When a health care provider at UCHealth University of Colorado Hospital gets an accidental needle stick, there is no confusion about what to do. He or she follows a protocol that includes a clinic trip and incident report. The obvious goal: protect the provider.
The process has been much less clear for nurses, physicians and other providers confronted with verbal and physical abuse from angry patients and distraught caregivers. Ditto the emotional burden providers carry when a patient dies unexpectedly or endures physical and emotional pain that can’t be easily assuaged. Individuals trained to deal with a wide variety of clinical problems may founder in these waters. The difficulties worsen when they treat patients with illnesses, diseases and injuries complicated by behavioral and mental health issues.
At UCH and hospitals around the country, providers facing these kinds of challenges too often have had to rely on their own resources to cope. But that approach often has diminishing returns. Even the strongest individuals’ emotional tanks can run dry, said Jamie Nordhagen, RN, nurse manager of the Oncology Unit at UCH.
“We need ways to support staff and to acknowledge the effects that accumulated stressful situations have on them,” Nordhagen said. Failing to do so, she added, can have long-term consequences for nurses. They risk succumbing to “decreasing feelings of joy and purpose” and may “struggle to connect” with colleagues and patients.
Time to REST
The hospital is addressing the challenge with the recently formed Resiliency Education and Support Team (REST), six staffers (see box) trained to help tamp down emotional stress. They serve the hospital’s Emergency Department and inpatient and intensive care units. The initiative, which officially launched July 1, aims to establish a process for nurses to report stressful situations and get professional support from REST.
The effort, which has the support of the hospital’s executive leadership, also includes providing education, such as Crisis Prevention Institute training, and raising staff awareness of emotional support resources like HeartMath and free counseling services through UCHealth’s Employee Assistance Program.
The core of the REST strategy is encouraging staff to report “critical incidents,” such as violent or abusive behavior from patients, draining emotional distress of family members, or unexpected patient deaths. The bedside nurse or CNA involved, together with the charge nurse, completes and submits a form that describes the incident. The most serious require that the REST team be paged and the unit manager notified. Otherwise, the report is emailed to the REST team, which is to respond to the staff member within 24 hours. The team solicits and logs information about the incident and offers support and additional resources.
Speaking up, speaking out
It’s important to initiate and respond to the report promptly, said Sara Stowell, MSW, LSW, manager of UCH’s Behavioral Health Program and a REST leader. She noted, for example, that critical incident debriefing is routine in the military – and for good reason.
“The sooner you debrief, the better you are about processing what occurred,” Stowell said. “It’s more productive for the team and the individual and helps to prevent the incident from manifesting itself in a negative way.”
The tell-tale signs of an individual’s accumulated stress – frequently referred to as “burnout” or “compassion fatigue” – include frequently calling in sick, requesting not to care for a patient, or crying unexpectedly, Stowell said. These and other signs of mounting pressure, in turn, take a toll on units and the entire hospital. Left unaddressed, they can drive an individual to change careers, she added.
“We are trying to improve staff’s ability to handle the pace of the hospital and changes in our patient population,” Stowell said. “To do that, we have to give them the tools and resources they need to manage the challenges.”
The REST initiative follows a “rapid improvement event” and pilot earlier this year in the BMT/Oncology and Medicine Specialties units. The pilot also emphasized the importance of emotional support for staff caring for a growing population of patients with behavioral and mental health issues faced with dwindling community resources for treating the problems.
“There are fewer options for these patients,” Nordhagen said. “When it is unsafe for us to discharge them, they stay on inpatient floors for psychiatric issues.” That, in turn, heightens the challenges for a unit like Nordhagen’s, which cares for patients struggling with varieties of cancer and arduous recoveries from bone marrow transplants.
Protecting emotional reserves
As a charge nurse on the Oncology Unit, Katie Donovan, RN, recognized that reality and the growing emotional burden it imposes on nurses and other providers. She developed the REST protocol as her credentialing project for UEXCEL, the hospital’s professional development ladder for nurses.
Donovan said her undergraduate studies in psychology as well as her observations and experiences as a nurse the past four-and-a-half years, all at UCH, spurred her work on the REST initiative. She has seen her colleagues struggle with recurring anxiety, emotional stress, and digestive issues, often linked to experiences with emotionally demanding patients, such as those who refuse care, or caregivers whose own stress makes them abusive to hospital providers.
“I see the wear on staff. I don’t like feeling helpless,” Donovan said.
The array of resources REST offers is vital, she added, but the program’s success relies on staff moving away from a go-it-alone mentality when they experience abusive behavior or the loss of patients with whom they have formed bonds.
“The act of acknowledging that something happened that isn’t okay is therapeutic in and of itself,” Donovan said. “The experience is validated.”
That acknowledgement can be a difficult step for some nurses to take. “It will be a long haul,” Nordhagen said. “We have a tough-it-out mentality.”
It also requires providers thinking differently about how they provide care, Donovan noted.
“Nurses, by virtue of the care we provide patients, are interested in emotional well-being. It’s part of our vocabulary,” she said. When patient behavior crosses acceptable boundaries, however, the equation must change, she added. “At that point, it’s not about the patient. The question is, ‘How are you [as a nurse] processing it?’”
Changing the culture
It’s too early to assess the effects of REST, but the measuring tools are in place. On a broad scale, the National Database of Nursing Quality Indicators (NDNQI) in July began tracking assaults on nurses as part of an effort to assess and ultimately improve workplace safety.
“We’ll be able to go into the NDNQI database and see how we match with other hospitals,” Stowell said.
The strength of that comparison will rest on the data the hospital collects. Donovan points to staff learning to regularly report incidents and, when appropriate, request debriefings. With solid information in hand, she hopes to see individual units and the hospital as a whole respond with operational changes and additional resources to decrease the incidences of physical and emotional aggression and strengthen staff’s sense that their work environment is safe. That, in turn, could help to decrease turnover, a key concern for any hospital in a competitive environment.
Success hinges on providers accepting that reporting incidents that affect their emotional health is just as important as reporting accidents like needle sticks that endanger their physical health, Stowell said. That will require an “ongoing resiliency strategy” that includes regular training and education that highlights available resources like HeartMath, she said, adding that managers will be asked to encourage staff to develop plans for managing their emotional health as part of their yearly goal setting.
Donovan too looks for the day that emotional resiliency training is routine for all new clinical providers at UCH.
“I want to see when people come to the hospital and are precepted that we tell them, ‘This is how we handle these incidents,’” she said. “It should be part of our culture and our expectations.”
Nordhagen called on her colleagues to drive that change. “People need to own their self-care,” she said. “We owe it to ourselves and we have a professional obligation to make sure that we are okay to take care of others.”
REST Responders at UCH
- Anne Dondapati Allen
- Tacy Farrington
- Helen Lim
- Gina Napolitano
- Jamie Nordhagen
- Sara Stowell