Usui Reiki With Yvonne Oakes

Making A Difference… A Sense of Achievement

One of the very best and most precious compliments I have received is related to my work.

In 1990 I was instrumental in establishing and subsequently managing until 1995 our Health Board’s Palliative Care Unit.

Our then Director of Nursing Services made an impromptu visit one day and said to me

“You can actually feel the care as you walk through the doors”

To me, that is the highest accolade a Ward Sister can receive!

Looking back..

I have recently been sorting through memorabilia from my nursing career, and came across an assignment I wrote in 1992.

Today, the detail of what we achieved may seem very small, but I think it possibly set the scene for the changes we now take for granted and feel very proud and grateful to have accomplished this. It was written at a time when patients were expected to conform to the needs of a ward, rather than the other way round; when there were ‘toilet rounds’ and ‘back rounds’ and when many patients felt they lost their identity.

The assignment is a study of the grieving process experienced by patients with a terminal illness. The reason for undertaking this study, was the fact that nurses appeared to be very aware of relatives’ grief both during their loved one’s illness and following their death, but often did not appreciate the patient’s grief – grieving for their life, for unfulfilled dreams and ambitions, grieving for those they were leaving behind.

I noted that many nurses tried to ‘cheer the patients up’ and ‘make light’ of the situation, or withdraw from the patient. Therefore the aim of the study was to increase the nurses’ understanding of and their role in the patient’s grieving process, thereby enabling my ward staff to assist the patient in reaching a stage of acceptance, and for them to hopefully die at peace having been able to share their worries, fears, anger and even thankfulness with someone, with a deeper understanding.

The study was divided into 3 sections:

  • The stages of the grieving process
  • The role of the nurse
  • The effect on the nurse caring for those who are terminally ill.

In this article, I will share sections 2 & 3 with you, as written in 1992.

The role of the nurse

Orem (1980) states that the aims of health care are to enable the individual to live as themselves, understand their illness, participate in their care, approach death in their own way and to be with family and friends and health care workers in an environment of security and trust. There are many ways in which a nurse can help meet these aims.

Firstly, there is the preparation of the physical environment to convey the message of security and welcome. Joy Robbins (1983) says that a clean, bright building conveys the sense of good management, order and care. Bright decoration and carefully tended flowers and plants are reminders of hope, love and the natural world outside. Carefully chosen pictures convey the feeling that here is a place that is aware of more than physical need. Also, to be greeted by smiling staff, who look neat and presentable transmit the message of high morale and a happy atmosphere.

Another important factor is the philosophy of the ward and the way in which care is organised. Our ward philosophy is one that believes that care should be patient-directed. If the patients wish to stay in bed all day – they can; if they wish to wear outdoor clothes – they can; if they wish their relatives to be present twenty four hours a day and participate in their care – this is encouraged.

Hospital routines apart from meal times and medication rounds are abandoned, and these we will be looking into in the near future. If all the patient wants or needs is for someone to sit and talk with them, or simply sit there, perhaps holding their hand – this is what we do. At the moment on the ward, we are using team nursing, but we are working towards primary nursing as we feel this can only lead towards a better nurse-patient relationship, and hopefully greater trust will develop and less isolation felt.

When conveying the message of security and trust, we want the patient to know that even though a cure may not be possible, they can feel safe in hands that are skilled to meet the needs of the present circumstances, whatever those needs are. It is not always easy to send clear messages but as Joy Robbins (1983) states

“The nurse will convey an attitude of caring if there is interest in her tone of voice, if he/she uses eye contact, stands close enough to the patient to encourage conversation, stands still to indicates she is not in a hurry, and pauses to allow time for replies to questions. Better still would be the situation if the nurse sat either on or by the bed, so that she is at the same level as the patient”

In the area of communicating with grieving patients, it is essential that the nurse tries to acquire attitudes that will be of maximum help. She must remember that actions speak louder than words, and the nurse who demonstrates gentle, effective care for the patient, given in an unhurried manner, with simple courtesy and concern is communicating a positive and caring attitude which will help the patient at all stages of their illness and grieving process.

The nurse must learn to nurse with empathy, which Rogers (1961) states is

“Being able to understand how the patient is experiencing this situation; not how she thinks she would feel in the same situation”

The nurse must try to learn to give the patient Unconditional Positive Regard, that is, not judging the patient; giving good nursing care no matter what the patient says or does (as often the patient’s anger may be directed at medical or nursing staff) or what choices they make. The nurse must also show realness, that is, being genuine and honest, so that again the element of trust is there.

These skills, as well as other attitudes and feelings mentioned through the course of the assignment are not often acquired automatically, and nurses need to receive ongoing training and support from their peers and seniors to help them adjust to this sphere of nursing.

Performing ‘ordinary, everyday’ tasks is also an opportunity to convey a message of security if carried out with gentle assurance. If the nurse ensures privacy and involves the patient in every action and decision, she will boost the patient’s dignity and make her feel more like a real person. If after performing tasks, the nurse pays attention to how she replaces the patient’s things within easy reach, it shows that her needs have been anticipated and the patient will then know that if she should become totally dependent, she will be in safe hands.

It has been said (Bend, Lloyd, Cooper 1990) that there is no special technique which you have to employ to help someone who is grieving; that it really boils down to being there and listening.

‘Being there’ sounds simple, but it is not. This is due partly to the strong emotions which are evoked in us when the patient expresses their thoughts and feelings, and also because nurses are used to ‘actively doing’ and can feel or be made to feel guilty for ‘just being there’ – when in fact it is probably the most helpful element of care for the patient.

Throughout this study, I have written as though all patients are aware of their diagnosis and prognosis, and obviously this is not always the case. However, a study by Hinton (1963) found that at least 75% of patients dying in hospital indicated to an observer that they were aware of impending death.

As a ward team, we have found that patients who know their diagnosis and prognosis are somewhat easier to care for, in the psychological sense because there is no collusion, and an atmosphere of trust is established. Situations in which family members but not patients are informed of the diagnosis are becoming less frequent as the trend towards truth-telling increases. However, it can be very stressful for the nurse when this is not the case, particularly if the patient is distressed by his ignorance and is asking for more information (RJ Dunlop and JM Hockley 1990).

The effect on the nurse caring for those who are terminally ill

As with many spheres of work, terminal care carries it’s own type of stress, and those caring for the dying have a great need themselves for emotional support. Each individual nurse will determine her own level of involvement, and this will vary widely. However, because our Unit has a maximum of six patients at any one time, the nurses there (myself included), develop deep emotional bonds with them and their families.

Because of the closeness felt between nurse and patient, when death occurs the nurse can be bereaved in the same way as she would following the death of anyone with whom she has had a close relationship. Many emotions are aroused, with guilt, sadness and anger being most common, and nurses as a team should recognise that these emotions are normal, and support each other through it.

To meet the needs of the ward staff (all staff, at all levels), a stable, permanent team rather than one whose members are periodically moved to other wards or departments is essential. (Alison Charles-Edwards 1983). Given this form of permanence, deep relationships can form between members, and the best form of support can be given and received- namely friendship. To this end, we as a ward team decided in one of our regular monthly meetings, that we would go out socially together once a month, so that we indeed look to each other as friends, not just colleagues.

One of the greatest emotional needs, but probably one least thought about in palliative care, is the need for humour. It rarely offends either patients or relatives to see the staff laughing, especially if they are included – although of course discretion is required. A hushed, humourless atmosphere can be very depressing for patients, relatives and staff. There are few better ways of relieving tension and strain than laughter.

Another way in which we support each other is in our staff support group. When the ward first opened eighteen months ago, we decided that if any member of the team began to feel drained or felt they could not ‘cope’ with the attachment or loss of a patient, then they should be encouraged to talk about it and share their feelings. Three months ago, this was again highlighted following a particularly sad period when we had encountered the deaths of several younger patients. The support group where staff talked frankly about their feelings, and openly wept was felt to be of great benefit to the 99% of staff who attended. They reported feeling “much better and refreshed” coming from there. It is strongly recommended that it continues on a regular basis, with staff being given time to attend.

Establishing links with specialist hospitals, foundations and teams also provides us with another form of support and a way of increasing and improving our knowledge and skills. It has built our confidence in our ability to give first class care and service to our patients.

Death in the first person

Before she died, a student nurse reflected on the nursing care she was receiving and we had this posted in our ward office..

“I know you feel insecure, don’t know what to say, don’t know what to do, but please believe me, if you care, you can’t go wrong. Just admit that you care…. I have lots I wish we could talk about. It really would not take much more of your time, because you are in here quite a bit anyway. If only we could be honest, both admit to our fears, touch one another. If you really care, would you lose so much of your valuable professionalism if you even cried with me? Just person to person? Then it might not be so hard to die…. in a hospital…. with friends, close by” (Anon 1970).

So much great progress has been made over the last 30 years, but I believe the foundation and the fundamental philosophy of providing care to the terminally ill, that we worked to in the 1990s stands strong today… treating people as individuals, in a way in which you would want to be cared for yourself…

Being proud of what you do, having a sense of achievement, serving others and making a difference adds to our own sense of self worth and wellbeing too..

I hope you have enjoyed reading this article. Please feel free to comment, and or contact me to discuss any aspect of this if you wish. Thank you, with love, Yvonne.

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