Hello, my name is Cindi. Many of you reading this will be familiar with the ‘#hello my name is…’ campaign, started by Dr Kate Granger in 2013. At the age of 29, Kate was diagnosed with a rare form of cancer and she noticed that many hospital staff did not introduce themselves before doing a procedure as part of her care. She also noticed that, when someone did introduce themselves, it made her feel human. Her campaign focused on making that human connection between one person who is vulnerable and suffering, and another who wishes to help.
The Royal United Hospitals Bath is an acute hospital with over 5,000 staff, and approximately 3,500 of these are clinical and medical practitioners. We serve a local population of 500,000 patients, and last year over 80,000 patients presented at our A&E department. We do not close our doors and this creates a particular kind of dynamic, where the demands on our staff are ongoing, rarely easing.
Every day our staff encounter physical traumas, death and dying, chronic ill health and critical care. They regularly see, hear, smell and feel things that cover the whole range of human experience, from pre-birth to death. They remember many of their patients, and their patients’ stories, for years and years.
What is it like to work here?
There are many qualities that are shared by healthcare workers, regardless of their work settings. They hold a passion for healthcare and their work is a vocation for them. They strive for standards of excellence that are evidence led and rigorous. Often they are creative and innovative people, who participate in the ‘miracles’ of medicine and healing, and thrive on the fast pace of medicine. They are genuinely compassionate, able to bear witness to a whole range of human experience.
Hospital staff encounter intense, sometimes raw, emotions in their work with very ill patients, such as fear, anger, grief, disgust, vulnerability, helplessness and hopelessness. Each day they face the unexpected and uncontrollable, as events occur that could not have been predicted. The numbers of patients coming into A&E can feel overwhelming. Working in this pressure-cooker environment is further challenged by our culture of increasing scrutiny and hostility.
How we support our staff: employee assistance programme
We are an on-site counselling and support service for hospital staff, which has been in operation for 21 years. Our services include a standard package of six counselling sessions, bespoke support where needed, especially following minor incidents, and support, training and reflective supervision for our leaders and their teams.
Many hospital staff work shifts, which means that it is nearly impossible to contract counselling sessions with them as we would in a workplace where staff work office hours. We have learnt that, in order to engage with staff, we need to adopt a friendly, flexible and compassionate approach, always navigating our way between therapeutically holding our boundaries, while making empathic human connections and being flexible with appointments. We get to know our clients in ways that other therapists normally would not, sometimes having ‘moments of therapy’ in the corridors. Our interactions with the organisation are compassionate and often informal, and therapeutically we do not close our doors. The value of this is almost impossible to quantify, yet it allows us to reach and support a wider range of staff.
The continuum of trauma: normal daily pressure
Traumatic experiences are part of the very nature of an acute hospital and I sometimes find it helpful to think about a continuum of trauma which ranges from normal daily pressure to a declared major incident. In the rest of this article, I describe how the different points on this continuum are experienced in the hospital, using the stories of some of our clients, with their kind permission.
Terry's story: ‘I never thought when I came into this job that I would be part of it'
Terry is part of the cleaning team on our oncology ward. There is a quiet and sensitive compassion about him, alongside a respectful sense of humour. He likes to get to know patients on his ward in a gentle way, noticing as he cleans their bed space what pictures they have around them, whether they support a football team or if there are clues to hobbies they enjoy; and, with an easy curiosity, he will ask about them.
Terry once spoke about what it was like to come into his job and how there were aspects of his role that no one had prepared him for, and probably could not have. He recalled a particular patient, an older man named Bill, who had had several admissions to the ward over some time. This time, Bill had been there for a few weeks and they came to build a rapport through a bit of banter when Bill felt up to it, or quiet moments when Bill reflected on his illness and coming death. These spaces of reflection held an intimacy not shared with the medical or nursing staff, because the focus between Bill and Terry was not on Bill’s care, but rather on the connection they had made. One day, Terry came in and Bill did not respond with his usual banter. Terry worked quietly around him and, when Bill held out his hand, he sat next to him and held his hand for a few minutes, and Bill quietly passed away.
So many of our staff go about their roles unseen and, like Terry, they intuitively and selflessly connect with patients and relatives, becoming part of an emotional journey that they were not expecting, and learning how to take it in their stride.
The continuum of trauma: duress
Duress is a term we use for the pressures and traumas that accumulate over weeks, months, years and decades. Many clinical staff experience times in their careers when this build-up can become overwhelming and debilitating.
Natalie's story: ‘I’m an experiences nurse and I've coped with a lot of death before. I shouldn't be feeling like this.'
‘Natalie’ has been nursing for over 20 years and has worked in different wards and departments. She came to our service following three patient deaths in quick succession, so she had not had time to process one death before another happened, and the last one was very unexpected.
Natalie told me, ‘Every time I drive in to do a shift, I have a terrible fear of something going wrong. I feel like I’m on the edge and any minute I’m going to fall off.’ Here, she expressed her fear and anxiety, her sense of dread, and high levels of arousal, all of which are typical trauma symptoms.
It can be very powerful for people to tell the stories of the patients or events that brought them to our service, and to allow the meaning behind their distress to unfold. My experience is that there is always a meaning to be found within the traumas, and the relief that comes with that discovery of meaning can be enormously normalising.
The continuum of trauma: minor incidents
Minor incidents can include a drug error, an unexpected patient death, a difficult birth, suicide or even a problem with the fabric of the building. When these incidents occur, the doors of our hospital remain open.
Fiona's story: ‘This was always my number one dream job and I very seriously did wonder whether I would have to leave, but because of the care I received, I am still here!'
It was a normal early evening in the intensive care unit (ICU) on 22 November 2011, when an oxygen cylinder held by a nurse as she fitted it to her patient exploded, enveloping the bed space in a wall of flames. Thick black smoke filled the unit as staff frantically, and successfully, evacuated the patients and their relatives. Fiona, a consultant in anaesthesia and intensive care medicine, was on duty that night.
What followed was a long journey of recovery, lasting several years, for all who were present during the explosion, and for those who were on the periphery or off duty at the time. As is the case with traumatic incidents, everyone experienced and responded to it differently and needed different supportive interventions, which ranged from individual to group debriefings held daily for a few weeks, to more structured trauma support.
For Fiona, it was important that she managed to keep working, supporting and being supported by her colleagues and being part of the interim measures put in place for the care of the very ill ICU patients. It was a dark, frightening, tearful time and she truly doubted her ability to ever recover and resume her number one job.
Fiona told me, ‘It was horribly tough, but because I knew that it was normal, that I wasn’t going mad, that it would eventually get better with time and that the flashbacks and nightmares would go away, I was able to hang in there.’ Psychoeducation and normalising played an important role in the early days after the fire; those of us working with the staff repeatedly offered them reassurance that their responses were normal and helped them to understand why they were feeling as they were, as they began to come to terms with what had happened.
During our work together, we also identified that Fiona, like many doctors and consultants, had not paid much attention to her own self-care. It was normal for her to work long hours and to have an active home life as a mother. Together we found small coping and self-care strategies that she was able to use, and these became the foundation for a changing lifestyle that included self-care. Fiona told me, ‘You taught me some very vital life skills. Doing such a tough job, and juggling work with home life, I do really remember that I must look after myself, and these days I am much kinder to myself.’
Fiona has become a champion of wellbeing among the teams she works with and quickly supports anyone involved in a traumatic incident. She told me, ‘I truly believe that I have been able to use what I learnt from my experience to help consultant colleagues and trainees who have been involved in traumatic events themselves.’
Fiona’s story illustrates three of the outcomes we aim for in our trauma support: to educate and normalise the experience of trauma; to improve self-care and wellbeing for the longer term; and to disseminate good practice among the wider hospital staff population.
The continuum of trauma: major incidents
Fortunately, we have experienced very few major incidents so far, and this is the only time our hospital is likely to close its doors. In the event of a major incident, which could result in mass casualties, our counselling and support service would be involved in setting up a rest centre for family and friends of patients involved in the incident.
Trauma risk management (TRiM)
TRiM was developed by two mental health nurses in the Royal Marines and is an evidence-based, peer-led risk assessment process.1 The model is based on the premise that people prefer to speak to someone they know and trust following a traumatic incident, and that this is especially true where staff work closely with their colleagues in challenging environments.
We were the first acute hospital to introduce TRiM, and we initially trained 14 practitioners from different roles and departments across the site. Now in our fourth year, we have responded to 72 incidents and supported over 230 staff.
Any member of staff can contact our TRiM email address and let us know that an incident has happened and who was involved. They can also refer themselves by asking to see a TRiM practitioner. Everyone who contacts us receives a post-trauma handbook and an invitation to meet for a risk assessment, usually between three and seven days after the incident. A follow-up session is held one month later and, where risk factors have been identified with someone, they can receive trauma support from our counselling and support service.
In addition to the benefits of quick support to individuals and groups, we have also found that, as TRiM practitioners, we are able to hold people in mind when they’ve been involved in more than one incident. This is important as they are more likely to be at risk of harm to their mental and physical health and may need additional support.
Conclusion
Trauma takes many forms in the field of healthcare, and it is our duty to be trauma aware. As therapists, we have much to offer to staff and the organisation, normalising, educating and drawing on interventions from trauma therapy. Like Dr Kate Granger, we find that it is the small, quiet, informed responses and acts of kindness that are the most powerful.
My colleagues and I have learned over the years how vital it is that our service holds a real sense of calm, set as we are within a pressured hospital environment; the organisation relies upon us to be a calm and safe place. This means that, as practitioners, we have come to prioritise our own self-care and peer support, which in turn has strengthened us as individual therapists and as a team.
I would like to conclude with the words of one of our TRiM clients: ‘It’s been a very emotional journey. What mattered most to me was the kindness and the right kind of support I received along the way. And afterwards I knew you were there and would quietly check in with me now and again. It was a terrible thing to have to go through, but I have learned how to listen to myself and allow myself to recover, and I believe I’m a better person and a better nurse for it.’
Cindi Bedor is a trauma therapist and has led workplace counselling services for over 15 years. She has a passion for supporting healthcare staff and bringing therapy into the everyday world of employees, managers and organisations.
References
1 Greenberg N, Langston V, Jones N. Trauma risk management (TRiM) in the armed forces. Journal of Army Medical Corps 2008; 154(2): 123–126.