BY: BETH PERRY, RN, PhD
Dr. Perry is associate professor, Centre for Nursing and Health Studies,
Athabasca University, Edmonton, Alberta, Canada
Prayer, Music, Touch, and Silence Can All Be Therapeutic in Caring for the
People who care for the seriously ill and dying must be strong and sensitive.
God grants caregivers these gifts in order that they can improve the quality
of living and the quality of dying. This strength and power does not necessarily
manifest itself in complex ways. Rather, it is sometimes seen in the simplest
gesture rendered by the caregiver with sincerity and grace. In this article,
I will explore the powers of prayer, music, touch, and silence. At first, these
all seem to be small and insignificant interventions. But when done with "great
love," they make a difference in the life, and death, of those in our care.1
Stories about Nurses
To demonstrate the power of the simple gestures of shared prayer, music, touch,
and silence, I will tell several stories. Some are drawn from a study I conducted
of exemplary nurses who provide care for patients with cancer.2
The participants in this study were nominated by their peers, who described
them as "nurses they would want to have care for them, or for family members,
in a palliative care situation." I conducted interviews with these nurses,
observed them at work, and asked them to recount memories of patient interactions
that had changed them or the way they practiced nursing. Following the interviews,
I analyzed their recollections and observations using a multidimensional analysis
derived from the phenomenological perspective.3
Perhaps the stories told here will remind some Health Progress readers
of patients they once provided care for. These stories illustrate what I believe
is the essence of exemplary palliative care. Stories are especially appropriate
in articulating the actions of nurses caring for the dying because "stories
are the juncture where facts and feelings meet."4 I will offer
further analysis of the caregiving experience through several short poems (see
below and pp. 51 and 52). According to one authority, poems are the perfect
medium for giving voice to the tacit and unspoken.5 These poetic
interpretations also come as close as is possible to capturing the emotion of
The Power of Prayer
Many of the stories told by the nurses I interviewed provided insight into
their spiritual beliefs. In many cases, their spirituality developed as they
cared for people who were dying; the caregivers were faced with patients'
questions about the existence of a greater power and with concerns about what
happens after death. In their stories, some nurses shared their emergent beliefs
about God and everlasting life. Many gave examples of how they had learned through
experience to utilize the power of prayer as they prayed with, and for, their
Marie, one of the nurses I interviewed, said, "I pray for my patients
now. When they are dying, especially, I pray for them out loud, at the moment.
It is my way of assuring their safe passage. I truly believe it; and I know
that, if they are aware, they will understand. Really, it is for me as well
as for them." Marie then went on to tell a story illustrating how she relies
on prayer to help facilitate the transition from life to death.
"The process of dying can take a long, long time," Marie said. "Mr.
Johnson had been in the last stages for about two weeks. He was a very religious
man, and we had shared many talks about his illness. I was there when he was
originally diagnosed, and I had come to know his family well. They had been
keeping vigil day and night at his bedside, reading to him and praying his favorite
prayers. He was very much at peace, but we all wondered silently, 'Why
was this taking so long?'
"It was Tuesday morning, and I was his nurse that day. When I did my assessment,
I found his breathing was irregular and his extremities were very cold and mottled.
I knew that the time for his passage had come. I quickly found his wife and
daughter and whispered, "It's time." I placed one of his hands
in his wife's hand, and the other in his daughter's and I simply stated,
"He's going home." Tears flowed as they said goodbye. I cried
too. No matter how prepared you are for death, the final moments are always
hard. I felt very privileged to be present with them. I reached out to them,
and we formed a tiny circle around his bed. Together we recited an 'Our
Father' and prayed for his safe journey.
"I can't tell you how very special I felt to be part of that intimate
circle. It was a gift to me that would give me a great deal of strength in the
deaths I would stand by in the days to come."
As we gather
In Your name,
We open our hearts
To Your will,
And sense Your
blessing in our souls.
The Power of Music
Sound, which is part of everyday life for most people, can elicit a wide range
of emotional responses. Music, in particular, affects people deeply.6
Music therapy has been defined as "the prescribed use of music to aid in
the prevention or amelioration of physical, psychological, or cognitive problems."7
Research has shown that, among hospitalized patients, the positive effects of
music therapy include reduced anxiety and pain and increased relaxation.8
Indeed, music therapy appears to be an excellent noninvasive technique that
can offer some patients additional comfort during times of stress.
Consider, for example, a story told by a nurse called Sue. She chanced on the
use of music to calm the anxiety in a severely disquieted man.
"A year or so ago, I was working as a shift manager on nights," Sue
said. "A man of about 35 years of age became increasingly restless and
agitated. We will call him Mark. Mark had a progressive brain disease that was
unlike anything I had seen in 25 years or more of nursing. That night, Mark
required two-to-one nursing care. As [my colleague] Jane and I worked with our
patient, we observed that, in spite of his verbal lashing-out, Mark never once
cursed. [Jane] remarked that he must not have curse words in his normal vocabulary
because, usually, what is in a mind comes out in confusion. I looked at his
bedside table and saw a Bible.
"The night wore on with Mark's continual agitation, yelling, and
extreme restlessness. He would bite his hands and arms and grab on to anything
near him. At one point, I heard Mark repeat a series of words in a garbled fashion
and recognized the words of an old hymn. I began to sing the hymn, and immediately
he became quiet. The change was instantaneous and profound. Jane was able to
leave for a break while I sat beside him, singing every hymn I could remember.
As long as the hymns were sung, Mark rested.
"We later found out that Mark had been a lay pastor. He was loved by many,
many people; and he died a terrible death that sucked every bit of dignity from
this previously dignified, gentle man. I loved being his nurse because none
of the usual textbook interventions worked [with him]. Mark required flexible,
creative nurses who were not afraid to try the unconventional.
"Large doses of artificial sedation made no difference, but somewhere
in the deepest levels of this man's mind, the songs of praise and worship
touched him. It was a profound night because all my years of training and education
came down to the simple singing of a tune."
When all else seems lost,
And I flail with fear,
And descend into despair
Music can reach me,
And again–I remember
And again–I am found.
The Power of Touch
In the caregiving professions, touch may be one of the most powerful of all
the various nonverbal methods of communication.9 Touch is invaluable
in enhancing the nurse-patient relationship.10 Used skillfully, touch
can provide comfort, facilitate social interaction, confirm a diagnosis, trigger
the release of pent-up emotion, and even help caregivers maintain a connection
between themselves and otherwise unresponsive patients.11
In spite of its obvious importance, touch has received only marginal attention
in nursing research studies. Because touch is more difficult to quantify than
other forms of therapy, and because there are many different kinds of
touching, its effectiveness tends to be assessed subjectively, which causes
some people to remain skeptical about it.12 In fact, one writer has
suggested that such skepticism has prevented caregivers from reflecting on their
own use of touch and its potential as a contribution to high-quality care.13
One particular example of the power of touch to provide comfort can be seen
in a field note I made as I witnessed a nurse consoling a patient who was very
short of breath.
"Even before we entered the room, I could hear the desperate gasps for
air. As I laid my eyes on [the patient], I could see his struggle. Starved for
oxygen, physiologically by his disease and psychologically by his mind, he fought
for every breath. I watched as the nurse walked to his side and took his hand.
In a very soft and reassuring voice she said to him, 'Take it easy; relax;
take it slower.' Her words were matched by repetitive strokes of his forearm.
She was so calm herself, and, as his eyes fixed on hers and he felt the softness
of her touch, together they slowed his breathing down until the desperation
THE COMFORT OF A TOUCH
Soothe, support, strengthen,
You can do it with,
Just a perfect touch.
The Power of Silence
Silence is powerful. It is pure, precise, and in some sense, perfect, and it
was commonly used as a purposeful intervention by some of the nurses in my study.14
Silence is especially effective for transmitting feelings and emotions–experiences
for which we do not have words. Compassion, acceptance, and support, for example,
are often communicated best by silence. In an emotionally laden environment,
such communications are frequently necessary, even though the words we have
available are often too limited to communicate such subtle and intense meanings
Words are often inadequate; they can be imprecise and awkward. It often takes
many words to convey a single sentiment; and when one tries to put one's
feelings into words, there is sometimes potential for misinterpretation. On
the other hand, a silent moment can convey a myriad of emotions, precisely and
accurately. Jane, one of the nurses in the study, succinctly said, "Silence
is more filled with communication than words ever can be."
The following story about a nurse-patient interaction demonstrates the power
of silence in breaking thorough barriers and offering care in a seemingly hopeless
circumstance. The story was told by a nurse named Candice.
"Whenever I would try to 'care' for Will, he would erupt in
anger and dismiss me from his room," Candice said. 'A real curmudgeon'
was how the staff referred to Will. He had lived a hard life riddled with experiences
of abandonment, struggle, and rejection. Now here he was, in his final days
of life in our hospice, with no one and nothing to live or die for. He must
have felt very much alone.
"As his nurse, I tried very hard to reach inside and help him to come
to some peace with the life he had led. I wanted so much for him to know the
love of the Lord before he died; but even my small acts of caring, like an offer
of a hot coffee or an extra blanket, were sharply refused.
"It is hard not to take such constant rebuttal personally. But I did persevere;
and I made sure that when I passed his room I would stop in, say 'Hi,'
and ask if there was anything at all I could do for him. One day, to my surprise,
when I asked if I could sit with him awhile, he nodded yes. So I pulled a chair
up to the side of his bed, lowered the rail and sat, in silence. What could
I say? I admit I was afraid to speak because I was certain he would send me
out, so I sat very quietly praying inside my heart. The next day, when I again
asked if I could sit with him, he agreed–as he did the next and the next.
Each time the routine was the same: Pull a chair close, lower the rail, and
"One day when I came by, the door to Will's room was closed. On asking
the other staff, I found that he had died in the night. Although I was saddened
by his passing, I felt a small pang of relief knowing that perhaps the silence
we had shared had in some small way comforted Will and aided him on his journey."
Words, words, words,
Against my protective
wall of isolation.
They do not crack it.
Gentle, silent presence
Passes through the wall.
And dismantles it.
Without even leaving a mess.
God's Gifts to Caregivers
The stories I've told here demonstrate the power of the simple gestures
of shared prayer, music, touch, and silence. These are capabilities afforded
to those who care for the seriously ill so that they may improve their patients'
quality of living, as well as their quality of dying. God grants the powers
and understandings we need to give comfort and care. May we all be thankful
for these gifts, and may we use them generously to make a difference.
- Mother Teresa, No Greater Love, New World Library, Novato, CA, 1997,
- Beth Perry, "I Am a Nurse," Canadian Oncology Nursing Journal,
vol. 6, no. 1, 1996, pp. 6-13.
- Beth Perry, Exceptionally Competent Nursing Practice (PhD diss.,
University of Alberta, 1994).
- Robert Fulford, The Triumph of Narrative: Storytelling in the Age of
Mass Culture, Broadway Books, New York City, 2000, p. 9.
- Max Van Manen, Researching Lived Experience: Human Science for an Action
Sensitive Pedagogy, Althouse Press, London, Ontario, 1997, p. 10.
- M. J. Brunges and G. Avigne, "Music Therapy for Reducing Surgical Anxiety,"
Association of Operating Room Nurses Journal, vol. 78, no. 5, November
2003, p. 816. The researchers used music before and during surgery to help
patients to become less anxious and more relaxed.
- O. J. Sahler, B. C. Hunter, and J. L. Liesveld, "The Effect of Using
Music Therapy with Relaxation Imagery in the Management of Patients Undergoing
Bone Marrow Transplantation: A Pilot Feasibility Study," Alternative
Therapies in Health and Medicine, vol. 9, no. 6, November-December 2003,
p. 70. The researchers successfully used music therapy with bone marrow transplant
patients to reduce their pain and nausea, the two most common side effects
associated with transplantation.
- J. F. Byers and K. A. Smyth, "Effect of a Music Intervention on Noise
Annoyance, Heart Rate, and Blood Pressure in Cardiac Surgery Patients,"
American Journal of Critical Care, vol. 6, no. 3, May 1997, pp. 183-191;
J. M. White, "Effects of Relaxing Music on Cardiac Autonomic Balance
and Anxiety after Acute Myocardial Infarction," American Journal of
Critical Care, vol. 8, no. 4, 1999, pp. 220-230.
- Perry, "I Am a Nurse."
- Elizabeth Arnold and Kathleen Underman Boggs, Interpersonal Relationships:
Professional Communication Skills for Nurses, 3rd ed., W. B. Saunders,
London, England, 1999, p. 108.
- Perry, "I Am a Nurse."
- C. A. Estabrooks and J. M. Morse, "Toward a Theory of Touch: The Touching
Process and Acquiring a Touching Style," Journal of Advanced Nursing,
vol. 17, no. 4, April 1992, pp. 448-456.
- E. Tutton, "An Exploration of Touch and Its Use in Nursing," in
Richard McMahon and Alan Pearson, eds., Nursing as Therapy, 2nd ed.,
Stanley Thornes, Gloucester, England, 1998, pp. 142-169.
- Perry, "I Am a Nurse."
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