Living bereavement: an exploration of health care workers' responses to loss and grief in an NHS PDF
Preview Living bereavement: an exploration of health care workers' responses to loss and grief in an NHS
City Research Online City, University of London Institutional Repository Citation: Holman, C. (2006). Living bereavement : an exploration of health care workers' responses to loss and grief in an NHS continuing care ward for older people. (Unpublished Doctoral thesis, City University London) This is the accepted version of the paper. This version of the publication may differ from the final published version. Permanent repository link: http://openaccess.city.ac.uk/id/eprint/8523/ Link to published version: Copyright and reuse: City Research Online aims to make research outputs of City, University of London available to a wider audience. Copyright and Moral Rights remain with the author(s) and/or copyright holders. URLs from City Research Online may be freely distributed and linked to. City Research Online: http://openaccess.city.ac.uk/ Living Bereavement: An Exploration of Health Care Workers' Responsest o Loss and Grief in NHS Continuing Care Ward for an Older People Cheryl Holman, A thesis s ubmittedt o City University in accordancew ith the the degree PhD requirementso f of Department Adult Nursing of St Bartholomew School Nursing Midwifery of and November2 006 1ý For My Mum Dad and q- CONTENTS LIST OF TABLES 10 ............................................................................... ACKNOWLEDGEMENTS 11 ................................................................ DECLARATION 12 ................................................................................. ABSTRACT 14 ........................................................................................ ABBREVIATIONS 15 ............................................................................. CHAPTER I- INTRODUCTION: LIVING BEREAVEMENT IN A, CONTINUING CARE WARD FOR OLDER PEOPLE 16 ................................. Key from 17 messages the research ................................................................... BACKGROUND TO THE STUDY 20 .................................................................. The work basede ducationp roject that precededt he research 21 ...................... The 22 researchp roject ...................................................................................... The loss 24 complexity of and grief ................................................................... Living bereavement 28 ....................................................................................... Psychoanalysis 29 and emotions ........................................................................ A 32 combined social and psychoanalyticm odel .............................................. OVERVIEW Ot THE THESIS 35 ........................................................................ CHAPTER 2- NHS CONTINUING CARE IN EAST LONDON: DISCOVERING A HIDDEN COMMUNITY 41 .................................................. THE NATIONAL POLICY FOR CONTINUING CARE FOR OLDER PEOPLE 42 ............................................................................................................. The for 43 Tootso f continuing care older people ............................................... A to home home 45 move care and care at ............ ........................................... A LOW PRIORITY IN THE LOCAL AREA 47 ................................................... The hidden Willow Ward 49 population of ........................................................ Piecing together the backgrounds 50 residents' ................................................. Piecing togethert he backgrounds 56 stafrs ....................................................... Cultural diversity in Willow Ward 59 ................................................................ OPENING THE DOORS TO WILLOW WARD 61 ...........................I. ................ Taking a look at the unique community 63 ..... The tensionb etweenh omely hospital 64 and ................ ..... The residents' profound dependence 66 ....................... ..... Residents a nd their families 71 .. ......................................................................... SUMMARY 76 ....................................................................................................... 5 CHAPTER 3- THEORETICAL PERSPECTIVE: EXPLORING PSYCHOANALYTIC APPROACHES TO INDIVIDUALS AND ORGANISATIONS 78 ............................................................................................. RATIONALE FOR ADOPTING A PSYCHOANALYTIC APPROACH 78 ....... PSYCHOANALYTIC CONCEPTST HAT ARE CENTRAL TO THE THESIS 83 .............................................................................................................. A development 84 psychoanalyticu nderstandingo f .......................................... PsychologicalD efences 90 ................................................................................. PSYCHOANALYTIC CONCEPTST HAT ARE CENTRAL TO THE RESEARCH DESIGN 92 ...................................................................................... Ile function 93 creative of containment ............................................................ Psychoanalytic approachesto organisations 97 ................................................. SUMMARY 102 ....................................................................................................... CHAPTER 4- LITERATURE REVIEW: THE COMPLEXITY OF LOSS IN CONTINUING CARE INSTITUTIONS 103 ..................................................... METHOD 104 ... ....................................................................................................... FINDINGS FROM QUALITATIVE FIELD METHODS 105 ................................ Limitation of single perspectives 106 ................................................................... Ignored temporal component 107 ......................................................................... Constraint of context 107 .. ................................................................................... FINDINGS FROM THE SURVEY TYPE RESEARCH 110 .................................. Less diversity III ........................ ....................................................................... Bias towards death 112 ......................................................................................... Acknowledgement of complexity 112 .................................................................. Need for wider perspectives 113 .......................................................................... Focus on emotional response 114 ........................................................................ INTERVENTION STUDIES 115 ............................................................................ Diversity of approach 116 ...................... .............................................................. CONCLUSIONS FROM THE LITERATURE REVIEW 118 ................................ STUDY AIMS AND OBJECTIVES 121 ................................................................. SUMMARY 122 ....................................................................................................... CHAPTER 5- METHODOLOGY AND METHODS: PSYCHOANALYTIC PARTICIPANT OBSERVATION 123 .............................. PSYCHOANALYTIC PARTICIPANT OBSERVATION 125 ............................... METHODS OF DATA GENERATION 128 ........................................................... ParticipantO bservation 129 ................................................................................. The Reflective Work Groups 133 ......................................................................... The Tavistock SupervisionG roup 136 ................................................................. Old age observation 137 .................................................................................. Work based discussion 138 .............................................................................. The researcher instrument 140 as research ..................................................... DATA ANALYSIS AND FEEDBACK TO PARTICIPANTS 144 ........................ Pata analysis 145 .................................................................................................. Links between feedback analysisa nd 147 ............................................................ 6 Psychoanalyticallyi nformed data 149 synthesis ................................................... ETHICAL ISSUES 150 ............................................................................................ Negotiating 152 consenta nd participation ........................................................... Negotiating 153 care staff participation ............................................................... Negotiating the boundariest o the 155 researchr ole ............................................ ASSESSING THE QUALITY OF QUALITATIVE RESEARCH 158 ................... Credibility 160 ...................................................................................................... Transferability 161 ............................................................................................... Dependability 161 ................................................................................................ Confirmability 162 ............................................................................................... STRENGTHS AND LIMITATIONS OF THE METHOD 163 ............................... SUMMARY 168 ....................................................................................................... CHAPTER 6- INTRODUCTION TO THE FINDINGS: THE EMOTIONAL DEMAND OF WORKING WITH COMPLEX LOSS IN CONTINUING CARE 170 ........................................................................................ CHAPTER 7-A TRAJECTORY OF LIVING BEREAVEMENT: THE CARE STAFF'S PERCEPTIONS OF THE EMOTIONAL DEMAND OF THEIR WORK 177 .................................................................................................... Working 178 with shockedr esidents ................................................................... Working 181 with grieving relatives .................................................................... Working 182 with anxious residentsa nd relatives ............................................... Working degenerating bodies 185 with minds and .............................................. Working dying 187 with residents ....................................................................... THE HIDDEN EMOTIONAL DEMANDS OF WORK WITH LIVING BEREAVEMENT 192 ................ Working 192 with non-rcsponsiver esidents ........................................................ Working doubt 194 with self and guilt ................................................................. Working hurtful 198 with residents ...................................................................... Working in isolation 201 ...................................................................................... THE TRAJECTORY OF LIVING BEREAVEMENT: DEVELOPING UNDERSTANDING THROUGH SOCIAL RESEARCH 202 ............................... Disorder from the start 203 .................................................................................. Unboundedb odies 205 and emotions ................................................................... The death 207 certainty and uncertainty of .......................................................... SUMMARY 209 ....................................................................................................... CHAPTER 8- PSYCHOLOGICAL DEFENCES AGAINST LIVING BEREAVEMENT: AVOIDING AND GLOSSING OVER THE UNBEARABLE AND UNACCEPTABLE EMOTIONAL DEMAND 212 ........... Keeping out strangers 220 .................................................................................... Being on the offensive all the time 221 ................................................................ Denying residents' capacity 222 .......................................................................... Valuing feistiness ignoring and the 223 non-responsiveness ............................... Believing in Willow Magic 227 ........................................................................... Being like family a 230 ........................................................................................ 7 PSYCHOLOGICAL DEFENCES AGAINST LIVING BEREAVEMENT: DEVELOPING UNDERSTANDING THROUGH COUNTER- TRANSFERENCE 232 ............................................................................................ PSYCHOLOGICAL DEFENCESA GAINST LIVING BEREAVEMENT: DEVELOPING UNDERSTANDING THROUGH PSYCHOANALYTIC THEORY 235 ........................................................................................................... Dealing the dependent by with residents'p rofound statesc aused mental degeneration 236 and physical ............................................................................. Being denied t he sense o f reward and satisfactionw hen a personb eing for better 240 cared gets ....................................................................................... Having lifclcss 242 sustainedc ontactw ith a senseo f void .................................. SUMMARY 245 ....................................................................................................... CHAPTER 9- TUNING IN: DEVELOPING THE CARE STAFF'S CAPACITY FOR EMOTION WORK 248 .............................................................. An accounto f a residenta nd his wife's living bereavement 250 ......................... Uncovering the emotionald emand 257 ................................................................ Taking in the unbearablea nd unacceptable e motional demand 259 .................... Giving back the emotionsi n a more manageablefo rm 262 ................................. THE CREATIVE FUNCTION OF THE RESEARCH: DEVELOPING UNDERSTANDING THROUGH PSYCHOANALYTIC THEORY 265 .............. Resistingd oing and encouragingb eing 267 with emotions ............................ ... Preventing . non-therapeutica ction 269 ................................................................. Improving the quality of relationshipsb y acknowledging emotionsincludingt hose c onsideredt o be negative 272 ...................................... SUMMARY 275 ....................................................................................................... CHAPTER 10 SWITCHING OFF: THE FUNCTION OF SOCIAL - SYSTEMS AS A DEFENCE AGAINST ANXIETY IN THE CARE FOR OLDER PEOPLE UNIT 277 .......... . . ......................................................................... Splitting up the residents 278 . ................................................................. ......... Splitting up emotionalr oles and responsibilities 287 ........................................... The upstairs-downstairs 296 effect ....................................................................... THE FUNCTION OF SOCIAL SYSTEMS AS A DEFENCE AGAINST ANXIETY IN THE CARE FOR OLDER PEOPLE UNIT: DEVELOPING UNDERSTANDING THROUGH PSYCHOANALYTIC THEORY 300 .............. Rationing resourcesf or making things better 302 ................................................ Willow Ward 304 -a peculiar sort of refuge ........................................................ It's dumping a 305 ground ................................................................................... Fixed ways of thinking 305 .................................................................................. A false senseo f power over non-existence 306 .................................................... SUMMARY I 306 ..................................... .................................................................. CHAPTER 11 DISCUSSION AND CONLUSIONS: THE UNIQUE - CONTRIBUTION OF CONTINUING CARE STAFF 309 ..................................... Strengths a nd limitations of the study 309 ........................................................... Exploring the care staffs view of a trajectory of living bereavement 311 .......... Uncovering the care staff's emotionalr esponses 312 .......................................... 8 Developing the for 315 participants'c apacity working with emotions ................ The impact of the emotional responseso n the social organisation of care 315 ... DISCUSSION AND CONCLUSION: DEVELOPING UNDERSTANDING THROUGH THEORY 317 ..................... The loss in 318 complexity of continuing care .................................................... The 320 creative potential of methodso f containment ........................................ Social systemst hat supportp sychologicald efences 321 ..................................... RECOMMENDATIONS FOR HOW THE ORGANISATION COULD IMPROVE THE CAPACITY OF ITS STAFF TO WORK WITH THE EMOTIONS LINKED TO LOSS IN CONTINUING CARE 324 ........................... Recommendationsfo r designatedl eadersi n 324 continuing care organisations. Recommendationsfo r facilitators Reflective Work Groups 326 of ..................... Recommendationsfo r in 327 care staff working continuing care organisations. THE CONCLUSIONS IN A WIDER CONTEXT 329 ............................................ 329 Considerations for policy ............................................................................. Considerationsf or 331 research ........................................................................... 334 Considerationsf or education ......................................................................... SUMMARY 336 ....................................................................................................... APPENDIX 1- GLOSSARY OF TERMS 338 ......................................................... APPENDIX 2- EXAMPLE OF HOW DATA WERE RECORDED IMMEDIATELY AFTER THE FIELD WORK AND AFTER THE TAVISTOCK SUPERVISON GROUP 343 ............................................................. APPENDIX 3- CONFERENCE PRESENTATIONS RELATED TO THE THESIS 347 ................................................................................................................. APPENDIX 4 EXAMPLE OF THE FORM USED TO REVIEW -AN THE DATA 349 ........................................................................................................... APPENDIX 5- DATA FROM A REFLECTIVE WORK GROUP 350 ................ REFERENCES 361 .................................................................................................... BIBLIOGRAPHY 383 ................................................................................................ 9
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