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Code Lavender: A tool for staff support

Stone, Rabbi Susan, B., DDiv, BCC

doi: 10.1097/01.NURSE.0000531022.93707.08
Department: INSPIRING CHANGE

Code Lavender for staff support

Rabbi Susan B. Stone is director of spiritual care at Hillcrest Hospital, Cleveland Clinic, in Mayfield Heights, Ohio.

The author has disclosed no financial relationships related to this article.

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CODE LAVENDER is a crisis intervention tool used to support any person in a Cleveland Clinic hospital. Patients, family members, volunteers, and healthcare staff can call a Code Lavender when a stressful event or series of stressful events occurs in the hospital. After the code is called, the Code Lavender team responds within 30 minutes. We offer Code Lavender, on average, twice a month at Hillcrest Hospital.

This article describes a Code Lavender event at Hillcrest Hospital, a 496-bed acute care hospital that's part of the Cleveland Clinic. This staff-support intervention was offered during 2016 to a group of hospital caregivers who'd been intimately involved with a patient over a 3-week hospitalization before she died unexpectedly. Code Lavender's efficacy, implications, and wider applicability are also discussed.

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Who's involved?

The Code Lavender team usually comprises representatives from the spiritual care and healing services departments, and other hospital-based support services (such as employee assistance, music therapy, wellness, the ethics consultation service, and art therapy), and volunteers.

Staffed by holistic certified nurses and other practitioners, the healing services department offers complementary therapies such as Reiki, meditation, and acupressure. The spiritual care department is a part of many patients' medical teams. This department's staff includes a director who's a board-certified chaplain, a board-certified holistic nurse who coordinates healing services and reports to spiritual care, part-time chaplain interns, and numerous volunteers. Considered part of the nursing administration, the spiritual care department reports to the hospital's CNO.

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Code Lavender: What it is and isn't

Code Lavender is an intervention that's used when challenging situations threaten unit stability, personal emotional equilibrium, or professional functioning. Code Lavender uses evidence-based relaxation and restoration interventions to help people meet their immediate responsibilities and make enough sense out of the situation to let more lasting solutions emerge later.

Research shows that Code Lavender doesn't prevent burnout or stress.1 Instead, Code Lavender is akin to psychological first aid. According to the National Child Traumatic Stress Network, psychological first aid is an evidence-informed approach for helping people of all ages and their families after traumatic events.2

Support is given through Code Lavender by providing:

  • a purposeful physical presence
  • individual or team support
  • debriefing and follow-up
  • complementary therapies
  • prayer and other affectively based interventions
  • tea and snacks.
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Prompting incident

Following a car crash, a 23-year-old woman who was 19 weeks' gestation was brought to the hospital by ambulance. She was stabilized in the ED and transferred to the ICU, where she had multiple medical interventions for her injuries for 3 weeks. This patient was the mother of a toddler and enjoyed a large, extended family that included siblings, parents, stepparents, and grandparents.

Her course of healing wasn't linear, but was marked by both progress and setbacks. Prior to her death, clinicians were discussing transferring her to a postacute care unit. An obstetric ultrasound performed in the ICU showed her baby was growing normally. The patient was sitting up in a chair and conversing with a nurse when she became confused and slumped down in her seat. The nurse called a rapid response, which became a full code blue lasting 3 hours. While the medical team attempted to resuscitate her, the obstetrics team attempted unsuccessfully to save the fetus. Throughout the resuscitation attempts, her family was present, with more and more members gathering as events unfolded.

As the chaplain, I was paged after the patient died. I was in the hospital within 30 minutes.

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Spiritual care interventions

Immediate needs included creating space for conversation and crying. I served as an involved bystander, spiritual presence, and prayer facilitator for anyone who requested support.

The following day, I consulted with the managers of all involved units and departments, and enlisted the participation of our coordinator of healing services, who was an RN, and the employee-assistance program director, a licensed independent social worker (LISW). We set a date and time for the Code Lavender, secured a meeting space, and decided on a format and a time limit of 1.5 hours.

Our healing services coordinator prepared supportive materials including mandalas, prayer cards, aromatherapy inhalers, and feedback forms for attendees. Mandalas are Hindu and Buddhist religious symbols used as focusing and relaxation tools. (See Mandalas can be used for Code Lavender.) Their geometric constructions allow repetitive coloring that many find to be relaxing. We offer essential oil aromatherapy as personal-use inhalers.

The days before the Code Lavender were spent getting out the word both formally and informally. The most effective inducement to attendance by far was a personal call from or chat with the nurse manager, and staff coverage was promised if necessary.

During this time, I visited the involved units as well, letting staff know that I was there intentionally. Many of my conversations weren't with staff who'd been directly affected, but with coworkers who wanted to support those affected.

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Details of Code Lavender

Beginning. The Code Lavender proceeded as follows:

  • an opening prayer by the chaplain, introductions and a general case review by the LISW, and an opening prompt by an RN
  • a listening round in which every participant spoke uninterrupted for 2 minutes, often in response to a prompt. Our prompt for the opening round asked participants to reflect on what they wanted to say about this incident in this forum.
  • a conversation enabled by all three facilitators; lasting nearly an hour, it was structured around these questions:
    • – What did you do immediately to process your feelings after this patient's death?
    • – What do you wish you'd done at that time?
    • – What can we, as a group or individually, help you do at this time to make sense of this death?

This was followed by a closing listening round and offering of healing materials to take home, including aromatherapy inhalers and mandalas.

Following days. The spiritual care department continued to conduct intentional rounding on various shifts and days including weekends, in the ICU and obstetric units as well as the transportation and environmental services departments. Each department's leadership was involved in making phone calls, checking in with staff, and encouraging participation by offering on-shift coverage when needed.

The conversations with hospital leadership about the unexpected death's impact on caregivers and reports at morning huddle were extremely important for planning and implementation. Our explanation of Code Lavender and our offerings to support staff helped establish Code Lavender as an important modality and enabled administrators and nurse leaders to speak knowledgably and supportively to their staffs as they encouraged attendance.

Finally, we reviewed participants' comment sheets, held an interdepartmental debriefing, and solicited narrative reports from participants, nurse managers, and upper-level administrators.

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Conclusion and follow-up

Code Lavender adds to the healing environment of a hospital. The message a Code Lavender sends to staff is that ongoing, in-depth support is available to help alleviate suffering. At our institution, support for Code Lavender shows its value to patients and caregivers. Self-care is not merely touted as something staff should do on their time off; it's enabled and valued as part of a healthy working environment. Furthermore, interdisciplinary interaction is seen as one of the most positive aspects of Code Lavender.

In our evaluations, we learned that managers were grateful for the structure we offered them in supporting their staff. They were glad they could say, “Do this. Go here. Talk to them.” The concrete plan and our follow-up eased their stress as well.

Other uses of Code Lavender include supporting caregivers living with long-term, chronic stress that's often experienced in critical care units with patients whose course of treatment (including code status) causes moral distress. In such cases, the spiritual care department will also partner with ethics and other services such as art and music therapy.

Successful Code Lavender events must have nurse manager and senior leadership buy-in. If administrative personnel don't support such interventions, staff won't take the time or make the emotional investment needed for fear of being seen as “weak” or “needy.”

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Recommendations to increase effectiveness

  • Provide in-house education, especially for healthcare providers, about Code Lavender's benefits.
  • Perform additional research, such as a longitudinal study comparing a control group with caregivers in hospitals where Code Lavender is available.
  • Formalize debriefing forms to enable long-term study.
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Questions for further reflection and study

We found that staff didn't quite know what to expect from Code Lavender. They'd heard about Code Lavender but hadn't experienced it themselves. This may have worked to our advantage. When we asked, “Were your expectations met?” the immediate answer from most staff was, “Yes.” Our frontline staff and all caregivers are pleased by the effectiveness of just this one intervention.

As Code Lavender becomes a more frequent intervention, the question becomes, “How can we build this into the culture to help ensure it doesn't become simply another item to check off?”

Future work will need to focus on any lasting effects of this intervention. Involving patients and their families in this work is especially important. In a healthcare environment filled with new projects, metrics, and ideas, caring for our caregivers is and always will be central to future success.

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REFERENCES

1. Johnson B. Code Lavender: initiating holistic rapid response at the Cleveland Clinic. Beginnings. 2014;34(2):10–11.
2. National Child Traumatic Stress Network. Psychological first aid. 2016. http://www.nctsn.org/content/psychological-first-aid.
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