Nursing professionals as a nationwide concern

www.Nursing2020.com August l Nursing2020 l 53 DREAMLAND MEDIA/iSTOCK
BY SANTHINY RAJAMOHAN, PhD, RN; CYNTHIA R. DAVIS, PhD; AND MEREDITH ADER, MLS
REST: Break through to resilience
THE SHORTAGE of nursing professionals is a nationwide concern. The
Bureau of Labor Statistics predicts
that the demand for nurses will increase to 12% between 2018 and
2028, which is much higher than the
estimation for all professions. The
Bureau also estimates that 203,700
new RNs will be needed each year
for the next 6 years to keep up with
expected openings due to retirement
and new demands.1,2 These estimates
do not factor in the effects of the
COVID-19 pandemic.
Manomenidis indicates that approximately 40% of nurses have
reported burnout in the US, and
nursing burnout is also a concern
worldwide.3
The high attrition due
to burnout contributes to patient
and family dissatisfaction.4
Nursing
schools are not able to keep up with
the demands of nursing vacancies
resulting from burnout.
Strong evidence suggests that resilience is crucial to improving quality of
care and supporting nurses in reducing burnout.3,4 This article discusses
how nurses and nursing students can
use the REST mnemonic described
here as a tool for building the resilience they will need to meet challenges throughout their nursing careers.
Defining resilience
Resilience is an individuals aptitude
for overcoming an adverse life circumstance with a hopeful attitude,
Abstract: Strong evidence suggests that
resilience is crucial to improving quality of
care and supporting nurses in reducing
burnout. This article discusses how nurses
and students can use the REST mnemonic
described here as a tool for building the
resilience they will need to meet challenges
throughout their nursing careers.
Keywords: burnout, compassion fatigue,
resilience, stress
Copyright 2020 Wolters Kluwer Health, Inc. All rights reserved.
54 l Nursing2020 l Volume 50, Number 8 www.Nursing2020.com
utilizing healthy internal coping
mechanisms and external resources,
such as supportive work environments, mindfulness-based stress
reduction training, and assertive
communication skills training.3,4
Teresa Stephens, in her 2013 study
of nursing student resilience, concluded that successful navigation of
perceived stress and adversity is an
individualized process of development of what she labeled as protective factors: maintaining a flexible
attitude, developing a strong support
system, practicing faith, and increasing knowledge.5
Cumulative successes
from use of these strategies leads to
enhanced coping/adaptive abilities
and well-being.
The acronym REST puts these
strategies into a practical format that
nurses and nursing students can use
to categorize protective factors. The
acronym represents the following:
Relationships (relationships with
self and others)
Exercise (care of the mind, body,
and spirit)
Soul (compassionate emotional care)
Transformative thinking leading to
thoughtful action.
The following discussion examines
each element in detail.
R is for relationships
with self and others
It is vital for nurses to recognize the
emotions they feel when they face
stressful situations in school, home, or
work. Being aware of ones true emotions is the first step toward building
resilience.6
In order to become selfaware, an individual needs to have a
healthy relationship with the self. Giving ones self permission to feel emotions and showing genuine care and
kindness toward self are important.
One cannot pour from an empty cup;
taking care of the self (filling ones own
cup) is essential to caring for others.
Self-care for many includes some
aspect of spirituality or religion.
According to Kor and colleagues,
spirituality is the degree to which a
person affirms and honors a sacred
or transcendent force in his or her
life, while religiousness tends to
focus specifically on a belief in God
or adherence to a particular religious
denomination.7 In either case, data
clearly show a strong correlation between spirituality/religiousness and
resilience.8 The overarching theme is
that the person who has a spiritual
or religious focus also tends to have
a sense of purpose in life. This sense
of purpose helps to increase the individuals sense of self-value and builds
resilience in the face of adversity.
Relationships with others are also
recognized as a significant predictor
of resilience.6
Genuine loving connections and supportive relationships are important to building and
supporting resiliency. For example,
having a mentor in the form of a
big sister/brother in college and
learning from a healthy, confident
role model can help a novice nurse
minimize burnout. Forming and
sustaining interpersonal connectedness with a trusted mentor can help
students and new nurses sustain
their resilience. In addition, positive
interactions with peers and social
connections improve self-protection.
In their 2018 study, Manomenidis
and colleagues identified a higher
level of education and mental preparation as positive contributing factors
to resilience and anxiety as a negative
factor.3 Anxiety often contributes
to low self-esteem, which affects
intrapersonal and interpersonal relationships.9 Though mild anxiety
can sometimes initially help with
self-protection when someone faces
adversity, prolonged anxiety undermines overall health.
E is for exercising care of the
body, mind, and spirit
Physical and mental health are significant contributors to resilience. For
example, regular physical activity or
exercise can help an individual maintain a healthy lifestyle and function
more efficiently throughout the day.
Ruegsegger and Booth highlight the
more extensive, far-reaching health
benefits of physical activity such as
cardiopulmonary fitness, but also
include data from various studies
suggesting improvements in overall
mental health as well.10 Chemical
changes that occur in the brain during exercise include the increase
of brain-derived neurotrophic factor (BDNF). This neurochemical is
important in neuronal cell health,
growth, and differentiation. Additionally, increased production of
BDNF, along with lactate, a natural
byproduct of cellular activity, has
been shown to play a beneficial role
in overall brain health.11
Sleep is an important component
of mental functioning, and the quality of sleep has been shown to influence learning. Okano and colleagues
conducted a study of 100 students in
a chemistry course at the Massachusetts Institute of Technology over an
entire fall semester.12 The study participants were each equipped with a
fitness tracking device to follow their
daily activity level and sleep patterns
throughout the semester. The data
collected clearly support the conclusion that better and more consistent
sleep quality and longer uninterrupted sleep periods correlate with better
academic performance.
Maintaining a balanced sleep
schedule is evidently crucial to academic success, yet many common
habits interfere with quality sleep.
Numerous studies focusing on various age-groups have shown that the
blue wavelengths of light emitted by
many screen types, including those
on cell phones and computers, can
inhibit the onset of sleep when these
devices are used at night. The blue
light disrupts melatonin production
and normal circadian rhythms, delaying onset of sleep.13
Paired with physical activity,
meditation is another strategy nurses
Copyright 2020 Wolters Kluwer Health, Inc. All rights reserved.
www.Nursing2020.com August l Nursing2020 l 55
can use to improve cognitive function and build resilience, but they
must commit to it to enjoy its full
benefits. Edwards and Loprinzi
showed that among already active
college-age students, 10 minutes of
focused mindful meditation three
times a week, along with 10 minutes
of aerobic exercise, was not enough
to demonstrate improved cognitive
functioning.14 In their conclusion,
they recommend that individuals in
this age-group, particularly if they
are already physically active, should
aim for 9,000 steps (about 5 miles)
per day, along with focused meditation. Another study by Schone and
colleagues suggests that 15 minutes
of focused meditation (mindful
breath awareness) three times a week
improved cognitive functioning.15
In a study of 60 female subjects
(mean age, 23), Zhang and colleagues
coupled yoga training sessions with
aerobic exercise and focused attention meditation.16 They concluded
that, as hypothesized, a mind-body
exercise intervention improved implicit emotion regulation; in other
words, the ability to achieve and
maintain a sense of well-being.
Clearly, the overarching theme of
all of these studies is that to maintain physical and emotional health
and a resilient brain, an individual
can strengthen the and build resilience with
aerobic exercise, yoga, and focused
meditation.
S is for soul, or compassionate
emotional care
A quick look at mythology provides
an important contextual understanding of what we have come to call our
souls. Psyche, whose name means
soul in Greek, was the wife of
Cupid. In her quest to win Cupid,
the soul had to overcome long
separations, painful trials, and seemingly impossible challenges before
earning the reward of being united
with her love.17
What can nurses extrapolate
from the myth? The soul is the
place in which we are mentally and
emotionally tested. It is the place,
most importantly, where the display
of resilience through tribulations
produces success in overcoming.
Tribulations are to be expected.
Intentional care of the soul provides a learned response drawn from
previously experienced compassion.18 Compassion, inwardly aimed,
reflects feelings of self-kindness,
common humanity, and mindfulness
during times of pain or failure rather
than harsh self-criticism. It encourages perceiving ones experiences
as part of the larger human experience.19 It does not validate narcissism or self-centeredness, which are
sometimes negatively associated with
high self-esteem.20 Nor is compassion necessarily empathy, which
implies the inference of what another
person is feeling.21 Compassion does
not seek to improve a persons sense
of self-worth or status but rather
originates from a sense of caring and
desire for the well-being of ones self
and others. It also aims to decrease
separation from peers. Thus, compassionate care for the soul becomes
a restorative agent that is both received and given.
A preemptive coping/adaptive
strategy is to recognize the unseen,
often damaging, self-talk that nurses
and students may internalize. This
strategy regulates and negates caustic
and destructive self-talk.
Developing preemptive strategies necessary to navigate stresses
incurred during nursing school can
have a bilateral benefit. A compassionate response to the souls experience of adversity (recognizing
the imperfect nature of humanity
and extending grace) not only insulates against harsh self-talk, but
also appears to have a ripple effect,
resonating with peers and ideally
creating a mutually compassionate
experience.22
T is for transformative thinking
Most will agree that knowledge is
powerful, but knowing what is best
does not always translate into practical actions, especially when it comes
to caring for self. Nurses are in a
caring profession and compassion
fatigue is a real phenomenon challenging the nursing profession. Why
is it difficult for nurses to practice
self-compassion so that they are in
the best health to provide quality
care for their patients? Promoting
reflective practice may be the key to
helping nurses and nursing students
formulate practical action plans.
For transformative thinking to
take place, the individual facing an
adverse situation must spend time
considering what might have gone
wrong, what went well, what might
have been a barrier to utilizing available resources, and what can be done
differently moving forward. Exploring the meaning of life and inner
purpose, as well as spirituality, may
add strength to an individuals transformative process. Once this personal debriefing takes place, authentic,
self-reflective answers can begin to
change thinking and new learning
may take place. The hope is that
with new, transformative thinking
and learning, the nurse will be better
equipped to handle future adversity
and rebound more quickly.
Based on our experiences working
with nursing students, the authors
believe that transformative thinking encourages individuals to keep
the bigger picture in the forefront
when facing life challenges. Seeing
adverse experiences in the light of
the desired long-term outcome helps
individuals cope and to have hope.
For example, reminding a nursing
student who is facing challenges that
he or she is nearing graduation provides a hopeful perspective. Encouraging students to have an optimistic
view by reminding them about
their coping resources such as faith,
prayers, family connections, church/
Copyright 2020 Wolters Kluwer Health, Inc. All rights reserved.
56 l Nursing2020 l Volume 50, Number 8 www.Nursing2020.com
community support, mentors, exercise, meditation, and other elements
of self-care can help them switch
their thinking from feeling stuck
in one place. Providing support and
reminding them to follow the REST
pathway may allow them to work
through their challenges and bounce
back stronger. Learning to handle
stress keeps us moving forward and
allows us to become more resilient.
Implementing REST for students
Collaboration is a must when considering implementation of REST in
a nursing program. Educators may
consider partnering with the counseling department or wellness center,
or the colleges learning or student
success center, to provide workshops
on a regular basis, either weekly or
bimonthly during the first year of
college. Assessment could be done in
the form of pre- and postsurveys. A
preassessment could include a REST
evaluation, and implementation could
include educating students on the
need to engage each component to
be successful, creating small goals to
improve in any area that is lacking. To
keep up with progress efficiently, simple questions can be formulated with
answers recorded each week during
tutoring sessions. For example, if the
student reports a lack of consistent
sleep during the preassessment, a goal
could be to increase sleep to a specified number of hours a night. A question for each tutoring session may
include something like, How much
sleep were you able to get on average
each night this past week? Further
assessment, of course, would be done
and potentially correlated with increased academic success.
Most colleges offer a to freshmen. This course
could use a similar approach, combining both the pre- and postsurveys but
also implementation goals for anything that students discover is lacking.
Another suggestion is to work
specifically with advising faculty and
ask them to consider implementing
REST with a small pilot group of students who are willing to participate.
Other resources
Incorporating a practical formula
such as REST into the nursing curriculum can help students remember
the essential components of resilience,
but other resources are also available.
For example, the National Academy
of Medicine recently initiated a plan
to support the well-being and resilience of clinicians by promoting
evidence-based recommendations to
fight against clinician burnout. For
more information, visit https://nam.
being.23 In addition, the
American Association of Colleges
of Nursing promotes self-reflection
activities that nurture personal health
and well-being, as well as resilience,
which are indicated in the baccalaureate nursing education essentials.
Developing resilience as part of
nursing programs assists students
as they face daily challenges and
provide the best possible care for
patients throughout their nursing
careers. Future research into the
incorporation of the REST formula
in the training of nursing students
and the professional care of practicing nurses would be appropriate for
developing a framework to support
a resilient profession.
REFERENCES
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Grossman JC. Sleep quality, duration, and consistency are associated with better academic performance
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13. Knufinke M, Fittkau-Koch L, Mst EIS,
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Malinowski P. Mindful breath awareness meditation facilitates efficiency gains in brain networks:
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Rep. 2018;8(1):13687.
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exercise improve implicit emotion regulation ability:
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17. Bulloch A. Psyche: from gods, goddesses and
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18. McRay BW, Barwegen L, Haase DT, et al. Spiritual
formation and soul care in the Department of Christian Formation and Ministry at Wheaton College.
J Spiritual Formation Soul Care. 2018;11(2):271-295.
19. Neff KD. The development and validation of
a scale to measure self-compassion. Self Identity.
2003;2(3):223-250.
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of compassion-evoking images in a Mexican sample. Percept Mot Skills. 2007;105(2):661-676.
22. Kukk Christopher L. Compassionate Achiever:
How Helping Others Fuels Success. New York, NY:
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Santhiny Rajamohan is an associate professor of
nursing at the Roberts Wesleyan College School of
Nursing in Rochester, N.Y. Also at Roberts Wesleyan
College, Cynthia R. Davis is a biological and chemical
sciences professor of biology, and Meredith Ader is
Golisano Library access services librarian.
The authors have disclosed no financial relationships
related to this article.
DOI-10.1097/01.NURSE.0000684196.97792.03
Copyright 2020 Wolters Kluwer Health, Inc. All rights reserved.

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