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Psychological Support for Staff on the Rapid Response Team: Reflecting on Practice

08 February 2019

Fiona Finlay, Anna Baverstock and Jackie MacCallam considered the need for coping strategies by rapid response teams following the death of a child.

Dr. Fiona Finlay1, Dr. Jackie MacCallam1, Dr. Anna Baverstock2

1 Children’s Services, Virgin Care, St Martin’s Hospital, Bath, UK

2 Musgrove Park Hospital, Taunton, UK

Corresponding author:

Dr. Fiona Finlay

Email: [email protected]

Telephone 01225 394514

Consultant paediatricians Dr Fiona Finlay and Dr Anna Baverstock and clinical psychologist Dr Jackie MacCallam reflect on their professional experience to explore the importance of acknowledging the emotional impact of the work of rapid response teams, considering their need for psychological support, as well as a number of coping strategies for both individuals and teams.

Abstract

Rapid response teams attend scenes where children have died suddenly and unexpectedly. Rapid response staff - school nurses, health visitors, community children’s nurses, paediatricians and police officers, may be involved in difficult scenarios and inevitably see the aftermath of serious, traumatic injuries, for example, road traffic accidents, suicide by hanging and other acute events. In these circumstances, professionals are also likely to witness significant distress in others. Through reflective practice of their professional experience the authors raise the importance of acknowledging the emotional impact of this work, alongside considering the challenges of providing psychological support to staff who work on rapid response teams. Facilitating staff to ‘keep their metaphorical batteries charged’ is also discussed, alongside coping strategies that can be used both by individuals and teams.

Introduction

'When an infant, dies suddenly and unexpectedly, the sense of loss and terrible grief may overwhelm not only the parents but also the physician’ (Mandell, 1987)

Rapid response teams attend scenes where sudden, unexpected deaths have occurred (Department for Education, 2015). The rapid response team usually consists of a health professional – a school nurse, health visitor, community children’s nurse or paediatrician, and a police officer. Their responsibilities include collecting information about the child’s death, evaluating the reasons and circumstances of the death, liaising with coroner and pathologist, and considering the needs of the bereaved family in terms of on-going support. A multi-agency approach is considered key to the effective investigation of an unexpected death, and it is an expected statutory duty for such deaths to be investigated with thoroughness, compassion and care (Royal College of Pathologists, 2016).

Staff attending a rapid response visit have often never met before, working in different places and for different agencies (health and police). Generally, they meet just prior to the scene visit, and once this is completed, they return to their respective work bases, with little time to reflect, recover or prepare for their next task. There is often little opportunity for rapid responders to talk through events with each other, and the next opportunity for them to meet in a formal way is generally at the local child death review, which may be some months later. 

As well as being witness to a child death, a rapid responder will also be exposed to the raw emotions of shock, distress and grief of the family and others present. Sudden deaths are by their nature unanticipated and can often involve traumatic injuries, such as those from road traffic accidents or death from suicide. Being involved with distressing events is challenging in itself, but being in a family home or public place often adds additional stress due to the unpredictable nature of the situation and unfamiliar environment.

Due to the nature of the role, the authors – two paediatricians and a psychologist, believe that rapid response team members are a vulnerable group in terms of risk to psychological well-being, for example, post traumatic distress. We know that effective formal support, or specific psychological support, is rarely available routinely for team members, and we are aware that some staff may feel they ‘should be able to cope’, making it more difficult for them to seek help or talk about their emotions.

Although it has been recognised that there is no standard way to help staff deal with the emotional impact of patient deaths (Leff et al, 2017), our own reflections are that the psychological well-being of staff on rapid response teams needs specific consideration and facilitation. To enable this to take place, we believe staff need to be empowered and supported both individually and within teams. In this article we will highlight some of the challenges, benefits and potential solutions to offering staff support for managing the emotional and psychological impact of the rapid response role. 

Aims

The aim of this paper is to use reflections from practice to raise awareness, promote recognition and offer ways to address the psychological support needs of staff on rapid response teams. In addition, we will discuss how staff can be enabled to maintain their own psychological well-being, build resilience and continue to work in a compassionate way. 

Method

Reflective practice and conversations with staff were used to inform the content of this paper, alongside information gained from local audits and the literature. The clinical experience and knowledge of the authors was drawn upon throughout.

Reflections and discussion:

“Caring for dying patients has an emotional impact on the physicians and if unaddressed can lead to burn-out and potentially compromise patient’s care” (Eng et al, 2015).

The literature suggests that staff can struggle psychologically following the death of a patient, with grief and loss being a key area for stress (Hammerschmitt &Murphy-Ende, 2007, Plante & Cyr, 2011, Eng et al, 2015). Our clinical experience and conversations with staff mirror this, as illustrated by these thoughts shared by professional colleagues: ‘Was everything humanly possible done?’, ‘It was so brutal - an awful death that will stay with me’, ‘I wonder how the family are coping…how precious the lives of my children are…’, ‘She looked like my 5-year-old, she died so quickly’ (Baverstock & Finlay, 2006). 

Staff who are more aware and more able to self–care, undertaking activities independently to promote and maintain personal well-being, are better at coping and continuing to provide compassionate care, and are less likely to suffer from compassion fatigue or burn-out (Sansó et al, 2015, Sanchez-Reilly et al, 2013).

As rapid response visits can happen at any time, the staff involved need to be psychologically prepared to leave what they are doing and attend to the child death. Using the analogy of the charge on a phone battery, this means that staff should ideally start each day on full or nearly-full charge. On days where there is a large drain on reserves, as is likely to be the case following a rapid response visit, re-charging is important. The authors reflection is that re-charging is one of the things which enables staff to maintain their own well-being and continue with their work in a focused and compassionate way. Functioning on low or reduced battery charge runs the risk of reduced effectiveness and satisfaction, poor concentration, increased doubt, fear and worry, and can lead to reduced psychological and physical well-being. If left ‘uncharged’ compassion fatigue and ultimately burnout may occur, with staff experiencing symptoms such as fatigue, anxiety, apathy, irrational fear, poor concentration, oversensitivity, poor self-care and sickness (Baverstock & Finlay, 2016, Sansó et al, 2015). 

Following a rapid response visit and child death we need to be able to acknowledge that everyone has been through an emotionally draining experience (Ward-Platt, 2018). Supporting the whole team is important, although it is acknowledged that this may be more challenging for rapid response teams who do not routinely work together. Additional effort may be required to ‘set time aside’ and ‘bring people together’ to provide support and ‘charge the team battery’.

From our experience and knowledge, we have suggested that a variety of strategies are useful for rapid responders when trying to keep their battery charged:

Talking about it – informal support from peers

“The key to attaining a good outcome for all staff is to do those informal, natural and humane things that in the best workplaces are part of the culture of the service: to look after each other. Effective informal care is something we can all do across hierarchies and across professions…. Good professionals look after each other” (Ward-Platt, 2018).

We have found that for many staff talking with others is very important to help them to feel supported, and to process and work through difficult events, thoughts and feelings. This is also highlighted in the literature - a participant in a study by Taylor and Aldridge (2017) said: “For me, by far the biggest source of support is the informal support that comes from the other team members…just kind of in and amongst everything else.” 

Creating a team culture which is trusting and open is a key element in creating positive well-being for staff, breaking down barriers to discussing work-related stress and enhancing awareness about early signs of burnout (Taylor & Aldridge, 2017). In our experience enabling staff to have honest conversations, where they feel able to share emotions, helps the processing of distressing events and is therefore helpful in supporting a wider sense of wellbeing. Talking with others can also reduce the fear of isolation and help create a supportive culture through honest and open sharing. When teams are fragmented, as is the case in rapid response teams, additional consideration and effort may be required to create opportunities for staff to talk about their work informally, in a safe and supported way. 

Talking about it – formal opportunities

Following a child death, the statutory child death process stipulates that a multidisciplinary, multi-professional meeting should take place (Department for Education, 2015). These meetings provide a vital opportunity for team members to meet and, if well-conducted, should enable joint reflection and expression of feelings and emotions (Ward-Platt, 2018) and be a positive experience for the team, as well as enabling them to learn from the case.

Supervision

Supervision is “what happens when people who work in the helping professions make a formal arrangement to think with another or others about their work with a view to providing the best possible service to clients, enhancing their own personal and professional development, and gaining support in relation to the emotional demands of the work” (Scaife, 2001). Reflecting on personal experience and that of colleagues, the author’s note the value of supervision, in providing valuable support for staff in managing their own psychological well-being, thoughts, feelings and behaviours, which in turn supports the ability to provide on-going effective care. This is evidenced in the literature also, for example, professionals who receive supervision are likely to be more clinically effective, have less time off sick and develop better workplace relationships (Wallbank, 2012).  The authors therefore argue that supervision, provided it is a positive and supportive experience, is a key factor in ‘re-charging the battery’ and should be available for all professionals working in rapid response teams, with a specific focus on the effect of rapid response work.

Building resilience

The Oxford English dictionary (2016) describes resilience as the ability to succeed, to live and develop in a positive way, despite stress and adversity that would normally involve a negative outcome; the capacity to recover quickly from difficulties. Resilience allows people to handle stress positively (Lee et al, 2015) or as the Japanese proverb says a resilient person is someone who will “Fall down seven times, get up eight”.

The authors observe resilience in colleagues who are dealing with very difficult circumstances and high emotion; staff continuing to go back in to difficult situations to offer help. They also recognise the importance and possibilities of enhancing and developing this resilience whenever possible.

Nedrow et al (2013) highlighted self-awareness and insight as key factors in building resilience. Taking this into account, the authors suggest that empowering staff to work in a self-aware and reflective manner can only be beneficial. One way to achieve this is to create a positive culture of open and honest sharing, where professionals are not afraid to admit they are struggling or ask for help. Providing regular supervision and reflective practice sessions is also likely to enhance self-reflection and positively influence resilience. 

Although resilience has been suggested as a protective factor in avoiding the development of post-traumatic stress disorder, this has not been widely explored, and it has been suggested that this area could be a focus for future research (Hollingsworth et al, 2018).

Mindfulness

Mindfulness: “Mindfulness means paying attention in a particular way; on purpose, in the present moment, and nonjudgmentally” (Jon Kabat-Zinn, 2004).

Mindfulness is a way of focusing on the present moment, whatever that moment is, using attention and the senses to do this. By using a present moment focus it allows us to move away from a past or future focus which has been found to be beneficial in managing anxiety, rumination and emotional exhaustion (Orellana-Rios et al, 2017).  Mindfulness, therefore, is another psychological strategy which can be used to help staff in managing work related stress and in reducing factors related to burn-out (Shapiro et al 2005, Martin-Asuero et al 2014, Gautier et al 2105, Orellana-Rios et al 2017, Moody et al 2013).

Offering group mindfulness sessions does not have to involve significant amounts of time for the benefits to be felt. One of the authors currently offers 10 minute mindfulness sessions on a monthly basis for a range of professionals who share an office base, which has also been evaluated very positively. Feedback included the following: ‘Surprising what a difference 10 minutes can make’, ‘Sessions have brought a sense of calm, albeit sometimes briefly, but long term have also helped me outside of work’ and ‘A brief time to help clear the mind and be better able to focus on the rest of the day’. Alongside this was a notable increase in desired feelings, for example, the desire to feel more grounded or calmer, as rated by participants at the end of each session. Once individuals have experienced mindfulness in a group session, some will continue this individually outside of the group. There are also many resources available on-line which could be used by staff teams with minimal input should they wish to introduce mindfulness as a regular part of their team meeting.

De-briefing support after a child death

De-briefing sessions focusing on experiences and emotional reactions provide opportunities for staff to reflect on the affective side of their work and foster an open forum that ‘normalises’ sharing one’s emotions (Leff et al, 2017; Eng et al,  2015). Although there is no clear national guidance or framework for best practice with regard to a de-brief following the death of a child (Hollingsworth et al, 2018) in our experience, and that of others, staff often request ‘de-brief type support’ following a failed resuscitation or a rapid response visit (Ireland et al, 2008). They want a chance to talk honestly about, reflect on and learn from their experiences, from both a clinical and an emotional point of view, and with someone able to offer a supportive interaction. 

Keene et al (2010) found that health care professionals caring for children with a life-threatening condition reported that de-brief sessions were one aspect of an effective approach to support them in managing their grief.  An internal service evaluation undertaken by one of the authors also revealed many positive comments from staff who were asked to reflect on the de-brief process including: ‘Supportive, helpful in clarifying facts and in explaining and normalising feelings’, ‘The opportunity to share difficult feelings, thoughts and emotions and to learn from the experience’, ‘Safe reflection and helpful to acknowledge the good and not so good’, ‘A vital part of the bereavement process’.

De-briefs can be offered on an individual basis, or to a team or group of professionals. To ensure that staff can attend a de-brief it is often more effective to have an immediate debrief when all the team members are present, as in our experience finding a suitable time and date after the event is challenging. However, concerns having been raised that debriefing sessions may have adverse outcomes for some individuals, including the development of an acute stress reaction or post-traumatic stress disorder (Hollingsworth et al 2018, Roberts et al 2009) so teams need to consider this and ensure appropriate facilitation and ‘debriefing’ support.

Schwartz Rounds

“To promote compassionate healthcare so that patients and their professional caregivers relate to one another in a way that provides hope to the patient, support to caregivers and sustenance to the healing process” (Schwartz Center for Compassionate Healthcare 2018)

Schwartz rounds, which originated in the USA in 1995, were named after an American lawyer, Kenneth Schwartz, who died from lung cancer. They provide a structured forum for multidisciplinary staff, clinical and non-clinical, to come together regularly to discuss and reflect on the emotional and social aspects of working in health care. They are a facilitated session where staff are enabled to share specific experiences and cases, with a purpose of recognising this experience and understanding the challenges and rewards that are intrinsic to providing care, not to solve problems or focus on clinical aspects of patient care. They can help staff feel more supported, allowing time and space to reflect on their roles. The underlying premise is that the compassion shown by staff can make a big difference to a patient’s experience of care, but to enable staff to provide compassionate care they must, in turn, feel supported in their work. Evidence and personal experience shows that staff who attend Schwartz rounds feel less stressed and isolated, with increased insight and appreciation for each other’s roles, a greater sense of collaboration, an acknowledgement of feelings, reduction in isolation and psychological stress, with an increase in compassion and empathy, and trust and openness with colleagues (Chadwick et al, 2016, Farr and Barker 2017, Hughes et al 2018). They also create a culture of openness for sharing thoughts and feelings, help to reduce hierarchies and focus attention on relational aspects of care (Goodrich 2011, Deppoliti et al 2015). Recommendations within The Francis Report (2013) to promote compassionate care includes the implementation of Schwartz rounds.


Conclusion

“To provide compassionate care staff in turn must feel supported in their work” (Point of Care Foundation 2018). 

Rapid response team staff are in a unique position, and by the nature of their role are likely to be subject to high levels of trauma and distress. In the authors’ opinion the opportunity for psychological support should be to offered to all rapid response team members. The authors have recommended a number of ways in which staff may re-charge their batteries, but support is required at team and service levels to enable this to happen in the workplace. Creating a culture which recognises and values the psychological and emotional needs of staff is key when promoting compassionate care. 


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