How do emergency room nurses cope – much less function – when they’re constantly surrounded by death?
Some mentally shut down.
“[They] just do their job, robotic-like,” said Christine Kovner, Ph.D., RN, a senior fellow at the Hartford Institute for Geriatric Nursing and a professor at the College of Nursing at NYU. “It's possible to do a job that way, but down the road the nurse likely would face consequences.”
Many others experience “death anxiety,” a state that makes them more conscious of their own mortality and creates a high level of stress and unease.
An article in the journal Emergency Nurse calls for hospital leaders to recognize the signs and symptoms of this condition and put interventions in place to help improve the mental health of their staff.
Who’s at Risk?
Nurses are especially vulnerable to the debilitating condition because of the nature of their work and the constant exposure to death, according to Mike Brady, a doctoral research student at Swansea University, lecturer at Open University, and clinical supervisor paramedic at South West Ambulance Service in the U.K.
Kovner says it’s not just nurses. “They might be more at risk because of the amount of time they spend with patients, but I don't know that they're anymore likely to have issues than physicians, physical therapists, or other health workers,” she said. “There's nothing inherent about being a nurse that would make them more susceptible.”
Nonetheless, Brady says healthcare organizations must make nurses aware of the risks of the disorder, also known as thanatophobia, and provide staff with access to interventions to prevent the condition from affecting their physical and mental health.
A New Concept
Although nurses may be well aware of the daily stress of the job and potential for burnout, Brady said in a statement that many emergency nurses and paramedics may be unaware of death anxiety, even though they're exposed to it every day.
Kovner said education is a key.
“Nursing programs vary a lot across the country and vary in terms of how they teach and work with students around the issue of death and dying,” said Kovner.
She said NYU's undergraduate program does address the topic.
Brady suggests organizations consider rotating emergency healthcare workers so they aren't overly exposed to mortality.
Healthcare administrators must also assess employees who are involved in critical cases against a trauma risk-management tool to see if they are at high-risk for death anxiety, he said.
Kovner, however, is dubious that rotating would help.
“I think people have to learn to deal with their work environment and, if they're having trouble, they should obtain help from the organization, within the community, or make a decision to take another job,” she said.
Kamienski added: “I think the idea of rotating individuals away isn't a practical solution at all. The ED must be staffed 24/7. All ED staff must be prepared to encounter life and death situations as often as they occur. This is also true for oncology and ICU nurses, and neonatal ICU areas. It simply isn’t practical to say: ‘You will be reassigned today, so you don’t have to deal with these situations.'"
Providing debriefing sessions after a traumatic incident is another way to combat death anxiety.
Kovner suggests organizations conduct small, weekly group meetings for staff members perpetually around trauma.
Professor Mary Kamienski, Ph.D., RN, a fellow of the Academy of Emergency Nursing and specialty director of the family nurse practitioner-emergency care track offered as a doctoral degree at Rutgers School of Nursing, said Rutgers fully supports the concept of debriefing employees following exposure to death or near death situations in, among other places, the emergency department.
However, she thinks many nurses will resist this approach because they feel it's mandatory to simply “move on.”
Teaching ‘Chaos Theory’
Another way nursing schools can help students cope with the stress they'll encounter on the job is to teach them the “chaos theory” so they can handle the intensity of the emergency room and keep calm in stressful situations.
While Kamienski believes there’s a place for the chaos theory in healthcare, further research would be required to determine “if learning it really can reduce death anxiety.” She goes on to say, “The entire concept should be defined and then explored. I doubt there's one answer.”
Elena Capella, Ed.D., assistant professor and director of the online Master in Nursing program at San Francisco's School of Nursing and Health Professions, says she teaches students that a “Zen-like mindset” is essential to handle the stress of 12-hour shifts, lack of sleep, and a poor diet.
Those issues, she said, can often lead to chronic sleeping problems, obesity, diabetes, and cardiovascular disease.
While Kovner said some evidence supports the calming effect of yoga and meditation, Kamienski doesn't embrace the Zen-like approach and thinks others won’t either.
“Some might find it helpful, but in my experience, most wouldn't,” she said. “[Nurses] seem to be more concrete in our thinking. Not hardened, but realistic.”