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Feature: BEHAVIORAL HEALTH

Benefits of mindful self-compassion for frontline nurses

Biber, Duke D. PhD

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doi: 10.1097/01.NURSE.0000827152.10997.19
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Recent research has found high levels of stress and burnout as well as moderate depression among frontline nurses during COVID-19.1 Such stress and burnout are exacerbated by the unpredictability of the pandemic. To prevent and address physical and emotional fatigue, nurses must engage in personal self-care. One evidence-based strategy that is growing in efficacy throughout healthcare is mindful self-compassion (MSC), which is the practice of treating oneself with the same kindness and compassion as one would extend to a close friend going through a difficult situation.2 This practice requires awareness to recognize personal suffering, stress, or exhaustion. MSC also promotes self-compassion through the awareness of difficult emotions (such as self-criticism, rumination) and the ability to cultivate awareness and compassionate action toward oneself.2 The article explores the benefits and strategies of practicing MSC for nurses, reviews the effectiveness of an MSC curriculum, and discusses practical techniques for nurses to put MSC theory into practice.

MSC for healthy coping

MSC entails three dyads to promote healthy emotional and behavioral coping: kindness versus criticism, common humanity versus isolation, and mindfulness versus rumination.3 For example, a nurse who has been working overtime shifts during the COVID-19 pandemic may feel physically and emotionally exhausted, and unable to help each patient due to overcapacity and limited unit staff. This nurse may become overly self-critical, feel inadequate to maintain quality care through such conditions, feel isolated from family or loved ones, and ruminate on these feelings. This is an example of maladaptive coping and a sign of burnout. When practicing MSC, this nurse may express self-kindness by understanding successful care despite limited resources, recognize common humanity in the overwhelming challenge posed by the pandemic on healthcare workers across the globe, and mindfully recognize feelings of fatigue and stress. With such connectivity to thoughts and emotions, nurses can become self-compassionate, which in turn promotes healthy coping. As posited in the Broaden-and-Build Model, MSC and positive emotional expression enable individuals to broaden their scope of possible emotions and behaviors.4 The Broaden-and-Build Model suggests that positive emotional expression increases thought-action repertoires. In other words, when a person expresses positive emotions like joy or gratitude, their choice of possible thoughts in response to such positive emotions expands. This leads to a wider variety of behavioral responses, often including creativity, playfulness, curiosity, and flexibility.5 The relationship between positive emotions (such as self-compassion), positive thinking, and adaptive behaviors helps people respond to difficult situations with flexibility and resilience.4 Engaging in mindfully self-compassionate thinking and behaviors add personal, emotional, and behavioral resources to a person's “toolbelt,” enabling them to overcome difficulties, stressors, or criticism.

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Training modules Content overview Content example
Discovering MSC Participants engage in a conceptual introduction to self-compassion with informal practices that can be used during the week. Participants engage in the Self-compassion Break, through which the three components of self-compassion are evoked through guided meditation.
Practicing mindfulness Participants receive formal and informal mindfulness practice training as well as the rationale for mindfulness in MSC. Participants receive 15-minute didactic teaching to build the foundation of mindfulness. They can engage in a Compassionate Body Scan, in which they pay sequential attention to each part of the body and resultant bodily sensations. This promotes a physical sense of self-compassion rather than criticism or shame.
Practicing loving-kindness Participants discover their own loving-kindness and compassion phrases for use throughout the day. Participants engage in an interpersonal, group cohesion exercise to build loving-kindness and trust.
Discovering your compassionate voice Participants learn how to motivate themselves with kindness rather than self-criticism. Participants practice Exploring Self-compassion through Writing, by writing a letter to themselves about a critical issue from a place of acceptance and compassion.
Living deeply Participants focus on the skill of compassionate listening. Participants practice Giving and Receiving Meditation, a self-compassionate breathing meditation technique to prevent caregiver fatigue.
Meeting difficult emotions Participants apply their skills by applying MSC to difficult emotions. Participants practice the Changing your Critical Self-talk meditation as a method to reframe their critical self-talk to be more friendly.
Exploring challenging relationships Participants learn the importance of MSC in their relationships and emotions, such as anger in relationships, caregiver fatigue, and forgiveness. Participants can engage in the Taking Care of the Caregiver meditation, in which they learn to keep their hearts open and help care for and nurture themselves at the same time they are caring for and nurturing others.
Embracing your life Participants end with positive psychology through savoring, gratitude, and self-appreciation practice. Participants reframe their inner dialogue so that it is more encouraging and supportive through the Identifying What We Really Want exercise.

Evaluating MSC effectiveness

Over the past 10 years, MSC has been incorporated into healthcare settings. A recent pilot study examined the effectiveness of an 8-week MSC training program on compassion fatigue and resilience in nurses.6 In this study, a sample of nurses from a variety of units including oncology, cardiology, maternity, intensive care, and urology participated in 2.5-hour MSC training sessions over the course of 8 weeks. The MSC training program included validated modules as well as a half-day in-service retreat. The module topics were: Discovering MSC, Practicing mindfulness, Practicing loving-kindness, Discovering your compassionate voice, Living deeply, Meeting difficult emotions, Exploring challenging relationships, and Embracing your life, (see Overview of the MSC curriculum2).

To evaluate the effectiveness of the 8-week MSC training, participants completed pre- and post-quantitative measures of mindfulness, self-compassion, resilience, burnout, and compassion fatigue. They also participated in focus groups at the end of the 8-week MSC training in which they responded to the question, “How did you experience the effects of this Pilot (MSC) training?”

From pre- to post-intervention, participants reported a statistically significant increase in self-compassion, mindfulness, compassion satisfaction, and resilience. Participants also experienced statistically significant decreases in compassion fatigue and burnout. The effect size Cohen's d effect size, which is the standardized difference between two means, ranged from d = .82 to d = 1.5 for all variables. Lastly, the major themes that emerged from the qualitative data included enhanced coping, positive mental state, and reduced stress.

While the mixed-methods results were significant, no follow-up was conducted to assess the sustainability of the results. That being said, the MSC training was practical, meaning each module could be tailored to later be applied to nurses' shifts when they returned to work. Participants reported strong satisfaction with the MSC training program, indicating the potential importance and enjoyment of applying such coping strategies in healthcare settings.

Practical techniques for nurses

This study is of special interest for a multitude of reasons. First, self-compassion training has been found to improve healthy behavior self-regulation as a means of coping, enhance resilience to difficulty and stressors, and promote healthcare job satisfaction.7-9 MSC is also easy to implement through in-service training, through various modalities such as face-to-face, online, podcast; in groups or individually; is free of cost; and can be tailored to the needs of the unit. While the MSC training discussed involved 2.5-hour sessions, research has found that people can reap the benefits of MSC through as little as 5 minutes of practice per day.7 Nurses are encouraged to engage in a moment of self-compassion during change-of-shift or huddle. Mindful self-compassionate cue words and reminders can be posted in the staff room or via weekly team emails. It is important for healthcare leaders to encourage nurses to reflect on stress management habits and negative emotional states related to their jobs. Through such awareness, nurses can begin to extend self-compassion both at and away from work. Self-compassion can also be elicited through journaling, letter writing, or imagery, all of which can be practiced at the beginning of a shift, during breaks, or at the end of a shift. Healthcare workers who regularly engage in self-compassion training may be more resilient to stressors and burnout, have stronger relationships at work, and provide compassionate care because they have first extended compassion to themselves.

REFERENCES

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Keywords:

behavioral health; burnout; meditation; mindful self-compassion; stress management

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