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Returning to the hospital for her postpartum checkup was painful for Beth Seyda. Her baby, Dylan, had lived only two weeks. He succumbed to infection after surgery to correct a congenital diaphragmatic hernia.

Seyda felt uneasy in the waiting room with expectant mothers and babies when she returned for her first postpartum appointment.

She finally felt safe in the examining room, until a nurse walked in and routinely asked whether Seyda was breast-feeding.

"It was very upsetting. And she felt terrible, too. She just saw it as a postpartum visit and didn't know there was anything different about it. I thought, 'Why isn't there something set up to keep this from happening? A different place to go.' For me, it boils down to how critical communication is, especially in an intensive medical situation," Seyda said.

Good communication
"Obviously, we can't know everything. But we can sure ask," said D.J. Pappas, who is a licensed professional counselor and administrative manager for bereavement services at Duke University Hospital in Durham, N.C.

Pappas, who was at the University of North Carolina Hospital when Dylan died, now facilitates a support group for bereaved parents there.

"People need to be able to communicate what they need," Pappas said.

One member of the group said she wanted people to stop avoiding her, to come up and say, "I'm sorry." But another participant said she was sick and tired of people saying they were sorry.

Mechanisms for communication among physicians on a care team are in place. Nurses may have to create their own mechanisms and include themselves in
the loop. They also may have to propose changes in the system.

Making decisions
When there is open communication, it is possible for nurses to offer patients and families choices and the ability to participate in decision making.

"There are a lot of decisions, and it would be helpful for people to know what those are," Seyda said.

For example, Pappas said, when a child is stillborn, one family may find staying on the maternity floor incredibly painful, but another may want to be there, to validate that they had a child.

Or, when faced with a terminal prognosis, one family may seek aggressive treatment right up to the end, while another will prefer only palliative care, said University of San Francisco School of Nursing Professor Betty Carmack, Ed.D., RN.

In other words, every situation is unique, and nurses can intervene more successfully if they understand what a given situation means to the individuals who experience it.

Nurses also need to speak up with physicians, said Martha Henderson, MSN, NP, RN, who works in a program on aging at University of North Carolina Hospital. When Henderson surveyed nurses, she found that the pain of an ethical dilemma led 20 percent of them to consider leaving their jobs, but she believes that this statistic will fall if nurses become more skilled in communication.

In difficult situations, nurses also should seek help from experts or consult ethics committees. They can request training in communication.

After her experience, Seyda, a market research consultant in Chapel Hill, N.C., who is now on the hospital's ethics committee, is helping produce a video about the experience of losing a child, "Creating Community: Supporting Families When a Child is Dying."

Grief experiences
Pappas invites people in to talk about their grief experiences. Projects such as these, part of a growing national interest in improved care for the dying, provide new methods and skills that can be transferred to any area.

Nurses also need to be aware of how their personal experiences will affect their sensitivity toward the needs of patients and families.

Psychotherapist Erica Rothman, who serves on the hospital's ethics committee, said that those experiences can get in the way, but can really add to it, too.

Rothman produced a video for families, "Those Who Stay Behind: When a Family Member is Dying."

In instances when Rothman has shown the video to health care professionals and let them talk about their own experiences, it has helped promote understanding of how those experiences affect them professionally.

"Until you understand your own attitudes, feelings and beliefs," Carmack said, "it is hard to be responsive to a client." Cultural beliefs and values, those of the nurse and the family, can play a significant part, too.

The nursing shortage means that new nurses are dealing with situations they wouldn't have had to handle in the past. Seasoned nurses often are overwhelmed and frustrated.

There will be times when a nurse says or does the wrong thing or situations and people are simply too complex, and nurses are expected to take on so much.

"Don't beat yourself up about it," Carmack said. "Learn from your mistakes and go on, because you'll be presented with another situation that you can handle differently."

After her heartbreaking office visit, Seyda sat down and penned 30 pages about her experience with Dylan.

She sent it to the physicians and nurses at University of North Carolina Hospital. About five of those pages were recommendations.

"There were situations that could have been better, and I suggested ways to make them better. But a lot of it was reinforcing the good things that were done. Nurses may not know how great a lot of these things are, things that in the grand scheme are minor, but that were so helpful," she explained.

She added, "Overall, the nurses were wonderful. They were with our son 24 hours a day. They were great at explaining all the medical and technical stuff at a level we could understand. Nurses have so much interaction with the family, so the opportunity is there for good communication," she said.