Nurse patient relationship and first case of death
The purpose of this essay is to discuss, analyse and reflect upon an acute event which took place when caring for a patient in practice. The writer has chosen to discuss the diagnosis, care and death of an 82 year old gentleman, named James Green (hereafter referred to as James). The writer will discuss the nurse-patient relationship experienced with James, and how his death affected the writer. Due to and to ensure confidentiality, the chosen patient’s name has been edited, which follows the guidelines of the Department of Health Code of Practice on Confidentiality (2003), NMC Code of Conduct [Confidentiality] (2008) and the Use of Patient Information (DH 2006).
The essay will begin with a discussion on reflection including definitions, its purpose, and the advantages and disadvantages of reflection in nursing and education. The essay will then describe the acute care event of his diagnosis and death and reflect upon this. The essay will be structured using Gibbs’ Reflective Cycle (1988) to enable the writer to consciously analyse what happened and why.
In certain areas of this essay, it will be appropriate to write in the first person, when describing the incident and discussing the thoughts and feelings experienced at the time (Webb 1992). It is not usually academically appropriate to use the first person, however, in reflective essays, personal thoughts and emotions are required in some areas and therefore Webb argued that it was certainly more appropriate to refer to oneself as “I” in those sections. From the section subtitled ‘Evaluation’, the writer will revert back to writing in the third person, as this is considered more academically appropriate for analysis and evaluation.
Reflection was appropriately described by Boud (2001) as “turning experience into learning” however, it has been considered an important tool in learning and development for many years. Reflection was first documented in 1933, by the philosopher, John Dewey, in his studies on psychology and the way one thinks and learns. Dewey thought of reflection as a form of problem solving, by relating ones’ experiences to earlier similar ones to explore any commonalities. Another concept of reflection is that it enables the nurse to solve problems or learn from actions through thinking consciously about an activity which would then enable one to learn from any task undertaken. This was argued by Mantzoukas and Jasper (2004) in their studies on reflection and ward activity. However, in nursing, one of the most significant studies on reflection was carried out by Donald Schön (1983; 1987) in his works on “The Reflective Practitioner”. Much of the nursing literature regarding and surrounding reflection refers to Schön, which indicates that his work is widely accepted in nursing and nursing education. It is also from Schön that the term “reflective practice” was born. Schön advised that reflection, is a form of story telling, that leads the nurse into selecting particular actions and details of an activity one would normally or abnormally carry out. This in turn allows the nurse to solve details of their actions and learn exactly what in fact they had carried out.
In nursing, reflection is used as an aid in recognition and development of knowledge and skills of chronic and acute illness, accidents and the care and treatment of a patient. Reflection following an experience in practice allows a nurse to revisit, explore and learn from an incident and gives an opportunity to relate the incident to theory. According to Maggs and Biley (2000) there are advantages to learning and evaluating practice through reflection. By allowing one to challenge opinions and theories in relation to an incident and relating these back to practice, the nurse can spend time discovering what happened and why. Reflection can be used to evaluate any clinical incident, positive or negative to attempt to better understand and contemplate the events which have taken place, and the behaviour, emotions and actions of not only the nurse, but the patient and others involved at that time Reflection allows time for one to think deeply about a situation and increase knowledge surrounding that situation (Hannigan 2001). These advantages were mirrored by Gustaffson and Fagerberg (2004).
Reflection in nursing is guided by various models of reflection, such as Gibbs’ Model of Reflection (1988), Johns’ model (1994), Kolb’s Learning Cycle (1984) and Atkins and Murphy’s model of reflection (1994). This essay will focus upon and use Gibbs’ Model as the structure for reflecting upon the acute care event witnessed in practice. Gibbs’ model is considered a useful framework by students for structuring reflection as it is clearly separated into smaller sections titled, description, thoughts and feelings, evaluation, analysis, conclusion, and an action plan, in the style of an ongoing cycle of learning and reflecting. Gibbs unlike most other models of reflection encourages the learner to think through emotions and feelings experienced (Jones and Alinier 2006). However, Rolfe et al (2001), and Jones and Alinier (2006) argued that the six sections in the cycle were unspecific and too general and that it assumes that all learners have the same needs. Despite this, for the purpose of this essay, Gibbs’ model is considered the most appropriate.
It would appear from the literature read, that there are many more advantages than disadvantages, for the use of reflection in nursing and nurse education. However a strong example which was found when searching for disadvantages was that some writers believe that not all those using reflection would feel comfortable writing openly and honestly about a situation, if they thought someone were to read it. This may be due to a lack of trust or a fear of humiliation or simply being unable to or not wanting to revisit uncomfortable situations or memories (Boud 2001; Tate and Sills 2004). Sumner (2010) discussed success in reflection in terms of moral maturity and found that nurses with little experience, as well as younger nurses, fail to have the experience and maturity to allow them to be comfortable and successful in reflection. Also, Dewey (1933) wrote that reflection only begins when an individual identifies a problem or a need to learn from an activity. If an individual is not to think of a problem or activity then reflection may not take place.
The structure of Gibbs’ reflective cycle will begin here with the first section of the cycle, detailing what happened in the Acute Care Event. For the purpose of structuring this essay, each section will be subtitled in accordance with the headings used in Gibbs’ Cycle.
As discussed in the introduction, the writer will here describe the illness and death of a patient being cared for in practice. The acute care event which will be focussed on is his diagnosis and death and the emotions felt by the writer following the loss of this patient.
James had presented in A&E after a fall at home and apart from a previous medical history of a myocardial infarction in 2007 and tachycardia, James was in good health. This was his first fall, however he had trouble recalling if he had tripped, or alternatively collapsed. Following his fall, it was reported he was having mobility problems and was notably short of breath and therefore he was admitted onto the ward, originally for overnight observation.
He was being cared for on the ward with regular observations, medication and was prescribed 2litres of oxygen through a nasal cannula for his shortness of breath and lower oxygen saturation (SpO2). He was scoring 0 on most occasions on his Early Warning Score (Morgan et al 1997), which indicated that he was quite well other than his noted shortness of breath. Within 4 days of being admitted to the ward however, James’ health had not improved and rather, had begun to deteriorate and he was being monitored regularly. He complained of pain in his lower abdomen and advised he had been suffering from constipation intermittently for several weeks. He was prescribed senna to relieve this, however his symptoms persisted. James was then sent by the medical team for an abdominal CT and X-ray, which diagnosed colorectal cancer, with large malignancies in both his colon and rectum, and metastatic cancer of the liver. Consultants sadly diagnosed this as terminal as all 8 segments of the liver were cancerous and the disease was too severe for him to benefit from active treatment and so they recommended he be managed conservatively, ensuring he was comfortable and pain free. The decision was made by the medical staff following discussion with James that resuscitation would not take place in the event of an arrest as doctors decided this would allow James a dignified and peaceful death, given his diagnosis and illness. This is the decision made in most cases with terminal illness or with the very elderly (Jevon 1999). Despite this, staff predicted he would be discharged as he was still well and self-caring.
Over the 2 weeks after his diagnosis, James’ weight decreased and his BMI dropped from19 to 16. His appetite lessened, and he became frail and unable to walk around the ward. On the fourteenth day following his diagnosis, James’ passed away around 7pm. I was caring for a patient at the bed next to him, when his family discovered he had passed away, and informed me. I closed the curtains around his bed and then reported his death to the nursing staff and my mentor, leaving James’ family to spend time with him and grieve. James was pain free at the time of his death and appeared settled and comfortable in the short time before his death that evening.
Thoughts and Feelings
This was my first experience of death, and James and I, along with other staff, had developed a strong Nurse-Patient relationship and rapport. He was a well liked patient on the ward and his diagnosis and death were sudden and relatively unexpected. The nursing staff allowed me to sit away from the ward as I was noticeably distressed, upset and unable to disguise my emotions. The break enabled me to compose myself away from the ward, James and his family and reflect upon what I had just experienced. I felt extremely sad that James had died and also felt as though I was unaware of how to cope or react having never seen a dead body and not experiencing death before. I found it difficult not to cry, knowing that some may find it inappropriate but informed the nursing staff of the fact that this was the first experience of death in an acute setting and that I felt inexperienced in how to deal with the emotions I was experiencing.
Over the course of the evening, when speaking to my colleagues, his family, and when at home after my shift, I experienced phases of sadness, powerlessness as a student nurse and guilt. I felt it was appropriate to discuss my experience with my family in order to share my feelings and receive comfort and support from others. Some writers argue that the feeling of guilt and powerlessness is because many feel that somehow they should have done more to prevent the death occurring, despite death in many cases being unavoidable (Kirchhoff et al 2002). Dakin (2003) discussed that the emotions felt by the nurse are more for the impact the loss has on the family, and will begin when observing the emotions of the family.
Gerow et al (2010) argue that the way a nurse copes during and after a first death, and whether they are supported by colleagues during this time, will affect their behaviour and emotions in future deaths. I feel I was well supported by my mentor at the time, in that she allowed me to take some time to compose myself after his death, and gave me the opportunity to decide whether or not I carried out last offices.
My personal thoughts are that at the time of the incident, I was experiencing a similar grief to that of the loss of a loved one or friend, as James and I had developed a strong nurse-patient relationship and he was an extremely popular patient with all the nursing staff during his time on the ward, although he was always aware of professional boundaries. I feel that in reflection of this event, I was not prepared for experiencing my first death and was unaware of how to cope during the incident and therefore perhaps, I was fearful and displayed too much emotion.
Kübler-Ross (1969, 1973), discussed grief as a five stage model, containing denial, anger, bargaining, depression and acceptance. When comparing the emotions felt during this time, it is quite possible that the feelings only cover the depression and acceptance stage of this five stage model. Her theory of grief was originally designed to incorporate the feelings of terminally ill patients into an understandable and recognisable model or cycle, however, the theory also includes a broader theory that those involved in a dying persons’ care may experience comparable "stages of adjustment." Some have argued that this theory is not relevant to many patient or others experiences surrounding death or illness and that since the publication of her book, there has been no further research or evidence to support the five stage model (Bonanno 2001).
Lange et al (2009), compared nurses attitudes and emotions when dealing with death regularly, to various attitude scales, such as The Frommelt Attitude Toward Care of the Dying (FATCOD) Scale (1991), in which it gives a range of potential thoughts and feelings a nurse may encounter and asks the nurse to compare their feelings to these suggestions and gives a total score. Their findings showed that the more experience a nurse had with death and care of the dying, the more positive their feelings and emotions were, and those with little or less experience, showed more negative emotions, such as fear. The study also showed that those with less experience would benefit from education and exposure to ensure they cope effectively with end-of-life care and death, which mirrors other literature on nurses emotions and coping (Lange et al 2009; Hegedus et al 2008; Dunn et al 2005).
The writer has read articles on the emotions experienced by students when coping with difficult situations and death which has allowed me to compare the way I felt, to the way other nurses feel in similar situations and literature has confirmed that the emotions felt by myself at the time of the incident are in fact quite common among nurses and in particular nurses with less experience in coping with death (Redinbaugh et al 2003; Lange et al 2009; Dakin 2003).
Prior to and after James’ death, following his diagnosis of terminal colorectal cancer, he was well supported by all health professionals involved in his care. He was notably low in mood and quite tearful at times in the 2 weeks before his death. He spoke at length about his feelings and asked a number of questions about his condition and about death. He would often inform the nursing staff of his gratefulness and ability to open up to them about his illness and discuss the shock he was suffering following his diagnosis. He would often advise us that he felt a comfort from knowing someone was there to listen and talk to him. James' care was well managed by staff, including the acute care incident of his death where dignity and respect remained a positive element of his care as a whole.
As previously documented, he was a popular patient on the ward and all health professionals enjoyed working with him. By deeming James ‘popular’, the writer has reflected upon this, and on the nurses’ attitudes towards other patients on the ward and whether care given to less popular patients was the same. Stockwell (1972) discussed the care given from nursing staff and attitudes, to popular and unpopular patients. This study challenged the opinion that nurses treat all patients the same in a non-judgmental manner and the conclusions found that those patients deemed unpopular were in fact treated less well than those deemed more popular. Reflecting on James and the other patients, this conclusion is fairly true of some, not all, nursing staff on the ward, in that there were similar patients whom were deemed more difficult to care for, and they were often not given as much time or support from staff. This theory has been revisited a number of times with different studies and reviews, many of which reaching the same conclusions as Stockwell (English and Morse, 1988; Carveth 1995; Conway 2000).
There are positive and negative elements to this, in that James was given excellent care and support during his time on the ward, and there is doubt whether the nursing and medical staff could have done more to reassure James or make him comfortable, however, it has made the writer realise that perhaps other patients were not cared for in the same way.
At the time of the incident, immediately after being informed of James’ death; the writer feels as though they coped well, giving the family time and privacy to come to terms with his death, away from nursing staff and other patients. The writer was strong enough to not show any outward emotion at the time, and it was only when informing the other staff, that sadness and distress occurred. The writer feels the way they coped around his family was a positive experience, as they could see sadness from a nursing point of view, but other emotions were appropriately fairly hidden until away from them. Some may argue that perhaps at the time there was too much emotion exposed overall, however, again, these emotions did not show in front of James’ family (Bolton 2000). However, one cannot say that a tear was not shed when speaking to them, but the writer believes this to be an appropriate way of empathising with the relatives of patients following the death of their loved one, and for that, the relatives are most grateful (Redinbaugh et al 2003).
Dakin (2003), on a study of emotions of nursing students, found that most, if not all, have experienced a sense of loss and grief and have become emotional at the loss of a patient at some point, but mainly in the earlier stages of training and on the first experience of death. Redinbaugh et al (2003) again, discussed the emotions of Doctors and in particular medical students, following the death of a patient. Their findings showed that the more time that is spent with a patient; the more vulnerable the doctor is to feelings of loss when the patient dies. Although this paper refers to Medical staff and students, this is true for all health professionals, and can relate very strongly to nurses.
As described above, the nursing staff allowed the writer to take some time away from the ward to stop crying and reflect upon what had and what was being experienced. One of the nursing staff came to discuss the writer’s feelings following his death and made sure the writer wasn’t experiencing too much shock or distress. The support from nursing staff given during that time, was a very positive experience and extremely beneficial to learning. This was the writer’s first experience of Clinical Supervision, giving the writer time to discuss what had happened and the feelings being experienced (Cutliffe et al 2010). Clinical supervision was described by the NMC (1993) as “…professional support and learning which enables individual practitioners to develop knowledge and competence…”. This best describes the support the writer was given during this time and Bonanno et al (2001) argue that talking, rather than writing, about one’s emotions following trauma or loss is highly beneficial to learning.
In this section, the writer will discuss how James was cared for during his time on the ward, and select key themes from the incident which will enable the writer to discuss and analyse certain elements of the incident. The key themes which have been identified from the description and on reflection are the nurse-patient relationship, grief, and coping with the first experience of death.
Prior to James’ death, following his diagnosis of terminal colorectal cancer, he was well supported by all Health professionals involved in his care. As previously documented, he was a popular patient on the ward and had a strong positive professional relationship with all staff involved in his care. The writer feels as though this was a positive element of James’ care and that effective communication took place between staff and patient in this instance. James appeared happy on the ward and would often praise nursing staff for their ability to talk to him and offer comfort in a distressing time.
The nurse-patient relationship was described as “a therapeutic relationship between a nurse and a client built on a series of interactions and developing over time” in Mosby’s Medical Dictionary (2009), which the writer believes to be a positive description and true to that of the relationship with James. The nurse patient-relationship in this instance is a factor of this acute care event that the writer has chosen to reflect upon. The nurse-patient relationship was documented by Peplau (1952) in the Interpersonal Relationship Model, where Peplau wrote of this being an essential element of nursing to enhance a patient’s well-being. This was an essential part of James’ care and an element that he himself was grateful for during a difficult and emotional time.
Pullen and Mathias (2010) wrote that the key to the patient feeling a sense of peace and well-being was based on effective communication and building a therapeutic relationship. Nicholson et al (2010) also discussed effective communication and relationships as a positive promoter of dignity.
Sumner (2010) wrote that effective nurse-patient relationships are only present when the nurse is competent, mature and experienced enough to manage themselves in the interaction. This could be seen as a disadvantage in nursing as a whole as many nurses are young and less socially mature or experienced. Also those fitting this category may believe this to be a false claim of younger nurses which the writer can also relate to. She also wrote that in caring as a nurse, there are two players involved, the patient and the nurse, who both have feelings and needs which need to be addressed in the interaction.
With relation to the connection with dying patients, many nurses find it difficult to approach a patient and build a positive nurse-patient relationship due to fear, or the fear of losing that patient. This however can frustrate the nurse as they may feel a duty to connect with that person as well as comforting the patient when they are in distress or are frightened (Moore, 1997). Mok and Chiu (2004) found that the nurse-patient relationship in palliative care often developed into more of a friendship, as a nurse would spend more time with the families and much more time listening to the fears of patients and attending to their needs. The relationship being seen as a friendship was due to the depth of intensity of the relationship. This is due to the patient discussing extremely personal and emotional aspects of their life which would not normally occur, however this is a one-sided intimacy (Spross 1996). This theory was true of the relationship the writer and other health professionals had with James. For this reason, it can be understood why nurses sometimes feel a great sense of loss after the death of a patient they have cared for, as a close relationship may have formed, particularly with long term patients.
Another key point recovered from this reflection, is that of the sadness and grief experienced, following the death of this patient. As documented in the section subtitled feelings, the writer feels as though they experienced a sense of loss which can be related to grief which may be similar to that experienced following the death of a friend. This is due to the positive nurse-patient relationship with James and as previously written, the fact that he was a popular and well thought of patient on the ward. Because his death was sudden following the diagnosis of colorectal cancer, the writer believes that none of the health professionals involved were prepared for his rapid deterioration and death.
Again, Kübler-Ross (1969; 1973), describes grief and loss as a 5 stage model, commonly known as the five stages of grief. In it, the stages described are, denial, anger, bargaining, depression and acceptance, however an individual may not experience these stages in the order Kübler-Ross described, nor may they experience all of the five stages. When comparing the emotions felt during this time to this model, it is quite possible that the feelings experienced only cover the depression and acceptance stage of this five stage model. However, in Kübler-Ross’s description of these stages, she writes that depression involves a person becoming detached from emotion, non-acceptant of affection or acceptant of efforts to improve emotion. When comparing this description to the emotions felt during this time, it may be possible that one did not experience depression in the form that is described and may only have experienced the acceptance stage of her five stage model. In this stage Kübler-Ross describes the acceptance as coming to terms with the loss (Kübler-Ross 1969).
Bonanno (2002, 2004, and 2009) is a popular critic of the work of Kübler-Ross and other theorists. In his studies, and his book titled ‘The Other Side of Sadness: What the New Science of Bereavement Tells Us About Life After a Loss’, Bonanno states that grief does not necessarily occur in stages, as has previously been argued, rather that it contains four common sections (trajectories) which different people facing loss will experience. The four trajectories, as detailed by Bonanno are resilience, recovery, chronic dysfunction and delayed grief. Bonanno has been highly acclaimed by many psychologists and his peers however he is criticised also for his argument that humans can be resilient, or hardy in the face of trauma, which overturns the theories we have become accustomed to such as Kübler-Ross’ stages of grief and Freud’s theory of repressed memories and coping.
Matzo et al (2003) argued that the loss of a patient can affect all involved, including the patient, the family and the nurse themselves and that a nurse will experience a personal feeling of grief and confront it with their own coping skills.
In terms of the sadness felt by the writer at the time of the death, as previously discussed, some may argue that from a professional perspective, expressing emotion in such way is not appropriate , however studies carried out have shown expression of emotion to be a healing power and can help with coping with distress in future incidents (Kennedy-Moore and Watson 1999, 2001; Pennebaker, 1997). In relation to this, Consedine et al, (2002), argue that inexpressiveness can be harmful and can cause delayed distress on the body, however some have argued that in terms of coping professionally, not expressing emotion or a lack of association with an emotional event, may be beneficial (Bonnano 2001).
In nurse education, the theory surrounding death and dying is taught in terms of definition, assessment and intervention, and all student nurses are aware of these from an early stage; however, little or no teaching is given on death, emotion, grief and the feeling of loss experienced by the nurse (Matzo 2003). This in turn can affect the way a student experiencing a death for the first time can behave and can affect the emotions experienced and displayed, as it did for the writer on the death of James. As discussed earlier Dakin (2003), found that most nursing students when asked to discuss an experience of death, have shared a sense of loss and grief and have become emotional at the loss of a patient at some point which has argued that the sense of emotion felt by the writer is in fact relatively normal, particularly when less experienced with emotion situations.
Following the incident, when reflecting upon what happened and the feelings of the writer, it could be confirmed by the writer that James was given excellent care and support during his time on the ward and in death, and there is doubt whether the nursing and medical staff could have done more to reassure James or make him comfortable. James was pain free at the time of his death and appeared settled and comfortable.
The writer feels this incident, although sad and emotional, to be overall quite positive, in that it has enabled the writer to learn from the emotions experienced and build strengths in dealing with similar situations. This incident and the chance the writer has had to reflect upon what happened at the time, has allowed the writer to discover the thoughts and feelings of the incident and relate them to literature. As this was the writers’ first experience of death and dying, there is no other previous clinical incident to relate these feelings and behaviour to, although a similar incident which has recently taken place, will be discussed in the next section.
From speaking with doctors and nursing staff on the subject of coping with the death of a patient and coping with the sudden diagnosis of terminal illness, the author has learned more about the topic and how to approach it. The writer has also found it positive to learn that the emotions experienced are common, particularly among nurses and that emotion is a natural human response that in some cases cannot be avoided (Dakin 2003; Matzo 2003; Redinbaugh et al 2003).
Working with and meeting James was a very heart warming and at the same time educational experience for the writer, in that his death, although emotional, has enabled the writer to learn from what happened and from the emotions experienced and build upon strengths in dealing with similar distressing experiences in their future training and career. The writer feels happy that had the opportunity to work with James, and happy, and thankful that it was him whom the writers' first experience of death was with.
From writing this reflective essay, the writer has learned valuable theory and skills in dealing with death and dying patients and how emotion is quite normal in the experience of death. From reading literature, it has helped me understand more about death, grief and about how nurses cope and develop coping skills when dealing with emotional situations. I felt it necessary to review literature, to compare my feelings and to discover if others experience similar a similar sense of loss. On discovering that the emotions felt following a first death experience are common, it gave the writer assurance and confidence that they would cope better the next time a death occurred in practice.
Coincidently, after reading this literature, recently, another elderly patient passed away whilst the writer was in practice. Similarly to James, she was a well liked patient on the ward and her death was relatively unexpected, although she was frail and elderly. From reflecting now upon how the writer coped with James’ death and how they coped with the death of the second patient, an 90 year old lady, the writer can see a substantial difference in the emotions felt during each incident.
This confirms that the writer has gained confidence, knowledge and skills in dealing with death and dying patients. The writer learned how to shed a tear without becoming overly emotional, and how to offer sympathy and support to the family of the deceased without showing too much sadness. The writer believes this is due to not only the literature read for this essay, but also the support received from the nursing staff following James’ death, and the clinical supervision received on the ward by nursing staff at the time. This mirrors Bonanno’s (2001) argument that talking about an incident and ones emotions is highly beneficial and potentially more beneficial that writing or reflecting about it.
The writer does feel however that student nurses should be given more education in how to cope with emotional situations, as this could prevent emotions taking over from professional duty. This topic has been discussed throughout this essay, including arguments from literature and the writer feels it would greatly benefit the careers of nurses (Lange et al 2009; Matzo 2003).
Overall, the writer believes they are now better equipped to cope with the death of a patient and to cope with caring for a palliative patient, although an incident may occur that is an extremely emotional one. The writer has learned a great amount from the experience in practice, and from reading literature and analysing and reflecting upon what happened and why the writer experienced the emotions at that time.