The emotional strain of healthcare

HOW DO YOU GUYS DO IT? –the emotional strain of healthcare – by Dr Johnny Iliff

“How do you guys do it”? “I could never do your job!” How many times have those of us in the healthcare profession heard those questions? Dare I say that, at least once in our careers, most of us will have been asked something similar by a patient to whom we have attended. It may have been as a Student Nurse helping an elderly dear to the commode or the Emergency Department Registrar putting a cannula into the arm of a 21 year old with a blood phobia.

Has anybody ever stopped to think, how DO we do it? This is something that has played on my mind of late. However, I want to probe a little deeper into the question.

The physical actions which we do on a day-to-day basis are sometimes the only thing seen by the lay person outside of the healthcare world, taking blood tests; changing soiled beds; running in circles looking for oxygen cylinders; administering antibiotics; filling in yet more forms – the list is endless. This is all simply on the surface with regards to the workload. I wonder how many people have considered what lies beneath?

Hospitals and other healthcare environments are not always like a ‘Carry-On’ film with bawdy humour and raucous antics. They undoubtedly have a heavy element of exposure to sadness and at times, unhappy endings. I’m sure most people have come home at the end of a long day and reported a sad case in which the heart strings are pulled to the limit, even at times shedding a tear. This is only natural, given that the work we do.  It is this empathy and compassion we strive for, using it to help others when they are at their most fragile and exposed. It is this emotional burden, sometimes perhaps forgotten by the public, which just might be the biggest strain of all.  Because we see it everyday, does it become second nature eventually, hopefully making it easier to deal with over time as we see more sad cases? To a certain extent, I think this is true – that we can become accustomed to sadness in regards to certain situations. However, is repeated exposure to such melancholy detrimental to the mental health and wellbeing of staff? Do we bottle it up because everybody else around us does?

To make it personal, I was deeply affected recently by a case whereby a very sick child presented to the department in which I worked. Given the seriousness of the situation with the child, emotions were already running high, however, soon the true horrors of the story began to emerge. Once images were taken and old notes retrieved, it soon became apparent that this child was perhaps the victim of non-accidental injury (NAI). What I was exposed to over the following hours truly shocked and angered me.

I think one of the most shocking features was the potential false emotion displayed by the “guardians”. Although unproven yet, there is strong evidence that one particular parent may have been the guilty party, with the acting prowess of an Oscar-winning actor.

The theatrics of the people involved left me with a sense of hatred, which I can honestly say I had never felt before. I wished that it was they who were left helpless and in unspeakable pain, rather than the little girl lying on the resuscitation bed with the ETT and enough broken bones to rival the career total of a professional rugby player.  It was very hard to look at these people and not think that the death penalty would be an adequate punishment for this, what I believe to be, attempted murder of a small child who had not even seen their second birthday yet.

The ethics of this case is not the purpose of this article, but moreover, how do we deal emotionally with repeated cases like this, which test your emotional bottle? My mind has been plagued of thoughts of rage and consternation, which I have been unable to comprehend in the last few days. I know I wasn’t the only one that night going through this, and I realise that there must be others in all the hospitals around the globe experiencing similar feelings in similar scenarios. But what do we do? Do we simply say ‘that’s life” and carry on? I don’t think so. This is not life, this is not even human nature, and to be honest I found it quite hard to accept and put to the back of my mind. I’m quite fortunate to live with some great friends who are also doctors who heard my rant about the case, we discussed it together (and buffered it with discussion of one of the guys’ pending dates) and I began to feel a bit better. It still dwells on me but the opportunity to vent thoughts and feelings towards something otherwise unfathomable helped.

The following days I found myself talking to one of the consultants involved, who as it turned out, had been just as affected as I. After chatting for a while, it made me wonder, that while we are very quick to get social workers and counselors to talk to patients in times of great stress, who do we talk to? What are our coping mechanisms?

Gradually healthcare is being taught to be more open, in the sense that we talk more, reflect on difficult experiences and open up about how we feel about them. It’s very easy to distance yourself from this and bottle it up and it should be acknowledged that this is not a healthy approach, particularly when the literature shows that doctors have a high risk of alcoholism, depression and suicide. A common linkage to these outcomes consistently suggested is stress within the workplace, in which I am sure emotional turbulence is included.  I genuinely believe it to be something that is under-appreciated, not only by the general public, but healthcare professionals as a whole.

To recount another case briefly, as a first year resident I was unfortunate to be involved in the resuscitation of a 3 month old baby who asphyxiated. An obviously distressing time for family, but also had a profound effect on the staff, with the mood of the department visibly changed for a week. One thing which will stick in my mind was the action of the Duty Consultant from that shift who took each staff member individually, from nursing to medical staff, through the progress over the following days and discussed the case, not only from the technical side but also the psychological side of it and how we were affected by it. Having gone into our discussion down in the dumps, I came out not satisfied but certainly feeling better. This idea of the ‘de-brief’ and discussion worked to lift some of that tension which was looming over us all.

After nearly 3 years practicing Medicine, one recurring theme is bosses advising me to look after myself, not in a selfish way, but rather, my wellbeing. The ability to communicate and discuss these upsetting clinical scenarios helped to relieve the strain, however, I cannot help but worry about those people in our workplace who don’t open up and discuss it, who let it play on their mind silently in the background and perhaps are becoming affected by it.

To go back to the question – how do we do it? – the answer is, I don’t know. What I do know, however, is that healthcare professionals have an extraordinary amount of compassion, putting patients and their families before their own wellbeing a lot of the time, particularly when it comes to carrying emotion and stress even when they have left the building. Sometimes this constant exposure can get to people and ultimately lead to deteriorating mental health. We are starting to identify this but maybe its time to take a regular slot for discussion and ‘de-brief’ of cases bothering us. Occupational Health Departments need to acknowledge this and perhaps be a bit more proactive with the emotional health of staff. We are quick to deal with depression, and other health issues, but lets look at sorting one of the aspects of why we get depressed and why we get stressed. Sometimes simply a holiday is not sufficient. We need someone to listen to us, listen to our thoughts, because when you’re the one listening all the time, it can get a bit too much at times and we cant help but take it home, because that’s the empathy and caring nature of our professions.

 

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Comments

  1. says

    Thanks for opening a window on the emotional side of your profession and be so open about it. I read this post with great interest and it just helped me overcoming a big writing impasse!

  2. says

    Thank you for this. I have had 6 months away from my speciality area in the past as a result of particularly emotionally challenging patient caseloads and have been trying to write a similar blog post, but possibly I’m not ready yet.
    In researching my intended post I found that BeyondBlue and RU OK? both have excellent online resources if assistance is needed to help with the emotional strain of healthcare.
    We need to let our people at all levels know that self care is as vital to healthcare as maintaining
    clinical currency.

  3. Sue says

    Great article -- thanks.

    Personally, I am more affected emotionally by a sense that I may have done something wrong, or that I am forced to practice in a way that I think is wrong, than the innate ”sadness” of the case. If I see a very sick baby or some sort of NAI, but have done all I could possibly do, I feel sad, but I tend not to take it home or have recurrent thoughts over it.

    If I feel I may have caused harm, or missed something, or have to practice in an inappropriate way that causes harm in itself (eg overly risk-averse or rigid ”protocol”), I do have ongoing sense of frustration and distress. Some things are very sad, but other things hurt your soul.

  4. Emma Merry says

    Thank you for sharing your experiences. As someone who has been practising medicine for 22 years now (crikey!)I can say that sometimes these situations and people really affect us. Not just from a “what else could I have done?” perspective but from a human suffering and fellow feeling perspective. Chris Poynter wrote a great blog on this topic recently on CritIQ, which I would recommend. Having spent 5 years in Palliative Medicine not that long ago, I think the single most important factor supporting my wellbeing and ongoing practice is monthly clinical supervision with a psychology professional. This is “de rigeur” for all Pall Med Drs, as well as most paediatricians, social workers etc and as an Intensivist, I think it should be compulsory for all those of us practising critical care.You may have to use CME funds as I do,or even fund it yourself but I think it’s well worth it. keep up the good work and the reflection…

  5. Gavin says

    I’ve never been able to answer this question. I really don’t know if I do cope, I get up the next day and do it all again, come what may. Maybe, there in lies the problem, not sure if as a profession anyone cares? Untill we go long term sick with stress or we start drinking too much.

  6. says

    Great to read to this article, and that this is being taken seriously.I was an LPN, in Long Term Care and Rehab for over 35 years working full time,and often back in the day mandatory overtime.I and my co-workers, would see, hear and experience situations that were extremely difficult,and where do you go with it, your emotion, as to be a professional,you were not to talk about anything.Then as computers evolved and the web, and I would read, that in some circles it, this de-briefing after events,that were very difficult was taking place, but not yet to nurses, or physicians.It really is important to overall mental health, to take a proactive approach, pure and simple!Thank you.

  7. says

    Having practiced medicine for six decades or so, I came to the conclusion that some of the really high wire acts in medicine are pediatrics, critical care, ER, neurosurgery/ neuro trauma with their heart rending mental and physical disability, psyche floors where patients lose touch with reality, oncology floors with incurable cancer ….the list is long. Working in these situations is emotionally draining in the extreme. We used to joke that physicians, nurses and other staff working there should take a sabbatical every six months to recover their mental faculties. Even worse are situations where health care workers are dragged in to deal with the abuse of the innocents by family members as is the case presented above. No matter what we do as care-givers there is no real resolution in such a situation. Our utter helplessness is traumatic in the extreme. Some of us are more vulnerable than others. Open discussion with sympathetic colleagues may be enough for some but counseling by experts should be available as needed.

  8. Meri says

    Thank you for your post. This is the 3rd on this topic I have read in the last few months (CritIQ & DFTB Death in paediatrics). These posts often get a lot of comments so it obviously hits a nerve. I too recently looked after a young child in a trauma resus in the middle of the night with the perpetrator a parent. My manager followed me up a few days later and asked two short questions, ‘are you ok?, were you happy with the way the resus went?’ Lucky for me I could answer yes & yes. However it has not always been the case. I have been a nurse for over 20yrs with last 12 in a tertiary referral centre so I have had my fair share of traumatic things to deal with. These questions were a first for me. In two short sentences it honoured my humanity, ability and gave me a voice. I have since spoken with other nursing friends to see if they have ever been asked anything similar. For the most part the answer is a resounding NO. De-briefs are few and far between on night duty, we usually have a back logged department, cranky families, there is no later on during the day time for us. Friends and family are great but unless you are there it’s not easy to understand. There’s also confidentiality.

    So thank you to my boss, I will pay it forward. Maybe we all can. It’s not hard, two short questions, a cup of tea and a genuine listening ear. We need to look after each other, praise easy, judge less and care a little more.

  9. says

    Thank you for this article. I’m a psychologist in the US, working with brain injury patients, and I feel a complete lack of support in this area. I care about my patients, and my co-workers are lovely, but the administrators are focused on productivity rather than quality, i.e., how many patients I see per day and am I generating sufficient income for the hospital. I know this is one of the flaws of our US “fee for service”, for-profit health insurance system. It feels dehumanizing for both patients and staff. Working with the most impaired patients, some in comas who have limited potential to recover, is a burn-out situation and I am ready to leave my profession to do something more gratifying. Even selling ice cream guarantees more happy customers and a greater sense of satisfaction. We desperately need the chance to debrief, to grieve for our patients, and to care for each other. You’re right, a holiday is nice but doesn’t meet this need for healthcare workers.

  10. says

    This is such an important discussion to have.

    I am a mental health nurse working in a general hospital (consultation liaison). Part of being employed by the mental health service is the expectation that I quarantine some time each month to sit with a trusted colleague (not my boss), and confidentially discuss/reflect on my work and the emotions it raises.

    The purpose of this is to keep me, my clinical practice and, consequently, my patients safe.

    It’s proactive, not reactive.

    It is evidence-based:
    for the managers: reduced sick leave, increased productivity, improved staff retention
    for us clinicians: reduced burnout, we spend less on grog, and enjoy our work more

    There are a couple of quick introductory explanations on how it works here:
    Nurturing the Nurturers http://meta4RN.com/nurturers
    Football, Nursing and Clinical Supervision http://meta4RN.com/footy

  11. says

    This beautifully captured what so many primary care physicians in the US and Great Britain are currently experiencing. Your realization of the role for “a regular slot for discussion and ‘de-brief’ of cases bothering us,” based on the need for “someone to listen to us, listen to our thoughts, because when you’re the one listening all the time, it can get a bit too much at times” found a whole range of sympathetic blog posts, one of which suggested “monthly clinical supervision with a psychology professional.”

    This state of affairs is what motivated my colleagues and me to describe our experiences with this phenomenon in our recently book, published by Springer NYC, “Clinical Uncertainty in Primary Care: The challenge of collaborative engagement.” In addition to providing general background on the role of case-based clinical uncertainty in clinical learning and practice, we describe six different approaches to collegial, small group approaches for supporting clinicians deal with case-based clinical uncertainty. (We believe ‘clinical uncertainty, ‘broadly defined, describes many of the anguished clinical patient encounters that primary care physicians experience.) The book can be accessed for free if your medical library has the Springer platform. Once connected to your library, put: http://www.springer.com/medicine/book/978-1-4614-6811-0 into the browser and follow the prompts to free download. The book should be published in softcover this summer at a more affordable price!

    The concept of ‘supervision’ itself holds much appeal -- the term is actually used in one of the six methods described in our book. Also, take a look at the blog, “Reidboard’s Reflections,” for some interesting posts about the traditional concept of supervision in the training and continued professional development of psychiatrists in the US, particularly as regards clinical certainty.

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