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GPNN Archives - St Christopher's Hospice

Do you feel safe in our care?

Starting with my own experience

Marie Cooper
Marie Cooper

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.

Building rapport

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.

Conclusion

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.

Find out more and join the GPNN


[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

GPNN nurses championing advancing palliative nursing

Farah Demachkieh, Senior Nurse at SANAD Hospice Lebanon and a Global Palliative Nursing Network (GPNN) Champion. Here, she reflects on their recent GPNN Champions meeting with Heather Richardson, Director of Academic Learning and Action at St Christopher’s Hospice.

A few weeks ago 16 nurses met together virtually to think about advancing palliative nursing and the place of being a leader in that endeavour.

By definition the group that met are working to become “champions” – proponents for the value of nursing; ambassadors for our colleagues doing great work in palliative care and change agents in relation to the impact that palliative nursing can have for people dying or bereaved.

In specific terms, we are working together to champion the new Global Palliative Nursing Network that brings nurses together around the world to advance palliative nursing.

Stronger leaders

We wanted to be inspired to be stronger leaders- through the work of others on the call and nurses that have influenced us. 

When we think personally about our ambitions to be the best nurse that we can be, these aspirations have often been most influenced by observing or studying the work of nursing colleagues – people whose impact on patient care is clear; individuals who can enthuse and inspire teams of people around them; leaders who bring energy and vision to an often tired and dispirited group; leaders who uphold nurses position, role, voices and demands. 

Individually and together we have been shaped and motivated by nurse leaders throughout our careers and also by reading about the lives and work of nurse giants – Mary Seacole, Cicely Saunders, Florence Nightingale to name a few.

Recently, on Waterloo station in London, GPNN facilitator and Director of Academic Learning and Action at St Christopher’s, Heather Richardson read a poem by Professor Laura Serrant, a nurse who had come over to the UK in the Windrush Movement, entitled “You called and we came”. Her commitment to achieving a vision of “health for all” and the personal upheaval she endured to do so is both moving and inspiring. She is a nurse leader of gigantic proportions with real influence, and Heather is keen to be more like her.

Transformational leadership

Our time together as “champions” has been very helpful in this regard. When we met last month we explored the American model of transformational leadership – focused on actions and behaviours to create then help others achieve a shared vision. It encourages modelling, enabling and encouraging as well as challenging processes that are unhelpful.

We looked through its perspectives at some of the shared characteristics of nurses Cicely Saunders and Florence Nightingale, articulated by Marie Cooper and Heather Richardson some years ago. There is strong resonance – a visionary leader and protagonist for excellent care amongst others.

Then we talked together about areas for collective and personal growth to become stronger leaders – achieving change and impact at local, regional and global levels. Recalling that event, thoughts that seemed to resonate the most are:

  1. How many leaders already exist in our membership; yet individuals often don’t see themselves as such. We owe it to each other to notice and articulate others’ leadership qualities so that they can refine and leverage them to better achieve their goals
  2. How supportive the network is as people grapple with personal and professional reflections of frustration when they can’t achieve the leadership potential they have or could bring to the challenges they face
  3. How valuable models such as that of “transformational leadership” are. We hope fellow champions will reflect on where they want to hone their skills then seek out help from the network (mentoring, coaching, formal learning) to become even more effective
  4. How important it is to model to fellow nurses how they can transform the death course; as the life course, of patients and their families and give them a sacred opportunity to a dignified goodbye, a goodbye that patients would want to experience, a goodbye that caregivers would want to cherish and remember and a goodbye that nurses would want to feel proud of. We both frequently encounter nurses who do not understand the extent to which they can contribute to improving people’s end of life moments because they have never seen how it can be done differently; instead they are very focused on saving lives. It is our role as champions not only to talk but also to model what palliative nursing is about.
  5. How “encouraging the heart” as one element of the transformational leadership model lies at the heart of palliative nursing that is driven by compassion. This reinforces the leadership attributes that are inherent to palliative nursing, often echoed by the champion nurses.
  6. How challenging the nursing process and advocating for and adopting “a public health narrative” could serve as a crucial act to advance palliative care. Nurses are very, rightfully, attached to the patient-staff narrative; however, in palliative care communities play a fundamental role in end-of-life care and as such nurses have the opportunity to empower communities to reclaim their unique role in supporting dying patients and bereaved family members.

We believe that the champions group and the wider nursing network creates a safe space for all the champions “to be” and to reflect on different attributes that they can hone, including leadership ones thereby helping enhance palliative nursing and fellow nurses.

Thank you all for your contribution.

Farah Demachkieh

Introducing the Global Palliative Nursing Network

Welcome

I am delighted to be introducing you to this new network launched via the Centre for Awareness and response to End of Life (CARE) at St Christopher’s on 12 May, the International day of the Nurse.

Global Palliative Nursing Network

The Global Palliative Nursing Network has been set up in response to many nurses who, having participated on various CARE programmes over the past few years wanted to stay in touch. They told us how they really valued conversations with peers and the opportunity to learn from colleagues working in different parts of the world. They enjoyed the similarities and differences with their own experience and the access provided by peers to contemporary nurse thinking

The new network will focus on personal and professional development. We are currently generating an early programme of learning and want to incorporate issues such the use of an ethical decision-making framework for every day nursing practice. In addition we are keen to consider emerging contemporary issues of interest to our members, for example ‘Re-encountering historical trauma at the end of life’ and advances in trauma informed care. This is in fact the topic for our first Spotlight Event which will take place on 11 July at 1pm (BST).

We welcome any nurse involved in providing palliative care for children, adults or both, across any care settings. We invite you to join and see whether this network could be of value.

We want to connect nurses with nurses and to share their knowledge and insights. Such relationships could help build a profession that is clear about its value, then more confident to design and deliver the care that our communities need and expect of nurses.

If you are a nurse we hope you will come on the journey with us as we grow the network and what It can offer your colleagues and profession.

What you can expect

When you join us, you can expect:

  • Blogs about contemporary nursing issues of relevance to palliative care with on-line opportunity to discuss the implications for practice.
  • A variety of webinars related to nursing available to a global audience.
  • Access to a broad range of virtual learning tools and resources via CARE
  • An invitation to an annual global nursing conference
  • Connection with a broad network of colleagues offering support and new insights into innovations and developments in nursing.

What we ask of you

This network is free to join but we hope that you will bring your expertise, insights and connections to the group and help us grow and flourish as a community. We hope that relationships will be reciprocal, and are confident that whilst many members may seek support for themselves, they may also be willing to engage with others who could benefit from their expertise.

We look forward to meeting you there!

Marie Cooper

Marie Cooper
Senior Nurse Advisor

Celebrating Palliative Care Nursing


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