By Lisa A. O’Connell
When our Med Surge ICU nurses encountered two difficult cases of medical futility, the managers of the unit thought a support group, or debriefing, would offer some self-care to the nursing staff. They didn’t name it, but their staff was feeling the effects of moral distress and its attendant sense of powerlessness. When they approached me, I recognized that creating a group format specifically to counter the effects of this distress would be helpful for our hospital.
I gathered with the two managers and listened to their thoughts. I shared information about moral distress, compassion fatigue, and burnout. “What are your goals for the group?” I asked. The nurse manager said that first, she wanted a space for her staff to vent — a “consequence-free zone” to relieve the burdens felt when facing extreme situations. Second, she thought learning some tools to handle this stress would be beneficial. Third, by offering comfort food and paying the nurses for attending, the managers hoped to show support for the staff. And the last, overarching goal was to avoid compassion fatigue and burnout, and thereby keep staff on the unit.
The managers wanted this group to be elective. We decided on a location near the unit and the time; the group would run from 7:45 to 9:00, both in the morning and evening. The assistant nurse manager announced the group and its purpose at rounds, and reminded and encouraged the staff several times in the weeks beforehand to attend.
I created a format that included six parts: introductions, decompression exercise, brief education about moral distress, rules for the group, conversation (the “consequence-free zone”), and wrap-up.
The introductions began with the nurse manager speaking to the participants about why the group was being offered. I, and later the chaplain who ran the evening group, took time to introduce ourselves and explain why we were qualified to run the group, and that as pastoral caregivers we were there to support staff. At this point, the managers left so staff could speak freely.
Next we did a brief decompression exercise. I chose to do a breathing exercise; the evening chaplain offered guided imagery. After the exercise we gave brief education about moral distress. We covered how moral distress is defined, the difference between moral distress and moral dilemma, the “residue” and stress that accompanies moral distress, and how moral distress can turn into compassion fatigue, burnout, and higher job turnover.
In going over the rules, we let the staff know that “what’s said in the group stays in the group!” Also we noted that one person would speak at a time, everyone’s feelings would be respected, and we would try to discuss one case at a time.
During the next 30 to 40 minutes, as chaplains, we led the conversation about cases that had recently caused the staff moral distress. We decided to discuss specific cases, with names, illnesses, treatment decisions, family members, etc. We were allowing the staff to lay it all on the table. If the discussion was slow to start, the chaplain would bring up a specific case, patient, or situation, and set the scene — giving details of the case, and asking staff, “What was so distressing about this case?”
As group leaders, we had in front of us reminder lists of how to facilitate. The first was “The Value of Debriefing,” which included items such as reminders to normalize feelings, assess the units’ strengths and weaknesses, re-establish perceptions of being in control, and to allow storytelling. Second was “Our Role,” which reminded us to set the tone, and to encourage discussion with questions such as “Did anyone else feel that way?” Reminders to be comfortable with silence and to enforce ground rules were also part of our role. And lastly we were to “Be There!” even if no one showed up for the group.
During the 10-minute wrap-up, the chaplain reiterated what was heard and asked if there was anything that the group wanted to bring to the manager, over and above just venting. We also offered tools to help the staff, including taking a break, deep breathing, and literature on stress. We had a brief discussion on what folks were using for relief. We talked about healthy crutches, such as exercise or meditation, and unhealthy crutches like drinking.
We ran the group four times and had 26 people attend over the course of a week. The members participated in all discussions, respected the rules, and were able to talk about specific cases, patients, and their feelings. Some portions were very emotional. They did ask us to take two items back to the management, and other conversations stayed within the group. The staff reported over the next few weeks that the group was very helpful. In the future, we plan to run the group quarterly, or whenever tensions run high due to specific cases.
Lisa A. O’Connell, BCC, is a chaplain at Good Samaritan Hospital in Cincinnati, OH.