Palliative and Supportive Care (2014), 12, 455– 464. # Cambridge University Press, 2013 1478-9515/13 doi:10.1017/S1478951513000527

Developing relationships: A strategy for compassionate nursing care of the dying in Japan

KAORI SHIMOINABA, RN, MNSG, PHD,1 MARGARET O’CONNOR, SUSAN LEE, RN, PHD,1 AND DAVID KISSANE, MD, FRANZCP2

RN, DN,

1

1

School of Nursing and Midwifery, Monash University, Palliative Care Research Team, Frankston VIC Australia Discipline of Psychiatry, School of Psychology and Psychiatry, Faculty of Medicine, Nursing and Health Sciences, Monash University, Frankston VIC, Australia

2

(RECEIVED January 25, 2013; ACCEPTED April 5, 2013)

ABSTRACT Objectives: The aim of this study was to explore the type of relationship and the process of developing these relationships between nurses and patients in palliative care units in Japan. The special contribution that culture makes was examined to better understand the intensity of nurses’ grief after the death of their patient. Methods: Thirteen Japanese registered nurses currently practicing in palliative care units were interviewed between July 2006 to June 2009. Theoretical sampling was utilised and the data were analysed using grounded theory methodology. Constant comparison was undertaken during coding processes until data saturation was achieved. Results: Significant cultural influences emerged both in the type of relationship nurses formed with patients and in the way they developed relationships. The type of relationship was termed ‘human-to-human’, meaning truly interpersonal. The cultural values of ‘Uchi (inside) and Soto (outside)’ have particular implications for the relationship. Four actions Being open, Trying to understand, Devoting time and energy, and Applying a primary nurse role, were identified as strategies for nurses to develop such relationships. The quality of this deeply committed encounter with patients caused nurses to grieve following patients’ death. Significance of results: Culture is a major influence upon the reasons, complexities, and impact that lie behind nurses’ behaviours. Attention is needed to support nurses to sustain a fundamental caring quality in their relationships with patients. KEYWORDS: palliative care, nursing, relationship, culture, grief

INTRODUCTION

experience grief after the patient’s death. Nurses encounter patients in their workplace as care providers; they are not family members, relatives or friends of the patient. However, if nurses grieve their loss when a patient dies, the patient-nurse relationship warrants close examination. The nurse-patient relationship is considered foundational, and its nature has been characterised by theorists and researchers as interpersonal, therapeutic, connected, involved, related or attached (McQueen, 2000; Williams, 2001; Graber & Mitcham, 2004; Mok & Chiu, 2004; Stein-Parbury, 2005; Lee et al., 2008). An important dimension has been described as a ‘therapeutic intimate relationship’, which is developed by openness, self-disclosure,

While Vachon (1995) highlighted the level of occupational stress that nurses can experience, less attention has been paid to their grief at losing their patients. Nurses’ experience of grief following the death of patients in palliative care settings has been examined in Greece and Hong Kong (Papadatou et al., 2002). Papadatou et al. (2002) pointed out that the depth of intimacy in the relationship formed between nurse and patient is one of reasons why nurses Address correspondence and reprint requests to: Kaori Shimoinaba, School of Nursing and Midwifery, Monash University, Palliative Care Research Team, PO Box 527, Frankston VIC 3166 Australia. E-mail: [email protected]

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456 acceptance, understanding and trust between nurses and patients (McQueen, 2000; Williams, 2001; Graber & Mitcham, 2004; Stein-Parbury, 2005). Trust gives a sense of security and makes it possible for patients to reveal their true feelings or personal information (McQueen, 2000). A sense of mutuality between nurses and patients is considered crucial for this quality to emerge (Williams, 2001; Stein-Parbury, 2005). The relationship may require that both the nurse and patient take into account the degree to which they respect and value the other as special, unique and memorable for both (Weissman & Appleton, 1995; Stein-Parbury, 2005). One of the positive features of the relationship is a sense of satisfaction and fulfilment based upon making a difference to these patients (Stein-Parbury, 2005). When the nurse-patient relationship has been special and memorable, it would be a natural response for nurses to grieve its loss. As a result, either the accumulation of grief or its suppression and the more serious consequence of burnout could become issues for nurses (Williams, 2001; Papadatou et al., 2002). The relationship with a patient ought to be viewed as a ‘professional relationship’ which is goal directed (Stein-Parbury, 2005). Indeed, nurses are taught to establish common goals to further the care agenda (Mok & Chiu, 2004). Stein-Parbury (2005) distinguished a social friendship from the professional relationship. However, Mok and Chiu (2004) recognised in Hong Kong that palliative care nurses often crossed this boundary to form a trusting relationship with their patients, akin to becoming part of the family or seeing their patient more as friend. SteinParbury (2005) emphasised the power inequality, yet a compassionate goal of care requires that the interaction is not cold or distanced. Mok and Chiu (2004) explained that nurses encourage entering more fully into the encounter and they take the initiative in building the therapeutic alliance, giving time and space to patients until they become ready to disclose deeper feelings. However, the corollary is that nurses could experience this journey as emotionally demanding and sometimes a burden, with the potential for over-involvement (Williams, 2001; Stein-Parbury, 2005). The types of relationship nurses form with patients and the positive and negative aspects of the relationship have been well documented. However, the processes by which nurses develop relationships with patients have not been well explored. Drawing upon the different explanations of the development of the nurse-patient relationship found in the work of Stein-Parbury (2005) and Mok and Chiu (2004), we recognise that the cultural background of nurses and the context of care may have an impact on the type of relationship and how it

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developed. However, there is no research related to cultural aspects of the nurse-patient relationship in Japan. This paper focused on the relationship between Japanese nurses working in palliative care units and their patients looking at the types of relationship they form and the way they develop this relationship. Understanding the types of relationship and how they develop may explain nurses’ experience of grief after patients’ death. The Japanese culture may be directly influential on the nursepatient relationship and consequently nurses’ grief, although its specific contribution has not been well understood. Given the ageing society and rising cancer mortality as a leading cause of death in Japan, palliative care was developed as a model of health care to support patients and family members at the end of life. Palliative care initially developed in-patient services with the first unit being established in 1981 (Kashiwagi, 1999). Today there are 255 palliative care units, with 4473 beds (Hospice Palliative Care Japan, 2012). Japanese government policy has emphasised the need to increase both community palliative care and consultancy teams in acute hospitals to meet increasing demands. One unique feature of palliative care in Japan is a tradition of long hospitalisation, with the average length of stay approximating 40 days in 2010 (Hospice Palliative Care Japan, 2010). In addition, the care provided is usually based on a primary nursing model, where a nominated nurse sustains continuity and responsibility for patient care from admission to discharge (Ritter-Teitel, 2002). Long hospitalisation and the use of the primary nursing model are suggestive of the potential close relationship between the nurse and the patient, and the nurse’s experience of grief after the patient’s death. Based on the perception that support for grief was neglected for Japanese nurses working in palliative care units, a survey was conducted with charge nurses in Japan (Shimoinaba et al., 2010). This survey revealed a perception by Japanese charge nurses that primary nurses in their wards tend to build close relationships with their primary patients. The special bond developed between a primary nurse and a patient raises Japanese cultural construct of “Uchi” which signifies mutual awareness of trust and connection. As a result, nurses grieve after patients’ deaths and their grief has represented an unmet needs; the necessary support systems were not in place (Shimoinaba et al., 2010). The use of primary nursing model is, however, not often practiced in other countries as the close relationship with primary patients is thought too great responsibility and a source of burden for nurses (Athlin et al., 1993). This study focused on Japanese nurses’ own experience of the care-giving bond that develops

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between the nurse and the patient in the setting of terminal illness. It explored the quality and nature of relationship as well as how culture influences the way they develop this relationship. This paper explicates the process used to develop these relationships. METHODS We employed grounded theory in a qualitative design because this enables sense to be made of the meanings and actions of participants, leading to strengthened arguments for change. Grounded theory is an approach to collecting and analysing qualitative data that aims to develop a theory (Strauss & Corbin, 1998). Ethics approval was obtained from the University ethics committee. The target population was registered nurses currently practicing in palliative care units in Japan. The selection criteria were kept simple to reflect the varied length of nursing and palliative care experience among participants (LoBiondo-Wood & Haber, 2006). The ‘Hospice Palliative Care Japan’ web site was used to identify existing palliative care units in Japan. In May 2006, this number was 159. Invitations and information were sent by mail to all 159 units. Nurses who were interested contacted the researcher and then prospective interview participants were selected from different palliative care units in different cities in Japan. Theoretical sampling continued throughout the study as more participants need to be recruited based on the emerging theory (Taylor et al., 2006). Eighteen interviews were conducted with 13 nurses: three nurses were interviewed twice and one nurse three times. All participants were female and aged between 29– 53 years old (Mean ¼ 37.8 year old, Standard Deviation ¼ 6.68). The range of nursing experience was 7 – 26 years (Mean ¼ 15.5 years, SD ¼ 6.31) and range of palliative care experience was 2 – 8 years (Mean ¼ 40.2 years, SD ¼ 22.6). Participants’ educational level varied; 8 nurses graduated from nursing school, 2 of them were nursing college graduates, one graduated with a 4 year university degree and 2 were undertaking Masters level courses when interviews were conducted. Both continued recruitment and re-interviewing of participants were required as data analysis progressed, until saturation was achieved and no further new themes emerged (Strauss & Corbin, 1998). Data were collected in Japan, using in-depth interviews of 55 – 90 minutes duration. A number of open ended questions were used, such as ‘what is the most satisfying aspect of caring for these patients?’ and ‘how do you feel when a patient dies?’; they were aimed at exploring the nurses’ caring experience, their relationships with patients and their

457 grief. Interviews were conducted at a place convenient to each participant, such as a quiet room in their hospital or a hotel meeting room. While the interviewer was bilingual in Japanese and English, participants used their first language (Japanese). All interviews were tape-recorded and transcribed in Japanese, then translated into English. Some translation difficulties were encountered when an equivalent explanation was not found between the languages and contextual translation was used (Lopez et al., 2008). In this study, some words were written in Japanese using Romaji (transcribing Japanese phonetically, thus avoiding loss of meaning during translation) and adding explanations of the Japanese words. The quality of translation was verified by a second qualified translator. Data collection was conducted over a three-year period (July 2006 to June 2009), and was completed after reaching data saturation. In grounded theory, data collection and analysis occur in parallel and interact continuously throughout the research process (Holloway & Wheeler, 1996). Interview transcripts were thoroughly read and analysed in both Japanese and English several times during the process of open coding, exploring similarities and differences between events, actions and interactions to apply conceptual labels to these. The first author analysed in both Japanese and English, and 2nd and 3rd authors analysed the translated versions of the transcripts. From the interview data, line-by-line open coding was undertaken and various themes emerged, which were displayed on a grid. Using these conceptual labels and constant comparison, axial coding assisted with finding categories that related to each other in terms of the conditions, actions/interactions and consequences (Strauss & Corbin, 1998). Selective coding was then undertaken, which was defined as “the process of integrating and refining the theory” (Strauss & Corbin, 1998, p. 161). During selective coding, all categories were unified around a theory (Liamputtong & Ezzy, 2005) that explained how nurses in Japan cared for patients in the context of death. Memos and field notes were written throughout the process of data collection and analysis, recording the analytic processes, which assisted with formulation of the theory. The term ‘trustworthiness’ is used in qualitative research to show how rigorous the study is and ensure that those participating in the research are identified and described accurately in a study. Credibility, auditability, and fittingness persist as criteria for judging the rigor of qualitative research (LoBiondo-Wood & Haber, 2006). Credibility was strengthened in the use of participants’ own words to build the theory as well as the use of multiple

458 people to analyse the data in both Japanese and English. The process of recording analysis as memos provided auditability; and theoretical sampling used in recruiting participants while the analysis of themes unfolded supported fittingness. RESULTS During the analysis of interviews with Japanese nurses working in palliative care, it became clear that they were describing a particular type of nursepatient relationship, providing insight into how they developed that relationship. Moreover, nurses described their experiences of grief as a result of the loss of such relationships. In describing these results, participants’ comments illustrate each theme and numbers in brackets refer to individual participants. The most representative comments are chosen here to highlight their experiences. Developing the Nurse-Patient Relationship The particular type of relationship nurses formed with patients was described as a ‘human-to-human’ relationship, one that is truly ‘interpersonal’. Participants used the word ‘human’, ‘human being’ or ‘person’ to describe their patients instead of using the word ‘patient’: Although our relationship is a patient-nurse relationship, it is also human-to-human relationship. (8.2) Palliative care is holistic care and [holistic care] is to see the person as a person. To see the person not setting him in a frame; to see the person as a whole having the things he cultivated, own history, and relationship with others. (10.1) Participants viewed the person as a unique individual, not one of a cluster of ‘patients’ which is a general word and does not convey individuality. When the term ‘patient-nurse’ relationship was used to describe the relationship, it implies an unequal relationship describing occupation or position in the totally different roles of a patient and a nurse. When described as a ‘human-to-human’ relationship, a person who receives care (a role as a patient) and a person who provides care (a role as a nurse) are equal as human beings; their relationship is closer than the professional ‘patient-nurse’ relationship. Nurses used their personal self, built on their own life history and loss/grief experience as well as their nursing knowledge and skills to provide care or develop relationships with patients. Their use of their personal self as well as their professional self to provide care made them able to provide ‘deeper interpersonal’

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care. In addition, their state of being as a person influenced their relationships with patients and family members. For example, one interviewee thought that patients and family members would stop sharing their issues if they perceived that nurses were emotionally distracted by their own issues; this interviewee also assumed that patients had such sensitivity. In order for participants to know their own emotional issues and put them aside, they need to understand their personal self: I have better understanding about myself after I came to the hospice. . .I was not good at . . .when I was working in the busy environment, I did not have time to think about [myself] deeply or [I] avoided looking at [myself]. But I have more opportunities to think about human relationships or communication in the palliative care. These give me an opportunity to understand myself. (7) Participants’ experience of working in the PCU and their use of the personal self gave them an opportunity to reflect on and learn about themselves; this is a natural component of using the personal self in ‘human-to-human’ relationships. Four elements, Being open, Trying to understand, Devoting time and energy, and Applying a primary nurse role, were identified as actions participants used to develop this type of ‘human-to-human’ relationship with patients. As discussed previously, participants described the relationship with patients as more than one based on a professional role between a nurse and a patient. I guess both of us were reserved with each other. He wanted to do everything by himself, and his wife was there for him. But they spent 4–5 months at the hospital and started feeling annoyed with each other. I recognised their feelings and offered to support him when he took a bath. After that, I saw him crying. I did not know what he was holding in his mind. . .I said ‘if you want to, please express what you are holding in your mind’. He started talking. He openly expressed how he would like to be cared, and what he likes and dislikes. The relationship was changed very much after this discussion. I experienced ‘changed relationship’ after this discussion and he became very open after that. (8) Seeing the patient’s emotional cue, the nurse offered empathic support, which enabled the patient to share his vulnerability with her; this naturally deepened the connection through trust and set up a therapeutic relationship through which more support could be given.

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A number of participants described a word ‘Enryo’ in their interviews, translated as ‘be reserved’ from Japanese into English in the above comment. There is a threefold meaning of ‘Enryo’: to have deep thoughts; to be moderate about what is said and in behaviour towards others; and to be moderate in activities respecting public discipline” (Shinmura, 1998, p. 258). The meaning of ‘Enryo’ in this context involved considering a person’s feelings deeply, and respecting personal and emotional space until they were invited by the person to engage with their personal and emotional self. Thus, ‘Enryo’ elucidates both a nurse and a patient considering each other’s feelings and respecting each other’s space. Interviewee 8 (above), added that a nurse acknowledged the time when the patient invited him/her to step into their emotional space, a process understood the Japanese as “Uchi” (see further Discussion). This was the moment the nurse-patient relationship was developed at a deeper interpersonal level, formed because both a nurse and a patient became open to each other; the relationship deepened, they became closer and were less reserved with each other. Being Open Being open was the participants’ quality of being authentic with the patients and themselves, and their ability to listen to them. They became open with patients, accepting how they were and what was said; and to themselves by recognising their own feelings. In other words, Being open meant participants faced their own ‘human’ side which has not been viewed as a general responsibility of nurses. One participant explained how openness was used to form a relationship with a patient: . . . I become a listener. I try to develop a relationship that the patient can express any emotions. (6) This comment showed the participant’s attitude to listening to the patient and her openness enabled the development of a relationship with the patient. This attitude is a clear pathway towards deeper attachment rather than avoidance. Listening was a common strategy or action participants used in forming the relationship with patients based on their emotional openness. The word ‘listen’ was translated from a Japanese word ‘Keicho’, frequently used in the interviews, the meaning of which is to “attend closely to what a person is saying and accept what is said” or “to listen from their heart” (Shinmura, 1998, p. 679). An attitude of willingness to listen with a non-judgmental view is necessary for ‘Keicho’ and is perceived as ac-

tive listening. Listening is of course a skill commonly used by nurses (Stein-Parbury, 2005) and an essential process to establish a therapeutic relationship (Fredriksson, 1999). In Japan, however, the kanji character ‘listen’ is made up with other small kanji characters of ear (listening by ear), eye (observing) and heart (listening by heart), an illustration of the disposition and attitude of ‘listening’ required of Japanese nurses. Participants showed that they made a determined effort to understand the patient as a person and as a holistic being. Participants explained the depth and quality of their listening and attitude: I just listened to the patient. I am with him, with his heart. I may cry with him. What can I say. . .I do not provide anything; I just listen to his heart. I feel it is great if I can support the patient who suffered emotionally and if he is relieved because I listen to. (2) The words ‘I am with him’ implied that the above participant was with the patient physically and emotionally, and she was ready and available to do that. She listened to the patient deeply from her heart, especially to his emotional suffering. She also said ‘I may cry with him’, which indicated her emotional engagement with the patient’s suffering. Close relationship between a nurse and a patient. . . . Perhaps, I think because I try to listen to the patient, patients say to me it is easy to talk to me. I try to listen to them in any timing. I know they are not seeking answers. (10) The recognition that patients identified time to talk about deep personal issues or emotional/spiritual pain, and that patients were not seeking an answer from nurses for such issues, were considered important by participants for effective listening. Participants’ openness towards patients was demonstrated by their readiness, honesty and acceptance of what they were listening to. Trying to Understand In order to develop a close ‘relationship’, participants made an effort to understand the patient’s holistic being, including their family background, coping strategies, expression of emotions, holistic needs and total pain (physical, emotional, social and spiritual). Trying to understand patients here was defined as ‘trying to know the patient’s personality, family context and coping strategies, how they feel and the meaning of their behaviour’, as explained by a participant:

460 I try to understand; the patient’s family, how the patient coped with difficulties in the past, or how he expressed his joy. (8) In trying to understand a patient’s emotional coping strategies, participants were keen to learn how the patient previously coped with a crisis in their life and how s/he expressed it. This would help participants deal with the patient who was facing their own death. Trying to understand patients’ needs illustrated participants’ attitudes to the patient as a ‘person’. Participants perceived that patients would not be sure whether nurses had a genuine understanding of them without them acknowledging that they understood the experience of suffering. Nurses are required to accept what patients are saying and seek what we can do for them. We need to try to understand their suffering; otherwise we cannot palliate their suffering. (10) When nurses step into their patients’ shoes, empathically validate their experience, show understanding and compassion, their respect and presence helps to contain the patient’s distress and ameliorate their suffering. Devoting Time and Energy Devoting time and energy referred to ‘nurses giving time and physical and emotional energy to the patients and their family members in order to develop relationships’, because they were aware of the very limited time left for the patients and family members. Spending a long time with patients gave participants an opportunity to get to know them. However, participants not only meant that the length of time was significant; they also emphasised the importance of the quality of time and the emotional energy they devoted to it, their authentic presence. A common strategy was to celebrate key events, such as a birthday or wedding anniversary. They usually used after work hours to organise and prepare these special events, recognising that it was the last time for both patients and family members to celebrate together. Participants perceived that this devotion assisted the development of the relationship. Sharing quality time was more important than the length of time. Although sometimes emotionally stressful, they felt that if they did not devote sufficient time and energy, they had not done their best. Applying the Primary Nurse Role The use of the primary nurse role was one of the structures that contributed to the way relationships

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developed with patients, especially strengthening aspects of continuity of care. A primary nurse in Japan tends to have responsibility for a particular patient’s care from admission to discharge, eventually including bereavement support, in order to enhance the quality of care. Care responsibility towards primary patients includes making and reviewing care plans, organising team and family meetings, and supporting events if patients wish. The primary nurse endeavours to know the patient better than other nurses, and participants believe it is an advantage for patients to identify a person on whom they can rely. An ideal [primary nurse] should be a person who knows [the primary patient] best. And have information [regarding the patient] most. In addition, primary nurse is the person who the patient and families can talk to (consistent “Uchi”, see Discussion). I think a primary nurse should be like that, but it is not easy. (12) Although the role of a primary nurse was acknowledged as often not easy for participants, its application was crucial to develop a trusted and committed relationship with the patient and family members. Participants distinguished the way they dealt with patients between their own primary patients and non-primary patients. Participants acknowledged that it was very difficult to develop a sufficient relationship with patients without providing continuity of care, and they believed that the model of primary nursing was fundamental. The resultant responsibility engendered true coordination and case management. [Role of a primary nurse is] a coordinator between a patient and his family members, among nursing staff, and between a physician and family members. In addition, [primary nurse is] an advocate who supports the patient in what he wants to say. And also [a primary nurse] is in the best position to provide information to the patient. (8) Acknowledging themselves as ‘being in charge’ of a particular patient’s care showed participants’ commitment and true dedication. Explanation about the nature of a primary nurse’s role to the patient helped identify this nurse as the person s/he could ask questions of. The coordination role smoothed communication with all in the multidisciplinary team, enabled advocacy for unmet needs, and enhanced quality of care.

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Impact of ‘Human-to-Human’ Relationships on Nurses The participants believed that the use of personal self had significant meaning for them as they faced their own personal issues witnessing patients’ deaths and family member’s grief. Nurses’ caring experiences in the palliative care units affected them professionally and personally and consequently, they may become vulnerable. Some participants recognised their vulnerability in the following comment: Palliative care . . .is probably to support patients and their families. . .and myself. Yes, I cannot care for patients and families without supporting myself. It may include other staff as well. . . If I have an issue or suffering, I need to put it [an issue or suffering] aside. Patients realise it as they have an ability to sense it. If so, patients do not talk [important things] to us. I need to care for myself. As I said before, [palliative care] is a care between human-to-human. (11) When participants recognised that palliative care is provided within the human-to-human relationship, they also realised that the caring experience impacted on them. Developing a special relationship resulted in participants experiencing loss and grief after a patient’s death as indicated in the following comments: We feel very sad when the patient dies because we look after them for a long time and develop rapport. (1) I feel sadness rather than stress. Yes, I feel sad to say good bye. It is a breaking off the relationship with the person, so I feel sad. (10) These common responses of sadness and grief were experienced because of developing ‘rapport’ with patients; their death was the breaking of a special relationship. Grief after the patient’s death is recognised as a more personal experience than workrelated stress and especially emphasised for the nurse in a primary patient relationship. And a sense of grief becomes strong after the primary patient’s death, if a primary nurse and patient establish a good and deep relationship. It is difficult to maintain [appropriate] distance. (2.2) Grief also caused nurses to reflect on how to maintain appropriate emotional distance with patients; they know they suffer painful emotions after a death as a consequence of this close and special relationship.

DISCUSSION This study revealed the type of relationship Japanese nurses form with patients in palliative care units and the strategies they use to develop such a relationship. In addition, the study disclosed nurses’ experiences of loss and grief after a patient’s death. The type of relationship was described as a ‘human-to-human’ relationship, which means nurses form the relationship with a patient as a ‘person’ using their personal self. During the process of analysing the interviews of participants, the cultural implications of nurses’ actions, especially how they develop a relationship with patients and the type of relationship emerged unexpectedly. Although there are other studies that report on the importance of developing relationships in palliative care (Mok & Chiu, 2004; Lee et al., 2008), this study demonstrated the link between cultural expectations and the development of professional relationships between nurses and patients. Particular questions about culture had not been asked in our interview, but were implicit in the study. As in other studies, cultural values do underpin nurses’ thoughts and the philosophy that guides their actions, even though they may not have been conscious of them (Markus & Kitayama, 1991). In this study, developing the nurse-patient relationship involved nurses exploring and forming a therapeutic alliance with patients throughout the delivery of care, including the way in which a nurse and patient deal with each other, which gradually becomes more important. They also viewed the ‘patient’ as a ‘person’ and described providing human-to-human care based on a human-to-human relationship, considered more than a professional role-based relationship. The nature of this resultant relationship, the ways that these were developed and the skills required are inextricably linked to the Japanese culture. Four elements: Being open, Trying to understand, Devoting time and energy, and Applying a primary nurse role, were identified as participants’ actions in order to develop a relationship with patients. Getting to know patients and establishing working relationships with them and their family members are common practice in health care, especially in nursing (Stein-Parbury, 2005). However, the particular contribution from the Japanese culture that influenced how people develop relationships related to the values of ‘Uchi and Soto’. ‘Uchi’ means inside and ‘Soto’ means outside (Makino, 2002; Hendry, 2003). These values play a major role in describing the salient relational contexts found in Japanese society (LeVine, 2001). After entering ‘Uchi’ and developing a relationship with a patient, there is a

462 consequent significant impact on nurses’ experiences of loss and grief when the patient dies. The cultural values ‘Uchi and Soto’ may be explained using the concept of visiting someone’s house. When guests visit a Japanese home, they are required to take off their shoes at the ‘Genkan’, a space between the external door and the inside of the house. Typically, a step or steps separate ‘Genkan’ from the house, so that this transitional zone is created. Thus both the external door and ‘Genkan’ divide ‘Uchi’ (inside) and ‘Soto’ (outside). Compared with Western-styled housing where the external door opens inwards, in a Japanese-styled house, this door opens outwards because of the space required to leave the shoes. Having a chat standing at the ‘Genkan’ and not taking off one’s shoes represents a brief or informal visit. Inviting someone into one’s house, which means removing their shoes, signifies the potential for a closer relationship to develop between the house owner and the guest. Taking off one’s shoes and entering the home requires commitment to enter the private world of the resident, as the guest cannot leave without putting their shoes back on. When people are ‘Uchi’ with their shoes off, the relationship between the resident and the guests becomes personal and common feelings emerge between them. (Donahue, 1998; Davies & Ikeno, 2002; Makino, 2002; Hendry, 2003). As stated by Markus and Kitayama (1991), participants may not be conscious that their thought and actions are based on their cultural values. Participants used a word ‘Enryo’, discussed previously, meaning to ‘be reserved’, this word encompasses thinking about a person’s feelings and respecting personal and emotional space until invited by the person to engage with their personal and emotional self. The nurse-patient relationship starts with ‘Enryo’; a nurse and a patient considering each other’s feelings and respecting each other’s space. Their attitude to ‘Enryo’ has an important connection to the cultural values of ‘Uchi and Sono’. ‘Uchi and Soto’ describes a relationship formed between participants and their patients; the house symbolises the patients’ heart, a sacred space embodying all that is unique about them. Before establishing a relationship, participants were standing ‘Soto’, literally outside the house. At this stage, nurses were reserved (‘Enryo’) and needed permission from the patients to step into the house ‘Uchi’. At the same time, participants were not just waiting for an invitation to enter ‘Uchi’, but their actions in being open and honest with the patient and their ability to listen encouraged this invitation. Participants described the moment when they were invited by patients to ‘step into’ and once invited into ‘Uchi’, trust was signified in the relationship, empowering them to seek knowledge about the

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patient, including their life history/experience. This is the ‘human-to-human’ relationship participants aimed to develop with their patients. Considering the peculiarity of inviting someone into their metaphorical house, ‘Uchi’, it is understandable that the relationship between a nurse and a patient becomes special and they form a close connection. Some participants described their relationship as ‘family-like’ conveying a new sense of duty and commitment through the cultural honour bestowed by ‘Uchi’. Within this culture, a Japanese person would have difficulty inviting many people to step into ‘Uchi’ as it is a distinctive privilege. This explains the reason why primary nursing is used and considered suitable in most palliative care units in Japan. The patient feels comfortable with the primary nurse once they establish this committed and trusting relationship, inviting her/him into ‘Uchi’. The primary nurse also feels that she knows the patient best and this distinguishes the relationship between their primary patients after being invited into ‘Uchi’ and other non-primary patients. Other researchers also report that primary nursing promotes greater continuity and individualised care, and improves the nurse-patient relationship (Athlin et al., 1993; Webb & Pontin, 1996; Smedley, 1998). At the same time, Athlin et al. (1993) pointed out that the primary nursing role can be demanding and burdensome for nurses because of the emotional involvement expected of them. Similarly to that indicated by Athlin et al. (1993), participants in this study understood the heavy burden and responsibility of the primary nursing role as well as the sense of satisfaction it brought. ‘Removing their shoes’ symbolises stepping into the relationship with the patient as a person, rather than in a more superficial nursing role. To be willing to engage in this commitment, the palliative care nurse needs to understand their own mortality, to face their own death anxiety. The resultant relationship shares characteristics of deeply ‘connected relationships’, establishing a human-tohuman bond (Weissman & Appleton, 1995; SteinParbury, 2005). Participants used this word ‘human’ or ‘person’ repeatedly to explain that the duty that followed became both a reward as well as an emotional burden. Such a commitment signified by ‘Uchi and Soto’ conveys the depth of the involvement that follows, which in turn leads to the experience of loss and subsequent grief after a patient’s death. Nurses grieved not only professionally after a patient’s death, but also personally, after losing the special relationship formed within ‘Uchi and Soto’ values. Once one appreciates the nature and depth of the caring relationship that tradition expects Japanese nurses to embrace, their

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Developing relationships in palliative care in Japan

bereavement care requires consideration within this cultural framework. Further research that focuses on culturally explicit interventions to develop nurses’ resilience, needs to be developed in the light of these results. LIMITATIONS OF THE STUDY This study was limited to only Japanese nurses in palliative care settings, so results cannot be generalised to nurses working in other countries and other settings. However, the findings conform with other research (Athlin et al., 1993; Weissman & Appleton, 1995; Fredriksson, 1999; Stein-Parbury, 2005) particularly in the way nurses develop relationships with patients whom they know to be terminally ill.

CONCLUSION The Japanese cultural values of ‘Uchi and Soto’ serve as a guide to the deep tradition that informs the therapeutic encounter for these nurses. Although much has been written about nurse-patient relationships in general, this study has demonstrated the inextricable link between Japanese nurses’ cultural values and how they develop, maintain and grieve their relationships with patients. The depth of the relationship explains the reason why the primary nursing system is so well accepted in palliative care units in Japan. At the same time, both anticipated and eventually actual grief after the patient’s death warrants consideration of the nurses’ care needs. Special education and support programs are called for to address these needs. Cultural sensitivity training is required for nurses and nursing students in relation to their practice, including this traditional ethos that guides their special commitment to their primary patients. These aspects need to be reflected in the cultural competence guidelines and ethical guidelines as part of professional conduct in clinical environments. Moreover, future research is required to develop appropriate workplace interventions to support nurses who experience loss and grief after the death of a patient with whom they had a special relationship. The ongoing support needs of nurses working in palliative care units warrant further examination.

ACKNOWLEDGEMENTS This research was supported by a postgraduate public health scholarship from the National Health and Medical Research Council, March 2008–May 2010. No conflict of interest has been declared by the authors.

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