How do you cope after a patient has just died? You still have a shift to get through and you still have other patients who require your best care. What kind of psychological effect will this have on you?
Nurses and Critical Incidents
A nurse’s wellbeing is critical to being able to perform their job effectively and provide excellent care. When a nurse encounters an adverse event or critical incident, this can impact on their emotional health and even lead to further physical problems. A term to describe these encounters and reactions is critical incident stress (CIS). A critical incident is described as an event that is sudden, overwhelming and threatening, and encompasses events such as assaults, threats, death and severe injury (Caine & Ter-Bagdasarian 2003).
It is normal to have emotional reactions to a critical incident, however these reactions can be harmful when the individual is unable to cope with how they are feeling (Department of Health & Human Services 2011). People with repeated exposure to traumatic events can also begin to develop symptoms which range from minor problems through to post traumatic stress disorder (Vaithilingam et al. 2008).
The severity of the stress that the person may feel following a critical incident is determined by their:
- Interpretation of the event
- Perception of the seriousness of the incident
- Length of exposure
- Personal coping strategies; and
- Social support.
(American Association of Nurse Anesthetists 2014)
Critical incident stress management and debriefing sessions were initially used to assist firefighters and emergency workers to cope with the traumatic events seen in their daily work. These debriefing sessions were found to reduce the incident of many major negative emotional outcomes that are not part of the normal stress reactions when witnessing a traumatic event (Vaithilingam et al. 2008; Department of Health & Human Services 2011). As nurses, we also experience a variety of critical incidents in our day-to-day working life, so these management strategies can be beneficial to helping us deal with traumatic events.
Some of these management strategies include ensuring the individual has ‘time out’ directly following the incident, small group support, debriefing, one-on-one support sessions, and follow up support (Department of Health & Human Services 2011).
When faced with a critical incident, individuals experience a stress response in which the sympathetic nervous system turns on its ‘fight or flight’ instinct; the body’s heart rate quickens, blood pressure rises and breathing becomes more rapid (Harvard Health Publications 2016). Demobilisation promotes rest and time out. It aims to calm workers following a critical incident and helps ensure their immediate needs are met. Demobilisation should occur before the end of the shift, and can include meeting up with everyone involved, summarising the incident, clarifying any concerns, inviting any questions, showing care and support to one another, and offering information on defusing and debriefing (American Association of Nurse Anesthetists 2014).
Defusing involves providing small group support and aims to conclude the experience of the incident and provide a more personal level of support. This should occur within twelve hours of the incident. During this time the group will review the event, clarify any questions and concerns, talk about what occurred, identify any needs, and organise follow-up debriefing sessions (Department of Health & Human Services 2011).
A debriefing is usually carried out three to seven days following the incident. Debriefing is a group support event that involves a structured discussion putting the incident into perspective. It is usually a few days following the incident, as by this time individuals have had a chance to think about the experience. It often helps individuals gain clarity after an event, as well as assist them in their emotional recovery (Department of Health & Human Services 2011).
Discussion about the event has been found to help the individual in further processing the event and understanding why it occurred. By people discussing and acknowledging their guilt and grief it can also encourage further discussion about errors in care, which can help change any institutional attitudes from blaming to learning (Vaithilingam et al. 2008). Debriefings can also be used as a learning tool to improve practice as they allow the group to identify any errors made and develop a plan for improvement (Salas et al. 2008).
Follow Up Support
Stress responses can occur in individuals at different times. Some individuals may find they need follow-up support even after the debriefing sessions, focussing on new aspects of the event or their stress reactions (American Association of Nurse Anesthetists 2014).
If you have experienced a critical incident and are having difficulty with managing your emotional response, you can seek help from a variety of support people including managers, human resources, your health and safety representative, and your doctor.
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- American Association of Nurse Anesthetists 2014, Guidelines for Critical Incident Stress Management, AANA, Park Ridge, IL, USA, viewed 29 July 2016 http://www.aana.com/resources2/professionalpractice/Pa…nt.aspx
- Caine, RM & Ter-Bagdasarian, L 2003, ‘Early Identification and Management of Critical Incident Stress,’ Critical Care Nurse, vol. 23, no. 1, pp. 59-65, viewed 1 August 2016, http://ccn.aacnjournals.org/content/23/1/59.full?cited-by=yes&legid=ccn;23/1/59
- Department of Health & Human Services 2011, Workplace Safety – Coping with a Critical Incident, Better Health Channel, Department of Health & Human Services, State Government of Victoria, Australia, viewed 29 July 2016, https://www.betterhealth.vic.gov.au/health/h…incident
- Harvard Health Publications 2016, Understanding the Stress Response, Harvard Medical School, Harvard University, Boston, MA, USA, viewed 29 July 2016, http://www.health.harvard.edu/staying-heal…response
- Salas, E, Klein, C, King, H, Salisbury, M, Augenstein, J, Birnback, DJ, Robinson, DW & Upshaw, C 2008, ‘Debriefing Medical Teams: 12 Evidence-based Practices and Tips,’ The Joint Commission Journal on Quality and Patient Safety, vol. 34, no. 9, pp. 518-27, viewed 29 July 2016, https://www.ahn.org/sites/default/files/file/Debrie….pdf
- Vaithilingam N, Jain, S, & Davies, D 2008, ‘Helping the Helpers: Debriefing Following an Adverse Incident,’ The Obstetrician & Gynaecologist, vol. 10, pp. 251-6, viewed 1 August 2o016
Sally is a Rehabilitation Clinical Nurse Specialist and Nurse Educator teaching the Diploma of Nursing. She is passionate about education in nursing so we can become the best nurses possible. Sally has experience in many nursing sectors including rehabilitation, medical, orthopaedic, neurosurgical, day surgery, oncology, emergency, aged care and general surgery. Sally's Blog.