1. Fahlberg, Beth PhD, RN, CHPN

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"WHY DID YOU decide to become a nurse?" I've asked this of many new nursing students over the years. Most respond, "Because I want to help people." These future nurses have been empathetic and eager to learn from, listen to, and help their patients.


Yet over time, as we become experienced nurses, we may become jaded. We see so many people in pain and suffering that we put up walls around our hearts and minds.


Our attitudes reflect how we think and impact how we talk about our patients. Negative attitudes are often evident when we judge and label people suffering from end-stage disease associated with poor decisions and addictions. These negative attitudes affect our behaviors at work as well as our interactions with patients and their families. It can prevent us from connecting with patients and providing the holistic, compassionate palliative care they need and deserve; the kind of care that first motivated us to become nurses.


How can we counter the tendency to engage in negative thinking and stereotyping? Start with the simple self-assessment exercise I describe here.


Assess yourself

Imagine that you're assigned to care for each of the patients below. What's your first thought when you read each patient description?


* Edna, 65, has end-stage chronic obstructive pulmonary disease (COPD). She's in the hospital for the third time in 4 months with a COPD exacerbation.


* Rita, 56, is a transgender woman with alcohol-associated end-stage liver failure and hepatitis C. She's been admitted for hepatic encephalopathy.


* Sidney, 45, was admitted with fluid overload associated with advanced heart failure. He weighs 450 lb (204.1 kg).


* Earl, 31, has a history of heroin use and mitral valve replacement for infective endocarditis. He's been admitted for cellulitis at an injection site and severe back pain.



Did you have a negative reaction to any or all of these patient descriptions? Did you find yourself labeling or judging them? Thinking that you wouldn't want to care for them?


Also consider how you'd describe each of these patients in talking with your coworkers or when giving patient handoff. Our choice of words reveals our attitudes and biases. For example, would you have labeled Rita as an "alcoholic," or Earl as an "addict"? Would you have described Sidney as being "noncompliant" with his prescribed diet?


Our actions also reveal our attitudes, and biases. Would you have responded slowly when Edna pushed her call bell for the third time in 2 hours to say she can't breathe? Would you have called Earl's healthcare provider immediately if the currently prescribed medication wasn't controlling Earl's pain?


When we think about our words and actions in these types of situations, we learn important lessons about ourselves, and our biases, both conscious and unconscious. We're also reminded that we can do better by integrating palliative approaches in what we think, say, and do by practicing empathy and compassion, respect, and kindness. And by seeing each patient as a person.


How attitudes impact care

Our nursing care is influenced by both our conscious attitudes and biases, as well as our unconscious, or implicit, biases. We often think of implicit bias associated with attitudes toward race or sexual orientation. However, bias, stigmatizing attitudes, and disparities in care have also been demonstrated toward patients who don't fit our values, such as patients who are obese and patients with addictions.1,2


Importantly, the stigma people feel from care providers can prevent them from seeking healthcare when they need it. Implicit bias has been identified as a potential reason that both primary palliative care and specialist palliative care consults aren't implemented as readily, or as widely as they should be in people with advanced COPD. This is particularly true for patients who continue to smoke.3


Here are some ways you can cultivate the positive attitudes that are essential to providing effective and compassionate palliative nursing care:


* Stop labeling. Dr. Bridget Johnston, a noted expert in palliative care and end-of-life issues, recently identified the practice of labeling palliative care patients as something nurses often do in daily practice. She goes on to say that "using labels...denies the person's identity and personhood, at a time when their illness is likely to be compromising their identity."4



Watch for your use of labels such as difficult, noncompliant, nonadherent, obese, alcoholic, drug-seeking and addict, and actively work to avoid using them. Not only does using this language reinforce your negative attitude, it can have a negative impact on how other members of the healthcare team think about and treat the patient.


* Connect. Rather than jumping to quick decisions or judgments about patients, open yourself to learning about them. This takes time, but it's worth the effort to cultivate the trusting relationships you need to provide palliative care for them.



When you work on connecting with Earl, for example, you might find that he's intelligent and funny and begin to appreciate him as a person. As anticipated, his pain is difficult to manage, but when you work with him using nonpharmacologic strategies combined with appropriate pharmacologic therapies, he's less anxious, his pain is significantly reduced, and he's not calling for pain medication as often.


* Listen. Be attentive to concerns, experiences, and feelings. Don't hurry your patients or ask leading questions, and don't try to "fix" them. Be open to learning what concerns them, what they're going through, where they've been, and how they feel about their future.



Using this approach, you could purposefully decide to sit down and listen to Rita early in your shift. You learn that she's on her own, estranged from her family, friends, ex-spouse, and children, "because I'm a drunk and a tranny," in her words. But even so, she feels lucky to be alive. You also learn that she's very concerned about being able to care for herself when she goes home. You incorporate her concerns into her discharge plan and facilitate appropriate social support.


* Learn. How does the illness impact your patients' life: their family, work, responsibilities, financial stability? When patients get angry or are "difficult," concerns about these types of issues are often to blame.



With this in mind, your response might be different when Edna uses her call bell and says angrily, "I want to be discharged right now!" Rather than responding, "You can't be discharged yet, you're not stable," you instead ask, "What's going on?" Edna begins to cry, saying that she just got a call from her boss who's threatening to fire her if she doesn't show up this morning. "I need this job. I've only been there 6 weeks, and this is my third absence because I've been sick." With this understanding of her situation, you're now able to advocate for a plan of care that can help her avoid losing her job while continuing to get the treatment she needs.


* Empathize. Try to understand what it would be like to be in your patient's shoes. How would I feel if I were in that situation? What would I experience that may cause me discomfort, worry, or distress?



In practicing empathy toward Sidney, you realize that he's frustrated about being in the hospital because of how he's been treated in the past. He says he avoids calling 911 because of his weight. You realize that he was worried about whether he'd fit on the transport stretcher. Based on past experience, he also believes the staff will resent having to lift him if he's too weak to stand on his own. With this understanding, and acknowledging your own potential biases, you work to promote his dignity and to prevent team members from displaying negative attitudes about caring for him.


* Give. Remember the "random acts of kindness" movement? I think we need to revisit this by practicing intentional acts of kindness. Make a point of doing something kind and unexpected for a patient or family member today. Do something that you don't have to that will fill a need, brighten their day, or take their mind off things during a tough time.



Get your patient's family coffee or a snack when they're waiting.


Sit down and ask about the patient's life or family. Be willing to listen if the patient is anxious about test results.


When caring for a dying patient, ask the family members what they'll remember about him or her, or how the person made them laugh.


Intentional acts of kindness can turn into some of the most fulfilling memories of your career. They're also what the patient and family will likely remember. Most important, these actions will cultivate positive attitudes in us and rekindle the compassionate spirit that led us to nursing in the first place.




1. Sleeper JA, Bochain SS. Stigmatization by nurses as perceived by substance abuse patients: a phenomenological study. J Nurs Educ Pract. 2013;3(7):92-98. [Context Link]


2. Flint S. Obesity stigma; prevalence and impact in healthcare. Br J Obes. 2015;1(1):1-40. [Context Link]


3. Brown CE, Jecker NS, Curtis JR. Inadequate palliative care in chronic lung disease. An issue of health care inequality. Ann Am Thorac Soc. 2016;13(3):311-316. [Context Link]


4. Johnston B. Moving on from patient labelling in palliative care. Int J Palliat Nurs. 2016;22(11):523. [Context Link]