Australian Red Cross & Australian Psychological Society (2020). Psychological first aid: Supporting people affected by disaster in Australia. 3rd Edition. www.redcross.org.au
Hildegard Peplau quote was completely made-up, but (to my mind, at least) it sums-up the vibe of Interpersonal relations in nursing: A conceptual frame of reference for psychodynamic nursing (1952) :
“The relationship is the therapy.”
NB: as far as I know, this not a Peplau quote, but [thanks Google] I see that it has been attributed to M. Kahn (1997). Between therapist and client: The new relationship
Joseph Heller quote from Catch-22 (1961): “People knew a lot more about dying inside the hospital, and made a much neater, more orderly job of it. They couldn’t dominate Death inside the hospital, but they certainly made her behave. They had taught her manners. They couldn’t keep death out, but while she was in she had to act like a lady.”
Hurley, J. & Linsley, Paul. (2012). Emotional intelligence in health and social care: A guide for improving human relationships. Routledge.
Mental Health Coordinating Council (2013). Trauma-Informed Care and Practice: Towards a cultural shift in policy reform across mental health and human services in Australia, A National Strategic Direction, Position Paper and Recommendations of the
National Trauma-Informed Care and Practice Advisory Working Group, Authors: Bateman, J
& Henderson, C (MHCC) Kezelman, C (Adults Surviving Child Abuse, ASCA)
Tim Winton quote from Cloudstreet (1991):
““Life was something you didn’t argue with, because when it came down to it, whether you barracked for God or nothing at all, life was all there was. And death.”
Woody Allen quote from Without Feathers (1975) “I’m not afraid of death; I just don’t want to be there when it happens.”
One more thing
In doing this session previously it has popped-up that it can be distressing being unable to contact relatives from a blocked/private phone number. Here’s a tip:
From: Paul McNamara Sent: Wednesday, 9 December 2020 17:00 PM To:0412345678@smsmessages.health.qld.gov.au Subject: To send an SMS via QHealth email type your message in the subject space and send using the mobilephonenumber@smsmessages.health.qld.gov.auformat. Also, you can copy & paste the message into ieMR, as I’ve done here.
More info on this theme @ Thinking Health Communication? Think Mobile.meta4RN.com/mobile
End
That’s it. As always you’re welcome to leave feedback via the comments section below.
Q: Why nurses?
A: Nurses are at the bedside 24 hours a day, 7 days a week. In previous pandemics/epidemics nurses experienced more occupational stress and resultant distress when compared to other professions.
And – little known fact – even when there isn’t a pandemic to deal with, nurses are more prone to suicide than most employed people. The authors are in the UK, but it’s the same in Australia.
Although there are lessons to be learned from SARS, MERS and Ebola, overall the evidence for supporting nurses’ psychological and mental health wellbeing during a pandemic is not very strong.
That disclaimer out of the way, here comes my interpretation of the key points from the paper:
1. Keep Maslow’s Hierarchy of Needs in Mind.
Starting at the base isn’t basic. It’s essential.
Start with
– hydration
– nutrition
– rest and recovery
– shelter from the storm
2. Safety is vital.
For #COVID19 that means that PPE is a non-negotiable need (don’t take my word for it, see Maslow’s hierarchy above).
3. Prioritise wellbeing.
Organisations that ask nurses to care for people who are #COVID19 suspected/positive should ensure that nurse wellbeing is a priority.
Q: How?
A: Insist on breaks, and – this often goes against the nursing culture/habits – make sure that nurses quarantine time for mutual support.
Q: Mutual support? What’chu talkin’ ’bout, Willis?
A: meta4RN.com/footy
4. Individual Support PRN.
Individual support should be available for nurses too.
Q: What sort of support?
A: It’s not one size fits all. It depends on what step you’re on.
Self Portrait 26/04/20
On the lower steps, support via trusted, loving family and friends might be all that’s required. That, and being intentional about self care.
5. Self-Care.
If you’re getting stressed on the boss’s time, you should try to get de-stressed on the boss’s time too. It doesn’t have to take hours, you might be able to make regular snack-sized self-care part of your everyday nursing practice.
6. Positive Practice Environment.
Good communication, a collegial multidisciplinary team, creative and collective problem-solving,and working as a team can go a long way towards dampening anxiety.
There’s more than one kind of PPE.
Aim for a Positive Practice Environment. 7. Time Out.
Embed safe places in the workplace. Something like a NOvid room would do the trick.
8. Supportive Senior Staff.
Last, but not least, senior nurses and other people in the hospital hierarchy should make themselves more available and visible than ever.
Care goes in. Crap comes out. End
That’s the summary of the key messages I took from the Journal of Clinical Nursing editorial. Check it out yourself via doi.org/10.1111/jocn.15307
Many thanks to Jackie Bridges (one of the paper’s authors) for giving positive feedback regarding the original Twitter thread. This blog post is a replica of that thread, just with most typos corrected.
Thanks for reading. As always you’re welcome to leave feedback and/or add your own ideas in the comments section below.
“Clean Hands. Clear Head.” is an animation of a mindfulness script that distills the content of my 2016 blog post “Hand Hygiene and Mindful Moments” into a short (less than 2 minutes) video. The voice part was recorded on an iPhone at a hospital sink #authentic. The visuals were done on Prezi.
Addit 29/03/20: to my surprise, some people want a text version. I won’t write out the whole thing (too long, a bit dull), but below are some key phrases:
This is my mindful moment. The anxiety and tension will be washed away. I will rub in the resilience and kindness that sustains me. After 20 seconds or so I will pretend I’m TayTay, and shake it off. 🙂 I will smile, then will intentionally slow my breathing. Me and my hands will be safe.
Feels free to use/modify PRN. I would be grateful for source attribution as “meta4RN.com/head”
Just in case it’s handy here is a PDF: CleanHandsClearHead
And here is a MS Word version: CleanHandsClearHead
Part 2. Surviving Emotionally Taxing Work Environments. March 2020 version.
On a related topic, for the last few years I’ve facilitated many hour-long, interactive sessions called “Self Care: Surviving Emotionally Taxing Work Environments.” for my fellow nurses at the hospital where I work. As at March 2020, I’m not confident that we’ll have an opportunity to meet face-to-face as a group all that often, so I’ve tweaked the session, tried to cut-down on the rambling, and have switched from hour-long interactive, to 20 minutes of well-intentioned, a tad-amateurish, youtube video embedded below:
Self Care: Surviving Emotionally Taxing Work Environments. March 2020 version. (video, 20 mins)
Here’s a link to the Prezi version of “Self Care: Surviving Emotionally Taxing Work Environments. March 2020 version”: prezi.com/xcejt9pgd0b3
Part 3. References & Resources.
I’m recycling and combining a lot of old ideas for the March 2020 version of “Self Care: Surviving Emotionally Taxing Work Environments.” Self-plagiarism? Nah – it’s a groovy remix of some favourite old songs. Regular visitors to meta4RN.com may recognise the repetition, and be quite bored with me using the website as a place to store updated versions of old stuff. Sorry about that, but it’s just so damn convenient. 🙂
Here are the resources and references used in the presentation: (because I’m recycling old ideas this list is ridiculously self-referential).
Australian College of Mental Health Nurses [www.acmhn.org], Australian College of Nursing [www.acn.edu.au], and Australian College of Midwives [www.midwives.org.au] (2019) Joint Position Statement: Clinical Supervision for Nurses + Midwives. Released online April 2019, PDF available via each organisation’s website, and here: ClinicalSupervisionJointPositionStatement
Eales, Sandra. (2018). A focus on psychological safety helps teams thrive. InScope, No. 08., Summer 2018 edition, published by Queensland Nurses and Midwives Union on 13/12/18, pages 58-59. Eales2018
Emotional Aftershocks (the story of Fire Extinguisher Guy & Nursing Ring Theory) meta4RN.com/aftershocks
Lalochezia (getting sweary doesn’t necessarily mean getting abusive) meta4RN.com/lalochezia
Nurse & Midwife Support nmsupport.org.au phone 1800 667 877
– we have specifically targeted 24/7 confidential support available
Nurses, Midwives, Medical Practitioners, Suicide and Stigma (re the alarming toll of those who undertake emotional labour) meta4RN.com/stigma
Nurturing the Nurturers (the Pit Head Baths and clinical supervision stories) meta4RN.com/nurturers
Queensland Health. (2009). Clinical Supervision Guidelines for Mental Health Services. PDF
Spector, P., Zhiqing, Z. & Che, X. (2014) Nurse exposure to physical and nonphysical violence, bullying, and sexual harassment: A quantitative review. International Journal of Nursing Studies. Vol 50(1), pp 72-84. www.sciencedirect.com/science/article/pii/S0020748913000357
Chen, R., Sun, C., Chen, J.‐J., Jen, H.‐J., Kang, X.L., Kao, C.‐C. & Chou, K.‐R. (2020), A Large‐Scale Survey on Trauma, Burnout, and Posttraumatic Growth among Nurses during the COVID‐19 Pandemic. International Journal of Mental Health Nursing. doi.org/10.1111/inm.12796
End
Thanks for visiting. Let’s join the kindness pandemic to offset some of the crap that goes with the COVID19 pandemic.
As always, your feedback is welcome in the comments section below.
Stay safe.
Paul McNamara, 25 March 2020, with an update on 8 December 2020
The nature of nursing will mean that we are likely to be are exposed to a range of challenges. It’s not unusual for nurses to witness aggression, feel unsafe, have first-hand exposure to other people’s tragedies, and to deal with the physical and emotional outcomes of trauma. This emotionally taxing environment can be pretty stressful. It’s something we should talk about.
I’m often asked to talk about this sort of stuff at inservice education sessions. This page is a 2019 update to support those sessions.
Printed handouts are so last century.
“Self care: Surviving emotionally taxing work environments” is planned as an interactive session accompanied by visual cues to give the discussion a bit of structure. Consequently, the transcript/dialogue of the presentation can not be included here. The visual presentation itself doesn’t use powerpoint slides. It uses the prettier (and free!) platform Prezi instead: prezi.com/skmu0lbnmkm5/first-thyself/#
I’m recycling and combining a lot of old ideas for the 2019 sessions. Self-plagiarism? Nah – it’s a groovy remix of some favourite old songs. Regular visitors to meta4RN.com may recognise the repetition, and be quite bored with me using the website as a place to store updated versions of old stuff. Sorry about that. I’ll pop-up a new and original post in coming days.
Here are the resources and references used in the presentation: (because I’m recycling old ideas this list is ridiculously self-referential).
Australian College of Mental Health Nurses [www.acmhn.org], Australian College of Nursing [www.acn.edu.au], and Australian College of Midwives [www.midwives.org.au] (2019) Joint Position Statement: Clinical Supervision for Nurses + Midwives. Released online April 2019, PDF available via each organisation’s website, and here: ClinicalSupervisionJointPositionStatement
Eales, Sandra. (2018). A focus on psychological safety helps teams thrive. InScope, No. 08., Summer 2018 edition, published by Queensland Nurses and Midwives Union on 13/12/18, pages 58-59. Eales2018
Emotional Aftershocks (the story of Fire Extinguisher Guy & Nursing Ring Theory) meta4RN.com/aftershocks
Football, Nursing and Clinical Supervision (re validating protected time for reflection and skill rehearsal) meta4RN.com/footy
Hand Hygiene and Mindful Moments (re insitu self-care strategies) meta4RN.com/hygiene
Lalochezia (getting sweary doesn’t necessarily mean getting abusive) meta4RN.com/lalochezia
Nurse & Midwife Support nmsupport.org.au phone 1800 667 877
– we have specifically targeted 24/7 confidential support available
Nurses, Midwives, Medical Practitioners, Suicide and Stigma (re the alarming toll of those who undertake emotional labour) meta4RN.com/stigma
Nurturing the Nurturers (the Pit Head Baths and clinical supervision stories) meta4RN.com/nurturers
Queensland Health. (2009). Clinical Supervision Guidelines for Mental Health Services. PDF
Spector, P., Zhiqing, Z. & Che, X. (2014) Nurse exposure to physical and nonphysical violence, bullying, and sexual harassment: A quantitative review. International Journal of Nursing Studies. Vol 50(1), pp 72-84. www.sciencedirect.com/science/article/pii/S0020748913000357
Zero Tolerance for Zero Tolerance (a reframing of reducing aggression) meta4RN.com/zero
It’s OK if you forget everything about today’s talk, just don’t forget that there is 24 hour support available via 1800 667 877 or https://nmsupport.org.au
On 21st December 2012 (Cairns time) nurses from the United Kingdom and Australia came together on Twitter using the #WeNurses hashtag. The planned Twitter chat was used to discuss issues raised by the much-publicised death of a nursing colleague – Jacintha Saldanha.
This curated version of the Twitter chat demonstrates nurses using social media in a constructive manner, and responding to the issues surrounding Jacintha’s passing with thoughtfulness and grace. This was in sharp contrast to the shrill, insensitive and ill-informed way the matter was discussed elsewhere on social media and in mainstream media in the UK and Australia.
I’ve used sub-headings in red to structure the chat as per the themes that emerged.
WordCloud created from the full transcript of the #WeNurses Twitter chat
Preliminary Information.
1.
1 hr until tonights joint UK / AUS #WeNurses chat – a sensitive subject tonight that we are hoping to learn from > http://t.co/3GRJMsuW
Unfortunately, Storify is shutting-down on 16 May 2018 and all content will be deleted.
I’m using my blog as a place to mimic/save the Storify pages I created and value.
End Notes
This archive of Tweets relate directly to two blog posts I wrote at the time. If you’re interested in elaboration re the context at the time, please visit these pages:
Questions of Compassion meta4RN.com/questions-of-compassion
WeNurses: Communication and Compassion meta4RN.com/WeNurses
As always, please use the comments section below for any feedback/questions.
I barely have time to write this blog post, let alone satisfy my lazily-never-pursued fantasy of writing a novel.
Luckily, the Queensland Writers Centre offered a solution: the eight word story.
Eight words is the perfect length for somebody with the attention span of a stoned goldfish (eg: me).
Yesterday, one of my eight word stories was published by the Queensland Writers Centre. Published on electronic billboards, that is. Billboards that grace the busy roads, roundabouts and motorways in and around Brisneyland.
Billboard at Bowen Bridge Road, Hertson
The story published was one of three stories I submitted on Twitter for the #8WordStory project.
THREE whole stories! That’s TWENTY FOUR words, you know! #TypistCramp
Intentionally, all three of the stories relate to my work experiences. When writing these stories I was ambitious to be ambiguous. When there are only eight words to write, the reader needs to be able to bring their imagination to the story.
Interestingly, the story that was the most ambiguous of the three is the one that made it to the billboards.
#8WordStory x3
She ignored her emotions while labelling his corpse. [source]
I wrote this remembering my experiences of being with patients during the last hours of their life and for the first hours of their death. Nursing’s unique role of caring for a person’s body both in life and death is rarely spoken about or acknowledged. It’s one of those peculiar privileges of nursing.
The story is ambiguous enough for people to project their own meaning (eg: Lea’s tongue-in-cheek Tweet). I’m cool with that.
Impersonating a calm person, the nurse continued working. [source]
I was thinking of a young medical ward RN who had just intervened when a patient tried to harm himself. We had a quick “corridor consult”. She asked a couple of unanswerable questions, shed a couple of tears, wiped her eyes, washed her hands, then assumed her usual energetic and positive demeanour.
One minute there’s a crisis. Next minute it’s business as usual.
Hold and contain three things: the crisis, the patient, your emotions (not necessarily in that order).
The midwife didn’t smile until he heard crying. [source]
About 1 in every 60 Australian midwives is a male. I thought it would be more interesting and ambiguous to cite that minority in this story.
Crying is usually considered in a negative light in mainstream society, but midwives know crying as a sign of life.
Billboard on Lutwyche Road, Lutwyche
My 15 minutes 8 words of fame.
Billboard on Beaudesert Road, Moorooka
The story provides the frame. The imagination does the work.
Billboard on Logan Road, Upper Mount Gravatt
Finishing-Up
Why don’t you give an #8WordStory a go too? Submit yours via Twitter or web page.
Small talk is the oil that keeps the machinery of interpersonal relationships running smoothly.
Small talk even has its own name. It’s called “phatic chat”.
Phatic chat has been described as “A type of speech in which ties of union are created by a mere exchange of words” by Bronislaw Malinowski (no relation to Barry Manilow). This is why I think it’s important that us health professionals be intentional about phatic chat.
Every, “Hello. My name is…” and “How are you today?” serves to create a working relationship between people. Health professionals rely on working, therapeutic relationships.
Academics (god bless their cotton socks) have even gone to the effort of researching and naming 12 functions of phatic communication (source):
(1) breaking the silence
(2) starting a conversation
(3) making small talk
(4) making gossip
(5) keeping talking
(6) expressing solidarity
(7) creating harmony
(8) creating comfort
(9) expressing empathy
(10) expressing friendship
(11) expressing respect
(12) expressing politeness
When we think about phatic chat in the health care setting, it’s not just a social lubricant, we can also see it as a stand-alone form of therapy. Think of phatic chat as the nonspecific factors of psychotherapy
BTW: “nonspecific factors of psychotherapy” an actual thing, let me google that for you: here
Phatic chat/the nonspecific factors of psychotherapy show the person that there is someone who is interested in them and their concerns. It helps people feel understood, accepted and respected. In my current gig – providing mental health support in the general hospital – I often get told by patients how good it is to be nursed by someone who is good at phatic chat.
It’s easy to imagine, isn’t it? Who would you rather attend to your vital signs, IV antbiotics, wound dressings, and pain relief in hospital: a friendly person who chats and listens, or someone unfriendly and officious who just goes about the tasks at hand? There’s more than one way to prime an IV line.
It sounds simple, and (to my ear anyway) pretty patronising. However, it’s clear that many clinicians do not routinely engage in phatic chat.
You may already know the story of Kate Grainger. Briefly, for those who don’t, Kate was a doctor in the UK who tweeted her experience of living with a terminal illness. One of the many observations she made was that it was refreshing, but actually pretty unusual, for hospital staff to introduce themselves by name and role when they came to see you in your hospital bed. That observation lead to this tweet:
That simple idea has been one of Kate’s greatest legacies (she died in 2016).
#hellomynameis = a very successful campaign promoting phatic chat in healthcare
I live and work a long way from the UK. Although I don’t wear a #hellomynameis badge, I borrow heavily from the idea that phatic chat is important, and toss-in a few more Aussie-fied ways to go about using it in the hospital setting. As argued above, phatic chat is important for building relationships and can be therapeutic in and of itself. Sometimes to be culturally safe you need to try a little harder to facilitate trust and rapport. With that in mind. here’s 4 ideas that usually (not always) work for me:
One
“Are you Cyril? G’day my name is Paul McNamara, I’m a nurse with the psych team here at the hospital. Is it OK if we sit down and have a bit of yarn?”
Two
Shaking hands is a respectful thing to do. I always offer a handshake when introducing myself to patients (they’re often surprised!).
Don’t worry infection control peeps, I’ve got that covered: meta4RN.com/hygiene
Three (this is my second favourite: I stole it from Professor Ernest Hunter)
Make a cup of tea for the patient. Even if they say “no thanks”, let them know that you’re making one for yourself anyway, so are happy to make them one while you’re at it. Take instructions on how the person likes it . Apologise if you make it too hot/strong/weak or spill it. Sip yours when they’re talking: if for no other reason, it let’s them know you’re not about to interrupt.
This might be the best journal article ever written by a psychiatrist:
Hunter, E (2008) The Aboriginal tea ceremony: its relevance to psychiatric practice. Australasian Psychiatry, 16:2, doi: 10.1080/10398560701616221
Despite the paper’s title, the same demonstrations of humbleness, politeness and respect work for whitefellas too.
Four (this is my favourite: I made this one up myself)
I nearly always use when Google Maps when introducing myself to people who have come to the hospital from out of town. “Oh you’re from Aurukun? I’ve been to Wujal Wujal, Laura and Hope Vale, but I’ve never been there. Do you mind if we use this map on my phone to see where you live?” It’s nearly always a great way to break the ice, especially when meeting with someone from a different culture. It sets the right tone of showing that you’re interested and approachable.
I’m lucky to work in a place where I meet with Aboriginal and Torres Strait Islander people all the time. By getting the Aboriginal/Torres Strait Islander person to show me around their community on a map, I’m acknowledging/demonstrating that they know stuff that I don’t know, and I’m prepared to learn from them. Sometimes I’m a bit more skilled at using the Google map app on my phone, so I get to show the person how I can be helpful, in a kind and respectful way. It probably doesn’t hurt that we’re both looking at the map together and working on the same task (it demonstrates that we can work together, and you don’t want to rush into making a heap of eye contact with someone you’ve just met). While we’re using the app to find their house, the local school, favourite fishing or camping spot, and other landmarks we’re getting to know each other a bit. I’m not left in that clumsy position of being accidentally too pushy, too intrusive, too task-orientated.
Spending a few minutes establishing rapport is what phatic chat is all about. The phone/map app is just a prop, but it’s a great prop.
In Closing
That’s it.
A while back I had a gig educating uni students. One of the best tricks-of-the-trade when in a uni lecturer role is to introduce people to words they have not heard before. This makes you look cleverer than you really are, and lends an illusion of credibility.
So, with that in mind, my call-to arms for health professionals is this:
Let’s embiggen phatic chat! It’s a perfectly cromulent thing to do. 🙂
Acknowledgement
The phrase/notion of “phatic chat” as a defence against the forces that seek to turn nurses into unempathetic box-ticking robots came to my attention via Professor Eimear Muir-Cochrane’s keynote presentation at the ACMHN 39th International Mental Health Nursing Conference, held in Perth, Western Australia, 22nd-24th October 2013.
Nurses and other health professionals are expected to attend to hand hygiene about eleventy seven times a day. The WHO and HHA recommend 5 moments for hand hygiene: before touching a patient, before clean/aseptic procedures, after body fluid exposure/risk, after touching a patient, and after touching patient surroundings. 57.4% of Australia’s nurses/midwives are hospital/ward-based [source], they’re doing A LOT of hand hygiene.
On top of that, while they’re going about their business and busyness, ward-based nurses are interrupted10 times an hour [source]. Yep, every 6 minutes there’s something or somebody distracting us from our tasks and thoughts. Dangerously disorderly much? Hopefully that doesn’t happen to neurosurgeons, commercial airline pilots, tattoo artists or Batman.
Especially Batman.
Pro-Tip: most of us can not do this at work. Only respond to distractions with face-slapping if you are Batman.
So, here’s the idea: if you’re going to do hand hygiene dozens of times a day anyway, don’t just do it for your patients: do it for yourself too. We’re not cold callous reptilian clinicians, we’re educated warm-blooded mammals who do emotional labour. We need to nurture ourselves if we are to safely continue to nurture others.
5 moments for hand hygiene & head hygiene!
Turn the 5 moments of hand hygiene into mindful moments. Make the 5 moments for hand hygiene 5 moments for head hygiene too. Yes, clean hands save lives – let’s not forget that clear heads save lives too!
Come up with a process/script that works for you, maybe something a bit like this:
Mindful Moment (The 30-Second Handrub Version)
Step towards the pump bottle with intent. This is my mindful moment. I’m taking a brief break.
Squirt enough to squish.
The rub is slippery at first. Frictionless fingers feel fine.
Feel the product texture and temperature. The rub is cooler than the air. The rub is cooler than my fingers. It feels nice.
Start with cleaning. The first half of my hand hygiene routine is about rubbing stuff off. Let the stuff I want to get rid of float away.
Move on to restoration, healing. The second half of my hand hygiene routine is about rubbing in resilience and health. Let the stuff that sustains me seep into my skin.
Check in on the breathing. The slower and deeper the better. If the breathing or the brain are running too fast, slow down and repeat steps 5 and 6.
There’s no rush. Slowly scan the surroundings. With any luck someone from infection control is watching.
Smile.
Breathing slowly, its time let the air rinse off the residue.
One more slow breath. Its time to get back to work.
Mindful Minute (The 60-Second Handwash Version)
Step towards the sink with intent. This is my mindful minute. I’m taking a brief break.
Let the water flow.
Feel the water flowing over both hands. The water’s warmer than the air. The water’s warmer than my fingers. It feels nice.
Start with cleaning. The first half of your hand hygiene routine is about washing stuff away. Let the stuff you need to get rid of flow down the drain. Let it flow away.
Move on to restoration, healing. The second half of my hand hygiene routine is about rubbing in resilience and health. Let the stuff that sustains me seep into my skin.
Check in on the breathing. The slower and deeper the better. If the breathing or the brain are running too fast, slow down and repeat steps 5 and 6.
There’s no rush. Slowly scan the surroundings. With any luck someone from infection control is watching.
Smile.
Breathing slowly, its time rinse both hands.
Breathing slowly, its time to thoroughly dry both hands together.
Throw the towel in the bin.
One more slow breath. Its time to get back to work.
Clean hands save lives. Clear heads save lives too!
Acknowledgements & Context
This is not my original idea. I first stumbled across the idea of combining hand hygiene with head hygiene via Ian Miller‘s November 2013 blog post “mindfulness during handwashing”: http://thenursepath.com/2013/11/18/mindfulnurse-day-8/. I’ve been using the idea myself and suggesting it to colleagues and students ever since. When I left the clinical environment for a few months, I found myself really missing intentionally punctuating my day with mindful moments. Since returning to clinical practice I’ve come to appreciate the strategy even more than I did when I first started using it 3 years ago.
So why am I blogging about it too? Why now? Well, on Monday I attended the Australasian College for Infection Prevention and Control 2016 conference to chat about Twitter [link to that presentation here. Also, check-out the #ACIPC16 hashtag here and here]. Luckily I was there for the opening plenary sessions, and was pleasantly surprised at the emotional/psychological literacy that was being displayed and advocated for. The opening presentations by Peter Collignon, Mary Dixon Woods and Didier Pittet all went to some lengths to emphasise the importance of emotional intelligence, constructive communication and building relationships. It was really impressive stuff; giving the hand hygiene and mindful moments idea a remix is my way to give recognition/thanks to the #ACIPC16 conference delegates and organisers.
Just so you know, a quick google search reveals that others have also thought of using hand hygiene as a mindful moment, eg this paper:
Gilmartin, Heather. (2016) Use hand cleaning to prompt mindfulness in clinic: A regular prompt for reflection could reduce distraction. BMJ 2016; 352 doi: http://dx.doi.org/10.1136/bmj.i13 (Published 04 January 2016)
and this video:
There are others too. Do you think using hand hygiene as a mindful moment could become mainstream?
End
That’s it. As always your comments are welcome via the space below.
I’m a nurse. Every day at work somebody is in crisis.
Every. Single. Day.
People have life threatening injuries and illnesses. People experience suicidal ideation and sometimes act on those thoughts. People experience delirium, dementia and psychosis – they lose touch with reality. People behave in unexpected and challenging ways.
All of these people are in crisis. They are having the worst day(s) of their life.
When you are part of the clinical team trying to help out these people it’s always useful to acknowledge and clarify the nature of the person’s crisis. It’s surprising what the individual’s perception of the crisis is. I’ve met a person who was desperately unwell – ICU unwell – who’s subjective crisis was that the cat was home alone without anyone to feed it. That was the crisis she wanted me to respond to. I’ve met quite a few people who need urgent medical/surgical interventions, but who perceive their biggest crisis as being unable to smoke a cigarette right now. I’ve had the peculiar privilege of spending time with people who have survived suicide attempts, who have experienced a crisis related to abuse, financial problems, relationship breakdown, and loss of job/role/independence/sense-of-self. An existential crisis in mind, body and spirit.
All of these people are in crisis. It is their crisis.
It is important to ascribe ownership. The nurse/midwife/physician/other clinician is not experiencing the crisis; they are responding to the crisis. We (the clinicians) have not been immunised against crises, but we do have the responsibility to do whatever we can to not get overwhelmed by them. Also, truth of the matter is, I’m not sure how long you would last if you responded to every day at work as an adrenaline-filled, too-busy-to-wee, emotional rollercoaster. That be the road to burnout and breakdown, my friend.
So, what do we do?
We use Jedi Mind Tricks, pithy sayings and clinical supervision. That’s what we do.
Clinical Supervision
I’ve written about clinical supervision before (here and here). Despite the name, it’s not about scrutiny. Clinical supervision is about reflecting on clinical practice with a trusted colleague, and asking simple questions of yourself: what did I do?; what were the outcomes?; how did I feel?; what lessons did I learn?.
The idea of clinical supervision is to acquire and refine clinical skills.
Pithy Sayings
A lot of us use and repeat pithy sayings such as the ED adage: “In the event of a cardiac arrest [or any other patient crisis for that matter], the first pulse you should take is your own.”
If you recognise your own anxiety you’re more capable of managing it. Intentional slow breathing is an excellent intervention for this. You can do it while you’re scanning the patient/file/environment.
Breath. Slowly.
It is not a crisis. A crisis is when there’s a fire, storm-surge, tsunami, earthquake or explosion that requires evacuation of staff and patients. If the hospital is not being evacuatedit’s not a crisis. It’s just another day at work.
Jedi Mind Tricks
The other thing I like to do when feeling anxious is impersonate a calm person. It’s like a Jedi mind trick. “This not the anxious nurse you’re looking for. This is a calm nurse.”
When impersonating a calm person I conjure-up a person who was a CNC when I was a student nurse at the Royal Adelaide Hospital. Part of the apprenticeship model of nursing education at the time was to give students experience in RN roles. I had been thrown into the Team Leader role on a day when the neuro ward was especially busy. There were emergency admissions, a stack of post-op patients – two of whom were really unwell, a person dying in the side room, and an inexperienced unqualified overwhelmed drongo (me) coordinating the whole thing. We were in trouble. We needed more nurses and a proper team leader.
I sought-out the CNC – a smart-as-a-whip young woman not much older than me (i was quite youngish 25 years ago). The CNC spent all of about 5 minutes with me prioritising the ward’s workflow:
“First things first. No need to shower/clean anyone unless they’re incontinent.” There goes about 50% of the morning’s workload in an instant.
“Don’t bother with routine 4-hourly obs unless the person looks unwell. Only the post-op patients and the clinically unwell patients need their obs done.” There goes another 10% of the work.
“Let’s get Fiona (the most experienced and skilled nurse on the shift) to look after the two dodgy post-op patients and nobody else.” The biggest concern was instantly taken care of.
“Bring all the nurses in here (a cramped nurses station overlooking 2 bays of 6 patients each) and tell them the plan. Make sure they all drink water and coordinate their breaks.” Got it. To look after the patients you need to look after the nurses.
“After you’ve told the nurses the plan, tell the patients/visitors who aren’t critically unwell the plan. They’ll understand we’re abnormally busy if we tell them.” Open, honest communication? Who’d have thought?
“Slow down your breathing. Use your humour. You’ll be fine. Come and grab me if you need.” My racing thoughts slowed. Panic evaporated.
We, nurses and patients alike, had a good shift. All the vital stuff was done. It wasn’t a crisis. It was a day at work.
I haven’t seen that CNC (her name is Lee Madden) since 1992, but I think of her every now and then. Whenever I see a crisis unfolding or see/feel anxiety rising, I wonder, “What would a calm person do?” and conjure an image of Lee floating serenely into the space. I channel Lee’s reassuring smile and clear understanding of priorities, and do my best to behave in the way she modelled to an impressionable overwhelmed student nurse.
Crisis? What crisis? I’m impersonating a calm person.
End
As always, you’re welcome to leave comments below.
August 8th is “Dying To Know Day” – an annual day of action dedicated to bringing to life conversations and community actions around death, dying and bereavement. More info about that here: www.dyingtoknowday.org
The first time I read “Field Notes on Death” by Lea McInerney was two years ago when I stumbled across it via the #DyingToKnowDay hashtag. It is a beautiful, poignant piece of writing, where Lea draws on her experience growing-up Catholic in the 1960s/70s, and later becoming a nurse. I’ve re-read Field Notes on Death four or five times over the last couple of years. I re-read it again this morning. Just as I did every other time, I quietly started crying about three quarters of the way through.
I cry too easily. I have been terribly embarrassed by this on many occasions. It’s not that I don’t think men shouldn’t cry, it’s just that I think I cry too easily. Too easily for my liking anyway.
A couple of things happened recently which make feel slightly less embarrassed.
One was seeing the generous, open display of grief shown by Adelaide Football Club players and staff after the death of the team’s coach. For those not familiar with Australian Rules Football, the players are mostly “blokey blokes”. They are men so manly they make other men question their manliness. They’re fit and fearless. Tonka trucks are nowhere near as tough.
These manly young men wept openly in public. Not embarrassed. Not ashamed. They have never been more inspiring. Never been better role models.
The other thing happened at work. I met a lady who was referred because of postnatal depression. My job involves listening mostly, but I ask questions too, in the hope of gaining an understanding of what support strategies would be most useful. When I asked her whether she had been more tearful than usual, she responded:
Where I grew up we have a saying that translates into English as “lives close to the water”. It refers to people who are sensitive. People who cry easily.
I have always lived close to the water.
It’s a lovely metaphor. Doesn’t everyone want to live close to the water? That’s where you’ll see some of the most beautiful views.
Trinity Inlet, Cairns
In Closing
Field Notes on Death is a great read. I intend to re-read it and re-share it every year on #DyingToKnowDay. I thoroughly recommend it to anyone, and think nurses and other health professionals who are exposed to end of life care/issues will find it especially useful.
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