August 7, 2012
This is a reflective essay based on my experiences whilst on my six week medical placement on a haematology ward at a local hospital. The aim of this essay is to discuss the psychological and sociological impact on the family when a loved one dies, and then focus on how the nurse supported the husband and relatives through their loss. I chose this particular incident as I felt very strongly about the care given to this patient shortly before her death, and felt the need to reflect on it further.
In order to help me with my reflection I have chosen Gibbs (1988), as the model to help guide my reflective process (see appendix 1). This model comprises of a process that helps the individual look at a situation and think about their thoughts and feelings at the time of the incident. Reflective skills help us to think about what could have been done, so that if a similar situation occurs again the experience gained can be used to deal with the situation in a professional manner (Palmer et al 1997).
To enable me to use this situation for my reflection the patient will be referred to as “Ann”. This is in order that her real name is protected and that confidentially maintained in line with the NMC (2002) Code of Professional Conduct.
Ann was a 58 year old lady married to a very loving husband, she had been previously diagnosed with multiple myeloma with secondary renal impairment, and had been receiving cycles of chemotherapy. My mentor and I were looking after Ann on the day concerned, her observations were within the normal limits but she continued to complain of shortness of breath. She became very anxious and I could tell by the look in her eyes she was frightened, and asked for me to “get someone quick” as she could not breathe properly. I called my mentor as he was nearby who came over and gave Ann some oxygen. Ann said to the nurse ” I can’t breathe” and seemed even more anxious and scared, she repeated several times that she could not breathe and each time the nurse replied very sternly and unsympathetically “you can breathe, you are talking to me.” Ann was by now clutching at my hand and asking me not to leave her alone, I reassured her that I would stay with her as long as she wanted me to. My mentor then summoned me to attend another patient nearby, so I explained to Ann and apologised that I had to go and reluctantly did as I was asked by my mentor. On returning to Ann she was found to be tachycardic and having great difficulty in breathing. The doctors then arrived and it was suggested that her husband be called as she was deteriorating. It was at this time I had previous arrangements and so had to leave the ward for a short time.
On my return to the ward a nurse informed me that there had been a cardiac arrest on the ward whilst I had been gone, I instinctively knew it was Ann. She had died alone, whist my mentor had been attending another patient. I was informed that an attempt had been made to resuscitate her, without success, she was then pronounced dead.
Ann’s husband and family were already waiting in the relatives’ room, and so were informed that she had passed away. It was the families wish to be left alone with Ann, to allow them to say their farewells, they were reassured by the nurse that someone was available should they need company at this very emotional time. My mentor then spent a short time with the family explaining the procedures and helping them with any information they wanted, including details on where to go for help and support if they needed and where to obtain the death certificate.
On reflection of the incident I felt that I did not act in the best interests of Ann, as the NMC (2002) (clause 1) states that I am answerable for my actions and omissions, regardless of advice or directions from another professional. I felt angry that I was made to leave a patient who was obviously very frightened and anxious, when there was no reason for me not to stay with her. Scrutton (1995) reinforces this by stating that the support of a friendly nurse in stressful situations can greatly reduce the anxiety and fear of the patient. I agree with this and felt that it was a shame that I was not there for her and feel she would have appreciated my company.
I understand that nurses are busy and have to prioritise their work but at this present time there was no urgent situation that required me to leave her.
I felt angry and annoyed that when the family came to view her body, the nurse involved actually started to show some concern for Ann when only a short time earlier he had no time for her at all.
It was a shame that a professional nurse acted in the way that he did, ignoring how anxious and upset she was becoming at not being able to breathe. The nurses` compassion and communication skills seemed to be very much lacking, not listening to her concerns and not showing any feelings towards her. Cooley (2000) acknowledges the requirement of all nurses to use basic interpersonal skills, to appear warm and welcoming to patients whilst allocating time and attention to communication. Fallowfield and Jenkins (1999) discuss how nurses can worry about not knowing what to say or saying the wrong thing when communicating with dying patients and their relatives, which can create barriers in communication. It was this lack of communication that led to a breakdown in the nurse-patient-relationship, with the patient being fearful of the nurses return to the bedside, and begging me not to leave her alone. Which was also in contravention of the NMC Code of Professional Conduct (2002) clauses, 1 – 2 – 5 and 7. By not listening, reassuring and comforting the patient, all of this added extra stressors to Ann who was already anxious and extremely scared. I feel that I should have reacted differently in this situation and been more confident and assertive and stand up to my mentor and say that I would stay with Ann, as she wanted me to.
I could not see any good points at first in the situation itself, however on reflection of the situation I think it made me take a good look inside myself and think of how I would have handled the situation if I were the staff nurse, again I keep coming up with the same thoughts of how important good communication, compassion and basic nursing skills are, being there to reassure a patient when they are scared or anxious, also being there to hold their hand and offer some support. Which in turn made me more aware of my own communication skills and how effective they are and if there is any room for improvement, due to this reflection process and looking within myself I have seen a vast improvement in my nursing skills and patient observations and the care I deliver. From my point of view it has been a good exercise in showing me how not to treat patients.
Informing the relatives of the death of their loved one is perhaps one of the most distressing and difficult acts performed by health professions, and must be handled with genuinely caring and sensitive manner (Reed 2002). The news of Ann’s death came as a great shock to her husband and relatives, even though they knew she was terminally ill they were not mentally prepared for her death, and so were in a state of shock and disbelief when initially informed of her death. Scrutton (1995) discusses how the death of a partner is the most difficult losses to come to terms with and the nurse has an important role in supporting relatives through this very emotional time. Kübler-Ross (1981) suggests that the presence of the nurse who was looking after the patient helps the family feel more at ease, even when the news is told by a member of medical staff.
According to Worden (1991) individuals react to loss in a variety of different ways, it is common for relatives to be angry, in disbelief or frustrated and nurses need to be aware of the differences responses to loss and offer appropriate support to the individual. Parkes (1988) theory of loss explains the challenges involved in situations of loss, which according to Worden (1991) can affect individuals in an emotional, physical, behavioural or psychological way. Parkes (1988) suggests a process of realisation, denial and avoidance followed by feelings of anxiety, restlessness and fear. Nurses must be fully aware of the range of emotions and the psychological affect the loss of a loved one can have on the family.
The relatives wanted to spend some time alone with Ann to say their goodbyes, so the nurse ensured they were given privacy to enable them to do this. Preparing the body for the relatives to see before the last offices is very important (Wright 1991). Alexander et al (1994) have highlighted the importance of this and have stated that the last sight of their loved one will remain in their memory of the relatives for a very long time, so it is the nurses responsibility to ensure that the appearance of the body does not disturb them.
The death of Ann has also had a great sociological impact on the family, they have suffered multiple losses: this being the initial loss of the person themselves, and a loss of roles and relationships the loss of the whole family unit, and finally the loss of hopes and dreams her husband and family had for their future together (Heming & Colmer 2003). It is the nurses’ role to support the family through these first stages of loss, to listen to them showing genuine care and compassion for the anguish and upset they are feeling.
I felt that the approach I took was not correct, after all the patients needs were paramount and although I am a student, I should have acted in the patients’ best interests. Overall I have found it very rewarding reflecting on this incident, I have been able to identify my weaknesses that can now be turned into strengths. I now feel that I am a stronger person growing in confidence and now will ensure I confront my fears of acting against someone in the defence of a patient.
Using Gibbs’s reflective cycle has helped me make more sense of the situation and put things into perspective, recognising how I can put this learning experience to positive use in my future practice as a Nursing professional. If this situation were to arise again I know I would now have the courage to question the nurses attitude at an earlier stage pointing out that ‘bad practice’ by anyone is not acceptable. I have made arrangements to discus this incident, and others I am concerned with to the ward manager, as it my first consideration to protect the interests and safety of patients, in line with the NMC (2002) Code of Professional Conduct, (clause 8). This reflection has highlighted the need to increase my knowledge and understanding of the process of loss and grief, I will address these issues by visiting the bereavement officer for the trust, listening and learning from the qualified staff and by reading relevant literature.
In conclusion it can be seen that the nurse has a very important role in supporting the patients relatives through their loss, emotionally, psychologically and a caring perspective. It can be seen from this reflection that effective communication and listening skills are the key to effective care to enable nurses to support families through their loss. Parkes (1988) model of loss has been useful in understanding the psychological impact of the loss of a family member, helping nurses to support those experiencing loss, although each person will react differently it gives nurses a framework enabling them to be more prepared.