Vicarious trauma and secondary traumatic stress can occur in populations of workers who are exposed to the traumas that others are experiencing. Critical care nurses caring day after day for suffering individuals, have a unique set of experiences that have an increased risk of developing compassion fatigue. Compassion fatigue has been well studied and mimics similarly to Post Traumatic Stress and is often called Secondary Traumatic Stress (Figley, 1995). High Adverse Childhood Experience scores produce an increased risk of major disease processes, most notably mental health disorders, like Posttraumatic Stress Disorders (Felitti, 1998). To combat these poor outcomes, the integration of compassion and resilience practices into nursing's daily lives and encounters can offer preventative solutions and decrease the burden of cost associated with high turnover, ultimately infusing better care for the sufferers whom these workers are providing.
Individuals who are exposed to childhood traumas display a major impact to their job performance, posing an economic problem for companies (Anda et al, 2004).
By promoting resilience in healthcare staff, reduction of costs associated with turnover will decrease throughout the organization. Staff turnover for nursing staff in the ICU and ER data will be extracted and annually assessed to determine the value of the resiliency program and whether is sustainability is worth continuous use of nursing resources.
ACEs have been associated with the development of several chronic conditions and including but not limited to alcohol abuse, depression, health related quality of life, poor work performance, financial stress, and suicide (CDC, 2016).
ACE scores affect women more than men and approximately 15% of women have 4 or more ACEs (CDC, 2016), and the nursing profession is predominantly filled with females, with 92% of the workforce employing women in 2003 (USDOL). Nursing Solutions, Inc reported on critical care areas like the emergency department and intensive care areas there is a higher turnover rate than in other areas. In 2017 the Intensive care had a 16.4% turnover with Emergency Room workers having 20% turnover. Interestingly the same percentage of the population have a high number of ACEs, although no research exists that link ACEs to critical care nursing turnover rates (2018).
ACEs have been found to increase poor work performance in employees. In a study conducted by Anda and colleagues, individuals were determined to be considered having poor work performance by measuring three indicators: absenteeism, financial distress, and serious job problems. The study found that those who had higher number of ACEs were more likely to report these indicators (2004). The economic impact of these associated indicators cost billions for companies each year (Anda, 2004).
No research exists on how many individuals in the critical nursing sector are affected and this grant would assist with identifying these individuals and treating them with the implementation of a resiliency and compassion based program, with the goal ultimately to not only improve the lives of these individuals but also the care of the patients they serve but control the economic impact of turnover.
The ACE questionnaire will be administered in a modified version like the CYW Adverse Childhood Experiences Questionnaire (ACE-Q) Teen Self-Report developed by Dr. Nadine Burke Harris, where a number only is reported to keep the anonymity of the individual’s experiences to decrease sample biases that may occur (Center for Youth Wellness, 2015). Individuals who score greater than 2 will be enrolled in to training courses that take place once a week offering a combination of group support sessions, mindfulness, awareness, and resiliency strengthening for 12 weeks. The RAND corporation “levers” of wellness, education, engagement, self-sufficiency, partnership, and efficiency will provide the core concepts of the program (Rand, 2019). Nursing educators within hospital will recruit nurse resiliency trainers to assist in providing the training intervention in a consistent approach, whereby practice sessions will take place prior to the live intervention course. Nursing educators will facilitate the program. In addition, during orientation processes the nursing educator will assess the ACE score of the individuals and set up resiliency training courses for the new team member to be help quarterly for all new team members.
Level(s) of Social Ecological Model (CDC, 2019 and Rand, 2019)
The resiliency program will utilize the CDC’s social ecological model to provide the framework of the potential prevention effect (CDC, 2019); Rand’s levers of community resilience training program will be adapted, with the modified content of the resilience program focus on the wellness, education, engagement, self-sufficiency, partnerships, and efficiency objectives (2019).
Individual: Wellness activities will aim to promote self-care among the nursing staff members, encouraging prioritizing exercise, a nutritious diet, and plenty of sleep. In addition, individuals enrolled will be provided education regarding risks of compassion fatigue and burnout and ways to have self-awareness of the potential onset of symptoms utilized a trauma informed approach. Lastly, “self- sufficiency” or self-efficacy will provide the confidence within the groups to take personal responsibility for recognizing when they need to act to resolve the dissonance they experience as a result of prolonged exposure to death and dying and incorporating strategies of mindfulness and meditation to help offset the discomfort that leads to vicarious traumatic experiences (Festinger, 1957).
Relationship: Partnerships among the group members will be promoted, along with matching each member of the group to a mentor who has completed mentorship and compassion training and has taken an active role in the program delivery. With the new concepts and reinforcement of mentoring, those within the group will be encouraged to engage in peer mindfulness activities, monthly group outings and become an active participant in program delivery to new employees.
Community: Leadership and key stakeholders will be involved in department training policy and procedure to promote ongoing efforts and ensure accountability of employees to maintain program goals. In addition, policy makers will be needed to ensure that discriminatory principles are applied when staff are transparent about their ACE statuses.
Societal: With a successful trial resiliency, compassion and mentorship training programs completed at one hospital yielding a positive association with the reduction of turnover, senior leadership adoption and infusion of the program across the healthcare system’s 14 other hospitals would lead to major societal shifts in understanding and utilizing a trauma informed approach with managing team members who have a high ACE and work in critical care areas.
Trauma-Informed Principles (SAMHSA, 2014)
Safety: During the delivery of the resiliency program training, individuals will be allowed to excuse themselves during any part of the program delivery and may use the meditation stations to help assist them in deescalating their trigger. Meditations stations will be incorporate within the organization to allow staff members to utilize what they learned in the practice on the job when they feel triggered. Prevention of re-traumatization will be practiced and calm, ambient environment off the units where patients are cared for will be the program’s setting.
Peer support and mutual self-help: Mentors will be available to provide support and improve the safety and integrity of the intervention program content delivery. Quarterly “Everyday Hero Assembly” where nurses who were faced with difficult challenges are rewarded for their bravery and courage to make the tough decisions needed to successfully save patient’s lives where family and friends are invited to celebrate the nurse.
Empowerment, voice and choice: Everyday Hero Assembly would overlap with this principle as it builds on empowering them to see those who celebrate their skills for caring for patients. It also gives them the opportunity to share their story with others in a celebratory way. In addition, mentor would have casual one on one meeting with the staff member at regular intervals to build on resiliency skills.
Trustworthiness and Transparency: Organizational leaders, professional development staff, educators, and mentors would embrace honest and open communication and eliciting feedback and recommendations at monthly staff and town hall meetings where leadership is available to hear the voices of the staff.
Collaboration and mutuality: Those enrolled in the program will be key partners in development of a trauma informed workforce, where suggestions on improving the environment to align with trauma informed approach practices and infusion of resiliency skills are shared, planned and implemented.
Cultural, historical and gender issues: Leadership involvement with the development of policies that support staff who have higher ACEs are key to ensuring that these individuals are protected and supported during their journey to healing and providing better care for themselves and their patients.
Public Health Framework
While maintaining a perspective that moving toward a trauma informed organization will take time, setting small attainable goals and modeling a framework that moves along a continuous path will provide the structure of this program. In addition to measuring overall staff turnover, it is imperative to measure how the program elements are being infused into the culture of the organization. Utilizing assessment tools, like Attitudes Related to Trauma Informed Care (ARTIC), would provide essential components on new strategies to apply (Philanthropy, n.d.).
Primary Prevention: Policy proposals to management, self-care promotional activities, meditating minds rooms developed, resiliency training for all new team members and compassion training for all team members .
Secondary Prevention: Annual ACE screenings for staff members
Tertiary Prevention: Weekly peer support groups and Employee Assistance Program (EAP)- free mental health services for staff.
Hospital efforts to incorporate the trauma informed approach will be shared across the organization with the information on background, strategies used, education instituted, evaluation and outcomes of the program with the goal of improving the understanding of trauma and its effects to the staff and patients across the health care system.
Project Outcomes
Employees enrolled in the program will be provided with knowledge and simulated experiences as tools to use when faced with difficult situations in the critical care areas and managing the emotions that may produce toxic stress and dissatisfaction in the workplace, thus increasing the turnover and costs ensued by the hospital system. Those who work alongside these employees will be provided with a separate training course that enlists in demonstrating supportive and compassionate perspectives of their coworkers, thus addressing attitudes and beliefs toward individuals who have higher ACEs. In addition, leadership will help facilitate its success with support of policy provisions and accountability for training completion.
Evaluation Plan
Employees with high ACE score will be provided with a survey evaluation before and after the 6 week training course, whereby their attitudes and beliefs about themselves and the meaning behind their work will be administered. This will help determine the influence of the course objectives. Coworkers attending separate course will also fill out a different survey where their attitudes and beliefs about those they work with prior to compassion course and then post course. Leaders will be asked to complete surveys as well before and after courses with attitudes and beliefs assessed as well as reporting on number of employees who left the unit to work for other companies, and if known, work in other career fields. Trainers will be assessed after each course to determine if there are areas where participants had additional questions, seemed more or less engaged, and/or felt discomfort during course with adjustments made to each subsequent course when appropriate. In addition, recommendations will be elicited from all individuals receiving training and stakeholders assisting in facilitating the training to help improve the course content for future course opportunities.
Staff Qualifications
Employees must work in Intensive Care Unit or Emergency Department with a full time status. Employees enrolled in resiliency course must be a registered nurse in the state of Florida with an ACE score of 2 or greater and have worked in the profession for at least one year. Employees enrolled in compassion course must be a full time registered nurse, scored 1 or less on the ACE questionnaire and have worked in the company for at least one year. Exclusions will not apply to those on FMLA or leave of absence, as those individuals may be the ones, we can be the most helpful to. Leaders are defined as the person or persons that oversee the individuals directly or indirectly and work within the hospital that employees are employed. Education specialists and trainers will be trained to provide the content to both groups, as well as serve as supportive group members post intervention.
References:
Anda, R. F., Fleisher, V. I., Felitti, V. J., Edwards, V. J., Whitfield, C. L., Dube, S. R., & Williamson, D. F. (2004). Childhood Abuse, Household Dysfunction, and Indicators of Impaired Adult Worker Performance. The Permanente journal, 8(1), 30-8.
Center for Disease Control and Prevention. (2016, April). Adverse Childhood Experiences. Retrieved from CDC website https://www.cdc.gov/violencepr.../acestudy/index.html
Center for Disease Control and Prevention (2019, January 16). The Social-Ecological Model: A framework for prevention. Retrieved from CDC website https://www.cdc.gov/violencepr...ecologicalmodel.html.
Center for Youth Wellness. (2015). ACE-Q Materials: ACE-Q Teen (self report) 13-19 y.o. Retrieved from https://centerforyouthwellness.org/cyw-aceq/
Felitti, V.J, Anda, R.F., Nordenberg, D., Williamson, D.F., Spitz, A.M., Edwards, V., Koss, M.P., and Marks, J.S. (1998). Relationship of childhood abuse and household dysfunction to many of the leading causes of death in adults. American Journal of Preventative Medicine, 14 (1), 245-257.
Festinger, Leon. (1957). The Theory of Cognitive Dissonance. Stanford, California: Stanford University Press.
Figley, C.R. (1995). Compassion Fatigue: Coping with secondary traumatic stress disorder in those who treat the traumatized. New York, NY: Brunner/Mazel.
Nursing Solutions, Inc. (2018). 2018 National Health Care Retention and RN Staffing Report. Retrieved from Nursing Solutions, Inc website http://www.nsinursingsolutions...entionreport2018.pdf
Philanthropy Network Greater Philadelphia, Thomas Scattergood Behavioral Health Foundation and United Way of Greater Philadelphia and Southern New Jersey. (n.d.) Trauma Informed Philanthropy: A Funder’s Resource Guide for Supporting Trauma-Informed Practice in the Delaware Valley. Retrieved from (Trauma Informed Approaches for Individuals, Communities, and Public Health taught by Lindsay King and Mark Hart at the University of Florida.
RAND Corporation. (2019). Resilience in Action. Retrieved from www.rand.org/multi/resilience-in-action.html
Substance Abuse and Mental Health Services Administration (SAMHSA), Division of the U.S. Department of Health and Human Services, prepared by SAMHSA’s Trauma and Justice Strategic Initiative (2019, July). SAMHSA’s Concept of Trauma and guidance for a Trauma-Informed Approach. HHS Publication No. (SMA) 14-4884. Rockville, MD: Substance Abuse and Mental Health Services Administration.
United States Department of Labor (USDOL), Bureau of Labor Statistics. (2003) Quick Facts on Registered Nurses. Retrieved from USDOL website https://www.dol.gov/wb/factsheets/qf-nursing.htm
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