Victoria University researcher Dr Helen Rook’s recently completed PhD research found Kiwi nurses felt conflicted and anxious at being unable to deliver care true to their nursing values because of pressures on the ward to discharge patients quickly, keep-up the paper work and keep costs down.

She said the nurses’ response– sometimes conscious and sometimes not – was to focus on essential duties like documentation and nursing tasks as a coping strategy. Sometimes this also lead to nurses cutting short patient conversations, ignoring call bells and in other ways withdrawing from their patients to protect themselves emotionally.

Rook’s PhD research  – prompted in the wake of the inquiry into patient neglect in Mid-Staffordshire – involved spending 300 hours observing nurses on medical wards in three district health boards, multiple interviews, checking nurse sensitive indicator statistics (like falls and pressure injuries), and measuring burnout levels. She concluded that the conflict that the nurses felt – between their personal and professional values and how they actually were able to practice nursing because of the constraints of modern healthcare – caused anxiety, exhaustion, cynicism and burnout.

Building and supporting nursing leadership at the ward level upwards was one recommendation by Rook to help nurses speak up and act on their concerns. Another was for district health board and other healthcare providers to put in place strategies to help mitigate the organisational dysfunction and financial constraints that lead to nurses feeling unable to consistently deliver compassionate, clinically competent care.

Withdrawing from patients a coping strategy for conflicted nurses

“In all of the wards the nurses said they were practising team nursing and yet there was very little evidence of that,” said Rook.  Instead they were observed to be mostly focussed on tasks and “getting things done”.  “They are very skilful at that,’ said Rook. “In order to protect themselves they use defensive strategies to protect themselves from anxiety.”

She said the conflicted nurses also used the coping strategy of withdrawing a little bit from the patients they were caring for.  So they tried not get caught in conversations with patients by using strategies like giving a quick smile.  “Or say ‘I’ll be with you in a minute’ and then pull themselves away as they know they have all this other stuff they need to get done.”

Rook said she also observed more overt withdrawal by busy nurses. “I watched nurses walking past patients who were calling out for help, and call bells that were unanswered, not because nurses were uncaring but because they had so many other things to do, to comply with.”

When she spoke to nurses about the organisational values at their DHBs – and the DHB’s strategies for improving patients care – she said a number expressed cynicism that while DHBs talked about focusing on partnership and respect most improvement projects were actually about discharging patients quicker, balancing the budget and ensuring the required documentation was done.  She said there was also a sense that the DHB’s emphasis on economics and managerialism was becoming more prevalent not less.

But she added that for her Phd she drew on the iconic nursing research carried out in a London hospital in the late 1950s by Isabel Menzies, who wrote about how nurses de-personalised patients to protect themselves from the anxiety of their work.

“That’s a long time ago – we’re 2017 now – but a lot of things that she found in that research I also found in my research.  Not a lot has changed in healthcare in the intervening years really…”

Be consciously present not emotionally numb

“Nurses go into the profession with an assumption that they will be caring for people who are sick, taking a moment to talk with them and build caring relationships,” said Rook.

But said the current culture didn’t allow for that and DHB’s managerial imperatives to get patients out of hospital quickly, combined with financial constraints, meant that it just wasn’t possible.  So nurses often responded by focussing on doing the essential nursing tasks.

“I think there is a bit of guilt in that we focus on tasks,” said Rook.  “I don’t think it’s such a bad thing if we do. Because that is what the public expect – they expect us to be able to do things for them.”

Rook said if the reality was that nurses’ coping strategy for pressured workloads was to focus on tasks, then nurses should take ownership of this new reality.  They needed to be vocal about the type of nursing care they were able to deliver, and why, and then deliver the task excellently.

“We need to be very clear that ‘okay we are going to focus on a task but we are going to be excellent in that task and in our interactions with people….even if is only a minute or two.”

She said nurses need to aim to be fully present with their patient even if “just doing a task” as that would be much more beneficial therapeutically.

“We need to be consciously present rather than emotionally numb in our patient interactions.”

But in the long-term she said it was imperative that nurses on the frontline were supported to build leadership skills and find their voice so the culture was changed and they could provide the nursing care that matched their personal and professional values. Also organisations had to introduce strategies that removed the constraints currently preventing nurses from delivering that care.

Rook, who is currently the Programme Director at the Graduate School of Nursing, Midwifery and Health at Victoria University of Wellington, graduates next week with her PhD in nursing.

She has a background in critical care nursing in the United Kingdom, Ireland and New Zealand, and has worked as a nursing academic in New Zealand and Ireland delivering undergraduate and post-graduate education.

Time management, or more specifically balancing your precious time, is a constant challenge for nurse leaders. The following are a few things that work for me. You might notice that some of my tips appear to be contrary to time management; however, if you can’t maintain a good balance during your working day then potentially you set yourself up for a pretty unproductive day!

In no particular order:

• Don’t sit longer than 30 minutes; even in meetings, stand up and walk about.
• Turn off your incoming email alerts.
• When you read your emails, deal with at least 75 per cent of them when they arrive.
• Avoid too much caffeine.
• Block out your diary with tasks you need to do (i.e. writing papers).
• Use headphones or earplugs (a clear ‘do not disturb’ sign).
• Block 30 minutes a day for lunch.
• Always make time for someone who is distressed.
• If you need to work longer hours, compensate yourself with a walk or power breaks.
• Look out the window and see if the sun is shining.

Carey Campbell, Chief Nurse Advisor, Southern Cross Hospitals

How to make the best use of your time (and that of others):

Know your work style and most productive times

• Work out when you are at your most productive – for some it’s first thing in the morning, for others it may be later in the day – and work on your most challenging tasks at that time.
• Try to mitigate any probable interruptions and deal with those before concentrating on your most important and challenging task.
• Work on that most important task for a good period of time before having a short break.
• We can’t all work at 100 per cent constantly – so complete some of the more mundane or easier tasks when your energy levels have waned.
• Strangely enough, I tend to get heaps done on a Friday – so that’s often when I ‘catch up’ with the things that I haven’t been able to finish during the week.

Be on time

• Use your Outlook calendar and set reminders to help you be on time for meetings and appointments.
• If it’s really important, or you have become ‘immune’ to your many reminders, set the alarm on your phone as well (the quacking duck noise is always a good one!).
• It’s such a timewaster for other attendees when meetings don’t start and finish on time, so try not to be THAT person who is always late!

Interruptions

• It is a totally unrealistic expectation never to have any interruptions in your work, especially as one of the key attributes of being a successful nurse leader is being available, approachable and accessible.
• The key to managing the impact of interruptions in your work is in how you react to these.

Some suggestions are:

• Don’t get caught up in others’ emotions and their ‘rush’ (they will always feel their request is urgent; however, most interruptions are not genuinely crisis-driven).
• Take a deep breath and clear your head so you can assess the situation objectively and react appropriately.
• Try to stay calm on the outside (even if you feel rushed on the inside).
• If it’s genuinely important, act.
• If it’s not important, remember that others’ disorganisation/panic/ drama should not make for your emergency!

Submissions welcome

This is the debut of a new regular section sharing leadership and management tips and ideas. If you have any ideas for future topics – or have tips on time management or other areas you would like to share – feel free to email [email protected].

“We surveyed people in 2016, just after the Health and Safety at Work Act 2015 came into force. It’s concerning that stress and fatigue, which are now clearly identified as hazards under the Act, are such key issues for this workforce. It’s become a legal issue, not just one of personal health and wellbeing,” says Dr Ravenswood.

More than 1345 workers in the residential aged care and home and community care sectors responded to the survey. The majority were health care assistants (919) but more than 400 nurses responded (362 registered nurses and 64 enrolled nurses) with the vast majority working in residential aged care. There were also 187 aged care manager respondents (70 per cent were registered nurses).

The survey was undertaken from May to July 2016 while the recently announced equal pay settlement – that will result in sizable pay increases for health care assistants and caregivers in the sector – was still under negotiation. Wages were a key issue for health care assistants/caregivers with 85 per cent of them being dissatisfied with their pay which they said did not fairly reflect their skills, responsibilities or experience

Nearly 70 per cent of nurse respondents also believed their pay did not fairly reflect their skills or responsibility. The hourly pay rates for nurses mainly fell between $25 to $34.99 per hour with the largest group (29%) earning between $27 to $29 per hour.  (The equal pay deal will see experienced health care assistant wages in the sector rise to $23 by 2021 and can rise to $27 if they attain a qualification.

When asked how satisfied they were with their job overall 56 per cent said they were satisified with the nature of the work providing the most satisfaction and the pay the least. About half of nurse respondents indicated they planned to look for a new job within the next 12 months and of those the most common reason was stress/burnout (20%) and employment conditions (18.4%).

The nurses also reported high stress levels with two-thirds of respondents indicating they felt the job “was more stressful than they ever imagined it would be”.

They also reported 372 incidences of work-related injury and illness in the previous 12 months with 100 of those being stress-related and the next most common being bruising (74) followed by back injuries (39). About a third reported they had experienced physical abuse at sometime during their work and 18.2 per cent often or very often but the most common was verbal abuse which 76 per cent of nurses had experienced from clients/patients.

The vast majority of nurses indicated they felt safe at work (78.8%). Nearly three quarters indicated they were happy with the tools and equipment required to do their job safely and two-thirds were satisfied they were told everything they needed to know to do their job safely

When it came to managers 60 per cent were satisfied with their pay (the majority earned between $30 and $44 per hour) and the majority felt they received respect and recognition for their work. The highest level of dissatisfaction with their work was the hours and a third did plan to look for a new job within 12 months with the most common reason being stress/burnout (31%).

That is a question that Margaret Hansen, professor of nursing at the University of San Francisco, is keen to find out. She presented the findings of her feasibility pilot – into delivering complementary therapies via mobile technologies to surgical patients in Iceland – to the Nurse Informatics Conference, which was held in conjunction with the Health Informatics New Zealand (HINZ) conference late last year in Auckland.

In 1987 Hansen was diagnosed with an malignant but operable brain tumour. In the days leading up to her surgery she was introduced to a visualisation technique aimed to help prepare her for surgery.

Using the technology of the day – a cassette tape deck – she listened to around two hours of recordings that led her through visualising her blood cells attacking the tumours in her brain. She says this visualisation technique significantly reduced her anxiety and fear and improved her post-operative healing.

Nearly three decades on, Hansen says this experience influenced her research into using complementary therapies to assist surgical patients. She also has a research interest in using mobile technologies to promote patient health and wellbeing and to enhance student learning.

Hansen says she chose to present on her complementary therapies feasibility study, which she carried out while on a Fulbright Scholarship to Iceland, for the Auckland conference because she “really, truly believed that New Zealand has a rich history of turning to nature – both the beach and the bush – to soothe and heal”.

She says there is growing evidence to back the idea of nature aiding healing and one influence on her study was a book called Blue Mind by marine biologist Wallace J Nicholls, which looks at the effects that being near or in water can have on people.

Her resulting study, which randomised 105 day surgery patients in Iceland to either one of four complementary interventions (delivered via mobile technologies) or a control group, confirmed the feasibility of using the technologies in a clinical setting without disrupting staff or causing physical complications.

And although the pilot study didn’t show any statistically significant differences in anxiety, pain levels, or perceived self-efficacy between the four intervention and one control group, there were “some interesting trends towards significance”.

In addition, among the group participants there were statistically significant findings, especially in the increase in perceived self-efficacy scores. Hansen believes that continued empirical research into the helpful effects of nature for peri-operative patients coping with anxiety and pain, and self-efficacy in healing, is merited.

The four interventions used in the study, published in 2015 in the Journal of the International Society for Complementary Medicine Research, were: audio relaxation technique (ART) or music intervention (MI), both delivered by iPod, or a nature video app with music (NVAM) or nature video app without music (NVA) that were both delivered on an iPad.

The participants were encouraged to listen and/or view the interventions twice a day – for a minimum of 15 minutes each time for each of the four days prior to surgery day and each of the five days following discharge from hospital.

ED nurse and racing car driver Alex Clark loves the rush of not knowing what’s around the corner.

When Alex Clark grabs a break from a stressful ED shift, she pictures herself putting the ‘pedal to the metal’ around a racetrack.

“It is quite calming – I know most people wouldn’t think that. But I guess it is like a meditation… and that’s also what I do when I’m readying to race.”

The alter ego of this 25-year-old Middlemore emergency department nurse is a BMW racing car driver, who this season took out her first victory on the track.

This may not be the stress release you would expect from a nurse who sees the aftermath of road crashes, but Clark says the sport she loves is safe. And both her job and hobby are good fits for a young woman who has come to realise that she thrives on adrenalin.

Clark grew up around motor racing. With a dad who dabbled in racing Minis when she was a little girl and a grandad who raced, she spent a lot of time as a kid at Western Springs Speedway. So when seven years ago her father once again got back on the racetrack in the BMW Race Driver series, the then-19-year-old nursing student took the chance to try it for herself.

Once she got behind the wheel during a motor sport fun day she fell in love with the technical demands and concentration that racing demands, as well as the buzz it provides.

The rush Clark got from the racetrack made her realise that she was more of an adrenalin junkie than she had ever thought. “I think it must definitely be in the blood.”

Nursing was also in the blood, with her mother being a nurse. Her career choice was sealed by seeing how well the nurses cared for her grandfather during his frequent hospital stays at the end of his life.

ED was not her first choice on graduating from AUT in mid-2014 – that was paediatrics – but the rush of never knowing what was around the corner appealed, so she applied successfully for a new graduate place at Middlemore Hospital’s ED.

“And I can’t imagine doing anything else. Every day is different, every patient is different and in every presentation the condition is different. I like that change – the not knowing is a big drawcard for me, as well as the adrenalin when the ambulances radio ahead with an ‘R40’ and you think ‘oh, what is coming in?’ And you try to stay calm while being absolutely terrified inside.”

Adrenalin is something her job shares with her hobby. “I’m an adrenalin junkie – I never thought I would be, but I am.”

Clark’s first motor racing season was six years ago after a family friend, former motorsport champion Todd Pelham, helped to prepare her for her debut on the BMW Race Driver Series. First up she had to qualify by racing around the track against “big, fast, scary cars”, getting up to around 180 kilometres per hour.

“Terrifying, but so exhilarating!”

Clark raced for three years with the support of her family ‘pit crew’ then, after two seasons off, she started racing again for the 2016-17 season. The season kicked off well, with her first ever victory in the 2 Litre category of the Castrol BMW Race Driver Series held at Hampton Downs’ race circuit in September.

Feeling safe

As an ED nurse Clark sees the aftermath of crashes on the road but says she feels very safe in her racing car on the track.

“Motor racing is so safe nowadays. I have all the safety gear – the belts, a roll cage and special neck restraints – so I’m at very little risk of being badly injured. Driving on the general road in a general road car is actually probably more dangerous.”

But she adds that being an ED nurse has put her off riding a motorcycle again.

“And I can’t watch motorcycle racing – it terrifies me as all I can see is the injuries that can happen,” she says.

So what do her ED colleagues think of her racing? “Most of them don’t know,” she laughs. “The ones who do know think I’m mad.”

But Clark highly recommends that other nurses give this meditative and addictive sport a spin.

PHOTO COURTESY OF GEOFF RIDDER

Mindful motorbiking

Kate Gibb, a nursing director for older people’s health, is a born-again biker who is totally smitten with her new motorcycle.

Kate Gibb admits she turns a few heads when she rocks up in her bike leathers to work meetings.

She doesn’t do it often, but if she has a meeting on her way home she will ask to be excused her for turning up in her leathers with a helmet over her arm.

Since getting back into motorcycling three years ago and buying her dream bike only last year, the director of nursing for older people’s health for the Canterbury District Health Board chooses two wheels over four wheels as often as she can.

And after a hiatus of seven or eight years without a motorcycle, this born-again biker wonders how she let herself go so long without an activity that she finds so good for her wellbeing.

Gibb first became hooked on riding dirt bikes around a cousin’s farm as a kid and took it up again in her early 20s. Her first motorcycle was a 250cc – the largest you could ride at the time on your learner’s licence.

“It was a little old dunger and I ended up taking it to bits in the garage for quite some time. And then we moved house and I couldn’t remember how to put it back together. So we ended up selling that one for parts.”

Without a motorbike to progress through to her full bike licence, however, motorbiking just fell off her radar over time.

But three years ago Gibb bought a Suzuki GSX 650cc and started progressing through her licence again. “It took me 19 years to go from my learner’s to my full licence,” laughs Gibb. “I finally got it just last year.”

Meditation on wheels

As soon as she got her full licence, Gibb got her dream bike – a Triumph Street Triple R 675cc – the bike she had been coveting since it first came onto the market in 2008. She says it is light, quick, nifty and just the perfect fun package. “It just flies around the race track.”

She says that the few times she has taken her bike around a track she has had so much fun she is very tempted to enter a race, but meanwhile she just enjoys track training days.

“It is very meditative,” says Gibb. “Total mindfulness, it really is – you must be so fully focused and can’t think of anything else. Particularly on the track as you are fully concentrating on hitting your lines perfectly and everything else goes out of your head – it is just the most beautiful, serene concentration with all the power and exhilaration at the same time.”

Riding on the road is admittedly less meditative as you need to focus on the other traffic, but Gibbs says that making sure she gets plenty of time on her bike is one of her key ways to wellbeing. “It’s sort of a unique regenerative kind of activity.”

Bike shop owners no longer do a double take if a woman turns up to buy parts, with motorbiking now an activity being taken up by a growing number of women.

But there is always the safety issue. Gibb acknowledges that motorcylists are more vulnerable on a motorbike than in a car.

“You’ve just got to do your best to make sure you’re riding safely and defensively, and there are some really fantastic safety initiatives since I’ve come back to riding.”

One of these initiatives is the excellent ACC-supported Ride Forever training programme (see resources box for details).

Bikers also need to invest in the best protective gear they can get their hands on and wear it, says Gibb.

“But at the end of the day you do need to accept that at any time somebody can come out at you and, if something does go wrong, you are more vulnerable.”

Gibb says that she actually feels safer on her motorbike than she does on a bicycle. And she adds that people can also get a false sense of security in a car.

“I’m not denying there isn’t a significant risk …but I love it so much that I’m prepared to take the risk.”

And Gibb says she has given some more passive and less risky ‘ways to wellbeing’ a go. “For a while I thought I should try mindful colouring or whatever you call it. But it didn’t quite ring the bell for me…”

Whereas time on her bike… well, that’s the ultimate stress-buster and path to relaxation for this nurse leader.

Bucking convention

Massey nursing school head Dr Mark Jones reflects on how his first schoolboy motorbike back in England gave him his nursing vocation and a lifelong passion for bikes and, eventually, bike safety too.

My Anglican minister dad’s plan was that shifting to a new parish was a good time for me to shift to a new school.

I wasn’t so convinced and instead saw it as a great excuse to get my first motorbike and commute to school. Unfortunately, one bike trip to school ended with me waking up in the care of the NHS. But as they say, every cloud has a silver lining and during my four-month rehabilitation at a local hospital I was looked after by a guy who would set me on my nursing journey.

Up to that time my potential career choice hadn’t evolved much further than a bit of a ‘Miss World’ notion that I would care for people and save the world. The aforementioned church upbringing had ensured a steady stream of folks needing assistance around the house. But, being unclear what form my ‘helping people’ would take, I had chosen subjects that had me tracking into teaching.

All of that changed when I met Neil. This was in the day when nurses had time to chat and even as a 17-year-old I could see this inspirational charge nurse was a great leader and passionate about his ability to care for people. So my bike accident steered me into a profession that wouldn’t have even crossed my mind.

I suppose motorcycling and my career have always been linked. Being a biker bloke and a nurse was a bit ‘out there’ and I guess increased my then tendency to buck convention. It also went down well with clients back in the UK when I eschewed the relatively posh health authority car for my bike to make calls as a Health Visitor (an English role that is a hybrid of New Zealand’s Plunket and Public Health Nurse roles). And I do think positive connections were made with the men in families I worked  with just because I showed up on a Yamaha rather than in a Rover.

Unfortunately, even after becoming a nurse, my sense of mortality  hadn’t quite caught up with reality. But another trip to hospital following a truck tangle saw me waking up to realising you could actually do something to minimise the chance of being killed while having fun on a bike.

Getting decent rider training was the way to go and – with the help of Britain’s grandly named ‘Royal Society for the Prevention of Accidents’ (RoSPA) – I learnt all about defensive riding skills and eventually became one of their instructors. After moving to New Zealand in 2005  I was an instructor for the Women’s International Motorcycle Association branch in Wellington, and working over in Oz gave me a whole new set of training challenges.

I now have less time to spare, but as an NZ Transport Agency-approved instructor I still enjoy offering motorbike training through ProRider – one of the providers of the ACC-funded Ride Forever training programme. I find this kind of education actually fits quite well with my day job. I have the satisfaction of passing on knowledge and helping people become better at what they love doing, be that biking or nursing. The youngest participant I have had on a Ride Forever course was a 16-year-old girl and the oldest a couple in their late 70s setting out to tour Australia. It is rather neat to be able to see someone who has never ridden a motorcycle take to the street safely and learn their craft with our further support as they hone their skills and expertise.

I have to admit though, that the teenage biker in me pops out from time to time as I enjoy our wonderful roads (anywhere out of Auckland!), but I know now what it takes to have fun and stay alive into the bargain – a good way to live by any measure.

The new Health and Safety at Work Act puts the onus on employers to eliminate or minimise risks to their workers’ health and safety – including their mental health.

Studies both here and overseas show that caring for others – who are often at their most vulnerable – in today’s fast-paced, high acuity, high workload health sector can come at a cost to the mental health and wellbeing of the carers.

It can lead to unhealthy stress levels, fatigue, emotional exhaustion, cynicism, compassion fatigue, moral distress and burnout. It can also be a trigger for anxiety and depression disorders.

But while nurses may talk about stress or feeling emotionally drained at the end of a day, it appears that few are likely to share that they have a mental health disorder like anxiety and depression.

Nursing blogger Barbara Docherty last year described depression as nurses’ “best kept secret” in a blog that went viral, attracted many social media comments and led to nurses taking the opportunity to confidentially share their stories.

It should not be a surprise that nurses suffer depression and anxiety as the 2012–13 New Zealand Health Survey found that one in six New Zealand adults (16 per cent) had been diagnosed with common mental health disorders (including depression and anxiety) at some time in their lives, and one in five New Zealand women.

Literature reviews also indicate that mental health issues are more prevalent in nursing and the other health professions than they are in the general population – probably because of the high stress and emotional demands of the work.

For example, a major review of the health and wellbeing of Britain’s NHS staff by Dr Steve Boorman released in 2009 found that sick leave taken by NHS staff was 50 per cent higher than in the private sector. About £1.3 billion of the £1.7 billion estimated annual cost could be attributed to mental health problems.

A recent study of nearly 3,500 Chinese nurses found an estimated 38 per cent had depressive symptoms. A 2012 study of 1,171 American nurses funded by the Robert Wood Johnson Foundation found that nurses had twice the rate of depressive symptoms of the general public (18 per cent, compared with 9.4 per cent).

An Australian retrospective study found elevated rates of suicide amongst nurses and female doctors, compared with other occupations, with one explanation raised being greater exposure to work-related stressors.

These are stark statistics. What are the possible reasons behind them and how could the mental health and wellbeing of nurses be better supported?

Emotional work

“I think we should work with the assumption that all nurses at some time are going to struggle because of the emotional work we do,” believes Dr Jacquie Kidd, a researcher in the field of nursing and depression.

Kidd’s PhD research drew on the experiences of 18 Kiwi nurses experiencing mental illness while practising. She believes that if both the profession and sector acknowledged that nursing is a vulnerable workforce under high emotional stress they would be more open to providing the early intervention and support required.

“I think we would be much healthier,” says Kidd, who is also a Waikato-based senior lecturer for the University of Auckland and teaches and coordinates a mental health new graduate programme.

She says programme leaders tell nurses starting out in their first mental health jobs that after a honeymoon period all of them will hit the wall and think they are hopeless nurses and wish they’d never chosen mental health nursing as a career. But the programme leaders also reassure them that when that happens they will be supported with whatever help they need, and that they will come through it.

Kidd thinks this type of approach should be extended to nurses throughout their careers because not only does the public place “huge” expectations on nursing as a caring profession, but the profession also puts high expectations on itself.

The fear of letting their colleagues or ‘the badge’ down may be one reason few nurses are ready to speak up when they are struggling, believes Kidd.

“In the beginning, depression and anxiety can feel like you are doing something wrong … you feel you’re not quite as good or as fast as everybody else and you are struggling to cope with patients and families that your colleagues just seem to be sailing through with.”

Kidd says by covering up and putting on a brave front of ‘coping’, struggling nurses can miss the early warning signs and the opportunity for early interventions to prevent mental health issues affecting their work. Pushed nursing colleagues may also struggle to feel compassion for a struggling colleague because they are worried about the impacts on their own workloads and mental health if they offer support and help.

Dr Stacey Wilson, a mental health nurse with a research interest in emotional competency, says there is also a sense that nurses should know better, as depression is somehow seen as “quite self-absorbing or selfish” and “nurses aren’t really allowed to be like that”.

Wilson acknowledges the irony that as a profession nurses encourage clients to seek help for mental health or addiction issues and are positive about mental health recovery. But personally it may be a different story because there is still a stigma attached to disclosing mental health issues as a nurse.

“I don’t know many nurses who would say that they are off on leave because of a mental health or a drug or alcohol issue,” says Wilson. “Some might say they are on stress leave.”

Both Kidd and Wilson believe that contributing to nurses’ stress and distress is the disjoint between what draws many nurses to the profession in the first place and the reality of the modern workplace.

“My impression is that what makes us resilient is the time we spend engaging with patients and families – because that’s where we get the sense we are doing a good job,” says Kidd. But working at full capacity can leave nurses little time to foster the relationships that give them energy.

“I think we are in an ever-decreasing circle – we’ve got less and less soul-feeding happening and yet we are giving more and more.”

Wilson says constant change in the health sector is another factor, along with nurses trying to juggle the demands of work with the pressure to do postgraduate work, look after families and attempt a semblance of work/life balance.

So what steps could be taken to better care for the carers?

Healthy workplaces

“If we expect the healthcare workforce to care for patients, we need to care for the workforce.”

This quote from the National Patient Safety Foundation’s Lucian Leape Institute is one of the philosophical drivers for nurse Janice Riegen’s work.

The clinical nurse specialist in occupational health and safety is passionate about the urgent need to create healthy workplaces in the health sector, including reducing the risk factors for anxiety and depression.

“What the literature is telling us is that anxiety and depression are going to be the leading cause of workplace absence for everybody in the next five years – not just in healthcare,” says Riegen. Contributing factors to this include psychosocial risks which Riegen says are becoming one of the biggest health and safety challenges in the modern day workplace worldwide.

Riegen’s master’s research was into what contributes to a healthy workplace and she has presented on the topic internationally. Waitemata District Health Board, who Riegen works for, has created a Healthy Workplace steering group – inclusive of the main unions. Last year the DHB’s board and senior management gave the go-ahead to a Healthy Workplaces Strategy for the organisation and its staff.

The three-year programme lists 15 actions ranging from developing an age-friendly working environment to offering mindfulness and wellbeing sessions, and from supporting best practice workload management to promoting good shiftwork and fatigue management practices.

Riegen says that any healthy workplace strategy needs to be holistic and look at all work aspects that can impact on staff health and wellbeing. “Because what the evidence tells us is that one-off things are no good.” The DHB have used the World Health Organisations ‘Healthy Workplace’ (2010) definition and action model as a basis for the work, along with New Zealand’s Te Whare Tapa Whā model.

So, for example, offering mindfulness and wellbeing sessions is good – but a strategy needs to permeate an organisation’s culture and address psychosocial risks as well.

Riegen says that doesn’t mean you shouldn’t do anything in the interim – she points out that Waitemata’s strategy has been five years in the making and is still a work in progress – but that the bigger picture should always be kept in mind.

Including that there is a very good business case for investing in healthy workplaces as having healthy staff – both physically and mentally – results in less absenteeism, ‘presenteeism’ and staff turnover and leads to greater productivity.

“Also in the last few years the research about the inextricable link between staff health and wellbeing and the safety and quality of the experiences and outcomes for the patients has nearly doubled,” says Riegen.

Safe staffing is definitely one part of a healthy workplace, Riegen says, and if you talk to nurses anywhere their main safety focus is on workload pressures. Excessive workload is a psychosocial risk (according to European Agency for Safety and Health at Work) that can contribute to mental health issues, along with a lack of involvement in decision-making and a lack of support from management or colleagues.

“I used to do bureau work and I could tell how healthy the workplace was straight away after walking in – just based on how I was greeted and welcomed.”

Teamwork and managers

The nursing literature agrees that teamwork – and good managers who foster it – is a very important component of nurse wellbeing in the workplace.

For instance, the Magnet Hospital research, which distilled the common characteristics of hospitals able to attract and retain satisfied nurses during nurse shortages, found that these hospitals not only had adequate staffing, but also offered professional autonomy, participatory management styles, well-prepared leaders and teamwork.

Alison Ogier-Price, who leads the Working Well programme for the Mental Health Foundation and has been working for a number of DHBs to help develop wellness programmes, sees training and supporting managers as crucial

“I see teams that function so well,” she says, “and the heart of it is always that manager who gets it – someone who likes people and gives people a sense that they are participating in decisions that are happening around them.”

But sometimes charge nurse managers (CNMs) are in the role due to seniority or their clinical skills and don’t have the skills to run a team of people. Or they are scared to raise mental health concerns with staff because of uncertainty around what is okay to ask about and what is not. Sometimes managers themselves are affecting the mental wellbeing of their staff because of their communication styles and, on occasions, bullying behaviour.

“Sometimes bullying issues arise through lack of training – they don’t realise what they are doing,” says Ogier-Price. She says that is why it is important to invest in training managers to listen to what’s going on, acknowledge it and respond by using positive and communicative management styles. Training should include communication skills, conflict resolution and team-building skills to create cultures where teams work well together and feel free to raise issues of concern.

Kidd suggests that charge nurse managers may do well to have the ongoing support of HR, rather than HR stepping in when things go pear-shaped.

Riegen says the evidence indicates that line managers should also be trained in supporting staff at risk of mental health issues because if staff have trusting relationships with their managers then they will turn to these people first when they are struggling at work. But line managers, who can be the meat in the sandwich between staff and senior management, also need the skills and the tools to take care of themselves.

“It seems to me it doesn’t matter what position you are in the hierarchy of nursing – the level of stress and the potential for developing a mental health problem that is work-related is pretty high,” says Wilson, who provides professional supervision for nurses, from new graduates to charge nurses. “I don’t think because [managers] are at the top of the food chain that they are any more resilient to the work pressures – maybe they are even more vulnerable.”

Everyone who Nursing Review spoke to agreed that in an ideal world one-on-one professional supervision would be more widely available to help both managers and their nursing staff to critically reflect on their practices, plan their careers and work through some of the challenges facing them in their work.

Wilson says it could also help to defuse anger and conflict in a team if an issue could be resolved by confidential supervision rather than “spreading around like a virus” and infecting everybody.

Stress management, emotional competence and building resilience

So in the real world what can you do, as a nurse, to contribute to the mental wellbeing of yourself and your colleagues in a pressured work environment?

For a start, be kinder and more compassionate to yourself and be kind to your colleagues, who may be struggling around you.

“We’re a highly educated workforce that works in very difficult and challenging situations in some of the most dire times in people’s lives,” says Wilson. “We need a little reminding that nurses are valuable people and it is worth spending a little time being a little compassionate to yourself and working on your emotional competency so you are in good shape for work.”

Ogier-Price, who specialises in applying positive psychology to organisational wellbeing, agrees, saying that nurses generally don’t take good care of themselves and – strangely enough – don’t always have the information or skills to recognise when and how much support they need.

She has been offering wellbeing workshops in collaboration with the quake-challenged Canterbury DHB for the past three years, and after being called in to support other DHBs has come to believe that ‘care for the carers’ information is lacking in the health sector. In her role with the Mental Health Foundation she was commissioned to write a white paper for the Ministry of Health on the topic – something like a ‘working well’ guide for the health sector.

Ogier-Price says a health and wellbeing culture should permeate an entire organisation and include reducing the stigma of mental health illness so that people struggling with anxiety and depression feel more able to speak up.
In larger organisations this can include having access to EAP (Employee Assistance Programmes) that typically offer three free and confidential sessions with a counsellor or psychologist about personal and work issues that may be affecting workers’ productivity.

Kidd, for one, thinks that nurses could be making much more use of EAP. “Just having somebody who is paid to listen to you and talk about your woes … can really help to crystallise what you might need to do to help yourself feel better.”

Ogier-Price says organisations should also promote or offer programmes that help people to maintain and sustain their mental wellbeing.

Encouraging exercise is one example, as there is a growing body of evidence that physical exercise can be effective for people with mild to moderate depression. Programmes that can help people to relax, such as yoga, meditation or mindfulness, are also available, plus others that focus on the other important components of wellbeing, such as nutrition and sleep. Wellbeing workshops such as those offered at Canterbury DHB can teach nurses how to better care for themselves as carers.

Ogier-Price says an absolutely ‘core concept’ that she emphasises in her workshops is the need to build social networks at work, as this is where people spend so much of their lives. This includes creating a work environment where socialising can occur, such as a lunchroom, which she acknowledges can be challenging in busy wards with little private space. Finding a way for staff to get together regularly should be a priority, she says, even if it is just getting together for special morning teas once in a while.

After listening to nurses offload during wellbeing sessions, Ogier-Price is also interested in whether the idea of facilitated support groups, similar to those offered by Alcoholics Anonymous, could be helpful.
Another approach that Ogier-Price encourages in her workshops is for nurses to boost their wellbeing by “basically doing the stuff you enjoy doing”. She says that to avoid chronic stress nurses need to routinely and frequently de-stress during the working day.

“People need five minutes off every hour to de-stress so for the next hour they can function that much better.”

This may be as simple having a laugh or an enjoyable conversation. In a particularly busy day it may be just grabbing a minute to go into the corner and take some deep, calming breaths. In longer breaks it could be grabbing a chance to take a walk outside, knit or do a Sudoku puzzle – whatever helps them to relax.
Apart from stress management, Ogier-Price says other training programmes that could benefit nurses include assertiveness training and boundary setting to help them deal with both difficult patients and colleagues (see p.8 for some stress management tips).

Wilson and Kidd also believe that pre-entry and ongoing nurse education should acknowledge that nursing is emotionally draining work and help them to build the self-awareness and emotional competency skills needed to be resilient and care for themselves and others.

But it is not up to nurses alone to care for themselves – what is also needed is a health sector that cares for its carers. Creating a healthy workplace for carers – to paraphrase the World Health Organization’s healthy workplace motto – is the “smart thing, the legal thing and the right thing to do”.

When compared with an active control, mindfulness meditation programmes can help reduce negative dimensions of psychological stress such as anxiety, depression, stress/distress, in some clinical populations, but their effectiveness is uncertain for improving positive dimensions of mental health and stress-related behaviour.

CLINICAL SCENARIO

Mindfulness meditation has become fashionable for treating stress, stress-related health problems, and promoting wellbeing. You decide to review the evidence for the effectiveness of this therapy. In order to appraise the most robust evidence you are careful to choose evidence that has controlled for the placebo effect in its study design.

QUESTION

Is mindfulness an effective therapy for treating psychological stress, stress-related problems and promoting wellbeing?

SEARCH STRATEGY

PubMed-Clinical queries (Therapy/Narrow): mindfulness AND psychological stress, wellbeing

CITATION

Goyal, M., Singh, S., Sibinga, E.M., et al., Meditation programs for psychological stress and well-being: a systematic review and meta-analysis. JAMA internal medicine, 2014. 174(3): pp. 357-368

STUDY SUMMARY

A systematic review assessing the efficacy and safety of meditation programmes on stress-related outcomes in a diverse adult clinical population. Inclusion criteria were:

Type of study: Randomised controlled trials (RCTs) with an active control conducted in a general or clinical setting. Studies were to include adults with a clinical (medical or psychiatric) diagnosis, defined as any condition (eg, high blood pressure, anxiety) including a stressor.

Types of interventions: Structured meditation programmes (any systematic or protocol meditation programme that follows predetermined curricula) consisting of at least four hours of training with instructions to practice outside the training session, including mindfulness-based programmes, mantra-based programmes, and other meditation programmes.

Comparison: Active control, defined as a programme that is matched in time and attention to the intervention group for the purpose of matching participants’ expectations of benefit.

OUTCOMES

Stress-related outcomes that included anxiety, depression, stress, distress, wellbeing, positive mood, quality of life, attention, health-related behaviours affected by stress, pain and weight. Adverse events.

STUDY VALIDITY

Search Strategy: A comprehensive search strategy was used to search electronic databases – MEDLINE, PsycINFO, EMBASE, PsycArticles, Scopus, CINAHL, AMED, and the Cochrane Library – through to June 2013. Reference lists of relevant reviews and included studies were also reviewed. No publication date or language restriction applied.

Review process: Initial screening of titles and abstract, and then full text of those meeting initial selection criteria, were independently reviewed by two trained investigators. Data extracted included intervention fidelity (dose, training, receipt of intervention and participant adherence). Study quality was assessed independently and in duplicate. Differences in opinion were resolved through consensus.

Quality assessment: Reputable methods were used to assess the risk of bias within the included studies. The strength of evidence for each outcome was graded after considering the following four domains: risk of bias, directness, consistency, precision. The assessment of publication bias and its impact on results provided.

Overall validity: A high-quality review involving a large number of RCTs of varying risk of bias.

STUDY RESULTS

A total of 18,753 citations were screened, of which 1,651 full-text articles were assessed for eligibility. From these, 47 RCTs met inclusion criteria and were included in this review. Most trials were short-term but duration ranged from three weeks to five years. Fifteen trials studied psychiatric populations, including those with anxiety, depression, stress, chronic worry, and insomnia. Five trials studied smokers and alcoholics, five studied populations with chronic pain, and 16 studied populations with diverse medical problems, including those with heart disease, lung disease, breast cancer, diabetes mellitus, hypertension, and human immunodeficiency virus infection.

There was moderate evidence that in comparison with non-specific active control (ie, not a known therapy), mindfulness meditation programmes resulted in small improvements in both anxiety and depression at eight weeks and at three to six  months, and pain severity (see table) and low evidence that mindfulness meditation improved stress/distress and mental health-related quality of life.

There was low evidence of no effect, or insufficient evidence of any effect, of meditation on positive mood, attention, sleep, substance abuse and weight. In comparison with specific active controls (comparing effectiveness against known therapies such as drugs, exercise, and other behavioural therapies), there was no evidence that meditation programmes were better for any outcomes. No harmful effects from meditation were reported.

Table: Summary of Results

COMMENTS

• In comparison with other reviews, restricting inclusion criteria to RCTs with an active control provides greater confidence in these results.
• Mindfulness meditation programmes are a useful option for addressing psychological stress but the optimum dose, duration and instructor experience for effective mindfulness training stress reduction programmes is unclear.
• The programmes involved in this review typically provided around 20 to 27.5 hours of training over eight weeks. This level of support may not be readily available to many clinical populations.
• High-quality research with a longer follow-up time is needed to confidently establish the effect of mindfulness meditation on positive dimensions of mental health and stress-related behaviour.

Reviewer: Cynthia Wensley RN, MHSc. Honorary Professional Teaching Fellow, University of Auckland and PhD Candidate, Deakin University, Melbourne. [email protected]

The Church is looking for someone just like you to…

An elderly Samoan man has just turned up, can you translate…

Auntie is sick, can you just pop round after work…

We are looking for a Māori nurse for this working party, you’d be great…

Sorry to wake you up, but Mrs Toleafoa from down the street has had a turn…

Few nurses see their profession as just a job. But the expectations placed on Māori and Pacific nurses by themselves, their employers and their communities can make an already demanding profession even more challenging.

This is particularly true now, when health strategies stress the need for more Māori and Pacific nurses to help counter poor Māori and Pacific health statistics, while the percentage of Māori and Pacific nurses still lags far behind the actual populations (see statistics sidebar).

So there are too few nurses and too much need. How does this impact on Māori and Pacific nurses? And how do they cope?For her PhD thesis, organisational psychologist Dr Lisa Stewart looked at whether the occupational stress experienced by Māori health workers was different from their mainstream counterparts.

She says two themes emerged, one being the cultural expectation from Māori communities – shared by Pacific communities – that Māori nurses and other health workers give back to the community in some kind of service. The second was institutional racism – often caused by misunderstandings and a lack of cultural competence – which added to Māori health workers’ stress loads.

Community expectations

Māori and Pacific are not the only cultural groups where community and family expectations outside of work are important, says Stewart. But that cultural expectation is very real.

She recalls as a young university student in the 1980s being told by Māori student association leaders that, on graduating, Māori students like herself should help their whānau, hapū and iwi in some way, be it serving on the marae committee or helping out at kohanga reo.

Kerri Nuku, kaiwhakahaere of Te Rūnanga o Aotearoa NZNO, agrees and says being a nurse within a whānau group can lead to additional expectations.

“You will be the contact person for aunty down the road who is not really sure whether she should rock on down to the doctor’s or just put a bandage on it,” says Nuku. “We hear stories of nurses, particularly who work in rural communities with high population Māori, that in the supermarket people come up to you when you are trying to do your shopping at the weekend and ask you for your advice because you are whānau, because you are Māori and because you are approachable.

“Then if you’ve got somebody sick within the whānau, you go to work, do your work and then come home and take over your shift caring for the sick whānau member. You build your own roster around them so that caring doesn’t stop when you leave the hospital grounds or workplace.”

This sense of duty begins as nursing students, believes Jackie McHaffie, who is in charge of the Tihei Mauri Ora stream of Wintec’s bachelor of nursing programme and has been involved with the programme for around 15 of its 25 years.

“There’s a cultural component that is always going to be there and will add to your duties above and beyond being a registered nurse.
They try and give as much as they can back and in doing so they often burn out.”

Dr Sione Vaka, Tonga’s first male nurse, who is now a lecturer for Massey University’s School of Nursing, says likewise there is an expectation from the Pacific community for nurses to deliver as much support as they can. For him this means that in addition to his day job he is on the executive of the Tongan Health Society; he’s also vice-president of the Pacific Island Mental Health Professional organisation, chair of his church’s health committee, a member of both the Tongan Nurses Association of New Zealand and the Aotearoa Tongan Health Workers Association, informal mentor to Pacific postgraduate students from a variety of institutions, feedback provider on Pacific mental health research – and he also holds various other community service positions. And this is all after cutting back his out-of-work commitments to fit his targeted areas of expertise.

Workplace expectations and institutional racism

Then there are the workplace expectations that can be placed on a scarce and already stretched thin Māori and Pacific nurse workforce.

Stewart says one of the stress issues unique to Māori that emerged as a theme during her research (which assessed the work stress levels of 130 Māori health workers, including nurses) was institutional racism; for example, workplaces playing lip service to the Treaty of Waitangi and related policies aimed at improving health outcomes for Māori.

And Stewart says when organisations do recognise bicultural responsibilities – like holding a powhiri to welcome new graduate nurses – non-Māori managers can see this as a Māori-only role, adding an extra layer to Māori nurses’ workloads.

She says it doesn’t have to be that way. A positive example was an organisation she worked at where it was clearly expected that a Māori staff member would lead the karanga but all ethnicities and nationalities were invited to be part of the waiata group that performed support songs and helped set up the powhiri, including food if that was involved.

McHaffie adds that Māori nurses who work for organisations where they may be one of the few or only Māori can find themselves approached for advice on all things Māori, as well as being expected to say the karakia or sing a waiata. But there are also high cultural expectations placed on Māori who are working for Māori providers, which can extend the working day and week for Māori if they need to attend hui or practice for iwi cultural events. Then on top can come expectations for postgraduate study. McHaffie says that over the years she has seen some graduates burn out after struggling to cope with the pressure to be not only a good nurse but also a good Māori nurse.

Nuku says she’s also heard of hospitals placing Māori new graduates in particular units or wards well known to be “not conducive to Māori … oh I will just put it out there… they are areas known to be racist” in the hope of trying to change the behaviour of the staff. “So these are conscious decisions that are being made that put our nurses in unsafe places because nobody has dealt with the issue of racism.”

Nuku and her NZNO colleague Eseta Finau, who heads the Pacific Nursing Section (PNS), also both receive reports of interview processes and panels that are seen as discriminatory and demoralising for Māori and Pacific nurses.
Finau says an ongoing issue for many Pacific-trained registered nurses is being used as “cheap labour” by rest homes while struggling to afford time off to attend the English language training they need to become registered in New Zealand.

Another workplace expectation often adding to the stress loads of already stretched nurses is the belief that Māori and Pacific nurses should be allocated the Māori and Pacific patients, without the workload impact being considered.

“Why are Māori patients the sole domain of Māori nurses and why are Tongan patients the sole domain of Tongan nurses? Aren’t all patients the domain of all nurses?” asks Stewart.

Vaka echoes this, saying sometimes non-Pacific nurses are keen to transfer the care of a Pacific patient to a Pacific nurse, saying they would do a better job.

He believes it is important to encourage other nurses to be comfortable and confident in working with Pacific people, rather than trying to refer all patients to a potentially already overloaded Pacific nurse or Pacific health service.

Not a burden

Community, and employer, expectations may be high of Māori and Pacific nurses but often so are the nurses’ expectations of themselves in doing their best to improve the health outcomes of their people.

Stewart says Māori and Pacific nurses don’t usually see this work as a burden but more a natural extension of being part of a community. “I find when I’m giving back to a really good cause – and I’m helping the whānau in some way – as much as that’s work, it also feels really, really good and has a way of energising you too.”

So giving can be good – it’s over-giving that can be the issue.

Finau says family upbringing is also a major influence, with multitasking just something you do when you’re from the Pacific. “Because at home you grow up with so many kids around, there are family things and church things … and you just learn to juggle and cope with things. Giving back to the community is just another thing you take on and being a nurse you manage your time.”

Stewart’s research found that occupational stress was not lower in kaupapa Māori health providers than in mainstream providers – on the contrary, role overload and organisational constraints were all higher. But the coping strategies were better, which matched earlier research findings (see retention sidebar) that the top factors encouraging Māori health workers to stay with a health provider included being able to make a difference to Māori health and to their iwi or hapū, and that Māori practice models and approaches were valued.

Nuku agrees, saying Te Rūnanga o Aotearoa used to see nurses shifting from Māori provider groups to DHBs because of the money, but, despite pay parity being an ongoing issue (see sidebar), she says the reverse is also happening. “What we are feeling is that there is a trend that they are going back because they can’t cope with the amount of racism that is happening in workplaces.” There is also a frustration that poor Māori health statistics are used as “a patu [weapon] against ourselves”; innovative strategies that do work don’t get sustainable funding; and the Māori nursing workforce is still static, despite strategies aimed at boosting recruitment and retention.

“I don’t think we have looked enough at how we support Māori and Pacific nurses in the workplace,” she says.

Cultural competence of all staff important

One step in the right direction, believe many, is placing value on cultural, as well as clinical, competence in the workplace.

“If all of our nurses were culturally competent to deal with all of the cultural groups that they see in their practice, then the burden of being responsible for Māori patients becomes everybody’s responsibility – not just Māori nurses’ – and Tongan patients are not only the responsibility of Tongan nurses,” says Stewart.

Vaka says he is aware, through non-Pacific nursing friends, that some have a fear they will do something wrong when caring for Pacific patients, so they look to transfer them when possible. He agrees a better approach is for all nurses to upskill themselves culturally, seek advice and “have a crack” themselves in looking after Pacific people.

“If we are able to learn more about one another and how to work with different cultures – it is such a diverse community that we are living in at the moment – it would be improving our overall health care as well,” he says.

Stewart also believes the handover of patients to Māori or Pacific nurses is not intentionally malicious but more a lack of understanding and a lack of confidence in being able to work effectively with those client groups. “The reality is that as a Māori when I go into a health service would I prefer to work with a Māori member of staff? Sometimes I would, but I know the reality is that I won’t. But what I do expect as a Māori health user is that when I use the health services I get treated with dignity and respect in the same way that every other cultural group would expect to be.”

Nuku says there are expectations that registered nurses be culturally competent and clinically competent “but time and time again clinical competency outweighs the need for nurses to be seen to be culturally appropriate.” She says, as an example, that nurses must undergo ongoing professional development to be deemed clinically competent, whereas it is accepted that nurses will be still culturally competent after attending, though not necessarily participating in, a Treaty of Waitangi workshop five years previously. “It’s almost like a default that we sanction ignorance around working in Aotearoa and the unique relationship we have as tangata whenua.”

Mentoring and supervision

Having strong support mechanisms for Māori and Pacific nurses in hospitals and other organisations is also seen as key to recruiting and retaining nurses.

Nuku says strong mentoring programmes are needed not only for new graduates but also for Māori nurses throughout the continuum of nursing until retirement.

McHaffie also recommends that her graduates find a cultural advisor or mentor from whom they can obtain advice or talk to about situations that may arise. Nurses can also seek support from the Māori health units that are often within larger DHBs.

What is needed and wanted by many Māori nurses, believes Stewart, is cultural supervision, just as clinical supervision is offered to nurses in the mental health sector, to support best practice.

Networking with other Māori health professionals also emerged as an important coping strategy for stress, says Stewart,
but this was often seen by non-Māori managers as a social activity, rather than a chance to share ideas, download and support each other. “There seems to be a lack of understanding about what organisational conditions need to exist in order for Māori nurses and other health professionals to be most effective at their job.”

Likewise, Pacific Nursing head Eseta Finau says one of the most important roles of the country’s various Pacific nurses associations – such as the umbrella NZNO Pacific Nursing Section, the Samoan Nurses Association, the Tongan Nurses Association (which she also leads), and other Pacific nursing groups – is the support and mentoring they provide for members.

But when she invites nurses to join the NZNO Pacific Nursing Section and help to train a new generation of leaders, she says employers often won’t allow them to attend in work time. “Yet this is all towards the wellbeing and the future of our Pacific people in the communities that we live in.” With many Pacific nurses being the breadwinners for their family, it is a big ask to take a day off to attend a meeting, but committed nurses will use precious annual leave to attend, which Finau says is “just not fair”.

She says one way to deal with stress and burnout is by supporting people to be trained to fill leadership positions such as in the PNS to share the load.

Learning when to say ‘no’

An important skill for preventing burnout is the art of when to say ‘no’. Culturally, this is not always simple for Māori and Pacific nurses.

Stewart says it is actually harder for Māori and Pacific nurses to say ‘no’ to their cultural communities then it is to say ‘no’ to people at work.

Finau acknowledges saying ‘no’ can be an issue for Pacific nurses. “Some of us are just too polite and say ‘yeah’, ‘yeah’, ‘yeah’ and don’t say ‘no’ to anything. And commit and commit and you can tell they are over their limits. It’s a cultural thing – just trying to be nice and serve others rather than thinking about what you can do and what you can cope with.”

The result is that nurses can learn to cope and over-cope, but Finau says she can say ‘no’. “I know when to say ‘no’ and tell them when this is enough and when things are rubbish.”

Vaka says he used to overcommit to a lot of community projects and, combined with his PhD study, this left too little space for family time. “No wonder my wife would call my PhD the ‘other woman’,” laughs Vaka. He realised he had to be very selective in what extra commitments he said ‘yes’ to and now, unless he believes his expertise in health and research is going to be well-used, he will recommend another person. But it is still not easy.

“At the moment I am still struggling to say ‘no’ to people. But I think I know now how to say ‘no’ nicely,” laughs Vaka. “And I think for us Pacific people we need to know when to say ‘no’, as we need to reassess when we have enough on our plate already if we want to deliver a good quality service [to our work and our community]. Don’t be scared of saying ‘no’.”

Stewart agrees that it helps if nurses prioritise which goals are most important to them and decide how to make the best use of their time and expertise to meet those goals. This includes being aware of their own capabilities and when they are at risk of burnout “rather than just blindly saying ‘yes’ to everything.”

Conclusion

With its small numbers of nurses and high population needs, the Māori and Pacific health workforce is unfortunately at real and ongoing risk of burnout. Helping the existing workforce look after itself seems essential if that workforce is to have the rapid growth required to meet government targets and community needs.

One part of the equation is for funders and employers to keep working at better supporting and fostering this scant workforce. Another may be for communities to be realistic in the expectations they place on their nursing members. The last is for nurses themselves to do their best to look after themselves (see sidebar for some ideas).

“Nurses are no strangers to reflective practice – it is just a matter of reflecting on themselves rather than their work,” says Stewart.

“The reality is that if we aren’t looking after ourselves, how can we do our best to look after our communities? The best way we can serve our communities is to make sure we are well ourselves.”

• it’s easier to manage stress when you’re physically fit
• exercise and stretch throughout the day
• huffing/puffing (aerobic) exercise will help you to generate endorphins, which lift mood.

Humour

• smile – when you smile, your brain automatically produces endorphins
• laughter produces even more endorphins
• play funny games, share jokes, read cartoons and books, and watch videos
• start a humour box at work –collect cartoons, jokes and props which help you laugh
• laugh on the way home about one funny thing that happened during the day.

Separate home from work

• leave unfinished work at work
• leave work while you still have energy – otherwise, you will grind yourself to a standstill
• never work in bed – the bedroom should be a place of fun and relaxation
• have a shower and change your clothes when you get home from work
• distract yourself from work-related thoughts by losing yourself in a good book, movie, conversation, or even an attempt at juggling!

Make life easier on yourself

• carry things in a backpack or trolley rather than loading yourself with a heavy bag
• wear comfortable clothes — buy the right size (especially shoes and trousers) and wear low heels
• pay someone to clean the house, mow the lawns, or do things you don’t have time to do
• if things don’t work – fix them or throw them out.

Boost your stress immune system

• change the words you use to change your perception:
• feel the difference between saying ‘I’m depressed’ and ‘I’m feeling a bit down’ or between ‘I’m stressed’ and ‘I’m challenged’
• in a difficult situation tell yourself ‘that’s interesting’ and notice the difference
• physical touch will boost our immune system, so have a massage or stroke the cat.

Develop support networks

• take time out to nurture your relationships – go for walks, do things together, welcome them home.
• you don’t have to go through life alone – share your problems and successes with other trusted people
• Be ready to admit that you need help.

Change patterns of beliefs

• take a good look at your beliefs and challenge them — they often feel comfortable because we’ve had them a long time but they’re not always true
• look at some of the beliefs and expectations you have about yourself and see if they’re really relevant e.g. “I’ve always been like that”, “it’s easier to do it myself”, “no pain, no gain” or “life wasn’t meant to be easy”
• change the beliefs you want to change by changing your thoughts, mixing with positive people or listening to motivational tapes.

Nutrition

• eat breakfast
• eat from the food pyramid
• be especially careful to eat nourishing food
• when you’re under a lot of stress.

Give yourself bonuses

• send yourself flowers
• buy in take-aways
• go to a movie.

Always have a purpose in life

• if you’re not happy with something, do something about it
• change one thing in your life at a time and stick to it for six weeks to set a pattern which will last for a long time
• the most long-term changes are the ones we slowly absorb into our life.

Set boundaries

• learn to say “no!
• decide how much time you’re going to give and stick with that i.e. “when I’m on, I‘m on, and when I’m off, I’m off”.

About the author: Annette Milligan is the founder of Nelson’s INP Medical Clinic (formerly known as the Independent Nursing Practice) and workplace health and safety firm Ramazzini.