Watch and listen to Cynda Rushton, PhD, RN, FAAN, and AACN’s chief clinical officer, Connie Barden, MSN, RN, CCRN-K, FAAN, discuss the current state of our community and how nurses can help support themselves and one another during this difficult time.
Connie Barden: Hi, I'm Connie Barden, Chief Clinical Officer at the American Association of Critical-Care Nurses (AACN). And I'm thrilled today to get to chat with Dr. Cynda Rushton. Cynda is the Anne and George Bunting Professor of Clinical Ethics at Johns Hopkins University School of Nursing and the Berman Institute of Bioethics there. Cynda, we're so thrilled that you're here. Thank you for joining us.
Cynda Rushton: Thank you, Connie. It's my pleasure to be here.
Connie Barden: I also want to welcome those who are joining us virtually. I know that you all have a lot to deal with right now. We are all living in a world, both personally and professionally, we've never seen before. AACN sees you, we hear you, and in fact, that's one of the reasons why we're having this chat today. We really see ourselves not just as your professional organization, but as a community of nurses. And so coming together for conversations like these, we think are really important. So I invite you, those of you joining us, to pop your comments into the comment section below, ask questions, comments to one another, let us know how you're doing, and we'd love to learn from your thinking. But let's get going. Cynda, do you know the first thing that comes to mind for me is our title, we entitled this thing, I'm not okay. And we're talking about dealing with baggage from a prolonged pandemic. What does that bring up for you when you think about such a thing?
Cynda Rushton: Well, Connie, it has been quite a journey, hasn't it? In so many ways nurses have shown up, they have gone above and beyond to provide care in these really extreme circumstances, where we've had scarcity of all kinds, including people, to deal with the number of people who need our care. And alongside that has been a lot of frustration that despite the sacrifices that nurses have made, it's like the finish line keeps getting moved, and they have not had a break, even though they keep showing up again, and again, and again. What I've heard is that nurses don't feel heard, they don't feel appreciated and understood. And in the sessions I've been doing with nurses throughout the pandemic, they speak about the isolation of what they have witnessed and participated in over these many months.
Their worry is about their own health and that of their families, the extra weight that they've carried to accompany dying people at the end of their lives when their families couldn't be there. And how they, day after day, put on that PPE garb and provided care to sick patients. Many of them do feel abandoned by their organizations. Early on it was lack of PPE. And then often they were asked to fill the vacant shifts. And then when the wave passed, some of them were even furloughed. So there is the accumulated despair and anger. And some of that has even been intensified because many of them feel they've been abandoned by society.
Nurses take a very strong social covenant with their patients, that's why we are the most trusted profession, I do believe. And yet at the same time, our service to the country is not a unidimensional commitment. Many nurses feel like they've shown up over and over again to provide care. And many Americans have refused to take basic public health precautions that would have prevented them from actually needing critical care in the first place.
And I think that is, for many nurses, the final blow, the feeling that our patients have turned against us in a way that has often been the fuel for our work. So I think there's a sense of exhaustion. There's a sense of people feeling morally injured and discouraged and angry. And at the same time, I have to also pause and acknowledge the incredible courage and compassion that we've seen. So I feel like there's the whole continuum. There is so much to celebrate and to honor, and there's also a lot of residue that has accumulated over these many, many months.
Connie Barden: Thinking about that, we are accustomed to nurses having incredible physical demands, and emotional demands, that's it. But you used the terms, distress, despair, and anger, like this continuum. And I don't know that nurses are always comfortable with those extreme types of emotions, especially in this prolonged type of environment, particularly anger. So certainly we see some of the causes, you delineate the causes, but what are the consequences of these types of extreme emotions that we need to be concerned about, that people are probably feeling?
Cynda Rushton: Well, first of all, anger has a bad rap. We often have a negative connotation of anger as, that's as a negative emotion, but in its most fundamental form, anger is just energy. And so if you think about it, it comes up when there's a threat to something that we really care about, our identity, how can I see myself as a good nurse in this situation? When our safety is threatened, when our values, the things that matter most to us. Our commitment to relieve suffering, to benefit others. And our sense of who we really are, our personhood is threatened in some way. And it can be, for some people, our go to emotion when we feel fear, or anxiety, or helplessness, or frustration, and it's not unexpected in the circumstances we've been in, we feel helpless to change our patients' choices.
We feel powerless to change the fact that we're in a pandemic, that the efforts that we are undertaking are really not producing the results that we want. So on the one hand, anger is an expected and justified response to a violation of something that really matters to us, our beliefs, our values, and in my work moral outrage is an expected response when there's been a violation of some really important value.
If you think about how our nervous system works, we resonate with each other, positively and negatively, our energy connects us. And so right now, I think there is a collective anger that has really accumulated. And the question is, is when we become angry and we stay in a chronic state of anger, what happens? And I think this is where anger has two sides. It can be unregulated and spewed everywhere, causing more harm, or it can be harnessed and regulated and used in a way that may produce better outcomes.
People feel completely depleted and they start feeling as if they are victims, because they have no power. So when I think about the consequences of anger, one of the things that can happen is it overwhelms our sense of our basic goodness. And we start wondering, who am I now? Who am I in this circumstance? I don't really recognize myself anymore. Am I a good nurse or not? And that kind of thinking, I think really is a lot for us to carry, because what happens is if we don't process our anger, it starts seeping into other areas of our lives. We start being short with our colleagues, our friends, our family, we shut down, and we shut out people who actually want to be of support.
And sometimes in situations where it's prolonged, like it's been in this pandemic, it can accumulate and it paralyzes us, or else we end up turning it on ourselves and we become really self-critical. I failed, I didn't do enough, or we become really depressed. And we're seeing all of those symptoms right now in our world, but in our workforce. And so it's really important to be able to recognize that anger has a purpose and many of us are not sure what to do with it. We feel like we shouldn't feel that way and yet we do.
Connie Barden: That was exactly one thing I was going to ask you, some people besides not feeling they should feel that way, actually feel guilty if they're angry. And if you combine this lack of compassion, or empathy for a nurse, that can be very unsettling.
Cynda Rushton: We have heard messages from the time we were little that anger was not acceptable, that only positive emotions were the things we ought to express. And we shouldn't feel this way about our patients, and we certainly shouldn't say it out loud, but what happens is, I think when we deny it and we try to hide it, it starts oozing out somewhere else. And I think it can become overwhelming that we don't know what to do with it. And yet what's really needed, I think, is we need for us to, first of all, acknowledge that the emotion is there and to really honor it so that we can begin the process of letting go of it so that it doesn't have this tight grip on us anymore.
Connie Barden: On a daily basis when I'm just having this range of emotions of all kinds, how can I shake loose of it maybe every day at the end of a shift?
Cynda Rushton: That's a great question, because the truth of the matter is people who are at work, they're holding it all together. And one of the things that I've heard so many times from my nursing colleagues is, I get in the car every day and I cry, or I scream. And in that little sanctuary of my car, I just let it all out. And I think those are really important practices to allow ourselves, not because we're weak, it's because we need the emotional release of what we've carried all day long, most people have been holding their breath the entire shift. We haven't taken a full breath. And so we can do that. Some people, they need to, at the end of their shift, as they wash their hands the last time, to let whatever has persisted through the day to let it go down the drain, or when you get in the shower, when you get home, to let that shower be the place to really rinse off all the residue, the anger, just let it go down the drain.
Some people, they need to move their bodies, because we do harbor a lot of our anger in our body. I have a student of mine who is very interested in dance therapy, and there's a lot of evidence that moving our body is an important way to release stress. So, dancing, running, hitting the punching bag, whatever it is, doing some physical activity to let loose whatever has gotten stuck. And another one that has been really, really effective for some people is journaling. Being able to write it down. There's something about the act of writing it down in a lot of detail. Our mind loves the detail, and if we can put it on the paper, then we can begin to say, oh, I've let go of just this little bit of this.
Connie Barden: Yeah. I'm going to imagine that people listening and visiting with us right now, this is bringing up a lot for them. So those of you who've joined us, please jump into the chat, we want to hear and see what you're thinking and feeling. So just a reminder, there's a comment section here. We'd love to hear from you. Cynda, I know from your work you have some very useful notions about people do exactly what you're talking about, identifying these various emotions, whether it's anger or other things, and then steps to move forward to work with it so that we don't hurt ourselves and others. Can you talk a bit, I don't know that there's a straight line process, but what can you share with us about that?
Cynda Rushton: Well, I think one of the things that scares us is if I express my anger, I might get out of control, but it's really important to be able to express it so that it becomes something we can work with, and it's not just this toxic poison that is, basically used against ourselves, because over time the people who really are burdened most are us. And so the question is, is how do we harness it and use it as a guide and a motivator for action? And the first step in that is we need to really name what has caused this response to occur in the first place? What is it that feels threatened or betrayed? And to be able to say that out loud. I've spent so much time with nurses in healing circles and small groups and one-on-one, and being able to say, I am angry. I am really, really angry. And I'm angry at whoever it is, helps us to begin to own it.
And then to be able to notice, where is this anger showing up in my body? Because most of us carry anger in our body, in our jaws, in our neck, in our shoulders. Just think about at the end of your shift, the body is just on lockdown. Your heart, I don't feel any empathy. I feel nothing. What is your mind doing? And often the mind starts going in a continuous circle about all the wrongs and all the things that have happened that have resulted in the betrayal of what matters most to us. So paying attention and noticing, where am I carrying this? How we can create a kind of kindness toward our own experience. People are hurt, they feel abandoned, they're scared, we're frustrated and sad. And instead of pushing those feelings away to see if there's a way that we can extend a little bit more compassion to ourselves, just like you would to a good friend, or to a patient who's suffering. To be able to allow ourselves to feel things just as they are.
Connie Barden: Now, are you saying that we accept it? You're just going to tell me, yeah, just accept it. You're upset. You're angry. You're whatever. Is that the same thing?
Cynda Rushton: Well, I think accepting it doesn't mean you agree with it. It doesn't mean that it's justified in terms of the things that have caused it are somehow extinguished, but it's also accepting in ourselves, this is how I am right now, and also maybe even asking on what circumstances has this anger been helpful to me, and how might it be detrimental to me, now and in the future? How long might this anger be useful? Because it is energy. And I think that we're not suggesting that we overlook the very real consequences of what has happened, but rather to allow ourselves a little bit of space to explore where's this coming from? What might be possible for us to be able to meet this reality in a way that reflects who we really are? And how we can make, in the moment, our values visible. How we can let go of what is really weighing us down related to this anger.
One of the things I learned from one of my critical care colleagues during this pandemic, as we were doing a session, exploring just these very questions, is when we think about letting go of being angry, it feels like we're abandoning our truth in some way. But what this nurse said was, letting go doesn't mean you don't care. It means you're letting go of the grip of this emotion that is actually causing you and others a lot of suffering by holding onto it. And sometimes just by doing that, it allows us to feel like we're capable again, that we can make peace with the hard choices, and to reclaim who we really are, not the disabled view of ourselves that we've come to create.
And to find a way for us to accept that the circumstances that we've been in have created a whole host of baggage, moral residue, if you will, that even when we've done the right thing, there are unmet obligations and commitments. And part of our job is to see if there's a way to make peace with the fact that I did the best I could in the circumstances that I was in, and to turn some compassion toward our own limits, that the reason we're depleted is not because we're weak, it's not because we're not strong enough, or smart enough, it's because the circumstances have demanded more than our resources were able to offer. And so I feel like it's really, really important right now for us to be honest, to name the sources of our anger, and to inquire to see if it's possible, that we might be able to let go of what's not serving us so that we can continue in whatever way we can in our role as a nurse.
Connie Barden: Cynda, let me ask you one more question, what about the folks who feel right now, first of all, I don't have time for this, pause, reflect, all of that kind of thing, or just, I'm not ready for it? I am angry. I'm mad, and I'm not ready to not be mad right now. Stop telling me I need to work through it, and that kind of thing. No, I just need to be mad. What do we do with that?
Cynda Rushton: You're absolutely right. You can't be somewhere you're not. And so part of this process is if we can acknowledge, I am angry, and this is what I'm angry about. That's okay to be where you are right now. Doesn't mean it's going to be that way forever, but for right now, it is serving a purpose of some sort. And I think the question is, is how long will this anger be useful to you? And how is it useful now?
It may be that the anger is the thing that allows people to keep showing up. And that energy is what propels people forward. And we need to know ourselves well enough to know when it's the right time for us to put that down. And it may not be any time soon, but at least if we can see it for what it is, and pay attention to, how is this affecting me in my life? Is this serving me? Is this hurting me more than it's helping me? And if we can keep track of that, then that's probably the place where we can say, this isn't working out so well right now, but for the moment it's where I am.
Connie Barden: Is there anything we can learn for our years of patient care where people don't like such good choices sometimes? We still are there to take care of them.
Cynda Rushton: We need to have spaces where we can talk about the emotions that go along with the choices and what we're asked to do. But in the moment, we have skills that we can draw on. We know how to show up, we know how to be respectful. And those are parts of our experience, I think, we need to remember right now, that your effort is not dependent upon the patient's choice, but rather in how you deliver your care and concern, regardless of the choice that they've made.
Connie Barden: If someone is in a position where they feel like they have no options, they can't do this anymore. That's what you're talking about. Taking a pause, reevaluate.
Cynda Rushton: And not to be in too much of a hurry, we didn't get here overnight. We're not going to get out of this overnight, obviously, but I think it's important to pay attention to the anger and to use it as a tool for inquiry. I want to share this quote by Steven Levine. And he says, "The investigation of anger leads us directly to the love beneath, to our underlying nature. When we bring anger into the area where we can respond to it, where we can investigate it, where we can embrace it, it emerges into the light of our wholeness. Then anger is no longer a hindrance, but a profound teacher." And so, one of my final questions for all of us is what is this anger here to teach me? And that is a big question to sit with, and one that I think is worth engaging and that investigation to explore.
Connie Barden: I can't thank you enough, Dr. Cynda Rushton for joining us here and I look forward to the next time we get to chat on whatever comes next. Thank you.
Cynda Rushton: Thank you, Connie.