Working Through Loss

I will never forget the high-pitched groan, on the verge of a scream, the sound of someone’s heart splicing into pieces and falling to the floor around us. She looked at me with hollow eyes as I passed her, her dead baby. The baby wrapped in a blanket, perfectly round head, and if you didn’t know better you may not even realize it’s now a shell, grey little fingers and toes, blueish-tinged lips. I focused on tasks, so that I didn’t break down and cry. I avoided her looks for answers and kept cleaning, much like a robot on autopilot. I wanted to embrace her, tell her isn’t not her fault, that one day she will find a way out of her grief, but I didn’t want to sound like a liar. This would derail this young mother and I knew that.

 More than one life was lost that day. And when I went home, I went home to my happy healthy and alive children.

Nurses are vicarious witnesses to many forms of loss, trauma, and suffering. And in a work environment that doesn’t permit time to reflect or acknowledge, it can be challenging to attempt to move forward. I think it’s safe to say most of us take this home and try to cope the best we can.

I have nursed for ten years and have had many traumatic cases, but I have never had an official debriefing. Often it takes too long for that to happen and I have already debriefed myself. Health care teams try to talk about a big case after; discuss what went well and what could we have gone better, but for the emotional stuff we push that to the back burner. Why? Because there is a full emergency department to tend to, there is equipment to be cleaned in preparation for the next big case. Even in 12 hours there is little time to think about what happened. As nurses, we are so different in what we need during a traumatic event. Some of us want to talk, other’s wanting to get back to work and distract themselves. I usually resort to crying in the bathroom, then getting my shit together and carrying on.

There are different ways of describing the loss and trauma nurses face, and literature is always trying to figure out the right term. But whether you call it, vicarious trauma, mental exhaustion, or burnout the result is the same. Stress, anxiety, depression, and many other symptoms caused by our intimate nature of our work.

In this post however, I want to focus not specifically on “burnout” but the issue that proceeds this, and that is loss. Being privy to people’s loss and suffering is significantly important to the health and wellness of nurses and all health care professionals. Witnessing people losing their family members, their jobs, their independence, over time can cause damage to one’s psyche.

It might not be our loss per se, but it still has an effect. To watch a mother, loose her daughter, a husband, loose his wife, or a patient, loose their mobility. It’s a delicate aspect of our role that we often don’t acknowledge. We are getting better at dealing with critical cases and employers are attempting to better debrief their workers, but the simple everyday loss that nurses are privy to is difficult to address.

In the above-mentioned case of the baby’s death it would be obvious, that experience could leave a nurse with mental exhaustion, and formal debriefing was offered. But in less dramatic cases it’s not something we talk about. For example, caring for someone who suffered a life changing accident, now can’t continue their livelihood because of a loss of function, isn’t as overtly traumatic. But as the vicarious bystander it can be an uncomfortable aspect of our everyday work. And if you see little losses everyday over time that affects your mental wellbeing. Can cause you to be short with patients/family, irritable, give you anxiety, and make you loath coming to work. I also think it is safe to say, as a nurse, you can’t even pinpoint the experience that is at the root of your change in mood, because it isn’t one experience – it’s culminative. That’s where the challenge lies. If it was one big experience that is easily defined and recognized as traumatic, then intervention for the staff is clear. But if these experiences are less definable, less obvious, it’s not only challenging for managers to address, but it can also be challenging for the nurses to recognize and advocate for themselves.

However, if not dealt with then there are many effects those little losses this can have on us.

• Burnout – I recently read some interesting debates on social media, were nurses are advocating to get rid of the term burnout, as it lends to the idea of victim blaming, and doesn’t adequately define the phenomenon. Mental Exhaustion has been coined a better term but no matter what you call it the effects are the same. And yes, I will acknowledge that critical cases can cause mental exhaustion, but also, so can bearing witness daily to loss in all shapes and forms. I often find myself when I have some quite time, thinking about the phone call. You know the call you get when you find out someone in your family has cancer, or was in an accident, or has had a heart attack. I often envision my mom calling me and telling me my father is in the hospital, “they think it’s his heart”. I would fly to their home and fling myself over his bedside and demand answers. It hasn’t happened yet, however, it’s always in the back of my thoughts, and to be honest I get a weird sense of comfort when thinking of these horrible things that could happened. I feel it’s because I constantly see loss and trauma. The patient will survive the heart attack but seeing the families shock and the change that happens when a serious health event occurs, leaves its invisible mark – that mark however superficial we want to think it is, will eventually become a wound.

I think about one of our last fentanyl OD, that I wrote about in my post F@#$ You Fentanyl: A Nurse’s Narrative. I wrote about the loss that a community has when epidemics occur and how that’s really under valued and reported. But I didn’t touch on how that affects the nurses working with these patients. We are a small team in rural medicine and when one of our patients, who we deal with on a frequent basis, passes away it’s a big deal. I remember when we lost a patient very dear to us and we were chatting about it, some nurses felt uncomfortable, that it was breaking confidentiality to share the news of their death, and that was sad to me. Why can’t we talk about it? Why can’t we acknowledge the loss of our community? Why can’t we collectively grieve?

• Leaving the Profession – This leads me to the fact that nurses leave their jobs because of loss and trauma. And if they don’t leave their job, they change areas work. This may be feasible in an urban area, where there are options, but in rural sites, the ability to change your work is limited. The fact that nurses must leave the profession also speaks to the nurse having to maintain their mental wellbeing and leaves little for the employer to be responsible for. And this isn’t right. I have sat on a Joint Health and Occupational board for 4 years and we rarely talk about the mental health of our workers. If we do it’s in reference to under reporting and how you need to prove your mental exhaustion. If I reported every situation that cause me some form of stress, I wouldn’t have time to do my job. Why in a profession of caring for those who suffer do we need to prove anything. It should be built into the job, like PPE (personal protective equipment) for the soul.

• Substance Misuse – Now I can relate, after a hard set of work, I will drink a bit too much wine and the emotions will come flying out, and often my husband is at the receiving end of my rants. Although therapeutic in the short-term not the best way to deal with loss. And if that continues to be the way of relieving stress or being able to live with these experiences, it could result in long-term addiction issues. Trauma, loss, abuse, decreased sense of self-worth can be the foundation to addiction and unfortunately can be the daily experience of a nurse. And again, there is little upstream thinking when we look at the cause and effect of the mental wellbeing of nurses. It’s like we don’t want to go there, perhaps it’s because of long held stigmas around mental illness, or that we are still operating with the idea that wellness is a personal issue – only affected or changed by the person who is suffering.

• Relationship Issues – Irritability is often my first indication that I am struggling. Not always aimed at my coworkers or patients, but to those closest to me. I talk a lot about my husband receiving the brunt of my rants or stress, and it’s true. It’s comes out when my kids are acting up and I loose my shit, normally my kids arguing of who gets to play Minecraft first isn’t a big deal, but after work it makes me go crazy and that’s not fair to my children, or to my husband.

Witnessing loss can also affect who we have relationships with and how close we get. It’s easy to become isolated when your struggling. You may say no to girl’s night out, because somewhere in the back of your mind your trying to limit loss. If you don’t have connections, you can’t lose them.

• Anxiety/depression – I think most normal healthy humans, have a predisposition to having feelings of anxiety or depression (or both) depending on your personality type. And that’s ok, anxiety can be a motivating feeling and depressive thoughts can be a good reminder to appreciate what you have. The problem lies when these thought-process and or feelings affect our reasoning and or mood. Thusly, can also affect your functioning. If your functioning in the world in impaired by anxiety and or depression, it’s time to talk with a professional.

• PTSD – It is clear, that if you witness trauma and or loss it can have a lasting life-changing affect. Now termed Post Traumatic Stress Disorder, society has gotten better at creating support for first responders, the military, and those living within the trauma. But up until this year, nurses have been negated from the dialogue on PTSD. I hate to sound like a raging feminist, but hello I am, and this is clearly related to the fact most nurses are female. And I still think in 2019 we view women as being able to deal with this trauma. Hey, we are made for it, we are sensitive, reflective, and nurturing. Not only can we deal with our own trauma, we can deal with everyone else’s too. Not true, in fact most nurses I know who are complete badasses at their job have very little awareness for their own mental wellbeing. And again, we must stop thinking mental wellbeing is a personal issue. If your wellbeing is affected by your job than it is a workplace issue. And deserves collective thought and engagement. In Canada, nurses have been added to the list of workers who are presumed to have mental injury related to their jobs. This recognition helps workers get faster access to support. Initially when the legislation was introduced nurses and other workers where not included – sadly I wasn’t surprised. Just another example of nurses having to not only advocate for our patients but also for our professional self.

Here is a quick summary on this issue from the BC Nurses Union.

https://www.bcnu.org/news-and-events/news/2019/bcnu-applauds-government-decision-to-include-nurses-in-mental-injury-presumption-legislation

Another resource from the BC Government, if you are so inclined.

https://news.gov.bc.ca/releases/2019LBR0010-000695

What can be done to help us with loss?

I am not the expert on health and wellness in the workplace, but I have lived through many experiences that have left me feeling uncomfortable, fragmented, and frankly disempowered. But then I think, how do I cope? I have worked for a decade and not once have I needed to be off for burnout, I feel engaged with my profession, and I continue to make myself vulnerable to my patients’ experiences. What makes me so special?

Nothing, I am not that special and there are hundreds of nurses doing the same thing every day working hard and moving forward. Its our innate resilience that keeps us going, it is the badass attitude that I won’t let this define me. It’s the thinking about what the experience meant to me and why it rubbed me. It’s the reflection on what is in my control and what’s not. It’s the connection with my colleagues, family, and friends that reminds me that I am not alone in this. It’s the bad jokes and morbid humour that allows me to cope.

Little things can accumulate everyday until it takes a toll on your psyche. Being aware of this is the key to navigating these feelings and by nature of nurses being practitioners of empathy, we inevitably risk our own health and wellness in order to get the job done. This post includes a worksheet on how to work through loss, but in order to get into the proper head space for emotional deconstruction you best be trying to keep your physical health up to snuff. Marathon runners don’t show up to the big race without training first. Sleeping, eating, and exercise seem too simple to be foundation to personal and professional success, but guess what? It is.

1. Get 8 hours of Sleep – yah, I said it. I am a shift worker too, so I know this seems cliché but it’s straight up true. How do you feel when you get no sleep? Perhaps irritable, cranky, and or lacking patience. So how if you are perpetually tired can you deal with your job? Or even your everyday life? I know these nurses; they don’t sleep on their first nightshift and so they end up running on stress hormones to get them through their block. Stress hormones are ok in the short-term, but we all know over time can affect your cardiovascular system, and lead to significant health problems. The point is, get some sleep!
2. Eat Well – because I get stuck at work and literally can’t leave to get food, I force myself to eat right by only packing healthy food. And on my days off I find it is easier to continue this pattern. Not to say I won’t be found pounding back chocolate or ice cream, it’s all in moderation. The healthier you eat the better you feel, and this can make a difference between a good shift or a bad shift. I also try on nightshift to not eat after 11 pm, because I don’t think you would normally be up at 3 am eating a hamburger and fries. Your GI track can barely keep up with your wacky schedule so why make it more difficult? Yogurt, popcorn, veggies and dip are great snacks, and I also try and limit the amount of caffeine on nights and drink tonnes of water. Water is an awesome energy booster and doesn’t give you heart palpitations if you have too much.
3. Get some Exercise – My life changed three years ago when I downloaded the 7 minute App – there I said it. Even I matron of a young family, full-time shift worker with a side hustle, manage to workout for 7 minutes on my days off. And because it’s based on Hight Intensity Interval Training (HITT) I feel like I get a great cardio work-out too. The other great feature is that you don’t need a gym or equipment and can be done anywhere. Check it out if you are struggling to fit fitness into your life. The results are not instantaneous but over a long period of time I have been able to get my core back into shape after two kids and I feel like I have energy to make it through 12 hours of work with some to spare.

Link to the 7 Minute App (and no I am not getting paid in anyway to recommend this application, I just love it!)

https://apps.apple.com/us/app/7-minute-workout-challenge/id680170305

We all know that exercise is great for your mental health, and all that releasing of endorphins is a natural stress reliever, so get your buns moving. The other exercise I love for mental balance and stretching is Yoga. 10 minutes of yoga is a like all day at the spa, if done right, and it works your cardio but also stretches and releases tense muscles which can plague nurses. I often feel when I am having physical pain my mood goes in the shitter and a few minutes of downward dog can turn it around.

Ok so you got some sleep, you had a big bowel of broccoli, and worked out for an immense 7 minutes – girl it’s time to take on your mindset!

Remember the guy who came into the emergency and looked like your uncle, and his headache was a brain met and he is going to die, maybe not today, but sooner than he would want? Yah, that one, the one made you snap at the housekeeper about cleaning a room. What’s your plan to deal with that one?

It’s not easy to have a solution to all the vicarious forms of loss we see. And sometimes you need something more tangible. A guide you can use. I created this worksheet as a practical, immediate tool, that nurses or any HCP’s can use to reflect and move forward on workplace issues dealing with loss. This worksheet can also be applied to personal losses or I invite you to give to a friend who is struggling. It’s my gift to you and your gift to give yourself.

In order to get the most out of this tool, I suggest taking a few minutes to yourself in a quite space with a big glass of water and work it out on paper.

There are no right or wrong answers and it’s your process, so trust it.

Download your FREE guide here.

I have added some other thought-provoking tips to use with the guide.

Working Through Loss – Worksheet and Guide

Positive Affirmation: This experience will not define me, rather I will define this experience and move forward centred and connected. Positive affirmations work to change your mindset. If you repeat positive thoughts eventually you can change how you process events so that you promote healthier coping.

SQUARE ONE: You must acknowledge what makes you feel they way you do. For example, I had a recent patient that I was caring for, that I felt frustrated with and it was difficult for me to be kind. This was such I change from my usual way-of-being I had to stop and reflect on what the root of my issue was. And you know what, it wasn’t really about the patient, I was feeling the effects of an ethical dilemma.

Acknowledge the Loss – through thoughtful reflection, ask yourself these questions and write down your answers.

• How did the experience make you feel? It’s ok to feel emotions but when the emotions are uncomfortable or affect your ability to be professional it warrants further investigation.
• What did the experience mean to you? Some experiences may remind you of something personal in your life and can lead to difficulties when processing the events. Perhaps how you feel is more about the circumstance, the system, ethics or legalities.
• Where is the conflict or struggle for you? I like using the term rub, what rubs you? What is at the root of the problem. It may be that you feel something is medically futile, maybe you have conflict with being an advocate. Explore the underlying “rub” and you will be able to start to make connections to move forward.

SQUARE TWO: Part of being a professional is being a life-long learner. You can only learn if you stop and make connections about how you feel and why. In this space, it’s is about finding the gifts each negative or traumatic event can bring to you. Perhaps, seeing a palliative care patient suffer brings you to strive for better symptom management for all palliative care patients.

Making Meaningful Connections – Even the worst experiences can hold value, ponder what meaningful connections you can make about this experience that can serve you in the future.

• Who can you talk to about this experience? It can be helpful to talk with a colleague or friend about your experience. Sometimes it’s better to talk with an objective person like a counsellor who doesn’t know you.
• Can you pull something positive out of this experience? It may be a subtle but it’s there, the good that isn’t always easy to see. Open your mind and explore what gift this experience/loss can give you.
• What strengths did you show during this experience? We don’t always behave the way we would like and there is always room to grow, however, even in times we think we are struggling we are doing a lot of things right. Find the positive and focus on how your innate strength served you in this experience.

SQUARE THREE: I originally coined this square creating balance, but then I read something from Rachel Hollis, where she explored the idea that balance isn’t always possible. That inevitably you will work too much, or too little, depending on where you are in your life right now. The better ideal to strive for is feeling centred. That all this chaos is happening around you, but you can handle it because you are grounded and centred.

Creating a Centre – You have acknowledged the loss/experience and have placed meaning to it, now visualize what you need to centre yourself.

• What do you need to feel grounded? Is it time for a vacation? Do you need to work harder on the physical aspects of health? What makes you feel alive?
• How are you going to achieve a sense of being centred? What does that “balance” look like you for you?
• What supports can be utilized to help you? Can you talk with a friend? Maybe you need to bring your experience up with others who may understand what your going through? Are there supports available through your work or in your community that could be used to help?

SQUARE FOUR: Hey life is shitty sometimes, but poop is a great fertilizer (that’s my crude way of saying learn from your experiences good and bad). Take what you need to move forward and do it with a sense of satisfaction because change is uncomfortable, and self exploration is challenging – But you got this!

Moving Forward – create the plan to move forward in a manner that fosters resilience and builds your capacity to grow and change. I think this is clear enough.

• Acknowledge your boundaries and limits.
• Be gentle with yourself.
• Ask for help when you need it.

Inevitable we all with have loss in our lives, and when your job is to connect with people who are suffering you will vicariously witness even more loss. The accumulation of experiences over time can leave nurses vulnerable to also suffer. The takeaway is that currently there are not a lot of practical supports available deal with little losses that we see, so use this worksheet and guide to work through these experiences and foster your resilience.

Peace + Love,

MA.

More Resources

Look for an upcoming post on Trauma Informed Services/Practice – which will take a closer look at Loss and Trauma and examine ways nurses and organizations can implement TIP.

For some front-line psychosocial support during the Opioid Crisis, look at the Collective Care in the Zone of Fabulousness.

https://vikkireynoldsdotca.files.wordpress.com/2019/04/mrt-zone-of-fab-workbook-v2.pdf

The Tend Academy has great information on Vicarious Trauma, and Mental Exhaustion with techniques and resources on how to deal.

https://www.tendacademy.ca/