“We will be here with her. We will hold her hands for you guys. Okay? ….I don’t want someone to die alone.”
Sara Reynolds, ICU Nurse, Phoenix, Arizona
Death, Through a Nurse’s Eyes, Produced by Alexander Stockton and Lucy King, February 24, 2021, New York Times
Copyright 2021 by Patricia Benner, R.N., Ph.D. FAAN
The COVID-19 Pandemic has claimed over 500,000 lives in the United States alone. When we think of the family and friends who are suffering grief and loss of these 500,000 lives, the tragedy swells. A 15-minute documentary recently featured in the New York Times brings the viewer close to the emotional costs of caring for many patients at the end of life in the COVID-19 Pandemic. Producers Alexander Stockton and Lucy King filmed the work of nurses inside of the I.C.U. of Valleywise Medical Center in Phoenix for two days. Two nurses wore cameras, documenting what it’s like to care for the sickest COVID patients. This video has gone viral, perhaps because it captures the patients’ families and nurses’ experiences in gripping, realistic ways that do not minimize the challenges or skirt the very real care demands, loss, and grief of caring for so many critically ill and dying patients. This 15-minute film entitled Death, Through a Nurse’s Eyes, New York Times, February 24, 2021, gives the viewer a close-up look at the stark pain inside a COVID-19 I.C.U. It captures the agony of dying for patients, families, and nurses—who in this Pandemic stand in as surrogates for families not able to be with their loved ones during COVID. As a former I.C.U. nurse, I am captured by how gripping and real the nurses’ skill of involvement with patients, families, and each other is shown. The nurses know and support one another, realizing that no one outside their community can really understand what they are living through. The nurse manager, Sara Reynolds, knows the patients, their families, and the nurses she works with. This kind of connected leadership builds an effective community of practice with shared goals and notions of good practice. The nurses support one another as they jointly care for their patients.
This film presents the collective experience of patients, families, and nurses all over this country and the world. As the ones who work to preserve life and midwife death for patients and their families, the hidden and intimate roles of nurses come to the forefront. I have always championed nurses’ frontline life-saving and astute clinical reasoning that yield life-saving early warnings and effective rescue of patients near death. The COVID Pandemic has presented a steep learning curve for recognizing symptoms, charting expectations for the disease trajectories, and for generating effective interventions. There were no past statistics or guidelines based on prior patient histories to guide expectations, early warnings, or interventions. Nurses and physicians, as well as scientists, learned as they went. And this was part of the ongoing uncertainty and quandary in caring for COVID patients and families. I think that nurses’ critical diagnostic and urgent interventions are under-represented in public media and social imagination. Clinical reasoning and nursing interventions for COVID patients are still a work in progress, with unknowns more prevalent than experience and empirically-based knowledge. Self-doubt about what was best for the patient was frequent in this context of learning. With COVID, experiential learning with each patient was crucial. What is known and at the forefront of these nurses’ care (despite lack of knowledge about this new virus) is their understanding of the centrality of care of the body and preserving personhood and social connections with the patient and loved ones. This film brings home the reality that direct comforting nursing care of the body (e.g., holding patients’ hands, positioning, cleaning, grooming, preventing the devastating effects of being immobile and bedridden) is at the frontline of preserving life, personhood, and humanity. Frontline nursing care bears witness that the patient is sustained in personal acts of care usually done by the patient or the family when they can (Fagin & Diers, 1983). In the scenes of this film, neither patient nor family can do the usual acts of care of the embodied person. The nurse steps in and with skillful ministrations for fragile, immobile embodied persons to keep the patient’s body and personhood as safe as possible. They guard against threats of bodily deterioration, loss of humanness, and recognition of the person and family in their lifeworlds. These ordinary feats become essential and extraordinary in the isolation and infection prevention measures common to the COVID-19 Pandemic. Under normal circumstances, our embodied personhood is a taken-for-granted background that we don’t think about, but in illness and breakdown, our embodied comportment, moods, and personhood, our stance, meanings, and concerns all move to the foreground of our existence. Care of the body in illness is central to preserving personhood as well as mobility and integrity. Likewise, we take for granted our everyday lifeworld organized by our concerns, relationships, and practices, but in extreme illness, dwelling in our lifeworld is disrupted by loss of capacities our normal activities.
Death eventually comes to all, but some deaths are more bearable than others. Nurse Sara Reynolds and the other nurses in this film show us how being with, holding hands, care of fragile imperiled bodies, preserving family connections, spiritual practices, and most of all, honoring, and preserving the personhood of known and loved embodied human beings are at the core of person-and family-caring practices of nurses. This nurse’s personal account of her connection and grief over her many dying patients reveals exquisite skills of involvement. . Skills of involvement, authentic engagement with others are often made visible when they are missing. Somehow this film captured the skills of involvement of the nurses caring for patients in this COVID I.C.U.; the nurses’ skills of involvement were neither blocked outpatient and family suffering nor by the nurses’ own self-protection and distancing. The nurses focus on the one’s cared-for. Sara Reynolds grieves for the lives of her patients and their families. She remembers the particular patient’s four-year-old grandson’s hope for his grandfather. When asked what she would say to other nurses, Sara Reynolds expressed her desire to thank other nurses, demonstrating solidarity and understanding of the challenges and human costs of caring practices essential for precariously critically ill patients and families. What I am pointing to is the evidence abundant in this short video of what it looks and sounds like to get skills of involvement “right.” The focus is on the patients and families, not the character, courage, or skills of the nurse. Patients and families are valued and cared for, and this care rings true as the nurses describe their experiences. The viewer resonates with the real connections between nurses, patients, and families.
Accounts of this kind of authentic connection can be distorted or impeded by sentimentalism or moralism (Logstrup, 1997). According to Logstrup, sentimentalism is when the person blurs boundaries between the other’s life and their own, elaborating the pain and suffering as if they were occurring in their own life. Logstrup (1997) calls this an incurvature of emotion. Moralism is similar, according to Logstrup, in that the person focuses on their own character pushing their attention away from the person or situation involved. With moralism, Sara Reynolds might have given advice for improvement or praise for the strength and courage of other caregivers. But instead, she thanks them. Another example of moralism is when the person focuses on their own character strengths or virtue, rather than on the one cared for and their needs. The nurses in this video engage in neither sentimentalism nor moralism. They focus on the needs of patients and families and their concerns. It is inspiring and telling to read the many comments in response to this New York Times video. We present this film and the comments engendered by it as a starting point for diverse discussions of nurses’ roles during the COVID Pandemic. We need to acknowledge the realities of nurses now. This film shows how nurses confront and withstand the challenges and tragedies of care of the dying and their families during the COVID Pandemic. At the same time, they also care for patients, families, and each other while facing their own challenges and stresses of their daily lives apart from their work. Skills of involvement are essential for expertise in nursing (Benner, Hooper-Kyriakidis, & Stannard, 2011) because they open up the possibilities for noticing salient aspects of nursing care and attunement in particular situations, allowing the nurse to accurately see what patients need in ways that respect and attend to their concerns.
Will the aftermath be a time of epidemic levels of Post-Traumatic Stress Disorder (P.T.S.D.) as suggested by the filmmakers? Or, will it be a time of meaningful acceptance of the courage and significance of caring for critically ill COVID-19 patients under truly extraordinary circumstances? Will nurses’ own acknowledgment and acceptance of their commitment and skilled know-how that enabled them to meet the challenges they confronted ameliorate the psychological impact of the trauma inherent in caring for many dying patients? How might meaningfulness and fully connecting with patients and families while enacting their professional nursing responsibilities and challenges alter the aftermath of the nurses’ experience? Will the trauma recede as the nurses realize how central their work was to the well-being of patients and families?
I think that the exquisite skills of involvement and connection to the humanity of his or her patients and families will protect nurses from the worst experiences of P.T.S.D that are exacerbated by alienation and meaninglessness, and disconnection from and avoidance of the lived history and experience of the trauma (Benner, Halpern, Gordon, Kelley, 2017). I think that responding—doing what needs to be done, saying what needs to be said at the moment and acknowledging the human connection and grief will lessen the P.T.S.D. for these nurses.
How might nurses collectively share their experiences and support one another during this time? This film is an excellent beginning. You might want to compare this documentary with other documentaries on health and nursing care during the pandemic. Most of all, we want to learn the exquisite skills of involvement with patients, families, and team members that these nurses show us.
Benner, P., Halpern, J., Popell, C.L., Kelley, P.W. (2017, November)Beyond Pathologizing Harm: Understanding Post-traumatic Stress Disorder in the Context of War. Experience Journal of Medical Humanities. https://doi.org/10.1007/s10912-017-9484-y, 2017.
Benner, P., Hooper-Kyriakidis, P., Stannard (2011) Clinical wisdom and interventions in acute and critical care nursing. Springer.
Death, Through a Nurse’s Eyes, Produced by Alexander Stockton and Lucy King, February 24, 2021, New York Times https://www.nytimes.com/video/opinion/100000007578176/covid-icu-nurses-arizona.html?src=vidm
Fagin, C., Diers, D. (1983) Nursing as metaphor. New England Journal of Medicine 309:116-117 DOI: 10.1056/NEJM198307143090220
Logstrup, K.E. (1997) The ethical demand. Introduction by H. Fink & A. MacIntyre. Notre Dame Univ. Press.