Research shows that trauma care professionals are at high risk for burnout, post-traumatic stress disorder and other mental health conditions. These conditions can negatively affect job performance, relationships and quality of life, and they raise the risk of substance abuse, depression and suicide. How can trauma providers maintain their mental health in an environment of chronic stress?
Barbara Koffske Reid, PhD, MA, MEd, LMFT, has spent much of her career studying the effects of stress on mental health, with a focus on the challenges of healthcare providers. She spoke about stress at the Eastern Association for the Surgery of Trauma (EAST) 2016 Annual Scientific Assembly in San Antonio. In a session entitled “Caring for the Elephant in the Room,” Dr. Koffske Reid and colleagues Sandra Strack-Arabian, CSTR, CAISS and Heena Santry, MD, MS, FACS examined ways to combat the burnout epidemic in trauma care.
Dr. Koffske Reid is a core faculty member at Cambridge College in Cambridge, Mass., where she developed and currently directs the Bachelor of Science in Wellness and Health Promotion. She explained how trauma professionals can use self-care strategies to reduce the negative effects of stress.
Q. How did you get interested in provider stress?
When I was directing the Bachelor of Science in Human Services major at Cambridge College, I was seeing my students struggle with the effects of chronic stress. As adult learners they were dealing with multiple responsibilities—full-time jobs, caring for their families, maybe caring for aging parents. They were doing important work and honestly not getting paid much, so there were also financial stressors. The stress in their lives was mounting, and I felt they needed some way to learn how to take better care of themselves. So I developed a course that gave them the opportunity to understand the impact of stress not only on their physical and mental health, but on their relationships, their family life and their ability to concentrate, focus and do quality work. The goal was to take a systemic look at stress and to see that taking better care of yourself was absolutely the responsible thing to do. So for the past 18-plus years I have been teaching and studying in this area, and I see a marked difference in those who are able to implement self-care strategies.
Q. What are trauma providers experiencing today in terms of stress?
Today, most people are experiencing very high levels of chronic, unrelenting stress. The term I use is “normalized stress”—we have all become so accustomed to being stressed out that it has truly become the norm. When talking about the world of trauma care, the situation is even more urgent. We have conditions like compassion fatigue, burnout and PTSD, all of which are increasing at alarming rates in this environment. People in this field are constantly facing life-threatening, time-sensitive demands. They are dealing with life-threatening situations, critically ill patients, high mortality rates, patients’ families, and many administrative demands, not to mention whatever is going on in their own personal life.
Q. How do you explain compassion fatigue?
Compassion fatigue (CF) is when you have focused so much on the needs of others and caring for others, that you neglect your own needs. For those in trauma care, the risk is particularly high given the intense nature of their work. People experiencing CF often report feeling emotionally exhausted, depressed or anxious. They may lose their sense of satisfaction in their work and may not be responding as quickly, effectively or as compassionately as they had at other times when they may have felt more balanced in their life. They may experience depersonalization, a feeling of becoming disconnected—going through the motions, but not being fully present. This may be the result of repeated exposure to such traumatic events to the point where the provider has become traumatized, referred to as vicarious traumatization or secondary trauma. Without adequate self-care, this can lead to burnout and even PTSD. When trauma care providers take better care of themselves, it helps to build resilience to handle the demands of their work more effectively. They tend to make better decisions, may be more focused, and have quicker response time, which can lead to increased effectiveness and greater job and life satisfaction—without as much wear and tear on them.
Q. How do people respond when you talk about these issues?
The most common reaction is “I get it, but I don’t have time.” This information certainly resonates with people and oftentimes they recognize these problems in themselves, but the feeling is “I just don’t have the luxury to take care of myself.” I find that to be true whether we’re talking about a student or a business professional or a healthcare provider. The other thing is the hesitancy to talk about the feeling that you can’t fully cope. Particularly in the healthcare profession, it is hard to acknowledge that you’ve got depression or you’re feeling compassion fatigue or feeling burnout. I think people feel that somehow they’re not living up to expectations. Oftentimes people keep it all to themselves, and then it usually shows up as either a physical or mental health symptom. It can also show up in the person’s relationships or in frustration with work.
Q. How do you convince people they need to take action?
I think most people understand that this chronic, normalized stress can have a significant negative impact on their lives and work. However, sometimes people need to be convinced of the “business case” for self-care, that it really is the smart, responsible thing to do. They need to see that there are concrete benefits to taking better care of yourself. In the healthcare environment, self-care may give you an edge that others don’t have, such as being more focused and being capable of better decision making, due to having more balance and finding healthy ways of coping with the existing stressors. And it can really make a huge difference when you model the value of self-care for others—residents, interns, coworkers and the entire trauma team.
Q. What can trauma providers do to manage their stress better?
The first step is awareness. You have to be able to look at yourself objectively or hear what somebody else is saying to you about the red flags in your life. Then if you are not ready to make major changes, look for small, simple, doable steps that you can take to help manage the stress in your life. Things that don’t necessarily require a lot of time. People will tell you they don’t have an hour to sit and meditate. But you can learn to take deep breaths when you feel the stress is just choking you. For some people the key might be exercising—walking, running or swimming. Physical activity provides an immediate release of endorphins, which (unlike antidepressant medications) have an immediate impact. Being around supportive positive people, having meaningful work, laughter, good nutrition—there really are so many things we can do.
Q. How does sleep affect the way we experience stress?
So many of us think we can just do without sleep. People think they are making it through the day on three or four hours of sleep, but in fact there are measures that show our ability to focus, concentrate, and respond quickly and accurately are compromised. We all need to make sleep a priority. You can reinforce the message to yourself that if you get enough sleep, you will be in a better situation to do the tasks that need to get done. Sleep when you can, cut back on alcohol and caffeine (particularly later in the day) and fuel yourself with good nutrition, which also plays a major role in how we experience stress. When we cut down on sugar and processed foods and start feeding our bodies with real whole foods, we often experience more energy, more clarity of thought, less brain fog.
Q. What about “negative thought patterns”?
Yes, the other big thing is noticing the things you are saying to yourself. I’m talking about the negative thoughts that kick in automatically. You miss your child’s recital or game, and before you know it you are thinking, “I’m never there, I’m not a good enough parent, etc.” You have to be able to catch that and say to yourself, “Wait a minute. First off, is this true? Is this thought contributing to my stress?” If the answer is yes… “What can I say that’s actually more accurate and is maybe a little more compassionate?” You could say, “I might not get to every single event, but I spend a lot of good quality time with my child, and I’m doing the best that I can.” The key is to learn to stop that onslaught of negative thoughts that do not contribute to our health and really escalate stress.
Q. Could you talk more about self-compassion?
Sometimes we are really good to others. A friend or colleague talks to us about what is going on in their life, and we might have incredible advice for them and treat them with kindness, patience and understanding. But then we don’t do the same thing for ourselves. Being able to treat yourself with the same level of care and compassion that you would show to a friend is critical. It comes back to how we talk to ourselves. Is our self-talk compassionate or is it the harsh, berating self-judgment that just makes the whole situation worse? If we can have more optimism and a more positive mindset toward ourselves, it really makes a difference in terms of how we see ourselves, our feelings of capability and confidence, and how we show up for work and life. The other really effective and important component here is gratitude. What are we thankful for? Nothing will change your mood more quickly than taking a quick inventory of what you appreciate in your life right now.
Q. What can trauma medical directors or program managers do to help their team?
As much as possible, lead by example. Help people see that there is a value in taking good care of themselves. This is so much easier said than done, but setting that tone is critical. Ultimately, it goes back to the idea of a business model for self-care. The more people take care of themselves, the better they will be able to do their job and the more effective they will be.
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