40 years ago, the prognosis for small premature babies was not nearly as good as it is today. Dedicated physicians, nurses, and hospital staff of the time, worried about their little patients, and monitored them more intensely, which only added to the general level of stress in the NICU. Everyone, including the babies, suffered from overstimulation. Nurses and doctors were "burning out" at an alarming rate. Something had to change.
In the mid 1980’s I began to realize that I needed to change my working environment if I was to live as long as I wanted. The previous four years had been sleep-deprived journey from fellowship to private practice in neonatal intensive care medicine.
The Neonatal Intensive Care Units (NICUs) in the 1980’s were very bright and noisy places. Survival of smallest babies was very uncertain so an undercurrent of anxiety constantly flowed through the staff. That anxiety motivated NICUs to monitor the heartbeat of every baby and amplify the signal as a loud electronic BEEP. We wanted to be alert to a slowing heart rate—an indication of possible trouble.
Photo by Sharon McCutcheon https://unsplash.com/@sharonmccutcheon?utm_source=wix-media-manager&utm_medium=referral
However, with dozens of babies in the nursery, there were dozens of monitors, each emitting 2-3 loud BEEPs every second, and unless you were at the bedside, it wasn’t really possible to detect changes in any individual heart rhythm. Therefore, audible alarms—each with a unique sound—were added to alert the staff that a heart rate was too slow, or a breathing pause too long.
Monitors and alarms weren’t the only source of noise in the NICU. Mechanical ventilators of the day—primitive by today’s standards—also contributed to the noisy environment. Trying to talk over the background noise required everyone to speak loudly, further contributing to the general cacophony.
The NICU—a crucible of stress
Many of the babies in the nursery were critically ill, so the lights in the NICU were kept very bright—to better observe the baby. Lights were on “high” day and night with no attempt to mimic circadian rhythms. Frequent laboratory tests (which often required poking the heel for blood) were thought necessary and were done without regard for timing or the baby's sleep cycle.
As the physician in the NICU, I was responsible for the medical care delivered to the babies. We conducted rounds in the harsh, constant light, over the BEEP, BEEP, BEEP of the monitors, the loud voices of the staff, and the regular WOOSH, WOOSH of the ventilators.
We genuinely thought this intense monitoring was in the best interest of the babies and, in fact, survival was improving. In hindsight, it was total visual and auditory overload—layered on top of sleep deprivation—and it was not as effective as we wanted it to be.
Unable to pay attention to every stimulus and still be able to follow a train of thought, much of the stimuli was simply (and subconsciously) ignored. We now know that this suppression of stimuli, this willful ignoring of the environment, takes considerable energy and depletes the cognitive reserves we all need.
Habituation to stress—suppressing the abnormal
I thought about all of this one relatively quiet evening while at home and not on call. I sat in my comfortable chair, TV off and the room darkened, and reflected on my situation. From my point of view, I was handing the demands of the NICU rather well. Yet the medical journals of the time were full of articles on stress and burnout in the NICU, and the suicide rate among physicians was higher than many professions. Like my colleagues in intensive care medicine, I shared similar working conditions—the intense lighting, the constant noise, the frequent interruptions, the sleep deprivation, and the burden of responsibility. All that had to be taking a toll on my physical and emotional health. At that point, I realized I had become habituated to the NICU environment. What had come to feel “normal” to me was not at all normal and was probably adversely affecting my health and well-being.
The same had to be true for the staff—the nurses, respiratory therapists, unit clerks, X-Ray technicians, nutritionists, physical therapists and others who crowded the NICU. And it had to be true for the families of the babies. Not only did they have to deal with the same stressful physical environment we did, they were also riding the profound emotional roller coaster of uncertainty about their baby’s survival.
Most importantly, it had to hold true for our little patients as well. It seems so obvious now, but it came as a real insight at the time. Our patients, especially the tiny preemies, showed little to no outward signs of distress in spite of the hostile environment we inadvertently created for them. But they had to be suffering. I could go home from time to time, but they had no respite.
How can you heal when you are disturbed frequently at irregular intervals and forced to live in a hostile environment of bright lights and loud noises?
Crescent Lake, Olympic National Park. The opposite of bright artificial lights and loud noises. Could some time in nature help me comprehend the amount of stress I was under, undo my habituation to it, restore some balance, and motivate me to minimize environmental stress for my patients? Photo: © Donald J. Rommes
I realized our NICU provided effective conditions for the delivery of medical care for very ill babies but, at least back then, didn’t do enough to provide for the human needs of our vulnerable, defenseless patients—like sleep, quiet, and nurturing. Something had to change.
I decided to start by getting myself out of that environment for a while to reset my senses and regain my perspective. I needed to remember what “normal” was. Then, I needed to understand what “stress” was and what caused it before I could try to reduce it in the NICU and in my life. Maybe, I thought, I should spend a week in nature.
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