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
Consultation liaison psychiatry services (CLPS) are, typically, based in a general hospital setting to provide the dual services of mental health clinical assessment/treatment and clinician support/education. The clinical and education roles overlap – a lot.
A significant part of the CLPS job is undiagnosing mental illness. Undiagnosis is often correcting a misdiagnosis, and also serves to validate the emotions and experiences of people (Patfield, 2011; Lakeman & Emeleus, 2014). It is not unusual for CLPS to be asked to see somebody who is emotionally overwhelmed or dysregulated. Sometimes this is in the context of mental health problems often in the context of significant stress. Naturally, we do not want to ‘psychiatricise’ the human condition. Of course, you cry when you are sad, and of course you are anxious when, like Courtney Barnett in ‘Avant Gardener’, you are not that good at breathing in. Of course, you’re frustrated when you are in pain or do not understand what’s going on.
Validating understandable and proportionate emotions is important.
It is equally important to make sure that somebody who has experienced mental illness previously does not have every presentation to the hospital/outpatient clinic seen through that lens. That is called “diagnostic overshadowing”; which is a significant problem.
Diagnostic overshadowing is where physical symptoms are overlooked, dismissed or downplayed as a psychiatric/ psychosomatic symptom. It must be one of the most dangerous things that happen in hospitals.
The President of the Royal Australian and New Zealand College of Psychiatrists, Professor Malcolm Hopwood, said in May 2016, “I sometimes think that the worse thing a person can do for their physical health is to be diagnosed with a mental health disorder.” Prof Hopwood cited stigma and discrimination in the health sector as contributing problems to early mortality amongst people with mental health problems.
People, hospital clinical staff included, are often shocked when they find out that people diagnosed with mental illness die between 10 and 25 years younger than the general public. Although suicide is a contributing factor to high mortality rates amongst this part of the community, it is alarming to note that the overwhelming majority – 86% – of people with mental health problems who had a premature death did not die from suicide (Happell & Ewart, 2016).
About 60% of people who experience mental health problems experience chronic physical health problems too. Poor mental health is a major risk factor for poor physical health, and vice versa (Harris et al, 2018).
The lived experience
Diagnostic overshadowing happens outside of hospitals too. In the example below, understandable and proportionate human emotions were misinterpreted as psychopathology. The cascade of events that followed makes for a sobering read:
Eight years ago I was diagnosed with bipolar affective disorder (BPAD) and recovered enough to commence a PhD. Unable to obtain travel insurance for a conference due to my diagnosis, I disclosed the reason to my supervisor. Unfortunately, he began to see all stress (normal to a PhD student) as BPAD symptoms and decided I was incapable of completing the PhD and progressively began to discriminate against me. My mental health started to decline. I imagine this must have validated his belief that I was an unsuitable student.
I received some help from the university, with an advisor indicating that my supervisor was undermining my work. The advisor was promoted. Despite not knowing me, his replacement did not believe my account and disagreed with my psychiatrist’s assessment of my mental state. Other staff and graduate students joined the belief that I could not cope, alienating me from the entire department.
After almost 18 months of fighting, I was once again depressed and felt defeated. I left the degree and lost my scholarship. It was one of the hardest things I have done. After, I was unable to gain employment; overqualified for most positions, lacking experience for the rest, and no references. After five months of constant rejections and lingering grief from losing the PhD, my self-worth and coping ability were so diminished, I made a very serious suicide attempt. I was so distressed that I could not see another solution.
Seven months later and I still have no paid employment. I have been undertaking volunteer work to regain some meaning in my life and have set myself up for the long-term with a new field of study. However, this does not pay the bills, and living like this is taking its toll. Sometimes I do not know where my next meal will come from, I have lost friends because of their attitude towards mental illness, and have withdrawn from health-related activities because of a lack of finances. Most days I cope and can find meaning in what I do, some days are much harder.
Questions for Reflection
Assuming that you – the person reading this – is a health professional, we have some questions we would like you to reflect on.
Have I ever witnessed a person’s mental health history influence how their presenting complaint was investigated or treated?
How does my workplace prevent mental health stigmatising and diagnostic overshadowing?
What can I do to support good holistic patient care without falling into the trap of diagnostic overshadowing?
References
Happell, B. & Ewart, S. (2016). ‘Please believe me, my life depends on it’: Physical health concerns of people diagnosed with mental illness. Australian Nursing and Midwifery Journal, 23(11), 47.
Harris, B. Duggan, M. Batterham, P. Bartlem, K. Clinton-McHarg, T. Dunbar, J. Fehily, C. Lawrence, D. Morgan, M. Rosenbaum, S. (2018). Australia’s mental health and physical health tracker: Background paper. Australian Health Policy Collaboration issues paper no. 2018-02, Melbourne, AHPC.
Lakeman, R. & Emeleus, M. (2014). Un-diagnosing mental illness in the process of helping. Psychotherapy in Australia, 21(1), 38-45.
Patfield, M. (2011). Undiagnosis: An Important New Role for Psychiatry. Australasian Psychiatry, 19(2), 107–109.
McNamara, P. & Callahan, R. (2018). Diagnostic Overshadowing. News, Summer 2018 edition (published December 2018), Australian College of Mental Health Nurses, page 17.
End Notes
The article above is a tidied-up version of a blog post that Bec and I collaborated on in October 2018 (see meta4RN.com/shadoworiginal). This is not called self-plagiarising, it’s more like doing a studio version of a demo tape. 🙂
Many thanks to Sharina Smith for encouraging us to submit the article to ACMHN News.
I work in a general hospital doing mental health clinical work and education. The two roles overlap. A lot.
A significant part of the job is undiagnosing mental illness. It’s not unusual for us to be asked to see somebody who is emotionally overwhelmed or dysregulated. Sometimes this is in the context of mental health problems, often it’s in the context of significant stress. We don’t want to psychiatricise the human condition. Of course you cry when you’re sad. Of course you’re anxious when, like Courtney Barnett in ‘Avant Gardener‘, you’re not that good at breathing in. Of course you’e frustrated when you’re in pain and/or don’t understand what’s going on.
It’s important to validate understandable and proportionate emotions.
It’s equally important to make sure that somebody who has experienced mental health problems previously doesn’t have every presentation to the hospital/outpatient clinic seen through that lens. That’s called “diagnostic overshadowing”. It’s a real problem.
Diagnostic overshadowing is where physical symptoms are overlooked, dismissed or downplayed as a psychiatric/psychosomatic symptom. It must be one of the most dangerous things that happens in hospitals. The President of the Royal Australian & New Zealand College of Psychiatrists, Professor Malcolm Hopwood, said in May 2016, “I sometimes think that the worse thing a person can do for their physical health is to be diagnosed with a mental health disorder.”
It’s a big deal. About 60% of people who experience mental health problems experience chronic physical health problems too. Poor mental health is a major risk factor for poor physical health, and vice versa. [Source: Australia’s mental and physical health tracker 2018]
Diagnostic overshadowing happens outside of hospitals too. In this example, understandable and proportionate human emotions were misinterpreted as psychopathology. The cascade of events that followed makes for a sobering read:
Assuming that you – the person reading this blog post – is a nurse, midwife or other health professional, I have some questions I’d like you to reflect on.
Have I ever witnessed a person’s mental health history influence how their presenting complaint was investigated or treated?
How does my workplace prevent mental health stigmatising and diagnostic overshadowing?
What can I do to support good holistic patient care, without falling into the trap of diagnostic overshadowing?
End
Sincere thanks to Bec (aka @notesforreview on Twitter) for giving permission to share her tweets re mental health stigma and diagnostic overshadowing. Her first-hand account is a powerful cautionary tale.
Paul McNamara, 1st October 2018
Short URL meta4RN.com/shadoworiginal
Update as at 15th December 2018
Bec and I tidied-up this blog post and it’s now been published.
On Monday 17th September 2018 I’ll be presenting to the Cairns & Hinterland HHS palliative care team regarding clinical care and clinical supervision. It 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: http://prezi.com/gtsqjgs9zdby
This page serves as a one-stop directory to the online resources used to support the discussion, and as an easy way for me to find the presentation. 🙂
I’m recycling and combining a lot of old ideas for the session (there’s that self-plagiarist vs groovy remix of favourite old songs thing again), so this list below is ridiculously self-referential:
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
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.”
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.
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.
The nature of nursing will mean that we are likely to be are exposed to a range of challenges.
Feeling unsafe, witnessing violence, tragedy and dealing with trauma are some examples.
This emotionally taxing environment can result in tension with colleagues, family and friends.
This session will begin day two of the conference by creating an opportunity to discuss the following:
What are the professional implications of working in challenging areas of nursing and healthcare?
How can we maintain unconditional positive regard?
Why self-care matters and how to practice what we preach!
What’s all this then?
“First Thyself” 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/#
This page serves as a one-stop directory to the online resources used to support the discussion.
I’m recycling and combining a lot of old ideas for the session (there’s that self-plagiarist vs groovy remix of favourite old songs thing again).
Here are the resources and references used in the presentation:
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
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
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.
Below is a metaphor I heard in 1994 via an impressive man called Greg Holland. Greg is retired now, but when I met him he was a CNC with a public community mental health service. Even after all the years that have followed, Greg remains one of the most skilled communicators and mental health nurses I’ve ever worked with.
Greg was talking with a couple of young fellas who had been diagnosed with schizophrenia. Greg was explaining the importance of trying to avoid relapses of psychosis. The key messages for these young blokes was to keep taking the prescribed medications, and stay away from things that make psychosis more likely: things like cannabis, amphetamines or heaps of alcohol. That’s when Greg used this metaphor (his verbal version was shorter than my written version, but the general story is the same):
If you accidentally broke your leg skateboarding or playing football, you’d have to have your leg in plaster for about 6 weeks. You would have to be really careful with it during that time, and it would probably get really uncomfortable and itchy most days. Then, if there were no complications, after 6 weeks you’d be able to get the plaster cast off, and start building up your strength in that broken leg. A physio might recommend some exercises, but you probably wouldn’t get back to playing football or skateboarding for a few months. Rehabilitation takes a bit of time and effort, but as a young fit man you’ll make a full recovery. No worries.
If you broke the same leg again, it might be more of a big deal. You might need surgery, and they might need to strengthen the bone with steel plates or rods and screws. Sometimes people need to have external fixation: metal devices that are screwed into the bones, but sit outside the body, above the skin to stabilise the fractures. It will be messier, more painful, take longer to get out of hospital, and your leg muscles will get pretty weak. You’ll probably make a full recovery still, but it will just take more time and effort.
If you break your leg a third time, the orthopaedic nurses and doctors are going to think you’re either really unlucky or stupidly reckless. They’ll suggest that you stop skateboarding and playing football altogether. Your leg will get operated on, and the fractures will get stabilised, but the recovery will be really slow. You could end-up with a bit of a limp.
If you keep on breaking the same leg over and over again, say five, six, seven times, you will definitely end up with a limp. Might need a walking stick or something.
If you break the same leg often enough and bad enough you’ll probably end up lame: permanently disabled and unable to walk. You’ll wish you’d listened to the orthopaedic nurses and doctors, and had never gone back to skateboarding or playing football.
It’s kind of the same with psychosis.
If you lose touch with reality once or twice you’ll probably make a full recovery.
But if you keep on having psychotic episodes your brain might develop a bit of a “limp” – it will still work, but not as good as it used to work.
If you have lots of psychotic episodes you might end up disabled and unable enjoy life to the fullest. You’ll wish you’d never gone back to smoking gunja or getting pissed.
That’s why I’m working with you to prevent or cut down on psychotic relapses. Does that make sense to you?
I really like the broken leg/psychosis metaphor. I use a shortened version of the above script a fair bit at work, and people usually respond well to it. I’m very grateful to Greg Holland for introducing the analogy to me. It’s a good metaphor that I hope that others will find useful to use/adapt in their clinical practice too.
meta4RN 