It's 6 hours into Grace's 12-hour shift on a busy medical-surgical unit. Upon entering Sarah's room, a young mother recently diagnosed with thyroid cancer, Grace's heart feels like it stops for a brief moment when she sees Sarah lying on the floor pale and lifeless. Her first reaction is disbelief; however, there's no time to waste so she quickly calls for help. “I need some help in here!” Did I yell loud enough? Her mind begins to race. Did people hear me? Should I get her off the floor? Does she have a pulse? Is she breathing? When did I last give her pain medication? What were her last vitals?
Grace starts CPR and her colleagues arrive. Her heart is racing, yet she feels like everything is unfolding in slow motion around her. Her colleague asks for an update on Sarah and Grace's mind goes blank. She shakes her head to bring herself into the present moment and away from the “What did I miss?” question swirling in her mind. She takes a deep breath and all that comes out is, “I was discharging her.” For a brief moment, she thinks of Sarah's husband and son, and how she told them they would be together tonight. But, no, she can't think of them, she needs to think of the emergency at hand and focus on what technical skills are needed to help Sarah.
The code team arrives and Grace has composed herself. By this point, her heart has slowed a little and she's able to provide a medical history. The team works together to connect monitors, start I.V.s, and administer medications. Sarah's pulse returns and, as her bed is being transferred to the ICU, Grace takes what feels like her first breath since finding Sarah on the floor.
Still in disbelief and quietly asking herself over and over what she could have done differently, the phone rings and snaps her back into reality. A physician is calling to give orders for another patient. An hour has gone by like the blink of an eye and suddenly Grace is overwhelmed with a rush of anxiety knowing all of the work that still needs to be accomplished. Grace takes the physician's orders and immediately goes back to work as if nothing happened.
The emotionally charged assignment in our scenario is typical for many nurses. But what if the story was put on pause the second the patient got transferred to the ICU? What if it was the organization's culture for the nurse to turn over all of her assignments to another nurse after such events? What if it was expected and not optional for the nurse to take a break for self-care after a stressful event?
Urgency of self-care
Two Hackensack Meridian Health hospitals have implemented programs to help support nurses as they're continually faced with intense assignments. A 2013 survey of 508 healthcare employees working for 243 healthcare employers found that 60% reported job burnout and 34% planned to look for a different job, citing heavy patient loads, small staffs, and high stress levels as their reasoning.1
Compassion fatigue, burnout, and chronic stress are an all too familiar reality for many nurses. Nursing is a giving profession, but nurses risk these negative effects if time isn't taken to replenish and rejuvenate, especially surrounding traumatic events. In addition to performing many concrete functions, the essential product caregivers deliver is themselves.2
Compassion fatigue is the physical, emotional, and spiritual result of chronic self-sacrifice and/or prolonged exposure to difficult situations. This may render a person unable to love, nurture, care for, or empathize with another's suffering.3 Burnout is linked to increased workplace demands; rising healthcare expectations; lack of resources; and interpersonal stressors that lead to cynicism, ineffectiveness, and diminished caring.4,5
Betty Ferrell, editor-in-chief of the Journal of Hospice & Palliative Nursing, states that there's a critical need for our profession to see self-care as urgent—not something we do when all else is done, but something we must do.6 The key message for nurses is acknowledging that stressors and their effects exist and committing to self-care.
Organizational endorsement is a foundational step in implementing supportive measures such as a Code Lavender room. The goal is a workplace environment in which the healthy focus on self-care mandates support that's caring, compassionate, and nurturing for nurses, as well as patients.7
Soothing the human spirit
Southern Ocean Medical Center, a member of Hackensack Meridian Health, started a Code Lavender program on its night shift similar to the Healing Services team at the Cleveland Clinic.8 A Code Lavender is called to provide nursing team members with emotional and physical support in a timely manner following stressful and traumatic events. Initiated by a team member—either the person directly affected or a colleague—a call is placed to the ED secretary to enact the process. The supervisor, charge nurse, and a member of the Code Lavender response team are notified and report to the unit within 30 minutes. Presently, the response team is comprised of volunteer nurses, mental health specialists, and clergy members.
Arrangements are made to cover the affected team member's assignments so support is provided if he or she chooses to go to the Code Lavender room. This dedicated space offers holistic therapies, such as a lavender diffuser, meditative music, and journaling and additional supportive resources. (See Table 1.) A member of the Code Lavender response team accompanies the individual to the room and explains its contents. The response team member may then stay with the affected individual to listen, talk, or provide privacy.
Once the affected team member returns to work, there are ongoing resources available. He or she can choose to wear a lavender bracelet or a small lavender pin as a reminder of solidarity. All staff members are encouraged to take a minute to slow down, breathe, and try to remove the weight of stress from their shoulders.9 Additionally, a designated individual may provide a follow-up phone call within 2 to 3 days.
Jersey Shore University Medical Center, also a member of Hackensack Meridian Health, chose to create a mobile Lavender Kit before implementation of a dedicated space. The goal, like that of the Code Lavender room, is to provide nurses with timely emotional and physical support following a stressful situation. To access the kit, which is available 24/7, an affected team member or manager contacts the nursing supervisor. When the kit is utilized, the team member's name and unit are noted in a log to provide information for follow-up.
Once the kit arrives, it's the responsibility of the charge nurse and supervisor to find a quiet space and provide patient coverage for the affected team member. Housed in a large rolling laptop bag, the kit contains items such as warm eye masks, chocolate, and inspirational quotes. The affected team member is then contacted within 72 hours to discuss his or her experience and any need for further support.
The Code Lavender room and Lavender Kit were introduced at Hackensack Meridian Health to complement additional initiatives. The first initiative is the Hackensack Meridian Integrative Health & Medicine department.10 Services offered include nutrition counseling, acupuncture, and health coaches, with the overarching goal of balancing mind, body, and spirit. The second initiative is modeled after the University of Missouri Health Care's forYOU team, which provides support to its clinicians when an unanticipated medical event or error occurs.11 These programs work in tandem to promote the health and well-being of team members as they give selflessly to provide emotional and physical care to patients and families.
Initial staff reactions to the Code Lavender initiative were excitement and eagerness to take advantage of the programs. Many nurses recognized the value in improving their work environment. Interviews were held with nurses after completion of education about the programs to determine their response. One nurse shared the following comment, “I didn't know what Code Lavender was. Last time, I just went to the bathroom and cried for 20 minutes. I wish I had a better place then. Now I have. This is what I need, a peaceful place to clean my soul.” Another nurse indicated, “Things must change. We need to allow ourselves to stop being strong all the time.” Yet another commented, “I needed a break. I just needed to get off the floor. I didn't have a place to go. Now I do.”
To ensure ongoing success and sustainability, the adoption of these programs is supported at every level of the organization. Support is demonstrated through dedicated spaces within the facilities, a commitment to staff education, continued funding, and management advocacy. The implementation teams plan to track quantitative outcomes and recognize the necessity for further research regarding the impact of these interventions on staff satisfaction, retention, and patient outcomes. At this juncture, the Code Lavender initiative is in its infancy stages, but we anticipate seeing robust results. A culture that supports healthy nurses is truly the only option.
1. Bodenheimer T, Sinsky C. From triple to quadruple aim: care of the patient requires care of the provider. Ann Fam Med
2. Joinson C. Coping with compassion fatigue. Nursing
3. Walker L, Avant K. Strategies for Theory Construction in Nursing
. 4th ed. Upper Saddle River, NJ: Pearson Education; 2005.
4. Bush NJ. Compassion fatigue: are you at risk. Oncol Nurs Forum
5. Maslach C. What have we learned about burnout and health. Psychol Health
6. Ferrell B. Code lavender. J Hospice Palliat Nurs
7. McHolm F. Rx for compassion fatigue. J Christ Nurs
8. Cameron M. Healing services “code lavender”: creating a positive environment for nurses and innovating patient care. https://my.clevelandclinic.org/ccf/media/files/nursing/notable_spring09.pdf
9. White J. “Code lavender” designed to relieve stress in hospital staff, patients. www.healthcarebusinesstech.com/code-lavender-stress-hospital-staff
10. Hackensack Meridian Health Integrative Services. What is integrative medicine? www.meridianhealth.com/service/integrative-medicine