key: cord-0058970-m9mxbdw8
authors: Cohen-Serrins, Julian
title: The COVID-19 Self-Care Survival Guide: A Framework for Clinicians to Categorize and Utilize Self-Care Strategies and Practices
date: 2020-09-29
journal: Shared Trauma, Shared Resilience During a Pandemic
DOI: 10.1007/978-3-030-61442-3_37
sha: 4ee4acaf597b0a99e37a5ff98ce161fb3d5135b5
doc_id: 58970
cord_uid: m9mxbdw8

The COVID-19 pandemic has created an unrivaled need among clinicians to utilize resources aimed at mitigating the effects of this shared trauma. Despite the pre-existing need for organizationally based infrastructure to support these workers, the ongoing crisis necessitates the production of a guide for workers to access self-care procedures that are useful now. This guide seeks to intuitively organize self-care practices and procedures according to their type. It describes direct interventions for clinicians to remedy their own occupationally induced stressors, as well as provide conceptual strategies to foster sustainable resiliency-focused behaviors. Finally, this guide seeks to define a variety of self-care concepts and practices that match the range of clinicians working to stymie the pervasive effects of the pandemic. It excludes practices that conflict with CDC recommendations to prevent COVID-19 exposure and spread, such as any practice where maintaining social distance is not possible. Although it cannot inoculate clinicians to the profound effects of a shared trauma such as the COVID-19 pandemic, the goal is to bolster clinicians operating without sufficient structural resources to sustain their crucial services.

The COVID-19 pandemic has created a crisis that is unprecedented in both presentation and spread. It has created a global tragedy perpetuating illness, death, and economic disarray. Currently, the pandemic has killed over 800,000 people worldwide (Johns Hopkins University Coronavirus Resource Center 2020) while millions more are hospitalized and suffering (COVID-19 Hospitalizations 2020) . Clinicians on the front line treating those affected by COVID-19 are battling the virus's lethal effects on their clients and themselves. They confront daily their clients' suffering and death (along with their own fears of contracting the virus and spreading it to loved ones) in a work environment profoundly affected by limited revenue and resources. The overwhelming needs for services caused by this catastrophe renders it near impossible to initiate the vital process of creating organizationally rooted infrastructure needed to mentally and physically support their workers.

Instead, the best option is to create a guide for those who have limited resources to mitigate the profound occupational stress incurred from the COVID-19 pandemic, thereby benefitting from the implementation of their own self-care practices and strategies. Self-care is a flexible term used in a multitude of contexts. It is fundamentally a deliberate personal or professional action or strategy undertaken by an individual to reduce stress (Lee and Miller 2013) . This guide seeks to provide selfcare resources that are specifically actionable to individual clinicians affected by the pandemic. It excludes practices that conflict with CDC recommendations to avoid and prevent COVID-19 exposure and spread, such as those where maintaining social distance is not possible and those involving contact with frequently touched surfaces, indoor areas, and large crowds (implementing safety practices for critical infrastructure 2020). This guide cannot treat or eliminate the immense stress incurred by the pandemic, nor is it meant to replace robust preventative and responsive organizational procedures to support workers (see Chap. 27, this volume) . Instead, it represents a tertiary effort to categorize and define self-care strategies and practices for those in immediate need. The guide aims to be an accessible organized framework of self-care resources to be creatively and individually applied within the workplace by clinicians during the COVID-19 pandemic.

Prior to implementing these self-care measures, clinicians should assume a mindset focused on recognizing the sources and potential easing of their occupational stress. Clinicians, along with their administrators, need to critically examine their specific working conditions in order to combat its detrimental psychosocial and physical effects. This recognition may be a catalyst to help administration view employees not as capital or labor power, needing subsistence resources and maintenance to continue functioning, but with a humanistic lens valuing their need to be secure and supported in the workplace. The predominant view of clinicians is that they live to serve, requiring only enough gratitude to endure the shared traumatic effects of COVID-19 without additional resources (Palmieri 2017) . However, clinicians need both structures and resources to persevere.

The application of self-care to meet such profound needs requires practice. While each of the techniques and strategies described may offer some immediate mitigating effects, research has shown that their continued use and refinement lead to a more significant and positive effect (Jha et al. 2010 ). This may be due to the effectiveness of self-care practices themselves, along with prioritizing self-care. Since adequate research regarding the optimal synthesis of these self-care concepts does not yet exist, it is recommended that this guide should be understood as a reference resource for clinicians to individually sample and thus refine, to meet their specific occupational circumstances and needs.

The structure of this guide intends to make self-care intuitive for clinicians practicing during the COVID-19 pandemic. There are three main self-care categories in this guide: mindfulness, setting boundaries, and finding enjoyable activities outside of work. The exploration of mindfulness contains three main sections: meditation, applied mindfulness practices, and the intersection of mindfulness and technology. The section on meditation aims to define meditation along with its benefits. Under the topic of applied mindfulness, this guide provides an exploration of mindful eating and mindfulness practices using one's surroundings. The three areas that encompass the intersection of mindfulness and technology are mindfulness applications (or apps), mindfulness on social media, and live virtual mindfulness groups. Following the discussion on mindfulness, this guide examines two structurally focused self-care practices that clinicians can establish individually that support their physical and psychological health: setting boundaries to promote self-care and allowing time for enjoyable activities outside of work. This guide provides a layout of useful self-care practices within the context of the COVID-19 pandemic and prioritizes a conceptual understanding of the resources available for clinicians.

The most researched self-care practices are mindfulness techniques. Mindfulness is the practice of being authentically present and aware of the current moment (Spickard et al. 2002; Krasner et al. 2009 ). This awareness may include one's momentary surroundings, emotions, or physiology and endeavors to create a disposition less fixated on aspects of life that are unchangeable, specifically those in the past or future (Epstein 1999) . Mindful actions represent the most direct and individualistic interventions for self-care as they rely upon reflective actions.

Additionally, their fit with the individualistic norms of capitalist-driven societies has allowed mindfulness techniques to become increasingly numerous and innovative (see Cohen-Serrins, Chap. 27, this volume). Today, mindfulness practices are used as an intervention for a myriad of psychosocial conditions, including occupational stress and combatting some elements in the sequelae of trauma (Muir and Keim-Malpass 2019; Ortiz and Sibinga 2017) . The following mindfulness techniques are included based on their utility for clinicians specifically within the workplace.

Meditation is considered the oldest spiritually rooted form of self-care with historical estimates suggesting that it may have emerged among Hindus as early as 1500 BCE and integrated into Buddhist practices in the eleventh century (Everly and Lating 2002) . However, meditation does not require a religious affiliation, historical knowledge, or even a distinct philosophy. Rather, it requires four conditions: (1) a relatively quiet space; (2) a consistent and calming thought or sound; (3) a comfortable position; and (4) a passive mindset (Everly and Lating 2002) . Once such conditions are satisfied, meditation requires one to sit still, think calming thoughts or listen to calming sounds, and take slow relaxing breaths.

Clinicians can be flexible in establishing these conditions. For example, a quiet space can be any space where the clinician will not be interrupted by loud noises. The consistent sound can simply be one's own breathing, and the comfortable position is entirely subjective (one can stand, sit, lean, lie down, or even walk). Therefore, meditation is a mindfulness strategy that can be practiced in most workplaces including a community clinic or hospital and be applied during one's personal life outside of the workplace. The straightforwardness and flexibility of meditation make it a tested and evidence-based stress reduction practice for clinicians (Burke and Hassett 2020) . While meditation can be difficult to sustain, the benefits are numerous, extending beyond stress reduction to brain health and neuroplasticity (Yang et al. 2019; Tang et al. 2019; Adluru et al. 2020 ). There is established and ongoing research in the neuroscience fields that explore the benefits of sustained meditation practice (Yang et al. 2019; Tang et al. 2019; Adluru et al. 2020) . Additionally, as meditation has become highly popular, it also has the benefit of being a socially recognizable and accepted practice. The sight of one meditating is likely to be synonymous with clinicians coping rather than projecting their COVID-19-related work stress, allowing meditation to be a stigma-free self-care practice.

Despite its reputation, mindfulness is not relegated to meditation, and as mindfulness has had a resurgence in popularity over the last 20 years (O'Donnell 2015), it has been applied in a plethora of creative ways, adapting to distinct environments and populations. As such, specific mindfulness practices have shown efficacy in the workplace, especially for mitigating occupational stress (Guidetti et al. 2019) . As clinicians in the field today face the pandemic in both their personal and professional lives, it is necessary to emphasize some applied mindfulness practices that offer utility for practicing clinicians and have undergone peer review.

Mindful Eating One such practice is mindful eating or when one focuses their undivided attention to the process and sensations of what they are eating (Lyzwinski et al. 2019) . This can include the texture, taste, smell, and the effect of the food on the body over time as one eats (Lyzwinski et al. 2019) . Mindful eating is a slower process in order to provide an adequate time to gain a frame of mind conducive to mindful awareness. Additionally, it may be helpful to take small bites of food so as not to overwhelm one's senses or interfere with bodily responses. If done properly, mindful eating should provide an immersive and mindful experience to accompany nourishment.

Because eating engages all of our senses, it is an ideal activity to achieve the goal of mindfulness: the awareness of and focus on the present. Mindful eating exemplifies the type of practice beneficial to clinicians as it highlights that many do not take time during their workday to eat sufficiently. Since the COVID-19 pandemic has permeated and compromised all aspects of normal life, building these practices into something as basic as eating may be a feasible and intuitive method.

An equally accessible practice for clinicians involves using our surroundings as a vehicle to mindfulness. Using the perception of our surroundings as a mindfulness technique requires selecting an aspect of our environment that is largely static, such as an object or physical structure in the workplace, to perform a sensory-and detail-oriented examination of that object. For example, a hospital social worker could choose a noticeable part of their surroundings such as an emergency exit sign or a desk lamp. Once an object is selected, the clinician would deeply explore the object, including the colors of the object, its size, construction materials, illumination, sounds emitted, and moving parts. The goal of this exercise is to temporarily turn one's focus on to something in the current environment and away from past, current, and future sources of stress. During COVID-19 it is essential to perform this mindfulness exercise without engaging the sensation of touch. Although touch is crucial for our connection to the world, it is ill-advised to touch the object as public health agencies caution the avoidance of frequently touched surfaces (implementing safety practices for critical infrastructure 2020).

The intersection of technology and mindfulness has been building in popularity well before the COVID-19 pandemic (Van Emmerik et al. 2020 ). Due to our increased reliance on technology during the pandemic, mindfulness technology has become an indispensable area for clinician-focused self-care practices. Using technological resources to facilitate mindfulness, such as mindfulness apps on a phone or tablet, pre-recorded YouTube videos, or live mindfulness classes on Zoom, that guide users through a variety of mindfulness practices may, on a surface level, seem counterintuitive because the use of technology is not consistently associated with health or wellness. However, when applied properly, technological innovations related to mindfulness provide the ability for clinicians to harness the expertise and wisdom of experts who otherwise would be inaccessible due to travel and in-person gathering restrictions during the pandemic. It also allows for such expertise and wisdom to be accessed immediately when needed and privately. Clinicians should use mindfulness technology in a space and time with an attitude that prioritizes selfcare purposes.

Perhaps the most researched mindfulness intervention is the use of mindfulness applications (or apps) due to their accessibility (Van Emmerik et al. 2020) . Mindfulness apps can be accessed on several devices including a cell phone, computer, or a tablet and provide a guided practice or sequence of exercises to a consumer (Van Emmerik et al. 2020 ). These apps can provide guidance on meditation techniques and applied mindfulness practices with content tailored to the specific user. Typically, the apps involve audio guidance but may also include written instructions and imagery or be entirely text-based. Additionally, because these apps are delivered without the use of printed material, they provide both new and improved mindfulness practices.

A vast array of choices for mindfulness apps exists. While there are organizations providing mindfulness apps for a fee, such as the "Head Space" app, there are also a multitude of free apps available, including YouTube channels providing content. Although there is no preferred or optimal app for mindfulness, what should be sought is an app that facilitates an authentic experience. It is important to consider the type of mindfulness exercise employed, the length of time required, and its compatibility to a specific work environment. For example, while a spoken-guided 20-minute meditation accompanied by music may be enticing, it may not be feasi-ble in a busy hospital ICU environment, whereas a 60-second meditative breathing exercise without audio is a more feasible option.

Another venue to both practice and learn more about mindfulness is social media. There is, again, a vast amount of social media posts, accessible through nearly every social media platform. One can learn about mindfulness apps, new applied practices, theories, and even live events with experts. The only challenge to optimally harnessing social media is to ascertain what is beneficial for one's specific needs. For example, a Google search of the term "mindfulness practices at work" generates over 44 million results, an incomprehensible amount of information (Google's Mindfulness Practices at Work 2020a). The same search on LinkedIn yields 231000 results, still an enormous amount (LinkedIn Mindfulness at Work 2020b). Therefore, it may be advantageous to first develop a specific question regarding mindfulness and search for results on the social media platform that one is most comfortable using.

Another way to use this resource is to learn through social media who is producing app-based or virtual mindfulness content and what kinds of mindfulness content is available for specific audiences. Various platforms provide users with apps to consume or information to make them better consumers of mindfulness practices. According to the PEW Research Center, in 2019, 72% of adults in the United States use some type of social media (Demographics of Social Media Users and Adoption in the United States 2020). As mindfulness has grown in popularity, its overlap with the global pandemic will include a growing collection of resources for those interested in learning more about applying mindfulness and those seeking to add to their established routines.

Although mindfulness is an individually facilitated practice, there are communities and organizations providing self-care resources in live virtual meetings. While social media can facilitate communication about mindfulness practices, due to face-to-face meeting restrictions from COVID-19, some venues and organizations may offer similar virtual classes online accessed globally. In fact, the pandemic may have accelerated the availability of virtual mindfulness groups and classes. These resources tend to require at least 30 min of undivided attention and access to an uninterrupted space. Clinicians who are isolated from their families and friends due to pandemic-related work, and who may be seeking a health-focused community experience, may benefit from this resource.

Establishing proper boundaries may be a difficult endeavor during pandemic conditions, but its importance to clinicians cannot be overstated. The overwhelming number of people and communities afflicted may cause one's work to become relentless, complex, dangerous, and debilitating. These realities make boundary setting a potentially dystonic but indispensable step for clinicians to establish. Prior research indicates that all professionals require a balance between workplace autonomy and structure to thrive. In 1979, Dr. Robert Karasek's demand and control model sought specifically to define the proper qualities and amounts of autonomy and structure in order to facilitate employee wellness and success. Recent scholarship applying his model has emphasized the importance of moderating job demands such as clinician caseload (Jalilian et al. 2019; Brandtzaeg et al. 2018) . Adherence to Karasek's model is challenging under COVID-19 conditions. In the absence of organizationally produced infrastructure, establishing manageable boundaries such as a self-care practice to reduce the demands of and increase control over one's work is necessary.

The establishment of workplace boundaries can be segmented into two areas: working hours and post-working hours. During working hours for clinicians in certain environments, such as large clinics or hospitals, it becomes impossible to tightly regulate caseloads. Since COVID-19 has caused a dramatic spike in service needs, clinicians cannot be expected to limit their caseloads. However, there is legal precedent and established norms relating to taking breaks during the workday (Tippett 2018; Lim et al. 2016) . During this time of acute stress, every clinician needs to establish a routine of taking a break, ideally a full reprieve from the work environment, in order to rejuvenate themselves psychologically (Sos and Melton 2020) . Such breaks may be the best opportunity for clinicians to practice the self-care practices previously described. If enough clinicians were to establish this self-care practice as a part of their professional values, it may incentivize and normalize breaks for their co-workers and provide the foundation for future organizational policy discussions on promoting breaks during the workday.

Once a shift is complete, clinicians should ideally disengage from all workplace communications (Aranda and Baig 2018) . This is especially pertinent during the pandemic. Disengagement requires that clinicians establish an emergency communication policy at their workplace and then actively choose not to engage with workplace activities including emails, contact from clients, and calls or texts from co-workers about work-related topics. Such stringent measures are an opportunity for clinicians to have enough physical and psychological rest to work though the exorbitantly stressful current working conditions. Clearly some clinicians may not fully have this ability, as they may be "on-call" or covering several roles outside of their job title. Nevertheless, it is still essential to emphasize the value of establishing individual workplace boundaries delineating time at work from time outside of the work environment.

Notably, the establishment of boundaries is the only self-care procedure that requires communication with other people. Clinicians should have the ability to frequently and easily communicate with co-workers. Although communication about boundaries with management and leadership are necessary to ensure that breaks are fully respected, it is also important to inform co-workers and supervisees about communication boundaries. Having these conversations at any level of an organization helps co-workers respect self-care practices and also may ease the initiation of other self-care practices and strategies.

The final area of self-care for clinicians during the COVID-19 pandemic builds on the establishment of boundaries and involves finding safe and accessible outlets to release the physical and emotional energy caused by prolonged work in the current environment and renewal of energy for the next day. Such stress, if unmitigated, has been linked with increased emotional regulation issues, sleep disturbances, depression, and anxiety (Van der Klink et al. 2001) . While the aforementioned self-care practices and strategies are in place to relieve stress, they are not meant to replace meaningful hobbies or activities that bring joy to an individual. Although some hobbies and activities are impossible due to restrictions during the pandemic, the foundation and enactment of enjoyable nonwork activities can be developed and can help to shift one's attention away from a stressful workplace and in turn elevate one's mood.

Included in the category of creating time for enjoyable and meaningful activities is allowing time for rest, as adequate sleep is a causal factor for replenishment of one's body and mind (James et al. 2017) . Contemporary research on the area of workforce well-being among nurses places proper sleep hygiene and the allocation of adequate sleeping time as a principal element of any successful self-care routine (Allison 2007; Denyes et al. 2001) . Indeed, without the balance of both engaging in pleasurable activities outside of work and an ample sleep schedule, self-care practices cannot meet the monumental challenges posed by the pandemic.

Although making time for hobbies and enjoyable activities is obviously a subjective task, there are two elements most likely to be beneficial. The first is to find activities or hobbies that are expressive, meaning, any activity where one feels that they can fully release their authentic cognitions and emotions. When in the workplace, clinicians are not often provided a time and space to be expressive and authentic. Seeking expressive activities provides a way to release the cognitive and emotional impacts of experiencing a shared trauma while simultaneously being required to perform a caretaking role with confidence and precision. Contemporaneous research undertaken during the COVID-19 pandemic has suggested that clinicians participating in expressive activities has a therapeutic effect, specifically in relation to elucidating the processing of and coping with traumatic events in the workplace (Reed et al. 2020) .

The second element of a successful self-care-oriented hobby or meaningful activity is physical activity. Aside from the known benefits of physical activity, such as cardiovascular health, physical exercise is an excellent and important method for reducing the psychological aspects of stress (De Vries et al. 2017) . Before the COVID-19 pandemic, the range of physical activities for clinicians were numerous. However, the pandemic necessitated that gyms, team sports, and any indoor activities be closed. Instead, self-care-focused physical activities include at-home workouts with an app or YouTube channel or outdoor activities that one can do individually such as running, biking, hiking, or swimming. While the chosen method of physical activity is variable, undertaking sustained physical exercise represents an ideal selfcare activity for clinicians during their free time.

This guide defines categories of self-care practices and strategies (Table 37 .1) pertinent for clinicians operating during the COVID-19 pandemic. While the range of resources listed are not exhaustive, the conceptual dissection of each type allows readers to understand the core elements of each category and apply them toward creating their own individually customized self-care routine. The execution of many detailed elements of each self-care action outlined depends on the clinician's individual occupational environment and resources. For example, if a clinician is deciding between performing a mindful eating exercise and an observational self-care exercise, the clinician's work environment and allocated free time during the workday will impact their decision. Rather than describing a strategy for each clinical environment, this guide challenges readers to commit to internalizing an awareness of self-care in their professional life and provides them with the logical tools to adapt accessible practices.

Although this guide presents preeminent and, hopefully, effective self-care resources to alleviate occupational stress on clinicians, they should not be adopted in lieu of organizationally structured approaches for mitigating the effects of shared trauma, occupational stress, and burnout. Indeed, the creation of this guide should be considered in the context that during the COVID-19 pandemic, it is unreasonable to expect historically overwhelmed organizations to adopt innovative and effective 

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