Helping Nurses Develop Techniques for Managing Stress: Interview with Kate Kravits, RN, MA

In this interview, Kate Kravits, RN, MA discusses her development of a successful psycho-educational self-care program at the City of Hope, located in Duarte, California. Kate Kravits, RN, MA is a Senior Research Specialist in the Division of Nursing Research and Education, City of Hope National Medical Center. What led you to develop the psycho-educational self-care program for nurses at City of Hope? It is actually quite a nice story of multiple disciplines and professional outlooks coming together to do some good. We’re a comprehensive cancer center, so most of our patients are oncology patients. In our ICU, we have a lot of patients who are critically ill, which is similar to most ICUs, except that in our ICU many of the people who are admitted are at end of life. So this is a highly stressful environment for our staff, who have treated many of these cancer patients over a longer period of time and are now caring for them in their final days in the ICU. The critical care staff have had the opportunity over time to build relationships with these patients and their families until ultimately the disease progresses and they lose the patient. So one day the manager of our ICU approached one of our staff psychologists and said “My staff are really in trouble — we’ve had a series of losses of patients who my staff were really close to.” The ICU manager asked if someone would be able to help them develop an intervention for the staff that was not just talking about their loss or grief. I was then called into the process by our director of nursing research; at the time this was occurring I was the director of education for the institution. So as we sat down to talk about a plan, it became clear that we all wanted to do something to help. Our director of research knew of an opportunity with the UniHealth Foundation — they were looking to support a project that helped promote nurses’ well-being. Therefore, we took this opportunity to create a project that became a multi-year process of over 3 years. The process was funded, and we developed a psycho-educational intervention that used three different frameworks to look at what we wanted the nurses to learn how to do. The psychologist who was originally present with the project and I created a curriculum that focused on helping the nurses as individuals discover new coping mechanisms that would support them more completely when they reached these places of loss that were going to be an inevitable part of their job. What were the components of the program? We consolidated the program into a 6- to 8-hour day, and the framework we used was the Lazarus & Folkman coping series. We also used neuroscience to provide education to the staff to help them understand that the experiences that they were having, the stress that they were feeling, and the symptoms that came from those situations were all normal adaptive coping strategies that are physiologically normal for us as human beings. We wanted to take away the stigma they were feeling that they weren’t good enough or that they wouldn’t be able to tolerate this. What we wanted to share with them was that this was a normal consequence of the very difficult work that they do. So what were the ways to help bolster them through the really rough times? We used art therapy (collages, etc.) to help them capture some opportunities for coping; this was surprisingly helpful, and allowed them to consider coping options that they might not otherwise have been aware of. We taught and practiced relaxation and guided imagery, so they could immediately have that as a skill set for themselves when they left the room. Then we did some work that came out of the cognitive behavioral intervention strategies, which was to help them build a wellness diary. This included positive affirmations that they would make up that were personal to them, that they could have as a focal point when they were having a difficult time. We also had them build a plan of how they would like to increase certain positive coping mechanisms in their life, and we addressed the physical realm, the emotional realm, the social realm, the cognitive realm, and the spiritual realm. We wanted to send the message that their wellness plans were active, living documents, and that there would be some things that would work and alternatives they could select as they began to practice these behaviors to improve their overall sense of well-being and find coping mechanisms that could be called upon when they were in trouble with the stress of the job. How many nurses participated initially? Is the program ongoing? Over the course of the 3 years, we had over 300 nurses. When the funding concluded, the institution was going through a leadership transition and we were not able to continue the educational program for our staff. However, we have since hired our leader and there have been new negotiations recently to either reinstitute this program or refine the program for the staff at the City of Hope. So it’s taking some time, but as you know, economic forces can impact an organization and you have to think whether or not you can support the program. Fortunately, it floated back up to the top of our priority list, so we will be working on reinstating the program within the institution, not as a research study this time, but as a formal part of what we do with the nursing staff. What were the results from the program? How soon did nurses notice a change in their stress levels? It’s been a couple years since the ending of this study, but we recently did interviews with a random sampling of the participants, and there were fascinating comments related to their continuing to use the wellness diary. So that is very interesting - studies show people are more successful when they write down their desired behavior changes, and we had hoped that people would have used the diary as a living document, and out of these interviews we’re finding that people really did do that and found it very helpful. Of the participants who were inclined toward art, they found the art piece as something they could continue to do for themselves and allow them to get some grounding in a different kind of way. However, the wellness diary seemed to make the most impact. How can these techniques be utilized by other nurses? Can they be applied to nurses in all departments? Yes, I do. In our study we did not confine the program to the ICU nurses, although they were the voice that initially brought the issue to us. We took nurses from every department in our institution, including new nurses and graduates, as well as our incumbent staff. So we had a wide range of experiences in nursing. Our assumption in the beginning was that we were creating a preventative intervention for the new nurses so they wouldn’t have stress when they came in. I later saw that was such a naive thing to think, because what we found out was that these nurses were already carrying a full load of life experiences with them when they entered nursing, and on top of that, they were learning to take care of people who were catastrophically ill. Therefore, they were probably some of the most stressed people within our subject group! After the third year, we opened up the program to other institutions in southern California, and we saw responses from a whole range of staff there as well. The people who we talked to that came who were in leadership positions both within our own institution and other institutions talked about certain kinds of things that have come forward. For example, in terms of the nursing lounges, some practical ideas that were being used were to have relaxation tapes available (from sources such as Amazon.com) as well as headphones and MP3s so that nurses could simply have a 15-minute break to listen to a tape and come back out feeling regrounded. Other places redesigned their nursing lounge areas as a place of meditation. Nurses tend to gravitate and talk about their struggles about burnout and stuff, but they often will only do it informally in the parking lot or on the way home from work. However, the nurses who attended this program learned to intentionally put together groups that they could talk to from their own unit teams. The topic of ‘compassion fatigue’ and the burden of providing compassion caring to patients was certainly a common topic that began to be recognized as ‘this is an aspect of our work’. This is not just the medications we deliver or the physical symptoms that we manage — in fact, we’re offering these patients parts of ourselves, and that is work too. But somehow it legitimized the dialogue, and even though institutionally we didn’t move forward with formally structured classes or interventions, the staff took to it, and I found that very hopeful. I’ve been doing nursing for 35 years now, and I remember the days when we were actively discouraged by our leadership from engaging in being sorrowful or tearful at all for our patients — we were supposed to tough it out. It was a developmental issue in the profession those years ago, and as someone who has stayed in this profession, it is nice to see people legitimize this aspect of our work. Why do nurses so often experience a higher rate of burnout? I think it comes from our historical roots in providing service — in some ways I believe it came out of that religious quasi-military type tradition where we’re here to provide service to others, and there is something not okay for us to recognize our own needs. We’ve lived in that model in nursing as a sort of unstated paradigm for a very long time. However, what is nice about this is that by acknowledging the nature of our work and making it legitimate to talk - not whine - but talk about our stress is a real factor in what we do. We are legitimizing the notion that in order to provide service well, the first person we must serve is ourselves, outside of the care units. We must eat right, live healthy lives, and not smoke — as a rule we must be our own best guardians of our health in order to be wonderful guardians to the people who come to us for assistance. Is there anything else you’d like to add? 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