By Elizabeth Schultz, John W. Ehman and Ray Lewis Jr.
It is remarkable to watch Trauma/Emergency staff respond to crises. Their calm confidence can seem like a medical variation on the pastoral theme of non-anxious presence. One patient is bleeding, another is in pain for unclear reasons, a third is angry and abusive while being treated. But physicians, nurses, and other staff just move through their jobs with great professionalism. It’s easy for chaplains to overlook how much stress is buffeting providers and how much effort it takes to handle that. Chaplains are generally in a physical position to support staff, but it usually takes some intentional, relational positioning on our part to be most effective.
Every time a trauma team assembles at the Level 1 and Level 2 facilities within Penn Medicine, a chaplain is there. Over 2,600 trauma patients a year are brought to the Penn Presbyterian Medical Center in Philadelphia, and over 2,200 to Lancaster General Hospital in Lancaster, PA. Tens of thousands more are treated annually in the two emergency departments, where chaplains are involved as well. That’s enough activity around patients and families to keep any chaplain busy, but our position allows us a special opportunity also to support the staff alongside us.
Consistency in pastoral care is extremely significant. Many emergency department staff often guard their own hearts, because of what their work shows them: the trauma and wrong that has been done to their patients. For this reason, chaplains must work intentionally on building relationships with staff. Watching chaplains care for patients and families on a consistent basis, day to day, helps to build trust in their eyes. Staff will watch as we listen to, care about, and connect with people. Then, slowly, those staffers give us the chance to care for them, and they begin to feel comfortable building relationships with us.
Four interrelated pathways can help support staff:
First, acknowledge their effort. Let them know that they are seen and appreciated. A quick and well-timed comment can send a message that celebrates the dedication of the provider and stands against any sense of being taken for granted. It is not the place of the chaplain to “validate” the provider, but we can help bring appreciation of the staff to voice.
Second, affirm their spirit. See beyond what they do to the very heart of why they do it, and lift up their motivation in treating such challenging patients and families. The sheer pressures of the healthcare environment can distance providers from the spark inside that first brought them into a caring profession. By affirming indications of the spirit that underlie caring actions — perhaps purely something like bedside manner — chaplains honor how care is much more than a medical service; it is an expression of truest self.
Third, hear them when they wish to process their experiences. This might occasionally happen in a private space during a break, but typically it will take place in brief moments between treatment and documentation. Yet active listening works even in short exchanges. If staff members know that they can be heard deeply without having to say much, they will probably feel less apprehensive in sharing vulnerabilities. Little experiences of feeling heard on the fly can lay the groundwork for more substantial interactions at planned times.
Fourth, hallow their work. Connect the staff’s caring explicitly with what can be understood as sacred. Actions can range from an informal “Bless you” to a formal reflection or prayer. Inviting staff to be present for a prayer at a patient’s bedside is one way, especially at a traumatic death. Communal occasions might take place through the year, like unit blessings or pastoral letters or staff memorial services. A growing number of hospitals seem to be conducting a Blessing of the Hands ritual once a year. Emergency administrators can be good partners in brainstorming about how to show reverence for the work life in their areas.
At Penn Presbyterian, one meaningful event every year is a service of remembrance for trauma patients who died from violence. With families in attendance, staff members read initials of the deceased (for confidentiality) while lighting memorial candles. This is often a profound — and for many a spiritual — event that some have linked to their sense of calling. Another supportive initiative is staff debriefing programs. A chaplain regularly leads a discussion in a Rounds series on the personal and interpersonal dynamics of being a caregiver. Out of that has grown a plan for debriefings after resuscitations, so staff may reflect on the emotional and spiritual significance of the events.
At Lancaster General Hospital we have adopted a post-code pause in the Emergency Department. When a death occurs after a code blue, a chaplain invites all responders to stay for a moment before they disperse. She or he reads a script that calls to mind the humanity of the patient and recognizes the heroic efforts of the team. Attendees are invited into 10 to 15 seconds of silence to use in any way they feel comfortable. Then the chaplain checks in to see how individuals are doing, providing a chance to “read” the room, address acute distress, and notify management if further interventions may be warranted, such as a debriefing.
We also emphasize building and strengthening relationships between all emergency staff and the chaplains. Many times a nurse, aide, or unit secretary has said to a chaplain, “Thank God it’s you” or “I’m so glad you’re here.” When we ask why, they say, “I know you will do your job well and I can do mine with less stress,” or “I don’t have to worry about this grieving family because I know you will take good care of them.”
But how do we build this trust with CPE students rotating through the ER? First, we utilize our emergency staff chaplain as a bridge of trust with the ER staff. Change is difficult, and in a stressful environment where teamwork is so important, changes in the team can produce anxiety. But the staff chaplain helps the ER staff adapt to change. In addition, a trauma nurse who sits on our CPE advisory committee also helps orient new students to the department.
Lastly, we may ourselves model constructive coping. We are willing to talk about this, to name stressors and their effects, and to champion self-care. We are often in awe of the staff around us who seem to take anything in stride, but we should remind ourselves that sometimes they are looking with need at us and are open to us. Remaining aware of just that can be foundational to our interactions and interventions.
Elizabeth Schultz, BCC, John W. Ehman, BCC, and Ray Lewis Jr., BCC, are staff chaplains with Penn Medicine.
