Abstract
Nurses have a key role to play in therapeutic interventions for bereaved and grieving families. In this article, hermeneutic inquiry is used to uncover what families found helpful or useful with respect to therapeutic conversations with advanced practice registered nurses. The findings show that nursing expertise is important in family nursing practice. Expertise in the relationship allowed the family to find healing and hope by addressing core constraining beliefs. Clinical judgment, or sense, was significant in guiding the therapeutic conversation. Lastly, how problems are framed and how families are positioned have implications for outcomes and therapeutic change.
Keywords
The death of a family member, although an experience inevitable in our lives, is often one of great difficulty and suffering. Since the beginning of the past century, professionals have been involved and curious about not only the nature of grief, but also how to be helpful to the bereaved. Nurses encounter death and grief in almost every practice setting. By virtue of the nature of their work, they are strategically situated and have opportunities to address the suffering of families who are bereaved. They therefore have an important role and ethical obligation to contribute to grief work and research (Cody, 2007; Pilkington, 2006; Reed, 2003).
Nurses are positioned to be helpful to families in different ways than other health care professionals. For example, in palliative/end-of-life care, nurses have been identified by families to have the most significant role in bereavement support (Wilson, 2003). Nursing does not have the history or mandate to diagnose and prescribe, but rather to understand (Cody, 2000; Pilkington, 2006) and to work with families to alleviate suffering (Wright, 2005). This may allow nurses to work with bereaved families more easily in a nonpathologizing manner, encouraging instead a collaborative and cooperative stance (Wright & Leahey, 2009, 2013). Nursing research about grief and interventions with grieving families is thus likely to contribute unique knowledge.
How grief has been conceptualized has shifted in the past couple of decades (Moules, Simonson, Fleiszer, Prins, & Glasgow, 2007; Moules, Simonson, Prins, Angus, & Bell, 2004; Sandler, Wolchik, & Ayers, 2008; Worden, 2009). Historically, it was thought that when one worked through the appropriate steps of the grief process, bonds with the deceased could be discontinued and healing would thus occur (Davies, 2004). In recent decades, theory has shifted to embrace the idea that grief may mean continuing bonds with the deceased (Klass, 2006; Klass, Silverman, & Nickman, 1996) and that it is a lifelong, life-changing experience (Moules, 1998; Moules et al., 2004; Moules et al., 2007) requiring reconstruction of meaning (Neimeyer, 2001, 2010). Rosenblatt (2008) suggested that many people will never reach a time when they completely stop grieving.
How grief is conceptualized matters because it influences how practice and research are approached. For example, much of the intervention research across disciplines looks at outcomes only at 1 year following the intervention. If grief is thought of as a lifelong experience, it would be worthwhile to see if interventions have longer-term outcomes. Furthermore, if grief is viewed as a psychological process that proceeds through stages, interventions will be framed very differently than if the social, spiritual, relational, cultural, and functional aspects of a family are considered (Moules, 1998).
There is an increasing amount of research and theory focusing on experiences of families who are grieving (Walsh & McGoldrick, 2004), and it has been identified that further research using a family lens is needed (Moules et al., 2007; Stroebe, Stroebe, & Hansson, 2006; Worden, 2009). Kissane and Bloch (2002) developed the family focused grief therapy model to address the lack of literature on grieving families. It focuses on identifying families in palliative care who may be “at risk” for maladaptation to loss. Nonresearch literature focuses on the experience of family and several authors offer theoretical and clinical descriptions (Balk, Wogrin, Thornton, & Meagher, 2007; Stroebe, Hansson, Schut, & Stroebe, 2008). There remains limited research on family-focused interventions with grief.
In a similar vein, much of the nursing literature relies on outdated conceptualizations of grief and focuses on the experience of grief, rather than nursing interventions related to grief (Thirsk, 2009). This is congruent with much of nursing research, which has tended to focus on the description of phenomenon and less on specific nursing practices or interventions (Bell & Wright, 2007). Although there is a plethora of nursing literature describing the phenomenon of grief in varying populations and contexts, the literature often includes suggestions for practice that are vague and are not theoretically grounded or well researched (Thirsk, 2009). Our aim in this research was therefore to understand the nature of family nursing interventions with families experiencing grief. This research attends to many gaps in nursing knowledge: It examines family nursing interventions based on a theoretical model of advanced practice nursing, the practice studied and the research design reflect contemporary theories of grief that acknowledge the significance of family and the lifelong nature of grief, and it offers an in-depth exploration of nursing interventions with families experiencing grief.
Method
Context
The study examined advanced practice family nursing interventions guided by the Illness Beliefs Model (Wright & Bell, 2009; Wright, Watson, & Bell, 1996). The interventions examined took place at the Family Nursing Unit, University of Calgary, which was an outpatient family nursing clinic housed in an academic faculty setting. The purpose of the Family Nursing Unit was to assist families; prepare advanced practice nurses; and conduct research on families, illness, and Family Systems Nursing (Bell, 2008; Wright, Watson, & Bell, 1990). This advanced practice with families takes place in the milieu of therapeutic conversations focused on understanding and alleviating suffering. This is achieved through uncovering and challenging constraining beliefs—those beliefs that “perpetuate problems and restrict options for alternative solutions to problems” (Wright et al., 1996, p. 5) and inviting and reinforcing beliefs that are more facilitating in their ability to “soften suffering” (Wright & Bell, 2009). All therapeutic conversations identified in this article as “sessions” with the families were videotaped.
Participants
Families were invited to participate in the research interviews if they had presented to the Family Nursing Unit with a concern about grief in the past 10 years (at the time of the study). Although grief may occur in many situations of loss, this particular study focused on grief following the death of a family member. Four family members from three families consented to participate. The three nurses who had worked with these particular families were then contacted and also consented to participate. Further description of the families is found in the findings section. Ethical approval was received from the local health ethics research board, and all ethical aspects of research were maintained throughout the research process.
Study Design
Hermeneutic inquiry, guided by the philosophical hermeneutics of Hans-Georg Gadamer, was used for this research (Gadamer, 2004). The nursing interventions examined took place in a milieu of relationships, language, and therapeutic conversations. Hermeneutic inquiry has been shown to be a useful and appropriate approach to studying these types of nursing practices (Chesla, 1995; Moules, MacLeod, Thirsk, & Hanlon, 2010; Moules, McCaffrey, Morck, & Jardine, 2011; Tapp, 2004).
Data collection
Data collection occurred from 2007 to 2009. Once the three families were identified and consented to participate, their clinical work was reviewed. This included videotapes of the family sessions (12 videotapes), documentation by the clinical teams for each of the 12 sessions, 10 therapeutic letters, and one outcome study. 1 Relevant portions of the family session recordings were transcribed. These data were used to understand the context and concerns of the family members and clinical team and to note significant events in the sessions. Significant events were ideas or conversations that stood out as unusual, changes in family member affect, or conversations noted as important by the clinical team. Research interviews were then conducted and transcribed verbatim.
Analysis
Text generated from the interviews was read and reread, and interpretive memos were made when portions of the texts stood out as significant to understanding. Gadamer (2004) contended that noticing of significant aspects is when understanding begins, in other words when you are addressed by the text. Interpretive memos were expanded on by reviewing data from the family sessions, the research transcripts, and literature. This brought new understanding(s) of the clinical work—what Gadamer would have referred to as a fusion of horizons.
In hermeneutic inquiry, the researcher may turn to the literature to seek help in understanding (Jardine, 2006), and consequently the literature aids in analysis and in fact becomes data. Literature is not used to support, verify, or confirm findings, but rather to further explore, understand, and find meaning and history to what it is the participants have to say about the topic. The process of analysis/interpretation is metaphorically referred to as the hermeneutic circle where “beginning conjectures are developed and put into play in writing, in practice, and in dialogue to sound out their merit and credibility” (Tapp, 2004, p. 563). This interpretive writing is presented here as the research findings.
Findings
The three families in this study all had very different experiences at the Family Nursing Unit. Rather than focusing on saturation or repetition in the data, Gadamer (2004) argued for the “fecundity of the individual case” (p. 34). In other words, “[O]ne deviant case that does not fit conventional wisdom may tell us more than 999 that do” (Walter, 1996, p. 9). In this regard, although the families varied considerably in what they recalled to be useful about the conversations, the findings still contribute to our understanding of family nursing interventions with grief.
Christine, Amy, and Ryan
Christine attended three sessions with her two eldest children, Amy and Ryan, following the deaths of two members of their family. Christine’s youngest son, aged 18, had died in a drinking and driving accident 2 years prior to the sessions, and her husband had died from a myocardial infarction 1 year following their son’s death. The research interview with Christine took place 10 years after the conclusion of the clinical work. Amy and Ryan declined to be interviewed for this research. Data presented in this analysis are from the family sessions, the outcome interview, Christine’s interview, and the nurse’s interview.
What stood out most in the research interview was the detail that Christine could recall about the clinical work that had taken place 10 years prior. She described several aspects of the sessions that were useful. One of these aspects was the nurse who worked with their family and their relationship with her. Another aspect was Christine remembering the supervisor of the session commenting in the reflecting team that she had hope for their family. The following interpretations further explore the role of the nurse in the relationship and conversation, and the key aspect of hope in therapeutic conversation.
“I can just be me.”
In the first session, Christine explained that she believed she had not been as “available” to her children as she should be as a mother, and this had contributed to her youngest son’s death. Following the two deaths in her family, she continued to think she had not been available to help her two oldest children in their grief. Her two adult children, who attended the session with her, stated that she had always been available to them as a mother. They explained to the nurse that they had told their mother this on several occasions. At the beginning of the second session, Christine surprisingly explained that she no longer felt any guilt around this feeling of availability to her children. The nurse explored this change in thinking.
Why is it, do you think, that you were able to hear your children in the session when you weren’t able to hear them before?
Maybe because I wasn’t alone having to hold us all together. I could just be me in a session . . . I don’t have to be in charge, I can just be me.
In the research interview, the nurse was asked about this significant shift in beliefs for Christine, and what it might mean for the nurse to take on the role of “holding a family together.”
I think maybe there was a freeing of some of that responsibility of “okay, somebody else is going to guide the conversation, somebody else is going to take it . . . I can indulge myself in what I’m feeling.”
In the research interview with Christine, she was asked how it was helpful to talk with a nurse, rather than talking to family or friends about her grief.
I felt no real emotional burden that I had to protect anybody, or that I had to be any particular way, you know? I just could really be me. Which I realize that now, over the years . . . this was very special, you know, because there’s not, I can’t think of a whole lot of situations where I can totally just be me . . . [the nurse] was really looking after Amy and Ryan and I could sort of let that go.
The nurse was able to help Christine with her suffering because of her role as a professional, as someone outside the family. Although Christine’s children had told her previously that she had been available to them, somehow having additional support to hold the family together allowed Christine to hear things differently; it allowed her to “just be me” and because she could now hear and believe this, she found some healing.
Valid and just
Christine explained another aspect that stood out from the sessions was the nurse herself:
One was not a thing; it was [the nurse]. You know she was so present in our pain. I don’t know how else to describe it. But she was so present, she was with us, and that in itself was so healing, was so validating.
Ryan reported in the outcome study, “We got the justification that we were looking for, for someone else to tell us we were still normal and still sane.” Validating a family’s experience means going beyond simple acknowledgment, but actually supporting their experience, from the stance of someone in authority. With the policing of behaviors (Walter, 1996) that can occur in Western society around grief, it is understandable that families may not think their experiences of grief are a valid experience—that somehow their experiences are not justified. The approach and role of the nurse during these therapeutic conversations allowed the family members to feel valid and justified in their experience of grief, and this was healing for them. This seems to point further to the role of the professional as someone external to the family; the support from someone in an authority position aided in their healing.
Objectivity
In the outcome study, when Amy was asked what had been the most helpful thing in the sessions she stated, “The objective way of looking at trauma.” The word objective stood out in this statement because it is troublesome in some regard. This notion of objectivity does not fit with the theoretical underpinnings of the Illness Beliefs Model, because “objectivity assumes that there is one ultimate domain of reference for explaining the world” (Wright et al., 1996, p. 38). Often, being objective implies an effort to remove all emotion, history, and intuition from a situation, and value “facts” over everything else. It is perhaps common that experts or professionals are believed to be objective, implying that they have some knowledge or power to be able to see things the way they really are.
It did not seem, in the review of this clinical work, that the nurse was objective in the sense she had the “correct” or “true” version of the events, or that the nurse knew the “right” way for the family to think, feel, or be. In looking at trauma or grief “objectively,” perhaps the nurse refrained from making assumptions about how the family had interpreted the events and circumstances in their life. She was open to the family’s interpretations and was skilled at offering and facilitating more helpful interpretations to come forward. Perhaps this “objectivity” reflects the ability of the nurse to not assume she already knew how the family had interpreted the death and what meanings they had attached to it. Perhaps being objective could also mean looking at an event not as a neutral thing, but as a topic that becomes a thing of suffering only as a person makes interpretations about it or attaches meaning to it. The topic of grief, by itself in the world, does not absolutely and only bring suffering.
Perhaps what brings meaning to the topic or events are the interpretations that people make of them, these interpretations are influenced by the beliefs that people hold, the lens through which they view the world. In this way the meaning and interpretations that the family members make out of a death determine their emotional response, their suffering, their experience of grief. In being “objective,” the nurse was able to then recognize the meaning, beliefs, and strengths that this family had. She was better able to then offer support or change with the beliefs that were causing suffering.
Hope lives in Pandora’s box
In the very first session, Amy asked the clinical team, “Is there hope? Like across the board, is there hope for good times ahead or is it always going to be tainted?” In the reflecting team, the supervisor commented, “I sense a very strong family and am very hopeful for them. There will always be sorrow but I have a lot of hope for them as a family for a better future.” The nurse further commented on this notion of hope in the research interview.
I’m guided by the belief that families, in their time of greatest despair, need hope. . . . That you’ve got to believe that things are going to be better than they are now, that there’s going to be good times ahead. You know, and you can believe that, without believing that you have to say goodbye.
In Greek mythology, hope is connected to Pandora’s box. Zeus sent Pandora a box to play a trick on her husband Prometheus (Graf, 1993), knowing that Pandora’s curiosity would result in her opening the box (Grant, 1962). The box contained all the evils, maladies, illness, and sorrow that roam the world (Grant, 1962; Morford & Lenardon, 1977). Differing versions report either that Zeus willed her to close the box (Morford & Lenardon, 1977; Nietzsche, 1986) before hope could escape into the world or that hope remained in the box “since this, for good or harm, remains within our own control” (Grant, 1962, p. 109). Nietzsche (1986) interpreted hope as the worst of all evils:
Now man has the box of good fortune forever in the house and is amazed at the treasure he possesses in it; it stands at his service, he reaches for it when he desires to do so; for he does now know that the box Pandora brought was the box of evil and regards the evil that has remained behind as the greatest piece of good fortune—it is hope. For what Zeus wanted was that man, though never so tormented by other evils, should nonetheless not throw life away but continue to let himself be tormented. To that end he gives men hope: it is in truth the worst of all evils, because it protracts the torment of men. (p. 45)
In the interpretations of this myth, it is debated whether hope is a curse or whether it is good. Morford and Lenardon (1977) argued that hope does seem to be the one thing that “enables man to survive the terrors of this life and inspires him with lofty ambition” (p. 49), but it is a curious inclusion in a box full of evils. This family had experienced a great deal of sorrow in their lives. Amy began the sessions wondering if there is hope, and if so, how one obtains it. Indeed, hope is the thing that enables people to carry on with their lives, surviving the terrors. Somehow the conversations with the nurse allowed hope to emerge, metaphorically, from the bottom of Pandora’s box.
Hope has been found to be a key ingredient to success in therapeutic encounters. The family member has to believe that there is hope for things to change and that someone can help them with this (Hubble, Duncan, & Miller, 1999). The nurse was asked in the research interview how a therapist could contribute to feelings of hope with a family.
I would argue that the hope might be generated by doing some other good work. Yes, Christine said that [us] having hope for them was helpful. But it was the other challenging of constraining beliefs that made the biggest difference for them. I think the help people are hoping for is a relief of their pain, their depth of suffering . . . a softening of suffering. I believed I was helpful to them because Christine said that some of her pain had lifted “I’m a lot more at peace.”
It may be that because of the work of the nurse and the clinical team challenging their constraining beliefs, they were suffering less and were more at peace. In this way, the family was able to believe that they were going to be okay, to hope for things turning out okay, or to be able to look forward to something. This confidence in hope was articulated by Christine in the research interview. When asked what was most helpful for her family to find healing, she stated, “Just the real confidence that I felt from [the nurse] and the team, that as a family, you’re going to be okay.”
Overall in this clinical work, there were likely several other unarticulated practices that contributed to the effectiveness of this clinical work. Although Christine did report that Amy and Ryan were doing well now, with their own families, it would have enhanced this research to have their perspectives. Lastly, hope and healing are not passive processes and willingness and work between the family and the clinician has lead to sustained alleviation of suffering, over the past 10 years, allowing the family to find that needed hope to carry them on.
Edward and Martha
Edward and Martha’s daughter, Cynthia, died at the age of 32 from a myocardial infarction after living with diabetes and chronic kidney disease. They attended five sessions, approximately 2 and one half years after her death. Edward attended all five sessions, Martha attended two sessions with him. The research interviews took place 7 years after the conclusion of the clinical work. In the analysis of the clinical records, and research interviews with both the family members and the nurse, what stood out was the possibility of two core constraining beliefs that were causing them suffering that had not been addressed in the clinical work. Data presented in this analysis are from Edward and Martha’s interview, the nurse’s interview, transcription of the sessions, and review of documentation of the clinical work.
A sense of the heart
When asked in the research interview what Martha recalled as helpful from the sessions, she responded,
I was extremely upset, and quite angry. I thought, why am I sitting here behind this glass and being reviewed by people that don’t know me, that don’t know what I’m going through, and what a broken heart I have, how angry . . . to be very honest, I didn’t get one thing out of that, nothing.
When Edward was asked what he recalled as helpful, he said that he had gone to other counselors previously as well, “but I didn’t find any of it really helpful. None of it was helpful.”
The constraining belief identified in documentation of the sessions was that Edward believed he had lost connection with his daughter. The clinical work focused on reclaiming this relationship. In review of the videotaped sessions, however, it seemed he was suffering more with a belief that fathers should ensure that their daughters are safe. In the first session for example, he commented that his daughter would still be alive if it were not for her boyfriend at the time. He also stated, when Cynthia was alive, the relationship with her boyfriend was such that he was never sure she was safe. Now, after her death, he continued to wonder if she was okay and still did not feel able to protect her.
In the research interview, Edward stated,
You know a lot of people just pay lip service when someone dies—“they’ve gone to heaven.” . . . I guess when it’s someone I was supposed to look after, but didn’t or couldn’t anymore, it’s so hard.
This belief was never directly addressed in the clinical work. If he had believed that he had somehow failed his daughter, it is understandable how this would contribute to a remarkable amount of suffering.
A second possible belief became apparent after the research interview with Edward and Martha. The couple had continued to see counselors in the 7 years since this clinical work, stating they “had a psychologist on retainer.” Both had been on antidepressants, and Edward had gone through electroconvulsive therapy. It was interesting the perseverance that Martha and Edward both had in continuing for numerous years to somehow find hope or healing for their “broken hearts.” Might it be that continued suffering in grief had a purpose for them? Perhaps there was something about continued suffering that they thought honored Cynthia’s death. Perhaps they held another core belief that parents must forever suffer after the death of a child. This is a hypothesis, however, and was evident only in the research interview, which took place 7 years after the sessions. It may not have been captured if the research interview had been done only in the 6 to 12 months after the intervention, and thus there are implications for timing in looking at outcomes from grief interventions.
In the research interview with the nurse, she stated that she was quite surprised by Edward and Martha’s responses that the sessions were not helpful.
I didn’t have any sense of the intensity of that anger or the sense that she didn’t want to be there in such a strong way. . . . It’s kind of sad that she felt . . . judged, or feeling like she was under a microscope. . . . I didn’t have any sense of that at the time.
The nurse further reported she had the sense that the clinical work had been very helpful, especially to Edward. When asked why she thought it was so powerful, or what was it that made her think it had been useful, she replied,
I think the sense that I had of, between me and him in the room, you know. And there was almost a sense of sacredness about it, or that I just felt that he felt a connection with his daughter in a way that was very different than any other way that he’d been able to connect before in anything he’d done in that grief journey up until that point. . . . There was a quietness about it, that he seemed to be really, I don’t know, within himself. . . . I felt that went really well.
The review of videotapes uncovered some support for the “sense” that the nurse had. At the fifth session, Edward reported that the clinical work had been helpful. He further talked about positive change in himself and his wife, which is why the decision to conclude the clinical work was likely made.
Therapeutic change is thought to occur as “the belief at the heart of the matter is distinguished, challenged, or solidified” (Wright et al., 1996, p. 81). If the core constraining belief was thought to be at the “heart” of the suffering, how do clinicians know that they are dealing with the heart, and not just the periphery? There is a possibility that a problem at the heart can cause signs and symptoms in the periphery, and it is even possible that there may be symptomatic, temporary relief from interventions aimed at the periphery. A change at the level of the heart would have a more profound and longer-lasting impact than changes in the periphery. What would be the difference in sustainability of therapeutic change if the beliefs that were challenged were not core but peripheral beliefs? This may be why Edward had reported the sessions to be initially helpful, but then did not reflect this change as sustained a number of years later. For clinicians to know they are at the “core” of something in clinical work likely requires subtle and sophisticated judgment, what the nurse in the research interview referred to as “sense.”
Gadamer (2004) described sense as knowing whether something belongs or is correct, and this requires judgment or taste. Knowing what belongs and what does not in a therapeutic conversation is an art, requiring one to be cultured, experienced, and wise with a topic. Cioffi (1997) argued that the intuitive sense that nurses use for clinical decision making has often been discredited by the dominant scientific paradigm, and this has led to nurses not talking about how they do make decisions. On the other hand, Cioffi stated this intuitive knowledge is the knowledge that is most frequently used by nurses for clinical decision making in uncertain situations. She described this sense as “a subtlety of knowing operating beneath consciousness that is borne of experience and available in memory for recall with a sense of appropriateness in clinical situations” (Cioffi, 1997, p. 204).
The nurse may have had the sense that the clinical work was on track because they were attending to some beliefs, but they may not have been core beliefs. Therefore, the changes that Edward noticed at the end of the sessions were not sustained. Developing and, furthermore, articulating this decision-making process for nurses is important.
This identification of beliefs may not be the whole reason why the clinical work was not, 7 years later, reported as useful. The nurse offered in her interview,
If grief is really a journey that you have for life, and not that any one thing is going to be the thing that resolves grief, I don’t think that, I think there are things that help you walk through life with the grief that you carry. . . . So I think there may be a piece of that in here, yeah, because I really do think that helped him in the short term.
It is possible that nursing practices and interventions may be useful to families for a season, a reason, or a lifetime; just because they are not sustained for a lifetime may not necessarily mean that they were not needed and useful at the time.
Dianne
Dianne came to her first session 6 weeks after her husband died from cancer. At the time of his death the couple had 4-year-old twins. Dianne participated in four sessions that occurred over a 4-month period. The interviews for the research project took place 4 years after the conclusion of the clinical work. Data presented in this analysis are from Dianne’s interview, the nurse’s interview, and transcription of the sessions.
In initial review of the videotapes and session documentation, it did not appear that Dianne had found the sessions to be helpful. Dianne frequently asked the nurse and the team if they were learning enough from her, if she was “upset enough to be here,” and if she had been helpful in the process of learning grieving for the team. Dianne responded in the research interview that she had not found the sessions to be helpful and wondered if they had been helpful for educating the team. Instances such as these, when sessions were not seen as useful, also have something to offer in terms of understanding nursing practice with families. One interpretation of why the sessions were not helpful was related to timing, as has been reported elsewhere (see Thirsk & Moules, 2012).
Customer for change
When asked in the research interview what was useful or helpful in the sessions, Dianne asked, “When do you help someone?” It was apparent that Dianne was confused as to the purpose of the sessions. The nurse who worked with Dianne concluded in the research interview that Dianne was not really a customer for change during the sessions.
I don’t think she was a customer for the work that we were doing in the way that many people are coming in and saying, okay, I’m stuck, something isn’t working. . . . I’m open to some new ideas for change. . . . Because she really wasn’t looking for anything, for her not to be able to identify what she was coming for, was a pretty good indicator. . . . We were sort of trying to help her come up with something that we can be helpful for. . . . People know when they’re stuck . . . help that’s not perceived as helpful, isn’t helpful!
The concept of “customer” for therapy has been described in the literature as someone who seeks change for themselves (MacDonald, 1994) or a ready buyer (Ziegler, 2010). The alternative descriptions of people who come to therapy are “complainants” or those who want others to change and “visitors” who do not wish to see any change (MacDonald, 1994; Ziegler, 2010). The original conceptualization of the “position” of the client by Fisch, Weakland, and Segal (1982) explored how it is that clients come to therapy based on who is complaining about the problem—termed the “complainant”—and offered suggestions for working with clients based on their presentation to therapy.
Fisch et al. (1982) described that typically people come to see a therapist because they are distressed and are looking for some help with that distress. They also identified the “window shoppers” who
come in primarily at the behest of another person and are therefore in the office under duress or coercion. . . . They are not truly customers but obscure this by acting as if they are. . . . [They] are not in treatment to make any change in the stated complaint. (pp. 39-40)
Dianne was referred to the sessions by a neighbor who was very concerned about her after the death of her husband. It was not clear what was said between the neighbor and Dianne in the referral, and how Dianne was referred may have affected what she thought the purpose of the sessions were. It was likely that Dianne was not attending because of her own desire to seek change, but perhaps at the behest of her neighbor.
A common error can be made when the therapist continues the sessions as if the person were “ready to get down to business” (Fisch et al., 1982, p. 40). However, there is the possibility of “renegotiating the contract” (Fisch et al., 1982, p. 40) and still having a good outcome. This occurred in the first session when Dianne wondered whether or not she needed to be there. The team offered that perhaps people could go to counseling not only when they were stuck but also to receive support and have a sounding board for things that they were doing well in their lives. Although it was not explicit that Dianne agreed to this renegotiated contract, it may have been assumed because of her continued attendance at sessions. Another hypothesis about the renegotiated contract would be that Dianne’s attendance was to fulfill the purpose of offering the team an opportunity for learning and for research. This was supported by Dianne’s comments in the sessions such as “I’m not sure if I’m helpful for anything” as well as the nurse’s comment in the research interview:
We made it very clear that we learn from our clients right? . . . Which is a way of lowering the hierarchy and leveling the playing field . . . we were learning from her so we could be helpful to people who needed help, and she didn’t identify herself as really needing help.
If this was the understanding that Dianne had of the purpose of the sessions, then her response in the research interview of “when do you help someone” makes sense. She was not identifying herself at that time as being in distress and needing help, and the sessions continued under the implied contract of her helping the team to learn and understand.
Discussion
It matters that nurses have expertise and bring this expertise into their practice with tact, wisdom, and judgment. Throughout the three cases, the nurses’ expertise as professionals was as important to the effectiveness of the clinical work as any particular “intervention.” It is useful for families who are grieving to be able to let go of worry and know that the professional is there to hold things together. This allows for a freeing to “just be me,” as Christine suggested, to indulge in emotions, and to hear things differently. The nurse needs to be a stranger so the family does not have to worry about them. As strangers, or moreover “compassionate strangers,” nurses can be involved in the process of healing, but not involved in the problem (Robinson, 1996, p. 161). Walter (1996, 2000) wondered if grieving was more of a social process than an internal process, and, therefore, trends in families affect grief. “Those who knew the dead person are often physically separated from one another. Families are spread around the country if not the world” (Walter, 1996, p. 16). He further suggested that, in the absence of someone who knew the bereaved, a sympathetic listener such as a counselor is often sought, but he thought this may be a poor substitution for families.
This research demonstrated the nurse being a stranger is beneficial in ways beyond being an empathetic ear. Nurses need to have expertise, or an authority, to be legitimate at validating someone’s experience. People seek out the expertise of professionals with hope and expectation that the professional can help (Hubble, Duncan, Miller, & Wampold, 2010). It is the professional who is able to validate the family’s experience in a way that family and friends perhaps cannot. The professional may also be able to “hold things together” so that things can be heard and understood differently between family members, and hopefully lead to some healing.
Hope has been found to be a key ingredient for success in therapeutic conversations—family members need to believe that there is hope for change, and that someone can help with this (Hubble et al., 1999; Hubble et al., 2010). Hope is a concept that is frequently discussed in nursing and described in nursing literature. It may not be that a nurse can give a family hope, but this research demonstrated that there are particular practices that seem to foster hope in therapeutic conversations—the validation, curiosity, and work of challenging beliefs to alleviate suffering.
More particular to the actual interventions, the nurse needs to demonstrate good skill and clinical judgment, to uncover and challenge the core constraining beliefs. In advanced nursing practice, Gadow (1995) argued that expert clinical assessment is based on “combining knowledge from nursing theory and research with knowledge about a specific client” (p. 25), uniting general and specific knowledge. Benner (1984) has explored aspects of intuitive judgments for nurses and also how the expert nurse’s knowledge accrues over time through a nurse’s practice. “Expertise in complex human decision making, such as nursing requires, makes the interpretation of clinical situations possible, and the knowledge embedded in this clinical expertise is central to the advancement of nursing practice and the development of nursing science” (Benner, 1984, p. 148).
In relation to the Illness Beliefs Model, this means making sound decisions about constraining beliefs, whether or not they are core beliefs or the beliefs that are causing the most suffering. “As health care providers, we have an ethical mandate to . . . uncover, distinguish, and make a clinical judgment about which beliefs will foster healing and which beliefs are holding family members captive in their illness suffering” (Wright & Bell, 2009, p. 179). Attention to beliefs also means knowing the interpretations that family members have made about themselves and the world in relation to their grief and helping to reinterpret; this is where some healing and hope may be found. Having the clinical judgment to know if core beliefs have been uncovered, or the beliefs that are causing the most suffering are the ones that are being addressed, likely is developed through experience. Further research into how this particular competence is developed in students or novice practitioners is warranted.
Conceptualizing families as customers for intervention has implications beyond the presenting concern of grief and could inform nursing practice in a variety of contexts and circumstances. Fisch et al. (1982) had several conceptualizations for people attending therapy: complainants, window shoppers, customers, clients, patients, and nonclients. Wright et al. (1996) stated that families know when they need to seek help, what the most important thing to seek help with is, and what is helpful or not. It is interesting to think of the application of this idea to other areas of nursing practice, perhaps where nurses are invested in particular changes or outcomes, that may not be the identified problems or goals of the families. This is related to how nurses use their expertise and think about change. If it is believed that nurses hold the expertise to determine what the problem is, then they also decide who is in need of intervention and who needs to change. It may be possible, however, that change is more likely if problems are defined and determined by families, and the focus is on providing interventions to families who are seeking a change with their current situation.
This has implications for models of practice that identify “at-risk” families (see, e.g., Kissane & Bloch, 2002), which implies that the professional is the one who identifies the problem and the need for change. Rather, this research and previous knowledge of therapeutic change (Fisch et al., 1982) encourage the family members to approach the professional because they are in some distress they would like help with. Perhaps because nurses do not have the mandate to diagnose and pathologize, but rather to understand, they are more easily able to allow for the family to identify and negotiate the problem to be worked on, using their expertise in the ways described in this study.
Reflections on Research
Having access to a rich and varied set of data offered a very unique and exemplary opportunity for understanding. This allowed the analysis to move back and forth between the original family intervention and the recollections of the clinical work by the family members and the nurses. There was also the unique opportunity to interview family members and the nurses who worked with them several years after the interventions. All of the families agreed to be interviewed and were eager to participate in research. The interviews themselves varied in their focus on the clinical work. Although Christine was able to recall specific details about the work, her family had also been seen the longest time ago—10 years. The other families, although they did not recall the same specifics of the clinical work, were able to discuss their experiences of continuing to live with grief. Edward and Martha commented in their research interview, after the recorder was turned off, that the conversation was one of the most helpful they had because they had never had a prior chance to hear about how the other was living with their grief.
Reflections for Practice
Grief may not always be seen as being in the domain of nursing practice. Certainly in this particular context, and this particular practice, there were therapeutic conversations between nurses and families who were grieving. Yet throughout this research, countless comments from colleagues, family, and friends were made questioning why a nurse would be studying grief. It was apparent and supported in the literature that nurses encounter family members experiencing grief frequently, not only in hospice palliative care, but also in critical care, in perinatal care, in pediatrics, and among aging populations in the community. Although topics such as death, dying, and grief are topics of concern to nurses, as evidenced by the plethora of literature in nursing on these topics, it may not be perceived in society that it is the role of the nurse to have these types of therapeutic conversations. If nurses are not perceived as having expertise in this area, then the opportunity to offer effective interventions is affected. This requires further exploration in nursing education, research, and practice.
Limitations
The validity and rigor of a hermeneutic study are judged by its trustworthiness, credibility, and transferability (Moules, 2002). The research depicted in this article was part of a doctoral dissertation and, therefore, feedback from content and methodology experts (thesis supervisor and supervisory committee) was incorporated in the analysis and findings. Validation through advice and suggestions from experts improves plausibility, relevance, and importance in interpretive inquiry (Angen, 2000). There are many interpretations that could have been made. The usefulness of those presented in this article will be further judged by others based on their fit or relevance to the topic (Koch, 1996). The findings in this study are transferable if they are seen as recognizable and fitting in other contexts and circumstances.
The interactions that were captured in this research reflect an advanced practice in family nursing, in a unique clinical environment. The particular interventions that are described may be out of context and expertise for generalist nursing practice. Although there were only three family cases analyzed, the depth of analysis achieved through multiple sources of data added to understanding of nursing interventions. Additional cases would likely uncover further interpretations and understanding of family nursing practice. There are numerous, interconnected factors that contribute to change and positive outcomes in therapy (Goldfried & Davila, 2005), and this article has attempted to further explore only one piece. It does matter who the family is, and it is not only the professional who can make all the difference. Tallman and Bohart (1999) proposed that perhaps the most significant factor in effective therapeutic work is the client’s own ability to heal, with the therapist acting as a facilitator and resource provider. This was not an aspect thoroughly explored in this research, but it is important to explore in future research.
Although it was interesting and unique to research families several years after the intervention, there are likely multiple considerations to make when looking at longer-term outcomes. Family interventions occur in the context of complex lives, and events and circumstances may have changed and evolved that have continued to affect a family’s experience of grief. These interviews did contribute to further understanding of what happened in the clinical work, but would have been less meaningful had other data from the clinical work not also been available.
Conclusion
The present study contributes to family nursing literature in a number of unique ways. The interventions studied were based on an established theoretical model for advanced nursing practice with families, reflected contemporary theories of grief, and explored family interventions in depth. It was clear that the expertise of the nurse was important to the clinical work. This expertise allowed for the presence of the nurse to hold up the family, to be “objective,” to offer validity to their experience, and to challenge core constraining beliefs such that hope could find a way into the family. Expertise in clinical judgment and sense are important parts of practice to know if the heart of the matter that is being addressed and that the problem or contract has been adequately negotiated with the family. These ideas not only may be transferable to family nursing practice in other contexts and populations but also may contribute more broadly to the knowledge of grief interventions with families.
There is a belief in our society that if we do everything right, no one will suffer. It is supported by the paradigm that believes we can control and manipulate our worlds entirely—but there is nothing anyone can do to escape grief. Death is not something that we can overcome. Perhaps grief brings suffering that we can never escape because it also means we have lived and loved. Perhaps it is in grief that we are still reminded about the nature of our lack of control over some aspects of our worlds, the nature of human suffering, and the ever-present possibilities of hope that allow suffering to be something beyond pain and anguish. The nursing practices and interventions that are offered to families are done so with these things in mind and with the obligation to honor and sustain love lived and living.
Footnotes
Declaration of Conflicting Interests
The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding
The authors disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This article depicts one aspect of Lorraine Thirsk’s doctoral dissertation research (supervised by Dr. Nancy Moules), which was supported financially in part by a doctoral fellowship from the Social Sciences and Health Research Council of Canada.