It's Time For a New Kind of Nurse

 

    Nurses are leaders and innovators in healthcare. Dame Maud McCarthy identified and described "shell shock" (PTSD) in WWI. Elise Sørenson, a Danish nurse, created the ostomy bag in 1954 and the crash cart was invented by nurse Anita Dorr in 1968. In recent years nurses have developed smart wound dressings with built-in biosensors that in conjunction with AI-run predictive wound healing algorithms. In fact, nurses have been problem-solving and improving healthcare delivery worldwide since the inception of the profession, almost 200 years ago. 

    During this time, an unseen malady has been moving through healthcare. Modern psychology and neuroscience have developed to the point that we finally possess language to describe the professional afflictions that have plagued healthcare. Words like compassion fatigue, vicarious trauma, moral injury, burnout, PTSD, substance use disorder, existential dread, etc. have entered our lexicon. These definitions of various mental, physical, emotional, and spiritual disorders have provided us with a fluency for articulating our suffering. Nurses, Doctors, allied health care professionals, firefighters, etc. need help combating these occupational insults. 

    I believe that nurses are the answer to this problem. Not just any nurse, but one who is an experienced caregiver trained in occupational health, psychiatric treatment modalities, mental wellness, addiction, spirituality, and community health with a strong education in management and life coaching. 

    This healer of the healers or Metacare Practitioner (MP) will act as a counselor of sorts for their respective institutions. They will administer measurement tools to the workforce for compassion fatigue and burnout surveillance. They will host workshops and lectures on diverse wellness modalities like breath work, mindfulness, grief navigation, conflict resolution, communication in the workplace, meditation, yoga, Qigong, forest bathing, grounding, etc. Additionally, the MP will have a seat at the table and report to the C suite regarding the state of the healers.

    When at-risk providers are identified, the MP will set aside time to work with that individual one-on-one to drill down to core beliefs, initial sensitizing events, triggers, etc., and develop recovery strategies. Then, the individual will report back to their MP regularly until they return to a healthy baseline. If the plan fails to provide objective and subjective results in a mutually agreed-upon timeframe, the MP will be responsible for working with the provider's physician, psychologist, clergy, sponsor, and HR to gather more resources and care until the individual's depleted state has been reinvigorated and restored. There will be times when entire clinics, wards, units, or even hospitals are suffering and more widespread, institutional measures will be necessary to bring compassion, morale, and job satisfaction back online. 

    The MP role fits nicely into established nursing theory. In fact, Dorothea Orem's self-care model is a powerful philosophical gestalt to support this new field of Nursing. The theory is patient-focused and promotes agency in the process of healing. Self care as the name implies is implemented and sustained by the individual. Self-care deficits are responsible for the emotional and spiritual depletion that leads to compassion fatigue, burnout, substance use disorder, self-harm, and attrition. This is where education, MP support, and coaching can affect healing. This therapy is entirely patient-centered. Ultimately, only a properly motivated and self-actualized individual can save themselves, because these spiritual, psychological, and emotional insults are deeply personal, multifactorial, and display a wide therapeutic inter-individual variability. 

    In conclusion, it's clear that our schools have done a fantastic job teaching us how to care for others, but have neglected to teach us how to care for ourselves. Many times, healthcare providers lack even the language to articulate their suffering. It is time for a new leader to rise up from the ranks and be a beacon of education, hope, compassion, and love. The time is now and nurses already possess all the tools to solve this problem. We simply have to arrange the pieces of the puzzle properly. The time has come for Metacare. 

The Practical and Compassionate Case for Metacare

"Meta is when something refers back to or is about itself, like a book about books or a meme about memes." -Dictionary.com

    Even before Covid, our healthcare providers were in trouble. Mental health issues were on the rise, job satisfaction was falling, and risk for burnout was rising (1). The system that taught us how to heal had neglected to teach us how to care for and heal ourselves. We deserve better and as a healthcare family, we can do better. 

    Mental health awareness and treatments for healthcare providers are fairly new concepts. Research began to emerge in the 80s and 90s centered around nurses who served in Vietnam (2). Conditions such as burnout, compassion fatigue, moral distress, and PTSD began to be described and uncovered in our caregivers. As the language for the conditions affecting our caregivers evolved, so did the therapies and interventions aimed at treating it. Initially, these included, counseling, psychotherapy, and medications.

    In recent years, more spiritual and holistic approaches are being implemented to great success and gaining traction. Treatments and modalities such as yoga, mindful meditation, forest bathing (Shinrin Yoku), group therapy/debriefing, tapping (EFT), cognitive behavioral therapy, hypnosis, Reiki therapy, HIIT programs, acupuncture/pressure, massage therapy, psychadelic-assisted psychotherapy, and many more are assisting individuals in healing and stress/anxiety management. 

    The addition of new and innovative therapies is a promising development. However, varied and complex conditions call for a more sophisticated solution and problem solver. The answer to this dilemma is to develop a dedicated caregiver to the caregivers. This individual should have a high level of compassion, empathy, and curiosity regarding the human condition. This meta-care professional will have attained a high level of knowledge of anatomy, physiology, pharmacology, pathophysiology, psychology, and have real world experience of the burden of caregiving. Armed with this first hand experience and knowledge base, they can act as guidance counselors for the hospital staff, institutional health/wellness program leads, and navigation beacons for those seeking more personalized care. 

    Conditions like compassion fatigue, burnout, vicarious traumatization, chronic stress/anxiety, insomnia, existential dread, moral injury, PTSD, etc. are complicated and carry subtle inter-individual nuance. So, there isn't a one size fits all approach to treatment. This is where the meta-care practitioner will shine. This system is anchored in A, E, I, O, for you principles, Agency, Empowerment, Independence, and Ownership. She will listen to the individual, allowing them to debrief, and recommend homework as a first line treatment. Then, during follow up, the individual can grade what is working and abandon those interventions that aren't speaking to the issues. Ultimately, the caregiver will discover the healing modalities that address their suffering and begin the healing process. Retaining this caregiver (the cost of onboarding a nurse is 22-64k) will save money, result in staff with greater resiliency, stimulate post traumatic growth, and spur development of localized mentors on floors and units. 

    If we view the hospital as an organism, this new internally focused approach to healing and self compassion will allow the organization to heal and function at higher levels. The care that the hospital exhibits for itself will radiate into the community. This institutional self care and resilience will foster a healthier work force, cement customer loyalty, and increase market share, leading to healthier balance sheets.

1. Rotenstein, L. S., Torre, M., Ramos, M. A., Rosales, R. C., Guille, C., Sen, S., & Mata, D. A. (2018). Prevalence of Burnout Among Physicians: A Systematic Review. JAMA, 320(11), 1131–1150. https://doi.org/10.1001/jama.2018.12777

2. Mussell, P. G., Cumberland, G. D., & Riddick, L. (1988). Posttraumatic stress disorder. A real entity in death investigation. The American journal of forensic medicine and pathology, 9(1), 74–75.

3. https://www.rwjf.org/en/library/research/2009/07/business-case-cost-of-nurse-turnover.html

A Bird in the Hand

    I got home from work the other day and a small bird had become trapped in my screened porch. It was frantically flitting side to side and I attempted to shoo it out the door. The bird refused to be herded. Each time I would close in, it would dart over or under me to hide in the corners behind furniture. After a few minutes of this insane and fruitless endeavor, I realized that I would have to change my tactics.
    A pattern eventually emerged. I could get her to a corner and work her upwards until she freaked and her behavior became erratic. Ultimately, it became clear that there was only one option and it would be dicey. I was going to have to ensnare the bird with my hands quickly and then secure her without causing harm.
    The small bird followed the plan perfectly. I boxed her in and lunged. Her small and delicate body vibrated in my hand and she chirped excitedly and pinched at my fingers with her beak. I had to fight my instincts to let her go. Quickly and gingerly, I moved through the open door and she bursts from my hands back to her forest home. I had such a sense of relief and a rush of peace after rescuing this magical little creature.
    Later that day, I sat down to meditate. As usual, I settled in and settled down, but occasional thoughts would flit through my mind. "Oh, I'm thinking about my day", let go, back to the anchor of the breath. "Hmm, now I'm following a daydream down a rabbit hole. How long have I been doing that?" Let go and back to the breath.
    Teachers of meditation use several analogies or metaphors to illustrate how we should consider our thoughts when meditating. One of the simplest and most commonly used is clouds in the sky. Clouds are always forming and moving. They are ephemeral and completely out of our control. They are also devoid of intent. We never judge a cloud, feel proud of its fluffiness or shame because it's wispy and falls apart. We notice the cloud or thought, acknowledge it exists and let it pass. This works beautifully, most of the time.     
    However, on this day, a stubborn thought loop kept reappearing. I was so curious and hungry to explore it that I couldn't let it go. I would become aware of it, acknowledge it and try to come back to the breath, but it would pop back up. In actuality, I was just chasing it from one corner to another in my mind.
    Then, I remembered the bird! This tenacious and evasive idea was just like that energetic little creature, but now zipping around the edges of my psyche. I gathered my resolve, moved in to corral this elusive yarn, and lunged. Gotcha!  I could feel it struggling and tickling the edges of my mind as I walked it to the open door. I felt that same sensation of peace and relief. Finally, I was able to break the loop by imagining myself capturing and setting that notion free back into the ether forest of ideas.
    I can't control the birds. Others will probably find there way back into my porch from time to time and that's ok. They don't mean me any harm. They're just doing what birds do. I also don't have to toil and struggle to shoo them away because now I know how to handle them.

Help Yourself, Hype Yourself

    We all need a cheerleader or a hype man. The hype man is the individual who is responsible for keeping the momentum of a show going, motivating the artist, and pumping up the enthusiasm of the crowd. He or she functions like an emotional barometer, constantly evaluating the feel of the environment and injecting energy into lulls and adding exclamation points to the performance. There have been many, sometimes even multiple people on the stage, but no one was greater than the one and only Flava Flav. 

    We all have a version of Flav in our heads. You could even say that we are that hype man. Sometimes, he's just not able to do his job properly. At this point, you probably are wondering, "what in the hell is he talking about?" Well, hang in there. I will arrive at my point shortly. 

    Experienced meditation teachers often use a metaphor to explain our inner mindscape. They speak of the "monkey mind." This aspect of our mind is the equivalent of an angry, or my favorite description, drunken monkey thrashing around the confines of our psyche. At times, the monkey jumps and screams and swings around shaking branches and throwing poo. We cannot escape him, so we must learn to live in harmony. This is where meditation comes into play. Meditation is being a witness to the mind and making peace with the monkey. 

    Well, it occurs to me, that the analogy breaks down in our fast paced and frenetic lives, so far removed from nature. Additionally, this inner self is much more sophisticated and crowded than a single drunken monkey. I see it performing all sorts of complex and creative tasks in myself, as well as others. Luckily, western medicine tackled the complex puzzle of the mind and developed a more detailed, albeit hotly debated, psychological framework. 

    In the 1920's, the renowned Austrian neurologist, Sigmund Freud, elaborated on the monkey mind. He referred to this primitive, neurotic, pleasure seeking, instant gratification aspect of ourselves as the id. The id craves the basic resources, e.g. food, clothing, shelter, and is characterized by it's violent and sexual tendencies. This new explanation of the psyche was incredibly important because it introduced the westernized, scientific community to this idea of the monkey mind. So, we began to have a common language between mysticism and scientific determinism. Each independent actor in the play of life could get on board with this idea regardless of bias or operating paradigm. Something was in our head and it was making us crazy, or at least anxious, sad, angry, etc...

    In order for us to bring this full circle, it's important to become aware of this internal situation. It's also imperative to accept that we are married to this monkey or id for life. We don't judge the monkey because, he appears randomly and we have no control over his initial state. However, with awareness and practice, we can learn to occupy the monkey or shine light on the id's behavior and course correct. 

    Once we accomplish this task, we get out of our own way, Flav wakes up, and we gain the ability to hype ourselves. This development is a critical step in becoming self actualized. The negative self talk loses it's punch, the damaging narratives that we construct become simple bedtime stories to be discarded, facades crumble, the truth of manufactured urgency and self imposed anxiety is revealed, and labels peel away. Under this new paradigm, we gain a new level and degree of psychological freedom that is peace filled and blissful. Then, we are capable of operating at our fullest potential and we can confidently face the actual slings and arrows of life.

    

This is all Temporary

    

    We're all just passing through. I think it's important to stay aware of this fact. We often get so caught up in ourselves and the drama of life that we lose sight of this fundamental and undeniable truth. We make big deals out of nothing and fail to notice the splendor and magic that is right in front of our faces. 
    The Latin phrase memento mori literally means, "remember that you have to die." The great Stoic philosopher, Seneca, advocated contemplating one's death before sleep and upon waking. Christians in the middle ages riffed off of the idea and developed the artistic expression of the Danse Macabre (Dance of death). They would illustrate the Grim Reaper dancing a pope, king, child, and laborer to the grave. The Buddha said, "some do not understand that we must die, but those who do realize this and settle their quarrels." Even sundials are notoriously famous for their clever inscriptions meant to remind us of the fleeting nature of time. One of my favorites is related to us in the podcast, S-town. It reads, "Life is tedious and brief." All these words, images, and ideas resonate so strongly within me that they create a sense of existential urgency. 
    Memento mori, this simple phrase or mantra is the ice bucket challenge for us to wake up and see this life for what it really is, an amazing and utterly fascinating journey. The ego pulls at us so strongly sometimes that we get consumed by our I, me, and my's. Our fears overwhelm and paralyze us. The id constantly whispers and nags about the four Fs. Sometimes, we just give up, wallow in our misery and fume at perceived wrongs. All the while, precious sands fall through the hourglass, never to be touched again.  
    Mindfulness is a buzzword that's thrown around everywhere these days. You see it on magazine covers and hear Dr Phil talking about it and you probably have a friend like me who drones on about it, ad nauseam. Also, talking about being aware and engaging in mindful awareness are two completely separate things. The term mindfulness is over used so much that it loses it potency. It's also shrouded in mysticism, which can be a real turn off to some, and it's ephemeral. The constant barrage of external stimuli, e.g., crying kids, phone calls, work emergencies, horrible drivers, etc. are constantly pulling us away from this magical space of the now.
    So, what do you do? Well, simply recall that this is all temporary, all of it. Richard Carlson knows this and wrote one of my all time favorite books, Don't Sweat The Small Stuff... and it's all small stuff. In one of the chapters, he reminds us that nothing is a big deal until we make it a big deal. This simple, yet insightful revelation reminds us that WE ascribe context and meaning to situations. The initial emotions that bubble up from our unconscious mind are fast and automatic and important to acknowledge, but they can be tempered and tamed by our slower, but more rational frontal lobe. So, memento morti, look at the beauty, and practice the pause. It gets easier. 


Additional reading

Keep Calm in Chaos
Stoic Emotions 
     

The Value of a Mantra

    We've all heard the old aphorism, "an idle mind is the devil's playground".  I don't know that this is necessarily true, but an idle mind does allow one to daydream and chase internal narratives down rabbit holes. This in and of itself isn't a bad thing. However, when we are stressed, sad, or angry, an idle mind can be a breeding ground for some extremely unhealthy thoughts.
    I've always enjoyed words of wisdom, idioms, aphorisms, mottos, quotes, and proverbs. Some of these introduced to me in early childhood, like my maternal grandmother's, "if you're going to do something half-assed, don't do it at all!" have guided my work ethic. Others, like the quote from the Taoist sage, Lao Tzu, "nothing is softer or more flexible than water, yet nothing can resist it." have reminded me to relax, be patient, and go with the flow. I often think about these ideas in different contexts, roll them around in my mind, and assess their authenticity. I'm not looking for absolute, objective truth, but how do they speak to me and my experience.
     Different situations and chapters of our life call for different ideas and axioms. What works for one person is often perceived as corny and trite by another. However, when a proverb is deemed authentic and accepted by the psyche, these little reminders or nuggets of truth can be mental anchors, continually bringing us back from unhealthy and destructive thoughts. They can also help us persevere and push through difficult periods in life.
    When these words of wisdom are boiled down and reduced to their most concentrated form of truth, a mantra is formed. The Sanskrit word mantra literally means thought behind speech or action. The word is defined as a statement or slogan repeated frequently. Mantras are powerful psychological and spiritual tools. When regularly employed, they have the potential to free and empower us.
    The best mantras are short, pithy, and easily repeated. Two of my favorite personal mantras are "misery is optional" abbreviated from a quote by Tim Hansel and "flow like water" derived from the aforementioned quote by Taoist master Lao Tzu. I have repeated these words so many times over the years and they have kept me from wandering the mirrored mazes of my mind.
     I recently helped a young man find his mantra. He was angry, aggressively apathetic, and not taking care of himself. Actually, he was being quite self destructive. We spoke about the importance of loving ourselves and making good choices to move in a good direction. He related to me that he didn't care about anything any more. Eventually, we came to the realization that he had lost his mother a couple of years ago and felt lost without her.
    His grief and hopelessness resulting from her absence was causing him such pain that he was hurting himself with his choices. He spoke about her incredible love and I reminded him that her love still resided in him. She was part of him and he still had all of the love that she had given him. I helped him realize that she would continue to resonate in this world as long as he shared that love. However, he had to care for himself in order to give that gift to the world. His mantra was born and became "my mother lives in me". This realization changed the lens with which he viewed himself and completely flipped the way that he related to his health. He became sacred to himself.
    This is the power of a good mantra. It changes our paradigm and pulls us back to the now. I encourage you to develop a personal mantra today. Please share your favorite mantras it the comments. Thank you for reading. Go forth and shed light.
   

Crossfit Juice fast 2013

    The inaugural 2013 Crossfit juice fast is in full swing. I started Superbowl Sunday again this year. I haven't had a bite or chew of food in five days. I'm going to stay on until Saturday morning. I've worked out (WOD'd) every day this week. I'm going to WOD tomorrow and Saturday too. So far, this has been much easier than my previous experiments. 

    Last year was great. My strength and flexability increased and I got so much better in the gym. My weight was steady at 207lb. Unfortunately, my diet fell apart around October last year when I took the family to Disney. My barely 4 pack of abs went into hibernation... Things got worse in November and December. 

    In my family, the holidays have always meant rich, yummy foods and lots of it . I lost my discipline for a minute and got lazy with my diet. My Crossfit workouts were the only thing keeping my weight in check. However, I had noticed my endurance falling off and body weight movements were starting to suck, e.g. pullups, hand stand push ups, squats, and especially ring dips. Somehow, I WAS able to finally get a ring muscle up on Dec 22nd!

    On Jan. 19th, I started a forty day paleo challenge in my gym (box). This lifestyle is relatively easy for me due to my experience with these juice fasts. I'm learning more about the biochemistry of paleo and I buy into it. All the evil lectin stuff is a little over the top, but the basic tenets and science is sound. Best of all, it works and is a realistic lifestyle in my family situation.

    I'm down fifteen pounds since the start of the challenge. I indulged last Saturday for my little girl's birthday party. This was a decision I made, not a cheat. I plan on transitioning to juice and mostly raw fruit and veggie paleo next week and then finishing out the month normally. I'm also going to up my cardio to keep the fat coming off. I'm still using 20 oz of unsweetened almond milk with 2 scoops of cytosport whey after I WOD and before bed to assist in recovery and prevent sarcopenia (I know whey isn't officially paleo). 

    Psychologically, this has been a breeze. I watched a lot of Diners, Drive-ins, & Dives the first night. However, after a little food porn, I was good. Today was the first time I felt hungry. This was quickly cured with a little beet, celery, pear, green apple juice. My body feels great and is recovering normally. 

    Slowly, I'm facing and conquering my food addiction. I have found a couple good paleo cookbooks, Everyday Paleo and Well Fed. Also, my wife is on board and transitioning the family to this lifestyle. We are playing with different recipes and teaching the kids about paleo. Saturday, I'm going to make some fresh guacamole and use some red cabbage to eat it with. I'm so excited! Is that weird?