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Valuing the heart and soul of nursing.

The five-pointed star of the New Zealand registered nurse medal inspired one nurse to reflect on how the original symbolism of each point can be related to current nursing care, and the importance of soulful care in an environment which does not value the totality of nursing's contribution.

Nursing isn't what it used to be. That's a catch cry of many nurses today. It begs the question, what did nursing used to be? What has changed and what is it that we have lost?

Of the all major reforms of our health system, the reforms of 1993 were arguably the most damaging for nurses. These saw area health boards reconfigured into crown health enterprises, bringing in a new era, the "business" of health. Directors, predominantly from business, were appointed to make "ration-al" decisions about funding, with the aim of doing more with less. Many senior nursing positions were disestablished and, over time, overall nurse numbers reduced. Over the last two decades, the effects of these 1993 reforms have changed the nature of what nursing "used to be".

The increased workloads and pressures of the current health environment mean nurses must prioritise their interactions with patients. (1) When one hardly has time to provide the bare essentials of nursing care, the time to "be", to hold that hand, to allay fears about a procedure through education and reassurance, is simply not there. This makes nursing work stressful, dissatisfying and exhausting. One commentator puts it like this: "Today, nurses search for soul in a dry corporate environment where the true soul of the nurse is dismissed and disregarded". (2)

In a recent Kai Tiaki Nursing New Zealand, NZNO professional nursing adviser Lorraine Ritchie wrote: "nurses ... do not go to work in the morning thinking about their patients as business units or bed numbers, but as human beings with needs". (3)

This, I'm sure, is not the future for nursing Grace Neil envisaged when she developed the New Zealand nursing medal as a "symbol of service in the alleviation of suffering" in 1895. (4) The medal is a five-pointed star of middle-eastern origins: the red cross at the centre represents the blood and cross of Jesus Christ; the white background represents the purity expected in the life of the nurse; the blue represents honour and loyalty; the gold, charity. (4)

Stars have long been used for navigation and I believe the values Neil inculcated into early New Zealand nurses with the medal and accompanying creed, The Five Pointed Star, can still guide us today. The five points of the star are the hand, the foot, the knee, the breast and the head. Focusing on the five points of the star, I will share some nursing stories that illustrate each point of the star. We all have our stories of those patients who leave their mark on our soul.

The Hand: "That my hand shall ever extend to help, comfort and relieve the sick and suffering." (4)

Aristotle called the hand, the "instrument of instruments", and hands are seen as symbols of human action. (5) The context here is of nursing as a calling, or even mission, with "caring" as the central motivator. The five points of the star can be related to the caring concepts developed by nursing theorist and researcher Kristen Swanson (see box opposite). (6)

Nursing theorist Jean Watson relates nursing to the nature of our shared humanity, and says that "by attending to, honouring, entering into, connecting with our deep humanity, we find the ethic and artistry of being, loving and caring". (7)

What better way to extend help and comfort to those who are sick and suffering than through touch? Nurses are intimately involved with bodies, most often with task-related touch--taking observations, bathing, dressing wounds, repositioning. Caring touch is also important when words are not enough--holding a hand, a hug for the elderly person with dementia or a relative who is struggling.

Colin's story

"Colin was a 51-year-old-man in our unit, who looked fit and well to the casual observer. He was admitted with a mediastinal tumour that had infiltrated the heart muscle. We were told he could die at any time. He had a thick novel on his bedside table and I wondered if he would live long enough to finish it.

During one shift, Colin rang his bell and we found him grey and groaning, experiencing severe chest pain. We drew up morphine and administered it. Colin hissed between groans, "what a bitch of a way to die!" We murmured our assent, I turned up the oxygen and asked Colin, whose fists were firmly clenched, "Would it help to have a hand to squeeze?" and offered my hand. Through gritted teeth he said "yes" and gripped my hand tightly. I held his firmly too, as if trying to transmit some of my strength to him, and my colleague stroked his arm on the other side of the bed. We stayed like this, no words spoken, in it together, until the worst was over, some 10 minutes or so, then I relinquished his hand. Colin died three days later, his novel, like his life, unfinished.

The Foot: "That my feet shall not fatter, loiter nor linger, when journeying to alleviate the suffering and the sick." (4)

Feet symbolise being at one's service, and following or receiving instructions. Nurses' feet are standing on the holy ground of shared humanity.

The foot reminds us of the ever present tension between "doing" and "being" that nurses experience. A practice nurse colleague told me her practice of taking a few moments to chat with patients on the telephone after responding to their initial query, was viewed with disdain by the practice manager, as this was not "revenue generating".

"Being" has been described as a form of "doing". Nursing theorists Josephine Paterson and Loretta Zderad say "there is a kind of being, a 'being with' or 'being there' that is really a kind of doing, for it involves the nurse's active presence." (8) We need to encourage healthcare managers and leaders to see "being" as "doing" and of value too.

Hannah's story

An elderly woman named 'Hannah phoned Healthline, a telephone triage service, where nurses are expected to complete calls in an average of 9.3 minutes or less. She had longstanding nausea and had been vomiting daily. She had been to her GP several times but had been told each time it was just anxiety related to her husband's death a year ago. No tests or bloods were done. I listened patiently. I'm not sure when she felt she could trust me, but she started to tell me the story of how her husband died. I knew I was going to listen as long as it was going to take.

Her husband suffered from bipolar disorder which had for many years been well controlled with medication. They had a happy life together and had just returned from an overseas trip, which they had enjoyed very much. On their return, her husband had become very low and his usual medications did not seem to be helping. This particular day he had been out working in the garden and decided to come in for a sleep. When he woke, Hannah decided she, too, would have a rest. Her husband tucked her up in bed, snuggling the covers in around her, gently stroked her face and told her how much he loved her, pulled the curtains and closed the door so she could rest.

He then walked to the local park, sat on a bench and took a fatal overdose of sleeping tablets. It was a policeman's knock she heard at the door when she woke, not her husband's.

His death had devastated her, she found it hard being alone in the bed, in the house which now felt too big, and felt his absence when she went out--alone. Then there were all the things which needed fixing.

I was able to draw on my experience of divorce and of losing my father suddenly, to empathise with her and share just enough of my own experience for her to know I knew some of what she was talking about.

I reassured her that her symptoms were real and should be actively followed up. At the end of the conversation, she thanked me and said I was the first health professional who had actually listened to her. The call took 38 minutes.

The Knee: "That my knee shall bow to the Almighty Creator in asking for guidance and aid in my endeavour to relieve the suffering of the sick." (4)

The knee symbolises humility and reverence. How many times have we, as nurses, knelt at the feet of a terminally ill person sitting in their lazy-boy chair or next to their bed, marvelling at their ability to bear their illness with such grace and dignity?

There is ever-increasing dialogue about spirituality in nursing. Spirituality is distinct from the narrow confines of religion. In the words of Stephen Wright, "at its essence spirituality is about connecting with people". (9) As nurses, we like to think ourselves as holistic, but the reality is we often don't have time, or sometimes the skills, to provide spiritual care.

Author of Care of the Soul in Medicine Thomas Moore talks about bodily symptoms as the voice of the soul, and suggests that for some, illness is in fact a force for healing. Illness is part of our common human experience. (10)

He also points out that medicine has respect for the body, but not the soul. The soul "is the invisible factor that draws people together, brings out their humanity, and gives depth and meaning to what they do" (10) and "if you regard the body as a thing, you will have less respect for it than if you see it as the presentation of a person in context and relationship". (10)

Ignoring soul, our own and that of the patient, even while attending to their physical body, can impact on their vulnerability to disease and ability to recover. This has been called a lack of emotional intelligence. (11)

Brian's story

* Brian was a man in his late 60s, a devout Christian who had been caring for his wife for some years. She had been reluctant to go into care so, even though he had metastatic cancer of the rectum, he still cared for them both. He developed difficulty walking at home but was reluctant to come in for assessment, as he feared not being able to go home again. Within 24 hours, he was admitted with spinal cord compression and unable to use his legs. While in our unit, Brian was often anxious in the evenings. He liked someone to sit with him, which wasn't always possible. I had a Filipino competency assessment programme student, Jacob, helping me care for Brian. Jacob came to me and, in that way only someone who speaks English as a second language can, said that, as Brian was a Christian and he was a Christian, he felt Brian's anxiety and need for comfort in his soul. He asked if it would be okay to sing to Brian. Over the next two evenings, he sang hymns Brian knew sitting quietly at the bedside in the darkness of the evening, his voice deep and gentle, as it carried out into the hallway as I passed. Each time Brian drifted off to sleep peacefully.

The Breast: "That my breast shall be a safe and sacred repository for any secret entrusted to me or divulged through sickness or delirium or otherwise obtained." (4)

The breast is closely related to the heart and symbolises honesty and loyalty, as well as being a metaphor for the inner life.

In times of vulnerability, patients often "go deep", sharing things they may have never told anyone before about things they have done, or sharing anxieties and fears they feel unable to share with their family.

Various commentators have written about the phenomenon of the "wounded healer", (2,10,12) where the helper knows what it is like to be hurt and in need, and uses these wounds as a source of healing to relate more fully and empathetically with the patient. Robinson writes: "the nurse knows, at least on an unconscious level, that the effects of true healing go both ways.... The nurse communicates with the patient somewhere between soul and spirit with rituals directed to the body. She experiences nuances, openings, a shift of the body, or an expression, ail while maintaining presence with the vulnerable patient". (2)

Moore proposes there is also the "healed healer, the doctor [or nurse] who by witnessing the courage and deep humanity of his/her patients has become more of a person him/ herself. (10)

Nursing involves emotional labour. Palliative care expert Deborah Holman articulates the delicate balance nurses walk--"expected to manage their emotions in order to present a professional demeanour and maintain professional boundaries, while at the same time provide genuine caring behaviour to their patients". (13)

Those who possess emotional intelligence have been described as being able to "acknowledge the significance of human feelings and ... use their hearts as well as their heads when deciding how to act". (14)

Jean's story

* Jean was 95, largely independent, if becoming frail. Tall, slight and strong in will, if not in body, staff reported that Jean was unresponsive. On examination, Jean had good colour, no cyanosis, her observations were normal and she was warm. We wondered if she might be "playing possum", but couldn't be sure.

The facility several other staff and I tried to wake her, without success, even with the bluff of calling an ambulance (something we knew Jean would not want). I had a gut feeling she was okay but the facility manager wanted action, so I telephoned her sister, who lived out of town, to let her know. She commented, "Jean and I have been trying to die for years but it just hasn't been happening!" and seemed to take it all in her stride--I wondered if she was a little envious even.

Next, I called the GP who confirmed that, as per Jean's advance directive, no further action needed to be taken. I documented all this and returned to check Jean. I noticed her eyelids were moving slightly--as if she were awake and trying to appear asleep--just as my seven-year-old son does. I knelt down next to the bed and let my hand rest on her forearm. "Jean," I said, "how are you doing?" She opened her eyes and said, "I'm lying here trying to die but you people keep prodding and poking me!"

I explained gently that when your heart has been beating regularly for 95 years and you are ostensibly well, that it doesn't always stop when we want it to. She smiled and asked for a poached egg on toast for lunch! Jean has been very much alive since, and we seem to have an understanding.

The Head: "That I will constantly pursue and study the secret arts; that I will exercise my knowledge to the benefit of those suffering bodily or mental distress, and will disseminate such knowledge among others as my preceptors authorise and direct." (4)

The head symbolises intellect. Many of us are pursuing study, including battling our way to a nursing masters or PhD. On International Nurses Day this year, nurse blogger Diane Goodman wrote: "At various times in my career I have sought to advance my skills, obtain more initials, further my education, broaden my horizons, and gain recognition via the use of networking and social media. At NO time did I really sit back and think, this is it. I've made it, I'm the nurse of my dreams, I'm there ... sit back, applaud yourself, and think ... I've made it. You're a nurse, there is absolutely nothing better." (15)

We can place too much emphasis on intellect, on gaining knowledge, amassing those all-important letters after our name that allow us to climb the ladder, without resting in what we have already achieved.

Florence Nightingale was one of the first to suggest nursing was an art; however, there are those who propose it is not. One nursing theorist attempted to define the concept of the art of nursing, after analysing 59 narratives on nursing database, CINAHL, that discussed the art of nursing. She arrived at the following definition: "The art of nursing appears to consist of expert use and adaptation of empirical [the science of nursing] and metaphysical knowledge [an awareness that things are not always visible, audible or palpable; intuitive] and values. It is relationship-centred and involves sensitively adapting care to meet the needs of individual patients. In the face of uncertainty, creativity is employed in a discretionary manner. Artful nursing promotes beneficent practice and results in enhanced mental and physical well-being among patients. It also appears to result in professional satisfaction and personal growth among nurses." (16)

It is our stories that make visible the art and soul of nursing. We need to articulate these better, if we are to provide evidence that "being" is "doing", is of value to the patient and is, as we know, beneficial to the health system as a whole.

The use of technology in health care has increased exponentially in the last decade. It is easy to lose sight of the patient's humanity when one is monitoring pumps and other electronic equipment, or taking digital observations with a "nurse on a stick". What happened to the gentle touch of the nurse, as she felt for a radial pulse, feeling the quality and regularity of the patient's heartbeat, noting the temperature and turgor of the skin?

The poem The Doctor's Laptop (left) applies to all of us who use technology in patient care.

Nursing isn't what it used to be, and we know what it was wasn't perfect either. Whatever else a market-driven health system does, it can't rob us of our sense of calling, our humanity, our heart and soul. To humanise the system we work within, we need to maintain our power by "being" who we really are as nurses, telling our stories and articulating the heart and soul of nursing. I hope this reflection will help you navigate your ongoing nursing journey with renewed vision and hope.
The Doctor's Laptop

   The day came when not even paper
   passed between us. A laptop appeared
   on the vast expanse of desktop
   that had always stood
   between my doctor and me.
   It gulped down my story--an
   indigestible slurry
   of symptoms, dates and question marks--and
   short, sceptical pauses.

   It preceded us into the exam room
   where it sat with its back to my nakedness
   in a pointed show of disinterest,
   then led us again to the room with the desk.
   There, in silence
   it assigned diagnoses
   researched best practices
   sent referrals
   insurance forms
   and the date of my next appointment
   to linked computers and printers
   in distant locations.

   I envy the laptop its capacity, certainty
   and complete absence of need.
   I envy it the doctor's thoughtful touch,
   attentive gaze,
   and the deference it gets--though
   it hasn't the wit
   to fancy itself a healer,
   or wise.

Veneta Masson

* All names and some details have been changed to protect patients' privacy.

(1) McCloskey, B.A. & Kiers, D. K. (2005) Effects of New Zealand's health reengineering on nursing and patient outcomes. Medical Care; 43: 11, pp1140-1146.

(2) Robinson, E.A. (2013) The Soul of the Nurse. Santa Barbara: Spann Robinson.

(3) Ritchie, L. (2014) Valuing Nurses' Stories. Kai Tiaki Nursing New Zealand; 20: 4, pp28-29.

(4) History of the Five Pointed Star. (1933) The New Zealand Nursing Journal; 26: 3, 132.

(5) Rowe, K. (1999) Dead hands: fictions of agency, Renaissance to modern. Stanford, CA: Stanford University Press.

(6) Swanson, K. (1991) Caring defined: A comparison and analysis. International Journal for Human Caring; 13: 1, pp16- 31.

(7) Watson, J. (2003) Love and Caring: Ethics of face and hand, an invitation to return to the heart and soul of nursing and our deep humanity. Nursing Administration Quarterly; 27: 3, pp197-202.

(8) Paterson, J. & Zderad, L. (1988) Humanistic Nursing. USA: National League for Nursing.

(9) Wright, S. (2011) The heart and soul of nursing. Nursing Standard; 25: 30, pp18-19.

(10) Moore, T. (2010) Care of the soul in medicine: healing guidance for patients, families, and the people who care for them (1st ed.). Carlsbad, CA: Hay House.

(11) Goleman, D. (1996) Emotional intelligence: why it can matter more than IQ. London: Bloomsbury.

(12) Nouwen, H.J.M. (1994) The wounded healer: ministry in contemporary society. London: Darton, Longman & Todd.

(13) Holman, D. (2014) The emotional labour of caring for patients at end of life. End of Life Journal; 4: 1, pp1-5.

(14) Stein-Parbury, J., Crisp, J. & Nagy, S. (1993) Patient and person: developing interpersonal skills in nursing. Melbourne; Edinburgh: Churchill Livingstone.

(15) Goodman, D.M. (2014, May 7) We Should ALL Be Rock Stars. Reflections PRN.!comment=l. Retrieved 11/11/2014.

(16) Finfgeld-Connett, D. (2008) Concept synthesis of the art of nursing. Journal of Advanced Nursing; 62: 3, pp381- 388. doi:10.1111/j.1365-2648.2008.04601.

(17) Masson, V. & Dickerson, R. (2008) Clinician's guide to the soul. Washington DC: Sage Femme Press.

Jacqueline Brown, RN, BN, PGCert(palliative care), is a triage nurse for Healthline and volunteers as a chaplaincy assistant at Nelson Marlborough District Health Board. This article was developed from a presentation she gave at the College of Primary Health Nurses' conference in August.


Knowing       Striving to understand an event from the          Head
              perspective of the other individual and the
              impact of meaning of that event on the life of

Being with    Being emotionally available to the other,         Breast
              making oneself available on an ongoing basis,
              and sharing feelings, whether they are happy or

Doing for     The carer should assist the individual in dong    Hand
              what he/she would do for 'the self if
              circumstances were otherwise.

Enabling      A process whereby the carer assists the other     Feet
              as he/she passes through the transitions of
              life events that are unfamiliar.

Maintaining   Requires persevering faith in the other's         Knees
belief        ability to persevere through a transition or
              event with a resolve to face the future with

The five points of the star can be related to the caring concepts
developed by nursing theorist and researcher Kristen Swanson.'
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Title Annotation:viewpoint
Author:Brown, Jacqueline
Publication:Kai Tiaki: Nursing New Zealand
Article Type:Viewpoint essay
Geographic Code:8NEWZ
Date:Dec 1, 2014
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