NR 351 Break Through to Resilience Article Worksheet

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REST: Break through to resilience BY SANTHINY RAJAMOHAN, PhD, RN; CYNTHIA R. DAVIS, PhD; AND MEREDITH ADER, MLS 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. DREAMLAND MEDIA/iSTOCK Keywords: burnout, compassion fatigue, resilience, stress 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 individual’s aptitude for overcoming an adverse life circumstance with a hopeful attitude, August l Nursing2020 l 53 www.Nursing2020.com Copyright © 2020 Wolters Kluwer Health, Inc. All rights reserved. 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. NR 351 Break Through to Resilience Article Worksheet

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 one’s 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 one’s 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 one’s 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 individual’s 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 main- tain a healthy lifestyle and function more efficiently throughout the day. NR 351 Break Through to Resilience Article Worksheet

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 54 l Nursing2020 l Volume 50, Number 8 Copyright © 2020 Wolters Kluwer Health, Inc. All rights reserved. www.Nursing2020.com 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. NR 351 Break Through to Resilience Article Worksheet

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 mind-body connection 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 one’s 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 person’s sense of self-worth or status but rather originates from a sense of caring and desire for the well-being of one’s 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 soul’s 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. NR 351 Break Through to Resilience Article Worksheet

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 individual’s 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/ August l Nursing2020 l 55 www.Nursing2020.com Copyright © 2020 Wolters Kluwer Health, Inc. All rights reserved. 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 college’s 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. NR 351 Break Through to Resilience Article Worksheet

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 first-year seminar course 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. edu/initiatives/clinician-resilienceand-well-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 1. American Association of Colleges of Nursing. Fact sheet: nursing shortage. 2019. www.aacnnursing. org/Portals/42/News/Factsheets/Nursing-ShortageFactsheet.pdf. acter strengths, subjective well-being, and prosociality in middle school adolescents. Front Psychol. 2019;10:377. 8. Dewi D, Hamzah H. The relationship between spirituality, quality of life, and resilience. Adv Soc Sci Educ Humanit Res. 2019;349:145-147. 9. Momeni KM, Moradi S, Dinei S, et al. The relationship between quality of life, spirituality, and resilience and suicidal thoughts in students of Razi University. Ann Trop Med Public Health. 2017;10(3):586-588. 10. Ruegsegger GN, Booth FW. Health benefits of exercise. Cold Spring Harb Perspect Med. 2018;8(7): a029694. 11. Magistretti PJ, Allaman I. Lactate in the brain: from metabolic end-product to signalling molecule. Nat Rev Neurosci. 2018;19(4):235-249. 12. Okano K, Kaczmarzyk JR, Dave N, Gabrieli JDE, Grossman JC. Sleep quality, duration, and consistency are associated with better academic performance in college students. NPJ Sci Learn. 2019;4:16. 13. Knufinke M, Fittkau-Koch L, Møst EIS, Kompier MAJ, Nieuwenhuys A. Restricting shortwavelength light in the evening to improve sleep in recreational athletes—a pilot study. Eur J Sport Sci. 2019;19(6):728-735. 14. Edwards MK, Loprinzi PD. Experimental effects of acute exercise and meditation on parameters of cognitive function. J Clin Med. 2018;7(6):125. 15. Schöne B, Gruber T, Graetz S, Bernhof M, Malinowski P. Mindful breath awareness meditation facilitates efficiency gains in brain networks: a steady-state visually evoked potentials study. Sci Rep. 2018;8(1):13687. 16. Zhang Y, Fu R, Sun L, Gong Y, Tang D. NR 351 Break Through to Resilience Article Worksheet

How does exercise improve implicit emotion regulation ability: preliminary evidence of mind-body exercise intervention combined with aerobic jogging and mindfulness-based yoga. Front Psychol. 2019;10:1888. 17. Bulloch A. Psyche: from gods, goddesses and mythology. Credo Reference. 2012. https://searchcredoreference-com.ezproxy.roberts.edu/content/ entry/mcgods/psyche/0. 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. 20. Baumeister RF, Bushman BJ, Campbell WK. Self-esteem, narcissism, and aggression. Curr Dir Psychol Sci. 2000;9(1):26-29. 21. Mercadillo RE, Barrios FA, Díaz JL. Definition of compassion-evoking images in a Mexican sample. Percept Mot Skills. 2007;105(2):661-676. 2. US Bureau of Labor Statistics. Occupational Outlook Handbook. Registered Nurses. 2020. www.bls.gov/ ooh/healthcare/registered-nurses.htm. 22. Kukk Christopher L. Compassionate Achiever: How Helping Others Fuels Success. New York, NY: Harper Collins Publishers; 2017. 3. Manomenidis G, Panagopoulou E, Montgomery A. Resilience in nursing: the role of internal and external factors. J Nurs Manag. 2019;27(1):172-178. 23. Melnyk BM. Burnout, depression and suicide in nurses/clinicians and learners: an urgent call for action to enhance professional well-being and healthcare safety. Worldviews Evid Based Nurs. 2020;17(1):2-5. 4. Brown S, Whichello R, Price S. The impact of resiliency on nurse burnout: an integrative literature review. Med/Surg Nurs. 2018;27(6):349-378. 5. Stephens TM. Nursing student resilience: a concept clarification. Nurs Forum. 2013;48(2):125-133. 6. Tubbert SJ. Resiliency in emergency nurses. J Emerg Nurs. 2016;42(1):47-52. 7. Kor A, Pirutinsky S, Mikulincer M, Shoshani A, Miller L. A longitudinal study of spirituality, char- 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 56 l Nursing2020 l Volume 50, Number 8 Copyright © 2020 Wolters Kluwer Health, Inc. All rights reserved. www.Nursing2020.com Criteria Ratings Pts 35 pts Reference for Assigned Journal Article: 32 pts Meets Exceeds O pts Developing No reference provided. Creates a reference for the assigned article using correct APA format including items in Creates a reference for the assigned article using correct APA format including items in left column. 3- 4 elements missing or incorrectly done. 40 pts Exceptional Creates a reference for the assigned article using correct APA format including author(s), year, article title, journal name, volume number, issue number, page numbers, italics, parentheses, punctuation, double line spacing, and hanging indent. Includes DOI if available. 0-2 elements missing or incorrectly done. NR 351 Break Through to Resilience Article Worksheet

Create a reference for the assigned article using correct APA format including: author(s), year, article title, journal name, volume number, issue number, page numbers, italics, parentheses, punctuation, double line spacing, and hanging indent. Include DOI if available. left 15 pts Needs Improvement Creates a reference for the assigned article using correct APA format including items in left column. 7 or more elements missing or incorrectly done. OR creates reference for article other than the assigned article. column. 5- 6 elements missing or incorrectly done. 40 pts Quotation with Citation: 35 pts 31 pts 13 pts O pts Exceptional Types the assigned quotation from the assigned article using correct APA 28 pts Meets Types the assigned quotation from the assigned article using correct Exceeds Types the assigned quotation from the assigned article using correct APA format including items at left with 2- 3 minor Needs Improvement Types a quotation other than the assigned quotation OR from a non- assigned article. OR has 6-7 minor Developing More than 7 errors in APA quotation and citation format OR no quotation provided. format Type the assigned quotation from the assigned article using correct APA format including quotation marks, names of author(s), year, page abbreviation, page number, parentheses, and punctuation. APA 35 pts errors. including quotation marks, names of author(s), year, page abbreviation, page number, parentheses, and punctuation with 0-1 minor format including items at left with 4- 5 minor errors. errors error 40 pts 32 pts 15 pts O pts 35 pts Exceeds Meets Paraphrased Area and Citation: Type appropriately paraphrased version of the assigned sentence using correct APA format including names of author(s), year, punctuation, and parentheses. Developing More than 7 errors in APA paraphrase and citation format OR Exceptional Types appropriately paraphrased version of the assigned sentence using correct APA format including names of author(s), year, punctuation, and parentheses with 0-1 no Needs Improvement Types a paraphrased version of a sentence other than the assigned sentence OR from a non- assigned article. OR has 6-7 minor Paraphrased version of the assigned sentence is mostly appropriate using correct APA citation including names of author(s), year, punctuation, and parentheses with 2-3 32.0 pts Meets Paraphrased version of the assigned sentence is minimally appropriate using correct APA citation including names of author(s), year, punctuation, and parentheses. OR citation has with 4-5 paraphrase or citation provided. 40 pts errors. NR 351 Break Through to Resilience Article Worksheet

Inappropriately paraphrases words or ideas that the authors cited from another error. errors. errors. source. 60 pts 48 pts O pts Meets Summarizes Assigned Article Summary: Clearly summarizes the major content of the assigned article using 175-200 a fair Exceptional Clearly summarizes the major content of the assigned article using 175-200 Developing No article summary is provided. amount of the content 53 pts Exceeds Summarizes the major content of the assigned article using 175-200 words. Content includes most of the main ideas of the words. words. Content assigned article. Content includes a fair amount of the main ideas from includes main ideas from across 23 pts Needs Improvement 23.0 pts Needs Improvement Provides a summary but assigned article is not used. OR any of the following: • Word count is 75-124 or 251-300 (51- 100 words over or under required amount). • Content includes few of the main ideas from across the entire article. Specifics are Content includes main ideas from across the entire article. Specifics are excellent. from across across the The 60 pts the entire article. Specifics are excellent. The Summary must contain appropriately formatted assigned quotation, assigned paraphrased sentence and other paraphrased areas, and citations. Summary contains appropriately formatted assigned quotation, paraphrased sentence and other paraphrased areas, and citations. the entire article. Specifics are good. The Summary contains mostly well formatted assigned quotation, paraphrased sentence and other paraphrased areas, and citations. entire article. Specifics are fair. The Summary is missing the assigned quotation, assigned paraphrased sentence, or citations. OR word count is 125-165 or 210-250 (10-50 words over or under required amount). poor. • The Summary is missing the assigned quotation, assigned paraphrased sentence, AND citations.