn’t pay (Judd, Stutzman & Davis, 2010).

The Carnegie Corporation set up the first statistical system for the Frontier Nursing Service

May, June, July 2020 The Bulletin 17and accumulated the largest source of Obstetric data on rural populations in the United States. According to Dr. Dublin of Met Life, “If such service were available to the women of the country generally, there would be a saving of 10,000 mothers’ lives a year in the United States, there would be 30,000 less stillbirths and 30,000 more children alive at the end of the first month of life” (Breckinridge, 1952, p. 312). Mary Breckinridge’s dream became a reality that resulted in the first postgraduate midwifery training–the Frontier Graduate School of Midwifery–in the United States and women in rural Kentucky received health care that saved their lives and those of their babies.

Common threads run through all these stories that can positively impact nurses and other healthcare providers today.

What lessons can we learn from these nurses and physicians?1. Hand hygiene is vital, not just in a pandemic, but at all times. Although

hand sanitizers with 60% alcohol are fine, there is nothing better than vigorous scrubbing with soap and water for at least 20 seconds. Videos on social media show the correct technique, but everyone must remember that faucets and door knobs are germ-filled. You need to use a paper towel to touch these surfaces when you are in a public facility. Remember to avoid touching your face with unwashed hands. Thank Semmelweis when you wash your hands as his patients and colleagues should have done then!

2. Sanitation has the utmost importance in all settings. Routine cleaning of frequently touched surfaces must be practiced. Such surfaces include tables, doorknobs, light switches, countertops, handles, desks, phones, keyboards, toilets, faucets, and sinks. Cleaning with soap and water while wearing disposable gloves is a good starting point, followed by use of cleaners appropriate for use on these surfaces. Remember to thoroughly wash your hands after carefully removing your gloves. Thank the Sanitary Commission at Scutari and Lillian Wald of Henry Street for their attention to sanitation and cleanliness.

3. Social distancing is imperative. We no longer line patients up in long rows eighteen inches apart in our health care facilities, but virus transmission occurs with person-to-person contact. Staying six feet apart can protect you from respiratory droplets when someone coughs or sneezes. If you are that person, use a tissue or the inside of your elbow and wash your hands immediately with soap and water for 20 seconds or use a hand sanitizer (60% alcohol) if soap and water aren’t available. Thank Mary Breckinridge for taking health care to individuals.

4. Government assistance is not always available to meet provider and patient needs in a timely manner. Individuals must take precautions to protect themselves and others when government assistance is not available. Remember when Nightingale considered clothing for soldiers more important than furnishing a church at Pera and when Clara Barton provided supplies to Union troops that weren’t available from the Army quartermaster.

5. Nutrition is as important today as it was for Crimean and Union soldiers. Everyone needs to have their nutritional needs met to stay healthy in times of crisis. Schools are providing meals for students while complying with orders for closure. Food banks are stretched to provide for community needs. Creative approaches are needed to ensure that those who need food receive it. Remember how Nightingale’s two diet kitchen at Scutari enabled wounded soldiers to receive a warm meal instead of waiting 3-4 hours and how Barton’s wartime efforts ensured food for soldiers who otherwise would have gone hungry.

6. The power of the press and public is often not clearly understood. Nurse leaders like Nightingale and Breckinridge knew how to mobilize these resources to the advantage of their patients. In times of war and pandemics, fear is paramount and messages from sources, such as the press, must be accurate to avoid unnecessary panic and anxiety in the public. There is a need for information that is honest and truthful. Both of these nurse leaders shared specific details about the health of the soldiers and the health of rural pregnant women. These details were shared in data that the public could understand and support.

7. Focusing on facts and data is a natural progression to #6 above. Historic nurse leaders realized that accurate facts and data are vital to success. Nightingale’s use of statistical analysis informed her advocacy for sanitary reforms in the British Army, India, and District Nursing in rural England to improve the lives of at-risk populations. Wald’s reports and data about the healthcare needs of immigrants in New York tenements resulted in public health and community nursing in the United States, which has positively impacted multiple lives since then. Mary Breckinridge’s devotion to data and statistical analysis resulted in the largest source of Obstetric data in the United States and validated that the Frontier Nursing Service saved maternal and infant lives.

8. Helping organizations should be recognized for their importance in the current healthcare environment. The American Red Cross founded by Clara Barton continues to provide blood services across the country as well as providing funds to address humanitarian needs locally, regionally, and globally. Community health nurses continue to serve clients in homes and clinics as Lillian Wald and her staff did at Henry Street. Frontier Nursing Service continues to provide care for rural underserved women as it did in the time of Mary Breckinridge. These and other organizations are there to support those in need during this pandemic and afterward.

9. Philanthropy seems odd to include here, but it is essential to confront health-related issues both now and in the past. Lillian Wald began her community work with the support of a philanthropist in New York. The funding she received made a positive difference in the lives of immigrant families and their children over 40 years. Mary Breckinridge and the Frontier Nursing Service relied on philanthropy to weather the Great Depression and continued to provide support to rural pregnant women and their children.

10. Self-care is vital for everyone and some of our historic nurse leaders neglected their own self-care while promoting it to those they served. This was true of Nightingale who worked herself to exhaustion in the Crimea while striving to improve the health of wounded soldiers. Clara Barton’s performance in the Civil War was similar. Lillian Wald’s approach was different. Although she worked hard on multiple projects, Wald was a happy person who relaxed and enjoyed her opportunities to have robust discussion with her Henry Street colleagues. When she met Albert Einstein in 1938,

his parting words were “I want to thank you for your smile” (Block, 1946, p. 172). Mary Breckinridge also practiced self-care by spending time on horseback visiting remote Kentucky settlers and giving riding lessons to new nurse-midwives and public health nurses. When back injuries curtailed her ability to ride, she enjoyed interacting with families at her home in Kentucky (Breckinridge, 1952).

Self-care is possible using the following approaches:• Focus on the facts and risks about COVID-19, not rumors. Go to legitimate

sources that will also give you tips about how to care for yourself and others.• Social distancing is not social isolation. You need to connect with others via

phone, Skype or other electronic means if you can’t meet in person. You need to be able to share your concerns and feelings without judgment.

• Give yourself permission to take breaks from pandemic news and make time to do some activities you enjoy. Take care of your body: look for humor and laugh, try to eat healthy, well-

balanced meals, drink plenty of water to stay hydrated, avoid alcohol and drugs (except prescribed medications), exercise regularly (walking is therapeutic), get enough sleep (seven hours daily is a good goal), take stretch breaks and meditate if helpful, use respiratory hygiene-do periodic coughing and deep breathing exercises, get some fresh air, use hydrogen peroxide mouthwash, read a book, or engage in another activity you enjoy.

Most of all, ask for help if you feel overwhelmed and unable to cope. Your healthcare provider, pastor, counselor, or support person can listen and support you (CDC, 2020).

These are just a few of the nurse leaders from Nightingale’s time to the early 20th century who have informed our practice as nursing has evolved to meet today’s and tomorrow’s challenges. We will weather this crisis as we have many others and our history will give us the strength we need to move forward. Thank you for all you do in these turbulent times.

ReferencesBlock, I. (1969). Neighbor to the world: The sotry of Lillian Wald. New York, NY, Thomas Y.

Crowell Company.Breckinridge, M. (1952). Wide neighborhoods: A story of the Frontier Nursing Service.

Louisville, KY, The University Press of Kentucky.Brown-Pryor, E. (1987). Clara Barton, professional angel. Philadelphia, PA: University of

Pennsylvania Press.Brusie, C. (2020, January 7). Nurses ranked most honest profession 18 years in a row.

Retrieved March 26, 2020, from Nurse.org: https://nurse.org/articles/nursing-ranked-most-honest-profession/

CDC. (2020). Coronavirus (COVID-19). Retrieved March 24, 2020, from Coronavirus Disease 2019: coronavirus.gov

Cook, E. T. (1913a). The Life of Florence Nightingale (Vol. 1). London: Macmillan and Co., Ltd.

Cook, E. T. (1913b). The Life of Florence Nightingale (Vol. 2). London: Macmillan and Co., Ltd.

Council on Foundations. (2020). A call to action: Philanthropy’s commitment during COVID-19. Retrieved March 26, 2020, from Council on Foundations: https://www.cof.org/news/call-action-philanthropys-commitment-during-covid-19

Judd, D., Sitzman, K., & Davis, G. (2010). A history of American nursing: Trends and eras. Sudbury, MA: Jones and Bartlett Publishers.

MacDonald, L. (2014, October 30). Florence Nightingale and her Crimean War statistics: Lessons for hospital safety, public administration and nursing. Retrieved March 23, 2020, from Gresham College: https://www.gresham.ac.uk/lectures-and-events/florence-nightingale-and-her-crimean-war-statistics-lessons-for-hospital-safety-

Trueman, C. N. (2019, December 18). Ignaz Semmelweiss. Retrieved March 23, 2020, from The History Learning Site: https://www.historylearningsite.co.uk/a-history-of-medicine/ignaz-semmelweis/

Wilkie, K., & Moseley, E. (1969). Frontier nurse: Mary Breckinridge. New York, NY, Julian Messmer.

Williams, B. (1948). Lillian Wald; Angel of Henry Street. New york, NY: Julian Messner.

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Calling for Appropriate StaffingSusan Trossman, RN

Reprinted with permission from ANA on the Frontline, as seen in American Nurse Today

When asked why appropriate staffing was so important, Tracy Viers, MSN, RN, CCRN, didn’t hesitate for a second.

“The bottom line is it’s all about patient safety and positive outcomes,” said Viers, an ANA-Illinois member and intensive care unit (ICU) staff nurse at Blessing Hospital in Quincy, Illinois. “Good patient outcomes are dependent upon nurses, who can’t do their best when they have too many patients and tasks.”

And that inability to provide every patient with the best possible care also causes nurses, no matter where they work, incredible physical and emotional stress, she added.

The American Nurses Association (ANA) wants appropriate staffing to be the rule—not the exception—across care settings. To that end, the association continues to increase and widen its efforts, knowing that complex problems require a multipronged approach.

One effort involves pursuing a unified legislative and regulatory approach to achieve ANA’s staffing goal. Another is an educational and outreach campaign launching this fall to provide nurses with guidance and tools to help them make an immediate case for appropriate staffing and implement practical, comprehensive staffing plans. Among these resources is ANA’s Principles for Nurse Staffing, which was recently revised to make it more applicable to all settings and to emphasize nurses’ critical role in ensuring healthcare facilities meet their mission of providing patients and communities with quality, safe, and cost-effective care.

Assessing the problemIn a 2019 ANA membership survey of more

than 6,700 nurses, 93% identified staffing as an important issue, with 72% identifying it as “extremely important.” And when asked to name their top three nursing issues, “early career” nurses (zero to four-years of experience) and “up and comers” (five to 14 years of experience) named staffing as a priority far more than any other issue.

Texas Nurses Association member Bob Dent, DNP, NEA-BC, FAAN, FACHE, FAONL, who helped revise ANA’s staffing principles, pointed to years of research showing that appropriate nurse staffing leads to better patient outcomes and fewer adverse events. Studies also have linked appropriate staffing to cost savings that result from preventing complications and readmissions.

Yet findings from an ANA Enterprise HealthyNurse® Survey gathered between February 2017 and May 2019 revealed that more than a quarter of the 18,500-plus respondents said they were often assigned a higher workload than they felt comfortable

with. About 52% responded that they frequently must work through their breaks to complete their assigned workload and 53% often have to arrive early or stay late to get their work done.

Speaking to staffing as a national issue, Washington State Nurses Association (WSNA) member and neuro-trauma ICU staff nurse Danielle O’Toole, BSN, RN, CCRN, said, “Nurses are continually being asked to do more and more and more with less.”

She also affirmed the ANA’s survey findings about nurses working nonstop. For years, nurses in her facility didn’t take rest and meal breaks for fear of overburdening their coworkers and putting their patients at risk. “Anything can happen in 30 minutes, especially in an ICU where you have critical I.V. drips,” O’Toole said.

Looking at the principlesAlthough ANA’s revised principles include additional

information, such as referencing the Institute for Healthcare Improvement’s triple aim efforts to improve health system performance, this resource continues to provide nurses with an important framework to help them develop, implement, and evaluate appropriate nurse staffing plans and activities. It includes core components of appropriate staffing such as:

• RNs at all levels within a healthcare system must have a substantive and active role in staffing decisions to ensure they have the necessary time to meet patients’ care needs and their overall nursing responsibilities.

• All settings should have well-developed staffing guidelines with measurable nurse-sensitive outcomes specific to that setting and the healthcare consumer population they are serving that are used as evidence to guide daily staffing.

• Staffing needs must be based on an analysis of the patient’s or consumer’s healthcare status, such as acuity and intensity, and the environment in which care is provided.

Other considerations include RNs’ competencies, experience, and skill set; staff mix; and previous staffing patterns that have shown to improve care outcomes.

Dent reinforced the importance of nurse involvement and collaboration—such as through the implementation of staffing advisory committees—to attain appropriate staffing and good patient experiences and care.

“It’s important that nurses aren’t questioning whether they are really making a positive difference for their patients,” said Dent, who recently left his long-time leadership role at Midland Memorial Hospital in Texas and is now vice president and chief nursing officer of three facilities within the Emory Healthcare system. “I’ve found that if nurses have a positive and healthy work environment—and appropriate staffing is a component of that—then their patients are getting good care and having great experiences.”

The ANA document also outlines specific principles related to healthcare consumers, RNs and other staff, the organization and workplace culture, the practice environment, and staffing plan evaluation—all of which can guide direct care nurses and those at other levels in making sound staffing decisions and plans.

For example, staffing decisions should take into account factors such as the age and functional ability of patients and healthcare consumers, as well as their cultural and linguistic diversities, scheduled procedures or treatments, and complexity of care needs.

On the other side of the equation, nurses’ level of overall experience (novice to expert), educational preparation, language capabilities, and experience with the population being served should be among the factors considered.

“Staffing is complex,” said Deborah Maust Martin, DNP, MBA, RN, NE-BC, FACHE, who also contributed to the revised principles. “We need to look at patient outcomes and how we get the best match of patients and nurses.”

The principles of staffing document also emphasizes other key points, such as calling mandatory overtime an unacceptable solution to achieving appropriate staffing, ensuring that nursing students aren’t counted as staff, creating a workplace culture that leads to retention, and identifying costs of nursing care in patient billing and reimbursement requests to provide visibility to the value of nurses and nursing services.

Maust Martin, a Wisconsin Nurses Association member, noted that the principles are designed to be applicable to nurses working in all settings, from acute care to school and community-based practices. The term “healthcare consumers” instead of “patients” shows the broad reach of nurses’ roles and the populations they serve.

Pursuing other effortsMany state nurses associations and specialty-

focused organizational affiliates also are engaging in a range of efforts to address this priority issue.

In Washington State, O’Toole testified before legislators about nurses’ inability to take needed rest and meal breaks and the impact it has on nurses and patients. Her advocacy and that of other WSNA nurses and staff led to the passage of a state law providing breaks and overtime protections for nurses, effective in January 2020. Her facility, Tacoma General Hospital, hired “break relief” staff to cover nurses during those times as a result of legal action by WSNA, and the new law reinforces the hospital’s obligation to ensure nurses get breaks.

“I’m taking my first breaks since the law passed,” said O’Toole, who also is chair of her WSNA local. “We also have a robust staffing committee that meets once a month that is 50-50 staff nurses and management to address staffing issues.” The committee additionally reviews the efficacy of every unit’s staffing plan, including negotiated standards, every 6 months to determine if any changes are needed.

ANA-Illinois Executive Director Susan Swart, EdD, MS, RN, CAE, said the association plans to introduce legislation to strengthen the state’s existing staffing law, which went into effect in 2008 and was based on ANA’s earlier staffing principles. The law requires healthcare facilities to have staffing committees made up of at least 50% direct care nurses and that staffing decisions are based on patient acuity, skill mix, and other key factors.

“We want to put some teeth in the law so the committee isn’t advisory but has real pull,” Swart said. “We know from our recent member survey that nurses continue to struggle with staffing and workplace issues that are connected with understaffing.”

ANA-Illinois also is working with the Illinois Hospital Association’s new chief nursing officers group to more immediately strengthen and raise the profile of staffing committees. Part of their strategy is to include information about staffing committees, including their purpose, as a routine part of orientation in all facilities, Swart said.

“We want nurses to feel empowered and that their participation is valued and respected,” Swart said. That requires an institutional culture that supports nurses, as well as nurses at all levels working together to implement staffing solutions.

One staffing solution that Viers believes can be instrumental is having a dedicated charge nurse on every unit who doesn’t have to carry a patient assignment. That would leave the charge nurse free to mentor new nurses and handle all the other issues that routinely crop up during the course of a shift. (Her Illinois facility has a professional practice committee that addresses staffing issues.)

ANA-Illinois board member and staff nurse Lauren Martin, RN, CEN, also thinks it’s critical that nurses from all shifts are represented on staffing committees.

“Night shifts tend to not be staffed as well as day shifts, and oftentimes it’s new nurses, who are just learning the job, working those shifts,” said Martin, who works in a specialty long-term care facility. “So, we really need to increase nurses’ involvement on committees and in other ways to solve staffing issues. That includes looking at all the factors that are causing inappropriate staffing.”

Both Dent and Maust Martin added that nurses must think about new ways to manage staffing needs—whether it’s adjusting shift length, having long-time nurses support novice nurses through ongoing, virtual mentoring, or piloting new models of care.

Noted Dent, “We all have a piece of the pie when it comes to addressing nurse staffing.”

— Susan Trossman is a writer-editor at ANA.

ResourceAccess ANA’s new staffing webpage for key

documents and tools at www.nursingworld.org/PrinciplesForNurseStaffing.

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The Nature TinctureJackie Levin, MS, RN, AHN-BC, NC-BC

Reprinted with permission from DNA Reporter February 2020 issue

Jackie Levin earned her BSN from the University of Vermont and MS in Holistic Nursing from the College of New Rochelle, and a BA in Women Studies from the University of Massachusetts in Amherst. She is a Nationally Board Certified Advance Practice Health and Wellness Nurse Coach and certified in Healing Circles, Ericksonian Hypnosis and Healing Touch. Jackie is the Executive Director of Leading Edge Nursing, a published author, public speaker, and patient advocate with more than 30 years of experience in healthcare. Through Leading Edge Nursing, Jackie’s work is transforming healthcare organizations and cultures of stress into workplaces that generate health and wellbeing from the inside out. Jackie is a trained mindfulness instructor, a Nationally Board Certified Advanced Practice Holistic Nurse and Wellness/Leadership Coach, co-authored chapters in four editions of the textbook Holistic Nursing: A Handbook for Practice. Jackie authored two virtual and in-person programs, Room to Breathe: Rewiring for Ease the 7-lesson online mindfulness program for health professionals and Medicine Walks and the Art of Transformative Inquiry day-long retreat to reconnect with the heart and soul of our healthcare practice. Jackie can be reached by email at [email protected] or at her office at (206) 304-7703.

“Those who contemplate the beauty of the earth find reserves of strength that will endure as long as life lasts” (Carson, 1956).

There are reasons people seek out nature when the stress of the world weighs heavy on their hearts. There are reasons people pick up stones and shells from a beach and set them on their desks or shelves or nurture potted plants to grow. Many people have pets and others walk to a local park or travel further into the wilderness, for joy and solace. Perhaps it is the vastness of nature and the recognition of an individual smallness that calls them to be befriended by the natural world. Or perhaps people find some sense of belonging—an essential component of life—from the way nature enfolds and entwines, without judgement or discrimination, all: the healthy, the sick and the dying.

Wilson (1984) called this magnetic pull for a close connection with other forms of life “biophilia.” Neuroaesthetics scientist Nancy L. Etcoff (as cited in Pak & Reichsman, 2017) believed the draw and benefits of affiliating with nature’s beauty is part of our evolutionary design. But does time in nature or natural environments actually have healing effects? Can time in nature have a beneficial impact on the practice of nursing and on how nurses show up as leaders and administrators? And how does someone gain this benefit amidst their busy lives and work schedules?

When the resource of time is limited“…[Work] and life are not separate things and therefore cannot be balanced

against each other except to create further trouble” (Whyte, 2009, p. 12).Whyte (2009) proposed the pathway to wellbeing is the recognition there is

an ongoing relationship and need for continuous dialogue among three major life commitments, also known as the three marriages: the commitments to work, to significant personal relationships, and to oneself. The third relationship, which requires time for introspection, care of one’s body, and mental and physical rest, is specifically a difficult one to attain and then maintain, is why Whyte disposes of the idea of “work-life” balance—arguing balance is unachievable.

When the resource of time is limited, individuals must be good communicators among and between the three marriages. This is not advocation for equality of time, but an equity of value and devotion to achieve an integrated wholeness. In the same way the body’s cells requires an intelligent cell membrane to maintain a healthy boundary for what it allows in and out of the cell—not for competition but for communication and the health of the whole body. One way to generate health and wellbeing is to take time in nature. The field of ecopsychology, the study of the mind, body, and spirit health benefits upon humans when they take time in nature or natural environments is rapidly growing, especially in response to the increased time spent inside and in front of electronic screens. Bratman, Hamilton, and Daily (2012) defined nature as areas that include a range of plants and nonhuman animals, landscapes such as gardens and parks to wildernesses and includes non-living elements like sunsets and large horizons as those found at the ocean or in the mountains.

Research The good news is the benefits of time in nature and time with nature doesn’t

have to take someone far from home or days in the wilderness. In the Bratman, Daily, Levy, and Gross (2015) study, sixty participants were randomly assigned to either a 50-minute walk in a natural or an urban environment in and around Stanford, California. The nature walk group resulted in the following benefits: “decreased anxiety, rumination, and negative affect, and preservation of positive affect as well as cognitive benefits (increased working memory performance)” (Bratman et al., 2015, p. 41) when compared to the urban group.

Hunter, Gillespie, and Chen (2019) conducted an eight-week study on stress reduction as measured by salivary cortisol. The researchers allowed their 36 participants to “choose the time of day, duration and place of their Nature Experience (NE)” to match more of our ever-changing and unpredictable schedules. NE was defined “as spending time in an outdoor place that brings a sense of contact with nature, at least three times a week for duration of 10 minutes or more.” (Hunter et al., 2019. p.722). The researchers found an NE of twenty and thirty minutes offered the most benefit to the study participants.

A six-week intervention comparing the effect of critical care nurses taking their breaks indoor only or in the hospital garden showed “significantly reduced emotional exhaustion and depersonalization” for the garden break-time group (Cordoza et al., 2018).

The systematic review by Byeongsang et al. (2017) on the practice of Shinrin-Yoku, Japanese for Forest Bathing, showed benefits for all ages, from the healthy

young college student to the elderly with chronic illness on multiple systems: cardiac and pulmonary function, immune function, inflammation, oxidative stress, stress, anxiety, depression, and emotional response.

Indoor Nature ExposureBecause people spend so much time indoors, spaces that include naturescapes

are growing in popularity and in recognition of their health benefits. DuBose et al. (2018) explained that according to the Samuelian Institute, qualities that enhance an indoor nature experience include:

Spaces that evoke a sense of cohesion…and [have a] homelike environment, access to views and nature, light, noise control, barrier-free environments…[These] environments can induce physical and emotional responses such as happiness, joy, and relaxation…all of which are antecedents to healing. (p. 43)

How to bring nature into your three commitmentsIn developing a dialogue among your three commitments, think about the ways

you already incorporate nature into your personal time, your relationships and at work, and identify ways you can amplify these. If you take walks by yourself, can you sometimes include your partner or a friend, or make a phone call to your family when you are taking a walk. If you tend to stay indoors during your work break, can you now include one or two times a week, a walk outside? Even in urban environments, many cities have created indoor and outdoor green spaces for public use. If you have a neighborhood park, make a relationship with just one tree. Visit it as if it were a relative and become familiar with the changes it makes throughout the seasons.

As in any wellness strategy, people have personal preferences and different access to nature environment. If you don’t have much green space in your neighborhood or near your work, bringing in clippings of rosemary or peppermint, for color and refreshing scent, or even grow rosemary in a potted plant for your home or office space, can improve mood and a sense of wellbeing.

No matter what your role is in healthcare, there is stress, overwhelm, and frustration that impact your health and wellbeing, mood and digestive system, how well you fight off colds or how well you attend to the needs of staff, colleagues and administrators. Taking a tincture of nature can be one avenue to bring more vibrancy to your personal life, work life and relationship life.

References:Bratman, G. N., Hamilton, J. P., & Daily, G. C. (2012). The impacts of nature experience on

human cognitive function and mental health. Annals of the New York Academy of Sciences, 1249(1), 118.

Bratman, G.N., Daily, G. C., Levy, B.J., Gross, J. J. (2015). The benefits of nature experience: Improved affect and cognition, Landscape and Urban Planning, 138, 41-50.

Byeongsang, O., Kyung J. L., Zaslawski, C., Yeung, A., Rosenthal, D., Larkey, L., & Back, M. (2017). Health and well-being benefits of spending time in forests: Systematic review. Environmental Health and Preventive Medicine, 1(1). https://doi.org/10.1186/s12199-017-0677-9

Carson, R. (1956). Sense of wonder: A celebration of nature for parents and children. Retrieved from https://www.goodreads.com/work/quotes/2339969-help-your-child-to-wonder)

Cordoza, M., Ulrich, R. S., Manulik, B. J., Gardiner, S. K., Fitzpatrick, P. S., Hazen, T. M., Mirka, A., & Perkins, R. S. (2008). Impact of nurses taking daily work breaks in a hospital garden on burnout. American Journal of Critical Care 27(6), 508-512

DuBose, J., MacAllister, L., Hadi, K., and Sakallaris, B. (2018). Exploring the concepts of healing spaces. Health Environments Research & Design Journal. 11(1), 43-56.

Hunter, M. R., Gillespie, B. W., Yu-Pu Chen, S., (2019). Urban nature experiences reduce stress in the context of daily life based on salivary biomarkers. Frontiers in Psychology, 10, 722.

Pak, F. A., & Reichsman, E. B. (2017). Beauty and the brain: The emerging field of neuroaetheestics. Retrieved from https://www.thecrimson.com/article/2017/11/10/neuroaesthetics-cover/

Whyte, D. (2009). The three marriages: Reimagining work, self and relationship New York: Riverhead Books.

Wilson E. (1984). Biophilia. Cambridge, MA: Harvard University Press.

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