Imagine a typical day in a hairdressers: people having their hair cut, stylists chatting to customers, holiday destinations discussed. A normal, average day. Then imagine one of the customers suddenly drops to the floor, has a cardiac arrest and dies. This is not a normal day. For many nurses, dealing with traumatic human experiences amongst everything else the job entails, is part of a normal day. What makes nurses able to cope with the spectrum of human suffering on a daily basis, when it is outside of the realms of most people’s normal daily routines? Is it personality type? Is it training? Is it government policy? Or are we just superhuman? It would appear not.
Research into reasons behind poor nursing care shows that dealing with human suffering as part of your job demands a great deal of the individual. In ‘Time to care? Responding to concerns about poor nursing care’, a policy paper produced by researchers from the University of Birmingham in 2011, it is acknowledged that dealing with distress, tragedy, death and dying as part of the nurses everyday role can have an impact on the health and wellbeing of nurses. The paper quotes a 1960's study by Menzies which says: “Nurses are confronted with the threat and the reality of suffering and death as few lay people are. Their work involves carrying out tasks which, by ordinary standards, are distasteful, disgusting and frightening.” These are strong emotions to contend with.
However, the emotional labour of care appears to go largely unnoticed – both by nurses themselves, and by those who regulate and employ them. Emotional labour was a term first coined by sociologist Arlie Hochsfield in 1983 and has been defined as: “the induction or suppression of feeling in order to sustain an outward appearance that produces in others a sense of being cared for in a convivial safe place.”
If the emotions required of nurses in order to care for patients are constantly suppressed, or acknowledgement and management of this induction or suppression doesn’t happen, then the end result can be burnout . Burnout can lead to nurses taking more sick days, detachment from the job, and ultimately can be one of the factors behind poor care. This then begs the question; in order to care for our patients, how do we as nurses care for ourselves? Equally we also need to ask, how do our employers play a part in caring for us as well?
Whilst working as an A&E nurse in a busy London hospital, I began to feel the cost of the emotional labour of my job. As well as looking after acutely unwell patients who often required specialist interventions in a critical time period, I tried my best to remember the ‘little things’ that made a patient’s experience in a potentially frightening and unfamiliar place just that little bit more safe and reassuring. Even if I was abused by patients, who may have simply chosen me as I was in a uniform, I tried to remember that they may be anxious, vulnerable, in pain, scared. They had no idea that I may have just come out of the resuscitation area after performing chest compressions on a gravely ill patient, or that I had just been speaking with a family who had learned that their son may never recover from an acute bleed on the brain. How could they know? I found that I could cope with a combination of all of these elements of my job for a while, but after a year and a half, I became tired and ready to move on.
In volume 3 of the Report of the 2013 Mid Staffordshire NHS Foundation Trust Public Enquiry by Robert Francis it states that in order to have a caring culture within the NHS, the essential ingredients must include the ‘acceptance that patient’s needs come before one’s own’. I think this should come with a caveat: in order for this to be achieved, initially we must identify what our own needs are and ensure that we have help and support in place if we find we are struggling to cope . Only then will we be able to genuinely accept this ‘essential ingredient’, both personally and institutionally. After all, it takes superhuman strength to give your last glass of water to someone when you are parched yourself.
I spoke to Counsellor Andrew Bernhardt, who counsels individuals who have experienced burnout, and who also trains social workers who specialise in the field of child protection in the UK and in Europe. Discussing burnout, he says: “one of the distinguishing features of the onset of burnout is that, being a process, it happens over time and is not the result of one single bad day at work, or one off trauma. It’s a reaction to continuous stress which has not been managed or even acknowledged....distinguishing burnout from other stressors isn’t easy but a tell-tale sign in professionals is growing detachment from the core part of the job. In short we stop caring.....this is where professionals in healthcare, social services and teaching can become capable of committing acts of neglect or cruelty which should never be excused but they can sometimes be understood.” This thought is echoed by Professor Jill Maben, the Director of the National Nursing Research Unit at Kings College Hospital, in an article in the Guardian about bridging the empathy gap in the NHS: “Healthcare staff come into the profession to help others. If nurses cannot give the care that they want to give, they experience moral distress and cope by erecting a shield to protect themselves.”
I asked Andrew Bernhardt how we can start to recognise burnout in ourselves: “burnout tends to manifest itself in different ways and will vary in intensity and duration according to the individual. A loose collection of signs that tend to cluster together are loss of sleep, feelings of being overwhelmed, becoming excessively emotional, feeling inexplicably tearful, constant tiredness, drinking to excess and other signals that the physical and psychological system is beginning to crack under the strain.” He was keen to point out, however, that often the last person to perceive that they are becoming burned-out is the sufferer. Reverend Professor Stephen Wright, Chair of the Sacred Space Foundation and associate professor to the Faculty of Health and Social Care at St Martin’s College, Carlisle, writes, “Burnout is a form of deep human suffering at every level – physical, psychological, social, spiritual – which occurs when old ways of being in the world no longer work and start to disintegrate.” Burnout is something we should be aware of, something we should take seriously and something we should try to prevent.
A simple first step each individual nurse can take is to acknowledge that in order to care for other people, you must first take time to care for yourself. I asked Reverend Professor Stephen Wright if he had any advice for nurses on how to care for themselves day-to-day. Here are his ten tips:
- Take a look at your life and ask yourself how you express self-compassion, and how you yourself are taken care of.
- Eat a healthy diet with proper meals and breaks.
- Make sure you get a good night’s sleep.
- Take plenty of exercise.
- Use some form of spiritual practice such as daily meditation.
- Find someone – such as a partner or close friend -with whom you can talk through problems at work.
- Affirm and keep clear boundaries between work and personal time – have a life outside of work!
- Make sure you have access to professional support – e.g. union membership or supervision.
- Have time out regularly to get taken care of such as a weekly massage, a “me” day once a month, or go on a retreat.
- Pursue a hobby/interest that has nothing to do with work which absorbs attention and brings joy.
It may also help to keep a diary where you can jot down how you are feeling, and take the time to reflect on any issues at work or home that have been troubling you. This is all part of acknowledging that how you feel matters, and by doing this you are investing in yourself. Slowing down for a while to identify problems and work through issues can help you deal with situations better if they arise again.
Starting and maintaining self-care is important. However, if the NHS wish to retain a healthy and happy workforce it is crucial that they acknowledge the emotional labour of nursing, and put measures in place to monitor and promote the wellbeing of its staff. Professor Jill Maben led an important piece of research for the National Institute for Health Research (NIHR) in 2012 entitled ‘Exploring the relationship between patients’ experiences of care and the influence of staff motivation, affect and wellbeing’. This clearly proved the correlation between staff wellbeing and the quality of patient experiences.
The research recommended that NHS organisations should monitor the levels of job demand, invest in leadership and supervisor support and invest more in creating well functioning teams. The report also suggested that patient experience and staff wellbeing should be regularly monitored.
In the post-Francis Inquiry era, there are a raft of papers from the RCN, The NMC, The Department of Health, think-tanks, universities and charities that highlight the failings of the system and recognise that staff wellbeing and engagement plays a vital part in helping to achieve compassionate care. So how is this translating into reality in the fractured, cash-strapped, target-driven NHS?
I remember asking a senior nurse how she coped with working on a busy acute ward and if she had any advice for me as a relatively new staff nurse. Her answer was worrying: “have a large glass of wine at the end of the day and try to forget about it.” It may have been naive, but I had imagined that when I started working as a nurse there would be a safety net in place for us, and that we would be given time and space to discuss, or ‘debrief’ from what we experienced day-to-day. In reality I found that most chances to talk about how we were feeling and how certain events may have affected us, such as the death of a young person, were ad hoc and often interrupted.
The policy paper ‘Time to care? Responding to concerns about poor nursing care’ identified three themes which influenced the quality of nursing care and which all required actions in order to improve patient experience, they were: Environment of care, Education and Development and Emotional labour of Nursing. With regards emotional labour the paper states: “Boards should recognise the emotional labour of nursing and establish a systematic approach to supporting nurses, using one of the models suggested in this paper.” The paper highlights models such as reflective practice and supervision, de-briefing using the model the Samaritans have devised, and introducing Schwartz Centre Rounds as a tool to support staff.
Schwartz Centre Rounds are an American innovation which have been introduced to the United Kingdom by the Point of Care Foundation, which is an independent charity working towards improving patient’s experiences of care and increasing support for staff. The Point of Care Foundation grew out of the work of the Point of Care Programme at the King’s Fund, which was set up to look at a very vital and human element of 21st century medicine: care and compassion within healthcare, and how we can improve patient’s experiences and enable staff to deliver better care. In the 2008 paper ‘Seeing the Person’, the concept of Schwartz Centre rounds were introduced.
Schwartz Centre Rounds are organised monthly and are a multi-disciplinary forum where staff – ranging from porters and cleaners to consultants and medical directors – are presented a particular case involving patient care by a pre-selected panel, and are given the opportunity to discuss and reflect upon the case, with the emphasis being on the emotional and social, rather than the clinical, challenges faced by staff. The Rounds are designed to tap into the human connection between patients and care givers, and subsequently greater empathy and compassion is grown not only between staff members themselves, but between staff and patients, resulting in better patient care and more supported staff. At the time of writing 66 organisations including Hospitals, Hospices, primary care and mental health trusts, are participating in Schwartz Rounds, and the results are encouraging. It is worth noting that Sir Robert Francis Q sits on the board of trustees for the Point of Care Foundation.
Professor Jill Maben is currently leading the first national evaluation of Schwartz rounds in the UK, and writes: “In the US, staff involved in Schwartz Rounds reported an improved ability to deal with the psychosocial demands of the job, better team-working and a greater organisational focus on delivering patient-centred care.” Dr Jocelyn Cornwell, Director of the Point of Care Foundation, commenting on the Francis Report: one year on, in February 2014, says: “ since the Francis Inquiry, senior managers have become more focussed on the quality of care, and are listening more intently to feedback from both patients and staff about how services are delivered....Our research shows that supporting staff, both at strategic level and through operational initiatives like Schwartz rounds, can have a real and direct impact on improving the quality of care.”
It seems so glaringly obvious to say that the more we feel supported at work, and the better we care for ourselves, then the better care our patients will receive. Yet culture change is slow, and the NHS can often appear to ignore those whose opinions and experiences they should listen more closely to – namely its staff and its patients.
If as nurses we can take more time to care for ourselves on a personal level, and demand more from our employers on an institutional level, then perhaps a change will slowly come: Make sure you get proper breaks at work. Ask your ward manager or team leader if you can attend a Schwartz round. If you don’t have Schwartz Rounds in your place of work, ask your manager if they've heard of them. Encourage students to reflect upon their practice. Reflect upon your own practice. Ask about organising proper supervision. Enquire about how you make time for regular debriefings. The next time you go for an interview make a point of asking how the Trust manages and monitors staff wellbeing. Show them that it’s important to you.
Show them that you care.