Nurses' Care for Selves and One Another

In a nutshell . . . .

Nurses' care for selves and one another completes the six ideas of the Therapeutic Milieu. As the five previous ideas built on one another, they prepared us to be best able to care for ourselves and one another. In a big way, our ability to care for ourselves and one another determines our ability to care for the sick, injured and vulnerable people who depend on our care.

Three components of this idea are discussed: our need to care for our outward life of body and senses, our need to care for our inward life of mind and spirit, and our need to create and maintain relational harmony among ourselves as we work together to care for patients and manage patient care.

Limited relational harmony among professional nurses is widely recognised as a notorious problem – commonly called bullying. Careful Nursing avoids calling this problem bullying – and, instead, thinks the more on-target description of this problem is – disruptive relational behaviour.

You will see that mythic images from Greek mythology are used as a novel approach to thinking about and reflecting on this problem.

Suggestions are given to guide reflection on our behaviour, to enhance our contribution to harmonious relational behaviour and to minimise our contribution to disruptive relational behaviour – so that we may truly care for ourselves and one another.

Introduction

Nurses' care for selves and one another is the sixth concept of the Therapeutic Milieu. Only when all five foregoing Therapeutic Milieu concepts have been actualised by nurses, are they fully prepared to care for themselves and one another.

At the same time, as noted above on the Therapeutic Milieu introductory page, nurses have a dual caring responsibility to care for both patients and to care for themselves and one another. It is widely recognised that in order to care for others it is necessary to first care for oneself. From a patient care perspective this sixth concept of the Therapeutic Milieu can also be viewed as its first concept.

Nurses' care for selves and one another concerns nurses' attentiveness to their own health and the health of one another in ways that strengthen and support their own and their colleagues' healing and therapeutic capacity. It includes nurses' nourishing their inward lives through the creative use of their minds and spending at least five minutes of personal time every day in meditative "stillness". It also includes nurses nourishing their outward life, for example, good nutrition, rest, relaxation and exercise, enjoyment of social activities and having a sense of humour.

Nurses care for themselves and one another encompasses their contagious calmness, their engaging together intellectually to provide knowledge-based care for patients, their respecting their own and one another's inherent dignity, their regarding one another with benevolent affection and optimising the safety and restorative features of their practice surroundings.

These characteristics of nurses' care for themselves and one another support open, harmonious, healing and constructive communication and relationships among nurses and militate against them engaging in disruptive relational behaviour, for example, bullying and aggression. For nurses to truly care for sick, injured and vulnerable people it is necessary that they first care for themselves and one another.

While many nurses do care for themselves and one another, nurses generally face many challenges in achieving this aim (Kushner & Ruffin 2015) and do not always place emphasis on its achievement (Mills et al. 2015).

In Careful Nursing nurses' care for selves and one another is a three-fold endeavour:

♦ Firstly, attending to our outward life of body and senses to preserve our physical fitness, stamina, dexterity and use of our finely tuned senses required for clinical practice.

♦ Secondly, attending to our inward life of mind and spirit so we are enlivened and strengthened spiritually, psychologically and socially/relationally, as is essential for engaging in healing nurse-patient relationships.

♦ Thirdly, attending to our care for one another and creating relational harmony among ourselves to provide the professional relational structure necessary for our effective operation of the therapeutic milieu and relational continuity in nursing practice.

Following from the Careful Nursing philosophy, we understand ourselves as unitary human persons whose outward life of body and senses and inward life of mind and spirit are distinguishable realities in our essential unitary being. While the three endeavours noted above are addressed mainly from the perspective of the outward or inward life, we are aware that both realities are always part of one another.

Following from the Careful Nursing philosophy, our practice of "stillness" for at least five minutes during personal time each day provides us with a foundation for being aware of ourselves and our self-care needs and supports our human relational responsibilities in practice.

Attending to our outward life of body and senses

As unitary human persons our body and senses reflect our individuality and are of obvious immense importance since it is through our senses that we know and it is through our material body that we act (De Young et al. 2009).

Due to practice related stressors we face many threats to our bio-physiological-sensory health, including fatigue, insomnia, and diseases such as hypertension and asthma (Raab 2014. Nahm et al. (2012) observe that nurses sustain strains and injuries to joints and muscles, tend not to engage in balanced regular exercise, can develop poor sleep patterns, and eat irregularly leading to overweight/obesity. However, a large cohort of nurses responding to a self-care survey reported that they only sometimes considered care of their body an important aspect of self-care (Malloy et al. 2013).

We each know what we need to do

Richards (2013) proposes that we are generally well aware of solutions to these threats to our physical health but have difficulty implementing solutions into a personal programme of self-care. We are encouraged to develop our own physical self-care programmes. Richards emphasises that self-care is not self-indulgent. Rather, it is an important process of identifying needs and adopting self-care behaviours over time; a process which requires change, adaptation and flexibility. This process begins with self-assessment and commitment to making small changes incrementally until a sustainable pattern of physical self-care is achieved.

Attending to our inward life of mind and spirit

As nurses, our need to care for ourselves is most prominently documented in relation to high levels of psychological stress, emotional exhaustion and burnout due to factors such as stressful practice environments, role conflict, high patient acuity, increased paperwork and inadequate staffing patterns (Blum 2014, Mills et al. 2015, Crane & Ward 2016).

Further, these stressors not only harm us; they also disable the most distinctive aspect of our professional practice, our ability to engage in healing nurse-patient relationships (Kushner & Ruffin 2015, Mills et al. 2015, Crane & Ward 2016); the distinctive and vitally important context of all nursing practice. Nurses' psychological stress and emotional withdrawal are cited as major causes internationally of patient dissatisfaction with hospital based care (Raab 2014).

Interventions

Relaxation and stress reduction techniques and psycho-educational interventions are widely recommended to help us reduce stress and burnout (Kravits et al. 2010). The practice of brief periods of mindfulness has been found to decrease stress and related symptoms (Blum 2014, Slatyer et al. 2017).

We can also draw on personal resources as a self-care approach to ameliorating stress responses to demanding practice situations. Bagay (2012) describes the use of self-reflection to gain understanding of conflicting practice issues. Bjarnadottir and Vik (2015) describe how nurses practicing in relationally demanding situations reflect on the meaningfulness of their strong commitment to nursing practice, as a form of self-care.

In Careful Nursing the practice of "stillness" for at least five minutes during personal time every day is considered essential to developing and maintaining our awareness of our inward life of mind and spirit. As indicated in the Philosophy page the practice of "stillness" can be thought of in different ways. Essentially "stillness" is a type of meditation and meditation has been shown to decrease stress and burnout in hospital-based nurses and have a positive influence on their practice (Santos et al. 2016). Nurses report that daily practice of "stillness" enhances their ability to experience contagious calmness and has a positive influence on their practice.

Attending to care for one another and practicing in relational harmony

Professional nursing is primarily a relational practice both in how we care for sick, injured and vulnerable people and how we work together to manage their care. In hospital and other institutional settings we practice in close relationship with one another rather than as individual practitioners. Our 24/7 relational continuity in practice is a distinctive nursing characteristic and essential to patient safety. It requires that we care for one another and practice together in harmony.

A particular practice challenge

However, our relationships with and care for one another can be fraught with difficulties. Research indicates that internationally from 30% to almost 90% of nurses surveyed have experienced, or observed other nurses experiencing, varying levels of hostility, aggression or bullying behaviour among themselves in their practice setting (Stanley et al., 2007; Vessey et al., 2011). Amongst healthcare workers internationally nurses are reported to experience the highest level of bullying (Ariza-Montes et al. 2013). The literature is brimming with theories about bullying in nursing; for example, because nursing is a female-dominated profession and because nurses are an oppressed group.

Many strategies have been implemented to eliminate hostility and bullying amongst nurses, for example, 'no tolerance' policies, caring leadership approaches, and screening, education, and behaviour monitoring programs. But despite much attention being given for around thirty years to eradicating this destructive behaviour amongst nurses, it is reported to remain extremely common and a growing problem (Castronovo et al. 2016, Olender 2017).

Taking a different perspective

In a brief attempt to gain a different perspective on this problem and how we can try to eliminate it from our practice, let us use a more accurate term to describe it and consider it in relation to our human nature.

Disruptive relational behaviour

Moore et al. (2013) adopted the term 'disruptive relational behaviour' (p. 172) to describe negative relationships among nurses referred to in the literature as lateral or horizontal violence or bullying. The Moore et al. term is more accurate and apt for nursing. Moore et al. (2017) later modified the term to 'disruptive nurse-to-nurse relationships' or 'disruptive nurse relationships' (p. 24). Whichever of the Moore et al. variations is used they speak directly to the heart of this problem faced by nurses.

The relational nature of nursing

It is possible that disruptive relational behaviour is a problem in nursing because of the distinctively relational nature of our profession. Aside from nurse-patient relationships, our management of practice in hospitals is also a relational undertaking, from management of patients' care by staff nurses to management of overall patient care by directors of nursing. A distinctive professional nursing responsibility is to provide 24/7 relational continuity of care for patients, a responsibility essential to patient safety. This responsibility means that we are in close, focused relationship with one another continuously and this situation may, in itself, give rise to our relatively high level of disruptive relational behaviour. Why could this be?

Reflecting on our human nature

As human persons we have a human nature. It is well known that our human nature can be the source of much goodness and kindness in human relationships and also the source of much badness and cruelty in human relationships. In our human nature we all have the capacity to be fallible. Human history is steeped in relentless aggression and violence. Human aggression and violence are recurring themes in world literature. Could disruptive relational behaviour amongst nurses be a reflection of this fallible aspect of our human nature?

Perhaps in order to help human beings understand our human capacity for goodness and badness, mythic images and symbols of our human propensities have emerged in all cultures. These symbolic images are widely understood to portray attitudes and activities which all human persons have the capacity to express, whether or not the images themselves are portrayed as male or female (Neumann, 1963).

For example, in ancient Greek mythology the goddess Hygieia is identified as a goddess of nursing. Hygieia symbolically personifies nursing attitudes and activities such as calmness, kindness, tenderness and healing. She is addressed in the Orphic Hymns as Hygieia of the gentle hands, implying that her hands have a special therapeutic quality. Hygieia was viewed as a bearer of life's transforming power and a compassionate friend of humankind. She is often portrayed in a harmonious relationship with a serpent which she is feeding and which symbolises life's rhythmic flow, its power of self-renewal and continuous transformation. In feeding the serpent she symbolises the nourishment of the flow of life. Hygieia personifies goodness in nursing and the fostering of healing and health in the community (Cooper 1978, Wroth 1984).

In contrast to Hygieia, is the Gorgon of ancient Greek mythology who surely personifies disruptive relational behaviour. Gorgons symbolically personify the antithesis of nursing attitudes and activities. They are sometimes portrayed as venomous snakes. They have a powerful gaze that can turn their victims to stone. They have a big mouth and many teeth because they eat and devour their victims. Although the Gorgon represents an extreme, shades of the Gorgon can underlie any degree of disruptive relational behaviour from subtle insult or intimidation to thinly veiled offence or harassment.

Can we use reflection on our human nature to help us diminish disruptive relational behaviour?

When we look at and reflect on Hygieia, a symbolic image of nursing, and Hygieia's antithesis, the Gorgon, can they help us reflect on these aspects of ourselves. In our commitment to nursing values we would all be able to identify with Hygieia and seek to express the attitudes and activities she portrays. Because we all have a human nature we would also be able to identify lurking within us intimations of the Gorgon with the capacity to let themselves loose in our nurse-to-nurse relationships.

In the case of the Gorgon, can it help us become aware of aspects of ourselves that we would rather not recognise? Is it possible that by becoming more conscious of these aspects of ourselves and reflecting on them, we would be able to better recognise them arising in us? Is it possible that we would then be able to 'nip them in the bud', so to speak, before they expressed themselves in our nurse-to-nurse relationships?

Generally, as human persons, we constantly struggle against aggressive tendencies to bring kindness and harmony to our relationships with others. It is probably safe to say that a good number of us have at times been disrespectful, abrupt or subtly hostile to other nurses in our practice setting. How many of us can say that we have never been dismissive, resentful, patronizing, or impatient with a nurse colleague? That we have never gossiped, or ignored or made fun of a nurse colleague? How many of us can say that we have never had times when we have felt discouraged and irritable and not taken it out on nurse colleagues to some extent?

In addition, when we engage in any form of disruptive relational behaviour we fail to respect the inherent dignity of the nurses with whom we practice and fail to respect our own inherent dignity. Thus, we are harming ourselves as well as our colleagues. We may be being hard on and impatient with ourselves, neglecting and abusing our capacity to be kind and gentle with ourselves. Engaging in disruptive relational behaviour can also be viewed as a serious form of professional self-harm.

Nurses' care for selves and one another 'I will' statements

Sit quietly in a chair, close your eyes and take a moment to relax and recall your experience of stillness. Bring to mind your practice experiences over the past three months.

On a scale of 1 to 10, how do you rate your attentiveness to and care for your outward life of body and senses?

On a scale of 1 to 10, how do you rate your attentiveness to and care for your inward life of mind and spirit?

On a scale of 1 to 10, how do you rate your care for the nurses with whom you work?

On a scale of 1 to 10, how do you rate the frequency with which you have been disruptive in nurse-to-nurse relationships?

Based on your assessment of your current level of caring for yourself in your professional practice and caring for the nursing colleagues with whom you work, decide what you will do to further enhance your care for yourself and for the nurses with whom you practice?

Examples of nurses' care for selves and one another 'I will' statements:

. . . treat nurses I work with respectfully and with kindness regardless of their personality

. . . watch out for opportunities to help nurses I work with

. . . . . . . . . . . . . . . . . . . . . . . . .examine how I look after myself and see how I can do it better

. . . . . . . . . . . . . . . ...... . . . . . . help nurses I work with resolve interpersonal conflicts and work toward common goals

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