University of Virginia School of Nursing
With activities from yoga, meditation, T'ai Chi and clowning, UVA's Compassionate Care Initiative aims to promote nurses' self-care to better patient care. "Resilient Nurses" podcast tells how.

Since 2014, the School's Compassionate Care Initiative has sponsored RESILIENT NURSES, a public radio documentary series heard on more than 78 NPR stations and nationwide on SiriusXM satellite radio, and downloaded more than 11,000 times.

Produced by award-winning producer David Freudberg, the series takes a no-holds-barred look at the challenges faced by those in the nursing profession, RN burnout, and the many ways some nurses are harnessing the power of mindfulness and resilience to fight it. Episodes 1 through 4 are available here.

Now, in two additional productions, Freudberg examines nursing’s future, and how nursing schools like UVA’s are preparing new nurses for the difficult, if exhilarating journey ahead.

Episode 5

"Nurses give and give and give — and then kind of keel over,” says UVA School of Nursing dean Dorrie Fontaine, who reveals the School's new efforts to purposefully teach resilience and compassion techniques during nursing school to minimize burnout among students leaving the cocoon of academia.

How can new nurses deepen a sense of self-awareness? How might they approach stress symptoms they experience while in training? How can they manage competing demands in the clinical setting? Faculty and students reveal their techniques.

Listen to Episode 5

 

Episode 6

Nurses have a culture that’s “eating our young, where we check ourselves and our wholeness and our well-being at the door in order to go through our tasks,” says Katherine Todd, director of nursing at a community hospital in the Twin Cities area.

Todd and others at the University of Minnesota’s Center for Spirituality and Healing describe ways out of this trap. One question to examine, according to Center founder Mary Jo Kreitzer, is this: what gives nurses their sense of purpose and meaning? Cultivating an intentional practice of self-care and mindfulness can prepare nurses of the future with personal and professional resilience.

Listen to Episode 6

 

Resilient Nurses - Episode 5 Transcripts

 

SPEAKER 1: This special podcast, hosted by award-winning radio documentary maker, David Freudberg, is presented by the Compassionate Care Initiative at the University of Virginia School of Nursing.

ALLY LENHOFF: Sophomore year was when we first left the classroom setting for our clinicals, and it was definitely scary. There's about six of us that go with one instructor, and it's crazy. You get one patient, and you're basically thrown into it, but it's such a good way to learn.

DAVID FREUDBERG: That's Allie Lennhoff, a senior nursing student with an interest in pediatrics at Endicott College in Beverly, Massachusetts. Her roommate, also a senior nursing student there, is Stephanie Paine.

STEPHANIE PAIN: I mean, the first clinical is definitely the scariest, because we just weren't really sure what to expect. And we weren't really comfortable walking into patients' rooms and having so much control over what to do with them, and giving them their medications, and doing their assessments. And then as the years went on, clinical became more exciting, because it became a little bit-- not easier, but you became much more comfortable in the situations. And you were more comfortable talking to the nurses, and the doctors, and asking people for help.

DAVID FREUDBERG: When you say it's a little scary at first, what is scary?

ALLY LENHOFF: I think the fact that we are not used to the hospital setting. We learn in the classroom, but then you have to take those skills that you learn and put them to use. It's so different than when we're practicing, maybe in our simulation lab, because these are real people that we're dealing with. And I mean, honestly their lives are in our hands at that point in time. And it's overwhelming, but it's exciting, too.

DAVID FREUDBERG: These bright, caring young people will soon be challenged to apply their newfound knowledge in a famously demanding occupation. And nurse educators in different regions of the United States are thinking deeply about ways to make it easier for the new nurses to endure.

DORRIE FONTAINE: You know, I think if we look back through history, we will see that nurses give, and give, and give, and then kind of keel over. And I think we really want people to come into this profession for the long haul.

DAVID FREUDBERG: That's Dorrie Fontaine in Charlottesville, from her vantage point at the famous campus founded and designed by Thomas Jefferson. Dorrie serves as dean at the University of Virginia's School of Nursing. She's a national leader in efforts to advance the state of nursing education toward bringing up a new wave of practitioners-- nurses who have learned skills of self-care that cultivate a capacity for personal and professional resilience, and who are then well positioned to provide optimal care for the whole person, the patient who nurses work hard to serve.

DORRIE FONTAINE: We really have to say that it is OK to care for yourself, and to really build compassion across the profession, that people will look out for each other. And I think it starts as a student. And many of us that have been prepared as health care providers-- recently or in the past-- I don't think self-care was viewed as positively as today.

DAVID FREUDBERG: Which is ironic, because we're talking about a health care profession.

DORRIE FONTAINE: Totally. Well, just look at Florence Nightingale and the Crimea. The lady with the lamp working 20 hours day and having her nurses constantly there. I mean, they did a lot of wonderful work. Our profession, you know, she is the leader. But again, she was not known for taking care of herself, for sure.

 

DAVID FREUDBERG: In this podcast, part of our series, Resilient Nurses, we'll listen to nursing deans, professors, and to students at various stages of development in their nursing careers. We'll start here in Charlottesville, then in the next half hour travel north to Minneapolis to hear from an inspiring group of nursing educators and students at the University of Minnesota. Our focus is to explore emerging approaches to training the next generation of providers for compassionate care of patients and compassionate self-care. We call our program, Nurses of the Future.

Gina DeGennaro has practiced oncology and the end-of-life palliative care nursing for over 30 years. She's an associate professor at the University of Virginia, teaching in the doctoral program at the School of Nursing. And she developed an Introduction to Resilience Course.

GINA DEGENNARO: So we tell the students, this course is all about you. This is for you to learn about you. It's about developing an awareness of how they respond to events, how they respond to thoughts, to increase their awareness of what thoughts are coming into their mind. So if they're noticing negative thoughts, to have an acceptance of those thoughts. That, OK, this is what I'm noticing today, that--

DAVID FREUDBERG: Instead of being very judgmental.

GINA DEGENNARO: Instead of being very judgmental, yes. So it's an acceptance practice, and it's also a body awareness practice. So they learn how their body is responding.

DAVID FREUDBERG: In the hectic rhythm common in nursing, it can be easy for practitioners to tune out warning signals their own body may be telling them. Perhaps it's a sign to slow down or to take a moment to recenter. And in the clinical setting, where time is frequently of the essence, stopping to regroup might seem like a luxury. But finding ways to do that is key to maintaining self-care for nurses.

GINA DEGENNARO: They choose a number of different strategies and resilience modalities, but they're very personal, and they're all very different. So while one student might return to the arts-- maybe they were a musician or a painter as a younger person-- they'll return to that for this course. And they'll log how their body is feeling at different times when they're doing this, how they've been feeling, what their reactions to stress were, how they've managed the breath, how they've learned to be more aware with the breath throughout the course of the semester.

They have hours, practice experiential hours, where they will mindfully exercise, where they will just focus on work that they're doing in exercise, in running, or in swimming. They have designed sleep care protocols when they've noticed that their sleep is distressed, when they begin to notice that. So we teach them an awareness of what are you noticing in your body, and what would you what would you like to do to try to treat that for yourself.

DAVID FREUDBERG: Students at the resilience course may be experiencing a wide range of stress-related symptoms, whether from common academic pressures or the special conditions encountered in clinical training. For example, students undergoing gastrointestinal disturbances may opt for a mindful eating protocol.

GINA DEGENNARO: And they might choose a meal, one meal a day, where they eat it in silence. They share gratefulness for the food, for where it came from. I would say an underlying theme of our course is mindfulness-- being really present and aware-- but it's also gratefulness.

So sometimes when student-- one student was very stressed and anxious every morning when she went to clinical. And so we talked about different things that she might do to try to address that. And one thing that worked for her was as she walked to the clinical rotation in the morning, she said thank you, thank you, thank you, and just repeated that. And that that was an opportunity for her to take care of patients. And that worked for her, so that when she arrived at the hospital, she wasn't as breathless.

The students are able to then notice all of the symptoms that they have-- that they're short of breath, their hands are sweaty, they are able to report headaches. You know, things that they have going on, that once they put their self-care plan into place, those things are reduced.

TIM CUNNINGHAM: I think it's very pertinent with nurses, because often we have a 30-minute break during a 12-hour shift, period.

DAVID FREUDBERG: Tim Cunningham is assistant professor of nursing at UVA and serves there as assistant director of the Compassionate Care Initiative. He's an emergency pediatric trauma nurse.

TIM CUNNINGHAM: And in those 30 minutes, we're supposed to use the bathroom, hydrate, eat food. And so I think with a gratitude practice, especially looking at food, that can help. You still consume. You still are going to have time to eat the food even if you have 30 minutes or less. Some days we don't have any breaks, and same for physicians. But having those practices in taking even a few milliseconds, that can mean the world in both enjoying food, processing the food, and recognizing that even in a short break, you can still consume nutritious food and take care of yourself. So eating, I think, is really important for medical professionals. And recognizing how we eat or don't is really essential.

GINA DEGENNARO: And they have written back to us after they've graduated to say, everybody needs this course. Everybody needs to be able to learn how to become more aware of how their body is feeling in different situations, and how to learn how to really calmly respond to that, that that was one of the things that really helped them during their school time.

 

DAVID FREUDBERG: Health care dollars today are stretched ever thin at the same time as the United States faces a shortage of nurses. This is related to our aging population. Today, more Americans are over age 65 than ever before, and the incidence of chronic disease requiring additional medical resources is on the rise. So the up and coming generation of nurses will enter a work environment often characterized by high demand. Dean Dorrie Fontaine.

DORRIE FONTAINE: You might have four, five, six other patients with competing demands, and family members that all want answers. You know, when are they going to make rounds? And are they going for this test? And they said they might go home tomorrow, is that going to-- all of this is coming at you.

DAVID FREUDBERG: So what is the skill of being able to be that air traffic controller, where you have all these stimuli bombarding you, and you, nevertheless, work to be fully present to the needs of the various human beings?

DORRIE FONTAINE: Trying to stay calm, and I always say to our-- people are watching you all the time, so you need to be that calm presence. Even if you don't feel like it inside, you need to feel that you can handle the situation. And pausing to be reflective and respond without being stressed and raising your voice. So we really are trying to teach our students to be reflective and to feel confident that they have the wisdom to choose to do the right thing. And it doesn't happen overnight. These are 18, 19, 20-year-olds. And they are in an environment, as we've said, where they're seeing a lot and listening to a lot of harshness.

JULIE HAIZLIP: So just to follow up on that. One of the things that I always talk to students about is when you go into a situation, in a health care situation, where things are a little bit hairy, the first thing you should do is take your own pulse.

DAVID FREUDBERG: Physician Julie Haizlip specializes in pediatric critical care and teaches at the UVA School of Nursing.

JULIE HAIZLIP: The idea that if you are revved up, and your sympathetic nervous system is kicked in, and you're going in with all of this nervous energy, then you're going to be in a mode where you're reacting instead of acting intentionally. And so this idea of just recognizing, OK, I've been triggered in some way, and I need to stop and take that deep breath before I do anything, so that I can make sure that I'm doing what I really intend to do.

DAVID FREUDBERG: Because the stakes can be high for a patient's well-being and for health care institutions' budgets when the quality of care is compromised. If providers are frazzled, it can lead to medical errors and lapses in care. They carry a high human and financial price tag.

JULIE HAIZLIP: There's a fair amount of research that's going on now that actually links quality and patient safety and the caliber of the care that's provided to the well-being of clinicians. What they found was there was an association between burnout of nurses and physicians and hospital-acquired infections. So central line infections, urinary tract infections, and ventilator-associated pneumonia. And this is a major source of morbidity in our hospitalized population. And so now we're able, actually, to start making some correlations between the level of burnout of clinicians and the incidence of some of these things that are happening in health care systems.

DAVID FREUDBERG: And the risks of burnout for new nurses fresh from the classroom are significant. Dorrie Fontaine.

DORRIE FONTAINE: We are producing, here at the University of Virginia School of Nursing, several hundred nurses a year. And the statistics are that about 37% are in the workforce and want to leave after that first year. Only about 14% do, but the fact that a third really have a broken heart. And it's not what they signed up for. The patients are sick. There's not enough staff. The electronic medical record gets in the way.

DAVID FREUDBERG: So a priority for nursing education is to train students in certain competencies that will empower them amidst the stresses of modern nursing to withstand and even thrive in the clinical setting. Some of the practices that we are advocating for our students are some very basic, basic ideas. So taking a deep breath. Before you go in a patient's room when you wash your hands, take a deep breath, kind of center yourself, ground through your feet, stand tall, and be ready to walk in that room. Nurses wash their hands 100 times a day, maybe more.

And we're telling our students some of these very simple, simple things. And I think the good part of this is every time we teach this, we're reinforcing it for ourselves, because everyone has been a practicing nurse. Many still are and are also teaching, or are physician colleagues. And the benefits of this is it's a nice cycle that we are reinforcing what we all know to be to be good practices.

 

DAVID FREUDBERG: You're listening to Nurses of the Future, an exploration of new directions in nursing that are intended to help nurses develop greater capacities to provide whole person care of patients, and in the process, to care for themselves. I'm David Freudberg. We continue our visit at the University of Virginia School of Nursing.

GINA DEGENNARO: When a nurse enters a room with a patient, and a nurse has a calm presence about her, him or her, and is able to really interact with the patient, being present with them-- at least, my experience is that the patients notice that.

DAVID FREUDBERG: Gina DeGennaro focuses on improving symptom management at the bedside.

GINA DEGENNARO: The patients appreciate that. And they can tell when someone is genuinely listening to them and present with them, and that they are the only person in the room for that nurse. And that might translate into feeling really well cared for and being heard, when there are things that they need to have done, get taken care of later on in the day.

DAVID FREUDBERG: So you're saying when a nurse is inwardly quiet, it facilitates greater responsiveness and attunement to the patient?

GINA DEGENNARO: To the patient's needs. When a nurse enters a room, and she herself is more aware of how she is feeling, and then translate that to the patient-- as in, I want now to take the best care of you and to be here for you and I will be here for you all day, and the patient hears that-- then the patient, I would imagine, would feel a lot more confidence in just having that interaction with the nurse rather than a nurse who might come in and be looking at a computer or looking somewhere else or talking to someone else or over the patient. So I think that the eye contact, I think that the touching, all of the things that we do when we really are connecting with another human being, are really some of the very important things that we bring to each encounter.

DAVID FREUDBERG: And it's in these tender patient encounters that a synergy may occur. Some of the skills that nurses develop in taking care of themselves can inform their interactions with patients. This can include techniques that nurses may demonstrate for patients at the bedside.

GINA DEGENNARO: We teach the students that what they learn about taking a moment with the breath or taking a moment to pause, those are all techniques that they can teach their patients. So that if they enter a room and a patient is breathing rapidly, or a patient's pulse is very rapid, they could actually sit, be with the patient, hold a patient's hand, and teach the patient to breathe. Teach the patient to breathe with them, and to follow their breath, and help the patient learn their technique. And our students do have stories of how they've connected some of these practices with patients and been able to teach them, so that they can use them later on when they need them, when they're alone.

DAVID FREUDBERG: So what does drawing from one's own experience add to the ability of a nurse to then explain this practice to a patient and teach the patient about it?

TIM CUNNINGHAM: So drawing from my own experience in dealing with physical pain--

DAVID FREUDBERG: Tim Cunningham.

TIM CUNNINGHAM: --and learning techniques of breathing through pain, both pain that I bring onto myself when I'm training and running 60 miles, or pain from accidents and injuries, I've learned that through breathing, focusing on the pain where it is, allowing the breath to kind of move the pain through my body, and let it then exit somewhere. And I visualize pain sort of as water flowing through a creek, or something that's moving and not stagnant and not holding on.

A trick that I use, working in the emergency department, that I've worked both with pediatric patients and adult patients, is when a patient comes in severe pain, and I'm giving them pain medication, if it's morphine, if it's IV ketorolac, as I'm slowly pushing the medication, I'll tell the patient, one thing that you can do to help yourself right now-- I recognize you're in pain. It sounds really awful, but this is something that you can do that will help. As I'm pushing this medication-- and I show them the syringe, so they can see me actually pushing the medication-- I say, I want you to take deep breaths, and I want you to visualize how that pain is changing as I'm pushing this medication.

And I never say it's going to go away, because that would be a lie. But I say it's going to change, and you're going to notice that change. It's nice when you're pushing morphine or Dilaudid, because you notice that change very quickly when you feel it. But even with slower-acting pain medications, if a patient is breathing and more aware of where the pain is, they'll notice the subtle changes as it moves through their body.

And then afterwards, I check back in with them, and I say, did the pain medication help? Yes or no? Did the breathing help? And often, people say yes, the breathing helped, even if the pain medication didn't seem to work. So I think, for me personally, and I think also with patients, it's a way to empower the patient and say, in this moment of sickness, you might feel like you have no control over anything. A-ha, you actually can control your breathing. And I'm going to work with you in controlling your breathing. And I think sometimes when patients regain a sense of control that can help mitigate symptoms.

DAVID FREUDBERG: And so does this build on your own personal experience?

TIM CUNNINGHAM: It absolutely builds on my own personal experience in managing my own pain and also managing my own emotional pain from traumatic experiences that I've had in my own life. When everything feels like it's falling apart, my breath is still happening.

 

DAVID FREUDBERG: We've heard about some of the special skills taught to nursing students through the University of Virginia's Compassionate Care Initiative. And for the students themselves, the prospect of entering health care can feel a little daunting. Evie Stinger, raised in northern Virginia, liked science in high school and sought out the personal interaction that nurses have with patients. And that means the well-being of real people is on the line.

EVIE STINGER: There's just a lot of possibility for error. And it's not something like advertising, where if you mess up, the product isn't sold. It's someone's life, so that's scary to me, because there's a lot of different things that can go wrong if you do something incorrectly. And just knowing all of that-- you can study it, but I think, at least, in my experience in clinicals, it's different than in the classroom.

JANE MUIR: So I think the biggest thing that concerns me right now is getting wrapped up in this, oh, well, it's always been done this way.

DAVID FREUDBERG: Jane Muir, also a Virginian, majored in Spanish language and nursing as an undergraduate. She decided to become a nurse when a friend with a brain tumor was impressed by nurses who especially advocated for their patients.

JANE MUIR: Being somebody who's a new product out of this curriculum, an institution where we want to be critical-thinking nurses, we want to be present, we want to be aware, we want to take care of ourselves, we want to be resilient, and coming into a community where there are nurses who may not have necessarily been educated in that environment, or maybe they've seen so much they've been desensitized from something just from many years of working-- so I think that's something that I fear is not only do I have to be resilient in terms of the stress that I face, but resilient in terms of the values that I developed when I was a nurse, and knowing that people may say, well, that's not realistic to do this or that, knowing that it is possible, because my teachers have paved the way for me and told me like it is. This is possible to be balanced, and it's possible to be aware and present with your patients and keep that going to provide good care.

DAVID FREUDBERG: And maintaining balance is an essential and sometimes elusive life skill, especially for health care providers. To Jane Muir, it's a relevant theme in her interactions with patients, who may be struggling to regain a sense of balance in lifestyle behaviors.

JANE MUIR: Relaying to patients that life is a balance, and it's not about being perfect. It's not about eating perfect 90% of the time. It's not about exercising every day vigorously. It's just about taking small steps forward, like one component at a time, because often, we have patients who present with multiple medical complications. And it's-- we want to target every single thing.

Oftentimes, I just feel like it's our job to provide patient education, which can be very overwhelming for patients. And I, again, I just think relaying. We've got to start with one thing, and it's a balance, and we don't have to be hard on ourselves, and it's about spending more time with the people in our lives who we love, and it's about having the ability to feel present day to day. I think if we can relay that to our patients, then it's really powerful.

And it's not about getting the prescription and checking off everything on the discharge instructions, which is often overwhelming for patients. It's stressful to come into the hospital. The patients don't want to be in a hospital. They don't want to be told to take 50 medications. They don't want to be told you need to go here, here, and here. So I think it's part of our job to tell them, one step at a time towards your health and progress.

DAVID FREUDBERG: And it's a message that Jane Muir has taken to heart in her student life and early days of nursing, where the weight of professional responsibilities and the sheer physical workout on an active day in the clinic can take a toll.

JANE MUIR: Throughout undergrad, I taught fitness classes at the school's gym. And I still teach classes, group fitness. That's always been key for me, to release from whatever tension, stress that I have. And since I started nursing, I've had to cut back and really readjust when I exercise and take some days off, just because working 12 hours is physically so exhausting. Your body is so sore. I've never felt so achy in my life, and I grew up playing competitive sports my whole life. And coming off of a shift and just completely passing out, and waking up, and being so sore. And your eyes are puffy even if you got enough sleep.

And, again, that goes back to being in this community, where we've been taught listen to your body. Don't grind gears. Don't white knuckle it. If you need to take a break, you need take a break. You need to listen to your body, because your body's going to know what you need. So being someone who's very type A when it comes to, like, I've got to exercise, I've got to do this, I've got to do that, which is very common in this community at UVA. There's a lot of perfectionist personalities. There's a lot of type A. Being able to-- I realize that a form of self-care for me has to been to stop, and just do less, and know that if I do less, I'm recharging, and I'm giving more the next time I go into work. And life isn't about doing the same exact thing every single day. It's about adapting to whatever changes come your way. And that's resiliency. That's bouncing back when you see something come at you.

 

SUBJECT 1: Usually I like to go run, because I don't really think about a lot of stuff. It's a way to just kind of step back, and just listen to my breathing, and get outside. And that kind of helps me. That's one of the ways that I de-stress is going on a run, or going on a walk outside. And I think that-- because I like doing it, it helps me stay active. And I think that helps a lot.

I also, I like keeping a journal. And just, like, before I go to bed, empty out any thoughts that are in my mind, circling around. Usually that helps me fall asleep really quickly. It's just kind of cool, also, to go back through the days. And if I'm feeling really-- if I'm feeling down or something, going back through and looking at good days, and kind of helps bring things into perspective, too.

ERICA HERNANDEZ: Recently, I've been exercising more, which has been really helpful.

DAVID FREUDBERG: Erica Hernandez, a UVA nursing student who was born in Bolivia and raised outside Washington D.C.

ERICA HERNANDEZ: I also, like Evie said, do like to write. So after-- I try, at least, after each clinical experience that I have that impacts me in some way, I try to reflect on what happened, whether that be a good thing or a bad thing that occurred during clinical. I like having that. And that's kind of my me time to really consider what could I have done better in this situation, or maybe just realized that I really couldn't have done anything more than I did. And I think that's something really important to acknowledge as a nursing student. And also just in the future as a nurse, I think that's going to be very helpful.

SUBJECT 2: I'm still pretty green, but I would imagine that there's a lot of moving parts. But then when you get out there, it's something different, and it just kind of piles up. And I think here at UVA with the Compassionate Care Initiative, we get a lot of exposure to that.

And it's kind of always in our ear. Take care of yourself and check in with yourself. And I think if I didn't have those tools, then I would have probably already felt the stress a lot more. I know that there is stress, and I know that I need to take care of it, instead of kind of pushing it down. And I think if I pushed it down, it would build up so much quicker.

DAVID FREUDBERG: You're listening to Nurses of The Future, part of our podcast series, Resilient Nurses. I'm David Freudberg. You can learn more at humanmedia.org. That's human media dot O-R-G. And we invite you to subscribe to the free weekly podcast from our public radio series. Lots of stimulating documentaries and dialogues you may be interested in on health care and many other topics. It's available at iTunes and Stitcher. That podcast is entitled Humankind on public radio. Thanks very much for listening.