I See You, Nurse – a poem by Connor Bond

Sometimes another human can put words into form that capture your own feelings and views better than you can articulate yourself. Connor Bond (@Trauma_Mouse), Scottish Emergency and Critical Care nurse working in central London did just that with his poem “I See You, Nurse”. Connor shared this on stage at DAS SMACC in Berlin after winning the SMACCSLAM poetry/spoken word competition. Although I’d heard Connor’s poem when judging the competition, I was floored when sitting behind him, watching and listening as he stepped to the centre of the round stage in the middle of the Tempodrom. This will be released via the SMACC podcast in due course, but for whatever reasons personal or otherwise, I feel like a lot of us could do to hear this now. Over to Connor…


“After moving from the North of Scotland two years ago, I’ve worked between an emergency department and critical care in central London. Nursing on the frontline in a capital city can present it’s own unique issues, but I truly believe that we canall find ourselves facing challenges derived from our health systems, patients or upon reflection internally.

I often find myself uncomfortable when adorned with the title of “Saint” or “Angel”; I do feel that this is my vocation, but I hardly float around my ICU with a halo in situ! As nurses we are incremental to the holistic patient experience and often responsible for interventions that will drastically improve outcomes – I shall always remain proud of that.” Connor Bond


 

I See You, Nurse

Remind me, why do I do this?
Why I chase the rush
of chaos, of drama
of resus & trauma

Why I’ve held distraught mothers
Cared for fathers
and leant by the bedside to explain to brothers,
why their sister simply won’t wake up after
I switch off infusions
and call out after her.

On the surface I’ll hold steady,
dry and stern
but I crack on the underground home.
I hold thankless floodgates in my hands
Staying strong for
another shift,
another patient,
another family looking to be shown
Improvement in those lines and trends that I’ll struggle to decipher to a devastated mother, who wants her baby home.

But we’ll still push and still go
Stretching resources, and ourselves.
I’m doubled with patients,
double strength pressors,
double pumping,
double shot espresso for that fourth night in a row.

And then the ward round comes
and I ask myself
have I done enough?
are these lines labelled, is my bedside straight?
but can we be too tough,
on one another
and ourselves?

They call nurses “Angels”,
but my wings are long singed
from holding too tight to Dear Nightingale’s lamp,
but I carry on because I will it,
and because i can,
Because I’ve seen eyes open after weeks without sedation,
while family rallies behind a young man with such determination
as he takes his first steps for the second time in his life.

We are not Saints
We are not Angels
I will never cause miracles at handover
But I’ll give them my mind,
my hands,
my words
until my best is enough, no more.

ALiEM – How I Stay Healthy in EM


Those who know me, are acquainted with the fact that I love to keep fit (some may say a little obsessively). It was a privilege to be able to share a little of my personal philosophy and also be the first nurse to post in the How I Stay Healthy in EM series on Academic Life in Emergency Medicine. This series, edited by Dr Zafrina Poonja and features an insight into how people balance the pressures of working in Emergency with staying well themselves. For my offering head here.

 

Take the Resilience Challenge

There are many pressures in healthcare, all of which have an impact on people who work on the front lines. Resilience Challenge, a new interactive videogame, aims to raise awareness about these pressures.

http://game.resiliencecentre.org.uk/

In the early 2000’s, Safer Healthcare Now and other initiatives were launched to improve the 10% error rate in hospitals worldwide. After over a decade of research, and billions of dollars of funding, the error rate remains unchanged. So what went wrong? There are several perspectives on why patient safety hasn’t improved. These include a) we didn’t understand safety as a culture, not just individual errors b) we need to strengthen what goes right, not just eliminate what goes wrong, and c) we need better engagement between researchers and clinicians to makes sure that researchers are asking the right questions and clinicians are implementing the results.

Resilience Challenge is one way that researchers at in the Centre for Applied Resilience in Healthcare (CARe) at King’s College London are addressing these questions. We are studying how we foster organisational resilience in order to improve patient safety and support clinicians to provide high quality care. Organisational resilience is the ability of a system to adapt safely to pressures in healthcare. The Resilience Challenge videogame supports nurses, doctors, and healthcare professionals to explore this concept, and understand what it means in practice. Organisational resilience is not about individuals coping with poor working conditions; it’s about creating better environments in hospitals so that people can give great care.

The videogame is based on guiding a patient’s journey through the hospital safely. It combines comic book style visuals with accurate medical imagery to create an experience that is both familiar and imaginative. We want to engage with people from a broad range of backgrounds including healthcare students, professionals, and the public to understand the pressures healthcare providers face at work, and how organisations can support clinicians and safe decision-making. 

The Resilience Challenge is part of CARe’s wider work to inform policy about healthcare safety. The game is designed to raise awareness of the pressures on healthcare professionals and to start conversations about what can be done at an organisational level to support successful decision-making. CARe’s goal is to make healthcare systems work safely for everyone involved.

The Resilience Challenge was created through a collaboration between King’s College London’s Centre for Applied Resilience in Healthcare (CARe) and Karman Interactive, brokered and supported by the Cultural Institute at King’s.

Play the game, and please complete the survey at the end to support CARe’s research.

Learn more about our work here: http://resiliencecentre.org.uk/

 

All About That Base? Why Nursing Needs More Than Evidence

Evidence-based nursing. This is the focus of most of the modern nursing discourse (including this blog! Controversy ahead…). In all of nursing’s domains of practice, evidence-base is a hot topic, showing that we are up-to-date, safe, and professional.

There’s just one problem. Being ‘evidence-based’ does not mean nursing is any of these things.

Our profession has doubled down on evidence-based framing in recent years, in alignment with medical professionals. This is nothing new; nursing pioneers have long aligned nursing with aspects of the natural sciences and medical sciences in order to give nursing credibility[i]. I get the sense that nursing’s drive towards evidence is to appear credible alongside medicine, as much as it is to actually improve patient care.

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There are several reasons why evidence is not enough to form the basis of nursing knowledge:

  1. Evidence is not automatically right or good.

One only needs to say “Wakefield” and we know that scientific evidence can be flawed[ii]. While this is an extreme example, there are many published studies that are not rigorous or are clouded by conflicts of interest. Just because something has been studied or published does not make it accurate, safe, or useful.

  1. The knowledge to practice gap is slow.

Estimates vary, but we know it can be 10-17 years for knowledge to be translated into practice. Even then, it is extremely difficult to change nursing (or medical) practice, and have these changes last. And waiting 2 decades for changes in practice won’t serve our patients in the meantime.

  1. Standardization is not a good idea.

We know that evidence does not necessarily serve all people or populations. For example, when a study shows that an intubation technique works well in one setting, it does not mean it is safe for all settings. The idea that, if we standardize our care, we will improve patient safety, is fundamentally flawed[iii].

  1. In many cases, evidence does not exist.

How should nurses practice in the context of Zika virus? We are still learning this. There are patients with Zika who need care in the meantime, and we can’t wait until we have an answer to nurse them.

  1. Evidence is not ethically neutral.

Evidence is influenced by politics and economics, from start to finish. There are important issues which have not been researched because there isn’t funding available, or other issues are more politically attractive. Even when evidence is available, it can be difficult to fund or adopt; safe staffing ratios are a prime example. Greatest need does not always drive research priorities or implementation.

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So what are nurses to do?

I advocate a return to a comprehensive understanding of what makes up nursing knowledge. Carper wrote this paper in 1978[iv], and it’s still relevant and useful today.

Carper outlined that nursing has 4 kinds of knowledge:

  1. Art
  2. Science
  3. Ethics
  4. Experience

If we return to seeing nursing practice as a comprehensive body of knowledge, we can outline nursing work as being multidimensional. Evidence-based nursing has us leaning so heavily on science, that we lose the other factors in our conversations about nursing.

When we are supporting people with mental illness, we know that if we provide community supports, medication, and cognitive-behavioral therapies, we will have better outcomes than if we provide medication alone. This same logic can apply to how we use Carper’s types of knowledge.

We can form the basis of our practice with the art of nursing. We can say, no matter who I meet today, I will promote their dignity, or I will be caring, or whatever works in your practice. When we have a specific problem, such as acute kidney injury, we can use our scientific knowledge and our experience to provide expert care. We can advocate for vulnerable people because this is part of the ethics of nursing. These types of knowledge work together, and give us comprehensive nursing practice.

I think most nurses already integrate different types of knowledge in their practice. What we can change is how we talk about it. We can talk about how we apply different types of knowledge in our work. If we explain nursing knowledge in these domains, it may support nursing students to develop their practice. It may also be easier to talk about challenges, such as ethical dilemmas, when we move away from an overemphasis on evidence.

I believe in the vital role of evidence in nursing practice, as I am a nurse researcher, working to build our professional knowledge base. But I also see that we need more, and we can steer our professional conversation back to the multi-faceted knowledge that really makes up our base.


References

[i] Wuest, J. (1994). Professionalism and the evolution of nursing as a discipline: A feminist perspective. Journal of Professional Nursing10(6), 357-367.

[ii] Godlee, F., Smith, J., & Marcovitch, H. (2011). Wakefield’s article linking MMR vaccine and autism was fraudulent. BMJ342, c7452.

[iii] Learn more: http://resiliencecentre.org.uk/fact-sheets/safety-i-and-safety-ii/ Full disclosure- I am a member of the Centre for Applied Resilience in Healthcare.

[iv] Carper, B. A. (1978). Fundamental patterns of knowing in nursing. Advances in nursing science1(1), 13-24.

 

Managing Exposure: Resilience in ICU

Authored by Jennifer

Editor’s note (Jesse Spurr): This summary explains Jennifer’s research study for her Master’s thesis, where she set out to learn how  critical care nurses become resilient. You can read the entire thesis here, watch a short YouTube video here, or a detailed YouTube video summary here. I see the effects of burnout and, conversely, the protective shroud that resilience on a daily basis in the ICU. I believe this is an important line of inquiry for anyone who works in critical care.

 

Managing Exposure: A Grounded Theory of Burnout and Resilience in Critical Care Nurses

Burnout was identified in nursing in 1978[1], and continues to be problematic in the profession[2]. There are many factors that make critical care settings challenging places to work, and burnout among critical care nurses remains high[3]. However, we also know that resilience is an important factor for critical care nurses. Resilience can be defined as “the ability of an individual to adjust to adversity, maintain equilibrium, retain some sense of control over their environment, and continue to move on in a positive manner.”[4] Essentially, resilience is the ability to address something difficult in one’s life in a healthy, positive way. Resilience is important for a lot of professionals, including teachers[5] and soldiers[6], and it was suspected that resilience would be important for nurses as well.

Resilience has been widely studied, in a variety of contexts. However, many of these studies have focused on personality traits associated with resilience, or prevalence rates of resilience or burnout. In this study, I explored how resilience actually happens; that is, how nurses go from experiencing adversity to becoming burnt out or resilient. By explaining how nurses become resilient, we can support nurses by making the process of resilience more visible and easier to manifest. This research is important because we know that resilient nurses call in sick less frequently[7], and can provide safer care to patients and their families. There are nursing and economic benefits to having a resilient nursing workforce.

I spoke with 11 nurses in critical care settings, for up to 90 minutes. We discussed a variety of topics about their experiences at work, their efforts to cope with challenges, and their beliefs about the nursing profession. I combined all of this information to create a framework showing how nurses become resilient. I hoped that if I could illustrate how nurses become resilient, we could make it easier for nurses to follow this process.

So how do nurses become resilient? By Managing Exposure. This model explains how nurses become burnt out or resilient, which opens the door to strategic interventions.

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It is important to note that this model is presented as being linear and one directional for ease of explanation. In reality, these processes are dynamic and fluid.

 

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Resilience begins when nurses face adversity. There are many forms that adversity can take; for the purposes of this study, the focus was on adversity that is found in the workplace. Nurses reported several levels of adversity that they encounter every day at work. These included broad, societal influences, such as a lack of respect for nursing. Nurses reported that many people (including patients, families, and nurses’ family members) did not understand or appreciate the role of nurses in critical care. This lack of understanding translated to disrespectful treatment and a lack of support.

Adversity was also found in the culture of the unit, practical concerns, the nature of critical care nursing, and interpersonal conflicts. Nurses described difficulty caring for patients when they plan of care was not what a nurse thought would be best for the patient. Nurses also reported that an inability to access vacation time from work made it difficult for them to address burnout.

There are lots of factors that constituted workplace adversity for nurses. Rather than see these as a list of problems, it is important to recognize that each point is a place where intervention can make a difference. There are concrete opportunities in the workplace to decrease the amount of adversity faced by nurses. While it is impossible to have an adversity-free workplace, there are many ways to decrease adversity and make nursing more manageable.

 

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The factor that moves this model forward is awareness. When nurses had awareness about how they were being affected by workplace adversity, they could make choices to manage their exposure to this adversity. Awareness created the opportunity for nurses to take action.

In order to have awareness, nurses required a disclosure of information that was relevant to their work. They could perceive and understand this information, reflect on it, and consider the outcomes of different courses of action. Based on these potential outcomes, a nurse would choose how to respond.

Awareness is important because it is how nurses understand their experiences and make decisions. If nurses did not have awareness, they would become burnt out.

 

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The most important part of this model is Managing Exposure. This is the actions that nurses take to address workplace adversity.

When nurses work in infectious environments, they put on protective equipment, limit their time in sensitive areas, remove the equipment when they leave the area, and clean their hands as they move away. Nurses can use these same strategies psychologically as well, in order to manage their exposure to workplace adversity.

These actions fell broadly into 4 categories:

Protecting: Strategies that nurses used to emotionally protect themselves from adversity, and offload when they were overwhelmed. This included developing a protective shell against emotional concerns, and delegating tasks to colleagues.

Processing: How nurses made meaning from their experiences in critical care. The most common form of processing was talking about challenges at work, especially during change-of-shift report. This time was preferred because it was private, normal, and nurses could talk to someone who shared their experiences.

Decontaminating: Restorative processes that nurses can use to be rejuvenated after difficult experiences. These included developing supportive relationships at work, and outside of work. Nurses also managed exposure by engaging in meaningful activities that were either physical, such as yoga, or creative, such as knitting.

Distancing: The need for nurses to be physically away from the patient bedside. This included short periods of time, such as breaks or a few minutes to recover after a crisis. Nurses also periodically needed longer breaks, such as granted vacation. Ultimately, many nurses recognized that it was difficult for them to manage their exposure to adversity in critical care, and would begin planning to leave the unit years in advance, in anticipation of their own burnout.

 

Nurses told me that they were the most resilient when they could easily use these strategies, with the support of their colleagues, families and organizations. Nurses who used a variety of these strategies told me that they felt more resilient than nurses who only used one or two strategies.

 

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There are a variety of ways that nurses experienced the process of Managing Exposure. Nurses reported they were thriving when they loved their work, and felt passionate, energized, and fully engaged. Nurses achieved resilience when they were able to face difficulties in the workplace, and feel good about the nursing care they could provide. Nurses described themselves at a survival level when they said they struggled at work, but they were trying to retain their compassionate approach to patient care. Finally, nurses reported burnout when they saw patient care as a series of tasks rather than a caring act. They felt anxious before or after work, had difficulty separating their professional and personal lives, and felt like they did not have adequate time to recover between shifts.

It is likely that burnout can lead to post traumatic stress disorder (PTSD), but as PTSD is a psychiatric diagnosis, it was beyond the scope of this study to investigate it directly.

 

So what is the bottom line?

The major finding of this study is that nurses who are burnt out and nurses who are resilient are coming from the same pathway. Just as dating can lead to breakups or marriages, the exposure to adversity can lead to burnout or resilience. Nurses who are burnt out are not bad people, or lacking in personal coping skills. They are having difficulty managing their exposure, which can occur because of personal challenges or systemic barriers. For example, previous studies have identified burnout as a source of increase sick calls7. My research adds another dimension to this: nurses are experiencing burnout and they are trying to manage (potentially by requesting vacation, or trying to seek out interpersonal support). If nurses are not able to manage, such as not being able to get vacation hours granted, or being overwhelmed at home and unable to spend time with support people, they resort to calling in sick because they see no other options. The findings of this study clearly demonstrate that resilience and burnout are not entirely determined by individual nurses. There are systemic factors that can overwhelm a nurse, in spite of good personal coping skills. Workplace adversity can have a toxic impact on nurses, and needs to be taken seriously.

 

The findings of this research study also demonstrate the power of intervention to foster nursing resilience. Nurses shared stories of managers, educators, and colleagues, who had supported them through teaching and advocacy. It is clear that nurses learn how to promote their own resilience, and can be positively impacted by the people and systems around them.

 

Nurses who are resilient give better care to patients. It is important that nurse leaders consider how to support nurses to manage their exposure, to promote safe, dignified health care delivery.

 

To learn more about this research, and see how it may apply to your settings, please see:

A short YouTube summary of the project is here: https://www.youtube.com/watch?v=Z4F-x0dx0mo

A longer YouTube video that describes the details of the project is here: https://www.youtube.com/watch?v=cUHpyqq0M8U

And the full thesis document is available here: http://hdl.handle.net/10791/183 Chapter 4 of the thesis explains the findings of the study in the participants’ own words.

 

References

[1] Shubin, S., & Milnazic, K. (1978). Burnout: The professional hazard you face in nursing. Nursing8, 22-27. Retrieved from: http://journals.lww.com/

[2] Epp, K. (2012). Burnout in critical care nurses: A literature review. Dynamics, 23, 25-31. Retrieved from: http://www.caccn.ca/en/publications/dynamics/

[3] Khamisa, N., Peltzer, K., & Oldenburg, B. (2013). Burnout in relation to specific contributing factors and health outcomes among nurses: A systematic review. International Journal of Environmental Research and Public Health10, 2214-2240. doi: 10.3390/ijerph10062214

[4] Jackson, D., Firtko, A., & Edenborough, M. (2007). Personal resilience as a strategy for surviving and thriving in the face of workplace adversity. Journal of Advanced Nursing, 60, 1-9. doi: 10.1111/j.1365-2648.2007.04412.x

[5] Taylor, J. L. (2013). The power of resilience: A theoretical model to empower, encourage and retain teachers. Qualitative Report18, 1-25. Retrieved from: http://web.b.ebscohost.com/

[6] Simmons, A., & Yoder, L. (2013). Military resilience: A concept analysis. Nursing Forum48, 17-25. doi:10.1111/nuf.12007

[7] Schaufeli, W. B., Bakker, A. B., & Van Rhenen, W. (2009). How changes in job demands and resources predict burnout, work engagement, and sickness absenteeism. Journal of Organizational Behaviour, 30, 893–917. doi: 10.1002/job.595