- Email: [email protected]
What is behind our masks?
Ned H Cassem, MD
What is behind our masks? While holding a retractor as a medical student a t one of my first encounters with surgery, I incurred the wrath of a rather cantankerous lefthanded surgeon when, after h e exposed a large gallbladder full of stones, I let out sort of a low, long whistle. He turned on me and said, “This is an operating room-not a movie theatre!” (I didn’t realize I was in church.) And yet when you think about it, there is in the operating room very often a sense of hushed awe, of marvel, of miracle workers, of artistic and heroic exploits. Nor can anyone deny that events of wonder and inspiration are produced in operating rooms. Of course, nobody ever gets angry there--“Hey, culture that guy”-we merely identify the sources of contamination (a handy disguise for ire). We have to admit that there are times in all operating rooms when they are like mismanaged preschool nurseries. We see temper tantrums, sulking, pouting, and objects dumped on the floor like Pablum. We have all witnessed OR psychopathology, much of it regressive. What is behind our masks? Are we hiding?
To me, the greatest thing about the movie “Mash” was the memories that it brought back-fond memories of days in operating rooms during my surgical clerkships. “Mash” is a mask, one of the more successful and creative masks used in dealing with traumatic interior feelings. It is one of our healthier sublimations, actually. I would like to talk about some of those things that go on behind the mask. What are our vulnerabilities? What threatens and what puts us on the spot? Four of the threats are: the work, the patient, our fellow nurses, and the physicians. Work as a &eat. Sometimes, when we talk about emotional reactions to work, we may forget that the work load itself is devastating. In fact, the work is impossible. When we asked the nurses in our coronary care unit (CCU) what their worst sources of conflict were, they put heavy lifting, not emotional conflict, a t the top of their 1ist.l Heavy lifting is a CCU reality often minimized or forgotten. The work that you do is very threatening-an abdomen full of bullets, a ruptured abdominal aortic
d+ AORN Journal, July 1974, Vol 20, No 1
79
aneurysm, abscesses that form in old operating sites requiring re-exploration-these cause a lot of internal trauma for you. So your work is impossible. You have to think and act fast. And you must keep your cool a t the same time.
Patients as threats. The most frightening things about patients are: how sick they are; how scared, mad, or sad they are; or, at times, how old
Ned H Cassem, MD, is an assistant
professor of psychiatry at Harvard Medical School at Massachusetts General Hospital, Boston, where he also serves as psychiatric consultant to the coronary care unit. He is a graduate of St Louis University and Harvard Medical School. This article is based on his presentation at the 1974 AORN Congress. they are. It is more difficult to work with people a t both ends of the continuum, both the young and the very old. The converse of how sick, frightened, or old they are is how heavy our responsibilities are, because patients come to us with desperate situations that we are expected to improve or even reverse and that is a threatening, demanding thing.
For what patient problems do nurses ask psychiatric help? More than half of the consultations that resulted from requests from our CCU nurses were for patients who were scared or depressed.z Whst is our response? In the operating room you can anesthetize the patient, which in effect not only stops his or her misery, but stops yours too, because then you don’t have to listen to the patient. I have often wondered what it would be like if we had acupuncture for every procedure. How would we feel if the patient were watching us during surgery? I’m sure it would make us extremely uncomfortable, not because we don’t want our work watched, but because we would have the added responsibility of attending to the personal feelings of the patient. Doing the surgery is demanding enough! One difficulty, however, is that some would like to anesthetize the patients outside the operating room as well. It’s a reaction we can’t help. When patients come to us, they are often already in pain or feel miserable. Some of the things we do in order to restore their health inflict even more pain. We turn them, cough them, suction them, give them respiratory therapy, change adherent (especially burn) dressings, incise them, pound on their chest for ventricular tachycardia-all because we are trying to help. But our dilemma is this: the more we allow ourselves to become involved (that is, to empathize), the more we may feel cruel or guilty for inflicting pain, and, thereby feel we’re dehumanizing the person. On the other hand, if we try not to be involved, to become tougher or colder, then we feel as
AORN Journal, July 1974, Vol 20, N o 1
81
(Rapid first impressions are best. Place an X on the line at the number which seems to convey best your impression) Census:
Admissions ___ i
Date
Discharges
start of shift
Initials
Transfers
end of shift
(circle)
shift= D-E-N perm-float
Today the unit seems or feels:
1
1.
2. 3.
4. 5. 6. 7. 8. 9. 10.
Fig 7. The atmosphere assessment scale was used in a study done in 7972 fo assess the effect that death and other events have on CCU staff members. The adjective checkfist was filled out b y nurses on each shift studied. Additional characieristics numbers 17 to 30 are lively, in conflict, apathetic, overwhelming, hostile, cheerful, irritating, a disaster, together, sad, complaining, up tight, secure, blue, harmonious, heavy, catty, boring, close, and the way I like it. Space also is available for comments (arrests, emergencies, DNRs).
though we are aIso dehumanizing the
staff reactions to an expected death.
patient. It is a genuine dilemma.
Sometimes we all know a patient is
What patients do to threaten us most of all is to die. To assess the effect that death and other events have on staff members in our CCU, I designed the Atmosphere Assessment Scale (AAS). It is an adjective check list filled out by the nurses on each shift studied (Fig 1).The scale contains four subscales presented in Table 1: anxiety, discouragement, conflict, and harmony. The AAS scores in Fig 2 illustrate
going to die. The AAS scores shown centered about the death of a 34year-old coronary patient, whose parents had died in their 40s and ~ O S , his brother a t 41 and sisters a t 38 and 41-all of coronary heart disease. He had angina since age 14.This was his first myocardial infarction (MI). He came into the unit with a large anterior MI, developing a large aneurysm, and in cardiogenic shock. The intra-aortic balloon pump rescued
82
AORN Journal, July 1974, Vol 20, N o I
him from shock, but only temporarily, for angiography told us he was not going to make it. Moreover, we knew that he was going to die on about the 30th day. After his first arrest, an episode of ventricular tachycardia he had to be thumped out of, discouragement scores rose steadily. The staff was becoming demoralized because we knew he was dying and we were helpless. It was a difficult thing and it took about a week for us to recover. On the other hand, sudden death can have its own pattern of effects on the staff. Fig 3 presents scores on the day of a sudden death that occurred when we were on morning rounds. The victim was a 53-year-old man who was admitted the night before with an inferior MI. His condition was quite stable and we weren’t really worried about him. As we were standing in the corridor outside his room talking, the head nurse noticed sudden bradycardia appear on his monitor. She called for atropine and went into his room instantly. (We were still standing flat-footed outside.) Even though there was a smooth resuscitation effort, the man’s myocardium ruptured and he died. Discouragement scores were sky high, as were anxiety scores. One nurse, who had developed a special relationship with him, said that she had just waved a t him through the window and had turned around to the medication closet to get something when he arrested. At the sight of the arrest she found herself absolutely paralyzed. It took her four or five minutes before she could function. During that time there were people there to take over for her, but she felt very guilty. Later, however, when at afternoon report we reviewed the
a4
Table 1 Subscales of atmosphere assessment scale Anxiety
Discouragement
1. tense 3. frightening 14. overwhelming 22. uptight
5. 20. 24. 26.
Conflict -
Harmony
9. 12. 15. 17. 24. 27.
frustrating in conflict hostile irritating complaining catty
discouraging sad blue heavy
2. smooth 8. coordinated 19. together 25. harmonious 29. close
arrest, group performance, and the nurse’s paralysis, it was pointed out that she was probably the most caring and empathetic person in the unitso she was especially vulnerable to losing somebody like that. During the meeting the nurse was able to gain the reassurance of knowing that nothing had gone wrong in spite of her lapse. She was not excused, but was reinforced for her good traits. Note that the high and low scores in Fig 3 were taken before and after the group meeting. The dramatic fall in depression, anxiety, and conflict scores between the beginning and end of the staff meeting suggests that the meeting was helpful in dealing constructively with the feelings. These are two examples of what happens to us when patients do what we don’t ever want them to d d i e . Fellow nurses as threats. A third source of threat comes from disordered interpersonal relationships. A common manifestation of a troubled unit is the accentuation of competitiveness and the desire t o be
AORN Journal, July 1974, Vol 20, No 1
recognized as competent. AAS scores for two sets of interpersonal difficulties are presented in Fig 4. First, there were interteam manifestations of competitive jealousy. For example, the CCU nurses were criticized by the floor nurses: “What a bunch of prima donnas! They’ve got it so easy, with a patient-to-staff ratio of nearly 19, and here we are with 40 patients on the floor and just two of us. But they do the complaining. They’ve got it so soft and they think that they are so smart and know everything. ”
bleshooting the equipment. Once an arterial line was not functioning and the nurse from the research group came in, fiddled around with it awhile, couldn’t get it going, and said she was going to get one of the technicians to fix it. As she left, I heard one of the CCU nurses say, “See, they don’t know any more about it than we do.” A little nonprofessional gloating. When competitive feelings within the unit become intensified, the behavioral consequences can be disastrous for staff morale. The newest nurse, instead of being viewed as someone who needs help, is immediately identified as the unit klutz who can’t do anything right. The nurses most guilty of doing this are not the senior people, but those who were most recently new themselves. They “prove” their competence by downgrading the work of the most junior persons. We find many scapegoats. In an
In our CCU we saw the situation reverse when from among the coronary nurses a research group was developed to care for patients in a new cardiogenic shock room. One day I heard a CCU nurse say, “They are so stuck up, they think they know it all.” The research nurses were often called in to teach the rest of us in CCU about care of pulmonary arterial lines, the computer, or trou-
$
an expected death.
Harmony
-
\
10 -
$ 8l P
P
6-
cr,
P P
4-
I
1
1
1
1
3
1
l
5
1
1
7
1
1
9
l
1
11
DAYS
86
AORN Journal, July 1974, Vol 20, No 1
SUDDEN DEATH
Harmony
Conflict Discouragement Anxiety I
I
1
Day 1
I Day 7
Fig 3. AAS mean scores of CCU nurses before and offer a staff meeting on the day of a sodden death.
earlier study Dr Hackett and I asked the CCU nurses to rank the sources of their worst difficulties in the CCU. Was it research, patient problems, or all the responsibility? Named first by a wide margin was the nursing administration, closely followed by scheduling and staffing (also someone else’s fault). So we scapegoat upward too. The supervisor is always inept, we hear; the supervisor is too old, too dumb, not up on things, doesn’t know enough; there is never any good guidance around for evenings. A two-fold need is being expressed. There is a need to have somebody around who knows everything and a t the same time a need to be a totally independent person who can stand on her own two feet. Of course, the head nurse can’t
win. Staff nurses will say, as they did to our head nurse, “Why don’t you help out once in awhile?-is it just beneath your dignity to pick up a few things on the floor when you come into a room-the least you could do is that.” The head nurse thought she would try this, but the first time she picked something UP the staff nurse looked a t her and said “I can do it,” as though it had been a slur on her competence that the head nurse came in and started fiddling around in her domain. So the head nurse is damned if she does help and damned if she doesn’t. Because of our needs for approval and preservation of self-esteem, few duties of the head nurse are more important than giving approval and praise whenever they are deserved. &+o
88
AORN Jou~nal,JuZy 1974, VoZ 20, No 1
91
I NTER-STAFF CONFLICT
INTRA-STAFF CONFLICT
4
r
l4
c
GROUP CONFRONTATION
4
Anxiety 21 l
1
1 l 1
11
3
l1
11
5
1 1
7
1
~1
11
9
11
11
1 1 1
13
11
11
15
1I
11 I 11
17
1I
19
1l
l1
21
DAYS
Fig 4. AAS mean scores of CCU nurses during periods of interpersonal conflict.
A further lesson can be gained by inspecting the morale scores following death in the CCU (Fig 2-4). During the events of the expected death, the discouragement score rose. What is curious is that harmony score rose as well. Even on the day of the sudden death (Fig 3 ) , it remained a t 12, higher than average. So staff can get involved and even upset about their patients without harmonious functions being impaired. In fact, there is a suggestion that harmony score increased during the difficult period. However, when conflict within the group is present, group function is more threatened. Therefore, we need worry less about how sick patients, the recovery room or I C U responsibilities affect staff morale, than about the damaging effects of interpersonal
conflicts. This is a primary reason for giving some attention to group interaction and seeing that it functions well.
Physicians as threats. The surgeon is always the favorite target of wrath. Listen to the complaints: “He is such a prima donna.” “What actors . . . we know why they go into surgery. They are sadists, cold, don’t have any feelings, can’t deal with people. They’re Neanderthal men! They go into the OR to get rid of their aggressions.” All nonsurgeons tend to stereotype surgeons. But maybe none of us really appreciates what it’s like for the surgeon. A particular example is riveted in my memory. One of the best cardiac surgeons in the country was reviewing the tragic and unexpected postoperative death of an
AORN Journal, July 1974, Vol 20, N o 1
91
18-year-old girl in whom he had replaced mitral and aortic valves. She died after developing a spontaneous and irreversible pulmonary diffusion defect for which no treatment was known. Despondent, he told one of the nurses something I’ve never forgotten: “You know, here was somebody who could have gone on for another year. Maybe it would have been a very difficult year, but a t least it would have been another year. But because of something I did with my two hands, she’s dead.”
If honest, we must admit that no feeling of personal responsibility can be a heavier burden than those of the surgeon. How misguided it may be to label him brutish, cold, or aloof when you know that it would be so much more helpful to realize he appears that way, not because he lacks human feelings, but precisely because he feels all the same things you feel. You would do much better saying to the surgeon after a bad day, with a gentle pat on the a m , “Look, it’s been a rotten day, but you have to remember, you did everything you could.” You will get a lot further that way than you will be perpetuating the animosity and bad feeling that we all tend to displace on surgeons. Surely we must be jealous of that vast responsibility that they have. Nurses call other nurses “prima donnas” out of jealousy. They may also be jealous of the surgeon when they apply that label to him. Finally, what‘s behind your mask? Why are you in the operating room? Because you like to be with unconscious patients? Because once they are anesthetized, you don’t have to relate to them or feel anything for
92
them? Or is it the physical closeness of the OR in which we can feel close without having to relate more maturely? We are in the operating room, I think, because it is a threat. We like that. We see people a t their best and at their worst and have a chance to maximize the best and minimize the worst. We have a chance in our own way to put our own lives on the line, our own self-esteem and self-respect. The operating room teaches three basic lessons of life. First, that suffering and pain and misery are part of life and to enter the battle against them is worth the trouble we get into in the process. Second, it’s too big a job to do alone-we need a team effort. Finally, vulnerability itself may be essential to human life. Anne Morrow Lindbergh has written:
I do not believe that sheer suffering teaches. If suffering alone taught, then all the world would be wise, since everyone suffers. To suffering must be added mourning, understanding, patience, love, openness and the willingness to remain vulnerable.‘ So wear your mask. It’s okay. Besides, we can still see your eyes. You can’t hide the glares, the twinkles, filling up, the fear, the hope. Stay vulnerable.
0
Notes
I . Ned H Cassem and Thomas P Hackett, ”Sources of Tension for the CCU Nurse,” American Journul of Nursing, 72 (1972) 1426-1430.
2. Ned H Cassem and Thomas P Hackett, “Psychiatric Consultation in a Coronary Care Unit,” Annals of Infernal Medicine, 75 (1971) 9-14.
3. Cassem and Hackett, op c;f.
4. Anne Morrow Lindbergh, Hour of Gold, Hour of Lead. 212.
AORN Journal, July 1974, Vol 20, No 1
What is behind our masks? While holding a retractor as a medical student a t one of my first encounters with surgery, I incurred the wrath of a rather cantankerous lefthanded surgeon when, after h e exposed a large gallbladder full of stones, I let out sort of a low, long whistle. He turned on me and said, “This is an operating room-not a movie theatre!” (I didn’t realize I was in church.) And yet when you think about it, there is in the operating room very often a sense of hushed awe, of marvel, of miracle workers, of artistic and heroic exploits. Nor can anyone deny that events of wonder and inspiration are produced in operating rooms. Of course, nobody ever gets angry there--“Hey, culture that guy”-we merely identify the sources of contamination (a handy disguise for ire). We have to admit that there are times in all operating rooms when they are like mismanaged preschool nurseries. We see temper tantrums, sulking, pouting, and objects dumped on the floor like Pablum. We have all witnessed OR psychopathology, much of it regressive. What is behind our masks? Are we hiding?
To me, the greatest thing about the movie “Mash” was the memories that it brought back-fond memories of days in operating rooms during my surgical clerkships. “Mash” is a mask, one of the more successful and creative masks used in dealing with traumatic interior feelings. It is one of our healthier sublimations, actually. I would like to talk about some of those things that go on behind the mask. What are our vulnerabilities? What threatens and what puts us on the spot? Four of the threats are: the work, the patient, our fellow nurses, and the physicians. Work as a &eat. Sometimes, when we talk about emotional reactions to work, we may forget that the work load itself is devastating. In fact, the work is impossible. When we asked the nurses in our coronary care unit (CCU) what their worst sources of conflict were, they put heavy lifting, not emotional conflict, a t the top of their 1ist.l Heavy lifting is a CCU reality often minimized or forgotten. The work that you do is very threatening-an abdomen full of bullets, a ruptured abdominal aortic
d+ AORN Journal, July 1974, Vol 20, No 1
79
aneurysm, abscesses that form in old operating sites requiring re-exploration-these cause a lot of internal trauma for you. So your work is impossible. You have to think and act fast. And you must keep your cool a t the same time.
Patients as threats. The most frightening things about patients are: how sick they are; how scared, mad, or sad they are; or, at times, how old
Ned H Cassem, MD, is an assistant
professor of psychiatry at Harvard Medical School at Massachusetts General Hospital, Boston, where he also serves as psychiatric consultant to the coronary care unit. He is a graduate of St Louis University and Harvard Medical School. This article is based on his presentation at the 1974 AORN Congress. they are. It is more difficult to work with people a t both ends of the continuum, both the young and the very old. The converse of how sick, frightened, or old they are is how heavy our responsibilities are, because patients come to us with desperate situations that we are expected to improve or even reverse and that is a threatening, demanding thing.
For what patient problems do nurses ask psychiatric help? More than half of the consultations that resulted from requests from our CCU nurses were for patients who were scared or depressed.z Whst is our response? In the operating room you can anesthetize the patient, which in effect not only stops his or her misery, but stops yours too, because then you don’t have to listen to the patient. I have often wondered what it would be like if we had acupuncture for every procedure. How would we feel if the patient were watching us during surgery? I’m sure it would make us extremely uncomfortable, not because we don’t want our work watched, but because we would have the added responsibility of attending to the personal feelings of the patient. Doing the surgery is demanding enough! One difficulty, however, is that some would like to anesthetize the patients outside the operating room as well. It’s a reaction we can’t help. When patients come to us, they are often already in pain or feel miserable. Some of the things we do in order to restore their health inflict even more pain. We turn them, cough them, suction them, give them respiratory therapy, change adherent (especially burn) dressings, incise them, pound on their chest for ventricular tachycardia-all because we are trying to help. But our dilemma is this: the more we allow ourselves to become involved (that is, to empathize), the more we may feel cruel or guilty for inflicting pain, and, thereby feel we’re dehumanizing the person. On the other hand, if we try not to be involved, to become tougher or colder, then we feel as
AORN Journal, July 1974, Vol 20, N o 1
81
(Rapid first impressions are best. Place an X on the line at the number which seems to convey best your impression) Census:
Admissions ___ i
Date
Discharges
start of shift
Initials
Transfers
end of shift
(circle)
shift= D-E-N perm-float
Today the unit seems or feels:
1
1.
2. 3.
4. 5. 6. 7. 8. 9. 10.
Fig 7. The atmosphere assessment scale was used in a study done in 7972 fo assess the effect that death and other events have on CCU staff members. The adjective checkfist was filled out b y nurses on each shift studied. Additional characieristics numbers 17 to 30 are lively, in conflict, apathetic, overwhelming, hostile, cheerful, irritating, a disaster, together, sad, complaining, up tight, secure, blue, harmonious, heavy, catty, boring, close, and the way I like it. Space also is available for comments (arrests, emergencies, DNRs).
though we are aIso dehumanizing the
staff reactions to an expected death.
patient. It is a genuine dilemma.
Sometimes we all know a patient is
What patients do to threaten us most of all is to die. To assess the effect that death and other events have on staff members in our CCU, I designed the Atmosphere Assessment Scale (AAS). It is an adjective check list filled out by the nurses on each shift studied (Fig 1).The scale contains four subscales presented in Table 1: anxiety, discouragement, conflict, and harmony. The AAS scores in Fig 2 illustrate
going to die. The AAS scores shown centered about the death of a 34year-old coronary patient, whose parents had died in their 40s and ~ O S , his brother a t 41 and sisters a t 38 and 41-all of coronary heart disease. He had angina since age 14.This was his first myocardial infarction (MI). He came into the unit with a large anterior MI, developing a large aneurysm, and in cardiogenic shock. The intra-aortic balloon pump rescued
82
AORN Journal, July 1974, Vol 20, N o I
him from shock, but only temporarily, for angiography told us he was not going to make it. Moreover, we knew that he was going to die on about the 30th day. After his first arrest, an episode of ventricular tachycardia he had to be thumped out of, discouragement scores rose steadily. The staff was becoming demoralized because we knew he was dying and we were helpless. It was a difficult thing and it took about a week for us to recover. On the other hand, sudden death can have its own pattern of effects on the staff. Fig 3 presents scores on the day of a sudden death that occurred when we were on morning rounds. The victim was a 53-year-old man who was admitted the night before with an inferior MI. His condition was quite stable and we weren’t really worried about him. As we were standing in the corridor outside his room talking, the head nurse noticed sudden bradycardia appear on his monitor. She called for atropine and went into his room instantly. (We were still standing flat-footed outside.) Even though there was a smooth resuscitation effort, the man’s myocardium ruptured and he died. Discouragement scores were sky high, as were anxiety scores. One nurse, who had developed a special relationship with him, said that she had just waved a t him through the window and had turned around to the medication closet to get something when he arrested. At the sight of the arrest she found herself absolutely paralyzed. It took her four or five minutes before she could function. During that time there were people there to take over for her, but she felt very guilty. Later, however, when at afternoon report we reviewed the
a4
Table 1 Subscales of atmosphere assessment scale Anxiety
Discouragement
1. tense 3. frightening 14. overwhelming 22. uptight
5. 20. 24. 26.
Conflict -
Harmony
9. 12. 15. 17. 24. 27.
frustrating in conflict hostile irritating complaining catty
discouraging sad blue heavy
2. smooth 8. coordinated 19. together 25. harmonious 29. close
arrest, group performance, and the nurse’s paralysis, it was pointed out that she was probably the most caring and empathetic person in the unitso she was especially vulnerable to losing somebody like that. During the meeting the nurse was able to gain the reassurance of knowing that nothing had gone wrong in spite of her lapse. She was not excused, but was reinforced for her good traits. Note that the high and low scores in Fig 3 were taken before and after the group meeting. The dramatic fall in depression, anxiety, and conflict scores between the beginning and end of the staff meeting suggests that the meeting was helpful in dealing constructively with the feelings. These are two examples of what happens to us when patients do what we don’t ever want them to d d i e . Fellow nurses as threats. A third source of threat comes from disordered interpersonal relationships. A common manifestation of a troubled unit is the accentuation of competitiveness and the desire t o be
AORN Journal, July 1974, Vol 20, No 1
recognized as competent. AAS scores for two sets of interpersonal difficulties are presented in Fig 4. First, there were interteam manifestations of competitive jealousy. For example, the CCU nurses were criticized by the floor nurses: “What a bunch of prima donnas! They’ve got it so easy, with a patient-to-staff ratio of nearly 19, and here we are with 40 patients on the floor and just two of us. But they do the complaining. They’ve got it so soft and they think that they are so smart and know everything. ”
bleshooting the equipment. Once an arterial line was not functioning and the nurse from the research group came in, fiddled around with it awhile, couldn’t get it going, and said she was going to get one of the technicians to fix it. As she left, I heard one of the CCU nurses say, “See, they don’t know any more about it than we do.” A little nonprofessional gloating. When competitive feelings within the unit become intensified, the behavioral consequences can be disastrous for staff morale. The newest nurse, instead of being viewed as someone who needs help, is immediately identified as the unit klutz who can’t do anything right. The nurses most guilty of doing this are not the senior people, but those who were most recently new themselves. They “prove” their competence by downgrading the work of the most junior persons. We find many scapegoats. In an
In our CCU we saw the situation reverse when from among the coronary nurses a research group was developed to care for patients in a new cardiogenic shock room. One day I heard a CCU nurse say, “They are so stuck up, they think they know it all.” The research nurses were often called in to teach the rest of us in CCU about care of pulmonary arterial lines, the computer, or trou-
$
an expected death.
Harmony
-
\
10 -
$ 8l P
P
6-
cr,
P P
4-
I
1
1
1
1
3
1
l
5
1
1
7
1
1
9
l
1
11
DAYS
86
AORN Journal, July 1974, Vol 20, No 1
SUDDEN DEATH
Harmony
Conflict Discouragement Anxiety I
I
1
Day 1
I Day 7
Fig 3. AAS mean scores of CCU nurses before and offer a staff meeting on the day of a sodden death.
earlier study Dr Hackett and I asked the CCU nurses to rank the sources of their worst difficulties in the CCU. Was it research, patient problems, or all the responsibility? Named first by a wide margin was the nursing administration, closely followed by scheduling and staffing (also someone else’s fault). So we scapegoat upward too. The supervisor is always inept, we hear; the supervisor is too old, too dumb, not up on things, doesn’t know enough; there is never any good guidance around for evenings. A two-fold need is being expressed. There is a need to have somebody around who knows everything and a t the same time a need to be a totally independent person who can stand on her own two feet. Of course, the head nurse can’t
win. Staff nurses will say, as they did to our head nurse, “Why don’t you help out once in awhile?-is it just beneath your dignity to pick up a few things on the floor when you come into a room-the least you could do is that.” The head nurse thought she would try this, but the first time she picked something UP the staff nurse looked a t her and said “I can do it,” as though it had been a slur on her competence that the head nurse came in and started fiddling around in her domain. So the head nurse is damned if she does help and damned if she doesn’t. Because of our needs for approval and preservation of self-esteem, few duties of the head nurse are more important than giving approval and praise whenever they are deserved. &+o
88
AORN Jou~nal,JuZy 1974, VoZ 20, No 1
91
I NTER-STAFF CONFLICT
INTRA-STAFF CONFLICT
4
r
l4
c
GROUP CONFRONTATION
4
Anxiety 21 l
1
1 l 1
11
3
l1
11
5
1 1
7
1
~1
11
9
11
11
1 1 1
13
11
11
15
1I
11 I 11
17
1I
19
1l
l1
21
DAYS
Fig 4. AAS mean scores of CCU nurses during periods of interpersonal conflict.
A further lesson can be gained by inspecting the morale scores following death in the CCU (Fig 2-4). During the events of the expected death, the discouragement score rose. What is curious is that harmony score rose as well. Even on the day of the sudden death (Fig 3 ) , it remained a t 12, higher than average. So staff can get involved and even upset about their patients without harmonious functions being impaired. In fact, there is a suggestion that harmony score increased during the difficult period. However, when conflict within the group is present, group function is more threatened. Therefore, we need worry less about how sick patients, the recovery room or I C U responsibilities affect staff morale, than about the damaging effects of interpersonal
conflicts. This is a primary reason for giving some attention to group interaction and seeing that it functions well.
Physicians as threats. The surgeon is always the favorite target of wrath. Listen to the complaints: “He is such a prima donna.” “What actors . . . we know why they go into surgery. They are sadists, cold, don’t have any feelings, can’t deal with people. They’re Neanderthal men! They go into the OR to get rid of their aggressions.” All nonsurgeons tend to stereotype surgeons. But maybe none of us really appreciates what it’s like for the surgeon. A particular example is riveted in my memory. One of the best cardiac surgeons in the country was reviewing the tragic and unexpected postoperative death of an
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18-year-old girl in whom he had replaced mitral and aortic valves. She died after developing a spontaneous and irreversible pulmonary diffusion defect for which no treatment was known. Despondent, he told one of the nurses something I’ve never forgotten: “You know, here was somebody who could have gone on for another year. Maybe it would have been a very difficult year, but a t least it would have been another year. But because of something I did with my two hands, she’s dead.”
If honest, we must admit that no feeling of personal responsibility can be a heavier burden than those of the surgeon. How misguided it may be to label him brutish, cold, or aloof when you know that it would be so much more helpful to realize he appears that way, not because he lacks human feelings, but precisely because he feels all the same things you feel. You would do much better saying to the surgeon after a bad day, with a gentle pat on the a m , “Look, it’s been a rotten day, but you have to remember, you did everything you could.” You will get a lot further that way than you will be perpetuating the animosity and bad feeling that we all tend to displace on surgeons. Surely we must be jealous of that vast responsibility that they have. Nurses call other nurses “prima donnas” out of jealousy. They may also be jealous of the surgeon when they apply that label to him. Finally, what‘s behind your mask? Why are you in the operating room? Because you like to be with unconscious patients? Because once they are anesthetized, you don’t have to relate to them or feel anything for
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them? Or is it the physical closeness of the OR in which we can feel close without having to relate more maturely? We are in the operating room, I think, because it is a threat. We like that. We see people a t their best and at their worst and have a chance to maximize the best and minimize the worst. We have a chance in our own way to put our own lives on the line, our own self-esteem and self-respect. The operating room teaches three basic lessons of life. First, that suffering and pain and misery are part of life and to enter the battle against them is worth the trouble we get into in the process. Second, it’s too big a job to do alone-we need a team effort. Finally, vulnerability itself may be essential to human life. Anne Morrow Lindbergh has written:
I do not believe that sheer suffering teaches. If suffering alone taught, then all the world would be wise, since everyone suffers. To suffering must be added mourning, understanding, patience, love, openness and the willingness to remain vulnerable.‘ So wear your mask. It’s okay. Besides, we can still see your eyes. You can’t hide the glares, the twinkles, filling up, the fear, the hope. Stay vulnerable.
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Notes
I . Ned H Cassem and Thomas P Hackett, ”Sources of Tension for the CCU Nurse,” American Journul of Nursing, 72 (1972) 1426-1430.
2. Ned H Cassem and Thomas P Hackett, “Psychiatric Consultation in a Coronary Care Unit,” Annals of Infernal Medicine, 75 (1971) 9-14.
3. Cassem and Hackett, op c;f.
4. Anne Morrow Lindbergh, Hour of Gold, Hour of Lead. 212.
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