6:30pm 17th July 2016 :: Think: Health

Intensive care units are stressful places to work, but it’s not just dealing with the sickest people in the hospital causing compassion fatigue for nurses. And when it comes to chronic heart failure, does anxiety cause the problem, or just make it worse? Plus we go to a children’s hospital to hear music therapy in action.

Presenter/Producer: Ninah Kopel
Producer: Sam King

Samantha Jakimowicz – PHD student at the University of Technology Sydney Faculty of Health
Jeffrey Vongmany- PHD student at the University of Technology Sydney Faculty of Health
Dr. Phillip Newton- Director of Research Students in the Faculty of Health at UTS, and Senior Lecturer in the Centre for Cardiovascular and Chronic Care
Matt Ralph, Music Therapist at the Sydney Children’s Hospital in Randwick


Ninah Kopel: Hello, I’m Ninah Kopel. Welcome to the show. Today we look at the link between chronic heart failure and anxiety. Are mental disorders making heart problems worse or just exacerbating existing issues? We’ll find out. And:

Matt Ralph, Ruby and others (singing): “In Sydney Children’s Hospital, in our situation, fighting bad bugs with chemo and hydration…”

Ninah Kopel: Prescribing music for sick kids. I go to a children’s hospital to see music therapy in action. But first, nurses in Intensive Care Units have a difficult job. They have to monitor screens and all the technical medical stuff, while juggling the emotional stress of working with some of the sickest patients in the hospital. And they’re expected to smile the whole way through. Samantha Jakimowicz, from the University of Technology Sydney Faculty of Health is doing her PhD on this topic. She’s looking at just how burnt out nurses in Intensive Care Units or ICUs can get by comparing their compassion fatigue levels with their compassion satisfaction levels.

Samantha Jakimowicz: Compassion fatigue has two sides to it. There’s compassion satisfaction and compassion fatigue. And compassion satisfaction is the good feeling that you get when you’re caring for people – it’s like the altruistic side of things. Compassion fatigue has been studied a lot in Canada, the States and the UK and it’s been looking at burn out and the secondary traumatic stress components of that that make up the compassion fatigue.

Ninah Kopel: And is it something that’s specific for nurses, or are doctors and other healthcare professionals experiencing the same problems?

Samantha Jakimowicz: They do. And I think there’s not a lot of research on the medical profession itself on compassion fatigue, but if you look at the nurses, the nurses are at the bedside, usually for 12-hour shifts. So they are with the patient, they’re treating the patient, they’re with the family for that whole time. The doctors are there as well and they’re making decisions on the medical side of things and hopefully talking with the nurses about it and working out plans. But the doctors come and go. They’ve got a number of patients that they’re looking after, whereas the nurses are looking after one, maybe two if it’s a high-dependency unit.

Ninah Kopel: So it’s easier for them to be emotionally invested in those people.

Samantha Jakimowicz: Yeah, yeah, definitely.

Ninah Kopel: So you talk about this idea of patient-centred nursing, which is an interesting idea to me because I assume that all nursing would be patient-centred.

Samantha Jakimowicz: A lot of people do. So, even though patient-centred nursing should be across the board, often things get missed. Patient-centred nursing involves the rights of the patient, the autonomy of the patient and the shared decision-making of the patient. It involves providing a compassionate presence as well as a professional presence – having professional boundaries. It also involves the right to technology and the best medical care possible. Sometimes some of those things are compromised in intensive care. When you’ve got a patient who’s incubated and can’t communicate – if they’re on life-support or if they’re sedated or unconscious…so, who knows what they would want. So, it’s hard to keep their rights and their decisions – was there an advanced care directive somewhere that we don’t know about? You know, that sort of thing. So, those sorts of things can be compromised in a situation where they’re so sick.

Ninah Kopel: When we are talking about these ICU settings, are there any particular stresses that come from that for nurses that they have to handle in their jobs and day-to-day work?

Samantha Jakimowicz: Well, some things that have come up in the interviews is really the ICU ideology or the medical dominance of ICU where people are going in there for treating and, I mean, it’s part of the physician’s training that they treat at all costs. And sometimes that is good and, of course, the patients have the right to that treatment. But sometimes you’ll get patients that might have a poor prognosis and the nurses can see that the prognosis is poor and their standard of living before they came in will be much worse if they continue with treatment. And sometimes the nurses felt like they were torturing their patients by continuing treatment when they knew that ultimately, the patient wasn’t going to survive. So that caused them a lot of moral distress and they took that home, a lot of them. Sometimes in ICU palliation is not seen as a success, whereas you can have a situation where the patient’s wishes are being abided by the families. They’re OK with it and you’ve made the patient comfortable – you’ve been there providing the compassionate support and that’s a good situation for the nurse and the best situation probably for the family.

Ninah Kopel: So those are some of the concepts that you’re dealing with in your research. What is your research actually aiming to discover or find out?

Samantha Jakimowicz: What I’m doing – and almost finished doing – is finding out what the level of compassion satisfaction and fatigue the intensive care unit nurses have got in Australia, and whether that’s impacting the level of patient-centred nursing they’re providing, and what support they need to be able to give the best patient-centred nursing. Also, I’m looking to see if there’s a link between providing patient-centred nursing and the nurse feeling compassion satisfaction. So I think it’s important not to just concentrate on the negative side of things – it’s important to enhance the good stuff. So, to help nurses be happy in their work, it’s a bit of a problem with the nursing workforce that there’s a shortage and that’s affecting the critical care nursing workforce just as much as the general workforce. As populations are ageing, more are required because you’re getting more older people in intensive care. As people are coming into intensive care they’re thinking, “Oh, I’m going to get fixed there, because that’s the place where everyone goes,” you know, that’s the highest level of medical care… and that’s not always the case.

Ninah Kopel: So it’s not just the patient interactions and the stress of having that intensive care unit around the nurses that is stressful, it’s also the workplace politics and events that are happening.

Samantha Jakimowicz: Definitely. One thing that I’ve found in my research is that nurses depend on each other. So to debrief… if they’ve been involved in something that’s traumatic or a procedure that’s traumatic or a death after they’ve been looking after a patient for a period of time and become quite attached to the patient and family… all of those sort of things, sometimes it’s hard to go home and just talk to their husband, wife, children, partners or whoever, because they may not understand if they’re not in that working environment. So nurses talking to each other – they understand that. So that is something that I’ve found is really really important to the nurses.

Ninah Kopel: And you mentioned that shortage of nurses, which is always interesting to me, because it seems like a lot of people are studying nursing?

Samantha Jakimowicz: It is, I mean, we’ve got a lot of new grads going through here, and there aren’t enough new grad positions. It’s good to have the new grads going through and employing them, but critical care nurses, to be able to cope with the difficult things that are happening to them, need to have quite a few years of experience. I actually found in my study that the nurses with the postgraduate qualifications had a high level of compassion satisfaction, so it’s really important to have that continued education and that time put into learning more to be able to get the satisfaction out of the role. I think the nurses that are burnt out haven’t maybe worked out a coping mechanism or they’ve got different personalities – those sorts of things we need to look at because I think they’re just leaving. I don’t think that they’re starting to work it out.

Ninah Kopel: I know that you’re not quite done with your research, but you’re almost there…

Samantha Jakimowicz: Almost…

Ninah Kopel: What’s most surprised you about this whole process?

Samantha Jakimowicz: So the levels of the nurses’ compassion satisfaction and fatigue are average. Now ideally, it would be better to have high compassion satisfaction and low fatigue. I sort of thought there’d be more higher fatigue, but I’m pleased that there’s some resilience there with the nurses. I’m needing to find out more about what we can do to get the compassion satisfaction up. The nurses are keen to get some help. So, I was surprised – the participation rate was fantastic and they’re really keen to talk about it and keen to do something about it to look after themselves, which ultimately helps their patients, which is really important.

Ninah Kopel: Samantha Jakimowicz, PhD student in the Faculty of Health at the University of Technology Sydney.

[Music plays]

Female: Think:Health on 2ser 107.3.

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Ninah Kopel: You might not know much about chronic heart failure, but the end stage heart disease is a massive issue in Australia and one of the most common reasons for hospitalisation in people over the age of 65. Up to 50% of people with severe chronic heart failure will die within a year of diagnosis, and to make matters worse, mental health disorders like depression and anxiety frequently compound the problem. PhD student Jeffrey Vongmany set out to examine the relationship between anxiety and chronic heart failure, which we will sometimes refer to as CHF in this story. He joined Producer Sam King and Dr Phillip Newton from the University of Technology Faculty of Health to discuss his research. And to begin with, Sam wanted to know what CHF actually is:

Phillip Newton: So chronic heart failure is really end stage heart disease. There are a number of underlying causes and essentially there are two broad types of heart failure. One is where it’s an issue with the pumping of the heart and the other is where it’s a problem with the filling of the heart, and essentially, because of these issues, it can no longer meet the metabolic needs of the body, and you get a whole range of different symptoms. So people come fatigued, they come short of breath, they can start to retain fluid, so they become really quite adenomas or “fluid-overloaded” as we say. And this causes a whole range of issues, impacts on their quality of life… we know that is causes them to be hospitalised quite frequently – it’s the most common reason that people over the age of 65 are actually hospitalised, so it’s a major health issue.

Sam King: What does a typical treatment course look like? Is it intensive?

Phillip Newton: Yes, again, it depends on the cause. So, if it’s a pumping failure, we have lots of different drugs that we know work, and then there’s other therapies such as devices, pacemakers and biventricular pacemakers, but also diet and lifestyle. And so, we try to encourage people to self-manage, so there are heart failure disease management programs, primarily nurse-led, or teaching strategies around self-management, trying to restrict their fluid, trying to restrict the salt in their diet, although that’s a little bit controversial, but also managing their medications and how to take them, because these people can be on 10, 15, 20 different types of medication, so that’s quite a complex regime they have.

Sam King: Sure, especially when you add mental illness to it, I mean, I understand that a mental illness like depression can lead to more hospital visits and a higher risk of death for these patients. Why is that?

Jeffrey Vongmany: OK, so with depression, it’s got some physiological mechanisms that kind of exacerbate what leads to hospitalisations and death in heart failure. In terms of the physiological mechanism, there’s something called the hypothalamic pituitary adrenal axis – the HPA axis – and this leads to… well, when you have depression, and also in the case of anxiety, you have an increased vasoconstriction, so the blood vessels become smaller in diameter and you also have an increased in stroke volume, and this can exacerbate any underlying defects that comes with heart failure.

Sam King: Kind of like what happens when you get stressed? You get a higher heart rate and your blood pressure goes up? That sort of thing?

Jeffrey Vongmany: Yeah, like that.

Sam King: How much can that impact on someone’s life?

Jeffrey Vongmany: In the case of depression, it affects their quality of life. Evidently, they’re depressed so this can influence their psychosocial needs. So, for example, in their interactions with family and friends, they may not feel they have enough support, but in terms of health outcomes, there’s been a lot of evidence – a lot of strong, robust studies and reviews of these studies – that depression does lead to increased hospitalisations, and also death in these patients.

Sam King: All right, so it’s good that there’s a lot of information out there on depression specifically, but you guys are looking to shed some light on the symptom of anxiety. So what’s the difference first of all.

Jeffrey Vongmany: Actually, with the diagnostic manual of mental disorders, Addition 4, which is right before the newest Addition – Addition 5 – anxiety and depression were distinct diagnoses, but now, as of Addition 5, the latest one, they have now made anxiety as a specifier of depression, so it’s no longer a separate diagnosis. The reasons for this maybe to help… well, it’s beyond me why they’ve made a new distinction as a specifier, but it could help in increasing awareness of anxiety. So, if a clinician looks at clinical practice guidelines of depression because they know it’s common in heart failure, then they’d see in the guidelines to also look at anxiety as a specifier for depression.

Sam King: Well, how much research is there on anxiety and the impact on these patients?

Jeffrey Vongmany: Not many in comparison to depression – it’s kind of a newer area of research. But the thing is, also the effects of anxiety are a bit more subtle, from the review I recently published, my team and I found that anxiety did not contribute to mortality, so, no increased risk of death. And this is also been replicated in other recent reviews as well. But we did see the possibility… so it’s not certain yet that anxiety leads to an increased hospitalisation.

Sam King: I’m going to go out on a limb for a bit – it seems logical that having a condition like chronic heart failure can make people pretty anxious, maybe even people who wouldn’t have a mood disorder. Do you think anxiety is caused by CHF physiologically, or is it something that builds up as a result of living with it every day?

Jeffrey Vongmany: The prevalence of anxiety in the general population currently stands at approximately 10%. In the cardiovascular population, specifically heart failure, this has been pulled a bit higher to around 13%. So yes, we can imagine that if you have heart failure, you’d be anxious anyway, but there is still a little bit more of an increased population of people with anxiety, but that’s just the prevalence of clinically diagnosed anxiety. But in terms of clinical influential anxiety where the symptoms are present, but they may not necessarily have the diagnosis – that prevalence is a bit higher, and that’s around 55%. So, for the remaining 45% – they don’t have anxiety, and that’s what’s interesting about that statistic.

Sam King: OK. I guess what I’m driving at is – correct me if I’m wrong – could high anxiety be a red flag for heart failure patients? Could it be a diagnostic tool?

Phillip Newton: No, I don’t think it’ll be a diagnostic tool – what you have to be a little bit careful of is, there’ll be people who will have underlying anxiety issues well before they have heart failure and then there will be people that become anxious when they become acutely unwell because of their heart failure. There may be common pathways, and there may be common influences in there, but in terms of it being a cause, I don’t think we know enough about that at the moment, so no, I can’t see it being an early screening tool…

Sam King: Sure, I mean there are a lot of grey areas with anything related to mental illness. How did you guys go about researching this report you’ve put out?

Jeffrey Vongmany: We decided to look at psychological disorders in a project we’re running with St Vincent’s Hospital – Phil (Phillip Newton) knows about it and Phil helps run it as well. It’s a lace study, and that kind of jogged my interest into conducting the review, and also at the time, there was no existing reviews looking at anxiety in the heart failure population.

Sam King: What was it that surprised you most about the results?

Jeffrey Vongmany: That anxiety did not contribute to mortality, so increased deaths in heart failure patients, but at the same time, with the current evidence that stands, I guess even though it’s been consistent, there hasn’t been a lot of studies that have investigated yet. There’s only been maybe 10 studies to date that look at anxiety and death and also anxiety and hospitalisation.

Ninah Kopel: PhD student Jeffrey Vongmany chatting with Producer Sam King and Dr Phillip Newton from the University of Technology Sydney Faculty of Health.

[Music plays]

Male: You’re listening to Think:Health on 2ser 107.3.

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Ninah Kopel: Sadness, sickness, fear – they’re all words that would be easy to associate with a children’s hospital. But as well as the doctors, nurses and specialists working tirelessly to make sick kids better, there are people around to make them happier as well, and that’s where music therapy comes in. I went to Sydney Children’s Hospital in Randwick to hear music therapist Matt Ralph in action and to see just how powerful a healing tool music can be.

Matt Ralph (singing): (fade in) “We’ll help you get better…” (fade out)

Ninah Kopel: Walking into the hospital, it’s much cheerier than I was expecting. Artworks line the brightly coloured walls, clown doctors roam the halls, and Matt is never too far away with his trolley of musical instruments. In a room in an oncology ward, mostly for kids with cancer, Ruby is hard at work with Matt and her family, perfecting the lyrics to this special song. It’s a thankyou message to the Great Britain Olympic team, who’ve taken time out of their training for Rio to wish her better in video messages.

Matt Ralph (singing): “…With chemo and hydration. Team GB Go for Gold…”

Ninah Kopel: The hospital runs a fun program for kids where every test or treatment they receive they get this unique colourful bead, which they string together, kind of like one of those friendship bracelets you used to make as kid. For the kids here, it’s a colourful portrayal of their experience here in hospital. Ruby’s is at the front of the room, and it’s colourful, but long.

Matt Ralph and Ruby (singing): “Everyone competing, go, go…”

Ninah Kopel: But right now isn’t time for tests or treatments. Ruby is in bed surrounded by her creative team – her parents and Matt the music therapist – and there all working really hard to find the perfect words to finish this song. Luckily Ruby is pretty on the ball with the lyrics.

Matt Ralph: “Singing this with me…” But then we need something like…

Ruby: Light… plight.

Matt Ralph: You are such a good rhymer!

Ninah Kopel: Music has always been a part of Matt’s life, but when he first started learning, he had no idea that he and his guitar would end up spending so much time in a hospital.

Matt Ralph: You walk into a bay with six beds and all the curtains are drawn. And I walk in with my trolley of instruments and say, “Hey! How’s everyone going! Hi!” I have a little chat, “I’ve got a new song. Do you want to play this?” And then I nip around and say, “Hey do you want to play too?”; “Oh yeah, that’d be nice!”; “Ok, well, I’m just going to pull the curtain back so you can see each other.” And you know, ten minutes later, all the curtains are drawn, the sun’s coming through, all the kids have got instruments, the parents are relaxed, the nurses are more relaxed, the doctors have easier access to see the kids and that’s an important role, and that’s easy for a music therapist to achieve, because that ‘s the nature of music, is to have a group, you know, a jam session.

Ninah Kopel: But Matt was bringing music to these corridors before he even studied music therapy as a Captain Starlight for the Starlight Foundation.

Matt Ralph: I just wanted to know more about music therapy, so whilst I was a Captain Starlight, I studied at UTS a Masters of Music Therapy just to actually increase my knowledge as to why it works so well, and then when I graduated – I think that was 2012 – it just so happened that this position came up at the hospital and you know, it took a few conversations before I actually realised, “Oh, I could actually work as a music therapist.” But now, I absolutely love it.

Ninah Kopel: When he transitioned from Captain Starlight to Matt the music therapist, it took a bit of explaining, but the kids were soon on board.

Matt Ralph: They were good about that, and I came up with little stories like, “Oh my goodness, I loved Earth so much that I actually got a visa to stay here for a while and now I’m actually doing a human job!” So I was actually this kind of alien music therapist there for a while. But they got the joke, and you know, they seemed to work through that.

Ninah Kopel: But what really is music therapy? What could Matt do with his Masters in music therapy that he couldn’t do as Captain Starlight?

Matt Ralph: As a Captain Starlight, the emphasis is on entertainment and distraction and recreation, whereas with music therapy, you can name your therapeutic objective. You can say, “I want to reduce isolation for this child,” whereas that’s not really in the scope of perhaps Captain Starlight. Of course, you’re actually achieving the same thing by involving kids in quizzes and things like that, but as a music therapist, there’s another focus, it’s another layer. The parents would actually talk to me in a different way. They’d want to know more about me and I just sort of felt as though I wanted to talk to them on that level, so music therapy became an easier way to do that.

Ninah Kopel: Music therapy might not seem as hard a science as medicine, but it has clear goals: stress reduction, family bonding and empowerment.

Matt Ralph: There was a young boy who had an accident and was in ICU. He started off in incredibly bad shape. They had no idea how it was all going to go. It was day by day. This boy was really into sport and hadn’t even thought about music at all. Music wasn’t necessarily a part of his life and his experience. And here he is in the ICU with very limited movement. He’s from the country, the family are very stressed, he’s obviously extremely stressed and upset. For days, months, you know, a long time in this ward, through first meeting him as a Captain Starlight and realising that music could be his thing. I had no allegiance to music necessarily – I just saw that music could be something that he could do. We started off by just finding what he was interested in and having conversations about that. And if you are in hospital and you can’t move and the only thing you can do is communicate, well you want to be engaged about what you can do, or what you’re interested in. And so, he was very much into motor-cross bikes, so we searched lots of photos and we found one of his heroes and asked him to come in and meet him, and this opened up the community to what he was going through, so he felt like there was a large community support for him. We put posters of all the motorbikes he liked around the room, so there the things that he likes but can’t do, so what can he do to complement that. Well, he could make choices about things at this point and so we started making soundtracks to the photos of all the motorbikes that he liked and then finding video footage of him riding his motorbike and putting it together and then creating music to that. And he started to enjoy that, and as he started to get more movement, he might play and instrument and we’d record that, so music was something that he could do. It gave him experiences of success, and also during this time, we’re transitioning between Captain Starlight to say LiveWire, which is the adolescent program to music therapy. We were able to show those slideshows and show the music that he created on the TV network at the hospital which goes across the whole hospital to all the beds in all the wards, so all the kids can see, which took him from his very isolated room to being able to communicate and get feedback from other kids across the whole hospital and then he got his motorbike fixed by a mechanic up in his country town and being able to create something together – giving him the opportunity to feel as though he can, with his limited amount of movement at this point, still make something to send back to the mechanic to say thank you so much. So we wrote this song and you know, we put it together with some images and emailed it to him and he felt empowered by still being able to communicate and give to the community.

Ninah Kopel: For sick kids in hospital, there are a lot of treatments they have to have, a lot of treatments they have to do, and a whole bunch of things they wish they could do, but might not be able to. Music therapy is one of the few things that’s not only fun, it’s completely their choice. They can say no to Matt and his trolley of instruments whenever they want and that’s completely OK. But Matt’s pretty good at encouraging kids to get involved, even with the older kids, who can be harder to win over.

Matt Ralph: I wouldn’t necessarily just walk in and say, “Oh, are you into music?” Because if she says no, well then it’s hard for me to sort of justify why I’m still talking to her. So I won’t say, “Hi, I’m a music therapist, are you into music?” because the answer will be “No.” I’ll say, “Hey, how are you?” and I’ll notice something like if she’s got an artwork or a drawing and I’ll say, “Oh, that’s fantastic, did you do that” and I’ll just chat to her about what she likes, you know, “Is that a charcoal or a pencil drawing?” What influenced her drawings… just founding out who she is other than just someone with an illness. Just finding out about what they did with the artwork… and then I’ll perhaps ask her if she wouldn’t mind sharing her artwork with the others. I’ll say, “Oh, someone here – they love artwork. Can I show her your drawing?” And generally they’ll say, “Yeah, ok.” For this particular girl, we made a slideshow of all her artwork, which then lead perfectly onto, “It’d be perfect to have some music for that, so let’s get the laptop out, let’s get the iPad,” and so often with adolescents, they’re very much into technology, so we’ll create some really great things with the iPad and the good thing about that is then you’ve got a file and they can share that file, email it to their friends, email to their family. And they can email it to their friends and say, “Let’s not talk about my illness, let’s talk about this fantastic drawing I’ve just done and this fantastic music.”

Ninah Kopel: Would you say that all music is therapy?

Matt Ralph: I would, but you know, some people wouldn’t. It’s a bit controversial. You know, some people say you shouldn’t necessarily encourage children to listen to very dark music when they’re going through a very dark time, and there are research finding that actually say it’s probably a good idea to prescribe music just like you’ll prescribe anything. My angle on it is that I would rather them find some way to express or to work through or to find support and if music is there thing – if they find some sort of company and it reduces their feeling of loneliness, if they’re in a way stretching across and relating to somebody else who’s feeling this, perhaps that would work against the depressing nature of the music.

Ninah Kopel: But in Ruby’s room today, the music is all upbeat. The family and Matt are practicing a few more times before they round up the nurses, record their video and send if off to the Great Britain Olympic Team as they prepare for Rio.

Matt Ralph: So let’s go from the top. (Singing with Ruby and others) “A big hello, to Team GB, got Matt and Red Cat singing this with me. We loved the video, from the Rowing Men’s Eight. And the doctors and nurses thought it was great…” (fade down)

Ninah Kopel: Don’t forget, if you want to hear more from us at Think:Health, you can find us online at or you can find us in your favourite podcast app. Just search “Think Health” and don’t forget to subscribe.

Matt Ralph, Ruby and others (signing): “Fighting bad bugs with chemo and hydration, Team GB, go for gold in Brazil! Do your best, I know you will!” (fade down)

Ninah Kopel: Remember as well, I’m not a doctor, so if the show has raised any questions for you, head to your doctor. This show is produced with the assistance of the University of Technology Sydney and 2ser. I’m Ninah Kopel, see you next week for more Think:Health research and news.

Matt Ralph, Ruby and others (signing): “Everyone in Team GB, go, go, go, go! Everyone in Team GB, go, go, go, go, go! Everyone in Team GB go for gold, gold, gold!” (cheering, applause, laughter).



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