Candid Conversations With Families
I feel sorry for hospital patients. They are required to wear flimsy backless gowns and frequently subjected to invasions of privacy. I have been a hospital patient three times, each time as a woman giving birth- one huge violation of decency after another. After my last child was born, I had not one single shred of decency left. I can strip my clothes off at the drop of a hat, not that anyone is very excited to see me do it. Patients are outsiders in the circus ring of activity called healthcare, often clueless about what is wrong with them and what we are doing about it. We poke and prod them, sometimes without the courtesy of a 'Hello' or even announcing our names. Even more upsetting to patients and families is the often lackadaisical attitude of their caregivers, as if what is happening to them is not important to us.
Let me first say most nurses recognize the importance of each patient care activity they participate in. Sometimes, we know this so deeply that the burden of caring for sick people becomes very heavy. We look for ways to decompress or compartmentalize our stress. Is it any wonder the number of nurses who are suffering as substance abusers? Like most frenetic professionals, we medicate our selves with food, alcohol, drugs, and any number of self-destructive habits. Nurses who can not find ways to relieve their stress are the burn-outs. They are the people who change career paths in the name of self-preservation. They are the casualties of an over-worked, under paid and under- respected profession.
And then you find the survivors- the nursing "dinosaurs." They are the few rare individuals who have leaned to live well while caring for others. They are typically tough, smart and have lots of common sense. They have seen trends, statistics, colleagues and patients come an d go. They recall memories of patients who have long passed with clarity and feeling. But most important- they laugh.
Why is laughing important in an environment like a pediatric intensive care unit? There have been credible studies that have examined patients' positive response to humor. I surmise the result is the same with nurses. It is unfortunate that patients often perceive our laughter as lack of caring or concern. I can understand their feelings but I hope I can shed some light on the other side of the story.
I remember recently standing our nurses station talking nonsense with some peers. It was the first moment I had to catch my breath that day, well past the breakfast I did have a chance to eat. The unit was heavy with really sick kids and the strain was wearing on the staff. As we were discussing the facial characteristics of one of our attending physicians (akin to a weasel) who had just busted through complaining about something, a young man approached our desk. He was red-faced, despite the dark circles under his eyes. He looked tired and unshaven. I could see his hands clutched so tightly his fingers were blanched white. I knew his child had been in our unit for a few days and was getting sicker, despite our best efforts. In rounds, I heard mention of his prognosis and knew time was very short for his son.
Trembling with anger, he said with fury, "Don't you know there are sick people in here? You shouldn't be laughing. You are being too loud! My son is ..sick!" I knew what he was going to say, but could not. "My son is dying." That was the meaning. We all checked ourselves, profusely apologized for our loudness, as his child's nurse gently escorted him back to his room, trying to calm him. I was ashamed. I was embarrassed. How callous we had been! We were laughing and this man's son way dying. Surely these two things can not co-exist in the same place.
After a lot of thought, I realized I was wrong about this. It was right we apologized to this man who was obviously stricken with grief, looking for some way to express his anger, his loss of control. I know parents of chronically ill and critically ill children appear angry with nursing staff, as if we are the enemies. It took a long time to realize what this is about, and even longer to have the courage to talk with parents about it. When we loose control in one area of our lives, we will seek to express it somewhere else. The father in my story saw a situation where he could express anger safely- to a bunch of strangers acting unseemly outside his child's room. A father can’t be angry with a child who is sick. He had no control over a disease that had no cure. His role in his child's life had been reduced from a provider to a bystander. There was literally nothing he could do, except hold a swollen hand and whisper soft reassurances of love. He could no longer say, "Everything is going to be alright." The father knew this was not true. It was not going to be alright. But were we wrong to be laughing?
A week later, the little boy died in the arms of his mother and father. I was there when his suffering ended and it was a blessing. Simultaneously in other rooms and floors, there were conversations happening, smiles erupting and laughter echoing through the hallways. Where else can the juxtaposition of laughter and death occur so closely? Does laughter equal ambivalence toward patients and their suffering? After lots of soul-searching I concluded that without laughter, there would be nothing left to fight for. Life would not be worth living. Laughter, gut-busting hilarity is the stuff that makes saving lives worthwhile. It has to be okay to laugh, otherwise there would be no nursing dinosaurs left. It is the only way to survive and even thrive in the nursing profession.
Maybe it is time we have candid conversations with families about their perception of caring and the presence of laughter among grief and loss. I find parents and children are just waiting for an opportunity to talk openly about their anger, fears and their feelings of helplessness. Perhaps it is time as caregivers to ask ourselves how we feel about those same issues. Perhaps then can we hope to have a multitude of dinosaurs roaming amongst us once again. They would be a welcome addition to the human race, as far as I am concerned.Last edit by sirI on May 13, '082May 16, '08 by Annie09I'm divided on this issue. You mention that the only times you were a patient was to give birth. As humiliating as that is, as I have had the joy of birthing four - along with the memory of a group of 10-14 pre-med students coming into my room while laboring with child #2, to view what a cluster of pregnancy-related hemorrhoid's look like - our hospital stays still had a happy ending for us, didn't they? I mean, we had a healthy baby to bring home - to love and to enjoy.
This couple's world was falling apart. They were not going home with their child. Their world was crumbling around them and he could do nothing to control this. Sure this patient's father may have misjudged /targeted / mis-interrupted your jovial time, and I don't think the question you posed, does "laughter equal ambivalence toward patients and their suffering? is so.
Rather, have you considered that the patient's perception of your "jovial moment" to them may have been perceived as being very alienating, serving to compound their already wrenching situation and making a very needy, grieving family feel even more isolated amidst their own devastation, although not intended on your parts?
It's not wrong to laugh and joke, as this is a healthy way to let off stress. But I feel the time and the place we express this may deserve additional consideration. As nurses, I feel we are to do our best to understand what our patient's are experiencing, and patients expect/assume to a degree, we have some knowledge /insight in what they're going through. I've never worked in critical care, nor have I, thank God, ever lost a child - so this is only my unrealized opinion - but as a profession, aren't there other places we can go to to let out our stress - away from the ear- and eye-shot of the patients? To me, while I'm on the floor it's mostly all about the patient and what they are going through. Our patient's look to us for strength, especially when their worlds are falling apart. Perhaps I'm not "getting" what you are trying to say. I wish to learn from your experience, as I desire to go into hospice nursing. Awaiting your reply.Last edit by Annie09 on May 16, '086May 16, '08 by gal220RNDear Annie:
I am so glad you have really considered this issue in your heart. If my story gets nurses to think how they feel about laughter in critical situations, they will be better prepared to deal with them when they arise.
I do believe this occurs more visibly in critical care units, because we so frequently do not leave the bedside for more than a few minutes at a time.
I agree that if the dad in my story felt anger and anguish, we needed to be more sensitive and certainly apologize for hurting him, which we sincerely did. My idea is that perception is not always reality, and it is our job to help families understand this as best as possible. Ultimately, the dad in my story was angry- period. If he did not take it out on us, he would have expressed it somewhere else- or worse yet, held it in and not expressed it at all.
Please do not mistake my thoughts for callousness. Quite the contrary, I was one of the ones who cared to the point of self-destruction. I have had to learn to survive, but not at the expense of the peace and comfort of my families. They are the reason I do what I do- and love it still today.
Thanks again for your thoughtful comments.
Godspeed1Jun 19, '08 by Liddle Noodnik GuideQuote from heelgalWhat is an interesting juxtaposition is that - they can't allow themselves to laugh, and we can't allow ourselves to be too angry or sad. Just imagine how tough our jobs would be if we really felt what we felt those first several times we lost a patient.Why is laughing important in an environment like a pediatric intensive care unit?
Thank you for this article!!!2Jun 25, '08 by WarEagle4LifeMy reply comes from a unique perspective - both as a PICU nurse and as a parent who has had a child in intensive care several times - she has a severe congenital heart defect that defied correction for 6 years of her life. We've spent a lot of time with nurses when in we were in the parent role - we saw them cry when things didn't go well with another patient and realized that when they were laughing, they were also hurting tremendously on the inside.
Interestingly enough, the only time we were offended was when we were asked to not be laughing or joking when another child was dying. We didn't feel we had been - our daughter was not doing so great either - on dopa, dobuta, epi, multiple runs of albumin, several units of PRBS's, nitric going along with high vent setting and sats in the mid 80's.
Laughter can seem so inappropriate, but it is also such a stress reliever. We, as a family, would laugh at times when I'm sure to those on the outside it would seem terribly disrespectful to our daughter whom we were told absolutely would not live much longer (happily, she is 19 years old). Sometimes you've cried so much that there is nothing left in a vast, empty dark place. Then, something is said that is totally off the wall and the laughter begins. What a relief! There is another emotion to feel!
Even today, as we cope with the neurological implications of her conditions, I find a way to laugh at what isn't particularly funny. It is how I cope.
As part of the PICU team, we do try very hard to be respectful to our families/children who are dying. We have our safe places to go (med room and a lounge that is away from "the action". Our secretaries are good at reminding "keep it down."
I remember one dad in particular whose son was very ill - we had nearly lost him several times. It was a Saturday afternoon, we were just a tad too relaxed and having to our yearly continuing education stuff. One RN was on the "compressed gases" portion and was asking some silly questions. Another responded with the old joke - if you want to see/smell compressed gas... - this dad walked out of the room at that point. We were red faced, trying not to explode with laughter and dying of embarassment at being caught by a family member. Dad just started laughing and told us he really worried about us - we always seemed so tense, so serious, he wondered if we every let our hair down and laughed.
Our work is serious business and we do explain to families that sometimes the stress gets to us and we laugh to cope with our emeotions and we do apologize. The families also see our tears and pain. We can only try to do our best, but in the end, we are human as well as nurse.1Jul 13, '08 by in2ICUI'm not in NS yet, but am wondering if during school or in training nurses are taught to be aware of these stresses and given suggested methods for coping?
Personally, I use exercise. I have NEVER been an excerciser, but my mom is dying (maybe days away now) and during her 8 months of decline the treadmill in the basement has been my best friend. At 42 minutes of walking briskly those endorphins kick in and save me for the rest of the day. I consider it "burning the bad stuff right out of my system."
I guess if I keep this up for years the byproduct will that I will be in awesome shape... because reading these stories tells me that Mr. Treadmill and I are going to have a long life together.0Mar 18, '09 by Wendy_LeebovWhat a wonderful article. Thanks so much for taking the time to write it and share it. Families go through so much, and one of the gifts we can give is to help them keep on living, breathing and laughing during their distress! You said that so well. Thanks again.
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