Chapter 19: Self‐care and wellbeing
Skip chapter table of contents and go to main content
Source: Adapted from DH ([18]).
Related theory
Working in a caring role can be profoundly rewarding. Being alongside others when they are at their most vulnerable and scared is a privilege and incredibly fulfilling. Most choose the caring professions because they want to look after people and positively respond to human needs. Skovholt and Trotter‐Mathison ([72]) describe the joys, rewards and gifts of practice that this close connection to others in need can bring as ‘having a ringside seat in the human drama and at times assist in making the drama turn out well’ (p.12). In other words, we do it because we get a lot from giving and caring; specifically, Skovholt ([71]) suggests four ways in which those in caring roles are rewarded:
- Caring roles provide a sense of identity and connection to others.
- Those in caring roles receive a type of love and status in the eyes of those they help (and of course money).
- Caring roles provide a unique opportunity to learn from those receiving care: this learning may encompass life and its deep, profound themes, such as how we cope with pain, what is important and what gives life meaning.
- Caring roles provide direct social reinforcement through affirmation, approval and positive feedback, which gives purpose and a sense of self‐worth.
These ideas were first proposed as the ‘helper therapy principle’ by Riessman ([65]).
When a person begins a career in care, they often have very high expectations of themselves and little thought is given to the effect of the work either physically or emotionally. Statistics show that caring work has an impact on the wellbeing of the carers. Drawing figures from the 2013 Absence Management Survey, carried out by the CIPD ([8]), the Royal College of Physicians (RCP [63]) reported that ‘NHS staff had 15.7 million days off sick in England alone in 2013–14’ (p.2) and that ‘sickness absence rates [in the NHS] are 27% higher than the UK public sector average, and 46% higher than the average for all sectors’ (p.3).
Monthly absence figures reported by NHS Digital ([52]) indicate that the number of days lost to sickness has not changed significantly in the past five years, with the highest rates in the following occupational groups: healthcare assistants, ambulance staff and nurses. NHS Employers ([53]) suggests that the leading causes of absence in NHS staff are:
- Mental ill health: this is estimated to account for more than a quarter of staff sickness absence in the NHS. It was found that 38% of NHS staff in England reported having suffered work‐related stress and/or being unwell as a result of work‐related stress during 2013 (National NHS Staff Survey Co‐ordination Centre [47]).
- Musculoskeletal disorders: with staff frequently engaging in physically demanding activities, musculoskeletal disorders are a major cause of illness and injury in the NHS workforce. They have been estimated to account for nearly half of all NHS staff absence (Boorman [3]).
- Unhealthy lifestyles leading to problems such as obesity and overweight: the government has estimated that around 300,000 NHS staff are obese, with a further 400,000 overweight (Cross‐Government Obesity Unit [14]). Long hours of work, shift patterns and an environment that lacks facilities (e.g. a place to rest, exercise equipment, a café and a good working environment) contribute to the challenge of maintaining a healthy eating, sleeping and exercise routine (RCP [63]).
The national political response to these issues began with a review of health and wellbeing in the NHS, which was followed by the Boorman Report (Boorman [3]). These initiatives detailed the current health and wellbeing of the NHS workforce and highlighted the need for improvement so that absence rates would drop. It was anticipated that less absence would make a significant difference to the patient experience, outcomes and the quality of care, and would also have financial benefits.
It has taken some time for significant action to begin at a national level to drive and support a focus on staff wellbeing in the workplace, but such efforts are now forthcoming. For example, the Royal College of Physicians and other professional organizations have made the case that ‘our healthcare system's greatest asset is the people who deliver it’ and that ‘for this system to provide safe, sustainable, patient‐centred care, it is critically dependent on a healthy and engaged workforce with good mental and physical wellbeing’ (RCP [63], p.2). In 2018, NHS Employers published the NHS's Workforce Health and Wellbeing Framework, which gives equal recognition to organizational enablers (e.g. yoga classes and provision of healthy food) and specific health interventions (e.g. encouraging staff to take the required amount of exercise and eat healthy food) as necessary to improve the health and wellbeing of NHS staff (NHS Employers [53]).
Wellbeing
The ancient Greeks debated the concept of wellbeing: it was a core issue for philosophy and ethics. In recent years, as more research has been done on happiness, the term ‘wellbeing’ has gained more attention in economics and psychology, and has therefore been integrated into thinking and policy development (Fletcher [25]). Although a definition of wellbeing was offered at the beginning of this chapter, there is no agreement on a universal definition because it is dependent on why it is being defined.
The Department of Health report Wellbeing: Why It Matters to Health Policy (DH [18]) proposed that wellbeing should be a core concept underpinning health policy and gave a number of reasons as to why it should matter (Box 19.1). The report defines wellbeing in the context of health policy as ‘feeling good and functioning well’ and states that it ‘comprises an individual's experience of their life; and a comparison of life circumstances with social norms and values’ (DH [18], p.6). Wellbeing exists in two dimensions:
- subjective wellbeing (or personal wellbeing), which is how people think and feel about their own wellbeing, including their life satisfaction and whether their life is meaningful
- objective wellbeing, which is based on assumptions about basic human needs and rights, including aspects such as adequate food, physical health, education and safety.
Separately, the Office for National Statistics ([55]) created the ‘Well‐Being Wheel’, which illustrates the 41 statistical dimensions of national wellbeing (Figure 19.1).
Figure 19.1 The ‘Wheel of Wellbeing’. Source: Reproduced from Office for National Statistics ([55]).
Box 19.1
Why wellbeing matters to health
- Adds years to life
- Improves recovery from illness
- Is associated with positive health behaviours in adults and children
- Is associated with broad positive outcomes
- Influences the wellbeing and mental health of those close to us
- Affects how staff and healthcare providers work
- Has implications for decisions for patient care practices and services
- Affects decisions about local services
- Has implications for treatment decisions and costs
- May ultimately reduce the healthcare burden
Subjective wellbeing, it is proposed, increases life expectancy and improves not only health but also recovery from illness and injury. It is also associated with positive health behaviours in adults, such as eating a good diet, taking regular exercise, and less smoking and alcohol consumption (DH [18], pp.9–11). Significantly, if people are happy, this positively influences the subjective wellbeing of others they come into contact with, particularly their friends and neighbours (DH [18], p.13).
Thin ([75]) describes people working in healthcare as ‘happiness facilitators’. In a formal healthcare setting, nurses are generally in closest contact with patients compared to other healthcare professionals, which means that nurses’ wellbeing is most likely to affect the quality of patients’ experiences (Maben [42]).
Section 3a of the NHS Constitution states that ‘the NHS commits to provide support and opportunities for staff to maintain their health, well‐being and safety’ (DH [17], p.8). Therefore, the NHS encourages organizations to promote staff wellbeing, but it is also significant to note that staff wellbeing can improve the quality of patients’ experiences and health outcomes (DH [19]). Studies show that there is a connection between healthcare sector staff wellbeing (on the one hand) and how patients rate the care they receive and their health outcomes (on the other); NHS organizations that have more favourable indicators of staff wellbeing (e.g., in relation to bullying, harassment and stress) have better attendance, lower staff turnover, less agency spending, higher patient satisfaction and better outcome measures (Boorman [3], Dawson [16], Raleigh et al. [60]).
Stress
However, it is also recognized that work is not necessarily always good for wellbeing because, while employment can improve self‐esteem, it can also be stressful (McManus and Perry [44]), so staff wellbeing initiatives need to involve the enhancement of positive psychological wellbeing as well as the reduction of negative pressure (e.g. stress) (DH [20]). There is a great deal of disagreement both among academics and in popular opinion as to exactly what the definition of stress is, although all agree that it is very complex. In their study on workplace stress Sulsky and Smith ([74]) define stress as ‘any circumstance that places special physical and/or psychological demands on an organism leading to psychological, physiological and behavioural outcomes. If these demands persist over time, long term or chronic undesirable outcomes or strains may result’ (p.6). This definition seems to be in stark contrast to the World Health Organization's ([83]) definition of occupational stress as ‘the response people may have when presented with work demands and pressures that are not matched by their ability to cope’.
In the context of looking at how stress affects nurses, it seems to be most useful to define stress as a dynamic process, not just a reactive one. It is an ongoing process that affects the body and the mind, rather than an in‐the‐moment response to demands and pressure. This definition, which has been widely adopted in occupational stress literature, is called the ‘transactional approach’. Mark and Smith ([43]) use this definition to encompass both fields of thought on stress (i.e. that it is an ongoing process but also an in‐the‐moment response), stating that an environmental demand becomes a ‘stressor’ only when the individual perceives that it exceeds their available physical, emotional and psychological resources and threatens their wellbeing. This threat then triggers psychological, physiological and behavioural responses or ‘strain’ in an attempt to cope.
Anatomical and physiological factors
Recent studies in neuroscience have helped to develop a further understanding of the physiology of stress and its physical as well as emotional impacts. This knowledge has also assisted in the identification of evidence‐based self‐care strategies that can help individuals to cope more effectively with the demands of working in healthcare.
Physiologically, stress is the ‘fight‐or‐flight response’, in which the whole of a person becomes prepared to respond to a ‘threat’, either by recruiting all of their strength to physically defend themselves or by moving as quickly as they can to escape. This response can be switched on by an internal process – that is, by thoughts alone. As adrenaline and cortisol are released into the body, one of the immediate impacts is the redirection of blood to the muscles, lungs and heart, which prepares them to respond with as much strength and speed as they are able. This, however, means that other organs have less blood supply, with immediate – but survivable – consequences. Thus, blood is directed away from the prefrontal cortex and other parts of the brain, which affects our ability to make creative, logical and rational decisions in the moment and also our ability to remember the event afterwards. The gastrointestinal system also has less blood available, so digestion is impacted. In addition, many other micro‐processes are interrupted, such as cell regeneration, which is important for processes including growing, learning and healing (Holroyd [33]). The cortisol also breaks down complex compounds in the body (such as sugars, fats and proteins) so they are available for energy to power the immediate fight or flight.
Physiologically, humans have evolved to survive brief periods of stress without any long‐term damage (Cozolino [11]), but ongoing or chronic stress has physiological as well as psychological consequences. The continual release of cortisol and the continual breakdown of fats and proteins result in:
- inhibited inflammatory processes, which is a natural response to injury or a foreign agent in the body – this explains why cuts do not heal and we get mouth ulcers when we are stressed
- over the longer term, inhibition of white blood cell production, reducing immunity – this is why, after working for weeks in a busy, stressful environment, we may become ill as soon as we go on holiday
- damage to the hippocampus (the part of the brain that is essential for regulating emotions and memory)
- a decrease in plasticity and neural growth, inhibiting the ability to stop the fixed unhelpful and destructive thought patterns that can maintain the stress response (Cozolino [11]).
If we are experiencing stress for a considerable period of time, it can translate into our musculoskeletal system as well. It is experienced as tense muscles, rigid posture and a decrease in flexibility, which increases the risk of musculoskeletal injury. Additionally, when a person is stressed, awareness of body posture and position often decrease.
Psychological factors
What stresses an individual is very personal: what one individual views as stress, another will view as pressure and therefore their responses will be very different. A key driver that turns pressure into stress is what is known as ‘rumination’ (Waugh [79]). This is the mental process of thinking about the same thing over and over – either something that happened in the past or something that could happen in the future – and attaching a negative emotion to it.
The types of pressure that nurses experience are many and varied. Some are organizational (through targets and monitoring of performance) whereas others are political or managerial and are common to many professions. However, the unique pressures of healthcare are the expectations of patients and their families, which can often feel overwhelming. We add to this with the pressure we put on ourselves to fulfil our ‘mission’ to help, heal and show compassion.
Nursing requires a well‐developed ability to empathize. Empathy allows nurses to connect with the people they are caring for and help them on a more than physical level. It is the empathetic connection to a patient that gives you the feeling that you have really been able to help them and that you have made a difference. Likewise, when a patient has experienced empathy from a nurse, they feel understood and valued as an individual.
Wiseman ([82]) summarized the defining attributes of empathy in nursing as the ability to see the world as others see it, be non‐judgemental, understand another's feelings and then communicate that understanding. Empathy is psychologically demanding; to be empathetic, you have to give up part of yourself and for a time connect with another person on a deeper level. Sometimes as a nurse this will be all you have to offer; you cannot ‘fix’ the problem for the person, just be with them in their distress and be the anchor for them to hold on to. However, sitting with those in distress can be psychologically or emotionally costly: Figley ([23]) observes that ‘the very act of being compassionate and empathic extracts a cost’, that ‘in our effort to view the world from the perspective of suffering, we suffer’ and that ‘the meaning of compassion is to bear suffering’ (p.1434).
Empathy happens spontaneously and unconsciously and you may find yourself copying the facial expressions and body language of the person you are caring for. This is totally normal and the more naturally empathetic you are, the more this will happen. The empathetic response can be triggered by any part of the sensory nervous system: visual, auditory and touch are the most common. Empathy is not just a feeling and set of behaviours but also a physiological response to the distress of others; we all have mirror neurones, which can be described as chains of neurones inside us that communicate with those in others without any regard for the fact that we are distinct from each other (Ward [77]). Keyser ([40]) uses the phrase ‘a little bit of you becomes me, and a little bit of me becomes you’ (p.221) to describe what happens when we see another in pain, and this assists humans in the ability to be empathetic. This can have a profound effect on our mental health; at the extreme this is ‘burnout – a state of physical, emotional and mental exhaustion caused by long term involvement in emotionally demanding situations’ (Pines and Aronson [56], p.9) and there is often no return. As Victor Frankl ([26]) said, ‘what is to give light must endure burning’ (cited in Gentry and Baranowsky 2013, p.16). This quote powerfully describes the inevitability that ‘fixing the broken, healing the sick, comforting the lost and witnessing those who are dying’ can be painful work (Gentry and Baranowsky [28], p.16). To ensure that we don't burn out, we need to refuel – we need to learn self‐care.
Compassion fatigue
‘Compassion fatigue’ is a term used to describe the occupational stressors unique to providers of healthcare (Sinclair et al. [70]). It has been suggested that the term was first used by a nurse (Carla Joinson) in 1992 to describe a unique form of burnout experienced by caregivers resulting in a ‘loss of the ability to nurture’ (Joinson [37], p.119). However, the recognition of compassion fatigue as a concept is more commonly attributed to Dr Charles Figley, an American professor and expert in trauma, who in the 1980s observed that many of the care staff he worked with suffered from very similar symptoms to those they were caring for, even though the trauma was not happening directly to them (Coles [10]). Before this ground‐breaking work, care staff affected by their work were labelled as suffering from stress or burnout, but Figley and his team identified that burnout can occur in situations where empathy and compassion have not been demanded, whereas compassion fatigue occurs where empathy and compassion are a key ask of the caregiver (Coles [10]). Compassion fatigue occurs when a carer feels overwhelmed by the amount they expect themselves to give. Burnout occurs when a carer feels they have nothing left to give.
Figley ([22]) initially used the term ‘secondary stress disorder’ for what he was observing, but it is also referred to as ‘vicarious trauma’ and is increasingly referred to as ‘compassion fatigue’. It is necessary to note that more recently there have been questions raised about the conceptual validity of compassion fatigue (Sinclair et al. [70]); however, naming it has significantly helped to develop interventions to address and prevent it among nurses and other healthcare professionals (Gentry and Baranowsky [28]).
Compassion fatigue is conceptualized as beginning with the empathetic response (explored in the previous section), which allows those in the caring profession to connect with a patient and feel how they are feeling, but also opens them up to absorbing and experiencing their trauma, suffering and pain, known as vicarious traumatization. This exposure stimulates our flight‐or‐fight response and its associated physiological responses (see above). However, the professional context in which we are working means these responses have to be suppressed. Continual suppression has consequences for both physical and mental health.
Compassion fatigue can be considered as an alarm system that alerts us that we need to take steps to care for ourselves before we experience burnout. It can be defined as ‘the natural consequent behaviours and emotions resulting from knowing about a traumatizing event(s) experienced by another [and] resulting from helping or wanting to help a traumatized or suffering person’ (Figley [22], p.7). As Reman ([64]) said, ‘the expectation that we can be immersed in suffering and loss daily and not be touched by it, is as unrealistic as expecting to be able to walk through water without getting wet’ (p.52).
Symptoms of compassion fatigue
The symptoms of compassion fatigue are caused by the body's empathetic response to vicarious trauma. It is vital that you recognize these feelings in yourself and see them as a call to action; if you ignore them, they will not go away and will only get worse.
Figley ([22]) organized the symptoms into four phases: anxiety, irritability, withdrawal and robot.
Phase 1: anxiety
Physical symptoms
As the vicarious trauma stimulates your nervous system into flight or fight, you will experience the effects of adrenaline, which include raised heart and breathing rates, shaking and muscle tension. You will find it hard to think clearly and concentrate and may have trouble sleeping. You may find that you become hypervigilant, cannot relax and are very impulsive.
Internal narrative
You may find that you are telling yourself that you are the only one who can do the job properly: it's your mission and you are the first one in and the last one out from work every day. You know that your job is stressful, but you tell yourself that you are okay and coping, and you expect other people to do the same. Outside work you may find yourself volunteering for extra activities at clubs or societies or challenging yourself with sports or hobbies. You may have become accustomed to the feeling of anxiety and actively seek out the feeling. For example, when you are on holiday, you may find it impossible to relax and find that relaxing in itself causes you to feel stressed.
Grace's story
Grace had been working as a nurse for 20 years and had become a clinical nurse specialist. She had teenage children and a supportive partner. She had always been seen as extremely capable and the type of person who always got the job done; she went above and beyond what was expected of her. Away from work, Grace was the chair of her children's school's parent–teacher association, ran marathons for charity and worked as a St John Ambulance volunteer. She took a promotion with lots of extra responsibility and initially really enjoyed the work, but she began to notice that she was feeling different. She noticed that her memory was not as good as it had been and she was forgetting quite important things outside work, such as parents’ evenings or family events. She began waking extremely early in the morning, feeling very fatigued and not enjoying her time off as much as she used to. One day in her car, on her way home from an important meeting, she suddenly felt as if she couldn't breathe and thought she was having a heart attack. She went to see her GP and was told that her blood pressure was very high and she was suffering from stress. She was completely devastated as she felt this meant she wasn't coping with her work. Although she felt guilty and initially said that she couldn't take time off, her GP insisted that she did. In the following weeks she hit rock bottom and at first she couldn't understand what was happening to her, but she began to realize the impact her job had been having on her mental and physical health and on her family and friends, who had been trying to tell her for a long time that things were not right.
Phase 2: irritability
Physical symptoms
These may include headaches, fatigue and multiple minor illnesses as the immune system is affected by the chronic stress. They might also include musculoskeletal problems, in particular chronic neck and back pain. You may also find that you are eating too much or too little, and eating things you know are not good for you.
Internal narrative
The people you are caring for are now starting to irritate you. You may feel that people at work and at home are putting unreasonable demands on you and you just can't deal with it all. You may feel very guilty about this but then start to worry about the guilt. You may tell yourself that there is nothing you can do to change the situation and that if you just ignore the way you are feeling it will go away. You may justify using alcohol or eating unhealthily to help you cope even though you know that this is not the right thing to do.
Phoebe's story
Phoebe had only ever wanted to work as a nurse. Her mother was a nurse and her father was a social worker, and lots of other family members also worked in health and social care. She trained in a big London hospital and then worked on busy wards gaining experience and promotions. She married a fellow nurse and had two young children. Her trust introduced an appraisal system that included feedback from both colleagues and patients. Staff were asked to write a reflective piece on how they saw themselves performing. Phoebe took the paperwork home to write the reflection on her day off. Having completed it, she left it out and having read it her daughter asked Phoebe who the document was describing; it said, ‘this nurse is really great at her job, really funny and sweet and caring’. Phoebe thought her daughter was joking and laughed, saying that it was her. Her daughter looked at her strangely and said, ‘but this person is nothing like you – you're irritable, short tempered, tired all the time and constantly complaining about everything!’ Phoebe was horrified, and when she questioned her family and friends they all agreed. Phoebe began to realize that the job had taken over her life and that she had put her job first to the detriment of not only her mental health but also her home life.
Phase 3: withdrawal
Physical symptoms
You have chronic fatigue, and constant aches and pains. You neglect your physical and emotional health. You may need to take time off work but when you do, you don't feel any better on your return.
Internal narrative
You tell yourself that the only way you can carry on is to shut out the outside world after work. You may not feel like talking to anyone about how you feel as they will not understand, so you begin to withdraw from colleagues, family and friends. You may feel angry at the world and justified in complaining a lot about work and your colleagues. You may admit that you are feeling differently about work, and you may feel guilty that you are not as engaged as you once were and aware that you are protecting yourself emotionally. You won't admit it to them, but those who describe you as negative or pessimistic may have a point.
Steve's story
Steve had been working as an A&E nurse for just over a year. Following a very traumatic incident in the department, he started to feel very different at work and at home. His managers noticed that he was habitually late for shifts and training and was very disengaged from the rest of the team. They tried to talk to him about what was going on but he became very defensive. Steve was feeling anxious all the time, having problems sleeping and dreading going into work each day. He was having flashbacks and nightmares, and found that instead of going out with his mates after work or at the weekends, all he wanted to do was go home and shut the curtains and zone out.
Phase 4: Robot
Physical symptoms
The physical symptoms in this phase are very similar to those suffered by people with depression. They include headaches and generalized aches and pains, digestive problems, and a general feeling of low‐level anxiety and very low mood.
Internal narrative
You tell yourself that just turning up and ‘doing the job’ is the best way to be. Nothing good is going to come from doing anything positive and nothing bad is going to come from being negative. Empathy and compassion for the people you care for are no longer required; the functional requirements are all that matter. You may admit that you are not coping and so feel resentful towards others who are. You are staying in your job because you're not able to do anything else.
Naheed's story
Naheed trained to be a nurse after becoming very disillusioned with the corporate job he'd had before. His first role was at a large dementia care home and he quickly became a dedicated and conscientious member of staff whom colleagues, clients and families universally loved. The workload was very heavy and Naheed soon found himself feeling that he was the only one who was doing the job properly. Over time, this turned into resentment and irritation with the rest of his team. He suffered from chronic back pain but never allowed himself to be off sick. Naheed felt less and less empathy towards the patients and their families; this upset him and he felt guilty. He felt compelled to continue as he had given up his other job for this one. Eventually his colleagues began to describe him as ‘hard and unfeeling’ and families no longer sought him out for support. A relative made a complaint and he was asked to explain his behaviour to the management team and forced to resign.
