I have often reflected in the total absence of training that we have to deal with those situations. Nursing training prepares to “save lives” but it does not prepare us to face death. Death is almost considered a failure. I mostly refer to how to be more therapeutic to those grieving families. What do we say to them? What is the best way to act? What sign should we look for? Because the people who remain are the source of my own grief, I tend not to get excessively involved with them. I do feel my duty to alleviate their pain. I attempt to facilitate ways to express their pain, however ineffective it is. I attempt to answer questions the most honest and compassionate way I am able to and obtain the most adequate resources available to them. From a personal point of view, I struggle to find a balanced point that can meet the dying patient’s need with the needs of the relatives and remain somehow protected from my own feelings.
Question 3: You are practicing as an Oncology APN in a unit where the nursing staff recently experienced a significant amount of deaths. The nurse manager has asked you to help with an intervention that addresses these losses for the staff. Using the exercises in the book, how would you proceed with collaborating with the nurse manager to address this?
The support available for nurses after patients’ death is often only informal. There should be a structured (Lenart, Bauer, Brighton, Johnson, & Stringer, 1998). I would analyze what is the current situation and what resources are available at the present time. If there has been an unusual increase in the number of deaths or traumatic events, a debriefing session should be sought with promptness. The possibility of a counseling session with a professional therapist could be indicated and should be considered.
Then my focus would be training and preparing the staff for future circumstances. A careful analysis of the educational needs would be the first action. Then a programmed damage-control system should be created. There is no possibility of preventing those situations or predict when they will occur, but a good program could minimize the impact on the staff. Teaching of self-awareness, helping nurses to identify when they are suffering symptoms could lead to an earlier search for help and thus, reducing the accumulation of stress and burnout.
The creation of end of life protocols, where a step by step, progressive acceptance is promoted could also help the nurses to feel more control over their own feelings. Knowing what is to be expected, the road to follow is likely to reduce anxiety. The involvement of the families could also promote acceptance among them and thus, reduce the risk from feeling grief vicariously.
Question 4 Moral distress is a common sequel of oncology nursing practice. Using the tools in Chapter 7, how would you evaluate your most recent practice environment?
I work on a busy Emergency Department. I truly believe that we are fortunate regarding moral distress since we are not so often confronted with moral dilemmas. This advantage can, in turn, become counterproductive. We are less prepared when this type situation arises. In fact, using the reflection model from Bush and Doyle, 2012, I have realized that my work place is seriously deficient on that area (Bush & Boyle, 2012). Even when there is a wealth of communication and multiple committees to improve department functioning, there is a complete absence of an open forum where problems can be discussed. I recently had a distressful event caused mostly by systemic flaws. I fruitless attempted to bring those issues to open discussion. I was assured that there would be a quality assurance review and that I would be invited to participate. I ignore if that review ever happened but I was never communicated about it. There are not regular interdisciplinary rounds. The clinical nurse specialist was promoted to a new position. Her duties have been divided between other individuals and that has surely impacted the availability of a role model and a support figure. We have not had any education on ethics since I joined the department and, even there is an ethics committee available in the hospital, I had never witnessed anyone consulting them. The nurse manager does have an open door policy to discuss any issues, but there is decidedly limited feedback on the process afterwards.
Question 5: What chapter “hit home” the most for you in the book? Why? Recognizing your connection with this content, what will you do in the immediate future that addresses these issues?
I found that the burnout chapter was the most close to my own experience, especially because the case study somehow paralleled my own trajectory. I find being a nurse extremely demanding. However, I feel that the reasons that are usually mentioned have more to do with other people’s suffering and the nurse own requirements are always secondary. Nurses are expected to be always gentle, empathetic, competent, compassionate and knowledgeable. Besides, mistakes are usually poorly tolerated and frequently commented among other nurses in a derogatory way. On the other hand, it is hard to stand out as a good nurse. Nurses that are usually identified as “good nurses” by patients, other professionals and their own colleagues are usually those who smile more often, have a more cheerful attitude or, even, are more resilient to patients’ belligerent attitude. There is a extraordinarily small consideration to the quality of your clinical work. Relatively trivial things, such as being skillful at IV insertion or fast in execution of physician orders, are too often considered qualities of a good nurse. I have spent my professional life trying to be aware of why we do things, rather than doing things because someone has ordered them. I used to keep a reflective diary where I analyzed patient encounters. I used them to reflect about my deficits, research about them and try to improve as a nurse. I have abandoned that type of activities. The likely cause was the insidious onset of burnout.
I have been aware of this feeling for some time. I already have taken steps to further my education and “unstuck” myself from the general nursing environment. However, my reasons to go into advanced practice. I believe that advanced practice nurses can be a exceptional role model that empowers bedside nursing itself. Other possible action that I could take is reframing the way I think about my current job. I am fortunate to work with a group of people that are young, enthusiastic and energetic. I am also lucky to work in a department and a hospital that probably have more awareness about nurses than many others I encountered in the past.
Question 6 Identify 2 realistic healthy behaviors that you will institute to promote your own “self-healing” in your personal and professional life.
The nurse practitioner program has meant that I had to abandon myself for these two years. I have decreased my exercise level, I sleep less and my diet has certainly suffered the effects of not being able to cook my own food. I expect that I can return to a healthier life style with adequate rest, nutrition and exercise. I would also hope for an improvement on my social life and to be able to travel more. I always found that my mind was too preoccupied by nursing and events that happened at work. I usually find those thoughts intrusive and hard avoid. I think that the most efficient way of setting those thoughts aside was to engage in something that required my attention. I plan to dedicate myself to two recently discovered interests, motorcycle restoration and electric bicycle building. I would expect that returning to a regular job would allow me to dedicate more time to those hobbies. In a more personal aspect, I would need to increase attention to spend more quality time with my partner, and maybe schedule date nights more regularly.
Other realistic possibility is re-initiating my self-reflective journal. That would serve two different purposes, improve my arsenal of clinical, emotional skills and somehow get to know myself and how I react to different situations better . I found this to be really good exercise. The difference is that I was in a more naive, enthusiastic and energetic part of my life and my career. I believed that abandon it was a reflection of increasing disappointment and settling of burnout. I discovered through this exercise that I had more likely experienced compassion fatigue, and not burnout. The reflective practice diary together with my transition into advanced practice may help to re-encounter my old naive energetic self.
Bush, N. J., & Boyle, D. A. (2012). Moral Distress Self-healing through reflection (pp. 99). Pittsburgh: Hygeia Media.
Lenart, S. B., Bauer, C. G., Brighton, D. D., Johnson, J. J., & Stringer, T. M. (1998). Grief Support for Nursing Staff in the Icu. Journal for Nurses in Staff Development, 14(6), 293-296.
Ullrich, C., & Maye, O. (2007). Fatiga por compasión del personal de los cuidados intensivos pediátricos. Pediatr Clin N Am, 54, 1005-1026.