By Ankita Arora
(May 2020) Fifteen years ago, Marc Moss, MD, was running a health study in Atlanta that looked at the long-term outcome of ICU patients, focusing on their psychological distress and symptoms of depression and anxiety.
That’s when he made an unexpected discovery.
Several research coordinators running the study were former ICU nurses and they were telling Moss that the symptoms they observed in their patients were the same as the reasons they left nursing.
The words of those former ICU nurses provided the eureka moment that led Moss and his research team in a new direction. Collectively, they saw an unmet need to understand the effects of the working conditions in critical care units on health care providers. Moss and his research team found widespread presence of anxiety, burnout, and mental stress among the professionals who were there to care for others.
“In the ICU, we see a lot of tragedy and are never taught or given the right skillset to learn how to deal with it,” said Moss, who is now head of the Division of Pulmonary Sciences and Critical Care at the University of Colorado School of Medicine.
The research produced by Moss’s research team has contributed to a body of knowledge that serves as the basis for the National Academy of Medicine (NAM)’s recognition that burnout is a significant issue affecting the delivery of health care.
Burnout syndrome is characterized by high level of emotional exhaustion, depersonalization leading to increased cynicism, and feelings of a lack of personal accomplishment at work.
Driving these symptoms is an extraordinarily difficult work setting: critical care units where professionals unrelentingly see death, tragedy, and immense grief. This is especially evident during the recent COVID pandemic that is filling ICUs with critically ill patients.
“In a matter of a few days, nurses often go from talking to patients to putting them on life support and if the patient passes away performing their post mortem care without having the time and space to process the loss,” said Moss./p>The psychological distress that professionals encounter in that environment can result in symptoms of post-traumatic stress disorder (PTSD). In a study led by Moss, researchers found that PTSD numbers for critical care nurses were markedly increased and at levels that were higher than that reported by war veterans who have come back from Afghanistan and Iraq.
The increased rates of burnout syndrome and PTSD have severe consequences on clinicians and their work, resulting in reduced work efficiency and more frequent medical errors. In some cases, professionals develop a negative self-image and in the most shattering cases they commit suicide.
Initially, when Moss and colleagues would present their data showing burnout in nurses, they would encounter resistance. Providers denied they were burned out and community members would be less than sympathetic. The medical professionals were afraid they would look weak, Moss said. While those outside the profession would dismiss burnout as whining. They would hear statements like “you choose this profession and you knew what it takes.”
An improved understanding of the personal costs for patients and providers and the financial implications or hospitals and clinics prompted a re-evaluation of working conditions. ICU nurses have turnover rates of 17 percent to 20 percent per year. That churn adds costs for recruitment and limits investments.
Moss applied for a grant from the National Endowment for the Arts (NEA) in response to a 2018 call for applications. His proposal aimed to strengthen resilience among health care professionals who work in the critical care environment.
With the $150,000 awarded by the NEA, Moss and his colleagues established the Colorado Resiliency Arts Lab (CORAL) to create and then study a creative arts therapy program for critical care professionals.CORAL offers a safe space for health care professionals to express and process psychological distress through the arts.
With creative arts therapy, medical professionals engage in a range of expression – visual art, music, dance, and creative writing – to identify, accept, and overcome psychological stress. Creative arts therapy provides ways for medical professionals to express their feelings, which they might otherwise contain or suppress.
CORAL partners with the Ponzio Creative Arts Therapy Program at Children’s Hospital Colorado on visual arts, music and dance therapy, and with Lighthouse Writers Workshop to provide access to creative writing therapy.
CORAL currently is recruiting ICU professionals for a clinical trial at the Lighthouse Writers Workshop in Denver to test the efficacy of four different modalities (creative arts, music, dance/movement, and writing) over a 12-week period.
The Lighthouse Writers Workshop was formed 24 years ago create a community for writers and encourage creative writing as an art form. Its mission now includes exploring literary art as a tool for emotional expression, especially for people facing difficult challenges, including patients with cancer diagnosis and youths from poor neighborhoods.
“When you take an experience that has pulled apart your sense of self and write it in a story that captures that event, it allows you to take control and demystify that experience,” said Michael Henry, executive director at Lighthouse Writers Workshop. “There is abundant anecdotal evidence that these workshops help, but the lack of quantifiable data to prove it has been missing so far. This collaboration provides the missing link and that’s been immensely exciting.”
Henry designs the sessions to build up in intensity, starting with basic elements of good writing and assigning pieces like “describe your grandmother’s kitchen” or “what’s the story behind your name” to help participants develop a comfort zone. Then, the sessions progress to thematic topics like, “describe your best day at work” and “recount one of the most stressful days at work.”
The arts give permission for people to ease the pressure to constantly produce and then offer a vehicle for them to process difficult feelings and eventually transcend them into something beautiful,” says Katherine Reed program manager at the Ponzio Creative Arts Therapy Program.
At Children’s Hospital Colorado, the Ponzio Creative Arts Therapy is a part of psychiatric treatment for kids with eating disorders, autism, and Asperger syndrome.
During the past five years, Reed has received requests from hospital staff members to provide similar kinds of art therapy to address burnout, compassion fatigue, and to promote team building. In 2018, when Moss approached Reed to ask for help with his program, they realized working together they could have an even greater impact.
In 2019, Reed and her team did 36 hours of resilience building for groups all across the campus, serving 818 professionals in total.
Creative activities have included creating large murals using caps of medicine bottles that have been collected by the emergency department. Other groups have been “scrapbooking” filling blank books with images, ideas, words, crafts, or any medium they can fit. Ultimately, they are encouraged to share the images and use those as building blocks to express and process feelings.
“Arts turns us from victims of our trauma to creators,” said Reed.
A persistent challenge for Moss and the team is that medical professionals are reluctant to take time out from their busy schedules to participate in the trial. It is difficult for critical care healthcare professionals to accept that burnout can also hit the best practitioners in the field and they are sometimes resistant to taking time for mental health care.
Eventually, the team hopes their work could lead to a studio space in a clinical setting where staff could go during breaks express themselves through creative arts. They would also like to provide evidence that having dedicated time in staff schedules for art and recreation will improve patient care and clinical performance.