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

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.

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 6 Transcripts

[MUSIC PLAYING]

CREW: 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.

[MUSIC PLAYING]

DAVID FREUDBERG: This is the second half of Nurses of the Future Look at New Paths in Nursing Education. I'm David Freudberg, host of this podcast series entitled Resilient Nurses. We now travel to Minneapolis for a fascinating visit with faculty, students, and graduates of the Center for Spirituality and Healing based at the University of Minnesota.

The center, founded in 1997, strives to help people strike a balance among body, mind, and spirit. It's not just about physical health, but also our interconnectedness with each other, the environment we're in, and how we identify a sense of purpose to guide us through life challenges and opportunities. And for nurse educators, that means enhancing an appreciation of the whole person.

KATHERINE TODD: Why I even went into leadership is because I realized it is true, we have a culture that was eating their young, a culture where we check ourselves and our wholeness and our well-being at the door in order to go through our tasks after we clock in and make sure that we document and deliver care. And there's so much more about being in care and in service to another that we were missing.

DAVID FREUDBERG: Katherine Todd is director of nursing and hospital operations at a local community hospital in a large health care system in the greater Twin Cities. Her doctorate focused on how professionals integrate holistic healing practices into the current medical model. And she's looking for ways to help nurses acquire a greater capability for resilience.

KATHERINE TODD: Because when we're not bringing our whole selves, we're missing it for the patient. I've seen that happen. I think we've all been a part of that.

DAVID FREUDBERG: When you don't bring your whole self--

KATHERINE TODD: Yeah, you don't bring your whole self.

DAVID FREUDBERG: --you're missing something in your care of the patient.

KATHERINE TODD: You are. It's very difficult for you to show up and demonstrate true empathy. And I think our goal is to be a solid support for the patients.

MARY JO KREITZER: Students are so filled with joy and aspiration when they enter nursing. And for many of them, it's a career that they have deeply yearned to be in.

DAVID FREUDBERG: Mary Jo Kreitzer, founder of the center, is professor at the University of Minnesota. She helped establish the nation's only doctoral program for nurses in integrative health and healing. As a seasoned nurse educator, she saw a need.

MARY JO KREITZER: We would nurture them as students. And then when I would encounter them after they had been in practice, sometimes as short as a year or two years or three years, it was stunning to me how the practice of nursing had impacted them, sometimes very negatively. While they had deeply meaningful experiences, and while they still felt a calling to be a nurse, often they were very raw from the experiences that they had had working as a nurse in the health care system. And the amount of stress that they encountered, the impact of sometimes systems that don't work very well, just the emotional impact of kind of caring for people in the most vulnerable times of their lives, what I learned was that they hadn't been prepared for that in this part of their educational process.

DAVID FREUDBERG: Mary Jo Kreitzer is coeditor of Integrative Nursing from Oxford University Press.

MARY JO KREITZER: One of the most important skills is a skill around self-awareness. And self-awareness is beginning to understand my own strengths, my own challenges, my weaknesses, my vulnerabilities. And that might sound like a simple skill to teach. But in reality, we spend a lot of our lives on autopilot. And we sometimes will arrive at a destination, and we don't remember driving there. Or we eat a meal, and we never remember tasting the food, because so much of life is on autopilot.

And what mindfulness teaches us is to slow down and be in the present moment. And if I slow down enough to be in the present moment, then I notice what I'm feeling, what I'm experiencing myself. And I'm much more likely to be able to kind of pick up cues if I'm with a patient, for example, or with a family member. So if I had to say where's a starting place in a curriculum of nursing education, I would say beginning with teaching skills of self-awareness and mindfulness would be a really important foundation.

[BABY CRYING]

KATHERINE TODD: Time for your bottle. You're ready to eat. I've got your lunch here. You're going to do a good job eating this time, right?

DAVID FREUDBERG: This is the Family Birth Center in St. Louis Park, Minnesota. As director of nursing here, Katherine Todd, a graduate of the University of Minnesota, sees her role as the nurse to her nurse colleagues.

KATHERINE TODD: I said, OK, we're going to have a requirement here. I want everybody to start the day in the lounge. I asked them to stand in a circle with me. And I had my Tibetan singing bowl. And I closed my eyes and hit the bowl and invited them to breathe and just center themselves--

[TIBETAN SINGING BOWL CHIMES]

I want you to take a nice, deep breath, settle into your chair.

--and to think about what they were holding and what they could let go. And then I asked each one of them to go around and tell me, what word would you be holding coming in today? And it was interesting-- fear, anxiety, stress, restlessness, lack of sleep, all of these things.

I'm like, if that's serving you, then you want to nurture it during your day. And if it's not, without judgment, let's figure out how to let go of it. So if it's passing through the doorway into the patient's room, breathe into that space and let go of the anxiety or the stress. And find a time that you'll do it. Maybe it's entering your password into the computer.

It's amazing, after three years of doing that, the transformation in the team. So we only did that. We focused on that piece. And we watched our patient experience scores improve. We watched our quality scores improve. We watched our engagement scores with staff improve. And all we were doing was focusing on mindfulness and resilience in our team, simple. And it was only five minutes in the morning or in between shifts.

[MUSIC PLAYING]

MEGAN VOSS: Part of the conversation on what can be in the curriculum and what do we teach our next generation is reframing the definition of well-being and taking it deeper.

DAVID FREUDBERG: Megan Voss leads integrative therapy efforts at the University of Minnesota Masonic Children's Hospital. She specializes in oncology, hematology, and blood and marrow transplant.

MEGAN VOSS: Wellness has been a fad forever. And exercising and dieting was sort of the start of it. And a healthy weight is important. And those things matter.

But what I truly learned in going through the doctorate in integrative health and through Mary Jo and the Center for Spirituality and Healing is that that health, or the physical health, the exercise and nutrition, is one sliver of the pie of total well-being. And we've learned to define it differently. We've learned to include things like security and purpose and relationships and environment. And it's all of those things working together that equal true well-being.

DAVID FREUDBERG: Today, Megan teaches a graduate-level course at the center on well-being and resiliency for working health professionals.

MEGAN VOSS: One of the things that I talk to my students about is looking at well-being the same way we look at Maslow's hierarchy of needs. And that bottom level is meeting basic needs, food, clothing, and shelter. And if you're working 12-hour shifts, and you're never seeing the light of day, and you're getting home, and you're collapsing so you can wake up and you can do it all over again, you're barely meeting your basic needs. You're barely making time to go to the bathroom, maybe drink one glass of water at the end of the day, and get some form of calories into your body, and then sleep. But if you're constantly running on E, and you're constantly trying to keep your head above water to meet those basic self-care needs, you're never freeing up space and time to work up the pyramid or to work at those higher levels of self-care, the things that matter in your heart and in your soul and in your mind.

MARY JO KREITZER: It's so important early on to really invite nursing students to reflect on what does it mean to be a nurse. What does it mean to be a healer? You know, what is, really, healing?

DAVID FREUDBERG: Mary Jo Kreitzer, director of the Center for Spirituality and Healing.

MARY JO KREITZER: Often, I think we have focused on the technical acquisition of knowledge and skills. And so often, students are excited about that. And that's really what they want to focus on, is they want to have skills so that they can leap into practice.

DAVID FREUDBERG: And that's, of course, very important.

MARY JO KREITZER: And of course that's very important. But one other dimension of well-being that we haven't touched on yet that I think is so important is purpose. And purpose and meaning in our work, in whatever we do, is so vitally important. And purpose is so connected to our health and well-being.

DAVID FREUDBERG: Does purpose give focus?

MARY JO KREITZER: Purpose gives meaning. Purpose gives meaning to what we do. And so I think, you know, we often talk about stress in the work environment, and how do we reduce stress, and how do we reduce burnout. But I think an equally important conversation is, how do we enhance purpose and meaning and alignment with purpose and meaning?

So I really like, whether I'm working with nurses in a hospital or whether I'm working with nursing students, to really explore with them, who are you? And what's important to you? What are your values? And what are your gifts and your talents? And how do you want that to be expressed in the work that you do? And many people went into nursing because they had a deep desire to serve people.

SUBJECT 1: Excuse me.

SUBJECT 2: Yes?

SUBJECT 1: Do you know where I could find [INAUDIBLE].

SUBJECT 2: If we have any, they're back in the [INAUDIBLE].

MARY JO KREITZER: Sometimes nurses discover that because of the nature of the work environment in which they're working, they're so removed from the bedside that they're either pulled into an administrative post, or they spend a lot of time managing technology or focusing on documentation, all things that are also important. But if we remove nurses too far from the bedside, that can really erode their sense of purpose and meaning. So what's really important is to help people find alignment in what they do, and to find the right fit.

Unfortunately, in nursing, there are so many opportunities, in terms of the clinical settings, and patient populations, and whether you want to be in direct care, whether you want to be a teacher, whether you want to be in leadership. But helping to guide people to kind of find that right place in the world is critically important. And I think that's really a way to build resiliency.

[MUSIC PLAYING]

DAVID FREUDBERG: You're listening to Nurses of the Future, a podcast exploring new directions in education intended to help nurses develop greater capacities for care of the whole patient, and in the process, for care of themselves. I'm David Freudberg. We continue our visit at the University of Minnesota Center for Spirituality and Healing.

MEGAN VOSS: Just about a year ago, I took care of a young man who had four different types of cancer over his short life. And everyone kept talking about, what can we do next?

DAVID FREUDBERG: Megan Voss

MEGAN VOSS: He'd been through countless rounds of chemotherapy and two stem cell transplants. And everyone was still talking about what we would do next, even though if you looked at him, this was a body that couldn't take any more treatments. And I would see him for integrative therapies. And we would talk about a variety of things.

And when his parents would leave the room, and it was just he and I, with his eyes closed, even, he would talk to me about, I know I'm dying. No one's talking about the fact that I'm dying. But I know I'm dying. And I'm OK with that. I just wish everyone else was. And those are the types of things that patients aren't going to share with you unless they know that you're also OK with dying, that you can hold the space for dying, because that's a really tough space to be in.

DAVID FREUDBERG: And also if you're OK with being authentic and vulnerable with them.

MEGAN VOSS: Yeah, and non-judgmental, and not to say, no, you're not dying. We're talking about more chemotherapy later today. It becomes this interesting conundrum, because the family wants to be strong for the patient, and the patient wants to be strong for the family. And you're right. There is no vulnerability, even amongst many families.

And so how the nurse can bring him or herself to the table and be an intervention is by creating that safe space, setting that stage, modeling vulnerability, and maybe planting the seeds. You know, I would give him ideas of how he might bring that conversation up with his parents in the room, or how maybe his parents might stay in the room while we worked together. And these were wonderful parents, who also knew. But there's many levels of knowing. And sometimes, just because you know something is happening doesn't make it easy for you to be able to address that.

DAVID FREUDBERG: For many families, navigating communication can be complex, especially when intense emotions are inevitable, as in the case of a dying loved one or other health crisis. And these dynamics present a special challenge for nurses, who must wade into territory that's likely to be very charged for the patient, the family, and the provider. Connie Delaney is professor and dean of the University of Minnesota School of Nursing.

CONNIE DELANEY: I think it is so essential to show, if you will, the side of us that's vulnerable, because at its core, we're calling the question on ourselves, as well as others, on whether we are fear or love-based. When we're love-based, this mutual respect, the sharing with one another, the respect for different roles, lifting up our humanness, it creates a safety for being authentic about those aspects. Particularly in nursing, as you know, when it comes to our relationship with families and patients, we're the most trusted profession, year after year.

DAVID FREUDBERG: More even than journalists.

CONNIE DELANEY: I think so.

[LAUGHTER]

There's a piece of that most trusted profession that relates back to we are steeped in putting patients and families first. We're steeped in putting students first in academia. So calling the question on we're all human beings. We all have vulnerabilities. And it's OK to be a human being and share.

DAVID FREUDBERG: Because it's more authentic.

CONNIE DELANEY: It is authentic.

MARY JO KREITZER: Historically, vulnerability so much has been seen as a sign of weakness and something to avoid.

DAVID FREUDBERG: Mary Jo Kreitzer.

MARY JO KREITZER: But when we allow ourselves to be vulnerable with another person, that creates the space for the other person to also open up in a way that we can really discover who they are. And so as a teacher, if I portray to students that I'm all-knowing, that I never make mistakes, that I am perfect, that creates an expectation that students would feel that they had to kind of be modeling that, and sort of be showing up for me in that way. But when I can model for my students that I don't know all the answers, and that I struggle, and that there's a lot that I don't know, and that we're going to be in a process together of codiscovery, that gives them permission, I think in a whole different way, to also be vulnerable and open to me.

[MUSIC PLAYING]

DAVID FREUDBERG: Wanda Baker, a pediatric nurse for over 30 years, is pursuing her doctorate in nursing at the University of Minnesota. For health providers, she says, practicing self-awareness and being centered are key.

WANDA BAKER: It needs to start right from the get-go. So it's as important as knowing how to use a stethoscope, take a blood pressure, do a lab. It's actually more important, I would say, because it's the foundation from which everything else is built.

DAVID FREUDBERG: Also studying for a doctorate of nursing practice is Maureen Anderson, who's worked in pediatric emergency nursing and home care nursing. She has professional and personal motivations to better understand health care for the whole person.

MAUREEN ANDERSON: I saw patients frequently come back into the ER doors. It was a fairly revolving system. And there was nothing keeping people out. They said, I was told to do this, or I was told to take my meds. But they didn't know how to bring that into their actual lifestyle. And so I was motivated to go back into integrative health, to figure out how to make health care a little bit more seamless, so that we wouldn't just tell patients what to do, but actually how to do it.

On a personal level, I'm interested in integrative health and well-being and resiliency, because I've been a diabetic for nearly 20 years and have lived that life where providers have told me what I need to do. But I wanted to find a different way of how to do it. I wanted to find a way that each day, I wasn't just going through the diabetic roles, but I was actually living this holistic lifestyle, where it wasn't just eating and activity, but it was incorporating stress management. It was incorporating aspects of spirituality, emotional, the mindset of what is this whole holistic health and well-being that leads to resiliency long-term.

DAVID FREUDBERG: And frequently, that requires setting aside some downtime for moments of self-reflection and contemplation that can nourish the interior life through meditation and prayer or techniques like yoga, that invite nurses to take time for being, rather then relentless doing. Maureen Anderson.

MAUREEN ANDERSON: I would identify with being more of a spiritual person than identifying with a religion. That's personal for me. But how it looks like in my day-to-day, I wake up in the morning and I say a prayer of gratitude, just thank you for allowing me to wake up to experience this day.

I pray with each of my meals. Thank you for giving me this opportunity to eat. I can eat. I can fulfill the needs of my own physical body, so that I can go and provide care for my patients. And I do that in a family setting. I encourage my family to be involved in my prayer. And that has helped me tremendously throughout my own life.

And then with patients, I think people are always surprised at how often patients want people to pray with them and just be with them in that sacred space. And that is something that I've always offered to patients, and many patients requested.

[MUSIC PLAYING]

WANDA BAKER: At the beginning of my nursing career, I didn't deal with stress very well.

DAVID FREUDBERG: Wanda Baker taught pediatric and family nursing in Nova Scotia, Canada, and has practiced in the central High Arctic.

WANDA BAKER: And I was very much, I would say a very grounded person to begin with, very mature. But I didn't have any kind of practices developed to sustain myself. So when I faced things that were overwhelming in my nursing practice, as well as my personal life, I floundered. It was just an extraordinarily distressing time for me.

We had six people die in our immediate family and very close friends within the space of 13 months. And I was the primary care provider, being the nurse in the family, looking after the well-being of everybody who was grieving. I was grieving as well, but that kind of was tucked aside.

And to compound that, I was in charge on nights one particular weekend in the intensive care unit, pediatric intensive care. And we had four children die that weekend. I took three of them. I carried three of them to the morgue.

And that was just-- that was my breaking point, quite literally. And I came face to face with my fragility and realized that if I was going to be able to grow, as a person and as a nurse, I needed to change what I was doing. So I did. I took time to actually connect with myself and to begin to develop practices that I knew would sustain my own growth, my self-awareness about what I needed. And it just took off from there.

[MUSIC PLAYING]

I would say the consistent thing that I do almost every day is meditation. And I can probably remove the almost, because if I don't sit on my little pillow, I am in a meditative state while I'm doing something that's a day-to-day activity. So a treat for me is baking bread. So that is extraordinarily meditative.

DAVID FREUDBERG: Can I assume also, part of the treat is then eating the bread?

WANDA BAKER: Eating it, smelling it, everything. So it's a whole sensory experience. That nourishes me deeply. And you know, my cat-- I am very connected to this cat. It's been a wonderful discovery for me over the years.

I play the piano. That's a meditative state for me. I tuck in rejuvenation in a walk to the car. I go for a walk around the lake. And I may not walk around the lake. I may get sidetracked by a beautiful leaf that's sitting on the surface of the lake. And I'll stop. And that is what my meditation is.

So that's where I refill. And that has been so helpful for me over the years working with children who die, children who have diagnoses that nobody would imagine children should have those diagnoses, and families that are faced with horrific, absolutely horrific choices-- they're not choices-- and being able to be whole myself so that I can sit there and honor the wholeness in them.

DAVID FREUDBERG: Nurses may encounter similar emotional currents in the neonatal ICU, where Rebecca Bese has performed most of her professional service for a decade. She's pursuing her doctorate at the University of Minnesota as she prepares for a transition to psychiatric nursing. Rebecca will have a dual specialty in integrative health and healing and mental health.

REBECCA BESE: For me, especially working within mental health, and again, going back to those difficult emotions that we have to sit with sometimes, having done my own work, I've had depression for many, many years, very serious depression that I had to learn how to sit myself with those emotions. And that's part of where some of that deep reflective practice has come through, and other very difficult experiences. My brother committed suicide.

So having to live with that, but being able to hold space for myself has allowed me to hold space for other people who are going through their own difficult, emotionally taxing circumstances. And I find that when I'm able to hold space and accept every single one of those emotions that come up, that they are more willing to sit with those, as well, and to start being more honest with both me and themselves about what it is they need to go to that next place that healing might start emerging.

But there is such a disconnect. People are so afraid to feel difficult emotions that they just want to cut them off and say not today. I'm not dealing with that. But our bodies still harbor all of that. And that's when we start having some of those complications with health, oftentimes, that there is. For many people with chronic mental illnesses, you will also see other physical symptoms starting to emerge, like diabetes and high blood pressure and chronic pain. So when we start having that integration, and I really believe it's the provider's place to hold that space for all of those difficult things to come up, then you have some of that deeper level of healing that starts to emerge.

[MUSIC PLAYING]

WANDA BAKER: I am self-caring, which is a mind, body, spirit way of being.

DAVID FREUDBERG: Wanda Baker.

WANDA BAKER: And that overflows into everything that I do. So when I nurture and care for myself, then that literally bathes people that I'm caring for in that comfortableness, that presence, that sacred space that we want people to be cared for within. You know, if I was doing an assessment with a child, they may have been on a ventilator, sedated, paralyzed, supposedly not able to be too aware of anything, I believe that they're always aware and that we bring our presence to that bedside in a healing way. And it impacts their outcomes. You can see it on monitors. You can see the difference between walking in a room in a frenetic, anxious, hyper mode and comparing that to walking in a room and working step by step and quietly and gently, doing the same amount of work in the same amount of time.

DAVID FREUDBERG: So when you say you can see it on the monitors, are you referring to vital signs?

WANDA BAKER: I'm referring to vital signs, absolutely. As the caring presence of someone is at the bedside, and we have a calm presence there with them, and we're providing care in a loving way, care that involves putting your hands on somebody, listening to them, interruptions in what they were just before you came into the room, so you're in their space. You can soften the impact of that, so that when I listen to a chest, or when I did listen to a chest, I didn't see a heart rate pop up, because I was able to gently, progressively move into that space that they're within.

REBECCA BESE: We need to start talking more about spirituality and the role that plays within our health and well-being.

DAVID FREUDBERG: Rebecca Bese.

REBECCA BESE: We need to start talking about purpose, and what does that look like? We need to start talking about nutrition and the choices that we make every day at the meals that we eat and how we're nourishing our body. We need to talk more about sleep.

We need to really start taking a more holistic approach of looking at people in terms of all the lifestyle things, start talking about community and your relationships. And do those nourish you, or do those deplete you? And what can you do moving forward? All these things in our life, they all impact our health and our well-being.

DAVID FREUDBERG: Students at the University of Minnesota School of Nursing Center for Spirituality and Healing.

[MUSIC PLAYING]

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.

CREW: This podcast project is supported by the Compassionate Care Initiative at the University of Virginia School of Nursing. To learn more, please visit compassion.nursing.virginia.edu. That's compassion.nursing.virginia.edu.