Nurses’ ‘being there’ as an expectation of psychosocial support

Is the debate over whether psychosocial support is really offered more to do with expectations of how it is offered? Studies that identify psychosocial support as missing illustrate palliative care nurses as focussing on tasks instead of, for example, sitting down with a patient and discussing their concerns (Beckstrand et al. 2009, Johnston and Smith 2006, Haraldsdottir 2011). When availability, as discussed above, is matched by nurses being willing to spend time with patients, psychosocial support is considered more effective (Richardson 2002, Morgan 2001, Johnston 2002, Seymour et al. 2003, Bradley et al. 2010). This is referred to as ‘being there’ and can mean nurses simply sitting with a patient. ‘Being there’ is especially valued, by nurses, when it prevents patients who are dying from being alone in a single-room (Beckstrand

et al. 2006, Hopkinson et al. 2003, Kuuppelomaki 2003, Benner 1984, Rowlands and Noble

2008).

Haraldsdottir’s (2011) ethnomethodological study of two wards in a Scottish city-based hospice, sought to explore the idea that nurses provide psychosocial support by ‘being there’ for patients. Analyses of observations of care and meetings, and informal conversations, concluded that nurses adhered to an organisation-led, task-oriented, routine of working and nurses were never observed spending time purely talking to or sitting with patients. Nursing time spent with patients carrying out physical care was not respected and often registered nurses were disturbed during care episodes. Completing tasks seemed to take priority over patients’ needs. The psychosocial needs of patients were not considered in organisational aspects of care. This was justified by the suggestion that avoiding psychosocial needs is a useful coping mechanism: patients would cope better with the challenges of their disease, through avoidance; and nurses could manage their workload more effectively. On the occasions when nurses did respond to patients’ psychosocial needs, they were observed changing the subject or making light of the psychosocial need. However, the absence of ‘being there’ as described above does

not equate to an absence of psychosocial support, it simple means the concept was not witnessed (Haraldsdottir 2011). Patients were not asked about their perception of, or desire for, nurses ‘being there’. Two main concerns exist with the suggestion that a lack of ‘being there’ equates to a failure of ward nurses to provide psychosocial support.

Firstly, what are patients views about ‘being there’? Patients in Johnston’s (2002) study were reported as valuing nurses ‘being there’ but no exploration was made of what patients meant by this: was it spending time with patients or simply that the nurses were available? Johnston’s (2002) study gives valuable insights into what patients and nurses perceive as important qualities in palliative care nurses. However, use of the phenomenological approach fails to illustrate the reality of how care is provided in practice and has the potential of researcher bias from preconceptions from her own palliative care nursing background. Taylor (1994), in her observational study, gives an alternative patient view to the concept of ‘being there’, suggesting it is emotional support and physical care provided simultaneously. This view reflects the way psychosocial support is described by patients in both Skilbeck and Payne (2003) and Cannaerts

et al. (2004) studies as part of practical interactions and by other patients who request nurses

combine psychosocial support with other aspects of care such as symptom control (Seymour et

al. 2003, Buckley and Herth 2004). These findings suggest that perhaps ‘being there’ in the

way patients, not nurses, desire may occur. The second concern about the concept of ‘being there’ relates back to the organisational issues of psychosocial support. Some palliative care nurses feel that being with patients in this way is ‘not getting on with your work’ (James 1992, Roche-Fahy and Dowling 2009).

The variation between the findings, and the age of the studies, discussed in this sections support the value of carrying out further observational studies of hospices. One of the questions that arises is: have the organisational constraints of hospices changed over the years so that nurses

can no longer find the time for the ‘being there’ ideal of psychosocial support? Or, in reality, is ‘being there’ a much sought after concept that has rarely existed for ward nurses?

2.5 Conclusion

The four sections above all raise valuable points that demand reconsideration of whether nurses can offer psychosocial support in a hospice ward, and, if so, how. As with the literature reviewed in Chapter One, Maslow’s (1943) hierarchy of needs can aid this exploration of in- patient hospice nursing. When the studies above found that psychosocial support was provided, patients described higher levels of psychosocial needs being met by specialist nurses. The key facilitator for this support was proffered as the development of a nurse-patient relationship. When studies reported care by ward nurses, there was a more common suggestion that nurses avoided patients’ psychosocial needs, focussing instead on completing their duties for the day.

Two main issues arise from the literature discussed in the previous chapter and above. Firstly, there seems to be relative agreement on the types of psychosocial needs palliative care patients have, which are illustrated in Figure 1.1. However, there is little understanding of whether and how these needs are expressed to nurses by palliative in-patients. Answering these questions is the first aim of this study. Secondly, the studies above present opposing views over a number of issues, including: the existence of a ‘psychosocial climate’; whether physical or psychosocial care takes priority; and the importance of building nurse-patient relationships. This continuing debate suggests there may be a different way to consider how psychosocial support is truly offered. The extent to which psychosocial support is really offered by palliative care nurses remains unclear. Further studies are required to explore the reality of practice in specialist settings to understand how nurses can more fully meet patients’ psychosocial needs. The first step in meeting patients’ psychosocial needs is in recognising and acknowledging them; this study identifies whether and how nurses do this immediately after the needs are expressed.

A common limitation across the studies reviewed in this chapter is that they have relied on self- report data (Devery et al. 1999, Taylor et al. 2001, Johnston 2002, Kuupelomaki 2003). Caution must be taken in regards to self-report studies as research participants can be unwilling to voice criticism of their care (Nagington et al. 2013). What is indicated is the need for evidence generated from observation, which is divorced from the proclivities of individuals to misrepresent actions. A few studies have adopted an observational method (James 1992, Ingleton 1999, Lawton 2000, Haralsdottir 2011) which enrich the evidence base. However, they do not explore the minutiae of psychosocial needs of palliative care in-patients or how nurses respond to them. Nor do they match their interviews to the observations on the care provided (Skilbeck and Payne 2003, Mok and Choi 2004, Walshe and Luker 2010, Herber and Johnston 2013) thereby failing to provide an all-inclusive exploration of the reality of nursing care of patients. The literature reporting psychosocial needs and their support in palliative nursing has a paucity of theoretical frameworks. As noted in Chapter One, Maslow’s hierarchy of need may be a useful theoretical lens with which to view the literature and explore nurse psychosocial support in hospice wards.

The first two chapters of my thesis have identified a need to develop a clearer understanding of the reality of palliative care nurses’ provision of psychosocial support. My study contributes to this understanding by exploring, for the first time, whether and how palliative care in-patients in one ward express their psychosocial needs to nurses and how the nurses immediately respond. In the following chapters I discuss my study which explores the aims above. Chapters Three and Four discuss methodological considerations, while Chapters Five and Six present my findings. This thesis is concluded by a discussion comparing the literature to my findings (Chapter Seven).