Saturday, November 24, 2007

Attachment, Anticipatory Grief, and Goodbyes

Faced with returning to my full-time job in mid-December following my six-week medical leave-of-absence, it has become painfully apparent to me that my days there are numbered. With the prospect of a job-share having fallen through, I face a slew of choices vis-a-vis my employment status, and the possibilities, while exciting in their potential, also open up tender emotional areas of attachment and anticipatory grief.

Having worked in my current position for seven years, a great deal of my identity as a nurse has revolved around serving low-income, inner-city populations whose vulnerability to disease and psychosocial dysfunction makes them ripe for our services. An endless well of need and dependence, my group of 80 patients have lived in my brain and heart for all of these years, and my emotional closeness with a number of them makes it most difficult to consider leaving my position for new horizons.

I have practiced nursing in a manner in which "therapeutic use of self" is a frequent technique of connection and teaching, using examples from my own life and struggles with chronic illness and depression as teaching tools and methods of expressing sincere empathy. Such disclosure, as well as my very personalized approach to nursing practice and therapeutic relationships in general, engenders an emotional intimacy that is slightly outside the norm for medical and nursing practice. For this reason, I have become quite invested in the lives and well-being of some of my patients, and I fully realize that this is a potential factor in the eventual development of burnout and compassion fatigue over time. I recently wrote a blog entry about vicarious traumatization, a phenomenon which is more than theory for me. It appears that my patients' trauma and traumatic histories have also begun to trigger my own personal trauma history, further exacerbating my feelings of burnout and compassion fatigue.

With time on my hands during this leave of absence, I have had opportunity to reflect on my relationships with a number of patients, and the notion of saying goodbye and terminating said relationships brings me great pain. As I conjure a mental image of this patient or that patient, I experience a wincing sensation wherein I think, "Oh, no! How will I say goodbye to him/her?" And the thought of each patient of whom I am fond evinces yet another uncomfortable sensation of loss.

This workplace where I have given my all for seven years is like no other I have experienced. United in our mission to serve the poorest, sickest, and most dysfunctional sub-populations, we are also united in a day-to-day feeling of being overwhelmed, of swimming against a steady current of unquenchable need, and of knowing that our collective and individual levels of stress are potentially hazardous. As much as we complain about our patients and their neediness, there must also be an aspect of attachment and addiction to such drama on our parts as well. There must be some secondary gain for us as we slog through the challenges of our days, striving to keep our heads above water in a current which changes directions---and depth---without notice or sympathy for our collective and individual plight. The undercurrent of family and camaraderie under duress keeps us afloat, even on the worst of days.

Within the adjacent inner-city community health center with which we partner to care for our patients---and where our patients receive their primary healthcare---there is a team of doctors with the majority of whom I have developed stellar working relationships. These doctors, all of them very committed to the care of the disenfranchised, poor, and chronically ill, have consistently treated me with a level of respect and professionalism unparalleled in my experience as a nurse. This sentiment is echoed by most of my nurse colleagues, and the learning and teaching which these working relationships engender is priceless. On a first-name basis since the beginning, my opinions and suggestions are taken seriously by these docs, and our discussions are never one-way---rather, there is an exchange of ideas focused on the ultimate goal of improved health and function for our mutual patients, although I frequently do feel that I am left with more responsibility than I can handle. Still, I see that my efforts are recognized and appreciated, and that my opinion is thoroughly and thoughtfully considered. If I am mistaken, it is always pointed out in a gentle and kind way with a goal of teaching and learning which is free from games of power and hierarchy, with few exceptions.

So why leave, you may ask? Why walk away from a situation in which satisfying professional relationships, clinical skill development, and challenging medical and psychosocial situations stimulate my mind, spirit and soul? It is because this level of engagement and deep involvement with extremely needy and often dysfunctional patients over a long period of time has whittled away at my core, slowly but surely damaging my ability to enjoy life outside of my work, causing such levels of stress that my personal quality of life has become diminished. Whether directly related to this job or simply a matter of synchronicity and coexistence , my own constellation of chronic illness, chronic pain, and long-term struggles with major depression are necessitating a change of lifestyle, a ratcheting down of the intensity I experience vis-a-vis my professional life. Perhaps I understand and empathize with my patients so well because of my own chronic illnesses, but because of those personal issues, that empathy, while helpful and useful therapeutically for my patients, is slowly but surely eroding my own ability for healing.

Drawing on my interest in Buddhism, I realize that these sensations and feelings, while sincere and quite real, are a manifestation of attachment. Various attachments arise in relation to possessions, people, relationships, circumstances, and even feelings and sensations. My reluctance to leave my workplace after seven years is, to a large extent, a reflection of a certain level of comfort I have developed, even though that comfort paradoxically coexists with burnout, overwork, and a growing sense of frustration with the intensity of the work and the programmatic dysfunctions of our organization. How to reconcile all of these factors and stay on the same path without incurring further personal damage?

I am at a turning point in my career. There are new avenues of nursing and my professional self which I long to explore, yet slogging away on the front lines of inner-city nursing practice---and the stressors therein---is most likely keeping me from pursuing those new avenues, my energy consistently sapped by the vicissitudes of the ol' 9 to 5.

So, I'll keep thinking, reflecting, meditating on it, and embrace these three more weeks of my leave of absence. Returning to work in mid-December, I fully expect at this point to return with my 30-day notice of resignation in hand. Sad, true, difficult, painful, challenging........necessary. And in the immortal words of Michelle Shocked, "the secret of a long life is knowing when it's time to go".
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