|Year : 2020 | Volume
| Issue : 2 | Page : 110-115
Flattening the curve of emotional distress during COVID-19
Nicole Defenbaugh1, Lorraine A Dickey2
1 St. Luke's University Health Network, Hospital in Fountain Hill; Lewis Katz School of Medicine - Temple University, Pennsylvania, USA
2 St. Vincent Healthcare, Montana; Phoenixville Hospital - Tower Health, Pennsylvania, USA
|Date of Submission||26-May-2020|
|Date of Acceptance||27-May-2020|
|Date of Web Publication||29-Jun-2020|
Dr. Nicole Defenbaugh
800 Ostrum Street, Bethlehem, PA 18015
Source of Support: None, Conflict of Interest: None
Aims: The aim of this article is to examine how the facilitation of narrative sessions aids in “flattening the curve” of distress and anxiety experienced by healthcare professionals during the COVID-19 pandemic.
Methods and Material: Sixty-eight participants were surveyed. Quantitative and qualitative data were collected through postsession surveys, copies of stories submitted by participants, and de-identified statements captured by facilitators during the sessions. Two primary themes were used (i.e., difficult/challenging and uplifting/inspiring) to structure the writing prompt and to analyze participant stories. Using a layered account, the authors narrate their experiences as session facilitators and the anonymous experiences of session participants.
Results: Results show that 90% of participants reported the ability to listen more closely, 92.5% reported improved resilience, and 92.5% reported the ability to immediately apply what they practiced or witnessed in the narrative sessions.
Conclusion: Engaging in narrative writing and sharing stories verbatim in online sessions has the potential to address moral distress, increase active listening, and build resilience for health-care professionals. This article highlights the critical role of engaging health-care professionals in reflective practices to process, reflect, and share their personal and professional experiences related to the impact of COVID-19.
The following core competencies are addressed in this article: Interpersonal and communication skills
Keywords: Active listening, COVID-19, emotional distress, health care, narrative, resilience
|How to cite this article:|
Defenbaugh N, Dickey LA. Flattening the curve of emotional distress during COVID-19. Int J Acad Med 2020;6:110-5
| Introduction|| |
The faces appear. One by one. Unknown faces in an unknown space. We have collectively gathered to discuss experiences living and working in the COVID-19 pandemic. There is something strange and familiar facilitating an online narrative session. Like Alice peering through the looking glass—the Zoom images, a hyperreal mirror—I silently watch as participants appear one-by-one. When the introductions are over, it's time for the narrative prompt: “Please take 3 minutes to write about an experience you've had during the COVID-19 pandemic (personally or professionally) that was either difficult/challenging or, alternatively, uplifting/inspiring.” The reflection commences, and the participants begin to write. I wait for 3 minutes, preparing myself to hear the stories of life, death, fear, hope, and gratitude working on the frontlines. But a facilitator can never truly be prepared for what they are about to hear.
Facilitator account of participant stories
Heart-wrenching. Heart-warming. Out of balance. In balance. Chaotic. Composed. Full of frustration and fear. Full of gratitude and joy.
| Subjects and Methods|| |
In this article, the authors use a layered account  to reflect the 12 online, narrative sessions conducted by the authors from March 30 to May 12, 2020. Sixty-eight participants were surveyed. Participants were located in the U. S. – some in epicenter “hot spots” of COVID-19 – and other countries across the globe (e.g., Australia). We layer in multiple voices (i.e., facilitators and participants), statistics from postsurvey data, original stories written by the participants and given to the authors with their permission to publish, and notes taken by the facilitators during the sessions. All of the narratives are de-identified to protect the privacy of the participants and to protect the patients and institutions where they work.
It was only a few months earlier that we (authors as facilitators) were leading face-to-face narrative sessions for a group of learners. In mid-March, however, in-person gatherings ended, and sheltering-in-place began. We already knew that sharing personal experiences through stories can positively transform how we care for others and ourselves. The narrative encounter also enhances our resilience. We have seen this with in-person narrative work for over a decade., During this pandemic, we are no longer able to meet in person. The days of intimate gatherings around a small table are now a thing of the past – at least for now.
Today, in this online space, there is critical work to be done on the frontlines. We are fortunate to have an hour with a group of health-care professionals that are often from different departments: medicine/surgery, patient experience, intensive care unit (ICU), and neonatal ICU, to name a few. As facilitators, we must adapt to the virtual space, the unknown faces, and the trauma that is about to emerge from the participants' stories. We ask participants to, “Read your story verbatim to honor the words you have chosen”.
| Addressing Anxiety and Emotional Distress|| |
Dr. Dickey developed these online narrative groups to “flatten the curve of distress” [Figure 1]. The primary goal is to help health-care providers remain resilient in the face of intense feelings and to avoid feeling overwhelmed or emotionally numb. The “flatten the curve” phrase is borrowed from public health messages to slow the spread of coronavirus. We engage in this virtual platform to address the recently reported increase in anxiety felt by 72% of health-care providers due to the COVID-19 outbreak. We do not provide therapy, and these are not support groups, but the space is supportive, and participants are able to address the emotional impact of treating patients during this novel pandemic. The United Nations' recent policy brief, “COVID-19 and the Need for Action on Mental Health,” not only addresses the impact of the disease on patients but also mentions frontline health-care workers and first responders as a specific population group showing high degrees of COVID-19-related psychological distress.
|Figure 1: Flatten the distress curve. Permission given by The Narrative Initiative|
Click here to view
The narrative sessions further address the need to discuss emotions by encouraging participants to share stories about stress, difficult decisions, witnessing death, and the possibility of infecting families and loved ones with coronavirus. As one narrative participant stated in the survey, “There is a real need for healthcare professionals to start talking more about what they are going through in this COVID world.” A thematic analysis of the sessions [Figure 2] shows that the majority of participants shared difficult stories of anxiety, sadness, and fear. In pre-COVID face-to-face sessions, 75% of first-time participants shared appreciative stories. Narrative COVID-19 groups, however, are showing the inverse with 75% of participants sharing difficult/challenging stories.
|Figure 2: Themes from narrative COVID-19 stories. Permission given by The Narrative Initiative|
Click here to view
”Guilt of working at home and not being at the hospital”
”Am I doing enough?”
”Rollercoaster of emotions”
”We knew this was coming”
”Been through hell and back”
In addition to the ability to share feelings, the sessions have an impact on how participants perceive its applicability to clinical work. Over 92% of participants (n = 41) strongly agreed or agreed that they can immediately apply what they practiced or witnessed in the narrative session. As one participant noted, “I would use this to help my team validate how they are feeling and dealing with these challenging times.” Narrative writing and sharing are crucial to self-care and wellness in health care, as other participants have added. There is validation in telling your story and value in being heard. Moreover, there is evidence that writing and sharing stories can be applied to their work as health-care professionals.
As a facilitator, the story that stands out for me was a participant's reference to feeling like a soldier. Multiple participants commented that they feel like they're in battle, donning armor to protect themselves from this unknown enemy. But these clinicians recognize that the masks and face shields they wear are also a barrier to their patients. Others discuss feeling like “a prisoner of war.” The struggle between being a soldier and fighting a novel enemy clashes with the metaphor of the prisoner in this pandemic war, coalesced with feelings of not being able to connect with patients. The battle metaphor is common. Gratitude and guilt. The hero and victim are sometimes the same person.
| Listening and Bearing Witness|| |
Narrative sessions provide space for difficult or challenging stories to be shared without fear of judgment. As the facilitators state in their introduction, “Listen closely to what others say. Practice listening without expectation, judgment, or bias.” Our survey results show that nearly 90% of participants (n = 40) either strongly agreed or agreed that their experience in the narrative session increased their ability to listen without judgment. As one participant noted, “… I think what you modeled was a sort of structured, analytical active listening—it carried the reflective piece of listening to a whole new level for me.” Participants shared their intimate stories, revealing deep-seated fears, concerns, and hope. For one participant, they shared with others the heaviness they felt being healthy and economically stable.
Sleeping at night, through the night, has been particularly difficult. My heaviness comes from my privilege. I have a beautiful home. I'm privileged to be working. I have a supportive partner. However, there is a pain in my chest, a real one that is worrisome – not to my health but the guilt of my health. Who is hurting? Where are they and can I help – will I help? The heart aches physically and for the unknown – is fueled by numbers, graphs, masks, gloves, and being healthy.
In these narrative sessions, health-care professionals are invited to discuss, explore, reflect upon, and be listened to. Similar to the concept of “close reading,” participants benefit from hearing others' stories by deepening their understanding and appreciation for the storyteller. As clinical storytellers, participants further develop skills in the one-hour session to actively listen, which is an important skill in patient care. As one participant stated, “This has reminded me and shown me the importance of listening closely to the words and emotions behind my patients' experiences, rather than trying to just “get to the point” or get a general summary of their concerns.” Another participant echoes these words by writing, “I will listen more for particular words that are being used by someone when they are sharing an experience or story. I will reflect back those key words of emotion, so they know I'm actively listening.” As facilitators, we model how to listen with empathy and the critical role of silence in encouraging the expression of feelings.
The next participant begins. The story is short. “He's dead!” The story's ending, “this could be anyone of us.” There is no need to elaborate. The story speaks for itself. My initial response is one of gratitude, “Thank you for sharing your story” followed by, “Let's take a few seconds before responding,” to give time and space for the emotions to be heard and felt by others. We wait in virtual silence; in this way we honor the person who died and the storyteller who witnessed his passing.
In these sessions on living and working in the pandemic, we bear witness to the lived experience of health-care professionals around the world in various professions. Participants are sharing their personal stories of trauma, grief, and inspiration. As others listen, we ask them to be present and acknowledge the meaning behind each story. In doing so, we witness stories that have yet to be shared or, until now, remained untold. As facilitators, we often ask, “What was it like to write/read/share your story?” We acknowledge that in addition to stories too difficult to tell, there are others that desperately need to be heard.
Participant story (abbreviated)
…I take my family out of safety
To give of my time, my talent, of my treasure
To the soup kitchen, to the hospital, to the clinic
Everyone is staying at home, safe and sound, but as for me and my family
We continue to work, tirelessly. I am so tired.
| Community Support and Building Resilience|| |
The United Nations' recent policy brief further discusses the need for social support during this time, especially for first responders and frontline workers. The report discusses the need for community support that can provide “psychosocial support and sources of resilience.” By facilitating these narrative sessions, we engage in shared understanding and support. As facilitators, we validate the participant as a writer, regardless of what is written. We also show appreciation by saying, “Thank you” after each story is read and letting each person know they are being cared for during this time. We remind each participant that they matter  as health-care workers, family members, and participants of the narrative group. In this way, we create an hour of social support and a sense of community. As one participant stated in the postsurvey, “It'll (narrative session) serve as a reminder of how everyone has a story, everyone is going through something and we aren't alone.”
Individual narrative sessions were composed of participants from the same hospital or health-care network. Participants represented a variety of areas/fields (e.g., medicine = 10%, nursing = 27.5%, and administration = 45%) and education levels (e.g., residents, attendings, and leaders), but they shared a unified identity working for the same system during the COVID-19 pandemic. Yet, distancing practices and government restrictions increased a sense of emotional separation and loneliness. Narrative sessions brought people together, online, to be present and provide a sense of community. Through the act of writing and reading stories, we assist participants in slowing down and making sense of experiences that may feel shapeless or formless. We strive to provide a community of active listeners and storytellers. Stories that may be too difficult to share with others or that may feel “inappropriate” to discuss at work are given a stage to be shared and an empathic audience to listen and connect. In this way, we attempt to create “palpable relationships” between the storyteller and participants by listening to and sharing COVID-related experiences.
Coordinating with and assisting our ICU unit with a young positive COVID patient that was being placed on ECMO and needing to be transferred to another hospital. Assisting with the transport and working with our team to create a smooth transition to provide the best option for care was a special feeling even though there was no certainty of success.
We know that workplace burnout and well-being  along with resilience are critical topics in health care that have been widely discussed and studied., Writing and sharing narratives not only allow us to feel connected but also have the power to increase our resilience. Survey data revealed that 92.5% of participants (n = 41) strongly agreed or agreed that this experience increased their resilience. Resilience, or the ability to quickly recover from difficulties, has become even more crucial for clinicians to develop, both personally and professionally, in the face of COVID-19. We strive to create resilience during a time of significant burnout for those treating COVID patients. As Charon states, narratives provide us “…the chance to restore power or control to those who have suffered.” [6, p. 181] Although Charon is referring to restoring power to patients, health-care workers also suffer. In these sessions, we hear both stories of helplessness and attempts at building resilience. For example, as one participant noted, “I have the ability to flex and dodge.” Another commented, “I have established a COVID-free zone in my office.” As facilitators, we help the storyteller to recognize the meaning in their own story and to identify the control they have or forgot they have. In this way, we address resilience and help re-moralize those who work in health care.
The participant said, “I wish I had superpowers.” My conclusion at the end of one session, after hearing a LOT of distress and folks doing what they can even though they are worried about not being protected enough while working with COVID patients, “Your superpower is doing what you can right now with what you have.” I've used this in several sessions and it seems to resonate with healthcare professionals.
| Discussion|| |
Given the uncertainty of this novel virus, these narrative sessions have the potential to assist health-care professionals to emotionally decompress, address anxiety, feel they are being heard and supported, and enhance their sense of resilience. Even if participants do not feel like they have superpowers, we do our part as narrative facilitators to help participants experience the power of their own stories by reflecting on their chosen language and words. Participants not only bear witness to each other's story, we help empower them to be the master of their own narrative. Narrative writing and sharing one's story verbatim can re-moralize participants during this COVID-19 pandemic by helping them gain a sense of control over their own story, their own experiences, and their own lives.
The authors would like to acknowledge the health-care professionals who participated in the narrative COVID-19 sessions and also give special thanks to Jen Christman from Tall Pines Graphic Design for help with graphics.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
Ethical conduct of research
Participants were informed of the narrative session, given the option to/not to participate, asked to complete an online survey, and invited to share their de-identified story for research and publication. Applicable EQUATOR Network (https://www.equator-network.org/) reporting guidelines were followed.
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[Figure 1], [Figure 2]