NURS 6914 Week 11 reflection example

The Weight I Carried Home From a Case on Paper: A Driscoll Reflection on Moral Distress, Compassion Fatigue and Grief in Palliative Nursing

Student Name

College of Nursing, Walden University

NURS 6914: Advanced Palliative Concepts and Interdisciplinary Perspectives

Instructor Name

Month Day, Year

The Weight I Carried Home From a Case on Paper: A Driscoll Reflection on Moral Distress, Compassion Fatigue and Grief in Palliative Nursing

What?

Midway through this term, I wrote a discussion post about a composite man in his last days who begged to be sedated until he died because he could not bear the terror of waiting. The case was invented, yet I found it hard to stop thinking about him. I drafted the post late at night, rewrote the position paragraph four times and woke the next morning still turning over whether respite sedation was enough. Over the following week, I noticed a heaviness I recognized. It resembled what I carried during two years on an oncology unit, where a run of deaths happened close together and none of them was ever talked about as a team. We cleaned the room, admitted the next patient and moved on.

This reflection uses three questions from Driscoll's reflective model (Driscoll, 2007), What? So what? Now what?, to examine that heaviness: what it is, what it means for my practice as a palliative advanced practice nurse and what I will do about it.

So What?

Three concepts from this term's readings could describe what I felt, and they call for different responses, so it matters which one fits.

Moral distress. Jameton (1984) used the term moral distress for the pain of being sure what ought to be done yet blocked from doing it by the setting one works in. When I think of my oncology years, part of what I felt fits this definition: I believed the deaths should have been acknowledged, and the unit's pace made that impossible. The heaviness after writing the sedation post is different. No one prevented me from acting; the difficulty was not knowing with certainty what was right. That is moral uncertainty, not moral distress.

Compassion fatigue. Figley (2002) wrote of compassion fatigue as the wearing down of a helper's empathy by steady exposure to other people's suffering, a cost that includes taking on some of their trauma as one's own. My inability to stop thinking about an imagined patient could be an early sign of this: an empathic response that did not switch off.

Grief. Some of what I felt is plainly grief, both for the invented man, whose situation I had to imagine in detail, and, belatedly, for the patients on my old unit whose deaths passed without a moment of pause. Grief is not a disorder. It is the normal cost of caring about people who die.

To see where I stand, I completed the Professional Quality of Life Scale, which measures compassion satisfaction, burnout and secondary traumatic stress (Stamm, 2010). My compassion satisfaction score fell in the upper part of the average range, and burnout in the lower part of average. My secondary traumatic stress score was in the average range but higher than the other two would predict. I read this as a nurse who still finds meaning in the work, is not burned out, but carries more of patients' suffering home than is sustainable over a career in palliative care.

What It Means for My Practice

Palliative care will put me in the presence of death more often than oncology did. If I carry each death home the way I carried an invented one, I will not last. The readings suggest that the problem is not caring too much but caring without the practices that let grief be expressed and set down. On my old unit, the absence of any ritual after a death meant that grief had nowhere to go. I also notice that I am better at noticing moral distress in colleagues than in myself; I would have encouraged a colleague to talk about the heaviness I have been carrying quietly.

There is a professional reason to take this seriously as well as a personal one. A clinician carrying unacknowledged grief may begin, without meaning to, to protect herself by keeping patients at a distance: shorter visits, fewer questions about fears, a quicker move to the next task. I recognize that pattern from my last year on the oncology unit, when I stopped asking families how they were coping because I did not have room for the answer. The patients in palliative care deserve a nurse who has room. Making that room is part of the work, not a luxury added to it.

Finally, the distinction between moral distress and moral uncertainty matters for how I respond. Moral distress calls for changing the conditions that block right action, for example by raising concerns about workload or unit practices. Moral uncertainty calls for better deliberation: talking cases through with colleagues, consulting an ethics service and accepting that some choices will remain hard even when made well. I had been treating both as private burdens, and neither is best carried alone.

Now What?

I will keep three practices.

A pause after each death. When a patient on my caseload dies, I will take a moment, alone or with colleagues, to say the person's name and one thing I remember. Many palliative teams use a brief pause of this kind, and I intend to propose it to my future team if it is not already practiced.

Regular debriefing. I will seek a clinical supervision or peer debriefing group and attend monthly, using the time to talk about cases that stay with me.

Measuring myself. I will repeat the Professional Quality of Life Scale every six months during my first two years as an APRN, and treat a rising secondary traumatic stress score as a signal to seek support rather than a verdict.

These practices will not prevent me from feeling the weight of the work, and I do not want them to. What I want is a way to carry it that lets me come back the next day able to offer the same attention. The man in my sedation post needed a clinician who could stay present with his terror. So will the real patients who come after him.

References

Driscoll, J. (2007). Practising clinical supervision: A reflective approach for healthcare professionals (2nd ed.). Baillière Tindall Elsevier.

Figley, C. R. (2002). Compassion fatigue: Psychotherapists' chronic lack of self care. Journal of Clinical Psychology, 58(11), 1433-1441. https://doi.org/10.1002/jclp.10090

Jameton, A. (1984). Nursing practice: The ethical issues. Prentice-Hall.

Stamm, B. H. (2010). The concise ProQOL manual (2nd ed.). ProQOL.org.