超越临床能力：优先考虑和支持护士的心理和精神健康

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Nursing demands physical, emotional, and spiritual energy and requires a commitment to strong ideals and values. Nurses often bring their whole selves to work. They bring who they are to the care they provide. As a result, workplace stressors and chronic exposure to suffering can cause personal distress in nurses in many domains. Training and professional development should emphasize nurses' mental health and spiritual health and provide language and skills in these areas. In a recent editorial, Robinson (2022) emphasized the importance of emotional and spiritual preparation and readiness in the career development of nurses. Although clinical knowledge and skills are essential, nursing schools and health care organizations must also provide knowledge and tools to address the personal impact of work in nursing. Therefore, we aim to recommend interventions that may prevent potential stress injuries and heal existing wounds.

Stress reactions and mental health exist on a continuum with a broad spectrum between healthy, injured, and ill (Watson & Westphal, 2020). Similarly, a range of prevention to treatment efforts can be made to address burnout, traumatic stress, and moral injury among nurses. To improve and protect the mental health and well-being of nurses, institutions must cultivate a culture of wellness, which involves translating evidence-based interventions into clinical settings (Melnyk et al., 2020) and nursing education (Goddard et al., 2022). In addition, educators and leaders must provide education about help-seeking to reduce stigma and remove barriers while providing nursing students and nurses with direct referrals for mental health counseling and steps to access these resources.

Burnout

Burnout is a psychological syndrome characterized by emotional exhaustion, depersonalization, and reduced personal accomplishment (Maslach et al., 1996). Chronic stress with lack of recovery and insufficient resources (i.e., when your well runs dry) leads to burnout (Schaufeli et al., 2009). Tackling nurse burnout requires a parallel process with intervention occurring at the individual and system levels.

Self-Care and Self-Compassion Training

At the individual level, skills can be taught to identify and mitigate burn-out symptoms and promote mindful self-care practices. Self-care and self-compassion skills are important features in interventions that aim to reduce burn-out (Duarte et al., 2016). Nurses might be inclined to neglect themselves and their own needs, for practical reasons (e.g., too much to do in too little time) and as a response to the nursing milieu. Mindful self-care training is imperative so that nurses learn to prioritize recovery and tend to their well-being. Self-compassion skills allow nurses to extend kindness and grace to themselves during moments of suffering, failure, or inadequacy (Germer & Neff, 2013).

Nurses often believe they need permission from others and themselves to practice self-care and be self-compassionate, while an inability to do so affects their well-being and care for patients (Andrews et al., 2020). Therefore, self-care and self-compassion training is important within nursing education and professional development. Programs on self-care and self-compassion integrated into learning and clinical environments can include didactic courses, interactive workshops, experiential learning forums, and psychoeducational groups.

Burnout Intervention

We developed and studied a psycho-educational group program called RISE© that teaches skills around its four themes of resilience (i.e., stress recovery, coping), insight (i.e., cognitive awareness, mindfulness, emotional identification and expression), self-compassion (i.e., self-validation, combatting negative self-talk), and empowerment (i.e., boundaries, values alignment). These skill sets, along with social support and emotional processing, can help prevent or reduce symptoms of stress and burnout and improve well-being (Sawyer et al., 2021). While addressing burnout at the individual level, organizational integration of programs, such as RISE, demonstrates a commitment to workforce well-being.

System-Level Changes

The onus of resilience and healing cannot solely be on the individual nurse. As system-level factors are often primary drivers of burnout, organizations are obligated to implement system-level changes to address these factors. The work environment must foster autonomy, empowerment, and processes that enable nurses to give the level of compassionate care they are called to give (Brooks Carthon et al., 2021).

Traumatic Stress

Nurses may face challenging or traumatic experiences directly (i.e., work-place violence) (Liu et al., 2019) or indirectly, as they witness the suffering, crisis, and trauma of others (Bock et al., 2020; Kellogg et al., 2018). As Robinson (2022) recollected, “It was a lot to send a young nurse into the anguish and anger of families dealing with pediatric cancer without preparing me emotionally or spiritually for the journey” (p. 2).

Educational Training

Educational training can help nurses identify traumatic stress injuries or even posttrauma disorders, enhance coping and protective factors, mitigate risk factors, and access treatment. On the individual and system levels, teaching nurse educators and leaders to recognize and intervene early can help prevent more dire consequences. When it comes to trauma, knowledge is power.

Stress First Aid (SFA) is a manualized training that can be incorporated into the learning and practice environments of new nurses. SFA is a self-care and peer support model, adapted from the military (Watson & Westphal, 2020). With this educational training, nurses can be equipped with practical skills to identify and address stress reactions in themselves and others. The model can also provide nurses with skills to reduce the severity of symptoms or serve as a bridge to more targeted mental health treatment (Watson & Westphal, 2020).

Trauma-informed care (TIC) is an evidence-based care delivery framework implemented in a variety of service sectors, including health care. TIC is an educational training that aims to increase knowledge and understanding of trauma and its adverse effects on individuals, communities, and organizations. This knowledge is infused into all aspects of care and service provision (Kimberg & Wheeler, 2019; Substance Abuse and Mental Health Services Administration, 2014). TIC is centered around reframing the question “What is wrong with you?” and asks instead “What happened to you?” (Kimberg & Wheeler, 2019).

Although TIC was originally developed as a patient-facing framework, it is gaining traction as an approach to influence workforce mental health, teamwork, and workplace culture (Oral et al., 2020). In addition, a trauma-informed pedagogy is proposed as a call to action for nursing schools to guide educators, researchers, and leaders in building foundational skill sets in nursing students and new nurses who may face chronic stress and trauma exposure (Goddard et al., 2022).

Posttraumatic Growth Interventions

Posttraumatic growth is a concept that describes the experience of growing through adversity (Tedeschi & Calhoun, 2004). Five main elements of posttraumatic growth interventions include education (e.g., trauma literacy), emotional regulation skills, disclosure, narrative development, and service. Posttraumatic growth can be facilitated through interventions or programs, such as peer support, psychoeducation, counseling, or debriefing groups (Xu et al., 2016; Yılmaz et al., 2018).

Moral Injury

Moral distress is the emotional fallout that occurs when constraints prevent doing what is right (Pendry, 2007). Further, moral injury is the “psychological, biological, spiritual, behavioral, and social impact of perpetrating, failing to prevent, or bearing witness to acts that transgress deeply held moral beliefs and expectations” (Litz et al., 2009, p. 697). Moral injury occurs when moral distress accrues and progresses.

Self-Reflection Interventions

Moral distress and injury can lead to spiritual exhaustion, which often results when service starts to feel like victimization. When professional caregivers' own needs consistently get sidelined, it can take a toll on their emotional and spiritual health, and serving others begins to feel like personal deprivation. Spiritual fatigue is a sign that one has become separated from themselves, and they need to reconnect. As Robinson (2022) noted:

In hindsight and with years of reflection, however, I wish I had understood [the physician's] pain at that moment instead of failing to recognize that his apparent contempt was more likely human moral injury from watching the parents extend their child's suffering to postpone their own.

(p. 2)

The first step toward spiritual and moral resilience is self-awareness. Self-reflection interventions can help nurses learn about thinking patterns, emotions, values, and belief systems, which inform their worldview and sense of self. They can also receive training to identify symptoms of spiritual fatigue and learn adaptive coping strategies to reconnect to the self through healthy emotional boundaries, aligning core values with behavior and choices, connecting to meaning and purpose, and recognizing and responding to personal needs.

Consultation and Peer Support

Moral resilience and courage can come from practical training to access consultation and peer support during morally distressing situations. In 2004, the American Association of Critical-Care Nurses developed the 4 A's model for reducing moral distress among nurses, which has since guided training to build moral courage (Edmondson, 2010). This model, which involves the four actions of Ask, Affirm, Assess, and Act, leads nurses through (1) using self-reflection to identify their symptoms and gain self-awareness, (2) accepting the responsibility to address the source of moral distress, (3) preparing to take action, and (4) making efforts to address the source—even if they feel fear while doing so.

Moral Injury Treatment Interventions

In military service members and Veterans, moral injury interventions involving spiritually influenced cognitively based processing (Pearce et al., 2018) and acceptance and commitment therapy (Nieuwsma et al., 2022) have reported positive outcomes. Such evidence-based interventions can be adapted for nurses and their experiences.

Conclusion

Through such efforts, nursing schools and organizations can take action to address the stress injuries of burnout, traumatic stress, and moral injury among nurses. As nurses are exposed to many workplace stressors and human suffering, they can be supported through education and interventions that prioritize and nurture their mental and spiritual health.

全文翻译（仅供参考）

护理需要身体、情感和精神上的能量，并且需要对坚定的理想和价值观的承诺。护士经常全身心投入工作。他们将自己的身份带到他们提供的护理中。因此，工作场所的压力源和长期遭受痛苦会导致许多领域护士的个人痛苦。培训和专业发展应强调护士的心理健康和精神健康，并提供这些领域的语言和技能。在最近的一篇社论中，罗宾逊 ( 2022) 强调情绪和精神准备以及准备在护士职业发展中的重要性。尽管临床知识和技能是必不可少的，但护士学校和医疗保健组织也必须提供知识和工具来解决护理工作对个人的影响。因此，我们的目标是推荐可以预防潜在压力损伤和治愈现有伤口的干预措施。

压力反应和心理健康在健康、受伤和生病之间存在广泛的连续统一体（Watson & Westphal，2020 年）。同样，可以采取一系列从预防到治疗的措施来解决护士的倦怠、创伤性压力和精神伤害问题。为了改善和保护护士的心理健康和福祉，机构必须培养一种健康文化，这涉及将基于证据的干预措施转化为临床环境（Melnyk 等人，2020 年）和护理教育（Goddard 等人，2022 年））。此外，教育工作者和领导者必须提供有关寻求帮助的教育，以减少污名和消除障碍，同时为护理学生和护士提供心理健康咨询的直接转介和获取这些资源的步骤。

燃尽

倦怠是一种以情绪衰竭、人格解体和个人成就降低为特征的心理综合症（Maslach et al., 1996）。缺乏恢复和资源不足的慢性压力（即，当你的井干涸时）会导致倦怠（Schaufeli 等人，2009 年）。解决护士倦怠需要一个并行的过程，在个人和系统层面进行干预。

自我照顾和自我同情训练

在个人层面，可以教授技能以识别和减轻倦怠症状并促进有意识的自我保健实践。自我保健和自我同情技能是旨在减少倦怠的干预措施的重要特征（Duarte 等人，2016 年）。出于实际原因（例如，在太短的时间内做太多事情）以及作为对护理环境的回应，护士可能倾向于忽视自己和自己的需求。有意识的自我保健培训势在必行，这样护士才能学会优先考虑康复并照顾他们的健康。自我同情技能使护士能够在痛苦、失败或不足的时刻向自己表达善意和优雅（Germer & Neff, 2013）。

护士通常认为他们需要他人和自己的许可才能进行自我保健和自我同情，而无法做到这一点会影响他们的福祉和对患者的护理（Andrews 等人，2020 年）。因此，自我护理和自我同情培训在护理教育和专业发展中非常重要。融入学习和临床环境的自我保健和自我同情计划可以包括教学课程、互动研讨会、体验式学习论坛和心理教育小组。

倦怠干预

我们开发并研究了一个名为 RISE© 的心理教育小组计划，该计划围绕其四个主题教授技能：复原力（即压力恢复、应对）、洞察力（即认知意识、正念、情绪识别和表达）、自我同情（即自我验证、打击消极的自我对话）和赋权（即界限、价值观一致）。这些技能组合，连同社会支持和情绪处理，可以帮助预防或减轻压力和倦怠症状并改善幸福感（Sawyer 等人，2021 年）。在解决个人层面的倦怠问题时，RISE 等项目的组织整合表明了对员工福利的承诺。

系统级更改

复原力和康复的责任不能完全由护士个人承担。由于系统级因素通常是职业倦怠的主要驱动因素，因此组织有义务实施系统级更改以解决这些因素。工作环境必须培养自主权、赋权和流程，使护士能够提供他们被要求提供的富有同情心的护理水平（Brooks Carthon 等人，2021 年）。

创伤性压力

护士可能会直接（即工作场所暴力）（Liu 等人，2019 年）或间接面临挑战或创伤经历，因为他们目睹了他人的痛苦、危机和创伤（Bock 等人，2020 年；Kellogg 等人） ., 2018 年）。正如 Robinson ( 2022 ) 所回忆的那样，“让一名年轻的护士在处理儿科癌症的家庭中陷入痛苦和愤怒，却没有让我在情感上或精神上为这次旅程做好准备”（第 2 页）。

教育培训

教育培训可以帮助护士识别创伤性压力损伤甚至创伤后疾病，增强应对和保护因素，减轻风险因素，并获得治疗。在个人和系统层面，教导护士教育者和领导者及早识别和干预有助于防止更可怕的后果。谈到创伤，知识就是力量。

压力急救 (SFA) 是一种手动培训，可以融入新护士的学习和实践环境中。SFA 是一种自理和同伴支持模式，改编自军队（Watson & Westphal，2020 年）。通过这种教育培训，护士可以掌握实用技能来识别和解决自己和他人的压力反应。该模型还可以为护士提供减轻症状严重程度的技能，或作为更有针对性的心理健康治疗的桥梁（Watson & Westphal，2020 年）。

创伤知情护理 (TIC) 是在包括医疗保健在内的各种服务部门实施的循证护理提供框架。TIC 是一项教育培训，旨在增加对创伤及其对个人、社区和组织的不利影响的知识和理解。这些知识被注入到护理和服务提供的各个方面（Kimberg & Wheeler，2019 年；药物滥用和心理健康服务管理局，2014 年）。TIC 的核心是重新定义“你怎么了？”这个问题。而是问“你怎么了？” （金伯格和惠勒，2019 年）。

尽管 TIC 最初是作为面向患者的框架而开发的，但它作为一种影响员工心理健康、团队合作和工作场所文化的方法正在获得关注（Oral 等人，2020 年）。此外，建议采用创伤知情的教学法，呼吁护理学校采取行动，指导教育工作者、研究人员和领导者为可能面临慢性压力和创伤暴露的护理学生和新护士建立基础技能（Goddard 等人，2009 年）。, 2022 )。

创伤后生长干预

创伤后成长是一个描述逆境中成长经历的概念（Tedeschi & Calhoun, 2004）。创伤后成长干预的五个主要要素包括教育（例如，创伤素养）、情绪调节技能、披露、叙述发展和服务。创伤后成长可以通过干预或计划来促进，例如同伴支持、心理教育、咨询或汇报小组（Xu et al., 2016 ; Yılmaz et al., 2018）。

道德伤害

道德困扰是当约束阻止做正确的事情时发生的情绪影响（Pendry，2007）。此外，道德伤害是“实施、未能预防或见证违反根深蒂固的道德信仰和期望的行为所造成的心理、生物、精神、行为和社会影响”（Litz 等人，2009 年，第 697 页） ）。当道德痛苦累积和发展时，就会发生道德伤害。

自我反思干预

道德上的痛苦和伤害会导致精神疲惫，当服务开始感觉像是受害时，通常会导致这种情况。当专业护理人员的自身需求不断被搁置时，可能会对他们的情绪和精神健康造成影响，并且为他人服务会开始让人感觉像是被剥夺了个人权利。精神疲劳是一个人与自己分离的标志，他们需要重新连接。正如罗宾逊 ( 2022 ) 所说：

然而，事后看来，经过多年的反思，我希望我当时能理解[医生]的痛苦，而不是没有认识到他明显的蔑视更有可能是看着父母延长孩子的痛苦以推迟他们自己的痛苦而造成的人类道德伤害.

（第 2 页）

迈向精神和道德复原力的第一步是自我意识。自我反省干预可以帮助护士了解思维模式、情绪、价值观和信仰体系，从而影响他们的世界观和自我意识。他们还可以接受培训以识别精神疲劳的症状，并学习适应性应对策略，通过健康的情绪界限重新与自我建立联系，使核心价值观与行为和选择保持一致，与意义和目的建立联系，以及识别和响应个人需求。

咨询和同行支持

道德韧性和勇气可以来自实践培训，以便在道德上令人痛苦的情况下获得咨询和同伴支持。2004 年，美国重症监护护士协会制定了 4 A 模型来减少护士的道德困扰，此后该模型指导了培养道德勇气的培训（Edmondson，2010 年）。该模型涉及询问、肯定、评估和行动四个动作，引导护士通过（1）通过自我反省来识别他们的症状并获得自我意识，（2）接受解决道德根源的责任痛苦，（3）准备采取行动，以及（4）努力解决源头——即使他们在这样做时感到恐惧。

道德伤害治疗干预

在军人和退伍军人中，涉及精神影响的基于认知的处理（Pearce 等人，2018 年）和接受和承诺治疗（Nieuwsma 等人，2022 年）的道德伤害干预报告了积极的结果。这种基于证据的干预措施可以适应护士及其经验。

结论

通过这些努力，护士学校和组织可以采取行动解决护士的职业倦怠、创伤性压力和道德伤害的压力损伤。由于护士面临许多工作压力和人类痛苦，因此可以通过优先考虑和培养他们的心理和精神健康的教育和干预措施来支持他们。

原文链接：

https://journals.healio.com/doi/10.3928/02793695-20220705-01

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