Written By Charlotte DiBartolomeo, CEO of Red Kite Project
It was the middle of the night and a young man named Robbie had just died. No one actually announced his death to me while I waited my turn to see a doctor in the emergency room, but I knew it just the same. I knew it because the dead man’s brother rushed into the waiting room gunning for the “friend” who’d brought Robbie an hour too late to the E.R. and who’d undoubtedly supplied the drugs that killed him. Robbie’s brother had no tears, just a powerful anger for the emaciated friend standing before him, trying to apologize. Trying to fix what could never be fixed again.
“You apologize to my mother you disgusting piece of garbage,” Robbie’s brother shouted at him, spit flying from his mouth. “You tell that to my mother when she gets here and see what good that does.” In an instant, the security guard moved towards Robbie’s brother. And just as swiftly, Robbie’s brother backed off. Hands clenched, face twisted with dread.
Then my name was called and I was wheeled to an examining space and placed on a bed with only a curtain separating me from the body of the dead man whose mother was coming. I watched the residents and nurses buzz about from bed to bed, taking temps, and checking blood pressure. And I waited. Waited for a doctor, and waited for Robbie’s mother.
I never saw her face because I was lying on my side trying not to look. Not wanting to witness the darkest moment in this woman’s life. But I listened for her. I heard her footsteps running at first across the floor, then her pace deliberately slowing down as she readied herself for that thing that no mother can capably prepare. When she reached his body, she let out a tiny gasp before the unbearably long guttural wail that spilled from her mouth and ushered in a lifetime of mourning.
What was even more striking than Robbie’s mother’s grief was the fact that no one, not a resident or nurse came to her side in her moment of suffering. Not one stopped to place an arm around her to comfort her. Not one asked her if they could get her something or someone to call. They ignored her as if she were a voice from a television set turned up too loud. When I remarked to the nurse caring for me how sad I was for Robbie’s mother, and how difficult it must be to witness death and people grieving, she agreed, “Yeah, we see this all the time. It is really sad. You just have to turn it off or you’ll go nuts.” I realized at that moment that what my nurse was describing was the concept of dissociation; the human response to extreme pain and suffering as a way to adapt. It may seem like a good idea in the short run, but the cost to our bodies and relationships is greater than one might think.
That’s why when I teach my course, Trauma Informed Care to nursing and counseling students, I begin by stating, “This is a course on being human, experiencing and witnessing trauma, what it costs us, and how we adapt as humans in order to survive.” By speaking about patients in terms of “we” and “us” I’m encouraging my students to remove the psychological barrier between patient and healer. My goal is twofold: first, to view patients as human beings who have traumatic experiences, rather than just symptoms to be diagnosed; second, for students to acknowledge their own psychological wounds while still becoming healers. The opening talk works. Not only are students eager to share stories of personal traumatic experiences and how it led to their choosing nursing and health professions, it also ignites a frank conversation on the dehumanizing culture grinding down both patient and healer and what the profession’s leaders need to do to change the course.
Managing catastrophic injuries, diseases and patient deaths takes a psychological toll on medical professionals. The evidence lies in several recent studies capturing depression and rising suicide rates among physicians, medical students and nurses. A study funded in 2012 by INQRI found that nurses suffer from depression at twice the rate (18%) of the general population (9.4%). Physicians are also at great risk, reporting twice the rate of psychological distress and attempted suicide as their non-medical professional counterparts.
What’s even more disturbing about this research is the overwhelming evidence that medical professionals are among the last to seek help for their distress for fear that it will stigmatize them. Instead, doctors, nurses and medical students will suffer in silence, often self-medicating with prescription drugs and alcohol. A USA Today 2014 review states that more than 100,000 doctors and nurses are abusing pain medication each year in the nation. The outcome of staff impairment translates to reduction in patient quality of care, hospital policy violations, accidental patient deaths and costly malpractice suits.
In order to intervene, hospital leaders must address the root of the problem: the gap in medical education regarding professional trauma exposure; then transform trauma education into meaningful action and policy changes to better support their personnel. But the challenge of starting the conversation on professional trauma exposure is more complex than simply setting aside time for education.
Tearing down the Super Hero Myth
“Keep it moving,” is the mantra medical professionals use to build a veneer of resilience as they attend to one life-threatening crisis after another. The Super Hero Identity that nurses and doctors are indoctrinated with from their first clinical rotations reflects the myth that the professional may constantly be exposed to patients’ traumatic events without it impacting their own wellbeing. Underneath the veneer, ones resilience is eroding when medical professionals don’t take the time to acknowledge the traumatic effects of witnessing patients and their families’ anguish.
Thanks to mirror neurons, which help us emotionally simulate the experiences we observe in others, we human beings are hardwired for empathy. To witness another’s suffering results in a similar survival chemical rush that patients and their families experience during moments when survival is at stake. Without support, the continuous flood of stress hormones into the body leads to traumatic effects and the potential for Complex PTSD. Therefore, it’s essential for the professional to take the time to dispel these chemicals, reframe the event, and replenish. Super Heroes may not need acknowledgment, peer support and down time, but human beings do.
The Truth about Resiliency
To be resilient is to be flexible and tough, like an extra strength rubber band.
Resilient people believe that whatever happens, they will ultimately find ways to overcome. They have the capacity to move forward and recover after loss. Resilient people view problems as a challenge to hurdle, and identify resources to access when those challenges occur. However, resiliency is not so much a character trait as a framework for a state of being. If we think of resilience as an investment fund where resources are stored, we have a much better chance of yielding a larger profit. When resources are plenty, resiliency is high. But if the account is near empty or overdrawn, resiliency is lost.
Who is Responsible for Staff Resiliency?
Too often, medical professionals put off self-care in favor of the double shift or the long call. The newly certified emergency medical technician, nurse or resident seeking to distinguish herself as a hard worker willing to put in the extra shift, may end up costing the organization in higher turnover rates, absenteeism, long term illness and disastrous errors. When this happens, the rest of the staff wonders what went wrong. Instead of expecting your frontline medical professionals to be solely responsible for their self-care, the organization’s leadership must set the tone to nurture a culture of resilience.
Five Actions for Building a Culture of Resilience
In spite of the flood of media coverage on Post Traumatic Stress Disorder in recent years, medical professionals have yet to catch up on the neurobiology of trauma, particularly how childhood trauma disrupts normative brain development, and how multiple professional trauma exposures lead to complex trauma within their profession. The gap in education may be the result of the failure of the American Psychiatric Association to include a more comprehensive discussion of developmental trauma and its causes in the DSM-5 (The Diagnostic and Statistical Manual of Mental Disorders). In order to address the gap in education, medical systems should offer seminars to staff regarding the impact of professional trauma exposure on team members and ways to identify and intervene when traumatic stress becomes an obstacle to resilience.
2. Shift Policies
Educating staff is only useful if the medical system backs up staff with supportive policies. Translating trauma related education into meaningful action requires the leadership to review present policies and practice and be willing to change them in order to develop a more compassionate and resilient culture. Examining how staff works, the hours they keep and what they’re choosing to sustain them should take priority in the policy review.
3. Build Safe Space
We can’t heal from traumatic effects if we don’t have safe space to retreat to. In fact, a major reason survivors of trauma self-medicate is to quiet the anxiety they’re feeling. Developing safe relational space is more than brick and mortar. It’s creating an atmosphere where staff is allowed to show emotion and ask for help without fear they will lose their reputation as a professional, or worse, lose their job.
4. Incorporate Mindfulness Techniques and Body-based Practices in your Staff’s Daily Routine
Listening to our bodies and releasing traumatic stress when our competency and quality of life is jeopardized from professional trauma exposure is probably the most important action we can take to guard against numbing and burnout. Yoga, martial arts, and walking meditation are all activities that encourage healthy embodiment and may be counted upon as external resources when the job becomes overwhelming.
5. Acknowledge the hard cases
Just as patients get attached to their nurses and doctors, medical personnel have their favorites too. When a patient dies, especially when the patient is young or the death is unexpected, nurses and docs should be given permission to grieve, to shed tears and feel the loss. Acknowledging our emotions is how we maintain our humanity and ultimately protect our resilience.