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Reflection is always concerned with the development of poise – the ability to know and manage feelings. The practitioner has reflected to understand their feelings. This cue now prompts them to consider how they might manage their feelings in order to respond differently. They may need to confront any lurking negative thoughts, fears, or feelings that seem to get in the way. In Buddhism, this scrutiny is called Apramada, what I term ‘the guard at the gate of the senses’ ever watchful for any negative mental events that may influence responding differently (Sangharakshita 1998). It is an aspect of being mindful acting like a diligent censor, keeping the mind alert, and moving towards the vision which the practitioner desires.

Practitioners often wear metaphoric suits of armour to protect themselves from the anxiety and emotions of caring and the suffering of others. Jade, one of the primary nurses at Burford Hospital said ‘I don’t come to work dressed in protective armour’ (Johns 1993). Dewey (1933, p. 30) observed:

Unconscious fears also drive us into purely defensive attitudes that operate like coats of armour – not only to shut out new conceptions but even to prevent us from making new observations.

Dewey believed that anxiety limited the practitioner’s ability to learn through experience. The professional is closed to protect self rather than open to possibility. ‘Armour’ is akin to professional detachment.

Logstrup noted the radicality of the ethical demand (1997, p. 44):

The demand asks me to take care of the other person’s life not only when it strengthens me but also when it is very unpleasant because it intrudes disturbingly into my own existence.

Hence, why we might strive to meet the demand to care for the life of the other, it opens us to our own vulnerability and why we may wear suits of armour to survive.

Coming to an understanding of one’s vulnerability begins a journey to unlearn defence mechanisms and learn to cope with it more effectively. The practitioner may need to review and develop their support mechanisms within the practice. To be able to say – ‘I’m struggling‘ without being judged incompetent. In my experience, there is little organisational sensitivity to the profound nature of caring work. The lack of recognition of emotional labour (James 1989; Bolton 2000) that somehow emotional work is natural women’s work, and therefore is unskilled doesn’t need to be taught, and is not valued, when emotional work is the greatest gift nurses can offer patients. Taylor (1992, p. 1042) noted a theme within the literature of how nurses have been dispossessed ‘of their essential humanness as human beings and as people, by emphasising their professional roles and responsibilities’. Taylor draws attention to the fact that nurses are human too and, as such, are vulnerable to the same issues that face their patients and families. The lack of recognition of humanness in nursing through a focus on roles and responsibilities has led practitioners to strive to be something they were clearly struggling to cope with. Consequently, they risk becoming alienated from themselves in their efforts to cope with and live with the contradictions in their lives. Jourard (1971) noted that such striving damages ‘the self’ and reinforces the need to cope in a vicious downward spiral of self‐destruction towards burnout and a state of anomie.

The reality of today’s NHS is that nurse shortages are reportedly reaching crisis point (Hall 2003); bed occupancy is constantly ‘red alert’. In such an environment, Wall et al. (1997) note that NHS staff suffer considerably more stress than any other workforce, with 28% recording levels above the symptom threshold. Wind the clock forward. BBC News reports that NHS Foundation Trusts need to resubmit their financial plans. Only essential posts should be filled. The news asks what impact on patient care. What impact on staff morale and stress. Pick up my local newspaper and staff morale at RCHT is low.¹⁰ Wind the clock forward to the 2019 general election and the conservatives are proposing 50 000 more nursing jobs. Tides turning. So why let it get so bad in the first place and putting lives at risk and in misery for both patients and staff?

Tools such as the feeling fluffy–feeling drained scale can help practitioners focus on stress factors and work at reducing them. At the end of your next shift, stop, reflect, and mark how stressed you feel along with the feeling fluffy–feeling drained visual analogue scale (Figure 4.2).¹¹

Stewing in our own juices is not healthy. Imagine your body is like a water butt‐ slowly filling with stress. As it fills, we are more tired and more intolerant but contain it, that is until you feel you are drowning and then one of two things happens. Either you blow up inside and have a breakdown, or else you snap and ‘blow your top’. You rage at events or people (Wilkinson 1988; Parker 1990; Pike 1991).

Pike (1991, p. 351) writes:

Moral outrage ensues when the nurse’s attempts to operationalize a choice is thwarted by constraints. The outrage intensifies when these constraints not only block action, but also force a course of action that violates the nurse’s moral tenets.

Then ask yourself:

 What factors contribute to your sense of feeling drained?

 What factors contribute to your sense of feeling light and fluffy?

 What do you need to do to home feeling more fluffy and less drained?

 Use this scale over a period of time to monitor stress patterns and any improvement in your ‘fluffiness’.¹²

FIGURE 4.2 The feeling fluffy–feeling drained scale.

Many practitioners wear this T‐shirt. However, the water butt does have a drainage tap. Through reflection, the practitioner can learn to monitor her stress levels and open her tap. She can then drain and convert the stress into positive energy necessary to take appropriate action to resolve the sources of stress (Hall 1964) just as the gardener draws water from the water butt to water the flowers and nourish their growth. However, the tap might be blocked, requiring help to unblock it – again, the value of guidance. If stress accumulates then the risk of burnout looms large on the horizon. Cherniss (1980) describes burnout as a process in which ‘the professional’s attitudes and behaviours change in negative ways in response to job strain’ (p. 5). Maslach (1976) suggested that the major negative change in those experiencing burnout in people‐centred work was ‘the loss of concern for the client and a tendency to treat clients in a detached, mechanical fashion’ (p. 6). McNeely (1983) observed that when practitioners felt they had lost the intrinsic satisfaction of caring, they became focussed on the conditions of work, for example, off duty rosters and workload issues, characteristic of bureaucratic models of organisation. McNeely believes that bureaucratic conditions are antithetical to human service work and strongly advocated that such organisations needed to move to collegial ways of working staff in order to offset the risks of burnout. Burnout is a descent into a black hole when the caring self has been scrapped away on the uncaring sharp edges of systems.

And yet, burnout can be a healing space, where the practitioner can recover/discover herself. It may be dark, lonely, and painful but it can still be a necessary healing space. Such healing is a journey to discover rather than recover because recovery suggests returning to what she was before, only for the hurting to start all over again.

Benner and Wrubel (1989) believe that the answer to stress and burnout is to reconnect to caring rather than the development of personal detachment, as advocated by Menzies‐Lyth (1988). Caring is a reciprocal relationship. If nurses and other healthcare practitioners are expected to care, then they need to work in caring environments. If the practitioner is suffering, it is likely that other colleagues also suffer, sapping their energy and limiting their availability to be with patients. And yet often, practitioners seem to need to cope, to not expose their vulnerability as if it is a weakness not to cope or admit to strain. They would prefer a collusive silence. To care, we need ways to penetrate the silence to support each other and create a therapeutic team – a team whereby its members are actively and genuinely available to each other. As such, the reflective practitioner is mindful of their colleague's well‐being. Then suits of armour can be discarded.

Consider the following questions:

 Are adequate support systems in place?

 Are people stressed or worse, burnt‐out?

 If so, why do you think that is?

 Do you see seeking help as a strength rather than weakness?

 Do you explore your anxiety as a learning opportunity?

 Are you truly available to support your colleagues?

The human response to manage anxiety is to control their environment, and with it, the source of their anxiety. Unfortunately, the mismatch of expectations within healthcare is wide with a consequential impact on morale and patient care.

It follows that the ability to know and manage self or ‘poise’ is a vital attribute of the practitioner seeking to realise desirable practice. Practitioners may well sacrifice integrity to manage anxiety and stress, and thus view the reflective project as an overt threat to their security or rather their insecurity. In my experience, very little education in practitioner training focuses on self‐management except perhaps an hour or two on stress management.