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Taming the trauma

Ensz, Catherine E.F. BSN, RN, CPN

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doi: 10.1097/01.NME.0000723380.74038.4f
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Whether it's the ED nurse triaging a new mom with a cough and high fever, the ICU nurse monitoring the ventilator settings of a fragile older patient, or the public health nurse working tirelessly to trace contacts of COVID-19 cases, it has become evident to the general public that nurses play a critical role in combatting the virus. As the rate of contagion continues to rise in parts of the US, something else that has become abundantly clear is the trauma associated with COVID-19. Nonmedical laypersons are weeding through data from various news sources, struggling to stay safe and well and, at worst, dealing with a potentially deadly medical diagnosis.

In recent years, trauma-informed care has been at the forefront of conversations regarding psychiatric care. Individuals who experience trauma may have “ongoing problems with sleep or physical pain, encounter turbulence in their personal and professional relationships, and feel a diminished sense of self-worth due to the overwhelming amount of stress.” The negative impact of trauma on mental, emotional, and physical health is well documented. At every level of interaction within the healthcare system, nurses need to be ready with responses and interventions that leave patients with as few adverse or traumatic experiences as feasible. Nurses equipped with a clear understanding of how to help patients anticipate or avoid, manage or mitigate, and heal from trauma can have a positive impact during the COVID-19 crisis.

Case study

It's 1430. You've just returned from your 8-minute lunch and restroom “break.” It's your third of four shifts this week in a busy suburban ED. You were excited to take the job as a new graduate RN 10 months ago, which included a sign-on bonus and 3-month nursing fellowship. You completed the fellowship and have been working both day and night shifts and every other weekend, even picking up extra shifts to pay off the student loans from your BSN degree.

You're confident in your nursing skills, but equally relieved when you see that your nurse mentor is on the same schedule as you this quarter. The last couple of weeks have been especially hard. Although you feel grateful not to be facing a catastrophic number of COVID-19 cases, your community and ED are seeing an alarming increase in positive cases.

You don your N-95 mask, your name carefully written in bold letters on the front and still mostly intact on its third day of use; a wrinkled yellow gown that under normal circumstances would've been tossed after one use with one patient; and a new set of gloves. Things seem to be changing every day and you're grateful today for fresh gloves.

Your hospital-issued mobile device buzzes and your charge nurse informs you that you have a patient waiting for you in B-7. Mike the ED tech is already in with Mrs. Sanchez and updates you on her vital signs. Her oxygen saturation is 96% on 2 L of wall oxygen and her temperature is still elevated at 103.4°F (39.7°C) despite her report of having taken acetaminophen before she left the house. Her heart rate and cycling BP are elevated according to the monitor on the wall. Mike tells you to let him know if you need help getting labs or an I.V. as he dashes out.

You begin your exam and attempt a brief history and physical for Mrs. Sanchez, quickly realizing that the 68-year-old woman speaks little English. You can sense her fear. Her eyes well up with tears as she adjusts the nasal cannula. You pop your head out of the curtain and call out to Mike who has just finished next door. You know that he's busy like everyone else, but he's fluent in Spanish. He agrees to help.

You learn that this is Mrs. Sanchez's second visit to the ED this week. She was sent home 5 days ago because her oxygen was “okay,” but told to return if she felt worse. The hospital called her home a couple of days after the initial visit to let her know that she had tested positive for COVID-19. Her husband dropped her off today, unable to stay due to the new COVID-19 protocol. Before leaving, he told the triage nurse that she “can't take deep breaths and her fever won't go away.” With Mike's help, you learn that Mrs. Sanchez has felt ill for 6 days. She and her husband have tried to be safe, but he manages a busy landscaping crew and she takes care of her five grandkids during the day so her own kids can go to work. Two of the toddlers had a runny nose last week but she can't think of any other sick contacts.

She has a history of hypertension and had a cardiac stent placed 3 years ago. One of her grandkids has severe asthma and she's very worried that she may have infected the child. Despite the dose of ibuprofen when she got to the ED, her fever isn't improving and her oxygen saturation is now hovering in the low 90s. It looks like Mrs. Sanchez will be staying the night in the hospital. The medical intern walks in and you leave to discuss the anticipated care plan with the charge nurse managing admissions.

Driving home that night, you reflect on Mrs. Sanchez and her family. What has their experience with COVID-19 looked like up to this point? How would your patient's story unfold?

AMP up your patients

Patients experiencing trauma can present with a variety of physical manifestations. Although you likely can't ameliorate all trauma-related physical symptoms, consider how AMPing up your patient can help ameliorate the effects of COVID-19-related trauma.

Anticipate/avoid. How can you help your patient avoid trauma in the first place? With facility policy in mind, is it possible to make some creative accommodations? Be aware of your facility's protocols regarding COVID-19 and anticipate which of these are likely to feel traumatizing to your patient population. Avoiding unnecessary trauma should always be the goal. Giving patients options when possible empowers them and gives them a sense of autonomy. If you know that your patient speaks limited English and can't have family at the bedside, an option may be to make sure you're paired with a coworker who's bilingual and ensure that simple instructions on how to utilize interpretive services are visible in your patient's room.

Manage/mitigate. Sometimes medical trauma can't be avoided completely. In such cases, we're called on to manage or mitigate the unavoidable trauma. This may mean having a family member present via video to help an anxious patient go through the history and physical with the admitting team. It could mean allowing a parent to hold a toddler during the COVID-19 nasal swab test instead of restraining the child on an exam table. In both cases, cooperation and accuracy are likely to improve with accommodations.

Promote healing. It's understood that the COVID-19 pandemic will continue to traumatize those in its path. As individuals and their communities begin to resume some semblance of normalcy, nurses are needed to facilitate the ongoing efforts to help them heal from experienced trauma. To the nurse on a step-down unit, this may mean helping the patient who has been intubated for a month shower for the first time since admission. To the public health nurse, this may be facilitating socially distanced group therapy sessions for people who've lost a partner to COVID-19. Just as nursing school taught us to plan for discharge at the patient's arrival, we should start planning for healing at the patient's exposure to trauma.

Let's now reconsider Mrs. Sanchez's case using the AMP mnemonic:

A: What could have been done to anticipate potential trauma and/or help avoid it? The healthcare team who assessed Mrs. Sanchez earlier in the week provided anticipatory guidance in telling her when to return to the ED if needed. Many electronic medical records have codes or symbols that denote a patient who speaks a language other than English. As soon as Mrs. Sanchez checked into the ED the second time, there should have been an alert that she would need interpreting services.

M: We understand that Mrs. Sanchez has already tested positive for COVID-19 and her symptoms have worsened, necessitating in-patient hospital admittance. The floor nurse taking over her care has an important role to play in managing/mitigating the trauma during her hospital stay, no matter how short or long. An overnight stay without family being at the bedside can feel scary in the best of times. The general public has now heard many stories of patients entering the hospital, the viral symptoms escalating quickly, and the patient staying for a prolonged admission if not succumbing to the disease without family presence. Keeping Mrs. Sanchez appraised of her lab results and orienting her to the floor and her care plan are important steps in the process. Remember, knowledge is power. Keeping patients updated empowers them and helps mitigate fear of the unknown.

P: Mrs. Sanchez has substantial underlying health concerns that complicate her COVID-19 status. An important part of patient education at every level across the healthcare spectrum is empowering patients to advocate for themselves. Using interpretive services to show Mrs. Sanchez how to keep an accurate, updated record of her diagnoses, medications, and medical appointments in a travel-sized notebook or on her phone will ease her communication with healthcare professionals in the future, especially if restrictions remain in place that don't allow for a family member to be at her side. It's critical that the discharge nurse thoroughly reviews Mrs. Sanchez's discharge instructions and confirms her understanding.

Mrs. Sanchez's discharge goal needs to include understanding follow-up care and when to seek emergency evaluation/treatment. Patients with COVID-19 who required hospitalization and/or had a more challenging course of illness are reporting prolonged healing time and lingering adverse reactions, including malaise and shortness of breath. It's imperative that Mrs. Sanchez receive discharge messaging of realistic expectations, as well as reasonable restrictions on her release from the hospital, to help diminish additional COVID-19-related trauma.

It isn't just your patients

Nurses are told consistently that we need to “take care of ourselves” and make sure to “practice self-care.” The concept of self-care is challenging under normal circumstances. Add a global pandemic to the mix and it can feel more like a burdensome undertaking than a desirable activity. The images of nurses bending over outside of patient rooms with red indentions on the sides of their noses have popped up all over social media and on TV commercials; however, many nurses have voiced a disconnect in their experiences once they leave the clinical setting.

The same nurse who took scrupulous care of her coveted N-95 mask so it would last her three shifts this week stands in line at the grocery store behind an overzealous customer arguing with store management about his right to shop mask free. The public health nurse who has called 40 people with positive COVID-19 results this week in an effort to stop the spread logs on to a video call with extended family only to have her father-in-law proclaim that he believes the virus is “a hoax” and has decided to take his vacation to the nation's current hot spot anyway. The mental and emotional dissonance between what nurses are experiencing professionally and the response from some members of the public to the healthcare community's directives and explanations are taking a toll.

When reviewing safety instructions before takeoff, airline crews tell us to put on our own oxygen mask first before helping others. When applied to our current state, this means that you must take care of your body, mind, and spirit if you hope to continue caring for others. Consider these key strategies for better self-care:

  • Hydrate. Carry water with you whenever possible. Each time you remove your mask, have a few ounces. Make it a habit: Mask off equals water break.
  • Go outside. As nurses, we understand the importance of vitamin D. Being outside in nature is a mood booster, and infectious-disease experts have agreed that socially distancing outside is optimal because it eliminates the concern for indoor air exchange.
  • Try to limit social media use and exposure to nonmedical news sources. Nurses working on the frontline of the pandemic understand its reality. We don't need to be bombarded with others' “take” on COVID-19 or feel the compulsion to correct every family member's and friend's false reporting. This practice of letting go can help free up your mental load.
  • Exercise. Moving your body releases mood-boosting endorphins. Studies also show that exercise can boost immunity.
  • Meditate/pray/practice yoga. Prayer practices and other meditative exercises can help regulate breathing and lower heart rate, and may decrease anxiety.
  • Sleep. Quiet hours are a part of the daily routine at many healthcare institutions for a reason—humans need rest. Turn off the TV and the lights. Make sure that the room temperature is comfortable. Night-shift nurses and those who rotate need to be especially mindful of sleep-wake cycles and establishing good sleep hygiene.
  • Eat well. Don't forgo healthy eating. All nurses can understand the need for a preshift caffeine fix in the form of a large Americano, but don't forget to balance the coffee and breakroom treats with healthy whole grains, green leafy vegetables, and lean proteins.
  • Seek community. Humans are communal creatures. We need relationships with others to sustain good mental health. We've learned how extraordinarily communicable COVID-19 is, but that doesn't eliminate the need for relationships. Digital applications have become literal lifelines for patients in hospitals and long-term-care facilities who are physically separated from their families during the pandemic. Whether or not you live alone, consider using technology to reach out to others.
  • Get help. Most hospitals and other larger healthcare institutions have some form of employee-assistance program that offers mental health counseling either free or at a discounted rate. If you're feeling overwhelmed with the responsibilities facing you professionally and/or personally during the pandemic, seek help.

The path forward

Nobody knows how extensive the illness and loss of life attributed to COVID-19 will be. Similarly, nurses can only predict the level of trauma patients will continue to experience as a result of the pandemic. Something nurses do understand is the toll that traumatic experiences can take on patients' physical, mental, and emotional well-being. By using the AMP mnemonic, nurses are reminded to anticipate and potentially avoid trauma, manage or mitigate unavoidable trauma, and promote healing for patients at various levels of care. And by not ignoring our own need for self-care, we can remain resilient to continue caring for our patients.

memory jogger


Remember AMP to ameliorate the effects of COVID-19-related trauma for your patients.

A: Anticipate/avoid

M: Manage/mitigate

P: Promote healing


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