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STUDENT
RESPONSES TO FILM
Students answered the
following questions, after viewing the film "Wit."
The movie follows a middle aged intellectual professor, from
diagnosis of her ovarian cancer to her death. The health care
professionals who treat her remain aloof throughout, able
to discuss only her treatment and blood counts, and completely
unable to show compassion or understanding of her dying process.
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Identify the
4 central figures in this film and describe these
characters and how you view their personalities and
roles.
Patient:
She analyzed and viewed each
experience from her perspective as an intelligent
scholar, never letting emotion get in the
way…She never wanted to admit she needed
help until she hit rock bottom. The patient
does not ask for anything above or beyond
the norm, physically or emotionally. This
presents her with a challenging dilemma once
she becomes aware that she is dying and vulnerable.
Fellow: The fellow in this film may be
viewed as an awkward, immature, self-serving
pompous jerk, or as someone who is afraid
of sensitive subjects and unsure of how to
handle them….His role highlighted the
dichotomy between the research role and the
patient care role. He was preoccupied with
his future plans to become a great researcher
and he perceived his residency as a hindrance
to getting there. He treated the patient like
a science project; a rat in an experiment.
His character was offensive and annoying.
Attending physician: He had one goal
in mind, to have her complete the intended
protocol of treatment, regardless of her outcome
or experience along the way. He was out of
touch with humanity. He was more concerned
with testing new chemotherapeutic drugs than
with the well-being of his patient. The patient
wanted to hold on to hope that each new drug
would cure her, and the physician's false
sense of reassurance robbed her of her right
to informed consent
Nurse: The nurse/pt relationship grew
over time. The nurse became advocate, confidant,
comforter, caretaker, and listener. The patient
began to trust her and open up about her fears
and anxieties, which was a tremendous risk
for the patient…
The primary nurse was the only true caregiver
of all the health practitioners. She expressed
kindness and empathy. She advocated for the
patient and always had her best interests
at heart. I thought the nurse's character
was tactful and sincere.
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How are death and dying viewed
by the director in this film? Discuss.
When a patient is actively dying
in a hospital, it goes against the hospital's main
objective, which is to heal and make well, therefore
the medical staff struggled…This patient did
not have any friends or family…The medical
team completely neglected the patient's emotional
and psychological needs….The nurse was the
only person who spoke to the patient about the emotional
and psychological aspects of death and dying.
This movie acknowledges
the cruel realization of the indignity of
dying in a society which is ruled by science
and technology, rather than by the heart
and soul…The director elicits both
sorrowful and humorous responses in the
viewer. He brings the viewer face-to-face
with the tender emotional expressions of
this unfortunate woman as she dies a slow
and painful death.
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Is this Registered Nurse a good
role model or not? Explain and comment.
The nurse persevered and was
able to build a trusting relationship with the
patient who then was able to share her fears
and anxieties. The role of the nurse was multifaceted;
however the role of advocate took precedence.
The medical team did not always have the best
interests of the patient in mind, therefore
it was refreshing to see the nurse advocate
for the patient whether it was regarding pain
management, DNR status, or protecting her dignity….This
film provided a picture of what the role of
the nurse might look like in a situation where
a patient is actively dying…
Although she disagreed with the orders of the
resident and physician, she remained professional
and never bashed the doctor or resident doctor
in front of the patient. In fact, she pointed
out their good qualities as excellent researchers
as she segued into the issue regarding the treatment
not working, in spite of their best efforts.
As the patient lay in a near coma, the nurse
tenderly massaged lotion into her hands, demonstrating
real kindness and respect. Ultimately, the R.N.
acted heroically in her advocacy to honor the
patient's wish to be DNR status…
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What will you take away from this
film and will it affect your future clinical practice?
I believe that the advocacy the nurse exhibited is
the thing that I'll most take away. I feel comfortable
with the emotional side of death and dying….however
at this time I am less comfortable with the role of
nurse as advocate… as a new nurse it will be
difficult to stand up for my patients when I may mistakenly
believe that others on the team know more and therefore
know what's best for my patient…. This movie
provided a more concrete example of what the role
of advocate might look like.
It is the human side of nursing; involving compassion,
empathy, and knowing how and when to say the right
thing that will be my ultimate challenge, and it is
this aspect of my job that I really want to excel
in and work at the most. This film drove home just
how important these nursing attributes are.
I have experienced the death of loved ones. What I
have learned from those experiences as well as this
film, is that the quality of one's life cannot and
should not be measured by one's success in work or
professional career alone. Life is precious and every
individual is worthy of respect and kindness.
THOUGHTFUL
STUDENT RESPONSES
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Do you fear death?
I feel that death can occur
at any given moment in my life and for that reason I always
feel the intensity of its possibility; however it is not
a fear. Having recently experienced the death of my brother
in a motor vehicle accident, the reality of death and
unexpected nature of it hit close to home for me and for
that reason I appreciate every day that I have to spend
with my family and friends.
Yes. I'm young and look forward
to a long and fulfilling life. Perhaps later in life after
I accomplish the many goals I have set forth, I would
feel differently.
The truthful answer is I don't
know…I am prepared for the unexpected, through my
will and powers of attorney and such…I fear the death
of my loved ones, the void I would feel without them,
far greater then I fear my own death. Ultimately, I fear
suffering in the face of my impending death, more than
death itself.
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How comfortable have you been dealing
with pain and suffering (and even death) during your clinical
experiences in this program?
I had a patient who was dying of pancreatic
cancer and was extremely close to death. He spoke and
understood limited English, therefore communicating was
challenging and he did not have family or friends at the
bedside. I felt a strong desire to spend as much time
as possible with him, because he was alone and no one
in my opinion should die alone. He was receptive to my
company and my compassion although our verbal communication
was limited. His body language reinforced this fact. When
I left that day I went home and cried for him and the
family that he may or may not have had…
To be honest, I'm not very comfortable.
It is difficult to watch someone in severe pain, as I
have on more than one occasion during my clinical experiences.
I try to keep in mind that everyone expresses pain differently,
and it is the expression of pain that causes me discomfort,
not the pain itself.
I will never truly be "comfortable,"
nor do I desire to be, lest I lose sight of the importance
of caring and advocating for the patient to "live"
without pain and suffering even in the face of death.
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Critique the treatment and medical
and nursing care you have observed for the dying during
your time in this program.
I worked with a patient who had a PEG tube
in place which caused him severe diarrhea. He would become
aware of the diarrhea after it had begun and he was mortified
when I had to change his diaper. I felt so badly. I comforted
him by telling him not to be embarrassed, and that it
was okay. He eventually calmed down and I finished cleaning
him. My heart went out to him. I could only imagine how
difficult it must be, to be unable to maintain the dignity
of going to the bathroom in private…A little while
later it was time for me to leave and I said goodbye and
thanked him for the time we spent together. He smiled
at me and thanked me for spending the day with him. I
felt we had made a connection that day and I was proud
of my work with him. The following week I learned that
he had died that night after our time together. I was
saddened by this news, but I also felt privileged that
I had the opportunity to provide him with quality care
just before his death.
I witnessed some behaviors
by physicians that were both unprofessional and disrespectful.
If I were a registered nurse working with such a physician,
I would have serious ethical and professional issues to
consider.
STUDENT
MODULE EXAMPLE: INTELLECT
INSPIRE PROJECT: Psychosocial
and Cognitive Developmental Processes in Aging: Normative
and Disordered (I)
Context: Psychosocial theories
of aging suggest that a sense of integrity regarding one's
life is necessary in order to dispel despair and fear of impending
death (Erikson, 1963). The irony of aging is that physical
and cognitive deficits create challenges to the ability to
self express spontaneously, to relate to others, and to experience
a sense of freedom. Losses of functioning in physical, social,
cognitive, vocational and financial spheres can result in
depression and a sense of despair that interferes with the
ability to view one's life as an integrated whole. Additionally,
a move to a retirement community, nursing home or extended
care facility results in a loss of independence for aged individuals.
This presents challenges not only for the aged individual,
but also for healthcare providers who are often lack the knowledge
and experience to engage with them about the psychological
and existential life issues that they face.
Currently 13% of the total US population is now age 65 or
older and this percentage is expected to double over the next
40 years. Dementia is a dramatic and growing health problem
given the exponential growth of elderly among the US population.
Many of the dementias, like Alzheimer's disease (AD), are
progressive, deteriorating neurological diseases that alter
and destroys the brain nerve cells and neurotransmitter mechanisms.
Dementia is devastating not only for the individual but also
for families and health providers.
This module is intended to assist
the nurse clinician in physical, cognitive and emotional management
aspects that arise for both the primary patient and family.
Working with family caregivers is key in the effective management
of persons experiencing senile dementia. In addition to standard
nursing interventions, the Creative Arts Therapies, which
include music, art, dance/ movement and drama therapy are
powerful tools for tapping into other forms of cognition which
can help the elderly access memories and revive vital aspects
of themselves that previously lay dormant, and experience
a sense of internal mobility and freedom that would otherwise
be denied them.
Primary Goal of Module: Students will explore both
normative and disordered physical, cognitive and emotional
developmental processes in the elderly and learn to assess
and promote healthy functioning and intervene appropriately
with patients and families when decline is evident.
Evaluation: Students will submit an annotated bibliography
on the 2 journal articles and a reaction summary to the Web
based multi media case on dementia. Optional diary of clinical
experiences may be submitted for extra credit. All assignments
are due on 2/9/04 except teaching plan due: 3/9/04
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Module Assignments
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Readings
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Media
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Class and Field Experiences
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Miller (2003) Chapter 24, review Chapter 7
Newman, B.M, & Newman, P.R. (1999). Development
through life: A psychosocial approach (7th ed.). Belmont,
CA: Wadsworth Publishing Company, pp. 469-538. (Optional
recommended)
National Institute on Aging. (2000) Progress Report
on Alzheimer's Disease: Taking the Next Steps. Silver
Spring, MD, Alzheimer's Disease Education and Referral
Center
Smith, A.G. (2000). Exploring death anxiety with older
adults through developmental transformations. The
Arts in Psychotherapy, 27, (3), pp. 321-331.
Greenwood D, Loewenthal Del, Rose T. (2001) A relational
approach to providing care for a person suffering
from dementia. Journal of Advanced Nursing. 36 (4)
583-590.
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A four-part case on
the progression of a patient experiencing dementia
and his family will be available to you in the Gerontology
Course Clinical Communication Center. The Case is
entitled "The Final Amnesia." Read all four
parts of the case and visit the web links at the end
of each part.
From the 4 part case, readings and
in class discussion, in a bulleted list summarize
the 10 most important concepts or applications that
will influence your clinical practice with patients
experiencing dementia and their families.
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In Class Work:
1. Cognition and Aging - Concepts and
Case Study
2. Art experiential.
3. Creative Arts in Therapy and the
Elderly-Transcending the Physical
4. The Crabbit Old Woman - Reading
and Discussion
5. Synthesis - Integrating concepts
into clinical application.
Teaching Plan:
Dementia: Nursing interventions with individuals and
families.
Revised 1/04
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STUDENT
WORK RELATED TO ABOVE MODULE: INSPIRE: INTELLECT
Teaching Plan: Inspire Module (I) Intellect
Geriatric Population and the Federal Election
Assessment
We tackled the INSPIRE project
module, INTELLECT, by defining and addressing a patient need
in a local skilled nursing facility. We observed that residents
with high cognitive functioning ability tend to be neglected
by staff, as activities are directed primarily toward those
with lower cognitive abilities. These residents who are more
intellectually capable generally refuse to attend such events,
and tend to spend too much time alone in their rooms napping
and watching television. We created an event for this group,
that was both intellectually challenging and that encouraged
independence. Our event involved presentations and discussions
about the upcoming federal election, and dissemination of
practical information about the voter registration process.
Our challenge: stimulate the cognitive
ability of the higher functioning residents and encourage
their independence.
Our method: discussions/presentations
re: the two candidates, George W. Bush and John Kerry and
their opinions on important issues; and practical advice re:
how to register to vote, including how to fill out absentee
ballot applications.
Planning and Implementation
Each of us chose one of the following
issues: healthcare, prescription drug coverage, the economy,
education, abortion and capital punishment. We researched
and created presentations on these issues.
We put together a brightly decorated billboard with all of
the above topics highlighted. We designed a poster that highlighted
information about filling out and turning in absentee ballots.
Both billboard and poster were centrally located during the
months leading up to the election. We also set the mood by
decorating with red, white and blue streamers and by playing
patriotic music, to add visual and auditory appeal to our
module.
At the completion of our presentations,
we asked some questions on the information discussed and handed
out prizes (sun visors) for those whose answers were correct
or almost so. We then asked some fun trivia questions (ex.
"Who's the oldest?") and gave out American flags
for prizes.
Evaluation
With our red, white and
blue streamers, patriotic knick-knacks, and themed music,
we created the perfect atmosphere for informative presentations,
for reminiscing and for having fun. The residents loved the
music, which brought back memories and resulted in spontaneous
wheelchair dancing! They told anecdotes and shared their memories
of American presidents who served long before our time. We
had an excellent turn out, with full participation from our
attendees, who ranged in age from mid-60's to 100+ years of
age. We achieved our goals by providing them with an opportunity
for intellectual stimulation, and by giving them both practical
advice and voter registration materials.
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STUDENT
MODULE EXAMPLE: PHYSICAL
INSPIRE Project:
Activity-Exercise Pattern (P)
Context: Maintaining maximal
movement in health and in the presence of various disorders
remains a significant means of personal contact, sensation,
exploration, pleasure and control. Over the course of a lifetime,
mobility as well as agility change. Aging produces changes
in muscles and joints, particularly of the back and legs.
In old age, one moves more slowly and purposefully, sometimes
with more frequent thought and caution. In addition, falling
is one of the most frequent and serious probabilities associated
with the aging process. Maintaining mobility may mean the
difference between an independent, active community life and
maintenance of self-respect versus institutionalization and
a sedentary life-style. Overall, promoting maximal mobility
and improving functional independence have been identified
as national objectives for our nation (Healthy People 2010).
This module will explore major factors related to mobility
in aging. Particular focus will be placed on the role of selected
interventions, which specifically arrests or delays age changes
related to impaired movement, including moderate exercise
programs, isotonic and isometric exercise, confidence enhancing
strategies, weight control, and home safety.
Primary Goal of Module:
Students will explore the phenomena of mobility in the elderly
and learn health prevention/promotion approaches to maintain
a physically active life style.
Evaluation: Students will
submit an annotated bibliography on the research article and
a one-page reaction paper highlighting the media assignments.
Optional field experience assignments may be submitted for
extra credit. One teaching plan per student for the entire
course. All assignments are due on 2/23/04 except teaching
plan due: 3/9/04.
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Module Assignments
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Readings
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Media
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Field Experiences
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Miller (2003) Chapter 18 Mobility and Safety
Research Focus:
Van Haastregt, J. et al (2000)
Preventing Falls and Mobility Problems in Community
Dwelling Elders: The Process of Creating A New Intervention.
Geriatric Nursing, 21,309-314.\
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Go to: http://www.nih.gov/nia
search "Exercise" and order a free copy
of: Exercise: a guide from the National.Institute
on Aging. This site will be
useful for both field
Assignments.
2. Go to:
http://www.nof.org/
Use selected information and resources to develop
the teaching plan.
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Optional:
1. Conduct an environmental safety assessment in your
facility.
Assessment form will be given out in class.
2. Develop a teaching plan for a female (74 years)
who has Type 1 Osteoporosis. Past history includes
a Colles' fracture of the distal forearm one year
ago. She is taking Fosamax 10 mg. daily.
Teaching Plan:
Assisting patients or staff with fall prevention techniques.
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STUDENT
WORK RELATED TO ABOVE MODULE: INSPIRE - PHYSICAL MOBILITY
Introduction:
Physical activity is vital to both mental
and physical health in the aging adult (Health Canada [HC],
2003). Overwhelming evidence led the Department of Health
and Human Services to develop, within Healthy People 2010,
national objectives for increasing the number of adults who
exercise regularly (Edelman & Mandle, 2002, pp. 718).
To maintain independence and perform the activities of daily
living adequately, the older adult must be able to walk, stretch,
and maintain muscle strength and performance. Age related
changes that affect mobility include: decreased bone density,
hardening of tendons and ligaments, reduced muscle size and
strength, reduced sense of balance, altered gait due to pain
or injury, and reduced reaction time. Despite these inevitable
changes, older adults can, with proper ability-dependent exercise
programs, maintain and reduce restrictions on their physical
mobility.
The nurse facilitates older
adult exercise by first teaching its benefits, a vital step
in motivating participation. (Edelman & Mandle, 2002,
pp. 719). The nurse and patient then design a program that
will maintain strength, flexibility, and balance.
Elderly individuals with physical
limitations and chronic disease also benefit from increased
activity. Exercise optimizes their physical capacity and assists
in reducing the effects of chronic diseases and conditions
(HC, 2003, 4). Approximately 60% of older adults are inactive
(HC, 2003, 4). This inactivity leads to loss of bone and muscle
strength, a drop in performance of the heart and lungs, as
well as loss of flexibility (HC, 2003, 4). To combat these
affects, regular activity programs must be implemented. Such
programs begin with flexibility exercises, which are the least
strenuous and can be performed on a daily basis.
Plan:
We student nurses implemented exercise
and activity teaching sessions with residents in a local long
term care facility, with a goal of combating their knowledge
deficit related to proper range of motion exercises for optimal
joint flexibility.
On the residence floor solarium, we arranged
3 participating patients, who were seated in either wheelchairs
or regular chairs, in circular formation, which enhances learning
through mirroring. We placed ourselves in the center of the
circle, each one of us facing each resident, to provide focal
points for demonstration. The session began with didactics
about the benefits of increased activity. Then, we discussed
maintaining and increasing flexibility through everyday activities,
and included information about appropriate timing and duration
of those activities. We emphasized the importance of consistency--practicing
flexibility exercises at least once daily. We then asked each
participant to name, based on our presentation, two benefits
of increasing physical activity.
Next, we student instructors demonstrated
several flexibility and range of motion exercises. Then we
helped them perform every exercise, each one for a given number
of repetitions as specified in the interventions section of
this teaching plan. At the end of the exercise progression,
each patient demonstrated two of the exercises just performed
during instruction, with the student instructors providing
feedback. At the end of the session, we entertained questions
and provided positive feedback to the participants for their
efforts in the program.
Regarding Participants' Physical
Abilities:
Resident #1: Patient demonstrates
limited range of motion when attempting to raise hands over
head while dressing. Patient experiences difficulty turning
head to look out window when seated in chair. Patient demonstrates
limited ability to lift legs vertically when seated in chair.
Patient is wheelchair dependent and nurse dependent for transfer
due to instability when walking and stiffness related to DJD.
Resident #2: Patient demonstrates
limited range of motion when bending at waist while attempting
to put on shoes. Patient demonstrates difficulty with raising
legs vertically when seated in chair. Patient utilizes furniture
for support when ambulating short distances and is wheelchair
dependent for long distances. Patient is able to transfer
from bed to chair with some assistance from nurse.
Resident #3: Pt. demonstrates
limited ability to get out of bed relative to inflexibility
of knees, demonstrates difficulty ambulating from chair to
bathroom with use of walker, and demonstrates difficulty putting
on socks and shoes during AM care.
Goals:
Resident will be able to verbalize 2 benefits of exercise
by end of teaching session.
Resident will participate in 5
sitting active range of motion exercise activities, as appropriate
to ability, within 15 minute teaching session.
Resident will return demonstrate
2 of the 5 exercises taught by end of 15 minutes teaching
session.
Interventions:
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Assess for resident's ability
to ambulate and perform ADLs effectively and safely on
daily basis by observing resident performing actions such
as ambulating, dressing, and bathing. Teach resident benefits
to exercise including:
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Inform residents of practical
daily routine methods to maintain or increase flexibility
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Use shoe tying as an
opportunity to bend and stretch at the waist to touch
toes (HC, 2003, 7).
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Use dressing as a time
to reach overhead and stretch arms overhead (HC, 2003,
7).
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When seated, use this
position to lift legs vertically and hold. Stretch,
flex and extend feet while performing this exercise.
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Reach wide laterally
for items within reach to the periphery. Use the opportunity
to stretch. Do not overextend while reaching, as this
could cause injury (HC, 2003, 7).
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Consider every opportunity
while performing ADLs to stretch and reach. Minimal
effort has benefits (HC, 2003, 7).
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Important points for
stretching and safety
- Begin with stretch and hold
exercises for five minutes to warm up (HC, 2003, 7).
- Do not stretch rapidly or suddenly;
move gradually (HC, 2003, 7).
- Stay relaxed. Do not stretch
so that it becomes painful (HC, 2003, 7).
- Breathe regularly. Do not attempt
to hold your breath (HC, 2003, 7).
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Teach 5 sitting flexibility
/ range of motion exercises (Edelman & Mandle, 2002,
pp. 720), including:
- Side lateral raises (10 reps
x 1 set)
- Lateral arm circles (10 reps
x 1 set)
- Touch toes from sitting position
(5 reps x 1 set)
- Head rotation/lateral shoulder
touch (10 reps x 1 set)
- Leg extension (10 reps x 1
set)
Evaluation:
Goal
1 achieved. All 3 residents
in teaching session verbalized 2 benefits of exercise by end
of teaching session:
- Resident #1 stated, "If I
do these exercises, they may help in my range of motion
and help me sleep better."
- Resident #2 stated, "These
exercises can help with my constipation and help me become
more flexible."
- Resident #3 stated, "These
exercises will help me with my walking because it will
help increase my range of motion in my legs and I may
even lose some weight."
Goals 2 and 3 achieved.
All three residents participated in the 5 sitting exercises,
as observed by student nurses, as appropriate to ability by
the end of the 15 minute teaching sessions. Each resident
returned and demonstrated 2 exercises:
- Resident #1 demonstrated lateral
arm raises and head rotation.
- Resident #2 demonstrated toe touch
exercise and lateral arm circles.
- Resident #3 demonstrated leg extension
and toe touch exercise.
References:
Edelman, C., & Mandle,
C. (2002). Health promotion throughout the lifespan
(5th ed.). St. Louis, MO: Mosby, Inc.
Health Canada (2003, December 4). Canada's physical activity
guide to healthy active living for older adults. Retrieved
August 17, 2004, http://www.hc-sc.gc.ca/hppb/fitness/pdf/guide_handbook_older.pdf
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