Historical Trauma in Caregivers

Nurses are angels.

Nurses are heroes.

Nurses are the most trusted profession.

Nurses are humans with human experiences.

Sometimes messages about nursing involve an image of nurses that are amazing and often superhuman. They work 12-hour shifts caring for the sick and dying without thanks or a primetime tv show (that’s for the doctors). This image is because nurses do work hard and they do this work is often very difficult circumstances. They chose a profession that relies on the combination of science and compassion to help people through the most difficult moments of their life.

But nurses are not angels and they are not superhuman. They are very human.

There is a lot of discussion about burnout in healthcare these days. Part of that is a greater body of research on burnout that is finally reaching the bedside. The other part of that is in an era of social media, where nurses are finding a voice to talk about it. Under the umbrella of burnout comes compassion fatigue, vicarious trauma, and secondary traumatic stress. One often mentioned but not detailed point in the literature about burnout is how personal trauma increases your risk for burnout, compassion fatigue, etc. In fact, a recent study of 211 students in a BSN program saw a correlation between adverse childhood experiences (A.C.E.) and burnout.

According to the CDC, “Adverse Childhood Experiences (ACEs) is the term used to describe all types of abuse, neglect, and other potentially traumatic experiences that occur to people under the age of 18. “

The research on A.C.E. originated in a Kaiser study of around 17,000 participants. The study found a significant relationship between A.C.E. and health and well being. A.C.E. are organized into three groups, abuse, neglect, and household challenges. The higher the number of A.C.E., the higher the risk for negative outcomes like depression, substance abuse, cancer, and more. A.C.E. increases a person’s chronic stress and may make them more likely to engage in risky behavior. People with a score of six or more tend to die 20 years earlier than those without. As a reminder, having adverse childhood experiences doesn’t mean you will also have all of those negative effects, and some people are quite resilient.

This area of the research is especially interesting to me for multiple reasons, but the primary reason is that when I look at the A.C.E. survey, I have an A.C.E. score of 7. And I did experience some of those lasting impacts (hello teen pregnancy). But I chose a career where I believed I could make a difference and help others because of my adverse childhood experiences. In fact, in nursing school, I was voted the most caring nurse. I see similar reasons in my nursing students too. They often talk about wanting to make a difference.

We know that A.C.E. are not uncommon. So what happens to the nurses with A.C.E. when they care for others? According to that 2018 study, student nurses with higher numbers of A.C.E. had a higher level of burnout and depression. And one thing I tell my students about our most difficult life experiences is that one day you inevitably run into something that brings up those past experiences. It may be your patient reminds of yourself or someone you knew. It may be that your patient is experiencing the same adverse event you did. We are often in a caregiving moment that also brings us face to face with our life experiences. Nurses need to be prepared for how to handle it. In school, we often learn how to use therapeutic conversation skills or lifespan psychology to care for our patient. But there is not enough conversation about how our experience impacts our care or how we manage our emotions through it.

Emotional labor is a key aspect of burnout in new nurses.

So what can you do for yourself?

Learn about A.C.E. See what your score is (there are a few different questionnaires, this is one).

Develop a mindfulness practice. Yoga or meditation.

Get a therapist. Find strategies to help you work through your experiences and develop strategies you can use when you encounter triggers at work.

Have boundaries. Stop working extra or so many days in a row. Stop being the only nurse who will take the abusive patient that reminds you of someone you grew up with.

These events were out of your control, but what you do today is in your control.

How to Take a Leave From Nursing: even if you are not a single, traveling nurse

In 2017, I was burned out. From cancer nursing, from busy fast-paced hospitals with constant change, from caring for my children, from graduate school… from everything. I wanted a break. But I still had responsibilities and I couldn’t just leave them all to run away to Europe. I wasn’t a travel nurse and I wasn’t young and just out of college taking a gap year. So I devised a plan to take a leave of absence from nursing.

http://

This video was pretty specific to my unique situation and opportunities, but let me know if you did anything similar or have any advice for other situations!

What I Wish I Had Known as a New Nurse

When I graduated from nursing school in 2004, I applied and interviewed for only one job. I wanted to work in pediatric oncology. In my interview, the manager asked me how I would deal with death. I replied that everyone deserves compassionate care through all stages of life, even at the end of life,  and that it should be provided by people who really care. I wanted to be able to provide that kind of compassionate care.

I got the job and started a new graduate training program that lasted 13 weeks. We learned a lot about cancer, chemotherapy, managing side effects, and the psychosocial aspects of cancer care. But even from the beginning, some conversations and lessons were lacking or absent.

I remember getting a letter mailed to me at home from my preceptor introducing herself to me. It was a thoughtful way to be welcomed onto the unit. I learned a lot from my preceptor, who was very experienced. But there were a few things I learned over the years that I wish would have been included in my new grad orientation program.

Making a Mistake Does Not Make You a Bad Nurse

Everyone makes mistakes. Everyone. Let’s say that again. EVERYONE MAKES MISTAKES. Even the perfect nurse on your unit. Obviously, none of us want to and none of want our mistakes to harm patients. But the ways in which a hospital achieves that is to create and design systems that prevent mistakes. Every time we introduce something new into a system, there’s a chance for mistakes. New drug? People could make mistakes when they are still learning it. New equipment? People might program it wrong, clean it wrong, etc. But also, new people. New nurses, new doctors, a new chance for miscommunication.

I remember making my first mistake on the night shift. It was with medication. We used to store all of the similar types of syringes in the same pyxis drawer. Even if they were different doses and had different patient names on them. So when my patient was upset and wanted medication in a hurry, I grabbed the wrong syringe. Luckily, I was the right dose. This was before barcode administration. But I felt like a bad nurse. I failed the basic rights of med administration.

But I wasn’t a BAD nurse. I was a human nurse. I was dealing with my emotions, a panicky kid, another nurse telling me to hurry, and a poorly designed system.

Perfectionism is Not Necessarily a Good Thing

Maladaptive Perfectionism is a term to describe the perfectionism that has been observed in nurses from internal or external pressures. Following along with the idea that making a mistake makes you a bad nurse, is this idea that is often pushed in nursing school and throughout the profession. Some of it is internal and some of it is external messaging.

When I joined my first nursing council, we had a portion of the meeting here we examined errors, without knowing who made the error and discussed the next course of action. We were supposed to be operating under a just culture frame work. But despite that, there were always inevitable conversations that nurses would have where they said how could they do that and I would never…As a recovering perfectionist, I was right there with them, reinforcing the same ideas that we needed to be perfect 100% of the time and internalizing the message. But the outcome of that messaging was only a creeping doubt that I was not a good nurse because I was not perfect. We needed to hear the message that we were not perfect and could not expect to be, which was why we needed better systems.

Compassion Fatigue is Inevitable

In nursing school, my classmates voted me the Most Compassionate Nurse. I am sure it was based on an occasion in our first semester where a classmates patient yelled at me and I ended up eating my lunch with them and talking about their frustrations. I was a highly idealistic, compassionate new nurse committed to making a difference. What I didn’t know at the time, was that the research shows is that I was at high risk for burnout and fatigue. I also had my own life experiences, that included past unresolved trauma, that made me at risk for poor coping. How many of us go into nursing to make a difference because of past experiences? Have we fully come to terms with those experiences?

New nurses under thirty who are highly idealistic are at higher risk for dealing with the burnout spectrum. I wish I would have known that what I loved about nursing, the compassion satisfaction I get from caring for others, had a cost. That all of the kids I would care for with cancer who would not survive would take a toll. And I wish I would have been taught strategies to manage and deal with it.

A lot of what we do to prepare nurses is about the science and art of caring for others. But not enough of it is about the science and art of caring for ourselves in order to sustain the care we provide for others. What are some things you wish you would have known as a new nurse in order to sustain your career as a caregiver? Leave a comment below!

Cultivating A Practice of Gratitude

In 1998, I bought a journal to start a practice of gratitude. I was living off $524 a month plus food stamps and I was a single mother. I didn’t have a car. I had my hours cut at work when they found out I was pregnant. They didn’t fire me, just said there were no extra hours for me this week. Or the next week. And the week after that.

I was struggling every day with sadness, stress, and anxiety about the past and the future. I was constantly wondering what was going to happen and how was I going to make it better. I had generally been a pretty optimistic person and a believer in planning my way int a better future. But this time, I was not so sure. I wrote some pretty depressing thoughts down one day really questioning what the purpose of everything was. I was really looking for something different. So I watched a lot of Oprah because television was free. She had recently started Change Your Life Television, which was a content change in for her talk show. It was just what I needed. I watched and tried to implement the advice of various guests. I got a journal and I wrote down things like, I am grateful that I paid my phone bill. I am grateful that I got a ride instead of having to use money for the bus.

I tell that story to people all of the time. I learned a lot from watching Oprah. Practicing gratitude was an essential lesson for my life. I learned to appreciate small things, which is why today, I still get a good feeling from paying bills and my taxes. I don’t often hear people say that they are happy to pay their property taxes, but I am. I remember when I lived in a small apartment with no yard or even a balcony. I remember when I needed to use taxpayers money to buy top ramen and Krusteaz pancake mix. When I pay taxes, sometimes I think that I might be helping someone out. Someone who needs Medicaid.

For the last twenty years, I have had to return to this practice of gratitude repeatedly. And it is a practice. It turns out I couldn’t just use it that one time and move on. Life happens in all kinds of beautiful and very difficult ways. Gratitude has been helpful in working through hard times in my marriage and relationships. It helped me to focus on the value of my relationships even when things were really hard. I used gratitude when I was scared about the things I could not control that were happening to loved ones. In those moments, I was grateful I could miss work. I was grateful for health insurance.

“When we focus on our gratitude, the tide of disappointment goes out and the tide of love rushes in.”

Kristin Armstrong

Sometimes practicing gratitude sounds like putting your head in the sand and ignoring the difficulties around you. When you are a caregiver, you sign yourself up to do work to help others. When you see others suffer, you may feel guilty being happy about what you have. Is it fair to be grateful when people are sick, are homeless, are separated from their loved ones? But gratitude isn’t about ignoring the plights of others. Its creating and fostering resilience in your life to navigate through difficult times. Gratitude changes the way you see things and experience the things around you. Gratitude is how you can get back up and help others. I know I would not be here if it weren’t for the help of others. My gratitude for help keeps me working to help others be successful in their own goals. My gratitude gives me energy when other things are using up that energy.

So how do you cultivate a practice of gratitude?

Do it every day.

Choose to do one of the things on the list below. But remember to set your intentions to do these things. This isn’t a to-do list to pressure you or to make you feel like you aren’t doing enough. It doesn’t mean you won’t have hard days. Its a strategy for managing the hard times and finding joy in the present moment. And remember, its a practice. So we keep practicing. If you aren’t very grateful today, you can get up and try again tomorrow.

  • Use a journal to write three things you are grateful for.
  • Go around the dinner table with family or friends and say something you appreciate about each other (we used to do this with our kids when they all lived at home)
  • Sit outside for 5 minutes each day and practice being present. Let go of thoughts about the past or the future and use your senses to experience the moment. See, feel, hear, etc.
  • Put a calendar reminder on your phone to pause, breathe and express gratitude.
  • Pray or meditate.
  • Volunteer for a charity.
  • Write a thank you note to someone who has helped you.

Travel and Blood Clots: Should You Be Worried?

Staying healthy while traveling is important, especially in today’s world. Travel has become more accessible than ever due to a strong U.S. economy and airfare deals. The more we travel, the more we have to consider the health risks of travel. The Center for Disease Control (CDC) website lists common health travel concerns. These include things like medications, jet lag, mental health, bug bites, etc. One of the concerns on the list is Deep Vein Thrombosis (DVT) and Pulmonary Embolism (PE). When I travel, I know this is a risk, but I always wonder, how much of a risk is it?

What is a DVT?

A DVT is a blood clot that is formed in a large vein. This blood clot can block blood flow through the vein. The symptoms of a DVT is swelling, heat, redness, and/or pain in the arm or leg. A PE can occur when the clot breaks off and travels to the lung blocking blood flow in an artery. Symptoms could include chest pain, coughing up blood, a fast heartbeat, and/or difficulty breathing.

Are you at risk for a DVT?

The risk for a DVT depends on certain factors. Blood will clot with lack of circulation and with certain existing problems. The CDC advises about a general risk for DVT while traveling and with certain conditions. If you are traveling by plane, bus or train, your risk is increased by the length of your travel, how dehydrated you are, and by how little you move (which helps circulate your blood).

Your risk also increased with the following conditions:

  • A previous blood clot
  • A family history of blood clots
  • a known clotting disorder
  • Recent surgery, hospitalization, or injury
  • Using estrogen-containing birth control or hormone replacement therapy
  • Current or recent pregnancy (talk to your doctor about travel)
  • Older age (risk increases after 40)
  • Obesity
  • Active cancer (or undergoing chemotherapy)
  • Other serious illnesses (talk to your doctor about travel risks)
  • Any limitations in movement (casts, disabilities)

How do you prevent a DVT?

There are a few things you can do for DVT prevention:

  • Drink plenty of fluids
  • Avoid caffeine and alcohol to stay hydrated
  • Get up and move around every 2-3 hours if possible. If driving, make frequent stops (you will have to if you stay hydrated!)
  • Do lower leg exercises in your seat. Raise and lower your heels while keeping your toes on the floor or raise and lower your toes while keeping your heels on the floor.
  • Compression socks: In a Cochrane review (expert database for organizing scientific evidence) on DVT with air travel that lasts 5 hours or more showed a decrease in symptomless DVTs after flying. They help circulation in general, so if you get swelling in your feet while traveling, these could help. I find that my feet don’t get cold on flights when I wear them (I am always cold on the plane).
  • Medication for prevention of blood clots for certain problems (not common)

Where can I get compression socks?

They can be easily found online or at health or uniform stores (nurses wear them for work). They usually cost around $20 but they are a good investment and you won’t be wearing them every day. But when you are shopping for compression socks, you want ones that are going to work for you. They are usually a bit of work to put on and should be long enough to go up until just below your knee. They shouldn’t fall down when you walk. They should fit snug for the whole flight and shouldn’t loosen later in the flight.

Caregiver Burnout: How to Recognize Symptoms of Burnout

Caregivers

This one is for the caregivers. The parents, grandparents, children, spouses and other family members caring for loved ones. The partners, friends, foster parents and families of choice. The home health aides, nurses, social workers, occupational therapists and other professional caregivers. The emergency workers, international aid workers, and community outreach workers. You. The ones who are caring for someone who needs help.

Caregivers are doing the work in a variety of circumstances and for a variety of reasons. But ultimately those reasons boil down to caring, whether you’re getting paid or are doing it just because you see a need and want to help. And there are a lot of you out there. According to Caregiving and AARP in 2009, there were 16.8 million families caring for a child with special needs. According to the Bureau of Labor Statistics, 41.3 million Americans are giving unpaid care to elderly people. There are almost 3 million registered nurses in the US.

Some of you are working 12-hour shifts, some of you are working nights, and some of you are spending 30 unpaid hours a week providing for a child’s special needs. All of that work can put a strain on families or lead to burnout in caregivers.

Burnout

What’s burnout? According to WebMD, burnout is a state of physical, emotional, and mental exhaustion that may be accompanied by a change in attitude — from positive and caring to negative and unconcerned. The strain on family caregivers is influenced by a combination of stressors, resources (or lack of), and perceptions about their roles. These factors can lead caregivers to feel exhausted, overwhelmed and isolated. And caregivers typically don’t want to burden their loved one, which often causes them to internalize their feelings. The combinations of strain and internalized emotions can lead to health problems of their own in caregivers.

According to the Self-Healing Through Reflection Workbook, professional caregivers experience burnout as job stress that accumulates over time as physical, emotional, and mental exhaustion (Bush & Boyle). This experience is affected by workload, resources, personal coping skills, leadership and workplace support. The previously mentioned workbook is an excellent resource for nurses.

Symptoms include:

  • Withdrawal from patients, friends and family
  • Anxiety
  • Loss of interest in activities previously enjoyed
  • Feeling blue, irritable, hopeless, and helpless
  • Feeling “numb” or apathetic
  • Changes in appetite, weight, or both
  • Changes in sleep patterns
  • Getting sick more often
  • Feelings of wanting to hurt yourself or the person for whom you are caring
  • Emotional and physical exhaustion
  • Excessive use of alcohol and/or sleep medications
  • Irritability

Professional Caregiver? Click here to get the self-assessment to see if you are experiencing burnout.

Family/unpaid caregiver? Take this self-assessment to see if you may be experiencing burnout.

How to Stay Hydrated While Traveling

Water is Essential

Water is one of life’s most basic needs. You can’t live without it. Remember when we were in school and we learned that we were 70% water. It’s closer to 60%, but that’s still a lot of water.

So where is it and what does it do?

Water is in all of our body’s cells. Just think of how many things feel bad without moisture, our eyes, our skin, and our mouth and nose. Those things are more external, but we need that moisture internally too. It lubricates and cushions joints, regulates temperature, protects sensitive tissue like our brains. Our saliva, blood, and waste is made up of water. Some vitamins we take in need water to be absorbed. If we don’t get enough water, we may feel tired, dizzy and we may have some trouble with short-term memory and other cognitive skills. If we get too dehydrated, we can have a drop in our blood pressure and

So how much water should we drink in a day? According to the Institute of Medicine, around 80% of our water comes from fluid intake with the rest coming from food. In general, adult men should drink13 8-ounce cups and adult women should drink 9 8-ounce cups of beverages. If it is hot, dry, or you are working hard, you need to drink more.

However, when we travel, we sometimes forget about how important it is.

Stay Hydrated While Traveling

Here are 5 ways to stay hydrated while traveling:

  • Bring your own water bottle and keep water with you everywhere you go
    • We know airport water is seriously overpriced and it just adds more plastic into the environment. Instead, bring your own flask or water bottle to fill up once you are past security. If you are worried about space, get one with a carabiner that you can attach to your bag, so it isn’t taking up space inside your bag.
  • Choose water as your beverage when eating out
    • It’s fun to try the local aperitif, but make sure to drink a glass or two of H20 with meals.
  • Avoid drinking too much caffeine or alcohol
    • What’s a vacation without an espresso in Italy or coffee in Vietnam? I love coffee. But don’t overdo it. Caffeine and alcohol are both diuretics. They make you produce more urine to get rid of instead of keeping that fluid in the body.
  • Be careful about eating foods that can cause traveler’s diarrhea
    • Some street food, meat that is raw or at room temperature can be contaminated. Avoid buffets. Wash your hands. Some people pack antibiotics or drugs like Immodium for their trip, you can ask your doctor if they think its necessary.
    • While I have never been sick in another country, I have gotten sick right here in the USA. Sometimes we can’t control how people prepare food.
  • Use this map to see if the tap water is safe where you are traveling
    • Some places surprised me in eastern Europe (I already had tap water there without knowing about this and thankfully I did not get sick)

Real Talk: Depression and Emotional Triggers in the Media

For people with mental illness and those with loved ones who have a mental illness, the news about the loss of Anthony Bourdain to mental illness can really bring up a lot of emotion. Emotions you might have thought you had moved through. I know for me it did. Especially coming right after the news of Kate Spade, on the anniversary of Kalief Browder’s death. All of these individuals lost battles with mental illness.  My family has been impacted by mental illness, from distant family members to my closest loved ones. Because of this, waking up to hear about the loss of someone’s beloved family member really brought up my own past emotions, or at least, what I’d like to believe are past emotions.

Reading this may open you up to painful emotions

Hearing the news, I went right back to a time in my life when a loved one of mine was newly diagnosed with depression. I was terrified of losing my loved one. I took time off from work (thanks to FMLA), put in a good chunk of hours scouring to find a psychologist and a psychiatrist, drove them to appointments, and searched the internet for things that improve mood. I bought omega 3 fatty acids, vitamin d supplements, and dragged them on walks after dinner. I was frantically and desperately trying to ensure that what amounted to my greatest fear wouldn’t happen to my family. Waking up and reading how it happened to someone else’s family brought back all of that pain and fear. I can’t read any articles that want to offer up details because I immediately picture the suffering of those experiencing this tragedy. I went right back to those feelings of fear and pain. I didn’t lose my family member, but these events remind me, that despite looking at my loved one and fighting like hell to get them help, we lose some people to this illness. And my imagined control over the situation is just that, imagined. This is a chronic health problem, and my loved one may experience periods of good health and have relapses in health. It’s a painful thing to face.

Are you or a loved one experiencing triggers from the news?

This may be the case for you or your loved ones. Th experiences you are having are real. So what can you do next?

First, if you think your loved one is experiencing a serious mood change or is at risk of harming themselves, reach out. If you think they are at risk, call the National Suicide Prevention Lifeline (1-800-273-TALK) for help.

What are the signs of depression? According to the National Institute of Mental Health, some signs and symptoms could include the following:

  • Persistent sad, anxious, or “empty” mood
  • Feelings of hopelessness, or pessimism
  • Irritability
  • Feelings of guilt, worthlessness, or helplessness
  • Loss of interest or pleasure in hobbies and activities
  • Decreased energy or fatigue
  • Moving or talking more slowly
  • Feeling restless or having trouble sitting still
  • Difficulty concentrating, remembering, or making decisions
  • Difficulty sleeping, early-morning awakening, or oversleeping
  • Appetite and/or weight changes
  • Thoughts of death or suicide, or suicide attempts
  • Aches or pains, headaches, cramps, or digestive problems without a clear physical cause and/or that do not ease even with treatment

Self Care for Emotional Triggers

When you feel like the news or the media is triggering intensely painful feelings, you can practice some self-care.

  • Know that its normal to experience these feelings. Feelings are real, but how you react and recover differ from person to person.
  • Recovering can include finding ways to cope that help you and don’t harm you.
  • Ways to cope with emotions can include:
    • exercise
    • logging off of the news and social media. Allow yourself a break.
    • journal your feelings
    • reaching out to loved ones
    • Trying a relaxing activity like yoga, meditation, or guided imagery
    • Set goals and priorities for the day. Don’t ask too much of yourself, but organize your tasks and plan for them. Maybe today you need to be at home close to loved ones or a comforting situation. Maybe cleaning will provide that physical activity you could use.
    • Look for comfort, not numbness. Spending time with a pet, play music, watch a funny movie that you love, instead of self-medicating with alcohol. Be careful, alcohol and drug use can increase in triggering events.
    • Avoid judging yourself. Be kind to yourself. You aren’t weak, bad, or less than for having feelings.
  • Some of these a hard to do while traveling. Find an online yoga course to do in your room. Skype a family member if they aren’t with you. Don’t miss sleep, eat healthily and exercise because these all affect your mood.
  • Give yourself some space. If your feelings last longer and it’s affecting your work and your health, reach out to a professional (Clinical social worker, marriage and family therapist, psychologist)

Today, after reading the news, I logged off and took my dog for a hike. My feelings came with me, and I still felt them. But moving and spending time with my dog, while he tried to catch lizards brought me some relief. I hope you can find yours.