Healing Through Communication
The Practice of Caring
Carol Leppanen Montgomery
Putting the Caring Back into Health Care
Caring is becoming increasingly important in the health care field, particularly as there are more of us, and people are living longer with conditions that are chronic, rather than curable. These patients do of course still require being cared for.
Caring is also increasingly important because many are disillusioned with the health care system as it exists, with its somewhat myopic medical-model-based perspective. The medical model is not as effective as we might imagine because it tends not to view patients from a holistic perspective and rather ignores the human side of healing, as well as the individual patientís
We advocate transitioning to a care based model, which emphasizes the importance of caring for the patients and reducing their feelings of vulnerability with respect to their care.
Unfortunately, a very major obstacle to the existence of a care-based model is the rising cost of health care. Because "quick fixes" are desired by those concerned with cost control, they are unlikely to recognize the value of attending to a patient in an emotional/holistic way. One of the risks of not recognizing the value of caring in health care is that health-care professionals themselves kind of give up on caring as much as they might due to the stresses involved in this not being valued and from being short staffed. As various studies do indicate a connection between the aspects of being/feeling cared for and the physiological healing process, it would be a shame if the importance of caring is not recognized and utilized.
So, what is caring? Caring is a natural element of being human. Although Freud and the psychoanalysts would disagree because they view humans as being driven by forces that must essentially be controlled. Although certainly man has some self serving tendencies, we also have innate caring responses. Our survival as a species requires this due to our inherent vulnerability. The human infant is vulnerable for an extended period and our social structures are formed around the necessity of caring. However, although caring can be defined as a natural state of involvement with and responsiveness to others, at a professional level more than this is required. That is, professionals need to be very skilled in communication and commitment so that they are able to stay therapeutically involved when the going gets rough, so to speak.
Although there are good communication and interviewing skill models developed by the Humanistic traditions, there are some reasons why they may not translate well to the health-care setting. Many of these guidelines are better suited to a formal counseling setting than to the health-care setting. Some counseling techniques may in fact distance the client if too much emphasis is placed on being objectively distanced, and not enough on being subjectively involved and compassionate. This becomes particularly significant when dealing with patients who may not even be conscious, yet the health caregiver still needs to be able to know how to express caring to the client in some kind of meaningful way.
Theoretical Foundations of Caring
This chapter examines both communication and theories that relate to caring, and theories of caring from both nursing and philosophical perspectives.
Relational Communication - focuses on analysis of a relationship rather than of the individual during a given communication, i.e. the communication is the relationship. An understanding of the report aspect and the command aspect is necessary to the understanding of relational communication. The report aspect is the content of the message, the command aspect deals with the relationship between the parties communicating. For example, a clerk in a hospital might ask a patient for their insurance card. While the content of the message is clear, the clerk and patient will also begin a process of communication which will influence how the patient feels about the care institution. Depending on the relational elements of the communication, the patient may feel cared for or dehumanized, or something in between. It is interesting to note that the relational aspects of communication are more noticeable in a disharmonious relationship than in a healthy one. Nevertheless, all behavior has some message value and hence one is always communicating something. This translates to the healthcare field in that all behaviors/interactions between caregivers and patients are interpreted as either caring or non-caring.
Metacommunication - is a concept of relational communication which refers to any communication or discussion of a specific communication event. We also need to be aware of the difference between digital and analogical communication. Digital communication involves using symbols and words are symbols. Analogical communication involves representing something with a "likeness" and includes non-verbal communication. For example, "I love you" is the digital form of communication, while physical attentiveness, embracing and long soulful looks would be the analogical communication of love. In the healthcare field much of the communication is analogical in nature.
Next we examine the concept of confirmation. Basically confirmation involves the recognition of another and acknowledging anotherís communication via relevant response. For example a patient suffering from Alzheimerís disease tried to grab hold of anyone walking by. Although most staff tried to avoid this patient, one nursing student was able to recognize the patients existence by responding the patient. She would take the patients arm and take her for a little walk, giving validity and recognition to the patient as a human being.
Empathy is a communication concept frequently used to understand the role of the professional in the therapeutic relationship. Traditionally it has been expected that the therapist would kind of actively merge with the feelings of the client and then pull back in order to maintain objectivity. This view has been criticized by some in the communication field who support a broader framework. There seems to be some confusion or disagreement as to what boundaries are appropriate in a healthcare setting. Perhaps boundaries which are appropriate in a psychoanalytic setting are too restrictive in the healthcare setting.
Feminist psychology offers additional insights into issues of relational communication. Here it is felt that "masculine" issues such as autonomy are overemphasized. Although male psychological growth necessitates an increase of distance from the primary love object, usually the mother; female psychological growth involves identification with the mother and emphasizes relationships and attachments rather than autonomy. Feminist psychology feels that the value of these characteristics has been not only minimized but pathologized. Validation of the natural inclination to become involved with the concerns of others is the primary point made by the feminist perspective with respect to caring.
Next we examine some theories of caring which have been developed in the fields of nursing and philosophy which are relevant to the communication aspect of caring.
Mayerhoffís Theory of Caring - Milton Mayerhoff, a philosopher, viewed caring as an existential position which provides order and meaning to life. Mayerhoff offers the following as the primary necessary ingredients to caring:
A) Knowing- to care we must have knowledge of the other in order to respond appropriately to their needs.
B) Alternating Rhythms- a kind of dance as one modifies behavior in response to the other and the circumstances.
C) Patience- involves allowing one to grow in their own time and space.
D) Honesty- Caring for another as they actually are as opposed to how one would like them to be.
E) Trust- having faith in the ability of the other to self-actualize in their own way and time.
F) Humility- entails a willingness to learn from the one being cared for and avoiding arrogance on the part of the caregiver.
G) Hope- possessing a hope for the other to grow both in the present and future.
H) Courage- refers to the courage to follow the lead of the other into unknown territory.
Jean Watsonís Theory of Caring in Nursing
Watsonís theory incorporates a metaphysical element which is particularly appropriate with respect to the client/caregiver relationship. The relationship between the client and caregiver involves a shared humanity and vulnerability, the experience of which allows them to feel part of something greater than themselves. Also the two experience the phenomenal fields of the other, thereby creating a third phenomenal field. Caring allows both parties to access a universal force greater than the individual, thereby creating a transpersonal harmony, which can actually facilitate the self- healing process.
Gendrons Analysis of the Expressive Form of Caring Communication
Diane Gendron analyzes caring communication as the gestalt of what the client perceives. The following four elements are identified:
Human feelings have forms which can be expressed through art. They include elements such as tone, rhythm, balance, harmony and unity. These are also present during caring communication. Various emotions also have patterns which are recognized on the neurological level.
Channels of Communication
These include both verbal and nonverbal. It is the nonverbal which communicates the relational element of a message. An estimated 55%-70% of feeling is communicated nonverbally, via physical appearance, eye movements, utilization of space, voice, touch etc.
Dynamic Sensorimotor Responses - In studying the affective sensorimotor patterns of infancy, Werner and Kaplan (1963) found that objects are given structure, form and meaning by an organismic integration of sensory, affective, imaginative and postural experiences. This allows for a transcendence of the usual understanding of sensory elements to a more organismic understanding; for example, a harsh color or a sweet sound.
Metaphor of Orchestral Music - This metaphor includes the themes of polarity, temperature, force, texture-shape, and directionality. These themes then interact within the dimensions of harmony and melody. The basic idea being that the communication between client and caregiver can be likened to a well-orchestrated symphony.
Gaut identifies three meanings associated with caring: A) attention and concern, B) responsibility for providing care, and C) regard or fondness. These must be incorporated with the proper knowledge and action to become caring acts.
In conclusion, caring is recognized as a complex communication event which takes place on various levels, including the biological, behavioral and metaphysical.
Caring Begins With the Caregiver
The caregiver possesses a certain way of being in the world and of relating to others that successfully supports the communication between the caregiver and client. This way of being incudes seven qualities: 1) person, rather than role, orientation, 2) a concern for the human element in health care, 3) person-centered intention, 4) transcendence of judgement, 5) a hopeful orientation, 6) a lack of ego involvement; and 7) expanded personal boundaries.
Person Versus Role Orientation:
This refers to the quality of the caregiver which allows the caregiver to relate to the client on a more human, intimate, truly caring level. The caregiver has the ability to transcend the "professional" role and relate to the client as a fellow human being. Caregivers can sometimes get caught up in their role of providing structure and safety for the client, and while this is important, it is also important not to lose sight of what is really going on for each individual on a real level. A willingness on the part of the caregiver to really reach out, and not just react in a rote manner, can bring a very healing, even transforming, element to the relationship between the two.
Concern for the Human Element of Health Care:
The successful caregiver has a philosophical outlook which recognizes the wholeness of the person and also is aware of the vulnerability of the human being in the technological setting of health care. This involves the ability to see the client as a person and not to dehumanize the client by reducing them to the set of tasks one needs to provide for them. This would include a willingness to listen to oneís own intuition regarding what a client might actually need from the caregiver at a given time, rather than what the caregiver might think should be on the agenda.
Caring is motivated by a desire on the part of the caregiver to connect with the client in a helpful manner. This kind of helping/caring is different from the frequently depersonalized agenda of the clinical/curing perspective. Basically the caring perspective has no other agenda than to connect with the client.
Health care professionals are of course expected to be non-judgmental. Nevertheless it can be quite difficult to be so, or at least requires a special quality and awareness. After all, most people have certain sets or types of people whom they would normally incorporate into their lives.
Caregivers need to have the ability to accept a wider variety of humanity. Even the people we may find most difficult to accept, or to find some redeeming quality in, are still human beings and it is not the place of the caring professional to judge them.
It is important for successful caregivers to have a hopeful orientation. A positive outlook on the part of the caregiver can assist both the client and the caregiver by giving them the strength to carry on and not give in to despair, when an outlook might otherwise seem bleak. It is also apparent that clients also often live up to the expectation of the caregiver , be it positive or negative.
Lack of Ego Involvement:
The significance of a lack of ego involvement on the part of the caregiver hinges on the importanceof not minimizing the fact that the primary situation/experience is that of the client. That is, the caregiver in essence is more beneficial if they can realize that they are entering the experience of the client. To do this successfully it is important for the caregiver not to be in need of "doing all the doing" and to assist the client in a subtle way to have their own experience and to become empowered.
Expanded Personal Boundaries:
Successful caregivers define their interests in terms of others as well as themselves. There is an awareness of our interconnectedness and interdependence which facilitates caring as a creative form of self expression which enhances both the self and others.
Caring in Action: Behavioral Qualities
There are eight qualities of caring expressed at the behavioral level: 1) empowerment through the mobilization of resources, 2) advocacy, 3) authenticity, 4) responsiveness, 5) commitment, 6)being present with, 7) creating positive meaning and hope, and 8) competence.
Empowerment Through Mobilization of Resources:
Again the emphasis lies in empowering the client by helping them to mobilize their own resources. The caregiver ideally helps the client access resources, such as family and friends, and then kind of steps back a bit.
In the health-care setting, clients are naturally somewhat vulnerable, and it is sometimes appropriate for the caregiver to take an active and/or assertive role in advocating on behalf of the client. For example, although the job of a psychologist was only to provide psychotherapy, she could not ignore the fact that she knew her client had no money for food and medication and therefore interceded with the hospital business office and arranged a temporary loan for her client. On occasion advocacy can even require direct confrontation and conflict, which is often difficult for caregivers who generally prefer win/win situations.
It is important for caregivers to be able to be honest with their clients. This frequently involves the utilization of humor and expressing affection. Sometimes, however, if a caregiver is angry or frustrated regarding some element involved in dealing with a particular client, being "authentic" involves expressing their feelings to their client, rather than ignoring the presence of the situation. This is not, of course, a carte blanche for the caregiver to "lose it," but rather the realization that both the client and caregiver can benefit from a perspective of honesty.
Being responsive means being very tuned in to the client and what they need at any given time, rather than having preconceived notions about what would be helpful. This involves being sensitive to subtle nonverbal cues and responding to the patient as an individual human being. Being responsive includes treating all clients with respect and caring. One operating room nurse, for example, would always make it a point to take the patientís hand, make eye contact and tell the patient before they lost consciousness that they would be taken care of, that they were healthy, and that she would see them in recovery. This was because she knew many people had an unexpressed fear of dying while under anesthesia, and she wanted to reinforce in the mind of the patient that she expected them to wake up.
Commitment is shown by going "the extra mile." Obviously a caregiver is always committed to the well-being of their clients. Sometimes, however, they are extra committed. This means extending themselves more than required, giving those clients who need it extra support and assistance; for example, a nurse in a burn unit having a mother bring a child to her house so she could check a dressing for her; or a nurse going in on her day off to fix a patientís hair because the patient said it would make her feel so much better about going into surgery.
Being Present With the Patient:
It is important to be aware of the fact that just being with a client is an important way to demonstrate caring. That is, a nurse or other caregiver need not always be performing technical tasks to be helpful.
Creating Positive Meaning and Hope:
Caregivers tend to be optimistic, which is important both in helping them deal with difficult situations and in helping them to be able to offer hope to their client. Some patients are very alienated and lacking in hope. A caregiver can often help them to find some meaning and hope by demonstrating that they think the patient is valuable as a human being. The ability to find meaning in oneís life often facilitates healing, or if healing isnít possible, it can at least provide a person with a sense of their lifeís having significance.
Technical competence is an important part of the communication of caring. A patient does need to know and feel that their caregiver is competent. Some health care professionals are of the school that technical competence is primary and that an emotional attachment actually gets in the way of technical competence. However, many caregivers seem to be finding the opposite to be true. They find that when they are "in love" with their patients that they often reach an almost transcendent level of competence.
Caring Unfolds With the Client
This chapter deals with the relational qualities of caring. These qualities manifest in different ways in different relationships between clients and caregivers. Participation of both client and caregiver in the relationship is implicit; however, this chapter focuses primarily on the role of the caregiver. The relational qualities of caring include 1) deep emotional involvement, 2) self-awareness and purposeful use of self, 3) intersubjectivity, 4) aesthetic qualities, and 5) transcendent qualities.
Deep Emotional Involvement:
Many caregivers see caring as a deep and emotional relationship between the self and other. Contrary to the traditional view which maintains caregivers should be careful not to get too involved with their clients, many caregivers are finding that being emotionally involved with their clients enhances the relationship for both parties. If you feel for a client it is natural to develop a bond with them.
Self-Awareness and Purposeful Us of Self:
In order to successfully maintain a deep level of emotional involvement, it is necessary for the caregiver to have a high level of self understanding. That is to be aware of their own "weak points," such as perhaps doing too much for the client. The successful caregiver is always learning about themself. It is very difficult for the caregiver to do this kind of self examination alone. It is important for caregivers to talk to others and to vent their feelings, as well as to view themselves as part of a caregiving team.
An inherent part of a deep caring relationship is that it requires both the client and the caregiver to participate in creating the relationship. Both are also affected by it. Frequently the caregiver finds that they have changed and grown in some way as a result of the shared relationship. Reciprocity on the part of the client is frequently expressed as appreciation for the care. The paradox here, however, is that appreciation is a plus for the caregiver, but shouldnít be expected or required.
There is a natural aesthetic quality present in caring relationships, particularly those which are going well. This sense of synchronization, or effortlessness, reminds us that therapy is an art, or a kind of blend of science and art. Being connected with the client, and paying attention to where they are at, frequently facilitates this level of relationship. One caregiver mentions the importance of attending to the eyes of the client for clues as to how the client may really be feeling.
Caregivers who are able to function with a lack of ego involvement and to enter the realm of the other allow themselves to become a part of something larger than the individual. The spiritual elements of the caregiver/client relationship are acknowledged and valued by many. Some caregivers ask God for strength and assistance in their work. Others use the analogy of pulling energy from the "abundance" or higher power, however they may conceive of it.
Caring Is Contextual
The Health-Care Environment
As we have seen, caring isnít an individual process in which a caregiver "fixes" the problem of the client. Rather it is an act of participation, which focuses on empowering the client in his/her ability to access their own resources for healing and problem solving. The caregiver needs to remember that they really canít control the outcome of the clientís situation. These are the elements which making caring contextual. The study on which this text is based didnít attempt to uncover all of the contextual properties that affect the communication of caring. It did however focus on three significant features which must be considered an integral part of the caring experience. The first of these is the intensity of the circumstances inherent to the health care environment itself. Second, most care provided in the health care environment is done as part of a team, therefore team participation must be considered. Third, the participation of the client must be acknowledged, the participation of the client is instrumental in determining what form caring will take and whether a caring relationship is possible.
The Intense Nature of the Health-Care Context:
Many caring incidents in the health care setting are necessarily characterized by crisis of some sort. As a result the client is extremely vulnerable. The nature of the health-care context effects the process of communication in that it allows for rapid bonding and heightening of the powers of communication. Nurses in operating and recovery rooms, for example, frequently find that they experience intimate and intense contact with their patients. Although this contact is of relatively short term duration, it is not in any way construed as superficial. Some feel that the survival instinct of the patient takes over and allows for trust to occur relatively rapidly, whereas it would normally develop over a longer period of time, such as in a counseling relationship. Again the ability of the caregiver to be tuned in to the needs of the patient is invaluable. Often a hug, or the rocking of a frightened child can have a profound effect on the well being of the client.
It is very valuable to have team involvement and participation for caregivers, as this fosters an environment conducive to the emergence of caring. Although caring can and does occur outside of a team environment, it is more likely to occur in an environment which consists of supportive inter-connections between team members. The team supported approach offers the caregiver emotional support, which assists the caregiver in being able to remain involved with their clients. Also this approach allows for the caregivers to "share the experience of caregiving" with others who uniquely appreciate the value of caregiving.
The participation of the patient helps to determine the way communication will unfold in a caring relationship. Although it is not essential that the patient participates, (because true caring transcends requiring reciprocity and caregivers usually manage to connect on some level with the spirit of the patient), it is very desirable. The patientís response, no matter how simple, opens the door for the caregiver to more accurately get an idea of what they need, or how much they need. One psychiatric nurse describes her experience with a catatonic patient while she was a student nurse; she would sit in front of the patient and just talk to the patient about whatever and after awhile the patient started to nod her head and to speak. On the last day the student nurse was assigned to that facility, the patient even walked her to her bus. The nurse explains, "The energy had to start somewhere, with one person, but itís the mutuality of it that gives it power. She responded, that was literally all she had to do." Another valuable element of patient participation involves those patients who actually manage to transcend despair by finding meaning in their situations. These patients actually inspire and renew their caregivers with their spirit. As one nurse describes a patient, "This lady had courage. She was grace under pressure." Another says, "My patients have taught me my philosophy of living and dying."
The Distinct Nature of a
Professional Caring Involvement
The objective of this chapter is to clarify the characteristics which make caring a unique form of communication and to make the distinction between productive caring and destructive forms of excessive involvement. This chapter will review the following qualities that make caring unique as a form of communication: 1) self-awareness and purposeful use of self, 2) lack of ego involvement, 3) empowerment through the mobilization of resources, 4) transcendence, 5) aesthetics, and 6) contextual support.
Self-Awareness and Purposeful Use of Self:
The risks inherent in the wrong kind of involvement with the client, necessitates a sophisticated level of self-awareness and understanding on the part of the caregiver regarding the caregiverís relationship with a client. Caregivers need to process their own personal feelings regarding the relationship, in a manner which allows them to stay focused on the needs of the client. For example, a counselor may have to guard against becoming so emotionally upset about what their client has experienced, that they lose their ability to "get beyond" their own feelings. Not surprisingly, this brings us to the examination of "appropriate" boundaries in the client/caregiver relationship. As mentioned in an earlier chapter, the traditional viewpoint has been that the caregiver needs to be quite vigilant against becoming too, or even very, emotionally involved with their client. This perspective arises basically from a fear of "losing control" and behaving in a somehow inappropriate manner with the client. Obviously it is necessary to behave in an appropriate manner with oneís client, however many accomplished caregivers are finding that this does not necessitate a lack of emotional involvement with their client. These caregivers, in essence, challenge traditional assumptions about what is an appropriate amount of distance to have between client and caregiver. By trusting their instincts and being creative as to the boundaries that exist in the relationship, they are able to achieve a therapeutic perspective of the client rather than the therapeutic objectivity associated with more traditional caregivers. This is not to imply that accomplished caregivers do not use boundaries, rather they are more flexible about what boundaries are appropriate in which situations.
Lack of Ego Involvement:
It is critical that caregivers be able to enter caring relationships with the ability to maintain awareness that the "experience of the illness" belongs primarily to the client and that their role as caregiver, is not that of "knight in shining armor." That is to say that the successful caregiver is more interested in assisting the client and in assisting the client to discover their own resources, than in being the person who "swoops in and fixes everything." The ability to keep ones ego involvement in perspective, not only empowers the client, but also assists the caregiver in participating fully in the experience of the client, without taking on the experience as their own.
Empowerment Through the Mobilization of Resources:
One of the most important behavioral characteristics of caring which helps to identify it as the right kind of involvement is the mobilization of both internal and external resources to empower the client. As previously mentioned the successful caregiver is able to step back from the limelight and to assist the client in finding their own power.
Transcendence offers the caregiver a way to rise above an ego centered involvement with the client and to participate in an experience that is greater than the caregiver. A caregiver who is truly able to attain this level of caring, usually notices a loss of self consciousness combined with a feeling of joy that comes with experiencing a connection to the "greater power or source." This has been variously described as the fundamental sacredness, unity of all life, shared phenomenological fields and universal psychic energy. Whatever one calls it, it seems to allow for a real connection on a spirit to spirit level, as well as a realization that the "abundance" is out there, waiting to be drawn upon.
There is a certain aesthetic flow associated with the "right kind" of caring involvement. This is primarily characterized by a feeling of harmony and an easiness associated with the relationship with the client. In contrast when a caregiver is involved in a relationship that is not going well, the aesthetic flow is characterized by feelings of awkwardness, discord and/or disharmony on the part of the caregiver.
Successful caring stems from a perspective of a contextual web of interconnection rather than from a position of isolation. This helps caregivers maintain a balanced perspective. It is important for the caregiver to receive some of this contextual support in the form of ego gratification, as well as joy and pleasure, from their personal lives, otherwise the risk is run that they will use their clients to gratify these needs. The personal history of the caregiver also comes into play as a resource that allows caregivers to help their clients create hope and healing. Some caregivers draw on a healthy and supportive personal history, while those caregivers who "grew up on the other side" often feel a special empathy with their clients and have managed to draw positive meaning out of past negative experiences.
Another important element in healthy caring, is that the caregiver feels a context of connection. This involves realizing that they are not the only one who can help the client. Caregivers who feel this way have lost their connection to context and are operating from a position of isolation. Even when it may appear there is not much available in the way of other resources for the caregiver to connect with, the expert caregiver is able to perceive themselves in connection with others.
The Transformative Effects of Caring
Effects on the Caregiver: Many caregivers find that there is a transcendent quality which is often involved in caring which is like a "peak experience." One nurse says that without "that spark", caregiving would be bleak. A psychiatric nurse said, "You begin to believe that thereís some magic to you. I did not believe that, but there has to be some part of me that did believe that. I took risks. I...think that if you really believed there wasnít magic,...you wouldnít take risks." The alchemical effects also enhance self-esteem and feelings of personal empowerment in the caregiver.
The nature of the intense intimacy which occurs in a caring relationship, seems to allow the caregiver to experience on some level, the positive effects of their caring. For example, one nurse says, "A part of them is a part of my heart, and helping to heal them, by bringing them to a peaceful end, or however that healing takes place, heals my heart."
It is repeatedly found that successful caregiving experiences do not deplete the caregiver, i.e. produce "burnout." Rather they enhance the caregiver and create in them an energizing and pleasant feeling, the "high." An oncology nurse says, "I donít think caring causes burnout. I think it prevents it...[Caring is] an unending thing, I never get tired of it."
Effects on the Patient:
Both caregiver and client are effected by the mutuality of the caring relationship. However because the client is inherently more vulnerable, the effects on the client are intensified. This section examines some of the ways caregivers feel their clients have experienced transformations as a result of the caregiving relationship.
One of the primary effects caregivers have noted on their patients as a result of the caring relationship, is that this seems to inspire the patient to care more about themselves, i.e. be less apathetic. One occupational therapist, for example, notices that if she doesnít connect with a child, the results of the therapy are not significant. " Caring is what mobilizes the kid... Then you see them start to get better.
The caring relationship also seems to help clients to heal the pain associated with emotional loss, such as the death of a loved one, abandonment or simply the trauma and isolation that the patients illness may cause. The caring relationship helps the client to reestablish a sense of connection. One example involves a four year old boy suffering from cancer. Following admission to the hospital, he became very withdrawn and wouldnít talk to anyone. One evening a nurse intuitively sensed that he needed comfort and just sat with him and rocked him for an hour and a half. After that the boy not only started talking again, but he started to respond to treatment as well. Seven months later he was at home and still responding well to treatments. The rocking and connecting experience seemed to be the turning point, helping him to reconnect with his world in a healing way.
Another frequently noted effect that a positive caring relationship has on clients is that it seems to promote self-integrity. They seem to experience a heightened sense of self and integrity which manifests itself in the form of increased strength, courage and ability to persevere. For example, one nurse had an elderly female patient who had been in the hospital for months, with every conceivable complication. This nurse went out of her way to help her preserve her sense of independence and dignity. The patient was an artist, so the nurse arranged to have some of her work displayed in the patients room to help her "regain some of her self-esteem and self-respect." The patient did recover and often would visit the hospital to thank her caregivers.
The Emotional Risks of Caring
Professionals in the health-care field see on a daily basis, things that most people never see, such as death, suffering, and the seeming senselessness of events which alter the lives of people forever. We have seen that those caregivers who are able to really connect with their clients are usually richly rewarded by a sense of fulfillment. For some caregivers however getting really involved has resulted in a negative experience for them. An examination of some of these experiences is helpful in helping to avoid or at least minimize these difficulties.
The emotional risks associated with the caring process fall into two categories. One is the experience of personal loss and the second one is emotional overload.
Experience of Personal Loss:
As one caregiver explains, "Every time you get involved with somebody, you risk a lot. You stand to lose something." Much of the loss had to do with the death of patients. Although most caregivers experience grief when a patient dies, particularly one where that special connection was present, these caregivers also felt a sense of their lives having been enriched by the experience of knowing that person. In a way the positive outweighed the negative.
However not all experiences with the death of a client are perceived in such a positive way. One nurse was very devastated by the death of a child she had been caring for, and as a result she has compensated by keeping an emotional distance from patients in an attempt to avoid the intensity of pain. "Each time I let someone like that come into my heart, when they die, itís just like I close off even more, itís just like, okay, Iím going to do what I have to do. I can feel sorry for you but thatís it, you know, when you die you are gone. I wonít even remember your name."
Thus we see how some caregivers who experience the loss of a special patient feel that they kind of shut down, they start perceiving their work as "just a job", they "lose that spark."
Why are some caregivers able to continue feeling intense satisfaction in their work, while others are devastated and themselves somewhat deadened? It seems to have a lot to do with the interpretation of the experience by the caregiver. These meanings stem from both personal and contextual resources and will be further explored in chapter ten.
Emotional overload occurs when a caregiver is overwhelmed by their exposure to, and experience of human trauma. This can lead to disillusionment and exhaustion, otherwise known as ...."BURNOUT."
As one nurse puts it, " I feel like in 6 years Iíve probably aged 20 or 30 years, and I probably have seen more in 6 years as far as human nature and the basics of human life, more than most people will ever see in a lifetime."
The nurse quoted above, who withdrew following the death of a child patient said, "Itís kind of like, unlike the parents who can continue to mourn over this person that they lost, you have to pick yourself up, go back into that unit, and take care of somebody elseís child who wants you to feel pretty much the same way you did about that other kid...They want you to be totally emotional. They want you to think they have the most gorgeous baby...Itís just like, isnít it enough that I am busting my butt for 12 hours without a break to keep your gorgeous child alive? Do you have to have all of me?"
When emotional overload occurs, caregivers seem to become unable to integrate or reconcile these intensely emotional events in a positive way. The caregivers are themselves experiencing the kind of emotional loss described in the last chapter, the kind which is healed by caring. The caregivers need caring, yet some caregivers do not have access to the kind of caring that might help heal their wounds. All people have limits as to how much stress they can effectively deal with. Often caregivers who experience a great deal of stress can integrate the experience and come to view it in a positive light. Those caregivers who for whatever reason donít have the resources which enable them to create positive meaning from their experiences, frequently end up disengaging emotionally.
Coping With the Emotional Demands of Caring
We have seen that some caregivers are able to derive much satisfaction from their work, while others are depleted and drained by their caregiving experiences. It seems that the meaning the caregiver attaches to and derives from, the caregiving relationship is the critical factor which will result in the experience being interpreted in a positive or negative manner. This chapter looks at how some caregivers cope with the emotional demands of caring.
Personal Resources That Sustain Caring:
Spiritual and philosophical resources are paramount in the caregivers ability to attach positive meaning to an often stressful occupation. Caregivers are constantly faced with human mortality. This circumstance however actually creates great potential for spiritual growth. Generally caregivers who are able to view life and death from a transcendent perspective are better equipped to deal with the apparent "unfairness" of many of their experiences. Those caregivers who are not able to feel that sense of "spiritual connectedness" are more likely to be devastated by the loss of a patient to whom they have become close.
Basically it seems that the caregivers who feel that life continues in some fashion after death; either that the spirit actually survives, or that a person lives on in a sense as long as they are not forgotten, seem to be able to attach some sort of sense to their experiences, particularly the experience of loss of a patient. However those caregivers who believe that when you die, thatís it, are less likely to find any positive meaning when a patient dies and are more likely to end up withdrawing emotionally.
Dialectical Flexibility is another potential personal resource of value to the caregiver. This requires of the caregiver an ability to remain fluid and feel comfortable with, essentially, a constant state of flux. Interestingly, a part of maintaining this balance involves knowing when to assert oneself either on behalf of themselves or the patient. One has to know when to take and maintain control and conversely when to let go of control. Successful caregivers also need to maintain elements in their personal lives that in some way provide balance or relief from the stresses of their work. Some caregivers do this by seeking out beauty, perhaps by going to a museum or the ballet. Others particularly find joy in seeking out the company of babies, reminding them of the beginnings of life, in order to balance their frequent contact with the end of life. Finally successful caregivers also need to remember that they cannot fix it all. They are not God, and as one caregiver put it, "You have to sometimes limit the amount of responsibility that you are willing to take on...God didnít save him so why should I think I should have been able to?"
Contextual Resources That Sustain Caring:
It would be unrealistic to expect the support needs of caregivers to be met by personal resources alone. This context must examine patient-centered support, caregiver-centered support and reciprocity.
Patient-centered support refers to the fact that caregivers need the participation of others in order to do the job of caring. If the "team" is not functioning well, it can be very rough on the caregiver. For example, one caregiver felt that as the result of racism and negligence, a Hispanic patient died, a patient whose death she believed was preventable. She believed a lack of support from members of her team, (night nurses didnít call the doctor) and then when she came on and called the doctor, he refused to respect her assessment and didnít come, caused the death of this patient. In this case she felt she lost because her skills were not respected and the caregiving team was dysfunctional. On other occasions when truly everything in the caring process went well, that is the team worked as a team and what could reasonably be done was done, even though a patient might still die, she felt the situation was positive.
Caregiver-centered support continues to focus on the importance of a supportive work environment for the caregiver. Again it is very helpful if co-workers help each other and treat them with compassion. If a particular caregiver is for example having a hard time dealing, for whatever reason, with a particular situation, other caregivers present frequently are sensitive to this and help out. Again the opportunity for finding some kind of balancing factor is of great benefit, as is sometimes having the opportunity to know how patients are doing after they recover, i.e. the positive elements of their efforts. Although this sometimes happens spontaneously by a patient getting in touch, unfortunately the mechanistic nature of most hospitals does not particularly facilitate these opportunities.
Reciprocity between the patient and caregiver effects both the caregivers ability to respond to the patient and their ability to find meaning from the caregiving experience.
Although patient participation is not a prerequisite for caring to occur, unresponsive patients and those who tend to exploit their caregivers, make it more difficult for the caring relationship to be positive. It is important to note that vulnerability is not solely the domain of the patient, sometimes the caregivers feel vulnerable as well. Nevertheless some caregivers do find even the so called "difficult patient" to be a challenge they can rise to, frequently resulting in the facilitation of an authentic interaction between caregiver and patient.
Interestingly, those special patients who are able to transcend their illness and, in the case of terminal patients, come to terms with death, tend to be the very patients who enhance the ability of the caregiver to find positive meaning in their experience as well. The flip side of the coin however, is that it can add to the stress of the caregiver if the patient who is dying is unable to accept death. As one nurse who has had a lot of experience with the deaths of AIDS patients says, "So many of [the AIDS patients] are not ready to die because itís such an unsettled disease...And I think that is why I feel so much more comfortable with the oncology patient if he comes and says well this will be my last admission...and you know you can talk about it...Once you can talk about death and get it out in the open, I think nurses feel a relief and a transcendence, a feeling that I can help you to get through this...[When] my job is to just help with the physical things...itís some very gruesome physical things...I donít get anything back."
Those caregivers who are able to really engage with their patients, by taking the risks inherent in such involvement, are often rewarded by witnessing some of lifeís most authentic moments. Such caregivers undergo continuing transformation and growth and make excellent mentors for others in their field.
Implications for Practice and Education
Reclaiming the Value of Caring: Caring is a process which requires both technical ability and heart, or caring communication. Because the health care establishment tends not to recognize the value of the latter, many practitioners are reluctant to share some of their more significant experiences in the area of caring communication. Practitionerís tended to relate fairly "run of the mill" stories at first about their caring experiences, but as trust was gained during the interview process, they would frequently relate more personally and spiritually significant accounts.
Because many caregivers are undervalued both in terms of pay and respect, their "caring" itself has often been trivialized by the medical/scientific model of healthcare. Contrary however, to the medical establishments attitude that caring is almost a weakness, effective caring/communication actually requires a very strong and courageous caregiver in possession of exceptional communication skills.
Promoting Caring Communication in Education and Practice:
The use of stories is an extremely valuable tool. For example, one nursing student told a story which involved a cardiac arrest case on an ICU. In the midst of resuscitation efforts, which were apparently not going to be successful, the patients daughter walked into the room. Normally she would have been hustled out and, she was given the suggestion to wait outside, but she responded "I need to see my father die." The attending physician hesitated a few moments and then declared the patient dead. He asked the woman if she wanted to hold her fathers hand and when she did, she broke down. The medical personnel all were quite respectful and sensitive and gradually left her alone to finish her goodbyes. The student described feeling the presence of a strong spiritual energy. This story serves to not only show how well caring can work and but to assist in giving her peers an enhanced perspective that they may not have experienced for themselves yet. The analogy is also made of the story resembling an improvisational concert, how to respond can not be taught in books and it will tend to vary a with each encounter depending upon the circumstances involved.
It is also important to look at the use of language in the health care field. The lingo which the medical profession often uses, frequently dehumanizes and confuses the patient. For example, one man had a sign posted on the wall behind his bed which read "NPO" (this actually means nothing by mouth) but he didnít know this and why would he? He thought it meant "neuropsychological observation." Another nurse also took for granted the typical signs above beds, such as "Get patient up for meals", until she saw one which said "Mrs. Garcia prefers to sit in a chair for meals." Might it not be a significant change for the better, if peopleís names were always written in charts in place of the word "patient"? The idea is to use communication which makes caregivers more aware of the patient as a human being , rather that an object.
The ideal care delivery system would allow for and encourage caring communication and personal involvement with patients combined with appropriate time allocations. If this isnít done, increasing numbers of health care providers are likely to suffer from burnout and either leave the field or withdraw emotionally.
We have seen that caregivers generally care inherently, and if they are allowed to do so without suppression and are supported in their efforts, their wisdom can be invaluable in enhancing the whole dynamic between care giver and receiver.