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 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 (NSW DoPI 2016; Better Health Channel 2011).

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 (NSW DoPI 2016). An individual's response to a critical incident will depend on their perception of the specific event. The symptoms may range from emotional responses and physical health effects (e.g. decreased performance and concentration) through to post-traumatic stress disorder in some cases (AANA 2014).

The severity of the stress that the individual 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.

(AANA 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 incidence of many major negative emotional outcomes that are not part of the normal stress reactions when witnessing a traumatic event (Vaithilingam et al. 2008; Better Health Channel 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 in 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.

(Better Health Channel 2011)

Critical incident stress management patient death

Demobilisation

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 Publishing 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 may 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 (Better Health Channel 2011).

Defusing

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 12 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 (Better Health Channel 2011).

Debriefing

A debriefing is usually carried out three to seven days following the incident. Debriefing is a group support event that involves a structured discussion where the incident is put 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 (Better Health Channel 2011).

Discussion about the event has been found to help individuals process the incident and understand why it occurred. Discussing and acknowledging guilt and grief can also encourage further discussion about errors in care, which may 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 (AANA 2014).

If you have experienced a critical incident and are having difficulty 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.

Additional Resources

References

American Association of Nurse Anesthetists 2014, Guidelines for Critical Incident Stress Management, AANA, viewed 11 November 2020, https://www.aana.com/docs/default-source/practice-aana-com-web-documents-(all)/guidelines-for-critical-incident-stress-management.pdf
Better Health Channel 2011, Workplace Safety - Coping With a Critical Incident, Better Health Channel, viewed 11 November 2020, https://www.betterhealth.vic.gov.au/health/healthyliving/workplace-safety-coping-with-a-critical-incident
Harvard Health Publications 2016, Understanding the Stress Response, Harvard Medical School, viewed 29 July 2016, https://www.health.harvard.edu/staying-healthy/understanding-the-stress-response
New South Wales Department of Primary Industries 2016, Critical Incident Stress, NSW DoPI, viewed 10 November 2020, https://www.dpi.nsw.gov.au/__data/assets/pdf_file/0011/249824/guide-critical-incident-stress.pdf
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://pubmed.ncbi.nlm.nih.gov/18792656/
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 2016, https://obgyn.onlinelibrary.wiley.com/doi/full/10.1576/toag.10.4.251.27442

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