Recharging compassion in paediatric trauma

Nurses in paediatric trauma services must be especially proactive with self-care strategies, to manage the personal impact of encountering so much intense suffering over time.

In my paediatric nursing career spanning more than 30 years, there have been many wonderful times of profound fulfilment, knowing that I made a positive difference in the life of a family.

My career focus over the last 10 years has been in paediatric trauma, and during this time, I have developed a paediatric trauma service in a quaternary major trauma centre in Brisbane that admits about 1000 paediatric trauma patients for longer than 24 hours each year.

About 10 per cent of these patients are critically injured and need to stay in hospital for prolonged periods of time. It is this group of patients that has a heavy impact on our personal resources, including our compassion and our ability to feel empathy. This impact is a well-recognised phenomenon known as ‘compassion fatigue’.

Compassion is defined by psychiatry professor Harvey Max Chochinov as “a deep awareness of the suffering of others woven with the wish to relieve it”.

Compassion fatigue has been described as the ‘cost of caring’ for others. It often has profound emotional ramifications when nurses feel consumed and are unable to energise or reinvigorate themselves. It is an indirect response to their patients’ suffering. Compassion fatigue is cumulative over time and is evident in nurse’s personal and professional lives.

Much has been written about compassion fatigue for frontline healthcare workers, particularly those working in adult emergency departments (ED). Within the fast-paced environment of EDs, there are high-acuity, complex cases, high patient turnover, overcrowding, performance measures and targets to meet, plus access block. In addition, there have been recent increases in patient addictions, illicit substance abuse, violence, aggression, dying patients, the critically unwell and the severely injured.

While there is a large amount of literature about compassion fatigue in adult care, not much has been written about paediatrics and compassion fatigue; it is often forgotten. Yet caring for children presents unique challenges, eliciting a detailed history of the events requires attentive listening, coupled with well-honed clinical skills.

While children are vulnerable because of their developmentally influenced anatomy, focus is not only on physical injuries, but also on the emotional and social needs of the child and their family. The paediatric patient and family unit are a package, and as so, the frightened or indeed the strong-willed child with their parents needs compassion and understanding.

Consider the paediatric trauma nurse co-ordinator who is exposed to many complex and confronting situations.

The trauma nurse co-ordinator’s first meeting with the injured child is often in the chaotic ED, at a trauma call. The following morning, when visiting the patient and his or her family in the highly stressful intensive care unit, the nurse is required to review patients with life-threatening injuries; for example, the child with a spinal injury after falling from his skateboard who will never walk again.

Perhaps a child who has suffered a non-fatal drowning, who looks perfect externally but the nurse knows about the hypoxic insult to the toddler’s brain.

The nurse must ignore the smell of the patient extricated from a house fire, now covered in dressings and attached to a ventilator.

The trauma nurse will round on the ward, to ensure tertiary surveys have been completed for the 10-year-old daredevil who chose to ride his BMX bike without a helmet on the road.

On the next ward, the trauma nurse may spend some time explaining  neuro-rehabilitation to the parents of the 6-year-old pedestrian who ran out behind the school bus to surprise her mother but was knocked down by another parent. The nurse may also speak with the young girl who fell from her horse and was crushed by its almost 500-kilogram weight.

Fortunately, children are resilient and they usually heal quickly but there are occasionally long-term patients, such those with traumatic brain injuries undergoing their neurological rehabilitation, or children with large-percentage burns who require extended rehabilitation, or the infant with all the unexplained injuries, who may have no visitors and is waiting for foster-care placement.

The concept of the ‘second victim’ relates to the impact on healthcare workers who are involved in medical errors that cause harm to the patient, the ‘first victim’.

Almost all healthcare professionals become what is deemed the ‘second victim’ at least once in their careers. Is it a medical error if your CPR was ineffective because it did not revive the child with catastrophic injuries?

Studies show that error involvement can have a tremendous negative impact on healthcare workers, leading to burnout, depression, professional crisis and, ironically perhaps, jeopardising future patient safety.

The paediatric trauma nurse co-ordinator follows the patient’s journey from the day of admission until the day of discharge. Are the trauma nurse co-ordinators not, therefore, immersed in vicarious suffering on a daily basis, and on occasion over prolonged periods of time? Consider the critically injured child who does not survive, and the nurse’s self-reflection, rumination, debrief and disclosure, along with the death review.

Nurses hear the stories from injury scenes told with such intensity – and they hear similar stories so often – that it has an impact on them. Eventually, the nurse loses a certain spark of optimism, humour and hope. It is not the most difficult story you have ever heard, but the thousands of stories you don’t even remember hearing about, that can cumulatively affect the trauma nurse.

Regardless of where a workplace is located, the first intervention step to help nurses cope with adversity is to review the resources that are available in your workplace. Resilience does not have to be innate, it can be taught and developed.

With this in mind, most Australian hospitals now include an Employee Assistance Program (EAP) as part of their human resources department. The primary purpose of EAPs is to provide employees with supportive counselling for personal and work-related issues.

Talking about one’s concerns and feelings with an appropriate person can give support and hope to the nurse, and assist with the development of an action plan to address compassion fatigue. Often, an EAP will present formal classes on topics such as managing time, balancing a budget, communicating effectively and reducing stress.

These classes are designed to enhance work-life balance and provide help for employees experiencing conditions such as compassion fatigue. Seeking out a mentor, supervisor or experienced nurse or peer who understands the norms and expectations of one’s role may assist in identifying strategies that will help with the current work situation. Some examples of helpful strategies might include: changing the work assignment or shift; recommending time off or reducing hours; encouraging attendance at a conference, or becoming involved in a project of interest or activities that promote work-life balance.

Pastoral care departments or social work departments also offer a variety of activities to support nurses and healthcare staff. The goal of pastoral care is to meet the spiritual needs of patients, families and staff, including nurses.

Supportive activities include facilitating reminiscence during times of loss or death, offering prayer and comfort, organising activity retreats for hospital staff, and providing spiritual help through individual counselling and group programs.

Developing positive self-care strategies and healthy rituals is important for a nurse’s recovery from compassion fatigue. Healthy rituals practiced on a regular basis that replenish personal energy levels and enhance feelings of wellbeing include activities that promote adequate nutrition, hydration, sleep, and exercise. Walking, running, dancing, gym, cycling – it does not matter; find your thing and incorporate it into to your daily life.

Perhaps try a new approach to self-care, such as a yoga class, massage, mindfulness, meditation, tai chi, et cetera

Paediatrics is a specialty area that presents challenges, but the rewards are enormous. Compassion fatigue is often one of the challenges. It is a well-recognised phenomenon that may affect a paediatric trauma nurse over time if conscious steps are not taken to address it.

There are myriad online resilience training programs and applications highlighting the prevalence of compassion fatigue in our healthcare system, and empowering nurses with the skills to self-preserve, to reconnect professionally, socially, emotionally, physically and cognitively. These will help enable nurses to be empathetic and compassionate, focused and optimistic about the future.

Tona Gillen is nurse manager, trauma, at Lady Cilento Children’s Hospital in South Brisbane.

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