Do you feel safe in our care?
Marie Cooper offers an insight into the Polyvagal Theory and its application to one's sense of safety
Starting with my own experience
Undergoing inpatient treatment some years ago, I wish somebody had given thought or even asked me how safe I felt whilst in hospital.
There were times when I felt safe, seen, and cared for, when I could ask questions and felt I had a connection with those caring for me.
But there were too many times when I felt unsafe and vulnerable and unable to speak due to fear of being judged as unreasonable.
You might be thinking that this is an exaggerated response, particularly given my background as a nurse, my experience of working in hospital and my usual confidence to articulate important needs. What I learnt is that these are not sufficient and for many, their experience of fear may be amplified. The literature identifies several key factors that often contribute to patients feeling unsafe[i] .
I am struck by the fact that this too was my experience. Such factors included; lack of information with regards to decision making, not being able to voice my concerns because nobody asked or had time, it would seem. Being attended to by nurses who were unskilled in technical procedures and had poor practice. I recall having to be vigilant all the time to ensure my physical safety as best I could and not feeling able to voice any of my worries.
How can nurses respond?
In the dynamic world of healthcare, nursing must stand as a beacon of compassion and advocacy[ii] .The practice of nursing is deeply rooted in the art of fostering safety and connection, not only in physical care but also in emotional support.
The Polyvagal Theory which I invite you to explore as a means of understanding how to change patients’ experience from one of isolation and fear to one of feeling safe and held, is a groundbreaking concept introduced by Dr. Stephen Porges[iii]. I offer it because its content resonates profoundly with the principles of nursing. This theory emphasises the crucial role of safety and connection in shaping human responses to stress and interactions. It serves to validate the fundamental values of nursing, and specifically highlights how safety and connection are core tenets in providing therapeutic relational nursing.
This all became clear for me in the light of my own experience as an inpatient when I read a book by Deb Dana introducing the Polyvagal Theory[iv]. It resonated powerfully with what I sought from those caring for me – to have a sense of safety, to be ‘seen’ and have some degree of connection.
Understanding the Polyvagal Theory
The Polyvagal Theory explains how the autonomic nervous system responds to different social and environmental cues. As humans, we like our fellow creatures in the animal kingdom, are constantly scanning our environment for safety. Think about when you walk into a party or work event alone, how are you feeling, what are you looking for?
Dr. Porges introduced the concept of three hierarchical neural circuits, each associated with a distinct physiological state.
- The ventral vagal complex represents a state of safety and connection, promoting social engagement and emotional well-being.
- The sympathetic Nervous system represents our fight-or-flight response
- And the dorsal vagal complex is associated with shutting down and immobilisation when the perception of danger is imminent. One can go into a state of inertia and at worse dissociation as a way to cope.
Appreciating these different states is a good place to start.
Then recognising how we shift between them and how we feel in each state helps us realise that our ability to connect, manage ourselves and our environment is not consistent. Different stimuli will move us from a positive place of social connection to one of preparedness to fight or flight, or at worst shut down and collapse.
As we become aware of these states we can start to appreciate similar experiences on the part of people in our care and those we work with. Shifts from one to another are not necessarily to be feared but benefit from recognition and comprehension. Once we have insight, we can then work to address their impact on our lives.SWTT Polyvagal Chart 2023 – Ruby Jo Walker LCSW
The visual is shared with kind permission from https://www.swtraumatraining.com/polyvagal-theory
Creating a sense of Safety in our Nursing
The fundamental role of nursing was articulated as early as Florence Nightingale. She wrote about the importance of vigilance, keeping those in our care safe and creating an environment to support their healing and recovery or maintaining comfort in their dying. She recounts how she sits with a young dying soldier reading his letters for him and finding out ‘what is in his heart [v]‘ .
The Polyvagal Theory underscores the importance of creating such an environment that promotes feelings of safety and security. Nurses play a pivotal role in establishing this environment by enacting their values, being competent in practice and offering a therapeutic presence and relationship. Feeling safe not only reduces a person’s stress and anxiety but also enhances their ability to ask for what they need, regain agency and to feel confident to express how they are really feeling.
The need for connection
Connecting with those in our care is integral to the practice of palliative nursing[vi]. The Polyvagal Theory emphasises the ventral vagal complex, which is activated when individuals feel safe and connected. In nursing, fostering a sense of connection involves generative listening, empathy, and building trust[vii]. Nurses who show genuine concern and engage in therapeutic communication create a bridge of trust that can significantly impact patients’ emotional well-being. This sense of building connection should also extend beyond patient nurse interactions to encompass the entire healthcare team, working collaboratively to create a psychological safe workplace. If you are working in a person-centred culture everyone matters and should feel safe and connected in some meaningful way.
Reducing Stress and Anxiety
Working in the field of palliative care we know stress and anxiety accompany a person who is ill, living with uncertainty and facing loss. The Polyvagal Theory highlights the physiological responses associated with such chronic stress the resulting impact on overall health which ensues.
Nurses armed with this knowledge can assess and implement care strategies to mitigate stress, such as creating calming environments, offering relaxation techniques, and employing distraction therapies. By acknowledging and addressing patients’ emotional states and existential worries, we can contribute to a positive shift in the autonomic nervous system, promoting rest, healing, and ultimately a sense of peace.
Rapport helps build trust and I would argue is an essential aspect of relational nursing care. The Polyvagal Theory underscores the significance of building trust as it aligns with the ventral vagal complex’s activation and the resulting state of safety and connection. In the case of my dying father’s care, I witnessed a nurse create rapport through her authentic presence and communication in one short moment of care. The impact on all of us was palpable and I will never forget it. When we are experienced as being trustworthy there is more likely to be more honest communication, leading to more person-centred decision making, better care experience and improved outcomes.
The Polyvagal Theory has profound implications for the nursing profession, shedding light on the neurophysiological underpinnings of safety and connection. As caregivers, nurses hold responsibility for creating an environment that promotes emotional well-being and facilitates healing. By aligning nursing practices with the principles of the Polyvagal Theory, it assures practitioners and those we care for that what we offer is fundamental to our shared humanity; by forging authentic connections with patients, we enhance the overall patient experience and outcomes.[viii] As the world of healthcare continues to evolve and at risk of becoming even more transactional, technological and interventionist, the unwavering focus on safety and connection reaffirms nursing’s vital role in fostering a more humane, person-centred care approach.
Connect with us through the Global Palliative Nursing Network
Our aim for the Global Palliative Nursing Network (GPNN) is to establish a worldwide network to provide peer support and professional development for all nurses working in palliative care – wherever they are.
We’re designing it to complement existing networks following recent engagement with over 1200 nurses around the world interested to advance their practice.
This network follows the recent success of our community of practice for pioneering nurses, the Global Fellowship in Palliative Care we run with Institute of Palliative Medicine, Kerala and two UK specific nursing programmes.
[i] Kenward L , Whiffin C , Spalek B. Feeling unsafe in the healthcare setting: patients’ perspectives British Journal of Nursing 2017 26:3, 143-149
[ii] Abbasinia M, Ahmadi F, Kazemnejad A. Patient advocacy in nursing: A concept analysis. Nursing Ethics. 2020;27(1):141-151. doi:10.1177/0969733019832950
[iii] Porges, S. W., Porges, S. W., & Porges, S. W. (2011). The polyvagal theory: Neurophysiological foundations of emotions, attachment, communication, and self-regulation
[iv] Dana, D., & Porges, S. W. (2018). The polyvagal theory in therapy: Engaging the rhythm of regulation. W.W. Norton & Company
[v] Nightingale F. Notes on nursing ‘what is it, what it is not ‘ Florence Nightingale 1968 Dover Pub p48
[vi] Davies B and Oberle K (1990). Dimensions of the supportive role of the nurse in palliative care. Oncology Nursing Forum. 17(1): 87-94
[vii] Leslie JL, Lonneman W. Promoting Trust in the Registered Nurse-Patient Relationship. Home Healthc Now. 2016 Jan;34(1):38-42. doi: 10.1097/NHH.0000000000000322. PMID: 26645843.
[viii] Johnston B and Smith L (2006). Nurses’ and patients’ perceptions of expert palliative nursing care. Journal of Advanced Nursing. 54(6): 700-709
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