The Marathon of Crisis: “We Want to Live Also”

None of us expected the pandemic to last this long. In March, we rallied against the growing and terrible virus, the SARS-CoV-2 (severe acute respiratory syndrome coronavirus 2). At that time, we hunkered down, businesses temporarily closed to stem off the rising numbers of infection, and we all kind of figured it would end in about six months. It has not. Crises aren’t supposed to last this long. The nature of this beast is that its danger is unseen; its end is unseen; and its messaging couldn’t be more confusing.

So I didn’t think last April, when my research team and I received a small seed grant from our university called a “COVID Rapid Response Grant,” that the pandemic would be surging in the way it is now, seven months later. In my naivety, I quickly put together an online survey with the major inclusion criterion of having respondents be frontline, critical care nurses. Data collection lasted from mid-June through beginning of September.

My research assistant and I are swimming in the data, tackling a subset of the items, the open-ended responses. This is the qualitative stuff that as Cheryl Beck states (I paraphrase here), puts muscle on the skeleton bones of understanding. It’s rough going. The nurses had a lot to say.

On one hand, it validates so many nurse-specific and nurse-patient specific traumas that I articulate in my theory. Insufficient resource trauma (i.e., not enough personal protective equipment, not enough trained critical care nurses), vicarious trauma (i.e., patients passing alone; families in distress at not being with loved ones); workplace violence (i.e., families frustrated and taking it out on nurses); disaster trauma (i.e., fearful of endangering self and others); and system/medically-induced trauma (i.e., patients being coded and ventilated). These all seem so sterile when I list them but come alive in the narratives that reflect fear for self and fear for their family’s safety if exposed to the virus from them, agony, anxiety, intrusive thoughts, nightmares, isolation, abandonment, suffering, exhaustion. One nurse added: We… will be forever changed.”

They report feeling intense guilt over the limited care they can offer to the patients. I read the texts and re-read them. Then, my eyes see unassuming words buried in the single spaced narratives; a seemingly quiet voice stood out: “We want to live also.”

As I consumed this sentence, I was reminded of the period in my life when I was a full-time writer. I believe in the power of words and of the writer, the truths they can convey. At a visceral level, the writer decides the order of placement, the punctuation for emphasis, the parsimony over emotive phrases, even the phonemic sounds, soft versus hard, such as “puppy” and “paw” versus “dog” and “god.” In this moment, I saw this quote and envisioned an exhausted individual who just wanted to be done with it all and alive to move forward with life. But I think there is more.

This tiny, five-word, soft-sentence encompassed a primary reality: a nurse wanting to exist after this pandemic. The nurse used peripheral words surrounding the statement: the “hospital” viewed nurses as “bodies” to take care of patients, an objectification of the nurse. Beyond the words, the owner of this voice asks, “What about us?” As if to inquire gently, “Have you forgotten about us? Are we an afterthought?” A sentence sends a reminder when there should be none needed, but sends it nonetheless to those who see nurses as “bodies” to care of the sick patients: “We want to live also.”

And perhaps a second message is conveyed by the voice wanting to live – right now – without the trauma, without the fear. The existential plea to the “hospital” to affirm nurses’ right to exist and recognize their right to particular, individual, lived experiences amid a global pandemic. And the system responsibilities to acknowledge that they have provided services and supplies for some individuals to live, but perhaps not all. The “also” after this humble statement is noteworthy: “We want to live also.”

Based on my middle-range theory of nurses’ psychological trauma, one antidote is to use trauma-informed care of self and peers. Demonstrating trauma-informed care principles for self and fellow nurses is a critical piece, especially offering a sense of safety. This is a space occupied only when safety can be authentically assured. Unless organizations step up, safety is scarce. My theory is clear: the solutions to such psychological trauma must be shared between the individual and organization. Resiliency can grow when the environment allows. Fertile soil includes sufficient resources, supportive management, a safe work environment, and mental health services. Importantly, management has to de-objectify nurses and view us as sovereign professionals, individuals who have choices. Second, there will be a time when the pandemic is under control, perhaps when a healing space opens for posttraumatic growth. A few nurses also shared narratives where resiliency and posttraumatic growth existed now. One nurse, who had lived through the “HIV, Toxic Shock, Legionaires, H1N1 and so many other diseases,” seemed able to cope with the current pandemic: “I’ve learned that I can rise above it.” One of the few narratives that contrasted sharply from the majority.

My research assistant, Anna, and I meet virtually to discuss these voices (I can’t call them data right now as they seem so intimate). We discuss our reactions, our general thoughts because I want to authentically make sense of them. I feel responsible to the nurses who offered them to us. Anna is about 30 years younger than me. Yet she and I agree on what we see and feel from the voices, and perhaps within ourselves. There is truth: “We want to live also.”

References

Beck, C. T. (2015). Developing a program of research in nursing. Springer.

Foli, K. J. & Thompson, J. R. (2019). The influence of psychological trauma in nursing. Sigma Theta Tau International Publishing.

Foli, K. J., Reddick, B., Zhang, L., & Krcelich, K. (2020). Nurses’ Psychological Trauma: “They leave me lying awake at night.” Archives of Psychiatric Nursing, 34(3), 86-95. http://doi.org/10.1016/j.apnu.2020.04.011

COVID-19 and Psychological Trauma

I feel guilty as I write this. You see, I’m home with my family, safe and warm. Protected. Others, my comrades and fellow nurses are not. But I can guess, and have read and been informed of what they are facing on the front lines: reassigned to new hospitals and new duties, rendering care, sometimes coerced by employers, without adequate protective equipment. No masks. No gowns. No testing to know who is indeed positive for the virus. One of my students wrote to me, expressing her ethical dilemma of whether to care for patients while she went unprotected, potentially cross-pollinating other patients and her family. They – her employers – had reminded her that she has ethically pledged to do so. Her note brought it to a personal level to me. What could she do, she asked me? I advised her to document, to bring others into the demands of adequate protection, and to consult the CDC guidelines, contact her county health department and so forth. I felt my advice was not nearly enough, a defective response to an impossible riddle.

We are in a pandemic, a global disaster, if you will. The United Nations Office of Disaster Risk Reduction: International Strategy for Disaster Reduction (2017) defines disaster as:

A serious disruption of the functioning of a community or a society at any scale due to hazardous events interacting with conditions of exposure, vulnerability and capacity, leading to one or more of the following: human, material, economic and environmental losses and impacts. Annotations: The effect of the disaster can be immediate and localized, but is often widespread and could last for a long period of time. The effect may test or exceed the capacity of a community or society to cope using its own resources, and therefore may require assistance from external sources, which could include neighbouring jurisdictions, or those at the national or international levels (n.p.).

That about sums it up, doesn’t it? But what of the nurses’ psychological trauma experienced in the disaster?

My student described insufficient resource trauma, the lack of tangible and intangible resources necessary to render safe and quality care. The resources include knowledge, supplies, nursing staff, and other professionals.

My Middle Range Theory of Psychological Trauma includes this type of psychological trauma and the trauma experienced by being a social actor in the midst of an unfolding disaster (see Figure). Nurses will surely face secondary/vicarious trauma as they witness patients’ suffering and offer comfort and caring. They may participate in system or medically-induced trauma as patients are placed on ventilators, relinquishing control of their bodies. For some patients who lived through the Great Depression, memories of austere times may be invoked, causing anxiety and reflective of historical trauma.

Physicians are often tasked with triaging during disasters as the resources become more strained. But I have met with nurses who were involved in the California fires not too long ago. They felt forgotten and overlooked when the post-fire debriefings took place, as if their place in the healthcare hierarchy removed them from sitting at the healing table.

Another graduate nursing student emailed me about her class assignment. She probably won’t be able to finish it because of all the activities she is being called to do in her hospital, an ever changing world filled with chaos and uncertainty. When I weigh the final paper with saving lives, is there any doubt about what priority I should endorse?  But this is territory I’m unfamiliar with.

What I can do is remind myself that my world should be revised, amended, and my teaching should be trauma-informed. I should lace my work with compassion and an understanding of the overwhelming need for people to feel safe, their voices to be heard, and their recovery to be purposeful and inclusive. I can give names to the trauma they are exposed to and by doing so, offer them a path to express this psychological injury now and in the future so that recovery can unfold.

References

Foli, K. J., & Thompson, J. R. (2019). The influence of psychological trauma in nursing. Indianapolis, IN: Sigma.

United Nations Office of Disaster Risk Reduction. (2017). Terminology. Retrieved from:  https://www.unisdr.org/we/inform/terminology.

 

Say It Ain’t So:  Graduate Students Shade Nursing Theory!

Karen J. Foli, PhD, RN, FAAN

I’d finished grading the last of the master’s-level students’ theory in nursing papers. I’d turned in final grades and then, the message came through: anonymous student course evaluations were ready for my review. I took a long sip of water and put my organic, no preservative, granola bar aside.

Steady, old girl, I said to myself. You have tenure. How bad could they be? I’d done my very best in this hybrid-structured course. The graduate students met on campus about five times throughout the semester and the rest of the “class meetings” were virtual. I liked the hybrid structure as it offered the students a sense of community; yet the online component allowed them to be self-directed as adult learners. I tried to impart a rudimentary foundation of the philosophy of science, and used discourse that included logical positivism, epistemology and ontology. The course content included a deep dive into concept analysis, nursing theorists and the major health behavior theories and – I thought – many applications of nursing theory to practice decisions and interventions. Assignments were student-personalized, asking for them to express their own philosophies of nursing care, present on nursing theorists’ work, and take a stab at concept analysis or critique a published analysis.

Yet, here I sat, wanting to avoid the dreaded student evaluations. No delaying it any longer.  I logged into the student evaluation portal and winced as I read the polarized comments. Many were very complimentary: “Course well organized. Grading was clear with helpful comments given on papers.” A continuation of gratifying comments: “Didn’t think I’d like theory, but I did. Liked the examples. Related it to real life. Dr. Foli’s passion really came through and helped make the class enjoyable.”

Then, one student’s comments made me stop. “Too many readings. I didn’t read most of them. I had to take time away from studying for patho and that’s what a nurse practitioner needs to know.”

Flinging the granola bar into the trash (it tasted like sawdust anyway), I reached for the Little Debbie Valentine cake.

What??? I had practically done summersaults trying to get the practice-to-theory connection in this class. And then I paused to reflect on my audience: students enrolled to become primary care nurse practitioners. Many continued to work at the bedside in highly stressful jobs. They all had personal responsibilities, some of which overwhelmed them (an ill child, a sick mother).

When I spoke to the class at the beginning of the semester, I asked them a question that I didn’t need a public response to: “Are you running from something in your current job or running toward a goal of being a nurse practitioner?” Upon hearing this question, I always looked for the nonverbal responses: heads slightly turned down, eyes glancing sideways. Mouths in grimaces. The ones that seemed to embrace the new career path continued to look directly at me.

So I knew from the beginning of the semester this was a tough audience. These folks were frontline, point-of-service providers who had witnessed and experienced nurse-specific trauma on an ongoing basis. Sadly, for the majority of them, nursing theory meant little.

They were here in this first semester graduate class to learn the facts, just the facts. Or as Chinn and Kramer (2015) describe it: empirical knowledge. As advanced practice nurses, they would be tasked to diagnose, prescribe, recommend a treatment plan, and manage illnesses. They’d also engage with the patients to promote wellness and encourage disease prevention. What did theory have to do with all that?

Well, as I read the students’ comments, I wondered what more I could do to ensure they saw the connection between all the ways of knowing (Chinn & Kramer, 2015), how to apply middle-range theories to their practices, and use theory as an organizing framework to track efforts. I wanted them to see patients as dynamic individuals, not merely as objects that may or may not adhere to a treatment plan.

As I put the Little Debbie wrapper in the trashcan, I felt invigorated (it could have been the sugar rush). They may have thrown some shade at theory, but I pulled out the course syllabus, reviewed it, and made note of how I could continue to refine the course so that every student would see the value of theory in primary care. I did this because it’s so important for our profession. Nursing theory gives us identity, ways to increase nursing science/nursology and patient care practices. As the Year of the Nurse and Midwife, the timing couldn’t be better!

What about you?  If you have suggestions for me on how to strengthen the theory-to-primary care advanced practice connection in a master’s level course, please forward them in the comments below.

Or, better yet, go to Nursology’s Teaching/Learning Strategies (https://nursology.net/resources/teaching-strategies/) and complete the form to submit a strategy to strengthen the link between advanced practitioners’ theory-guided knowledge and nursing practice.

Thanks in advance for your help!

Nurse-Specific Trauma: Let’s Give It a Name

Welcome to Karen J. Foli, PhD, RN, FAAN who is joining the
Nursology.net blogging team! Karen is the author of the
Middle Range Theory of Nurses’-Psychological Trauma, the
Middle Range Theory of Parental Postadoption Depression
and co-author of the recently published book
The Influence of Psychological Trauma in Nursing

Karen J. Foli

When I was earning my PhD, my cognitive world opened up. I learned about how discourse not only reflects reality, it creates reality. In my estimation, The Influence of Psychological Trauma in Nursing allows us to see a reality that eluded us before. Decades later, I find my work in nurse-specific trauma reflecting truth and creating a reality that nurses experience, but couldn’t name. Therefore, their reality of it didn’t exist.

We often hear about compassion fatigue. Its etiology is linked with secondary or vicarious trauma, created by seeing others suffer and experience traumatic events. Conversations abound about how nurses need to be resilient and use resiliency as a buffer to mitigate secondary trauma and secondary traumatic stress. The issue of individual versus organizational culpability in nurse-specific trauma is one that is needed, and for another time…

In addition to secondary trauma, there are six additional nurse-specific and nurse-patient-specific traumas that I have named, described, and provided context for (Foli & Thompson, 2019): historical or intergenerational trauma; workplace violence, system-induced or medically induced trauma, second-victim trauma related to medical errors, trauma from disaster work, and insufficient resource trauma. This final type of trauma is one that I have recently coined based on a current study, the findings of which I will present at the upcoming American Academy of Nursing conference as an e-poster (Foli, 2019).

Insufficient resource trauma. Now that’s a new reality. Every single nurse I have spoken to quickly nods their head in affirming its existence. It’s the trauma that occurs when nurses do not have the knowledge/expertise, personnel, accessibility to other professionals, supplies, and tangible and intangible resources to fulfill their ethical, professional, and organizational responsibilities.

As a nurse… think of being placed in an unfamiliar patient situation with no one to call for help. Think of the shift you are working with an overload patient assignment and two of your patients “go bad.” Think of the phone incessantly ringing on your day off to come in because of short staffing and the guilt experienced because there is no way you can work another shift and be safe. Think of the medication that will be late because pharmacy made an error and the physician on call hasn’t answered the page and you need an answer stat. Think of going into a supply room for the dressing kit and the shelf is empty. But most of all, think of the patients’ call lights that go unanswered because there aren’t enough nurses to render care.

It’s not just a shortage of resources that cause insufficient resource trauma. It’s the push to do more in the time we have, including tackling the electronic health record and as we’ve known for years, sicker patients. In a recently published letter to the editor, “Decline of the American Nursing Profession,” Vignato (2019) describes the decreasing time spent with patients: “.. changes in our health care system are transitioning nurses away from a therapeutic relationship…With these time constraints, nurses are left to complete scripted tasks” (p. 255).

As a result, patients don’t obtain the care they need and deserve. The tendency to see them as tasks to do increases. Nurses leave the units at the end of their shifts feeling guilty, anxious, and isolated. It’s the stuff that kills our spirits.

A common metaphor used in understanding trauma, the iceberg, symbolizes the large mass of “stuff” that’s underneath what is visible. The proportion is such that what is above the water is a fraction of the frozen ice beneath the water’s surface. In the hidden, murky depths lies our processing of trauma, our feelings, needs, desires. Above the surface, for all to see are our behaviors that are born from trauma.

While I believe this metaphor is useful, I also assert that nurse-specific trauma, as events and habitual occurrences, are readily visible to others (Foli & Thompson, 2019). We have an audience watching most of our traumas day in and day out. But are we, our peers, our leaders paying attention?  Let’s give these traumas a name, let’s build reality, and then, let’s get to work on preventing what we can prevent and fixing what we can fix.

References

Foli, K. J. (Accepted; 2019). Nurses’ trauma: “They leave me lying awake at night.” E-poster. American Academy of Nurses 2019: Transforming Health, Driving Policy Conference, Washington, DC, October 24-26, 2019.

Foli, K. J., & Thompson, J. R. (2019). The influence of psychological trauma in nursing. Indianapolis, Indiana: Sigma.

Vignato, J. (2019). Letter to the editor: Decline of the American nursing profession. Journal of the American Psychiatric Nurses Association, 25(4), 255-256. doi: 10.1177/1078390319826702