We want to feel safe and it is important to reflect and think carefully about our human spectrum. People try to help people.
Care has a necessary emotional cost. Caring relieves pain and suffering when the person being cared for – the “patient” – can see the impact on the caregiver – the “health professional” – it is this connection that makes people feel comfortable.
Empathy, a necessary part of good care, has been described as being in the water with someone who is not drowning. While caring may not always involve such an overwhelming experience, having no cost at all is as possible as walking in water without getting wet.
Compassionate care brings meaning, joy and satisfaction to “professionals” and, we believe, “patients” want. However, compassionate care can create anxiety and distress for caregivers – a natural, real part of nursing. So the challenge is, how do we deal constructively with this anxiety and pain?
Helpful and unhelpful responses.
Our sense is that we’ve created a broad culture aimed at simplifying healthcare delivery that seems to reward and encourage unhelpful, formulaic responses to anxiety, and we wanted to suggest ways that could help us drive more useful coping styles .
What do we mean by “unhelpful responses”?
Sometimes people take practice and work to avoid, numb, or get rid of the anxiety that arises naturally in a caring dynamic.
We believe that an unhelpful response is anything that leads to “not thinking,” which occurs at both the individual and institutional level.
Isabel Menzies Lyth has been writing for nearly 70 years about how organizations like hospitals are developing ways to combat the anxiety that comes with caring for and being close to people in very vulnerable states.
These “defenses” may not be consciously designed to address anxiety, but rather their role is to protect healthcare workers. Importantly, these defenses create suboptimal conditions for patient care and workers to develop healthier, more mature coping styles.
What is the defense like?
Defense can take many forms, such as aspects of the mechanical processes we use, such as having detailed protocols for everything – so that we don’t have to think; “professional” detachment; constant busyness, constant change; Words label people.
Clinical processes can encourage attention to discrete tasks and possibly label people based on clinical status, which can be managed by implementing standardized protocols and rituals.
These practices can make it more difficult to develop a holistic relationship with an individual, and they also help avoid intense emotional experiences.
How are “useless” methods enhanced?
When we become aware of the strong feelings of our colleagues, we can become pathological and personal. We interpret any expression of anxiety as an individual colleague’s “problem” – which can be quickly and neatly swept away by offering counseling or wellness kit solutions, purifying the rest of the environment.
Our view is that this approach is designed to improve the healthcare experience by introducing more mechanistic solutions, rather than spending time and effort understanding our defenses. Ironically, these further “solutions” just add more layers to our defenses.
What does a “helpful” response look like?
We thought it would be more helpful to notice anxiety, name it, and talk about it freely and safely in a supportive relationship or context. It’s not about judging it’s “bad” or getting rid of it. We might call it “sit together” or “control” anxiety.
This may be in a more formal support space, such as clinical supervision or various forms of reflection or listening spaces, or it may be more informal, just the daily relationship structure of our work – team check-ins, breaks with colleagues are just a matter of our daily chat, we can say “wow, I had a really rough morning” and then feel not only heard, but really heard.
It can be anything that helps to think about what we are doing and why, how it might affect us, and how that in turn affects the way we work.
How can we develop our ability to respond in such beneficial ways?
Imagine if we could occasionally step back and take the stand of a curious observer—discovering our inner Attenborough and sharing what we observed if we wanted to.
Our feeling is that supportive relationships allow each of us to have a sense of security to think aloud and explore our clinical experiences in a way that we can be sure there will be no judgment or criticism.
Additionally, we believe that supportive relationships can bring some challenges, some advantages—being around, while also appreciating differences as a way to keep thinking fresh and open.
Relationships are best balanced between support and challenge, support to meet our human needs, and challenge to improve our ability to think and grow by acknowledging that we are human, imperfect and likely to make mistakes.
Both support and challenge need to be approached with empathy, and when done right, may allow us to have difficult conversations and embrace critical thinking without getting caught up in confrontation.
While many of us nod to the idea of these more helpful responses, in practice they are difficult to implement. Adopting a more helpful way of responding takes a lot of effort and commitment.
This seems even more difficult in the current context of a pandemic where everyone is exhausted on multiple levels. Individuals can’t “just do” this – these things need to be made easy at the organizational level.
When we’re exhausted, and there are so many competing needs, it’s easier to do things that seem like an immediate relief, like finding a common protocol or toolkit off-the-shelf, when in reality those things may be more of a problem.
Our feeling is that the greatest pressure is navigating the complex process we have implemented. Paradoxically, the process performed to eliminate anxiety can actually cause more anxiety.
What about power and hierarchy?
We talk about compassionate healthcare, person-centred healthcare, shared decision-making, and collaborative care, but we also identify “patients” and “professionals,” creating the potential for tricky power dynamics, and often having dominant narratives and Led by professionals.
Hierarchies also exist among healthcare professionals, where power and status are defined through different grades and pay grades. We talk about working in a multidisciplinary way, but we don’t usually talk about hierarchies.
Power is all around us and can get in the way of honest conversation – who speaks first? How are decisions made? None of this is inherently bad, but our sense is that it is useful to bring some of these power and relationship dynamics into our conversations.
As a reflection exercise for now, you might consider your own working conditions and ask, “Would I have done things differently if I could?” If the answer is yes, what is the power that prevents you from doing so?
It may seem so obvious that it doesn’t need to be said, but it may be so obvious that it is often forgotten: The “us and them” of the profession and the patient is socially constructed, as psychiatrist Irvin Yalom suggests, we may Each can be better described as a “fellow traveler”.
Embrace our humanity
We truly know that vulnerability, suffering and eventual death are part of our shared human experience. Perhaps we exaggerate and industrialize the role of “health care” and the mechanism of health care. Perhaps we have lost touch with our shared humanity.
There is no carefree way to take care of another person. Our desire is to embrace anxiety and know support is available.
The problem is that when we feel anxious, we often see ourselves as imposters and not good enough. However, as Neil Gaiman put it, “Maybe there are no adults, only those who work hard and are lucky enough to be a little bit beyond their depths, we all do our best, and that’s all we can really look forward to. “
We would argue that the best job we can do is not to avoid our anxiety, but to acknowledge it, talk about it, understand it, and learn from it.
To embrace our humanity is to embrace our imperfections and vulnerabilities. We are dynamic, loving creatures.
Uncertainty and anxiety are inherent in healthcare, and we need to weave in useful ways to confront and manage this anxiety – rather than building layers of problematic defenses against the situation – to provide honest exploration of some of the complexities Space; space we can admit we are afraid of, we don’t have all the answers, but we’re trying to be our best, let’s ask how we can help each other.
these authors
Charlie Jones is a clinical psychologist at the North Bristol NHS Trust. Dan Warrender is a Lecturer in Mental Health Nursing at Robert Gordon University Aberdeen.
The authors will discuss this article at the Resurgence Reader Group meeting on May 23, 2022.Book a free space Now.
