Health care writing program builds resilience for frontline trauma during COVID pandemic

Editor’s note: This story was originally published by Rocky Mountain Public Media and was shared via AP StoryShare.

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A research-based writing program is helping ICU nurses and other frontline health care workers cope with the extended trauma and stress of working through the COVID-19 pandemic.

Narrative Expressive Writing is a series of five online writing sessions in which participants receive constructive feedback from trained mental health professionals.

The program has allowed health care workers to feel heard, while measurably reducing their stress levels.

"I think what I’ve learned is what I’ve always thought, which is that health care providers work in a very stressful environment," said Dr. Meredith Mealer, associate professor of medicine at the University of Colorado Anschutz Medical Campus, who started the writing program. "It has me concerned about turnover rates and whether we’re going to have the appropriate staff to care for patients."

“There’s a very high prevalence of anxiety, depression, post-traumatic stress disorder, and burnout syndrome," Mealer said. "Add on top of that a pandemic where they have all of their beds full, the mortality rate has increased, fears about personal safety and the safety of their loved ones are piled on top of that — we’re seeing a lot of providers in distress.”

Mealer has spent the past two decades researching resilience in health care workers. Little did she know how much that work would be needed in 2020.

As a bedside ICU nurse, Mealer first noticed how much nurses were struggling with the stressful work environment. Over the years, through her research, she found “a significantly high rate of depression, anxiety, PTSD, and burnout syndrome” in health care providers. However, she also found that health care providers with higher levels of resilience had less psychological distress.

So, when COVID-19 hit hospitals, Mealer knew that her work could be applied.

In March, Mealer rolled out the expressive writing program in two cohorts: local and national. The local program with CU Anschutz, the Rocky Mountain Regional VA Medical Center and the Children’s Hospital, is funded by the Rocky Mountain MIRECC for Veteran Suicide Prevention. The national program is funded by the American Nurses Foundation.

"We have just under a thousand participants, which is impressive for a writing intervention and it seems like we get 20 to 30 new people enrolling every day," Mealer said. "We have a lot of providers that are writing just about the emotional toll that this has had on them."

Participants have written about themes of distress, including the possibility of getting COVID-19 and transmitting it to loved ones; seeing both the young and old die; witnessing chronic health conditions from the virus; and simply the stress of overwhelming numbers in hospitals.

Reading about this trauma also can impact the mental health providers who give feedback to the participating health care workers. Mealer holds weekly to bi-weekly debriefs with the providers to work through the vicarious trauma they might be experiencing. Mealer reads the narratives herself. “They are very powerful and traumatic,” she said.

But Mealer sees the program working. Perceived stress levels have gone down in participants — at least in those not experiencing dramatic increases in COVID-19 patients.

"We have a visual analog scale that looks at perceived level of stress on a sliding scale," Mealer said. "What I’ve seen so far is there’s been a 10-point reduction in perceived level of stress."

And she has received unsolicited positive feedback from health care workers.

"Please extend my thanks and gratitude to your team. I have found the expressive narrative exercise to be profoundly beneficial and a powerful tool in helping me process some of the difficult challenges and emotions that have arisen since the inception of the COVID-19 pandemic," one participant wrote.

Mealer believes the writing intervention could be customized to benefit different professions.

"The manual that’s been written tailors writing prompts based on what the situation is," Mealer said. "So, you could take this to pediatric respiratory therapists, and you could make that prompt very specific…or you could take this intervention and apply it to a classroom teacher in middle school. So, I think this has applicability outside of the health care profession."

Writing samples from the program

"What surprised me was how young the Covid + patients were and how sick they became, it was unbelievable the complications they were exhibiting. Blood clots everywhere, multi-organ failures, heart damage, and kidney damage, some patients said they "felt fine" and then suddenly they couldn't breath, and then they were dead."

"Covid is bringing back such traumatic memories of taking care of patients and coding them all the time — they just keep running through my mind — coding multiple patients multiple times a day not only in our ICU but we ran the code team for the whole hospital it's like all I see in my head is this loop of death and knowing I can't go help makes me feel terrible."

"And then I got pulled to the ICU. And I felt like I was in a war zone. And I knew the media wasn't lying. Actually, they weren't telling the half of it. And then my coworkers started getting sick. And then they were patients in the ICU on the vent. And it felt like everything was falling apart and we were just in survival mode."

"But this patient, this day, was the day it changed for me. I realized I could protect my boys if I didn't see them. They could stay with my ex and his mom would be there to take care of them. This decision weighed on me. It has been one of the hardest decisions I have ever had to make. I felt like there was no good choice. That day I knew in my heart I had to make the choice, I would not see my kids so I didn't expose them to this virus. At the time, I didn't even know how bad it was going to get, how scary this virus can be, how sick people get. I just knew I could make this choice to try to protect them."

Feedback from participants 

"You likely noticed my writing sessions exceed the 20-30 minutes. Journaling has always been helpful, but I find these sessions much more valuable during the time of COVID. I am not sure how this connection was forged, but I do appreciate the opportunity, thank you."

"Please extend my thanks and gratitude to your team. I have found the expressive narrative exercise to be profoundly beneficial and a powerful tool in helping me process some of the difficult challenges and emotions that have arisen since the inception of the COVID-19 pandemic. The exercise has helped me to conceptualize and make sense of my experiences and implications for the future both personally and professionally. Further, the exercise has helped me to delineate any lessons learned and personal growth derived from my experiences. Thank you."

"I can not believe that this is my last writing session. Time flies fast, and I have enjoyed this writing journey since the beginning. I was not that kind of person who writes very often. In fact, I barely wrote anything down to reflect my feelings before I started this writing session. When I started my first one, I did not really know what to write or how to write in order to express my feelings about how the COVID pandemic affects my life. After completing a couple of journals, I realized I have been writing down my real feelings about the whole situation, and I am getting better and better each time at expressing my feelings."

Resources

• CU Anschutz: Tell your story with COVID-19 Narratives 
• CU Anschutz COVID-19 resources for mental health: Coping in the Face of Uncertainty 
• Volunteer: CU Anschutz Well-Being Support Line