Title : Code lavender: Recognizing and responding to emotional crises amongst nurses

Introduction: It is widely accepted that nurses working in hospitals experience heavy physical and emotional burden, requiring them to maintain a level of health and fitness that enables them to meet the demands of their jobs. [1] Despite this reality, it was not until the global Covid-19 pandemic that the issue of Nurse health and wellness came sharply into focus. [2] One effect of this has been the elevation of employee wellness from being solely provided through reactive occupational health services, to being a strategic business priority, with many healthcare organizations actively invested in proactively identifying and implementing practices and solutions to maintain and elevate nurse health and wellbeing.

While King Faisal Specialist Hospital and Research Centre (KFSH&RC) in the Kingdom of Saudi Arabia (KSA) has always maintained a strong and committed focus on employee health and wellness, like many organizations, it was not immune to the effects of the pandemic. At the Jeddah hospital, over a third of the employees are nurses which means that nurse sickness and absence has a tangible and negative impact. Since 2020, Nursing Affairs has developed operational goals related to enhancing Nurse health and wellness. With this lens, attendance at the Magnet Hospital conference in 2022 where an example of a Code Lavender (CL) program was presented, led to the collaborative creation in 2023 of a low-cost emotional crisis response program at Jeddah hospital.

This case report shares the journey from the initial idea to the establishment and operation Code Lavender program at Jeddah hospital and includes a review of the literature on Nurse health and wellness. The outcomes and future direction of the CL program are shared with the intention to inform and provide a practical exemplar that other organizations could choose to utilize in developing their own CL programs or other health and wellness initiatives.

Organizational and Psycho-social stressors among Health Care Professionals

Working in a hospital setting can be rewarding but  it is important to acknowledge that this is often in the context of a stressful and demanding work environment .[2]  It is well established that healthcare work is physically, cognitively and emotionally demanding  [3]  and can be classified as extreme work .[4]  Garavan et al (p1604)  [5] define extreme work as “elements of day-to-day work that are characterized by the increased effort or intensity that employees must use to deliver work outcomes.”

Nurses form the largest group amongst health care professionals and  are exposed to stressors at work such as high emotional demands related to dealing with  illness, and death,  aggression at work,  heavy physical demands when caring for patients, [6-8] exposure to infectious diseases [9-10], human and other resource limitations [11-12] opportunities for development and sometimes the behavior of the direct line manager (e.g. quality of leadership, inequity of opportunities, rewards given) [13] and the lack of a work -life balance. [14]

Within the literature the consequences of work related stressors for nurses which include burnout, which is a state of emotional, physical, and mental exhaustion characterized (amongst others) by decreased performance, cynicism, and feeling ineffective [15] low confidence, high job dissatisfaction, [16] increased risk of making medical mistakes, involvement in workplace violence [17] and unhappiness. [14] Chronic stress negatively affects employee health, causing anxiety, depression, and cardiovascular diseases, [18] which in turn leads to job dissatisfaction, and the intention to leave the profession prematurely. [19-20]

Personal and traumatic events like the death of a loved one, divorce, separation, pregnancy, change of home, financial issues, children leaving home, [21] are not confined to the home; they spill over into the workplace, resulting in symptoms such as increased emotional exhaustion, distractedness and reduced performance. [22]Mather et al [22] reported a history of traumatic life events was independently associated with burnout symptoms. A study by Keller et al, showed statistically significant results showed independent associations between  stressful life events: serious family problems-odds ratio (OR) 1.71 (CI = 1.36–2.15), physical illness OR 1.44 (CI = 1.17–1.77), divorce or separation OR 1.40 (CI = 1.15–1.70), and burnout symptoms were also found to compound occupational strain. [23]

The Growing Importance of Well-being at Work

There is growing awareness of the importance of nurse well-being at work and of actions to improve it. The International Council for Nurses (ICN) has urged “urgent and decisive action to be taken to put nurse well-being at the center of health systems and enable nurses to provide essential care, support thriving populations and economies, and advance universal health coverage and the sustainable development goals”.[24] Globally, well-being is acknowledged as an issue worth addressing , for the wellness of the current, and future, nursing workforce.[25-26] Effective strategies for supporting nurses in the various  context within which they practice, can be utilized by nurse leaders and healthcare organizations to maintain, and improve wellness and employee satisfaction.[27]

Code Lavender- an emotional crisis intervention approach

One approach to providing real-time support to health care workers after the occurrence of   stressful events is Code Lavender (CL). CL is an emotional crisis tool used to support staff, patients, family members, volunteers, during or following a stressful event or series of stressful events that sometimes occur in the hospital. [28] The term "Code Lavender" was originally coined to convey a sense of urgency, similar to other codes used for emergencies in healthcare. CL was originally developed to respond to and support individuals experiencing emotional or spiritual distress, with a dedicated team providing immediate support. The word "lavender" refers to the calming properties of the lavender plant, whose scent and essential oils are known to reduce anxiety and promote relaxation. [29-30]

CL was originally introduced to increase acts of kindness in the workplace [31] in 2004 in Hawaii by Dr Erl Bakken and was later introduced to Cleveland Clinic by Dr Bridget Duffy in 2008. It continues to be a source of psychological first aid for staff, patients and caregivers. [29] For example, Cleveland Clinic’s CL program recognizes that clinical staff are human beings who are also affected by severe situations-for example the death of a patient or a loved one just as much as anyone else, even to the point of desensitization.[32] The CL code emphasizes privacy and confidentiality  and is therefore referred to as a quiet code, in that it is  not publicly announced over the organization’s intercom unlike a code green or blue. Activation of a CL is voluntary, hence it cannot be activated for a person without their agreement.[28]

CL is used when situations threaten personal emotional equilibrium, professional functioning, and or stability of the unit. When a CL is called, the CL team responds within 30 minutes.[28] CL has also been recognized as a brief intervention to  prevent nurses from experiencing long-term mental/ emotional trauma. According Gregory [33] it has been adopted by various organizations and uses evidence-based relaxation and restoration interventions to assist in meeting their immediate responsibilities as a precursor to more permanent solutions. CL support typically includes: 
•    A purposeful physical presence 
•    Individual and/or team support  
•    Complementary therapies  
•    Prayer and other affectively based interventions. [28]  
 
A Code Lavender: Case Study

The Nursing Affairs division of King Faisal Specialist Hospital and Research Center –Jeddah adopted the CL program since in January 2023. KFSHRC-J is a Magnet re-designated hospital that places strong emphasis on nursing excellence, and on the well-being of nurses which is viewed as  essential for delivering high-quality, patient-centered care and sustaining a healthy work environment.

KFSHRC-J is a multicultural organization with 1179 registered number of nursing staff of which 58% are expatriates. Besides the usual stressors associated working in healthcare, expatriates are faced with challenges such as living and working in a new cultural and physical environment; cultural isolation, gender norms [34-35] homesickness and loneliness, [36] and the physical effects of a hot climate (dehydration, headaches, and exhaustion).[37]

In October 2022, the Chief Nursing Officer (CNO) and KFSHRC J Magnet representatives attended the Magnet Conference in Philadelphia, United States of America (USA).  The CL program was presented at the conference and one KFSHRC-J delegate was particularly impressed and upon return, inquired about the possibility of implementing the initiative across Nursing Affairs at KFSHRC-J as an emotional support tool for staff.

A CL task force was set up, under the guidance of the CNO (a certified coach) with the responsibility for exploring the development of a context/culturally specific CL program.  As a magnet hospital since 2013, there is a shared governance structure and process in place and Head Nurses and other Nurse Leaders were consulted to ascertain their support for such a program. Information sessions were provided the bolster their understanding of CL and the scope of the program was modified based on their feedback. Modifications were made to the Cleveland Clinic model of the program to ensure cultural congruence with the local context. For example in Cleveland clinic, the CL program allowed for pet dogs to be utilized as a calming component, however within KFSHRC-J this was not deemed culturally appropriate. A vote was taken to determine support for a trial of the program.. Having secured agreement and made the modifications, in November 2023, the CL program/service was launched within Nursing Affairs. The service is available 24/7 and is accessible to all nursing affairs staff.

In developing the program, first-responders were identified based on specific criteria, which included being perceived as trustworthy, their position in the organization (e.g. Nurse Retention & Employee Well-being Specialist and Nursing Supervisor) possessing strong communication and active listening skills, having an interest in serving others, and the ability to respond within thirty minutes. Current first responders include the Chair of the Nurse Management Sub-council, Chair of the Ethics Sub council, Nursing Recruitment and Retention Co-coordinator, Occupational Health Nurse, Senior Palliative Care Nurse and a clinical bedside nurse. The wider CL team include the  Nursing Research Senior Specialist, Employee Relations Counsellor, Psychiatrist and the Magnet Nursing Program Director.

As part of the preparations for going live, first responders underwent training to equip them for their roles. The training included listening skills, use of effective questioning, de-escalation techniques, privacy and confidentiality, and the appropriate use of touch.   
The structure and activation process includes: 
•    Eligibility : all of nursing affairs  
•    Trigger criteria: work related or personal stressors/trauma causing acute need for support 
•    Activation process: mobile telephone or MCD  
•    Responders: on call systems for day and night shifts and during public holidays • Who can activate: self-activated or by peers/colleagues/staff members (See Figure 1 )  Components of the intervention:  
•    Immediate emotional first aid: provides compassionate, non-judgmental support to individuals in distress by offering a safe space, active listening, emotional validation, and reassurance, while guiding them toward appropriate next steps. 
•    Confidentiality  discreet activation processes, confidential communication limited to necessary personnel 
•    Access to a quiet space  
•    Conversations (a hug)or listening support with first responder 
•    Breathing exercises  
•    Referrals to the psychologist or family medicine practitioner if needed following the CL 
•    Follow up visits if agreed (See Figure 1) 
•    Provision of the CL kit: which  consists of a 20ml of aromatherapy lavender oil, a herbal tea bag, a hand sized stress ball, a piece of chocolate and a note from the CNO that read’s ‘We are here for you”. The tea bag included in the kit allows the responder to prepare a comforting cup of tea for the individual in distress, helping to establish rapport and encouraging open conversation. The stress ball serves as a mindfulness aid during the call-out and can also be used as a teaching tool to demonstrate self-soothing techniques, such as a calming palm massage  (Figure 2) . In keeping with the confidentiality of the process the initial CL toolkit (Figure 3) was changed to the smaller toolkit.

Outcomes of the CL program at KFSHRC-J

Initially, the uptake of CL was low due to staff ‘mistrust’that the service would be ‘confidential’ and a perception that it was a service to encourage employees to take sick leave. Some stakeholders also expressed concern that employees who used the service would be seen as being mentally or emotionally weak or inadequate in some way. However, open leader endorsement from the Programme Directors and Head Nurses created an awareness that help-seeking behaviors are important to manage stress towards achieving well-being.

Currently, CL has blossomed to be a service that is viewed as being trustworthy, of practical value to nurse leaders an employees alike, and most importantly, and emotionally beneficial to users. Since the launch of the program, a total of 41 CL activations were recorded, predominantly related to work place stressors such as increased workload, team dynamics, trauma codes, and needlestick injuries. We believe the CL program is positively influencing staff retention, as insights gathered from individual events are being used to address broader issues, for example, identifying and responding to recurring themes in staff feedback. Verbal feedback from users of the service has been overwhelmingly positive, with comments such as: 
•    ‘It gave me a moment to regroup, be heard and get on with the shift’ 
•    ‘I am happy we have this service, it makes me feel valued and seen to be human too’ 
•    ‘It was my first patient death, and I didn’t know how to feel, my colleagues and nurse clinician were worried about me and they called for a Code Lavender, the support I got from my team calling Code Lavender for me was touching, and then the code lavender responder sitting beside me and listening to me processing my shock was a cherry on the top”

Future Directions

Over time, changes and modifications have been made to the CL program. For example, the original CL kit was deemed ‘too obvious’ and ‘too big’ by the respondees and it was modified to a smaller pocket sized kit, in keeping with the confidentiality of the process.  The CL program has been incorporated in the General Nursing Orientation as part of the Recruitment and Retention department. There has been a widespread call out amongst other non nursing departments to have the CL program implemented across the organization and perhaps sponsored as a well-being team by the corporate wellness office.

Impact of CL

Evidence indicates that the promotion and enablement of worker resilience is a key strategy to address and diminish the pervasive effects of workplace stress .[38] The Promoting Adult Resilience (PAR) programme used in a pilot study with mental health nurses in Australia indicated that coping self-efficacy significantly increased, and anxiety significantly decreased, with stress levels significantly lower after the program. Participants were able reinforce understanding and strengthen their resilience. [39-41]

Mental health stressor can be mitigated by leaders who are attentive to the resilience of their staff. A Cl program can alleviate immediate emotional distress by helping staff to   to process critical incidents and help normalize the physical and psychological reactions related to an incident.  [42]

Conclusion: Nurse health and wellness is now an important priority for nurse leaders and more broadly for healthcare organizations. There is support in the empirical literature that supports why this needs to be the case. By creating alignment between organizational priorities and employee needs, and by leveraging shared governance, Nursing Affairs at KFSH&RC- Jeddah hospital has been able to develop and implement an effective and trustworthy CL program which has borne professional, organizational and personal benefit. In sharing this case, it is hoped that other healthcare organizations would also consider developing localized versions for their employees and achieve similar results. 

To be updated shortly..