Correctional Nurse Self Care: Resilience

 

 

Peligro, cuerda rotaLast week’s commentary on the burden of moral distress brought forth the concerns and experiences of several more correctional nurses. Each of these courageous nurses described a turning point where they chose to act rather than stay silent and address the needs of their patients; each also paid a price, including termination, depression, failing health and so forth. I too, had to leave a position I had been in for 17 years because I was “in the way” of achieving the cost savings the organization had promised. This past year I witnessed a colleague being walked off the job because while she was trying to improve nursing practice she didn’t have the full support of the facility health authority. These are tremendous consequences for nursing professionals committed to quality patient care. One nurse commented that it is “easy to blame the nurses that are working with the inmates daily” rather than look up the chain of command to the organization itself and the managers responsible for the delivery of services. These experiences and the accompanying reality are the reason resilience has been identified as an essential quality to nurture as part of the caring practice of the nursing profession (Tusaie & Dyer 2004, Hodges et al. 2005, Warelow & Edward 2007).

Resilience refers to the ability to bounce back or recover from adversity (Garcia-Dia et al. 2013). Others describe resilience as the ability to grow and move forward in the face of misfortune or adversity; to adapt to adversity while retaining some sense of control and moving on in a positive manner (Jackson, Firtko & Edenborough 2007). Resilience has been suggested as a strategy for nurses to manage the emotional and physical demands of caring for patients as well as reduce their vulnerability to workplace adversity (excessive workload, organizational restructuring, lack of autonomy, bullying and violence).

The good news is that resilience is not a personality trait, that we either have or not, but instead consists of behaviors, thoughts and actions that can be developed and fostered to strengthen and adapt to our circumstances. Strategies that help build personal resilience include:

Professional relationships which are supportive and nurturing

A key component in the lives of resilient people is positive social support; having one or more people in the profession who are role models and can be called upon for guidance and support when needed. At least some of these individuals need to be from outside the immediate workplace so that support is unbiased and safe to receive, especially when the workplace is laden with tension. Another feature is that the relationship needs to be nurturing and one that fosters offers encouragement, reassurance, and individual professional growth; such as a mentoring relationship. In thinking about this, my professional network was developed among the members of the Oregon Chapter of the American Correctional Health Services Association. We meet twice a year and each meeting includes training, social time and the opportunity to discuss the workplace challenges we each struggle with. The relationships built through this local organization with other correctional nurses over the years have sustained me during many periods of crisis and change.

Maintain positivity

Positive emotions, including laughter, increase energy, change perceptions and help cope with adversity. Positivity comes from optimism or an ability to visualize potential benefits or positive aspects of an adverse situation. Considering a situation in a broader and longer-term perspective can build optimism. Indeed forcing oneself to think positively develops a greater range of resources and broadens the inventory of possible solutions in the midst of adversity (Jackson, Firtko & Edenborough 2007). The readers’ comments about their experiences with moral distress express an optimistic and positive view that reaching out to each other will create a collective voice to improve conditions in correctional health care. Techniques suggested to support positivity include visualizing what one wants rather than what is feared, identifying what brings joy to one’s life, maintaining hope for a positive outcome and laughter.

Develop emotional insight

Emotional insight is the capacity to identify, express, and recognize emotions; to incorporate emotions into thought; and to regulate both positive and negative emotions. When faced with adversity, emotion is inevitable, however we often are focused on the “who, how, what, when and where” of what is happening; unaware of how emotion is effecting us. When we can identify our emotional response to a situation we can switch our parasympathetic nervous system on and respond in a calm and rational manner and not suffer the effects of a “fight or flight” response. Understanding our emotional needs and reactions provides further insight into how we cope and may yield new ideas about how to improve our response in the future. Specific techniques suggested to develop emotional insight are relaxation exercises, guided imagery, meditation, deep breathing, journaling and reflection. See an earlier post about the use of reflection for professional growth.

Achieve life balance and spirituality

Highly resilient persons express existential beliefs, have a cohesive life narrative and appreciate their own uniqueness. This has also been described as having an anchoring force in life. In nursing, we often use the term achieving a work-life balance which is to engage in activities that are physically, emotionally and spiritually nurturing. This includes being clear about our mission in professional life, the reason for being a correctional nurse, so that we aren’t distracted in challenging times. Activities that support a balanced life include getting enough sleep, eating healthy, regular exercise, and maintaining a spiritual practice. You may want to revisit a recent post introducing self-care for correctional nurses. Another suggestion is to write and then send a letter to yourself recognizing your strengths and expressing gratitude for the work that you do.

Reflective practice

Reflection is a way to develop insight and understanding about situations so that knowledge is developed and can be used in subsequent situations. A concrete experience, such as losing one’s job or experiencing an ethical dilemma is used as a catalyst for thinking and learning. Journaling is especially helpful in adult learning because putting an experience into writing ascribes meaning to the people, places and events involved in the experience. Reflection is an opportunity for self-discovery; many people report better relationships, greater personal strength and self-worth, a deeper spirituality and heightened appreciation for life as a result of the self-growth that takes place after adversity. One of our readers said exactly that… “I have learned so much about myself, and systems change, and leaders vs managers.” I have to agree based upon my own experience; I am a stronger, more skilled professional than I ever was and have more to give others as a result of the self-discovery that took place after leaving, so long ago, a job I loved.

 

No one wants to experience workplace adversity and professional burnout and yet we know from our own experience and those of our readers, it is a reality in correctional nursing. Recognizing and building resilience personally and within our organizations is a strategy that is becoming part of the profession’s uniform. Below are several excellent resources for developing nursing resilience:

  1. Resilient Nurses: How health care providers handle their stressful profession. Written and produced for Public Radio. Consists of two ½ hour interviews with several leading nursing experts. The second segment includes techniques used to handle unusual strain as well as everyday stressors in nursing. It also includes a relaxation audio, a booklet, a CD and a list of resources.
  2. How can nurses build resilience and master stress? A summary of a 16 week series on Activating Resilience in Nursing and Leadership by Cynthia Howard. Links are included to other posts in her series on resilience.
  3. University of Virginia School of Nursing, Compassionate Care Initiative, is dedicated to teaching nurses resilience and compassion in health care. The site includes a link to “nurses thrive!” an online community of nurses dedicated to promoting resiliency. Also includes resources for building resilience through guided practice and exercise.

Do you recognize aspects of your own path to professional resiliency in these descriptions? What has helped you adjust or rebound from adversity? Please share your experiences or advice by responding in the comments section of this post.

References:

Garcia-Dia, , J., DiNapoli, J.M., Garcia-Ona, L., Jakubowski, R. & O’Flaherty, D. (2013) Concept Analysis: Resilience. Archives of Psychiatric Nursing 27; 264-270.

Hodges, H.F., Keeley, A.C., & Grier, E.C. (2005) Professional resilience, practice longevity, and Parse’s theory for baccalaureate education. Journal of Nursing Education 44, 548-554.

Jackson, D. , Firtko, A., & Edenborough, M. (2007) Personal resilience as a strategy for surviving and thriving in the face of workplace adversity: A literature review. Journal of Advanced Nursing.

McGee, E. M. (2006) The Healing Circle: Resiliency in Nurses. Issues in Mental Health Nursing 27; 43-57.

Sieg, D. (2015) 7 Habits of Highly Resilient Nurses. Reflections on Nursing Leadership 41 (1).

Sullivan, P., Bissett, K., Cooper, M., Dearholt, S., Mammen, K, Parks, J., & Pulia, K. (2012) Grace under fire: Surviving and thriving in nursing by cultivating resilience. American Journal of Nursing, 7 (12).

Tusaie K. & Dyer J. (2004) Resilience: a historical review of the construct. Holistic Nursing Practice 18, 3-10.

Warelow, P. & Edward, K-l. (2007) Caring as a resilient practice in mental health nursing. International Journal of Mental Health Nursing 16, 132-135.

 

For more on moral distress and courage see Chapter 2 Ethical Principles for Correctional Nursing in the Essentials of Correctional Nursing. You can order a copy directly from Springer Publishing and receive $15 off as well as free shipping by using this code- AF1209.

Photo credit: Peligro, cuerda rota@alejandro dans- Fotolio.com

 

Moral Courage: Being Assertive

sassy child with arms foldedSpeaking up in the face of a moral dilemma takes courage. No one likes conflict…well, almost no one….and nurses, it is found, would rather compromise than confront, according to at least one research study. Overcoming a natural inclination to ‘go along to get along’ takes conflict management skill. Like so many other nursing skills, it comes with practice. Being assertive in a moral situation is easier when assertive communication is a natural part of professional practice.

Knowing Me – Knowing You

Assertive communication starts with a good understanding of your own feelings about the situation and a desire to understand the feelings and perspectives of others in the group. Thoughtfully considering the situation, and your best response to it, allows an objective analysis of emotions that reduces the chance for an unhelpful aggressive or angry response.

Whenever you are distressed about a clinical situation, mentally identify your specific emotional response to become familiar with defining your feelings. Also consider the perspective of others in the situation. “Step into their shoes” and try to imagine their emotions and motivations. By evaluating all perspectives you will be prepared to assertively engage in a constructive conversation about the event.

Build-A-Response

Practicing a planned response to a situation during less significant concerns can help when the stakes are higher. One helpful model for constructing an assertive communication involves four parts:

  • A nonjudgmental explanation of the behavior to be changed
  • An admission of the asserter’s feelings
  • An explanation of the tangible effect of the other person’s behavior on the asserter or someone else
  • Announcement of the desired behavior change solution you want, or an invitation to problem-solve.

Putting these pieces together might creates a communication like this to the Med Line Officer: “When you call Inmate Jones a lousy pervert during pill line I feel upset. It is demeaning and it is important to me that we are civil with each other. Could you avoid this practice?”

By overcoming the desire to compromise and the fear of conflict, you can respond to challenging ethical situations in your correctional nursing practice. Evaluating your own feelings, seeing the perspective of others, and planning an assertive response will develop moral courage to respond when needed.

Have you developed assertive responses to moral situations in your setting? Share your experiences in the comments section of this post.

Read more about ethical practice in corrections in Chapter 2: Ethical Principles of Correctional Nursing from Essentials of Correctional Nursing. Order your copy directly from the publisher. http://www.springerpub.com/product/9780826109514#.UDqoiNZlQf4 Use promotional code AF1209 for $15 off and free shipping.

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Moral Courage: Dealing with Uncertainty

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Some ethical issues are obvious and the course of action is clear. A nurse who sees a colleague has documented administering a narcotic when the patient has not received medication requires reporting. However, correctional nurses are often faced with uncertain ethical situations that create decision stress and can lead to immobilization. A nurse who is asked to perform a blood draw for drugs may wonder if the activity will be used for a therapeutic or disciplinary outcome. Moral courage requires skill in dealing with uncertainty in an ethical situation.

Uncertainty of the Moral Situation

An uncertainty about the actual moral situation can hinder the courage to act. Consideration must be given to the actual ethical concern present. Strength for action is developed by clearly articulating the professional values that have been breached. Taking time to thoughtfully consider personal and professional valuing can help pinpoint the real issue embedded in the situation. In addition, confidentially discussing the concern with a spouse, leader, or trusted peer can lead to clarity. Sometimes putting into words the concerns of the situation give voice and vocabulary that strengthen resolve toward action.

Uncertainty of the Outcome of Action

A previous post  discussed the C-O-D-E model for moral courage. The 3rd element of this model is managing danger (D). Our uncertainty about the danger involved in acting or ‘speaking up’ about a potential ethical issue can be very real. Anxiety and a visceral ‘fight or flight’ response can ensue. How can we deal with the uncertainty of the outcome of our action?

Self-soothing. In an emotionally charged situation, free-floating anxiety or even anger can cloud judgment and be immobilizing. Immediate stress-reduction activities can be initiated such as taking a deep breath, slowly counting to 10, or speaking calming words to yourself like “I can do this” or “I have handled many things worse than this”. These are methods of self-soothing that can help to reduce anxiety and encourage clear thinking.

Cognitive Reframing. Worry about the negative outcome of an ethical action can be reframed by actively seeking positive alternative perspectives. Although concerns about job security, peer support, or humiliation may be very real, they can be balanced by positive outcomes of taking action such as personal integrity, strength of character, and satisfaction in doing the right thing in a difficult situation.

Lachman provides a logical progression to guide action in response to fear. Working through this list can help to clarify next-steps in an ethically uncertain situation.

  • Identify the risk you want to take
  • Identify the situational fear you are experiencing
  • Determine the outcome you want and what you have to do to achieve it
  • Identify resources accessible to you
  • Take action

Have you dealt with ethical uncertainty in your correctional nursing practice? Share your situation and how you dealt with it in the comments section of this post.

Read more about ethical practice in corrections in Chapter 2: Ethical Principles of Correctional Nursing from Essentials of Correctional Nursing. Order your copy directly from the publisher. http://www.springerpub.com/product/9780826109514#.UDqoiNZlQf4 Use promotional code AF1209 for $15 off and free shipping.

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Moral Courage: How Do I Find Some?

Little superhero

Tanya was working in a state prison in the nursing pool to make extra money for her college tuition. She was studying to be a nurse practitioner and thought it would be a good experience for her. Although she was learning much from her shifts there, she was also distressed by the treatment of a mentally ill inmate in solitary confinement for striking and injuring one of the officers.  Even in the short time she had been working there she had observed significant mental deterioration. In addition, the officers were rough and rude with this inmate; she assumed due to his injuring one of their own. Tanya was starting to lose sleep over this but she didn’t know what to do about it.

Nurses can experience moral distress over situations they observe in the correctional setting. Moral distress is experienced when painful feelings arise over the awareness of a morally inappropriate activity but feel they cannot respond due to various obstacles. A common obstacle is that of the institution or organizational culture. This is what Tanya is experiencing. Distress can also come from the uncertainty of what action to take and what consequences might ensue. For example, could Tanya be sanctioned, rejected, ridiculed, or fired if action is taken?

Finding moral courage to overcome distress and act in the face of these potential consequences is challenging. As in an emergency situation where all-out effort is needed, nurse ethicist, Vicki Lachman, suggests that we should call a code. That is an acronym for a 4-step process for finding courage to act in the face of a moral dilemma.

Call a C-O-D-E when Moral Courage is Needed

C Courage to be moral Where does my strength come from?
O Obligations to honor What is the right thing to do?
D Dangers to manage What do I need to handle my fear?
E Expression and action What action do I need to take to maintain my integrity?

Courage to be Moral

Taking a moral action requires courage. Where does the strength come from? For many nurses the strength comes from alignment with the ethical standards of our profession. A review of the Code for Nurses can provide strength for action. Look for the particular element of the code that is in violation and ponder the importance of action for your own professional integrity as well as for the good of the patient in the situation.

Obligations to Honor

The Code for Nurses is the ethical standard of nursing practice and establishes a nurse’s patient-centered valuing that is foundational to the profession. This is the primary place to determine our obligation in a moral dilemma. However, correctional nurses work within a security framework with its own value system. It can be important to consider what values drive others involved in the situation. The Institute of Global Ethics, as described by Lachman in another source, reviewed a wide variety of ethical codes and developed a list of the 5 primary values found in all of them: honesty, respect, responsibility, fairness, and compassion. Which of these values might be motivating others in the situation? These can then be considered in working through an action plan for response.

Dangers to Manage

Nurses must acknowledge and manage the fear engendered in taking action in a risky situation. Successfully overcoming fear is, in fact, a definition of courage. Working through the prior steps can help in managing danger as they provide objective reasons for the action and establish the importance for proceeding. This can be powerful and should not be under-estimated.

Also suggested in the process of ‘decatastrophizing’ which in involves working through the ‘what if’s’ of the situation. By objectifying fear, it can be demystified and balanced with the positive outcomes of action. This helps to cognitively reframe the situation and reduce negative thoughts. It also turns thoughts toward planning and action-taking rather than dwelling on fear.

Expression and Action

The final step in the CODE process is to take the practical action that will overcome fear and resolve the issue. Action in a situation such as Tanya’s requires both assertiveness and negotiation skills. It requires an understanding of the organizational reporting structure. It requires the ability to be collaborative rather than confrontational with other disciplines.

Tanya was able to garner the moral courage to respond to her moral distress. Through her actions the inmate was re-evaluated by mental health services and a treatment plan was initiated. She continues to work at the facility and is developing collaborative relationships with her healthcare and custody peers. She has resolved her moral distress and feels good about the outcome.

Have you needed to confront a moral dilemma in your correctional nursing work experience? Share your thoughts and experiences in the comments section of this post.

Read more about ethical practice in corrections in Chapter 2: Ethical Principles of Correctional Nursing from Essentials of Correctional Nursing. Order your copy directly from the publisher. http://www.springerpub.com/product/9780826109514#.UDqoiNZlQf4 Use promotional code AF1209 for $15 off and free shipping.

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Moral Courage: Do You Have What It Takes?

Courage And RiskA recent news story describes an investigation into 148 female inmate sterilizations in the California Prison System between 2006 and 2010. Inmates report being coerced into tubal ligation surgery following in-custody births. Although the situation is still under investigation, this news story reveals one of many moral situations encountered in correctional health care. One wonders if others in the facilities questioned the actions of the physicians performing these procedures in violation of prison healthcare policy which requires administrative approval of any elective procedure.

Possibly more than any other nursing specialty, correctional nurses confront moral dilemmas in the clinical setting. Clashing worldviews of security and healthcare along with the political and social implications of healthcare delivery to criminals create a quagmire of ethical concerns. Many correctional nurses work in solo practices in small facilities without benefit of a healthcare management structure that supports standard healthcare practices. Even in larger systems, ethical practices may be overruled by a security structure that is not attuned to the patient care implications of custody practices.

Moral courage is the courage to take action on a moral issue by overcoming fear of the consequences. The potential for reprisal, social isolation, and termination can lead to fear in responding to a moral issue such as patient coercion. Self-doubt can also cloud the issue. If no one else in the organization is addressing or responding to unethical or immoral practice, a nurse can question her interpretation of the situation.

Do you have what it takes to respond with courage when confronted with a similar ethical or moral issue? How can correctional nurses strengthen their moral courage?

Back to Your Roots

One way to gain moral courage is through reflection on the defining elements of our professional practice. In addressing concerns nurses can have as whistleblowers, Lachman suggests a need to return to our professional roots. As professionals we must be loyal to the definition of nurses as those who alleviate suffering and advocate on behalf of a patient’s well-being. Therefore, as nurses, we can garner the moral courage to act in the face of unethical colleagues, patient safety violation, or fraud by reflecting on the need to report these behaviors as part of who we are as professionals.

Tempered with Wisdom

Moral courage in nursing practice also requires wisdom. The courageous among us can be rash in responding to what, on first review, is an unethical practice. Yet, a wise nurse considers all the facts and perspectives before sounding the alarm. A wise response is determined based on full information; while misdirected courage can lead to foolhardy actions. Wisdom tempers courage to, instead, seek the right response in any situation.

Practice Makes Perfect

Intentionally practicing moral courage can develop the skill and habit of responding even in the face of fear. Some consider courage to be equivalent to fearlessness; but that is a distortion of the concept. Courage means overcoming fear by acting in the face of adversity. By practicing the skill of overcoming small fears, a nurse can develop moral courage by progression. For example, courageously overcoming fear to respond to rude behavior from a colleague develops the moral courage muscle. Like strength training for our physical muscles, our moral courage muscle must be stressed with ever increasing weight.

What would you do if you saw that providers in your setting were performing elective procedures without appropriate administrative clearance as noted in the opening story? How would you seek out enough information to take the right action? Would you know the mechanism to use to report the situation? Would you have the moral courage to take action? Share your thoughts in the comments section of this post.

Read more about ethical practice in corrections in Chapter 2: Ethical Principles of Correctional Nursing from Essentials of Correctional Nursing. Order your copy directly from the publisher. http://www.springerpub.com/product/9780826109514#.UDqoiNZlQf4 Use promotional code AF1209 for $15 off and free shipping.

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