| | Life in recovery: Rebuilding from trauma☆☆☆Abstract Trauma can cause visible, often profound physical injuries for patients. The emotional and social drain that families and health care providers experience can also be life-altering. REBUILD is a program designed by a level 1 trauma center that incorporates former patients and their families in a support group to aid previous and new patients, their families, and care providers by sharing mutual experiences and learning from each other. Health care providers have found that participating in the program has been personally gratifying and professionally beneficial by preventing burn-out. (Int J Trauma Nurs 2002;8:70-5.)
The impact of trauma  Trauma can have devastating effects to both the physical and emotional health of a person. Trauma survivors, including the patient, family, and significant others, are suddenly confronted with multiple stressors, such as painful and debilitating injuries, frightening rescue and emergency room treatment, uncomfortable, unplanned, and confusing hospitalization, and a potentially overwhelming financial burden. The stressors continue throughout the recovery process when persons may feel social isolation, insurance or financial headaches, family stress, chronic or recurring pain, and continuing feelings of anger, depression, or guilt.1, 2 Trauma centers are typically well-equipped to address a patient's physical needs. However, devoting resources to psychosocial and emotional recovery is more difficult to justify. Once discharged, trauma survivors may find little support in the community to help them to recover. For example, an estimated 9% of motor vehicle crash survivors develop post-traumatic stress disorder in which they relive the traumatic event repeatedly and suffer from hyper-alertness, survivor guilt, depression, and difficulty concentrating.3 The emotional toll does not stop with the patients and families. Medical professionals who care for trauma patients often suffer parallel symptoms, manifested in feelings of burnout, detachment from one's own feelings or those of others, and anxiety.4 Trauma caregivers work long hours under consistently stressful situations. They are trained to remain calm, professional, and technically competent during crisis conditions. Caregivers may become emotionally distant and even callous to avoid being paralyzed by excessive identification with their patients.5, 6 Neglecting the emotional needs of trauma patients may result in further traumatization of the patient, and negative long-term effects on their recovery.7, 8 Addressing emotional needs The failure to recognize or address emotional needs of trauma patients can lead to increased anxiety and feelings of helplessness during recovery. Patients who experience their caregivers as indifferent, unconcerned, or callused exhibit more anxiety and feel less trusting of their caregivers. Those who describe their caregivers as empathetic and caring report higher levels of acceptance of their situation and greater confidence in their medical providers. Initiating and maintaining a trauma support program The staff of Inova Fairfax Hospital, a level 1 trauma center in Northern Virginia, recognized the need for a formal emotional support program. In 1995, an orthopedic trauma surgeon and the orthopedic trauma social worker joined together to initiate the hospital's first trauma support group. This group, facilitated by the social worker, later expanded to include additional community activities, and was named “REBUILD” in 1996. These additional community activities included arranging visits between the REBUILD members (the trauma survivors attending the support group) and newly hospitalized patients and arranging caregiver education in which the trauma survivors presented their perspectives on the trauma and recovery experience. In 2000, the Inova Regional Trauma Center obtained grant funding from the Centers for Disease Control to hire the social worker and an assistant to manage and expand the program. Today, REBUILD is a program that uses a combination of support groups and educational seminars to address the psychological, educational, and emotional needs of trauma survivors and their caregivers. Survivors attend support groups, which are used widely in the health care field.9 The groups and activities help patients and families to recognize symptoms of distress, develop a supportive community, engage comfortably with others, recognize the value of their knowledge, and better cope with the recovery process.10 The educational sessions consist of visiting new patients while still hospitalized and participating in community seminars. Creating any new program requires vision, patience, and careful design. The REBUILD program was based on (1) an experienced facilitator, (2) a method to identify potential group members including survivors and family, (3) structured activities (e.g., group meetings or community education sessions), and (4) the inclusion of “key players” during the start-up phase to ensure hospital support. When creating a new program, the focus should remain on the participants' interests, needs, and unique expertise to allow the program to develop naturally into a wider community. Identifying patients for group support Figure 1 provides a flow chart of how patients are connected with the REBUILD program.
Nurses and trauma physicians can refer patients, who are more than 18 years of age, do not suffer from a psychosis, and can speak English, directly to the coordinator. The REBUILD coordinator, assistant, and graduate students make presentations to the bedside nurses and trauma physicians about the program. The REBUILD staff creates pamphlets and newsletters to educate the caregivers and public. The printed material is placed in all trauma units and hospital lobbies. The trauma social workers screen all patients for referral during the discharge planning process and educate the patients about the program. If appropriate, the social workers arrange with the REBUILD staff for a supportive visit from a current REBUILD member. Patients are placed on the REBUILD mailing list and receive quarterly newsletters and support group schedules. Those interested in attending a support group meeting can contact the office or visit a Web site for more information (http://www.rebuildtrauma.org). Structured activities Medical professionals are invited to join the group, discuss their role, and learn about the survivors' experience of trauma, treatment, and recovery. Group members provide support to newly hospitalized patients and offer their perspective in community presentations to medical providers (described below). Key players The key players invited to participate in the development of REBUILD included the Director of Trauma Services, the Patient Care Director of the orthopedic unit, the social worker, and the orthopedic surgeon. When support groups for traumatic brain injury and spinal cord injury were initiated, key physicians and nurse managers were included in the planning meetings to facilitate a healthy referral base, nursing unit involvement, and space availability for the meetings. Rebuild group activities Group meetings REBUILD offers several types of support groups. Patients are assigned depending on their principal injury. The original group was formed in 1995 for survivors of general/orthopedic trauma. This support group meets twice per month for 2 hours. Ten to fifteen survivors and family members discuss their experiences and focus on the philosophical, emotional, and spiritual aspects of the recovery journey. Survivors process their fears and anxiety while they struggle with accepting their current level of functioning. New support groups have formed to include survivors and families of spinal cord injury and traumatic brain injury. Each group has unique cultures and goals. The spinal cord injury group meets for 1
½ hours once a month at the hospital. The group consists of an equal number of survivors and family members. They focus primarily on education and exchange information regarding community resources. Guest lecturers are invited and provide a focus for discussion and inquiry. Guests include surgeons (e.g., orthopedic, neurological, or plastic), urologists, psychiatrists, physical therapists, nurses, and community agency representatives. The participants express a high degree of acceptance of their situation, choosing to focus on the practical rather than philosophical aspects of recovery. Family members provide mutual support and acknowledge the difficulties of caring for their loved ones. The newest group was formed in April 2001 to support those affected by traumatic brain injury. It is the largest group with 20 to 35 participants each meeting. In addition to survivors and family members, staff from the neuroscience-trauma unit participate on a regular basis. The group meets monthly on the neuroscience unit and lunch is provided. The traumatic brain injury participants are expressive, emotional, and talkative. New patient visits Survivors who participate in the orthopedic and general support group and express an interest in doing more are invited to visit newly hospitalized trauma patients. The group facilitator assesses the survivor's readiness and will not include someone who expresses a high degree of unresolved anger or depression. The facilitator obtains verbal consent from the patient before the visit to ensure that the new patient is interested and willing to receive such a visit. Newer support group members are paired with experienced members during visitation and are encouraged to watch and listen for the first few visits. Group members visit trauma patients before each meeting and all of the visits are discussed in the support group meetings. In some cases, newly hospitalized patients are not ready for visits. Only a few patients with a new diagnosis of spinal cord injury in the acute phase of injury have shown an interest in meeting with veteran survivors. Patients with an acute traumatic brain injury are frequently too confused or disoriented to benefit from a visit during their hospitalization. However their family members are often receptive to visits and support. Community education In 1996, after a local paramedic visited the REBUILD support group, he helped arrange the first presentation at the county fire and rescue academy. Now in the 6th year of community work, members of REBUILD make presentations to hospital staff, county EMS training classes, and local nursing schools. The 1 to 2 hour program format consists of the facilitator making introductions, 3 to 7 survivors describing their experience from their perspective, a general group dialog, and a more in-depth discussion. During the discussion period, medical providers are offered an opportunity to reflect on their own experience and to acknowledge the stressful yet satisfying experience of critical care medicine. Recovering trauma patients are able to thank the care providers and provide them with a rare opportunity to see the patient's progress since injury. The use of victims as educators is common practice in Victim Impact Panels where persons who were seriously injured or who had loved ones killed in an alcohol-related crash speak to driving-while-intoxicated (DWI) offenders.11, 12 These programs attempt to deter drinking and driving and are geared toward offenders. REBUILD is different in that it focuses its educational efforts on care providers in the community. The use of former patients to train health care providers appears to be unique based on the lack of reports of similar programs in the social work and nursing literature. REBUILD presents educational seminars approximately 20 times each year to audiences ranging in size from 10 to 100. In 2001, the REBUILD coordinator surveyed 246 trauma care providers, including prehospital providers, physical and occupational therapists, social workers, nurses, and physicians to determine the effect of the REBUILD presentation on providers' understanding and awareness of the patient experience. Preliminary evaluation of the data suggests that nearly 100% of respondents agreed that the presentation helped them gain a better understanding of the patient's experience, made them feel better prepared to provide emotional support to their patients, and made them more aware of how their words and actions affect their patients. All of the respondents felt that participation in the program would improve their practice. They indicated that the presentation made them more aware of how one's words used during treatment can have a long-lasting emotional impact, and that they anticipated feeling better prepared to communicate compassion and caring. Many providers also commented on an increased interest in their work, and a re-invigoration and commitment to their profession. A common comment was, “This is why I became a paramedic (fireıghter, nurse, therapist, etc): to truly make a difference in peoples' lives.” Through community presentations, REBUILD appears to be helping care providers recognize the importance of their work and the tremendous impact they have on the trauma survivor's experience. Summary Trauma is often a life-altering, unexpected, and frightening event in the lives of patients and their families. Trauma care providers can find caring for trauma patients to be stressful and overwhelming. The experience of one unique support group has been positive for both patients and care providers who may experience parallel symptoms of anxiety and depression. The REBUILD program addresses the social and emotional needs of recovering trauma patients through a system of support groups, patient mentoring, and community involvement. This program also helps caregivers to reduce the incidence of burnout and insensitivity by engaging patients and caregivers in dialog about the trauma experience. References 1.
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J Stud Alcohol. 1999;60:514–520. Anna Bradford, MSW, ACSW, LCSW, is a trauma social worker and REBUILD coordinator at Inova Regional Trauma Center, Falls Church, Virginia ☆☆ Reprint requests: Anna Bradford, MSW, ACSW, LCSW, Inova Regional Trauma Center, 3300 Gallows Road, Falls Church, VA 22042. PII: S1075-4210(02)00002-0 doi:10.1067/mtn.2002.126363 © 2002 Emergency Nurses Association. Published by Elsevier Inc. All rights reserved. | |
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