








key: cord-288460-4flu5jvx
authors: Dimino, Kimberly; Horan, Kathleen M.; Stephenson, Carolene
title: Leading Our Frontline HEROES Through Times of Crisis With a Sense of Hope, Efficacy, Resilience, and Optimism
date: 2020-10-01
journal: Nurse Lead
DOI: 10.1016/j.mnl.2020.05.011
sha: 
doc_id: 288460
cord_uid: 4flu5jvx

The coronavirus 2019 (COVID-19) pandemic has changed the trajectory of health care delivery in the United States and the whole world. Frontline nurses—essential warriors in this fight—complete exhausting shifts and experience the moral distress that comes with making difficult ethical decisions. This deeply human crisis requires a deeply human response. To augment the mental health of their frontline staff, nurse leaders must tap into their staff’s psychological capital (PsyCap). PsyCap is characterized by having high levels of HERO (i.e., hope, efficacy, resilience, and optimism). In this article, we describe strategies that nurse leaders can utilize to foster PsyCap in their nurses.

I n all the news about coronavirus disease 2019 (COVID-19), little attention has been paid to the support nurses need to maintain the balance between hope and despair. As a country and a world, we grieve the loss of normalcy, the loss of stability, and the loss of our loved ones. The country and the media praise nurses as frontline heroes in this battle against despair. They are commended for their resilience and their unselfish willingness to run into the fire while others are running the other way. These nurse heroes are recognized as soldiers of hope, but are these essential employees being supported as such by their organizations?

Under these extraordinary circumstances, the promotion of our frontline nurses' well-being is more critical than ever. Nurse leaders are being called not only to help their organizations manage uncertainties, but also to guide, support, empower, and lead frontline nurses who are bearing witness to unfathomable fear, grief, and suffering. To avoid burnout and a massive nursing shortage during and after this pandemic, nurse leaders have a responsibility to find ways to preserve the well-being of their frontline staff. In this article, we provide recommendations for how we, as nurse leaders, can use our leadership skills, professionalism, and humanity to lead our nurses during this crisis.

The deeply human COVID-19 crisis craves a deeply human response. How we, as nurse leaders, address these unprecedented events being lived by our frontline nurses will markedly impact their experiences throughout this crisis and beyond. While many outside of the health care industry focus on protecting financial capital, on the frontlines, we're seeing the value of other types of human capital. In particular, psychological capital (PsyCap) is in high demand. PsyCap an individual's positive psychological state of development, PsyCap is characterized by having high levels of HERO (i.e., hope, efficacy, resilience, and optimism). It is timely for leaders in nursing to learn about and invest in PsyCap development of their nurses so that the impact can serve as the foundation for our road to recovery.

Reporters and politicians won't let us forget that the COVID-19 crisis is inherently an infectious disease crisis, but it is also a deeply human crisis. Nurses providing direct care for COVID-19 patients practice in high-stress, potentially life-threatening environments. As a result, they are likely to experience psychological distress. Research suggests these nurses face serious risks of developing post-traumatic stress symptomatology (PTSS) along with a variety of other psychiatric morbidities. 1 Recent real-life examples back up the science. A significant proportion of frontline nurses treating COVID-19 patients in China reported symptoms of depression, anxiety, insomnia, and distress. 1 Dr. Perlis, a psychiatrist at Massachusetts General Hospital reminds us that "while the peak of the COVID-19 virus remains to be seen, it will ultimately subside however, what will remain are the consequences of chronic stress including major depression and anxiety disorders." 2 This worldwide pandemic has caused a radical shift in healthcare practices in hospitals all over the globe. Resources are low, whereas tension and loss are high. These organizational challenges also increase pressure on individual nurses in hospital settings. Frontline nurses know how to evolve and adapt to the medical acuity and complexity of COVID-19. However, if they don't have the resources to protect their mental health, their well-being will suffer. They may experience profound changes in their personal and professional relationships, changes to how they view their careers, financial hardship, or even death. This deeply human crisis craves a deeply human response. How we, as nurse leaders, address these unprecedented events being lived by our frontline nurses will markedly impact their experiences throughout this crisis and beyond. Nurse leaders can support the psychological well-being of frontline nurses navigating high-risk and hectic work environments. Nurse leaders who provide supportive engagement and transparency will cultivate a caring cultute in the work environment and reap the benefits from dedicated staff who will provide high-quality patient care. Alternatively, a lack of leadership, support, and effective communication will leave nurses feeling unappreciated, isolated, and devalued. Let's turn now to strategies for supporting frontline nurses during this crisis and beyond.

Although many outside of the health care industry focus on protecting financial capital, on the frontlines, we're seeing the value of other types of human capital. In particular, psychological capital (PsyCap) is in high demand. PsyCap is an individual's positive psychological state of development and is characterized by having high levels of HERO (i.e., hope, efficacy, resilience, and optimism). 3, 4 These four pillars of PsyCap can be encouraged and cultivated in frontline nurses supporting them to thrive in overwhelming circumstances. 5 Psychological capital will get us all through the COVID-19 crisis.

The following includes PsyCap "HERO Within" development guidelines from various published studies. Many of the strategies discussed here are adapted and applied to pandemic nursing from PsyCap 101: Your Guide to Increasing Psychological Capital. 4 For those in leadership roles, there is a reciprocal relationship between what you give and what you get from others. This characterizes authentic leadership. 6 Consequently, by investing in their own well-being, nurse leaders are more likely to portray a sense of hope, efficacy, resiliency, and optimism, and to encourage others to exhibit them as well.

When fostering hope, it is important to set clear organizational and personal goals that are both specific and challenging. The goal should be demanding, but not impossible. If the nurse's level of hope is low, start off with an easy goal in order to achieve some degree of hope before attempting a challenge. Once the goal is set, use a step-by-step method to break the goals down into substeps to make the goals more manageable. This method also allows frontline nurses to experience small successes as they make progress toward greater goals.

One practice is to conduct daily hope huddles. Shift changes involve exchanges of updates and reports between incoming and outgoing shifts of nurses. Why not create intentional moments of hope during these meetings? Nurse leaders can begin with positive and inspirational quotes to empower the staff and thank them for providing patients with positive experiences during their hospitalizations. In addition to the traditional handoff, nurse managers can accentuate positive outcomes from the previous shift and recognize meaningful staff contributions. This practice can lift the mood and bolster both arriving and departing staff. 7

Four widely recognized sources of self-efficacy development were identified by Bandura 8 (Figure 1 ).

Here are four ways to support frontline nurses to strengthen and foster self-efficacy:

1. Encourage them to focus on past successes (mastery experiences). Self-efficacy is usually realized through past experiences. 8 Whereas individuals most often develop self efficacy by successfully mastering skills, in a leadership environment, it is often about encouraging others to appreciate past successes, rather than creating them. Self-efficacy can be challenging for individuals with a high external locus of control because they find it difficult to internalize success, instead attributing positive experiences to factors outside of their control. 9 Therefore, by identifying specific competencies, skills, and experiences which contribute to past successes, nurse leaders can engineer mastery experiences, thereby increasing self efficacy among their staff. 2. Encourage awareness of role modeling (social modeling). Seeing nurse leaders, such as charge nurses, clinical nurse specialists, nurse managers, nurse educators, supervisors, and nurse scientists, in similar situations overcoming obstacles reinforces the confidence that frontline nurses themselves can succeed. In order for this type of positive psychological transference to have the desired effect, nurse leaders should be perceived by frontline nurses as authentic, connected, and similar to themselves. 3. Create situations for success (social persuasion). As leaders, in addition to verbally encouraging and persuading frontline nurses, we can position nurses for success by being mindful of placing them in a supportive environment. This encourages selfefficacy. 4. Reframe negative experiences (psychological responses). How we frame our physical and emotional reactions to stressful situations affects how we judge our ability to process and make decisions under pressure. Those demonstrating high levels of selfefficacy are actually able to enhance their performance by perceiving barriers and challenges as motivating, instead of frustrating. Nurse leaders experience negative psychological responses, too.

However, we can learn to reframe these negative thoughts by discussing psychological responses with other nurses. For example, if we can learn to recognize our stress as motivation to accomplish a challenge, rather than a loss of control or power, this can greatly support development of self-efficacy.

When individuals respond to adversity with actions that will lead to thriving as opposed to surviving, they are resilient. 10 All humans experience adversity. Resilience is literally recoiling quickly after an insult! High levels of resilience at work are associated with better working performance among nurses. 11 Nursing is known to be highly stressful, and fostering resilience would be extremely useful as an investment to combat such negative effects, while yielding positive organizational benefits. 11

Resilience is a combination of three characteristics: 12 Being Realistic It's important to be realistic about personal strengths and weaknesses. It is also crucial to look for good reasons to be positive even in the face of despair, but not to get discouraged when the turnaround of events is delayed, remembering that sometimes things get worse before they get better. When we manage our expectations, we can manage our disappointments.

Resilience involves utilizing our abilities to improvise and discover novel ways to accomplish our goals. As role models, it is critical for nures leaders to cultivate creativity. In a meeting or daily huddle, collaborating and brainstorming different ideas to solve a problem can strengthen frontline nurses' creativity. 12 Searching for Meaning Resilience also requires managing feelings and impulses. One way to practice this is to look for meaning. The ability to find meaning in situations where we have no control over the outcomes is at the core of resilience.

Optimism is defined as making a positive attribution about succeeding now and in the future. 13 People who tend to internalize their successes often believe they have to invest in work and effort for good things to happen to them. Optimistic individuals believe that no matter the effort, their future will yield positive outcomes. 4

Contrary to what some believe, optimism can be developed. It's all a matter of training oneself to focus Awareness of emoƟons and reframing experiences in a posiƟve way Figure 1 . Four Sources of Self-Efficacy.

on the positive. Leaders, for example, can encourage optimism in their colleagues by sharing past experiences and empowering them for future opportunity. One strategy for providing nurses with a way to enhance their optimism is to institute an exercise during shift report called "3 Good Things." 14 In this exercise, nurses are encouraged to write down and share three good things that happened to them during their shift and the causes of those events. When practiced regularly during daily report time, nurses will reframe their daily experiences on positive things. Sharing three good things personalizes and humanizes the interchange between nurses. This often results in more generous posturing towards each other.

Develop a multidisciplinary strategy team from key functional areas to oversee well-being initiatives for frontline staff. Recruit senior leaders to meet with frontline nurses to communicate the organizational commitment to the unit team. These sessions reinforce to staff that hospital leaders appreciate and value their specialized work. Offer leadership training to supervisors to ensure that they have the skills needed to support and maintain a healthy and healing work culture. Key topics include effective communication, conflict management, team building, and stress management. Arrange for psychologists and social workers to meet with frontline nurses individually or in groups to debrief, vent, and provide support as needed. Recognize that new graduates and less experienced nurses are at a higher risk for experiencing psychological and moral distress during and after this crisis. Incorporate special sessions during residency and/or orientation programs to address this. Cultivate a culture of caring in combination with an integrative therapies approach by offering wellness programs including Reiki, therapeutic touch, massage, aromatherapy, yoga, etc. Encourage mind/body approaches to become calm, centered, and fully present as part of your nurses' daily routine.

A TAKE HOME MESSAGE To achieve all of the above, nurse leaders need to invest in developing the PsyCap of their frontline nurses through long-and short-term interventions. So, what is the first step health care organizations can do to develop nurses' PsyCap? Simply introducing nurse leaders to the concept by empowering them to recognize and embrace their own personal level of HERO and encouraging them to do the same for others.

Because we do not often hear this concept used in the professional setting, taking the first step is critical to maximize this powerful resource.

Researchers consider PsyCap to be a fundamental asset of authentic leadership, which is unique and vital for nursing. 5 Authentic leaders possess a great deal of hope, efficacy, resilience, and optimism. With these attributes, nurse leaders are well equipped to lead frontline nurses in facing the challenges of the COVID crisis. Therefore, a developed and well-managed, PsyCap initiative can provide enormous benefits for nurse leaders, frontline staff, and health care organizations.

PsyCap helps nurses to maintain a commitment to their organization, and sustain dedication to providing exceptional, evidence-based patient care, even in the most overwhelming circumstances. But most of all, PsyCap helps nurses to heal.

With the increasing complexity of health care and the current and pending aftermath of the COVID-19 crisis, it is timely for leaders in nursing to learn about and invest in PsyCap development of their nurses so that the impact can serve as the foundation for our road to recovery.

Factors associated with mental health outcomes among health care workers exposed to coronavirus disease 2019

Exercising heart and head in managing coronavirus disease 2019 in Wuhan

Psychological Capital: Developing the Human Competitive Edge

Psycap 101: Your Guide To Increasing Psychological Capital

Compassion fatigue and psychological capital in nurses working in acute care settings

The Power of Positive Thinking

Hope Huddles Connect Front-Line Nurses Amid COVID-19 Crisis

Self-Efficacy: The Exercise of Control

Generalized expectancies for internal versus external control of reinforcement

Positive psychological capital: Measurement and relationship with performance and satisfaction

High resilience leads to better work performance in nurses: evidence from South Asia

How resilience works

Optimism, coping, and health: assessment and implications of generalized outcome expectancies

Positive psychology progress: empirical validation of interventions

Carolene Stephenson, PhD, RN, FNP, is nurse scientist at Hackensack Meridian Health and adjunct clinical instructor at Passaic County Community College in Passaic



