DEALING WITH TRAUMA / DIFFICULT SITUATIONS IN TEAMS

1. Providing management support following traumatic incidents at work Guidance for managers Healthcare staff can occasionally be exposed to large or small scale incidents which are extremely distressing and out of the range of normal experience. These may include witnessing unexpected death or injury, experiencing or witnessing aggression or threat, being involved in a road collision or other accident. Most people will have some reaction but will recover within a few days or weeks; however some will have longer-lasting reactions which may, in a few cases, be severe and result in sickness absence. However, there is clear evidence that the way in which an organisation responds to a traumatic event at work can reduce individual symptom levels and subsequent absence. An important factor influencing an individual’s response is their perception of how supportive their employer has been. These guidelines describe evidence-based good practice in the management response to a traumatic event. Support on the day Immediate support The response offered on the day of the incident is the single most important factor in determining how supportive the organisation is seen to be. As far as possible, the manager should aim to: • Make contact with the staff member as immediately as possible • Behave in an empathic manner, e.g. show concern, check that the person is not returning alone to empty house • Respond in a personalised way, e.g. by telephone or in person rather than by standard letter. • Provide practical support. This may include giving help with a witness statement, giving authorisation to leave work early, providing additional help with outstanding tasks for the day, helping with paperwork such as filling in an accident report, explaining the process, driving them home, arranging for someone else to take over if they are unable to continue working, helping them to deal with the police. Defusing meeting This is a brief meeting (e.g. 15 mins) held at the end of the shift or working day to gather people together before they go home. The aim is to stabilise and re-orientate staff before they leave. The manager should summarise the events, explain what the next steps will be, offer praise and support and provide an opportunity for brief comments and questions. The tone should be concerned and supportive but avoiding intense emotional discussion. After a few days The manager should hold a supportive meeting with the people involved to offer a chance to talk through what happened and to monitor well-being. The aims of this meeting should be to: • Provide an opportunity for the employees to describe what happened. This should remain a discussion about facts and events, it is best to avoid an emotional re-experiencing of the event.

2. • Encouragement to describe reactions since the incident and current feelings, particularly with regard to fitness for work. • Normalise reactions i.e. in most situations, reactions to traumatic events are most usefully seen as normal reactions to an abnormal event and they may continue for a few weeks. • Provide information about how to obtain further support, for example through Occupational Health or Resolve Staff Support Service. • Maintain expression of support and concern. Resolve Staff Support Service Resolve’s Incident Support Service can provide: • Support, advice and information to managers • Leaflets about common reactions to trauma and basic information about coping • Leaflets about managing some specific situations: Verbal or physical aggression, the death of a staff member, team stress following investigations. • Support meetings for teams or groups who have experienced a traumatic incident • Training for managers on responding to traumatic incidents at work Resolve’s counselling and psychological therapy service is available for individuals who have more severe or continuing reactions to trauma. Other Resolve services available include Mediation, Psychological Consultation workshops and Team Events. For details contact Resolve Staff Support Service on 01246 515951 or resolve@dchs.nhs.uk

3. Personal Reactions to Traumatic Events What to expect……and what to do Introduction As member of staff working for the NHS it is possible that you have to deal with traumatic incidents during the course of your work. This can include situations such as personal violence or abuse; the effect of violence and abuse on respondees; unexpected or violent deaths; times of feeling helpless, when your professional skills cannot be used and having continuous exposure to distressing and difficult experiences. Dealing with issues such as these can be seen as a normal part of the job. Many of us find ways of dealing with the impact of difficult incidents such as the use of humour, talking with colleagues or a family member or friend. However, some incidents or issues may at times have a particular impact on an individual or a group of staff. The physical and psychological experiences which follow such incidents can be intense. You may also be surprised by reactions that are unfamiliar and appear to be out of character. Whilst these reactions are NORMAL responses to shock and/or loss, they can cause some concern. It is helpful to know what these reactions are likely to be, so that you can recognise them. This booklet offers information and advice which helps you to understand and cope with your reactions and suggests where to get further help if needed.

4. Normal feelings and emotions you may experience Anger Intense feelings of anger may be caused by seemingly minor events. More constant anger may be felt about the injustice and senselessness of what happened or towards those who appear to have caused or let an event happen. Sadness Deep feelings of sadness are common, especially when people have been injured or tragic deaths have occurred. Also feeling sad for what has changed, and for loss of faith in the world or the future. Helplessness Crises can draw out the best in us, but they can make us feel powerless, particularly if we have been unable to help or make a difference. Fear There may be fears of damage to yourself and people you know, or of being left alone or leaving those you care for most. Other fears may be about breaking down, losing control, having unbearably intense feelings, or worries that the original incident may happen again. Guilt Rather than feel relieved at having survived when others have been killed or injured, it is not uncommon to feel guilty. You may question whether you deserve to have survived, and regret things that you have or have not done. Numbness The shock of an event can leave you feeling numb and emotionally exhausted. Feelings you used to have may be blocked for some time. Shame You may feel ashamed at having been exposed as helpless, “emotional” and need others and for not having acted or reacted as you would like to have done.

5. How you can be affected physically Physical sensations are often reactions to stress. They may occur very soon after a serious incident but can develop many months later. Some common sensations are... • feeling tense and uptight • tiredness • sleeplessness • bad dreams • fuzziness of the mind including loss of memory and concentration • dizziness • palpitations • shakes • difficulty in breathing • nausea or diarrhoea • menstrual disorders • change in sexual interest • muscular tension which may lead to pain e.g. headaches or neck and backaches Remember You may experience some or all of these reactions only occasionally or all the time. Typically reactions start to lessen within a week or so, before fading away altogether over a longer period of time. If they do not, then it is important that you should take the initiative and talk to someone about your reactions to extreme stress.

6. Other reactions and behaviours Reliving the event The impressions left by an event may be so strong that it is re-lived long after it actually happened. Flashbacks and dreams are common, as is the re-experiencing of the feelings which surfaced during or after the event. Sometimes, too, you may suddenly start to feel as if the original event is about to happen again. Re-experiencing can be very distressing and frightening, but is not at all unusual. Changes in habits You may find you change your eating, drinking and smoking habits to help you deal with the difficult feelings. Privacy In order to deal with feelings you may find you want more time alone or to just be with people close to you. People may notice you withdrawing from your normal contact with colleagues, family or friends. Activity To be active, to help and give to others may give some relief. However, over activity can be detrimental if you overtire yourself or divert attention from the help you need for yourself. Support You may find you seek out the company of people you can talk to about your experience. Changes in outlook on life Serious incidents can change your outlook on life in important ways. You may find it hard to see a future for yourself. Relationships Stresses and strains previously taken as being part of life can appear unbearable to someone who has been through a serious incident. Withdrawal from close contact with family and friends can lead to difficulties in relationships, along with a growing sense that "nobody can possibly understand what I am going through". This mistaken view is a major obstacle to seeking help and support at a time of need. Other people are your main source of comfort at a time of crisis.

7. Who is most at Risk? No one knows in advance how you or anyone else may react to a particular stressful event. Your training and experience offer you some protection compared with members of the public, and having some warning about what you may have to deal with, so that you can prepare psychologically also helps. What is happening in the rest of your life may impact on your resilience in coping with incidents. For example if you are experiencing particular stressors in your personal or work life, such as loss or bereavement, poor health, unexpected changes or difficulties in your family, then your reactions might be more marked than when your life is calmer. Other factors which may impact on your resilience include: • if the nature of the incident has particular meaning for you, for example, the victim is close in age or situation to a family member • accumulated exposure to many incidents, particularly if some of these are already unresolved • if you had prolonged exposure at the scene, • if you felt personally threatened or at risk If, when looking back on the incident, you recognise feeling as if you were not part of the event, acted as if you were on 'automatic pilot', or felt so confused during the incident you had difficulties making sense of what was happening, it is possible that you may experience some difficulties processing what happened.

8. What you can do to help yourself It’s important to remember that these reactions are normal. Our systems have a normal recovery process and your reactions will usually reduce or disappear of their own accord after a few days or weeks. Let yourself experience the feelings you have about what happened, and express them Take every opportunity to review the experience yourself and with others. Make sure you know what did happen rather than what you think happened. Show this booklet to your family or other people you feel comfortable talking to so that they understand what is happening and how they can help Don’t Do Bottle up your feelings Avoid talking about what has happened Let your embarrassment stop you giving others the chance to talk Expect the memories to go away quickly your feelings may stay with you for some and be with your close family and friends time. Exhaust yourself with over activity to stop Take opportunities both to be physically feeling active and to relax. Try to keep to your normal routines as much as possible Make any big life changes Make as many daily decisions as possible which give you a feeling of control over your life Drink or use other forms of self-medication Have a balanced diet and keep to regular to excess patterns of eating If you have difficulty sleeping, talk to your doctor Drive more carefully. Be more careful around the home and with machinery. Accidents are more common after severe stress. DO TAKE CARE! Allow yourself to be part of a group of people who care. Take time out to sleep, rest, think .

9. Advice for Family members and Friends of someone involved in a

10. traumatic incident • Listen carefully, if they wish to talk • Spend time with the person • Reassure them that they are safe • Give them some private time • Don't take their anger, irritability or other feelings personally • Don't tell them that they are "lucky it wasn't worse". Traumatised people are not consoled by those statements. Instead tell them that you are sorry such an event has occurred and you want to understand and assist them

11. When to ask for help Reactions to stressful events usually fade as time passes. Some of these can be extremely distressing, may go on for a long time, or have a special and personal meaning for you. Under such circumstances you may wish to seek help. You should consider this if: • You feel that you cannot handle intense feelings or body sensations • You feel that your emotions are not falling into place over a period of time • You can find no relief from tension, confusion and exhaustion. • You find yourself getting uncontrollably angry • You continue to have body symptoms • After a month you continue to feel numb and empty • Memories, dreams and images of the event continue to intrude on your consciousness. • You continue to have nightmares and poor sleep • You have become overactive to avoid feeling upset • You have no person or group with whom to share your emotions and you feel the need to do so • Your relationships seem to be suffering badly, sexual problems develop or people keep commenting on how much you have changed • You find yourself more accident prone • You continue to smoke, drink or take drugs to excess since the event • Your work performance is affected • You are feeling very down on yourself or have lost all hope for the future • You feel "burnt out"

12. Who can you talk to ? You may be able to overcome your reactions to extreme stress on your own. A colleague, your manager, a family member or friend in whom you have confidence can provide practical help and support. Within Sheffield you can self refer to Workplace Wellbeing, a service that offers short term, confidential therapy for SHSC employees (using a range of modalities including counselling, therapy and specialist approaches such as EMDR and CBT) or ask your GP to be referred to IAPT (Improving Access to Psychological Therapies). IAPT provides guided self help, counselling and cognitive behavioural therapy, depending on the severity and complexity of your symptoms. Your GP, who may treat you themselves or refer you to a local specialist services. You can ask your manager to refer you to your Occupational Health Service, who might offer support themselves or have access to other sources of support. After some major accidents and other disasters special support groups are set up for survivors and their families. Details of these may be advertised in the local press, or arranged through organisations such as the British Red Cross

13. Self Rating Questionnaire Incident................................................................................................. Date.................. Have any of these reactions caused you distress recently? If so place a in the appropriate box. The four boxes will allow you to consider the question on several occasions. I felt irritable and angry? I was jumpy and easily startled? I found myself acting or feeling as if I had returned to the incident itself? I had trouble falling asleep? I had trouble concentrating? Reminders of the event made me feel sick? I was watchful and on guard? If you experienced one or more of these reactions you may find it useful to talk to your line manager or someone else who is close to you.

16. PIPS informed Staff support session structure. Based on Post Incident Peer Support (PIPS) group sessions. Will depend on the ‘event’/focus and whether a single incident (perhaps patient death) or ongoing stressor. • Intro structured nature of session, not therapy different stages (as below) not focussing on emotional experiencing re. events as contraindicated / can be unhelpful •Focus on facts around events / situation, the ‘what’s happened’, if in group go round in chronological order, ‘what do you know from your perspective?’. Often ‘fills in the gaps’. If individual might highlight need to ask others for more info. Redirect away from focus on emotional experiences at time • Reactions after the event: how have you reacted afterwards? Here there will be a risk of getting too focussed on exploring emotional reactions to the crisis. Use of validation and normalising responses: usually happens naturally in group settings though may need some ‘drawing out’ or highlighting common experiences: “doesanyone else feel like that / did anyone else experience that?” Focus on emotions, thoughts and behaviours. Also in groups draw out effective coping responses. • Psycho-education and information giving. Both about normal reactions in this time: may help to direct people to web based info, perhaps prepare a list of common responses from web resources: emotional distancing, sleep disturbance, avoidance, over-reading news information etc. Also effective coping responses and signposting. • Summing up plus offer to meet again.