Chapter 88: Putting Caring Into Practice: Caring for Self

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Imagine a patient sitting on your exam table.

You pull up their chart and, well, the subjective and objective findings are just glaring.

Oh, absolutely.

Red flags everywhere.

Right.

I mean, they are reporting chronic sleep deprivation, a complete cessation of exercise and a diet consisting mostly of, you know, whatever they can eat in three minutes flat.

Probably out of a vending machine.

Exactly.

Their cortisol levels are likely sky high and they admit to feeling this constant heavy guilt about neglecting their family.

It's a classic presentation.

It is.

And if you saw this patient, you would immediately initiate an aggressive, comprehensive You wouldn't even hesitate.

But what if the person looking back at you from that chart is actually you?

Yeah, that is the exact reality we are confronting today in this deep dive.

It requires a fundamental shift in perspective.

It really does.

Because you, as an advanced practice nursing student, you spend so much time logging into your clinical portals, prepping for practice Q &As and, well, obsessing over how to manage complex diseases like diabetes or hypertension for someone else.

Right.

For the patient.

But to effectively heal others,

you must first direct health supporting activities toward yourself.

It's grounded in what we call the circle of caring model.

The circle of caring.

Yeah.

The core premise is incredibly simple,

but easily forgotten.

You cannot use your strength as a source of replenishment for others if your own reserves are entirely depleted.

Okay, let's unpack this.

Because to really master this, we have to stop treating self -care as some soft optional buzzword.

We need to start treating it like a rigid clinical protocol.

I love that.

Yeah.

So today, this is a warm one -on -one tutoring session for you, the student.

We are going to look at your own health with the same rigorous lens you apply to your patients.

Which is exactly how Chapter 88 approaches it.

Right.

This protocol has its own foundational science, a clear pathophysiology of how stress infects you, a specific assessment strategy, and a highly detailed evidence -based management plan.

I really love that clinical framework.

Because before we can diagnose a problem, we always have to understand the baseline anatomy and physiology.

So what does that look like here?

Well, if we are looking at the nursing domain, that means strictly defining what caring and self -care actually mean.

And historically, the medical community didn't take this seriously at all.

No, they definitely didn't.

Researchers like Godfrey and colleagues, they actually had to analyze 139 different definitions of self -care published over decades just to pin down what we were talking about.

Wait,

139 different definitions?

That's wild.

I know, right?

Because for so long, self -care was viewed as a low -quality or ineffectual behavior.

It was just dismissed.

Exactly.

But now, it demands urgent, critical attention.

Let's look at how major organizations define that baseline health today.

The World Health Organization, they take a very mechanical approach.

Fair folkshittle.

Yeah.

Their definition focuses heavily on outcomes, maintaining health, preventing disease, and coping with illness.

And they note this can be done with or without a health care worker.

Right.

But then you look at the American Holistic Nurses Association, the AH &A.

Their definition goes much deeper into the subjective human experience.

Okay.

How so?

They require the integration of self -care into one's life to achieve harmony and balance.

They explicitly state that nurses must be aware of being an instrument of healing.

An instrument of healing.

I like that.

Yeah.

You aren't just a mechanic fixing a body.

Your state of being impacts the patient.

And Dorothea Orem's classic nursing theory builds on this, defining self -care as those independent activities you perform to promote and maintain your well -being throughout your entire life.

So I have to push back slightly here on behalf of our listeners.

Sure.

Go ahead.

When we start talking about harmony, balance, and being an instrument of healing, I can see your eyes rolling.

I mean, isn't self -care just a modern social media trend?

Oh, I see where you're going.

We see it everywhere on our feeds, right?

Buy this expensive bath bomb, book this luxury spa weekend, drink this overpriced smoothie, and call it self -care.

How does that concept actually apply to an advanced practice nurse drowning in charts in a busy clinic?

It is such a valid skepticism.

I mean, we really have to separate the commercialization of self -care from the clinical reality.

Thank you.

Yes.

Major professional organizations treat this as a rigorous standard, not a weekend luxury.

The American Nurses Association implemented the Healthy Nurse, Healthy Nation initiative specifically to combat the reality that nurses are often less healthy than the populations they serve.

Wow.

Less healthy than their own patients.

Exactly.

It is an evidence -based necessity.

But what's fascinating here is framing your self -care as a direct form of patient teaching.

Wait.

How is it patient teaching?

By successfully managing your own health and modeling those healthy lifestyle behaviors, you are actively promoting self -care in your patients.

If you are chronically stressed, exhausted, and burnt out, your patients read that energy.

You are the clinical baseline they are looking to.

Oh, that makes total sense, which brings us perfectly to the mechanism of injury.

Now that we have established what baseline health should look like, let's explore the path of physiology.

The path of physiology of stress.

Right.

Why is staying healthy suddenly so profoundly difficult for nurse practitioners?

We can trace the etiology of this stress by looking at the specific systemic pressures you face, starting with the macro -level system changes.

Think about the massive shift in responsibility over the last few years.

The Future of Nursing 2021 report demands that MPs function to the full extent of their education and licensure.

Which is great, right?

It's a huge, necessary victory for the profession, but it's a heavy mantle to carry.

Combine that full practice authority with the Affordable Care Act.

The ACA rightfully increased patient access to care, bringing millions of people into the system.

But inherently, that caused a massive spike in patient demand for primary care practitioners.

You are seeing more patients with more complex needs carrying a higher level of ultimate clinical responsibility.

And then you add the insurance and technology factors on top of that clinical load.

It's a perfect storm.

It really is.

MPs are frequently dealing with reimbursement rates that are lower than those of physician providers for the exact same care.

That creates an underlying financial pressure on clinics, which translates to pressure on you to see patients faster.

And faster means less time to actually think.

Exactly.

Plus, you have this massive uncompensated time suck of administrative burdens.

You are spending hours completing prior authorizations just to get your patient the medication you already know they need, or filling out endless forms for schools and workplaces.

And that leads perfectly into the technology paradox.

The electronic health record, the EHR, is a marvel for data tracking and continuity of care.

But it has created a massive time demand during the actual patient visit.

Oh, the charting.

It never ends.

Right.

You're constantly split between making eye contact with the human in front of you and feeding data into a screen.

Honestly, dealing with the EHR and the endless insurance paperwork feels exactly like a chronic low -grade infection.

A chronic low -grade infection.

That is a phenomenal analogy.

Thanks.

I mean, it doesn't necessarily kill you all at once, but it just constantly drains your immune system, your time, your cognitive bandwidth, your emotional energy, leaving you incredibly vulnerable when an acute stressor hits.

It is a chronic depletion of your reserves.

And speaking of acute stressors,

consider the massive pivot to telehealth during the COVID -19 pandemic.

Oh, wow.

Yes, that changed everything.

Nursing is a profession historically built on physical touch, presence and direct observation.

Suddenly, having to learn how to assess, diagnose and care for complex patients remotely through a webcam stripped away your primary tools.

It's like trying to practice medicine with one hand tied behind your back.

Exactly.

It added a whole new layer of diagnostic anxiety.

You're constantly wondering, did I miss a subtle physical cue because the video quality was poor?

That anxiety compounds the documentation burden.

And those are just the stressors localized to your clinic.

We have to broaden the scope to the global and societal stressors you absorb every day.

Global travel means primary care providers can never let their guard down.

Right.

You have to constantly anticipate and adapt to outbreaks.

We've seen SARS, H1N1, Ebola, Zika, and obviously the devastating long -term impacts of COVID -19.

The hits just keep coming.

And on a societal level, you are managing the fallout of the opioid epidemic, poverty and joblessness.

And well, there's a very specific rising mental health toll from social media.

A bullying, the comparison culture.

Exactly.

And the anxiety it produces severely impacts the patient populations you treat, meaning you are managing more psychiatric and emotional distress in a standard primary care visit than ever before.

Finally, we have to look at the professional stressors that act as the final blow to your immune system.

The Institute of Medicine demands interdisciplinary health care teams.

Which sounds great on paper.

On paper, collaborative care is the gold standard.

But in practice, it often leads to blurring roles.

Different professionals are constantly trying to expand or protect their scope of practice.

Plus, APRNs are dealing with ongoing legislative confusion around the doctorate of nursing practice, the DNP.

It's just constant friction.

There is a constant underlying tension.

You are squeezed between the traditional nurturing role of being a nurse and the diagnostic, authoritative role of a primary care provider.

You are constantly negotiating professional boundaries and fighting to advocate for patients in a system that sometimes actively resists letting you do your job effectively.

OK, so if we treat the systemic stress like a chronic infection, we know that when it goes unmanaged, clinical symptoms inevitably appear in the provider.

But here is where we need to apply our clinical reasoning.

We have to make a differential diagnosis.

We are looking at two distinct conditions that are often lumped together but require completely different management plans.

Compassion fatigue versus burnout.

Can we break down the exact mechanisms of each?

Absolutely.

Let's start with compassion fatigue.

The defining characteristic here is that it occurs suddenly.

Like an acute event.

Yes.

It happens acutely when a caregiver cannot rescue or save an individual from harm.

Think of a traumatic loss or a catastrophic patient outcome that you just couldn't prevent.

That sounds devastating.

It is.

The mechanism here is a profound emotional rupture.

It manifests very specifically as intense feelings of guilt and distress.

Because it is an acute emotional trauma, the resolution of compassion fatigue is highly variable and uncertain.

It takes time to process that failure to rescue.

Contrast that with burnout.

The research, specifically citing Valent's work, defines burnout as something that arises and declines much more slowly.

It's insidious.

Yeah.

Burnout occurs when a person consistently cannot achieve their goals due to systemic barriers.

The clinical presentation is completely different from compassion fatigue.

Instead of acute guilt, burnout manifests as deep frustration.

And exhaustion.

Right.

It is a profound sense of a loss of control.

Often the early symptom is increased willful effort, meaning you just try to push harder, work longer hours, and brute force your way through the systemic blockades.

But ultimately that fails, leading to diminishing moral and emotional exhaustion.

So why does distinguishing between the two matter so much for an NP student?

I mean, if I feel terrible, I feel terrible, right?

That's the trap.

Because mistaking burnout for compassion fatigue guarantees you will write the completely wrong self -care management plan.

Oh, definitely.

If you are experiencing burnout because the EHR is crashing and you have zero control over your schedule, taking a weekend yoga retreat isn't going to cure that fundamental loss of control.

You'll come back on Monday and the EHR will still be broken.

Exactly.

Conversely, if you have compassion fatigue from a traumatic patient loss, trying to organize your schedule better or join a committee won't address the acute guilt and grief you are carrying.

This raises an important question.

NP's are trained to be uniquely excellent at spotting these subtle differential diagnostic clues in their patients.

Why do they so frequently ignore these exact textbook red flag findings in themselves?

I'll tell you why.

Because they avoid taking the time in the middle of a packed 12 hour shift to take their own vitals.

They just keep pushing.

Yep.

They just power through.

Which means we need a reliable way to assess ourselves.

Once we understand the differential diagnosis, how do we objectively measure our own stress before we write a treatment plan?

We shouldn't just be guessing at our viral load, so to speak.

Precisely.

You need an objective assessment strategy.

The standard diagnostic tool for this is the Professional Quality of Life Scale or the Pro QOL scale.

Pro QOL.

Okay.

It is specifically designed to measure three vital things.

Your levels of compassion satisfaction, which is the positive feeling you get from doing your job well, your level of burnout, and your level of secondary traumatic stress.

It gives you measurable data on your emotional state.

Once you have that objective baseline, you can finally move to the interventions, the actual treatment plan.

But we can't just jump straight into therapies.

There are foundational principles that must be present for any specific intervention to actually work.

The groundwork.

Right.

The first principle is resilience.

And I want to be clear.

Resilience is not just toughing it out or silencing your complaints.

Resilience is defined as the active ability to positively adjust to stressors.

It is a muscle you build through laughter, humor, deep self -reflection, and spirituality.

The second foundational principle is positive intentionality, which is a truly fascinating concept from nursing theorist Gene Watson.

Oh, Gene Watson's work is great.

It really is.

Positive intentionality is a form of focused consciousness.

It is the understanding that where you direct your mind actually matters.

By consciously focusing your thoughts and actions on positive intentionality, you actually enhance caring energy.

So it's not just a mindset.

It's an active practice.

Yes.

Watson's theory suggests that this focused consciousness directly leads to healing and improved health, both for you and the patient.

It's about consciously directing your purpose rather than just mechanically going through the motions of an exam.

And tying directly into that focused consciousness is the concept of emotional intelligence, which is heavily supported by Heffernan's research.

Emotional intelligence is your ability to recognize your own emotions in real time, understand what those emotions mean, and crucially realize how they are physically and emotionally affecting the people around you, your colleagues, and your patients.

That's all connected.

It is.

Heffernan found a direct positive correlation between self -compassion and emotional intelligence among nurses.

You cannot be emotionally intelligent toward a patient if you are actively berating yourself internally.

You have to be able to extend the exact same grace you give your patients to yourself.

With those foundations of resilience, intentionality, and emotional intelligence set, we can look at the specific alternative therapies for your management plan.

And these aren't just They are evidence -based interventions.

That's the key distinction.

First is mindfulness -based stress reduction.

The physiology behind this is well -researched.

By engaging in mindfulness, you actively down -regulate your sympathetic nervous system, pulling yourself out of that chronic fight -or -flight state, and reducing both acute anxiety and chronic depression.

Then there are therapies focused on energy fields, like therapeutic touch.

And this isn't just a metaphor.

It was developed by nurses Dora Coons and Dolores Krieger.

Krieger's work is foundational.

Yeah, Krieger actually applied the principles of energy field interactions to create a sequential clinical process.

The nurse deliberately directs their positive intentionality toward the patient's well -being to modulate their energy field.

It has been proven clinically useful for reducing pain, improving wound healing, and creating deep relaxation.

Similarly, there is Reiki.

This is a complementary energy therapy designed to rebalance the energy field around a person.

The mechanism here is about restoring a positive state of energy flow to clear blockages caused by trauma or stress.

It helps manage that chronic stress load and brings the individual back to a baseline state of peace.

Those are fantastic micro -level interventions for acute symptom management.

But what about a long -term macro -level health promotion strategy?

For that, we look to the Blue Zones, based on Buettner's extensive research.

The Blue Zones are so interesting.

Right.

These are the geographic areas with the healthiest, longest -living populations in the world.

They don't just have good genetics.

They follow specific behaviors known as the power of nine.

And if we look at the mechanisms behind the power of nine, they directly combat the pathophysiology of NP stress we discussed earlier.

So what are some of the components?

It includes moving naturally throughout the day, rather than just intense, forced gym sessions.

It requires having a clear, articulated purpose in life.

It emphasizes downshifting.

Downshifting, like in a car.

Sort of.

Downshifting isn't just taking a nap.

It's an active routine like meditation or prayer that physically interrupts the HPA axis to stop the continuous production of cortisol, which otherwise degrades your tissues over time.

Oh, wow.

That's powerful.

It also includes the 80 % rule for eating, meaning you stop when you are 80 % full, which radically changes your metabolic and inflammatory load alongside maintaining a heavily plant -based diet.

But implementing all this requires support.

You cannot do it in a vacuum.

The most critical intervention is developing your own inner circle of trusted peers.

You need a team.

Exactly.

Think about it this way.

If you have a patient presenting with multi -system organ failure, you don't treat them alone.

You bring in cardiology, nephrology, endocrinology.

You build a team.

When you, the provider, are experiencing severe burnout or compassion fatigue, your emotional systems are failing.

Right.

You're in multi -system failure emotionally.

So you shouldn't try to manage that severe case alone.

You need peer coaching, debriefing, and mentoring to rebuild your resilience.

It's like consulting a team of specialists.

That is the perfect transition because in nursing school, knowing the theory and the definitions only matters if you can apply it safely and effectively to a real human being.

So let's talk about Jane.

Yes, Jane R.

is a case study from the chapter.

But, well, we all know Jane.

Some of us are Jane.

Let's evaluate her to model proper clinical reasoning.

Okay.

Let's look at Jane's subjective and objective findings.

Jane is an NP with 10 years of experience in family primary care.

She works in a busy urban community health center.

On paper, she's a rock star.

She sees 24 to 26 patients in an eight -hour day, and four to six of those are brand new, complex patients.

That is a massive load.

It is.

But behind the scenes, there is a massive red flag finding.

Jane is taking her EHR documentation home.

She is spending two to three hours every single night and occasionally a full day on the weekend, just responding to emails, checking labs, and charting.

That right there is the mechanism of injury.

She has completely eroded the boundary between her restoration space, her home, and her depletion

Totally.

Now, look at her clinical symptoms.

Subjectively, she complains of constant worry about missing a subtle diagnostic clue.

She feels immense, heavy guilt that she is neglecting her husband.

Objectively, she reports a complete cessation of exercise, a terrible diet, and a total lack of restorative sleep.

She is in a state of advanced systemic burnout.

Here's where it gets really interesting.

How do we fix Jane?

What is her management plan?

It starts with that inner circle we talked about, interprofessional collaboration.

She doesn't do it alone.

Right.

She talks to her mentor, the senior NP who originally oriented her.

They sit down and realize they are both drowning.

So they escalate it.

They take it to the macro level.

They bring it up at a staff meeting and realize almost all the providers in the clinic are suffering from the exact same systemic infection.

Together, they take this issue collectively to administration, framing it as an unacceptable, unsafe institutional situation.

But notice the clinical reasoning here.

Jane didn't just try to work harder.

She didn't buy a new planner to fix her time management.

Right.

No toxic positivity.

Exactly.

She assessed her baseline.

She utilized peer coaching.

She advocated for systemic change at the administrative level to treat the root cause of the burnout.

But she didn't stop there.

She knew she also had acute symptoms that needed immediate treatment.

So she applied an evidence -based alternative therapy.

She self -referred to a nurse colleague who practices therapeutic touch.

And the results were tangible.

As a result of those therapeutic touch treatments directing positive intentionality toward her depleted energy field, Jane's physical symptoms actually improved.

She started sleeping through the night, her baseline anxiety decreased, and because she was finally resting, she found the renewed physical energy to start exercising again.

It's incredible.

Jane's ultimate cure required a dual approach.

Micro level personal therapies to restore her own energy field and macro level workplace advocacy to fix the systemic infection of her workload.

That case study perfectly synthesizes everything we've discussed today.

Protecting one's own health is not a selfish act.

It is not a luxury.

It is a strict evidence -based clinical requirement.

It is a core competency of advanced practice nursing.

You literally cannot skip it.

No.

The science is entirely definitive.

If you drain your own energy field, if you ignore your own path of physiology of stress, and if you refuse to take your own emotional vitals, you simply cannot be a safe, effective instrument of healing for your patients.

You have to actualize the circle of caring for yourself first before you can extend it to anyone else.

So as you prepare for your clinicals tomorrow or your next shift, we want to leave you with a final thought to mull over.

Something to really think about.

If you were to pull out a blank chart right now, sit on the exam table and document your own vital signs for positive intentionality and resilience today, what would the clinical notes say?

What is your objective baseline?

Be honest with yourself.

And more importantly, if you saw those exact same numbers on a patient's chart, would you allow them to walk out of your clinic without an aggressive intervention?

Thank you for joining us for this deep dive.

A warm thank you from the last minute lecture team.

Take care of yourselves out there.