Staff and Systems Issues

The pediatric critical care workload is physically, technically, and psychologically demanding and carries a heavy emotional toll by virtue of staff members' continual exposure to critical illness, death, and the intimate personal lives of strangers (Beari-son 2006; Colville 2001; DeMaso and Meyer 1996; Ferrell and Coyle 2008). Through prolonged and persistent exposure to the suffering of children and families, high levels of acuity, and frequent encounters around death and dying, clinical staff are vulnerable to "compassion fatigue" (Meadors and Lamson 2008). Caregivers are particularly vulnerable when they have increased involvement in long-lasting and/ or complicated cases, personal identification with a child or family, underdeveloped coping strategies, or previous history of trauma (DeMaso and Meyer 1996; Meadors and Lamson 2008). The unremitting stress of the pediatric critical care setting can also contribute to problems in communication and collaboration among care providers, and this may have personal, systemic, and clinical implications (Hawryluck et al. 2002).

The mental health consultant can work with staff to help build awareness about the normalcy of stress-related reactions, promote discussion of such topics in a shame-free and supportive environment, and provide psychoeducation regarding techniques to help manage or minimize symptoms (Meadors and Lamson 2008; Peebles-Kleiger 2000). Staff may be taught to recognize personal factors that contribute to difficulties in working with particular patients or families. The consultant may facilitate awareness around staff feelings, expectations, and attitudes and the extent to which these are reciprocally influenced by clinical work (Hansen et al. 1986). Staff support groups may provide an optimal forum for such interventions (Beardslee and DeMaso 1982; Montgomery 1999). When systemic communication breakdowns or difficulties are evident, the consultant can work with staff to identify and ameliorate sources of conflict. The consultant can also be helpful in facilitating staff discussion about the ethical issues that abound in pediatric critical care (Gill 2005) and in educating staff about ways to maximize the effectiveness of behavioral interventions with patients and families (Hansen et al. 1986).

The mental health consultant in pediatric critical care is not invulnerable to the grief and sadness overshadowing this setting (DeMaso and Meyer 1996), although the reactions around these day-today experiences are often overlooked (Koocher 2005). The unrelenting sense of urgency accompanying consult requests, the expectation to provide a "quick fix" in the face of overwhelming and affect-laden circumstances, and the perception of being misunderstood or underappreciated by other staff can evoke significant responses in the mental health consultant (DeMaso and Meyer 1996). These coun-tertransference reactions may lead to avoidance of particular patients or situations and can take a toll on the consultant's overall well-being. To evade such unwelcome responses, the consultant is advised to maintain a balanced workload; pursue hobbies, physical exercise, and other pleasurable and personally nurturing activities; and seek ongoing supervision and emotional support from mental health colleagues (Colville 2001; Peebles-Kleiger 2000; Shulman and Shewbert 2000).

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