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Seriously ill patients generate a 'primitive fear'


More attention should be paid to the psychological impact on nurses of providing care to increasingly acutely ill patients, according to a report produced by a health think tank for the Mid Staffordshire Public Inquiry.

It recommends that nurses and other staff be given specific opportunities by trusts to reflect on their practice.

The report draws on research by psychologists that found death, disease, and physical and mental degeneration generate a primitive fear in people.

It argues that to deal with this, nursing staff may distance themselves for their own emotional protection – the uniforms, procedures and targets found in healthcare settings providing “organisational barriers to retreat behind”.

Report author Jocelyn Cornwell, director of the King’s Fund Point of Care Programme, told Nursing Times it was easy for nurses to become “overwhelmed”, as they dealt with more acutely ill patients in increasingly shorter times.

She said: “You can’t expect staff to provide thoughtful, sensitive care unless they themselves feel supported, and part of a team which allows them to reflect on the nature of the work that they do.”

The Point of Care Programme works with hospital staff to help them provide quality care. It was asked to produce a report by the Mid Staffs public inquiry to help it form recommendations on improving patient care.

One of the approaches the programme advocates is the introduction of regular meetings between hospital staff to discuss their experience of providing care.

Known as “Schwartz rounds” – after a successful US programme – they begin with an informal presentation from two or three members of staff, usually about an issue that presents a particular challenge, before discussion is opened up to those in the room.

So far six hospital trusts in the UK have started holding them with four more, including a mental health trust, planning to introduce them. They are held at lunchtime and the trust is asked to commit to providing lunch.

Dr Cornwell hopes more organisations will consider introducing them. She said: “We try to stop people trying to solve problems or telling each other what to do; that’s not what it’s for. It’s an opportunity to reflect, no more, no less than that.”


Readers' comments (9)

  • michael stone

    Not quite 'my area', but I think this article is probably right: 'feelings around death' are TRULY WEIRD.

    My mother was 'peacefully terminally comatose' for about 4 days, at home, before she died. She died at 8-15 am, and I wasn't sure if the GP started work until 9am: but the arrangement, and 'understanding', was clear - my mum was definitely dying, so when she died the GP would certify the death.

    I could see no point in calling out either a cover GP before hours, or the actual GP until I was sure my mum had indeed died, and when I called at 9am it turned out the GP had disappeared to Europe at the start of a long weekend, reception told me to call 999, and then I had an EXTREMELY unsatisfactory interaction with 999.

    Basically, they EXPECTED me to have called someone immediately my mum 'died', and couldn't understand 'my waiting': I, having been watching my comatose and dying mother for 4 days, couldn't grasp how 'emergency' came into this, at all.

    But the really weird bit, is this. It turns out that about 4 people out of every 5, seem to say (having not been in a similar situation) 'I would have called someone immediately'. When you ask 'Why - what would calling someone immediately achieve ?' they can't give a reason - they end up saying 'I don't know why - I would just want to call someone, immediately'.

    Now, they might not actually feel like that, if they had watched a comatose and dying parent for several days - but I find this 'I would NEED to call someone immediately' 'weird' (and even the people who say it, can see it 'lacks logic').

    'Feelings around death' are truly peculiar, and are very difficult to 'understand' - EVERYTHING 'connected to death' seems to be very complicated !

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  • At last nursing crawls out of the dark ages and starts to recognize and reflect upon the burden of emotional work on it's workforce. Can't think of any other profession that has such a parsimonious attitude to its own health and development by ignoring the obvious. Little actual mentorship, no regard to being a role model, no de-briefing of staff who experience extremely intense emotionally distressing situations. The NHS might have to invest something other than stick or carrot in it's pastoral care of staff to bring down the sickness and absence statistics. How enlightened would that be?

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  • michael stone

    Anonymous | 31-Oct-2011 10:39 am

    The 'Death of a Dog in the Night-Time' piece, which ran a few months ago, made it clear how nurses were shocked by running over animals when driving. The 'confusion' was 'how can killing a rabbit upset me so much, when I see people dying all the time ?'.

    Which seems to support, what you wrote - the NHS probably does not adequately discuss the issues around death with its own staff: it definitely does not adequately discuss death, with dying patients and their relatives, so a failure to discuss death 'internally' isn't a surprise.

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  • Anonymous | 31-Oct-2011 10:39 am I wouldn't get too excited just yet. Just because there is an article saying there SHOULD be more attention paid to emotional stress, psychological impact, etc of Nursing, it doesn't mean that the powers that be will take a blind bit of notice.

    I think that this is something that should be looked at much more in depth across the whole of Nursing, not just in acute areas, and much, much more attention should be paid to looking after the workforce, I totally agree with you on that.

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  • michael stone

    mike | 31-Oct-2011 12:33 pm

    Your 'should' point is valid here, as in many other places - it is often obvious what 'should' happen, yet it often does not happen.
    I was more interested in the fact that this has picked up on the way that 'death and dying' seem to do very peculiar things to peoples' minds, and that those effects are not adequately investigated or understood, or dealt with in training.

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  • Little One

    This doesn't come as a shock to me at all, I can still remember the abject terror that went through me upon realising that the patient who's hand I was holding had died, or the sheer panic and emotional distress I felt upon looking after my first really poorly patient. We need lots more support and education surrounding death and dying, and how to cope with it.

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  • As more and more is expected of Frontline staff who are often confronted with sudden and/or unexpected death of patients.
    I agree more consideration is needed to allow staff the time to reflect on such instances during the shift.
    All shifts should allow for proper structured breaks and time for staff to reflect, share and learn from each other.
    Many shifts are so busy we rarely speak to each other apart from in these acute situations using medical jargon.
    We need breathingtime to reflect and share to keep the staff healthy and happy.

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  • Nurses are always expected to 'cope' with everything that is thrown at them, and sadly are made to feel incompetent if they don't. Even more sad is that the so-called incompetence is often escalated by colleagues.

    Having said that, we are a little kinder to each other than we used to be. Back in 1973, in my first year, second placement and my first encounter with a patients death, I was sent to inform the relatives, on my own. On my next placement I was left alone supporting a deceased patient on their side, when air expired from their lungs. You can imagine my shock, horror and total unawareness of what had just happened. How I didn't shoot my back to the wall and drop that poor person, I will never know, what a fright!! It was that notion of not being able to cope that didn't stop one from doing these tasks. Before anyone comments on 'not questioning' poor practice in those days, that wasn't the case. If patients were put at risk, we did question. Just wanted to make that clear. We weren't so good at protecting ourselves.

    Today, the pace is faster, with more bureaucracy, etc. but I feel the notion of 'having to cope' remains deep rooted in our profession. I believe this should not just be limited to death and dying. It can be distressing too if you cannot get to change a soiled bed because of other pressures on your time. We should have regular disussions on what went well as well as what didn't, and staff to be supported in expressing their feelings, emotionally and psychologically.

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  • michael stone

    I think that ‘death’ is definitely something which crucially depends on ‘whose death it is’.

    During the past 3 years, I found a housebound cousin, whose shopping I used to do, dead in his home, then 7 weeks later my mum died at home. Two of my married friends, have lost 3 of their parents between them during the last 2 or 3 years, and I have discussed their feelings about the deaths. There was a fiasco after my mum’s death, followed subsequently by the PCT annoying me for about 6 months – I became very depressed. My friend Paul’s mum died at home, in ‘good’ circumstances: even so, he tells me that 12 months later he still swaps channels if a funeral comes on, and he stopped listening to The Archers (a 30-year-plus listener) when Nigel fell to his death from a roof. Pam’s father’s death was in hospital, and not pleasant at all: this was in an e-mail to me:

    ‘Finally, based on some of our recent experiences with our mothers and now with Pam's father, society and its systems are not ready to accept that there is a time when people are ready to die and that they should be allowed to in the most humane manner possible. Talking about such a topic still appears to be very much taboo. As Pam has said several times recently, including to medical professionals: "We treat animals at the end of their lives better than we treat humans".’

    Now, it simply CANNOT be the same thing, to ‘experience the death of a patient’. Because any half-way normal human being, is DAMAGED to a significant extent, if their wife, father, son, brother, etc, dies – it is definitely something your psyche tends to struggle with. So if the death of patients, had anything like the same ‘strength of effect’, the cumulative effect would be a complete mental collapse – to avoid that, somehow nurses and doctors MUST ‘become hardened to death’. It just has to be like that – you couldn’t repeatedly experience the deaths of ‘those close to you’ and emerge relatively unscathed !

    And there is another thing about deaths, which isn’t the same point, but is relevant when ‘thinking about deaths’. Nurses see a lot of deaths, and any individual death, is one of many. So, to a nurse or doctor, a particular death can seem to be unusual. Relatives tend to experience only a very limited number of deaths ‘close up’, and in isolation from each other: so, to relatives, whatever is going on with ‘their death {the one they are watching happen}’, is taken to be ‘normal’. This can lead to problems regarding the interpretation (both ways) of people’s behaviour, and it can lead (especially for deaths at home) to false assumptions (both ways) about WHY relatives, or nurses, are behaving in a particular way.

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