Considering vulnerability, the wounded healer archetype can be a helpful metaphor for palliative care practice. The wounded healer is an ancient symbol that dates back to Greek mythology. More recently, the wounded healer archetype was popularized by Carl Jung, who posited that only the wounded physician can heal. Jung believed that the healer actually took over the suffering of the patient in the same way that combining two chemical substances creates a changed agent representing both substances.

Applying the wounded healer archetype to nursing practice, we may find ourselves in situations where we literally take on the feelings of our patients, and perhaps of their family members. This assumption of feelings can be a painful process and, while reflection can help in recognizing these dynamics, reflection alone is not enough.

It’s essential for nurses working in these highly charged situations to get support and clinical consultation from trusted others. Clinical consultation may be provided by an individual or a group; regardless of the source, however, a prerequisite to helpful clinical consultation is your ability to trust in that person or group. Clinical consultation can serve multiple purposes; the two that will be highlighted here include validating affect and enhancing insight. (See Validating affect and enhancing insight.)

Reflection is typically triggered when something goes wrong. Otherwise, our actions are often on automatic pilot. But, when a glitch or a problem happens, we’re called to the moment. We may ask, “What happened?” and consider the situation in more detail. If you use reflection alone, however, your own “truth” may be endlessly reinforced and your may not see things from another perspective.

Of course, you may not be ready to hear what you could do differently to alter the outcome of a situation. Certainly, if you’re feeling sad and distressed, it’s important to have your emotions validated. However, remaining open to considering alternative views will let you keep your perspective open and minimizes the chance that you’ll experience burnout.

Likewise, if you’re providing clinical consultation, ask: “Do you want support or do you want feedback?” Most people choose both—but support first. Asking that question encourages the other person to consider what she needs at that particular time. It also reinforces the notion that these are two different but complementary actions.

Also, consider that the wounded healer motif is different from the walking wounded motif. The wounded healer recognizes her vulnerability, while the walking wounded live with trauma without understanding its impact.

Every nurse brings a personal history to practice. Your personal history includes your previous experiences and your understanding of their meaning. (See How to comfort a coworker, page 284.) Working closely with dying people may propel you to experience your own vulnerability while also becoming more open to the experiences of others. This openness may lead to transformative moments that heighten your appreciation of life.

Caregivers, especially female caregivers, have a tendency to attend to the feelings of others more than to their own feelings and needs. Focusing on interactions and the importance of relationships is a form of altruism that can be profoundly important in shaping our planet in positive ways. However, excessive self-sacrifice can leave one feeling angry, tired, even bitter.

It’s essential that, as caregivers, we attend to our own needs as well as the needs of others. A first step in doing this is exploring our reasons for self-sacrifice. Offering the self should be a choice rather than an obligation. When one offers self out of choice, the self is enlarged rather than diminished.

Healthy self-sacrifice involves a balance on several levels. We balance taking care of others with taking care of ourselves. We balance autonomy with dependence. We balance our energy and our own needs. Healthy self-sacrifice emphasizes self-respect and a commitment to care of the self. Yet, in our culture we have little language that even describes how care for self and care for others should complement each other. We might learn from Eastern culture and belief systems such as Buddhism, which recognize the idea of intricate interdependence. Each of us is embedded in a living matrix that challenges the very notion of a dualism between autonomy and dependence.

Lack of self-care has historically been a problem in nursing; nursing education and practice may too often reinforce what Gordon calls the virtue
script. The virtue script emphasizes self-sacrifice, altruism, and feeling content that these virtues offer their own rewards. These messages contribute what remains as a caring dilemma in nursing, the perceived idea that nurses must care even when caring isn’t valued by Western society.

The helping relationship involves a person giving help, a person receiving help, and the value of the help itself. In palliative care nursing, choosing the right kind of help is essential. That involves not only knowing what is appropriate at one point for our patients and their families, but also being aware of what is needed for ourselves.

Traditionally, many of us have been socialized to be emotionally separate from our work, thus avoiding emotional upheavals. Although keeping emotionally distant may help us avoid getting involved, most of us come into this work to become involved and invested in the care of others. Devaluing care, or limiting our investment in care, separates us from the emotional satisfaction that comes from doing meaningful work.

There are road maps for identifying healthy aspects of caring. Self-awareness has already been addressed as an essential quality for healthy caregiving. In addition, other qualities are needed for healthy caregiving. (See Qualities of healthy caregivers.)

Nurses develop skill along a beginner-to-expert trajectory. The job of the beginner is to master the multiple tasks required in nursing practice. As you grow in experience and expertise, you can participate in more of what makes excellent caregiving fulfilling and aesthetically pleasing. It’s essential that experienced nurses are aware of this trajectory so as to be kind to nurses new to the palliative care field. Even nurses with several years of experience in other practice settings will be advanced beginners again when moving into a new practice area. Allowing the advanced beginner time to learn new clinical skills and supporting the learner along the way are methods of facilitating successful integration into palliative care.

Recognizing the trajectory involved in developing expertise may reduce the new nurse’s feelings of role stress. Role stress has been described as the difference between a person’s perceptions of a particular role and her achievement within that role. New nurses, especially, are at risk for role stress when their actual job performance doesn’t match the expectations they have of what their performance should be. Role stress may also be worsened when dealing with “difficult” patients, families, and colleagues.

The phenomenon of perceptual vigilance causes your attention to be drawn toward certain behaviors. Subsequently, if you believe that there will be a problem, you’ll tend to find supporting evidence to confirm your belief. But, are people really difficult, or is it our response that creates difficulty for us?

When we label another person difficult, it’s because we’re looking at that person’s behaviors rather than looking with them at the cause of the behaviors. The looking at process is one that we use when doing an assessment. We observe subtleties in breathing, skin color, and edema. During the mental status exam, we assess for affect (external manifestation of mood), thought process, and judgment. The looking at process enables us to recognize a rapidly deteriorating situation and to intervene before the situation becomes even worse. Looking at is an essential part of nursing practice.

Just as looking at is valuable, so too, is looking with. Looking with the patient has an important role to play in palliative care practice. Looking with involves considering what it might be like to be that other person. Looking with allows you to cultivate empathy for the other. Generally, the responses of others are understandable if you know what the other’s point of view is. This knowledge involves paying attention to context, including the patient’s history and his unique way of viewing the world. Let’s return to the case example and consider how the patient may be feeling.

Candice’s symptoms are becoming more severe. The things she previously used to cope — minimizing and denying — are no longer working

well. As Candice’s coping mechanisms fail to control her anxiety, she shows her feelings in other ways. She’s frustrated because she’s losing her ability to function. So, like many patients, she moves to control the things around her that she can control. Demanding cold water, which may be seen by the nurse as an irritating minor request, becomes Candice’s way of taking some control over her experiences and of not feeling so alone.