Michelle Schuster:
So it wasn't really, until I was able to start working at Boston Children's that I left my previous job that I realized I still had these feelings of waiting for the other shoe to drop. I was waiting for my shifts to get so bad, as I had experienced previously, or waiting for those moments of, "Okay, I know it could be bad, when's it going to happen?"So I was always kind of hypervigilant, and after weeks, which turned into, you know, a month and two months of, "Okay, the shift was good. Oh, my shift was great. Oh, okay. Nothing bad happened," I recognized that something deeper was going on.

Nacole Riccaboni:
Wondering what that something deeper was? Michelle is describing job-related PTSD. And yes folks, PTSD in nursing is a real thing. Don't believe me, listen to our guests, Michelle and Tricia break it down for you. They both are nurses at Boston Children's Hospital and experts on this very subject. This issue is so important, as many of us are suffering with COVID anxiety and stress right now, and we should not be doing that silently.

Nacole Riccaboni:
My name is Nacole Riccaboni, I'm a critical care nurse working in Florida, and your host for SHIFT Talk. This podcast is brought to you by SHIFT a new community for nurses ready to make a change. SHIFT is sponsored by the Robert Wood Johnson Foundation. Follow us on Instagram at shiftnursing, and for more awesome stories and real talk about nursing, head over to our website at shiftnursing.com. One final note, this episode was recorded in mid-July, and things with COVID might've changed between now and then. Let's begin.

Nacole Riccaboni:
So Michelle, why don't you tell us about your experience as a pediatric oncology nurse and your experience with burnout?

Michelle Schuster:
Yeah, so I started as a pediatric oncology nurse just over five years ago, and it's definitely a profession where you get into it because you feel so connected to patients and families, and you want to give your all, and the nurses that I work with, and I know for myself, we, you know, you put a hundred percent into every single shift and sometimes it can lead to burnout, but something more that I experienced was PTSD.

Nacole Riccaboni:
Now, how would you describe the burnout versus the PTSD? What is the difference in your mind?

Michelle Schuster:
Yeah, so burnout is something that is a little bit more commonly talked about in the profession and it's something that there is more literature out there about, but PTSD is really, it goes a little bit deeper and it affects the nurse, not only in the shift, but after the shift and it can have more lasting effects. Sometimes burnout can kind of come and go with heavy patients assignments, or just kind of the ebbs and flows of the unit, but PTSD kind of sticks around, and it lingers even after the busy-ness of the certain acuities end.

Nacole Riccaboni:
Okay. And what type of things were you experiencing during your episodes or events that took place?

Michelle Schuster:
Some of them involved my first experiences with end of life patients. So when I was working at my first job on a pediatric oncology floor within an adult hospital, I got reports from my day nurse, I was working the night shift, and I was told that the patient was nearing end of life, it could happen on my shift. So as a new graduate nurse, I had just come off orientation. I was about maybe, you know, three or four months off orientation. And I was like, "Okay, this is going to be my first experience with it. Okay." You know, I was definitely nervous, but I was trying to be as ready as possible going into the room, understanding that that's something that comes with this aspect of the job. So when I walked into the room, I realized that the mom did not know just how far progressed her son was. And she started asking me questions about, "Why is he so sleepy? Why is his oxygen so low? What is really going on here?" So there was kind of this element of, I walked into the room kind of feeling my own worries about how am I going to comfort this, or how am I going to be able to navigate the situation, but then to recognize that the parent didn't even recognize how severe and how close to end of life her child was, that was something that made this first patient experience extra heavy.

Michelle Schuster:
But when I looked back, what made it extra stressful was feeling alone through it, and feeling like I didn't have that support system, or just navigating it almost without a map. That's kind of how it was for me. I had ended up going home that night, and I talked to my husband. And I was just so upset and distraught. And I was telling him that, "I can't continue on in this field that I love so much because I feel like that passion and that drive for what got me into it is slowly fading away. And I feel like pieces of myself are getting chipped away, chipped away." And I had to make a change. I loved working in pediatric oncology. I loved the patients, the family, the medicine, the disease processes. I really loved that aspect of it, but I couldn't stay at that institution. So it wasn't really until I was able to start working at Boston Children's, that I left my previous job, that I realized I still had these feelings of waiting for the other shoe to drop. I was waiting for my shifts to get so bad as I had experienced previously, or waiting for those moments of, "Okay, I know it could be bad, when's it going to happen?" So I was always kind of hypervigilant and after weeks, which turned into, you know, a month and two months of, "Okay, this shift was good. Oh, my shift was great. Oh, okay. Nothing bad happened," I recognized that something deeper was going on. And it was at that point that I did seek out seeing a therapist, and after talking with her and kind of going through some of my past experiences at my previous job, she was the first one who told me that, "You know, the way that you're speaking of these incidents in these events, it sounds like you have post-traumatic stress disorder due to your work related situations." Sitting in that therapy session, it was a light bulb. It was a moment where I was like, "I had never considered that nurses could have post-traumatic stress disorder if they weren't deployed or weren't related to the military." So that was, yeah, that was really enlightening for me personally. And that's where my interest was, "Well, if I don't know about it, maybe a lot of other people don't know about it. And I want to find out more about PTSD and nurses and what this phenomenon really is."

Nacole Riccaboni:
Tricia, hello.

Patricia Dwyer:
Hello.

Nacole Riccaboni:
And I wanted to ask you what decided, actually, what made you devote your career to researching kind of workplace issues and burnout?

Patricia Dwyer:
So I think that's one of the reasons why myself and Michelle had this instant connection, because early in my career as a new graduate nurse, I also experienced sort of like a traumatic event. I refer to it as my "Orange Popsicle" story, because if anyone remembers what it's like to be a new grad, it's like most of the time you just feel, you know you start your new job and you feel kind of like a fish out of water for a long time. But I remember that night so vividly that, it was the first night that I really started to feel, you know, "Okay. You know what, I, I get this." I felt super in control of my assignment. And I had made rounds on everybody and everybody was doing great. So I went to the kitchen about like one o'clock in the morning to get myself an orange popsicle. And I sat down at the desk and I'm eating my orange popsicle, and all of a sudden I hear that a code is being called on my unit, but I was covering a far end of the unit, so this event happened on the other side of the unit. So at first I was kind of like stunned. It seemed almost surreal, but I, you know, put my popsicle down, and I ran down there, and it was, you know, it was my first time actually witnessing a code. I had never seen that before, not in my training as a nurse, and I guess even, you know, in my life experience, I had never really witnessed that kind of human suffering. And I was sort of in charge of taking care of the mother, and needless to say it was a very, you know, distressing situation. And by the time I got back to my desk several hours later, this orange popsicle had melted all over the place. And I'm talking, this happened 30 years ago, so we've come a long way, but I just remember going to my car and just crying. And for like a long time after that, I kept having these reoccurring sort of flashbacks of this mother's eyes and her sobbing and screaming for her child. Like I could hear it at night and I thought, "Oh my God," but I didn't know what was going on. So it was from that moment forward that I kind of was always interested in understanding this sort of like emotional toll of practice. Like how do these events affect us as nurses over time, and how do we need to protect ourselves?

Nacole Riccaboni:
I thought the popsicle story was going to be this funny, joking story. It's clearly not, and I'm sorry that you experienced that.

Patricia Dwyer:
No, but to this day, like if I see an orange popsicle, I can feel the little hairs on the back of my neck. Like I just, it brings me back every single time. It really, really does.

Nacole Riccaboni:
My husband tells me all the time that I talk in my sleep. He's like, "When you started nursing school, you would talk in your sleep." He's like, "For the past two years you talk and you mumble, and you're having full conversations." And I didn't even know it. He's like, "You're talking about work, it's work related. Why do you think that is?" I said, "I have no idea."

Patricia Dwyer:
We're trying to process it in some way, you know, the stuff that we have to deal with. So that was sort of the popsicle story. But back then, I mean, this is 1989, you know, we didn't talk about these things in nursing. Like there was nobody to debrief the situation. We just kind of like went on, and if you don't know what you're experiencing, you can kind of suffer in silence. So I think, you know, as a profession, we really need to think that we shouldn't be suffering in silence, that we should really understand that we can be exposed to some traumatic things in our profession, in the nature of our job, it's our business. So we kind of have to equip ourselves with the knowledge to say, "Hey, you know what, if I'm experiencing these things, maybe this is PTSD." So I guess knowing what the symptoms are is really important for nurses.

Nacole Riccaboni:
Now, Michelle, can you go over maybe some general symptoms of PTSD? I know each person is unique, but maybe some general lists of things to look for?

Michelle Schuster:
Yeah. So kind of talking about it, one of those are intrusive thoughts or re-experiencing. So that could be intrusive thoughts, thinking about the dreams that you were talking about, thinking about, you want to be at home...

Patricia Dwyer:
The flashbacks that I was having.

Nacole Riccaboni:
Oh okay.

Michelle Schuster:
The flashbacks, yes. So that's re-experiencing those events, that every time Tricia saw an orange popsicle going forward, she is re-experiencing that a little bit. And it doesn't ever fully go away, but you can manage how you are kind of having that awareness of, this might happen when you see an orange popsicle or when you have something, just being aware of what it is, is so important. But another one that I really experienced was the hyperarousal and reactivity. So thinking about hyperarousal, I think of it as, what it felt like to me was waiting for that other shoe to drop. I was waiting for things to get bad or waiting for me to feel all those negative emotions that I had felt previously. So I was almost overreacting to situations, even if they weren't dangerous or stressful. I was like, "Okay, what do I need to be doing? How do I need to handle this?" And then I would have to take a minute and recognize, "This is not a dangerous situation. I do not need to be overly active and feeling all of those sensations that my body was going into overdrive when there was no threat." So almost like my amygdala was just kind of hijacked. It was just, you know, it was, that's kind of how I explain it, just that hyperarousal. That was something that I personally experienced the most.

Nacole Riccaboni:
Are there any other symptoms that you would generally, that nurses would generally look for, or are those kind of the generic ones that you tend to see?

Michelle Schuster:
There's another one that the literature talks about, and that's avoiding situations that are reminders of the events. So some nurses leave the profession altogether, some switch specialties. So some traumatic events happen, and some individuals might do everything in their power to avoid facing that type of situation again, or trying to do everything possible, to never be put in that situation. So that's kind of avoiding, avoidance is another symptom.

Nacole Riccaboni:
Now you mentioned that, and I had a coworker, we got in a, what I would say was traumatic involving family members and police and things like that, and she just never came back. She just, it was just as if she never came back to work. She never went back to the nursing profession. She does real estate now. And I ended up talking to her a couple of weeks ago and she was like, "I physically could not walk in the door to go back to the hospital. I was so traumatized. I tried to talk to people and I told other nurses that, and their reaction was, 'Oh, well, you know, you got to toughen up.'" And it was like, no one really understood how heavy that was for her to bear, and, for her to even be honest about it. Now Tricia, what would you say to the nurses out there that don't believe that nurses can experience PTSD, or they don't believe that it's a problem in this COVID pandemic?

Patricia Dwyer:
Well, I think the evidence, I guess the research, really says otherwise. So we did just look at this. We dug deep into about 24 different papers to synthesize all the research. And the big takeaway is that yes, it is a professional concern for us. So I think we have to be just open to the fact that we can experience work-related PTSD. So it happens, it's part of our job, but if we're armed with knowledge, if we're armed with awareness, then we can protect ourselves better, or we can seek help when we need it and still come back stronger and more resilient and better for our patients. So I think that's really the true message. Like Michelle said, it's not a sign of weakness. It's just an acknowledgement that, yes, not everybody will experience it, but if you experience these symptoms and they're ongoing, then you should look for some assistance. You should look at resources within your hospital and see what kind of support you can get for that. Because you can come back stronger and for better,

Michelle Schuster:
Exactly.

Nacole Riccaboni:
How are you and Michelle applying your research findings to help nurses who are struggling with the effects of the COVID-19 pandemic in general?

Michelle Schuster:
One of the programs that I've helped build at the hospital, in collaboration with someone who works in the professional development department, we started identifying gaps. Why don't we have a resiliency program for nurses? Let's fill that gap. Let's create that program for building resiliency, because the literature does show that resiliency can help reduce burnout, reduce PTSD effects, it really does help nurses. So my co-developer in professional development, we started this as a in-person class in November, before COVID hit, and it's called Mindfulness and Resiliency 101. And it's really just talking about how to incorporate resiliency and mindful practice into your every day, and how to make yourself more aware of what resiliency is and how to practice it, like applicable interventions you can either use for yourself or take back to your unit. But then COVID happened, so we adapted that in-person class to be able to be offered on an online Zoom format. So we were really adapting our teaching content to fit the needs of our learners. And that was all distance learning. I feel like our reach was able to expand more, because we were able to offer it so many times virtually. And we actually worked in collaboration with Sigma, the nursing organization, and put it on for their members, and over 500 people participated in this one live session. So it's been really great to spread the message about why resiliency matters, how to build it within yourself and how to take those active steps to become more resilient and mindful. That it's not about doing something for an hour every single day, but just small moments. It's about the frequency, not the length. And that's something that we kind of talked about, so just a little bit, every day is something that will become more common and more natural in your daily routine.

Patricia Dwyer:
Nacole, what do you think? Like, for me, I always feel like as a profession where there's a giving profession, but we're the first ones to like, not give to ourselves. Do you find that?

Nacole Riccaboni:
That's so true, I'll work a double, I'll be awake 20 hours, and I won't take care of myself. And my husband's like, "What are you doing?" I was like, "I don't know, my patients need me." And he's like, "Yeah, you're dying. And we haven't seen you for two days." I'm like, "Oh I know, I forgot about you guys."

Patricia Dwyer:
I know.

Michelle Schuster:
I know.

Patricia Dwyer:
We make all these sacrifices for others, but sometimes we don't really, I guess, mindfully make sacrifices for ourselves. So I think especially during this time when we're shouldering so much as a profession, just being aware of self-care for ourselves is going to be really, really important going forward.

Michelle Schuster:
I think we are really transitioning to a period where people are starting to talk about kind of that cost of caring and how to, especially now with COVID and people really thinking about the impact that this is going to have on our professionals. So I think talking about mental health awareness and making that less taboo is so important, because we want to be able to arm the caregivers and our nurses with as much power and information as possible so they can best take care of themselves, so that therefore our patients will have better outcomes, our families will have better outcomes. It really does start from within. And I think going forward, really just talking to each other more, talking about the importance of these big topics like PTSD. I think those are very important ways that are just going to continue to grow our profession and to make us even better.

Nacole Riccaboni:
And I think you're right, because no one tells you how to figure out the feelings aspect of nursing. You know, you go over all the disease processes, but no one ever told me how to manage a code or how to talk to a wife that her husband just died and they've been married for 50 years. No one walks you through how to handle the emotional baggage after you go home, or even during the situation itself.

Michelle Schuster:
Right.

Patricia Dwyer:
100%.

Michelle Schuster:
I do feel like that's where, you know, we can be better, and we need to start identifying those gaps so that we are teaching self-care and we are teaching aspects of resiliency in nursing school and to all health care professionals. The other week I was talking to my best friend who is a neuro-ICU nurse in Dallas. And we were having this really interesting discussion about how it seems like the rest of the world is just very afraid of getting COVID. But as nurses, we are terrified at the thought that we could spread it to someone we love, that we could possibly infect others. So we are carrying so much more of this invisible burden and it's definitely heavy. And I think talking about self-care, wellness, looking out for one another or someone that you love, just trying to be aware that post-traumatic stress disorder was happening before COVID. And it's definitely going to be exacerbated now and after.

Nacole Riccaboni:
Oh, for sure. I mean, I work on a COVID unit from time to time and I just, when I come home, I don't let my kids touch me. I don't want my husband touching me. And then I like take the hottest shower of all time. And even then, I don't think I'm clean enough. And then I hand sanitize. It's like, I'm scared to touch my baby. And then I feel guilty for not wanting to hold him right when I get home. And it's just my husband's like, "Why are you crying?" I'm like, "I don't even know there's a lot going on right now."

Michelle Schuster:
There are a lot of layers. So many layers.

Nacole Riccaboni:
If a nurse or organization lacks the resources that your institution has, what do you recommend they do? Or who would you refer them to in cases of stress or PTSD-like symptoms?

Patricia Dwyer:
Can we kind of take them by the hand, can each one of us take a role and like, say, "Okay, let me sit down with you right now. Okay, there's nothing available at the hospital to help you, but so let's look in your community. Let's, contact this person. Let's see if they can point us in the right direction." Sometimes that person just needs somebody to be like, "You know what? This is real, what you're experiencing right now. It's okay. And it's okay to admit that you need some help. So I'm going to sit with you, and we're going to find you someone to talk to, and they can best advise you of what you need and where to go."

Nacole Riccaboni:
That's so true. Michelle and Tricia, thank you so much for allowing me to interview you. I learned so much about my own problems and things that I need to work with. It's just really good to, like you both said, vent and process, because we're so stoic in our taking care of our patients, focusing on them. It's just great to hear and feel another counterpart tell you it's okay to feel and process. And if you need help, that's also okay.

Patricia Dwyer:
Absolutely. Nacole, thank you so much for having us on and helping us kind of bring more awareness to this issue, especially during this time. So I think, we really appreciate you talking with us. It was great.

Nacole Riccaboni:
Thank you. Thank you for all the resources I intend to looking those up as soon as we get done here, they're great. I have to share them with my coworkers. Thank you so much.

Michelle Schuster:
Yes, please do. Thank you. Thank you.

Nacole Riccaboni:
Thanks for listening to SHIFT Talk. This podcast is brought to you by SHIFT, a new community for nurses ready to make a change. SHIFT is sponsored by the Robert Wood Johnson Foundation. The views expressed in this podcast are of the guests and hosts only, and do not reflect the views of the Robert Wood Johnson Foundation. To learn more about our guests and hear more nurses talk about the important issues we're all facing right now, visit our website, shiftnursing.com and please subscribe, rate and review SHIFT Talk wherever you get your audio content from. Until next time, stay safe and keep being awesome.