When caring for patients with cancer, a number of situations arise that cause nurses to grieve. Nurses need time and space to grieve to prevent the untoward effects of cumulative grief. While providing a safe space for nurses to be vulnerable in grief, Songs for the Soul combines the healing effects of expressive writing, storytelling, and music to help nurses address the grief and suffering they experience in their work. The use of storytelling through music portrays an expression of their grief that matches the intensity of their caregiving experience.
Until a year ago, my entire nursing career had been in oncology—first as an inpatient and outpatient nurse, then as a nurse practitioner. To care with compassion required me to hold a space for each patient and maintain an emotional balance between fear and despair on one hand, and hopefulness on the other. I understood the gravity of that responsibility. I have learned endlessly and been inspired by so many of the individuals I have cared for. I have also experienced many losses.
Processing these losses is imperative to being able to continue to do this work. However, in my nursing education, I was not taught to address my own grief, nor was it discussed in my work environment. It was the rarest moment when I would have time to reflect on a loss or a very difficult circumstance before having to move onto the individualized needs of other patients. Over the years, I developed my own way of dealing with repeated grief, but I did not realize what I was doing until my grandmother was diagnosed with lung cancer. I grieved the loss of her upon her diagnosis. While the rest of my family held out hope for possibility, I mourned. I realized that I was also grieving the patients I cared for at their diagnosis. At first, I rationalized that this was a healthy way of coping. I believed I would not be hurt by a patient’s dying process; I could remain simply a vessel for caregiving. Now, I realize that I had lost hope that they would survive. Rather than insulate myself from loss, I was stuck in a state of perpetual grief. An essential step to my grieving process was missing, and, after 14 years of doing meaningful work that I loved, I had to step away from direct patient care. I continued to feel a great deal of compassion for patients, but my work began to cause pain—physically, emotionally, and spiritually.
I do not know if “compassion fatigue” fully describes my experience, but as I read the literature and shared my findings with colleagues, I learned I was not alone. In an effort to address the changing relationship I was having with a career to help others, I developed a program called Songs for the Soul (S4S) (www.song-soul.org). I wanted to create a program to help nurses address the grief and suffering they experience in their jobs. S4S combines the healing effects of expressive writing, storytelling, and music to facilitate a deeper exploration of the nursing experience.
I piloted the S4S program in Santa Fe, New Mexico, with a group of seven oncology, palliative care, and holistic nurses. For six weeks, the group met weekly to participate in an expressive writing workshop. The goal of the workshop was twofold—first, to show them that they can write. Many nurses do not think of themselves as writers. Because of this, they do not use writing as a means to process their work. The second goal was for them to write a story that would be turned into a song by a songwriter. My working hypothesis was that telling their story through music would deepen the nurses’ healing process.
The nurses wrote beautiful stories about their nursing experiences, involving love, friendship, loss, and gratitude. They wrote about a variety of topics, such as why they became nurses, what made them angry, the losses they had experienced, their grief, and memorable patients. Many of their stories had not been shared for years, sometimes decades. Throughout this process, they realized that they were not alone in their feelings of fear, sadness, joy, and self-criticism. They were not alone in grief.
After they completed the stories, the nurses met with a songwriter who put their nursing story into a song. The songwriter and nurse had an initial meeting to discuss the story, and then they met once or twice more to ensure the song was true to the nurse’s story and experience. Once the songs were finished, the nurses and songwriters gave a performance for their colleagues, close friends, and family members. In a small theater, each nurse took the stage to read her nursing story, followed by the songwriter’s performance of the nurse’s song.
My initial vision for S4S was that each nurse would have one healing song. However, through the sharing of the collection of stories and songs, I realized that the compilation of these stories and songs would be the catalyst for healing.
One of the common themes that emerged from this program was vulnerability in grief. To grieve is to be vulnerable, to be emotionally exposed and uncertain. When is it safe for healthcare professionals to be vulnerable in grief? We are taught to be there for others as they grieve; we are taught to protect patients in vulnerable situations and vulnerable populations, but we are not taught to be vulnerable ourselves and in our professions. If we are not supposed to be vulnerable, how are nurses to grieve? One of the nurse participants, Barb, was a seasoned nurse who spent the majority of her career in the emergency department. She wrote,
Death and dying; I stand by families, explain what the doctor said, “Your loved one has died, we did everything possible to save them.” Comfort offered, seeing their pain and tears; the agony is palpable in this moment of shock and disbelief. There is nothing I can do but stand beside them in this grief. It is only the beginning.
I will be the soldier walking with them. I offer comfort and assistance with all of the paper work, but, most of all, I offer my quiet, reassuring heart of unconditional love. I mean, where else can I be in this moment? The intensity of the pain is too much to bear, but, as a soldier, I put aside the immense pain that I am witnessing and stay the steady rock. I am the someone they can look to and know, this is really happening, isn’t it? Unconditional love, that place where we rarely go, the place in our hearts of just being, no judgment, just a simple offering of being present to their immediate needs.
We all know in the emergency department that life can be preciously short. Here today, gone tomorrow. . . . We really don’t know. So, as I witness death and dying, I know that, in the back of my mind, I am reassuring myself that maybe this won’t happen to my family. In my simple mind, I think, if I do this work, I am immune from my own feelings. Yep, I’ve already done the work by walking with these families through their shock, disbelief, and grief. My family will be spared.
I know, logically, this is not true, but it is a secret hope, an unconscious way of coping with all the pain. In this sea of darkness and pain, I have to find hope somewhere. These tragedies can happen to any of us, but somewhere inside I comfort myself with, if you do this hard work with the patients’ families, you won’t have to experience this sadness and pain, for it is huge. This happens time and time again, not every day, or all day, but frequently.
Barb stepped away from her emergency department nurse role after recognizing she had compassion fatigue. She became a certified holistic nurse. Through holistic training, she learned the importance of caring for herself on a deeper, wiser level, and she began to heal.
I realized, through my advanced holistic nurse training, that if I was to hold this space for patients, self-care was of the utmost importance. To be in a heart-centered space, we need to give our own heart the space of unconditional love. As nurses, we must tend to our own healing, so we may continue to do this holy work.
The nurses in S4S explained that the entire experience—writing, sharing their stories, and hearing their songs per-formed—honored the patients for whom they cared and their work, and also deepened their emotional healing. They were strengthened by their common experiences and unified by revealing to each other their vulnerability in grief. Most importantly, they recognized that they were not alone. S4S celebrates the soulful work of nurses and honors the depth of relationship that can occur when you care for patients with cancer and patients and families facing life-shortening illnesses. Storytelling through music was the medium used to express the beauty and sadness of the patients for whom we have cared.
We must have a safe space to be vulnerable and to grieve. We must feel grief and process it to move through bereavement. If we do not allow ourselves to be vulnerable, we do not mourn and the effects of repeat grief accumulates. As Barb’s songwriter, Natalia Zukerman, sang:
This is holy work
A simple offering
This is sacred space
This is my heart grieving
If I don’t take care of it
I can’t take care of you
Carolyn Phillips, MSN, RN, ACNP-BC, AOCNP®, is a Robert Wood Johnson Foundation Future of Nursing Scholar and PhD student in the School of Nursing at the University of Texas in Austin, and Barbara Welcer, RN, BAS, HNC, HTCP/I, is a nurse educator and energy medicine practitioner at the University of New Mexico Medical Group in Albuquerque. The authors take full responsibility for this content. Phillips was supported by an SVHsupport grant. The authors take full responsibility for this content and did not receive honoraria or disclose any relevant financial relationships. Phillips can be reached at email@example.com, with copy to editor at CJONEditor@ons.org.