Julie Kleese, RN, cries after sharing her experiences as an ICU nurse at OHSU Hospital in Portland, Ore., Aug. 18, 2021.

Julie Kleese, RN, cries after sharing her experiences as an ICU nurse at OHSU Hospital in Portland, Ore., Aug. 18, 2021.

Hanin Najjar / OPB

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The COVID-19 pandemic has been extremely hard on health care workers. They’re struggling with mental health issues, stress and the complex emotions that go along with treating people who chose not to get vaccinated. We hear from two people who provide support to doctors, nurses and hospital staff. Our guests are Adam Clark, a licensed clinical social worker and mental health provider for Coquille Valley Hospital and Kirk Ruehl, manager of soul care at Good Shepherd Health Care System.


The following transcript was created by a computer and edited by a volunteer:

Dave Miller: This is Think Out Loud on OPB, I’m Dave Miller. The COVID-19 pandemic has been extremely hard on healthcare workers. Many have been working long hours under stressful and supremely challenging conditions for almost two years now. Now, some are dealing with the complex emotions that go along with treating people who have chosen not to get vaccinated. We’ve heard a fair amount directly from healthcare workers over the last 20 plus months. We’re going to turn right now to some of the people who provide mental health support to doctors and nurses and hospital staff. Adam Clark is a licensed clinical social worker and mental health provider for Coquille Valley Hospital in Coos County; it’s on Oregon’s South coast. Kirk Ruehl is a chaplain with the Good Shepherd Health Care System in Hermiston. Welcome to you both.

Adam Clark: Thank you.

Kirk Ruehl: Thanks for having us.

Miller: Adam Clark first, my understanding is that neither of you focus solely or even primarily on healthcare workers, but that they are definitely a part of both of your professional practices. I’m curious if you find that healthcare workers that you see, if they’ve been seeking out more help during the pandemic?

Clark: Yeah great question. Absolutely. I think people are stressed. And health care is a stressful environment anyway. So at this time, it’s kind of exacerbating that existing stress. And then you’ve got ethical pieces of the vaccine, and changes that are happening rapidly in the medical setting. And so I see a lot more people that are seeking out that care, both in outpatient therapy, and staff that are at the clinic and hospital that are stressed and navigating both the professional demands and personal demands that are coming along with this pandemic.

Miller: Are there themes that have come up a lot in the work you’ve done with those two groups of health care workers?

Clark: There are some. One of the main ones I find is that healthcare workers, most of them really like to have solutions and to offer hope and treatment for people. And when it comes to something like this pandemic, there’s so many unknowns. We can’t say it’s going to be alright. And that’s moral distress that’s been impacting a lot of the clinic staff and a lot of my patients to say “I don’t know how this is going to be. If I can’t find my own hope, how can I find hope for my patients?” And I’ve seen people even leaving the field because of that stress.

Also, home environments in a rural setting. Sometimes, it’s slower to catch up on education and even vaccine engagement. And so you’ve got struggles as far as who gets vaccinated. Should I do this? What does that look like? How do I follow the science?

Miller: Kirk Ruehl, I noted in my introduction that you’re a chaplain because that’s language that I thought listeners would be familiar with. But if I understand correctly, your actual title, which you wrote on your business card, is manager of soul care. What does that job entail?

Ruehl: It’s a new title. And really what happened is we learned during the first part of the pandemic that our, I guess what Adam refers to as moral distress, was creating something of a burning platform for our employees. And our idea was to shift a little bit toward what do we do out of necessity for our staff? We had to create new, creative, and emotionally safe ways to hear them out. And frankly, soul care came out of a plea to administration that we address this in some way. And they responded, saying let’s have a new department, let’s give it a new title, let’s hire some more people, let’s enhance our chapel. Soul care is the soft underbelly of healing, is what I say to people.

Miller: Can you help me understand that? What is the connection between soul care, as you practice it and think about it, and healing?

Ruehl: Well, what I mean is soul care by itself can do little to cure people. Without soul care, however, there is little hope of healing anyone. When our new vice president of nursing came here and I went to him with some of these ideas, he said to me something that just changed my whole view, and I thought maybe we can help administration see how important it is to address this piece. He said “Kirk, there are people who come into this hospital, and the only thing we can treat is their soul.” And he wasn’t talking about bringing them to Jesus so much as he was talking about, how do we listen to them? How do we help them be known? How do we help them be valued? How do we help them belong? These are gifts of religious faith, but they’re also part of what it means to be human.

Miller: I want to go back to something you noted earlier, which is that one of the reasons you started having a different understanding of what your job entailed, what was necessary at the moment, was that health care professionals at this hospital system there were on a burning platform. Can you give us a sense for what they have been going through?

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Ruehl: Well, we have fancy terms for this now, but cumulative stress would be one of them. We had a critical incident stress management team here at the hospital, but we needed something altogether different. We needed something that addressed moral injury, ambiguous loss, and concrete losses like loss of normalcy, loss of connection, loss of safety, and frankly, a fear of what the future holds.

Miller: What does moral injury mean in the context of health care workers?

Ruehl: Well, it really is addressing things we can’t fix. Moral injury is suffering people experience when we’re in high stakes situations. Like Adam says, we’re in high stakes situations a lot in the hospital, but this is more drawn out, this is more draining. We don’t see an end in sight, as Adam said. Things go wrong and harm the results. And as I understand moral injury, that challenges our deepest moral codes, and the ability even to trust in ourselves, let alone others.

Miller: Adam, one of the really complex issues here is compassion fatigue, or in some cases, outright anger that some health care workers feel now towards their unvaccinated COVID-19 patients that they’re treating, sometimes then combined with a serious guilt for harboring negative feelings, because these are people who got into the field because they want to be healers. And from what I’ve read and heard, it can be really troubling to then feel anger towards the people that you truly do want to help. I’m just curious, first of all, if that’s something that you have encountered in healthcare workers that have turned to you for help?

Clark: Absolutely. I’m sitting here nodding my head because when I look at that, and when people have come to me with this, I look at it as a projection of our own distress. And even the engagement of secondary trauma. And what happens are these defense mechanisms that come up. If I’m a healer, if I’m someone that helps people to get better medically, I don’t have answers, and I’m putting in all of this work, I’m being asked to work double or triple shifts, some of my colleagues have left because of the stress or their own decisions regarding the vaccine. And then I see people that come in, and they are not vaccinated, and they’re not following the protocols, that it’s so easy to make them the enemy, to target them, and to say they’re the reason for my suffering.

And when I have conversations with either my colleagues or patients, I talk about what’s behind that distress. It has nothing to do with the patient, but our own fear, our own unknown, our own burnout, that compassion fatigue. And that stress is drawing people either toward negative coping skills, like drinking, or distraction, or avoidance. But my work is to focus on how do we get through this in a healthier way? How do we cope with meaning? And how do we turn this into something that’s going to help us get through a very scary period for a lot of individuals?

Miller: The devil’s advocate position there would be: you noted that it’s not actually about the patient in that moment, it’s about the fear or anxiety that the healthcare professional is dealing with internally. But numerically, isn’t it also about those patients? If 90%+ of people who are hospitalized for COVID-19 now are unvaccinated, and if that is to a great extent taxing the health care system, isn’t it truly about those patients, on some level that may be uncomfortable to deal with, but is also a fact?

Clark: Yeah. And you know, I actually agree with you. And, when I look at the projections of anger in the immediacy of the clinic, how is that going to help me serve myself or the patient? That anger towards that individual will just lead to reduced effectiveness of care, distractions, and mistakes, and ultimately lead to more burnout. So how do I reframe this for myself, and push this passion into further advocacy? Education? Looking at then serving the community and addressing systemic barriers and socioeconomic problems that are kind of leading to this cycle happening? Anger itself, although it might be justified, sometimes I would call it righteous anger, is it effective for that individual practitioner? And are there better ways to handle it in that moment?

Miller: Kirk Ruehl, I’m curious how you think about this same question, the really serious moral wrestling that many health care workers have been talking about over the last few months, since vaccines have become super widely available, and yet many people have chosen not to take them, and have ended up having to be taken care of by burned out healthcare workers. How do you help health care workers in that situation?

Ruehl: Well, in our hospital, we give them a place to tell their story, right? Putting flesh on that soul care idea we were talking about, what that looks like at Good Shepherd is we put together a program called Resilience Education and Peer Support. We wanted people to feel as if they weren’t problem children, they were just being human, and they were struggling with that moral distress. So what that means is we gave hour long, hour and a half long sessions that were just open to anybody to come in and tell their piece. And to your point, usually, all that anger would come out, a lot of frustration. But as we sat with it, and we sat in the pain and we had skilled people, much more skilled than myself sitting in the room helping that process happen. And then over time, what we moved to was a kind of education. When people know you’re not crazy, that’s called cumulative stress, when people know your discomfort is grief… We got a lot of sharp people. Nurses are sharp people, docs are sharp people, they want to solve things, they want to put it together. So when you give them a little education around that, it brings down the volume inside.

Miller: Adam Clark, a kind of mirror image of healthcare workers being frustrated or angry at some patients, is that some members of the public have become belligerent against nurses and other health care workers. There have been multiple reports around the country of assaults and threats against people who are trying to save their lives, which is a far cry from the beginning of the pandemic when people would ring bells and make noise nightly in support of heroic healthcare workers. I’m curious if you’ve seen or if you’ve experienced or you’ve heard about antagonism from members of the public, and how that’s affected healthcare workers?

Clark: Absolutely. I would actually say, for my practice and those that I work with, this is actually a more unsettling experience for healthcare workers and than projected anger over others not being vaccinated. Anecdotally, the complaints, and the volume of those complaints, and the distress that the patient has been bringing has increased dramatically. A lot more people are quicker to anger and irritation and frustration. And one of the things we talk about is that the system itself, the health care system, that was already strained before the pandemic, especially in a rural setting, has become strained even more. And people are still struggling with their own chronic illnesses, or aging, or sickness and cancer. And so then you add another layer of fear, and then you add quality assurance concerns in a rural setting, being unable to get certain things as quickly as maybe some urban areas, then that becomes: we are the enemy. Public facing becomes the enemy.

We recently had people even picketing and striking outside of a local hospital in the area here. And that’s kind of the reverse of what we talked about. Instead of the medical providers projecting that anger into the public or the unvaccinated, you’ve got the public projecting the anger to the medical workers, because who else are they going to take it on? That projection of that pain? And as Kirk talked about, that grief and that fear is coming up.

So we talk about coping skills. We talk about depersonalization, and how do you protect yourself from this experience on a day to day basis, to try to avoid that burnout?

Miller: Kirk Ruehl, I mean, this gets us to self care. I mean, one way to see this whole issue is like Russian nesting dolls of stress and anxiety and trauma with patients and their caregivers. And then people like you and Adam who are helping both groups. How do you take care of yourself?

Ruehl: I coined the term, I guess for myself, called kamikaze self care, which seems like an oxymoron. But I just have to do it. I have to do things like swim. I use silence, solitude, music, meditation, art, poetry. Humor is really important. I post good natured humor outside the chapel door. We just need to laugh. But most important, I give myself deep permission to explore what my humanity means when things are tough. And anybody that comes to see me, I do a lot of referring out because I don’t have Adam’s skills, but anybody who comes to see me where I’m thinking they’re dealing with this incredible distress, just give them permission to tell their story. I try to give them a safe place to land. And my good friends know that’s what I need from them.

Miller: Adam Clark, you’ve got 30 seconds before the music cuts us all off.

Clark: Sure. I would say that actually self care isn’t enough. We need radical compassion. We need radical self love. We have to look at what injuries are being triggered in us, and that’s how we’re gonna get through this together. It seems hard to conceptualize, but it’s really the only way. The anger is not going to get us there.

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