square bulletLove in the ER

May 24, 2016

From Juliana Wallace,  LCSW, CADC III, Social Work Supervisor, Oregon Health and Science University

It is suggested in Empathy and the Practice of Medicine that increasing narrative competence will result in stronger empathy in medical providers (Spiro, Curnen, Peschel, & James, 1993). One way the book suggests this can be accomplished is by reading and writing about your patient interactions therefore participating with the stories of the patients. It’s an interesting book that is ultimately addressing the same thing I am trying to address, years later, in a large medical system. The medical model with all of its increasing technology and disease curing advances is leaving behind the healing and caring elements that were first present in this field. And so begins my mission: bringing love to the emergency room (ER).

The first thing I did to bring Trauma Informed Care, in manageable pieces, to this system was to address some very obvious areas, which not surprisingly supported reading and writing as part of understanding the patients. Out came the red pen to the template Mental Health Assessment used by the social workers. I started by changing the very first words in our assessment. Instead of the heading, Presenting Problem which starts us out thinking, “what’s wrong with you” and “what’s the problem with you,” the assessment now states Presenting Narrative/Situation which helps us to think about the story behind what’s happened to bring someone to the ER. Then we added a Trauma Screen into the biopsychosocial section of the assessment with a prompt for clinicians, “Do you consider yourself a survivor of traumatic events?” Finally, Cultural Considerations was added as a header and asks clinicians to begin to think about how people’s culture may impact the clinical presentation.

I have learned that this section is the most complex to integrate in such a high demand and fast paced environment. It can elicit a standard demographic report by the clinician. We are also learning how issues such as homelessness and intergenerational poverty may contribute to the evaluation of them for things such as the mental status exam. While these changes may seem subtle it appears to support the idea that in our writing of the patient’s story and as medical staff read these assessments, we are in fact increasing narrative competence. The intentional changes to the tools we use is a powerful way to infuse Trauma Informed Principles into practice settings.

Additionally, we have ventured into training medical staff using an interprofessional model with social workers and nurses training together on Trauma Informed Care and De-escalation. The first hour includes the basics of Trauma Informed Care with concepts woven into the next 3 hours. I am finding that the training content is well received with the medical teams who are hungry for information and skills to provide compassionate care. We discovered that using the concept of “Universal Precautions” connects the idea that just like blood is always treated as infected we want to be practicing from a place grounded in Trauma Informed Care with each person we interact with. The harder part of this training is asking people who are literally working in a constant state of trauma and stress to create space within themselves for self-reflection, as well as to remain present in a calm and grounded space so that we can be operating from a place of empathy and compassion instead of reactivity. It’s not easy when you feel the need to protect yourself from the next emotionally taxing experience that can enter the department. So, sometimes I day dream and while in my dream land we provide an environmental space hidden near the Emergency Department that provides staff all they might need to find balance and allow for empathy development; a clinical supervisor just waiting to provide a supportive ear, calming colors and lights, comfortable seats, herbal tea, healing scents, and a yoga instructor who can do a 10 minute class on demand. Then we provide this all while on the clock and to all emergency room staff to access as frequently as they need or want during their shift.

Back in reality, my plan is to spend time modeling the Trauma Informed Care we just trained on, leading by doing, showing by example that it can work, and allowing each person to change their practice in the way that feels safe to them. We are staying on the path to create a new narrative about the ER. A story about a place where healing, connection, compassion, and empathy live alongside the medicine and technologies that cure.