In a trauma facility, it is important that there be training for the healthcare providers that gives them tools to manage their internal reactions to the day to day events, as well as create a safe space and encourage a sense of community. For healthcare workers in high trauma areas- such as the new COVID-19 units, post- traumatic stress syndrome (PTSD) has been on the rise, in 2011, 14% of nurses were diagnosed, in 2019 an estimated 40% of nurses suffer from the disorder. With the small amount of 18% of nurses feeling they are prepared with proficient self-care skills to manage the effects caused from day to day events of the work environment prior to the COVID-19 pandemic that number is expected to rise exponentially. In a perfect world, healthcare providers would be given mindfulness training as they enter their specified career coursework. Once the students graduate, the orientation at the facility could take these trainings and reinforce them throughout the orientation period to emphasize the importance of self-care.

Keywords: COVID-19, Mindfulness, Trauma

Introduction

In a trauma facility, it is important that there be training for the healthcare providers that gives them tools to manage their internal reactions to the day to day events, as well as create a safe space and encourage a sense of community. Historically, nurses are taught how to holistically care for patients and their families, however there is not a lot of focus placed on their own self-care. With the current COVID-19 pandemic, this self- care becomes essential as it allows nurses to defuse after taking care of critical patients and their families. It is important that we teach our nurses how to take care of themselves as well as the patients, in order to maintain best patient care outcomes. Nursing students and graduate nurses are notoriously stressed, with high impact exams and the need to learn mass amounts of information plus clinical skills, creates an area ripe for tension [1]. Add in a pandemic halfway through the semester, and anxiety levels increase even more. Once they graduate, however, this stress does not go away, it often intensifies for the first couple of years post-graduation [2,3].

Background

For healthcare workers in high trauma areas, such as the new COVID-19 units, post-traumatic stress syndrome (PTSD) has been on the rise, in 2011, 14% of nurses were diagnosed, in 2019 an estimated 40% of nurses suffer from the disorder [4,5]. Diagnosed cases are predicted to escalate in the upcoming post-pandemic days, prompting the VA system to send out a call of awareness to healthcare providers [6]. In trauma centers, after a traumatic event, a professional counselor might perform either an informal defusing session within 12-24 hours, or a formal structured debriefing within 3 days [7]. With our new sustained pandemic situation, the acute event has turned into a chronic elevated crisis level that is impossible to continually debrief. Healthcare workers need mindfulness training in order to be able to provide some relief to themselves [5].

Identified Gap

With the small amount of 18% of nurses feeling they are prepared with proficient self-care skills to manage the effects caused from day to day events of the work environment prior to the COVID-19 pandemic, that number is expected to rise exponentially [5]. Currently, nursing school curriculums do not prepare students to deal with the increased situational stressors of their jobs. Only 6% of nursing schools provide any type of mindfulness skills in the curriculum. [4,8]. In addition, with many hospital training programs being moved to on-the job training, there is a deficit of trainings tied to self-care and wellness.
John Kabat-Zinnis the creator of the University of Massachusetts' Medical Clinic's Stress Reduction and Relaxation Program, currently called the mindfulness- based stress reduction (MBSR) which seems to be the gold standard for mindfulness teachings at this time. His definition of mindfulness is "the awareness that arises from paying attention, on purpose, in the present moment and non-judgmentally" [9]. The everyday person can create a particular habit of being, that will allow them to forget what it is like to be unhappy, as being unhappy will be forgotten. This thought that choosing to be happy and remembering the feeling, is based on the Buddhist sati and encourages us to remember [10].
Mindfulness trainings have been associated with quizzical minds, an increased inter-relation between self and patient, heightened engagement, improved awareness of mistakes, and better clinical insight [11]. If they were intertwined in hospital orientation programs, it could improve the community of the hospital. The programs have been known to produce an increased a sense of satisfaction at work, less overtime needed to complete daily tasks and decreased rates of burnout, which then relates to decreased attrition, overall improved quality, and increased patient safety outcomes [8]. Which then relates to hospitals saving money, in addition to having happier employees.

Discussion-Implications for Nursing

Self-care and wellness activities are part of the nursing tool kit and are mandated by the ANA Code of Ethics fifth provision [12]. By performing self-care actions, the nurse can internally build up their empathy and compassion during stressful events promoting safety and higher- quality patient care. In addition, specific programs, such as the MBSR interventions, have had positive results with new nurses, and it is recommended that administrators institute mindfulness into academic curriculum and work facilities [2].
Nursing facilities can assist in creating a mindfulness environment by creating facility-based support groups that will screen the workplace for stressors and provide anticipatory guidance if there are any noted concerns. In addition, these support groups can have forums where self-care/wellness mindfulness strategies are discussed. On an administration level, protocols can be put in place to assess high-impact nursing floors for stressors and staff coping levels. Strategies can be implemented to help mitigate stressors and decrease stress when trauma events occur.

Conclusion

In a perfect world, healthcare providers would be given mindfulness training as they enter their specified career coursework. Once the students graduate, the orientation at the facility could take these trainings and reinforce them throughout the orientation period to emphasize the importance of self-care. This would provide the needed skills to help prevent the self-internalizing of traumatic events that are chronically witnessed. In turn, these skills would result in the following outcomes:
(1) Decrease in effects of job-related PTSD,
(2) Increase in healthcare provider self-care activities, and
(3) Decrease in nursing attrition rates/increase in job satisfaction.

Authors' Conflict of Interest

The authors declare no conflict of interest.

1.American College Health Association. American College Health Association-National College Health Assessment II: Reference Group Executive Summary Spring 2019. Silver Spring, MD: American College Health Association.
2.Marthiensen R, Sedgwick M, Crowder R (2019) Effects of a Brief Mindfulness Intervention on After-Degree Nursing Student Stress. J Nurs Educ 58: 165-168.
3.Tolouian A (2020) Taking time to enjoy some coffee! Adding mindfulness to the curriculum. Online Journal of Complementary & Alternative Medicine.
4.Mealer ML, Shelton A,Berg B,Rothbaum B, Moss M (2006) Increased prevalence of post-traumatic stress disorder symptoms in critical care nurses. Am J Respir Crit Care Med 175: 693 -697.
5.Greenberg N, Docherty M, Gnanapragasam S, Wessely S, (2020). Managing mental health challenges faced by healthcare workers during covid-19 pandemic. BMJ 26: 368.
6.National Center for PTSD (2020) Managing Healthcare Workers' Stress Associated with the COVID-19 Virus Outbreak. United States Department of Veterans Affairs.
7.Elhart MA, Dotson J, Smart D (2019) Psychological Debriefing of Hospital Emergency Personnel: Review of Critical Incident Stress Debriefing. International Journal of Nursing Student Scholarship 6: 37.
8.Penque S (2019) Mindfulness to promote nurses' well-being. Nurs Manage 50: 38-44.
9.Kabat-Zinn J, Hanh TN (2013). Full catastrophe living: Using the wisdom of your body and mind to face stress, pain, and illness. (2nd edn), Random House Publishing Group.
10.Gethin R (2011) On some definitions of mindfulness. Contemporary Buddhism 12: 263-279.
11.Gilmartin H., Goyal A, Hamati M, Mann J, Saint S, et al. (2017) Brief mindfulness practices for healthcare providers - A systematic literature review. Am J Med 130: 219.e1-1219.e17.
12.ANA American Nurses Association (2015) Code of ethics with interpretative statements.