January 21, 2021

Episode 43: How nurses can cope with the trauma of COVID-19

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Podcast

Description

The challenges facing nurses and nurse leaders are bigger and more urgent than ever before, and our guest for this episode is an expert on a topic that is on the minds of nearly every healthcare worker: how to process the collective trauma that has been inflicted as a result of the COVID-19 pandemic. 

Dr. Diana Hendel is the former long-time CEO of Long Beach Memorial. In 2009, one of her employees shot two of his supervisors before taking his own life, an event that profoundly changed Diana as a leader and a person. She spent the next six years working to heal the organization and a result, becoming a student of organizational trauma, a topic she says isn’t widely understood. 

After retiring from the hospital, Diana went on to launch an executive coaching and leadership practice to help other leaders who were dealing with this issue, and eventually wrote a memoir about her experience. She has now channeled her expertise into helping healthcare leaders and workers deal with the impact of COVID-19. 

In our conversation, Diana and I talk about the difference between trauma and stress, the existential crisis facing nurses and frontline care providers and how leaders can help their employees through the unprecedented challenges of this time. 

Links to recommended reading: 

Podcast

Transcript

Dan:
Welcome to the show Diana.

Diana:
Thank you, Dan, for having me, really a pleasure to be here.

Dan:
So I'm excited to chat with you. You're also doing a lot of work related to trauma, and stress, and all of the impacts that mental health impacts that our healthcare workforce is feeling right now and throughout the entire history of healthcare. What got you interested into that topic?

Diana:
Well, I was a long time CEO at Long Beach Memorial and Miller Children's, as you mentioned, and 12 years ago, our workplace experienced a horrific trauma, an employee came to work and shot and killed his two supervisors. And the [inaudible 00:02:32] that day in the aftermath changed me as a leader, changed me as a person, frankly, and I spent the next six years within the organization helping to heal the organization, but also really seeing the impact on the culture of the organization, many good parts, but also things that really had damaged the culture.

Diana:
So I became a student of organizational trauma and a lot had been written about trauma on individuals but very little about how it affects the culture of the organization. I ended up retiring after about six years after the shooting and launched an executive coaching and leadership consulting practice, but I noticed that many of my clients were coming to me specifically wanting help on how to navigate traumas that were impacting their organization. So wide variety of traumas. And so, I ended up publishing a memoir in March of 2020 that was describing my experience as a leader and a person navigating trauma in a workplace.

Diana:
But then of course COVID hit, and boy, every organization, and all healthcare organizations are right in the epicenter of it. I was approached by Dr. Mark Goulston to co-author a book about the traumatic stress that healthcare workers are facing. And so, much of the work in this last year has been helping leaders, helping healthcare workers navigate the traumatic effects of the COVID pandemic. So in a nutshell, that's what I've been up to in the last 10 months.

Dan:
That's such important work. And I think in one of your articles, you've made an important distinction as well, the difference between trauma and stress, can you dive into that a little bit?

Diana:
Sure. I would say that healthcare leaders and workers are amongst the most resilient, the strongest, the toughest people in our society, there's no doubt about that, and they're accustomed to adversity, they're accustomed to stress, but the COVID pandemic has really produced something above and beyond. It's really transcended what we can normally expect stress in the workplace. It has all the elements of trauma. It has fear of loss of life and loss of livelihood, fear for ourselves, fear for our loved ones. It has the ability to completely disrupt, and has disrupted our entire way of being. It's an existential crisis, if you will, and it has gone on for months, and months, and months.

Diana:
So the sheer enormity, the impact of loss of life and loss of livelihood, and the duration has really moved it into ongoing chronic traumatic stress and very different than the stress of adversity, the stress of perhaps not meeting a financial target or disappointment in and outcome far exceeds the experience that anyone's had in the past.

Dan:
That's a great distinction. And I'd love your perspective on this. One of the things that we've noticed as we place nurses all over the country and have this national view of what's going on in healthcare, it's been really interesting to see how organizations have reacted to the pandemic. In the beginning, it was very much rally, step up, "We can do this," that hero syndrome, the adrenaline, I think you talked about it in the book as well.

Dan:
And as it's gone on for nine or so months, it's changed and healthcare providers are now burned out on it. It's just been this chronic punch in the gut, but I'm also finding that the clinicians on the frontline, physicians, nurses, respiratory therapists have also been somewhat hesitant to seek help themselves, there's an armor that they have to break. What are you seeing in that? And is that specific to healthcare, and is that a trend that you've noticed?

Diana:
It is absolutely a trend I've noticed, and it is a trend not unique to healthcare, it's a trend that's common to organizations. And when I say organizations, I don't just mean companies, I mean, groups of people, communities, those that normally come together to serve in a collective. So we see that pattern and trend, and it's something that's, as I'd mentioned earlier, that the impact on organizations and their culture. But that trend of initially people come together, there's a great amount of comradery, bonding, teamwork, a spree decor.

Diana:
And particularly in healthcare, that is readily apparent, it's just on the surface, of course, those attributes because people view themselves as part of a collective serving a higher calling, if you will. They have deep sense of meaning and purpose. So it's not uncommon in healthcare to see that rally. But what is also very common in organizations that have been traumatized, it doesn't take long for a better polarization to take root within a company, or an organization, or within the nation.

Diana:
The questions of why predominate, "Why did it happen? Who knew? Who should have prevented it? Was there enough done?" So as those questions arise in combination with a wide range of points of view and a variety of narratives that each of us as individuals create, because remember that we're not all affected in the exact same way. Some of us are right on the front lines and seeing the death every day, some of us are worried about our children or infecting others, some are concerned about layoffs and perhaps losing our jobs. Some in our society have much further removed and see it as something that just a small number of people, frankly, are dealing with and not something that is directly affecting their everyday lives, except for the fact that they can't go and mingle at a mall.

Diana:
And so, because of that wide range of points of view and those wide variety of narratives, a fair amount of finger pointing starts to ensue and blame. And that's a common characteristic of organizations that have been traumatized. Another element is guilt. Guilt is very common in collectives that have been traumatized, and then often, shame. Depending upon the nature of the trauma, shame emerges. Sometimes the organization that has been traumatized worries that it's lost its external reputation or it's an internal reputation for that matter.

Diana:
So because of the nature and the complexity of the traumas and the COVID pandemic in particular, it becomes in some ways, unspeakable and hard for people to raise concerns that perhaps they're being emotionally traumatized or struggling with the effects of the trauma, because they get lots of mixed messages maybe within their organizations, or certainly within what they read online or as they leave their workplace in their scrubs and go to the grocery store fully masked and see others who taunt or downplay. So that is very common with organizations or collectives that have been traumatized and often the effects become stigmatized. So it is really this constellation of symptoms, if you will, that are common to organizations that have been traumatized.

Dan:
And it feels like the healthcare organizations are getting the brunt of it at all ends. So not only do they see it in the day-to-day work inside the facilities, but then like you said, they go into the community and they see people saying it's a hoax or not following guidelines, which also hurts. And then they're on social media sharing the excitement of getting the vaccine, or some turn towards the better, and then they get ripped on social media. It's like there's no safe place at this moment, it seems, for healthcare workers to get away from it and even take a break. And I know one of your passions is leading through trauma. What are some tactics that healthcare leaders at all levels can take to help their staff cope and find a place to just be themselves? Because it seems like there's not that in the society at the moment.

Diana:
Exactly. And I think one thing to recognize is that healthcare leaders themselves have been traumatized. So they aren't separate from the people, they are also charged and responsible for leading. So I think it's really important to recognize that that said, of course they have the responsibility to lead. And so, their ability to recognize their own traumatic response and to understand that being able to communicate in a authentic and often vulnerable way is really important. They can do both, it's very much a both end.

Diana:
They can express some of the feelings they're having, normalize them, if you will, to let people know that they're not impervious to the feelings. And also in the same communication, be very clear, and confident, and optimistic about how and what we can do together as a team to move forward. So I think it's very much this both end of being part of the organization, and being confident, and taking charge and leading. A key part of that is being able to listen to people within the organization. And that can be particularly challenging when you're listening to people who are anxious, afraid, upset, angry, perhaps, and it's hard to receive that, it's hard to bear witness to that without becoming defensive, or without ignoring it, or avoiding.

Dan:
Or wanting to solve their problem. I think that's also a reaction, is as a leader, you want to solve that issue in front of you. And sometimes that's not the right thing to do, you honestly just need to listen and be there and then potentially help find resources, but you don't have to solve it too.

Diana:
You've so hit the nail on the head. It's so key, is that rushing to solve somebody's feelings is exactly what causes them to shut down. And so, that ability to listen without solving and yet also be competent and in charge. And it's a struggle and a challenge, but I think it's really important to recognize the leaders themselves have been traumatized. What leaders and groups can do is double down on the unity, that initial phase where the comradery, and the bonding, and the teamwork were so high, reinforce that, speak to that, call that back out again. Every bit of energy needs to be about keeping the organization unified and not splintering, not stoking the flames of blame, or finger pointing, or becoming defensive. So those are some of the key things that leaders can do through the pandemic.

Dan:
That's great advice and I agree. One of the things that I was passionate about in the middle of the pandemic is creating a resource. So we've built a website that has some ideas and badge hangers for just sentences you can say to staff to start that conversation and start that listening. I think that's understated that that's a key skill that leaders need to have. And it's hard to do when you're in the middle of crisis. You're trying to manage patients coming in and out and all these different competing priorities, and it's hard to find time to have that conversation, but that could sometimes be the most impactful.

Diana:
It sure can be. And thinking about how they become leaders often is having all the answers, is fixing problems. And so, the very skills that perhaps had them appointed or promoted to a role are the ones that they also need to keep in check. And so, pivoting to that listening, pivoting to really hearing others is critically important.

Dan:
I love the title of your latest book, which is, Why Cope When You Can Heal? How Healthcare Heroes of COVID-19 Can Recover from PTSD. And I want to dig into that a little bit because one of the things I heard early on was, "Well, we need to build resilience." So you just meditate or take your mental breaks and just decompress and go do yoga or something. And it's like these very superficial solutions that slapped in the face of people who are seeing these things day-to-day like, "I'm going to go do yoga after I watched a whole ICU worth of people get sicker and sicker." It doesn't make sense. So I would love to hear how are you addressing that healing and how'd you come up with that title and what's behind it?

Diana:
Well, what's behind it is really exactly what you just said, in our experience, my coauthor and I, Dr. Mark Goulston, we don't doubt that in particular healthcare workers are amongst the best at coping. So coping is something they're adept at and have built resilience. Organizations and teams have been working on building resilience and remaining healthy emotionally for a lot of years because burnout is something that is such a challenge within healthcare.

Diana:
And so, we wanted to go beyond that to say it's more than simply coping and also raise awareness that many people do cope in very positive and socially acceptable ways like you say, adopting healthy habits. And those are great practices and ones that none of us would downplay, but they aren't enough to heal, to allow a person or to create space to heal from traumatic stress. To heal from traumatic stress, it's important that the feelings be felt and expressed, that the feelings be processed.

Diana:
This was born out of both Dr. Goulston and my personal experience, as well as our professional experience. I personally experienced PTSD after the workplace shooting. And I was told repeatedly, "You're strong, but look how much you've already gone through." And in some ways I understood what people were saying that the positive message and time will heal it and just get over it in essence and just put it behind you. I understood that message because I probably had given it to a lot of other people until I myself experienced trauma at that level and realized that while it was meant and all the best spirits and meant to be helpful, it actually made me so angry and upset to hear it because it dismissed the deep feelings I was having.

Diana:
And I didn't need to be told to be more positive, I was a very positive person. I needed to be helped with how to process those feelings. So that was why it was so core for both of us to both entitle a book and speak to the idea that it goes beyond coping, it is the need for processing in order to heal.

Dan:
And that gets to the underlying cause of it, that if you don't process those feelings, you're going to be coping for a really long time and not ever get to the system impact or the systems origin of it. And I think it's as similar when fixing healthcare systems, you can't just bandaid things together and solve it in the moment, you always have to have that system view. And that's your bodies and your mental health system view, is to go in and fix the origin of the issue and process that not just to pull on your boots and get through it.

Diana:
Yes, because while people, for the most part will cope in very positive and socially acceptable ways, over time, other habits can emerge. People will find themselves perhaps drinking more, sleeping less, other habits that perhaps are an attempt to numb or to cope with the stress they're feeling that have harmful effects. But I would also say, and I say this carefully, in some ways the positive coping can sometimes have harmful effects if we don't get to the root and process the trauma, because it perpetuates the trauma and drives it deeper and deeper without being able to surface it, and process it, and heal from it.

Dan:
That's really good insight for the leaders listening. You have to process it. At the end of the day, you got to get to the origin of this thing and positive or negative coping is a short-term solution. As the pandemic continues to go on, there's even more trauma now. Politically, the whole world seems like it's just a source of drama at the moment.

Dan:
One thing I've noticed being a nurse for a long time, being a healthcare leader is we don't make time in the "workday" to actually talk about these things or address them. So I know you do a lot of leadership coaching and executive coaching, how do you set up systems in a healthcare context that you make this a normal part of the workday, that when you show up to your shift, that you have some recognition of the things that happened the day before, or even after traumatic events like codes, and death, and those types of things to make it normal to actually sit down and process it right away rather than saying, "Well, that was a rough shift. Go home and I'll see you tomorrow?" What's some ways that you're fixing that problem?

Diana:
Well, exactly what you just said about how you systemize it. So from a leader perspective that we begin to talk about the traumas that occur and the need for them to be processed. And so, the vocalization of the importance of addressing it, naming it, if you will, so much trauma goes unnamed. And so, naming the trauma, naming that it would be normal and expected for people to be impacted, that's the opposite. The idea that you could go home and not be affected at all, that actually would not be normal for us as biological, social human beings, that it would be completely normal to be effected.

Diana:
And so, raising that awareness and in essence, creating permission for it to be talked about is really important. And I think sometimes we think that if we talk about it, that somehow we won't be able to stop talking about it or that it will reinforce as a feedback loop negativity. But I think when trauma happens, it's the exact opposite. It's the surfacing and talking about it that helps to begin healing it.

Diana:
So on a systems perspective, it needs to be allowed to be talked about, and it's best if leaders can model it, they'll open up the conversation. But then also I think helping and working with each individual to create a plan for each individual themselves on how they deal with when they're triggered at work, do they know what triggers them? What are the feelings that arise? What habits or practice could be put in place so that when they're triggered, they can employ those immediately? And so, we identify a good half dozen practices that can be helpful right in the workplace or when someone is triggered, and when there isn't time to fully process it, and yet you want to be able to arrest the damage done by the trigger or the trauma.

Dan:
And I know there's several systemized programs out there, trauma informed-care being one of them, there's cognitive behavioral therapy type interventions and things. Do you have recommendations on ones that leaders should start with or are they all equally valuable, or should they be used in different ways? What are your thoughts on that?

Diana:
I think used in different ways, I think modeling and speaking to the need for them is the first step. Secondly, is discussing each of them, having conversations about the applications of each. And I think it's not a one-size-fits-all. I think that some organizations and some individuals within the organization will garner better benefit from some of them than others, but I don't think it's a one-size-fits-all. And I think having a variety of modalities available to people is really important. And I think a modality that may work well for a person early in the trauma, they may find benefit from a different modality later. So I think having a variety available is really important.

Dan:
One of the things that I'm curious about, I would love your opinion on this is, when we've been interacting with some of the nurses, we have some resources, employee assistance programs and counseling programs available and those types of things, and we're getting some feedback from clinicians specifically saying, "I don't want to talk to just anybody. I don't want to start the conversation, telling them all the things that I've seen. I want to talk to somebody who may have been in my shoes or understands me. I want to talk to another nurse, or a physician, or at least someone who has experienced what I've experienced and then can help me cope through it." Is that something unique to healthcare that you've seen or do executives want to talk to other executives, or what's that dynamic like in your opinion?

Diana:
I think it's unique to healthcare because of the complexities of healthcare and because healthcare environments by their nature have a lot of stress and have a lot of traumatic stress. And so, I think for clinicians and those on the front lines to be able to talk to someone who gets it, who instantly knows and can put themselves in their shoes, who could relate to them is really important. I hear that time and time again, is that, "I need to talk to someone who can relate to me."

Diana:
I do think outside of healthcare, the leaders that I've been working with in organizations that have been traumatized, the leaders themselves are expressing. They want to talk to someone who gets it, if you will, who understands how trauma affects a leader as well, that they want someone who's been on the inside of that and has navigated that. Because often when they go to seek help for how an organization has been traumatized, often they'll get platitudes or an extension of a leadership best practice that doesn't really apply to trauma.

Diana:
And so, I am hearing that more and more, and I'm encouraging those who have retired from healthcare but still have close connection to begin to work with others, to begin to serve in this way as a trauma-informed resource with their former colleagues or with up and coming clinicians, helping to mentor them as well.

Dan:
I think that's key. And we saw a really interesting success with that. We worked with Ohio State University's College of Nursing and set up a wellness partner program where nurse practitioner students would be health and wellness coaches for nurses on the frontline, and we had, in a couple of days, over 200 nurses sign up for it. And I think it partly was that I get to talk to somebody in my tribe that can help me through this, and I think the healthcare professions have that innate need in some ways. So that's interesting, and I always wondered if that extended beyond.

Dan:
This all started from an experience that you had personally in your role and you turned it into something amazing. You've turned it into coaching others on how to deal with this, into books, into articles, into real passion related to this. And you could have easily gone the other way. You could have gone into frustration, and trauma, and poor coping, and all the other things that we talked about today. What was the spark that you said, "This is now my mission, and I'm going to turn this really negative experience into something to change organizations for the better?"

Diana:
Well, on the day of that trauma, as I stood before my colleagues and had to announce what had happened, and I had been a first responder to all three scenes, so I personally had been traumatized as well. In that very moment, I knew that very best of us, the comradery, the bonding, our common purpose, that sense of being a tribe that belong to something bigger than ourselves in that moment, that what was required for us to continue to go forward to heal was to unify. And that didn't mean that we didn't have disagreements or differing opinions, but that we were unified to our core. And having that experience that day, seeing the very worst of what could happen in humanity and also the very best at the same time so galvanized my calling. I loved being in healthcare, I loved being the leader of others who I'd grown up with, who I felt they were my family.

Diana:
I wanted to take that experience and make sure that it would still have meaning. One, we could pay tribute to the colleagues who'd lost their lives. Two, that we could remain a cornerstone in our community and trusted within the organization, but certainly external to the organization. I did not want it to define us, I did not want it to break us apart. What I did find is that a person individually could be shattered. I was shattered, but I was also intact. It was so much a both end. I could fully function, even though I had suffered this traumatic damage, this injury.

Diana:
So I was driven for the next six years to keep us unified and to be able to move forward without losing sight of what had happened or forgetting the people that we'd lost. But it was a very hard journey, Dan, and I was very broken, and I did have to step away and recover. And so, it had both elements. It had the elements of being very damaged, but also still galvanizing and the desire to move forward and create something out of a trauma and a tragedy.

Dan:
And thank you for sharing that. And one of the reasons I asked that question is, number one, I think it's just an amazing story. And then two, I think there's a lot of, in our realm, the nursing profession who are questioning whether they made the right career choice. They're in this trauma and we're hearing people wanting to leave the profession or take long breaks, or what do they do with this? And I think your journey may help lend insight into how do you take this crazy experience and turn it into something to shift the entire system to be better?

Dan:
And that's the call to action that I'm personally trying to make through the podcast, and in other ways is, in crisis, in trauma, you expose the cracks in the system, and now you can see them and you can go fix them. And if you can take that energy and channel it into fixing the system, you can create something better for your entire profession, your entire family, your cohort, your tribe, whatever it is. And I think that's what you did, and I would love the listeners to take insight from that and hopefully be able to do that in their own way as they go through and continue to go through these traumatic experiences over the next few months.

Diana:
The last chapter in our book, Why Cope When You Can Heal? Is a call to action. And I lay out what it means to be a healthcare worker, that sense of calling. But we, the rest of us, all of us owe it to our healthcare workers and leaders to support them, to step up. And the tragedy if people leave the profession because of what's happened. We owe them a debt of gratitude, but we also owe them our service to ensure that they are cared for, that they don't have to leave the profession that they love, that they don't have to leave the profession that is their calling, that is their life's purpose. And so, we're doing everything possible to be supportive and helpful and have that call to action so that people don't have to leave the profession.

Dan:
There's two worst case scenarios out of this current pandemic. One is we go backwards to where things used to be. I think that'd be the worst thing we could do. And two, we lose amazing people out of the profession that's literally saving the country. And so, I think we need to continue to bring this to light and provide resources. And I love that your book has that, and we'll be posting your book with a link to it on the show notes, and we'll put it on our website so people can get access to that too. What would you like to hand-off? We talked about a lot of heavy topics and I so appreciate you breaking it down and deep diving and telling your personal story as well. What is that one thing that a healthcare leader should take away that they could maybe do tomorrow to start the conversation around healing and coping with this pandemic?

Diana:
It is, remember why you do what you do and have those conversations with the people around you. Express that deep sense of shared purpose and know that you will get through it, that by staying united, staying together, you will get through it. It will be very difficult and continue to be very difficult. I, in no way in downplaying that, but the power when people come together, when they recognize what they're doing together, and they stay connected is enormous and it is tremendously healing. And so, I say a tremendous thank you to everyone on the front lines, no matter what their role, or rank, or title, no matter what their profession is within a hospital, I salute them, I send enormous amount of gratitude, and the rest of us need to be there for you, and we will be there for you. So thank you.

Dan:
I really appreciate that message. And it's amplifying exactly what we've been saying as well, which is we need the entire community, the entire nation to step up and support our healthcare workers because they're supporting us. So Diana, thank you so much for an amazing conversation. Where can people find you? Where's the best place? We linked the books on Amazon, but where else can we get more information about your work?

Diana:
Well, we have a website for Why Cope When You Can Heal? And it's whycopewhenyoucanheal.com. And it has information about the book, but it also has a lot of collateral material in addition to the book, and certainly the links to Amazon, both my memoir, Responsible, and we have a future book coming. I'll announce that mid-March we are also releasing a book called Trauma to Triumph, and it is a very tactical book about how to lead through trauma. It's rooted in healthcare, but it's applicable to all industries. And so, the memoir and Why Cope When You Can Heal? And Trauma to Triumph form a trilogy around how individuals and organizations can navigate and lead through trauma.

Dan:
Awesome. And maybe we'll have to have you back on when that launches and dive even more into some tactics leaders can do. Thank you, Diana, so much for being on the show and please check out the website, whycopewhenyoucanheal, check out the book, and like this podcast, leave us a comment if you love what we're chatting about. Till next time, we'll chat soon, and thanks for listening to The Handoff.

Dan:
Thank you so much for tuning into The Handoff. If you've liked what you heard today, please consider leaving us a review and subscribing on Apple podcasts or wherever you listen to podcasts. And for more information about Trusted, please visit trustedhealth.com. This is Dr. Nurse Dan, see you next time.

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