Taking Care of Care Providers: A Wellness Program for Pediatric Nurses

Abstract

The cumulative effect of professional stress and compassion fatigue within the health care profession has been receiving increasing attention. The impact can be especially worrisome for nurses who work with chronic illness populations, such as oncology. While interventions targeted at reducing nurses stress and promoting wellness are cited as necessary, they are often lacking in busy medical environments. In this article, the authors describe a newly developed 10-session wellness program that was offered on 2 occasions to both inpatient and outpatient nursing staff. The nursing staff chose the content areas, and each session used a combined approach of hands on and didactic learning. A description of the activity offered during each session along with the core competency and objectives measured are provided. Overall, staff found the wellness series very helpful to themselves and to their ability to positively change their job performance.

Background

The World Health Organization (2006) defines health to be a state of complete physical, mental, and social wellbeing. Recently, overall health has become synonymous with the term wellness. Swarbrick, D’Antonio, and Nemec (2011) describe 8 dimensions of wellness: physical, spiritual, social, intellectual, emotional, occupational/leisure, and financial. Clinicians, such as medical staff, nurses, and counselors, who work diligently to provide health-promoting care to others are often not as successful in taking the time to incorporate wellness behaviors in their own life. Over time this could contribute to compassion fatigue, a term that refers to the loss of ability to provide the same level of compassion and care for another person following prolonged, continuous, and intense contact with patients (Coetzee & Klopper, 2010) due to a depletion of the practitioner’s emotional and physical energy toward work (Figley & Gould, 2005). With increasing attention to the effects of compassion fatigue, staff wellness programs have become an important component of caring for professional staff. Symptoms of compassion fatigue include emotional exhaustion, cynicism, and a low sense of personal accomplishment (Maslach, Schaufeli, & Leiter, 2001). Continued compassion fatigue leads to burnout. The intense atmosphere of ongoing losses, an understaffed workforce, and a high-stress environment make nurses particularly vulnerable to both compassion fatigue and burnout (Medland, Howard-Ruben, & Whitaker, 2004).

No one would argue that hospital-based pediatric nursing offers the potential of a challenging and meaningful career, yet it also involves unique challenges related to repeated exposure to serious illness, trauma, pain, suffering, and death (Coetzee & Klopper, 2010). These experiences combined with frequent heavy workloads, staff shortages, inadequate management support, uncompetitive remuneration, poor working conditions, a lack of resources to work effectively, limited career opportunities, and unstable work environments all affect nurses’ emotional well-being, personal health, and, potentially, their ability to provide appropriate patient care (Buchan, 2006). These factors also place pediatric nursing staff at risk for emotional exhaustion.

Moreover, nurses, by way of their role in patient care, can develop strong attachments to patients and their families. Consequently, they may experience an intense sense of loss if a patient dies. Studies show that nurses are more likely to suffer extended mental anguish while caring for a dying patient (Engler et al., 2004) and internalize their grief symptoms (Hinds et al., 1994). Their grief has been shown to result in personal changes in energy, sleep patterns, and appetite (Hinds et al., 1994). Guilt, sadness, anger, shock, and relief at the passing of their patient have also been noted, but frequently nurses do not have or are unaware of available supports to cope with these emotions (Spencer, 1994). Less experienced nurses are found to be at a greater risk for increased anxiety and distress at the death of a patient (Hinds et al., 1994). Care has also become increasingly complex due to the need for nurses to learn new technologies, along with having the skills to sensitively communicate with families with multifaceted psychosocial needs. Additionally, pediatric nurses are often heavily invested in their patients and work, which can lead to difficulties with boundaries and work–life balance (Swetz, Harrington, Matsuyama, Shanafelt, & Lyckholm, 2009). Although nursing and other health care leaders recognize that nurses experience grief when their patients die, most nursing curricula include limited education on coping with loss and grief experienced in the work setting or the skills needed to maintain professional boundaries (Chan et al., 2008; Engler et al., 2004; Spencer, 1994; Wright & Hogan, 2008), which can leave early career nurses particularly vulnerable.

In 1997, the International Council of Nurses mandated that nurses have a unique and primary responsibility for ensuring that at the end of life individuals experience a peaceful death. The group made recommendations regarding the competencies necessary for nurses to provide high-quality care to patients and families during the transition to end-of-life care. The identified competencies include recognizing one’s own attitudes, feelings, values, and expectations about death and the individual, cultural and spiritual diversity existing in these beliefs and customs. The purpose of the competency statements was to assist nurse educators in incorporating end-of-life content into nursing curricula. Educational preparation for end-of-life care has been inconsistent and sometimes neglected within nursing curricula (International Council of Nurses, 1997).

Previous studies highlight strategies clinical staff have identified as ways to reduce burnout, namely, maintaining their own physical well-being and self-care, having supportive professional relationships, engaging in spirituality, and talking with others (Hinds et al., 1994; Spencer, 1994; Swetz et al., 2009). Despite staff acknowledging the usefulness of these strategies, nurses frequently report inadequate time to incorporate them into their personal or professional life (Spencer, 1994). Many pediatric hospitals have programs for patients and their families designed to reduce distress (Flannigan, 2010), yet few have established intervention programs for nursing staff to counter the emotional components, maintain balance, and help prevent physical and emotional exhaustion (Aycock & Boyle, 2009). Of the intervention programs that have been studied, nursing staff indicate positive reactions both immediately following the intervention and at a 6-month follow-up (Hinds et al., 1994).

The National Institutes of Health (NIH) Clinical Research Nursing Model of Care provides a framework for the delivery of high-quality nursing care to research participants. Dimensions within the Model of Care include the provision of direct nursing care and support, coordination of research and clinical activities, maintenance of informed consent/assent, participant safety, and protocol integrity. Clinical research nurses (CRNs) in the pediatric program at the NIH Clinical Center care for pediatric research participants with various diagnoses and differing levels of complexity. Multiple institutes of the NIH (eg, National Institute of Allergy and Infectious Disease; National Heart, Lung and Blood Institute; and the National Institute of Child Health & Human Development) enroll pediatric patients on research protocols. Some of these protocols include children who may be in good health who are enrolled as healthy volunteers, while most other protocols enroll children with life-threatening illness and refractory disease. Children enrolled on phase I trials are a vulnerable population, who frequently require long-term hospitalizations and pose specific physical, emotional, and psychosocial challenges. CRNs play a pivotal role in care coordination of the pediatric patient while maintaining protocol integrity.

With the intensity of multiple long-term patients and an increased number of pediatric patient deaths, staff began expressing feelings of emotional isolation, burnout, and compassion fatigue. In response, members of the psychosocial program of the Pediatric Oncology Branch of the National Cancer Institute (LW, SZ) collaborated with the nursing leadership to develop a Wellness Series for the nursing staff. The proposed goal of this program was to promote self-care, education, and teambuilding; develop proactive strategies to enhance staff wellness; and to provide a forum for the staff to discuss patient–staff interactions and more complex care giving scenarios. This article describes the overall wellness program, objectives for each session, evaluation outcomes, and provides recommendations for future programs.

Setting

The pediatric program of care at the NIH Clinical Center includes a 22-bed pediatric inpatient unit, an outpatient pediatric day hospital, and an outpatient pediatric clinic. Pediatric patients enrolled on a clinical research trial are cared for in 1 of the 3 patient care areas.

Program Development

Prior to initiation of a wellness programs, sessions for each series were developed based on nurses’ requests. Along with a form for nurses to indicate topics of interest, a suggestion box was also provided in nursing stations. This was created so that nurses could suggest topics anonymously. Ten specific topics were requested, and the psychosocial support group recruited experts from throughout the National Institutes of Health, including members of our own team, to lead each of these individual sessions. The wellness program has now been implemented twice. During the first series, each session was held once in the morning and once in the evening to accommodate both daytime and evening staff. The second series was held once on the inpatient unit and once in the outpatient clinic to accommodate all pediatric care staff.

Sessions were formatted to include a verbal educational component, a hands-on activity or interactive discussion, reading materials related to the topic, as well as time for staff to ask questions or present a case related to the wellness topic (see Table 1). Formal evaluations were conducted at the end of each session. Nursing staff completed a brief evaluation that asked the following: (a) Did the session provide new information, ideas, and discussion about areas that can potentially impact my work? (b) Did the session elicit participation from those who attended? (c) Was the overall quality of the instructional process an asset to the activity? (d) Will participation enhance your personal effectiveness? (e) Will you change your practice as a result of attending this session? Staff was also asked whether the wellness series should continue and to provide any comments/feedback as well as suggestions for future topics.

Table 1.

Overview of Wellness Sessions

Session Title	Core Competency Objectives	Activity
Series 1
Resiliency (Art Therapy)	To learn at least 3 methods that can   promote resiliency.	Staff members created a pocket-sized collage as   resiliency reminders, emphasizing strengths   and coping mechanisms.
Teambuilding (Psychosocial     Services)	To identify barriers to successful   teambuilding and key components to   satisfying working relationships.	Games were used to (a) illustrate how   “assumptions” about coworkers could   reduce teamwork and (b) build rapport   between staff members.
Communication with     an International Family     (Psychiatry)	To recognize at least 3 means of   reducing language and culture   barriers to care.	Targeted integrating cultural awareness into   care via discussion of case scenarios.
Communication (Psychosocial     Services)	To have knowledge of 6 effective   communication strategies.	Games and case scenarios were used to   (a) emphasize importance of effective   communication in the workplace, (b) identify   common causes of miscommunication, (c)   teach methods of nonverbal communication,   and (d) demonstrate use of effective   communication strategies.
Creating Awareness and     Developing Relaxation Tools     (Pain & Palliative Care Team)	To learn guided imagery techniques   that can promote relaxation.	Staff members participated in developing a   relaxation script, which was then practiced   and recorded in session and then distributed   to staff.
Creative Ways to Assess and     Treat Pain (Pain & Palliative     Care Team)	To become familiar with 3 or more   effective methods of assessing pain   in pediatric patients, as well as 4   methods of pain reduction and   alternatives to medication.	Staff members participated in discussion   surrounding a variety of case examples and   were provided with teaching related to   effective pain assessment and management.
“I Don’t Want To!” Working     with Those Who Push     More than the Call Button     (Psychosocial Services)	To learn a model of care directed   at diffusing tension and enhancing   effective communication between   the provider and the patient/   caregiver was presented.	Staff members were collectively asked to   identify examples of difficult patients.   Scenarios of difficult patients/caregivers were   provided to initiate discussion on effective   patient/caregiver management. Staff were taught 4 strategies in working with   difficult patients/caregivers.
Transition from Curative     to Palliative Care (Pain &     Palliative Care Team)	To identify 3 effective ways of   communicating with patients   receiving palliative care.	Staff were invited to discuss personal   experiences of difficult scenarios and group   discussion was held on how to effectively   manage discussing palliative care with   patients.
Blurry Boundaries     (Psychosocial Services &     Ethics)	To identify common boundary issues,   learn 4 appropriate methods of   communicating boundaries and 5   self-monitoring techniques.	Case scenarios were used to (a) illustrate how   boundary crossings can interfere with care   and (b) impact professional role.
Anxiety, Depression, and     Passive Suicidal Ideation:     Warning Signs and How to     Help (Psychiatry)	To identify at least 3 signs/symptoms   of anxiety, depression, and suicidal   ideation.	Staff were engaged in discussion of case   examples demonstrating “normal” and   “problematic” symptoms within a hospital   setting.
Series 2
Using an Interpreter to     Communicate with Patients     and Families (Interpretive     Services)	To name at least 3 reasons to use an   interpreter during communication   with non-English speaking families.	Case scenarios of miscommunication were   discussed and staff were encouraged to   problem-solve methods of improving   communication.
Teambuilding (Psychosocial     Services)	To identify barriers to successful   teambuilding and key components to   satisfying working relationships.	Games were used to (a) illustrate how   “assumptions” about coworkers could   reduce teamwork and (b) build rapport   between staff members.
Making the Connection:     Understanding the Treatment     Experience of International     Families (Social Work and     a Professional Medical     Translator)	To gain knowledge of 5 common   challenges that international families   face and to identify at least 3 areas   for intervention.	Findings of a current study evaluating the   treatment experiences of those families who   travel to the United States for care were   discussed. Options for intervention were   provided.
Communication with Patients     (Psychosocial Services)	To learn at least 3 components   of effective nurse–patient   communication as well as behaviors   to avoid.	Staff discussed case scenarios to facilitate   understanding and problem-solve potential   difficulties.
Medical, Psychosocial, and     Ethical Needs: The Role of     the Nurse at Time of Patient     Death (Psychosocial Services     & Department of Bioethics)	To be able to identify 3 signs of   impending death that families find   most stressful, interventions to   support the child and family at   the time of death, and post death   communication tools.	The presentation of a case where the parent   was perceived to have changed her mind   about the DNR order. Medical facts, ethical   considerations, psychosocial factors were   explored while examining possible outcomes   with different approaches. Three key journal   articles on end-of-life care were provided.
Patient Knowledge of     Prognosis (Psychosocial     Services)	To be able to identify 6   developmentally appropriate steps   when discussing prognosis with a   patient.	A training video was shown around which   discussion was generated regarding   discussing prognosis and how to meet the   patient/family where they are as prognosis   worsens.
Nursing Role in Transitioning     to Palliative Care (Pain &     Palliative Care Team)	To name 3 effective ways of   communicating with patients   receiving palliative care.	Staff was invited to discuss personal   experiences of difficult scenarios and group   discussion was held on how to effectively   manage discussing palliative care with   patients.
The Boundaries of Social     Media (Psychosocial Services     & Ethics)	To gain knowledge of 6 published   guidelines on appropriate use of   social media in nursing care.	Case scenarios were used to facilitate staff   discussion about boundaries related to use   of social media, including Facebook and   CaringBridge.
Assessment and Management     of Patient and Caregiver     Mood (Psychiatry)	To learn at least 3 appropriate and   effective means of assessing patient   and caregiver mood and to identify   at least 2 interventions.	Several case examples were presented to   facilitate staff discussion.
Massage for Stress Reduction     (Massage Therapy)	Staff members were taught methods of   self-massage for stress reduction.	Massages were provided to staff in 10-minute   intervals as a means of providing a relaxation   activity.

Results

In total, 126 evaluations were completed. The majority of the staff found the sessions to be effective in providing new information that they felt would enhance their work skills. More than 75% reported that the sessions would change (“completely” and “considerably”) the way they performed their job (see Figure 1).

Figure 1.

Staff evaluation of wellness sessions

In addition to ranking session utility, staff participants were provided open space to leave feedback on the sessions. The majority of comments related to the quality of the information provided: “This was informative and helpful,” “Excellent presentation. I enjoy learning new methods of self-care,” “This is the first time I’ve had to come to terms with one of my patient’s passing away. Thank you for educating and making me feel more at peace with the situation.” Positive feedback was also received regarding the format of the session: “Great activities—liked having an activity, discussion, reading, etc. Great for teambuilding, please continue,” “I thought it was an exceptional session for a short 1 hour—lots brought out with positive discussion and excellent facilitation of comments. Thanks very much.” The only negative comments provided were during sessions that entailed less didactic discussion. Most of these comments were similar (eg, “This was good, but getting us to talk with each other is crucial.”)

Discussion

We were able to successfully implement a Wellness Program for inpatient and outpatient pediatric nursing staff. Success for the program may be associated with staff involvement in providing the topics to be addressed; the combination of hands-on activities, didactic teaching, and case presentations; and the provision of new “tools” to be taken away from each session.

Several factors must be in place for the implementation of an ongoing staff support program to be successful. Assessment of staff needs is critical in identifying potential relevant topics or areas of concern. Content experts are needed to facilitate sessions and provide tools and resources related to each topic. It is also essential that hospital administrators acknowledge and support the need for wellness activities focused on the caregivers. At the unit level, time away from the bedside is required so that staff can be fully engaged in sessions without interruption.

Conclusions

Caring for critically ill and terminally ill children can generate grief reactions, stress, high staff turnover, difficulty concentrating, professional loneliness, and a sense of hopelessness when not addressed. In complex patient care settings where nurses are at risk for compassion fatigue and burnout, it is necessary to provide supportive care, offer educational opportunities, and teach new coping strategies on an ongoing basis.

Biographies

Sima Zadeh, MA, is a postdoctoral fellow in the Behavioral Science Core of the Pediatric Oncology Branch of the National Cancer Institute.

Lori Wiener, PhD, is codirector of the Behavioral Science Core of the Pediatric Oncology Branch of the National Cancer Institute and Head, Psychosocial Support and Research Program in the Center for Cancer Research.

Nicole Gamba, RN, BSN, CPON, is the nurse manager of the Pediatric Inpatient Unit and Day Hospital in the NIH Clinical Center.

Caroline Hudson, BSN, RN, CPON, is the clinical manager of the pediatric unit at the Clinical Center of the NIH.