Our latest post comes from Robert Maunder and Jonathan Hunter, authors of Love, Fear, and Health: How Our Attachments to Others Shape Health and Health Care. Both work at Mount Sinai Hospital and have first-hand experience of working in the midst of COVID-19. In this post, they give a first-hand account of what the current pandemic looks like from inside a hospital, and they let us in on a three-step process that can put the COVID-19 outbreak into perspective, and how we can all feel a little less overwhelmed.
I work in a hospital. A few weeks ago we were waiting for “the surge” of people needing treatment for COVID-19, waiting to see if the surge would overwhelm our capacity to provide intensive care. It was a bit like what I imagine it is like to drive a small boat around on the calm water of the Niagara River, just upstream from the cataract, unsure how great the danger might be around the next corner. The water is calm; the boater’s mental state anything but.
During those days of anticipation and planning I was asked to join the hospital’s “clinical triage working group.” The dry language of the group’s name doesn’t really convey the nature of the task – to sort out how to deal with one of the worst-case scenarios in a severe surge, when there are more patients requiring intensive care, especially assisted ventilation, than there are resources available. Who will be saved and who not? By what criteria? Who decides? Who enacts the decision? Who communicates it? How can the decision be appealed? How will we respond to the emotional harm that is inflicted on everyone involved? We reassured ourselves that we were confident that the policy would never need to be used; that we were just being prudent, using our time on the calm upstream waters of the Niagara to make sure that we had thought through every event that we could reasonably foresee. Still, I’m sure I’m not the only one who didn’t sleep well and cried a bit.
As unsettling as it was to work on “clinical triage,” it was a good process. Colleagues advised each other, each from their own area of expertise: intensive care, bioethics, nursing, spiritual care, psychiatry, respiratory therapy, and more. We acknowledged each others’ values and feelings. We addressed disagreements respectfully and, working on a timeline that was accelerated by the circumstances, we came to a consensus on what to recommend. We helped each other.
The surge that we anticipated did not come. Toronto, thus far in the first wave of COVID-19, has not experienced what happened in Wuhan, or northern Italy, or New York. Our curve has flattened enough that our intensive care units (ICUs) have not been overwhelmed. But as I write this, many of our long-term care homes are in crisis. Understaffed even before the pandemic, their residents and employees are facing the full force of the infectivity and lethality of the SARS-CoV2 virus.
Now, it is colleagues like Marcia who are in COVID’s glare. Marcia is a surgical nurse (fictional to protect the privacy of my colleagues, but there are many just like her). She has been providing care to surgical patients at our hospital for over 20 years. She was here as a young nurse during SARS in 2003 and she participated in our preparation for the 2009 H1N1 pandemic. COVID-19, however, is nothing like those events; it is more tiring, more frightening, more consuming. When the operating rooms were all but closed early in the COVID-19 pandemic, Marcia’s unit switched to caring for medical patients, “PUIs” (people under investigation for COVID-19), and then elderly patients with COVID-19 transferred from long-term care homes. Marcia was asked to shadow her colleagues in the ICU for a couple of shifts, in case she had to start working there during a surge. Now that the site of crisis has shifted, Marcia has been asked to volunteer to work in long-term care.
Marcia feels torn. She wants to go. Nurses, at least some of them, are like firefighters that way. They go towards trouble and pain instead of away from it. They accept some degree of personal risk in order to help others. On the other hand, Marcia worries about just how risky the long-term care home might be. Similar places have been described as being out of control in the news. Marcia can accept risk, but she has her limits. And what about her elderly mother who lives with her? Marcia’s mother depends on her; she couldn’t manage without her. Living separately in order to keep her mother at a safe distance isn’t an option. Talking to a co-worker who she has known for many years while on break, Marcia says, “I won’t refuse, but couldn’t someone else who doesn’t have a senior at home go instead?” She feels guilty saying the words out loud. “I feel the same,” says her friend.
Early in March 2020, when we were very much in the planning and anticipation phase of the not-yet-officially-declared pandemic, Jon Hunter and I decided to make a video to help our colleagues cope with what was about to happen. We knew what to say because we had sorted through the evidence about what helps healthcare workers to cope when we were preparing for the H1N1 influenza pandemic. And we knew how to make the video, because we had made a few previously to teach the principles that we later described in our UTP book, Love, Fear, and Health: How Our Attachments to Others Shape Health and Health Care. We favour videos with made-in-your-kitchen production values, in which we use sped-up film of a whiteboard lecture to make a few simple points. They are always credited to “The Men in Plaid,” a self-conscious joke about our sartorial style. This Men in Plaid video, How to Cope with Anything (including COVID-19), has been viewed over 8,000 times as I write this, two months after it was posted, so we hope we are providing some of the help we intended.
The steps to coping that we teach are simple. They are also not ours. We adapted them from a framework that was described by Susan Folkman and Steven Greer for coping with cancer. We teach nothing that you don’t already know, but we teach it because at times of stress, people forget what they know. As our collaborator in this work, Molyn Leszcz, says, at times of stress, it is helpful to make the implicit explicit.
So here is how to cope with anything. Step 1: Fix the things you can. Step 2: Find ways to feel better about the stuff you can’t fix. Step 3: If all else fails, pay attention to your most enduring values.
Let’s break that down a bit. The first step is problem-focused coping. It is what we always do first. It comes so naturally that we don’t even think of it as coping. It is just life: plan, prepare, identify problems to fix, get advice when the fixes aren’t obvious, get training about the technical stuff. If it works, you won’t even need to realize there was anything to cope with.
It was problem-focused coping that prompted the clinical triage working group to be formed. And that required that it include the right types of expertise, so that we could advise each other, and so that we could each anticipate challenges and solutions that we had seen before.
The second step is emotion-focused coping, finding ways to feel better about what we can’t fix. This is the step that usually feels like “real coping” because it takes effort and responds to distressing feelings. Having a sense of humour works (the outtakes from Men in Plaid videos are routinely sarcastic, off-colour, teasing, and immature). Self-care, like good nutrition, exercise, and sleep, fits in this category too, and is all the more important in an enduring stress like the current pandemic. Perhaps the most powerful of the emotion-focused strategies, no surprise to readers of Love, Fear, and Health, is the emotional support that we provide to each other. When Marcia speaks to her friend and gets a validating response, it sustains her, even though nothing has changed in her dilemma. The respect, cooperation, and collaboration that allowed me to feel that something good had happened through the deliberations of the clinical trial working group was interpersonal support of another kind.
The third step is meaning-focused coping. Most of us don’t explicitly attend to our values, the things that provide meaning and purpose, most of the time. Those with an existential bent, like Molyn, say that we tend to look away from the glare of the authentic. Martin Buber said we spend most of our lives in bad faith, taking comfort in self-deception. When our circumstances, especially circumstances of enduring suffering, rub our faces in how little control we have over our lives, it is time to make the implicit explicit. What do we value? What is the point? The answers can be revealing (I’m thinking of the anti-COVID lockdown protestor whose sign read “Sacrifice the vulnerable. I want my freedom,” providing remarkable clarity about how he values self-interest). In the hospital, it is helpful in moments like these to reflect on why we went into this profession in the first place. That motivation can get us through things we can’t fix, nor feel better about.
We all know how to get through this. We do it together, reminding each other that we have what it takes.
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