On the Other Side of the Rails
Leading Through Loss
Charlie Hawknuff, MSN, APRN, FNP-BC, CEN, TCRN, TNS
I awoke to an alarming text message from the ED supervisor: “Just wanted to see if you are aware what’s going on in the emergency department right now?” I was out of town for the weekend helping my family move so I had no idea what the text referred to. As the manager of a Level 1 emergency department, the options for what could be “going on in the emergency department right now” were endless and they all started to spiral in my mind. I immediately assumed the worst. Had there been a mass casualty incident? An internal disaster? Had someone been hurt?
To my dismay, I would learn it was something quite serious. One of our own had come into the emergency department in cardiac arrest. Our team had spent several hours overnight resuscitating one of our own team members and ultimately transferred them to the ICU. I could only assume none of the staff were going to be the same after this. By the time I was awake, the team had mostly gone home, but the feeling of helplessness from being several hours away quickly washed over me. What I wanted more than anything in that moment was to be physically present for my team. I felt as though I was failing them by not being there when they needed me the most.
I knew that wallowing in my own emotions was a luxury that I could not afford at that moment, so I took a deep breath and started to jump into action. I sent texts and emails to our director, our other supervisor, and our executive director to loop them in. I knew it was going to take a team approach to ensure our staff were supported through this difficult event. Explaining what was going on over and over somehow made it easier for me to process and focus on what needed to happen next. Next, I had to gather more information. Who was involved? How were the staff reacting? Were people sharing their feelings with each other? Had anyone conducted a debrief? Although there is mixed evidence on the effectiveness of critical incident debriefing, my own experience has shown that, at a minimum, understanding the medical care that was provided can help clinical staff process an event2. I had participated in many safety and quality debriefs and had seen clinical staff struggle with understanding whether everything that could have been done was done. Talking through the medical care after the event provided closure and assuaged guilt regarding perceived failures or missed interventions. Our charge nurse informed me that once our colleague was stabilized, the provider led a clinical debrief for the staff that focused on the medical care.
After gathering more information, I wanted to ensure the staff had access to the resources they needed. I drafted an email with details about our Employee Assistance Program (EAP) and sent it to all staff in the department. An important, humbling lesson I have learned in leadership is that I am not always the best resource or person for a job. A manager may not be able to provide every answer, but they should be able to connect staff with the best resources. Knowing that our organization had EAP available with highly skilled counselors allowed me to connect our staff to the right people. Our management team started to reach out to the staff involved individually to see how they were coping. As would be expected, staff fell all along the spectrum in their response to the event. Some staff reported trouble sleeping, loss of appetite, anxiety, crying, depression, replaying the events, guilt, and anger, and some were unable to return to work immediately. An added layer of complexity existed because our team member had recently transferred to another department, so not everyone in the emergency department had known them. Some staff did not have a personal response to the situation at all but were affected by the response of their colleagues; they seemed to be suffering from secondary traumatic stress due to their proximity to their coworkers.
When I returned to work on Monday, we received the news that our colleague had passed away in the ICU. Our leadership team realized that further assistance and support was needed. The trauma left staff in different stages of grieving and recovery. I reached out directly to EAP to determine a good course of action. We decided to hold a group debrief for anyone involved and contacted our colleagues from other departments who had been impacted. The debriefing was optional and was not limited to any particular group.
I gained valuable experience during this EAP-led debrief that prepared me to lead through crisis in the future. Not all hospitals have access to robust employee resources, however, so it is important to know what resources are available to facilitate critical incident debriefs and to practice using them whenever the opportunity arises. No matter your level of in-house support, there are resources available from International Critical Incident Stress Foundation, University of Maryland, Baltimore County, and Occupational Safety and Health Administration to train and guide emergency response leaders in critical incident stress management.
In the following days and weeks, staff approached us not only to thank us for our response but to continue discussing their feelings around the event. One employee commented that the email leadership sent about EAP so close to the event showed a level of awareness, involvement, and caring right away. We also received feedback that several staff members used the EAP resources, including counseling, and found them helpful. It is important to note that some studies have shown a reluctance among emergency nurses to participate in EAP, which should encourage leaders to offer other opportunities for support2.
The emergency department setting has long harbored an attitude of “get over it and move on to the next patient.” For years, discussions on personal feelings, secondary traumatic stress, and burnout have been avoided and dismissed. However, evidence on the impacts of secondary traumatic stress and posttraumatic stress disorder has shown that we can no longer adopt this attitude in health care. Although it can be healthy to compartmentalize feelings and some may choose not to openly discuss their response, creating an environment where staff feel they can share their feelings and that we do not stifle attempts to do so is important. We have to move forward and embrace the reality that our work environment is challenging. We have to openly discuss the effects of secondary traumatic stress if we want to develop healthy coping mechanisms and foster resiliency. This event was eye opening for me and fortified me as a leader. It hopefully serves as a crossroads for our own department, where we have opened the gates to these discussions. I want to encourage emergency nurses and leaders to be forward-thinking about how you would respond in such situations, before they occur. Having a plan in place is critical, although I hope you never need it.
So how do you prepare?
- Be ready to acknowledge trauma: Don’t let your unpreparedness prevent you from reaching out. Openly acknowledge the impact that events can have on team members by quickly communicating with staff. Let them know you are there to support them even before you have the specifics.
- Study critical incident stress debriefing (CISD): Leaders should be prepared to lead a CISD should the need arise. Look at the resources at your own facility and those offered by other organizations. Become comfortable with the idea and the process. Practice CISD concepts on less impactful cases so you and your team become comfortable.
- Know your resources: Familiarize yourself with what your hospital and community offer to support staff. Look for things like EAP, pastoral support, peer support groups, and confidential counseling services with healthcare worker experience.
- Be prepared for varied responses: Know that each staff member may respond differently and require different support. Some may want to utilize resources that you have provided while others will deal with the trauma in their own way. Some may appreciate a quick text message while others want to schedule time to talk to you.
- Learn to monitor for compassion fatigue and burnout: Watch your team for classic signs of burnout such as constant fatigue, negative feelings or dialogue about the work place, feeling overworked or underappreciated, lack of enthusiasm about work, or dreading coming to work. Tools like the Maslach Burnout Inventory can be helpful to objectively identify burnout.
- Always foster healthy coping mechanisms to build resiliency: Encourage staff to participate in healthy forms of expressions such as journaling and painting. Recommend healthy habits such as exercising and eating well. Discuss the importance of healthy sleep patterns.
These are just some of the ways in which you can be prepared if you find yourself faced with the loss of a colleague. Through preparation you will be ready to jump into action, building resiliency and healthy coping mechanisms with your team. By ensuring your staff are supported, you can mitigate the impact of secondary traumatic stress thus preventing burnout and compassion fatigue.
- Burchill, C. N. Critical incident stress debriefing: helpful, harmful, or neither? J Emerg Nurs. 2019; 45(6), 611-612. https://doi.org/10.1016/j.jen.2019.08.006
- McCall, W. T. Caring for patients from a school shooting: A qualitative cases series in emergency nursing. J Emerg Nurs. 2020; 46 (5), 712-721. https://doi.org/10.1016/j.jen.2020.06.005
Charlie Hawknuff, MSN, APRN, FNP-BC, CEN, TCRN, TNS
Charlie Hawknuff is the Manager of Emergency Services at Carle Foundation Hospital. Charlie’s nursing career began at Barnes Jewish Hospital where she worked for 5 years as a staff nurse in a surgical stepdown and the emergency department and then the last 4 years as Clinical Practice Specialist for Emergency Services. Charlie also has experience at Cardinal Glennon Children’s Medical Center as a staff nurse in outpatient hematology and oncology. She completed her MSN at Southern Illinois University Edwardsville and became board certified as a Family Nurse Practitioner. Charlie is one of the co-editors of the Journal of Emergency Nursing blog, On the Other Side of the Rails, and has served on her local chapter board of the Emergency Nurses Association in St. Louis, MO.
How to contribute
We encourage submissions from any reader who has been touched by the healthcare system. Some contributors may be involved directly in patient care and might want to share the impact a patient, family, or colleague had on them. Others may want to write about life “on the other side of the rails” …those moments when the caregiver becomes the patient…or maybe sees healthcare from the vantage point of a family member. Inquiries can be sent to [email protected]
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