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Acting on dilemmas in palliative care

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VOL: 97, ISSUE: 49, PAGE NO: 37

Mezzi Franklin, RN, SCM, DN, is a Macmillan clinical nurse specialist, North Devon District Hospital, Barnstaple

Caring for a dying patient can give nurses a real sense of fulfilment if they feel they have helped to achieve a dignified death and comforted the family. But too often this does not happen because the pressures of work limit the time that nurses can spend at the patient's side (Dunne and Sullivan, 2000).

Caring for a dying patient can give nurses a real sense of fulfilment if they feel they have helped to achieve a dignified death and comforted the family. But too often this does not happen because the pressures of work limit the time that nurses can spend at the patient's side (Dunne and Sullivan, 2000).

This affects the care they are able to give and can be a source of distress for nurses. A lack of understanding on communicating with particular patients and their families can also be extremely distressing for nurses and bad experiences may cause them problems when they encounter similar situations (Ruszniewski and Zivkovic, 1999).

It is essential to provide educational opportunities in palliative care to help nurses develop their skills in this challenging area of nursing. It is also important to create a time for nurses to reflect on their practice and, in doing so, wonder what would have happened if they had behaved differently.

Reflection enables nurses to ask themselves questions such as: 'What if I had found someone to be with the patient when I was called away? What if I had challenged the person in charge of managing that patient? Perhaps I could have asked for the Macmillan nurse to come and support my practice?'

In the real world these thoughts usually end up as an entry in nurses' reflective diaries. This may indicate good use of reflective practice, but what if they could take it one step further and safely explore the 'what ifs' in challenging situations? This approach might inform practice and help nurses to develop clearer insights into how they see themselves and respond to certain situations, and in turn enable them to improve the quality of the palliative care they provide.

One of the aims of The NHS Cancer Plan (Department of Health, 2000) is 'to build for a future through education, training and research'. About £60,000 has been allocated to each regional cancer network to fund palliative care education for district nurses, but it did not allocate funding for palliative care education for nurses working in acute trusts.

Most palliative and terminal care is provided in the community, but some patients remain in the acute hospital sector because, for a variety of reasons, they are unable to go home or to alternative accommodation. Providing nurses who work on acute medical and surgical wards with relevant education and support, enabling them to care for these patients, is therefore crucial.

At North Devon District Hospital in Barnstaple, we provide a multiprofessional palliative care programme of education. It includes sessions on the following subjects, during which discussion is encouraged:

- Breaking bad news;

- Symptom management in advanced disease;

- Care of the dying.

In my role as a Macmillan nurse, I am aware that palliative and terminal care for patients with incurable disease can create dilemmas and be a source of distress. People may have conflicting ideas on how best to care for a patient and Macmillan nurses often seek to encourage dialogue between the medical/nursing team, the patient and his or her carers.

During the course of the study days it became evident that health care professionals were often placed in the position of negotiator and adviser, but were at a loss when it came to advising and supporting patients and their families.

The educational facilitator then suggested that we introduce Forum theatre to the programme. I had recently completed a postgraduate diploma in drama therapy, during which I had studied Forum theatre, I felt there might be real value in using it to give nurses an opportunity to bring their experiences of palliative care to life and to explore them in the relative safety of the classroom, among colleagues who could provide peer group support.

Forum theatre was developed by Augusto Boal in the early 1970s as a way to explore issues by acting out real-life situations and trying to change the outcome (Schutzman and Cohen-Cruz, 1994).

A scene relating to a particular dilemma is enacted. One person is the protagonist, who is trying to solve the problem but being challenged and 'blocked' by others, who become the antagonists in the story. The scene ends unsatisfactorily, and it is then up to the audience to create a better outcome for all concerned, particularly the protagonist.

The ideal in Forum Theatre is that members of the audience take the place of the protagonist and explore their ideas of change. This gives them a feel for what it is like to be in that position and enables them to explore ideas in a safe environment.

However, there is a fine line between forcing and encouraging people to join in. If people are not keen to explore their ideas on stage they can direct from the audience.

Overcoming reticence
Most health care professionals do not like role-play (Pulsford, 1993), although the technique is increasingly popular in education, particular in relation to communication skills and breaking bad news (Wilkinson et al, 1998; Baile et al, 1999).

In pure Forum theatre, members of the audience create their own stories, which they act out to each other. I felt that this might be too much to ask of the participants so, with the help of the education department, I formed my own group of actors.

The story was written from personal experiences of working in palliative care and highlighted the problems and dilemmas that nurses face when working with people with cancer. The aim was to present each in such a way that the audience would feel compelled to make changes to create a better outcome.

The story also attempted to act as a vehicle for group discussion and cooperation. It did not matter if one idea was unsuccessful as another could then be explored. The important thing was to give people an opportunity to try out their own ideas.

Because of a general reluctance to participate in role-play (Kuipers and Clemens, 1998), we felt that it was important to prepare the group and explain what they could expect from a session.

In Forum theatre it is important to create a distance between the audience and the actors telling the story. This ensures that when members of the audience go on stage they feel as though they are moving into a different dimension.

As director I support and facilitate the group, encourage the audience to respond and play devil's advocate by challenging the status quo to get them to think differently and explore making changes to the story.

It is not only nurses who face dilemmas and problems in palliative care - they can happen to anyone involved. For this reason we wanted to tell stories that involved different people, such as junior doctors or health care assistants as well as nurses. Of most importance was the patient's perception of the world of palliative care and the views of his friends and relatives.

The story
Our story concerned an enthusiastic house officer who believed that patients should always be told the truth. The nursing team argued against this in relation to a fictitious patient, Sid Hicks, who had advanced dementia, because they felt that he would not understand. An argument ensued, the house officer alienated himself from the team and the nurses approached the consultant for support. In the end Mr Hicks was not told the truth. It was then up to the audience to change the story, working only with the house officer to resolve the dilemma.

The story began again and continued until someone in the audience called for the action to be stopped because they saw a different way for the doctor to behave. Once one person had made a suggestion and taken the place of the doctor to explore it, ideas came thick and fast: 'Why doesn't he ask the nurse to see Sid with him?'; 'Why doesn't he ask if a formal assessment of Sid's mental state can be carried out?'; 'What about valuing the nurse's opinion instead of challenging it? That way she might start to open up a little.'

Each change, no matter how small, such as sitting down instead of standing, was explored. Every person who had an idea was encouraged to take the stage, replace the doctor and explore it. If they were not happy to go on stage, they could direct the original actor from the safety of their chairs. An hour later, after much exploration, debate and participation, the dilemma had been resolved. The nurse agreed to return later that day with the doctor so that they could talk to Sid together and find out how he felt about his illness.

After any form of role-play it is important to reflect and process the events, ensuring that the group feels safe in the wake of the experience. When dealing with an emotive subject such as palliative care, people may be reminded of personal experiences. While not impinging on anyone's personal privacy, it is important to provide an arena in which people can reflect and share experiences.

After the session, there was a feeling of energy and resolution in the group and the participants reported that they felt excited by the experience.

At the beginning of the session I asked the participants to fill in a questionnaire to ascertain their opinions on drama in education. Most were fairly dismissive.

But a post-Forum theatre questionnaire told a different story. Without exception, all 14 participants reported that the experience was a positive and dynamic way of learning. Comments such as 'relevant' and 'thought-provoking' featured prominently in most people's questionnaires.

Introducing Forum theatre as an educational resource in palliative care has been a rewarding and worthwhile experience for all concerned. Further sessions for junior medical and surgical house officers have covered issues such as breaking bad news. The feedback has been positive.

Forum theatre is a valuable, supportive and innovative way of reflecting in action. Members of the group have to work cooperatively, supporting each other and deciding when they believe an idea has worked. They resolve the dilemma as a team, which is the essence of good patient care.

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