Healthcare Practitioners and Post-Stress

By Bonnie Hutchinson

Nobody chooses to become a first responder without expecting to encounter high-intensity situations.
Paramedic, emergency medicine practitioner, firefighter, police, dispatcher – the high intensity might even be part of what attracts anyone to such professions. As someone once said, “ Face it. We’re all adrenaline junkies.”

Yes, training can prepare first responders to deal with circumstances that most people don’t ever encounter. And yet and yet…

BLINDSIDED BY THE IMPACT
Especially in the early stages of their career, emergency healthcare practitioners may be caught unprepared. Even though they thought they were ready for high-intensity situations, there was more to it than they expected.

They were prepared with the professional skills required for medical emergencies. The incidents were within the range of “normal” for emergency healthcare. But they were not prepared for the impact on themselves. Their after-incident responses were more intense or took a different form than they expected.

For example, they expected physical impacts like higher heart rate and hyper focus during the incident. They knew they would not immediately “cool down” after the incident.

But it took a while to recognize that responses like irritation or self-doubt could also be part of their personal “post-incident” recovery pattern.
Even experienced first responders may discover they are more affected than they thought. It’s not this or that specific incident. It’s the cumulative impact of witnessing and dealing with more crisis and trauma in a month than most people see in a lifetime.
They rise to the occasion and deal with what they have to deal with in the moment. But after the crisis – what happens post-adrenaline?

• Being angry more of the time?
• Becoming aloof from family or friends who can’t possibly “get it?”
• Self-doubt? Second guessing? Wondering if you could have done better?
• Re-living the worst moments again and again?
• Becoming more jumpy and fearful outside of work?
• Nightmares?

As experienced practitioners, this is not what they expected.

BLINDSIDED BY UNUSUAL CIRCUMSTANCES
“Normal” or “usual” in the context of emergency medicine is not “normal” or “usual” in most people’s lives! But some circumstances are extra challenging.
Sometimes the follow-up impact of a particular incident is harder to deal with because it strikes home in a personal way. The patient is a child the same age as your child. Especially in small rural communities, the patient(s) may be known to you, or is even a close friend or relative.
Sometimes emergency healthcare practitioners have to deal with non-patient issues. Maybe a family member on scene is being difficult. Maybe someone is videotaping what you’re doing.

BLINDSIDED BY WORKPLACE FACTORS
During training, emergency healthcare practitioners talk about professional skills. They talk about medical and environmental factors that can affect patients. They talk about dealing with death.
But what they don’t talk about are situations like these.

• An on-going poisonous conflict with a co-worker.
• Being instructed to carry out procedures that you know are futile for critically or terminally ill patients.[1]
• Knowing the correct diagnosis and what’s most important to do next. Having that ignored by a healthcare practitioner who is higher in the medical pecking order.
• Even worse, knowing the patient in the above situation died and wondering if that could have been avoided if your advice had been followed.
You can talk with co-workers about the impact of dealing with patient trauma. But who do you talk to about the impact of disagreements with fellow healthcare practitioners?

WORLD HEALTH ORGANIZATION: BURNOUT IS AN “OCCUPATIONAL PHENOMENON”
Being blindsided by more-intense-than-expected impacts on you, being blindsided by organizational conflict – that is the stuff of burnout.
At its annual meeting in May 2019, the World Health Organization (WHO) listed “burnout” as an “occupational phenomenon.” At that assembly, WHO approved its most recent International Classification of Diseases (ICD-11).[2]

ICD-11 defines burnout this way:
“Burn-out is a syndrome conceptualized as resulting from chronic workplace stress that has not been successfully managed. It is characterized by three dimensions:

• feelings of energy depletion or exhaustion;
• increased mental distance from one’s job, or feelings of negativism or cynicism related to one’s job; and
• reduced professional efficacy.

Burn-out refers specifically to phenomena in the occupational context and should not be applied to describe experiences in other areas of life.”
Burnout is described in the chapter, “Factors influencing health status or contact with health services.” In that chapter, burnout is not classed as an illness or health condition.

The World Health Organization is developing evidence-based guidelines on mental well-being in the workplace. WHO expects to release the guidelines in 2022.

CAN YOU PREPARE FOR TRAUMA?
Preparing for situations of high intensity is part of medical first responder training. Paramedics, nurses and physicians know they will witness injury, trauma and death many times in their career.

They are taught to respond to life-threatening injuries from burns, vehicle crashes, workplace injuries or from violence at the hands of fellow human beings. They are taught to respond to cardiac arrest or respiratory failure.

Some emergency healthcare practitioners are even taught hard truths like these.
• No matter how skilled they are, they will not be able to resuscitate even half of patients whose heart stops or who cannot breathe.
• Despite their best intentions, they may during their career make an error that results in harm to a patient or even someone dying.

To the extent that any human being can truly be “prepared” for such things, emergency healthcare practitioners learn that such things can and do happen. They are given methods and resources to cope with such situations.

SIGNS OF BURNOUT AND POST-TRAUMATIC STRESS
Burnout and post-traumatic stress are related but not the same. Both are reasonable human responses to experiencing trauma – your own or someone else’s. But the two conditions have somewhat different sources and show up somewhat differently.

Burnout is a result of prolonged work-related stress.[3] It does not happen suddenly. It creeps up over time. Burnout is characterized by three types of symptoms:[4]
• Physical and emotional exhaustion. Signs include chronic fatigue, insomnia, forgetfulness, impaired concentration, increased illnesses; physical symptoms such as shortness of breath, gastrointestinal pain, dizziness or headaches; loss of appetite; anxiety; depression; anger.
• Cynicism and detachment. Signs include loss of enjoyment, pessimism, isolation and withdrawal, feeling disconnected, loss of empathy, feeling negative or critical of others.
• Reduced personal efficacy. Signs include feelings of apathy and hopelessness; increased irritability; more conflicts with colleagues; lack of productivity; poor performance; despite long hours, less and less accomplishment; feeling overwhelmed.
Post-traumatic stress response is considered “a psychiatric disorder caused by exposure to a traumatic event or extreme stressor that is responded to with fear, helplessness, or horror.” [5] Post-traumatic stress disorder is diagnosed after a person experiences symptoms for at least one month following a traumatic event. However symptoms may not appear until months or even years later.

Symptoms of post-traumatic stress can include three types of symptoms:[6]
• Re-experiencing the trauma through intrusive distressing recollections of the event, flashbacks, and nightmares.
• Emotional numbness and avoidance of places, people, and activities that are reminders of the trauma.
• Increased arousal such as difficulty sleeping and concentrating, feeling jumpy, and being easily irritated and angered.[6]

In a study involving several hundred nurses, of those with signs of burnout, about one out of five also had signs of post-traumatic stress. Of those with signs of post-traumatic stress, 98% had signs of burnout.[7]

WHAT HELPS?
Both emergency healthcare practitioners and their employers have a role to protect against and respond to the risk of burnout and post-traumatic stress.
WHAT HEALTHCARE PRACTITIONERS CAN DO

1. Be aware of the risk. The first thing that helps is being aware that burnout and post-traumatic stress are always-present risks. It’s not just the risk factors of the job. It’s also the type of people who are attracted to emergency healthcare. They are typically inwardly-driven high-achievers.
As Sherrie Bourg Carter says,
“Burnout is one of those road hazards in life that high-achievers really should keep a close eye out for, but sadly—often because of their “I can do everything” personalities—they rarely see it coming. Because high-achievers are often so passionate about what they do, they tend to ignore the fact that they’re working exceptionally long hours, taking on exceedingly heavy workloads, and putting enormous pressure on themselves to excel—all of which make them ripe for burnout.”[8]

2. Be willing to listen. Burnout creeps up gradually. The people around you may notice changes before you do. If someone suggests you may be showing signs of stress, curb your annoyance. Set aside your ego and listen! They could be right.

3. Be willing to watch. Similarly, be watchful of your colleagues and co-workers. If you’re concerned about someone showing signs of burnout or post-trauma stress, figure out a graceful way to draw it to their attention. Help them get help.

4. Be willing to ask for help. Be willing to talk. It’s quite likely your employer can provide access to professional help. You might also even initiate some form of in-house peer support. It can be healing and life-affirming to talk to people who “get it” because they are exposed to the same kinds of stressors that you are.

5. Look after your physical and mental health. When you’re busy and on the edge of overwhelm, or exhausted from days of long shifts and short sleep, it’s tempting for forget about the usual.
You know all this. Eat healthy food. Get enough sleep. Exercise. Take breaks. Learn resilience techniques. Tap into your inner strength. Hang out with positive people.
Do all the things that help you stay physically and mentally healthy, with the stamina to do the incredibly valuable work you’ve chosen.

6. Have joyful things in your life. For example, Dr. Scot Weingart, emergency physician and founder of EMCrit, is also a marathon runner. As well, his comments suggest that he has close connections with family, friends and colleagues.
As an emergency healthcare practitioner, you need at least one other thing in your life that is as engrossing and rewarding as your work is when it’s going well.

WHAT EMPLOYERS CAN DO

1. Make the health of employees a priority. That includes psychological health. That is not just “a nice thing to do.” It’s a cost-saving priority and a hassle-reducing priority. The impact of work-related stress includes absenteeism, high staff turnover, poor quality of work, ineffective decision-making and reduced productivity. Fostering employee health can help reduce the high cost of unhappiness.

2. Create an environment of acceptance that everyone is susceptible to mental health issues. Sometimes people don’t seek help because they’re afraid of being labelled as weak.
For example, Vancouver firefighter Greg Gauthier knew he was suffering from post-traumatic stress. He realized that as a supervisor he had to set an example for the rest of his crew that it was okay to reach out for help. It was okay to talk about the impact of what they’ve been through. He says, “There’s a stigma and we’re trying to break that down.”[9]

3. Provide access to training about the risk. Employers can ensure employees are trained to watch for indicators of burnout and stress in themselves and their colleagues.

4. Provide resilience training. Employers can make available resilience training. Topics should be include:
– An overview of what resiliency is and why it matters.
– How resiliency is related to prevention of post-traumatic stress response.
– Information for how to reduce arousal symptoms.
– Techniques for managing distressing emotions.
– Preparing for a crisis.
– Understanding the risk factors, such as severity of exposure.[10]

5. Ensure that employees who face burnout or post-traumatic stress have access to support such as in-house peer support, Critical Incident Stress Debriefing and other resources.

6. Check out how new technology such as Virtual Reality could help. A Forbes article by Sol Rogers has information about how virtual reality technology can assist people who experience post-traumatic stress and other psychological responses to stress.[11]

HONE CUE RECOGNITION
The mission of Hone Virtual Education is to help healthcare practitioners save lives. One way Hone helps you do that is through CUE Recognition virtual simulation training modules you can download to your smartphone or tablet.
CUE Recognition training modules don’t deal specifically with the impact of workplace stress. However, they can enable you to create such a strong set of core illness identification skills that your ability to accurately and quickly identify what is wrong with your patient won’t be as easily shaken as it otherwise may have been. That leads to better patient outcomes, better confidence and a happier career.
To find out more, visit www.honevirtualeducation.com where you can…
• Learn more about Hone CUE Recognition virtual simulation training;
• Be notified of updates and launch dates;
• Apply to be a beta tester as new modules are developed for healthcare practitioners in high pressure environments.

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Bonnie Hutchinson is a writer and lifelong learner with degrees in Education and Whole Systems Design as well as extensive training and experience in adult learning and teaching. As an organizational and evaluation consultant, she’s worked with many healthcare and healthcare practitioner organizations. She’s bestselling author of Transitions: Pathways to the Life and World Your Soul Desires.
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[1] Lynn E. Alden, Marci J. Regambal, Judith M. Laposa (December 2008), “The effects of direct versus witnessed threat on emergency department healthcare workers: Implications for PTSD Criterion A,” Journal of Anxiety Disorder, Volume 22, Issue 8. https://doi.org/10.1016/j.janxdis.2008.01.013, https://www.sciencedirect.com/science/article/abs/pii/S0887618508000479. Being ordered to perform “futile” procedures during end-of-life care was identified as a major stressor for ICU nurses.
[2] World Health Organization, May 28, 2019, “Burn-out an ‘occupational phenomenon:’ International Classification of Diseases,” https://www.who.int/mental_health/evidence/burn-out/en/
[3] World Health Organization (2019), op. cit.
[4]Sherrie Bourg Carter (2013), “The Tell Tale Signs of Burnout… Do You Have Them?” https://www.psychologytoday.com/ca/blog/high-octane-women/201311/the-tell-tale-signs-burnout-do-you-have-them
[5] Lynn E. Alden et all (2008), op. cit.
[6] Anxiety and Depression Association of America, “Symptoms of PTSD.” https://adaa.org/understanding-anxiety/posttraumatic-stress-disorder-ptsd/symptoms
[7] Lynn E. Alden et all (2008), op. cit.
[8] Sherrie Bourg Carter (2013), op. cit.
[9] Edmonton Journal (February 1, 2019), “First responders seek support in jobs full of trauma,” p. A6.
[10] Hospital News, “PTSD in healthcare professionals.” https://hospitalnews.com/ptsd-in-healthcare-professionals/
[11]Sol Rogers (May 15, 2019), “How Virtual Reality Can Help the Global Mental Health Crisis. https://www.forbes.com/sites/solrogers/2019/05/15/how-virtual-reality-can-help-the-global-mental-health-crisis/#5125393e28f7

Hone CUE Recognition on the App Store

The Hone CUE Recognition App will soon be available on the App Store for early adopters. When it is available - you will be able to download it via the link below.