A few months ago, I spoke at the Northwest Indiana Nurses Research Consortium about nurses and Self compassion (thank you Marsha King and Lynette Rayman for this opportunity). I traced the notion of giving mercy and compassion to oneself back to the genesis of why so many of us chose nursing as our profession: our expectation of compassion satisfaction. Many of us saw our mothers, aunts, and other family members pursue nursing as a career and listened to their stories with awe and thought, “That’s what I want to do, to be, when I grow up.” When the hope and expectation of obtaining satisfaction from helping others isn’t realized, our professional quality of life is impacted, and nurses may spiral into compassion fatigue (Stamm, 2010). Folded into compassion fatigue is secondary traumatic stress (Stamm, 2010). This type of trauma is enveloped into the work of nurses. In many instances, to offer care is to subject oneself to the patient’s suffering, their lived experiences during crises and the loss and suffering that is, at times, so intricately related to life and death (Foli, 2022). These co-lived experiences are part of the existential world of nurses.
Nestled into the phenomenon of secondary traumatic stress is our intrapersonal communication, especially self-talk. Kim et al. (2021) asserts that we need a balance in our self-talk messaging; negative self-talk may increase internal motivation and attention, while positive self-talk may increase inaccurate confidence. An important distinction to note, however, is that positive self-talk may not be the same as Self-compassion (Kim et al., 2021). Evidence also leads us to understand that we tend to have more self-talk when faced with conditions that bring anxiety and sadness (Kittani & Brinthaupt, 2023). Needless to say, nurses are immersed in disruptive and emotional events as they carry on with the work that they do.
A part of mindfulness, self-talk is related to Self-compassion (note I capitalize “S”) as intrapersonal messages are constructed. Self-compassionate messages we send and receive have been analyzed by Reyes (2012) in a concept analysis. The antecedent to Self-compassion is suffering (Reyes, 2012). In other words, a person/nurse needs to experience suffering to experience Self-compassion. Reyes (2012) forwards this definition:
In the discipline of nursing, self-compassion is a state of being consisting of self-kindness, mindfulness, wisdom, and commonality that transforms suffering and results in actions that improve the individual’s health and well-being as well as the health and well-being of others (p. 84).
This is a powerful word, then, because if we understand the concept of Self-compassion and its definition, we understand that not only can Self-compassion be seen as a vehicle to self-care and well-being of the nurse, but to others as well. We can even measure our level of Self-compassion through the Self-Compassion Short Form (Raes et al., 2011). Subscales include self-kindness, self-judgment, common humanity, isolation, mindfulness, and over-identification.
Is Self-compassion a part of the secret sauce to offset compassion fatigue and burnout? Duarte et al. (2016) offers such an idea and states that teaching Self-compassion and self-care skills may be a part of reducing nurses’ burnout and compassion fatigue.
To me, here are some examples of what Self-compassion/self-talk may be:
- “You tried your best. It was a hard shift, and you were short-staffed. You were able to do most of the things you needed to.”
- “I made a mistake when I was abrupt with the new nurse. What can I learn from this? How can I more productively deal with the stress I was under?”
- “What do I need right now to let go of these intrusive thoughts? I’m being too hard on myself.”
- “You sensed patient X needed you and you responded in an authentic way. You helped him deescalate.”
In contrast, negative self-talk and self-bullying may sound like:
- “You shouldn’t have taken that break. You didn’t get nearly enough done and left patients and others hanging.”
- “You’re too inefficient. Your attitude stinks. People don’t like you because you’re so negative and you can’t get your work done.”
- “You’ll never be as good as XX. She really is a nurse. You shouldn’t be asking for help as often as you do. You’re an imposter.”
However, there are additional aspects to burnout and compassion fatigue that have bearing on the mental health of nurses, such as the organizational conditions in which they work (Foli, 2022). The feeling that trust has been misplaced by the nurse results in a concept of institutional betrayal in nursing (Brewer, 2021). Although apparent from the conditions nurses worked through in the COVID-19 pandemic, the definition is straightforward, clear, and still relevant today:
“A conceptual definition of institutional betrayal is a deep violation of trust or confidence, or violation of moral standards committed by an institution toward a nurse.”
Brewer (2021) explains the outcomes of such institutional betrayal include intense feelings because of the trust placed; negative well-being; and intention to leave the workplace/profession. These consequences align with the outcomes from my middle-range theory of nurses’ psychological trauma, especially insufficient resource trauma (Foli, 2022). One can imagine the self-talk that may stem from institutional betrayal, which stands in contrast to Self-compassion:
- “Why do we always work short staffed?”
- “Being put on the schedule for a day I asked for off is the last straw. I’m looking for a new job.”
- “They treat us like ‘things’ instead of highly specialized professionals.”
- “My nurse manager hasn’t touched a patient in years. How is she supposed to know how I feel when I’m so tired, I can’t even move.”
- “If they tell me we’re going to do another quality improvement project, I’m going to scream!”
Certainly, such self-talk can quickly become toxic and invade our mindful presence – perhaps even influencing our own Self-compassion in a negative way. If we go back to Reyes (2012) definition of Self-compassion, we are reminded that suffering is an antecedent. The origins of the suffering matter, and the question of whether suffering is avoidable or not becomes of critical importance (Foli, 2022). In other words, is nurse suffering/trauma part of what we do, such as secondary traumatic stress and/or witnessing the unspeakable (Georges, 2011), or is it based on institutional betrayal and avoidable trauma? When we answer that question, we can build our intrapersonal communications on authentic Self-compassion and knowledge of Self (Chinn, et al. 2021). Self-compassion may lead us to examine our ontological selves and gain in knowing who we are and what we need to thrive in the world of nursing. Through knowledge of Self, we balance our other ways of knowing: empirical, aesthetic, ethical, and emancipatory (Chinn et al., 2021). Therefore, I assert it is through Self-compassion that we may be able to mitigate compassion fatigue, burnout, and increase retention and the well-being of others, but only with the assumption that nurses have an organizational environment that aligns with the trust we place in it and helps connect us with our true ontological Selves.
References
Brewer. (2021). Institutional betrayal in nursing: A concept analysis. Nursing Ethics, 28(6), 1081–1089. https://doi.org/10.1177/0969733021992448
Chinn, P., Kramer, M., & Sitzman, K. (2021). Knowledge development in nursing: Theory and process (11th ed.). Elsevier, Inc.
Duarte, Pinto-Gouveia, J., & Cruz, B. (2016). Relationships between nurses’ empathy, self-compassion and dimensions of professional quality of life: A cross-sectional study. International Journal of Nursing Studies, 60, 1–11. https://doi.org/10.1016/j.ijnurstu.2016.02.015
Foli, K. J. (2022). A middle-range theory of nurses’ psychological trauma. Advances in Nursing Science, 45(1), 86-98. doi: 10.1097/ANS.0000000000000388
Georges, J. M. (2011). Evidence of the unspeakable: Biopower, compassion, and nursing. Advances in Nursing Science, 34(2),130-5. doi:10.1097/ANS.0b013e3182186cd8.
Kim, Kwon, J. H., Kim, J., Kim, E. J., Kim, H. E., Kyeong, S., & Kim, J.-J. (2021). The effects of positive or negative self-talk on the alteration of brain functional connectivity by performing cognitive tasks. Scientific Reports, 11(1), 14873–14873. https://doi.org/10.1038/s41598-021-94328-9
Kittani, & Brinthaupt, T. M. (2023). Exploring Self-Talk in Response to Disruptive and Emotional Events. Journal of Constructivist Psychology, ahead-of-print(ahead-of-print), 1–15. https://doi.org/10.1080/10720537.2023.2194691
Raes, F., Pommier, E., Neff, K. D., & Van Gucht, D. (2011). Construction and factorial validation of a short form of the Self-Compassion Scale. Clinical Psychology & Psychotherapy, 18, 25—255.
Reyes. (2012). Self-Compassion: A Concept Analysis. Journal of Holistic Nursing, 30(2), 81–89. https://doi.org/10.1177/0898010111423421
Stamm, B.H. (2010). The Concise ProQOL Manual, 2nd Ed. Pocatello, ID: ProQOL.org.
Your post resonates with me. However, self-compassion talk only goes so far within institutions where institution betrayal is embedded in its culture. Looking elsewhere for employment or union action should be part of that self-compassion talk. Things won’t change unless we, as nurses, get militant about our rights to a safe and mentally healthy workplace.
Thank you for your comment. There is an urgent need for the environment/organization to provide the necessary resources and conditions for nurses to be able to do their work ethically and ensure their mental health. I wish you all the best, Karen Foli
Very nice article on an important notion around self-compassion. This applies to every moment and not just being a nurse. I do agree with Peggy Berry around some significant toxicity in the healthcare environment, especially following COVID. The unhealthy work conditions seem to be getting worse across the board — in the US and Canada. I think being resilient and doing self-care is important, but at the end of the day, we have to ask if nursing has become a profession where toxicity is just one more thing nurses are accepting as part of the job.
Thank you, Jennifer. I agree — self-compassion should apply outside the workplace as well. When we talk about quality patient care, the organizational culture and how professionals who are employed are treated has to be taken into account. If we listen to those who leave an organization, many, many times, it’s due to how the are “treated” or, more accurately, “mistreated.” Thanks again, Karen Foli
Karen,
Thank you very much for this very important blog. I would like to recommend that self-compassion be extended to nurse educators, who often are challenged by the work environment within a college or university.
Thank you, Jacqui! Your feedback means a lot, and I agree with your point. As an active nursologist and educator, I often don’t think of extending grace to myself.
Thanks for this important post! I agree with the comment about the importance of extending this to nurse educators, and would add teaching and modeling this for nursing students could be critical.
In case folks are interested in tools for building and practicing self-compassion, I’d love to share a few resources that I have found helpful.
Kristen Neff, a pioneer for research on self-compassion and co-developer of several interventions to build the skills of self-compassion, has a short, guided meditation to develop skills of self-compassion to support us in difficult caregiving situations. I incorporate it into my teaching and learners have found it very approachable. https://www.youtube.com/watch?v=jJ9wGfwE-YE
(Dr. Neff’s self-compassion scale, available on her website, is also a useful place to start a discussion about self-compassion in the classroom).
The Center for Mindful Self-Compassion offers a multi-week curriculum geared at improving self-compassion skills for healthcare workers: https://centerformsc.org/self-compassion-for-healthcare-communities-schc/
Lastly, The Garrison Institute, in collaboration with several leaders in in contemplative-based resilience, has released an app called Care for Caregivers, which features 8 guided practices including meditation and mindful movement: https://www.garrisoninstitute.org/initiatives/programs/contemplative-based-resilience/
Thank you, Jordon! Oh my gosh – these are amazing resources and I’m so grateful for them. Thank you for taking the time to comment on the blog and list this wonderful information — Karen
Thank you for your valuable perspective, Dr. Foli.
While I read your post, it reminded me of my clinical experience. When I started working at the hospital, I was assigned to the surgical ward. However, for several reasons, I felt clinical work wasn’t for me, began to blame myself for being weak, and eventually, I expressed my desire to resign. A few days later, the Chief Nurse Officer asked me to have a meeting with her. Because we used to know each other, I thought she was going to express concerns about my resignation. However, surprisingly, she said, “I believe you are the most intelligent nurse I’ve ever met, and I suggest you take a new position, Neurology specialized RN, focusing on the management of every patient with neurological disease regardless of patient care settings such as ER, ICU, general wards.” As a relatively new RN, I was grateful for the fact that, on behalf of the hospital, she trusted me and offered me a higher position that was usually reserved for senior RNs. So, I took the offer and kept working at the hospital for patients. I always crisscrossed the hospital all day, from the ground floor to the 10th floor, taking care of up to 100 patients during my shift. Thanks to her trust in me, with high confidence, I was able to work harder than I ever had.
I was unaware until now that this experience involved institutional trust. Reflecting on your post, I realize how her trust in me contributed to fostering my own sense of Self-compassion and enhancing the patient care. I do believe that Self-compassion can lead to the health and well-being of others, and it can be powered by coworkers, seniors, or the workplace environment. Therefore, I assert the necessity of specialized education focusing on Self-compassion. For example, new RNs could be taught how to look at themselves positively without criticizing themselves, senior RNs could be taught how to create a safe environment where colleagues do not experience self-doubt, and the institution itself could formalize all these things into a policy.
There is a term called the butterfly effect. One small change can lead to significant outcomes. The trust from the institution kept one nurse, and that nurse was able to improve the health and well-being of countless patients.