Pharmacokinetics
Open Resources for Nursing (Open RN)
Pharmacokinetics – Examining the Interaction of Body and Drug
Overview
Pharmacokinetics is the term that describes the four stages of absorption, distribution, metabolism, and excretion of drugs. Drugs are medications or other substances that have a physiological effect when introduced to the body. There are four basic stages a medication goes through within the human body: absorption, distribution, metabolism, and excretion. This entire process is sometimes abbreviated ADME.
Absorption is the first stage of pharmacokinetics and occurs after medications enter the body and travel from the site of administration into the body’s circulation. Distribution is the second stage of pharmacokinetics. It is the process by which medication is spread throughout the body. Metabolism is the third stage of pharmacokinetics and involves the breakdown of a drug molecule. Excretion is the final stage of pharmacokinetics and refers to the process in which the body eliminates waste. Each of these stages is described separately in the following sections of this chapter.
Research scientists who specialize in pharmacokinetics must also pay attention to another dimension of drug action within the body: time. Scientists do not have the ability to visualize where a drug is going or how long it is active. To compensate, they use mathematical models and precise measurements of blood and urine to determine where a drug goes and how much of the drug (or breakdown product) remains after the body processes it. Other indicators, such as blood levels of liver enzymes, can help predict how much of a drug is going to be absorbed.
Principles of chemistry are also applied while studying pharmacokinetics because the interactions between drugs and body molecules represent a series of chemical reactions. Understanding the chemical encounters between drugs and biological environments, such as the bloodstream and the oily surfaces of cells, is necessary to predict how much of a drug will be metabolized by the body.
Pharmacodynamics refers to the effects of drugs in the body and the mechanism of their action. As a drug travels through the bloodstream, it exhibits a unique affinity for a drug-receptor site, meaning how strongly it binds to the site. Drugs and receptor sites create a lock and key system (see Figure 1.1[1]) that affect how drugs work and the presence of a drug in the bloodstream after it is administered. This concept is broadly termed as drug bioavailability.
The bioavailability of drugs is an important feature that chemists and pharmaceutical scientists keep in mind when designing and packaging medicines. However, no matter how effectively a drug works in a laboratory simulation, the performance in the human body will not always produce the same results, and individualized responses to drugs have to be considered. Although many responses to medications may be anticipated, a person’s unique genetic makeup may significantly impact their response to a drug. Pharmacogenetics is defined as the study of how people’s genes affect their response to medicines.[2]
Media Attributions
- Drug Binding Barrier Animation
- “Drug and Receptor Binding” by Dominic Slausen at Chippewa Valley Technical College is licensed under CC BY 4.0 ↵
- This work is a derivative of Medicines by Design by US Department of Health and Human Services, National Institutes of Health, National Institute of General Medical Sciences and is available in the Public Domain. ↵
In addition to recognizing stress manifestations in oneself, health care professionals must identify signs of stress in others. All members of the health care team experience stress, and effective coping can quickly turn into ineffective coping when manageable, normal stress shifts to harmful stress. Nurses should understand how stress may manifest in a colleague and how one can help and intervene if signs of harmful stress occur.
The signs of harmful stress in a colleague often manifest in a similar manner to what is seen in oneself, but certain signs may be more readily identified by an external source. It is not unusual to identify the mental or behavioral signs of harmful stress in a colleague more rapidly than the physical manifestations. Individuals should be mindful of signs of harmful stress in others, such as changes in mood, irritability, signs of fatigue, increased errors, and absenteeism.[1] Individuals exhibiting these signs may be signaling they are struggling to manage harmful stress. It is important to promptly address these signs with the individual. The tendency to assume one can self-manage or will “get over it” can lead to feelings of isolation that will only perpetuate the stress.
When observing potential signs of harmful stress in a colleague, providing an opportunity to discuss the stressors can be a valuable avenue for promoting effective coping. It is important to remember that the individual exhibiting signs of harmful stress may not recognize they are impacted by stress, but having a colleague acknowledge one’s change in mood or attitude can open the opportunity for self-reflection. Although acknowledging signs of harmful stress in a colleague may feel awkward, asking if someone is okay and addressing signs of potential harmful stress can be a significant step in helping them cope. Acknowledgement can occur with statements such as, “I noticed that you seem more frustrated at work lately. Is everything okay?” or “You seem to be more quiet in the breakroom after our shifts. How are you feeling? I know the busy days can really add up.” Simple statements and questions open opportunities to share feelings and frustrations and also demonstrate caring for team members.[2] This approach creates dialogue about stressful experiences and provides support needed to positively address harmful stress.
In addition to demonstrating care for one’s colleague by inviting conversation about harmful stress, sharing resources is also helpful. It is important for nurses to know they are not alone in experiencing feelings of stress, and attention to these feelings can help one develop strategies to positively address them. Planning discussions with a trusted mentor or friend can be very helpful when exploring feelings related to stress. These discussions also provide an opportunity to share information regarding coping strategies such as mindfulness interventions, resiliency programs, or other formalized resources like employee assistance programs.[3] There are also routine workplace measures that significantly impact stress reduction. For example, many nurses do not take the time to ensure they are taking breaks, eating healthy meals, or simply removing themselves from the care environment for brief periods of time. Simple strategies that can dramatically reduce workplace stress include taking a brief walk outside during one’s lunch break or taking a few deep breaths prior to the beginning of a work shift. Other simple measures such as daily exercise and meditation can reduce stress and increase confidence to address the tasks at hand.[4] Although experienced nurses may already be incorporating these strategies, it is important for novice nurses to understand the value of these strategies.
Use the checklist below to review the steps for completion of “Primary IV Solution Administration.” Review the steps to safely administer all types of medication in the "Checklist for Oral Medication Administration" in the "Administration of Enteral Medications" chapter.
View an instructor demonstration of Primary IV Solution Administration[5]:
Steps
Disclaimer: Always review and follow agency policy regarding this specific skill.
- Gather supplies: IV fluid, primary tubing, tubing change label, and alcohol pads/scrub hubs.
- Verify the provider order with the medication administration record (eMAR/MAR).
- Perform the first check of the six rights of medication administration while withdrawing the IV fluids from the medication dispensing unit. Check expiration date and verify patient allergies.
- Remove the IV solution from the packaging and gently apply pressure to the bag while inspecting for tears or leaks.
- Check the color and clarity of the solution.
- Perform the second check of the six rights of medication administration.
- Perform safety steps:
- Perform hand hygiene.
- Check the room for transmission-based precautions.
- Introduce yourself, your role, the purpose of your visit, and an estimate of the time it will take.
- Confirm patient ID using two patient identifiers (e.g., name and date of birth).
- Explain the process to the patient and ask if they have any questions.
- Be organized and systematic.
- Use appropriate listening and questioning skills.
- Listen and attend to patient cues.
- Ensure the patient’s privacy and dignity.
- Assess ABCs (airway, breathing, and circulation).
- Perform the third check of the rights of medication administration at the patient's bedside.
- Remove the primary IV tubing from the packaging. If administering IV fluid by gravity, note the drip factor on the package and calculate drops/min. Perform the necessary calculations for the infusion rate.
- Move the roller clamp so that it is halfway up the tubing and clamp it.
- Remove the cover from the tubing port on the bag of IV fluid.
- Remove the cap from the insertion spike on the tubing. While maintaining sterility, insert the spike into the tubing port of the bag of IV fluid.
- Squeeze the drip chamber two or three times to fill the chamber halfway.
- Loosen the cap from the end of the IV tubing and open the clamp to prime the tubing over the sink:
- If using multiple port tubing, invert the ports to prime them and to prevent air accumulation in line.
- If the solution is an antibiotic, take care to not waste solution while priming the tubing to ensure the patient receives the correct dosage.
- Once primed, clamp the IV tubing and check the entire length of the tubing for air bubbles. Tap the tubing gently to remove any air.
- Replace or tighten the cap on the end of the tubing.
- Label the primary IV fluid bag with the date and time. Place the tubing label on the tubing near the drip chamber.
- Assess the patient’s venipuncture site for signs and symptoms of vein irritation or infiltration. Do not proceed with administering fluids at this site if there are any concerns.
- Based on agency policy, vigorously cleanse the catheter cap on the patient's IV port with an alcohol pad/scrub hub (or the agency required cleansing agent) for at least fifteen seconds and allow it to dry.[6]
- Assess IV site patency according to agency policy. Purge a prefilled normal saline syringe of air. Attach the syringe onto the saline lock cap. Undo the clamp on the extension tubing. Inject 3 to 5 mL of normal saline using a turbulent stop-start technique. If resistance is felt, do not force the flush and do not proceed with IV solution administration; follow up according to agency policy.
- Remove the syringe from the IV cap and then clamp the extension tubing.
- Vigorously cleanse the catheter cap on the patient's IV port with an alcohol pad/scrub hub (or the agency required cleansing agent) for at least five seconds and allow it to dry.
- Remove the protective cap from the end of the primary tubing and attach it to the IV port while maintaining sterility.
- Move the slide clamp on the saline lock to open the tubing.
- Set the infusion rate based on the provider order:
- For infusion pump: Set volume to be infused and rate (mL/hr) to be administered.
- For gravity: Calculate drop per minute.
- Assess the patient’s IV site for signs and symptoms of vein irritation or infiltration after infusion begins.
- Secure the tubing to the patient’s arm.
- Assist the patient to a comfortable position, ask if they have any questions, and thank them for their time.
- Ensure safety measures when leaving the room:
- CALL LIGHT: Within reach
- BED: Low and locked (in lowest position and brakes on)
- SIDE RAILS: Secured
- TABLE: Within reach
- ROOM: Risk-free for falls (scan room and clear any obstacles)
- Perform hand hygiene.
- Document the procedure and related assessment findings. Report any concerns according to agency policy. Include IV fluids on patient's input/output documentation.
Use the checklist below to review the steps for completion of “Primary IV Solution Administration.” Review the steps to safely administer all types of medication in the "Checklist for Oral Medication Administration" in the "Administration of Enteral Medications" chapter.
View an instructor demonstration of Primary IV Solution Administration[7]:
Steps
Disclaimer: Always review and follow agency policy regarding this specific skill.
- Gather supplies: IV fluid, primary tubing, tubing change label, and alcohol pads/scrub hubs.
- Verify the provider order with the medication administration record (eMAR/MAR).
- Perform the first check of the six rights of medication administration while withdrawing the IV fluids from the medication dispensing unit. Check expiration date and verify patient allergies.
- Remove the IV solution from the packaging and gently apply pressure to the bag while inspecting for tears or leaks.
- Check the color and clarity of the solution.
- Perform the second check of the six rights of medication administration.
- Perform safety steps:
- Perform hand hygiene.
- Check the room for transmission-based precautions.
- Introduce yourself, your role, the purpose of your visit, and an estimate of the time it will take.
- Confirm patient ID using two patient identifiers (e.g., name and date of birth).
- Explain the process to the patient and ask if they have any questions.
- Be organized and systematic.
- Use appropriate listening and questioning skills.
- Listen and attend to patient cues.
- Ensure the patient’s privacy and dignity.
- Assess ABCs (airway, breathing, and circulation).
- Perform the third check of the rights of medication administration at the patient's bedside.
- Remove the primary IV tubing from the packaging. If administering IV fluid by gravity, note the drip factor on the package and calculate drops/min. Perform the necessary calculations for the infusion rate.
- Move the roller clamp so that it is halfway up the tubing and clamp it.
- Remove the cover from the tubing port on the bag of IV fluid.
- Remove the cap from the insertion spike on the tubing. While maintaining sterility, insert the spike into the tubing port of the bag of IV fluid.
- Squeeze the drip chamber two or three times to fill the chamber halfway.
- Loosen the cap from the end of the IV tubing and open the clamp to prime the tubing over the sink:
- If using multiple port tubing, invert the ports to prime them and to prevent air accumulation in line.
- If the solution is an antibiotic, take care to not waste solution while priming the tubing to ensure the patient receives the correct dosage.
- Once primed, clamp the IV tubing and check the entire length of the tubing for air bubbles. Tap the tubing gently to remove any air.
- Replace or tighten the cap on the end of the tubing.
- Label the primary IV fluid bag with the date and time. Place the tubing label on the tubing near the drip chamber.
- Assess the patient’s venipuncture site for signs and symptoms of vein irritation or infiltration. Do not proceed with administering fluids at this site if there are any concerns.
- Based on agency policy, vigorously cleanse the catheter cap on the patient's IV port with an alcohol pad/scrub hub (or the agency required cleansing agent) for at least fifteen seconds and allow it to dry.[8]
- Assess IV site patency according to agency policy. Purge a prefilled normal saline syringe of air. Attach the syringe onto the saline lock cap. Undo the clamp on the extension tubing. Inject 3 to 5 mL of normal saline using a turbulent stop-start technique. If resistance is felt, do not force the flush and do not proceed with IV solution administration; follow up according to agency policy.
- Remove the syringe from the IV cap and then clamp the extension tubing.
- Vigorously cleanse the catheter cap on the patient's IV port with an alcohol pad/scrub hub (or the agency required cleansing agent) for at least five seconds and allow it to dry.
- Remove the protective cap from the end of the primary tubing and attach it to the IV port while maintaining sterility.
- Move the slide clamp on the saline lock to open the tubing.
- Set the infusion rate based on the provider order:
- For infusion pump: Set volume to be infused and rate (mL/hr) to be administered.
- For gravity: Calculate drop per minute.
- Assess the patient’s IV site for signs and symptoms of vein irritation or infiltration after infusion begins.
- Secure the tubing to the patient’s arm.
- Assist the patient to a comfortable position, ask if they have any questions, and thank them for their time.
- Ensure safety measures when leaving the room:
- CALL LIGHT: Within reach
- BED: Low and locked (in lowest position and brakes on)
- SIDE RAILS: Secured
- TABLE: Within reach
- ROOM: Risk-free for falls (scan room and clear any obstacles)
- Perform hand hygiene.
- Document the procedure and related assessment findings. Report any concerns according to agency policy. Include IV fluids on patient's input/output documentation.
Use the checklist below to review the steps for completion of “Secondary IV Solution Administration.” This checklist is used when fluids are already being administered via the primary IV tubing and a second IV solution is administered.
View an instructor demonstration of Secondary IV Solution Administration[9]:
Steps
Disclaimer: Always review and follow agency policy regarding this specific skill.
- Gather supplies: secondary IV fluid/medication, secondary IV tubing, alcohol wipe/scrub hubs, and tubing labels.
- Verify the provider order with the medication administration record (eMAR/MAR).
- Perform the first check of the rights of medication administration while withdrawing the IV solution and tubing from the medication dispensing unit. Check expiration dates on the fluid and the tubing and verify allergies.
- Verify compatibility of the secondary IV solution with the other IV fluids the patient is currently receiving.
- Remove the IV solution from the packaging and gently apply pressure to the bag while inspecting for tears or leaks. Check the color and clarity of the solution.
- Perform the second check of the rights of medication administration.
- Perform safety steps:
- Perform hand hygiene.
- Check the room for transmission-based precautions.
- Introduce yourself, your role, the purpose of your visit, and an estimate of the time it will take.
- Confirm patient ID using two patient identifiers (e.g., name and date of birth).
- Explain the process to the patient and ask if they have any questions.
- Be organized and systematic.
- Use appropriate listening and questioning skills.
- Listen and attend to patient cues.
- Ensure the patient’s privacy and dignity.
- Assess ABCs (airway, breathing, circulation).
- Perform the third check of the rights of medication administration at the patient's bedside.
- If the patient is receiving the medication for the first time, teach the patient and family (if appropriate) about the potential adverse reactions and other concerns related to the medication.
- Remove the secondary IV tubing from the packaging.
- Place the roller clamp to the “off” position.
- Remove the protective sheath from the IV spike and the cover from the tubing port of the IV solution.
- Insert the spike into the IV bag while maintaining sterility.
- Prime the secondary IV tubing. Back priming is considered best practice and is performed using an infusion pump or gravity with primary fluids attached:
- Vigorously cleanse the Y port closest to the drip chamber with an alcohol pad/scrub hub (or the agency required cleansing agent) for at least five seconds and allow it to dry.
- Connect the secondary tubing to the port closest to the drip chamber. Lower the secondary bag below the primary bag and allow the fluid from the primary bag to fill the secondary tubing. Fill the secondary tubing until it reaches the drip chamber, and then raise the secondary bag above the primary line.
- Hang the secondary IV solution on the IV pole with the primary bag lower than the secondary bag.
- Label the secondary tubing near the drip chamber.
- Set the infusion rate:
- For infusion pump: Set the volume to be infused and the rate (mL/hr) to be administered based on the provider order.
- For gravity: The roller clamp on the secondary tubing will be opened completely, and the roller clamp on the primary tubing will be adjusted to deliver the prescribed rate.
Take time to watch the IV fluid or medication to drip into the drip chamber to ensure the medication or fluid is flowing to the patient. - Assess the patient’s IV site for signs and symptoms of vein irritation or infiltration after infusion begins. Do not proceed with administering secondary fluids if there are any concerns about the site.
- Assist the patient to a comfortable position, ask if they have any questions, and thank them for their time.
- Ensure safety measures when leaving the room:
- CALL LIGHT: Within reach
- BED: Low and locked (in lowest position and brakes on)
- SIDE RAILS: Secured
- TABLE: Within reach
- ROOM: Risk-free for falls (scan room and clear any obstacles)
- Perform hand hygiene.
- Document the procedure and assessment findings. Report any concerns according to agency policy.
You have been working for six months on a medical telemetry floor and notice a change in your colleague Allie. Allie has been showing up to work late for her shifts and recently made a medication error when drawing up insulin. She mentions to you in the break room that she is having trouble sleeping and has been struggling with migraine headaches. Her husband was recently laid off from his position with a local manufacturing company, so Allie has been volunteering for extra shifts and overtime. Allie is typically good-natured and has a great sense of humor, but lately she has been short-tempered and irritable. As her friend and colleague, you want to see if there is anything that you can do to help
Reflective Questions
- Using your own words, how would you address your concerns with Allie?
- What strategies and assistance could you offer her?
As Allie’s colleague, you note many signs of harmful stress beginning to manifest in Allie’s physical, mental, and behavioral health. One of the first actions that you could take would be to invite Allie to discuss what you have noticed lately. Allie may not even realize that she has been exhibiting signs of ineffective coping and harmful stress. Opening the opportunity to discuss what you have seen and demonstrating that you acknowledge that she is in distress are important steps. Additionally, it is important to discuss with Allie what other resources are available to her. She may wish to reach out to the organization’s employee assistance program for assistance, or there may be other organizational resources available to her. Allie should also be encouraged to reach out to her manager to discuss the challenges that she is currently experiencing. This is an important part of mobilizing the resources around her so that she can continue as a successful employee within the organization.
Burnout: A condition manifested physically and psychologically with a loss of motivation.
Compassion fatigue: A state of chronic and continuous self-sacrifice and/or prolonged exposure to difficult situations that affect a health care professional’s physical, emotional, and spiritual well-being.
Harmful stress: Stress (also referred to as "distress") not adequately self-managed resulting in physical, mental, and behavioral consequences.[10]
Mindfulness: Awareness that arises through paying attention, being on purpose and in the present moment, and being nonjudgmental.
Normal stress: Stress (also referred to as "eustress") that does not have lasting consequences and is successfully managed by the individual who is experiencing it.[11]
Resiliency training: Educational sessions that foster feelings of mindfulness and sensitivity to self and cultivate professional development techniques that contribute to long-term engagement in the profession.
Self-care: Actions that individuals take to maintain health of oneself.
Learning Objectives
- Identify safety considerations for adults of all ages
- Indicate correct identification of client prior to performing any client care measures
- Describe industry standards and regulations regarding microbiological, physical, and environmental safety
- Differentiate safety considerations among diverse clients
- Apply decision-making related to measures to minimize use of restraints
A national focus on reducing medical errors has been in place since 1999 when the Institute of Medicine (IOM) released a report titled To Err is Human: Building a Safer Health System. This historic report broke the silence surrounding health care errors and encouraged safety to be built into the processes of providing client care. It was soon followed by the establishment of several safety initiatives by The Joint Commission, including the release of annual National Patient Safety Goals. Additionally, the Quality and Safety Education for Nurses (QSEN) Institute was developed to promote emphasis on high-quality, safe client care in nursing. This chapter will discuss several safety initiatives that promote a safe health care environment.
The impact of inadequate stress management for health care personnel can greatly impact health care organizations. When harmful stress is not adequately addressed, burnout can rapidly become a burgeoning problem resulting in absenteeism, decreased productivity, decline in care quality, staff dissatisfaction, and employee turnover. Work environment and lack of workplace support often contribute to feelings of burnout and job attrition.[12] Organizations must recognize the significance of stress in regard to the cyclical nature it plays in the retention of employees. For example, if one employee experiences harmful stress resulting in depression and anxiety, this may influence their timeliness and attendance at work. If the employee begins to struggle, they may be more inclined to phone in as “sick time” for shifts or even be a “no show” for a scheduled shift. When this occurs, the burden of their absence is passed on to other employees on the unit. Calls for overtime, mandated stay, or increased client care assignments quickly increase the burden on the other members of the health care team. As a result, the team members experiencing increased workload feel an impact on their own job-related stress. The compounded stress can quickly overtax an individual who has been managing normal work-related stress. Many individuals who were previously self-managing stress may struggle under these increased role demands. When there is a decrease in an individual’s “downtime,” there is even less reprieve from the stressful work environment. As a result, the organization and health care system become even more overtaxed, and the cycle perpetuates itself among other staff.[13] Managers and directors often struggle with rehiring and orienting staff at a rate that is suitable to offset the stress cycle and decreased retention within the organization.
Promoting Nurse Retention
Nurse leaders must be proactive in finding solutions to address clinical nurse and nursing faculty shortages and high nurse turnover rates. The 2018 National Healthcare Retention and RN Staffing Report states the following data[14]:
- The U.S. Bureau of Labor Statistics reports that 233,000 new RN jobs will be created annually.
- Forty-five percent of hospitals anticipate increasing their RN staff.
- Hospital turnover is at 18.2%, an increase from previous years.
- RNs working in emergency care, step-down, and medical-surgical units experience high turnover rates, with the highest rate of turnover for certified nursing assistants.
- The average cost of each RN turnover is $49,500, resulting in an average hospital losing an estimated $4.4 to $7 million due to turnover.
- Each percent change in RN turnover will cost or save the average hospital $337,500.
- It takes approximately 2.5 months to recruit an experienced RN.
- More than half of hospitals would like to decrease reliance on supplemental staffing.
- For every 20 travel RNs eliminated, a hospital can save an average of $1,435,000.
Unfortunately, many nurse leaders struggle to receive organizational support for recruitment and hiring in a timely fashion. Demonstrating the need for staff replacement often cannot be established until a staff vacancy exists. As a result, the retention cycle is further compromised when workload is impacted due to staff vacancies during the recruitment and orientation process. Many frontline nursing staff may not be aware of the rigorous challenges that nurse leaders face when requesting administrative support for additional staff positions. Most organizations require executive-level approval for hiring, and unit productivity is examined for rationale that additional staff are needed. The time required for this investigation and executive-level approval can be very challenging for staff nurses who experience the workload burden during the vacancies. During this time frame, nurse leaders may struggle to maintain team morale while also acknowledging the organization’s need to be financially responsible in staff hiring.
It is important for all parties to remain engaged in their current work roles during the recruitment, hiring, and orientation periods of new nurses. Trust in one another during this time is critical, and all parties must remember the needs of clients receive top priority. Providing optimal care to the best of one’s ability is of the utmost importance even when experiencing staffing challenges. Additionally, staff, nursing leaders, and administrators within the organization must unite to find actionable solutions that acknowledge the impact of stress and reduce the impact of harmful stress contributing to the burnout of colleagues. There is no simple solution. All individuals must be united in exploring strategies to reduce the occurrence of burnout and seek to make change to enhance the health and well-being of all involved.
As previously discussed, the action of providing nursing care can result in significant stress. The stress response is exacerbated when experiencing extreme or repeated stressors, such as client deaths. In some health care settings, nurses do not have time to resolve grief from one loss before another death occurs. This lack of time to resolve grief has been exacerbated during the COVID-19 pandemic where many units continually filled with clients requiring high levels of skilled nursing care. Additionally, some patients with COVID died without the face-to-face support of friends and family due to visitor restrictions. This resulted in the end-of-life transition supported solely by the health care staff. Many nurses felt additional stress due to supporting both the client and the client’s family during this challenging time.
Compassion fatigue and burnout occur frequently with nurses and other health care professionals who experience cumulative deaths that are not addressed therapeutically. Compassion fatigue is a state of chronic and continuous self-sacrifice and/or prolonged exposure to difficult situations that affect a health care professional’s physical, emotional, and spiritual well-being. This can lead to a person being unable to care for or empathize with someone’s suffering. Additionally, many individuals who experience compassion fatigue may become detached from the emotions associated with the care experience or client needs. These individuals can often appear numb to the severity of the circumstance of the events that are occurring. Burnout can be manifested physically and psychologically with a loss of motivation. It can be triggered by workplace demands, lack of resources to perform work professionally and safely, interpersonal relationship stressors, or work policies that can lead to diminished caring and cynicism.[15] See Figure 12.4[16] for an image depicting a nurse at home experiencing burnout due to exposure to multiple competing demands of work, school, and family responsibilities.
With the significant dangers of burnout and compassion fatigue within the nursing profession, it is important to acknowledge actions and strategies to facilitate self-care. Self-care can occur in many actions that individuals take to maintain self-health and is critically important for preventing compassion fatigue and burnout.
To facilitate self-care, nurses must recognize the need to take time off, seek out individual healthy coping mechanisms, and voice concerns within their workplace. Prayer, meditation, exercise, art, and music are examples of healthy coping mechanisms that nurses can use for self-care. Nurses should reflect on what actions bring them personal satisfaction and rejuvenation. These strategies should then be purposefully included to help reduce the influence of work-related stressors. For example, perhaps you are a nurse working in a busy Level 1 trauma center and emergency department. You are nearing the end of your third 12-hour shift and have the following day off. The unit manager approaches you and states that there has been an ill call for tomorrow’s evening shift. You are offered premium pay to come in and work. Although there is a part of you that is interested in receiving the premium pay, you also take a moment to think about your current situation. You are tired from working three 12-hour shifts the last three days and had plans to go to your child’s baseball game tomorrow evening. Taking stock of these reflective thoughts, you politely decline the additional shift. Acknowledging your fatigue and the satisfaction that you will feel in attending your child’s game are important parts of facilitating self-care. Although you could have chosen to work the shift, taking time to look inwardly on what will bring about the greatest rejuvenation and avoid burnout will help cultivate professional engagement.
Additionally, nurses must recognize when outside resources are needed to mitigate stress and facilitate self-care. Many organizations sponsor employee assistance programs that provide counseling services. These programs can be of great value and benefit in allowing individuals to share both individual and employment stressors. For example, employee assistance programs can address employment-related stressors, such as cumulative client deaths, as well as personal challenges impacting one’s work role, such as a family illness. The support of an impartial, trained professional can be very helpful as individuals navigate through stressful stimuli.
There are specific stress stimuli that may require specialized intervention. For example, after a client death resulting from trauma, many organizations hold debriefing sessions to allow individuals who participated in care to come together to verbalize their feelings. These sessions are often held with the support of chaplains to facilitate individual coping and verbalization of feelings. Debriefing sessions can be very helpful as individuals experience collegial support in working through traumatic stress stimuli.
Read more about the role of chaplains in facilitating coping in the “Spirituality” chapter in Open RN Nursing Fundamentals, 2e.
Reflective Questions
Throughout your nursing career, there will be times to stop and pay attention to warning signs of compassion fatigue and burnout. Here are some questions to consider:
- Has my behavior changed?
- Do I communicate differently with others?
- What destructive habits tempt me?
- Do I project my inner pain onto others?[17]
Strategies for Self-Care
By becoming self-aware regarding signs of stress, you can implement self-care strategies to prevent compassion fatigue and burnout. Use the following “A’s” to assist in building resilience, connection, and compassion:
- Attention: Become aware of your physical, psychological, social, and spiritual health. For what are you grateful? What are your areas of improvement? This protects you from drifting through life on autopilot.
- Acknowledgement: Honestly look at all you have witnessed as a health care professional. What insight have you experienced? Acknowledging the pain of loss you have witnessed protects you from invalidating the experiences.
- Affection: Choose to look at yourself with kindness and warmth. Affection prevents you from becoming bitter and “being too hard” on yourself.
- Acceptance: Choose to be at peace and welcome all aspects of yourself. By accepting both your talents and imperfections, you can protect yourself from impatience, victim mentality, and blame.[18]
Cultivating Care of Self
Taking care of oneself can feel as if it goes against the nature of the nursing role, but it is a vital component for professional success. Provision 5 of the American Nurses Association Code of Ethics states, “The nurse owes the same duties to self as to others, including the responsibility to promote health and safety, preserve wholeness of character and integrity, maintain competence, and continue personal and professional growth.”[19] In a profession where one spends most of their time thinking about the needs of others, it can be difficult to recognize when special care and attention is needed for one’s own health. However, there are many strategies that nurses can use to help them navigate stress and prioritize their own health and wellness. Although not every strategy may be “right” for every nurse, it is critical for nurses to find actionable interventions to help them address their own stress.
Here are some examples of stress management strategies:
- Meditation. Meditation can induce feelings of calm and clear-headedness, improving concentration and attention. Research has shown that meditation increases the brain’s gray matter density, which can reduce sensitivity to pain, enhance the immune system, help regulate difficult emotions, and relieve stress. Mindfulness meditation in particular has been proven helpful for people with depression and anxiety, cancer, fibromyalgia, chronic pain, rheumatoid arthritis, type 2 diabetes, chronic fatigue syndrome, and cardiovascular disease.[20] See Figure 12.5[21] for an image of an individual participating in meditation.
- Yoga. Yoga is a centuries-old spiritual practice that creates a sense of union within the practitioner through physical postures, ethical behaviors, and breath expansion. The systematic practice of yoga has been found to reduce inflammation and stress, decrease depression and anxiety, lower blood pressure, and increase feelings of well-being.[22] See Figure 12.6[23] for an image of an individual participating in yoga.
- Journaling. Journaling can help a person become more aware of their inner life and feel more connected to experiences. Studies show that writing during difficult times may help a person find meaning in life’s challenges and become more resilient in the face of obstacles. When journaling, it can be helpful to focus on three basic questions: What experiences give me energy? What experiences drain my energy? Were there any experiences today where I felt alive and experienced “flow”? Allow yourself to write freely, without stopping to edit or worry about spelling and grammar.[24]
- Prayer. Prayer can elicit the relaxation response, along with feelings of hope, gratitude, and compassion, all of which have a positive effect on overall well-being. There are several types of prayer rooted in the belief that there is a higher power that has some level of influence over one’s life. This belief can provide a sense of comfort and support in difficult times. A recent study found that clinically depressed adults who believed their prayers were heard by a concerned presence responded much better to treatment than those who did not believe.[25]
- Spiritual community. Join a spiritual group, such as a church, synagogue, temple, mosque, meditation center, yoga class, or other local group that meets to discuss spiritual issues. The benefits of social support are well-documented, and having a spiritual community to turn to for fellowship can provide a sense of belonging and support.[26]
- Nurturing relationships. Relationships with family, significant others, and friends aren’t static – they are living, dynamic aspects of our lives that require attention and care. To benefit from strong connections with others, you should take charge of your relationships and put in the time and energy you would any other aspect of your well-being. It can be helpful to create rituals together. With busy schedules and the presence of online social media that offer the façade of real contact, it’s very easy to drift from friends. Research has found that people who deliberately make time for gatherings or trips enjoy stronger relationships and more positive energy. An easy way to do this is to create a standing ritual that you can share and that doesn’t create more stress, such as talking on the telephone on Fridays or sharing a walk during lunch breaks.[27]
- Mindfulness. Mindfulness has been defined as, “Awareness that arises through paying attention, on purpose, in the present moment, and nonjudgmentally.” Mindfulness has also been described as, “Non-elaborative, nonjudgmental, present-centered awareness in which each thought, feeling, and sensation that arises is acknowledged and accepted as it is.” Mindfulness helps us be present in our lives and gives us some control over our reactions and repetitive thought patterns. It helps us pause, get a clearer picture of a situation, and respond more skillfully. Compare your default state to mindfulness when studying for an exam in a difficult course or preparing for a clinical experience. What do you do? Do you tell yourself, “I am not good at this” or “I am going to look stupid”? Does this distract you from paying attention to studying or preparing? How might it be different if you had an open attitude with no concern or judgment about your performance? What if you directly experienced the process as it unfolded, including the challenges, anxieties, insights, and accomplishments, while acknowledging each thought or feeling and accepting it without needing to figure it out or explore it further? If practiced regularly, mindfulness helps a person start to see the habitual patterns that lead to automatic negative reactions that create stress. By observing these thoughts and emotions instead of reacting to them, a person can develop a broader perspective and can choose a more effective response.[28]
- Nature. Spending time in nature is cited by many individuals as a spiritual practice that contributes to their mental health.[29]
- Physical activity. Regular physical activity, such as brisk walking, can relieve stress and tension. [30]
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