Self-Stewardship: An Ethical Imperative for Nurses

The profession of nursing and health care in general are in crisis. The COVID-19 pandemic has laid bare the fissures in a health care system that is supposed to allow clinicians to fulfill their ethical mandate to those they serve.2 A narrative that pits individual responsibility and system reforms as binary choices has intensified. Clinicians bristle at the suggestion that they are responsible for their own well-being, and systems have largely avoided the fundamental reforms that are necessary for healthy work environments. Simultaneously, evidence of burgeoning depletion, turnover, and exit from nursing accrues. How do nurses begin to reclaim their own health, well-being, and integrity amid these disorienting circumstances?Alicia is a critical care nurse who began her career during the COVID-19 pandemic. She has cared for dozens of critically ill patients, many with COVID and others whose illnesses became severe because they waited too long before seeking treatment. She’s held computer tablets for families to say goodbye to their loved ones, worked extra shifts, reused her N95 mask beyond its purpose, and taken on roles she felt unprepared for. She finds herself chronically exhausted, anxious at times, and experiencing frequent sleep disruption. Everyone seems to have “moved on” from the pandemic, but for her, there is a persistent heaviness that is associated with her work. She went into nursing to help people who were suffering and to make a positive contribution to the health of critically ill patients. She has appreciated the expressions of gratitude from her patients and those with whom she works. The learning curve has been steep, and she now feels more confident in her abilities to meet the unpredictable challenges of the intensive care unit. Now, 2 years later, she’s wondering if she still belongs in critical care, or nursing for that matter. Her nurse manager suggested she invest in some self-care activities, or to consider making an appointment with their Employee Assistance Program (EAP) provider. She cringed at the thought of either one. What should she do now? How can she stay true to her values as a nurse and continue to practice nursing? What can support her in making good decisions about her role and her profession? How can she regain her well-being and be in integrity with what matters most?For decades, clinicians have been advised to engage in “self-care.” Self-care has many definitions that incorporate aspects of taking action to promote one’s well-being and health. It encompasses activities such as rest and relaxation, cultivating healthy lifestyles, meeting basic human needs, and allocating time to support health and well-being.3 It has become a billion-dollar industry that markets products that tap into some deficiency that can be rectified by a scented candle or a new salve or device. These superficial understandings of self-care reinforce the presumption that the solutions to our depletion are external and temporary.Increasingly there has been a backlash of cynicism and pessimism by nurses and others about the value of investing in self-care. Some have interpreted it as a selfish indulgence or as an imprimatur to add one more thing to their long list of obligations at home or at work. Feeling time pressures to check more things off the list, many conclude “there’s no more hours in the day to allocate.” They lament that if they weren’t overworked or had healthier workplaces, they would have the bandwidth to engage in such activities. Others suggest that if their organizations gave them the time during the workday, they could be healthier and happier. There is likely truth embedded in each of these claims. But what is often missing are the deeper aspects of what it means to invest in one’s well-being and how doing so is linked to integrity.In our work focusing on moral resilience, a theme emerged from our data that we labeled as self-stewardship.4 We refined the definition as: “Self-stewardship embodies a commitment to know oneself, to responsibly and mindfully manage one’s personal resources, to recognize and compassionately respect one’s limitations, and to choose actions that are wholesome and life affirming.”1(p137) Self-stewardship goes beyond an ego-centered notion of self-care to a deeper inquiry that honors our basic goodness and humanity and acknowledges and engages the resources that are already within us and around us. It arises from a fundamental moral obligation to honor and safeguard our health and well-being because nurses are human beings worthy of regard for their dignity; this regard enables their service to others. It enables us to restore or retain our agency to choose what is right for us without giving away our power to others to determine what serves our integrity and well-being. Self-stewardship is fundamental to the ethical mandate reflected in the American Nurses Association (ANA) Code of Ethics, Provision 5: Table 1 outlines key attitudes and beliefs that support self-stewardship. Although it is not a panacea, self-stewardship offers a path for reclaiming our agency to choose what is right for each of us. When coupled with systemic reforms, it has the best chance of creating a sustainable and healthy nursing work environment.Knowing who you are and what you stand for in life and work is the core of self-stewardship. It invites a stance of self-respect and positive regard to honor one’s wholeness and that of others. This includes knowing what core values are most important to us, what nourishes and depletes us, and what makes us whole beings. Having a clear and accessible moral compass gives us the equanimity to stay true to ourselves amid confusion, uncertainty, or conflict. Beyond this, our moral compass allows us to live our values in our moment-to-moment presence and actions. As nurses, it also includes remembering why we have chosen nursing as our path and why the service that nurses provide matters.Cultivating self-awareness to become familiar with one’s somatic, emotional, and mental experience helps build the neuropathways needed to protect what matters most, including our health and integrity. This process of cultivation includes listening to the “call of conscience,” the somatic early warning system that helps us detect when we are in alignment with our values and when we are not and when threats are present.1,6 Awareness of oneself in this way is foundational to noticing and understanding our patterns of responses to situations that shift us out of our integrity and zone of resilience and what resources we have within us to restore balance and wholeness. Knowing oneself in this way requires self-honesty and courage to look beyond our defenses and habitual patterns to a deeper understanding of who we essentially are and what our purpose is in life and work. This stance invites us to examine our insecurities, fears, limiting beliefs, and biases that undermine our confidence in knowing ourselves and what is necessary for wholeness. Our capacity for trusting ourselves is fundamental to embracing what we know to be true and leveraging that knowing to make it visible in our actions and choices.Knowing who we essentially are and what we stand for creates the foundation to examine all the things we do consciously and unconsciously that contribute to our experience of well-being so that we can meet adversity with the resources we need to maintain balance and integrity. This means moving from autopilot or going through the motions to intentional choices about what serves us and what depletes us. We cannot know ourselves or our resources, commitments, and values when our nervous system is dysregulated. Knowing ourselves requires that we quiet the mind and listen to the wisdom of our bodies and our hearts. Without this, we risk acting out of unreflected beliefs or assumptions that can lead us to self-harm or harm to others. Engaging in a process of discernment allows us to discover the people, places, experiences, activities, and so on that engage our well-being, joy, contentment, strength, and awe. Conversely it also allows us to notice what depletes our life energy and integrity. As we become more depleted, we gradually lose track of what it is to be fully alive; as a result, our connection to and unification of our bodies, heart, and minds becomes fractured. Concurrently, we need to remember and connect to our unique inner capacities for resilience, wholeness, character, and strength as resources that can be amplified but not extinguished by external forces. Accessing internal resources that are life giving takes commitment to overcome our natural human bias to connect to negativity, to what is missing or is problematic. When our nervous system is dysregulated, our natural inclination is to amplify fear, frustration, or anger. Over time these patterns exhaust our vital energy.Taking an honest, critical look at all the commitments we have implicitly and explicitly made to determine which are nonnegotiable and which could be delegated or released helps us to choose more mindfully what serves us and our lives. Included in this examination is an awareness of our tendency to be overly responsible, to take on what is not ours to carry, or to have a sphere of concern that is disproportionate to our sphere of influence and agency. Nurses tend to feel responsible for compensating for myriad deficiencies within the clinical environment. Although the motivation to do so is often protecting their patients, it can inadvertently lead to unrealistic expectations, imbalances in effort, and frustration when their efforts are ineffective. Noticing these patterns helps to restore our ability to choose more mindfully what serves our life and work.Nurses are used to habitually overriding their bodies’ signals that they have reached a threshold of effort or exhaustion. Many nurses chronically abandon their own health and well-being by ignoring signals that are indicative of their basic needs for rest, nourishment, hydration, and so on. In situations that drain vital energy, especially when nurses may be expending disproportionate effort to bring about a particular result, we must look to evidence of our depletion in our thoughts, emotions, and bodies. As self-stewards, we must continuously calibrate clear, but not rigid, boundaries to help us resist being pushed past critical thresholds while we simultaneously expand the range of ways we can resource ourselves to remain whole and undiminished. This means that sometimes we must say no to requests or expectations in order to preserve our well-being and integrity. Developing the skills to say no in an integrity-preserving way allows us to claim our personhood and humanity. Doing so may be met with resistance from others as they adapt to new norms. Nonetheless, exercising one’s agency is an important signal of conscientiousness and integrity. Being truthful about our limits and taking action to protect our health and well-being requires practice and sometimes courage.Acknowledging our limitations requires us to extend the attitude of a kindhearted comrade to oneself by practicing compassion and generosity aimed toward our own situation. It requires that we relate to our own suffering and emotions with love, tenderness, and forgiveness rather than guilt, shame, or judgment. Pausing to reflect on what you might say to another nurse in a similar situation and inviting yourself to receive the feelings of kindness and compassion toward yourself helps to create more space to receive support and resources. Doing so supports a shift to viewing actions aimed at self-stewardship as a function of integrity rather than as deficiency or imperfection.Beyond acknowledging our limitations, self-stewardship invites us to humbly accept the circumstances we find ourselves in, rather than wishing they were different. Accepting reality does not imply that we agree with it or are abandoning efforts to change it. Rather, it allows us to shift our focus from what is not possible or ineffective to what is possible within our capabilities and sphere of influence. Easier said than done, it requires that we examine and perhaps let go of old narratives, limiting beliefs or attitudes, or habitual response patterns. This might include patterns of feeling unworthy, feelings of anger, resentment, or fear or thought patterns that reflect a scarcity mindset. Becoming aware of the ways that our minds reinforce our helplessness and powerlessness by refusing to accept the reality we are in creates an opportunity to choose. Beginning the process by noticing these patterns gives us insight about how we might begin to let go of what no longer serves us. It can also offer an opportunity to adopt a regular practice of intentionally writing down the things that need to be released in order for you to be whole and serve at your highest capacity and intentionally releasing them. Alongside this practice, it can create space to return to why you have chosen nursing as your profession and to reconnect to the memory of being aligned with your purpose. Remembering why we are here and the difference we make every day gives us fuel for investing in our integrity and wholeness.Enacting our choices engages our autonomy to choose what is beneficial to our health, well-being, and integrity. It involves a commitment to foster integrity in all aspects of our lives— biological, psychological, relational, spiritual, social, and moral/ethical. It is an opportunity to exercise our conscientiousness, agency, and choice in how we meet others and how we practice integrity-preserving actions that make visible who we are; in this way, we demonstrate what we stand for and embody self-respect.Unique to each person, enacting our choices is an evolving process that requires ongoing assessment, discernment, refinement, consistent commitment, and action. We nourish our purpose and sense of fulfillment when we allocate our talents, time, and energy in ways that bring about the highest and best outcomes. When we can derive meaning from our work despite the challenges, we are able to harness our moral resilience and ultimately our integrity. A firm grounding in our values and commitments enables us to transform adversity by creating a more complete and balanced account of our experiences, interpreted in a way that does not fundamentally reshape the architecture of our integrity. It orients toward where we are going without being stuck in where we have been. We cannot change the past, but we can be co-creators of our future.Let’s be clear about what self-stewardship is not. It is neither selfish nor self-indulgent when it arises from the core of who we are and what we stand for. When our ego is not the driving force, we are able to calibrate our efforts with the resources that are available to us so that we can serve in a way that is meaningful and beneficial. Instead of another thing on the to-do list, our action becomes integrity preserving and aimed toward health and wholeness.Self-stewardship is a lifelong practice; it is not confined to random or intermittent action but reflects intentional, persistent investment and choice. True self-stewardship emerges from within; it does not depend on the sanction of others but is enhanced when we are in integrity-enabling environments. Self-stewardship is not a method for increasing our tolerance to situations or people who threaten or violate our core values and well-being. Stewarding ourselves in response to these threatening situations gives us the clarity and fuel to respond to them in integrity-preserving ways, allowing us to avoid buying into narratives of “quick fixes” or attaining perfection in our actions or choices.Alicia’s situation is all too common. When we are depleted, the idea of self-stewardship may seem daunting. We may feel isolated, discouraged, and ineffective in our work. These are normal and predictable responses to situations that have exceeded our capacities. The feelings are not evidence of lack of resilience or resolve. Reframing the situation by seeing oneself as worthy of investment, regardless of what anyone else including her employer does, can motivate seeing the situation with fresh eyes. Recognizing the symptoms of depletion, burnout, and moral suffering is the first step in choosing how to respond differently. Turning toward the questions and discomfort long enough to gain insight about what will truly serve takes time and patience.Alicia can begin by taking stock of her current experience. Table 2 includes some questions that may help Alicia clarify her current situation. Noticing physical, emotional, spiritual, and moral symptoms may lead her to access EAP or mental health services. Or it could open the door to exploring other modalities to support her health and well-being. Noticing the impact of a repeating negative narrative about her role as a nurse and the impact of her practice environment on her perceptions may offer insight about what she has control over and what she does not.Adopting practices such as mindfulness, gratitude, or letting go can help by offering more resources and skills to deal with her chaotic, uncertain, and confusing clinical environment. Although it may seem inconsequential, pausing to balance the nervous system can have an impact on well-being and stability. Alicia may feel overwhelmed and think that pausing wastes time, that if she just just works harder, she will find the right answer. Self-stewardship is an ongoing process that is facilitated by holding lightly to our expectations of ourselves and the strategies that we adopt to it. herself to out some things without being too to the may offer enough space and to a new way of Doing so in with others can create a of and amplify this arises within the work environment or it the of the the noticing when fear, or and pausing before it on herself is a practice to down negative questions to and within the profession and her current role are best from a foundation of and first in actions aimed at self-stewardship may provide an environment to choose how to best her life energy, and in self-stewardship is a resource to engage in the discernment process that the that decisions will be on alignment of values and clarity rather than There is a risk when a is or to make without discernment, to the discomfort of the situation. actions may include clear boundaries beyond which she will not and in some herself from the current situation to offer her and This might a role in the current or another role within the of the made open the for decisions seems health care environment is in are the people in the Nurses Alicia are a of the of the COVID-19 pandemic. Although it is clear that health care systems need to be in ways that create and integrity-preserving workplaces, nurses can also regain their own agency to choose how to invest in regardless of what is around them. our in this way can be a resource amid confusion, and does not but it does our investment, commitment, and courage to shift from a of deficiency and to fully who we are and what we stand for. Without a commitment to being good of our own resources, we may continue to fear and negativity, Nurses are a of the health care system and now we must lead the way by truly what well-being and integrity is for our health care the and We know what will ultimately make a but we do know that that systems will shift in response to the actions of the people within it. As a and has a system is from of in a of have the to shift the system to a time you choose to invest in you contribute toward that